Every finding on record at The Shepherd's Center

The facility reported a census of 20 residents; the sample included 13. Based on interview and record review the facility failed to ensure staff adhered to the principles of antibiotic stewardship through monitoring for the appropriate use of antibiotics prescribed to prevent antibiotic resistance and spread of multidrug resistant organisms within the facility. Findings included:- Upon request, the facility was unable to provide antibiotic and infection surveillance logs.During an interview on 09/30/25 at 04:04 PM, Administrative Nurse E (Infection Preventionist) stated she had no electronic or paper records to show the collection and analysis of data to track/monitor antibiotics ordered, and laboratory reports received. Administrative Nurse E reported she would read the Electronic Medical Record every day to see if there were any new orders for antibiotics. She reported that she completed a verbal report of the facility's infections and antibiotic use at the Quality Assurance meetings.The facility's policy Antibiotic Stewardship Program, dated 04/01/25, documented the facility would implement an Antibiotic Stewardship Program, which will promote appropriate use of antibiotics while optimizing the treatment of infections. The Infection Preventionist was responsible to monitor every antibiotic ordered and complete an antibiotic time-out for antibiotics prescribed, summarize antibiotics prescribed, summarize antibiotic resistance based on laboratory data, tracking measures of outcome surveillance related to antibiotic use, and to report the findings.

The facility reported a census of 20 residents. Based on interview and record review the facility failed to complete a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. Additionally, the facility failed to complete a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents. This failure has the potential to affect all 20 residents.Findings included:- Upon request, the facility was unable to provide antibiotic and infection surveillance logs.During an interview on 09/30/25 at 04:04 PM, Administrative Nurse E (Infection Preventionist) stated she had no electronic or paper records to show the collection and analysis of data to track infection rates and identify trends. Administrative Nurse E reported she would read the Electronic Medical Record every day to see if there were any new orders for antibiotics. She reported that she completed a verbal report of the facilities infections, and antibiotic use at the Quality Assurance meetings.The facility's policy Infection Surveillance dated 04/01/25, documented the facility will closely monitor all residents that exhibit signs and symptoms of infection through ongoing surveillance and the facility had a systematic method for collecting, consolidating and analyzing data. The Infection Preventionist will document the data to a monthly infection control log. Continuous surveillance of measure outcomes of system improvements.

The facility reported a census of 20 residents; the sample included 13 residents. Based on interview and record review, the facility failed to complete a Quality Assurance and Performance Improvement Program (PIP) based on identification, investigation, analysis, and prevention of adverse events in the facility within the past year. Findings included:- Upon request the facility was unable to provide evidence of a PIP completed within the last year.During an interview on 10/01/25 at 03:14 PM, Administrative Staff A stated that she expected Administrative Nurse D to complete all the PIPs for the facility. Administrative Staff A stated she believed the last time a PIP was completed was one and a half years ago.The facility's policy Quality Assurance Performance Improvement Policy, dated 05/16/25, documented the facility had developed, implemented, and maintained an effective, on-going, comprehensive, data driven QAPI program focused on indicators of the outcomes of care and quality of life by addressing the full range of care and services provided by the facility. The facility developed PIPs to examine and improve care or services in areas identified as needing attention. Selection for focused PIPs would focus on incidence, prevalence and severity of problems or potential problems identified per PIP Prioritization Tool.

The facility identified a census of 20 residents. The sample included 13 residents. Based on observations, interview and record reviews, the facility failed to conduct a thorough facility wide assessment to determine the resources necessary to care for the residents competently during both day-day operations and emergencies. This failure affected all 20 residents residing in the facility.Findings included:- On 09/30/25, the Administrative Nurse D provided a Facility assessment dated [DATE]. A review of the assessment revealed the following. The assessment did not identify the specific staffing levels needed for each unit and the number of Registered Nurses (RN), Licensed Nurses (LPN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. The assessment lacked staffing levels required for each shift to include evenings and weekends. The assessment further lacked information for the contingency staffing plans for events that did not require activation of the facility's emergency plan but had the potential to impact resident care. On 10/1/25 at 01:54 PM, Administrative Staff A stated the percentage of staff had been added on 08/13/25, but the date was not on the assessment. She said she was unaware of the requirement to include the staffing levels, the contingency staffing plan, or the staff recruitment plan in the Facility Assessment. The facility policy Facility assessment dated [DATE] revealed the facility will evaluate the resident population and identify the resources needed to provide necessary care and service the resident requires on an annual basis and at any time of a significant change made to the care or services provided in the facility. Sufficient staff, appropriate competencies, and skills set necessary to care for all residents. Staffing needs for each shift day, evening, night and adjust as necessary based on any changes in the resident population, develop and maintain a plan to maximize recruitment and retention of direct staff, inform contingency planning for events that do not require activation of the facilities emergency but do have the potential to affect resident care including but not limited to availability of direct care nursing staff. The facility will review and update the assessment annually or whenever there is a need or if the facility plans for any change that would require a modification to any part of this assessment.

The facility reported a census of 20 resident with two satellite kitchens. Based on observation and interview the facility failed to prepare and serve food under sanitary condition to prevent the potential for food borne bacteria. This place the residents at risk for food borne illnesses.Findings included:- On 09/29/25 at 09:40 AM, during the initial tour of the main pantry, observation revealed a dented can of refried beans, one bag of carrots with a lot of frost in the bag covering the carrots. And one sleeve of hash browns with no date.In the south satellite kitchen on the south hall, observation revealed one bag of hot dogs with a date of 07/27/25 with lots of frost, and one bag of carrots with frost covering the bag.In the north satellite kitchen, observation revealed one bag of hot dogs with no date, and one bag of carrots with a large amount of frost in the bag. The mini freezer did not have temperatures recorded from 09/23/25 to 09/29/25. A revisit of both satellite kitchens on 09/30/25 at 01:00 PM revealed the mini freezer temperatures log had not been updated. Neither of the two kitchens had foot-activated trash cans available.On 10/01/25 at 03:35 PM, Administrative Staff A revealed staff were to date any items when opened and they were to make sure the outdated food items were thrown away. Administrative Staff A said temperatures were to be assessed and logged daily.The facility policy Food Preparation and Handling Policy documented the kitchen and equipment will be kept clean, neat, orderly, and well-maintained; the food items will be received, checked, dated with the receiving date and use-by date, and stored properly as delivery is completed. Food from broken packages, swollen or dented cans, or food with abnormal appearance or odor will be immediately discarded. The temperature of foods will be periodically monitored and documented.

