Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflects the resident's status for one (1) of sixteen (16) sampled residents (Resident #26). Resident #26's Quarterly Minimum Data Set (MDS) Assessment, dated 08/19/19, revealed the resident receive one (1) anticoagulant medication within the last seven (07) days of the look back period. However, the resident's Physician's Order's and Medication Administration Record (MAR), dated 08/2019 revealed the resident received (1) Plavix, an antiplatelet inhibitor, within the last seven (07) days of the look back period. Further, Resident #26's Quarterly MDS Assessment, dated 08/19/19, revealed the resident received antipsychotic medications seven (7) days during the last seven (7) day look back period. However, the Antipsychotic Medication Review question N0450, was coded that the resident did NOT receive antipsychotic medication and the gradual dose reduction (GDR) questions were skipped. The findings include: Interview with the Minimum Data Set (MDS) Coordinator, on 10/16/19 at 3:52 PM, revealed the facility utilized the Resident Assessment Instrument (RAI) Manual 3.0, as a guideline for accuracy of assessments. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2017, revealed the primary purpose of the MDS Assessment was to identify resident care problems, address resident problems in individualized care plans, and monitor the quality of care provided to residents. Additional review revealed the Assessment should be an accurate reflection of the resident's status. 1. Review of Resident #26's medical record revealed the facility admitted the resident on 01/10/19 with diagnoses including Viral Hepatitis C, Type II Diabetes, Hyperlipidemia, Hypertension, Major Depressive Disorder, Non-traumatic intracranial hemorrhage, and Flaccid Hemiplegia. Review of Resident #26's Physician's Orders, dated 10/16/19, revealed an order for Abilify five (5) mg, with a start date of 08/13/19. Further review revealed an order for Plavix, seventy-five (75) milligrams (mg) daily, with a start date of 08/19/19. Review of Resident #22's MAR, dated August 2019, revealed during the look back period for the Quarterly MDS Assessment, dated 08/19/19, the resident received one (01) Plavix (antiplatelet inhibitor) seventy-five (75) mg dose, on 08/19/19. Further review of the MAR, revealed the resident received Abilify (antipsychotic medication), 08/13/19 through 08/19/19 (seven days). Review of Resident #26's Quarterly MDS Assessment, dated 08/19/19, Section N, revealed the facility assessed the resident as receiving one (01) anticoagulant medication during the ARD look back period. However, review of the resident's Physician's Orders and MAR for the Assessment Reference Date (ARD) look back period, revealed the resident received Plavix, antiplatelet inhibitor medication on 08/19/19, and did not receive anticoagulant medication. Further, the resident's Quarterly MDS Assessment, dated 08/19/19, Section N, revealed the resident received antipsychotic medication seven (7) days during the last seven (7) day look back period; however, the Antipsychotic Medication Review question N0450, was coded that the resident did NOT receive antipsychotic medication and the gradual dose reduction (GDR) questions were skipped. Interview with the MDS Coordinator, on 10/17/19 at 10:15 AM, revealed Resident #26's antiplatelet inhibitor medication should not have been included in the MDS as an anticoagulant medication. Per interview, she was not aware Plavix was an antiplatelet inhibitor versus an anticoagulant medication. Further, Resident #26's Abilify was an antipsychotic medication and the MDS Assessment should have been coded to include the GDR information related to the use of antipsychotic medication. Further, she did not code the GDR information related to use of the antipsychotic medication due to human error. Continued interview revealed it was important to ensure the MDS Assessment was completed accurately because information on the Assessment drove the development and revision of the Comprehensive Care Plan and ensured care provided was the best care to meet the residents' needs. Interview with the Director of Nursing (DON), on 10/17/19 at 10:35 AM, revealed the Resident Assessment Instrument (RAI) Manual was the guideline used by the facility to ensure accurate assessments were completed. Continued interview revealed the MDS Assessments for Resident #26, should have been accurate related use of anticoagulant medication, and related to GDR attempts for antipsychotic medication use. Further, the MDS Assessments guided the development of the Comprehensive Care Plans and therefore the MDS Assessment was to be an accurate reflection of the resident's status in order for residents to receive appropriate services and individualized care. Interview with [NAME] Present of Reimbursement/Registered Nurse (RN), on 10/17/19 at 1:47 PM, revealed she expected the RAI manual to be followed to ensure the MDS Assessments were accurately completed. Further, it was important to have accurate MDS Assessments because the Assessments drove the care plan which was a guide in providing necessary and quality care. Interview with the Administrator, on 10/17/19 at 3:15 PM, revealed the facility was to utilize the RAI Manual as a resource to ensure accuracy of the MDS Assessments. Per interview, it was important for MDS Assessments to accurately reflect a resident's current status to ensure the Care Plan was developed or revised to address each resident's individual needs and to ensure resources were provided as necessary to meet resident care needs.

