Based on clinical record review, document review, and staff interview, the facility failed to provide a Medicare Notice of Non-Coverage (NOMNC) notification to the resident or their legal representative two days prior to the ending of services and failed to provide the Skilled Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) notice for 2 of 3 residents sampled (Resident #4 and #21). The facility identified a census of 37 residents. Findings include: 1. A Point Click Care (PCC) Electronic Census record showed Resident #4 admitted to Medicare Part A skilled services on 10/20/23 and discharged off of Medicare services on 10/26/23. A SNF ABN detailed Resident #4 would incur out of pocket expenses as of 10/28/23 due to no longer requiring care by a licensed therapist and no longer requiring skilled level of nursing care at $410 per day. The Resident Representative indicated the Resident did not want the care listed. The Resident representative signed the notice on 10/31/23. A NOMNC form detailed Medicare services would end on 10/27/23 explaining the Resident's appeal rights if they did not agree with the decision to end Medicare services. The Legal Representative signed the notice without a date indicating when they had been notified of their rights. The facility failed to provide a two day notice to the Resident's legal representative. 2. A PCC Electronic Census record showed Resident #21 admitted to Medicare Part A skilled services on 7/10/23 and discharge from service on 7/18/23. A Discharge of Therapies Notice detailed Resident #21 planned discharge from physical and occupational therapy services on 7/18/23. The Notice documented the facility as notified on 7/14/23. The Facility lacked documentation of a SNF ABN or NOMNC being provided to the resident or their legal representative. On 12/20/23 at 10:17 AM the Administrator reported the facility did not have a beneficiary notice policy. During an interview on 12/20/23 at 10:20 AM the Administrator reported she had been in the social services position prior to taking the Administrator position. She had been serving the beneficiary notices prior to September 2023. The MDS Coordinator took over serving the beneficiary notices in September 2023. The Administrator reported therapy provides them with a notice of when therapy will be ending. They try to call the legal representative/family the same day as the notice and see if they can come to the facility to sign the notices. If not, they mail the notices out to the legal representative/family. She reported they try to give a two day notice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review, the facility failed to provide a bed hold notice for 2 of 2 residents reviewed (Resident #10 and #21). The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 11/22/23 for Resident #10 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Review of the Clinical Census revealed Resident #10 transferred to the hospital on 1/07/23, 1/17/23, and 4/8/23. The clinical records for Resident #10 lacked documentation of any explanation of the bed hold notification to the resident or the resident's representative when the resident discharged to the hospital on 1/07/23, 1/17/23, and 4/8/23. On 12/20/23 at 8:43 AM, the Administrator reported she did not have a bed hold for the January and April transfers to the hospital. She reported the nurses do the bed holds when a resident transfers either with the resident or calls the family and gets a verbal consent to hold the bed and documents it. On 12/20/23 at 8:47 AM, the DON reported the bed hold is in the transfer packets and she expects the nurses to complete them. If it is not completed and she gets a verbal with the family then she should document it. A review of the facility Bed Hold Policy lacked documentation on when the resident or the resident's representative is provided a bed hold form upon transfer to the hospital. 2. A Health Status Note dated 5/12/23 documented Resident #21 went from the clinic to the local emergency room. The facility was notified the Resident had been moved to the medical surgical floor. A Nurses Note dated 5/15/2023 at 11:42 AM documented Resident #21 returned to the facility at 11:28 AM with a notation the resident admitted to the hospital on [DATE] and discharged on 5/15/23. A review of the May 2023 electronic medical record progress notes and assessments revealed no documentation of a bed hold completed. A review of the paper medical record on 12/19/23 revealed no documentation of a bed hold for 5/12/23. On 12/20/23 at 8:45 AM the Administrator reported she did not have a May 2023 bed hold for Resident #21.

