Every finding on record at Peak Resources - Brookshire, Inc

Based on record review, staff and Ombudsman interviews, the facility failed to send a copy of the Notice of Transfer/Discharge to the Ombudsman for 3 of 3 residents reviewed for discharge process (Resident #79, Resident #81 and Resident # 77). The findings included: 1.Resident # 79 was admitted to the facility on [DATE]. Review of the Discharge/Transfer Plan of Care form completed on 1/13/26 at 10:11 AM revealed Resident #79 was discharged to an assisted living facility on 1/14/26 due to health needs had been met. Review of progress note dated 1/14/26 indicated Resident #79 was discharged to another facility. Review of the Admit/Discharge Report (a cumulative list of residents that have either transferred or discharged from the facility during the reporting period) for the period of 1/1/26 through 1/31/26 revealed Resident #79 was discharged on 1/14/26 to another type of health care institution. An interview was conducted with the Social Worker on 4/16/26 at10:07 AM and she indicated Resident #79 was discharged to an assisted living on 1/14/26. She further revealed on 2/3/26 she emailed the Ombudsman a copy of the Admit/Discharge Report for the period of 1/1/36 through 1/31/26. She indicated the report noted Resident #79 had been discharged on 1/14/26 to another health care institution and that she was not aware the facility was required to provide the Ombudsman with a copy of the Notice of Transfer/Discharge. A telephone interview was conducted with the Ombudsman on 4/16/26 at12:49 PM. The Ombudsman confirmed she did not receive a copy of the Notice of Transfer/Discharge for Resident #79's discharge to an assisted living facility on 1/14/26. The Ombudsman indicated she had educated both the Social Worker and the Administrator as recently as 1/8/26 that the facility would need to provide the Ombudsman with a copy of all Notices of Transfer/Discharge for all discharges and emergency transfers. The Ombudsman explained that she instructed the facility to send a copy of the Notice of Transfer/Discharge for all discharges to the Ombudsman on the date the notice was issued. An interview was conducted with the Administrator on 4/16/26 at1:46 PM and indicated that the Ombudsman provided education on 1/9/26 to the Administrator and the Social Worker however he did not know that a copy of the Notice of Transfer/Discharge should have been provided to the Ombudsman at the time the notice was issued to Resident #79 and felt that the Admit/Discharge Report that was sent to the Ombudsman on 2/3/26 was all that was required. 2. Resident # 81 was admitted to the facility on [DATE]. Review of Resident 81's progress note dated 12/17/25 revealed Resident 81 discharged home on [DATE]. Review of the Admit/Discharge Report (report listing the admission and discharges for the facility) for the period of 12/1/25 to12/31/25 revealed Resident #81 was discharged on 12/17/25 to home. A telephone interview was conducted with the Ombudsman on 4/16/26 at 12:49 PM. The Ombudsman confirmed she did not receive a copy of the Notice of Transfer/Discharge for Resident #81's discharge to home on [DATE]. The Ombudsman indicated she had educated both the Social Worker and the Administrator as recently as 1/8/26 that the facility would need to provide the Ombudsman with a copy of all Notices of Transfer/Discharge for all discharges and emergency transfers. The Ombudsman explained that she instructed the facility to send a copy of the Notice of Transfer/Discharge for all discharges to the Ombudsman on the date the notice was issued. An interview was conducted with the Social Worker on 4/16/26 at 1:43 PM and she indicated Resident #81 was discharged to on 12/17/25. She further revealed on 1/8/26 she emailed the Ombudsman a copy of the Admit/Discharge Report for the period of 12/1/25 to 12/31/25. She indicated the report noted Resident #81had been discharged on 12/17/25 to home and that she was not aware the facility was required to provide the Ombudsman with a copy of the Notice of Transfer/Discharge. An interview was conducted with the Administrator on 4/16/26 at 1:46 PM and indicated that the Ombudsman did provide education to the Administrator and the Social Worker however he did not know that a copy of the Notice of Transfer/Discharge should have been provided to the Ombudsman at the time the notice was issued to Resident #81 and felt that the Admit/Discharge Report that was sent to the Ombudsman was all that was required. 3. Resident # 77 was admitted to the facility on [DATE]. Review of the Discharge/Transfer Summary dated 1/22/26 written by Nurse #1 indicated Resident #77 was transferred to the hospital due to ongoing discomfort and pain in her abdomen. The resident's representative requested Resident #77 go to the hospital. The provider was notified, and an order was written to send the resident to the hospital for an evaluation and treatment of an acute condition which could not be treated in the facility. Review of the Admit/Discharge Report (a cumulative list of residents that have either transferred or discharged from the facility during the reporting period) for the period of 1/1/26 to 1/31/26 revealed Resident #77 was transferred on 1/22/26 to the hospital for inpatient care. Resident #77 was expected to return to the facility. An interview was conducted with the Social Worker on 4/16/26 at 10:07 AM. She revealed on 2/3/26 she emailed the Ombudsman a copy of the Admit/Discharge Report for the period of 1/1/36 to 1/31/26. She indicated the report noted Resident #77 had been transferred to the hospital for inpatient care on 1/22/26 and that she was not aware the facility was required to provide the Ombudsman with a copy of the Notice of Transfer/Discharge. An additional follow up with the Social Worker on 4/16/26 at 1:32 PM revealed she was under the impression the notification to the Ombudsman only included the resident's name, date of discharge, and the discharge location. She was not aware that the Notice of Transfer/Discharge was required to be sent to the Ombudsman. A telephone interview was conducted with the Ombudsman on 4/16/26 at 12:53 PM. The Ombudsman confirmed she did not receive a copy of the Notice of Transfer/Discharge for Resident #77's discharge to the hospital on 1/22/26. She only received the Admin/Discharge Report that included the resident's name and location of her hospital admit. Resident #77 was listed as Discharge with Expected Return. The Ombudsman indicated she had educated both the Social Worker and the Administrator as recently as 1/8/26 that the facility would need to provide the Ombudsman with a copy of all Notices of Transfer/Discharge for all discharges and emergency transfers. The Ombudsman explained that she instructed the facility to send a copy of the Notice of Transfer/Discharge for all discharges to the Ombudsman on the date the notice was issued. On 4/16/26 at 1:44 PM, an interview was held with the Director of Nursing (DON). She stated she was unaware they were supposed to send the actual transfer documents to the Ombudsman. They were sending enough information (resident name, discharge date , location, etc.) monthly from the Admit/Discharge Report. The DON stated the Ombudsman requested the information to be sent weekly. She stated that going forward, they will send the actual discharge events weekly to the Ombudsman, including the Discharge Transfer Event for residents sent to the hospital. An interview was conducted with the Administrator on 4/16/26 at 1:46 PM. He indicated that the Ombudsman did provide education to the Administrator and the Social Worker. However, he did not know that a copy of the Notice of Transfer/Discharge should have been provided to the Ombudsman at the time Resident #77 was sent to the hospital. He felt that the Admit/Discharge Report that was sent to the Ombudsman on 2/3/26 was all that was required.

Based on record review, and staff, resident and physician interviews, the facility failed to notify the physician when a dental service consultation for a tooth extraction was not able to be scheduled for 1 of 1 resident (Resident #32) reviewed for dental services. The findings included: Resident #32 was admitted to the facility on [DATE]. Her diagnosis included exfoliation of teeth (process that allows the replacement of the primary dentition with permanent teeth) due to systemic causes, disorientation, hypertensive heart disease, chronic kidney disease, chronic diastolic (congestive) heart failure and periapical abscess without sinus (a dental abscess that occurs when bacteria infects the tooth's root and doesn't drain into a sinus). A quarterly MDS dated [DATE] revealed Resident #32 was cognitively intact. Resident #32 had no mouth pain, facial pain or difficulty chewing. A consultation/report letter dated 12/5/24 stated Resident #32 was seen in the dental office/oral surgeon for a consultation. Resident #32 was not a candidate for treatment to be done in the office setting. Resident #32 would need to be treated in a hospital setting. The recommendations stated that due to the health history of Resident #32 she was not a candidate for intravenous (IV) sedation in an outpatient setting. Resident #32 was referred back to the dentist to send to a hospital setting for the procedure to be completed. This note was signed by the Unit Manager who documented the consultation report was faxed to the contracted mobile Dentist on 12/6/25. The facility's facsimile cover page dated 1/22/25 indicated a referral for Resident #32 to be seen by an outside dental agency. The facsimile documented: please call the Unit Manager to schedule an appointment or if you have any questions, and that the resident required sedation. An interview with the Unit Manager on 2/27/25 at 11:28AM revealed consultation reports following an appointment would come to her either by fax or upon return from an appointment and she reviewed the consultations for further recommendations. She stated the oral surgeon recommendations dated 12/5/24 stated they could not perform the procedure (tooth extraction) on Resident #32 because they could not sedate her for the procedure. She stated following the recommendations from the oral surgeon on 12/5/24, she completed a referral for Resident #32 to be seen by a dental school on 1/22/25. The Unit Manager stated she was unsure of why she had not sent the referral to the dental school school before 1/22/25. During the interview, the Unit Manager was observed to review her emails. She stated she had not received confirmation that Resident #32 could be seen by the dental school for the extraction. She revealed she had not followed up with the dental school to determine if the procedure could be completed per the referral she completed (1/22/25). The Unit Manager indicated she should have followed up on the referral she sent to determine if Resident #32 could have an extraction at their office. During an interview with Resident #32 on 2/25/25 at 12:35pm, Resident #32 indicated she had to have her tooth extracted because she had some tooth pain. In an interview with the contracted mobile Dentist on 2/27/25 at 2:15pm he revealed he completed his initial exam on Resident #32 on 10/22/24. He recalled Resident #32 having sensitivity of a crown on the lower left side of her mouth. With tapping and percussion Resident #32 had a little bit of pain. Resident #32 had said her previous exam (prior to admission to the facility) indicated she needed an extraction. Resident #32 was apprehensive of needles which was the reason he referred Resident #32 to have an extraction of tooth #19 with the oral surgeon. The oral surgeon could do deep sedation for dental procedures. In an interview with the Physician on 2/28/25 at 9:58AM she revealed the oral surgeon felt Resident #32 needed general anesthesia to have her tooth extracted. It could be difficult to locate a dentist to do general anesthesia on Resident #32 due to her health condition from a cardiology standpoint. If the facility was unable to find an inpatient facility to do the dental procedure under general anesthesia, the facility should have made her aware so she could attempt to locate an alternative. She further stated Resident #32 was clinically stable and had no complaints regarding tooth pain prior to her appointment with the oral surgeon or thereafter. The facility needed to figure out how to take care of the resident's extraction but not in an emergency setting. The Physician stated she would need to talk with the nurse and Social Worker to identify a plan.

Based on record review and staff interviews, the facility failed to notify the resident/Responsible Party (RP) in writing regarding the reason for transfer to the hospital for 1 of 1 resident reviewed for hospitalization (Resident #70). Findings included: Resident #70 was admitted on [DATE]. His diagnoses included Type 2 diabetes mellitus with foot ulcer. Resident #70's admission Minimum Data Set, dated dated dated [DATE] indicated he was cognitively intact. Nursing documentation dated 1/03/25 at 2:10 PM indicated Resident #70 had been aware of his need to be transferred to the emergency room for evaluation. Messages had been left for his first and second contacts to call the facility regarding Resident #70. Resident #70 had been discharged to the hospital for an acute condition on 1/3/25. Record review did not reveal evidence of the discharge/transfer notice had been sent to Resident #70 or his Responsible Party (RP). Resident #70 did not return to the facility. On 2/27/25 at 5:31 PM an interview with the Business Office Manager (BOM) was conducted. She indicated she was responsible for the discharge/transfer notice and stated she had missed providing this to Resident #70 or his RP. She explained the Regional Business Office Manager had conducted an audit and discovered this had been missing. On 2/27/25 at 5:28 PM an interview was conducted with the Administrator. He stated the notice of transfer should be provided to the resident and/or RP. The facility provided the following corrective action plan with a completion date of 1/28/25. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 1/27/25 an audit was conducted by the Corporate BOM and her audit revealed that six (6) residents were noted to not have the discharge process noted in resident notes in the electronic health record (EHR) (noting Resident #70 was one of the identified residents). Families were not called, noted and/or issued a notice of transfer via mail while the BOM was out. These residents did not suffer any adverse effects related to the alleged deficient practice. Completed dated 1/27/2025 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by the alleged deficient practice. On 1/27/2025 facility reviewed all discharges from the past (7) seven days and no residents were affected related to the deficient practice. Completed date 1/27/25 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 1/27/2025 the Administrator provided education to the BOM and SW (Social Worker) pertaining to the documentation of resident notification of transfer/discharge from the facility. The SW, Administrator and /or designee will provide back-ups for the BOM when not at work. Moving forward it will be mailed, a phone call will be made and noted according to policy by the Business Office Manager, Social Services Director, Administrator, and /or designee. Any newly hired BOM, SW, DON and/or Administrator will be educated on this process during orientation. Completed date 1/27/25 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. All discharges will be reviewed in the daily clinical meeting to ensure documentation of notification of discharge/bed hold is noted in EHR. Administrator/designee will audit monthly X (times) 3 months the discharge notification process to ensure all parties are notified according to policy. The results of these audits will be brought to the QAPI (Quality Assessment and Performance Improvement) committee monthly X 3 months by the Administrator for review and further recommendations. Completed date 1/27/25 Include dates when corrective action will be completed: 1/28/25. Onsite validation of the corrective action plan was completed on 2/28/25. The initial 1/27/25 audit was verified. Evidence of an in-service on 1/27/25 given by the Administrator included the DON, BOM, and the Social Worker (SW). Interviews with the DON, BOM and SW verified they received in-service training on documentation of discharge from the facility and the resident discharge summary. Evidence of discharge and written notification monitoring was observed. The compliance date of 1/28/25 for the corrective action plan was validated.

