**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review and staff interview, the facility failed to provide bed hold information to residents when hospitalized . This affected one Resident (#46) of one resident reviewed for hospitalizations. The facility census was 44. Findings include: Review of the closed medical record revealed Resident #46 was admitted on [DATE] with diagnoses including severe sepsis with septic shock, dysphagia, type II diabetes mellitus, Wernicke's encephalopathy, acute embolism and thrombosis of deep veins of lower extremity, ileus, and gastrointestinal hemorrhage. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had adequate hearing, clear speech, vision impairment, a Brief Interview for Mental Status (BIMS) score of 13 out of 15, signs of delirium, and fluctuating periods and severity of inattention and disorganized thinking. The assessment further indicated the resident required extensive assist to total dependence for activities of daily living (ADLs). A review of the medical record revealed the resident was transferred to an acute care hospital emergency room on [DATE] after an acute change in condition. The medical record contained no evidence that bed hold information was provided to the resident or the resident's representative at the time of the hospitalization. Interview with Business Office Manager (BOM) #90 on 03/28/18 at 2:37 P.M. verified no bed hold notice was provided at the time of the hospitalization. BOM #90 further reported a bed hold notice was not warranted because the resident was discharged . Interview with Social Service Director (SSD) #50 on 03/28/18 at 3:41 P.M. revealed the resident's representative was planning to have the resident discharged to a different long term care facility, but the discharge had not occurred prior to the resident's hospitalization. SSD #50 verified the resident was hospitalized on [DATE] and not yet discharged . Review of a Bed Hold Notice provided by the facility documented, This notice is to be provided to the resident and his/her representative at the time of the transfer. In the case of an emergency, the paperwork should be provide within 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record revealed Resident #43 was admitted on [DATE]. A review of the admission physician order sheet signed and dated by the resident's physician on 02/16/18 documented diagnoses of anxiety disorder, major depressive disorder, and schizophrenia. The facility completed a comprehensive admission Minimum Data Set (MDS) assessment dated [DATE]. Section I of the assessment, which pertained to active diagnoses, contained no documentation of the resident's active diagnoses of anxiety, depression, or schizophrenia. Interview on 03/29/18 at 2:11 P.M. with Registered Nurse (RN) #100 verified the order sheet contained diagnoses of anxiety, major depression, and schizophrenia and the admission MDS dated [DATE] did not include these diagnoses. Based on resident record review and staff interview, the facility failed to accurately complete minimum data set (MDS) assessments. This affected three Resident's (#34,#27 and #43) of 14 reviewed. The facility census was 44. Findings include: 1. Review of the medical record for Resident #34 revealed the resident was initially admitted to the facility on [DATE]. Diagnoses included diabetes mellitus type two, bipolar disorder, lack of coordination, hypertension, pneumonia, hyperlipidemia, chronic obstructive pulmonary disease, muscle weakness, acidosis, cerebrovascular disease, and hypoxia. Review of the document titled, Evaluation of Oral/Dental Status dated 04/03/17, revealed the resident had no teeth. Continued review of the medical record for Resident #34 revealed the resident was assessed by the dentist on 01/30/18. Dental assessment documentation revealed the resident was edentulous. Review of Resident #34's admission minimum data set (MDS) assessment dated [DATE], section L specific to dental, section B. No natural teeth or tooth fragments (edentulous) was documented no. Interview on 03/28/18 at 1:57 P.M. with Registered Nurse (RN) #100 verified the admission MDS assessment dated [DATE], section L specific to dental status was incorrect. RN #100 verified Resident #34 was edentulous. 2. Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, anemia, blind in left eye, coronary artery disease, diabetes mellitus type two, edema, hyperlipidemia, hypertension, osteoarthritis, pneumonia, pressure ulcer stage three, ulcerative colitis, and a history of uterine cancer. Review of the document titled, Foley Catheter Justification dated 02/21/18, revealed Resident #27 had a urinary catheter in place to assist in healing of a perineal wound. Review of the admission MDS assessment dated [DATE], section H specific to bowel and bladder revealed no documentation of the indwelling catheter utilized by Resident #27. Observation on 03/27/18 at 9:39 A.M. of Resident #27 revealed a indwelling urinary catheter was in place. Interview on 03/27/18 at 9:40 A.M. with Resident #27 revealed the indwelling catheter was placed prior to admission to the facility. Resident #27 revealed the catheter was being used to assist with the healing of a pressure wound. Interview on 03/28/18 at 1:54 P.M. with RN #100 revealed Resident #27 had an indwelling catheter in place when the resident was admitted to the facility. RN #100 verified section H of