Based on record review and interviews conducted during the recertification survey 5/9/23 to 5/16/23, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. This was evident for 2 (Resident #108 and #144) of 4 residents reviewed for Resident Assessment out of a sample size of 35 residents. Specifically, the MDS assessments for Resident #108 and #144 were not submitted and transmitted within 14 days of the completion date. The findings are: The CMS RAI Version 3.0 Manual (Dated October 2018), documented the MDS completion date must be no later than 14 days after the assessment reference date (ARD). Comprehensive assessments must be transmitted within 14 days of completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date. The MDS assessment for Resident #108 with ARD of 3/13/23, documented a completion date of 03/27/23 and a submission date of 05/15/23, more than 14 days after the completion date. The MDS assessment for Resident #144 with the ARD of 01/20/23, documented a completion date of 02/03/23 and submission date of 05/15/23, more than 14 days after completion date. On 05/16/23 at 03:09 PM, the MDS coordinator was interviewed and stated they work with another facility to submit the MDS assessments in batches to QIES. The MDS department has a plan to address assessment submissions. The MDS Coordinator stated they are aware there are concerns with timely MDS submissions. 415.11 (a)(1-5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #23 had diagnoses of schizophrenia and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #23 was cognitively intact and received antipsychotic medication 6 out of the 7 days prior to the assessment. The Antipsychotic Medication Review section (N0450) documented Resident #23 did not receive antipsychotic medication and did not document whether a GDR had been attempted. On 05/15/23 at 12:19 PM, Resident #23 was interviewed and stated they are currently receiving Risperidone and began receiving the medication prior to their admission to the facility. The Medical Doctor Order last renewed 4/28/23 documented Resident #23 should receive Risperidone 1mg at bedtime for paranoid schizophrenia. There was no documented evidence the MDS for Resident #23 included their accurate antipsychotic use and GDR status. On 05/16/23 at 12:39 PM, the MDS Coordinator (MDSC) was interviewed and stated they filled out the MDS for Resident #112 and stated it was a mistake to document that Resident #112 did not receive antipsychotic. They missed this question. No one else checks the MDS assessments for accuracy. These mistakes do not happen often. On 05/16/23 at 10:40 AM, the Psychiatrist was interviewed and stated Resident #23 receives Risperidone and a GDR was not attempted due to the resident's risk for decompensation. 415.11(b) Based on record review and interview conducted during the Recertification survey from 5/9/23 to 5/16/23, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments accurately reflected the resident's status. This was evident for 2 (Resident #112 and #23)of 35 sampled residents. Specifically, 1) the MDS assessment for Resident #112 did not document the resident's dialysis treatment, and 2) the MDS assessment for Resident #23 did not document the resident's Gradual Dose Reduction (GDR) status. The findings are: The facility policy titled Assessments, Comprehensive (Minimum Data Set 3.0) dated 8/2022 documented the MDS is inclusive to all pertinent issues for the resident. 1) Resident #112 had diagnoses of anemia and coronary artery disease. The MDS dated [DATE] documented Resident #112 was cognitively intact and did not receive dialysis. On 05/10/23 at 10:10 AM, Resident #112 was interviewed and stated they have been receiving dialysis continuously since 2019. The Comprehensive Care Plan (CCP) for Hemodialysis dated 06/14/2021 documented that Resident is on Hemodialysis. Physician's order dated 4/25/2023 documented Resident #112 received dialysis 3 times weekly. There was no documented evidence the MDS for Resident #112 included the resident's dialysis treatment. On 05/11/23 at 11:20 AM, an interview was conducted with the Registered Nurse Supervisor (RNS #1) who stated Resident #112 has been on dialysis since admission to the facility. On 05/11/23 at 11:30 AM, an interview was conducted with the MDS Coordinator (MDSC) who stated when documenting residents' MDS, they physically look at the resident and check the progress notes, physician's orders, and physician's notes. They always check the data input with the assessment documented to ensure that each portion of the assessment matches what they saw