**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) The facility's policy and procedure titled Minimum Data Set (MDS) - v3.0, last reviewed 10/25/22, documented that an MDS assessment will be completed for all residents on admission, annually, quarterly and for all significant changes in resident functioning. The MDS will be completed by the interdisciplinary team and each discipline is responsible for completing their sections. The MDS coordinator schedules the residents' assessments and monitors their completion. Resident #230 was admitted to the facility with diagnoses that included vascular dementia and cerebral infarction. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident #230 had severe cognitive impairment with a BIMS of 4 and required extensive assistance of one person for daily activities like toilet use and personal hygiene. The assessment further documented that no alarms that monitor the resident's movements (including a wander/elopement alarm) were used on resident #230. The MDS assessments dated 3/1/22 and 5/27/22 did not document the use of elopement alarms either. On 04/06/23 at 12:56 PM resident #230 was observed sitting in bed in their room. A wanderguard was observed on the resident's right wrist. Shortly after, a picture of resident #230 was observed on the nursing station, with a note stating, risk of elopement. On 04/07/23 at 11:33 AM resident #230 was observed in the floor's common room, watching a movie with other residents. A wanderguard was observed on the resident's right wrist. The facility's incident report dated 4/25/22 documented resident #230 attempted to elope the facility and was stopped from entering the elevator by a staff member. The resident was fully clothed, was holding a duffle bag packed with clothing and had previously verbalized intentions to go home. A physician's order dated 4/22/22 documented resident #230 was to have a wanderguard checked for placement on every shift and checked for functioning on the 11PM-7AM shift. A Daily wanderguard check list for April and May 2022 documented resident #230 had a wanderguard on the left arm that was checked daily for placement and functioning, beginning on 4/22/22. A comprehensive care plan (CCP) titled Elopement Risk, effective: 10/28/2020, documented resident #230 had exit seeking behaviors and verbalized a desire to go home. The CCP had a goal that the resident will not make any attempts to leave facility and will be compliant in wearing a wanderguard. Interventions added on 4/12/22 included posting a picture at the nursing station and wanderguard use. The CCP was updated after the 4/25/22 incident, when visual monitoring was increased, and again on 8/17/22 when no changes were made. An elopement risk assessment, completed 4/22/22, documented resident #230 was at risk for elopement as evidenced by attempts to wander off the unit, verbalizing I'm going home, and a history of wandering/elopement. On 04/07/23 at 11:36 AM CNA #5 was interviewed and stated that resident #230's behavior changes daily. CNA #5 stated resident #230 tries to leave the unit at times, though not recently. Staff keeps a close eye on the resident with monitoring every 30 minutes. CNA #5 stated resident #230 has a wanderguard to prevent the resident from taking the elevator. On 04/07/23 at 11:47 AM LPN #2 was interviewed and stated that resident #230 is sometimes confused and changes every day, with strange behaviors. Resident #230 did attempt to leave a while ago; had a bag and said he/she was going home. He/she hasn't tried that in a while. LPN #2 stated that if a resident with a wanderguard goes into the elevator, it will start beeping and won't work until the staff enters a code. LPN #2 was not sure if resident #230 currently had a wanderguard on. On 04/07/23 at 12:14 PM MDS Assessor #2 was interviewed and stated they have worked at the facility for almost 3 years, always doing MDS. MDS Assessor #2 stated the wanderguard is to alert the staff if the resident is trying to leave the unit by making a sound. It is an alarm, and it has to be coded as an alarm. MDS Assessor #2 stated there is an order for this resident for the wanderguard. I probably miscoded this one. I didn't realize it is an alarm. I agree, it should have been coded. I completed the previous assessments for this resident and didn't code it. On 04/10/23 at 12:35 PM the MDS coordinator was interviewed and stated the facility has 3 MDS assessors and the work is divided by unit. Each assessor does the whole MDS assessment for their assigned units. The MDS coordinator supervises the assessors, does the scheduling of assessments, reviews and signs the books that are completed and does the submission. The MDS coordinator stated the person who completes the assessment is responsible for the accuracy. I review to make sure it is completed. I'm not required to check for accuracy. When we find an inaccuracy, we confirm and then do a modification and resubmit the book. It would be impossible to review every assessment for accuracy, not feasible. We already fixed the mistake with the wanderguard. On 04/11/23 at 12:11 PM the assistant director of nursing (ADNS) was interviewed and stated the MDS coordinator is in charge of overseeing the MDS assessments. The MDS department is supplied with a list of residents who are on wanderguard. That is an omission. I don't know why it wasn't entered. 415.11(b) 2) Resident #45 had diagnoses of Alzheimer's Disease unspecified, Mood Disorder unspecified mood affective disorder, and unspecified dementia without behavioral disturbance. The Level 1 Preadmission Screening and Resident Review (PASRR) dated 10/15/2022 documented Resident #45 had Alzheimer's disease and no serious mental illness. Resident #45 Hospital Discharge summary dated [DATE] documented the resident was prescribed quetiapine 150 mg extended release 1 tablet in the evening, Mirtazapine 7.5 mg (1 tablet at bedtime) and Donepezil 10 mg (1 tablet at bedtime). Diagnosis include Alzheimer's disease. No schizophrenia diagnosis documented. The Nursing admission Progress note dated 10/15/2022 documented Resident #45 was diagnosed with Alzheimer's disease. The order history for the resident documented on 10/15/2022, 11/10/2022 Seroquel XR (Quetiapine) 150 mg extended release for Alzheimer's disease unspecified. 12/06/2022 Quetiapine 100mg for Alzheimer's disease unspecified. 12/12/2022 Quetiapine 50 mg for Alzheimer's disease unspecified. 12/15/2022 Quetiapine 50mg for unspecified psychosis not due to a substance not due to a substance or known physiological condition. The Psychiatry Assessment on 10/17/2022 documented resident initial psychiatry consultation and current psychotropic medication include Mirtazapine 7.5 mg at hour of sleep, Donepezil 10 mg in the evening and Seroquel XR in the evening. Documented mental status evaluation history of dementia, mood disorder. Documented depressed mood and no sign suggesting psychosis. Diagnosis includes Mood disorder and Alzheimer's disease by history. The MDS dated [DATE] documented Resident # 45 was cognitively intact and had diagnoses of Alzheimer's disease and dementia unspecified severity without behavior/psych/mood/anxiety. The Psychiatry Assessment on 11/2/2022 documented the current psychotropic medications included Mirtazapine 7.5 mg, Donepezil 10 mg and Seroquel 150 mg in the evening. Diagnosis included mood disorder and Alzheimer's disease by history. The psychiatrist recommended reducing Seroquel to 100 mg at hour of sleep and monitor the resident's mood and behavior. The Medical Progress note dated 11/14/2022, written by the Physician's Assistant (PA), documented a plan to reduce Resident #45's Seroquel from 150 mg (milligrams) to 100mg. The assessment and plan was to continue donepezil for Dementia and supportive care. The note documented Resident #45 had a diagnosis of Schiz, and Seroquel was reduced per psychiatry recommendations. There was no documented evidence the resident was diagnosed with Schizophrenia. The MDS dated [DATE] documented Resident #45 was cognitively intact with no documented delirium, no behaviors and diagnosis of Alzheimer's disease and unspecified mood disorder and schizophrenia unspecified. Psychiatrist Progress note on 1/13/2023 documented resident meds included Melatonin 3 mg orally at hour of sleep (HS), Mirtazapine 7.5 mg at HS, Donepezil 10 mg in the evening and Seroquel 50 mg in the evening. Documented Quetiapine was reduced on 11/9/2022 and 12/12/2022. Melatonin was started on 1/1/2023, and Mirtazapine started on 10/15/2022. Resident #45 had a history of Alzheimer's Dementia and Mood Disorder with no signs of psychosis. The plan was to continue current medication and montior the resident's mood and behavior. There was no documented evidence the resident was diagnosed with Schizophrenia. The Medical Progress note dated 01/23/2023 written by the PA, documented Dementia continue donepezil, supportive care. Schiz -Seroquel, Remeron, psych follow-up. Per review of the medical record the medical notes on 11/14/2022 and 1/23/2023 were written by the same PA. The MDS dated [DATE] documented Resident #45 was cognitively intact with no documented delirium, no behaviors and diagnosis of Alzheimer's disease unspecified, unspecified mood affective disorder, unspecified psychosis no due to a substance or known physiological condition and schizophrenia. During an interview on 04/07/2023 at 12:33PM, the Registered Nurse (RN # 3) stated Resident #45's diagnoses include mood disorder, psychosis and Alzheimer's dementia and sleep deprivation. Resident #45 does not have any diagnosis of Schizophrenia. During an interview on 04/07/2023 at 02:31PM, the MDS