**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review the facility failed to ensure that the Minimum Data Set (MDS) assessment was coded accurately for a serious mental illness (Resident #10) and for the use of anticoagulant medications (Resident # 1, #3, #7, #21 and #33) for six (6) of 32 sampled residents. Findings include: Record review of the facility policy titled, Resident Assessment Instrument (RAI) Policy with no revision date revealed, It is the policy of this facility that the RAI will be done as follows: According to the guidelines specified by CMS (Centers for Medicare and Medicaid Services). Resident #1 Record review of Order Summary Report during initial pool revealed Resident #1 was not on an anticoagulant medication but was on Plavix, an antiplatelet medication. The resident was coded on the MDS assessment as being on anticoagulant and antiplatelet medication. Record review of Resident #1's Order Summary Report revealed an order dated 4/4/25 for Plavix 75 milligrams (mg) by mouth one time a day for Peripheral Vascular Disease. Review revealed there was no order for an anticoagulant medication. Record review of Resident #1's Minimum Data Set (MDS) Section N dated 7/7/25 revealed the resident was coded for receiving an anticoagulant. Record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] and diagnoses included Unspecified Atrial Fibrillation and Peripheral Vascular Disease. Resident #3 A record review of Resident #3's “Order Summary Report” with active orders as of 7/23/25 revealed an order dated 6/26/25 for Plavix 75 mg by mouth one time per day. There were no orders identified for an anticoagulant. A record review of Resident #3's MDS with an ARD of 7/03/25 under section N, revealed that Resident #3 was coded as being on an anticoagulant. A record review of the admission Record revealed Resident #3 was admitted by the facility on 6/26/25 with a diagnosis of Metabolic Encephalopathy. Resident #7 Record review of MDS Section N dated 6/9/25 revealed Resident #7 was coded as receiving an anticoagulant medication. Record review of Resident #7's Order Summary Report revealed an order dated 1/2/24 for Clopidogrel (Plavix) 75 mg by mouth daily for Peripheral Vascular Disease. Review revealed there was no order for an anticoagulant medication. Record review of Resident #7's admission Record revealed she was admitted to the facility on [DATE]. Diagnoses included Stage 3 Chronic Kidney Disease and Peripheral Vascular Disease. Resident #21 A record review of the “Order Summary Report” dated 07/23/25, revealed an order for Plavix 75 mg by mouth one time per day. There were no orders identified for an anticoagulant. A record review of MDS with an ARD of 04/23/25 under section N, revealed that Resident #21 was on an anticoagulant. A record review of the admission Record revealed Resident #21 was admitted by the facility on 10/08/24 with a diagnosis of Diabetes Mellitus. Resident #33 A record review of the MDS with an ARD of 04/24/25 under section N, revealed that Resident #33 was on an anticoagulant. A record review of “Order Summary Report” dated 07/23/25, revealed an order for Plavix 75 mg by mouth one time per day. There were no orders identified for an anticoagulant. A record review of the admission Record revealed Resident #33 was admitted by the facility on 01/20/25 with a diagnosis of Metabolic Encephalopathy. During an interview with the Registered Nurse (RN) MDS Coordinator on 7/22/25 at 1:30 PM, she revealed that Resident #1, #3, #7, #21 and #33 were on Plavix (Clopidogrel) and aspirin, and she coded Plavix as an anticoagulant and aspirin as an antiplatelet. She stated she was unaware that Plavix was an antiplatelet and not an anticoagulant medication and confirmed she should have coded this as an antiplatelet. She confirmed the MDS represents the care and condition of the resident and should be coded accurately, and she failed to do this when an antiplatelet was coded inaccurately as an anticoagulant. During an interview on 7/22/25 at 2:20 PM, the Director of Nursing (DON) confirmed that Plavix was an antiplatelet, not an anticoagulant medication. She stated her expectation was for the MDS, which represents the condition of the residents, to be accurately completed. She confirmed the facility failed to accurately complete the MDS assessment for these residents. Resident #10 Record review of Resident # 10's Significant Change MDS with an ARD of 1/9/25, revealed Section A 1500 coded as No, Is the resident currently considered by the state level II PASRR (Preadmission Screening and Resident Review) process to have serious mental illness and/or intellectual disability or a related condition? Record review of Resident # 10's Summary of Findings Report, from the PASRR Office, dated 8/18/23, under Mental Health revealed the individual meets criteria for having a diagnosis of mental illness as defined by PASRR. During an interview with the MDS Coordinator on 7/22/25 at 2:45 PM, she verified that the Significant Change MDS with an ARD of 1/9/25, for Resident # 10 was coded incorrectly. She agreed that the MDS should be coded correctly to ensure that the resident is receiving