The facility reported a census of 20 resident. Based interviews. the facility failed to employ a full-time certified dietary manager for the residents who resided in the facility and received meals from the facility kitchen. Findings included: - Upon request, the facility was unable to provide evidence of adequate training credentials for the Certified Dietary Manager (CDM).On 09/29/25 at 10:35 AM, Dietary Manager BB stated she did not have a certificate or experience with food handling prior to taking the position. She revealed she was currently in classes for her CDM.On 10/1/25 at 03:35 PM, Administrative Staff A revealed she placed Dietary Manager BB in the position and was not aware she needed to have certification, specialized training, or experience. Administrative Staff A said Dietary Manager BB was currently in classes to obtain her CDM.The facility did not provide a policy regarding Certified Dietary Manager.

The facility reported a census of 20 residents. Based on interview and record review, the facility failed to ensure complete the required annual evaluation for two of the five Certified Nursing Aide staff sampled. Findings included:-Review of the staff personnel files revealed the following:1.CNA N, hired on 08/02/23, had a performance evaluation dated 07/25/24 but nothing dated afterwards. 2. CNA O, hired 12/03/20, had a performance evaluation dated 05/06/24 but nothing dated afterwards.On 09/30/25 at 04:25 PM, Administrative Nurse D revealed she is planning on setting up the evaluations on a calendar and said they should be completed in a timely manner.The facility policy Staff Recruitment and Retention Policy, undated, revealed the facility recognizes staff members are the backbone of the organization. Their dedication, skills, and compassion directly impact the quality of care provided to our residents. The facility performs wage comparison and analysis on an annual basis to ensure the facility is offering competitive salaries and benefits to attract and retain qualified staff.

The facility reported a census of 20 residents; the sample included 13 residents. Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment in a timely manner for six residents; Resident (R)1, R2, R5, R14, R18, and R20. Findings included:- R1's Electronic Medical Record (EMR) recorded the Annual MDS, dated [DATE], which was completed on 03/18/25 and submitted on 04/01/25. (46 days later)R2's EMR recorded a comprehensive MDS dated [DATE]. R2's EMR recorded the Significant Change MDS was completed on 08/07/25 and submitted on 08/21/25. (13 days later).R5's EMR recorded a comprehensive MDS dated [DATE]. R5's EMR recorded the Significant Change MDS was completed on 07/29/25 and submitted on 08/21/25. (26 days later).R14's EMR recorded a comprehensive MDS dated [DATE]. R14's EMR recorded the Annual MDS was completed on 09/03/25 and submitted on 09/26/25. (9 days later).R18's EMR recorded a comprehensive MDS dated [DATE]. R18's EMR recorded the Annual MDS was in progress but not completed or submitted as required. (35 days later).R20's EMR recorded a comprehensive MDS dated [DATE]. R20's EMR recorded the Annual MDS was completed on 03/31/25 and submitted on 04/14/25. (52 days later).During an interview on 09/30/25 at 01:04 PM, Administrative Nurse E, the facility's MDS Nurse, confirmed that MDS assessments were in progress or completed late.During an interview on 09/30/25 at 05:10 PM, Administrative Nurse D stated she expected the MDS to be completed and submitted on time.The facility's policy Minimum Data Set (MDS) Accuracy Audits, undated, documented the facility is committed to ensuring the accuracy, timeliness, and completeness of all MDS assessments and refers to the RAI manual.

The facility had a census of 20 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for one resident. Resident (R) 10, related to psychotropic (alters mood or thought) medications. Findings included:- R10's Electronic Medical Record (EMR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and insomnia (inability to sleep).R10's 04/09/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 13, which indicated intact cognition.The MDS recorded R10 was administered antianxiety (a class of medications that calm and relax people), antidepressant (a class of medications used to treat mood disorders), and diuretic (a medication to promote the formation and excretion of urine) in the lookback period of seven days. The MDS lacked the documentation of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and hypnotic (a class of medications used to induce sleep), that R10 received in the lookback period.R10's 04/16/25 Psychotropic Drug Use Care Area Assessment (CAA) documented, triggered related the use of several psychotropic medications being administered to the resident during the reference period. Staff will continue to administer as ordered with monitoring of side effects and observe for changes in mood/behavior. R10's Care Plan dated 04/14/25 documented, R10 received psychotropic medication for the management of depression and anxiety which puts me at risk for adverse side effects. The plan instructed staff to administer vilazodone (an antidepressant) 20 milligrams (mg), by mouth every day. Trazodone (an antidepressant used for insomnia) 50mg, by mouth every day, hydroxyzine (antianxiety medication) 25mg, by mouth every day, and Abilify (antipsychotic medication) 5 mg, by mouth every day.R10's Physician Orders documented Abilify oral tablet, administer 5mg tablet, by mouth one time a day related to depression, date ordered 04/03/25 andHydroxyzine, administer 25mg tablet, by mouth every day related to anxiety, date ordered 04/03/25.During an observation on 09/30/25 at 08:25 AM Certified Medication Aide (CMA) R staff assisted R10 back to her room.During an interview on 09/30/25 at 12:55 PM, Administrative Nurse E, the facility's MDS Nurse, reviewed the 04/09/25 MDS completed for R10 for accuracy of the medications documented in section N and stated she should have documented yes for antipsychotic and hypnotic medications as R10 had been administered the medications in the lookback period.During an interview on 09/30/25 at 05:10 PM, Administrative Nurse D stated she expected the MDS to be completed and submitted on time.The facility's policy Minimum Data Set (MDS) Accuracy Audits undated, documented the facility is committed to ensuring the accuracy, timeliness, and completeness of all MDS assessments and refer to the RAI manual.

