**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the RAI Manual, record review, and interviews, the facility failed to ensure the quarterly comprehensive assessment for 2 of 2 residents (R)4 and R28 was transmitted timely. Findings include: Review of the RAI Version 2.0 Manual, Chapter 5: Submission and Correction of the MDS Assessments revealed MDS assessments are edited to verify that clinical responses are within valid ranges, dates are reasonable, and assessments are consistent with the previous assessments completed for the same resident. The facility is notified of the results of this evaluation on the Initial Feedback Report or the Final Validation Report. Timeliness Criteria: Assessment Transmission: Comprehensive assessments must be transmitted electronically within 31 days of the Care Plan Completion Date (VB4). All other MDS or MPAF assessments must be submitted within 31 days of the MDS Completion Date (R2b). A Performance Improvement Plan (PIP), which began with the arrival of the current Minimum Data Set (MDS) Coordinator on 03/28/24 was presented. The goal of the PIP was to ensure that all MDS assessments and care plans are up to date and completed in a timely manner. The PIP was in place until August of 2024. Review of the MDS assessments revealed R28 had a MDS due with a target date of 02/19/25. R28's MDS was not submitted until 04/16/25, which was more than 14 days after the target date and more than 31 days after the MDS completion date. R4 had a MDS due with a target date of 03/03/25. R4's MDS was not submitted until 04/16/25, which was more than 14 days after the target date and more than 31 days after the MDS completion date. During an interview on 04/16/25 at 05:30 PM, Licensed Practical Nurse (LPN)1 revealed she is a contract MDS nurse. LPN1 stated, I had a mess to clean up. The MDS nurse before me left unexpectedly. There were many late assessments. We did a performance improvement plan for late assessments. We should be pretty much caught up. LPN1 verified that R28's Quarterly assessment dated [DATE] remained In Progress. LPN1 also verified that R4's Quarterly MDS dated [DATE] remained In Progress. She stated that she did not know why the assessments continued to be in progress, but she would check on it. LPN1 revealed that the two assessments in question did not pull over when she submitted the batch, so these assessments were not submitted. During an interview on 04/17/25 at 02:56 PM, the Administrator revealed that LPN1 sends the MDS to a Registered Nurse (RN) in the consultant company. The RN signs the MDS and hits the complete button. A software issue did not allow the system to register that the RN hit the complete button, so the MDS' for R28 and R4 were not submitted.

Based on review of the facility policy, observations, record review and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent (%). Additionally, the facility failed to ensure an ordered medication for Resident (R)4 was administered timely. The medication administration error rate was 8 %. Findings include: Review of the facility policy titled, Medication Administration - General Guidelines, revised 02/25/2025 states: Procedures : B. Administration 10) An adequate amount of water (approx 4 ounces (oz.) or other acceptable liquid is offered with oral medications. More liquids may be necessary when administering certain medications (e.g., bisphosphonates). Check with the manufacturer's recommendations or pharmacist if unsure. 12) Medications are administered within 60 minutes before or after the medication administration record (MAR) scheduled times were possible. During a medication administration observation on 04/16/25 at 08:45 AM for R239 revealed Registered Nurse (RN)1 failed to measure out the appropriate amount of water for administering the Miralax. RN1 used a 4 oz. cup, however, it was not filled completely with water to equate to the required amount of liquid. Review of R239's Medication Administration Record (MAR) revealed an order that read, Clearlax Powder 510 gm [grams]. Mix 1 capful (17 gm) in 4-8 oz. liquid of choice and take by mouth daily. Review of R4's MAR revealed an order that read, Lantus Solostar U100 Insulin- 15 units subq once a day. The administration time was noted as 07:00 AM. Observation with RN1 of R4 revealed the Insulin was administered late at 09:10 AM. R4 had a 06:00AM blood sugar of 167. During an interview on 04/16/25 at approximately 11:32 AM, RN1 revealed that she forgot to measure the water for the Miralax. She stated she is use to the cups, so she did not think about it. RN1 revealed that she is not as use to the cart. She said, Time gets away from you, if you are not used to it. During an interview on 04/16/25 at 11:45 AM, the Director of Nursing (DON) revealed, I expect the nurses to give medications on time, measure out the necessary amount of liquid as the Physician ordered for the Miralax and practice good infection control when administering medication. We will review, have reminders and refreshers. We will conduct in-services on infection control when administering medication, proper timeframes for administering medications as well as measuring the necessary amount of liquid as the physician ordered for the Miralax. The DON was notified that the medication error rate is 8.0%.