the correct level of care. In an interview with the Director of Nursing (DON), on 7/22/25 at 3:00 PM she agreed that it was her expectation that the MDS would be coded correctly. A record review of the admission Record revealed Resident #10 was admitted by the facility on 5/19/22 with diagnoses of Schizoaffective Disorder and Major Depressive Disorder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and facility policy review, the facility failed to post Oxygen In Use signage for residents that utilized oxygen therapy for two (2) of four (4) residents observed. Resident #15 and Resident #25. Resident #15 and Resident #25 Respiratory Care Review of the facility policy titled, Oxygen Policy, with no date, revealed there was no documentation regarding Oxygen (O2) In Use signage to be posted for residents using oxygen. The facility administrator provided documentation, on the facility's letterhead, dated 11/3/22, that revealed, to whom it may concern, as (Facility proper name) including its building and grounds is a smoke free facility which prohibits the use of any and all smoking items. For this reason, the posting of such signs in and or near oxygen use is a [NAME] point. New residents and their family members are advised of this rule upon admission. Staff are advised as new hires and this rule is closely monitored by administrative staff. An observation on 11/1/22 at 12:52 PM, of the room entrance of the assigned room shared by Resident #15 and Resident #25, revealed there was no O2 In Use sign posted on the room entrance to indicate Resident #15, and Resident #25 used O2. An oxygen concentrator, with an oxygen tubing set-up for use, was observed for Resident #15 and Resident #25. An interview on 11/1/22 at 12:52 PM with Resident #15 revealed he used his O2 during the night. An observation and interview on 11/1/22 at 12:52 PM with Resident #25 revealed he was actively using his O2, and he revealed he used his O2 majority of the day, everyday of the week. An observation on 11/1/22 at 3:00 PM of the room entrance of the assigned room shared by Resident #15 and Resident #25 revealed, there was no O2 In Use sign posted on the room entrance to indicate O2 was in use in their room. The observation also revealed Resident #25 was actively using his O2. An observation and interview on 11/2/22 at 2:50 PM with Licensed Practical Nurse (LPN)#1 confirmed, there was not a O2 In Use sign posted on the room entrance for Resident #15 and Resident #25. She revealed an O2 In Use sign should have been posted on the entrance to alert visitors and staff of there being O2 in use in the room. An observation and interview on 11/2/22 at 2:52 PM with LPN #2 confirmed Resident #15 and Resident #25 did not have an O2 In Use sign posted on their room entrance. She revealed she would have to go back to check the policy to see if she should have posted the sign, but an O2 In Use sign would be a safety alert for residents using O2 and would let visitors and staff know to take necessary precautions before entering a room where O2 was in use. An observation and interview on 11/2/22 at 2:56 PM with the Director of Nursing (DON)#1, confirmed there was not an O2 In Use sign posted on the room entrance for Resident #15 and Resident #25. She revealed she would have to go and check the policy to see if it indicated an O2 In Use sign had to be posted for residents using O2 but confirmed the signage would have been a safety alert for residents using O2 and would have alerted visitors and staff to take the necessary precautions to avoid the likelihood of any incident or a negative outcome for a resident using O2. Record review for Resident #15 revealed an admission date of 2/10/22, with diagnoses of Unspecified Atrial Fibrillation, and Acute Respiratory Failure With Hypoxia. Record review for Resident #25 revealed an admission date of 6/9/22, with diagnoses of Chronic Systolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Unspecified, and Shortness of Breath. Record review of the Physician's Orders for Resident #15 revealed the order, O2 continuous at (@) two (2) liters per minute (lpm) / by nasal cannulas (bnc) (may leave off at intervals as tolerated) to wean off) O2, dated 3/15/22. Record review of the Physician's Orders for Resident #25 revealed the order, O2 continuous @ 2 lpm/bnc (may leave off at intervals as tolerated), dated 6/9/22. Record review of Section O of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 8/10/22, for Resident #15, revealed Resident #15 was captured for the use of O2 while a resident. Record review of Section O of the Quarterly MDS Assessment, with an ARD of 9/9/22, for Resident #25, revealed Resident #25 was captured for the use of O2 while a resident. Record review of Section C of the Quarterly MDS Assessment, with an ARD of 8/10/22, for Resident #15, revealed Resident #15 has a Brief Interview for Mental Status (BIMS) score of 11, indicating Resident #15 is moderately cognitively impaired. Record review of Section C of the Quarterly MDS Assessment, with an ARD of 9/9/22, for Resident #25, revealed Resident #25 has a BIMS score of 06, indicating Resident #25 is severely cognitively impaired.