Based on record review and staff interviews, the facility failed to electronically transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid (CMS) system timely for 3 of 3 residents reviewed (Resident #6, #15 and #28). The facility reported a census of 37 residents. Findings include: The review of Resident #6, Resident #15, and Resident #28 MDS assessments dated 10/17/23 documented a transmission date of 12/15/23. On 12/19/23 at 2:20 PM, the DON reported she expected any MDS to be transmitted in the timely manner. During an interview on 12/19/23 at 3:49 PM, the MDS coordinator reported MDS assessments should be transmitted in a timely manner. She reported within 24-hours of submission she gets a report if they are accepted or not. She verbalized she was aware of the late transmissions on the 3 residents. She verbalized she goes by the Resident Assessment Instrument (RAI) for reference for submission times. The CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's manual revised on October 2023 instructs MDS assessments must be submitted within 14 days of the MDS Completion Date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review, Center for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Resident and staff interviews, the facility failed to accurately complete the Minimum Data Set (MDS) Assessment to accurately reflect the status and care needs of the resident for 2 of 12 residents reviewed (Resident #9 & Resident #2). The facility identified a census of 37 residents. Findings include: 1. Resident #9's MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The Resident required limited assistance of one staff for bed mobility and extensive assistance of one staff for transfers. The MDS listed a diagnosis of Parkinson's Disease and indicated Resident #9 utilized bed rails on a daily basis as a physical restraint. The Care Plan with revised intervention date 2/20/22 detailed Resident #9 utilized two half bed rails up to assist with bed mobility/repositioning. A Bed Rail assessment dated [DATE] documented the following: a. Resident is able to make own decisions. b. Resident requested side rails. c. Resident has history of falls. d. Resident has problems with balance or poor trunk control. e. Recommended device for assistance with bed mobility. f. Side rails do not impede resident's freedom of movement. A review of the 802 Matrix provided by the facility on 12/18/23 revealed Resident #9 did not utilize restraints. On 12/18/23 Resident #9 reported she uses the half bed rails and the bed trapeze bar to move in bed, but it doesn't restrict her freedom of movement. During an interview on 12/20/23 at 9:45 AM Staff A, Licensed Practical Nurse (LPN) reported Resident #9 uses her half rails for bed mobility and positioning. She does not utilize restraints. On 12/20/23 at 12:56 PM the MDS Coordinator reported there are no residents that use restraints in the facility. She reviews the MDS information, signs the MDS and then submits the assessment. They have an MDS tool that they use to collect information. The DON would have collected the information on Resident #9 for that MDS. The MDS Coordinator reported she probably didn't go through the MDS with a fine tooth comb, but it is a coding error that she should have caught. She reported they don't have any audits for MDS accuracy. They have a nurse consultant but they are not familiar with the MDS. She reported she has one side rail up for bed positioning. Section P would only be coded as a restraint if they had a physician order for a restraint. It was a coding error. She uses the RAI Manual to ensure she is coding correctly. On 12/20/23 at 1:21 PM the Director Of Nursing (DON) reported she completed Resident #9's MDS and miscoded the bed rails as a restraint in section P. She reported she must not have caught it. She reported it was clearly a miscoding error and the RAI should be utilized for coding accuracy on the MDS. On 12/20/23 at 1:50 PM the MDS Coordinator provided a MDS Checklist reporting she used it as a tool to collect MDS data. The Checklist listed side rails and hospice areas to review. She reported she followed the RAI Manual for coding accuracy. The CMS LTC Facility RAI 3.0 User's Manual Version 1.18.11, Chapter 1, page 1-4 documents the RAI process has multiple regulatory requirements. Federal regulations at 42 Code of Federal Regulations 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status. 2. Resident #2's MDS assessment dated [DATE] showed a BIMS score of 1 indicating severe cognitive loss with diagnoses of Non-Alzheimer's Disease and diabetes mellitus. The MDS detailed Resident #2 required scheduled and as needed pain medication for mild occasional pain and documented a chronic condition with a prognosis of life expectancy of six months or less to live. The MDS lacked documentation of Resident #2's hospice level of care. Resident #2's Significant Change in Status (SCSA) MDS assessment dated [DATE] showed a BIMS score of 7 indicating severe cognitive loss and a diagnosis of Non-Alzheimer's Dementia. The Resident required extensive assistance with bed mobility, transfers, eating, toilet use, dressing, and personal hygiene. The resident needed scheduled and as needed pain medications for vocalized daily pain. The MDS lacked documentation Resident #2 had a prognosis of life expectancy of less than six months to live and lacked documentation of hospice level of care services. A Hospice Comprehensive Assessment and Plan of Care dated 12/14/23 documented Resident #2 admitted into hospice care services on 10/02/19. A review of the Point Click Care Electronic Census Record on 12/19/23 showed Resident #2 had been a resident at the facility since 2017. The CMS LTC Facility RAI 3.0 User's Manual Version 1.18.11, Chapter 2, Page 2-25 defines an SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing.