**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to provide a shower bed to accommodate activities of daily living (ADL) showers three times a week for one of two residents (Resident (R) 116) reviewed for accommodation of needs of 36 sample residents. This failure had the potential to affect R116's quality of life. Findings include: Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, revealed .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . Review of the Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R116 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease without dyskinesia. Review of the Height, dated 12/18/24 and located in the EMR Vitals tab, revealed R116 was 73.0 (6 feet one inch) Inches standing. Review of the Clinical Orders, dated 12/24/24 and located in the EMR under the Orders tab, revealed .Showers every evening shift every Monday, Wednesday, Friday . Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/25 revealed R116 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R116 was cognitively intact. Further review revealed R116 was dependent on staff for assistance with showers. Review of the Care Plan, dated 03/24/25 and located in the EMR under the Care Plan Detail tab, revealed R116 .The resident has an ADL self-care performance deficit r/t [related to] Decreased mobility, and [sic] Impaired balance . with interventions to assist with bathing. Review of the Treatment Administration Records (TARs) dated January 2025, February 2025, March 2025, and April 2025 and located in the Orders tab of the EMR, revealed R116 was documented as receiving showers by staff. Review of the Point of Care Response History (POC) look back 30 days located in the EMR POC tab, revealed showers were marked as Not Applicable from 03/19/25 to 04/16/25. Review of the Weights, dated 04/16/25 and located in the EMR Vitals tab, revealed R116 was 290.8 Lbs. [pounds]. During an interview on 04/15/25 at 1:18 PM, R116 stated the facility did not have a shower bed to accommodate his size. R116 stated, Doesn't mind the bed bath, but it would be nice to have a shower once in a while. Further interview revealed R116 talked to the Unit Manager, and she told R116 they were trying to get something worked out. R116 revealed it had been a month or two since he had not had a shower and that it was not possible to get into the whirlpool because of issues with standing. During an interview on 04/16/25 at 3:30 PM, Certified Nursing Assistant (CNA)3 stated R116 was receiving bed baths but was not getting showers. CNA3 stated the shower bed creaked when trying to turn him. CNA3 stated they had limitations with him because of his size. CNA3 stated he was taking up the whole shower bed. CNA3 stated they had a bariatric shower bed, but it was too small. CNA3 stated it had been two months since R116 was given a shower. During an interview on 04/16/25 at 3:51 PM, CNA4 stated R116 was getting bed baths instead of showers due to his weight. During an interview on 04/16/25 at 4:00 PM, CNA6 stated we have a bariatric bed, and it is not a good fit for him. He could not turn in the bed, he holds on to the handicap bar and he turns on the other side and he does not have a handicap bar, just the shower bed bar, the bed can roll over with [R116]. [R116] had been getting bed baths for two months and the family is aware. We have a shower chair, but it is not wide enough. During an interview on 04/16/25 at 4:11 PM, CNA7 stated [R116] gets a bed bath. The bariatric bed is hard for him to maneuver in and for the CNAs to maneuver. He is used to getting showers weekly. He is a two to one person assist with bed baths. The Unit Manager said she was going to work on it, and I have not heard anything else about it. I'm sure he was upset about going from showers three days a week to just bed baths. During an interview on 04/17/25 at 10:47 AM, the Unit Manager (UM)3 stated we were putting him on the trolley bed for showers. There was tilt when [R116] was placed on trolley. We put the showers on hold. [R116] just started to learn a different method to transfer. There is a therapy consult to guide us for showers. [R116] had been without showers for four weeks and had been getting bed baths. A consultation was placed yesterday for therapy for safe transfer. UM3 was aware of the situation prior to therapy consultation. The Unit Manager stated, We definitely want to accommodate him. During an interview on 04/17/25 at 04:09 PM, the Director of Nursing (DON) stated, the expectation is that if it is appropriate and the resident wants a shower, they are to be put on the shower schedule to accommodate their needs.

