Based on record review and staff interview, the facility failed to electronically submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for quarter 3 of federal fiscal year (FY) 2024 (April 1 through June 30, 2024). This failure occurred for 1 of 4 quarters reviewed. The findings included: Review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database revealed the facility failed to submit the required PBJ Staffing Data for the third quarter of federal FY 2024. The PBJ Staffing Data for the third quarter of the federal FY 2024 was blank. An interview with the Administrator on 03/11/2025 at 4:04 PM revealed she was aware the PBJ data for the third quarter of federal FY 2024 had not been submitted. The Administrator stated she attempted to submit the PBJ data on 08/13/2024. The Administrator stated each time she attempted to submit the PBJ data she received an error reading. The PBJ data was rejected each time. As a result, an error notification was displayed with each PBJ data submission attempt. The Administrator was not able to submit the PBJ data before the deadline of 08/14/2024. A follow-up interview on 03/12/2025 at 9:28 AM revealed the Administrator contacted the Quality Improvement and Evaluation System (QIES) help desk 09/26/2024 and was able to resubmit the PBJ data without error the fourth quarter of the federal FY 2024 on 11/14/2024. The Administrator verbalized she was educated by CMS support on how to run a PBJ Finale File Validation Report (FFVR) to verify PBJ data submissions. The facility provided the following corrective action plan with a completion date of 11/14/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility failed to submit the required Payroll Based Journal (PBJ) Staffing Data for the third quarter of the federal fiscal year 2024. The PBJ Staffing Data for the third quarter of federal FY 2024 was blank. No residents were affected by the 3rd quarter PBJ staffing submission rejection. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. The root cause of the error in submission was the format of the zip file. The file was created but did not contain the data. Upon review by the Administrator in facility quarterly QAPI star rating reviews, the PBJ Staffing Data for the 1st and 2nd quarter of federal fiscal year 2024 were submitted correctly. The 3rd quarter PBJ data was submitted by the Administrator on August 13, 2024, however rejected and not resubmitted because on 9/26/24, CMS support indicated it would not be used if submitted past the due date. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. CMS support educated Administrator on reports to run in QIES-CASPER to verify that submissions are accepted on 09/26/2024. The report is the PBJ Final File Validation Report (FFVR). Monthly reviews of PBJ report accuracy began in September 2024. PBJ preview reports are run in our scheduling/time clock system (OnShift) and reviewed for accuracy of the data and for file format by the Administrator. The goal is for these reviews to be completed by the 15th of the following month. PBJ staffing data is now reviewed monthly for completeness and accuracy by the Administrator and verified by the Staffing Coordinator. The file format review is an addition since this was a new problem with that submission and is completed by the Administrator. The Administrator is responsible for submitting the PBJ data. Moving forward, quarterly submissions of PBJ data will be completed 30 days after the completion of the fiscal quarter, which is 15 days prior to the deadline. This allows for correction of errors if the file is rejected. This will begin with the submission for the second quarter of fiscal year 2025. For 4th quarter PBJ data for federal fiscal year 2024, the data was submitted on 11/13/2024 initially and errors were found with the submission. The error notification was found by running the FFVR report in CASPER. The QIES help desk technician was able to assist on the afternoon of 11/13/2024 with the file submission and it was accepted on 11/14/2024 and verified accepted using the FFVR report in CASPER. The QIES help desk technician was able to help identify the file format issue and the Administrator was then able to make the correction. It was a compression issue which was corrected by creating the file and then converting it to a zip file outside of our staffing software (OnShift). Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Care Compare star rating data is routinely reviewed as part of our quarterly QAPI program and items identified as needing improvement addressed through an improvement process. The Staffing piece is reviewed and is directly related to the quarterly PBJ staffing submissions. This has been a part of our QAPI program since March of 2023. Beginning in September of 2024, the Administrator completes monthly reviews of the PBJ submission data for accuracy and correct file format along with the Staffing Coordinator by the 15th of the following month. It is recorded as complete on a spreadsheet once finished. This continues monthly indefinitely. There have been no issues identified with monthly reviews of staffing data or file format since the submission on November 14, 2024, and the submission of the PBJ data for the 4th quarter of federal fiscal year 2024 was successful, and the next submission is due May 1, 2025. The submission and accuracy audits will be done monthly, and audited records will be reviewed by the Risk Management/Quality Assurance Committee at our quarterly QAPI meeting. The first QAPI review that included the submission failure and subsequent corrections was 2/19/2025. The deadline for the next submission is May 15, 2025, but the facility plans to submit on May 1, 2025, so there is an opportunity to correct any errors. The audits by the Administrator and the Staffing Coordinator are completed monthly. PBJ submissions will be reviewed indefinitely at future QAPI meetings and presented by the Administrator. Corrective action completion date: 11/14/2024. The corrective action plan was validated on 3/12/2025 and concluded the facility implemented an acceptable corrective action plan. Interviews conducted with the Administrator revealed there had been no further noncompliance with the submission of PBJ data. Review of PBJ for the 4th fiscal quarter revealed compliance. The completion date of 11/14/2024 for the corrective action plan was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and staff resident interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Residents #64). The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia, vascular dementia, and hypertension. Resident #64's admission summary dated [DATE] indicated he had cognitive impairment and was using oxygen. A review of the physician orders for Resident #64 indicated an order dated 01/05/24 to apply 2 liters of oxygen for shortness of breath or for oxygen saturations of 90% or less as needed for shortness of breath. Resident #64's care plan dated 01/08/24 indicated a focus area of Resident #64 had oxygen therapy related to congestive heart failure and respiratory illness. The goal indicated Resident #64 would have no signs or symptoms of poor oxygen absorption through the review date. Interventions included, in part, oxygen settings were to be at 2 liters continuously via nasal cannula. Resident #31's oxygen saturations were documented in his Electronic Medical Chart as followed: 01/08/24 at 6:24 PM - 98% via nasal cannula 01/09/24 at 9:48 AM - 96% via nasal cannula 01/09/24 at 7:45 PM - 96% via nasal cannula On 01/08/24 at 2:08 PM Resident #64 was observed to be sitting in his wheelchair with his eyes open. He did not appear to be in distress. The oxygen regulator on the concentrator was set to 1.5 liters flow when viewed horizontally at eye level. On 01/09/24 at 8:41 AM Resident #64 was observed to be sitting in a chair, awake, and eating breakfast. He did not appear to be in distress. The oxygen regulator on the concentrator was set to 1.5 liters flow when viewed horizontally at eye level. On 01/09/24 at 10:13 AM Resident #64 was observed to be lying in bed, with his eyes open, and watching TV. He did not appear to be in distress. The oxygen regulator on the concentrator was set to 1.5 liters flow when viewed horizontally at eye level. On 01/10/24 at 8:55 AM Resident #64 was observed to be sitting in a chair, awake, and eating breakfast. He did not appear to be in distress. The oxygen regulator on the concentrator was set to 1.5 liters flow when viewed horizontally at eye level. On 01/10/24 at 12:51 PM Resident #64 was observed to be sitting in a chair, awake, and eating lunch. He did not appear to be in distress. The oxygen regulator on the concentrator was set to 1.5 liters flow when viewed horizontally at eye level. On 01/10/24 at 2:00 PM Resident #64 was observed to be sitting upright in his chair with his eyes closed. He did not appear to be in distress. The oxygen regulator on the concentrator was set to 1.5 liters flow when viewed horizontally at eye level. During an observation and interview on 01/10/24 at 2:09 PM with Nurse #1 she stated she was Resident #64's assigned nurse during the duration of the survey and checked the setting on the concentrator once a shift. She stated she viewed the settings at eye level. She stated she thought it was set at 2 liters because the top of the ball was touching the 2-liter line. She then adjusted the flow to administer 2 liters of oxygen as ordered. Resident #64 did not appear to be in distress during the observation. Nurse #1 checked his oxygen saturation during the observation, and it was 100% via nasal cannula. During an interview with the Director of Nursing on 01/10/24 at 2:40 PM, she indicated Nurse #1 was a new nurse; however, it was her expectation for oxygen to be delivered at the ordered rate.