Based on record review and staff interviews, the facility failed to provide written notification of the bed hold policy when a resident was transferred to the hospital for 1 of 1 resident reviewed for hospitalization (Resident #70). Findings included: Resident #70 was admitted on [DATE]. His diagnoses included Type 2 diabetes mellitus with foot ulcer. Resident #70's admission Minimum Data Set, dated dated dated [DATE] indicated he was cognitively intact. Nursing documentation dated 1/03/25 at 2:10 PM indicated Resident #70 had been aware of his need to be transferred to the emergency room for evaluation. Messages had been left for his first and second contacts to call the facility regarding Resident #70. Resident #70 had been discharged to the hospital for an acute condition on 1/3/25. Record review did not reveal evidence that the bed hold policy had been sent with Resident #70 when he unexpectedly discharged to the hospital on 1/3/25. Resident #70 did not return to the facility. An interview with Resident #70 was conducted via phone on 2/27/25 at 3:12 PM. He stated he had been in the hospital for about a week. When he was ready to discharge, he was told there were no beds available at this facility and was discharged to another rehabilitation facility. He stated he would have returned to this facility if a bed had been available. On 2/26/25 at 8:07 AM an interview with the Director of Nursing (DON) was conducted. She stated the nurses' print copies of the bed hold policy along with the transfer form and other information to send to the hospital. She stated this was not usually documented anywhere. An interview was conducted with Nurse #3 on 2/27/25 at 1:17 PM. Nurse #3 stated when a resident discharged to the hospital their demographic information, list of medications, diagnoses, emergency contact and code status information was sent with the resident. When asked about the bed hold policy Nurse #3 stated that it was usually sent but sometimes, they ran out of copies. On 2/27/25 at 5:31 PM an interview with the Business Office Manager (BOM) was conducted. She stated that the bed hold policy was not sent to Resident #70 or his Responsible Party (RP). She explained she usually sent the bed hold policy with the hospital information and would follow up with a phone call to the RP. She explained she had been off the day Resident #70 had been sent to the hospital, and she failed to follow up with the RP about the bed hold policy or mail the information. She explained the Regional Business Office Manager had conducted an audit and discovered her follow-up had been missing. On 2/27/25 at 5:28 PM an interview was conducted with the Administrator. He stated he was unaware of needing to allow a discharged resident to return to the first available bed when none were available at the time of their discharge from the hospital.

Based on record review and staff interviews the facility failed to allow a resident to return to the facility after hospitalization for 1 of 1 resident reviewed for hospitalization (Resident #70). Findings included: Resident #70 was admitted on [DATE]. Resident #70's admission Minimum Data Set, dated dated dated [DATE] indicated he was cognitively intact. His diagnoses included type 2 diabetes mellitus with foot ulcer and cellulitis of the right lower extremity. Resident #70 was transferred to the hospital for an acute condition on 1/3/25. Resident #70's hospital discharge summary dated 1/16/25 indicated the hospital case manager had noted [transferring facility name] had been Resident #70's long term care rehabilitation facility preference. The note indicated there had been no availability and Resident #70 had been discharged to another facility. An interview with Resident #70 was conducted via phone on 2/27/25 at 3:12 PM. He stated he had been in the hospital for about a week. When he was ready to discharge, he was told there were no beds available at [transferring facility name] and was discharged to another rehabilitation facility. He stated he would have returned to [transferring facility name] if a bed had been available. An interview with the Admissions Coordinator was conducted on 2/27/25 at 4:13 PM. She explained the bed hold policy had not been given to Resident #70 or his Responsible Party (RP) when he was discharged . She stated most of the time she spoke with the hospital case worker about bed availability and explained it probably was her who had said there were no beds available. She stated Resident #70 would have been allowed to return if a bed had been available. The Admissions Coordinator provided the facility census for 1/16/25 which revealed only one semiprivate female bed was available that day. The Admissions Coordinator explained she had not offered Resident #70 a bed when one became available. On 2/27/25 at 5:28 PM an interview was conducted with the Administrator. He stated he had been unaware of allowing residents to return to the first available bed when no beds were available at the time of discharge from the hospital. Messages were left for the Case Manager at the discharging hospital on 2/27/25 and 2/28/25 with no return call received.

Based on record review and staff interview, the facility failed to develop an individualized person-centered care plan in the areas of pain management, anticoagulant and diuretic use, and behaviors for 3 of 6 residents reviewed for comprehensive care plans (Resident #32, #21 and #63). The findings included: 1. Resident # 32 was admitted to the facility on [DATE] with a diagnosis that included pain. Review of Resident #32 comprehensive care plan dated 11/21/24 did not reveal a care plan for pain. Review of Resident #32's physician orders dated 11/21/24 stated Oxycodone 5 milligrams (mg) as needed for breakthrough pain, Oxycodone 5mg every 8 hours for pain, Gabapentin 300 mg at bedtime for pain and Gabapentin 600mg 2 times a day for pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 32 was cognitively intact and was administered pain medication. The pain medication was scheduled and as needed (PRN). Interview with MDS Coordinator #1 on 2/27/25 at 4:29 PM revealed she participated in clinical meetings every morning. During clinical meetings, updates to resident medications were discussed and reviewed which was how she was kept abreast of care planning needs. She stated Resident #32 should have had a care planned for developed for pain due to receiving oxycodone and gabapentin. She indicated she did not develop a comprehensive care plan due to her oversight. Interview with the Director of Nursing (DON) on 2/27/25 at 5:27 PM stated Resident #32 was prescribed scheduled and PRN medications for pain. Medications were reviewed in clinical meetings every morning to include the MDS coordinator. She stated there should have been a care plan developed for Resident #32's pain. 46725 2. Resident #63 was initially admitted to the facility on [DATE], readmitted on [DATE] with diagnoses that included dementia. A comprehensive Minimum Data Set (MDS) assessment was completed on 1/10/25 and indicated that Resident #63 was cognitively impaired, displayed no behaviors and had no upper extremity impairment. A review of the progress notes by Nurse #1 dated 1/30/25 revealed Resident #63 was observed sitting on the side of her bed with markers and appeared to have put green marker on her lips like lipstick. The active care plan was last reviewed and revised on 2/4/25. There were no revisions made that reflected the need for Resident #63 to have only non-toxic markers provided for her. A review of the progress notes by Nurse #2 dated 2/5/25 indicated Resident #63 was observed sucking on her markers and pointed to her lips and stated the word lipstick. An observation was made of Resident #63 on 2/26/25 at 8:38 AM. Resident #63 was seated in her wheelchair with bedside table in front of her and had non-toxic markers available in a container along with a coloring book. An interview was conducted with the Activities Director on 2/26/25 at 9:13 AM. She indicated that the family and the facility provided non-toxic markers to Resident #63 as coloring was important to her and staff were to redirect her as needed. An interview was conducted with the Unit Manager on 2/27/25 at 10:04 AM. She indicated Resident #63 had only non-toxic markers and per her family member's request, she was allowed to use non-toxic markers for an activity. She further revealed that staff have been told to redirect Resident #63 if she was seen sucking on markers or attempting to use the markers as lipstick. An interview was conducted with the Medical Director on 2/27/25 at 11:59 AM. She indicated that she was aware and in support of Resident #63 having access to non-toxic markers for activity purposes but would be concerned for Resident #63's safety if she had access to non-toxic markers. The MDS Nurse was interviewed on 2/27/25 at 10:21 AM and explained that the behavioral care plan should have been revised to indicate Resident #63 only needed to have access to non-toxic markers and to be redirected by staff if she was observed using markers as lipstick or sucking on the markers. The Director of Nursing (DON) was interviewed on 2/27/25 at 5:25 PM and stated that Resident #63's change in behavior was discussed in staff morning meetings and that the MDS nurse should have updated her care plan to reflect the change in behavior. 3. Resident #21 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation and essential hypertension. Physician orders dated 1/22/25 included Eliquis (an anticoagulant medication used to reduce the risk of forming blot clots) 5 milligrams (mg) twice a day and furosemide (a diuretic medication used to increase urine output by promoting the excretion of water and electrolytes from the kidneys) 20 mg once a day. January 2025 and February 2025 Medication Administration Records (MAR) recorded Resident #21 received Eliquis 5mg twice a day and furosemide 20mg once a day from 1/22/25-2/27/25. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #21 was cognitively impaired, was coded for anticoagulant use. Resident #21's care plan reviewed dated 2/4/25 did not include a focus for the use of blood thinners and/ or anticoagulants or the use of diuretics. On 2/26/25 at 1:31 PM MDS Nurse #1 was interviewed. She verified the care plan for Resident #21 did not include a focus for the use of anticoagulants or the use of diuretics. She stated that it should have been added at the time the MDS was completed. The Director of Nursing (DON) was interviewed on 2/27/25 at 5:25 PM. She stated that a focus for anticoagulant and diuretic use should have been added to Resident #21's care plan.

Based on observation, record review, and resident, staff, dentist, and physician interviews the facility failed to obtain recommended dental services for 1 of 1 resident (Resident #32) reviewed for dental services. The findings included: Resident #32 was admitted to the facility on [DATE]. Her diagnosis included exfoliation of teeth (process that allows the replacement of the primary dentition with permanent teeth) due to systemic causes, disorientation, hypertensive heart disease, chronic kidney disease, chronic diastolic (congestive) heart failure and periapical abscess without sinus (a dental abscess that occurs when bacteria infects the tooth's root and doesn't drain into a sinus). A quarterly MDS dated [DATE] revealed Resident #32 was cognitively intact. Resident #32 had no mouth pain, facial pain or difficulty chewing. She had no documented weight gain or weight loss. Her pain was documented at a 4 at its highest. Resident #32 was coded as receiving an opioid and she had scheduled and as needed (PRN) pain medication. A consultation/report letter dated 12/5/24 stated Resident #32 was seen in the dental office/oral surgeon for a consultation. Resident #32 was not a candidate for treatment to be done in the office setting. Resident #32 would need to be treated in a hospital setting. The recommendations stated that due to the health history of Resident #32 she was not a candidate for intravenous (IV) sedation in an outpatient setting. Resident #32 was referred back to the dentist to send to a hospital setting for the procedure to be completed. This note was signed by the Unit Manager who documented the consultation report was faxed to the contracted mobile Dentist on 12/6/24. The facility's facsimile cover page dated 1/22/25 indicated a referral for Resident #32 to be seen by an outside dental agency. The facsimile documented: please call the Unit Manager to schedule an appointment or if you have any questions, and that resident required sedation. An interview with the Unit Manager on 2/27/25 at 11:28AM indicated consultation reports following an appointment would come to her either by fax or upon return from an appointment and she reviewed the consultations for further recommendations. She stated the oral surgeon recommendations dated 12/5/24 stated they could not perform the procedure (tooth extraction) on Resident #32 because they could not sedate her for the procedure. She stated following the recommendations from the oral surgeon on 12/5/24, she completed a referral for Resident #32 to be seen by a dental school on 1/22/25. The Unit Manager stated she was unsure of why she had not sent the referral to the dental school before 1/22/25. During the interview, the Unit Manager was observed to review her emails. She stated she had not received confirmation that Resident #32 could be seen by the dental school for the extraction. Additionally, during the interview, the Unit Manager was overheard calling the SW to determine if Resident #32 had been placed on the list for the contracted mobile dentist. It was confirmed that Resident #32 had not been seen by a dentist after the oral surgeon's appointment on 12/5/24. She revealed she had not followed up with the dental school to determine if the procedure could be completed per the referral she completed (1/22/25). The Unit Manager indicated she should have followed up on the referral she sent to determine if Resident #32 could have an extraction at their office. During an interview and observation of Resident #32 on 2/25/25 at 12:35pm the resident was observed eating her lunch. The meal was of regular texture. Resident #32 was observed to have eaten 75% of her meal. When asked how she was, Resident #2 stated she was ok. Resident #32 did not exhibit any signs or symptoms of pain during the interview. Resident #32 indicated she had to have her tooth extracted because she had some tooth pain. Observation and interview with Resident #32 on 2/27/25 revealed the resident was eating lunch. Her meal consisted of regular texture. Resident #32 did not exhibit any signs of symptoms of pain while chewing. Resident #32 was asked about her meal and did not indicate she was having any pain. Resident #32 stated she had not had her tooth extraction completed yet. She required a prompt to recall past dental visits. The Social Worker (SW) was interviewed on 2/27/25 at 11:15AM. The SW stated she was responsible for completing referrals to include dental services. She had completed a referral for Resident #32 to see the contracted mobile Dentist on 10/7/24. The referral was made due to Resident #32 stating she needed a molar extraction. Any notes or recommendations from that appointment would have been reviewed and filed by the Unit Manager. The Unit Manager would then complete any after-visit notes. The SW stated she was not aware of the oral surgeon recommendations dated 12/5/24. She stated if the Unit Manager needed the SW to assist in scheduling, she (the SW) would have tried to research a hospital that might be able to provide Resident #32 with any needed treatment. She stated Resident #32 had not been seen by a dentist for an oral exam since the consultation with the oral surgeon on 12/5/24. In an interview with the contracted mobile Dentist on 2/27/25 at 2:15pm he revealed he completed his initial exam on Resident #32 on 10/22/24. He recalled Resident #32 having sensitivity of a crown on the lower left side of her mouth. With tapping and percussion Resident #32 had a little bit of pain. Resident #32 had said her previous exam (prior to admission to the facility) indicated she needed an extraction. The Dentist stated he did not take x-rays of tooth #19 (the tooth that required the extraction) to see exactly what the concern was, but he suspected possible nerve damage. He also assumed Resident #32's tooth sensitivity could have been from a possible abscess. Resident #32 was apprehensive of needles which was the reason he referred Resident #32 to have an extraction of tooth #19 with the oral surgeon. The oral surgeon could do deep sedation for dental procedures. He stated he could see a reply in the resident's electronic medical record from the oral surgeon on 12/5/24 with recommendations. The recommendations were to have the procedure done in a hospital setting, but there was no one in the area that he was aware of that would perform the type of procedure Resident #32 needed due to her medical condition and diagnosis. In an interview with the Director of Nursing on 2/27/25 at 5:27PM she stated Resident #32 had a dental consultation report from the oral surgeon on 12/5/24 that stated she (the resident) could not be seen due to IV sedation and her diagnosis. A referral had been sent by the Unit Manager for Resident #32 to seen by a dentist at the dental school in January. The Unit Manager should have followed up on the referral for the dental school before today (2/27/25). In an interview with the Physician on 2/28/25 at 9:58AM she revealed the oral surgeon felt Resident #32 needed general anesthesia to have her tooth extracted. It could be difficult to locate a dentist to do general anesthesia on Resident #32 due to her health condition from a cardiology standpoint. If the facility was unable to find an inpatient factility to do the dental procedure under general anesthesia, the facility should have made her aware so she could attempt to locate an alternative. She was unsure if Resident #32 had a dental visit by the contracted mobile Dentist following the 12/5/24 appointment with the oral surgeon. She would have expected a referral be sent out for Resident #32 to be seen for oral care before 3 or 4 weeks ago (1/22/25) but due to holidays in-between that time it could have caused delay. She further stated Resident #32 was clinically stable and had no complaints regarding tooth pain prior to her appointment with the oral surgeon or thereafter. The facility needed to figure out how to take care of the resident's extraction but not in an emergency setting. The Physician stated she would need to talk with the Nurse and SW to identify a plan.

Based on observation, record review, and staff interviews, the facility failed to implement infection control policies and procedures when Nurse Aide #1 and Housekeeper #1 failed to don all the required Personal Protective Equipment (PPE) before entering a room with a resident on special contact-droplet precautions. This occurred for 2 of 2 staff observed for infection control practices (Nurse Aide #1 and Housekeeper #1). The findings included: The facility's Infection Prevention and Control Program policy last revised on 12/23/24 and read in part: The infection Prevent and Control Program of this facility maintains an organized, effective, facility wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors, and employees. This program involves the collaboration of many programs and services within the facility and is designed to meet the intent of regulatory and accrediting agencies. Review of the facility's special contact droplet precautions last revised 12/23/24 read in part, personal protective equipment: put on in this order alcohol-based hand rub or wash with soap and water if visibly soiled, gown, fit tested NIOSH approved respirator (N95) or higher-level respirator, put on eye protection (face shield or goggles), and gloves. 1. An observation was conducted on 02/24/25 at 12:03 PM of Nursing Assistant #1 (NA#1). NA #1 entered room [ROOM NUMBER] to deliver Resident #127's lunch meal tray wearing only a surgical mask. The signage that was on the wall beside the room door read in part, special droplet contact precautions. An interview was conducted with NA #1 on 02/24/25 at 12:05 PM and she stated, it's confusing, I thought as long as I was not providing patient care it was ok, since I was just taking the tray in the room. An interview was conducted on 02/24/25 at 12:11 PM with Nurse #3. Nurse #3 stated Resident #127 was on isolation precautions for Respiratory syncytial virus (RSV) and Influenza. She indicated staff were supposed to put on the PPE prior to entering the room. 2. On 02/25/25 at 09:21 AM and observation was conducted of Housekeeper #1 in room [ROOM NUMBER] mopping the floor with a surgical mask and gloves on. The signage that was on the wall beside the room door read in part, special droplet contact precautions. During the observation the Unit Manager went to the door of the room [ROOM NUMBER] and instructed Houskeeper #1 to come out of the room and she informed him that he was supposed to have on a N95, gown and face shield as well. An interview was conducted on 02/25/25 at 9:24 AM with Housekeeper #1. He indicated he was not aware that he was supposed to put the PPE on that was listed on the special droplet precautions sign. During an interview with the Director of Nursing on 02/25/25 at 9:32 AM she stated, They're not reading the signs. The DON further stated, we haven't had an isolation in a while. The DON indicated she expected staff to read the signage and put on the PPE that was listed on the signage. An interview was conducted with the Administrator on 02/27/25 at 5:45 PM. He indicated staff should read the signs to understand the precautions before entering a room.

Based on staff interviews and record review the facility staff failed to immediately report an alleged allegation of abuse to administration for two (Resident #1 and Resident #2) of three residents reviewed for abuse allegations. The findings included: Documentation the facility policy entitled Abuse, Neglect, Misappropriation of Resident Property, and Exploitation dated as last reviewed on [DATE] stated in part under reporting, Any employee who witnesses or suspects that abuse, neglect, misappropriation of resident's property or exploitation has occurred, must immediately report the alleged incident to the nursing supervisor, who must immediately report the incident to the Administrator or Director of Nursing. Resident #1 was admitted to the facility on [DATE] and had multiple diagnoses one of which included Alzheimer's disease. Documentation on an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was coded as severely cognitively impaired. Resident #2 was admitted to the facility on [DATE] and had multiple diagnoses which included but was not limited to dementia and aphasia. Documentation on a quarterly MDS assessment dated [DATE] revealed Resident #2 was coded as severely cognitively impaired with behavioral symptoms not directed toward others for one to three days of the assessment period. An interview was conducted with Nurse Aide (NA #2) on [DATE] at 10:45 AM. NA #2 revealed she received a voice message on a social media application from NA #1 on Thursday, [DATE] in the afternoon. NA #2 stated she did not listen to the voice message until the evening of Friday, [DATE] at approximately 6:45 PM. NA #2 revealed the voice message she recognized to be from NA #1 indicated in part, NA #1 had popped [Resident #2] in the mouth and NA #1 bit Resident #1 after being bitten by Resident #1. NA #2 stated the voice message described Resident #1 to be the old white [female dog]. NA #2 revealed on the evening of Saturday, [DATE] the voice message would be expired and automatically be deleted so, before the evidence of the voice message was deleted, she went to a nursing supervisor (Nurse #4) and let her listen to the message. NA #2 stated she knew that NA #1 was not on the schedule to work in the facility until Tuesday, [DATE], so she was not concerned NA #1 would be in the facility in the next couple of days if the voice message was factual. An interview was conducted with Nurse #4 on [DATE] at 1:55 PM. Nurse #4 revealed NA #2 came to her home late on Saturday, [DATE] and informed her she had something for her to listen to. Nurse #4 stated she listened to the voice recording sent by NA #1 on the social media application, and stated she was in shock. Nurse #4 stated she recorded the voice message on her personal phone and when she returned to work on Monday, [DATE] she brought the voice recording to the attention of the Director of Nursing (DON). Nurse #4 stated she knew NA #1 was not on the schedule to work until [DATE], so at the time she thought informing the DON of the voice recording sent by NA #1 could wait until Monday, [DATE]. The Director of Nursing (DON) was interviewed on [DATE] at 1:25 PM. The DON confirmed she was made aware by the Nursing Supervisor on the morning of [DATE] of the voice recording made by NA #1 alleging abuse to Resident #1 and Resident #2. The DON stated she recognized the nursing staff did not report the allegation of abuse to her or the Administrator immediately and she initiated a plan of correction to make sure this did not happen again. The DON confirmed NA #1 did not work in the facility from [DATE] to [DATE] picking up extra shifts she was not assigned for and was suspended pending the outcome of the investigation on [DATE]. The DON also confirmed there was no evidence after an investigation was conducted to prove the alleged abuse of Resident #1 or Resident #2 occurred but, NA #1 was terminated from her employment for unprofessional behavior and insubordination. The facility's plan of correction dated as completed on [DATE] was reviewed with the following corrective actions put in place. Included in the plan was the assessment of Resident #1 and Resident #2 revealing no physical or residual adverse effects of the alleged abuse. An audit was conducted on [DATE] by Nurse #1, the Nurse Manager, to identify if there were any other allegations of abuse that had not been reported timely. All allegations of abuse for the past 30 days were reviewed by Nurse #1 and found to have been reported timely. On [DATE] the staff development coordinator provided education to Nurse #4 and NA #2 on the facility written policy and procedure for reporting abuse allegations. On [DATE] the staff development coordinator began educating all employees to include nursing, dietary, housekeeping, and therapy on the facility written policy and procedure for reporting abuse allegations immediately to a supervisor who should then report the allegation immediately to the Administrator or Director of Nursing. The education on reporting of abuse was completed on [DATE]. Any staff who were out on leave or on as needed status were educated prior to their assignment by the Director of Nursing/designee. All newly hired staff and contracted staff were to be educated on the abuse policies and procedures during orientation by the staff development coordinator. All employees receive training on abuse policies and procedures annually. An audit tool was developed to audit all allegations of abuse, neglect, misappropriation of resident's property or exploitation to ensure all the allegations have been reported immediately to administrative staff and state agencies as required by policy. The audits were conducted weekly for 12 weeks to ensure continued compliance with the plan of correction. The results of the audits were to be brought to the Quality Assurance Performance Improvement committee monthly for three months. The facility plan of correction was reviewed, and the following documentation, interviews, and observations were made for confirmation of corrective action. Documentation revealed skin assessments were conducted on [DATE] for Resident #1 and Resident #2. Documentation was reviewed of audits completed on [DATE] and [DATE] for reporting of abuse investigations revealed initial and continued monitoring. Documentation of education of abuse allegation reporting on [DATE] through [DATE] for the entire staff included signed confirmation. Staff, including Nurse #4 and NA #2, were interviewed to confirm knowledge of the policy for abuse allegation reporting was received and retained. Interviews and observations with residents revealed they felt safe and protected in the facility and did not reveal any evidence of unreported abuse. The facility's date of compliance of [DATE] was validated.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for 4 of 31 residents reviewed (Resident #20, Resident #21, Resident #36 and Resident #3). Findings included: 1. The facility's Pre-Admission Screening and Resident Review (PASRR) query form dated 4/20/2022 indicated Resident #20 had a Level II PASRR determination due to mental illness. Resident #20 had been admitted on [DATE]. His diagnoses included Schizoaffective disorder Bipolar type. The most recent Annual MDS assessment dated [DATE] did not indicate Resident #20 was currently considered by the state Level II PASRR process to have a serious mental illness. An interview with the Social Worker (SW) and MDS Nurse #1 was conducted on 10/25/23 at 12:55 PM. The SW stated she was responsible for including the PASRR information on the comprehensive MDS assessments except when she is off, then it would be the responsibility of the MDS nurses to include it in the assessment. The SW checked Resident #20's annual MDS assessment and stated it should have included the Level II PASRR for mental illness information. She further explained it had missed being marked. On 10/26/23 at 11:48 AM an interview with the Administrator was conducted. He stated he would expect the MDS nurse to code the PASRR information and any other resident information accurately on each applicable assessment. 46725 2. The facility's Pre-Admission Screening Resident Review (PASRR) notification letter dated 11/17/22 indicated Resident #21 had a [NAME] II determination with no expiration date. Resident #21 was admitted on [DATE]. Her diagnoses included Paranoid Schizophrenia. The most recent Annual MDS assessment dated [DATE] did not indicated Resident #21 was currently considered by the state Level II PASRR process to have a serious mental illness. An interview with the Social Worker (SW) and MDS Nurse #1 was conducted on 10/25/23 at 12:55 PM. The SW stated she was responsible for including the PASRR information on the comprehensive MDS assessments except when she is off, then it would be the responsibility of the MDS nurses to include it in the assessment. The SW checked Resident #21's annual MDS assessment and stated it should have included the Level II PASRR for mental illness information. She further explained it had missed being marked. On 10/26/23 at 11:48 AM an interview with the Administrator was conducted. He stated he would expect the MDS nurse to code the PASRR information and any other resident information accurately on each applicable assessment. 49295 3. Resident #3 was admitted to the facility on [DATE]. Record review indicated that resident had a physician order for Azithromycin antibiotics that started on 5/19/2023 and ended on 5/29/2023 for pneumonia. Resident #3 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that resident had a diagnosis of Pneumonia coded. An interview with the MDS Nurse #2 was conducted on 10/26/23 at 12:11pm. The MDS Nurse stated resident #3 had a history of pneumonia that was treated from 5/19/2023 to 5/29/2023 with antibiotics and did not have pneumonia diagnosed since. MDS nurse stated that pneumonia should not have been coded because it was not an active diagnosis during the look back period of the quarterly assessment. 4. Resident #36 was admitted to the facility on [DATE]. A hospice admission agreement dated 4/12/2023 was reviewed for Resident #36. The hospice admission agreement revealed Resident #36 was admitted to hospice services on 4/12/2023 and certified Resident #36 had less than 6 months to live. Resident #36 significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed that resident's prognosis was coded as no. Resident #36 Quarterly assessment dated [DATE] revealed that resident's prognosis was coded as no. An interview with the MDS Nurse #2 was conducted on 10/26/23 at 12:11pm. The MDS Nurse stated Resident #36 elected hospice and had a life expectancy of less than 6 months documented. She further indicated that resident's prognosis should have been coded as yes.