physically. Every team member that does the MDS assessment is responsible for checking accuracy after completion. The MDSC stated they check and sign for the completion before submission. Omission of dialysis treatment from Resident #112's MDS was human error that was just discovered and will be corrected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, conducted during the recertification survey from 5/9/23 to 5/16/23, the facility did not ensure a comprehensive care plan (CCP) was developed and implemented for each resident to meet the resident's medical needs identified in the comprehensive assessment. This was evident for 1 (Resident #23) of 35 total sampled resident. Specifically, Resident #23 did not have a CCP developed to address antibiotic therapy (ABT) use for a bacterial infection in their Arteriovenous graft (AVG). The findings are: The facility policy titled Comprehensive Care Plan dated 3/2023 documented the goals will address the resident's medical needs. Resident #23 had diagnoses of end stage renal disease (ESRD) and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #23 was cognitively intact and received dialysis treatment. On 05/15/23 at 12:19 PM, Resident #23 was interviewed and stated the Nephrologist at dialysis informed Resident #23 their AVG had a bacterial infection and the resident was placed on ABT. Resident #23 stated the nursing staff in the facility should know the resident is receiving ABT because the Hemodialysis Nurse (HDN) calls the facility nursing staff to update them. The Medical Doctor Order (MD) last renewed 4/28/23 did not document Resident #23 was receiving ABT. The Interfacility Situation-Background-Assessment-Recommendation (SBAR) Communication form dated 5/9/23 documented a pre-dialysis assessment of Resident #23 completed by the facility nurse. The post-dialysis section was completed by the HDN and documented Resident #23 had a AVG bacterial infection and received Vancomycin 1 gm intravenous (IV) drip at 1:45 PM. The Interfacility SBAR Communication form dated 5/11/23 and 5/13/23 documented Resident #23 received Vancomycin 1 gm IV at dialysis. The CCP related to ESRD and dialysis treatment for Resident #23, initiated 11/22/21 and last updated 3/7/23, documented to report abnormal labs to the Medical Doctor (MD) and administer medications as ordered. The CCP related to ESRD and AVG, initiated 11/22/21 and last updated 3/7/23, documented Resident #23 had no bleeding or infection at the AVG site. Documented interventions included monitoring Resident #23's AVG site daily for signs of infection. There was no documented evidence a CCP related to AVG bacterial infection and ABT were developed and implemented for Resident #23 once ABT was administered to the resident in dialysis. On 05/16/23 at 11:02 AM, Registered Nurse (RN) #1 was interviewed and stated Resident #23 does not have an infection and is not receiving ABT. After reviewing the Interfacility SBAR Communication form, RN #1 stated they did not receive a call from the HDN re: Resident #23's ABT and will have to get more information from the HDN, inform the MD, and document in the progress notes. Resident #23 is at risk for experiencing side effects on ABT and a CCP related to infection and ABT use would be developed by the RN. The dialysis unit and RN #1 communicate via the SBAR form but the if there are any special endorsements, the HDN calls the RN in the facility. On 05/16/23 at 11:21 AM, the Nurse Practitioner (NP) was interviewed and stated they communicate with the dialysis center re: and changes to Resident #23's medication regime. If Resident #23 had an infection and was receiving IV ABT, the dialysis center would call and communicate this to the NP. The dialysis center has not informed the NP Resident #23 is receiving IV ABT in dialysis. The NP and nursing staff would document and update the Resident #23's chart if they were aware the resident was receiving ABT. On 05/16/23 at 11:52 AM, the Director of Dialysis (DOD) was interviewed and stated the SBAR form was implemented to improve the communication between the dialysis center and the facility staff. The Nephrologist assessed Resident #23's AVG and it showed signs of infection. The Nephrologist ordered ABT for Resident #23 and the medication is being administered via IV when Resident #23 goes to dialysis. The facility staff are responsible for reviewing the SBAR form when the resident returns to the facility from dialysis to see if there are any changes to the resident's condition or treatment. On 05/16/23 at 01:42 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated the nurse on the unit is supposed to check the SBAR form from dialysis. The HDN is supposed to call the RN in addition to documenting ABT use on the SBAR form. Then the RN should document the ABT and inform the MD. Staff need to monitor for adverse reactions to ABT and this would be included in a CCP to address infection. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #23 had diagnoses of schizophrenia and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #23 was cognitively intact, had little interest or pleasure in doing things and felt down and depressed. Resident #23 also received an antidepressant. On 05/15/23 at 12:19 PM, Resident #23 was interviewed and stated they receive Zoloft and Risperidone to treat their depression. Resident #23 also sees the psychiatrist. The Medical Doctor Order (MDO), last renewed 4/28/23, documented Resident #23 was ordered to receive Sertraline 150mg daily for depression and Risperidone 1 mg for paranoid schizophrenia. The psychiatry consult dated 5/6/23 documented Resident #23 has periods of agitation and needs help and support. The CCP related to mood stated initiated 11/11/21 documented Resident #23 was withdrawn, sad, tearful, sleepless, and restless. The CCP was last updated 2/17/22 with an evaluation that Resident #23 sees the psychiatrist and is cooperative with care. There was no documented evidence the CCP related to Resident #23's mood was reviewed and revised upon MDS assessments dated 10/29/22, 12/5/22, and 3/7/23. On 05/16/23 at 11:02 AM, Registered Nurse (RN) #1 was interviewed and stated Resident #23 has periods of agitation that have improved but the resident still randomly gets upset and irritated. The resident is seen by psychiatry and receives Risperdal and Zoloft. On 05/16/23 at 11:21 AM, the Nurse Practitioner was interviewed and stated Resident #23 was admitted to the facility on Zoloft and Risperdal, and they had a history of attempting suicide. Resident #23 is currently stable with no suicidal ideation. On 05/16/23 at 12:28 PM, the Director of Social Service (DSS) was interviewed and stated the social workers are responsible for initiating and updating the CCP related to mood. After reviewing Resident #23's CCP related to mood, the DSS stated the CCP should have been updated to include quarterly evaluations and MDS assessments. The social work department tries their best, but sometimes they miss something. They perform audits of their documentation. 415.11(c) (1) Based on observations, record review, and interviews conducted during the Recertification survey from 5/9/23 to 5/16/23, the facility did not ensure that a resident participated in the review of their Comprehensive Care Plan (CCP, and a resident's CCP was not reviewed and revised upon each assessment. This was evident for 2 (Resident #112 and #23) of 35 total sampled residents. Specifically, 1) Resident #112 was not invited to attend CCP meetings to discuss their plan of care, and 2) Resident #23's CCP related to mood was not reviewed and revised upon each Minimum Data Set 3.0 (MDS) assessment. The findings are: The facility policy titled CCP dated 3/2023 documented the goals will address the resident's medical needs. 1) Resident #112 had diagnoses of Coronary Artery Disease (CAD) and end stage renal disease (ESRD). The MDS dated [DATE] documented that Resident #112 has intact cognitive status. On 05/10/23 at 10:08 AM, Resident #112 was interviewed and stated that they have been in the facility since 2021, and they have never been invited to any care plan meetings. Notice of Quarterly Meeting from 06/21/2021 to 04/17/23 did not document Resident #112 was invited to CCP meetings. Care Plan Meetings attendance dated 12/19/2022, 1/16/2023, and 4/17/2023 did not document Resident #112's attendance. There was no documented evidence Resident #112 was invited to their scheduled CCP meetings on 12/19/22, 1/16/23, and 4/7/23. On 05/11/23 at 11:20 AM, an interview was conducted with the Registered Nurse (RN) #1 who stated CCP meetings are held upon a resident's admission, quarterly and annually. Residents are invited to all the CCP meeting by the social services ahead of time. RN #1 does not recall seeing Resident #112 attend the CCP meetings. On 05/11/23 at 11:50 AM, the Director of Social Services (DSS) was interviewed and stated they send CCP invite letters to the families, and the recreation department helps with delivering the notices to the alert residents on the units. The DSS stated there was no documented evidence a CCP invitation was provided to Resident #112 and no documented evidence the resident attended CCP meetings.