Based on observations, record review and staff interviews, the facility failed to discard expired medications in 1 of 1 medication storage room (Juniper Hall Med Storage Room). Findings included: An observation was conducted on 01/08/24 at 10:11 AM of the Juniper Hall medication storage room in the presence of Nurse #1. The observation revealed 9 unopened bottles of aspirin Enteric Coated (EC) 81mg tablets with an expiration date of 12/2023 marked on each bottle. Nurse #1 verified the bottles of aspirin were expired, removed them from the cabinet and put them in a basket to return to pharmacy. Nurse #1 confirmed the medications should not have been in the medication storage room. An interview was conducted on 01/10/24 01:49 PM with the Director of Nursing (DON). She stated the facility stopped ordering bottles of over the counter (OTC) medications a long time ago and the pharmacy had been sending all OTC medications to each resident in bubble cards. The medications that were expired in the medication room were overlooked as they have not stored any OTC medications in the storage room for a long time now. The night shift supervisor checks the medication carts nightly for expired medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the resident, the resident's representative and staff, the facility failed to educate and offer the COVID-19 vaccine on admission and failed to maintain a resident's record of COVID-19 vaccine history. This was for 1 of 5 residents reviewed for immunizations (Resident #2). Findings included: Review of the undated facility policy revealed in part: · The facility will educate and offer the COVID-19 vaccine to residents, resident representative, or staff and maintain documentation of such. · The resident's medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine. b. Each dose of COVID-19 vaccine administered to the resident. c. If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Resident #2 was admitted to the facility on [DATE]. Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact. Review of Resident #2's medical record revealed no documentation that the COVID-19 vaccine was offered, contraindicated, administered, or refused. No documentation that the COVID-19 vaccine education was provided, and no documentation of previous COVID-19 vaccines received. An interview was conducted on 01/10/24 at 9:59 AM with Resident #2 and her representative. They both stated that Resident #2 had not been offered a COVID-19 vaccine nor had the facility asked for proof of vaccinations on admission. Resident #2 and her representative both indicated they thought she had received all doses of the COVID-19 vaccine. An interview was conducted on 01/09/24 at 11:05 AM with the Infection Control Preventionist/Assistant Director of Nursing (ICP/ADON). She indicated that vaccines should be discussed and offered on admission to the facility by the admitting nurse. If the resident has had some or all vaccines that information should be obtained and entered into the resident's medical record. Refusals should be documented in the nurses notes and under the immunization tab. She stated the COVID-19 vaccine was not offered to Resident #2 on admission. She further stated that prior to Resident #2's admission she was scheduled to receive a COVID-19 vaccine on 10/25/23, but she did not show up to the clinic to do so. The COVID-19 vaccine had not been offered or administered to Resident #2 as of 01/09/24. An interview was conducted on 01/10/24 at 1:14 PM with the Infection Control Preventionist/Assistant Director of Nursing (ICP/ADON). She stated she spoke to Resident #2 and her representative related to the COVID-19 vaccine in which they stated the resident had previously received them. She then stated upon further investigation Resident #2 had not received the COVID-19 vaccine and was not offered the vaccine upon admission. She confirmed Resident #2's medical record did not include her COVID-19 vaccine history, nor did it include documentation that the COVID-19 vaccine was discussed or offered on admission to the skilled facility. She felt it was an oversight that her COVID-19 status had not been discussed on admission. An interview was conducted on 01/10/24 at 1:49 PM with the Director of Nursing (DON). She indicated that vaccines should be discussed and offered on admission to the facility. If the resident has had some or all vaccines that information should be obtained and entered into the resident's medical record. She was