**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) reflecting anticoagulant medications for two (2) of fourteen sampled residents reviewed. (Resident # 11, Resident #23) Findings include: Review of the facility's policy, Minimum Data Set (MDS) Assessment dated May 2022, revealed, 1. PURPOSE AND ACCOUNTABILITY. The facility shall conduct an interdisciplinary assessment using the MDS assessment in accordance with Federal/State regulations. This assessment provides information on the resident's condition which is used to develop an individualized plan of care and to track changes in the resident's status. This policy applies to all members of the treatment team. 2. POLICY. It is the policy of the facility to utilize information from the Resident Assessment/Instrument (RAI) and to follow the Care Planning Process in accordance to State and Federal regulation to provide quality care and services which improve residents' quality of life . 4. PROCEDURE . I. Staff members who complete portions of the assessment attest to the accuracy of their section by signature . J. The completed MDS is verified and signed by the MDS Coordinator . A record review of the 2021 [NAME] Pocket Drug Guide for Nurses, revealed the classification of Plavix is listed as an antiplatelet. Resident #11 Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/23/23, revealed Resident # 11 had a Brief Interview for Mental Status, (BIMS) score of 13, which indicated the resident was cognitively intact. Section N revealed Resident #11 received anticoagulant medication for seven (7) days out of the seven (7) days in the look back period. Record review of the Identification and Summary Sheet revealed the facility admitted Resident #11 on 6/06/2005. Review of the facility's, Physicians Orders revealed the Resident #11 had an order for Plavix 75 mg (milligrams) po (by mouth) daily, prescribed on 5/15/17, and updated and signed by the physician on 9/11/23. Record review of the August 2023, Medication Administration Record (MAR) for Resident #11, revealed Plavix 75 mg was administered seven (7) days out of the seven (7) days in the look back period and all other days during the month. There were no anticoagulant medications administered. Resident #23 Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/9/23 revealed Resident #23 had a Brief Interview for Mental Status, (BIMS) score 13, which indicated the resident was cognitively intact. Review of Section N revealed Resident #23 received anticoagulant medication for seven (7) or the seven (7) days in the look back period. Record review of the Identification and Summary Sheet revealed the facility admitted Resident #23 on 6/24/15. Review of the facility's, Physicians Orders revealed Resident #23 had an order for Plavix 75 mg (milligrams) po (by mouth) daily, prescribed on 4/5/22, and updated and signed by the physician on 9/11/23. Diagnoses and comments indicated Resident #23 had a history of CVA (Cerebrovascular Accident). Record review of the August 2023 Medication Administration Record (MAR) for Resident #23, revealed Plavix 75 mg was administered seven (7) days during the seven (7) day look back period and all other days during the month. There were no anticoagulant medications administered. During an interview on 10/11/23 at 3:52 PM, Registered Nurse (RN) #1 confirmed she failed to code the MDS correctly, as she coded Plavix as an anticoagulant in section N. The nurse revealed she has problems separating the medications because anticoagulant medications also thin the blood. During an interview on 10/12/23 at 12:42 PM, RN #1 confirmed she failed to code the MDS correctly. RN #1 said she coded the Plavix as an anticoagulant in Section N, because she has problems separating the medications because both medications thin the blood. During an interview 10/12/23 at 12:47 PM, the Director of Nurses (DON) confirmed Plavix was not coded correctly. The DON confirmed Plavix is an antiplatelet and does not thin the blood. The DON said she expects the MDS nurse to code the medication correctly. During an interview with the Administrator on 10/12/23 at 1:05 PM, he revealed he expects the nurses to code the medications correctly on the MDS.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) regarding a urinary and bowel toileting program for one (1) of 26 MDS assessments reviewed. Resident #18 Findings include: A record review of the facility's statement dated 3/31/2022 revealed, (Proper Name of Facility) utilizes the RAI (Resident Assessment Instrument) for MDS guidance and submission. Resident #18 A record review of the Identification and Summary Sheet revealed the facility admitted Resident #18 on 8/22/2018. A record review of Resident #18's Quarterly MDS with an Assessment Reference Date (ARD) of 11/17/2021 revealed diagnoses of Hypertension, Bipolar Disorder, Pseudobulbar affect, and Glaucoma. Resident #18 was independent for toilet use and the coding for Section H0200 and H0500 revealed Resident #18 was on a