Based on observations, record reviews and interviews with residents and staff the facility failed to serve food that was palatable and at temperatures acceptable to 4 of 5 residents review for cold foods. (Resident #42, Resident #67, Resident #174, and Resident #177) This practice had the potential to affect other residents. Findings included: a. Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #42 was cognitively intact and independent with eating after assistance with meal set up. During an interview with Resident #42 on 10/26/23 at 2:30 pm she indicated she had concerns with all her meals being cold, this morning her breakfast was cold, she indicated she was served oatmeal, eggs, and toast. She indicated she did not eat her egg or oatmeal. She indicated she only ate her toast . Resident #42 indicated that she has complaint before, about the meals being cold. b. Resident #67 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #67 was cognitively intact and independent with eating after assistance with meal set up. During an interview with Resident #67 on 10/26/23 at 2:30 pm she indicated she had concerns with her meals being cold, this morning she indicated her oatmeal and eggs were cold, and she had toast . Resident #67 revealed she ate the cold food because no one would heat the food up. Resident #67 indicated that she has complained before, and no one did anything about the meals being cold. c .Resident #174 was admitted to the facility on [DATE]. Resident #174 Admission Minimum Data Set had not been completed. Resident #174 was cognitively intact and independent with eating after assistance with meal set up. Interview with Nursing Assistant (NA) # 2 on 10/25/23 at 10:15am who worked with Resident #174 indicated she was able to make her needs known. NA #2 also indicated she would set up Resident # 174 breakfast and lunch tray, however she was able to feed herself. During an interview with Resident #174 on 10/24/23 at 11:15am she indicated she had concerns with her meals being cold and the taste of the food was not good. She stated she would only receive a small amount of food and it would be cold on her meal trays. An interview was conducted on 10/26/23 at 9:15 am with Resident #174 during her breakfast meal and she revealed her breakfast was cold, and she also indicated her portion was very small. Resident #174 indicated she had reported to staff that the food was cold before and she hoped that it get better. d. Resident #177 was admitted to the facility on [DATE]. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] included that Resident #177 was cognitively intact and independent with eating after assistance with meal set up. During an interview with Resident #177 on 10/24/23 at 11:12 am she indicated she had concerns with her meals being cold at breakfast and the taste of the food was not good. An interview was conducted on 10/26/23 at 9:30am with Resident #177 during her breakfast meal and she revealed that the oatmeal and grits were running and cold. Resident #177 indicated she had no eggs this morning. An observation of the meal tray line service in the kitchen was conducted on 10/26/23 at 7:40am. The food items were placed on heated plates from a plate warmer. The plated meals were covered with insulated, dome shaped lids with bottoms. During an interview on 10/26/23 at 11:00 am., the Dietary Manager revealed he began working at the facility in May 2023 and did not frequently receive complaints from residents concerning the quality of the food. During an interview with the Dietary Manager and District Manager on 10/26/23 at 11:00 am indicated that their expectation was that all residents would receive good hot food and food on time daily. Interview was conducted with Administrator on 10/27/23 at 1:15pm he indicated that his expectation was for the dietary staff to provide palatable and hot meals to all residents daily.

Based on observations, record review, and staff interviews, the facility failed to assess residents' capability to self-apply a topical pain-relieving liquid and barrier ointment for 3 of 3 residents reviewed for self-administration of medications (Resident #47, # 39, #21). The findings included: 1.Resident #47 was admitted to the facility on [DATE] with diagnoses of other specified arthritis right knee and aphasia following cerebral infarction. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #47 was cognitively impaired. Review of the physician orders for Resident #47 revealed there was no physician order to apply a topical pain-relieving liquid. Review of the medical records revealed no assessment was completed for the capability of Resident #47 to self-administer a topical pain-relieving liquid. Review of the active care plan revealed no care plan for self-administration of medications. During an observation on 10/26/23 12:33 PM, a topical pain-relieving liquid roll on was in clear view on top of the television stand in the room of Resident #47. An interview was conducted on 10/26/23 at 12:35PM with Nurse #1 in Resident #47's room. Nurse #1 revealed the pain-reliving liquid should not have been left in Resident #47's room as she did not have an order for it. A telephone interview was conducted with the Medical Director, and she revealed the pain-relieving liquid should have been kept in a secure storage location and not left at the bedside. An interview was conducted with the Administrator on 10/27/23 at 12:43 PM and he revealed that all medications should be kept in a secure area such as the nursing carts or medication storage room unless there was an order for a resident to self-administer their medication. 2. Resident # 39 was admitted to the facility on [DATE] with a diagnoses of diabetes mellitus and macular degeneration. Review of the quarterly MDS assessment dated [DATE] revealed Resident #39 was cognitively impaired and required extensive assistance with personal hygiene. Review of the physician orders for Resident #39 revealed no order to self-administer a skin barrier ointment. Review of the medical records revealed no assessment was completed for the capability of Resident #39 to self-administer a barrier ointment. Review of the active care plan revealed no care plan to self-administer medication. During an observation on 10/26/23 at 12: 43 PM a container of zinc oxide barrier cream was observed on Resident #39's bedside table which was located directly beside Resident #39's bed. An interview conducted with Resident #39 on 10/26/23 at 12:43 PM revealed she was not able to recall any information about the container of zinc oxide barrier cream. An interview was conducted on 10/26/23 12:43 PM with Nurse #2 in resident #39's room. She revealed the zinc oxide should have been kept on the nurse's cart for safety and not left at Resident #39's bedside. A telephone interview was conducted with the Medical Director, and she revealed barrier creams should have been kept in a secure storage location and not left at bedside. An interview was conducted with the Administrator on 10/27/23 at 12:43 PM and he revealed that all medications should be kept in a secure area such as the nursing carts or medication storage room unless there is an order for a resident to self-administer their medication. 3. Resident #21 was admitted to the facility on [DATE] with diagnoses including rash and other nonspecific skin eruption, paranoid schizophrenia and altered mental status. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #21 was cognitively intact. Review of physician order dated 11/8/22 revealed an order to apply barrier cream every shift. Review of the physician orders for Resident #21 revealed there was no order to self-administer a skin barrier ointment. Review of the medical records revealed no assessment was completed for the capability of Resident #21 to self-administer a skin barrier ointment. Review of the active care plan revealed no care plan to self-administer medications. During an observation on 10/25/23 at 1:23 PM a tube of skin barrier ointment was found on Resident #21's bedside table. An interview conducted with Resident #21 on 10/25/23 at 1:23 Pm revealed she did not understand what the cream was for. An interview was conducted with Nurse #3 on 10/25/23 at 1:25 PM and she revealed the ointment should not have been left at the bedside as this medication should be stored on the medication cart and that the nursing assistant must have forgotten to return it to the nurse after use. A telephone interview was conducted with the Medical Director, and she revealed that the skin barrier ointment should have been kept in a secure storage location and not left at bedside. An interview was conducted with the Administrator on 10/27/23 at 12:43 PM and he revealed that all medications should be kept in a secure area such as the nursing carts or medication storage room unless there is an order for a resident to self-administer their medication.

Based on record review and staff interviews, the facility failed to revise care plans to reflect changes in dental status for 1 of 20 residents whose care plans were reviewed (Resident #15). The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses that included dysphagia. A review of the dental progress note dated 7/5/23 revealed patient has broken 10 mil, 24, 25, 26 edges are broken, recommended extractions 9, 10, 11. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was cognitively impaired. No dental changes were noted. A care plan that was noted to be last revised on 8/16/23, did not indicate Resident #15 was care planned for broken teeth. A telephone interview was conducted with the dental assistant on 10/25/23 2:16 PM. She revealed that the dentist discovered Resident #15's broken teeth during a routine examination and cleaning on 7/5/23 and recommended extractions. She further revealed that the extractions had not yet occurred due to Resident #15 having no related pain at the time of the examination but that the facility staff should have been monitoring Resident #15 to let the dentist know if pain developed which would have expedited the date for the extractions. On 10/25/23 at 5:08 PM, an interview occurred with the Minimum Data Set (MDS) Coordinator. After reviewing Resident #15' s active care plan and medical record she confirmed she had failed to update the care plan to reflect the change in dental status and felt that this was an oversight. The Director of Nursing was interviewed on 10/25/23 at 5:10 PM and indicated it was her expectation for the care plan to be an accurate representation of the resident.

Based on observations, record review and staff interviews the facility failed to maintain water temperature during the wash cycle of the dishwasher according to manufacturer's instructions, failed to discard expired food and beverages, failed to cover, label, and date opened foods, failed to do hand hygiene and glove use between food preparation and sweeping the floor, and failed to keep ice machine clean. The findings included: During the initial tour of the main kitchen on [DATE] at 9:35 AM to 10:20 AM revealed the following: 1. On [DATE] at 9:35 AM it was observed that the water temperature during the wash cycle of the dishwasher that used chemical sanitation was 100 degrees Fahrenheit during the wash cycle. The machine is a single rack low temperature chemical dishwasher. Dishwasher instructions posted on wall above dishwasher. Temperature range ,d+[DATE] degrees Fahrenheit listed on the machine. Interview with Dietary Manager on [DATE] at 9:36 AM revealed that the machine is a single rack low temperature chemical dishwasher. She stated per manufacturer instructions the water temperature is to be at 120 degrees Fahrenheit and the sanitizing chemical being used is bleach. She stated that the temperature was lower than expected. She stated that the sanitation concentration is tested 3 times a day. 2. Facility failed to cover, label, discard, and date foods. The following items were observed in refrigerators and dry storage available for use. A. In the walk-in refrigerator the following were seen: 1. One 128-ounce opened container of cole slaw dressing with no open date. 2. One box of muffins not covered and no opened date. 3. One package of Tortillas left open and no open date. B. In the reach in refrigerator #1: 1. One chocolate shake with a throw away date of [DATE]. C. Dry storage area: 1. One package of 24 count rolls with a package expiration date of [DATE] 2. Five packages of 24 count rolls with a package expiration date of [DATE]. 3. The ice machine had mold-like, black substance and pinkish slime-like substance on the lid and hinge. On [DATE] at 11:40 AM the Cook was observed sweeping the floor without wearing gloves. The Cook then donned gloves on, handled pots of cooking food, removed the gloves, and handled the pots of cooking food again without washing hands after the task. The Dietary Manager was interviewed on [DATE] at 2:34 PM in reference to food labeling and discarding foods/beverages on discard dates. She stated that it is everyone's responsibility for labeling food/beverages after opening and discarding foods/beverages on discard/expired dates. She stated she does daily checks. She stated per policy, opened foods are to be thrown away 7 days after opening. In reference to staff sweeping and not washing hands between handling and preparing foods, she stated she expected staff to wash their hands prior to handling the pots/food and prior to applying gloves. Regarding the dish machine, the sanitation concentration is tested 3 times a day. She stated the heat booster was not functioning properly, and a work order had been done. The kitchen shared the hot water heater with laundry and was currently alternating times of washing dishes and laundry to allow for proper washing and rinsing temperatures until the heat booster is repaired. Interview with the Administrator on [DATE] at 12:10 PM was conducted. The Administrator stated he expects the water temperature to be per policy regulations. He stated the heater booster is on schedule to be looked at today. Administrator stated it is dietary's responsibility to check the water temperature prior to using. Administrator stated his expectation is that dietary properly label and dispose of expired foods/beverages and to keep ice machine and other equipment clean. The Administrator stated his expectation is for all staff to wash their hands prior to handling foods.

