Based on staff interview, record review, and facility policy review, the facility failed to code the Minimum Data Set (MDS) accurately for a resident with a Mental Illness for one (1) of the 22 sampled residents. Resident #19 Findings include: Review of the facility policy titled “Nursing Assessment and Interdisciplinary Care Plan,” with a revision date of 06/2023, revealed: 2. Long Term Care Facility will conduct a comprehensive, accurate, standardized reproducible assessment upon admission and at regular intervals to ensure that each resident meet his/her highest practicable level of physical, mental, and psycho-social functioning: Physical and mental functional status . Record review of Resident #19's Significant Change MDS with Assessment Reference Date (ARD) of May 16th, 2025, revealed Section A 1500, Is the resident currently considered by the state level II PASRR (Preadmission Screening and Resident Review) process to have serious mental illness and/or intellectual disability or a related condition? coded as ''No. Record review of Resident #19's Summary of Findings Report, from the PASRR Office, dated 2/13/24 under Mental Health revealed the individual meets criteria for having a diagnosis of mental illness as defined by PASRR. During an interview with MDS Coordinator on 7/30/2025 at 2:00 PM, she verified that the Significant Change MDS with an ARD of May 16th, 2024, Resident #19 was coded incorrectly. She agreed that the MDS should be coded correctly to ensure that the resident is receiving the correct level of care. In an interview with the Director of Nursing (DON) on 7/30/25 at 3:07 PM, she agreed that it was her expectation that the MDS would be coded correctly. A record review of the admission Record revealed Resident #19 was initially admitted by the facility on 2/14/2024 with a diagnosis of Bipolar Disorder.

Based on observation, staff interviews, and facility policy review the facility failed to ensure hair restraints were utilized during food preparation to prevent contamination for one (1) of two (2) kitchen tours. Findings include:Review of the facility policy SANITATION AND INFECTION CONTROL with a revision date of 1/2025, revealed that Team members will wear hair restraints regardless of the length of hair or beard at all times in the kitchen. On 7/30/2025 at 11:00 AM during the kitchen tour with the Dietary Manager (DM), an observation was made of Chef #1 preparing food in the kitchen without a hair net in place. Chef #1 was wearing a black baseball hat, and his hair was sticking out approximately 3-4 inches in length from under the hat.An interview with the DM on 7/30/25 at 11:15 AM revealed she was aware Chef #1 was required to wear a hair net and stated, Yes, he should have a hair net on and I've told him he has to wear it. During an interview with the Administrator (ADM) on 7/31/2025 at 9:45 AM, she stated that she has had to talk with Chef #1 in the past regarding the hair net and their facility policy regarding food safety.

Based on staff interview, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of two (2) quarters reviewed. (2nd Quarter 2025)Findings include: Record review of the facility policy titled, “Electronic Staffing Data Submission Payroll-Based Journal” with a revision date of 6/30/25, revealed, “ .Mandated to submit to CMS (Centers for Medicare and Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .” Record review of the “PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 2 2025 (January 1 - March 31)” revealed “Excessively Low Weekend Staffing – Triggered = Submitted Weekend Staffing data is excessively low. No RN (Registered Nurse) Hours – Triggered = Four or More Days Within the Quarter with no RN Hours. Failed to have Licensed Nursing Coverage 24 Hours/Day – Triggered = Four or More Days Within the Quarter with <24 Hours/Day Licensed Nursing Coverage.” During an interview on 7/30/2025 at 11:25 AM, the Administrator (ADM) stated that the facility had recently transitioned to a new payroll system. She explained that, unlike the previous system, the new system did not automatically transfer data from the time clock, which resulted in missing staffing data for the second quarter of 2025 PBJ submission. The ADM acknowledged that she failed to verify the accuracy of the data prior to its transfer and submission, which led to discrepancies and errors in the quarterly PBJ report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for Activities of Daily Living (ADL)s for a dependent resident, as evidence of long, rough fingernails, for 1 (one) of 22 residents reviewed for ADL care. Resident #18 Findings include: A review of the facility policy, with an effective date of 03/2021, titled, Nursing Assessment and Interdisciplinary Care Plan under purpose; The purpose is to ensure resident's assessments will be performed by Registered Nurse and that all State and Federal regulations are implemented for MDS+. Under Long Term Care Facility; Revision of the Care plan states an evaluation of the problems, the goals and the interventions will be reviewed at the Interdisciplinary Team Conference and revised , including: Responsiveness to the interventions, Effectiveness of the interventions in resolving the resident's problem. A record review of the comprehensive care plan, with an onset date of 5/5/2017, and a revision date of 2/2/2018; reveals a problem of (Resident #18) has an ADL Self Care Performance Deficit r/t (related to) Old CVA(Cerebralvascular Accident) with Rt (right) sided Hemiplegia; with a goal of (Resident #18) will maintain current level of function in Bed Mobility, Transfers, Eating, and Toilet Use through the review date. Interventions include: BATHING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. PERSONAL HYGIENE/ORAL CARE: (Resident #18) requires extensive assist with personal hygiene. [CNA,LPN] On 10/10/22 at 11:03 AM an interview with Resident # 18 revealed that the resident had long, jagged fingernails on both hands. The observation revealed the resident had long, jagged fingernails on both hands with a brown substance under the nails on the right hand. An observation of Resident # 18 on 10/11/22 at 9:25 AM revealed the resident had long, rough fingernails on both hands and with a brown substance under the nails on his right hand. During an interview and observation on 10/11/22 at 3:40 PM Certified Nursing Assistant (CNA) #1 confirmed that Resident # 18's nails needed to be trimmed, but that CNAs did not trim nails. CNA # 1 revealed that she was responsible for reporting to the nurse that his nails needed to be trimmed and she had not notified any nurses. During an interview and observation on 10/11/22 at 3:47 PM the Director of Nursing (DON) confirmed that Resident #18's nails were long and she trimmed them after the Surveyor made her observation. During an interview on 10/12/22 at 9:00 AM the DON confirmed that the care plan was not being followed. Record review of Resident #18's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses which included, Cerebral Infarction due to Thrombosis of Unspecified Cerebral Artery, Hemiplegia, Unspecified affecting Left Nondominant Side. Record review of Resident # 18's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/30/22 revealed a Brief Interview for Mental Status (BIMs) of 15, indicating Resident # 18 is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and record review, the facility failed to provide nail care for one (1) of 22 residents reviewed for Activities of Daily Living (ADL) care. Resident #18 Findings include: The facility does not have a policy related to nail care. An observation and interview, on 10/10/22 at 11:03 AM of Resident # 18 revealed he had long and jaggad fingernails with a brown substance underneath them on his right hand. An observation of Resident # 18 on 10/11/22 at 9:25 AM revealed the resident had long jagged fingernails with a brown substance under them on his right hand. During an interview and observation on 10/11/22 at 3:40 PM Certified Nursing Assistant # 1(CNA) confirmed that Resident #18 had long jagged fingernails with a brown substance under them and needed to be trimmed. CNA #1 revealed that she does not trim fingernails, is responsible for reporting to the nurse when the nails need to be trimmed, and she had not reported to anyone that the resident needed his nails trimmed. During an interview and observation on 10/11/22 at 3:47 PM the Director of Nursing (DON) revealed Resident #18 nails were long before she trimmed them yesterday (after the Surveyor made her observation). Record review of Resident #18's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses which included, Cerebral Infarction due to Thrombosis of Unspecified Cerebral Artery, Hemiplegia, Unspecified affecting Left Nondominant Side. Record review of Resident # 18's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/30/22 revealed in section G that Resident #18 required extensive assistance with Hygiene and section C revaled a Brief Interview for Mental Status (BIMs) of 15, indicating full cognitive ability.