**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of respiratory care and active diagnosis for 2 of 14 residents reviewed for MDS accuracy (Residents #32 and #41). The findings included: 1. Resident #32 was admitted to the facility on [DATE] with diagnoses that included pneumonia. A record review indicated Resident #32 had a physician order dated 9/1/24 for oxygen via nasal canula at 2 liters per minute to maintain oxygen level of greater than 92%. A record review of Resident #32's February 2025 Medication Administration Record (MAR) revealed oxygen therapy was administered daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate Resident #32 had received oxygen therapy. An interview was conducted on 5/1/25 at 3:39 PM with Minimum Data Set (MDS) Nurse #1. She stated it was an oversight that MDS Nurse #2 did not code the use of oxygen therapy in the Special Treatments and Programs section of Resident #32's quarterly MDS assessment dated [DATE]. An interview was conducted on 5/1/25 at 3:56 PM with the Director of Nursing. She stated she expected the MDS assessments to be coded accurately. 2. Resident #41 was admitted to the facility on [DATE] with a diagnosis that included anxiety disorder. A record review indicated Resident #41 had an active diagnosis of bipolar disorder since 7/3/23. A review of the Medication Administration Record from 3/18/25-3/24/25 revealed Resident #41 received antipsychotic medication daily for bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate Resident #41 had an active diagnosis of bipolar disorder in the Psychiatric/Mood Disorder section. An interview was conducted on 5/2/25 at 9:33 AM with Minimum Data Set (MDS) Nurse #1. She stated it was an oversight that the MDS Nurse #2 did not code an active diagnosis of bipolar disease in the Psychiatric/Mood Disorder section of Resident #41's quarterly MDS assessment dated [DATE]. An interview was conducted on 03/06/25 at 10:50 AM with the Administrator. He stated she expected the MDS assessments to be coded accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop a care plan in the area of respiratory care for 1 of 14 residents reviewed for comprehensive care plans (Resident #32). The findings included: Resident #32 was admitted to the facility on [DATE] with diagnosis that included pneumonia. A record review indicated Resident #32 had a physician order dated 9/1/24 for oxygen via nasal canula at 2 liters per minute to maintain oxygen level of greater than 92%. The quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate Resident #32 had received oxygen therapy. A record review of Resident #32's February 2025 Medication Administration Record (MAR) revealed oxygen therapy was administered daily. Review of Resident #32's comprehensive care plan dated 2/27/25 did not reveal a care plan for respiratory care. On 4/29/25 at 11:12 AM, Resident #32 was observed in room in bed with the oxygen concentrator in use, but the oxygen tubing was not on Resident #32 who was observed to be coughing. An interview was conducted with Nurse #1 on 4/30/35 at 3:05 PM. Nurse #1 indicated Resident #32 was known to remove her oxygen tubing from her nose and forget to replace it therefore nursing staff had to monitor and reposition the oxygen tubing as needed to ensure her oxygen saturation remained above 92%. An interview was conducted with MDS Nurse #1 on 5/1/25 at 3:39 PM and she indicated that Resident #32 should have had a care plan developed for respiratory care and that it was an oversight. An interview was conducted with the Director of Nursing on 5/1/25 at 4:05 PM and she indicated that Resident #32 should have had a care plan developed for respiratory care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, Responsible Party (RP) and Nurse Practitioner (NP) interviews, the facility failed to prevent injury to a resident who sustained a laceration to his head when a corner shelf fell from the wall. This was for 1 of 2 residents reviewed for accidents. (Resident #55) The findings: Included: Resident #55 was admitted to the facility on [DATE] with diagnosis that included hemiparesis following cerebral infarction affecting right dominant side, unspecified dementia, dysphagia. Review of Resident #55 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and was dependent on staff for Activities of Daily Living (ADL's.) Review of incident report completed by Nurse#1 dated 8/31/23 revealed nurse aide (NA)#1 and NA#2 were getting Resident#55 ready to perform care when a corner overhead shelf fell landing on the bed and right side of the residents' forehead/scalp. The report further revealed Resident #55 sustained a laceration above his right forehead. The wound measured 2(cm) centimeters by .02 is width to the top of the resident forehead. The laceration had a very small amount of bleeding, was cleansed, and steri- strips were applied. The report indicated Resident #55 remained at baseline for his neurological status and he was unable to voice pain due to his cognition during the assessment. The RP and Nurse practitioner (NP), Director of Nursing (DON) and Administrator were notified. Resident #55's overall status was monitored. Review of facility summary of incident dated 8/31/23 revealed 