Based observation and staff interview, the facility failed to discard expired medications in 1 of 1 medication room and failed to date and label medication in 1 of 2 medication carts on the 100 hall reviewed for medication storage. Findings included: a. An observation of the medication room, on 4/07/22 at 9:32 AM revealed 2 unopened bottles of Vitamin E 90 mg (200 IU) tablet - expiration date 1/22 1 opened bottle of low dose aspirin tablet - expiration 4/21. During an interview on 04/07/22 at 09:35 AM with the Treatment Nurse regarding the medication room, she stated that all nurses were responsible for checking the medication room for expired medication. The Medical Records Clerk ordered supplies and removed the expired medication. An interview on 04/07/22 at 10:08 AM with the Medical Records Clerk revealed she ordered the supplies and checked the medication room once a week for expired medications and threw away any expired medication from the medication room. She reported that expired medications should not be in the medication room. b. An observation of the 100-hall medication cart on 4/07/22 at 12:01 PM, revealed: 1 bottle of loperamide [MEDICATION(S)] acid, anti-diarrheal medication, 2mg tablets - expired 3/2022 1 [MEDICATION(S)] inhalation aerosol inhaler, used to treat asthma, 110mcg - loose in the medication cart drawer with no open date or resident name. During an interview on 04/07/22 at 10:22 AM, Nurse #2 reveled that the 100-hall medication cart was her assigned cart for the day. She reported that she was not sure who reviewed the medication cart for expired or unlabeled medications. Nurse # 2 reported that all medications needed to be labeled with a resident's name and dated. She expressed that since that the inhaler did not have a name or date, it needed to be thrown away. An interview on 04/07/22 at 10:42 AM with Nurse Supervisor #1 revealed that the pharmacist checked the medication room monthly. Nurses were responsible for removing expired medications from medication carts and the medication storage room. Nurses were instructed to notify supervisor for unmarked meds and to remove expired medications per facility protocol. An interview on 04/07/22 at 12:30 the Director of Nursing (DON) revealed that nurses should check medication carts nightly for unlabeled and expired medications. She reported that nurses should be reviewing expiration dates when administering medications.

Based on resident and staff interviews the facility failed to offer or deliver bedtime snacks to 2 (Resident # 33 and Resident # 40) of 2 residents reviewed for the delivery of snacks. Findings included: A. According to the Minimum Data Set (MDS) for Resident # 33 she was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. On 04/04/22 at 11:26 AM an interview was conducted with Resident # 33. She stated that bedtime snacks were not delivered or offered. During a second interview with Resident # 33 on 04/06/22 at 09:47 AM she stated that she never received, and she was not offered a snack on 04-05-2022. B. According to the Minimum Data Set (MDS) for Resident # 40 she was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. On 04/04/22 at 11:28 AM an interview was conducted with Resident # 40. She stated that bedtime snacks were not delivered or offered at any time. On 04/07/2022 at 8:10 PM an interview with Nursing Assistant (NA) # 3 was conducted. She stated that she was assigned to Resident #33 and Resident # 40 on 04/05/2022. She stated that she does pass the ice, but she does not pass or offer snacks unless the resident specifically asks for one. She stated she does not take the snack cart door-to-door because these are long term care residents, they ask if they want one. On 04/07/22 at 9:26 AM an interview with Nurse # 3 was conducted. She stated yes and no to the bedtime snacks being passed. The NAs know which residents usually ask for snacks, so they bring those residents the snacks. Some NAs take the cart door to door, and some don't. She expected the NAs to take the snack cart door to door and offer each resident a snack. If an agency NA is on the hall, she will educate them on the residents and she tells them to pass snacks. On 04/06/22 at 11:05 AM an interview was conducted with the Dietary Manager (DM). She stated dietary takes snacks out three times a day and the nursing staff pass them out. The snack times are 10:00 AM, 2:00 PM, and 8:00 PM. On 04/07/22 at 12:32 PM an interview was conducted with the Director of Nursing (DON). She stated that she was unaware the snacks were not being passed. She stated her expectation was for the staff to pass snacks at scheduled times.

Based on observations, record review, and staff interviews, the facility failed to: 1) Post the appropriate signage for Transmission Based Precautions (TBP) as recommended by the Center for Disease Control and Prevention (CDC) and as directed by the facility's policy for 3 of 5 newly admitted residents who were not up-to-date with all recommended COVID-19 vaccine doses or whose vaccination status was unknown (Resident #65, Resident #66, and Resident #67); and, 2) Implement the required precautions and don personal protective equipment (PPE) as indicated by the signage posted on the door for 1 of 5 residents (Resident #216) observed to be placed on TBP. These failures occurred during a global pandemic. The findings included: Review of CDC guidance titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes (updated February 2, 2022) included recommendations specific for nursing homes on managing new admissions and readmissions. The guidance read in part: In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission, and should be tested as described in the testing section above; COVID-19 vaccination should also be offered. Review of a facility policy on [CONDITION(S)]-CoV-2 (Effective February 10, 2022) addressed Managing and Evaluating Residents. This policy read in part: New Admissions / Readmissions --COVID-19 status and vaccination status will be determined prior to admitting the resident . Up to Date: means a person has received all recommended COVID-19 vaccines, including ay booster dose(s) when eligible . --All residents who are NOT up to date with all recommended COVID-19 vaccine doses AND are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon readmission, and should be tested as described in the testing section; COVID-19 vaccination should also be offered . 1-a) Resident #65 was admitted to the facility on [DATE] and resided on the 600 Hall. Resident #65's medical record revealed she refused COVID-19 vaccination due to conscientious objection on 3/31/22 after admission to the facility. A review of the facility's record of the COVID-19 vaccination status of its residents (dated 4/4/22) indicated Resident #65's status as, Quarantine. An initial tour of the 600 Hall was conducted on 4/4/22 at 9:43 AM. An observation revealed three residents' rooms (Resident #63, Resident #69, and Resident #216) had signage to indicate the resident was on Transmission Based Precautions (TBP). Each of these three rooms also had a cart containing Personal Protective Equipment (PPE) placed next to the doorway. An observation conducted on 4/4/22 at 9:48 AM of the 600 Hall revealed there was no signage placed on or near Resident #65's doorway to indicate this resident was on TBP. However, a cart containing PPE was placed in the hallway next to Resident #65's door. An interview was conducted on 4/4/22 at 9:55 AM with Nurse #1. Nurse #1 was assigned to care for residents on the 600 hall. When asked, Nurse #1 reported she thought there were three - 600 Hall residents currently on TBP (Resident #63, Resident #69, and Resident #216). Upon further inquiry as to why a fourth PPE cart was on the 600 hallway, the nurse stated she was not sure what type of TBP precautions were in effect for Resident #65 but didn't think it was COVID-19 related. An observation and interview was conducted with the Assistant Director of Nursing (ADON) on 4/4/22 at 10:02 AM as he was changing the residents' TBP signage and placement of PPE carts on the 600 Hall. During the interview, the ADON reported he also assumed responsibilities as the facility's Infection Preventionist. At that time, the signage of TBP and placement of PPE carts for newly admitted residents on the 600 Hall were discussed. The ADON reported Resident #65 needed to be on TBP and to have a PPE cart placed next to her door. When asked who was responsible for posting a TBP sign and placing a PPE cart next to the resident's room, the ADON stated, During the week, I do. The ADON reported the quarantine status of a late Friday or weekend admission sometimes needed to be corrected when he came in on Monday. A follow-up interview was conducted on 4/7/22 at 9:34 AM with the ADON. During the interview, he reported the failure to post TBP signage on the weekend was due to a failure of communication between the Admissions staff and nursing. The ADON stated he typically knew about resident admissions ahead of time and would put a TBP order into the electronic medical record for a resident who was either unvaccinated against COVID-19 or whose vaccination status was unknown. An interview was conducted on 4/7/22 at 10:39 AM with the facility's Director of Nursing (DON). During the interview, the DON stated her expectation would be to have a better procedure in place to facilitate communication between Admissions and nursing staff with regards to a newly admitted resident's vaccination status and the need for initiation of TBP. 1-b) Resident #66 was admitted to the facility on [DATE] and resided on the 600 Hall. Resident #66's medical record revealed she refused COVID-19 vaccination on 4/4/22 after admission to the facility due to conscientious objection. A review of the facility's record of the COVID-19 vaccination status of its residents (dated 4/4/22) indicated Resident #66's status as, Quarantine. An initial tour of the 600 Hall was conducted on 4/4/22 at 9:49 AM. An observation revealed three residents' rooms (Resident #63, Resident #69, and Resident #216) had signage to indicate the resident was on Transmission Based Precautions (TBP). Each of these three rooms also had a cart containing Personal Protective Equipment (PPE) placed next to the doorway. An observation conducted on 4/4/22 at 9:48 AM of the 600 Hall revealed there was no signage placed on or near Resident #66's doorway to indicate this resident was on TBP. An interview was conducted on 4/4/22 at 9:55 AM with Nurse #1. Nurse #1 was assigned to care for residents on the 600 hall. When asked, Nurse #1 reported she thought there were three - 600 Hall residents currently on TBP (Resident #63, Resident #69, and Resident #216). An observation and interview was conducted with the Assistant Director of Nursing (ADON) on 4/4/22 at 10:02 AM as he was changing the residents' TBP signage and placement of PPE carts on the 600 Hall. During the interview, the ADON reported he also assumed responsibilities as the facility's Infection Preventionist. At that time, the signage of TBP and placement of PPE carts for newly admitted residents on the 600 Hall were discussed. The ADON reported Resident #66 needed to be on TBP and to have a PPE cart placed next to her door. When asked who was responsible for posting a TBP sign and placing a PPE cart next to the resident's room, the ADON stated, During the week, I do. The ADON reported the quarantine status of a late Friday or weekend admission sometimes needed to be corrected when he came in on Monday. A follow-up interview was conducted on 4/7/22 at 9:34 AM with the ADON. During the interview, he reported the failure to post TBP signage on the weekend was due to a failure of communication between the Admissions staff and nursing. The ADON stated he typically knew about resident admissions ahead of time and would put a TBP order into the electronic medical record for a resident who was either unvaccinated against COVID-19 or whose vaccination status was unknown. An interview was conducted on 4/7/22 at 10:39 AM with the facility's Director of Nursing (DON). During the interview, the DON stated her expectation would be to have a better procedure in place to facilitate communication between Admissions and nursing staff with regards to a newly admitted resident's vaccination status and the need for initiation of TBP. 1-c) Resident #67 was admitted to the facility on [DATE] and resided on the 600 Hall. Resident #67's medical record revealed she refused COVID-19 vaccination due to conscientious objection on 4/4/22 after admission to the facility. A review of the facility's record of the COVID-19 vaccination status of its residents (dated 4/4/22) indicated Resident #67's status as, Quarantine. An initial tour of the 600 Hall was conducted on 4/4/22 at 9:49 AM. An observation revealed three residents' rooms (Resident #63, Resident #69, and Resident #216) had signage to indicate the resident was on Transmission Based Precautions (TBP). Each of these three rooms also had a cart containing Personal Protective Equipment (PPE) placed next to the doorway. An observation conducted on 4/4/22 at 9:48 AM of the 600 Hall revealed there was no signage placed on or near Resident #67's doorway to indicate this resident was on TBP. An interview was conducted on 4/4/22 at 9:55 AM with Nurse #1. Nurse #1 was assigned to care for residents on the 600 hall. When asked, Nurse #1 reported she thought there were three - 600 Hall residents currently on TBP (Resident #63, Resident #69, and Resident #216). An observation and interview was conducted with the Assistant Director of Nursing (ADON) on 4/4/22 at 10:02 AM as he was changing the residents' TBP signage and placement of PPE carts on the 600 Hall. During the interview, the ADON reported he also assumed responsibilities as the facility's Infection Preventionist. At that time, the signage of TBP and placement of PPE carts for newly admitted residents on the 600 Hall were discussed. The ADON reported Resident #67 needed to be on TBP. He was observed as he moved the PPE cart located next to Resident #69's room to Resident #67's doorway, stating Resident #69 was also admitted over the weekend but was fully vaccinated and did not need to be on TBP. When asked who was responsible for posting a TBP sign and placing a PPE cart next to the resident ' s room, the ADON stated, During the week, I do. The ADON reported the quarantine status of a late Friday or weekend admission sometimes needed to be corrected when he came in on Monday. A follow-up interview was conducted on 4/7/22 at 9:34 AM with the ADON. During the interview, he reported the failure to post TBP signage on the weekend was due to a failure of communication between the Admissions staff and nursing. The ADON stated he typically knew about resident admissions ahead of time and would put a TBP order into the electronic medical record for a resident who was either unvaccinated against COVID-19 or whose vaccination status was unknown. An interview was conducted on 4/7/22 at 10:39 AM with the facility's Director of Nursing (DON). During the interview, the DON stated her expectation would be to have a better procedure in place to facilitate communication between Admissions and nursing staff with regards to a newly admitted resident's vaccination status and the need for initiation of TBP. 2) Resident #216 was admitted to the facility on [DATE] and resided on the 600 Hall. Resident #216's medical record revealed she refused COVID-19 vaccination due to conscientious objection on 3/28/22 (after admission to the facility). A review of the facility's record of the COVID-19 vaccination status of its residents (dated 4/4/22) indicated Resident #216 ' s status as, Quarantine. An initial tour of the 600 Hall was conducted on 4/4/22 at 9:49 AM. An observation revealed Resident #216's room had signage posted on her door to indicate the resident was on Transmission Based Precautions (TBP). A cart containing Personal Protective Equipment (PPE) was placed in the hallway next to her door. An observation conducted on 4/4/22 at 12:14 PM revealed a TBP sign continued to be posted on Resident #216's door and a cart containing PPE was placed next to her door. At that time, a Certified Occupational Therapy Assistant (COTA) student (COTA Student #1) was observed to enter Resident #216's room without donning a gown. He closed the door behind him. Review of the TBP signage for Special Droplet Contact Precautions posted on the door listed the required PPE to be donned prior to entering the room included a gown, an N95 or higher level respirator, protective eyewear, and gloves. A continuous observation of the resident's doorway revealed COTA Student #1 exited the resident's room on 4/4/22 at 12:42 PM. Upon his exit, he was observed to be wearing an N95 mask, eye protection and gloves (no gown). The therapist removed his gloves, then went back into the resident's room. Without wearing gloves or a gown, the therapist was observed from the hallway as he picked up the resident's call light and placed it next to her. He again exited the room. During an interview conducted on 4/4/22 at 12:45 PM, COTA Student #1 identified himself as a Certified Occupational Therapy Assistant student. When asked what PPE he was required to wear upon entering Resident #216's room, the student acknowledged he needed to wear an N95 mask, gown, gloves, and goggles. The student stated he realized he didn't have on a gown only after he had already started the therapy with Resident #216. When asked if he had received orientation at this facility regarding the PPE required to enter a room on TBP, the student said yes. However, he reported he received so much information that he forgot about the PPE. An interview was conducted on 4/5/22 at 10:40 AM with the Assistant Director of Nursing (ADON) on 4/4/22 at 10:02 AM. The ADON also assumed responsibilities as the facility's Infection Preventionist. During the interview, the ADON reported COTA Student #1 would be expected to follow the PPE requirements posted for a resident on TBP. An interview was conducted on 4/7/22 at 10:39 AM with the facility's Director of Nursing (DON). During the interview, the DON stated she would expect COTA Student #1 to observe the TBP signage and wear appropriate PPE when entering a resident's room. The DON reported the facility may need to put a plan into place to ensure a student received more extensive education on Day 1 with the Infection Preventionist prior to assuming resident care duties.

