Based on interviews and record reviews, the facility failed to ensure each resident was assessed using the quarterly review instrument not less frequently than once every three months for 3 (#1, #19, and #20) of 11 (#1, #5, #6, #7, #8, #12, #14, #15, #19, #20, and #22) residents reviewed for Resident Assessment. Review of the facility's policy titled, MDS Completion and Submission Timeframes with a revision date of July 2017 revealed the following, in part: Policy Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation: 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Resident #1 On 10/30/2024, a review of Resident #1's MDS assessments revealed a quarterly MDS with an ARD of 06/20/2024. Further review revealed no other MDS assessment had been opened or completed after 06/20/2024. Resident #19 On 10/30/2024, a review of Resident #19's MDS assessments on 10/30/2024 revealed a quarterly MDS with an ARD of 05/28/2024. Further review revealed an MDS was opened with an ARD of 08/27/2024, and the assessment had not been completed. Resident #20 On 10/30/2024, a review of Resident #20's MDS assessments revealed a quarterly MDS with an ARD of 06/25/2024. Further review revealed an MDS was opened with an ARD of 09/24/2024, and the assessment had not been completed. An interview was conducted with S4MDS on 10/30/2024 at 9:23 a.m. She stated she was one of the facility's MDS nurses. She stated quarterly MDS assessments should have been completed every three months. She reviewed Residents #1, #19, and #20's quarterly MDS assessments and stated they had not been completed quarterly and should have been. An interview was conducted with S3DON on 10/30/2024 at 11:58 a.m. She stated quarterly MDS assessments should have been completed every three months. She reviewed Resident #1, #19, and #20's MDS assessments. She confirmed Residents #1, #19, and #20's last quarterly MDS assessments had not been completed quarterly and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed for 1 of 1 (#21) resident reviewed for PASARR. Findings: On 10/30/2024, a review of the facility's policy titled Resident Assessment - Coordination with PASARR Program with a Copyright date of 2024, revealed the following: Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 5. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. Review of Resident #21's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Schizophrenia. Review of Resident #21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/30/2024, revealed an active diagnosis of Schizophrenia. Further review of Resident #21's Clinical Record revealed a Level I PASARR was completed on 01/17/2024. Review of the Level I PASARR form revealed Resident #21 had a diagnosis of Schizophrenia. Further review revealed a referral was not made to appropriate state designated authority for Level II PASARR evaluation and determination. An interview was conducted on 10/30/2024 at 12:30 p.m. with S3DON. S3DON stated when Resident #21's was admitted to the facility, a Level II PASSAR was not required because she was not expected to remain in the facility for greater than 30 days. S3DON confirmed a Level II PASARR should have been completed when Resident #21 remained in the facility longer than 30 days. She stated S5SW was responsible for submitting the Level II PASARR to the appropriate state designated authority. An interview was conducted on 10/30/2024 at 2:00 p.m. with S5SW. S5SW confirmed Resident #21 had a diagnosis of Schizophrenia, which meant the resident met the criteria to have a Level II PASARR submitted to the appropriate authority. S5SW also confirmed she was responsible for submitting the Level II PASARR for Resident #21, and the Level II PASARR had not been submitted to the appropriate authority and should have been.