2 NA's (NA#1 and NA#2) were preparing to perform morning care on Resident #55 when an overhead corner shelf fell from the wall and landed on the bed and hit Resident #55 in the frontal section of the forehead. One NA stayed with Resident #55 while the other went to retrieve a nurse. The nurse immediately entered the room to assist and ensure the resident was safe. The summary further revealed the DON and the facility Administrator were summoned to the room. Upon arrival the Administrator assisted with the removal of the shelving unit. The Administrator spoke with the aids about what happened. Next, the Administrator called for the Maintenace Director to come to the room to see if a conclusion could be made as to how or why the shelf fell. A definitive answer could not be made regarding how or why the shelf fell, and as a result the Administrator requested that all corner shelves be removed from residents' rooms to prevent further accidents and or injury. Review of Nurses Progress Note dated 8/31/23 revealed around 9:40 am NAs were getting ready to perform care on Resident #55. The shelf over the head of bed (in corner to the right side of resident room) had fallen. The shelf (top part) was lying on resident with the top part of the shelf on Resident #55 forehead. The shelf was removed, and Resident #55 had a laceration to the top of his forehead which measured 2 cm in length and 0.2 in width. The laceration was cleansed with Saline and patted dry, a Steri-Strip applied until bleeding stopped and antibiotic ointment applied. An ice pack was applied the first 20 minutes after incident. The forehead had no swelling and no drainage. The resident was alert and mumbling the whole time. The NP was notified as was the RP. No new orders were given and the NP stated to monitor vital signs (VS). If VS were out of range, and/or Resident #55 had a change in condition, send him out to Emergency Room. However, if Resident #55 VS remained stable do not send him out. Neuro Checks were initiated at 9:45 am and recorded onto a Neuro work sheet. Maintenance removed the shelf from Resident #55's room. Written by Nurse # 1. Review of Medical Record 04/17/24 revealed Resident #55 revealed he was not on anticoagulant. Review of Provider Progress Note dated 9/14/23 stated there were no new complaints. Resident #55 had recovered from the laceration. The assessment further stated his 2cm laceration on his forehead had well approximated edges and no surrounding erythema. Written by NP # 1. Observation of Resident #55 room on 4/17/24 at 9:30 am revealed resident room did not contain any overhead shelves. Interview with NA #1 on 4/17/24 at 10:00 am revealed the was in the room with Resident #55 preparing him for a shower on 8/31/23 and was awaiting assistance from NA #2 when the incident occurred. A corner shelf fell from the right corner of the room falling onto the bed and Resident #55. She stated the bed took most of the impact of the shelf falling, but it did hit Resident#55 on the top of his head. NA was unaware of what caused the shelf to fall off the wall. While NA #2 stayed with Resident #55. NA #1 went to get Nurse #1. NA #2 was interviewed on 4/17/24 at 10:10 am. She was assisting NA #1 with Resident #55 preparing to transfer Resident #55 for bathing. As she entered the room the shelf came off the wall barely catching the top of Resident #55's head. NA #2 further stated that NA #1 left the room to get the nurse, and notify the DON, the Administrator. Nurse #1came into the room and did an assessment. Multiple attempts were made to reach Nurse# 1 by phone. A message was left with no return phone call. An interview with the NP was conducted on 4/17/24 at 10:30 am. The NP declined to answer questions regarding the event as she was longer responsible for residents in the facility. She further stated that the event happened so long ago she was fearful of providing inaccurate information. An interview with the Director of Maintenance on 4/17/24 at 11:00 am revealed she recalled being summoned to Resident #55's room on 8/31/23 to determine how or why the shelf fell. She stated that no root cause could be identified and as a result, the Administrator requested that all corner shelves be removed from residents' rooms. The Maintenance Director stated no loose screws and no missing dry wall were observed. Resident #55's RP was interviewed on 4/17/23 at 1:30 pm. She stated she was notified by Nurse # 1 Resident #55 had sustained a laceration to the forehead after a shelf fell from the wall. She further stated by the time she arrived to the facility all the corner shelves had been removed from all resident rooms. The RP was unaware of how the shelf had fallen from the wall. Resident #55 did not have a scar and in her opinion did not suffer any ill effects from the incident. An interview was conducted with the DON on 4/17/23 at 2:15 pm. She could not recall specifics of how she learned of the event, but recalled going to the room where the nurse was conducting a head-to-toe assessment of Resident #55. She stated the resident had a small laceration on the top of his forehead near the scalp. The DON continued by stating that she was unsure if a root cause was determined for the shelf falling, but it was decided that removing all corner shelves would prevent potential harm. The RP and NP were notified, and the resident was not sent to the hospital for further evaluation. The Administrator was interviewed on 4/17/23 at 3:15 pm. She became aware of the incident regarding a shelf falling on Resident #55 during a daily morning meeting on 8/31/23 around 9:30 am. She stated that she and the DON reported to Resident #55 room and began to assist staff as needed. The Administrator stated that she assisted the nurse with removal of the shelving unit from the room. She further stated she began interviewing staff that witnessed the shelf fall and recalled summoning the Director of Maintenance to the room to assess the shelving. No root cause could be determined as to what or how the shelf came off the wall. To prevent injury to others the Administrator requested the removal of all corner shelves from resident rooms. The facility provided the following corrective action with a completion date of 09/4/23. The Administrator is the individual responsible for compliance with this action plan. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; Address how the facility will identify other residents having the potential to be affected by same deficient practice. After a review, Resident # 55 was affected by the shelf falling from the wall. The resident was immediately assisted and assessed. Resident NP and POA notified. The Maintenance Director immediately was notified to assess the corner shelf. This was completed on 8/31/23. After a thorough review, no other residents were affected at this time. To ensure all Resident safety, all corner shelves were removed in every room due to unknown cause of the shelf falling. This was completed on 8/31/23. Due to unknown cause of the shelf falling, education was conducted to all staff by Administrator/Maintenance Director on reporting any equipment, outlets, furniture, shelving etc. that may be compromised and/or damaged to be reported immediately to maintenance and also put on maintenance order board. Address what measure will be put into place or systemic changes made to ensure what the deficient practice. All corner shelves removed on 8/31/23. Ad Hoc QA Meeting was held to review incident on /8/31/23. The QA committee consists of DON, Administrator, MDS Coordinator, Nursing Supervisor, Human Resources, Social Worker, Plant Operations Manager, and other department managers. Maintenance Director assed the corner shelf to understand the cause of it falling. No known cause was made therefore the facility removed all corner shelves. Due to uknown cause of the shelf falling, education was immediately started on 8/31/23-9/4/23 conducted to all staff by Administrator/Maintenance Director on reporting any equipment, outlets, furniture, shelving, etc. that may be compromised and or damaged to be reported immediately to maintenance and also put on maintenance order board. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Include dates when corrective action will be completed. On 8/31/23, Administrator held an Ad hoc Quality Assurance Meeting. Due to unknown cause, Education started in every department to review on reporting any equipment, outlets, furniture, shelving etc. that may be compromised and or damaged to be reported immediately to maintenance and also put on order board. All corner shelves were removed on 8/31/23. Due to removing all corner shelves, no monitoring or performance needed. Corrective actions were implemented 8/31/23 to remove all corner shelves. All corner shelves were removed and completed 8/31/23. All education was conducted between 8/31/23-9/4/23. All corrective actions were completed on 9/4/23. On 4/18/2024 the facility's correction action plan was validated by the following: The facility provided documentation to support their corrective action plan including education provided to the Maintenance Director, and every department. The Maintenance Director audited and removed all corner shelving units in all resident rooms on 8/31/23. Observations were conducted of all residents' rooms and revealed no corner shelving. QAPI meetings were discussed with the Administrator and meeting notes were reviewed. There have been no further incidents accidents of falling objects onto residents. The facility's date of 9/4/23 for the corrective action plan was validated on 4/18/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to develop a comprehensive care plan for 1 of 2 residents (Resident #219) reviewed for pressure ulcers. The findings included: Resident #219 was admitted to the facility on [DATE] with a diagnosis that included joint replacement surgery, paraplegia, and unspecified fracture of shaft of left tibia. Resident was discharged to home from the facility on 2/26/22. A review of the comprehensive minimum data set (MDS) dated [DATE] revealed Resident #219 was cognitively intact and at risk for developing pressure ulcers. The care area assessment (CAA) dated 11/16/21 indicated to proceed to care plan for the prevention of developing pressure ulcers. A review of the care plan dated 11/16/21 revealed that Resident #219 was not care planned for being at risk to develop pressure ulcers. An interview with the MDS coordinator on 12/15/22 at 3:00 pm. She indicated that Resident #219 was coded correctly to be at risk for pressure ulcers and this should have been care planned and that it must have missed and not carried over as planned. A review of nursing progress note dated 11/17/21 indicated that Resident #219 developed a stage 2 pressure ulcer. An interview with the Administrator on 12/15/22 at 3:45 pm revealed that it was her expectation for the MDS nurse to have care planned this resident for being at risk for pressure ulcers.