Based on observations, interviews, and facility policy review, the facility failed to ensure medical records containing personal health information (PHI) were not accessible for one of one resident (Resident (R) 132) of 36 sample residents. This failure had the potential to allow inappropriate access to residents' records. Findings include: Review of the facility's policy titled, Electronic Medical Records, dated 2001, revealed the facility will make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use or disclosure. During an observation on 04/15/25 at 11:34 AM, the wise unit revealed one of the medication carts was in front of the nurse's station. The cart was locked but the computer screen was left unlocked and visible revealing medical information for R132. There were unidentified residents who walked by the cart. During an observation and interview on 04/15/25 at 11:35 AM, Registered Nurse (RN) 5 was observed sitting at the nurse's station before getting up and walking around to the med cart. RN5 said she did not realize she left the computer screen unlocked with resident medical information visible. She stated she knew she was supposed to lock the screen before walking away from the nurse's cart. During an interview on 04/17/25 at 2:14 PM the Director of Nursing (DON) said nursing staff were supposed to lock their computer screens when they walked away and to ensure they did not allow resident medical information to be accessed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure residents' right to participate in the care planning process was honored for one of one residents reviewed for care plans out of 32 sampled residents (Resident (R) 48). This failure placed the resident at risk for the care plan not being a person-centered care plan. Findings include: Review of the facility's policy titled Resident Participation - Assessment/Care Plans, dated 12/2016, revealed The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan.The Resident/Family Services Director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. Notices include: a. The date, time, and location of the conference; b. The name of each person contacted and the date he or she was contacted; c. The method of contact (e.g., mail, telephone, email, etc.); d. Input from the resident or representative if they are not able to attend; e. Refusal of participation, if applicable; and f. The date and signature of the individual making the contact. Review of R48's undated admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R48 was admitted to the facility on [DATE] with diagnoses that included hemiplegia with hemiparesis following a cerebral infarction affecting the right dominant side. Review of R48's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/24 and located under the MDS tab of the EMR, revealed R48 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R48 was cognitively intact. During an interview on 05/13/24 at 11:09 AM, R48 stated that he chose to stay in bed in his room and not leave his room. R48 said he only had use of his left arm and that he had to ask to have the television turned on to a station he liked due to cataracts and not being able to see very much. During the interview about his care, R48 stated, they don't invite me to care conference anymore like they used to, I'd like to be there. During an interview on 05/14/24 at 9:05 AM, R48 stated, I want to be invited to my care conference like I used to be, they would come in my room to have the meeting. During an interview on 05/15/24 at 9:59 AM, R48 stated, It's been a while since the last Team Conference (care conference) in my room, more than three or four months, I would like them to come in again. Review of R48's Team Conference, forms, located in the paper chart revealed interdisciplinary team conferences on 05/10/23, no documented evidence that R48 or a representative were invited or attended the care conference. The form documented, nurse spoke with resident who offered no concerns. Review of the Social Service Progress Notes, located in the EMR under the Clinical tab revealed Team Conferences were held: On 03/29/24, there was no documented evidence that R48 was invited or attended the care conference. On 01/02/24, there was no evidence that R48 was invited or attended the care conference. On 10/31/23, there was no evidence that R48 attended the care conference. On 07/25/23, there was no evidence that R48 was invited or attended the care conference. During an interview on 05/15/24 at 10:53 AM, the Social Service Director/Admissions (SSD/AD) stated, The Director of Nursing (DON) runs the team conferences and the resident's Social Worker would be the one who invited the resident. During an interview on 05/15/24 at 12:02 PM, R48's Social Worker (SW) stated, Sometimes he wants to go and other times not, it varies day to day. If it's not in my notes, I must not have documented if he participated or not. Sometimes the nurse will just have a conversation with him in his room. During an interview on 05/15/24 at 2:48 PM, the Director of Nursing (DON) stated, The resident has changed so much, he won't come out of his room, I didn't know he wanted to come.