Based on record reviews and an interview, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) prior to the discontinuation of Medicare Part A services for 3 (#25, #228, and #229) of 3 (#25, #228, and #229) residents reviewed for Beneficiary Notification. Findings: On 10/30/2024, a review of the facility's policy titled Advance Beneficiary Notice with a Copyright date of 2024, revealed the following: Policy: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. c. A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if resident is leaving the facility ore remaining in the facility. i. This notice is used when all covered services end for coverage reasons. Resident #25 Review of Resident #25's Beneficiary Notification Review form revealed his Medicare Part A skilled services last covered day was 08/11/2024. Further review revealed a NOMNC, Form CMS-10123 was not provided to Resident #25 prior to the discontinuation of skilled nursing services. Resident #228 Review of Resident #228's Beneficiary Notification Review form revealed his Medicare Part A skilled services last covered day was 09/18/2024. Further review revealed a NOMNC, Form CMS-10123 was not provided to Resident #228 prior to the discontinuation of skilled nursing services. Resident #229 Review of Resident #229's Beneficiary Notification Review form revealed her Medicare Part A skilled services last covered day was 10/09/2024. Further review revealed a NOMNC, Form CMS-10123 was not provided to Resident #229 prior to the discontinuation of skilled nursing services. An interview was conducted on 10/30/2024 at 11:47 a.m. with S4MDS. She confirmed she had not provided a NOMNC, Form CMS-10123 to Residents #25, #228, and #229 prior to their discharge from Medicare Part A skilled nursing services. She stated she was not aware the NOMNC, Form CMS-10123 should have been provided to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure: 1. Each residents' discharge was encoded in an MDS assessment for 3 (#7, #12, and #22) of 11 (#1, #5, #6, #7, #8, #12, #14, #15, #19, #20, and #22) residents reviewed for Resident Assessment; and 2. A resident's discharge assessment was completed and transmitted for 1 (#6) of 11 (#1, #5, #6, #7, #8, #12, #14, #15, #19, #20, and #22) residents reviewed for Resident Assessment. Review of the facility's policy titled, MDS Completion and Submission Timeframes with a revision date of July 2017 revealed the following, in part: Policy Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation: 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Review of the facility's policy titled, Electronic Transmission of the MDS with a revision date of November 2019 revealed the following, in part: Policy Statement: All MDS assessments and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS system in accordance with current regulations. 1. Resident #7 Review of Resident #7's Clinical Record revealed he admitted to the facility on [DATE] and discharged on 07/11/2024. Review of Resident #7's MDS Assessments revealed no discharge MDS was opened and/or completed. Resident #12 Review of Resident #12's Clinical Record revealed she admitted to the facility on [DATE] and discharged on 10/04/2024. Review of Resident #12's MDS Assessments revealed no discharge MDS was opened and/or completed. Resident #22 Review of Resident #22's Clinical Record revealed he admitted to the facility on [DATE] and discharged on 06/27/2024. Review of Resident #22's MDS Assessments revealed no discharge MDS was opened and/or completed. An interview was conducted with S4MDS on 10/30/2024 at 9:23 a.m. She stated she was one of the facility's MDS nurses. She confirmed Residents #7, #12, and #22 had discharged from the facility and discharge MDSs had not been opened, completed, nor transmitted and should have been. An interview was conducted with S3DON on 10/30/2024 at 11:58 p.m. She stated an MDS assessment should have been completed upon each resident's discharge from the facility. She confirmed Resident #7 discharged from the facility on 07/11/2024 and no discharge MDS was opened, completed, or transmitted and should have been. She confirmed Resident #12 passed away in the facility on 10/04/2024 and there was no discharge assessment opened, completed, or transmitted and there should have been. She confirmed Resident #22 discharged from the facility on 06/27/2024 and no discharge MDS was opened, completed, or transmitted and should have been. 2. Resident #6 Review of Resident #6's Clinical Record revealed she admitted to the facility on [DATE] and discharged on 07/12/2024. Review of Resident #6's Discharge MDS Assessment with an ARD of 07/12/2024 revealed the assessment was incomplete and not transmitted. An interview was conducted with S4MDS on 10/30/2024 at 9:23 a.m. She stated she was one of the facility's MDS nurses. She confirmed Resident #6's discharge assessment was incomplete and had not been transmitted. An interview was conducted with S3DON on 10/30/2024 at 11:58 p.m. She stated discharge assessments should have been completed within 7 days of the discharge and transmitted within 14 days of completion. She confirmed Resident #6 discharged from the facility on 07/12/2024. She confirmed the discharge assessment for Resident #6 was opened and not completed or transmitted and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all medical records regarding the residents code status consistently reflected the resident's wishes for 1(#136) of 16 residents reviewed for advanced directives in the initial pool process. Findings: Review of Resident #136's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #136's MDS with an ARD of [DATE], revealed, in part, the resident was assessed by the facility to have a BIMS of 15, which indicated she was cognitively intact. Review of Resident #136's current Physician's Orders revealed the following: [DATE] - Code Status: DNR Review of Resident #136's Physical Hard Chart revealed a Cardiopulmonary Resuscitation Form