Based on interview, record review, and review of the and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care for two (02) of sixteen (16) residents sampled residents (Resident #26 and Resident #35). Review of Resident #26's Comprehensive Care Plan (CCP), revised 06/15/19, revealed no documented evidence the CCP was revised after fall events on 07/11/19, 07/18/19 and 08/12/19, even though the Fall Investigations related to these falls identified specific fall interventions to be implemented to prevent falls of the same nature. In addition, review of Resident #35's CCP, dated 03/07/19, revealed no documented evidence the CCP was revised after the fall event on 08/16/19, even though the Fall Investigation related to this fall identified specific fall interventions to be implemented to prevent falls of the same nature. The findings include: Interview with the Minimum Data Set (MDS) Coordinator, on 10/16/19 at 3:52 PM, revealed the facility utilized the Resident Assessment Instrument (RAI) Manual 3.0, as a guideline for the CCP. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. 1. Review of Resident #26's clinical record revealed the facility admitted the resident on 01/10/19 with diagnoses to include, but not limited to Type II Diabetes, Major Depressive Disorder, Flaccid Hemiplegia, Non-Traumatic Intracranial Hemorrhage, and Disorder of Muscles, unspecified. Review of Resident #26's CCP, initiated 01/21/19 and revised 06/15/19, revealed the resident was at risk for injury related to falls as evidence by Muscle weakness, Diabetes, Major Depressive disorder, Sleep disorder, incontinence, Flaccid Hemiplegia/left side, cardiac problems, and decreased safety awareness. The goal stated the resident would transfer safety to and from all surfaces with assistance of two (2), and have no significant injury related to falls for ninety (90) days. The interventions included bilateral floor mats to floor, 01/15/19; pommel cushion, 01/18/19; therapy referral, 01/20/19; offer to bed after meals, 01/21/19; falling star program, 03/01/19; touch call light on right side, 04/30/19; and offer cool drinks, 06/05/19. Further review revealed an intervention, dated 06/05/19 to not leave alone in wheelchair in room. Review of the Fall Investigation, dated 07/11/19 at 4:15 PM, revealed Resident #26 sustained an unwitnessed fall in the room from his/her wheelchair. According to the Investigation, the resident attempted to transfer from wheelchair to bed. Further, the resident received no injury from the fall. Continued review revealed the resident stated he/she wheeled him/herself to the room and was trying to get in the bed. Per the Investigation, the immediate intervention was a low bed and the Interdisciplinary Team (IDT) intervention was a therapy referral and staff to assist the resident to lay down after meals and activities. However, there was no documented evidence the CCP was revised to include a low bed, therapy referral and staff to assist the resident to lay down after meals and activities. Review of the Fall Investigation, dated 07/18/19, no time noted, revealed Resident #26 sustained a fall in the hallway. According to the Investigation, the resident attempted to get up from his/her wheelchair unassisted after removing his/her pull away alarm. Further, the resident received no injury from the fall. Per the Investigation, the immediate intervention was to ensure the pull away alarm was out of the resident's reach. However, there was no documented evidence the CCP was revised to include ensuring the pull away alarm was out of the resident's reach. Review of the Fall Investigation, dated 08/12/19 at 5:00 PM, revealed Resident #26 sustained a fall in his/her room. According to the Investigation, the resident attempted to get into bed from his/her wheelchair unassisted. Continued review revealed the resident was in the common area awaiting dinner and was looking for a bathroom prior to the fall event. Per the Investigation, the immediate intervention was to resume pull away alarm and the IDT intervention was a three (03) day bowel and bladder re-assessment of toileting needs. However, there was no documented evidence the CCP was revised to include resuming the pull away alarm or a three (03) day bowel and bladder re-assessment of toileting needs. Review of Resident #26's Quarterly Minimum Data Set (MDS) Assessment, dated 08/19/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of seven (07) out of fifteen (15) indicating moderate cognitive impairment. Additional review revealed the facility assessed Resident #26 as requiring two (02) staff total assistance with transfers and was only able to stabilize balance between surfaces with staff assistance. Further review revealed the facility assessed the resident as requiring supervision with locomotion on the unit and as ambulation did not occur. 