**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to collaborate with the Hospice provider to ensure the development, implementation, and revision of the coordinated plan of care for one (1) of six (6) sampled residents (Resident #38). The facility failed to ensure Resident #38 had Physician's Orders to receive the Hospice services being provided for the resident. In addition, the facility failed to ensure Resident #38 had a Hospice Care Plan. The findings include: Review of the facility's, Hospice Services Agreement dated 12/31/2019, with the Hospice provider, revealed the facility and Hospice provider will jointly develop and agree upon a coordinated, interdisciplinary Plan of Care. Further review revealed the facility and Hospice provider were to periodically conduct joint reviews of each Plan of Care and modify the Plan of Care, if necessary for the involved Hospice residents. Review of the facility policy titled, Hospice Program, last reviewed 05/29/2018, revealed the Director of Nursing (DON), Assistant Director of Nursing (ADON) or clinical designee would be responsible for the collaboration with the Hospice representatives and coordination of the facility staffs' participation in the Hospice care planning. Continued review revealed the DON, ADON or clinical designee were also responsible for communication with Hospice representatives and other healthcare providers participating in the provision of care for the terminal illness of the resident and related conditions to ensure quality of care for the resident and family. Continued review revealed for the resident receiving Hospice services the DON, ADON or clinical designee were to obtain information from the hospice provider to include: the most recent Hospice plan of care; Hospice election form; Physician certification and recertification of the terminal illness; names and contact information for Hospice personnel involved in the Hospice care for the resident Hospice medication information; Hospice Physician and applicable attending Physician Orders for the resident. Further review of the policy revealed the DON, ADON, or clinical designee were to additionally ensure the facility provided orientation of policies and procedures including resident rights, appropriate forms, and record documentation requirements to the Hospice staff providing care to the resident in the facility. Review of the Resident Face Sheet in Resident #38's medical record revealed the facility admitted the resident on 07/26/2022, with diagnoses of Parkinson's Disease and Unspecified Dementia without behavioral disturbance. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #38 to have a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating severe cognitive impairment. Continued review of the MDS revealed the facility assessed Resident #38 to require extensive assistance with all Activities of Daily Living (ADLs). Further review of the MDS revealed not documented evidence the facility identified Resident #38 had received Hospice care prior to his/her admission or while a resident residing in the facility. Review of the facility's Care Plan, dated 08/16/2022 for Resident #38, revealed no documented evidence Hospice care plan had been developed for the resident. Review of the Physician Note dated 07/28/2022, revealed Resident #38 had been on Hospice at home prior to admission to the facility for long-term care. Review of the current active Physician Orders in Resident #38's electronic medical health record revealed no order for Hospice care present in the medical record. Review of the Form CMS-802 Matrix for Providers, received on 08/23/2022, present in the Resident #38's record revealed it identified the resident as being on Hospice care. Interview on 08/25/2022 at 10:14 AM, with State Registered Nursing Assistant (SRNA) #4 revealed Resident #38 had been on Hospice since admission to the facility (admission date was 07/26/2022). Further interview revealed SRNA #4 indicated she was not aware of the reason for Resident #8's Hospice services however. Interview on 08/25/2022 at 2:15 PM, with Licensed Practical Nurse (LPN) #1 revealed Resident #38 had been admitted to the facility on Hospice. LPN #1 stated Hospice nurses visited Resident #38 weekly at the facility, and Hospice aides provided care for the resident three (3) times a week. Continued interview revealed LPN #1 indicated she was not aware of the Hospice diagnosis for Resident #38 however. LPN #1 further stated there was no order for Hospice services for the resident and the LPN was unsure how staff were made aware Hospice was being provided for the resident. Interview on 08/25/2022 at 2:22 PM, with the MDS Coordinator revealed she was not aware of Resident #38 receiving Hospice services and could not identify why the resident required Hospice services. The MDS Coordinator stated Hospice was a new service that the facility was providing. She revealed Hospice was not provided by the facility; the service was provided by the contracted Hospice company, so there would be no Physician's Order or care plan completed by the facility. Further interview revealed the MDS Coordinator stated the Hospice service was not placed on the MDS assessment either. Interview on 08/25/2022 at 3:03 PM, with the Medical Records Clerk revealed there was no written documentation exchanged between the Hospice provider and the facility. Interview on 08/25/2022 at 3:10 PM, with the Hospice Social Worker (SW) revealed Hospice service began about three (3) months ago at the facility. The Hospice SW stated Resident #38 was on Hospice services related to his/her diagnosis of Parkinson's Disease with related Dementia. The Hospice SW further revealed the Hospice's medical records should be sending written documentation to the facility regarding Resident #38. Interview on 08/25/2022 at 3:21 PM, with the Hospice Executive Director (ED) revealed the facility and the Hospice company, had a contract for an extended length of time; however, they only recently began providing Hospice services to the facility's residents. The Hospice ED further stated the Hospice company should have been providing the Hospice Order and Hospice care plan for the resident and be involved in the care planning process. Interview on 08/25/2022 at 4:09 PM, with the Hospice Registered Nurse (RN) revealed a verbal report was given to the floor nurse and the supervisor after the Hospice nurse visited Resident #38. The Hospice RN further stated the exchange of information had been verbal, but written documentation would start being coordinated with the facility staff and sent to the facility. Interview on 08/26/2022 at 9:30 AM, with the facility's Nurse Consultant revealed the facility and Hospice should be coordinating the care being provided for Resident #38. Further interview revealed there should also be an order for the Hospice care being provided and a care plan should also be in place. Interview on 08/25/2022 