Based on observation, interview, and facility policy review, the facility failed to ensure food stored in the kitchen was covered and/or dated, free of scoops, and did not have expired manufacturer's use by dates. This had the potential to affect 140 of 141 residents who consumed food prepared in the facility's kitchen. Findings include: Review of the facility's policy titled, Food Storage, dated 2020, indicated, Guideline: Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded . 2. Refrigerated storage guidelines to be followed . Wrap food properly. Never leave any food item uncovered and not labeled. Observation on 05/13/24 from 7:35 AM to 8:03 AM of the initial kitchen inspection revealed the following: a. In a kitchen dry storage area a large plastic container which contained fish mix and a large plastic container which contained sugar were stored opened to air with their tops not completely closed. Additionally, a scoop was observed stored inside the container of sugar. During an interview on 05/13/24 at 7:40 AM, the Dietary Manager (DM) confirmed the containers of fish mix and sugar were stored opened and a scoop was stored inside the container of sugar. The DM stated the containers of fish mix and sugar should be completely closed by staff when stored and the scoop should not have been stored in the container of sugar. b. Observation of bread products stored on bread racks in the kitchen revealed a package of sliced bread with an expired manufacturer's use by date of 04/24/24, six undated packages of thawed hamburger buns, one undated package of thawed hot dog buns, and 15 undated loaves of thawed sliced sour dough bread. During an interview on 05/13/24 at 7:45 AM, the DM confirmed the package of sliced bread which had an expired use by date of 04/24/24 and the undated bread products stored on the kitchen's bread racks. The DM stated staff were expected to discard any bread product that had an expired use by date and to date bread products when they were removed from the freezer to thaw. c. Observation of food stored in a kitchen reach in refrigerator revealed a package of sliced ham and a package of sliced turkey that were undated and stored opened to air. During an interview on 05/13/24 at 7:50 AM, the DM confirmed the packages of sliced ham and sliced turkey stored in the reach in refrigerator were not covered and were not dated. The DM stated staff were expected to date and cover food items prior to storing them for future use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, resident interviews, staff interviews and record review, the facility failed to report an allegation of verbal abuse by 1 of 3 residents Resident (R)33 reviewed for abuse to the State Survey Agency. This failure created the potential for further abuse by the alleged perpetrator. Findings include: Review of the facility's July 2017 Abuse Investigation and Reporting policy revealed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee. to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials: f. The resident's Attending Physician; and g. The facility Medical Director. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. Review of the Profile tab of the electronic medical record (EMR) revealed R33 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease and psychotic disorder. Review of R33's quarterly Minimum Data Set (MDS) assessment, located in the EMR in the MDS tab, with an assessment reference date (ARD) of 05/13/22 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident exhibited signs of depression such as feeling down, feeling tired or sleeping too much, feeling bad about herself, and trouble concentrating. Review of R33's Care Plan dated 06/24/22, located in the Care Plan tab of the EMR, revealed, The resident has a potential for behavior: The resident has potential to be physically aggressive (hitting/kicking) r/t [related to] dementia, mood disorder, Psychotic disorder, delusional disorder, Parkinson's, depression, insomnia, [and] psychotropic med[ication] use. The approaches included: Administer medications as ordered. Monitor/document for side effects and effectiveness . Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Behavior Management: When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later . Complete Behavior Assessment every shift . [and] explain tasks to resident prior to implementing. In an interview with R33 on 07/19/22 at 1:09 PM, the resident stated she had not been abused in the facility. Review of a 06/21/22 Health Status Note, found in the Progress Notes tab of R33's EMR, revealed, When therapist entered room for therapy, resident stated she had been abused by staff. Told RN [Registered Nurse] she had been verbally abused but unable/unwilling to say account for what was said. Told nurse this had happened all day. (Nurse worked 7a-7p resident only awoke long enough to take meds [and] sips of liquids.) Had slept through AM care performed by CNA [certified nursing assistant]. On 07/20/22 at 11:27 AM, the Unit Manager (UM) provided an undated typed statement on blank white paper, written by the UM, documented, 6/21/22 Nurse stated that resident told the therapist she had been verbally abused by staff today. She was not able/willing to provide any details about the alleged abuse. Resident slept most of the day today and was only awake for short periods like to take meds and eat. She even slept through her bath this morning. She has a diagnosis of Parkinson's and has a long history of delusions and hallucinations. There was no evidence to substantiate the abuse. In an interview on 07/20/22 at 11:27 AM, the UM stated R33 had a history of making false accusations and she just slept all day on 06/21/22, so there was no reason to believe that she had been abused. The UM stated R33 even slept through her morning care, since she was recently readmitted from the hospital and was not feeling herself at the time. The UM added R33 also likely had a urinary tract infection which could cause delusions. The UM stated she did not feel the allegation should be reported to the State Survey Agency because it was a credible allegation. On 07/21/22 at 9:00 AM, the Director of Nursing (DON) stated R33's allegation on 06/21/22 was automatically considered unfounded because of all the circumstances, starting with R33's diagnosis of UTI, the fact she slept all day per the staff, and had a history of reporting false accusations. The DON stated there was no evidence of any abuse. The DON stated this allegation was not reported to the State Survey Agency because they would report only those allegations of abuse where abuse was actually suspected, and R33's allegation was not considered credible in this case. The DON stated she was cautious about reporting abuse allegations because, in the past, they had reported a witnessed incident of staff to resident abuse and received a citation due to the abuse actually occurring. On 07/21/22 at 11:25 AM, RN1 stated she recalled some of the details of R33's allegation on 06/21/22, but not all. RN1 stated a therapist, she did not recall who, reported to her that R33 said she had been verbally abused by staff. RN1 stated she reported the allegation to the UM. In an interview on 07/21/22 at 11:55 AM, the Administrator stated she was unaware of the resident's allegation, as it was investigated by nursing staff and not reported to her. The Administrator stated she did not feel the allegation was considered credible, so it did not need to be reported to the State Survey Agency. The Administrator stated her understanding was that only allegations of abuse where abuse was actually suspected to have occurred were to be reported and investigated. The Administrator stated the allegation was not reported as it was not considered a credible allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, resident interview, staff interviews and record review, the facility failed to thoroughly investigate an allegation of verbal abuse by 1 of 3 residents, Resident (R) 33 reviewed for abuse. This failure created the potential for further abuse by the alleged perpetrator. Findings include: Review of the facility's July 2017 Abuse Investigation and Reporting policy revealed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; j. Review all events leading up to the alleged incident; [and] k. Obtain statements from staff members as indicated. The investigator will consult daily with the Administrator concerning the progress/findings of the investigation. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator. Review of the Profile tab of the electronic medical record (EMR) revealed R33 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease and psychotic disorder. Review of R33's quarterly Minimum Data Set (MDS) assessment, located in the EMR in the MDS tab, with an assessment reference date (ARD) of 05/13/22 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident exhibited signs of depression such as feeling down, feeling tired or sleeping too much, feeling bad about herself, and trouble concentrating. Review of R33's Care Plan dated 06/24/22, located in the Care Plan tab of the EMR, revealed, The resident has a potential for behavior: The resident has potential to be physically aggressive (hitting/kicking) r/t [related to] dementia, mood disorder, Psychotic disorder, delusional disorder, Parkinson's, depression, insomnia, [and] psychotropic med[ication] use. The approaches included: Administer medications as ordered. Monitor/document for side effects and effectiveness . Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Behavior Management: When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later . Complete Behavior Assessment every shift . [and] explain tasks to resident prior to implementing. R33's care plan did not include a history of false allegations. In an interview with R33 on 07/19/22 at 1:09 PM, the resident stated she had not been abused in the facility. Review of a 06/21/22 Health Status Note, found in the Progress Notes tab of the EMR, revealed, When therapist entered room for therapy, resident stated she had been abused by staff. Told RN [Registered Nurse] she had been verbally abused but unable/unwilling to say account for what was said. Told nurse this had happened all day. (Nurse worked 7a-7p resident only awoke long enough to take meds [and] sips of liquids.) Had slept through AM care performed by CNA [certified nursing assistant]. On 07/20/22 at approximately 10:00 AM, an investigation into the above allegation of verbal abuse was requested. On 07/20/22 at 11:27 AM, the Unit Manager (UM) provided an undated typed statement on blank white paper, written by the UM, documented, 6/21/22 Nurse stated that resident told the therapist she had been verbally abused by staff today. She was not able/willing to provide any details about the alleged abuse. Resident slept most of the day today and was only awake for short periods like to take meds and eat. She even slept through her bath this morning. She has a diagnosis of Parkinson's and has a long history of delusions and hallucinations. There was no evidence to substantiate the abuse. In an interview on 07/20/22 at 11:27 AM, the UM stated R33 had a history of making false accusations and she just slept all day on 06/21/22, so there was no reason to believe that she had been abused. The UM stated R33 even slept through her morning care, since she was recently readmitted from the hospital and was not feeling herself at the time. The UM added R33 also likely had a urinary tract infection which could cause delusions. The UM stated she had conducted interviews with the three CNAs on duty that day to investigate the allegation, and she had attempted to interview the resident who did not respond. On 07/20/22 01:02 PM, the UM stated she had not interviewed the therapist, whom R33 reported the allegation to, and she was unsure which therapist it was. The UM also stated no additional resident interviews were completed as part of the investigation, stating, we did not go that far because she slept all day, and we already knew she probably had a UTI. She has a history of making accusations when she has a UTI. The UM provided three statements from the CNAs that were undated and written on blank white paper: Review of a statement written by RN1 revealed, On 6-21-22, I was the assigned nurse for resident in [room number]. I observed resident sleeping all shift. She awoke long enough to take crushed meds in applesauce with a few sips of liquids then immediately went back to sleep. CNA also reported she had slept during AM care [and] would not awaken for meals. I never saw or heard anything indicating abuse throughout my shift. Review of a written statement by CNA3 revealed, On 6/21/22 I, [CNA3], did not hear or see any type of abuse or neglect. [R33] was asleep every time I went by her room. Review of a written statement by CNA2 revealed, To whom [it] may concern I [CNA2] had [R33]. I tried feed her breakfast [but] couldn't get her awake. I let the nurse [RN1] no [sic] she even tried [to] wake her up and couldn't. [R33] said leave her alone she slept all day. Review of a written statement by CNA1 revealed, On 6/21/22 I worked and did not see or hear any kind of abuse on [R33] in [room number]; she was asleep all day. In an interview on 07/20/22 at 1:17 PM, the Occupational Therapist (OT) stated she was not working with R33 but would stop in her room to check on her or chat with her. The OT stated, She may have made a comment to me about being abused but stated she did not really remember. The OT stated she passed on what R33 said to [RN1]. The OT stated, I never saw anything or had any indication from the CNAs that something was wrong. On 07/21/22 at 9:00 AM, the Director of Nursing (DON) stated R33 had made similar allegations of verbal abuse back in 2020 and these allegations had been reported and thoroughly investigated but were not substantiated. The DON stated the resident's allegation on 06/21/22 was automatically considered unfounded because of all the circumstances, starting with R33's diagnosis of UTI, the fact she slept all day per the staff, and had a history of reporting false accusations. The DON stated there was no evidence of any abuse. The DON stated this allegation would have been unsubstantiated had the investigation been completed, as the resident could not have been abused because she was sleeping all day. The DON stated she would report/investigate only those allegations of abuse where abuse was actually suspected, and R33's