2. Review of Resident #35's clinical record revealed the facility admitted the resident on 09/09/16 with diagnoses to include, but not limited to Iron Deficiency Anemia, Vascular Dementia, Major Depressive Disorder, Insomnia, Peripheral Vascular Disease, Arthritis, Pain in knee, Muscle Weakness, and Osteoporosis. Review of Resident #35 CCP, dated 03/07/19, revealed he/she was at risk for injury related to falls as evidence by a history of falls, Anemia, Dementia, Osteoporosis, Psychotropic drug use, Insomnia, decreased safety awareness, and noncompliance with ambulatory device. The goal stated the resident would transfer safely to and from all surfaces; have no significant injury related to falls; and would have less than one (01) fall for ninety (90) days. The interventions, dated 03/01/19 included: rule out medical complications; periodic medication review; ensure safe environment; encourage and cue Resident to use walker; offer assistance as needed; falling star program; walker within reach; and ensure appropriate footwear. Further review revealed an intervention to transfer with limited assistance with walker, dated 09/06/19. Review of the Fall Investigation, dated 08/16/19 06:30 AM, revealed Resident #35 sustained an unwitnessed fall in the room from his/her bed. According to the Investigation, the resident attempted to transfer from bed to go to the bathroom. Further, the resident received no injury from the fall. Continued review revealed the resident stated he/she was cold and rolled off the bed onto the floor. Per the Investigation, the immediate intervention was nonskid socks. However, there was no documented evidence the CCP was revised to include use on nonskid socks. Review of Resident #35 Quarterly MDS Assessment, dated 09/02/19, revealed the facility assessed the resident as having a BIMS score of three (03) out of fifteen (15), revealing the resident was severely cognitively impaired. Additional review revealed the facility assessed Resident #35 as requiring one (1) staff for ambulation with a walker; and requiring limited assistance of one (1) staff for bed mobility, transfers and toileting. Further review revealed Resident #35 was assessed as always continent of bladder and bowel. Interview with the Minimum Data Set (MDS) Coordinator, on 10/16/19 at 3:52 PM, revealed it was her responsibility to revise the CCP during morning clinical meeting each morning after review of fall events that occurred in the last twenty-four (24) hours. Additional interview revealed after review of Resident #26's and Resident #35's Fall Investigations, their CCPs should have been revised after each fall event to include interventions to prevent falls of the same nature and ensure a safe environment. Further, it was important to ensure the CCP was a current reflection of the residents' care needs to assure quality of care and services. Interview with the Region [NAME] President of Reimbursement, on 10/17/19 at 1:47 PM, revealed she expected the RAI Guidelines to be followed related to revision of the CCP. Additionally, it was important for the CCP to be revised after each fall event for all residents to prevent falls of the same nature and to provide safe care. Further, the CCP should have been revised for Resident #26 and Resident #35 after their fall events. Interview with the Director of Nursing (DON), on 10/17/19 at 2:20 PM, revealed she expected the RAI Manual Guidelines to be followed to ensure the CCP was revised as necessary. Additionally, she expected the CCP to be revised after each fall event for all residents to ensure the facility was providing safe, necessary care. Per interview, the facility changed Electronic Medical Record (EMR) systems in June 2019 and the process in which the facility investigated and reviewed fall events changed. Additional interview revealed the new EMR system did not generate a twenty-four (24) hour list of Fall Investigations, like the old system did. Per interview, the facility identified this concern and started manually tracking falls on a white board. Further, the fall event for Resident #35 on 08/16/19 and fall events for Resident #26, on 07/11/19, 07/18/19 and 08/12/19 slipped through the cracks. Per interview, the facility failed to revise the CCP after the Fall Investigations. Interview with the Administrator, on 10/17/19 at 3:15 PM, revealed he expected the CCP to be revised with interventions after fall events per RAI guidelines. Further, it was important to ensure the CCP was revised to include fall interventions status post fall events to prevent an additional fall of the same nature and to provide safe care to meet resident needs.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who needs respiratory care is provided such care consistent with professional standards for two (2) of two (2) sampled residents reviewed for oxygen out of a total sample of sixteen (16) residents (Resident #32 and Resident #63). Observation on 10/15/19, revealed there was no date on the nasal cannula, oxygen tubing, nor the storage bag hanging on the oxygen concentrator to indicate when this equipment was last changed out for Resident #32. In addition, observation on 10/15/19, revealed there was no date on the oxygen tubing, humidified sterile water bottle, storage bag, or tracheostomy mask to indicate when this equipment was last changed out for Resident #63. The findings include: Interview with the DON/Infection Control Nurse, on 10/17/19 At 3:25 PM, revealed she was unaware of a written policy related to dating and changing out bottles of sterile water for humidified oxygen needs, tracheostomy mask, oxygen tubing, and nasal cannulas. However, she stated it was her expectation this oxygen equipment be changed weekly and dated. 