urinary and bowel toileting program. His Brief Interview of Mental Status (BIMS) score was 13, which indicated he is cognitively intact. On 03/29/22 at 8:05 AM, during an interview with Director of Nursing (DON), she explained Resident #18 can complete his Activities of Daily Living (ADLS) on his own time and is independent. Resident #18 will occasionally have incontinent episodes, but he will change himself and he toilets independently. On 03/29/22 at 9:50 AM, during an interview with Certified Nurse Aide (CNA) #3, she explained Resident #18 walks to the shower and bathroom independently and he is not on any special bladder or bowel training program. At 1:40 PM on 03/29/22, during an interview with Resident #18, he explained he has no problems going to the bathroom and is able to go by himself. On 03/30/22 at 10:00 AM, during an interview with CNA #2, he explained Resident #18 has had occasional incontinent episodes with urine, but not with bowel movements. He confirmed Resident #18 does not use a urinal and is able to toilet self. He also stated the resident is not on any special toileting training program. At 11:00 AM on 03/30/22, during an interview the DON, she explained the facility currently does not have a bowel and bladder training program. She reported Resident #18 can toilet without assistance. She explained she did not know that RN #2 had coded Resident #18 on the MDS as having been in a bowel and bladder training program and it is coded incorrectly, which is a MDS discrepancy. She explained she depends on the MDS nurse to code the MDS assessments accurately and to submit the MDS when assessments are due. She reported the facility currently does not check MDS assessments for accuracy prior to submitting. At 12:45 PM on 03/30/22, during an interview with RN #2, she reviewed Resident #18's recent MDS with an ARD of 11/17/21 and confirmed sections H0200 and H0500 were coded for a bowel and bladder training program. She explained Resident #18 goes to the bathroom on his own and he was not in a bowel and bladder training program during the seven day lookback period. She confirmed the MDS was coded in error, and it is a MDS discrepancy. On 03/30/22 at 12:50 PM, during an interview with RN #3, she viewed and confirmed Resident #18's Quarterly MDS with an ARD of 11/17/21 sections H0200 and H0500 were coded incorrectly due to Resident #18 had no orders for a bowel and bladder training program and those programs require an in-depth assessment. 03/31/22 at 10:30 AM, during an interview with the Nursing Administrator, she explained the facility does not have a MDS Policy, the facility used the RAI Manual for reference in completing the MDS. She confirmed the facility currently does not audit MDS assessments for accuracy prior to the MDS nurse submitting the assessments.

Based on observations and interviews, the facility failed to ensure smoking refuse was disposed of in a safe and sanitary manner for one (1) of two (2) smoking area observations. On 3/29/2022 at 4:45 PM, the SA observed Resident #17 smoking in the facility courtyard. When the resident finished smoking, he threw his cigarette onto the ground in a grassy area. Certified Nursing Assistant (CNA) #1 told Resident #17, You can't throw that on the ground. Resident #17 retrieved the cigarette butt from the ground and placed it in a Styrofoam cup that had water in it. Resident #17 stated that they had been throwing the cigarettes butts on the ground and why are we changing now. The SA observed a large amount of cigarette butts in the grass in the facility courtyard, which is the designated smoking area. On 3/29/2022 at 4:47 PM, an interview with Resident #17 revealed that he had always thrown his cigarette butts in the grass, and he had not been putting his cigarettes in a cup. On 3/29/2022 at 4:53 PM, during an interview with CNA #1, she confirmed Resident #17 threw the cigarette butt on the ground and that there was a large amount of cigarette butts in the grass in the courtyard. CNA #1 stated that when she takes the residents to smoke, she brings a Styrofoam cup with water for the residents to put the cigarettes butts in when they have finished smoking. She said she does not know what the other employees do when they are assisting residents with smoking. During an interview on 03/29/22 at 04:55 PM with the Administrator and the Administrator in Training (AIT), they observed and confirmed there was a large amount of cigarette butts in the grass in the courtyard. The Administrator said this could cause a fire by throwing lit cigarette butts in the grass. The Administrator said he did not know the residents were throwing the cigarette butts in the grass. Record review of the Identification and Summary Sheet revealed the facility admitted Resident #17 on 7/15/2005. Record review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 11/24/21 revealed Resident #17 had a Brief Interview of Mental Status (BIMS) of 03 which indicated Resident #17 is cognitively impaired.