Based on record review and staff interviews the facility failed to have a Registered Nurse (RN) scheduled for 8 consecutive hours a day for 1 (11/24/22) of 30 days reviewed. Findings included: The daily nursing schedules from 11/12/22 through 12/12/22 were reviewed and revealed there was no registered nurse (RN) on 11/24/22. Review of the timecards and RN scheduled staffing assignment sheets revealed the facility had no documentation of an RN present in the facility on 11/24/22 to meet the requirement for an RN at least 8 consecutive hours per day on each day. During an interview conducted with the Administrator on 12/15/22 at 9:30 am she stated there should have been an RN scheduled every day. However, on Thanksgiving Day (11/24/22) no RN was present in the facility An interview was conducted with Nurse #2 on 12/15/22 at 1:19 pm she indicated she was a RN and that she believed she worked on 11/24/22. Review of Nurse #2's timecard for 11/24/22 indicated she did not work. An interview was conducted with the Director of Nursing on 12/15/22 at 3:10 pm. She stated she expected the facility to have an RN staffed to meet the regulation for 8 consecutive hours a day, 7 days a week. During an interview conducted with the Administrator on 11/15/22 at 3:30pm she stated she expected the Scheduler to staff an RN for 8 hours per day, 7 days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments no later than 14 days after the Assessment Reference Date (ARD, the last day of the look-back period) for 4 residents (Residents #8, #7, #14, and #16) reviewed for resident assessments. The findings included: 1. Resident #8 was admitted to the facility on [DATE]. Review of the resident's Minimum Data Set (MDS) assessment revealed a quarterly MDS had an Assessment Reference Date (ARD, the last day of the look-back period) of 11/21/22. As of 12/15/22, 24 days after the ARD, the quarterly MDS dated had not been completed. An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator and she indicated she was behind in completing some assessments, which caused the assessment to be overdue. She indicated she was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fell behind in completing the assessments. She indicated the assessments should be completed in 14 days from the ARD. An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely. 2. Resident #7 was admitted to the facility on [DATE]. Review of the resident's Minimum Data Set (MDS) assessment revealed a quarterly MDS had an Assessment Reference Date (ARD, the last day of the look-back period) of 11/21/22. As of 12/15/22, 24 days after the ARD, the quarterly MDS dated had not been completed. An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator and she indicated she was behind in completing some assessments, which caused the assessment to be overdue. She indicated she was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fell behind in completing the assessments. She indicated the assessments should be completed in 14 days from the ARD. An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely. 3. Resident # 14 was admitted to the facility on [DATE]. Review of the resident's Minimum Data Set (MDS) assessment revealed a quarterly MDS had an Assessment Reference Date (ARD, the last day of the look-back period) of 11/22/22. The quarterly MDS dated [DATE] was signed/dated on 12/14/22 by the Assessment Coordinator to verify the assessment was completed (22 days after the ARD). An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator and she indicated she was behind in completing some assessments, which caused the assessment to be overdue. She indicated she was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fell behind in completing the assessments. She indicated the assessments should be completed in 14 days from the ARD. An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely. 4. Resident #16 was admitted to the facility on [DATE]. Review of the resident's Minimum Data Set (MDS) assessment revealed a quarterly MDS had an Assessment Reference Date (ARD, the last day of the look-back period) of 11/5/22. The quarterly MDS dated [DATE] was signed/dated on 11/21/22 by the Assessment Coordinator to verify the assessment was completed (16 days after the ARD). An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator and she indicated she was behind in completing some assessments, which caused the assessment to be overdue. She indicated she was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fell behind in completing the assessments. She indicated the assessments should be completed in 14 days from the ARD. An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely.