**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review and interview, the facility failed to document evidence the resident had received information to formulate an advance directive for 1 resident (Resident #42) of 17 residents reviewed for advance directives. The findings include: Review of the facility policy titled, Advance Directives, dated 10/2022, showed .On admission .facility will determine if the resident has executed an Advance Directive .provide information concerning the right to formulate an Advance Directive . Resident #42 was admitted to the facility with diagnoses including Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure and Opioid Dependence. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #42 was cognitively intact and was on hospice care. Record review showed no documentation Resident #42 was educated on formulating an Advance Directive. During an interview on 8/29/2023 at 10:51 AM, the Patient Liaison confirmed there were no Advance Directive documents and no documentation of education to formulate an Advance Directive in Resident #42's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to refer 2 residents (Residents #20 and #31), of 4 residents reviewed for Pre-admission Screening and Resident Review (PASARR), to the state-designated authority for a Level II PASARR after the residents were identified with possible serious mental disorders. The findings include: Resident #20 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Unspecified Dementia, Depression, Generalized Anxiety Disorder and Cognitive Communication Deficit. Review of Notice of PASRR (PASARR) Level I Screen Outcome dated 3/21/2022, showed .No PASRR Level II Required .DIAGNOSIS .No mental health diagnosis is known or suspected .Does the individual have a diagnosis of dementia/neurocognitive disorder .No .PSYCHOTROPIC MEDICATIONS .Xanax .Anxiety Disorder .Buspar .Anxiety Disorder .ADDITIONAL COMMENTS .Pt has not taken any medications in a number of months but unsure .Level I Outcome: No Level II Condition-Level I Negative . Record review showed Resident #20 had diagnoses of Depression added 3/21/2022, Unspecified Dementia with Behavioral Disturbance and Adjustment Disorder added 5/6/2022 and Psychotic disorder with Hallucinations added 5/20/2022. Resident #31 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Unspecified Dementia, Major Depressive Disorder and Generalized Anxiety Disorder. Review of a PASRR dated 11/17/2022 showed Resident #31 had diagnoses of Anxiety and Depression. Record review showed Resident #31 had a new mental health diagnosis of Psychotic Disorder with Hallucinations added 1/5/2023. During an interview on 8/29/2023 at 2:19 PM, the Patient Liaison stated she was responsible for PASARR. She stated Resident #20 had a PASARR dated 3/21/2022 with no mental health diagnoses noted and had diagnoses of Depression added 3/21/2022, Unspecified Dementia with Behavioral Disturbance and Adjustment Disorder added 5/6/2022 and Psychotic disorder with Hallucinations added 5/20/2022. The Patient Liaison also stated Resident #31 had a PASARR dated 11/17/2022 and had a new mental health diagnosis of Psychotic Disorder with Hallucinations added 1/5/2023, and new PASARRs should have been submitted after the new diagnoses were ordered. During an interview on 8/29/2023 at 3:03 PM, the Director of Nursing (DON) confirmed new PASARRs were not submitted with the new mental health diagnoses for Residents #20 and #31.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain a complete and accurate medical record for 1 resident (Resident #199) of 17 residents reviewed. The findings include: Resident #199 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Hypertension, Dementia, Arthritis, and Hypothyroidism. Review of Resident #199's admission Minimum Data Set assessment dated [DATE] showed a Brief Interview for Mental Status score of 3, which indicated the resident had severe cognitive impairment. Continued review showed, resident required extensive assist of 1 person for bed mobility, transfers, toileting, dressing, bathing, and required supervision for eating. Review of a weekly skin assessment for Resident #199 dated 5/16/2023 showed .bumps and redness noted to perineal area . Review of a nurse progress note for Resident #199 dated 5/16/2023 showed .no skin issues or break down at this time . Review of a Nurse Practitioner (NP) progress note dated 5/16/2023 showed .nurse reported irritated rash to groin area .irritated red rash with individual red satellite [red spots or small blister -like lesions] pustules .Cutaneous Candidiasis [fungi on the skin] .Lotrisone [medicated cream to treat fungi] twice a day for 10 days to manage Cutaneous Candida infection . During an interview on 8/30/2023 at 3:34 PM, the Director of Nursing confirmed the nurse progress note on the medical record dated 5/16/2023 was inaccurate for Resident #199.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation, and interviews, the facility failed to ensure signage was posted which indicated what personal protective equipment (PPE) was required for 1 resident (Resident #20) of 7 residents observed for Enhanced Barrier Precautions and Transmission Based Precautions. The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, with a revised date of 4/2023, showed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug resistant organisms .Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [Multi-Drug Resistant Organism] as well as those at increased risk of MDRO acquisition .Implementation of Enhanced Barrier Precautions .Staff will don gown and gloves immediately prior to entering the room for high-contact resident care activities .PPE will be discarded at the door upon exit of the room .Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves . Resident #20 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Urinary Tract Infection. Review of a physician's order dated 8/3/2023, showed an order for Enhanced Barrier Precautions due to Resident #20's history of Extended Spectrum Beta-Lactamase (ESBL) (bacteria that can't be killed by many of the antibiotics that doctors use) infection. Review of the comprehensive care plan dated 8/13/2023, showed .Enhanced Barrier Precautions r/t [related to] .Hx [history] of ESBL .Goals .Reduce transmission of multi-drug resistant organisms .Place sign on door or wall outside resident room indicating the type of precautions and required PPE .PPE will consist of gloves and gown .Apply PPE prior to providing care . During the initial facility tour resident screening on 8/28/2023 at 10:41 AM, there was no signage posted on Resident #20's door to indicate the resident was in isolation. Certified Nursing Assistant (CNA) #1 entered the room and wore a gown and gloves to provide care. This surveyor asked CNA #1 if the resident was on isolation and the CNA answered, .yeah . During an observation and interview, outside Resident #20's room on 8/28/2023 at 10:45 AM, the Infection Preventionist (IP) stated the resident was in Enhanced Barrier Precautions for a history of MDRO in the urine. The IP stated signage was to be posted on the outside of Resident #20's door to let anyone who entered the room know what PPE was to be worn in what circumstances. The IP confirmed no signage was posted on Resident #20's door to indicate the required PPE to provide care for the resident. During an interview on 8/28/2023 at 3:28 PM, the Director of Nursing (DON) stated Resident #20 required Enhanced Barrier Precautions due to history of MDRO in the urine. The DON confirmed signage was to be posted outside the resident's door to make anyone who entered the room aware of what PPE was required for resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to ensure a dialysis contract was in place for 1 resident (#46) of 27 residents reviewed. The findings include: Review of the facility policy Care of Residents Receiving Dialysis Treatments revised date 3/24/2020 revealed .4. Arrange for dialysis as ordered . Resident #46 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease, Type 2 Diabetes Mellitus, and Chronic Kidney Disease. Medical record review of a Physicians order dated 8/7/2021 revealed .Dialysis .Tuesday, Thursday, Saturday .at [named dialysis center] . Medical record review of the resident Plan of Care dated 8/9/2021 revealed, .I'm on dialysis treatments .3 times per week .my chair time is 10:45 AM . Interview and review of the Dialysis communication records with the Director of Nursing (DON) on 8/30/2021 at 9:40 AM, in the DON office, revealed resident is transferred to dialysis 3 times per week per the Physician order with communication between the dialysis center and facility. Interview with the Administrator on 8/31/2021 at 8:02 AM, in the Administrators office, revealed the Resident #46 was going to the dialysis center as ordered. Further interview confirmed the facility failed to have a contract with the dialysis center to provide dialysis services to residents in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a fall intervention for 1 resident (#18) and failed to develop a care plan to include the use of a lap belt for 1 resident (#33) of 21 sampled residents. The findings include: Review of the facility policy Care Plans, revised 11/2018, revealed .Identify needs .Include Physicians .orders Care Plans will be updated as changes occur . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Dementia, Hypertension, Macular Degeneration, Osteoarthritis, Muscle Weakness, and Anxiety Disorder. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Further review revealed the resident required extensive assist of 2 staff members for bed mobility and transfers. Medical record review of a fall investigation dated 5/19/19 revealed the resident had a fall from the bed on 5/18/19. Further review revealed .New Intervention Description .Bed bolsters [long pillow used for support] in place . Medical record review of the care plan dated 3/8/2019 and revised 5/18/19 revealed .I may fall because of .my cognitive impairment .floor mat added to left side of bed and bed bolster . Observation of Resident #18 on 6/3/19 at 11:40 AM, in the resident's room, revealed the resident lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation of Resident #18 on 6/4/19 at 1:47 PM, in the resident's room, revealed Resident #18 lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation and interview of Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/5/19 at 8:21 AM, in the resident's room, revealed the bed bolsters were not in use. Further interview confirmed .