The facility reported a census of 20 residents; the sample included 13 residents. Based on observations, record review and interviews the facility failed to develop a Baseline Care Plan for Resident (R) 14.Findings included:- R14's Electronic Medical Record (EMR) documented a diagnosis of myocardial infarction (heart attack) and major depression (major mood disorder that causes persistent feelings of sadness).R14's admission Minimum Data Set documented the resident admitted to the facility on [DATE].R14's EMR record lacked a Baseline Care Plan.On 09/30/25 at 05:20 PM, an interview with Administrative Staff D revealed she expected each resident to have a baseline care plan assessment completed upon admission. The facility policy for Baseline Care Plan, Neighbors Caring For Neighbors, undated, states the facility will develop an initial person-centered care plan within the first forty-eight hours of admission for every resident. The baseline plan will provide instruction for care of the resident. Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among all facility staff members, increase residents' safety, and safeguard against adverse events that are most likely to occur in the immediate days after admission.

The facility reported a census of 20 residents; the sample included 13 residents. Based on observations, record review and interviews the facility failed to develop a comprehensive care for Resident (R)14. Findings included:- R14's Electronic Medical Record (EMR) documented a diagnosis of myocardial infarction (heart attack) and major depression (major mood disorder that causes persistent feelings of sadness). R14's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS noted R14 had behaviors, including rejection of care during the look-back period; R14 was independent with all activities of daily living (ADL). R14's EMR lacked a comprehensive care plan. On 09/30/25 at 05:20 PM, Administrative Staff D said she expected the resident care plans to be completed in a timely manner. The facility's policy Person-Centered, Comprehensive Care Plan, revised 03/31/25, documented it is the policy of this facility to provide an individualized, person-centered interdisciplinary plan of care for all residents that is appropriate to the resident's needs, strengths, limits, and goals based on initial, recurrent, and continual needs of the resident. The comprehensive care plan will meet professional standards of quality. Care, treatment, and services are planned and provided to each resident in an interdisciplinary, comprehensive, collaborative manner to ensure that all interventions are appropriate to the needs of the resident.

The facility reported a census of 20 residents, The sample included 13 residents. Based on observation, record review and interview the facility failed to revise the care plan for Resident (R) 6 regarding pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) . Findings included:- R6's Electronic Medical Record (EMR) revealed the care plan dated 08/17/23 lacked wound care interventions. The care plan did indicate R6 at risk for cardiac complications and congestive heart failure dated 01/29/2024 with the following interventions check lung sounds and monitor/document labored breathing, monitor labs and vital signs as ordered. Monitor/document report any signs or symptoms of dependent edema of legs and feet, shortness of breath upon exertion, weight gain crackles and wheezes upon auscultation of lungs.R6's Physician's Orders documented to cleanse both buttocks per facility protocol; Pat dry, apply a dressing and change every 72 hours and as needed every day shift every three days for open area on the bilateral buttocks start date 05/05/25On 09/30/25 at 12:35 PM observed resident R6 sitting in her recliner working on her crochet refused to allow observation of wound care.On 09/30/25 at 08:23 AM Licensed Nurse LN G confirmed R6's Care Plan lacked any information regarding R6's wound care.During an interview on 09/30/25 at 05:20 PM with Administrative Staff D revealed she expected the care plans to be completed in a timely manner.The facility's policy Person-Centered, Comprehensive Care Plan revised 03/31/25 It is the policy of this facility to provide an individualized, person-centered interdisciplinary plan of care of all residents that is appropriate to the resident's needs, strength, limits and goals based on initial, recurrent and continual needs of the resident. The comprehensive care plan will meet professional standards of quality. Care, treatment, and services are planned and provided to each resident in an interdisciplinary, comprehensive, collaborative manner to ensure that all interventions are appropriate to needs of the resident.

The facility reported a census of 20 residents. The sample included 13 residents with one resident reviewed for discharge. Based on interview and record review, the facility failed to provide Resident (R) 28 a written notification of discharge to the resident and/or his representative as soon as practicable and failed to complete a recapitulation of R28's stay. Findings included:- R28's Electronic Medical Record (EMR) revealed a diagnosis of frequent falls, and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain).R28's 08/04/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. The MDS recorded R28 required maximal assistance with bathing, and dressing. The MDS recorded R28 was independent with ambulation. The MDS recorded R28's goal was to discharge back into the community, and she had an active discharge plan.R28's 08/11/25 Functional Abilities Self-Care and Mobility Care Area Assessment (CAA) documented R26 required assistance provided by the staff during the reference period. Staff would continue to provide care with activities of daily living (ADLs) as needed and anticipate the resident's needs.R28's EMR lacked a baseline care plan and comprehensive care plan.R28's Physician Orders documented to discharge R28 from physical therapy on 08/08/25 and may discharge home on [DATE].R28's Progress Note on 08/09/25 at 01:47 PM documented R28 discharged from the facility accompanied by her son and two other family members. R28 left via private vehicle.During an interview on 09/30/25 at 12:51 PM, Licensed Nurse (LN) G reported that Administrative Nurse E would complete the discharge summary and all the paperwork that was required for a discharge. LN G reported she would only complete a final assessment, review medications and write a progress note when a resident discharged .During an interview on 09/30/25 at 12:55 PM, Administrative Nurse E reported that the discharge paperwork would be completed by the charge nurse or Administrative Nurse D. Administrative Nurse E confirmed that the recapitulation of stay, and discharge summary, was not completed in the EMR for R28 and said the facility do not complete a paper discharge for or have the resident/responsible party sign any discharge paperwork.During an interview on 09/30/25 at 05:10 PM Administrative Nurse D stated she expected the nurse to complete a discharge summary that included a summary of their stay at the facility.The facility's policy Admission, Transfer and Discharge dated 08/22/22, documented upon admission, the resident/representative will be informed that if/when the resident is transferred to another health care facility, transferred within this facility, or discharged from this facility, the resident or his/her representative will be informed about the Facility Admission/Transfer/Discharge policies in addition to assurance of comparable care, treatment, and services regardless of the resident's payer source. Documentation or evidence of the resident's/representative's containing details of discharge planning and arrangements for post-discharge careResident's comprehensive care plan will contain resident's goals for admission and desired outcomes.