Based on staff interviews and record reviews, the facility failed to complete the comprehensive Minimum Data Set (MDS) for two (2) of 26 residents reviewed for comprehensive assessments, with the potential to affect 39 residents. Resident #15 and Resident #37. ` Findings Include: A record review of the facility's statement dated 3/31/2022 revealed, (Proper Name of Facility) utilizes the RAI (Resident Assessment Instrument) for MDS (Minimum Data Set) guidance and submission. A record review of Centers for Medicare and Medicaid (CMS) RAI Version 3.0 Manual dated October 2019 revealed, The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) . Resident #15 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #15 on 2/6/2013. Record review of the last completed MDS revealed a quarterly assessment with an Assessment Reference Date (ARD) of 10/27/21. Further review of the medical record revealed Resident #15's comprehensive annual assessment had not been completed. Resident #37 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #37 on 3/9/2020. Record review of the last completed MDS revealed a quarterly assessment with an ARD of 11/3/21. Further review of the medical record revealed Resident #37's comprehensive annual assessment had not been completed. On 03/29/22 at 11:04 AM, in an interview with Registered Nurse #2 (RN)/MDS Nurse, she stated that the MDS assessments are not up to date because she took the position approximately three months ago and received training for one and a half (1 ½) weeks. After training, she was working on her own and it takes her longer to complete the MDS assessments. She confirmed that she is behind on completing assessments and she knows it is important for MDS assessments to be completed in a timely manner. On 03/31/22 at 11:31 AM, in an interview with the Nursing Home Administrator (NHA)/ Nursing Home (NH) Director, he stated he was not aware the MDS assessments were not current, and he confirmed it is important for them to be up to date. The current MDS nurse took the position in October or November of 2021 and the Director of Nursing (DON) should check behind the MDS nurse. He stated the DON is also new in her position and she assumed the MDS nurse was completing assessments in a timely manner. On 03/31/22 at 10:30 AM, during an interview with the Nursing Administrator, she explained the facility does not have a MDS Policy and the facility used the RAI Manual for reference in completing MDS assessments and MDS submissions. She reported she was not aware the MDS nurse was behind on MDS assessments.