signed on [DATE] by Resident #136 representative, which indicated Resident #136 wished to receive CPR if found with no pulse or respirations. Review of Resident #136's face sheet revealed a Code Status of DNR. On [DATE] at 1:55 p.m., an interview was conducted with Resident #136. Resident #136 confirmed in the event of an emergency she would like to be a full code status. On [DATE] at 3:27 p.m., an interview was conducted with S4LPN. She stated in the event of an emergency she would refer to the hard chart or the physician orders in the electronic health record to determine a resident's code status. On [DATE] at 3:33 p.m., an interview was conducted with S10LPN. She stated in the event of an emergency she would refer to the hard chart or the physician orders in the electronic health record to determine a resident's code status. She confirmed Resident #136's hard chart showed she was a full code and the electronic health record showed she was a DNR. She confirmed the hard chart record and electronic health record should match and did not. On [DATE] at 3:38 p.m., an interview was conducted with S5LPN. She stated a resident's code status could be found in the hard chart or the electronic health record system. She stated if a resident was coding she would go to the closest record to obtain the code status. On [DATE] at 3:39 p.m., an interview was conducted with S2DON. She stated in the event of an emergency she would expect her staff to refer to the physical hard chart or the physician's orders in the electronic health record. She confirmed Resident #136 hard chart revealed she was a full code and that the electronic health record reflected she was a DNR. She confirmed the hard chart and the electronic health record should match to accurately reflect the residents' end of life wishes and did not. On [DATE] at 10:47 a.m. an interview was conducted with S3CC. She stated she conducted a full facility audit check for accuracy of code status on Friday [DATE]. She stated she checked the physician orders and face sheet which showed DNR for Resident #136. She stated she did not check the signed advance directive on the hard chart and should have. She confirmed the hard chart, face sheet and physicians orders should match to accurately reflect resident wishes. On [DATE] at 1:25 p.m., an interview was conducted with S14MD. She confirmed Resident #136 was a full code status. She confirmed the electronic health record and the hard chart code status should match to accurately reflect resident wishes and did not. On [DATE] at 2:09 p.m., an interview was conducted with S8LPN. She stated in the event of an emergency she would refer to the hard chart or the electronic health record to determine code status. She confirmed the electronic health record and the hard chart should match to accurately reflect resident wishes and did not.

Based on interviews and record review, the facility failed to electronically submit accurate payroll information for direct care staffing as required. Findings: Review of the PBJ Staffing Data Report for FY Quarter 3 2023 (April 1-June 30) revealed the following: Metric One Star Staffing Rating: This metric is suppressed for this facility and quarter Excessively Low Weekend Staffing: This metric is suppressed for this facility and quarter. Possible reasons for suppressed metrics: Invalid Data Review of the facility's CMS Submission Report PBJ Submitter Final File Validation Reports for 04/2023 revealed the following in part: Total Employee Link Records: Not Submitted Review of the facility's CMS Submission Report PBJ Submitter Final File Validation Reports for 05/2023 revealed the following in part: Total Employee Link Records: Not Submitted Review of the facility's CMS Submission Report PBJ Submitter Final File Validation Reports for 06/2023 revealed the following in part: Total Employee Link Records: Not Submitted On 10/11/2023 at 1:38 p.m., an interview was conducted with S1ADM. S1ADM stated in January of 2022 the time keeping system for the organization changed. S1ADM stated ZIP files containing employee data were uploaded into the PBJ. S1ADM stated the data was not transmitted due to the system changes, and because employee IDs had not been updated. S1ADM reviewed the aforementioned CMS Submission Report PBJ Submitter Final File Validation Reports for 04/2023, 05/2023, and 06/2023. She confirmed she had not previously reviewed the Total Employee Link Records which indicated Not Submitted. S1ADM confirmed the Total Employee Link Records were contained in the ZIP files which were uploaded, but not transmitted. S1ADM confirmed the information contained in the PBJ Staffing Data Report was not an accurate reflection of the facility's staffing.

Based on observations, interviews, and record reviews, the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety as evidenced by failing to: 1. Ensure opened foods were sealed properly; and 2. Ensured expired food items were disposed. Findings: Review of the policy titled Sanitation and Infection Control: Food Storage, revealed the following, in part: Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination. 15. Refrigeration: e. All foods should be covered, labeled and dated 16. Frozen Foods: c. Foods should be covered, labels and dated. On 10/09/2023 at 10:52 a.m., a tour of the kitchen was conducted with S13SFS. The following observations were made and confirmed by S13SFS. Dry Storage -4 unopened and 1 opened bag of marshmallows with an expiration date of 09/25/2023 Walk-in Cooler -1 opened and unsealed bag of romaine lettuce -1 large white plastic tub of boiled eggs with one corner of the lid lifted up and the inner blue bag open -1 opened and unsealed bag of parmesan cheese -1 opened and unsealed bag of mozzarella Walk-In Freezer - 1 opened and unsealed box of biscuits. On 10/09/2023 at 11:56 a.m., an interview was conducted with S6DNS. S6DNS was notified of the aforementioned findings and confirmed the items should have been sealed.

