Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 20 residents reviewed (Residents #12). This deficient practice was evidenced by the following: On 08/21/2024 at 9:44 AM, the surveyor observed Resident #12 in the bed. The surveyor reviewed the admission Record for Resident #12 which reflected that the resident was admitted with diagnoses that included Chronic Obstructive Pulmonary Disease (disease of the lung). The surveyor reviewed the Physician's orders for Resident # 12. There was an order dated 07/24/2023 for Oxygen at 2 liters per minute via nasal cannula continuous every shift. The July 2024 Medication Administration Record had documentation that the Oxygen was in use. The surveyor reviewed Resident #12's Quarterly MDS, an assessment tool utilized to facilitate the management of care, dated 07/19/2024. The MDS indicated no for Oxygen use for Resident #12. When interviewed on 08/26/24 at 11:36 AM, the MDS Coordinator stated that Resident #12 utilized Oxygen. He stated that the July 2024 MDS was coded incorrectly. NJAC 8:39-11.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 1 resident reviewed for Preadmission Screening and Resident Review PASRR (Resident #55) and was evidenced by the following: Resident #55 was a resident of the facility. The surveyor reviewed the Level I PASRR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for Resident #55 dated 07/04/2020 which was negative, meaning the resident did not have any mental illness diagnoses that could lead to a chronic disability. The surveyor reviewed the quarterly Minimum Data Set (MDS), an assessment tool dated 12/22/2021. The MDS reflected that Resident #55 had long and short-term memory deficits and did not have diagnosis of schizophrenia (a serious mental illness). The surveyor reviewed the quarterly MDS dated [DATE]. The MDS reflected Resident #55 had long and short-term memory deficits and had diagnosis which included schizophrenia. The surveyor reviewed the psychiatry consult for Resident #55 dated 02/01/2022. The consult included diagnoses of dementia and major depression with psychotic features. The surveyor reviewed the psychiatry consult for Resident #55 dated 03/01/2022. The consult included a new diagnosis of schizophrenia. During an interview with the surveyor on 08/22/2024 at 11:12 AM, the Clinical Social Worker stated that when a resident was diagnosed with a new psychiatric disorder, a new PASRR should be completed. She stated that when Resident #55 was newly diagnosed with schizophrenia a new level I PASRR should have been completed but was not. The surveyor reviewed the facility policy titled, PASRR Completion, with an issue date of 10/10. The policy reflected that PASRR screening will be completed in compliance with state and federal regulations. NJAC 8:39-27.1 (a)