Based on staff interviews and record reviews, the facility failed to complete quarterly Minimum Data Set (MDS) Assessment for 17 of 26 residents reviewed for MDS assessments, with the potential to affect 39 residents. Resident #7, Resident #10, Resident #13, Resident #16, Resident #18, Resident #19, Resident #20, Resident #22, Resident #23, Resident #26, Resident #27, Resident #30, Resident #31, Resident #33, Resident #34, Resident #35 Resident #36 Findings Include: A record review of the facility's statement dated 3/31/2022 revealed, (Proper Name of Facility) utilizes the RAI (Resident Assessment Instrument) for MDS (Minimum Data Set) guidance and submission. A record review of Centers for Medicare and Medicaid (CMS) RAI Version 3.0 Manual dated October 2019 revealed, The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non- comprehensive assessment for a resident that must be completed at least every 92 days . Resident #7 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #7 on 6/1/1976. Record review of the last completed MDS revealed a quarterly assessment with an ARD of 10/20/2021, which is more than 92 days. Resident #10 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #10 on 4/2/2001. Record review of the last completed MDS revealed a significant change in status assessment with an ARD of 11/11/2021, which is more than 92 days. Resident #13 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #13 on 3/4/2011. Record review of the last completed MDS revealed a quarterly assessment with an ARD of 10/13/2021, which is more than 92 days. Resident #16 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #16 on 11/5/2021. Record review of the last completed MDS revealed an admission assessment with an ARD of 11/11/21, which is more than 92 days. Resident #18 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #18 on 8/22/2018 Record review of the last completed MDS revealed a quarterly assessment with an ARD of 11/17/2021, which is more than 92 days. Resident #19 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #19 on 5/18/2015. Record review of the last completed MDS revealed an annual assessment with an ARD of 10/20/2021, which is more than 92 days. Resident #20 A Record review of the Identification and Summary Sheet revealed the facility admitted Resident #20 on 6/10/2010. A Record review of the last completed MDS revealed a comprehensive assessment with an ARD of 1/23/21, which is more than 92 days. Resident #22 A Record review of the Identification and Summary Sheet revealed the facility admitted Resident #22 on 8/15/2018. A Record review of the last completed MDS revealed a quarterly assessment with an ARD of 11/10/2021, which is more than 92 days. Resident #23 Record review of the identification and Summary Sheet revealed the facility admitted Resident #23 on 8/27/2018. Record review of the last completed MDS revealed a quarterly assessment with an ARD of 11/17/2021, which is more than 92 days. Resident # 26 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #26 on 08/10/2018. Record review of the last completed MDS revealed an annual assessment with an ARD of 11/03/2021, which is more than 92 days. Resident #27 A Record review of the Identification and Summary Sheet revealed the facility admitted Resident #27 on 4/4/2016. A Record review of the last completed MDS revealed a quarterly assessment with an ARD of 11/10/2021, which is more than 92 days. Resident #30 A Record review of the Identification and Summary Sheet revealed the facility admitted Resident #30 on 10/5/2015. A Record review of the last completed MDS revealed a quarterly assessment with an ARD of 10/27/2021, which is more than 92 days. Resident #31 A Record review of the Identification and Summary Sheet revealed the facility admitted Resident #31 on 8/16/2018. A Record review of the last completed MDS revealed a quarterly assessment with an ARD of 11/3/2021, which is more than 92 days. Resident #33 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #33 on 10/17/2016. Record review of the last completed MDS revealed a quarterly assessment with an ARD of 12/1/2021, which is more than 92 days. Resident #34 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #34 on 3/7/2019. Record review of the last completed MDS revealed a significant change in status assessment with an ARD of 12/12/2022, which is more than 92 days. Resident #35 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #35 on 11/14/2019. Record review of the last completed MDS revealed a quarterly assessment with an ARD of 10/6/2021, which is more than 92 days. Resident #36 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #36 on 11/20/2019. Record review of the last completed MDS revealed an annual assessment with an ARD of 11/10/2021 which is more than 92 days. On 03/29/22 at 11:04 AM, in an interview with Registered Nurse #2 (RN)/MDS Nurse, she stated that the MDS assessments are not up to date because she took the position approximately three months ago and received training for one and a half (1 ½) weeks. After training, she was working on her own and it takes her longer to complete the MDS assessments. She confirmed that she is behind on completing assessments and she knows it is important for MDS assessments to be completed in a timely manner. On 03/31/22 at 11:31 AM, in an interview with the Nursing Home Administrator (NHA)/ Nursing Home (NH) Director, he stated he was not aware the MDS assessments were not current, and he confirmed it is important for them to be up to date. The current MDS nurse took the position in October or November of 2021 and the Director of Nursing (DON) should check behind the MDS nurse. He stated the DON is also new in her position and she assumed the MDS nurse was completing assessments in a timely manner. On 03/31/22 at 10:30 AM, during an interview with the Nursing Administrator, she explained the facility does not have a MDS Policy and the facility used the RAI Manual for reference in completing MDS assessments and MDS submissions. She reported she was not aware the MDS nurse was behind on MDS assessments.