The facility reported a census of 25 residents. The sample included six residents reviewed for misappropriation and exploitation. Based on interview and record review, the facility failed to ensure the timely reporting of alleged exploitation to the State Agency (SA- a state governmental agency that provides oversight for the Centers for Medicare & Medicaid Services [CMS - the federal government agency that administers the nation's major healthcare programs]) or local law enforcement, as required, when the facility failed to report the allegation of exploitation of Resident (R) when Housekeeping Staff D coerced the resident to write her a check for $300.00. This deficient practice placed R1and other residents of the facility in immediate jeopardy with the risk for a negative psychosocial impact in safety and security. Findings included: - R1's Electronic Health Record (EHR) revealed diagnoses that included interstitial pulmonary disease (a disorder that causes progressive scarring of lung tissue), major depressive disorder (a major mood disorder which causes persistent feelings of sadness), and anxiety disorder (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 was independent with all cares. The Quarterly MDS dated 06/14/24, documented a BIMS score of 15, which indicated intact cognition. R1 was independent with all cares. Review of witness statements revealed the following: On 06/27/24, untimed, R1 documented that on 05/22/24 at unknown time, Housekeeping Staff D came into her room and asked for $500.00 with the promise to repay her the next day. R1 stated that she could not loan out that much money. On 05/23/24, Housekeeping Staff D returned to R1's room and requested a smaller loan of $300. R1 stated she was in pain from a recent fall and just wanted Housekeeping Staff D to leave her room, so she wrote a check for $300.00. Undated and untimed witness statement revealed Administrative Staff A documented on 05/27/24 at 01:38 PM, Administrative Nurse B notified her that Housekeeping Staff D requested $300.00 from R1 and that R1 wrote Housekeeping Staff D a check. Administrative Staff A documented she gave the directive to terminate Housekeeping Staff D effective immediately. Administrative Staff A then notified R1's family of the events, that Housekeeping Staff D was terminated, and the lost funds would be refunded to the resident. Administrative Staff A documented that two termination letters were sent to Housekeeping Staff D's last known address via certified mail, which were returned as undeliverable. Administrative Staff A further documented she held a staff meeting with the department managers and directed them to hold individual department meetings to advise the staff of what had happened and to reinforce the ANE training, specific to taking money from residents. Undated and untimed witness statement revealed Administrative Nurse B documented that on 05/27/24 at 01:32 PM, Administrative Staff L notified her of a possible exploitation of R1 and was going to confirm with R1. On 05/27/24 at 01:38 PM, Administrative Nurse B notified Administrative Staff A and Housekeeping Staff J. On 05/27/24 at 01:52 PM, a video call was completed between Administrative Nurse B with Administrative Staff L and R1 and R1 confirmed that she had written a check to Housekeeping Staff D and that it had been cashed. R1 further stated that when Housekeeping Staff D asked for the money, she was in pain from a recent fall and had given her a check for the $300.00 so Housekeeping Staff D would leave her alone. On 05/27/24 at 02:03 PM, Administrative Nurse B notified R1's family. On 05/28/24 at unknown time, Administrative Nurse B documented that Administrative Staff A spoke with R1's family who stated that he did not want the police involved since Housekeeping Staff D had been fired and the monies were refunded to R1. On 06/27/24 and untimed, revealed Administrative Staff L documented that on 05/27/24, she was informed that an unknown staff member had asked a resident for money. Administrative Staff L documented that she questioned R1 if it was true and R1 said yes. Administrative Staff L called Administrative Nurse B while in R1's room and completed a video call with R1. An undated and untimed witness statement of Housekeeping Staff J documented that on 05/24/24, Housekeeping Staff D and Housekeeping Staff J discussed one resident stating Housekeeping Staff D asked him for 300.00 dollars. Housekeeping Staff J documented that she had a teachable moment with Housekeeping Staff D, that staff should not even joke or even discuss things in front of residents, that she could get in trouble. On 06/27/24 and untimed, Housekeeping Staff J documented that on 05/27/24, Administrative Nurse B called her around 01:30 PM to ask her if she had heard that R1 was asked for money from Housekeeping Staff D. Housekeeping staff J documented she told Administrative Nurse B no. Housekeeping Staff J documented that on 05/28/24 she contacted Housekeeping Staff D and asked her to come to the facility to see her. Housekeeping Staff D replied at 02:25 PM, she was not able to come in. Housekeeping Staff J was unable to contact Housekeeping Staff D after that time. On 06/26/24 at 03:12 PM, R1 stated Housekeeping Staff D borrowed $300 from her in the last 2-3 weeks and that Housekeeping Staff D stated that she would repay the loan the next day, but she never came back to the facility. She felt exploited due to the housekeeper repeatedly asking for money and she would not take no for an answer, so R1 finally wrote the housekeeper a check so she would just leave her alone. R1 reported the housekeeper no longer worked at the facility. The facility offered to reimburse her for the lost funds from her (Housekeeping Staff D's) last paycheck. On 06/27/24 at 11:22 AM, R2 reported Housekeeping Staff D stated she wanted someone to give her $300.00 and would point at other residents walking by R2's room and ask R2 if she thought that they (the other residents) would give her money. R2 revealed that she told Housekeeping Staff D that she had no money and to not ask her again for any money. On 06/26/24 at 04:50 PM, Administrative Nurse B revealed that her expectation was for staff to notify the Director of Nurses, social services, or the Administrator if there were allegations and then the proper notifications could be done. On 06/26/24 at 03:50 PM, Administrative staff A confirmed the above information and stated that she did not notify law enforcement or the State Agency of the exploitation of the resident. She confirmed that they did terminate the offending employee and initiated reimbursement to the resident for the lost funds and stated that no solicitation and no gratuities were covered in the employee handbook which documented that solicitation of or by employees was prohibited. The facility's undated Abuse, Neglect and Exploitation Prevention policy documented that the facility would prohibit and prevent exploitation of residents and misappropriation of resident property. Further, defined exploitation as the unfair treatment or taking advantage of a resident for personal gain through the use of manipulation, intimidation or coercion. The facility would comply with the seven-step approach to detection and prevention. If an allegation is made, notification would make a report with local law enforcement agency and the State Agency, as required. The facility failed to ensure the timely reporting of alleged exploitation to the State Agency (SA- a state governmental agency that provides oversight for the Centers for Medicare & Medicaid Services [CMS - the federal government agency that administers the nation's major healthcare programs]) or local law enforcement, as required, when the facility failed to report the allegation of exploitation of Resident (R)1 when Housekeeping Staff D coerced the resident to write her a check for $300.00. On 06/27/24 at 10:10 AM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for failure to report to the State Agency and local law enforcement for the exploitation of the residents, which placed them in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 06/27/24 at 01:33 PM which included the following: 1. On 06/27/24 at 10:52 AM, all staff would receive either group or individual ANE training with a member of management. 2. On 06/27/24 at 10:52 AM, all staff were notified by the facility's communication app that prior to returning to work, staff must receive ANE training with a member of management. 3. On 06/27/24 at 10:52 AM, the facility's Medical Director and R1's primary care provider (PCP) was notified about the alleged exploitation of R1. 4. On 06/27/24 at 10:52 AM, the Long-Term State Ombudsman was notified about the alleged exploitation of R1. 5. On 06/27/24 at 11:30 AM an ad-hoc QAPI (quality assurance process improvement) meeting was held. The survey team validated the immediate jeopardy was removed on 06/27/24 at 01:40 PM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a scope and severity level of a F following the removal of the immediate jeopardy.