the admission MDS assessment dated [DATE], for Resident #27 did not identify the use of an indwelling catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of Minimum Data Set (MDS) assessments and staff interview the facility failed to have resident's re-screened for pre-admission screening and resident review (PASARR) level II services. This affected one Resident (#20) of two reviewed for PASARR II services. The facility census was 44. Findings include: Review of Resident #20's medical record revealed an admission date of 06/09/15 with diagnoses included muscle weakness, anxiety disorder, atrial fibrillation, major depressive disorder, insomnia, panic disorder, major depressive disorder and post-traumatic stress disorder (PTSD). Further review revealed the diagnoses of major depressive disorder and PTSD were added on 06/02/17 and panic disorder was added on 08/02/17. Review of a pre-admission screen (PAS) dated 06/16/15 revealed under section D (indications of serious mental illness) Resident #20 was documented as not having any of the mental disorders listed. Resident #20 was marked as being not applicable for PASARR II screening/services. Review of a significant change MDS assessment dated [DATE] revealed anxiety disorder, depression and PTSD were checked as active diagnoses. Resident #20 did not have active diagnoses of Alzheimer's disease or non-Alzheimer's dementia. Resident #20's brief interview for mental status (BIMS) score on this assessment was 15, cognitively intact. During further review of Resident #20's medical record no further PAS/PASARR screenings were found. During an interview on 03/28/18 at 4:52 P.M. Social Services Director (SSD) #50 confirmed Resident #20 was not be re-screened for PASARR level II services determination after the addition of major depressive disorder, panic disorder and PTSD to her diagnoses or after her significant change MDS assessment dated [DATE] was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and review of facility policy, the facility failed to document the resident's participation in developing the care plan. This affected one Resident (#33) of one reviewed for care planning. The facility census was 44. Findings include: Resident #33 was admitted on [DATE] with diagnoses including Alzheimer's disease, anxiety disorder, hypertension, and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had adequate hearing and vision, usually made self understood and understood others, had a Brief Interview for Mental Status (BIMS) score of three out of 15, had no potential indicators of psychosis, and required supervision for activities of daily living (ADLs). A Care Plan Conference Summary dated 03/06/18 revealed a care plan conference was attended by members of the interdisciplinary team and the resident's representative attended via telephone. The medical record contained no evidence the care plan was discussed with the resident or that it was not practicable for the resident to attend the care plan meeting. During an interview on 03/27/18 at 10:28 A.M., Resident #33 denied being invited to a meeting to discuss a care plan. Interview on 03/28/18 at 9:32 A.M. with Social Service Director (SSD) #50 revealed Resident #33 did not attend the care plan meeting because of the resident's cognition. SSD #50 verified the medical record contained no evidence that the resident was invited to or participated in the care plan meeting, or that it was not feasible for the resident to attend. Review of the Care Conference facility policy with revision date of 8/2015 revealed the facility would hold regular interdisciplinary care conferences for the purpose of providing resident, family, and team communication in planning and developing an individualized plan of care. The policy further indicated, Each resident shall be invited to participate in their conference. At the resident's discretion, the family shall be invited to participate also. The coordination of the care conference and documentation is the responsibility of the MDS Coordinator or his/her designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to timely schedule diagnostic services. This affected one (#34) of six residents reviewed for ancillary services. The census was 44. Findings include: Review of the medical record for Resident #34 revealed the resident was initially admitted to the facility on [DATE]. Diagnoses included diabetes mellitus type two, bipolar disorder, lack of coordination, hypertension, pneumonia, hyperlipidemia, chronic obstructive pulmonary disease, muscle weakness, acidosis, cerebrovascular disease, and hypoxia. Review of neurological consultation documentation dated 01/19/18, revealed Resident #34 was scheduled for magnetic resonance imaging (MRI) of the cervical spine on 01/30/18. Review of the progress note dated 01/29/18 at 2:11 P.M. revealed the MRI scheduled on 01/30/18 for Resident #34 was canceled due to payer source. Further review of the progress note dated 02/23/18 at 2:58 P.M. revealed the MRI for Resident #34 was rescheduled for 02/26/18. The medical record contained no documentation of the facility attempting to reschedule the appointment prior to 02/23/18. Interview on 03/29/18 at 2:00 P.M. with the Director of Nursing verified the medical record for Resident #34 contained no documentation of the facility attempting to reschedule the MRI until 26 days after the appointment was canceled.