Based on record review, observations, resident, and staff interviews the facility failed to provide incontinent care in a manner to maintain the resident's dignity for 1 (Resident #33) of 4 residents reviewed for dignity. Findings include: Resident # 33 was admitted to the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #33's Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15, she required extensive assist with 2 staff members for bed mobility, total dependence with 2 staff members for transfers, total dependence with 1 staff member for toilet use and bathing, and extensive assist with 1 staff member for personal hygiene and dressing. She was coded incontinent for bowel and bladder. There was no coded rejection of care behaviors exhibited. On 04/04/2022 at 11:50 AM an interview was conducted with Resident #33. She stated that on 04/01/2022 she waited from 8PM to 11PM for her call light to be answered. She stated at 11:00 PM the NA # 3 came in and changed her. She stated she was saturated with urine and needed to be changed. She stated she knew it was 3 hours because she looked at her clock and timed it. On 04/06/22 at 09:47 AM an interview was conducted with Resident #33. She stated she waited an hour for the Nursing Assistant (NA) to answer her call light on 04/05/2022. She stated she put the call light on at 8:37pm. She stated after 45 minutes she threw a box of tissues at the door to get someone's attention. She stated Nurse #3 came in, asked her what she needed and turned the call light off. Resident # 33 told Nurse # 3 that she needed to be changed because she was wet and had a bowel movement. Nurse #3 then turned the call bell back on so the NA would come and assist her. NA #3 came in approximately 15 minutes later and changed her soiled brief. She stated she timed this occurrence by looking at her clock. She stated that she was saturated and had a bowel movement. She stated she felt like she needed to take a shower because she smelled like urine and that she was embarrassed about it. She stated she did not request a shower at that time. On 04/07/2022 at 8:10 PM an interview was conducted with NA # 3. She stated that she was assigned to Resident # 33 on 04/05/2022. She stated she changed Resident #33 and that she had a bowel movement. She stated she doesn't recall how long the call light was on. She stated she does her rounds every 2 hours and the nurse can answer call lights too. She stated she did not work on 04-01-2022. On 04/07/2022 at 9:26 AM an interview was conducted with Nurse #3 She stated she remembers resident # 33 complaining that it took 3 hours for someone to answer her call light on 04/01/2022 and an hour on 04/05/2022. She stated she answers call lights and helps the NAs when she can but it's hard to do when she's doing her med pass. She stated she went into the room two or three times herself between 8:00 PM to 11:00 PM on 4-1-22. She stated she went into resident # 33's room to give her roommate a breathing treatment, Resident # 33 did not say anything to her at that time. She stated she went into resident # 33's room two or three times, but she did not change the resident. She stated she was on her med pass and that she does not remember if Resident # 33 stated she needed to be changed. She stated she expects the NAs to answer the call lights within 5 minutes. She stated she remembered resident # 33 telling her that the NA came into the room to answer the call bell that was on for over an hour and changed Resident # 33's soiled brief. She stated she was on her med pass and that she did remember that Resident # 33 stated she needed to be changed so she turned the call light off then back on. On 04/07/2022 at 12:10 PM an interview with the Director of Nursing (DON) was conducted. The DON stated she was unaware of the wait times for these days. The DON stated her expectation is for the call lights to be answered in a timely manner by all staff. She stated NA # 3 had worked on 04-01-2022.

Based on observation, record review, staff, and physician interview, the facility failed to maintain a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.7% for 2 of 26 residents observed for medication pass. (Resident #38 and #55). Findings included: Resident # 38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a medication administration observation on 04/07/22 at 08:45 AM, senna plus was administered to prevent constipation to Resident # 38. During an interview on 04/07/22 at 08:50 AM Nurse #3 revealed she had mistakenly given senna plus. 2. Resident # 55 was admitted to the facility on [DATE] with gastro-[CONDITION(S)] reflux disease and nausea. Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a medication observation on 04/06/2022 at 9:25 AM Nurse #1 administered [MEDICATION(S)] 5 milligrams (for nausea and vomiting). During an interview on 04/06/22 at 09:25 AM Nurse #1 revealed that breakfast had been served and stated that Resident #55 preferred all her medication after her meals. She reported that Resident #55 had expressed in the past that the medication made her feel sick when taken on an empty stomach. An interview on 04/06/22 at 12:51 PM with the facility's Medical Director indicated that [MEDICATION(S)] was prescribed for nausea and vomiting. When a resident refused to take medication before meals, the nurse can request an order to administer with meals. An interview on 04/06/22 at 02:39 PM with Nurse Supervisor #1 revealed that nurses were to inform the Medical Director if a resident does not want to take medications before meals and that the order should be changed.

Based on observation, record review and staff interviews, the facility failed to follow doctor's orders for preparation for an outpatient procedure that was scheduled on three different dates causing the resident not to be able to have the procedure for each date it was schedule for 1 of 1 resident reviewed for [CONDITION(S)] (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact and required extensive assistance with activities of daily living. He was also coded for hemodialysis services. Review of records revealed Resident #1's Vascular Specialist office faxed orders to the facility on [DATE] with instructions for a scheduled fistulagram, an x-ray to look at blood flow and check for blood clots or other blockages in the fistula, on 8/17/21 at 7:00 AM. Instructions specified Resident #1 to not eat or drink after midnight on the night before the procedure (NPO), and to take the pre-procedure medications prescribed. The pre-procedure medications were listed as: (1) At 7 pm the night prior to the procedure: [MEDICATION(S)] 40 milligrams (mg) 1 tablet (2) At 11 pm the night prior to the procedure: [MEDICATION(S)] 40 mg 1 tablet (3) Morning of procedure: [MEDICATION(S)] 40 mg 1 tablet and [MEDICATION(S)] 50 mg 1 tablet During an interview with the Director of Nursing (DON) on 10/20/21 at 10:40 am, she revealed she discovered the faxed instructions for Resident #1 from Vascular Specialist office was scanned by the facility's Medical Records personnel on 8/5/21, but the orders were not entered into the system by nursing. Therefore, the orders for the pre-procedure medications and NPO instructions were not carried through on 8/16/21 and 8/17/21. The DON also revealed the same orders and instructions were faxed from Vascular Specialist office for the same procedure scheduled for 9/2/21 at 8:00 AM. These orders were scanned by the facility's Medical Records personnel but not entered into the system by nursing. Resident #1 did not receive the pre-procedure medications or maintain NPO status for the scheduled procedure on 9/2/21. The DON stated that the nurses or nurse managers were responsible to place orders into the system. She further clarified that the orders were not placed into the system because the Medical Records personnel scanned the orders and nursing had not entered them into the system, which caused the pre-procedure medications to not be administered. During a telephone interview with Vascular Specialist office personnel on 10/20/21 at 11:15 am, she revealed Resident #1 had missed four appointments in 2021. The first appointment missed was on 1/2/21 for a follow up from the previous month. The other appointments missed were on 5/7/21, 8/17/21 and 9/2/21 to perform a fistulagram. The procedure was scheduled from the hemodialysis center to ensure the fistula was functioning properly. She clarified the appointments missed on 5/7/21, 8/17/21 and 9/2/21 were because her office had to cancel each scheduled procedure due to the failure of the facility to give Resident #1 the pre-procedure medications for his contrast dye allergy and maintain an NPO status per the instructions. Resident #1 was then sent back to the facility and the procedure was not performed each time. She indicated she was made aware from the nursing department when she called the facility on each of these dates to confirm if Resident #1 had the pre-procedure medications and was NPO the night before that he had not been given the medications and he was not NPO. She also indicated Resident #1 stated when he arrived to each of these appointments that he did not receive the pre-procedure medications for his contrast allergy, and he had eaten breakfast on the mornings of the appointments. She further revealed although the fistulagram was not done it was recommended to reduce complications such as infection During an interview with the Medical Director on 10/20/21 at 2:05 pm, she revealed she was not aware that Resident #1 had missed any appointments at Vascular Specialist office. She noted that Resident #1 received hemodialysis three times a week and had a contrast dye allergy. She indicated Resident #1 was sent to the hospital on 8/9/21 for acute chest pain during a hemodialysis visit. She stated that she did not think the missed appointments at the Vascular Specialist office contributed to the hospitalization because his fistula site was currently being accessed at the hemodialysis center three times a week with no apparent issues. The Medical Director discussed the usual process of orders received from outside providers and expected the facility's nurses or nurse managers to transcribe and implement accordingly. She stated that she expected nursing personnel to ensure the providers at the facility signed all orders from outside providers before they were scanned by medical records personnel. The Medical Director further stated that she felt there was no harm done, and there was a communication problem that caused the facility to fail to give the pre-procedure medications that resulted in the missed appointments for Resident #1.