The facility reported a census of 25 residents. The sample included six residents reviewed for misappropriation and exploitation. Based on interview and record review, the facility failed to thoroughly investigate incidents of misappropriation of funds and failed to protect the residents from further misappropriation when Housekeeping Staff D coerced Resident (R)1 to write her a check for $300.00. This deficient practice placed R1and other residents of the facility in immediate jeopardy and placed the residents at risk for further misappropriation of funds. Findings included: - R1's Electronic Health Record (EHR) revealed diagnoses that included interstitial pulmonary disease (a disorder that causes progressive scarring of lung tissue), major depressive disorder (a major mood disorder which causes persistent feelings of sadness), and anxiety disorder (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 was independent with all cares. The Quarterly MDS dated 06/14/24, documented a BIMS score of 15, which indicated intact cognition. R1 was independent with all cares. Review of witness statements revealed the following: On 06/27/24, untimed, R1 documented that on 05/22/24 at unknown time, Housekeeping Staff D came into her room and asked for $500.00 with the promise to repay her the next day. R1 stated that she could not loan out that much money. On 05/23/24, Housekeeping Staff D returned to R1's room and requested a smaller loan of $300. R1 stated she was in pain from a recent fall and just wanted Housekeeping Staff D to leave her room, so she wrote a check for $300.00. Undated and untimed witness statement revealed Administrative Staff A documented on 05/27/24 at 01:38 PM, Administrative Nurse B notified her that Housekeeping Staff D requested $300.00 from R1 and that R1 wrote Housekeeping Staff D a check. Administrative Staff A documented she gave the directive to terminate Housekeeping Staff D effective immediately. Administrative Staff A then notified R1's family of the events, that Housekeeping Staff D was terminated, and the lost funds would be refunded to the resident. Administrative Staff A documented that two termination letters were sent to Housekeeping Staff D's last known address via certified mail, which were returned as undeliverable. Administrative Staff A further documented she held a staff meeting with the department managers and directed them to hold individual department meetings to advise the staff of what had happened and to reinforce the ANE training, specific to taking money from residents. Undated and untimed witness statement revealed Administrative Nurse B documented that on 05/27/24 at 01:32 PM, Administrative Staff L notified her of a possible exploitation of R1 and was going to confirm with R1. On 05/27/24 at 01:38 PM, Administrative Nurse B notified Administrative Staff A and Housekeeping Staff J. On 05/27/24 at 01:52 PM, a video call was completed between Administrative Nurse B with Administrative Staff L and R1 and R1 confirmed that she had written a check to Housekeeping Staff D and that it had been cashed. R1 further stated that when Housekeeping Staff D asked for the money, she was in pain from a recent fall and had given her a check for the $300.00 so Housekeeping Staff D would leave her alone. On 05/27/24 at 02:03 PM, Administrative Nurse B notified R1's family. On 05/28/24, the following day, at an unknown time, Administrative Nurse B documented that Administrative Staff A spoke with R1's family who stated that he did not want the police involved since Housekeeping Staff D had been fired and the monies were refunded to R1. On 06/27/24 and untimed revealed Administrative Staff L documented that on 05/27/24, she was informed that an unknown staff member had asked a resident for money. Administrative Staff L documented that she questioned R1 if it was true and R1 said yes. Administrative Staff L called Administrative Nurse B while in R1's room and completed a video call with R1. An undated and untimed witness statement of Housekeeping Staff J documented that on 05/24/24, Housekeeping Staff D and Housekeeping Staff J discussed one resident stating Housekeeping Staff D asked him for 300.00 dollars. Housekeeping Staff J documented that she had a teachable moment with Housekeeping Staff D, that staff should not even joke or even discuss things in front of residents, that she could get in trouble. On 06/27/24 and untimed, Housekeeping Staff J documented that on 05/27/24, Administrative Nurse B called her around 01:30 PM to ask her if she had heard that R1 was asked for money from Housekeeping Staff D. Housekeeping staff J documented she told Administrative Nurse B no. Housekeeping Staff J documented that on 05/28/24 she contacted Housekeeping Staff D and asked her to come to the facility to see her. Housekeeping Staff D replied at 02:25 PM, she was not able to come in. Housekeeping Staff J was unable to contact Housekeeping Staff D after that time. On 06/26/24 at 03:12 PM, R1 stated Housekeeping Staff D borrowed $300 from her in the last 2-3 weeks and that Housekeeping Staff D stated that she would repay the loan the next day, but she never came back to the facility. She felt exploited due to the housekeeper repeatedly asking for money and she would not take no for an answer, so R1 finally wrote the housekeeper a check so she would just leave her alone. R1 reported the housekeeper no longer worked at the facility. The facility offered to reimburse her for the lost funds from her (Housekeeping Staff D's) last paycheck. On 06/27/24 at 11:22 AM, R2 reported Housekeeping Staff D stated she wanted someone to give her $300.00 and would point at other residents walking by R2's room and ask R2 if she thought that they (the other residents) would give her money. R2 revealed that she told Housekeeping Staff D that she had no money and to not ask her again for money. On 06/26/24 at 04:40 PM, Certified Nurse Aide (CNA) F, CNA G, CNA H revealed they all had abuse, neglect, and exploitation (ANE) training last October (2023), and in April 2024, with an online learning module. They all revealed that they had not received recent ANE training of any type since April 2024. On 06/26/24 at 04:43 PM, Dietary K stated the last time she had received ANE training was in April of 2024. On 06/26/24 at 04:48 PM, Licensed Nurse (LN) C revealed she had her last ANE training via an on-line learning module in April 2024. On 06/26/24 at 04:50 PM, Administrative Nurse B revealed that her expectation was for staff to notify the Director of Nurses, social services, or the Administrator if there were allegations and then the proper notifications could be done. Additionally stated that staff were educated, however as of 06/27/24 at 09:00 AM, the facility failed to produce documentation of staff training after the incident. On 06/26/24 at 03:50 PM, Administrative staff A confirmed the above information and stated that she did not notify law enforcement or the State Agency of the exploitation of the resident. She confirmed that they did terminate the offending employee and initiated reimbursement to the resident for the lost funds and stated that no solicitation and no gratuities were covered in the employee handbook which documented that solicitation of or by employees was prohibited. The facility's undated Abuse, Neglect and Exploitation policy documented that the facility would prohibit and prevent exploitation of residents and misappropriation of resident property. Further, defined exploitation as the unfair treatment or taking advantage of a resident for personal gain through the use of manipulation, intimidation or coercion. The facility would comply with the seven-step approach to detection and prevention. If an allegation is made, notification would make a report with local law enforcement agency and the State Agency, as required. The facility failed to thoroughly investigate incidents of misappropriation of funds and failed to protect the residents from further misappropriation when Housekeeping Staff D coerced Resident (R)1 to write her a check for $300.00. This deficient practice placed R1and other residents of the facility in immediate jeopardy and placed the residents at risk for further misappropriation of funds. On 06/27/24 at 10:10 AM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for failure to prevent exploitation of the residents, which placed them in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 06/27/24 at 01:33 PM which included the following: 1. On 06/27/24 at 10:52 AM, all staff would receive either group or individual ANE training with a member of management. 2. On 06/27/24 at 10:52 AM, all staff were notified by the facility's communication app that prior to returning to work, staff must receive ANE training with a member of management. 3. On 06/27/24 at 10:52 AM, the facility's Medical Director and R1's primary care provider (PCP) was notified about the alleged exploitation of R1. 4. On 06/27/24 at 10:52 AM, the Long-Term State Ombudsman was notified about the alleged exploitation of R1. 5. On 06/27/24 at 11:30 AM an ad-hoc QAPI (quality assurance, process improvement) meeting was held. The survey team validated the immediate jeopardy was removed on 06/27/24 at 01:40 PM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a scope and severity level of a F following the removal of the immediate jeopardy.