Based on interview and record review, the facility failed to ensure that the individual designated as the Infection Preventionist, completed specialized training in infection prevention and control. Findings: Review of the facility's Infection Control Binder revealed no documentation of S2DON and S11RN having completed specialized training in infection prevention and control. On 10/11/2023 12:26 p.m., an interview was conducted with S2DON. S2DON confirmed that neither she nor S11RN had completed the specialized infection prevention and control training. S2DON stated S15CRNC had the specialized infection prevention and control training and was overseeing them. On 10/11/2023 at 2:41 p.m., an interview was conducted with S2DON, S11RN, and S15CRNC. S15CRNC confirmed she completed specialized infection prevention and control training but was unable to produce documentation of the training. S2DON confirmed she had been over infection control since 04/21/2021 and had not completed specialized infection prevention and control training. S11RN confirmed she was the RN Quality Infection Preventionist since 07/11/2023 and confirmed she has not completed specialized infection prevention and control training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days. The facility failed to indicate the duration for the PRN order for 1 (#19) of 5 (#16, #19, #20, #21, and #174) residents reviewed for unnecessary medications. Findings: Review of the clinical record for Resident #19 revealed she was admitted to the facility on [DATE] with diagnoses which included Unspecified Anxiety Disorder, Unspecified Insomnia, and Moderate Recurrent Major Depressive Disorder. The admission MDS with an ARD of 09/20/2022 for Resident #19 revealed the following: BIMS = 15 (cognitively intact) Section N- Medications Medications received: days: antianxiety- 7 Review of the current Physician Orders for Resident #19 revealed the following, in part: Order Date: 09/13/2022 Start Date: 09/14/2022-Alprazolam 0.5 mg tablet give one tablet by mouth at bedtime as needed for anxiety. There was no documented duration or discontinue date for the PRN medication, Alprazolam 0.5mg. On 10/04/2022 at 10:51 a.m., an interview was conducted with S3LPN. She said Resident #19 was prescribed Alprazolam 0.5 mg PRN at night for anxiety. She said the medication was available for use and she would administer it to Resident #19 for anxiety if needed. She verified the Alprazolam 0.5 mg was ordered PRN and had no duration or discontinue date. On 10/04/2022 at 11:24 a.m., an interview was conducted with S5LPN. She said Resident #19 had Alprazolam 0.5 mg ordered PRN before bedtime for anxiety. She said the medication was available for use and she would administer it to Resident #19 before bedtime if needed. She verified the Alprazolam 0.5 mg was ordered PRN and had no duration or discontinue date. On 10/05/2022 at 2:00 p.m., an interview was conducted with S2MD. She verified she ordered Resident #19 Alprazolam 0.5 mg PRN at bedtime for anxiety. She confirmed there was no documented duration or stop date. On 10/05/2022 at 2:25 p.m., an interview was conducted with S1DON. She reviewed Resident #19's clinical record and verified Alprazolam 0.5 mg give one tablet by mouth PRN at bedtime for anxiety was ordered on 09/13/2022 and did not have a duration or stop date. She confirmed PRN psychotropic medications should be limited to 14 days and should be reevaluated by the physician for continued use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to accurately maintain documented records for 1 (#74) of 6 (#16, #19, #20, #21, #74, #174) residents reviewed in the final sample. The facility failed to correctly transcribe Resident 74's code status on the physician's orders and care plan. Findings: Review of the Face Sheet for Resident #74 revealed the resident was admitted to the facility on [DATE]. Review of physician's orders and care plan dated 09/28/2022 revealed the resident's code status was a full code. Further review revealed a signed physician order, dated 09/29/2022, which indicated the resident's code status was a DNR. A review of Resident's #74's clinical record revealed the physician's orders and care plan were updated on 10/03/2022 to reflect the resident's code status as a DNR. On 10/04/2022 at 12:25 p.m., an interview was conducted with S1DON. S1DON stated the facility did not enter the signed physician's order dated 09/29/2022 which changed Resident #74's code status from a full code to a DNR. S1DON stated the code status orders should be entered by the nurse when received, but the nurse (S4LPN) failed to enter the order into the physician's order set and care plan. S1DON also stated the evening nurse failed to catch the discrepancy in Resident 74's code status documentation during the routine chart audit. On 10/04/2022 at 12:54 p.m., an interview was conducted with Resident #74. Resident stated her code status should be a DNR and that she and her daughter had communicated that with the physician and facility at admission.