**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to have appropriate policies directing staff when to initiate basic life support by not ensuring documentation of a resident and their representative's choice to have emergency basic life support immediately when needed for one of twelve sampled residents (Resident #2). Findings include: Per review of Resident #2's physician's orders, care plan, and resident face sheet, in both the electronic medical record and paper medical chart, on [DATE], there was no indication of the resident or their representative's choice whether to have life sustaining treatment when needed. The facility policy CPR (Cardiopulmonary Resuscitation) states: In the event of a cardiac or pulmonary arrest, Wake [NAME] provides CPR according to physician orders and resident wishes. Residents requesting CPR have documentation behind the Advance Directive tab in his/her chart. Per interview on [DATE] at 12:46 PM, a registered nurse (RN) stated that Resident #2's code status was CPR according to his/her assignment sheet. When asked how s/he would know the code status of this resident if s/he couldn't find the assignment sheet s/he said s/he would look at the resident's face sheet, physician's orders, or the Clinician Orders for Life-Sustaining Treatment (COLST) form located under the advance directive tab. This RN confirmed Resident #2 did not have this information in their electronic record or paper medical chart. A list of residents titled Full codes (residents to receive CPR when needed) dated [DATE], was discovered during this interview on the cabinet where residents' paper medical charts were located. Resident #2's name was not on this list. This nurse confirmed that s/he should be on this list. Per interview on [DATE] at 12:59 PM, the Director of Nursing (DON) stated that a resident's code status would always be in the resident's chart on the face sheet and on the COLST form. S/he confirmed that there was no documentation for Resident #2 addressing resuscitation status present on their face sheet and that the resident did not have a COLST form. The DON confirmed the Full code sheet was not up to date. Per interview on [DATE] at 2:25 PM with the Medical Director, s/he stated that Resident #2 has been at the facility over a year without a completed COLST form. Per interview on [DATE] at 2:52 PM with the Director of Social Services, s/he stated it would be the physician's responsibility to determine the code status if it wasn't decided by the family or resident. It would be social services responsibility to enter the information into the resident's medical record but would not do it until s/he had a physician's order. S/he confirmed that Resident #2 did not have an order for CPR in their record.

Based on staff interview and record review the facility failed to ensure resident allergies were consistently identified throughout the resident's medical record for one of three residents sampled (Resident #6). Findings include: Per record review Resident #6's Physicians Orders lists allergies of raw apples, raw pitted fruit, and Aleve. These allergies are also listed in the resident's medication administration record. Per the Guidelines for Daily Care (tool used to inform Licensed Nursing Assistants (LNAs) of each resident's specific care needs) lists Allergies as Raw Apples, Raw Pitted Fruits, Aleve Review of Resident #6's care plan date 4/11/2022 reflects that she/he may need an epi [epinephrine] pen may have life threatening allergic reaction to peanuts and hazelnuts or pitted fruits. The care plan also states I need my nurses to know how to use my epi pen. I need my aides to make sure I am not fed any of the foods I am allergic to. and the care plan goal states My goal is to not have any exposure to the foods that I am allergic to, and avoid having life threatening allergic reaction. During interview on 6/22/2022 at approximately 1:15 PM when asked how staff would identify a residents allergies, she/he stated that they would review the Diet Sheets provided by the the dietary department. However, she/he did confirm that the peanut and hazelnut allergies were not listed consistently between the physicians orders, care plan, and Guidelines for Daily Care.