unaware Resident #2's vaccination information was not in her medical record. She felt it was an oversight that Resident #2's COVID-19 status was not addressed on admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medical Director, Psychiatrist, Director of Nursing, and Consultant Pharmacist interviews, and record reviews, the facility failed to identify the need to clarify a physician's medication order for crushing Bupropion HCl SR (a sustained release antidepressant) for 1 of 6 residents reviewed for significant medication errors (Resident #65). This resulted in Resident #65 receiving 11 crushed doses of the medication over a 6-day period. Findings included: Resident #65 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, vascular dementia, and cognitive communication deficit. Resident #65's admission Minimum Data Set (MDS) assessment dated [DATE] indicated her cognition was moderately impaired and she received an antidepressant 7 out of 7 days since admission. Resident #65 care plan initiated on 02/15/23 indicated she used antidepressant medication related to diagnoses of anxiety disorder. The goal included, in part, that she would be free from discomfort or adverse reactions related to antidepressant therapy. The intervention included, in part, to administer antidepressant medication as ordered by physician. A physician order dated 02/02/23 with an end date dated 03/08/23 indicated she would receive Bupropion HCl Extended Release (XL) 300 milligrams 1 time a day by mouth for depression. Another physician order dated 03/03/23 with an end date dated 03/08/23 indicated she would receive Bupropion HCl Sustained Release (SR) 100 milligrams by mouth two times a day for depression for 1 week and may crush in applesauce then increase to 150 milligrams. Review of the March 2023 Medication Administration Record indicated she received the following doses of the crushed Bupropion HCl SR: - 03/03/23 at 8:00 PM - 03/04/23 at 8:00 AM - 03/04/23 at 8:00 PM - 03/05/23 at 8:00 AM - 03/05/23 at 8:00 PM - 03/06/23 at 8:00 AM - 03/06/23 at 8:00 PM - 03/07/23 at 8:00 AM - 03/07/23 at 8:00 PM - 03/08/23 at 8:00 AM - 03/08/23 at 8:00 PM A physician note by the Medical Director dated 03/03/23 indicated Resident #65 was not taking Bupropion regularly and suggested to titrate Bupropion HCl SR so it could be crushed. A psychiatrist note dated 03/07/23 indicated Bupropion Extended Release (XL) was changed to the SR formulation with an order to crush. The noted stated neither the XL nor SR formulation should be crushed. Doing so would destroy the slow-release mechanism and can create a rush or other side effects. A review of the nurses notes from 03/03/23 through 03/08/23 indicated her mood was pleasant and there was no documentation of increased sadness or adverse side effects. During a telephone interview with the Consultant Pharmacist on 01/09/24 at 10:42 AM, she stated she would not recommend delayed release medications to be crushed. She stated even though Bupropion SR was being crushed for 6 days, she would not expect there be adverse side effects because it was a short amount of time. In a telephone interview with the Psychiatrist on 01/09/24 at 10:36 AM she stated prior to Resident #65 being admitted to the facility, she was hospitalized after a fall and hit her head without loss of consciousness. Prior to her admission to the facility, she was on a different antidepressant, but it was discontinued before her admission. She stated Bupropion was started at the time of her admission to the facility. She stated the XR nor SR formulation should be crushed because it could cause adverse side effects. She stated she did not know if any adverse side effects occurred when the Bupropion SR was being crushed because Resident #65 was already decompensating after her most recent hospitalization. During a telephone interview with the Medical Director on 01/10/24 at 11:44 AM, she stated Resident #65 had dementia and her health had been declining prior to her admission to the facility. She stated she was notified of Resident #65 not taking the Bupropion XR regularly because she was spitting it out. She stated she changed the order to Bupropion SR with the order to be crushed. She stated she was notified by the pharmacy that the medication should not be crushed. She stated the crushed doses that she received would not have caused any adverse side effects. Attempts to reach the nurses who administered the crushed Bupropion SR were not successful. The Director of Nursing (DON) was interviewed on 01/10/24 at 2:50 PM. She stated she was not the DON at that time. She stated if she noticed an order to crush a medication that should not have been crushed, she would have notified the Medical Director and would have sought clarification.