Assessor (MDSA #2) stated the diagnosis of Schizophrenia was documented in the PA medical notes dated 1/23/2023 and 11/14/2022 which are within the 60-day look back period. They added the diagnosis of Schizophrenia to the 1/23/23 MDS because Resident #45 was on Seroquel, had a diagnosis of unspecified psychosis, and Schizophrenia was written by two doctors in the medical record. After reviewing the admission documentation from the hospital and facility, MDSA #2 acknowledged Resident #45 was not admitted with a Schizophrenia diagnosis. MDSA #2 reviewed the psychiatry notes and acknowledged that Schizophrenia was not documented as a diagnosis for the resident. During an interview on 04/07/2023 at 02:31 PM, MDSA #3, who completed the 12/13/22 MDS, stated they added the diagnosis of Schizophrenia due to documentation in one medical note and the diagnosis of psychosis. MDSA #3 stated the diagnosis should be removed. The MDS should be accurate because it is important for the resident's care. On 04/11/2023 at 10:26AM, the Physician Assistant (PA) was interviewed and stated the resident mental health diagnosis includes mood disorder and Alzheimer's disease. Resident #45 has no other mental health disorders. They stated they reviewed psych notes and put down schizoaffective disorder. Schizoaffective related to mood disorder and schizophrenia has to do with behavior. Mood disorder and Alzheimer's are the resident's primary psychological diagnosis. On 04/07/2023 at 02:53PM, the Medical Doctor (MD) was interviewed and stated Resident #45 has mild Alzheimer's dementia, and the resident does not have Schizophrenia. On 04/11/2023 at 11:48AM, the Psychologist was interviewed and stated Resident #45 has adjustment disorder. The Psychologist stated they have niot seen Alzheimer's symptoms or cognitive impairment with Resident #45, and the resident does not have Shizophrenia or Schizoaffective disorder. On 04/07/2023 at 02:41PM, the MDS Coordinator was interviewed and stated to add a diagnois of Schizophrenia the assessor looks for the presence of psychotropic medications and the documentaiton of the diagnosis by two people. The MDS Assessor is responsible for checking accuracy, but is is not possible to check to make sure all assessments are accurate. The MDS should reflect the resident's current status, and phsycian't notes, history and physical, admission reords, and consults should be reviewed to complete the assessment. Based on observations, record reviews and interviews conducted during the Recertification/ Complaint Survey from 04/03/23 to 4/12/23, the facility did not ensure that residents' Minimum Data Set (MDS) assessments accurately reflect the residents' status. This was evident for 4 of 35 sampled residents (Resident #s 201, 45, 66, and 230). Specifically, (1) Resident #210's most recent MDS assessment did not reflect the resident used continuous oxygen; (2) The MDS incorrectly documented Resident #45 had a diagnosis of Schizophrenia; (3) The MDS documented Resident #66, who is legally blind, had no vision impiarment; (4) The MDS documented Resident #230, a resident with a wander alert device, had no wander alert device in use. The findings include but are not limited to: The facility policy titled MDS last reviewed 07/2017 documented interdisciplinary (IDT) members must verify the accuracy of assessment and the MDS is signed, certifying completion and accuracy. 1) Resident #210 had diagnoses which include Atrial Fibrillation (AFIB), Cerebrovascular Accident (CVA), and Dementia. The most Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented Resident #210 had severely impaired cognition. The MDS also documented oxygen therapy was not used. On 04/03/23 from 9:45 AM to 2:15 PM and 4/5/23 from 9:20 AM to 1:45 PM, Resident #210 was observed using continuous oxygen at a rate of 2 Liters (L) per minute. The Comprehensive Care Plan (CCP) for Respiratory Disorders dated 03/21/2023, last revised on 4/3/23, documented Resident #210 had acute respiratory failure, with hypoxia or hypercapnia. The interventions included to administer oxygen per physician order continuously at 2L per minute via nasal cannula. The Physician's order dated 12/15/22, last renewed on 3/14/23 documented orders for continuous oxygen via nasal cannula at 2 L/min. During an interview on 04/07/23 at 10:22 AM, the MDS Coordinator (MDSC) stated that their roles is to schedule the assessments and ensure they are submitted on time. The MDS Assessor is responsible for ensuring the accuracy of the assessment. Oxygen use should be included in the assessment, and it was an oversight. During an interview on 04/07/23 at 10:32 AM, the MDS Assessor (MDSA) sated they assess residents phyically and include any devices in use. The MDSA stated they knew Resident #210 was on oxygen but missed putting it on the MDS. It was an oversight.