Based on observation, staff, Physical Therapist, nurse practitioner, radiologist, and physician interviews and facility and hospital record reviews, the facility failed to provide supervision in accordance with Resident #1's 9/20/19 care plan when the resident who was assessed to be at a high risk for falls experienced 3 falls within a one-hour period of time. The third fall resulted in a transfer to the hospital where the resident was diagnosed with [REDACTED]. The facility also failed to transfer Resident #7 using 2 staff members and a mechanical lift according to her care plan which resulted in an incident where the resident received a left [MEDICATION NAME], mildly comminuted [MEDICAL CONDITION] tibia and fibula. This occurred for two of three sampled residents reviewed for accidents. Immediate Jeopardy for Resident #1 began on 9/22/19 when Resident #1 experienced two unwitnessed falls and then a third fall within a one hour period without increased supervision with intensity as identified on the care plan. The last fall resulted in increased weakness and a significant change in his mental status. Resident #1 was transferred to the hospital and diagnosed with [REDACTED]. Immediate Jeopardy for Resident #1 was removed as of 10/5/19 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. Immediate Jeopardy for Resident #7 began on 4/3/19 when a nursing assistant (NA #2) transferred Resident #7 by a mechanical lift without the assistance of a second person. NA #2 did not notify the facility, and initially told the facility that she had the help of another staff in the transfer. NA#2 also asked NA#1 to tell the facility that she helped NA#2 with transfering Resident #2. The resident sustained [REDACTED]. Immediate Jeopardy for Resident #7 was removed as of 4/4/19 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to complete staff education and ensure monitoring systems put into place are effective. The findings included: 1. Resident #1 was admitted to the facility on [DATE] from the hospital for rehabilitation. His cumulative [DIAGNOSES REDACTED]. A review of the resident ' s medical record included a baseline care plan dated 8/23/19. The care plan noted Resident #1 was assessed to have a high fall risk score of 21 from his admission assessment. A fall risk score of greater than 13 was indicative of a high risk. A review of Resident #1 ' s medical record included the following Interdisciplinary Team (IDT) progress notes, in part: --8/23/19 at 7:31 PM: Resident OOB (out of bed) walking unassisted through BR (bathroom) into next room - bed alarm sounding. Resident assisted back to room and to bed by nursing staff. Alarm in place and functioning. --8/30/19 at 12:47 AM: Resident was in his own bed at start of shift, appeared to be resting comfortably. During HS (hour of sleep or bedtime) med pass, resident was noted to be standing in (another resident ' s room), with only shirt and socks on . Around 0030 (12:30 AM), nurse heard a bed alarm sounding, and it was coming from his room. Resident had gotten out of Bed A and was sitting on Bed B. Resident was attempting to put the fitted sheet back on the bed. The nurse assisted him back to Bed A (his bed). --9/1/19 at 11:55 PM: This writer was notified that residents bed alarm was sounding, and that he was standing in his room, holding onto his bedside table. When this writer approached resident he was happy to say he had found his car. Resident had no physical evidence of pain or distress. He was placed in his wheelchair, and brought out to common area for closer supervision . Review of an Event/Incident report dated 9/4/19 at 1:15 PM revealed Nursing Assistant (NA). found Resident #1 in a doorway sitting on the floor in front of his wheelchair. The resident was reported to have been attempting to stand/transfer unassisted. The notes indicated the wheelchair ' s brakes were not locked and, Resident was not strong enough to hold his weight and ended up falling straight down to floor onto his buttocks from standing position. Resident #1 did not complain of pain. A physical assessment was completed and reported he had some blanchable redness (skin becomes lighter with pressure and color returns immediately with release) on his buttocks. Vital signs were stable. No new orders or fall interventions for this event were noted. A notation on the report indicated the resident was being sent out to the hospital on that date. Review of an Event report dated 9/4/19 at 2:42 PM reported Resident #1 was sent out to the hospital for evaluation of right-sided weakness. A review of the resident ' s hospital records revealed he was admitted to the hospital with [REDACTED]. Hospital records included the resident ' s history of present illness (dated 9/5/19) which reported a computed tomography (CT) scan of his head was negative for acute changes. Resident #1 was treated and discharged back to the facility on [DATE] with a principal discharge [DIAGNOSES REDACTED]. A review of the resident ' s medical record included a second baseline care plan (dated 9/13/19) for his readmission to the facility. The care plan noted Resident #1 was assessed to have a high fall risk score of 22 at that time. Safety interventions identified on this baseline care plan included the following, in part: bed alarm; low bed; mats on the floor; and non-skid socks. A review of Resident #1 ' s medical record included the following IDT progress notes, in part: --9/15/19 at 7:08 PM: Received report from previous shift nurse that resident is fidgety, anxious, and requires constant supervision throughout shift; upon arrival of tour, resident is noted to be making multiple attempts to exit wheelchair, walk without assistance, states that he needs to go home, or also that he needs to be present somewhere to sign a document; makes offers to staff to pay them money if they will give him a ride to 'home' or another destination on (name of a specific road). After multiple redirection and constant supervision resident is currently sitting quietly in chair. Note in MD (Medical Doctor) book to provide further assessment. --9/17/19 at 3:39 AM: At start of shift tonight, resident was noted to be in wheelchair by nursing cart on hall. Resident made several attempts to stand up without assistance. While this nurse was passing medications tonight, resident was seated beside med cart as well. Resident continued to stand up and walk whenever this nurse was out of his sight. Resident was seen taking off his PCA alarm (personal alarm) also several times. This nurse stopped med pass on two occasions and allowed resident to walk in the hallway while holding rail beside him. Nurse pulled wheelchair behind him and held his free hand on both occasions. Immediately prior to this note, resident was seen standing in the middle of the hallway, one door up from his room .Notified MD of residents restless behaviors this shift. --9/17/19 at 1:15 PM: Resident noted ambulating in hallway unassisted this shift. Alarm sounding, w/c (wheelchair) in room and resident walking up hallway several times. Assisted back to w/c by nursing staff and PSA (personal alarm) alarm replaced. --9/18/19 at 12:37 AM: At the start of shift, resident was laying comfortably in his bed, he appeared to be sleeping. During medication pass, resident was seen sleeping in Bed A (not his bed), in his own room. Resident was resistant to going into his own bed, so nurse advised CNA (Certified Nursing Assistant) to let him remain where he is, and to try again later in the shift. Review of a psychiatric consult revealed the resident was seen by a geriatric neuropsychiatry provider on 9/18/19 for initiation of a treatment plan and ongoing management. The resident was started on 125 milligrams (mg) [MEDICATION NAME] (a mood stabilizer) to be given every night at bedtime for three nights, then twice daily. The assessment/plan read, in part: Very impulsive with poor safety awareness contributing to attempts to get up independently and falls. Resident #1 ' s medical record also included a progress note written on 9/19/19 at 1:29 AM which read, Resident up out of bed and ambulating room and hallway without assistance multiple times this shift, requires constant supervision and redirection from daytime staff members; after several episodes of exiting bed, setting off bedside alarm and attempting ambulation in room with multiple redirects from staff for safety, resident currently sleeping quietly in bed. Further review of the resident ' s medical record revealed he was seen by a Nurse Practitioner (NP) on 9/19/19 upon request of nursing due to agitation and restlessness. The NP ' s notation indicated nursing reported Resident #1 was confused with poor safety awareness and poor impulse control. He was reported as requiring constant redirection and reorientation. The NP ' s notation indicated measures already being implemented by staff to address his behavior and risk for falls included pain assessment/management, frequent redirection, reorientation, toileting and personal alarm as well as adjusting his bed to a low position. It was also noted the resident ' s family had declined aggressive evaluation and treatment and the MD indicated he was going to be transitioned to palliative care. On 9/19/19, a [DIAGNOSES REDACTED].#1 ' s list of diagnoses. A review of the resident ' s most recent Minimum Data Set (MDS) was a 5-day assessment dated [DATE]. Section C of the MDS assessment revealed the resident had moderately impaired cognitive skills for daily decision making. Section G of the MDS reported the resident required extensive assistance with 2+ person physical assistance for bed mobility and transfers; he required limited assistance with one person physical assistance for toileting and walking in his room; and supervision with 1 person physical assistance for walking in the corridor. Section J of the MDS assessment revealed the resident had experienced two falls with injury (not major) since his last assessment. Section O of the assessment revealed the resident received Physical Therapy (PT) rehabilitation services 4 of the last 7 days with a start date of 9/13/19. Review of an Event/Incident report dated 9/20/19 at 8:08 PM revealed the resident had an unwitnessed fall on 9/20/19 at 4:00 PM. A summary of the investigation reported after a concert in the Dining Room, he was moved by the Activities Director (AD) to the Activity Room to do a puzzle. The AD noted she turned around to retrieve the puzzle from a desk across the hall. When she returned 20-30 seconds later with the puzzle, she found Resident #1 on the floor. A narrative note included on the Event/Incident report dated 9/20/19 at 8:08 PM further described the incident. It read, Resident stood up from his wheel chair and fell in the activities room at approximately 4pm. Resident stated he thought he hit his head on the bookcase. There is a bump on his right forehead and two small cuts over his right eyebrow. Physical assessment done. He MAEB (moved all extremities well), w/o (without) complaint of pain, no bruising noted. Neurochecks started and WNL (within normal limits). MD informed and (family member) informed during visit with resident at 5pm. Oncoming nurse informed. Will continue to monitor. Orders (interventions) for this event included, in part: every 15 minute checks; and, monitoring his status every shift for 72 hours for bruising, change in mental status/condition, pain, or other injuries related to fall. A review of Resident #1 ' s medical record included an individualized care plan with an area of focus related to the resident ' s risk for falls due to confusion/unsteady gait (created on 9/20/19). The interventions included the following, in part: increased staff supervision with intensity based on resident need (initiated on 9/20/19). Review of a Neurological Observations Form revealed periodic neurochecks and vital signs were initiated on 9/20/19 at 4:15 PM through 9/22/19 at 1:15 PM with no concerns identified. A Resident Monitoring Sheet initiated after the fall on 9/20/19 revealed the resident ' s location was recorded every 15 minutes from 9/20/19 through 9/22/19 at 8:30 PM. Review of an Event/Incident report revealed Resident #1 was found on the floor of his room after experiencing an unwitnessed fall on 9/22/19 at 7:35 PM. A notation from 9/22/19 at 7:47 PM (recorded as a late entry on 9/23/19 at 10:47 AM by Nurse #1) read: Resident had an unwitnessed fall in his room approximately 1935 (7:35 PM). Nurse went in to assess resident. He was sitting on his bottom with his back and head against the wall. Resident denies pain, and has no physical evidence of such. Full ROM (range of motion) in all 4 extremities without difficulty. Resident had strong hand grips in both hands. Nurse placed her foot in front of resident feet, held both hands, and assisted resident to a standing position, and then walked him 3 steps to his wheelchair. Nurse noted bleeding to left elbow after resident was seated there. Nurse cleansed elbow with NS (normal saline), applied TAO ([MEDICATION NAME] ointment), covered with dry gauze, and secured it with [MEDICATION NAME] (a transparent film dressing). Resident stated he needed to use the bathroom when nurse finished treatment, so nurse assisted him to bathroom and notified CNA of event. Resident had PCA in place while on the commode. No further concerns at this time. Orders (interventions) for this event were noted on the Event/Incident report to included, in part: Ensure resident is in sight of nursing staff at all times while awake. Review of a second Event/Incident report from 9/22/19 revealed at approximately 7:50 PM that evening, the resident's alarm sounded and he was found to have experienced an unwitnessed fall in the bathroom. A Nursing notation dated 9/22/19 at 7:50 PM (Recorded as late entry on 9/23/19 at 11:34 AM by Nurse #1) read as follows: This nurse had brought resident to the bathroom after he stated he needed to use the toilet. Nurse attached PCA to resident ' s shirt and grab bar behind him due to high falls risk, then notified CNA of resident ' s location, and asked that she assist him off the commode while nurse contacted MD. Resident ' s alarm was sounding within minutes of being placed on commode. He was found sitting on his buttocks with shoulders resting on wall behind him. Resident denies pain or discomfort, and has no new visible injuries. Resident has full ROM in all 4 extremities and strong hand grasps. Residents L[NAME] (level of consciousness) was at baseline. No slurred speech noted. Resident was assisted to standing with 2 staff members, and placed in wheelchair. Resident had PCA attached to shirt, and was sat in front of nurses station for close supervision. Nurse attempted to contact resident ' s (family member) again, to notify her of skin tear from previous fall, and of second fall. No answer at this time either. A review of a third Event/Incident report dated 9/22/19 revealed Resident #1 experienced a third fall from his wheelchair while sitting near the nursing station at approximately 8:30 PM on 9/22/19. A Nursing notation made on the report read as follows: (Recorded as Late Entry on 09/23/2019 12:37 PM by Nurse #1) While resident was sitting in wheelchair at nursing station, he was noted to be reaching for his brakes on several occasions. It also appeared as if resident was trying to stand up, but did not succeed. Nurse verbally redirected resident to stay seated to ensure safety. Approximately 2030 (8:30 PM), resident fell on to floor, landing on his right side. It appeared as if resident was pushing off his chair to stand, and it gave out. Wheelchair did fall onto its side as well, but landed just behind resident. This