[Resident #18] .is supposed to have them . Interview with the MDS Coordinator on 6/5/19 at 8:39 AM, in the MDS office, confirmed the resident was care planned for the use of bed bolsters. Continued interview and observation, in the resident's room, confirmed the bed bolsters were not in use. Interview with the Executive Director (ED) on 6/5/19 at 10:38 AM, in the ED's office, confirmed the facility failed to follow the care plan for the use of bed bolsters for Resident #18. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Dysphagia, and Constipation. Medical record review of the Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Continued review revealed the resident needed extensive assist of 2 staff members for bed mobility, transfer, toileting and had limited range of motion to all extremities. Medical record review of the Physician's Orders revealed .Self release lap belt in electric w/c [wheel chair] per resident request .4/10/19 . Medical record review of the care plan revealed no documentation of the use of a self release lap belt. Observation of Resident #33 on 6/3/19 at 3:19 PM, in the resident's room, revealed the resident sitting in an electric w/c with a self release lap belt in use. Observation of Resident #33 on 6/4/19 at 1:41 PM, in the resident's room, revealed the resident sitting in an electric w/c with a self release lap belt in use. Interview with the MDS Coordinator on 6/4/19 at 3:44 PM, in the MDS office, confirmed the lap belt had been in use since 4/10/19. Further interview confirmed the use of the self release belt had not been addressed on the resident's care plan. Interview with the ED on 6/5/19 at 7:35 AM, in the conference room, confirmed the facility failed to develop a care plan for Resident #33's use of a self release lap belt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a fall intervention to prevent accidents for 1 resident (#18) of 3 residents reviewed for falls of 21 sampled residents. The findings include: Review of the facility policy Fall Prevention Program, last revised 3/2017, revealed .Document the fall risk measures in the resident care plan .Assess for safety devices a minimum of once per shift for placement and functioning . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Dementia, Hypertension, Macular Degeneration, Osteoarthritis, Muscle Weakness, and Anxiety Disorder. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Further review revealed the resident required extensive assist of 2 staff members for bed mobility and transfers. Medical record review of a fall investigation dated 5/19/19 revealed the resident had a fall from the bed on 5/18/19. Further review revealed .New Intervention Description .Bed bolsters [long pillow used for support] in place . Medical record review of the care plan dated 3/8/2019 and revised 5/18/19 revealed .I may fall because of .my cognitive impairment .floor mat added to left side of bed and bed bolster . Observation of Resident #18 on 6/3/19 at 11:40 AM, in the resident's room, revealed the resident lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation of Resident #18 on 6/4/19 at 1:47 PM, in the resident's room, revealed Resident #18 lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation and interview of Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/5/19 at 8:21 AM, in the resident's room, revealed the bed bolsters were not in use. Further interview confirmed .[Resident #18] .is supposed to have them . Interview with the MDS Coordinator on 6/5/19 at 8:39 AM, in the MDS office, confirmed the resident was care planned for the use of bed bolsters. Continued interview and observation, in the resident's room, confirmed the bed bolsters were not in use. Interview with the Executive Director (ED) on 6/5/19 at 10:38 AM, in the ED's office, confirmed the facility failed to implement care planned intervention to prevent accidents for Resident #18.

Based on observation and interview the facility failed to properly label and store medications for 1 of 2 medication carts observed. The findings include: Observation and interview of the station 2 medication cart with Licensed Practical Nurse (LPN) #1 on 6/5/19 at 11:15 AM, on the station 2 hallway, revealed 2 medication cups in the medication cart with opened and unlabeled medications in the cups. Continued observation and interview confirmed LPN #1 had prepared the medications and placed the medications in the cups for administration to residents, and had then left the cart to do another task. Interview with the Executive Director (ED) on 6/5/19 at 12:34 PM, in the ED's office, confirmed the facility failed to properly label and store the medications in the medication cart.