**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure resident status was accurately identified on the Minimum Data Set (MDS) assessment for 1 of 2 resident (R25) reviewed for anticoagulant use. Findings include: R25's Face Sheet printed 8/6/25, included diagnoses of peripheral vascular disease (narrowing or blockage of blood vessels) , chronic atrial fibrillation (irregular heart rhythm), edema and chronic venous hypertension (high blood pressure in veins leading to insufficiency causing swelling) with ulcer and inflammation of bilateral lower extremities. R25's quarterly Minimum Data Set (MDS) dated [DATE], section N, included R25 was receiving a diuretic, antiplatelet, hypoglycemic and antidepressant medication. Anticoagulant medication was not checked as receiving. R25's physician orders dated 7/20/25, included warfarin sodium (anticoagulant/blood thinner) 1 mg tablet by mouth six times per week on Monday, Tuesday, Wednesday, Thursday, Friday and Saturday and 1.5 mg tablet of warfarin sodium one time a week on Sunday. During interview on 8/6/25 at 3:35 a.m., the director of nursing confirmed the MDS was coded incorrectly and confirmed R25 had received warfarin when the MDS was completed in June 2025. During interview 8/6/25 at 3:05 p.m., registered nurse (RN)-C, also identified as MDS coordinator, stated R25 has always been on warfarin so she must have just forgotten to check the anticoagulant box when she completed R25's MDS in June 2025. A policy on MDS coding was requested and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure fall risk interventions were completed after a fall for 1 of 2 residents (R6) identified at risk for falls to prevent further falls.Findings include: R6's Face Sheet printed 8/6/25, indicated R6 had diagnoses including heart failure, dementia, chronic kidney disease stage IV (severe irreversible damage to the kidneys) and chronic respiratory failure. R6's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R6 had a severe cognitive impairment with no delirium or behaviors. Activities of daily living (ADL's) included R6 uses a wheelchair and requires partial/moderate assistance for oral care and eating, and substantial to maximal assistance for toileting, showering, personal hygiene, bed mobility and transfers. Walking was not attempted. R6 has had one fall without injury since prior assessment. R6's Care Area assessment dated [DATE], indicated R6 was at risk for falls. See plan of care for fall interventions. Fall assessment last completed 8/4/25, identified R6 was at risk for falls and has had 1-2 falls in the past 3 months, has decreased safety awareness with impaired mobility. R6's plan of care last updated 5/27/25, indicated R6 was at risk for falls related to heart problems, terminal diagnosis of heart failure, takes medications that cause resident to be dizzy, tired, confused or weak and have trouble sleeping. Interventions included: bed low to the ground with wheels locked, remind to ask for help, therapy department performed Lift Chair Safety Assessment and is safe to use recliner chair in her room, keep important items within reach, frequent checks and night light on at night. Facility Incident Report dated 4/19/25 at 3:48 a.m., by licensed practical nurse (LPN)-A indicated R6 was trying to get up and go the bathroom and was found on the floor. Was observed in bed at 1:30 a.m. Current interventions and other factors included reclining chair, tray table, room close to nurses station, call light was in reach, but call light was not on. New intervention included floor alarm and teaching use of call light. No injuries noted. Interdisciplinary team review (IDT) completed 4/21/25, included R6 has had 1 fall within the last year. Intervention included floor alarm placed on floor while in bed and teaching of use of call light. Facility Incident Report dated 6/3/25 at 7:30 p.m., by LPN-B indicated resident was observed on floor and stated I thought I could get into my bed myself so I tried. R6 stated she landed on buttocks then onto her back and hit her head on the floor. Current interventions and factors included low bed, attempting to transfer without staff assist, call light in reach but was not on. No injuries. New interventions included a personal alarm and teaching on safe transfer techniques, and use of call light for assistance. IDT review, undated, included personal alarm was placed on person. 2 falls within the last 2 months. Facility Incident Report 7/30/25 at 4:00 p.m., by registered nurse (RN)-A included resident was observed on floor in front of her recliner. Recliner was elevated for her legs to be up. Call light was in reach but call light was not on. No injuries noted. IDT team review, undated, included 3 falls with the past 3 months. New intervention included recliner was unplugged and foot elevation pedal will not be used. On observation and interview 8/4/25 at 3:34 p.m., R6 was sitting in her wheelchair with a personal alarm on her chair and clipped to resident. Family member (FM)-A was sitting in R6's recliner in her room and stated R6 used her lift chair and fell out last week. FM-A stated they notified her of the fall and said they were going to unplug the recliner. FM-A used buttons on side of recliner and recliner began to put feet up and stated I guess they didn't unplug it as it still works. On observation and interview 8/5/25 at 9:23 a.m., R6 was sitting in her wheelchair with personal alarm on. R6 stated she does sit in her recliner sometimes but doesn't want to right now. R6 sorting through her drawers. Power recliner remains plugged in and working. On observation and interview 8/6/25 at 7:54 a.m., R8 was assisted to tub room by nursing assistant for hospice (NA)-A. Electric recliner continues to be plugged in and functioning. NA-A stated she has seen R6 in her recliner periodically when she comes. NA-A was unaware of any recent falls and is unsure if it should be plugged in or not. On interview 8/6/25 at 9:04 a.m., NA-B stated R6 has been evaluated for use of her electric chair and has been okayed to use it. NA-B stated she hasn't been told anything different and wasn't aware it needed to be unplugged. On interview 8/6/25 at 9:19 a.m., NA-C stated R6 does use her recliner and after lunch staff will generally put her in the recliner for awhile. NA-C stated we do have to watch her close or she will try to climb out of it when she gets tired of sitting there. NA-C stated he didn't believe R6 could use the electric chair control buttons but was not aware the recliner was not supposed to be plugged in. On interview 8/6/25 at 9:20 a.m., RN-B stated two weeks ago R6 was in her recliner with the legs up and she tried to climb out of it without putting the feet down. The recliner tipped down and she slid out. RN-B stated she was not aware the recliner was to be unplugged. RN-B confirmed the electric chair was plugged in and operational. On interview 8/6/25 at 10:42 a.m., the director of nursing (DON) stated she had heard the recliner was unplugged but never actually checked it herself. The DON stated it should not be plugged in and will see if therapy can evaluate R6 again for safe use and possibly remove the chair since it is easy for staff to just plug it back in if they want to use it. The DON stated after a new intervention is put into place, it should be documented in the communication book which staff review prior to working their next shift. The DON reviewed the communication book and stated no communication note was present regarding the unplugging of the electric chair. Facility Falls and Managing Fall risk policy dated 3/2018, included: - - Staff will implement a resident centered fall prevention plan to reduce the risk factor(s) of falls for each resident at risk or with a history of falls. - -If falling reoccurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. - -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. - - Position-change alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

Based on interview and document review, the facility failed to submit accurate data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed- Quarter 2, 2025, (January to March), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: The CMS payroll-based journal (PBJ) staffing data report indicated the following infraction: Excessively Low Weekend Staffing- Submitted Weekend Staffing data is excessively low.During interview on 8/4/25 at 12:45 p.m., director of nursing (DON) stated she was unsure why they would have triggered for low staffing and that they always had staff on the weekends. DON further stated they used agency staff on weekends to fill shifts their staff could not cover.During interview on 8/4/25 at 1:10 p.m., administrator, who oversees submission of the PBJ data, stated he recalled there may have been a delay in getting staffing hours from the agencies they work with to fill shifts, and that may be why it appeared they had low weekend staffing. Administrator further stated he was not aware of actual low weekend staffing and that weekends were always staffed by hired staff or agency staff. Administrator stated he would work with agencies to get accurate staffing hours submitted.Review of facility provided documents titled 2025 Master Nursing Staff Schedule and Time Card Report dated 1/1/25 -3/31/25, indicated the facility did not have low weekend staffing on any weekend during that time period.A facility policy on Payroll Based Journal Submission was not received.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 2, 2024), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: CMS PBJ (payroll-based journal) Staffing Data Report dated Quarter 2, 2024 (January 1 - March 31) triggered for failure to have licensed nursing coverage 24 hours/day. The infraction dates included: 1/28/24, 2/4/24, 2/25/24, 3/10/24, 3/24/24, and 3/31/24. During an interview on 7/16/24 at 10:39 a.m., with nursing staff scheduler (NSS)-C reviewed nursing staff schedules for the infraction dates. On each of the six dates, there had been licensed nurses scheduled 24 hours/day. During record review, timecard sheets for each of the 10 nurses covering the 18 shifts were reviewed and indicated the nurses who had been scheduled had been paid for working each of the 18 shifts. During an interview on 7/16/24 at 1:34 p.m., the director of nursing (DON) verified the facility always had a licensed nurse working 24 hours/day. During an interview on 7/16/24 at 1:55 p.m., the administrator was informed of the results of the PBJ Staffing Data Report and given a copy. The administrator stated the staffing file was automatically uploaded to CMS, and due to the formatting, was not able to see where a potential problem could have occurred. The administrator stated the facility did not use agency nurses for staffing, and if nursing leadership worked a shift, their hours were reflected in the data. The administrator was not sure why there had been inaccurate reporting and would investigate it. The facility Reporting Direct Care Staffing Information (Payroll-Based Journal) policy with revised date of August 2022, indicated direct care staffing information was reported electronically to CMS through the Payroll-Based Journal system. Complete and accurate direct care staffing information was reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. For auditing purposes, reported staffing information was based on payroll records, invoices, tied back to a contract, or other verifiable information.