nurse called 911 and resident ' s (family member) again, and again got no answer. (Family member) called back and spoke with this nurse just as 911 call ended. During this conversation, she requested resident be sent to (name of hospital) for evaluation .A second nurse was at resident ' s side while the phone calls were being made. Resident was log rolled onto his back, keeping neck as straight as possible, for thorough assessment. Resident was noted to have weakness in BUE (bilateral upper extremities) and non-reactive pupils. Resident was moving, as if trying to get up off the floor, but with noted weakness. Resident was attempting to respond verbally as second nurse was speaking with him, but he was unable to form words. Due to the significant changes after this fall, nursing staff allowed resident to stay on the floor until EMS (Emergency Medical Services) arrived to transport him to (name of hospital). Nursing staff was at his side the entire time, providing comfort and support. EMS left with resident around 2045 (8:45 PM). Resident had been on neuro checks at start of shift, which were being done as per order. New neuro checks started after initial fall this shift. A review of the hospital Emergency Department records from 9/22/19 revealed Resident #1 was not responsive to painful stimuli upon arrival to the hospital. A CT scan indicated he had a large subdural hematoma suggestive of recurrent hemorrhage. There was no indication on the report as to when the resident may have sustained a previous subdural hematoma. The family did not wish to have invasive interventions so comfort care measures were taken. Resident #1 passed away on 9/23/19 at 12:39 AM. An initial interview was conducted on 10/2/19 at 12:43 AM with Nurse #1 and follow-up telephone interviews were completed on 10/4/19 at 8:00 AM and 10/4/19 at 10:35 AM. Nurse #1 was the hall nurse who was assigned to care for Resident #1 the evening of 9/22/19 from 7:00 PM to 7:00 AM when he experienced three falls. Upon inquiry, the nurse described the events surrounding the resident ' s falls on 9/22/19. Nurse #1 reported she was in a room directly across the hall from Resident #1 ' s room when she heard his PCA alarm going off at the time of his first fall. When she entered the room, the resident was sitting up with his back against the wall, almost like he had landed against the wall and slid down. She reported he sustained a skin tear on his elbow with only a small amount of bleeding. Nurse #1 stated she also noticed a bruise on the resident ' s head first after the 1st fall, but it appeared to be an old bruise. The nurse reported the resident did not complain of pain, had full range of motion, and was able to stand up from the floor with assist of one then take two steps with assistance to his wheelchair. Nurse #1 reported the resident ' s strength and cognitive status were at baseline after the fall. The nurse reported she took him in the wheelchair to the treatment cart to get supplies for his skin tear. Resident #1 told her he needed to go to the bathroom, so she took him to his bathroom and helped him get seated on the commode. She connected his PCA alarm (described as an alligator clip that sounds when it is disconnected) to the resident ' s clothing and the grab bar in the bathroom while he was on the commode. The nurse reported she used the PCA alarm for the resident while he was on the commode as a precaution only because he had just had a fall. She stated she was still in the resident ' s room when she told NA (Nursing Assistant) #3 to come into the bathroom to supervise the resident. The nurse reported she did not intend to leave him unattended. Nurse #1 then went to the nursing station and called his MD and family about the falls. When asked, the nurse stated she did not know how long NA #3 stayed with him. The nurse reported that just before 8:00 PM, she heard Resident #1 ' s alarm go off while she was on the phone at the nursing station. She recalled staff went to check on the resident (including herself, NA #3, Nurse #3). Nurse #3 assessed the resident after the fall and he did not appear to have any new injuries at that time. Nurse #1 stated NA #3 brought the resident in his wheelchair to the central area near the nursing station after that second fall. The nurse reported as she worked on passing medications on the hall, she would put my eyes on him and at least look .I saw him trying to mess with the brakes and appear to start to get up and would remind him to be seated. Around 8:30 PM, Nurse #1 recalled she heard the resident ' s PCA alarm sound again. Although she did not see him actually fall, she stated it appeared he ' d slipped out of the wheelchair and he landed on his right side with the wheelchair tipped over behind him. Nurse #1 reported both she and Nurse #3 went over and simultaneously agreed the resident needed to be sent out to the hospital for evaluation, because it was obvious he had hit his head this time. The nurse reported although his vital signs were not abnormal, the resident was less responsive and much weaker after this third fall. A telephone interview was conducted on 10/2/19 at 12:33 PM with NA #3. NA #3 was identified as the nursing assistant assigned to care for Resident #1 the evening of 9/22/19 from 7:00 PM to 7:00 AM when he experienced three falls. The NA reported her assignment for that evening included two partial halls plus Resident #1 on a 3rd hallway. When asked, the NA described the events surrounding Resident #1 ' s falls on 9/22/19. NA #3 reported she had last checked on Resident #1 approximately 45-60 minutes prior to his first fall. After Resident #1 ' s first fall, she went to his room to see what had happened and if he was okay. When she entered the room, Nurse #1 and NA #4 had already helped him into his wheelchair. The NA stated she observed a knot on the resident ' s head at that time. After the resident fell a second time, she reported Nurse #1 called her to the resident ' s room. When she got to the room, she saw the resident in the bathroom as staff were transitioning him to his wheelchair. Upon further inquiry, NA #3 reported she was not aware Resident #1 was in his bathroom until after he had fallen the second time. She reported the resident did not appear to have any apparent injuries after his second fall. The NA stated she took Resident #1 in his wheelchair to the nursing station and locked the wheelchair brakes. When asked why she brought him there, the NA stated she wanted to place him where everyone could keep an eye on him. Approximately 10-15 minutes after he was brought to the nursing station, NA #3 stated she turned around a corner and saw him standing up. She told him to sit down and he did. A little while later, the NA reported the resident stood up again and fell down hard as he hit the tile floor. An interview was conducted on 10/3/19 at 2:26 PM with Nurse #2. A follow-up interview was completed with the nurse on 10/4/19 at 11:35 AM. Nurse #2 was the day shift (7:00 AM - 7:00 PM) hall nurse who was sitting at the nursing station the evening of 9/22/19 when Resident #1 experienced three falls. Upon inquiry, the nurse stated she saw Resident #1 being brought to the area by the nursing station while she was finishing up her charting for the day. Nurse #2 reported she was not sure who brought the resident to the nursing station, but did hear Nurse #1 say, I ' ve got some meds to give. Nurse #2 stated she was aware the resident was a high fall risk and needed to be watched. She did not recall anyone specifically asking her to keep an eye on the resident. Nurse #2 reported she heard Resident #1's chair alarm go off and she saw the resident as he began to stand up unassisted. The nurse reported she immediately told the resident to sit down and before she could get around the desk to him, he had already fallen. Nurse #2 identified the position where she was sitting at the nursing station, as well as where Resident #1 was sitting in his wheelchair. On 10/4/19 at 11:42 AM, the Maintenance Director was observed as he measured the height of the nursing station desk to be 45 and ½ inches high. On 10/4/19 at 11:55 AM, the Maintenance Director provided results of an additional measurement taken. Based on their reported locations, he determined Nurse #2 would have needed to walk 342 inches (28 and ½ feet) in order to get around the nursing station desk to where Resident #1 ' s wheelchair had been placed. An observation and a follow-up interview was conducted on 10/4/19 at 1:50 PM with Nurse #2. The observation of the nurse sitting at the nursing station revealed her eyes were approximately at the same level as the top of the desk at the nursing station. During an interview conducted with Nurse #2 at that time, the nurse was asked if she had been able to see the resident over the top of the desk when he was placed in the area of the nursing station on the night of 9/22/19. The nurse reported she could see the top of his head from where she was sitting because the resident was tall. An interview was conducted on 10/3/19 at 6:55 AM with NA #4. NA #4 was identified as the NA who was assigned to care for all residents on Resident #1 ' s hall (with the exception of Resident #1) from 7:00 PM - 7:00 AM on the evening of 9/22/19. NA #4 reported Resident #1 ' s hallway was her usual assignment and that she was typically assigned to care for him as well. She recalled Resident #1 was a fall risk and would constantly get up unassisted. She stated the resident ' s alarm, would go off constantly and reported she would go in to check on him and two minutes later the alarm would go off again. During the interview, NA #4 was asked to recall the events involving Resident #1 on the evening of 9/22/19. The NA reported when she went into the resident ' s room after his first fall that night, he was lying down on the floor beside his bed and Nurse #1 was already in the room with him. She stated the resident said he hit his head, but didn ' t say he was hurting anywhere. At that time, she could not see any unusual marks on his head. She assisted Nurse #1 to get him off of the floor, then left. After Resident #1 fell a second time that night, the NA recalled coming down the hallway when she heard his alarm sounding and Nurse #1 calling for NA #3 to help with the resident. The NA reported she saw NA #3 walking into the resident ' s room. When NA #4 got to his room, the resident had already been helped up into his wheelchair after having a fall in the bathroom. The NA stated she noticed Resident #1 started to develop a knot on his head, but she wasn ' t sure if it was from his first or second fall. This time he said he hit his head again when he fell . The NA reported the resident was still acting fine (normal) after the second fall. Resident #1 was brought to the nursing station. The next time NA #4 saw the resident was when she was coming down the hall and he was lying on the floor near the nursing station (after the third fall that evening). An interview was conducted on 10/2/19 at 1:15 AM with Nurse #3. Nurse #3 was identified as a hall nurse (not assigned to Resident #1 ' s hall) who worked the evening of 9/22/19 when the resident experienced three falls. Upon inquiry, Nurse #3 described the events of 9/22/19 surrounding the time of his falls. Nurse #3 reported she was not directly involved with the resident ' s first fall. However, Nurse #3 stated she went down to the resident ' s room after his second fall. When she entered the room, she saw NA #3 and NA #4 in the room with the resident already sitting in his wheelchair. The nurse stated she assessed the resident and checked his range of motion and hand grips. When she asked him what his name was, he spelled it for her. She recalled the NAs brought the resident out to the nursing station to keep an eye on him. Nurse #3 reported she was passing medications on another hall when she heard a noise that attracted her attention. She looked down the hall and saw Resident #1 lying on the floor on his right side by the nursing station. The nurse went to check him and reported, I got down on my hands and knees and started asking him questions .but he couldn ' t answer me. He tried to talk but nothing came out. The nurse stated she used a flashlight to check his pupils and they were non-reactive. She reported 911 was called within 5 minutes of the fall. Nurse #3 stated she stayed on the floor with the resident (did not move him) until EMS arrived and put him on the gurney. An interview was conducted on 10/4/19 at 1:55 PM with the Physical Therapist (PT) who was familiar with Resident #1. The PT reported she had completed the resident ' s Evaluation (dated 9/13/19) and Discharge Summary (dated 9/22/19). She reported therapy was working with the resident on strengthening, balance, wheelchair mobility and safety. Upon review of Resident #1 ' s Discharge Summary, the therapist confirmed the resident required minimum assist or upper extremity support to stand without loss of balance; he was unable to weight shift. He required contact guard assist and verbal cues for transfers. During the interview, the PT reported the resident was a very high fall risk and stated he needed someone to be with him all the time when he was transferred, walking and standing. Upon further inquiry, the therapist reiterated Resident #1 required someone touching him and cueing him for safety when he stood up and/or walked. An interview was conducted on 10/2/19 at 11:30 AM with Resident #1 ' s MD, who also served as the facility ' s medical director. During the interview, the MD recalled the resident and reported his confusion and impulsive behavior were likely the cause of his falls. The MD stated she felt the resident was evaluated in regards to the potential causes of his falls and she felt interventions were implemented appropriately by the facility. I think everything was done that could have been. During follow-up interviews conducted on 10/2/19 at 12:08 PM and 10/2/19 at 1:40 PM, the MD noted Resident #1 ' s family declined doing an imaging scan (magnetic resonance imaging or MRI) during his 9/4/19-9/13/19 hospital stay, so it could not be determined if he had a possible subdural hematoma at that time. The MD reported Resident #1 ' s hospital ED records appeared to indicate the cause of his death was a large subdural hematoma. When asked, she stated it may not be possible to determine which fall was the cause of the subdural hematoma. The MD noted the hospital radiology report from 9/22/19 suggested this was a recurring hematoma. Interviews were conducted with the Director of Nursing (DON) on 10/3/19 at 9:30 AM and 1:30 PM. During the interview, the DON discussed the procedures staff were expected to follow after a resident experienced a fall. She reported the hall nurse was required to do an assessment of the resident and to try and gain an understanding of what transpired so an intervention could be put into place to prevent future falls. After the resident was taken care of, she would expect the nurse to notify the resident ' s physician and family and to initiate appropriate interventions. If the fall was unwitnessed, neurochecks would also need to be initiated so the resident was monitored for any changes. Additionally, she would expect the nurse to document the fall on an Incident Report, an Investigation Sheet (a supplemental, hand-written form), and in the resident ' s medical record. The DON reported in-servicing on the topic of falls/accidents was initiated for the nurses on 9/23/19. A review of the list of nurses educated to date was conducted. The DON acknowledged not all nurses had received the in-service education as of this d