at 2:51 PM, with the Administrator revealed the facility just started taking Hospice residents within the last two (2) months and the process was new to everyone. The Administrator stated verbal communication was to occur to inform staff of the resident being on Hospice. She revealed she was unaware of any documents or care plans provided between the facility and the Hospice company. The Administrator further stated there should be a Physician's Order for Hospice and the MDS assessment should identify the Hospice services for the resident. An additional interview on 08/26/2022 at 11:49 AM, with the Administrator revealed her expectation was for Hospice services to be coordinated with the Hospice provider and facility staff. Further interview revealed the expectations were for an Physician's Order to be obtained, Hospice should be identified on the resident's MDS Assessment, and a Hospice care plan should be in place as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, it was determined that the facility failed to conduct an accurate Minimum Data Assessment (MDS) assessment for one (1) of seventeen (17) sampled residents. Resident #36 was noted to have limited range of motion to both upper and lower extremities; however, the facility failed to document that the resident had limited range of motion on the resident's 08/24/19 MDS. The finding include: Review of the facility policy titled, Resident Assessment, review date 07/31/18, revealed, The facility must conduct initially and periodically a comprehesive, accurate, standardized reproducible assessment of each resident's functional capacity. Record review revealed the facility admitted Resident #36 on 06/13/18 with diagnoses that include Cerebral Palsy, Contractures to the ankle and hand, and Epilepsy. Observation of Resident #36 on 09/25/19 at 1:15 PM revealed the resident was sitting in a recliner. The resident's bilateral upper and lower extremities were contracted. Review of Resident #36 Care Plan, revised on 09/25/19, revealed the facility planned care for the resident to have assistance with activities of daily living related to contractures. However, a review of Resident #36's Minimum Data Set (MDS) assessment dated [DATE] revealed no documented evidence that the resident had Functional Limitation in Range of Motion to the upper or lower extremities. Interview on 09/27/19 at 10:39 AM with the facility MDS Coordinator confirmed Resident #36 had limited range of motion to both upper and lower extremities. The MDS Coordinator stated the resident's previous MDS had been marked as having limited range of motion. She further stated that the resident's 08/24/19 MDS related to range of motion was an error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, it was determined that the facility failed to implement the care plan for one (1) of seventeen (17) residents. The facility developed a care plan for Resident #47 with an intervention to keep the catheter bag off the floor. However, observation revealed the resident's catheter was on the floor. The findings include: Review of facility policy titled, Comprehensive Care Plans, revised 07/19/18, revealed .The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. Record review revealed the facility admitted Resident #47 on 06/19/19 with diagnoses including Bipolar Disorder, History of Traumatic Brain Injury, Benign Prostatic Hyperplasia, and Reflux Uropathy. Review of Resident #47's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating little or no cognitive impairment. Further review of the MDS revealed the resident had a catheter. Review of Resident #47's Care Plan, revised 09/27/19, revealed the resident had an indwelling urinary catheter related to a diagnosis of Obstructive Neurogenic Bladder. The facility developed a goal for the resident to have no signs of urinary tract infection, with an intervention to ensure the urinary drainage bag did not touch the floor. Observation on 09/26/19 at 3:33 PM of Resident #47 revealed the resident lying on his/her bed. Further observation revealed the resident's urinary catheter and tubing were lying on the floor. Interview on 09/27/19 at 12:38 PM with the Director of Nursing (DON)/Infection Control Nurse revealed catheter bags should not touch the floor. She further revealed that she conducted walking rounds twice a day and had not identified any concerns with urinary catheters being on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review it was determined that the facility failed to ensure infection prevention was maintained for two (2) of seventeen (17) residents. Observation revealed Resident #37 and Resident #47's indwelling urinary catheter drainage bags and/or tubing were lying on the floor. The findings include: Review of the facility policy titled, Infection Prevention and Control Program, revised October 2018, revealed revealed, An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of facility policy titled, Catheterization, reviewed 05/23/19, revealed .avoid letting [the catheter] touch the floor. 1. Record review revealed the facility admitted Resident #37 on 07/26/16 with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, Neuropathic Bladder, and Diabetes. Review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Further review of the MDS revealed the resident had a catheter. Observation of Resident #37 on 09/25/19 at 2:02 PM and on 09/26/19 at 4:13 PM revealed the resident was in a low bed and the resident's urinary catheter bag and tubing were lying on the floor. Interview on 09/26/19 at 4:13 PM with State Registered Nursing Assistants #1 and #2 revealed they were aware that urinary drainage bags should not touch the floor and removed the drainage bag from the floor after the interview. 2. Record review revealed the facility admitted Resident #47 on 06/19/19 with diagnoses including Bipolar Disorder, History of Traumatic Brain Injury, Benign Prostatic Hyperplasia, and Reflux Uropathy. Review of Resident #47's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating little or no cognitive impairment. Further review of the MDS revealed the resident had a catheter. Review of Resident #47's Care Plan, revised 09/27/19, revealed the resident had a care plan that stated the resident had an indwelling urinary catheter related to a diagnosis of Obstructive Neurogenic Bladder with a goal to have no signs of urinary tract infection. The resident had care-planned approaches to not allow the drainage bag to touch the floor. Observation on 09/26/19 at 3:33 PM of Resident #47 revealed the resident lying in bed and the catheter, as well as the tubing, were lying on the floor. Interview on 09/27/19 at 12:38 PM with the Director of Nursing (DON)/Infection Control Nurse revealed a resident's catheter drainage bag should not touch the floor. She further revealed that she conducted walking rounds twice a day and had not identified any concerns with catheters being on the floor.