1. Review of Resident #63's clinical record revealed the facility re-admitted the resident on 09/23/19 with diagnoses to include Pulmonary Heart Disease, Chronic Obstructive Pulmonary Disease, and Tracheostomy. Review of Resident #63's Physician's Orders, dated 09/11/19, revealed orders for oxygen to be set at four (4) to five (5) liters per tracheostomy mask to tracheostomy. Further review revealed orders to change Tracheostomy Collar every Monday and change oxygen tubing every week per Respiratory Therapist and nursing as needed. Observation on 10/15/19 at 10:42 AM, and 11:47 AM, revealed Resident #63's oxygen was set at four (4) liters per tracheostomy mask to the resident's tracheostomy. However, there was no date on the oxygen tubing, humidified sterile water bottle, storage bag, or tracheostomy mask. Interview with Registered Nurse (RN) #1, who entered Resident #63's room during this observation, confirmed there was no date on the oxygen tubing, humidified sterile water bottle, storage bag, or tracheostomy mask. RN #1 stated the mask, oxygen tubing and sterile water should have been labeled with the date it was changed out. Continued interview revealed it was the Respiratory Therapist and the nurse's responsibility to ensure this equipment was changed out weekly and dated in order for staff to be aware of when it was last changed. RN #1 stated if the mask, tubing and sterile water was not changed out weekly, this could be an infection control issue as it could lead to a respiratory infection for the resident. 2. Review of Resident #32's clinical record revealed the facility admitted the resident on 02/01/18 with diagnoses to include Chronic Obstructive Pulmonary Disease. Review of Resident #32's Physician's Orders, dated 09/01/19, revealed orders for oxygen at two (2) liters per nasal cannula every shift. Further review revealed orders to change oxygen tubing every week per the Respiratory Therapist and nursing as needed. Observation on 10/15/19 at 12:27 PM, revealed Resident #32's nasal cannula and oxygen tubing was on the resident's bed. There was no date on the nasal cannula, oxygen tubing, nor the storage bag hanging on the oxygen concentrator, which was turned off. This was verified with the Director of Nursing (DON) who stepped into the room during the observation. Interview on 10/17/19 at 4:20 PM, with the Staff Development Coordinator, revealed nurses had received in-services from the Respiratory Therapist related to the need to change out and date oxygen masks, tubing, storage bag and sterile water for humidification at least weekly and as ordered. Interview with the Director of Nursing (DON/Infection Control Nurse, on 10/17/19 at 3:25 PM, revealed the Respiratory Therapist changed the bottles of sterile water for humidified oxygen, tracheostomy mask, oxygen tubing, and nasal cannulas weekly. Per interview, the bottles of sterile water for humidified oxygen were changed out when empty by nursing as the bottles did not last a whole week. Further interview revealed it was her expectation bottles of sterile water for humidified oxygen needs, tracheostomy mask, oxygen tubing, and nasal cannulas were dated when changed out. Further, the oxygen-tubing bag for storage of the tubing when not in use should be dated and changed out weekly as well. The DON stated it was important to date any oxygen equipment to ensure it was not used longer than a week in order to prevent infections which could affect the resident's health. Interview on 10/17/19 at 3:37 PM, with the Administrator, revealed he was not familiar with the facility protocol related to labeling and dating respiratory equipment as it was changed out. However, he stated the Respiratory Therapist and the nursing staff would be expected to change the respiratory equipment such as oxygen tubing according to facility protocol in order to prevent infection and illness.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to complete and submit Minimum Data Set (MDS) Assessments within the required timeframe. Review of the Final Validation Reports, dated 03/27/19 through 10/16/19, revealed seventeen (17) MDS Assessments were completed late and twenty-three (23) MDS records were submitted late. The findings include: Interview with the MDS Coordinator, on 10/16/19 at 3:52 PM, revealed the facility did not have a policy related to completing and transmitting MDS assessments, but the facility followed the RAI guidelines. Review of the RAI 3.0 User's Manual, Version 1.16, dated October 2018, Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). Entry and Death in Facility tracking records, information must be transmitted within fourteen (14) days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records). Further Review of the RAI 3.0 User's Manual, Version 1.16, dated October 208, Chapter 2, Assessments, revealed admission assessments must be completed