**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, staff and Medical Director interviews, the facility failed to protect a resident's right to be free from resident-to-resident abuse when Resident #2 hit Resident #1 with a grabber-reacher tool (a tool that assists people reach something to pick it up) multiple times on the right hand, injuring his right 4th digit fingernail. This affected 1 of 4 residents reviewed for abuse (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis that included multiple sclerosis, psychosis, anxiety disorder and mood disorder due to known physiological condition. Resident #1's Minimum Data Set (MDS), dated [DATE], revealed he was cognitively intact and had no behaviors. He had impairment on both sides of his upper and lower extremities and was dependent on staff for his activities of daily living and independently operated his manual wheelchair. Resident #1's care plan, last revised 01/02/25, indicated Resident #1 had been care planned for manipulative behaviors and physical and verbal aggression towards staff and other residents related to his anger and poor impulse control. Interventions included education to the resident on the importance of avoiding known triggers that could lead to the escalation of retaliatory physical aggression towards other residents, or by other residents to himself. Resident #2 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder and dementia without behavioral disturbance. Resident #2's quarterly MDS, dated [DATE], revealed he was cognitively intact and had no behaviors. He had impairment on one side of his lower extremities, was dependent on staff for bed to chair transfers, and independently operated a manual wheelchair. Resident #2's care plan, last revised 02/18/25, revealed Resident #2 had been care planned for his potential to be physically and verbally aggressive with staff and other residents and making false statements/accusations related to anger and poor impulse control. Interventions included de-escalation of the resident's physical and verbal aggression towards staff and other residents to ensure safety. An Initial Allegation Report for resident-to-resident abuse was completed on 03/11/25 after Resident #2 struck Resident #1 with a grabber-reacher tool and resulted in Resident #1 sustaining an injury to his right 4th digit fingernail. Notifications were made to the local law enforcement agency and to the State Agency on 03/11/25. A Progress Notes note written by Nurse #1 on 03/11/25 at 5:45 PM. in Resident #1's medical record detailed the altercation on 03/11/25 (no time noted) between Resident #1 and Resident #2. The nurse wrote that Resident #2 had been observed by another resident (Resident #6) striking Resident #1 with his reacher-grabber tool which caused injury to Resident #1's right 4th digit fingernail. The nurse indicated that wound care had been provided to Resident #1's finger and stated that a local law enforcement officer came to the facility and took statements from residents involved in the altercation as well as statements from witnesses of the incident. A Progress Note written by Nurse #4 on 03/11/25 at 6:18 PM in Resident #2's Medical Record detailed the 03/11/25 altercation between Resident #2 and Resident #1. The nurse stated Resident #2 said he had been in his room, watching television, when Resident #1 went into his room and started talking s**t to him and told him (Resident #2) that he (Resident #1) was going to f**k him up and that Resident #1 had swung at him. The nurse wrote that Resident #2 told her he had defended himself by hitting Resident #1 with his reacher-grabber tool. The Investigation Report, submitted on 03/14/25 by the Administrator, indicated she substantiated the allegation of resident-to-resident abuse after the investigation concluded. A summary of the incident details included, .All witness statement support incident occurring in hallway outside of [Resident #2's] room. Blood was noted on the floor in the hallway. [Resident #2] continued to state throughout the investigation that [Resident #1] kicked open his door, busted into his room, and asked him if he wanted to fight. None of the witness statements support this. [Resident #1] was in sight of staff in the hallway where they witnessed [Resident #2] hitting him with the reacher . The local law enforcement officer's Incident/Investigation Report, dated 03/11/25, indicated he had been dispatched to the facility and once there, took statements from Resident #1, Resident #2 and witnesses to the altercation. The officer reported Resident #1 informed him he had approached Resident #2 and told him he had a big head and then Resident #2 told him that he had a big head and then Resident #2 began to swing a reacher-grabber tool, hitting him (Resident #1) in his knee and cut his finger with the tool. The officer then spoke with Resident #2 who informed him that Resident #1 always called him names and threatened him. Resident #2 told the officer that Resident #1 had entered his room and told him that he was going to mess him up so he began to hit Resident #1 because he had been scared for his safety. The report indicated the officer also took a statement from Resident #6 who had informed the officer he had observed both of the residents talking in the hallway before Resident #2 hit Resident #1 with his reacher-grabber tool. The officer acknowledged in his report that he had closed the report as closed by exception, victim