**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure Resident #23 had an accurate and consistent advance directive in place throughout the medical record. This affected one (Resident #23) of eight residents reviewed for advance directives. The facility census was 31. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included severe protein-calorie malnutrition, weakness, and adult failure to thrive. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 06 which indicated severely impaired cognition. The MDS reflected Resident #23 required extensive assistance of one staff for dressing, personal hygiene, and bed mobility. Resident #23 was dependent with two staff for transfers and was unable to ambulate. Review of Resident #23's care plan revealed a code status of Do Not Resuscitate Comfort Care Arrest (DNRCC-Arrest). Review of physician's orders revealed Resident #23 was admitted to hospice care on 05/16/23 with a diagnosis of end stage protein calorie malnutrition with life expectancy of six months or less if disease runs its natural course. Resident #23 had a code status order, dated 07/05/22, of DNRCC-Arrest. Review of the Do Not Resuscitate (DNR) Order Form in Resident #23's chart revealed a selection of DNRCC-Arrest, dated 07/05/22, and signed by Resident #23's physician. The form stated providers will treat patients as any other without a DNR order until the point of cardiac or respiratory arrest, at which point all interventions will cease and the DNR Comfort Care protocol will be implemented. Interview on 07/18/23 at 8:47 A.M. with Director of Nursing (DON) revealed Resident #23 had received comfort care from staff and was actively dying. DON verified Resident #23 had a current order for a code status of DNRCC-Arrest and had not received any intervention to prolong or sustain life. DON stated Resident #23 should have had a code status of DNRCC. Review of the Hospice Interdisciplinary Group Meeting note dated 05/24/23 and timed 09:00 A.M. revealed Resident #23 was listed as a DNR Comfort Care (DNRCC). Interview on 07/18/23 at 2:00 P.M. with Hospice Registered Nurse (RN) #610 revealed hospice records listed Resident #23's code status of DNRCC. Hospice RN #610 accessed Resident #23's hospice records on her work tablet and revealed a signed DNRCC form dated 05/17/23, signed by the hospice medical director. Hospice RN #610 verified Resident #23 had been receiving comfort care at the facility and was actively dying. Interview on 07/18/23 at 2:18 P.M. with DON revealed the facility had no record of a DNRCC form dated 05/17/23. DON verified Resident #23's medical record was inconsistent, as the facility and hospice provider had different code status records for Resident #23. DON stated there was a breakdown in communication between the facility and the hospice provider and was not sure how it happened. Review of the facility policy titled Advanced Directive Policy and Procedure, dated 01/2022, stated each resident's advance directives are documented accurately in the record to allow for accurate verification at the time when the directive would be implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to accurately code Resident #23's Minimum Data Set (MDS) 3.0 assessment. This affected one (Resident #23) of eight residents reviewed for accuracy of assessments. The facility census was 31. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included severe protein-calorie malnutrition, weakness, and adult failure to thrive. Review of the physician's orders revealed Resident #23 was admitted to hospice care on 05/16/23 with a diagnosis of end stage protein calorie malnutrition with life expectancy of six months or less if disease runs its normal course. Review of section J of the MDS Significant Change in Status MDS assessment, dated 05/18/23, revealed the facility marked no to the resident having a condition or chronic disease that may result in a life expectancy of less than six months. Review of section O of the MDS revealed the facility had not marked hospice care under the section of special treatments, procedures and programs. Interview on 07/20/23 at 8:34 AM with Corporate MDS Nurse #600 revealed Resident #23 had a significant change in status assessment scheduled and completed after the resident elected for hospice. Corporate MDS Nurse #600 verified section J was incorrect as Resident #23 had a life expectancy of less than six months. Corporate MDS Nurse #600 verified section O was incorrect, and hospice care should have been marked. Corporate MDS Nurse #600 verified the MDS was not an accurate reflection of Resident #23's health status as of the assessment reference date of 05/18/23 and needed to be corrected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure effective and ongoing communication with Resident #23's hospice company. This affected one (Resident #23) of two residents reviewed for hospice services. The facility census was 31. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included severe protein-calorie malnutrition, weakness, and adult failure to thrive. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 06 which indicated severely impaired cognition. The MDS reflected Resident #23 required extensive assistance of one staff for dressing, personal hygiene, and bed mobility. Resident #23 was dependent with two staff for transfers and was unable to ambulate. Review of Resident #23's care plan revealed a code status of Do Not Resuscitate Comfort Care Arrest (DNRCC-Arrest). Review of physician's orders revealed Resident #23 was admitted to hospice care on 05/16/23 with a diagnosis of end stage protein calorie malnutrition with life expectancy of six months or less if disease runs its natural course. Resident #23 had a code status order, dated 07/05/22, of DNRCC-Arrest. Review of the Do Not Resuscitate (DNR) Order Form in Resident #23's chart revealed a selection of DNRCC-Arrest, dated 07/05/22, and signed by Resident #23's physician. The form stated providers will treat patients as any other without a DNR order until the point of cardiac or respiratory arrest, at which point all interventions will cease and the DNR Comfort Care protocol will be implemented. Interview on 07/18/23 at 8:47 A.M. with Director of Nursing (DON) revealed Resident #23 had received comfort care from staff and was actively dying. DON verified Resident #23 had a current order for a code status of DNRCC-Arrest and had not received any intervention to prolong or sustain life. The DON stated Resident #23 should have had code status of DNRCC. Review of the Hospice Interdisciplinary Group Meeting note, dated 05/24/23 and timed 09:00 A.M., revealed Resident #23 was listed as a DNR Comfort Care (DNRCC). Observation on 07/18/23 at 1:33 P.M. revealed Resident #23 in bed and appeared comfortable. Hospice staff and multiple family members were observed in Resident #23's room. Soft music played in the background. Resident #23 appeared unresponsive to the visitors and activity in the room. Interview on 07/18/23 at 2:00 P.M. with Hospice Registered Nurse (RN) #610 revealed hospice records listed Resident #23's code status as DNRCC. Hospice RN #610 accessed Resident #23's hospice records on her work tablet and revealed a signed DNRCC form dated 05/17/23 and signed by the hospice medical director. Hospice RN #610 verified Resident #23 had been receiving comfort care at the facility and was actively dying. Interview on 07/18/23 at 2:18 P.M. with the DON revealed the facility had no record of a DNRCC form dated 05/17/23. The DON verified Resident #23's medical record was inconsistent, as the facility and hospice provider had different code status records for Resident #23. The DON stated there was a breakdown in communication between the facility and the hospice provider and was not sure how it happened. Interview on 07/18/23 at 4:18 P.M. with the DON revealed code status is very important to communicate, and social services coordinates and addresses code statuses of residents on a routine basis and during care conferences. The DON stated social services coordinated the care conference meetings. The DON was unsure how often care conferences were held or if hospice staff had been invited routinely. Observation on 07/19/23 at 8:19 A.M. revealed Resident #23 in bed, appeared comfortable and in no visible distress. Licensed Practical Nurse (LPN) #508 was at bedside and stated that Resident #23 remained unresponsive, but stable. Interview on 07/19/23 at 9:40 A.M. with Social Services Director (SSD) #539 revealed she coordinated the care conference schedule. Care conferences were held on admission, quarterly, if there was an increased need, and following a significant change. Interview on 07/19/23 at 4:00 P.M. with Hospice RN #610 revealed she had not been invited to attend a care conference for Resident #23 since she admitted to hospice on 05/16/23. Review of the Care Conference Attendance form for Resident #23, dated 05/11/23, revealed the Licensed Practical Nurse Clinical Coordinator (LPN CC) #523 and SSD #539 were in attendance, and Resident #23's daughter attended via phone. A corresponding progress note dated 05/11/23 and timed 4:50 P.M. revealed Resident #23 was having increased pain and anxiety and family would like a hospice consult. Interview on 07/19/23 at 4:10 P.M. with LPN CC #523 and SSD #539 stated they held the phone conference to meet the needs of Resident #23's family member. SSD #539 verified no care conference had been scheduled since Resident #23 elected for hospice, and hospice staff had not been invited to attend a care conference with facility staff and Resident #23's family. Review of the policy titled Hospice, revised 08/2014, revealed a meeting will be held between hospice staff, facility staff, and family for care plan generation and continuity of care. Review of the facility policy titled Plan of Care Meetings Policy, dated 04/2022, revealed plan of care meetings are held following admission, at least quarterly, or with any significant change in condition. The policy further identified during the care plan meetings, advanced directives will be reviewed, and any changes indicated.

Based on observation, staff interview, and policy review the facility failed to ensure foods were stored in a clean and sanitary manner to prevent contamination and food borne illness. This had the potential to affect all residents. The facility census was 31. Findings include: During the initial kitchen tour with Dining Services Manager (DSM) #531 on 07/18/23 between 8:32 A.M. and 8:47 A.M. the following observations were made and verified at the time of discovery. In the walk-in freezer the following was observed: • A plastic bag of egg omelets was open, exposed to the air, and not dated. • A plastic bag of sausage patties was open, exposed to the air, and not dated and showed noticeable freezer burn. • A plastic bag of hamburger patties was open, exposed to the air, and not dated and showed noticeable freezer burn. • A box of frozen vegetables was open, exposed to air, and not dated. • A box of cod filets was open, exposed to the air, and not dated and showed noticeable freezer burn. In the walk-in refrigerator the following was observed and verified at the time of discovery. • A box of yellow onions was in the refrigerator revealed the onions were soft and multiple onions had begun to show signs of rot. • Observation of the door outside the walk-in in refrigerator noted a laminated sheet of paper taped to the door with a red stop sign reminding staff of proper food storage practices including asking the question Is it labeled? Review of the policy dated 10/01/14 titled Food Stock Rotation revealed any item opened must be dated with the opening date and wrapped after opening.