The facility reported a census of 25 residents. The sample included six residents reviewed for misappropriation and exploitation. Based on interview and record review, the facility failed to ensure Resident (R)1 remained free from misappropriation of funds, when Housekeeping Staff D coerced the resident to write her a check for $300.00. This deficient practice placed R1and other residents of the facility in immediate jeopardy with the risk for a negative psychosocial impact in safety and security. Findings included: - R1's Electronic Health Record (EHR) revealed diagnoses that included interstitial pulmonary disease (a disorder that causes progressive scarring of lung tissue), major depressive disorder (a major mood disorder which causes persistent feelings of sadness), and anxiety disorder (a mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 was independent with all cares. The Quarterly MDS dated 06/14/24, documented a BIMS score of 15, which indicated intact cognition. R1 was independent with all cares. Review of witness statements revealed the following: On 06/27/24, untimed, R1 documented that on 05/22/24 at unknown time, Housekeeping Staff D came into her room and asked for $500.00 with the promise to repay her the next day. R1 stated that she could not loan out that much money. On 05/23/24, Housekeeping Staff D returned to R1's room and requested a smaller loan of $300. R1 stated she was in pain from a recent fall and just wanted Housekeeping Staff D to leave her room, so she wrote a check for $300.00. Undated and untimed witness statement revealed Administrative Staff A documented on 05/27/24 at 01:38 PM, Administrative Nurse B notified her that Housekeeping Staff D requested $300.00 from R1 and that R1 wrote Housekeeping Staff D a check. Administrative Staff A documented she gave the directive to terminate Housekeeping Staff D effective immediately. Administrative Staff A then notified R1's family of the events, that Housekeeping Staff D was terminated, and the lost funds would be refunded to the resident. Administrative Staff A documented that two termination letters were sent to Housekeeping Staff D's last known address via certified mail, which were returned as undeliverable. Administrative Staff A further documented she held a staff meeting with the department managers and directed them to hold individual department meetings to advise the staff of what had happened and to reinforce the ANE training, specific to taking money from residents. Undated and untimed witness statement revealed Administrative Nurse B documented that on 05/27/24 at 01:32 PM, Administrative Staff L notified her of a possible exploitation of R1 and was going to confirm with R1. On 05/27/24 at 01:38 PM, Administrative Nurse B notified Administrative Staff A and Housekeeping Staff J. On 05/27/24 at 01:52 PM, a video call was completed between Administrative Nurse B with Administrative Staff L and R1 and R1 confirmed that she had written a check to Housekeeping Staff D and that it had been cashed. R1 further stated that when Housekeeping Staff D asked for the money, she was in pain from a recent fall and had given her a check for the $300.00 so Housekeeping Staff D would leave her alone. On 05/27/24 at 02:03 PM, Administrative Nurse B notified R1's family. On 05/28/24 at unknown time, Administrative Nurse B documented that Administrative Staff A spoke with R1's family who stated that he did not want the police involved since Housekeeping Staff D had been fired and the monies were refunded to R1. On 06/27/24 and untimed revealed Administrative Staff L documented that on 05/27/24, she was informed that an unknown staff member had asked a resident for money. Administrative Staff L documented that she questioned R1 if it was true and R1 said yes. Administrative Staff L called Administrative Nurse B while in R1's room and completed a video call with R1. An undated and untimed witness statement of Housekeeping Staff J documented that on 05/24/24, Housekeeping Staff D and Housekeeping Staff J discussed one resident stating Housekeeping Staff D asked him for 300.00 dollars. Housekeeping Staff J documented that she had a teachable moment with Housekeeping Staff D, that staff should not even joke or even discuss things in front of residents, that she could get in trouble. On 06/27/24 and untimed, Housekeeping Staff J documented that on 05/27/24, Administrative Nurse B called her around 01:30 PM to ask her if she had heard that R1 was asked for money from Housekeeping Staff D. Housekeeping staff J documented she told Administrative Nurse B no. Housekeeping Staff J documented that on 05/28/24 she contacted Housekeeping Staff D and asked her to come to the facility to see her. Housekeeping Staff D replied at 02:25 PM, she was not able to come in. Housekeeping Staff J was unable to contact Housekeeping Staff D after that time. On 06/26/24 at 03:12 PM, R1 stated Housekeeping Staff D borrowed $300 from her in the last 2-3 weeks and that Housekeeping Staff D stated that she would repay the loan the next day, but she never came back to the facility. She felt exploited due to the housekeeper repeatedly asking for money and she would not take no for an answer, so R1 finally wrote the housekeeper a check so she would just leave her alone. R1 reported the housekeeper no longer worked at the facility. The facility offered to reimburse her for the lost funds from her (Housekeeping Staff D's) last paycheck. On 06/27/24 at 11:22 AM, R2 reported Housekeeping Staff D stated she wanted someone to give her $300.00 and would point at other residents walking by R2's room and ask R2 if she thought that they (the other residents) would give her money. R2 revealed that she told Housekeeping Staff D that she had no money and to not ask her again. On 06/26/24 at 04:30 PM, Certified Medication Aide (CMA) E stated she would notify Administrative Staff A or Administrative Nurse B right away if she suspected, heard, or witnessed any type of abuse, neglect, and exploitation. On 06/26/24 at 04:40 PM, Certified Nurse Aide (CNA) F, CNA G, CNA H revealed they all had abuse, neglect and exploitation (ANE) training last October (2023), and in April 2024, with an online learning module. They all revealed that they had not received recent ANE training of any type since April 2024. On 06/26/24 at 04:43 PM, Dietary K stated the last time she had received ANE training was in April of 2024. On 06/26/24 at 04:48 PM, Licensed Nurse (LN) C revealed she had her last ANE training via an on-line learning module in April 2024. On 06/26/24 at 04:50 PM, Administrative Nurse B revealed that her expectation was for staff to notify the Director of Nurses, social services, or the Administrator if there were allegations and then the proper notifications could be done. Additionally stated that staff were educated, however as of 06/27/24 at 09:00 AM, the facility failed to produce documentation of staff training after the incident. On 06/26/24 at 03:50 PM, Administrative staff A confirmed the above information and stated that she did not notify law enforcement or the State Agency of the exploitation of the resident. She confirmed that they did terminate the offending employee and initiated reimbursement to the resident for the lost funds and stated that no solicitation and no gratuities were covered in the employee handbook which documented that solicitation of or by employees was prohibited. The facility's undated Abuse, Neglect and Exploitation policy documented that the facility would prohibit and prevent exploitation of residents and misappropriation of resident property. Further, defined exploitation as the unfair treatment or taking advantage of a resident for personal gain through the use of manipulation, intimidation or coercion. The facility would comply with the seven-step approach to detection and prevention. If an allegation is made, notification would make a report with local law enforcement agency and the State Agency, as required. The facility failed to ensure R1 remained free from misappropriation of funds, when housekeeping staff D exploited the resident of $300.00. R1 stated she felt coerced into providing housekeeping staff D as she would not leave the resident alone until the check was written. This deficient practice placed R1 other residents in the facility in immediate jeopardy with the risk for a negative psychosocial impact in safety and security. On 06/27/24 at 10:10 AM, Administrative Staff A was provided the Immediate Jeopardy (IJ) template for failure to prevent exploitation of the residents, which placed them in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 06/27/24 at 01:33 PM which included the following: 1. On 06/27/24 at 10:52 AM, all staff would receive either group or individual ANE training with a member of management. 2. On 06/27/24 at 10:52 AM, all staff were notified by the facility's communication app that prior to returning to work, staff must receive ANE training with a member of management. 3. On 06/27/24 at 10:52 AM, the facility's Medical Director and R1's primary care provider (PCP) was notified about the alleged exploitation of R1. 4. On 06/27/24 at 10:52 AM, the Long-Term State Ombudsman was notified about the alleged exploitation of R1. 5. On 06/27/24 at 11:30 AM an ad-hoc QAPI (quality assurance, process improvement) meeting was held. The survey team validated the immediate jeopardy was removed on 06/27/24 at 01:40 PM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a scope and severity level of a G following the removal of the immediate jeopardy.