refused to cooperate. An interview was conducted with Resident #6 on 04/02/25 at 12:58 PM. Resident #6 was coded as being cognitively intact on his 02/01/25 quarterly MDS. Resident #6 explained that on 03/11/25 he had observed Resident #1 in his wheelchair approach Resident #2 who had been sitting in his wheelchair outside of his room in the hall and in front of the doorway to Resident #2's room. As he continued to observe the two residents, Resident #6 described how Nurse #2 approached him as he sat in the hall and said he pointed to the two residents (Residents #1 and Resident #2) in the hall. He said Nurse #2 walked towards both of the residents and then the next thing he (Resident #6) knew, Resident #2 swung his reacher-grabber tool and struck Resident #1 with it and observed Resident #1 swinging his arms. Resident #6 indicated he thought Resident #1 had done that in self-defense from Resident #2. Resident #6 indicated that he did not hear any of the conversation between the two residents but could hear Resident #1 hollering. An interview was conducted with Nurse #2 on 04/02/25 at 2:55 PM. Nurse #2 confirmed she had worked from 3:00 PM until 11:00 PM on 03/11/25. Nurse #2 stated she had been walking down the Skilled A and B hall when Resident #6 stopped her and said, hey, they're fighting and pointed towards Resident #1 and Resident #2. She stated she looked in the direction of the two residents who were outside of Resident #2's doorway, in the hall. Nurse #2 explained Resident #1 was observed sitting in his wheelchair and facing Resident #2 who had been sitting in his wheelchair in the hallway, outside of his room's doorway. Nurse #2 further explained she immediately began walking towards the two residents and before she could get to them, Resident #2 began hitting Resident #1 with his reacher-grabber tool and that Resident #1 was observed trying to back up, holding his arms in a way to deflect the blows. Nurse #2 stated by the time she reached the residents, Resident #2 struck Resident #1 three to four more times with his reacher-grabber tool. She explained she pulled Resident #1's wheelchair away from Resident #2 and started to take him to his room when she noticed he was bleeding from his finger. Nurse #2 explained Resident #1's nurse provided treatment to his injured finger. Nurse #2 stated she did not know how the argument had started. Nurse #2 stated she provided a statement to the local law enforcement officer when he arrived at the facility. When asked about the residents' level of care required to perform their activities of daily living (ADL), the nurse stated Resident #1 was totally dependent on staff for his ADL and stated Resident #2 required extensive assistance with his ADL. She stated both of the residents were able to operate their wheelchairs independently after being placed in the wheelchairs using a mechanical lift. Nurse #2 confirmed both residents were alert, oriented and able to make their needs known. She stated both residents were known to be argumentative with each other, as well as with other residents and staff. An observation and interview were conducted with Resident #1 on 04/02/25 at 10:27 AM. Resident #1 explained that on 03/11/25, around 4:00 PM, he had started rolling down the hall in his wheelchair to visit another resident. Resident #1 further explained he rolled up to Resident #2 who had been sitting in his wheelchair in the hall, outside the door to his room, and told him, you have a big head. Resident #2 responded by saying to him, you have a big head. Resident #1 then asked Resident #2 if he wanted to fight and stated Resident #2 said no. Resident #1 stated Resident #2 then grabbed his reacher and started hitting him with it and he had tried to block Resident #2's blows with his arms. When asked about his relationship with Resident #2, Resident #1 declared that he did not like Resident #2 because he always starts trouble and that he had never liked him. When asked how he felt after being hit by Resident #2, Resident #1 said, I ain't scared of that boy. When asked about the injury he sustained during the incident, Resident #1 held up the fingers on his right hand and said they were fine and could not remember which finger had been injured. An observation of the fingers on his right hand revealed no outward signs of a healing/healed injury to any of the fingers on his right hand. An interview was conducted with Resident #2 on 04/01/25 at 3:10 PM. Resident #2 was observed sitting in his wheelchair in his room. Also present at this time was Nursing Assistant #2 who was providing a one-to-one observation. Resident #2 acknowledged he did not like Resident #1 and said that Resident #1 had told him that he hated white people. Resident #2 explained that on 03/11/25, at some time in the late afternoon, he had been napping while seated in his wheelchair in front of the TV in his room. He said Resident #1 kicked his door in, came into his room and began to fight with him. Resident #2 stated Resident #1 did not say anything to him and remained adamant he had struck Resident #1 with his grabber-reacher tool as a means of self-defense. When Resident #2 was informed that witness accounts of the incident placed both residents out in the hallway, Resident #2 maintained his story that Resident #1 kicked the door to his room open, entered the room and began to fight with him. Resident #2 stated he had witnesses that saw this and said to talk with Nursing Assistant (NA) #1. Resident #2 indicated that he was not afraid of Resident #1 and he had just been trying to protect himself after Resident #1 came into his room. An interview was conducted with NA #1 on 04/02/25 at 3:23 PM. NA #1 confirmed that she had worked from 3:00 PM until 11:00 PM on 03/11/25. NA #1 explained she had been walking towards the Nurses' Station on the Skilled A and B halls when she observed Resident #1 rolling down the hall in his wheelchair and headed towards where Resident #2 was seated in his wheelchair, outside of the doorway to his room. She thought Resident #1 would go on past Resident #2 but then she observed Resident #1 stop and begin to roll backwards, towards Resident #2. NA #1 stated she knew the two of these residents did not get along and started walking towards the two of them to prevent an altercation. Before she could get to them, she said she observed Resident #2 grab his reacher-grabber and swing at and strike Resident #1. NA #1 stated by the time she got to them, Nurse #2 had also arrived and explained that between the two of them, they got the two residents separated. As Nurse #2 pushed Resident #1 to his room, NA #1 said she told Resident #2 that he could not hit people and said he (Resident #2) told her that he could not help it because Resident #1 had told him he was going to beat his a**. She stated she then observed some blood on one of Resident #2's hand, assumed it had been from the altercation, and left him to inform a nurse. At the Nurses' Station, she spoke with the Unit Manager, Nurse #3. An interview was conducted with Nurse #3, on 04/02/25 at 1:45 PM. Nurse #3 confirmed that she was the Unit Manager for the Skilled A and B halls. Nurse #3 explained on 03/11/25 she became aware of the incident between Resident #1 and Resident #2 when she came out of her office located behind the Nurses' Station desk and heard yelling down the hall. Nurse #3 stated when she looked towards the commotion, she saw both residents in the hall, outside of Resident #2's room. She explained she observed Resident #2 swat Resident #1 repeatedly with his grabber-reacher as Resident #1 was trying to shield himself from the blows. She explained that Resident #1 did not have full control of his upper extremities because of his medical diagnosis. She described that Resident #1 sat in a semi-reclined position in his wheelchair and how he would not have been able to hit Resident #2 in retaliation if he wanted to. Nurse #3 described both residents as alert and oriented and stated how neither of them could get up out of their beds without the total assistance of staff using a mechanical lift to do so. She said that Resident #1 often rolled himself via wheelchair to other areas of the facility and enjoyed visiting with other residents and went to therapy and activities, all of which were located past Resident #2's room. Nurse #3 described Resident #2 as more stationary and said he often sat outside of the door to his room or outside in the smoking courtyard. Nurse #3 said Resident #2 had been known to make racist or disrespectful remarks to other residents and staff and would often not tell the truth when asked about incidents he may have been involved in. She also said that while Resident #2 hit Resident #1 during this incident, Resident #1 could be the instigator during arguments with residents and staff and stated that he sometimes feeds off being the victim as well and that he was not always truthful. Nurse #3 indicated that Resident #2's reacher-grabber tool had been removed from him by the Human Resources Director and he (Resident #2) had been placed on a one-to-one observation while out of his bed for his safety as well as the safety of other residents. An interview was conducted with the Human Resources Director on 04/02/25 at 2:39 PM. The Human Resources Director confirmed she had worked on 03/11/25 and stated the incident between Resident #1 and Resident #2 had occurred just prior to her clocking out for the day around 5:30 PM. The Human Resources Director stated after she clocked out and started walking back to her office, she heard Nurse #3 say, Oh my God, Resident #2 is hitting Resident #1. The Human Resources Director explained that she did not see the interaction between the two residents. She said she told Nurse #3 that someone needed to get Resident #2's reacher-grabber tool away from him. She stated she walked down to his (Resident #2's) room and asked him to let her have it. She stated that before he gave it to her, he told her, he started it. The Human Resources Director said she removed the grabber-reacher without incident and told him to stay in his room until everything got sorted out. An interview was conducted with the facility's Medical Director on 04/03/25 at 9:25 AM. The Medical Director explained he had been made aware of the 03/11/25 incident that involved Resident #1 and Resident #2. After talking with the residents, he felt that Resident #1 was the instigator of this incident, and Resident #2 the aggressor. He further explained that both residents lacked the appropriate coping mechanisms for handling a situation when anger and aggression were triggered. He stated Resident #2 had very little threshold for controlling his anger and impulsivity, and he believed Resident #2 was not a danger to himself or others provided he remain on the one-to-one observation. The Medical Director stated it was his expectation the facility provide a safe environment for all the