**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 #7 and #15), of 5 residents reviewed for PASRR, to the state-designated authority for a Level II Pre-admission Screening and Resident Review (PASRR), after the residents were identified with possible serious mental disorders. The findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness and Dysphagia. Review of a PASSR dated 7/21/2016 showed Resident #7 had diagnoses of Depressive Disorder and Anxiety. Record review showed Resident #7 had diagnoses of Mood Disorder added on 1/31/2020 and Delusional Disorder added on 7/17/2020. Resident #15 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia and Muscle Weakness. Review of a PASSR dated 2/13/2020 showed Resident #15 had a diagnosis of Anxiety Disorder. Record review showed Resident #15 had a diagnosis of Bipolar Disorder added on 10/8/2021. During an interview on 8/8/2023 at 1:19 PM, the Minimum Data Set (MDS) Coordinator stated PASSR should be resubmitted when there was a change in status or new mental health diagnoses were added. The MDS Coordinator confirmed the PASSR's for Resident #7 and Resident #15 should have been resubmitted after the new mental health diagnoses of Delusional Disorder on 7/17/2020, and Bipolar Disorder on 10/8/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to revise a care plan to include a change of code status for 1 resident (Resident #65) of 24 reviewed for code status and care plan. The findings include: Resident #65 was admitted to the facility on [DATE], with diagnoses including Encounter for other Orthopedic Aftercare, Weakness, Alcohol Abuse, and Unsheltered Homelessness. Review of Resident #65's POST form dated [DATE], showed .DNR [Do Not Resuscitate] .Limited Additional Interventions .no artificial nutrition by tube .Discussed with patient . The form was signed by Resident #65 on [DATE]. Review of Resident # 65's comprehensive care plan dated [DATE] revealed resident had documented to be a Do Not Resuscitate, Staff will not initiated CPR (Cardiopulmonary Rescuscitation) in the event that resident is found without a pulse or respirations. Review of Resident #65's POST form dated [DATE], showed .CPR-FULL CODE [all life saving measures to be attempted] .Full Treatment .no artificial nutrition by tube .Discussed with patient .The Basis for the order is .Patients Preferences . The form was signed by Resident #65 on [DATE]. Review of Resident #65's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 13 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Review of the active Physician's Orders dated [DATE] showed .CPR-FULL CODE .Signed Date: [DATE] 14:08 [2:08 PM] . During an interview on [DATE] at 2:00 PM, Registered Nurse (RN #1) stated when the resident was admitted it was his wish to be a Do Not Resuscitate (DNR). RN #1 stated the resident did not fully understand what a DNR was and after speaking with his son, his wish changed to be a Full Code. During an interview on [DATE] at 2:17 PM, the Director of Nursing (DON) stated Resident #65's wishes were to have full treatment if his heart were to have stopped at the facility, the resident did not have a cardiovascular event while at the facility. The DON confirmed the facility failed to revise Resident #65's care plan to reflect his updated code status wish to have full treatment.

**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 maintain a Physician's Order in the resident's chart for an indwelling urinary catheter for 1 resident (Resident #41) of 3 residents reviewed for indwelling urinary catheters. The findings include: Review of the facility's policy titled, Indwelling Urinary Catheter: Care and Maintenance, revised 4/2021, showed .guidelines for the maintenance .of indwelling urinary catheters .catheters will be .indicated per physician order . Resident #41 was admitted to the facility on [DATE] with diagnoses including Obstructive Uropathy (a structural problem preventing the normal flow of urine) and Difficulty Walking. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed severe cognitive impairment for Resident #41. The resident required extensive assistance of 2 staff with bed mobility and toilet use. The resident had an indwelling urinary catheter related to a history of obstructive uropathy. Observation of Resident #41 on 8/7/2023 at 10:19 AM showed the resident had an indwelling urinary catheter. Review of current physician orders for Resident #41 showed no order to maintain an indwelling urinary catheter. During an interview on 8/9/2023 at 9:35 AM, the DON stated it was her expectation that the policy and physician's orders were followed for residents with indwelling catheters. The DON confirmed there was no order in Resident #41's chart for an indwelling urinary catheter.