on the fourteenth (14th) calendar day of the resident's admission (admission date + 13 calendar days). Additionally, significant change assessments must be completed on the fourteenth (14th) calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days) . Continued review revealed comprehensive assessments should be completed on the ARD plus fourteen (14) days. Additionally, quarterly assessments must be completed no later than fourteen (14) days after the ARD (ARD plus fourteen (14) calendar days). Further, discharge assessments must be closed on the discharge date plus fourteen (14) calendar days. Continued review revealed Entry Assessments should be closed on the Entry Date plus seven (7) calendar days Review of the Final Validation Reports (FVR), dated 03/27/19 through 10/16/19, revealed seventeen (17) MDS Assessments were completed late and twenty-three (23) MDS records were transmitted late. 03/27/19, revealed five (05) MDS records were submitted late and two (2) MDS Assessments were completed late. 04/04/19, revealed one (01) MDS record was submitted late and one (01) MDS Assessment was completed late. 04/10/19, revealed one (01) MDS record was submitted transmitted late. 04/18/19, revealed two (02) MDS Assessments were completed late. 05/01/19, revealed one (01) MDS record was submitted late and one (01) MDS Assessment was completed late. 05/07/19, revealed two (02) MDS records were submitted late. 05/15/19, revealed one (01) MDS record was submitted late. 05/22/19, revealed three (03) MDS records were submitted late. 05/30/19, revealed three (03) MDS records were submitted late and one (01) MDS Assessment was completed late. 06/05/19, revealed three (03) MDS records were submitted late. 06/24/19, revealed three (03) MDS records were submitted late and three (03) MDS Assessments were completed late. 07/24/19, revealed one (01) MDS Assessment was completed late. 08/04/19, revealed one (01) MDS record was submitted late and three (03) MDS Assessments were completed late. 10/01/19, revealed one (01) MDS Assessment was completed late. 10/16/19, revealed one (01) MDS Assessment was completed late. Continued interview with the MDS Coordinator/Licensed Practical Nurse (LPN), on 10/17/19 at 10:15 AM, revealed she had been working as the MDS Coordinator for three (03) years and had received ongoing training related to MDS Assessments and most recently received training two (02) weeks ago related to the RAI Guidelines. Per interview, she was not aware that each type of MDS Assessment had different timeframes for completion and submission/transmission until the State Surveyor inquired and she read the section of the MDS related to completion and submission timeframes. Additionally, the facility had a new Electronic Medical Record (EMR) since June 2019 and the calendar she was familiar with was no longer available and she realized last week she was using the wrong report from the system to audit what Assessments needed to be closed and submitted. Further, due to the heavy workload, she was unable to complete her work per the timeframes and overtime was not approved. Per interview, the Regional [NAME] President of Reimbursement, was the MDS Supervisor; and she was supportive and would email weekly when MDS Assessments needed closed and submitted. Continued interview with the MDS Coordinator, revealed she gave the Assistant Director of Nursing (ADON) a list in Clinical meeting each morning of the MDS Assessments that were finished and she would sign them as being completed. Per interview, she submitted MDS records weekly and checked the FVR for accepted/rejected errors and printed the reports and placed them in a binder. Additionally, she did not look at the FVR for other error and assumed the MDS scrubber would catch errors before submission. Further, the assessments should have been completed and submitted per the RAI manual. Per interview, it was important to ensure the MDS Assessments were completed accurately and submitted timely because information on the Assessment drove the development and revision of the Comprehensive Care Plan and ensured care provided was the best care to meet the residents' needs. Interview with the Regional [NAME] Present of Reimbursement, on 10/17/19 at 1:47 PM, revealed she provided oversight and support with the MDS process in the facility. Per interview, she conducted spot checks for accuracy and timeliness and over the last year had identified late completion and late submissions of MDS Assessments. Additionally, she had been emailing the MDS Coordinator weekly system reports to ensure Assessments were completed and submitted per the RAI guidelines. Per interview, she was now monitoring more closely and had established an assigned day of the week for the facility to submit Assessments; which had helped with late Assessments. Continued interview revealed she expected the RAI manual to be followed to ensure the MDS Assessments were completed and submitted timely. Interview with the Director of Nursing (DON), on 10/17/19 at 10:35 AM, revealed the Resident Assessment Instrument (RAI) Manual was the guideline used by the facility to ensure accurate assessments were completed. Continued interview revealed she expected the RAI manual to be followed and for MDS Assessments to be completed and submitted timely. Interview with the Administrator, on 10/17/19 at 315 PM, revealed the facility was to utilize the RAI Manual as a resource to ensure accuracy of the MDS Assessments. Per interview, it was important for MDS Assessments to be completed and submitted timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure a resident who was discharged had a Discharge Summary that included all necessary information related to discharge for one of three (3) discharged sampled residents out of a total sample of sixteen (16) sampled residents (Resident #58). Resident #58 was discharged to another facility on 06/28/18; however, there was no documented evidence of a Discharge Summary which included: a recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; a final summary of the resident's status; reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter); and a post-discharge plan of care developed with the participation of the resident and, with the resident's consent, the resident representative(s), which would assist the resident to adjust to his or her new living environment. The findings include: Review of the facility's Policy titled Discharge Planning Standard of Practice, dated August 2017, revealed the facility was to develop and implement an effective discharge planning process that focused on: the resident's discharge goals; effective transition to post-discharge care; and the reduction of factors leading to preventable readmissions. Continued review revealed the Discharge Summary should include a Discharge Form which was to be completed by the charge nurse or designee for anticipated discharge home or to another facility; a medication reconciliation of pre-discharge medication with post-discharge medication; and discharge teaching instructions. Review of the facility's Policy titled Transfer or Discharge Documentation Standard of Practice, dated October 2017, revealed when a resident was transferred or discharged , details of the transfer or discharge would be documented in the medical record and appropriate information would be communicated to the receiving health care facility provider. Continued review revealed when a resident was transferred or discharged from the facility, the information documented in the medical record would include an appropriate notice provided to the resident and/or the legal representative; the date and time of the discharge; a summary of the resident's overall medical, physical, and mental condition; as well as the signature of the person recording the data in the medical record. Review of Resident #58's closed medical record revealed the facility admitted the resident on 04/07/18 with diagnoses including Dementia with Behavioral Disturbances, Alzheimer's Disease, Depressive Episodes, Unspecified Psychosis, and Generalized Anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a five (5) out of fifteen (15) indicating severe cognitive impairment. Continued review of the closed medical record revealed the resident was discharged on 06/28/18. Review of Social Worker #1's Progress Note, dated 6/22/18, revealed Resident #58's family requested information to be sent to another facility closer to the family. Continued review revealed Social Worker #1 sent information to the facility. However, there was no documentation indicating what information had been sent to the facility. Review of Resident #58's Comprehensive Care Plan, dated 06/05/18, and revised 06/22/18, and 06/27/18, revealed the resident's return to the community deemed not feasible at this time. The goal stated the resident would be accepting of and appropriate for long-term care. The interventions included: discuss desire to be discharged with representative quarterly and PRN (as needed). The interventions were updated on 06/22/18 to state the family requested information related to other facilities closer to home; and the family requested the resident be transferred to a facility closer to family. Further review revealed an update on 6/27/18, stating the receiving facility notified the facility they would accept the resident. A further update on 06/27/18, revealed the resident would be discharged on 06/28/18 to another facility; and the family would provide transport. Review of the Nurse's Note, dated 6/28/18, signed by Licensed Practical Nurse (LPN) #1, revealed Resident #58 was discharged with family. Further review revealed report was called to the receiving facility, and Physician's Orders were faxed to the receiving facility. However, there was no documented evidence other paperwork was sent to the receiving facility. Review of Resident #58's Discharge Instructions for Care dated 06/28/18, revealed the form was only completed to include the Resident #58's name, the date, and the name of the receiving facility. The form was not completed under the sections titled: Follow Up Physician Care for appointments; Medications; Treatments; Diet; Current Physical Status of Resident; and Referrals for Care. The form stated, The discharge instructions for care have been reviewed with me in a language I can understand, and my questions have been answered to my satisfaction. I have received the medications or prescriptions indicated above and acknowledge that the medications may not