residents who reside there and thought as long as Resident #2 remained on a one-to-one observation when he was out of his bed, that the facility was providing that safe environment. An interview with the Administrator was conducted on 04/03/25 at 10:54 AM. The Administrator stated that since the incident between Resident #1 and Resident #2 on 03/11/25, Resident #2 remained on a one-to-one observation until he went to bed at night. She explained that Resident #2 could not get out of bed by himself and therefore the one-to-one observation was not continued while he was in bed. She explained nursing staff did safety checks of him every 15 minutes. The Administrator further explained staff would continue to monitor Resident #1 and would assist him past Resident #2's room when he wanted to visit friends or attend therapy or activities, all of which were located past Resident #2's room. When asked how she thought this incident might have occurred, the Administrator stated no one could really say. She explained Resident #1 told her that he had planned on visiting his friend who resided across the hall from Resident #2, and she believed Resident #2 had been waiting in his doorway to confront Resident #1 because he thought he (Resident #1) was out to get him. The Administrator stated they tried to keep Resident #1 from any opportunity for him to antagonize Resident #2 as well as trying to keep him safe from Resident #2's aggression. The Administrator explained she put a Plan of Correction (POC) in place after meeting with her Interdisciplinary Team and provided a copy of it for consideration. She stated monitoring for this POC included keeping Resident #2 on a one-to-one observation for the duration of his stay at the facility and it would be reviewed in their monthly Quality Assurance and Performance Improvement (QAPI) meetings. The Administrator explained she did not include a facility-wide in-service training on their Abuse policy as she felt strongly it did not occur because of staff error. She also felt the staff executed their Abuse policy and procedures as they should have after the incident occurred. The Administrator explained she had issued Resident #2 a 30-day notice of discharge on [DATE] and discussed the incident between the two residents at an Ad Hoc QAPI meeting on 03/11/25. She had plans to continue to bring the situation to their monthly QAPI meetings until a safe discharge location for Resident #2 could be arranged. The facility provided a corrective action plan that was not acceptable to the State Agency as it did not include the following required components: address how the facility will identify other residents having the potential to be affected by the same deficient practice; address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; and indicate how the facility plans to monitor its performance to make sure that solutions are sustained.

Based on observations and staff interviews, the facility failed to label and date resident's personal food items and discard expired food items stored in 1 of 1 nourishment refrigerator. This practice had the potential to cause foodborne illnesses. Findings included: An observation of the nourishment refrigerator with the facility's Dietary Manager on 3/4/25 at 1:28 PM revealed the following: a. 2 yogurt cups with the expiration date of 12/31/24 b. A Ranch dressing bottle with the expiration date of 1/20/25 c. Partially eaten chicken wings and corn on the cob in a disposable plate with no date or label d. A 2-liter soda bottle approximately two thirds full with no label or date e. A plastic bottle with orange colored liquid with no label or date The Dietary Manager, who was present during the observation, stated that nursing staff were supposed to ensure the food items were labeled and dated and that expired items were discarded. An interview was conducted on 3/4/25 at 1:30 PM with the Assistant Director of Nursing (ADON) when she came into the nourishment room and placed the food items in the trash can. The ADON stated that nursing staff should have labeled and dated the food items before placing them in the refrigerator and discarded any expired food items. An interview was conducted with the facility Administrator on 3/4/25 at 2:14 PM. The Administrator stated that if there were any expired food items they should have been thrown out and all foods should have been labeled and dated before being placed in the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to maintain dignity for a resident with an uncovered urinary drainage bag, with urine visible for public view from the hallway. The reasonable person concept was applied as individuals have the expectation of being treated with dignity and would not want their urine visible to visitors, staff, and other residents, for 1 of 2 residents reviewed for dignity (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses including unspecified intellectual disabilities, mental disorder. The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #27 coded as moderately cognitively impaired was incontinent of bowel and bladder and had a foley catheter. The care plan dated 12/08/2023 had focus' of the residents impaired cognitive function or impaired thought processes and had a foley catheter in place. The interventions included to position catheter bag and tubing below the level of the bladder and away from the entrance room door. An observation of Resident #27 occurred on 02/26/2024 at 11:47 