**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident who exhibited new behaviors which resulted in additional psychiatric diagnoses for 1 of 1 resident (Resident #38) reviewed for PASRR. Findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses that included, in part, convulsions and congestive heart failure. She had a level one PASRR number upon admission. The medical record indicated Resident #38 was seen by psychiatry services in the facility on 10/7/21 and was noted to have a new onset of auditory delusions . and subsequently diagnosed with brief psychotic disorder and major depressive disorder. Additional visits with psychiatry were completed 12/28/21 and 7/25/22 and resulted in diagnoses of psychosis and schizophrenia. The medical record revealed a PASRR application was not completed to determine if a level two PASRR referral (the purpose of the Level two screening is to assure that individuals with serious mental illness entering or residing in Medicaid certified nursing facilities receive appropriate placement and services) was needed due to newly identified serious mental illness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 had moderately impaired cognition. She reported mood symptoms that included feeling down, feeling tired/little energy, trouble sleeping, and having trouble concentrating. Resident #38 refused care 1-3 days out of the seven day look back period. Additionally, she received antipsychotic and antidepressant medications for 7 of 7 days during the MDS look back period. The care plan, updated 11/23/22, included focused areas of verbal outbursts and being resistive to care. Interventions included, Observe for signs/symptoms of mania, racing thoughts, euphoria, increased irritability, frequent mood changes, pressured speech, and flight of ideas; psychiatric consult as needed. On 12/19/22 at 10:44 AM Resident #38's current PASRR number, dated 3/9/20, was provided by the Social Services Director and indicated a level one PASRR number. The cumulative diagnosis list was reviewed in the electronic health record and revealed diagnoses of major depressive disorder with an onset date of 5/5/21, psychotic disorder with delusion with an onset date of 4/23/22 and undifferentiated schizophrenia with an onset date of 7/25/22. On 12/19/22 at 2:23 PM an interview was completed with Nurse #1. She was familiar with Resident #38 and shared that the resident got angry at times, talked out loud to herself and demonstrated auditory hallucinations. She stated Resident #38 was successfully re-directed by staff when she hallucinated and was seen by psychiatry services every two weeks for therapy and medication management. MDS Nurse #1 was interviewed on 12/19/22 at 3:15 PM. She explained Resident #38's family member shared that the resident had exhibited psychiatric behaviors when at home but was never formally diagnosed with mental illness. MDS Nurse #1 said the resident exhibited visual and auditory hallucinations after she was admitted to the facility. The facility referred her to psychiatry and she was diagnosed with schizophrenia while at the facility. During an interview with the Social Services Director on 12/19/22 at 3:24 PM, she stated Resident #38 had diagnoses of psychotic disorder with delusions and schizophrenia and had outbursts at times. She acknowledged a new PASRR application was not completed for Resident #38 and said she wasn't aware one needed to be completed when a resident was newly identified with mental illness. On 12/20/22 at 9:55 AM an interview was completed with Resident #38. She confirmed she felt down sometimes and told staff if she wasn't feeling well. She denied auditory or visual hallucinations and could not recall if she had seen psychiatry services while at the facility. The Administrator was interviewed on 12/20/22 at 9:34 AM. He said Resident #38 had auditory hallucinations at times but was well controlled with routine psychiatric services and medication management. He shared when a resident was newly diagnosed with mental illness, the interdisciplinary team met and discussed the symptoms and treatment, reviewed psychiatric consults and the Social Services Director was responsible to complete a new PASRR application for possible level two referral. The Administrator stated the Social Services Director had been educated about the PASRR process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews the facility failed to provide nail care to 1 of 2 residents reviewed for Activities of Daily Living (ADLs) (Resident #17). The findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses which included: vascular dementia, generalized muscle weakness, transient cerebral ischemic attack, and cognitive communication deficit. Review of Resident #17's most recent Minimum Data Set (MDS) revealed a annual assessment with an Assessment Reference Date (ARD) of 11/23/22 revealed the resident's cognition was severely impaired. The resident required extensive or total staff assistance for all activities of daily living (ADLs). Review of Resident #17's care plan which was most recently reviewed on 11/23/22 revealed the resident was care planned as having required extensive assistance for all ADLs due to ADL self-care performance deficit related to weakness, cognitive deficit, and dementia. The goals listed for the resident were for the resident to be able to participate in part of ADLs as able and the resident would have her personal care needs met by staff daily through the next review. The interventions listed included one person to provide extensive assistance with personal hygiene, bathing, dressing, and grooming. An observation conducted on 12/18/22 at 2:22 PM revealed Resident #17's fingernails extended beyond her fingertips on all five fingers on each hand. All five fingernails on each hand were observed with dark debris caked under the free edge of each nail. An observation conducted on 12/19/22 at 4:04 PM revealed Resident #17's fingernails were freshly painted and extended beyond her fingertips on all five fingers on each hand. All five fingernails on each hand were observed with dark debris under the free edge of each nail. An observation of Resident #17 conducted on 12/20/22 at 9:25 AM revealed all five fingernails on each hand were observed with dark debris under the free edge of each nail. Resident #17 was up in chair, dressed appropriately and Nursing Assistant (NA) #1 was braiding Resident #17's hair. An interview with NA #1 was conducted on 12/20/22 at 9:30 AM. The NA stated Resident #17 was on her assignment. She further stated residents got a bed bath every day unless it was a shower day, or they refused. She explained a bed bath included cleaning nails. She further explained that residents received nail care during an activity provided by the Activity Department called Manicure Monday. The NA revealed during Manicure Monday a resident's nails got polished but sometimes they returned to the unit with food still under them. She said if she observed food under a resident's nails, she did the best she could at that time to clean them. An interview was conducted with the Activity Manager on 12/20/22 at 10:02 AM. She explained that during the Manicure Monday activity included filing, clipping, painting, and cleaning under the nails. She stated they did every resident who wanted to participate. If the resident couldn't go to the activity, they went to them and did a manicure. On 12/20/22 at 11:02 AM Resident #17 was observed in the dining room. An observation revealed her nails were neatly trimmed and no dark debris was observed under the free edge of the resident's nails. An interview was conducted with the Activity Manager on 12/20/22 at 11:20 AM. The Activity Manager revealed she painted Resident #17's nails on Manicure Monday. She said she may have missed cleaning under her nails. She stated I didn't have a stick and cleaned them with a wipe. The Activity Manager explained when a resident's nails are very caked with debris, they would need to soak and it was hard to do all that in one hour, when she had about 15 people to manicure. She further explained for Resident #17, she would have to sit and hold the resident's hands the whole time because of her cognition. An interview with the Director of Nursing (DON) was conducted on 12/20/22 at 11:31 AM. The DON stated the residents' nails should be checked and cleaned every day. She further stated it was her expectation for the residents' fingernails to be kept trimmed and clean. She explained nail care would be addressed with staff immediately.