The facility reported a census of 22 residents with two separate units and two resident kitchens. Based on observation, interview, and record review, the facility failed to store foods safely and sanitary manner to prevent food borne illnesses, for the 22 residents of the facility, in two of two resident kitchens. Findings included: - On [DATE] at 10:30 AM, an initial tour of the kitchen with dietary staff BB, revealed the following items of concern in the refrigerator: Two cartons of mighty shake (protein supplement drink) documented a thaw date of [DATE] and a warning on the label for the staff to use it within 14 days of the thaw date ([DATE]). A plastic bowl of grated cheese and a package of flour tortillas, both without an open date or a use by date. Dietary Staff BB verified the expired and undated items above. A continued initial tour, on [DATE] of the kitchen in house two, with Dietary Staff CC, revealed the following concerns in the refrigerator: A carton of a thawed mighty shake, with a thaw date of [DATE] and a warning label to staff to use it within 14 days of thawing ([DATE]). A carton of half and half (milk and cream) with an expiration date of [DATE] (22 days after it expired). Dietary Staff CC verified the expired and undated items above. On [DATE] at 10:00 AM, Housekeeping Supervisor V reported it was the responsibility of the dietary staff working in the kitchens to monitor the stored food for undated, unmarked items that needed removed. Review of the facility's policy for Dietary Purchases, Receipt and Storage dated [DATE], revealed the policy lacked guidance on dating and storing of open food items or monitoring the food items for expiration dates. The facility failed to store foods safely and sanitarily to prevent food borne illnesses, for the 22 residents of the facility, in two of two kitchens.