AM. Resident #27 was observed in his room, in Geri chair, in front of the door, with his urinary drainage bag uncovered and visible from the hallway with light amber urine noted. An observation of Resident #27 occurred on 02/26/24 01:48 PM. Resident #27 was observed in his room, in Geri chair, in front of the door, with his urinary drainage bag uncovered and visible from the hallway with light amber urine noted. An observation of Resident #27 occurred on 02/26/24 03:07 PM. Resident #27 was observed in his room, in Geri chair, in front of the door, with his urinary drainage bag uncovered and visible from the hallway with light amber urine noted. An interview with Nursing Assistant (NA) #1 was conducted on 02/27/2024 at 3:02 PM. The NA stated she was the aide for Resident #27 that day and was aware he had a foley catheter. The Aide stated the foley bag should have been covered. The Aide stated she did not know why it wasn't covered but reported it to the nurse earlier that shift. The aide also stated she would get something to cover his foley drainage bag. An interview with Nurse #1 was conducted on 02/27/2024 at 3:07 PM. The Nurse stated the foley bag should have a cover over it or placed out of site to avoid dignity issues. The Nurse also stated she would get a new bag with a cover. An interview with the Director of Nursing (DON) was conducted on 02/27/2024 at 3:14 PM. The DON stated the residents' foley bags should be covered to avoid any dignity issues. The DON also stated the Residents foley bag is usually away from the door and out of site.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, the facility failed to keep a catheter drainage bag from touching the floor to reduce the risk of infection for 1 of 2 sampled resident reviewed for the use of a urinary catheter (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses including unspecified intellectual disabilities, mental disorder. The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #27 coded as moderately cognitively impaired was incontinent of bowel and bladder and had a foley catheter. The care plan dated 12/08/2023 had focus' of the residents impaired cognitive function or impaired thought processes and had a foley catheter in place. The interventions included to position catheter bag and tubing below the level of the bladder and away from the entrance room door. A review of the urology report dated 07/14/2022 revealed Resident #27 had a diagnosis of urinary retention with urinary tract infections (UTI) episodes and likely secondary to not completely emptying bladder. An observation of Resident #27 occurred on 02/26/2024 at 11:47 AM. Resident #27 was observed in his room, in Geri chair, in front of the door, with his urinary drainage bag visible from the hallway. The catheter drainage bag was positioned on the floor. An observation of Resident #27 occurred on 02/26/24 01:48 PM. Resident #27 was observed in his room, in Geri chair, in front of the door, with his urinary drainage bag visible from the hallway. The catheter drainage bag was positioned on the floor. An observation of Resident #27 occurred on 02/26/24 03:07 PM. Resident #27 was observed in his room, in Geri chair, in front of the door, with his urinary drainage bag visible from the hallway. The catheter drainage bag was positioned on the floor. An interview with Nursing Assistant (NA) #1 was conducted on 02/27/2024 at 3:02 PM. The NA stated she was the aide for Resident #27 that day and was aware he had a foley catheter. The NA stated the foley bag should not have been touching the floor and she would adjust the drainage bag. An interview with Nurse #1 was conducted on 02/27/2024 at 3:07 PM. The Nurse stated the foley bag is usually on the side of the chair and off the floor and did not understand why it was on the floor. The Nurse also stated she had not noticed the bag on the floor that shift when she cared for the resident. An interview with the Director of Nursing (DON) was conducted on 02/27/2024 at 3:14 PM. The DON stated the residents' foley bags should be positioned off the floor to avoid any infection control issues. The DON also stated the Residents foley bag is usually away from the door, out of site and off the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff and physician interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 2 residents reviewed for respiratory care (Resident #15). The findings included: Resident #15 was initially admitted to the facility on [DATE] with the last readmission on [DATE]. Her diagnoses included chronic obstructive pulmonary disease and heart failure. Resident #15's care plan initiated 2/25/23 indicated Resident #15 was on oxygen therapy related to congestive heart failure. Interventions included oxygen at 2 liters per minute via nasal cannula. A Physician's order dated 9/18/23 indicated administer oxygen at 2 liters/minute via nasal cannula for oxygen saturations less than 90%. Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was cognitively intact and received oxygen therapy. Diagnoses included heart failure and chronic obstructive pulmonary disease. During observation on 2/26/24 at 10:23 AM Resident #15 was observed with the oxygen nasal canula. Resident #15's oxygen regulator on the concentrator was set at 3.5 liters/minute when viewed horizontally at eye level. During observation on 2/26/24 at 12:24 PM Resident #15 was observed with the oxygen nasal canula. Resident #15's oxygen regulator on the concentrator was set at 3.5 liters/minute when viewed horizontally at eye level. During observation on 2/26/24 at 2:07 PM Resident #15 was observed with the oxygen nasal canula. Resident #15's oxygen regulator on the concentrator was set at 3.5 liters/minute when viewed horizontally at eye level. Resident #15's oxygen regulator was verified with the Staff Development Coordinator (SDC) to be set at 3.5 liters/minute. During an interview on 2/26/24 at 2:07 PM with the SDC, she stated Resident #15 had a physician order for oxygen at 2 liters/minute via nasal cannula for oxygen saturations less than 90% and oxygen regulator should have been set at the physician ' s ordered rate. During an interview on 2/26/24 at 3:00 PM with Nurse #1, she stated Resident #15 had a physician order for oxygen at 2 liters/minute via nasal cannula for oxygen saturations less than 90%. Nurse #1 stated she had not checked Resident #15 ' s oxygen regulator since she started her shift at 7:00 AM. She verbalized she should have checked the regulator earlier when she went to check on Resident #15 and ensured it was set at the physician ' s ordered rate. During an interview on 2/28/24 at 2:34 PM with facility Administrator she stated nurses were supposed to check the oxygen concentrator to make sure it was set at the doctor's ordered rate. An interview was conducted on 2/28/24 at 2:49 PM with the Director of nursing (DON). The DON explained Nurse #1 Nurse should have checked the oxygen concentrator upon entering Resident #15's room during earlier medication administration and assessment to ensure it was set per the doctor's orders. She verbalized nurses were to follow physician ' s orders and obtain another order if they needed to titrate the oxygen rate. An interview was conducted on 2/29/24 at 11:10 AM with the facility Physician. He stated Resident #15 was a hospice patient and was receiving oxygen for comfort. The Physician stated nursing staff were to follow physician orders as given and to call the physician if they needed to titrate the oxygen rate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #38 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety disorder, bipolar disorder, and major depressive disorder. Record review indicated Resident #38 had a Preadmission Screening and Resident Review (PASRR) Level II Determination Notification dated 6/20/22. The significant change Minimum Data Set (MDS) assessment dated [DATE] was answered No to question A1500 which asked if Resident #38 had been evaluated by a level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition. The Minimum Data Set Nurse responsible for completion was not available for an interview during the survey. An interview was conducted on 12/13/22 at 12:24 PM with the Administrator. The Administrator explained she completed the PASRR for the residents at the facility; however, the MDS nurse had failed to complete the coding on the Significant Change MDS dated [DATE]. The Administrator stated the MDS coding should have been completed for Resident #38 PASRR Level II and she did not know why it was not done. Based on record review and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of Preadmission Screening and Resident Review (PASRR) Level II for 2 of 2 residents (Resident #19 and Resident # 38) reviewed for PASRR. Findings included: 1. Resident #19 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety disorder, bipolar disorder, and major depressive disorder. Record review indicated Resident #19 had a Preadmission Screening and Resident Review (PASRR) Level II Determination Notification dated 11/10/2021. The Annual Minimum Data Set (MDS) assessment dated [DATE] was answered No to question A1500 which asked if Resident #19 had been evaluated by a level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition. The Minimum Data Set Nurse responsible for completion was not available for an interview during the survey. During an interview on 12/15/2022 at 11:32 AM, Administrator stated she was responsible for completing the PASRR for the residents at the facility. She indicated Resident#19 had PASRR level II since 11/10/2021 and the MDS should have been coded. The Administrator indicated the MDS nurse failed to code the Annual MDS dated [DATE] to reflect Resident#19 had PASRR level II. She stated she did not know the reason the MDS nurse failed to code the MDS.

Based on staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the 10/28/2021 recertification survey. This was for a recited deficiency on the current recertification survey in accuracy of assessments. The continued failure during two federal surveys shows a pattern of the facility's inability to sustain an effective QAA program. Findings included: This tag is cross referenced to: F641: Based on record review and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in Preadmission Screening and Resident Review (PASRR) Level II for 2 of 2 residents (Resident #19 and Resident # 38) reviewed for PASRR. During the recertification survey of 10/28/2021, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of level II Preadmission Screening and Resident Review (PASRR). During an interview on 12/15/22 at 11:10 AM, the Administrator revealed the QAA committee meets monthly to discuss identified issues in the facility. She indicated PASRR level II was not discussed recently in the QAA meetings since she was not aware that the facility had concerns with coding PASRR level II accurately in the MDS.