be in childproof containers. Under this was a line for the signature of the person receiving the instructions which was not signed. The form further stated,detach yellow copy-and there was a place to mark who received the instructions including the Resident or Responsible Party. However, this section was left blank indicating the copy of the discharge instructions was not presented to the Resident or Responsible Party. Interview on 8/23/18 at 8:46 AM with LPN #1, who was assigned to Resident #58 at the time of discharge on [DATE], revealed when a resident was being discharged to another facility, it was the nurse's responsibility to print off the current Physician's Orders and MAR to send with the resident. She stated she had faxed the resident's Physician's Orders to the facility as per her Nurse's Note, dated 6/28/18. She further stated it was also the nurse's responsibility to fill out the form titled Discharge Instructions for Care and this form should include a general overview of the care the resident was receiving. Per interview, if the resident was being transferred to another facility, report should be called to the receiving facility. She revealed the verbal report should include a review of the resident's diagnoses, level of assistance needed, diet, and how the resident took their medication. Continued interview revealed the nurse should document report was called to the receiving facility and the name of the person receiving report should be documented, but the specific information given in report did not have to be documented. She stated she had completed the Discharge Instructions for Care form for Resident #58. She further acknowledged she had not completed the form correctly because the sections including Follow Up Physician Care for appointments; Medications; Treatments; Diet; Current Physical Status of Resident; and Referrals for Care were left blank. Continued interview revealed the entire form should have been completed with a copy given to the resident's representative, and a copy sent with the resident to the receiving facility. She further stated she also should have filled in the date and time of discharge, and signed the form. Interview on 8/23/18 at 8:35 AM, with Social Worker #1, revealed if a resident was being transferred to another facility she was responsible for sending information to the receiving facility including the resident's Face Sheet, History and Physical, any recent laboratory values, Hospital Discharge Summaries, Consults, as well as any further information requested by the receiving facility. She stated she took this information from Resident #58's medical record to fax to the receiving facility; however, did not keep a copy of the documents she sent to the receiving facility and did not indicate in the medical record which documents were faxed to the receiving facility. Per interview, there was no documented evidence Resident #58's Face Sheet, History and Physical, recent labs, Hospital Discharge Summaries, Consults, or other information had been sent to the receiving facility. Interview on 8/23/18 at 10:03 AM, with the Director of Nursing (DON), revealed there was a folder which contained a check list for the nurses to ensure that all the appropriate documents were sent with the resident upon discharge. Per interview, it was her expectation the nurse discharging the resident ensured all necessary paper work was completed and sent with the resident to the receiving facility. Further interview revealed the nurse who was assigned at the time of discharge was to complete the Discharge Instructions for Care form which was to be filled out in all sections with a copy sent with the resident to the receiving facility or given to the resident or responsible party on the day of discharge. She stated the nurse should sign and date the form as well. Further interview revealed the nurse discharging the resident should document verbal report was called to the receiving facility and document the name of the person who received the verbal report, but documentation related to the specific information given per verbal report to the receiving facility was not necessary. Additional interview revealed Resident #58's Discharge Instructions for Care dated 06/28/18, was not completed accurately as the nurse failed to ensure all sections were completed. The DON acknowledged there was no documented evidence all necessary discharge summary information was sent to the receiving facility per the Social Worker and nursing. Interview on 8/23/18 at 10:14 AM, with the Administrator, revealed it was her expectation nursing staff fill out the discharge forms correctly. She further stated it was her expectation the social worker communicate with the resident, the resident's family, as well as the receiving facility in regards to a resident being transferred and document this communication. She stated it was the nurse's responsibility to fill out the entireDischarge Instructions for Care form when a resident was discharged . However, she further stated this form was not completed accurately for Resident #58. The Administrator acknowledged there was no documented evidence all necessary discharge summary information was sent to the receiving facility per the Social Worker and nursing.