The facility reported a census of 22 residents with two separate units and two resident kitchens. Based on observation, interview, and record review, the facility failed to store foods safely and sanitary manner to prevent food borne illnesses, for the 22 residents of the facility, in two of two resident kitchens. Findings included: - On 02/05/24 at 10:30 AM, an initial tour of the kitchen with dietary staff BB, revealed the following items of concern in the refrigerator: Two cartons of mighty shake (protein supplement drink) documented a thaw date of 12/23/23 and a warning on the label for the staff to use it within 14 days of the thaw date (01/06/24). A plastic bowl of grated cheese and a package of flour tortillas, both without an open date or a use by date. Dietary Staff BB verified the expired and undated items above. A continued initial tour, on 02/05/24 of the kitchen in house two, with Dietary Staff CC, revealed the following concerns in the refrigerator: A carton of a thawed mighty shake, with a thaw date of 12/23/23 and a warning label to staff to use it within 14 days of thawing (01/06/24). A carton of half and half (milk and cream) with an expiration date of 01/15/24 (22 days after it expired). Dietary Staff CC verified the expired and undated items above. On 02/06/24 at 10:00 AM, Housekeeping Supervisor V reported it was the responsibility of the dietary staff working in the kitchens to monitor the stored food for undated, unmarked items that needed removed. Review of the facility's policy for Dietary Purchases, Receipt and Storage dated 04/21/13, revealed the policy lacked guidance on dating and storing of open food items or monitoring the food items for expiration dates. The facility failed to store foods safely and sanitarily to prevent food borne illnesses, for the 22 residents of the facility, in two of two kitchens.

The facility reported a census of 22 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hourly data for all nursing personnel by the required deadline. Findings included: - Review of the Fiscal Year (FY), Quarter 1- 2023 (October 1 -December 31), the facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following: On 10/01/23; Saturday (SA), 11/06/23, Sunday (SU); 11/19/23 (SA); 12/03/23, (SA); 12/10/23 (SA); and 12/11/23, (SU). Review of the FY Quarter 2-2023 (January 1- March 31), the facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following: On 01/07, (SA); 01/08, (SU); 01/21, (SA); 02/18, (SA); 02/19, (SU); 03/11, (SA); 03/12, (SU); 03/19, (SU); 03/25, (SA); and 03/26 (SU). Review of FY Quarter 3- 2023 (April 1 -June 30), the facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following: On 04/08 (SA); 04/09 (SU); 04/22 (SA); 04/23 (SU); 04/29 (SA); 05/07 (SU); 05/20 (SA); 05/21 (SU); 06/10 (SA) and 06/25 (SU). Review of FY Quarter 4- 2023 (July 1 -September 30), the facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following: On 07/30 (SU); 09/03 (SU); 09/04 Monday (MO); 09/23 (SA); 09/24 (SU). Review of the nursing schedule and clocking sheets for the above dates revealed adequate hours to account for 24-hour nursing coverage. Interview on 02/06/24 at 02:00 PM, Administrative staff A reported all the hours come directly off the facility's staffing program and she does not know how some hours transfer and others did not. They will have to check their system. Review of the facility's policy for Mandatory Submission of Uniform Format Staffing Information (PBJ) dated 10/16/22, revealed it is the policy of the facility to complete submission of staffing information format as specified by regulatory requirements. The facility has hired ( named management company) that will electronically submit to Centers of Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by the Centers of Medicare and Medicaid Services (CMS). The facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hourly data for all nursing personnel by the required deadline.

The facility reported a census of 22 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hourly data for all nursing personnel by the required deadline. Findings included: - Review of the Fiscal Year (FY), Quarter 1- 2023 (October 1 -December 31), the facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following: On 10/01/23; Saturday (SA), 11/06/23, Sunday (SU); 11/19/23 (SA); 12/03/23, (SA); 12/10/23 (SA); and 12/11/23, (SU). Review of the FY Quarter 2-2023 (January 1- March 31), the facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following: On 01/07, (SA); 01/08, (SU); 01/21, (SA); 02/18, (SA); 02/19, (SU); 03/11, (SA); 03/12, (SU); 03/19, (SU); 03/25, (SA); and 03/26 (SU). Review of FY Quarter 3- 2023 (April 1 -June 30), the facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following: On 04/08 (SA); 04/09 (SU); 04/22 (SA); 04/23 (SU); 04/29 (SA); 05/07 (SU); 05/20 (SA); 05/21 (SU); 06/10 (SA) and 06/25 (SU). Review of FY Quarter 4- 2023 (July 1 -September 30), the facility failed to have Licensed Nursing Coverage 24 Hours/Day for the following: On 07/30 (SU); 09/03 (SU); 09/04 Monday (MO); 09/23 (SA); 09/24 (SU). Review of the nursing schedule and clocking sheets for the above dates revealed adequate hours to account for 24-hour nursing coverage. Interview on 02/06/24 at 02:00 PM, Administrative staff A reported all the hours come directly off the facility's staffing program and she does not know how some hours transfer and others did not. They will have to check their system. Review of the facility's policy for Mandatory Submission of Uniform Format Staffing Information (PBJ) dated 10/16/22, revealed it is the policy of the facility to complete submission of staffing information format as specified by regulatory requirements. The facility has hired ( named management company) that will electronically submit to Centers of Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by the Centers of Medicare and Medicaid Services (CMS). The facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hourly data for all nursing personnel by the required deadline.