allegation was not considered credible in this case. On 07/21/22 at 11:25 AM, RN1 stated she recalled some of the details of R33's allegation on 06/21/22, but not all. RN1 stated a therapist, she did not recall who, reported to her that R33 said she had been verbally abused by staff. RN1 recalled she told the therapist R33 had been asleep all day and only woke her for medications. Also, R33's CNA reported she was sleeping during morning care, so she [RN1] was keeping an eye on her. RN1 stated, I don't see where she had been verbally abused because she hadn't been awake long enough. RN1 added the resident had frequent delusions and has made false accusations in the past. RN1 stated she attempted to interview R33, but the resident did not say anything during the interview. RN1 stated she used her nursing judgement since R33 had been asleep all day and she didn't see where she could have been abused. RN1 stated she reported the allegation to the UM. In an interview on 07/21/22 at 11:55 AM, the Administrator stated she was unaware of the resident's allegation, as it was investigated by nursing staff and not reported to her. The Administrator stated she did not feel the allegation was considered credible, so the nursing staff had taken the appropriate action. The Administrator stated her understanding was that only allegations of abuse where abuse was actually suspected were to be reported and investigated. The Administrator stated the allegation was not investigated further as it was not considered a credible allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, observation, interview, and record review, the facility failed to complete a Significant Change of Condition (SCOC) Minimum Data Set (MDS) assessment for 1 of thirty-one sampled residents Resident (R) 148, creating the potential that her care plan would not be revised to meet her needs. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, revised October 2019, revealed, If a significant change in status is identified in the process of completing any OBRA assessment except admission and SCSAs [significant change in status assessments], code and complete the assessment as a comprehensive SCSA instead . Decline in two or more of the following . Any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment . Resident's incontinence pattern changes . Emergence of a new pressure ulcer at Stage 2 or higher . Review of R148's Census tab in her electronic medical record (EMR) revealed she was admitted to the facility on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE]. Review of R148's quarterly MDS assessment with an Assessment Reference Date (ARD) of 04/14/22 revealed R148 required limited assistance from one staff member for locomotion on the unit, limited assistance with eating, was occasionally incontinent of bladder, and had no pressure ulcers. Review of R148's annual MDS assessment with an ARD of 07/06/22 revealed she required extensive assistance from one staff person for locomotion on the unit and eating, was frequently incontinent of bladder, and had an unhealed stage 2 pressure ulcer. An interview with the MDS Coordinator (MDSC) on 07/21/22 at 11:21 AM revealed that the 07/06/22 MDS assessment should have been coded as a SCOC assessment rather than an Annual assessment, because the resident had declined in two of her Activities of Daily Living (ADLs), was more incontinent of bladder, and had developed a pressure ulcer. The MDSC stated that the facility did not have a policy on completing MDS assessments, but used the Resident Assessment Instrument (RAI) manual.

Based on review of the CMS RAI Version 3.0 Manual, interview and record review, the facility failed to transmit Minimum Data Set (MDS) assessments per the required timeframes, for 1 of thirty-one residents, Resident (R) 252. Findings include: Review of the CMS RAI Version 3.0 Manual, revised October 2019, revealed MDS assessments are required to be transmitted to CMS within 14 days of the ARD. Review of the MDS screen of R252's electronic medical record (EMR) revealed MDS assessments were completed, but not transmitted, for a quarterly MDS with an Assessment Reference Date (ARD) of 11/18/20; a quarterly MDS with an ARD of 02/09/21; a quarterly MDS with an ARD of 05/03/21; an annual MDS with an ARD of 07/20/21; and a Death in Facility MDS with an ARD of 08/12/21. An interview with the Director of Nursing (DON) on 07/21/22 at 1:26 PM revealed that she had received notifications from the Centers for Medicare and Medicaid (CMS) for years that R252's MDS Assessments had not been transmitted, and the facility tried to transmit them with each notification but for some reason the assessments were not accepted. The DON stated that the facility had not reached out to CMS to resolve the issue as she felt it was something wrong with the facility's computer system.