**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Resident 30's record was reviewed on 5/12/25 at 1:57 p.m. The profile indicated the resident's diagnoses included, but were not limited to, multiple sclerosis (a chronic autoimmune disease that affects the central nervous system [brain and spinal cord]). A quarterly Minimum Data Set (MDS) assessment, dated 2/11/25, indicated the resident was at risk for skin issues. A physician's order, dated 12/13/24, indicated to apply Ammonium Lactate External Cream 12 % (used to treat dry or scaly skin in adults and children) to both feet topically (on the skin) at bedtime for skin integrity protection for 60 days. The order lacked a specific stop date for the treatment. A pharmacy recommendation, dated 4/17/25, indicated to discontinue (DC) the treatment order, since it had been active for longer than 60 days. The order history lacked documentation that an order had been written to DC the treatment order. During an interview, on 5/13/25 at 11:50 a.m., the Director of Nursing (DON) indicated she had assumed that the order was an as needed (PRN) order. The pharmacy recommendation should have been addressed. The Pharmacist should have caught this around the time of the 60 days, and requested that an end date for the treatment be obtained. During an interview, on 5/13/25 at 1:44 p.m., the DON indicated the recommendation was not designated for the physician to address, but was for the nursing staff to address. The Pharmacist should have provided an specific end date for the cream when the order was originally sent to the Pharmacy, but had failed to do so. On 5/13/25 at 1:38 p.m., the DON provided an undated document, titled, Pharmacy Consultation, and indicated it was the policy currently being used by the facility. The policy indicated, .Standards .5. Upon receipt of signed recommendations, orders are noted by the Director of Nursing or designee for implementation. 3.1-37(a) A. Based on interview and record review, the facility failed to prevent a delay in treatment after a fall with fracture for 1 of 3 residents reviewed for accidents (Resident 27). B. Based on record review and interview, the facility failed to ensure a treatment order was stopped or clarified after 60 days for 1 of 5 residents reviewed for unnecessary medications (Resident 30). Findings include: A. During an interview, on 5/12/25 at 9:40 a.m., Resident 27's Health Care Representative indicated the resident fell in December 2024 and fractured her hip. They thought the resident was not injured, so she was not sent to the hospital right away. The Health Care Representative indicated she normally placed the resident's walker next to her bed before she left in the evening, but the day the resident fell she had not ensured the walker was next to the resident's bed before she left. The Health Care Representative indicated since the resident's fall she always made sure the resident's walker was next to her bed before leaving for the evening. Resident 27's record was reviewed on 5/15/25 at 9:11 a.m. A significant change Minimum Data Set (MDS) Assessment, dated 3/14/25, indicated the resident had a severe cognitive impairment and had occasional urinary incontinence. Diagnoses on the resident's profile included, but were not limited to, unspecified fracture of the left femur (thigh bone). A Progress Note, dated 12/1/24 at 4:33 a.m., indicated the nurse was called to the resident's room after the resident was found on the floor on her back. The resident was alert with confusion and had not used her walker. The resident was assessed and had no open areas or bruising. As the staff moved her to bed, the resident indicated her hip and knee hurt. The resident's leg had no shortening, swelling, or disfigurement. The staff placed the resident in bed. The note indicated, This nurse will pass on the info to [physician name] and the next shift. The record lacked documentation the physician was notified of the resident's fall or left hip pain on 12/1/24. An xray report indicated an xray of the resident's left femur and knee was completed on 12/1/24 at 6:09 p.m. The results indicated an acute fracture of the neck of the resident's left femur. The results were reported to the facility on [DATE] at 8:07 p.m. The report did not indicate how the results were communicated to the facility. A Progress Note, dated 12/2/24 at 8:09 a.m., indicated the resident complained of left leg pain during day shift on 12/1/24. The nurse assessed the resident and contacted the physician for an xray order. The xray was ordered, and results came back on night shift of 12/1/24. Upon the return of the day shift nurse, xray results were found, and the resident had a fractured left femur. The nurse contacted the physician, and the resident was sent to the emergency room (ER). Hospital discharge instructions, dated [DATE], indicated the resident was discharged back to the facility after an open reduction internal fixation (ORIF) (repair) of the left femur. A Progress Note, dated 12/6/24, indicated the resident returned to the facility. During an interview, on 5/15/24 at 10:42 a.m., the Assistant Director of Nursing (ADON) indicated the facility staff should have called the physician when the resident fell, and the conversation and physician's response should have been documented in the resident's medical record. On 5/15/25 at 11:14 a.m. the ADON provided the following documentation of the physician notification of the resident's fall and pain. a. A text message thread included an undated and untimed message to the physician which indicated, .We had three falls last night The text message indicated the resident had some pain in the left hip and knee but no shortening, and she was able to lay on it. The resident seemed weak and did not walk well. There was no response from the physician. The next text message in the thread was on 12/1/24 at 3:13 p.m., and indicated the resident was still complaining of pain in the left leg, and requested an order for an xray of the resident's femur and knee. The physician responded, Yes. b. A fall report, dated 12/1/24, indicated the resident fell. The report indicated the physician was notified on 12/1/24 at 4:32 a.m., however, the Progress Note, reviewed above, was written one minute later than the report and indicated the physician would be notified at a later time. During an interview, on 5/15/25 at 11:14 a.m., the ADON acknowledged the fall report indicated the physician was notified one minute before the Progress Note was written which stated the physician would be notified at a later time. She was unable to provide further information regarding the notification of the resident's physician of the fall or the resident's reported pain. The ADON indicated when the physician was contacted, by text message or other means, the nurse should have documented the physician notification and the response in the resident's medical record. The reported time on the resident's xray report was the date and time the facility was notified of the results. The xray company faxed results and did not call the facility. The staff should have addressed the resident's fracture immediately when the report was received. During an interview, on 5/15/24 at 11:30 a.m., Certified Nurse Aide (CNA) 14 indicated if a resident fell the CNA called for help and waited for a nurse assessment before the resident was moved. If the resident complained of pain they should have notified the nurse. During an interview, on 5/15/24 at 11:32 a.m., Registered Nurse (RN) 9 indicated if there were signs or symptoms of a fracture after a resident fell they should not have moved the resident until Emergency Medical Services (EMS) arrived. If the nurse assessed the resident and assisted the resident to move, but the resident complained of pain when moving then the staff should have stopped moving the resident and sent them to the hospital. On 5/13/24 at 2:15 p.m., the Director of Nursing (DON) provided an undated document titled, Fall Risk and Post Fall Assessment, and indicated it was the policy currently being used by the facility. The policy indicated, .4. Conduct Physical and Mental Status Assessment .d. Assess limb strength and motion by asking the resident if he/she has pain and the location .e. If you suspect any injury to bone/joints, don't move until seen by a physician or transported to an acute care setting On 5/15/24 at 11:55 a.m., the ADON provided a document titled, Diagnostic Services, updated on 2/23/18, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To ensure that appropriate diagnostic services are available to the residents and to outline the responsibilities of provider services and facility staff .11. Licensed nurses are responsible for documenting the performance of laboratory tests and test results if performed in-house, and physician notification in the nurses's notes .14. Upon notification by the diagnostic service, the nurse in charge will notify the attending physician of abnormal lab and/or radiology results

Based on interview and record review, the facility failed to ensure a root cause analysis was completed and an intervention put in place after falls for 1 of 3 residents reviewed for accidents (Resident 27). Findings include: During an interview, on 5/12/25 at 9:40 a.m., Resident 27's Health Care Representative indicated the resident fell in December 2024 and fractured her hip. They thought the resident was not injured, so she was not sent to the hospital right away. The Health Care Representative indicated she normally placed the resident's walker next to her bed before she left in the evening, but the day the resident fell she had not ensured the walker was next to the resident's bed before she left. The Health Care Representative indicated since the resident's fall she always made sure the resident's walker was next to her bed before leaving for the evening. Resident 27's record was reviewed on 5/15/25 at 9:11 a.m. A significant change Minimum Data Set (MDS) Assessment, dated 3/14/25, indicated the resident had a severe cognitive impairment and had occasional urinary incontinence. Diagnoses on the resident's profile included, but were not limited to, unspecified fracture of the left femur (thigh bone). A Progress Note, dated 12/2/24 at 4:33 a.m., indicated the nurse was called to the resident's room when the staff found the resident on the floor on her back. The resident was alert but confused and was not using her walker. The resident was assessed, and there were no open areas or bruising. When the staff moved the resident she complained of pain to the left hip and knee. There was no shortening, swelling, or disfigurement in the resident's leg. The resident was put in bed. The note lacked documentation an immediate intervention was put in place to prevent another fall. A Post Fall Evaluation Note, dated 12/2/24 at 4:54 a.m., indicated the resident had an unwitnessed fall in her room, and the reason for the fall was toileting. The note indicated there were no injuries. The note lacked documentation of why the resident had not used her walker when attempting to ambulate to the bathroom or an intervention put in place to prevent further falls. A Progress Note, dated 12/2/24 at 8:09 a.m., indicated the resident complained of left leg pain during day shift on 12/1/24. The nurse assessed the resident and requested an order for an xray from the physician. The xray results came back on night shift on 12/1/24. Upon return of day shift, on 12/2/24, the xray results showed the resident had a fractured left femur. The physician was notified, and the resident was sent to the emergency room (ER). A Progress Note, dated 12/6/24, indicated the resident returned to the facility. A care plan, initiated on 12/18/24, indicated the resident had a left femur fracture related to a fall. Interventions included anticipate and meet the resident's needs, ensure the call light is within reach and respond promptly, change surgical incision dressing as ordered and as needed, encourage deep breathing and relaxation techniques, follow the physician's orders for weight bearing status, and modify the environment as needed to meet the resident's current needs. The care plan lacked resident-specific interventions to address the root cause of the resident's fall. A Progress Note, dated 12/20/24, indicated the resident's sitter came to the nurse's station and reported the resident was on the floor. The nurse entered the room, and the resident was sitting on the floor leaning towards her right hip. The resident said she wanted to scoot to the bathroom. The resident's sitter indicated the resident did not fall, and when the sitter woke up the resident said she was going to the bathroom then lowered herself gently to the floor. The resident was assisted to the bathroom and back to bed. The note lacked documentation of an intervention put in place to prevent further falls. A care plan, last revised on 4/3/25, indicated the resident was at risk for falls related to requiring assistance with activities of daily living (ADLs), decreased mobility, unsteady balance, history of falls, cognitive deficit, behaviors, incontinence, pain, shortness of breath, and the use of multiple medications. Interventions were reviewed and were dated on, or before, 1/5/23. There were no updated or revised interventions with the falls on 12/1/24, 12/20/24, or 5/4/25, included on the fall care plan. A Post Fall Evaluation Note, dated 5/4/25 at 4:19 p.m., indicated the resident had an unwitnessed fall in her room. The resident stated she was just standing in her room. The resident was found siting on her bottom in the doorway, with no apparent injuries. The root cause analysis questions were answered, but the note lacked documentation of an intervention put in place to prevent further falls. A Progress Note, dated 5/4/25 at 4:33 p.m., indicated the resident had an unwitnessed fall, in her room, around 3:45 p.m. The resident was found sitting up on the floor in her doorway. The resident stated she went down gracefully and did not hurt herself. The note lacked documentation of an intervention put in place to prevent further falls. During an interview, on 5/15/15 at 11:14 a.m., the Assistant Director of Nursing (ADON) indicated a root cause analysis should have been completed with each fall, and an intervention should have been put in place to prevent further falls. On 5/15/25 at 1:37 p.m., the ADON provided documentation from therapy the resident was evaluated as an intervention for the resident's fall on 5/4/25. At the same time, the ADON indicated the intervention should have been documented in an interdisciplinary team (IDT) note after the fall, but a note was not completed. The ADON indicated she was unable to find an intervention put in place for the falls on 12/1/24 and 12/20/24. 3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter (a semi-flexible plastic tube with one end inserted into the bladder) which is attached to a urinary drainage bag (a bag that collects urine) did not touch the floor for 1 of 1 residents reviewed for catheter care (Resident 52). Findings include: On 5/9/25 at 11:18 a.m., during an initial observation and interview Resident 52 indicated he was not sure why he had a catheter, but he thought it may be due to prostate cancer. Observed the resident sitting in a wheelchair in the main dining area. The catheter bag was attached to the bar under the wheelchair and was touching the floor. On 5/9/25 at 12:11 p.m., observed Resident 52 propelling self in wheelchair. Observed catheter bag dragging on the floor under the wheelchair. On 5/13/25 at 9:52 a.m., during interview with Registered Nurse (RN) 5 she indicated the catheter bag should never touch the floor and when she was positioning a drainage bag she would ensure the bag was not touching the floor. On 5/14/25 at 11:35 a.m., reviewed the medical record of Resident 52. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but not limited to retention of urine (a condition in which you are unable to empty all the urine from your bladder), malignant neoplasm of prostate (a tumor within the prostate gland), and benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland, often causing urinary problems). A care plan dated 4/15/25, indicated the resident had an Indwelling Catheter related to urinary retention. Intervention included but not limited to, prevent kinks in catheter tubing. An admission Minimum Data Set Assessment (MDS) dated [DATE], indicated the resident was cognitively intact and had an indwelling catheter since admission to the facility. On 5/13/25 at 1:37 p.m., the Director of Nursing (DON) provided an undated document, titled, Urinary Catheter Care, and indicated it was the policy currently being used by the facility. The policy indicated, .Standards .7. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor 3.1-41(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure proper cleaning and storage of respiratory equipment for 2 of 4 residents reviewed for respiratory care (Residents 50 and 270). Findings include: 1. During an observation, on 5/15/25 at 8:53 a.m., Registered Nurse (RN) 8 administered a breathing treatment to Resident 50. The nurse removed the breathing treatment mask from the resident at 9:08 a.m., she opened the chamber (this holds the liquid medication) and dumbed out the remaining medication left in the chamber into the trash can and returned the respiratory mask and tubing to a clear plastic bag. Resident 50's record was reviewed on 5/15/25 at 11:07 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a lung disease characterized by airflow obstruction, making it difficult to breathe) with acute exacerbation (a period where COPD symptoms worsen significantly beyond the usual day-to-day experience) and unspecified asthma (a chronic disease in which the bronchial airways in the lungs become narrowed and swollen, making it difficult to breathe). An admission Minimum Data Set (MDS) assessment, dated 4/16/25, indicated the resident was cognitively intact and received respiratory therapy. A physician's order, dated 4/9/25, indicated ipratropium-albuterol solution (a medication that can help people with lung problems, like asthma or obstructive pulmonary disease, breathe easier) 0.5-2.5 milligrams (mg)/3 milliliters (ml) inhale orally via nebulizer four times a day for COPD. A care plan, dated 4/10/25, indicated the resident had COPD and asthma. Interventions included, but were not limited to, give aerosol or bronchodilators (a drug that causes widening of the bronchi) as ordered, give oxygen therapy as ordered by physician, and head of bed to be elevated. During an interview on 5/15/25 at 10:25 a.m., Registered Nurse (RN) 9 indicated the nebulizer mouthpiece and medication chamber was to be rinsed out after use and once dried it should be placed in a bag until used again. 2. On 5/9/25 at 2:11 p.m., during initial observation the resident was sleeping in bed. Observed a clear storage bag next to the resident's bed. The storage bag was dated 5/9/25. A nebulizer unit, (a reservoir for holding the liquid for nebulization), and a tracheostomy (an opening surgically created through the neck into the trachea to allow air to fill the lungs) mask which adapts nebulizers for patients who have had a tracheostomy to receive inhalation therapy which the medication aerosol is inhaled and the nebulizer tubing was inside of the bag. The reservoir was observed to have clear liquid inside. Observed suction canister (a container used in medical procedures to collect body fluids and debris removed during treatment through suction pressure), was next to the bed. The canister was half full of green liquid. The suction tubing (suction tubing is used to remove fluids, secretions, or debris from the body, during procedures like suctioning the airway) was observed with green and white colored debris throughout the inside of the tubing. The suction tubing was placed inside of the bag with the nebulizer administration set. On 5/12/25 at 9:48 a.m., observed nebulizer equipment inside of a clear storage bag next to the resident's bed. The storage bag observed with clear fluid in the interior of the bag. The nebulizer administration set was wet and stored inside of the bag. On 5/13/25 at 9:45 a.m., observed nebulizer administration set in a clear bag next to the bed. The inside of the bag was wet, and the nebulizer administration set was wet. On 5/13/25 at 9:51 a.m., during an interview Registered Nurse (RN) 5 indicated after she completed a nebulizer treatment she rinsed the equipment and allowed it to dry and placed the equipment in the storage bag. On5/13/25 at 1:59 p.m., during an interview the Director of Nursing (DON) indicated the suction canister was a closed system and the suction tubing from the machine must be cleaned after use and stored in a clean bag separate from other equipment. She acknowledged the nebulizer equipment should be clean and dry before being placed in a clean bag. On 5/14/25 at 2:08 p.m., during interview Registered Nurse (RN) 9 indicated she would clean the nebulizer administration set and place it in the designated bag. If it was very soiled she would wash the equipment and allowed to air dry, before placing it into storage bag. On 5/14/25 2:15 p.m., the medical record of Resident 270 was reviewed. The record indicated the most recent admission to the facility was on 5/5/25. admission diagnosis included but was not limited to acute and chronic respiratory failure (a long-term condition where the lungs are unable to adequately exchange oxygen and carbon dioxide), traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain), and quadriplegia (a condition characterized by the paralysis or loss of function in all four limbs). A physician order, dated 5/5/25, indicated to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) mg (milligram) 3ML (milliliter) 1 vial via (by way of) trach (tracheostomy) every 6 hours for respiratory failure and 1 vial via trach every 4 hours as needed for congestion; shortness of breath. A care plan, dated 1/16/20, indicated that the resident had the potential for altered respiratory status/difficulty breathing related to tracheostomy status and diagnosis of acute and chronic respiratory failure. Interventions included but were not limited to, administer breathing medications as ordered and monitor for effectiveness and side effects. A quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident had a tracheostomy which required suctioning and received nebulizer treatments during the review period. On 5/13/2025 at 1:37 p.m., the DON provided an undated document titled, Nebulizer inhalation device sanitizing, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Respiratory equipment used with a mini nebulizer will be stored clean and covered between resident uses .4. The mouthpiece, T-piece nebulizer cup and lid will be washed with warm soapy water, rinsed thoroughly between each use with sterile water or tap water, and disinfected daily. All pieces are then rinsed thoroughly with tap water, drained, air dried in a clean location, then stored in a clean container On 5/13/2025 at 1:37 p.m., the DON provided an undated document titled, Suction machines cleaning and sanitizing, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .4.Suction water or saline solution through tubing into collection chamber, if needed to clear tubing 3.1-47(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medication was labeled properly and the facility failed to ensure expired medication was disposed of for 2 of 2 medication storage rooms reviewed for medication storage (Resident 49). Findings include: 1. On [DATE] at 10:00 a.m., the north hall medication storage room refrigerator contained an opened and undated multi use vial of Aplisol (a clear, colorless solution for injection as an aid in the diagnosis of tuberculosis) solution. During an interview, on [DATE] at 10:02 a.m., Registered Nurse (RN) 7 indicated she was not aware of how long the Aplisol was good for once opened, but she was aware it should be dated once opened. 2. On [DATE] at 10:11 a.m., the south hall medication storage room refrigerator contained an opened bottle of Mary's Magic Mouthwash (a compounded oral rinse used to treat mouth sores and pain, often associated with cancer treatment). The bottle contained a label that indicated it was for Resident 49 and was opened on [DATE] and had an expiration date of [DATE]. During an interview, on [DATE] at 10:14 a.m., the Assistant Director of Nursing (ADON) indicated the mouthwash should have been discarded two days ago on [DATE]. She also indicated the Aplisol solution was good for 30 days once opened and should have been dated when it was opened. On [DATE] at 2:52 p.m., the Administrator provided an undated document titled, Refrigerated Products Expiration Date, and indicated it was the current policy used by the facility. The policy indicated, .Aplisol injection discard open vials after 30 days On [DATE] at 1:31 p.m., the Administrator provided a document with a revised date of [DATE], titled, Medication Storage Policy, and indicated it was the currently policy used by the facility. The policy indicated, .22. No drugs or biological shall be stored which are beyond manufacturer's expiration date or facility established expiration date 3.1-25(j)

Based on observation, record review, and interview, the facility failed to accurately assess and document impairments in skin for 1 of 1 residents reviewed for skin impairments (Resident 15). Finding includes: During an observation, on 3/12/24 at 10:21 a.m., Resident 15 was sitting in her wheelchair in her room. The resident indicated she had a sore area behind her right ear, and it had been there for a long time. The resident indicated she thought it was caused by her glasses. A couple of scabbed areas were noted behind her right ear underneath where her glasses touched her skin. Excoriated skin tissue was noted as well. The resident also had a scabbed area on her cheek and nose and indicated she was told they were skin cancer spots. Resident 15's record was reviewed on 3/15/24 at 1:36 p.m. The profile indicated the resident's diagnoses included, but were not limited to, dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), disorder of the skin and subcutaneous tissue (medical condition that occurs in the subcutaneous layer), and type II diabetes (a long term condition in which the body has trouble controlling blood sugar and using it for energy). A quarterly Minimum Data Set (MDS) assessment, dated 2/14/24, indicated the resident was cognitively intact and had no open lesions or pressure ulcers. The record lacked a care plan regarding the skin alteration behind the resident's right ear. A weekly skin assessment note, dated 3/12/24, indicated Resident 15 had multiple cancer areas on her face but lacked documentation of the area behind her right ear. A skin sweep progress note, dated 3/7/24, lacked documentation of the resident's skin alteration behind her right ear. During an interview, on 3/15/24 at 1:54 p.m., Resident 15 was sitting up in her wheelchair outside of her room. The resident indicated the nursing staff had not looked at the area behind her ear and had not been treating it with anything. During an interview, on 3/15/24 at 1:56 p.m., Registered Nurse (RN) 8 indicated she was not aware of the area behind Resident 15's ear, but she was aware that she would pick at the sores on her face at times. During an interview on 3/15/24 at 1:57 p.m., Certified Nurse's Assistant (CNA) 20 indicated she was aware of the area on the back of Resident 15's ear and indicated it had been there for a long time. She indicated she had made a note of the area on the shower sheet dated 3/14/24 and it was reported to the nurse. The CNA indicated she thought the area had gotten bigger. During an interview, on 3/15/24 at 2:13 p.m., Director of Nursing (DON) indicated she was not aware of an area of the resident having a skin issue behind her ear. During an interview, on 3/15/24 at 2:37 p.m., DON indicated the wound nurse had noted areas on the resident's face but not behind her ear on the skin assessments. The DON further indicated she had reviewed progress notes and was not able to find any notes regarding the area behind the resident's right ear. The DON assessed the area and noted the scabbing and a small open area behind the ear. A head to toe assessment should be completed by the wound nurse when conducting skin sweeps. On 3/15/24 at 2:32 p.m., the DON provided an undated document titled, Skin Condition and Pressure Ulcer Assessment, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Resident's identified by the Braden Scale as being at risk of a skin breakdown, will have a care plan customized and initiated to address the at risk individual's skin care needs. 3. All areas of each resident's skin shall be inspected by his or her nurse and documented at least every seven days .9. The Director of Nursing will be notified of any new skin abnormality 3.1-37

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to address a significant weight discrepancy for 1 of 2 residents reviewed for nutrition (Resident 57). Finding includes: Resident 57s record was reviewed on 3/15/24 at 9:08 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified protein-calorie malnutrition (a disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). An admission Minimum Data Set assessment, dated 2/21/24, indicated the resident required supervision or touching assist with eating, and had no swallowing or nutrition disorders noted. The assessment lacked documentation of weight gain or loss. A physician's order, dated 2/14/24, indicated weekly weights and to review weights and report significant changes to physician. A physician's order, dated 2/16/24, indicated the resident was to have a regular diet with mechanical soft texture (a modified diet with a texture soft for people with difficulty swallowing or chewing). Review of the resident's weights indicated he weighed 108.0 pounds (lbs) upon admission on [DATE]. Subsequent weights included, but were not limited to the following: a. On 3/9/24 at 1:52 p.m., the resident had been weighed by Certified Nursing Aide (CNA) 18. His weight was measured at 104.8 pounds (lbs). b. On 3/9/24 at 2:54 p.m., the resident had been weighed by CNA 17. His weight was measured at 127.2 lbs. c. On 3/10/24 at 12:44 p.m., the resident had been weighed by CNA 17. His weight was measured at 127.5 lbs. d. On 3/11/24 at 5:59 p.m., the resident had been weighed by CNA 17. His weight was measured at 104.4 lbs. The record lacked documentation that the significant discrepancies in the resident's weights between 3/9/24 at 1:52 p.m., and 3/11/24 at 5:59 p.m., had been addressed by the facility. A nurse progress note, completed by Licensed Practical Nurse (LPN) 11, on 3/6/24 at 2:24 p.m., indicated the resident had been weighed on 3/5/24 at 5:56 p.m., sitting on the scale. His weight was measured at 104.2 lbs. A nutritional at risk (NAR) meeting note, dated 3/7/24, indicated the resident had lost 2 lbs. He was reported to eat 26-50% of his meals and had been provided a nutrient-rich caloric drink supplement with B-vitamins to help convert food to energy, two times daily. A nurse progress note, completed by Registered Nurse (RN) 14, on 3/8/24 at 10:36 a.m., lacked documentation of the resident's weight. A nurse progress note, completed by LPN 11, on 3/9/24 at 2:58 p.m., indicated the resident had been weighed on 3/9/24 at 2:54 p.m., sitting on the scale. His weight was measured at 127.2 lbs. A nurse progress note, completed by LPN 15, on 3/10/24 at 11:40 p.m., lacked documentation of the resident's weight. A nurse progress note, completed by RN 16, on 3/11/24 at 7:50 p.m., indicated the resident had been weighed on 3/11/24 at 5:59 p.m., sitting on the scale. His weight was measured at 104.4 lbs. A NAR meeting note, dated 3/14/24, indicated the resident consumed about 50 % of his meals, was on a regular diet, and was being weighed daily. He continued on his drink supplement and his weights had remained stable since admission. The plan was to discontinue being followed by the NAR committee at that time. The note lacked documentation of the weight discrepancies from 3/9/24 at 1:52 p.m., through 3/11/24 at 5:59 p.m. During an interview, on 3/15/24 at 9:51 a.m., the Director of Nursing (DON) indicated if a significant discrepancy of a resident's weight was discovered, the resident should be re-weighed to confirm the accuracy of the measured weight. During an interview, on 3/15/24 at 10:49 a.m., CNA 19 indicated if there was a significant weight discrepancy she would re-weigh the resident to make sure the weight was accurate. She would then inform the nurse and double check for any significant changes with the resident's health that could be causing the weight change. On 3/15/24 at 10:42 a.m., the DON provided an undated document titled, Certified Nursing Assistant (CNA) Rehab/LTC Orientation Checklist, and stated it was the orientation and annual competency checklist for the CNA's. The form lacked documentation of any competency measurement on weighing residents. On 3/15/24 at 10:42 a.m., the DON provided a document, dated 9/22/21, titled, Weighing Residents, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .4. A licensed nurse evaluates weight changes to determine if there is a 5% or greater weight loss/gain in one month and notifies the physician of unanticipated or undesired weight loss/gain .Rationale/Amplification: .A re-weigh should be taken with the licensed nurse present as soon as possible after an unanticipated weight reading is noted and prior to calling the physician 3.1-46(a)(1)

2. During an interview, on 3/12/24 at 9:21 a.m., Resident 39 indicated he used oxygen therapy per nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) during the nighttime. During an observation, on 3/12/24 at 9:21 a.m., an oxygen concentrator was in Resident 39's room and had a nasal cannula attached to it. The resident was not using oxygen at the time of the observation. Resident 39's record was reviewed on 3/13/24 at 10:02 a.m. The profile indicated the resident's diagnoses included, but were not limited to, multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves resulting in nerve damage), dependence on supplemental oxygen (used to keep your organs or tissues healthy), and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). A quarterly Minimum Data Set (MDS) assessment, dated 2/20/24, indicated Resident 39 was cognitively intact and was not marked as using oxygen therapy. A care plan, dated 6/17/21, with a revised date of 11/28/23, indicated resident had oxygen therapy related to ineffective gas exchange and chronic respiratory failure (occurs when a person's blood has too much carbon dioxide and not enough oxygen) and dyspnea (shortness of breath). Interventions included but were not limited to, oxygen 2L(liters) per nasal cannula during the night. The record lacked documentation of a physician order for the oxygen therapy at night. Review of a hospice clarification fax sent to the facility, dated 3/13/24, indicated the hospice company had requested an order for Resident 39 to have Oxygen therapy 3L as needed. The order was dated 1/31/24 but was not implemented into the resident's electronic health record. The March Medication Administration Record (MAR) lacked documentation of oxygen being used at night or as needed. Review of vital signs note, dated 2/5/24 at 7:07 a.m., indicated Resident 39's oxygen saturation was 100% on oxygen via nasal cannula. Review of vital signs note, dated 2/4/24 at 7:56 p.m., indicated Resident 39's oxygen saturation was 99% on oxygen via nasal cannula. Review of vital signs note, dated 2/1/24 at 3:24 p.m., indicated Resident 39's oxygen saturation was 100% on oxygen via nasal cannula. During an interview, on 3/13/24 at 11:35 a.m., Certified Nurse's Aide (CNA) 7 indicated Resident 39 used oxygen therapy at nighttime During an interview, on 3/13/24 at 11:36 a.m., Registered Nurse (RN) 8 indicated she thought Resident 39 had an order for oxygen to be used as needed. During an interview, on 3/13/24 at 1:18 p.m., Director of Nursing (DON) indicated Resident 39 should have an order in his chart for the oxygen use but he had been in and out of the hospital, so she wasn't sure if it was missed. On 3/14/24 at 9:45 a.m., the Administrator provided an undated document, titled, Oxygen Therapy, and indicated it was the policy currently being used by the facility. The policy indicated, .It is the policy of Providence Health Care to administer oxygen in accordance with physician's order and on emergency basis .5. Initial and ongoing assessments will be documented in the nursing progress notes .18. Record oxygen therapy on the treatment or special record and nursing notes if prn (as needed), Include type of catheter and liter flow 3.1-47(a)(6) Based on observation, interview, and record review, the facility failed to ensure a nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mask was stored properly when not in use and an self administration assessment was completed for 1 of 2 residents reviewed for respiratory care (Resident 113), and failed to ensure oxygen orders were in place for 1 of 2 residents reviewed for respiratory care (Resident 39). Findings include: 1. During the initial pool observation, on 3/11/24 at 11:24 a.m., Resident 113's nebulizer mask was observed un-bagged and sitting on his bedside table. At the same time, the resident indicated he had used the nebulizer earlier that morning and that it should have been placed into a bag, but the nurse had not been in since he had used the nebulizer. During a random observation, on 3/14/24 at 10:09 a.m., the resident's nebulizer mask was observed un-bagged and sitting on his bedside table. During a random observation, on 3/14/24 at 1:42 p.m., the resident's nebulizer was sitting, un-bagged on his bedside table. At the same time, the resident indicated that he had just used it right after lunch. He doubted it would not be placed in a bag by the nurse, until the next shift, if they put it in the bag at all. Resident 113's record was reviewed on 3/14/24 at 10:21 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems), unspecified respiratory failure (a condition in which the blood doesn't have enough oxygen or has too much carbon dioxide), and pleural plaque with presence of asbestos (areas of thickened tissue that form in the lining of the lungs caused by significant asbestos exposure). A baseline care plan, dated 3/11/24, indicated the resident had been admitted with a diagnosis of pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi). A physician's order, dated 3/8/24, indicated albuterol sulfate inhalation solution (medicine that is used for the relief of bronchospasms [the tightening and swelling of the muscles around the airways]), 2.5 milligrams (mg)/3 milliliters (ml) 0.083%. Inhale 3 ml orally via nebulizer in the afternoon for COPD. A physician's order, dated 3/8/24, indicated ipratropium (used to prevent wheezing, shortness of breath, coughing, and chest tightness in people)-albuterol inhalation solution 0.5-2.5 (3) mg/3 ml. Inhale 3 ml orally via nebulizer every 6 hours as needed for COPD. The record lacked documentation of an assessment to determine the independent use of the nebulizer by the resident. During an interview, on 3/14/24 at 1:57 p.m., Licensed Practical Nurse (LPN) 11 indicated she would set up the resident's nebulizer, but he used it himself. She was not aware of any assessment that had been completed to determine if the resident was able to use his nebulizer independently. During an interview, on 3/14/24 at 2:16 p.m., the Director of Nursing (DON) indicated the resident should have had an assessment to use the nebulizer independently. The nebulizer masks should be placed in plastic bags when not in use. On 3/14/24 at 2:25 p.m., the DON provided a document, dated 9/25/21, titled, Licensed Nurse or Respiratory Therapist Procedure Nebulized Mist Inhalation Treatment, and indicated it was the procedural documentation on the proper use of nebulizer equipment for the facility. The document indicated, .Procedure .Disassemble the nebulizer and place in plastic bag with nebulizer tubing

Based on record review, observation, and interview, the facility failed to ensure physician orders were followed for 2 of 5 residents reviewed for unnecessary medication review (Residents 35 and 37). Findings include: 1. On 3/13/24 at 11:00 a.m., the medical record of Resident 35 was reviewed. Resident 35's diagnoses on the resident's profile included but were not limited to, type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), Atherosclerosis (a thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), Hyperlipidemia (high cholesterol) is an excess of lipids or fats in your blood), Atrial Fibrillation (Fibrillation an irregular heart rhythm (arrhythmia) that begins in the upper (atria) of your heart), Hypertension (HTN) (also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure). Physician Orders include but are not limited to: Lisinopril Tablet 40 mg (milligrams) give 1 tablet by mouth one time a day for HTN hold for Systolic Blood Pressure (SBP) less (< ) than 100, 11/30/22. (The systolic blood pressure is the maximum blood pressure during contraction of the ventricles of the heart). Review of the medication administration records from 1/1/24 to 3/13/24 indicated the resident received Lisinopril 40 milligram (mg) by mouth once daily. Record lacked documentation of monitoring of the blood pressure. The weights and vitals summary record documentation indicated, the blood pressure had been assessed and the reading was entered into the summary report 10 days in total from January to March 2024. The most recent quarterly Minimum Data Set (MDS) assessment indicated the resident had a diagnosis of hypertension and orthostatic hypotension (a drop in blood pressure that occurs when moving from a laying down [supine] position to a standing [upright] position). The MDS indicated the resident was cognitively intact. A care plan, dated 2/19/21, indicated the resident had a diagnosis of hypertension. Intervention included but were not limited to, blood pressure readings as ordered/per protocol. Report significant abnormalities to medical doctor as needed. On, 3/15/24 at 9:03 a.m., the Director of Nursing (DON) provided an undated document, titled. Physician's Orders, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Facility nursing personnel will ensure clear, accurate and complete physician's orders. Procedure: .5 .Ensure any follow through is completed 2. Resident 37's record was reviewed on 3/13/24 at 10:13 a.m. The profile indicated the resident's diagnoses included, but were not limited to, diabetes type 2 with diabetic chronic kidney disease (diabetes [a disease that occurs when your blood glucose, also called blood sugar, is too high] that isn't well controlled can damage blood vessels in the kidneys that filter waste from the blood). A quarterly minimum data set assessment (MDS-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 11/23/23, indicated the resident had severe cognitive deficit and received hypoglycemic (medications that work by stimulating pancreatic insulin secretion, enhancing tissue sensitivity to insulin, or slowing the absorption of glucose in the intestines). A physician's order, dated 9/1/23, indicated glimepiride oral tablet (hypoglycemic medication) 1 milligram (mg). Give 0.5 tablet by mouth one time a day for diabetes. A care plan, dated 9/5/23, indicated the resident had a diagnosis of diabetes and received diabetes medications. A care plan, dated 9/5/23, indicated the resident had a diagnosis of chronic kidney disease. Interventions included, but were not limited to, lab/diagnostic work as ordered. A pharmacy recommendation, dated 9/15/23, indicated since the resident received glimepiride, to consider checking the resident's A1C (a simple blood test that measures the average blood sugar levels over the past 3 months) every six months. The physician agreed and signed the recommendation on 9/20/23. A copy of a physician's order, dated 9/20/23, provided by the Director of Nursing (DON), on 3/14/24 at 8:30 a.m., indicated to check the resident's A1C every 6 months. The record lacked documentation of the resident's A1C lab every being completed as ordered. During an interview, on 3/13/24 at 3:11 p.m., the DON indicated she had put the order in on 9/20/23, but the lab had never been completed as ordered. On 3/14/24 at 8:30 a.m., the DON provided an undated document, titled, Pharmacy Consultation, and indicated it was the policy currently being used by the facility. The policy indicated, .Standards: .5. Upon receipt of signed recommendations, orders are noted by the Director of Nursing or designee for implementation 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident's call light was within reach for the resident to call for staff assistance when needed for 1 of 24 residents rooms observed for call light availability (Resident 34). Findings include: On 3/12/24 at 9:36 a.m., observed the resident lying in bed. The call light was hanging on the wall several feet from the resident. On 3/13/24 at 10:51 a.m., observed the resident sleeping in her bed. The call light was not within reach of the resident. The call light was clipped to the wall several feet from the resident. On 3/13/24 at 10:58 a.m., during an interview with Certified Nurse Aide (CNA) 10, she indicated she did not know why the call light was not on the bed next to the resident. She acknowledged it should always be within reach for the resident to call for assistance. On 3/13/24 at 11:02 a.m., during an interview with Registered Nurse (RN) 8, she indicated the call light must be within reach. It was the last thing the staff check before they leave the resident's room. On 3/14/24 at 11:34 a.m., observed call light within reach and attached to the side of the bed. On 3/14/24 at 2:00 p.m., Resident 34's medical record was reviewed. Diagnoses on the resident's profile included, but were not limited to, chronic heart failure (CHF)(a condition that develops when your heart doesn't pump enough blood for your body's needs), chronic obstructive pulmonary disease (COPD)(a group of diseases that cause airflow blockage and breathing-related problems), Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), weakness, and age related physical disability. Physician orders included but were not limited to, observe for/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status every day and night shift for dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A care plan, dated 2/17/21, indicated the resident had an ADL Self Care Performance Deficit related to unsteady balance, incontinence, history of falls, cognitive deficits, pain, SOB, limited ROM, and multiple medication use. Interventions included but were not limited to, encourage her to use call light to call for assistance, and respond promptly. A care plan, dated 2/25/21, indicated the resident exhibited impaired cognition and was severely impaired cognition and is severely impaired with decision making, intervention included but were not limited to, provide consistent care and routine. A quarterly Minimum Data Set (MDS), a standardized assessment tool that measures health status in nursing home residents, dated 2/21/24, indicated the resident was not cognitively intact and she required assistance from the staff for all care. Review of a Resident Council note, dated 2/1/24, indicated, a resident had a concern that the aids weren't leaving their call light within reach before the staff leaves their room. On 3/15/2024 at 9:03 p.m., the Director of Nursing (DON) provided an undated document, titled, Call Light, and indicated it was the policy currently being used by the facility. The policy indicated, .1. All residents shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside and in the resident's bathroom 3.1-19(u)

Based on observation, interview, and record review, the facility failed to ensure beard restraints were worn in the kitchen serving area (on the skilled unit) and in the main kitchen food prep area for 2 of 2 kitchen observations. Findings include: 1. During an observation in the kitchen serving area (located on the skilled unit), on 3/11/24 at 11:40 a.m., the Dietary Director was placing whip cream on top of the vanilla and chocolate shakes. The Dietary Director was not wearing a beard restraint and his facial hair was exposed. 2. During an observation in the kitchen serving area, on 3/11/24 at 11:43 a.m., the Dietary Director was placing cinnamon pita chips onto 16 dessert plates from a serving pan. The Dietary Director was not wearing a beard restraint and his facial hair was exposed. During an interview, on 3/11/24 at 11:50 a.m., Dietary Director indicated he should have worn a beard restraint while prepping food that was to be served to the residents. During an interview, on 3/11/24 at 11:54 a.m., Dietary aide 5 indicated when you have facial hair it was to be covered with a beard restraint while in the food prep area. 3. During an observation in the kitchen, on 3/14/24 at 10:21 a.m., Dietary aide 9 was in the food prep area and was transferring applesauce and olives into separate containers and placed them in the refrigerator. The dietary aide was also preparing desserts for the lunch time meal, he was not wearing a beard restraint and his facial hair was exposed. On 3/11/24 at 2:20 p.m., the Dietary Director provided a document, with a revised date of 1/24, titled, Uniform Dress Code, and indicated it was the policy currently being used by the facility. The policy indicated, .Associates working with food .Restrain all facial hair with a beard net/restraint 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor a resident's request to be transferred to the hospital related to increased pain of a right femur fracture and without her signing a document saying the transfer was against medical advice (AMA) and without being informed her AMA transfer may result in the facility not allowing her to return for 1 of 3 residents reviewed for transfer and discharge (Resident B). Findings include: During a confidential phone interview, on 8/17/23 at 8:55 a.m., Resident B's friend indicated she had visited the resident on 8/15/23 at the facility. The resident informed her friend that she had a fractured right femur. She was unable to explain how the fracture happened. The friend indicated the facility had always called her with any condition changes until this one. She was not notified of the fracture. She observed the resident's external rotation to her right leg during this visit. The friend indicated the rotation had never been noted before. The friend had just been in the facility at the end of July 2023, and it was not seen at that time. During an interview, on 8/17/23 at 11:44 a.m., RN 3 indicated she was working day shift on the day of 7/30/23 and she noticed Resident B's right foot was rotated out. She had never noticed it before. She forgot to notify the oncoming night shift nurse, nor did she document any of her findings in the resident's medical record. She didn't notice any swelling or redness at that time. She messaged the night shift nurse at approximately 3:00 a.m. via text message about the resident's foot. The record lacked documentation related to the potential injury by the nurse. During an interview, on 8/17/23 at 2:45 p.m., Resident B indicated she had increased pain in her right leg related to a fracture and she wanted to be transferred to the hospital for further assistance. During an interview, on 8/17/23 at 3:00 p.m., the Administrator indicated Resident B was going to be sent out to the hospital against medical advice (AMA) because it was her request to be sent out to the hospital. She indicated the Medical Director did not feel her transfer was medically necessary. During an interview, on 8/18/23 at 3:15 p.m., the Administrator indicated staff understood Resident B was requesting and had the right to be seen in the emergency room due to pain and wanting a second opinion of her fracture, but the Medical Director said it was not necessary, the facility had her sign an against medical advice (AMA) form. Having the resident sign the AMA did not indicate the facility would not take her back. Her return would depend on rather the Medical Director wanted to continue caring for her. Resident B's record was reviewed on 8/17/23 at 10:50 a.m. The profile indicated the resident's diagnoses included, but were not limited to, quadriplegia (paralysis of all four limbs), respiratory failure unspecified with hypoxia (happens when you don't have enough oxygen in your blood, and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures). The resident required a mechanical ventilator (type of breathing apparatus that provides mechanical ventilation by moving breathable air into and out of the lungs). Review of Medication Administration Record (MAR), indicated in the month of August 2023, Resident B had complained of pain at a scale of 5 or higher 9 out of 17 days reviewed and required as needed pain medication to be administered in addition to the resident's routine pain medication. Review of bed hold policy, dated 8/17/23, Resident B was given a bed hold policy and indicated the resident was being transferred to the hospital and was marked as a transfer or discharge was necessary to meet the resident's welfare and the resident's needs cannot be met in the facility. Review of transfer or discharge request for hearing form, indicated Resident B's name on the form, there was no date and no resident representative signature on the form. Review of an orthopedic note, dated 8/18/23 at 2:54 p.m., the Orthopedic doctor indicated he had reviewed an x-ray that was completed on 8/1/23. The x-ray indicated Resident B had a non-displaced, subacute (a condition between acute and chronic) to chronic (long term) appearing intertrochanteric hip fracture with evidence of healing. The orthopedic doctor recommended continued non-operative treatment as long as the resident was not having significant pain and was tolerating transfers and positioning. He was aware the resident had transferred to a local hospital per patient request. A review of the hospital records included a Computerized Tomography (CT) of the low right extremity from the hospital, dated 8/17/23. The CT indicated Resident B had a subacute to chronic non healed comminuted (a bone that is broken in at least 2 places) right femur intertrochanteric fracture. A hospital note included an Orthopedic physician consultation note, dated 8/18/23. They were consulted due to Resident B's fracture. The orthopedic doctor at the hospital indicated the resident had a subacute fracture to the right proximal (situated nearer the center of the body or the point of attachment) femur, likely 2 to 6 weeks old. The physician planned to take Resident B to the operating room on 8/19/23 for a gamma nail (used to treat proximal femoral fractures) and fracture fixation (stabilize extremely misaligned broken bones by re-setting). Review of Operative note, dated 8/19/23, indicated Resident B had a preoperative diagnosis of an unstable fracture of the right proximal femur. The operation was an open reduction and internal fixation (put pieces of a broken bone into place using surgery) of the right proximal femur with 120-degree [NAME] gamma nail with proximal distal interlocking (metallic implants used for the repair of traumatic long bone fractures) and a long leg splint. During a phone interview, on 8/22/23 at 9:45 a.m., the Case Manager from the hospital indicated the resident wanted transferred to the hospital for a second opinion on her fractured leg. The resident's injury did require surgical intervention while she was at the hospital. Her surgery was performed on 8/19/23. Cross reference F626 and F684. On 8/18/23 at 1:15 p.m., the Administrator provided a document, with a revised date of 1/15/23, titled, Transfer and Discharge, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Resident or resident representative(s), if known have the right to participate in decisions regarding transfers or discharge and to request or agree to transfers with in the facility or to another facility or home . 5. The state mandated notice must be given to the resident or resident representative at least 30 days before the transfer or discharge .14. In the event of an emergency transfer, the state form shall be sent with the resident to the hospital for a resident review as soon as possible and provided to other required individuals This Federal tag relates to Complaints IN00415330 and IN00415942. 3.1-12(a)(6)(B)

Based on interview and record review, the facility failed to accept a resident back from the hospital without a 30-day discharge notice for 1 of 3 residents reviewed for transfer and discharge (Resident B). Findings include: During an interview, on 8/17/23 at 2:45 p.m., Resident B indicated she had increased pain in her right leg related to a fracture and she wanted to be transferred to the hospital for further assistance. Cross reference F622 and F684. During an interview, on 8/17/23 at 3:00 p.m., the Administrator indicated Resident B was going to be sent out to the hospital against medical advice (AMA) because it was her request to be sent out. The Medical Director did not feel her transfer was medically necessary. During an interview, on 8/17/23 at 4:05 p.m., Resident B's emergency contact individual indicated she was not made aware of the resident not being allowed to return to facility once discharged from the hospital by any facility personnel when the resident was sent to the hospital per the resident's request. During an interview, on 8/18/23 at 3:15 p.m., the Administrator indicated staff understood Resident B was requesting and had the right to be seen in the emergency room due to pain. Having the resident sign the AMA did not indicate the facility would not take her back. Her return would depend on if the medical director wanted to continue caring for her. Resident B's record was reviewed on 8/17/23 at 10:50 a.m. The profile indicated the resident's diagnoses included, but were not limited to, quadriplegia (paralysis of all four limbs), respiratory failure unspecified with hypoxia (happens when you don't have enough oxygen in your blood, and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures). The resident required a mechanical ventilator (type of breathing apparatus that provides mechanical ventilation by moving breathable air into and out of the lungs). Review of x-ray report completed on 8/1/23 at 4:55 p.m. The report indicated Resident B had an old or healing intertrochanteric right femoral fracture. Review of bed hold policy, dated 8/17/23, Resident B was given a bed hold policy and indicated the resident was being transferred to the hospital and was marked as a transfer or discharge was necessary to meet the resident's welfare and the resident's needs cannot be met in the facility. Review of transfer or discharge request for hearing form, indicated Resident B's name on the form, there was no date and no resident representative signature on the form. Review of case management note from the hospital, dated 8/18/23 at 4:35 p.m., indicated the Case Manager spoke with Administrator from the long-term care facility and she indicated Resident B had signed an AMA form to come to the emergency room for evaluation and treatment. The Administrator indicated the Medical Director did not feel as though the patient needed to come to the hospital and her needs could be met at the facility. The Administrator did not provide the Case Manager with an answer on rather the resident could return to the facility post discharge. Review of physician progress note, dated 8/18/23 at 7:01 p.m., the Medical Director indicated the patient was transferred to the hospital against medical advice. Given the facility policy and the resident's non-compliant behavior, the Medical Director deemed it was necessary to deny readmittance to the facility. During an interview, on 8/21/23 at 9:00 a.m., the Administrator indicated she would be surprised if the resident wanted to return to their facility since she wasn't happy here. She indicated the Medical Director was not keen on the idea of the resident returning to the facility from the hospital. During a phone interview, on 8/22/23 at 9:45 a.m., the Case manager from the hospital indicated the Administrator from the long-term care facility had denied Resident B's re-admittance back to the facility from the hospital. The case manager indicated she was not provided a 30-day discharge notice from the facility for the resident. She indicated the resident was not aware that signing an AMA form meant she couldn't return to the facility. The resident wanted transferred to the hospital for a second opinion. The case manager indicated her injury did require surgical intervention while she was at the hospital. Her surgery was performed on 8/19/23. On 8/18/23 at 1:15 p.m., the ADM provided a document, with a revised date of 1/15/23, titled, Transfer and Discharge, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Resident or resident representative(s), if known have the right to participate in decisions regarding transfers or discharge and to request or agree to transfers with in the facility or to another facility or home . 5. The state mandated notice must be given to the resident or resident representative at least 30 days before the transfer or discharge .14. In the event of an emergency transfer, the state form shall be sent with the resident to the hospital for a resident review as soon as possible and provided to other required individuals This Federal tag relates to Complaints IN00415330 and IN00415942. 3.1-12(a)(26)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and document a baseline for a new injury, failed to report an unknown injury for orders and treatment, and failed to follow up timely on an external rotation of the right leg resulting in the delay of care for 1 of 3 residents reviewed for quality of care (Resident B). Findings include: During a confidential phone interview, on 8/17/23 at 8:55 a.m., Resident B's friend indicated she had visited the resident on 8/15/23 at the facility. The resident informed her friend that she had a fractured right femur. She was unable to explain how the fracture happened. The friend indicated the facility had always called her with any condition changes until this one. She was not notified of the fracture. She observed the resident's external rotation to her right leg during this visit. The friend indicated the rotation had never been noted before. The friend had just been in the facility at the end of July 2023, and it was not seen at that time. During an interview, on 8/17/23 at 11:44 a.m., RN 3 indicated she was working day shift on the day of 7/30/23 and she noticed Resident B's right foot was rotated out. She had never noticed it before. She forgot to notify the oncoming night shift nurse, nor did she document any of her findings in the resident's medical record. She didn't notice any swelling or redness at that time. She messaged the night shift nurse at approximately 3:00 a.m. via text message about the resident's foot. The record lacked documentation related to the potential injury by the nurse. Review of text message, dated 7/31/23 at 3:28 a.m., RN 3 sent a text message to the night shift nurse and indicated she forgot to mention to her about Resident B's right lower extremity was turned outward and should probably have an x-ray. The nurse receiving the text message responded she had noticed it as well and would notify the Unit Manager. The electronic medical record lacked any notification or documentation of the nurses' findings. During a phone interview, on 8/18/23 at 11:45 a.m., the Medical Director indicated he was notified on 8/1/23 of an external rotation to Resident B's right leg while he was making rounds at the facility. A portable x-ray was completed on 8/1/23 and the Medical Director was notified of the results on 8/4/23. He consulted an orthopedic doctor regarding the x-ray results. The orthopedic doctor was unable to determine the age of the fracture due to the x-ray images were not clear due to them being from a portable machine. The orthopedic doctor advised the medical director to obtain another x-ray in one week. The orthopedic doctor advised keeping her leg as stable as possible during turning and repositioning and no mechanical lift transfers. The Medical Director indicated the resident's increased pain could be masked by her opioid medications that she already took routinely for pain. During an interview, on 8/18/23 at 12:32 p.m., Unit Manager 5 indicated she was told about Resident's B external rotation on Monday, 7/31/23 by RN 3. The Unit Manager spoke with the Medical Director on Tuesday 8/1/23 when he was at the facility making his rounds. She indicated the Medical Director placed an order for the resident to have a portable x-ray done on the right femur. The Medical Director was not notified of the external rotation the day that staff notified the Unit Manager. She indicated the x-ray was obtained on 8/1/23 as ordered but she did not get the results out of the computer system until 8/4/23. She indicated she had missed a day of work that week and she obtained the results when she was back to work on 8/4/23. The Unit Manager indicated not all nursing staff had access to pull the report from the system. Resident B's record was reviewed on 8/17/23 at 10:50 a.m. The profile indicated the resident's diagnoses included, but were not limited to, quadriplegia (paralysis of all four limbs), respiratory failure unspecified with hypoxia (happens when you don't have enough oxygen in your blood, and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures). The resident required a mechanical ventilator (type of breathing apparatus that provides mechanical ventilation by moving breathable air into and out of the lungs). Review of Medication Administration Record (MAR), indicated in the month of August 2023, Resident B had complained of pain at a scale of 5 or higher 9 out of 17 days reviewed and required as needed pain medication to be administered in addition to the resident's routine pain medication. Review of shower sheet, dated 7/28/23, indicated Resident B was given a bed bath and external rotation was not noted by staff. Review of shower sheet, dated 7/31/23, indicated Resident B was given a shower at 11:53 a.m. The shower sheet lacked any documentation of the external rotation being noted by staff. Resident B was transferred per mechanical lift for her shower on this day per the Director of Nursing (DON). A health status note, dated 8/1/23 at 1:40 p.m., indicated Resident B's right lower extremity was rotated outward, Medical Director notified, and new order received for x-ray. Review of x-ray report, completed on 8/1/23 at 3:40 p.m. The report indicated Resident B had an old or healing intertrochanteric (fractures of the proximal femur that occur between the greater and lesser trochanter) right femoral fracture. The record lacked a care plan for a fractured femur of unknown origin after diagnosis of x-ray. The record lacked any assessment documentation of the right leg in the electronic medical record from 7/30/23 to 8/18/23. The record lacked documentation physical therapy and or occupational therapy were requested to assess for positioning or transferring the resident related to fracture. A health status note, created on 8/7/23 at 10:57 a.m., with an effective date of 8/4/23, indicated Unit Manager 5 spoke with resident about her results of the x-ray. Resident B was unaware of how the fracture could have happened. The resident denied any falls or rough turning and/or pulling by staff. A health status note, created on 8/7/23 at 11:50 a.m., with an effective date of 8/4/23, indicated Unit Manager 5 paged the orthopedic doctor regarding Resident B's x-ray of her right femur. The orthopedic doctor indicated the resident did not require surgery and did not need to be sent to the emergency room. A health status note, created on 8/16/23 at 11:31 a.m., with an effective date of 8/11/23, indicated Unit Manager 5 called the orthopedic doctor's office to clarify if Resident B needed to be seen in his office. The orthopedic doctor denied the resident being seen in his office but would like a repeat x-ray in one week. A health status note, dated 8/17/23 at 3:02 p.m., indicated a registered nurse called the orthopedic doctor's office to see if he had received the follow up x-ray performed on 8/15/23 for Resident B. The nurse at the doctor's office confirmed that they had received but the doctor had not yet reviewed the x-ray. A health status note, dated 8/17/23 at 3:20 p.m., indicated RN 3 spoke with Resident B in her room. Resident B requested to go to the hospital for a second opinion of her right femur fracture because she was in a lot of pain and wanted to go. RN 3 medicated the resident with Ibuprofen (anti-inflammatory medication) 600 mg (milligram) by mouth and Xanax (anti-anxiety medication) 0.5mg by mouth for comfort. A health status note, dated 8/17/23 at 4:00 p.m., indicated Resident B was transported to the hospital via ambulance for evaluation per family request. During an interview, on 8/18/23 at 12:58 p.m., the Administrator indicated Resident B had been interviewed by staff to determine a cause for her fracture. Resident B was unable to recall anything out of the ordinary happening. The Administrator denied interviewing any staff regarding the root cause to the fracture. It was the nurse's judgement on when they should notify the doctor. The external rotation on Resident B's leg was not considered emergent by the staff. During a phone interview, on 8/18/23 at 1:15 p.m., the Wound doctor indicated he was last at the facility on 7/27/23 and had not noticed an external rotation to the right lower extremity. Review of an orthopedic note, dated 8/18/23 at 2:54 p.m., the Orthopedic doctor indicated he had reviewed an x-ray that was completed on 8/1/23. The x-ray indicated Resident B had a non-displaced, subacute (a condition between acute and chronic) to chronic (long term) appearing intertrochanteric hip fracture with evidence of healing. The orthopedic doctor recommended continued non-operative treatment as long as the resident was not having significant pain and was tolerating transfers and positioning. He was aware the resident had transferred to a local hospital per patient request. Computerized Tomography (CT) of the low right extremity, dated 8/17/23, indicated Resident B had a subacute to chronic non healed comminuted (a bone that is broken in at least 2 places) right femur intertrochanteric fracture. Review of a consultation note, dated 8/18/23, Orthopedic physician was consulted due to Resident B's fracture. The orthopedic doctor at the hospital indicated the resident had a subacute fracture to the right proximal (situated nearer the center of the body or the point of attachment) femur, likely 2 to 6 weeks old. The physician planned to take Resident B to the operating room on 8/19/23 for a gamma nail (used to treat proximal femoral fractures) and fracture fixation (stabilize extremely misaligned broken bones by re-setting). Review of Operative note, dated 8/19/23, indicated Resident B had a preoperative diagnosis of an unstable fracture of the right proximal femur. The operation was an open reduction and internal fixation (put pieces of a broken bone into place using surgery) of the right proximal femur with 120-degree [NAME] gamma nail with proximal distal interlocking (metallic implants used for the repair of traumatic long bone fractures) and a long leg splint. On 8/18/23 at 9:52 a.m., the Administrator provided an undated document, titled, Guidelines for Physician Notification for Change in Condition Overview, and indicated it was the policy currently being used by the facility. The policy indicated, 1. All significant changes in resident status are thoroughly assessed and physician notification is based on assessment findings and are to be documented int eh medication record .2. Medical care problems are communicated to the attending physician in a timely manner, concise, and thorough manner On 8/18/23 at 9:52 a.m., the Administrator provided a document dated 2/23/22, titled, Notification of Resident Change in Condition, and indicated it was the policy currently being used by the facility. The policy indicated.1. A licensed nurse shall immediately inform the resident, consult with the resident's physician, and the resident's representative when: .b. A significant change in the resident's physical, mental, or psychosocial status On 8/18/23 at 1:15 p.m., the Administrator provided an undated document, titled, Resident Assessment, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To gather comprehensive information as a basis for the identifying resident problems/needs and developing or revising an individual plan of care . 3. Other assessment monitoring shall be initiated and recorded on facility approved forms or in conjunction with the resident's clinical condition, assessed need and planned interventions .4. Other clinical assessments will be performed in conjunction with body systems, with specific problems/complaints This Federal tag relates to Complaints IN00415330 and IN00415942. 3.1-37

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident shower choices were met for 1 of 24 residents reviewed for choices (Resident 25). Findings include: During the initial pool interview, on 1/24/23 at 10:50 a.m., Resident 25 indicated his preference was to receive at least 1 shower a week but had only been getting one every-other-week. Resident 25's record was reviewed on 1/30/23 at 2:42 p.m. The profile indicated the resident had been admitted to the facility on [DATE], for diagnoses which included, but were not limited to, acute respiratory failure with hypoxia (acute or chronic impairment of gas exchange between the lungs and the blood causing hypoxia [a state in which oxygen is not available in sufficient amounts at the tissue level]) and acute kidney failure (when the kidneys suddenly become unable to filter waste products from your blood). A quarterly Minimum Data Set (MDS) assessment, dated 12/12/22, indicated the resident had no cognitive deficit and required physical help in part of bathing of 1-person physical assistance. An Activities of Daily Living (ADL-activities related to personal care) preferences care plan, dated 6/23/22, lacked documentation of the resident's preferences for receiving showers. The resident's task list, from the electronic medical record (EMR) indicated the resident was to receive baths 3 times weekly and as needed (PRN). Review of shower sheets, for December 2022 through January 30, 2023, indicated the resident had received showers on 12/8/22, 12/12/22, 12/20/22, 12/29/22, 1/2/23, 1/10/23, and 1/20/23, which averaged to 1 shower per week. During an interview, on 1/31/23 at 9:16 a.m., the Director of Nursing (DON) indicated she was not completely sure as to why the resident had not received the number of showers that he preferred and why the documented amount on his task reports indicated 3 baths per week. She deferred the question to the Unit Manager to determine if it was a scheduling issue. During an interview, on 1/31/23 at 9:23 a.m., Unit Manager 3 indicated the resident was supposed to receive 2 shower per week and she was unsure why the documentation indicated 3 per week. He was scheduled for a night shift shower and if, for some reason, the staff did not get to his shower (because he was asleep) they would complete the shower in the morning when he got up. She believed that the staff were not very consistent with completing the shower sheets. On 1/31/23 at 11:07 a.m., the DON provided a document, dated 2/9/22, titled, Procedures for Implementation of Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To ensure that .protects and supports the rights of all residents .4 .shall, to the maximum extent possible, encourage and assist residents in exercising their rights of autonomy and choice, deciding how they wish to live their everyday lives and receive care 3.1-3(a) 3.1-3(u)(1)

Based on observation, record review, and interview, the facility failed to ensure nail care was provided to a dependent resident for 1 of 24 residents reviewed for activities of daily living (ADL) (daily tasks related to resident care and hygiene) (Resident 50). Finding includes: On 1/23/23 at 11:57 a.m., Resident 50 was observed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television. On 1/24/23 at 10:11 a.m., Resident 50 was observed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television. On 1/25/23 at 1:31 p.m., Resident 50 was observed, with long, untrimmed fingernails with dark debris underneath the fingernails on bilateral (both) hands, while lying in bed, feeding himself from a bedside table. On 1/26/23 at 10:57 a.m., Resident 50 was observed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television. On 1/27/23 at 11:25 a.m., Resident 50 was observed with long, untrimmed fingernails with dark debris underneath some of the fingernails on both hands. Resident 50's clinical record was reviewed on 1/31/23 at 9:36 a.m. The resident was admitted to the facility, on 12/14/22, with diagnoses included, but were not limited to, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side (a mini stroke caused by a temporary disruption in the blood supply to part of the brain), hypertension (high blood pressure), and apraxia (difficulty with skilled movement, speaking, or doing everyday activities). An admission Minimum Data Set (MDS) assessment, dated 12/21/22, indicated the resident had a moderate cognitive impairment; had no documented behaviors nor rejection of care; required extensive assistance of two persons for bed mobility, transfers, toilet use, and personal hygiene, required total dependence of two persons for bathing, required supervision-oversight with encouragement or cueing with one person physical assistance when eating, had impairment on one side of the upper extremity and impairments on both sides of the lower extremities. A care plan, dated 12/27/22, indicated the resident had a self-care deficit with bed mobility, dressing, personal hygiene/oral care, eating, toileting, transfers, and locomotion on/off the unit with interventions included, but not limited to, encourage the resident to do as much for self as able in ADL areas daily to maintain current level of self-performance. On 1/27/23 at 3:15 p.m., the Administrator (ADM) provided Resident 50's shower schedule and shower sheets, which included nail care, for December 2022 and January 2023. The ADM indicated Resident 50 was on the shower schedule for three showers a week and nail care of trimming and cleaning underneath the fingernails should be provided with each shower. Nail care was documented as completed on 12/28/22 and 1/11/23. During an observation with the Director of Nursing (DON) of Resident 50, on 1/31/23 at 9:35 a.m., Resident 50 indicated staff had trimmed his fingernails the previous evening. Resident 50's fingernails were trimmed but were observed with dark debris underneath some of the fingernails on both hands. The DON observed the dark debris underneath Resident 50's fingernails and indicated Resident 50's fingernails needed to be soaked and the dark debris underneath the fingernails should have been removed when staff trimmed his fingernails. On 2/1/23 at 9:50 a.m., ADM provided and identified a document as a current facility policy, titled Procedures for Implementation of Resident Rights Policy, updated 2/9/22. The policy indicated, .Purpose: To ensure that Providence Health Care protects and supports the rights of all residents in the hope that they will contribute to the physical and mental well-being of residents and the affirmation of human dignity as specifically outlined in the Resident Rights Policy .26. Providence Health Care's policies, procedures, staff training, resident care, and business conduct will all reflect a philosophy that promotes maintenance or enhancement of quality of life and promotes dignity and respect of each individual person .a. Personal dignity will be promoted by good personal grooming and the appropriate assistance with bathing, dressing, hair and nail care which reflects the resident's personal preferences 3.1-38(a)(3)(E)

Based on record review and interview, the facility failed to ensure pharmacy recommendations were acted upon by the physician in a timely manner and that the physician provided rationale for decisions made on pharmacy recommendations, for 2 of 5 residents reviewed for unnecessary medications (Residents 21 and 35). Findings include: 1. Resident 21's record was reviewed on 1/26/23 at 11:45 a.m. The profile indicated the resident's diagnoses included, but were not limited to, stage 5 chronic kidney disease (when the kidneys are getting very close to failure or have already failed) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). An annual Minimum Data Set (MDS) assessment, dated 12/6/22, indicated the resident had no cognitive deficit, received routine pain medications, and received dialysis services. A physician's order, dated 11/30/22, indicated atorvastatin calcium tablet (drug used to lower the amount of cholesterol in the blood), 20 milligrams (mg). Give 1 tablet, by mouth, at bedtime. A physician's order, dated 11/30/22, indicated ergocalciferol capsule (a medication that works by helping the body to use more of the calcium found in foods), 1.25 mg. 1 capsule, by mouth, in the morning every Friday. A physician's order, dated 11/30/22, indicated gabapentin capsule (a medication used to treat seizures, but also taken for nerve pain), 100 mg. 1 capsule, by mouth, at bedtime for pain and 1 capsule, by mouth, once a day on Monday, Wednesday, and Friday for pain. On 1/26/23 at 9:50 a.m., the Director of Nursing (DON) provided pharmacy recommendations, for the resident, from January 2022 through January 25, 2023. Review of the pharmacy recommendations, indicated the following: a. A pharmacy recommendation, dated 3/16/22, indicated the resident was receiving atorvastatin and ergocalciferol 50,000 units every week. The Pharmacist was unable to locate recent labs for lips levels (fat in the blood) and Vitamin D levels. Requested to consider obtaining the labs with next lab orders. The recommendation lacked documentation that the physician had reviewed the recommendation, had written any new orders, or had signed and dated the document. Review of the historical physician orders indicated no lipid level or Vitamin D levels orders from 4/7/21 through 11/2/22, were observed. b. A pharmacy recommendation, dated 8/7/22, indicated the resident received gabapentin 300 milligrams (mg) three times a day. The resident's calculated Creatinine clearance (CrCl-the volume of blood plasma [fluid part of the blood that carries the blood cells] cleared of creatinine [a compound that is excreted from the body in urine]) was 11-15 milliliters (ml) per minute on ideal body weight. Patients on hemodialysis should receive by mouth maintenance doses based on CrCl as indicated for patients with renal impairment. A supplemental post-hemodialysis dose ranging from 125-300 mg PO should be given each 4 hours of hemodialysis. Recommendation to stop current order, and start gabapentin 100 mg, 2 at bedtime and 100 mg, 1 following each hemodialysis on Monday, Wednesday, and Friday. The recommendation lacked documentation that the physician had reviewed, signed or dated the document and lacked documentation of acceptance or declination, of the recommendation. c. A pharmacy recommendation, dated 8/7/22, indicated the resident had as needed (PRN) orders that had not been used in 3 months. The recommendation was to consider discontinuing the PRN medications of Benadryl (used to treat a variety of allergic disorders), cyclobenzaprine (skeletal muscle relaxant), Icy Hot patch (used to treat minor aches and pains of the muscles/joints), Preparation H cream (hemorrhoid treatment), Zofran (used to prevent nausea and vomiting ), Ibuprofen (pain/fever relief), Biofreeze gel (soothes minor pain of the muscles or joints), hydrocortisone cream (used to treat redness, swelling, itching, and discomfort of various skin conditions), Imodium A-D ( over-the-counter drug used to treat diarrhea), and Tums (used to treat excess stomach acid). The recommendation lacked documentation that the physician had reviewed the recommendation, lacked documentation of acceptance or declination, signature and date. d. A second pharmacy recommendation, dated 9/6/22, of the original recommendation, dated 8/7/22, to stop the order of gabapentin 300 milligrams (mg) three times a day and start 100 mg at bedtime and 100 mg, 1 following each hemodialysis on Monday, Wednesday, and Friday, was re-submitted by the pharmacist. The recommendation was accepted by the physician and the document signed and dated on 9/19/22. The original order dated 5/2/22, for gabapentin 300 mg capsule was discontinued on 9/19/22, and a new order was written, for gabapentin 300 mg capsule, give a capsule, by mouth, 3 times daily. The concerns identified in the recommendation originally dated 8/7/22, had been addressed until 9/19/22, 43 days after the recommendation had been written. e. A second pharmacy recommendation, dated 9/6/22, of the original recommendation, dated 8/7/22, which recommended considering to discontinue PRN medications which not been used in 3 months, Benadryl, cyclobenzaprine, Icy Hot patch, Preparation H cream, Zofran, Ibuprofen, Biofreeze gel, hydrocortisone cream, Imodium A-D, and Tums, was re-submitted by the pharmacist. The recommendation was accepted by the physician and the document signed and dated on 9/19/22. used to treat ulcerative colitis in adults). The concerns identified in the recommendation originally dated 8/7/22, had been addressed until 9/19/22, 43 days after the recommendation had been written. f. A pharmacy recommendation, dated 12/8/22, indicated the resident had received Ibuprofen 600 milligrams (mg), 1 every 6 hours as needed for fever. Due to Ibuprofen being nephrotoxic (poisonous or damaging to the kidney), it should be avoided in resident's with GFR (a test used to check how well the kidneys are working) below 30 milliliters (ml) per minute. The resident's GFR was 15 ml/minute. Recommendation was to stop Ibuprofen. The recommendation lacked documentation that the physician had reviewed and lacked documentation of acceptance or declination, signature, and date. Historical review of the physician's orders indicated the order for Ibuprofen had not been discontinued and was still an active order. g. A pharmacy recommendation, dated 1/9/23, indicated Apriso extended release (ER) (used to treat ulcerative colitis in adults), 0.375 grams (gm), give 4 capsules daily. Recommendation was to stop current order and start Apriso ER 0.375 gm, 3 caps daily. The physician agreed and signed and dated the document on 1/17/23. Review of the current physician's orders indicated the order had not been changed from the original order written on 12/1/22. Current order was for Apriso ER 0.375 gm. Give 4 capsule by mouth one time a day. h. A second pharmacy recommendation, dated 1/9/23, of the original recommendation, dated 12/8/22, to stop Ibuprofen 600 milligrams (mg), 1 every 6 hours as needed for fever, was re-submitted by the pharmacist. The physician had agreed and signed and dated the document on 1/17/23. The concerns identified in the recommendation originally dated 12/8/22, had been addressed until 1/17/23, 41 days after the recommendation had been written. During an interview, on 1/26/23 at 9:50 a.m., the Director of Nursing (DON) indicated the she had not been able to find any additional information related to the recommendations she provided. The facility had changed to a new pharmacy in August 2022. For the recommendations prior to that date no documentaion of physican review, rationale, signature, or dates were found. 2. Resident 35's clinical record was reviewed on 1/27/23 at 1:16 p.m. The resident was admitted to the facility, on 4/20/21, with diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a mini stroke caused by a temporary disruption in the blood supply to part of the brain), hypertension (high blood pressure), anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life), insomnia (difficulty sleeping or staying asleep), and heart failure. An annual Minimum Data Set (MDS) assessment, dated 12/29/22, indicated the resident had a moderate cognitive impairment, received an antidepressant (used to treat depression) and a hypnotic (sleeping pill) on a routine basis. An active physician's order, start dated 4/21/21, indicated sertraline hydrochloride (HCl) (brand name Zoloft) (medication used to treat anxiety and depression) oral tablet 25 milligrams (mg). Give 1 tablet, by mouth, at bedtime. An active physician's order, start dated 6/6/21, indicated Ambien (generic name Zolpidem Tartrate) oral tablet 5 mg. Give 1 tablet, by mouth, at bedtime, for difficulty sleeping. An active physician's order, start dated 3/3/22, indicated Zyrtec Allergy Tablet (generic name cetirizine HCl) oral tablet 10 mg. Give 1 tablet by mouth one time a day for allergies. On 1/26/23 at 9:50 a.m., the Director of Nursing (DON) provided pharmacy recommendations, for the resident, from January 2022 through January 25, 2023. Review of the pharmacy recommendations, indicated the following: a. A pharmacy recommendation, dated 4/7/22, indicated the resident was receiving Zoloft 25 mg daily since admission 4/2021 for anxiety and depression. The recommendation indicated, per federal regulations any medication when used to manage behavior, stabilize mood, or treat a psychiatric disorder is subject to GDR (gradual dose reduction) twice in two separate quarters with at least one month between attempts within the first year a resident is admitted on a psychopharmacological medication or after the facility has initiated a psychopharmacological medication. After the first year, it is subject to GDR once per year. A GDR is contraindicated if the continued use is in accordance with relevant current standards of practice, and physician has documented clinical rationale -or- Resident's target symptoms returned or worsened after most recent GDR attempt within facility and physician has documented clinical rationale and to review if a GDR may be attempted at this time. The recommendation lacked documentation that the physician had reviewed, signed, or dated the document and lacked documentation of acceptance or declination, of the recommendation. b. A pharmacy recommendation, dated 6/13/22, indicated the resident was receiving Ambien (Zolpidem) 5 mg daily at bedtime. The recommendation indicated, indicated, per federal regulations any medication when used to manage behavior, stabilize mood, or treat a psychiatric disorder is subject to GDR (gradual dose reduction) twice in two separate quarters with at least one month between attempts within the first year a resident is admitted on a psychopharmacological medication or after the facility has initiated a psychopharmacological medication. After the first year, it is subject to GDR once per year. A GDR is contraindicated if the continued use is in accordance with relevant current standards of practice, and physician has documented clinical rationale -or- Resident's target symptoms returned or worsened after most recent GDR attempt within facility and physician has documented clinical rationale and to review if a GDR may be attempted at this time. The physician checked Other on the recommendation form and wrote, stable - as is, signed by the physician on 7/11/22. The document lacked documentation of a clinal rationale for not attempting a GDR. c. A pharmacy recommendation, dated 8/5/22, indicated the following PRN (as needed) orders had not been utilized in 3 months per nursing administration records. Please consider discontinuing the following: Colace (stool softener) 100 mg capsules, Donnatal (used to treat stomach problems), 16.2 mg tablet, Imodium A-D (diarrhea medication) 2 mg tablet [2 orders], Meclizine (used to prevent and treat nausea, vomiting, and dizziness) 12.5 mg tablet, Dextromethorphan HBr (cough medication) liquid, guaifenesin (used to relieve chest congestion) 100mg/5 milliliters (ml) syrup, Lidocaine (anesthetic causing loss of feeling in the skin and surrounding tissues) 4% cream, and Pyridium (used to relieve symptoms caused by irritation of the urinary tract) 100 mg tablet. The recommendation lacked documentation that the physician had reviewed, signed, or dated the document and lacked documentation of acceptance or declination, of the recommendation. d. A pharmacy recommendation, dated 8/6/22, indicated the resident was receiving Cetirizine (Zyrtec) 10 mg tablet my mouth daily. Recommended to stop current order, due to poor kidney function blood work, and start Cetirizine 10 mg tablet my mouth qod (every other day). The physician had agreed to the recommendation and signed the recommendation on 8/11/22. Resident 35's record lacked documentation the Cetirizine order was discontinued and changed to every other day administration. e. A repeated pharmacy recommendation, dated 8/9/22, indicated the resident was receiving Zolpidem (Ambien) 5 mg daily at bedtime. The recommendation indicated, the use of hypnotics should generally be limited to 7-10 days of treatment per labeling from the FDA (Food and Drug Administration). This is also the regulation in nursing facilities. Per behavior meeting on 8/9/22, patient and family are resistant to changes in this medication. They also report that she does not exhibit any morning hangover effect or other side effects. While technically this cannot be documented as a clinical contraindication to change because the order is not in accordance with relevant current standards of practice, please take a moment to write a clinical rationale for continued use and reasons preventing a GDR at this time. The recommendation lacked documentation that the physician had reviewed, signed, or dated the document and lacked documentation of acceptance or declination, of the recommendation. f. A repeated pharmacy recommendation, dated 9/6/22, indicated the resident was receiving Cetirizine (Zyrtec) 10 mg tablet my mouth daily. Recommended to stop current order, due to poor kidney function blood work, and start Cetirizine 10 mg tablet my mouth qod (every other day). The physician checked Other on the recommendation form and wrote, Leave as is, signed by the physician on 9/14/22. The document lacked documentation of a clinal rationale for not attempting a GDR. g. A repeated pharmacy recommendation, dated 9/6/22, indicated the resident was receiving Zolpidem (Ambien) 5 mg daily at bedtime. The recommendation indicated, indicated, per federal regulations any medication when used to manage behavior, stabilize mood, or treat a psychiatric disorder is subject to GDR (gradual dose reduction) twice in two separate quarters with at least one month between attempts within the first year a resident is admitted on a psychopharmacological medication or after the facility has initiated a psychopharmacological medication. After the first year, it is subject to GDR once per year. A GDR is contraindicated if the continued use is in accordance with relevant current standards of practice, and physician has documented clinical rationale -or- Resident's target symptoms returned or worsened after most recent GDR attempt within facility and physician has documented clinical rationale and to review if a GDR may be attempted at this time. The physician checked Other on the recommendation form and wrote, Leave as is, signed by the physician on 9/14/22. The document lacked documentation of a clinal rationale for not attempting a GDR. h. A repeated pharmacy recommendation, dated 9/6/22, indicated the following PRN (as needed) orders had not been utilized in 3 months per nursing administration records. Please consider discontinuing the following: Colace (stool softener) 100 mg capsules, Donnatal (used to treat stomach problems), 16.2 mg tablet, Imodium A-D (diarrhea medication) 2 mg tablet [2 orders], Meclizine (used to prevent and treat nausea, vomiting, and dizziness) 12.5 mg tablet, Dextromethorphan HBr (cough medication) liquid, guaifenesin (used to relieve chest congestion) 100mg/5 milliliters (ml) syrup, Lidocaine (anesthetic causing loss of feeling in the skin and surrounding tissues) 4% cream, and Pyridium (used to relieve symptoms caused by irritation of the urinary tract) 100 mg tablet. The physician agreed and signed the recommendation, on 9/14/22, to discontinue all the medications listed on the recommendation form. i. A pharmacy recommendation, dated 12/6/22, indicated the resident was receiving Cetirizine (Zyrtec) 10 mg tablet my mouth daily. Recommended to consider ordering a more current blood work of a BMP (basic metabolic panel is a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys are working) or CMP (comprehensive metabolic panel is a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working) and recommended to start Cetirizine (Zyrtec) 10 mg qod at bedtime. The recommendation lacked documentation the physician had reviewed, signed, or dated the document and lacked documentation of acceptance or declination, of the recommendation. On 1/27/23 at 12:08 p.m., the Director of Nursing (DON) indicated the physician did not address the pharmacy recommendations in a timely manner and should have provided a clinical rationale when the recommendation was not accepted. The DON provided and identified a document as a current facility policy, titled Consultant Pharmacist Policy, dated 12/7/22. The policy indicated, .Purpose: To define the role and responsibilities of the Consultant Pharmacist and support personnel involved in consultation duties. To establish guidelines for timely reviews of residents' medication regimen .Responsibility: Director of Health Services, Consulting Pharmacist, Director of Nursing, Licensed Nurses, and attending Physicians .Policy: It is the policy of Providence Health Care to have an agreement with a long term care experienced, licensed pharmacist to provide consultation on all aspects of the provision of pharmacy services and perform monthly medication regimen reviews for all residents .Standards: 1. Responsibilities of the Consultant Pharmacist, or qualified designee, shall include but not limited to: .a. Conduct monthly, and for new admissions, drug regimen reviews for each resident and report any irregularities to the Director of Health Care Services, Director of Nursing and attending physicians as appropriate .11. In the event a problem or irregularity is noted during the review, the nurse in charge and/or Director of Nursing will be promptly notified. When necessary, the attending physician, Medical Director and Director of Heal Care Services will be notified. The pharmacist will notify the physician as appropriate .12. The written report of the Drug Regimen Review shall be discussed and given to the Director of Nursing and Director of Health Care Services. The Director of Health Care Services and Director of Nursing shall review the report for significant problems and initiate action(s) as necessary. The Director of Nursing shall forward the report to the unit managers for follow-up, physician contact, and corrections and physician recommendation review as appropriate 3.1-48(a)(1) 3.1-48(a)(2) 3.1-48(a)(3) 3.1-48(a)(4) 3.1-48(a)(5) 3.1-48(a)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure pharmacy recommendation were reviewed and addressed by the physician for 2 of 5 residents reviewed for unnecessary medications (Residents 2 and 21). Findings include: 1. Resident 2's record was reviewed on [DATE] at 1:59 p.m. The profile indicated the resident's diagnoses included, but were not limited to, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem), and mood disorder due to a known physiological condition (when various physical diseases or conditions create some form of mental health issue). An annual Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had severe cognitive deficit and received antispychotic, antidepressant and antianxiety medications. On [DATE] at 9:50 a.m., the Director of Nursing (DON) provided pharmacy recommendations, for the resident, from [DATE] through [DATE]. A pharmacy recommendation, dated [DATE]. indicated to consider a GDR (gradual dose reduction) of risperdal (medication used to treat mood disorder), 1 milligram (mg) at bedtime for mood disorder, buspar (medication used to treat anxiety) 5 mg every morning and 15 mg at bedtime for anxiety, and cymbalta (medication used to treat depression) 60 mg daily and remeron (medication used to treat depression) 7.5 mg at bedtime for depression. The resident had been on the medications since her admission on [DATE]. The form lacked documentation that the physician had revived or addressed the recommendation, and lacked a physician signature, and date. 2. Resident 21's record was reviewed on [DATE] at 11:45 a.m. The profile indicated the resident's diagnoses included, but were not limited to, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). An annual Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had no cognitive deficit and received antidepressant medications. On [DATE] at 9:50 a.m., the Director of Nursing (DON) provided pharmacy recommendations, for the resident, from [DATE] through [DATE]. A pharmacy recommendation, dated [DATE], indicated the resident received Paxil 10 mg daily for depression since [DATE] and was due for an annual evaluation for a possible GDR (gradual dose reduction). The recommendation lacked documentation that the physician had reviewed and lacked documentation of his acceptance or declination, signature, and date. Review of the historical physician's orders indicated there had been no change on the Paxil order from [DATE] until [DATE]. During an interview, on [DATE] at 9:50 a.m., the Director of Nursing (DON) indicated the facility had started with a new pharmacy in [DATE]. The pharmacy recommendations were from the previous pharmacy. She was unable to find any recommendations from the old pharmacy, which had any physician documentation, rationale, signatures, or dates on them. On [DATE] at 12:08 p.m., the DON provided a document, dated [DATE], titled, Consultant Pharmacy Policy, and indicated it was the policy currently being used by the facility. The policy indicated, .Standards .2. Each month the consulting pharmacist will review each resident's medication regimen to identify appropriate use, resident response, side effects and drug interactions, etc., in accordance with the stated purpose .11. In the event of a problem or irregularity is noted during the review, the nurse in charge, and/or the Director of Nursing .attending physician, Medical Director .will be notified 3.1-48(a)(3) 3.1-48(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications, biologicals, and feeding tube formulas were labeled, stored, and destroyed according to policy for 1 of 4 medication carts observed, and 1 of 2 medication rooms observed for medication and biological storage. Findings include: 1a. On [DATE] at 10:50 a.m., observation of the rehabilitation unit medication room with Registered Nurse (RN) 19, the following was observed, a. A plastic bin containing 32 cartons of Perative 1.5 cal (enteral formula) with an expiration date of [DATE]. b. A plastic bin containing 10+ bags of Peptamen 1.5 (for tube feeding) with an expiration date of 12/2022. c. A plastic bin containing 20 + cartons of Peptide 1.5 (Kate's Farm plant based formula) with an expiration date of [DATE]. A medication cart was also observed to have an opened and unlabeled tube of Lidocaine with Prilocaine (topical antiseptic) 2.5%-2.5% cream laying on top a roll of Acetaminophen 325 mg tablet packets for Resident 107. On [DATE] at 11:10 a.m., RN 19 indicated there were currently 4 residents receiving nutrition through feeding tubes to included Resident 4 who received Perative 1.5 cal boluses of 250 mg twice daily and a continuous feeding of Perative 70 ml/hr (milliliters per hour) at night. Resident 4's record was reviewed on [DATE] at 3:10 p.m. Physician's orders for Resident 4 included, Perative TB (tube feed) bolus of 250 ml daily at noon and 4:00 p.m. Perative TF every night shift 8:00 p.m. - 7:00 a.m. at 75 ml/hr with 40 ml hr water flush. A Medication Administration Record (MAR) for Resident 4, dated [DATE], indicated documentation the resident had received Perative 1.5 cal tube feeding daily as ordered. On [DATE] at 2:11 p.m., supply aide 20 indicated she stocked supplies on Monday, Friday, and as needed. 1b. During a random observation of Resident 40's room on [DATE] at 2:32 p.m., the following was observed, a. 2 vials of Albuterol 3 mg/ml (bronchodilator nebulizer medication) on a table beside her recliner. b. 1 opened and 1 unopened tube of Mupirocin 2% ointment (Bactroban used for moderate to severe bacterial infections). Resident record lacked documentation of an order or instructions for this medication. c. A medication cup with an unidentified white pill on the bedside stand among personal items. Resident record lacked documentation of an order or care plan for the resident to self-administer medications. During an interview on [DATE] at 10:58 a.m., Supply Aide 20 indicated she and the nurses were responsible for monitoring the expiration dates on supplies to include supplements and tube feeding formulas. When the supplements and tube feeding formulas were expired, they were to be pulled from the medication room and thrown in the trash. The last time she had thrown away formula from the rehabilitation medication room was on Monday [DATE], and she had not seen Perative 1.5 with the expiration date of [DATE]. Indicated on [DATE] she had pulled half a bin of [NAME] Farm supplement that was expired, and that morning she had pulled the 10+ bags of Peptamen that had expired on 12/22. During an interview on [DATE] at 11:18 a.m., the DON indicated, the nurse and consulting pharmacist were responsible for monitoring medication and supplement storage. Medications including pills and nebulizer treatments could not be left at the bedside without an assessment being done by the nurse managers. The supply person was responsible for checking expiration dates on the supplements and tube feed formulas. On [DATE] at 12:00 p.m., the Director of Nursing (DON) provided a Medication Storage Policy, dated [DATE], and indicated the policy was the one currently being used by the facility. The policy indicated, it was the policy of the facility that drugs and biologicals were be stored in a safe, sanitary, and orderly manner. Drugs and biologicals, prescribed by a physician, shall be locked in a medication room[s] or locked in a medication cart .External use drugs will be stored separately from drugs for internal use in the treatment cart .Drugs which had been discontinued, are outdated or deteriorated shall not be stored in the facility longer than 7 days .No drugs or biologicals shall be stored which are beyond manufacturer's expiration date or facility established expiration date . 3.1-25(m) 3.1-35(o)

B. On 1/23/23 at 11:50 a.m., Resident 40 was observed putting together a jigsaw puzzle in her room on a desk located at the foot of her bed. She indicated she was concerned her call button reached her when she was in bed and in her recliner, but if she fell by the desk where she often sat putting together puzzles, or by her television she would have to crawl to get to the cord on her recliner. She had tripped over her oxygen tubing on multiple occasions but caught herself by grabbing onto furniture before she fell. Resident 40 had reported her concerns to the Activity Director among peers during a resident council meeting, but she had never been given another cord. The resident's call light was observed where she indicated clipped to the arm of her recliner, and when stretched would reach the end of the bed but was taut approximately 3 feet off the ground creating a hazard. Resident Council Minutes, dated September 6, 2022, indicated, a resident said she would rather have a call light that she could wear since her call light wasn't always within her reach. Unit Manager (UM) 3 let the resident know that she had an idea about her call light since she sits on both sides of the room. She would let maintenance know about her idea to see if it would work. Resident Council Minutes dated October 2022 - January 2023 lacked documentation the call light request was followed up. Grievance Logs, dated September 2022 through January 2023, indicated there were no concerns documented for Resident 40. During an interview on 1/26/23 at 10:54 a.m., the AD indicated during a resident council meeting in September 2022, Resident 40 had reported when doing puzzles, the call light was not long enough to go from one side of the room to the other. UM 3 indicated she had an idea already so she would go to maintenance to get a double headed call cord. Maintenance was supposed to go in per UM 3's request to get a 2 prong call light, one for each side of the room. The AD indicated if a resident had a complaint reported during a resident council meeting, she would tell the responsible department head, who was supposed to address the issue. There was no current system of assuring issues were addressed such as being signed off. At this time, she was responsible for assuring concerns were addressed. During an interview on 1/26/23 at 11:01 a.m., UM 3 indicated the facility had recently installed a new call light system and she was not sure the system would handle split call light cords. Maintenance was supposed to be looking into it. During an interview on 1/26/23 at 11:15 a.m., the Maintenance Supervisor indicated, he did not recall getting a request to provide Resident 40 with a longer or split call cord, and upon observation of repair request cards, dated 2022, indicated there was no request card found. He indicated as he had no request card and had no email, to him, so this meant no request was passed on to him. The Maintenance Supervisor indicated if a resident requested a split call cord and one was available, the resident could have it. UM 3 should have filled out an orange maintenance request card and put it in the box at the nurse's station where he picked them up twice a day. Once a request was finished, he would then sign off on the card and file it away. He was supposed to receive requests or concerns on orange tickets at the nurse's station, but staff or residents/resident representatives often would call him, text, e-mail or just catch him in the hallway and report issues. During an interview on 1/26/23 at 11:34 a.m., the Administrator (ADM) indicated, residents were told at every resident council meeting that she was the grievance officer, and residents could get a grievance form by asking for one from the nurses on the floor. Once the ADM received a grievance form, she would fill out the grievance log and make sure it was followed up. She had never heard about Resident 40 requesting a different call cord. On 1/26/23 at 2:40 p.m., AD provided and identified a document as a current facility policy, titled, Resident Council Policy, dated 2/21/22. The policy indicated, .Purpose: To establish guidelines for assisting residents with the development and facilitation of a Resident Council in order to voice grievances, make recommendations, and participate in resolution of concerns .The facility must consider the views of a resident to family group and act promptly up the grievances and recommendation of such groups concerning issues of resident care and life in the facility. The facility must be able to demonstrate their responses and rationale for such response. This should not be construed to mean that the facility must implement as recommended every request of the resident or family group On 1/31/23 at 10:35 a.m., the Director of Nursing (DON) provided a Registration and Disposition of Complaints Policy, dated 7/9/22, and indicated the policy was the one currently being used by the facility. The policy indicated, Purpose: To ensure that residents and representatives have the opportunity to have complaints heard, reviewed, and when possible, receive resolution and/or appropriate disposition .The Director of Health Services shall be responsible for assuring grievances/resolutions are resolved and for informing appropriate individuals .Any facility staff member receiving a concern/suggestion is responsible to report the concern/suggestion to their supervisor and/or Department Manager, or to the Charge Nurse on duty and complete a Concern/Suggestion form .The Department Manager of the involved service will investigate the concern and as appropriate meet with the resident or responsible party to discuss resolution. Measures will be taken to ensure the concern is not repeated. Documentation of this investigation and resolution will be make on the report and returned to the Director of Health Care Services for review and filing .All resolution conferences will be documented and attempt make to have all parties, including residents or their representatives, sign the report indicating attendance .Grievances and concerns received from the Resident or Family Councils will also be recorded in the minutes or recorded on a Concern/Suggestion Form and promptly addressed by the Director of Health Care Services. A written response will be given to the Council at their next meeting . 3.1-3(l) 3.1-3(v)(1) A. Based on interview and record review, the facility failed to address grievances in a manner which could be tracked for 5 of 5 months reviewed for grievance resolutions of the Resident Council and the facility's grievance log. This potentially affected 63 of 63 residents who resided in the facility. B. Based on observation, interview, and record review, the facility failed to ensure a grievance provided during resident council was resolved for 1 of 1 resident reviewed for grievances (Resident 40). Findings include: A1. Resident Council minutes were provided by the Activity Director (AD) on 1/24/23 at 10:28 a.m. The minutes indicated the following concerns by the Resident Council: a. Cold food temperatures of the residents' meals b. Call lights taking too long to be answered by staff During the Resident Council meeting, on 1/26/23 at 9:30 a.m., the residents indicated the facility had not acted promptly upon the grievances of the cold food temperatures of the residents' meals and the call lights taking too long to be answered by staff. During an interview with the Activities Director (AD), on 1/26/23 at 10:12 a.m., she indicated she took minutes for the Resident Council meetings and then spoke with the Administrator (ADM), who was the facility's grievance officer, the department heads, and staff about the Resident Council's concerns. Food temperatures and call light concerns have been brought up at several of the Resident Council meetings. There was not a written follow-up for the Resident Council's concerns. On 1/31/23 at 11:20 a.m., a lunch meal test tray was requested from the Dietary Manager (DM) in the kitchen. Dietary Aide (DA) 25 temped the food on the steam table, while the DM wrote onto a food temperature log the temperatures of: green beans at 153.3 Fahrenheit (F), salmon at 188.4 F, and rice at 173.4 F. DA 25 then began plating the food onto a plate with a warming pellet underneath the plate and a plastic cover on top of the plate. She placed the plate onto a tray and placed the tray into a tray cart. The last four plates did not have a warming pellet underneath, only the plastic cover on top of the plate. On 1/31/23 at 12:43 p.m., DM observed the four meal trays without warming pellets underneath the plates and indicated the kitchen was short on four warming pellets for the residents' lunches. When the staff do not bring back the warming pellets after a meal, the kitchen was short on the warming pellets for the next meal. The test tray food temperatures were green beans at 114.8 F, rice at 120.7 F, and salmon at 113.9 F. The DM indicated the test tray food temperatures were cold and should have been at least 125 F. On 1/27/23 at 10:25 a.m., the Administrator indicated the dietary department had completed test trays and have requested the residents to notify the staff immediately if they had a concern with their meal being cold. She was the grievance officer. They had told the Resident Council verbally resolutions to the concerns with the cold food concerns, but the facility had not provided the Resident Council a written follow-up response to the residents' concerns. A2. On 1/27/23 at 11:05 a.m. the Administrator (ADM) provided a grievance log, dated September 2022 to January 2023, and indicated Resident 35's daughter had contacted the facility and had a grievance about the call light times taking too long for staff to answer for her mother, due to a fall from the toilet Resident 35 had sustained with a skin tear on 10/18/22. The ADM provided a call light log, titled Past Calls 10/18/22, and indicated Resident 35 had pressed her call light, on 10/18/22 at 7:15 p.m., and waited fifty minutes for the call light to be answered, had pressed her call light, on 10/18/22 at 10:11 p.m. and waited seven minutes and fifty-two seconds, and pressed her call light for assistance, on 10/18/22 at 10:57 p.m., and waited thirteen minutes when she fell off of the toilet due to trying to get up by herself without staff assistance. The ADM had completed and provided a document, titled Providence Health Care, INC. Concern/Suggestion Report, which indicated, Resident 35's daughter had a concern about Resident 35's fall, on 10/18/22, after having waited too long on the toilet for staff assistance after pressing the call light. Action taken and results indicated follow up on 10/24/22 would investigate the fall and call light time responsiveness. ADM documented on the concern grievance, the daughter was called on 10/24/22 to discuss and left a message. No additional follow up documentation was noted with a grievance resolution for the call light time responsiveness. On 1/27/23 at 10:25 a.m., the Administrator indicated she was the grievance officer and reviewed the daily (24 hours) and monthly log of the call light system via email. If she had found a concern of a delayed call light, she would go directly to the staff assigned to the unit and find out the reasoning for the delay in answering a call light. The after-supper call lights had a pattern of delayed response times, due to everyone wanted to go to bed and the staff shift change between 6:00 p.m. and 6:30 p.m. We have told the Resident Council verbally resolutions to the delayed response times for the call lights, but the facility had not provided the Resident Council a written follow-up response to the residents' concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an effective fall management program and failed to ensure fall interventions were personalized, implemented, and care planned for 4 of 4 residents reviewed for accidents (Residents 36, 31, 40, and 35). Findings include: 1. During an initial pool interview on 1/24/23 at 11:16 a.m., Resident 36 indicated she had multiple falls, but she was not sure when the last fall had occurred. Pointing to her head, she indicated she had pain in a bump on the back of her head and on her leg. The resident's private bathroom was observed to have pieces and strips of toilet paper on the floor around the toilet, and a clean brief on the sink with pieces torn out of it. Resident 36's record was reviewed on 1/27/23 at 1:24 p.m. Diagnoses on Resident 36's profile included, but were not limited to, history of falls, hemiplegia and hemiparesis (paralysis of one side) of left dominant side, anxiety disorder, age-related debility, difficulty walking, and lack of coordination. Resident 36's electronic medical record (EMR) indicated the following recent falls, a. On 11/5/22 at 1:00 p.m. while attempting to self- toilet. On 11/5/22 a new order for Macrobid (antibiotic) 100 milligrams (mg) 1 capsule by mouth two times daily for a urinary tract infection (UTI) for 5 days was started. Resident record lacked documentation a physician's order had been obtained for a urinary analysis (UA) that had been obtained on 10/27/22 before the fall. b. On 11/15/22 at 6:15 p.m. while attempting to self-toilet. On 11/19/22 a new order for Bactrim DS (antibiotic) 800-160 mg 1 tablet by mouth two times daily for a UTI for 7 days was started. Resident record lacked documentation a UA had been obtained to diagnose the UTI. c. On 11/27/22 at 9:30 a.m. while attempting to self-toilet. d. On 11/30/22 at 9:45 a.m. while attempting to self-toilet. e. On 12/20/22 at 7:45 p.m. while attempting to self-toilet. On 12/21/22 a new order for Macrobid 100 mg 1 capsule by mouth two times daily for a UTI for 10 days was started. Resident record lacked documentation a physician's order had been obtained for a UA that had been obtained on 12/15/22 before the fall. f. On 1/14/23 at 7:25 p.m. while attempting to self-toilet. On 1/8/23 a new order for a UA with culture and sensitivity (UA C&S) one time only for burning urination, increased confusion, and increased fatigue. Resident record lacked documentation the UA had been completed before the resident fell on 1/14/23. On 1/19/23 a new order for Bactrim DS 800 - 160 mg 1 tablet by mouth two times daily for UTI for 7 days was started. g. On 1/23/22 at 9:35 a.m. while attempting to self-toilet. h. On 1/27/23 at 4:00 p.m. while attempting to self-toilet. The resident record lacked documentation the physician and/or resident representative was notified of resident falls on 11/5/22, 11/15, 11/30, 12/20, 1/14/23, 1/23, and 1/27. No further documentation was provided during the survey. The resident record lacked documentation neuro check assessments were completed for resident falls on 12/20/22 and 1/27/23. No further documentation was provided during the survey. A Fall Risk Assessment, dated 12/20/22, indicated history of falls in the last 6 months, 1-2. This was an error in documentation as the resident record indicated over 5 falls at that time. A quarterly minimum data set (MDS) assessment completed on 11/15/22, assessed the resident as being cognitively intact. The resident required limited assistance of 2+ persons physical assist for bed mobility, and transfers, supervision of one person physical assist for walking in room, and extensive assistance of 2+ persons physical assist for toilet use. Mobility devices included a wheelchair. Occasionally incontinent of bladder and always continent of bowel. No trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had been attempted since urinary incontinence was noted in this facility. 2 or more falls since the prior assessment. A care plan for falls visible in the EMR, indicated Resident 36 was at risk for falls related to requiring assistance with Activities of Daily Living (ADL's), medication use, bladder and bowel incontinence, and history of falls. The goal was for her to be free of falls with injury through the review date. Care plan intervention updates included, a. 5/17/21 anticipate and meet her needs; encourage her to participate in activities that promote exercise, physical activity for strengthening and improved mobility; ensure she is wearing appropriate footwear when ambulating or mobilizing in wheelchair, ensure her call light is within reach while in room and encourage her to use it. Promptly respond to all requests for assistance; follow facility fall protocol, PT/OT (physical therapy/occupational therapy) and evaluate and treat as ordered or PRN (as needed). b. 5/26/21 review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. c. 11/10/22 PT evaluate and treat as ordered or PRN. d. 11/16/22 review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Resident needs a safe environment with: (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach). Educate resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure that resident is wearing appropriate footwear (Specify and describe correct client footwear i.e. brown leather shoes, tartan bedroom slippers, black non-skid socks) when ambulating or mobilizing in w/c. On 1/31/23 at 11:35 a.m. the Director of Nursing (DON) provided a fall care plan for Resident 36 with additional interventions and indicated she could not explain why the interventions could not be viewed on the EMR by others. The interventions included, a. 11/5/22 education provided on transfers. b. 11/23/22 offer toileting every 2 hours until finished with antibiotics. c. 11/27/22 OT (occupational therapy) and treatment for safety awareness. d. 11/30/22 2 hour safety checks until therapy is completed. e. 12/20/22 Urinary analysis (UA) culture and sensitivity (C&S) pending. f. 1/14/23 obtain repeat UA C&S. The resident record lacked documentation individualized interventions related to falls in the bathroom while attempting to self-toilet had been attempted or added to the care plan. During an interview on 1/30/23 at 2:20 p.m., Unit Manager (UM) 3 indicated, Resident 36 was capable of self-transferring and ambulating independently, but she was not supposed to. She would use her call light for assistance but would not always call for assistance when toileting. During an interview on 1/31/23 at 10:24 a.m., Registered Nurse (RN) 11 indicated, if a resident had an unwitnessed fall, the nurse would complete a head to toe assessment looking for injury to include vital signs. If the resident had an injury neuro checks were initiated, the physician notified, and the resident sent to the emergency department (ED). Fall documentation included a Risk Management Report and a Coms Post Fall Evaluation, both which fed documentation into the nurse's notes. The nurse was to notify the facility management, physician (MD), and family. Care plans on the rehab unit were updated by unit manager (UM) 19 and/or the care plan team. If the resident had a witnessed fall with no injury, the assessments, and documentation remained the same with follow up for 72 hours. Laboratory tests were completed only after contacting the MD for an order, writing the order, contacting the contracted lab company, and obtaining the sample. During an interview on 1/31/23 at 11:18 a.m., the DON indicated, at the time of a resident fall the nurse was responsible for implementing a new fall intervention. The interdisciplinary team (IDT) then reviewed all fall documentation and would determine the appropriateness of the intervention and change or add as needed. 2. During the initial tour on 1/23/23 at 2:28 p.m., Resident 31 was observed to be toileting independently in her private bathroom. Resident's walker was parked near the door to the hallway with a sign indicated, press call light for staff to help you walk. Please do not walk without staff. The resident call light was not activated. On 1/23/23 at 2:40 p.m., Resident 31 was observed exiting her bathroom in a wheelchair (wc) using her feet to propel and entering the common area in the hallway outside her room. The resident was sitting on a gait belt, had anti-tipper bars on the back of her wc, and a wanderguard bracelet (used to trigger an alarm and prevent an elopement or unauthorized leaving of the unit) on her right ankle. Resident 31 indicated she could go to the bathroom on her own. On 1/24/23 at 10:53 a.m., Resident 31 was observed sitting in her wc in the hallway outside her room, coat in hand, and indicated she was not sure if she had an appointment that day. Indicated the wanderguard on her right ankle was used so they could find her in case she got outside alone, had an accident, or got lost. On 1/26/23 at 10:18 a.m., Resident 31 was observed in the dining/activity common area asleep in her wc, with her head hung down towards her chest. On 1/27/23 at 9:53 a.m., Resident 31 indicated she was unsure why she'd had 2 falls in the past 2 days, but thought one was from getting up on the side of the bed, the wc was too far away to reach, the call light was on the back side of the bed, and when the mattress ultimately gave way, she slid to the floor. Indicated, thought she had a urine test, maybe yesterday. Resident 31's record was reviewed on 1/26/23 at 1:51 p.m. Diagnoses on Resident 31's profile included, but were not limited to, unspecified dementia, history of falling, repeated falls, lack of coordination, difficulty walking, unsteady on feet, and need for assistance with personal care. Post Fall Evaluation notes on 1/25/23 at 6:43 a.m., indicated on 1/25/23 at 5:40 a.m., Resident 31 had an unwitnessed fall in her room while attempting to self-toilet. The reason for the fall was not evident. The bathroom call light was not on at the time of the fall. Place resident on 30 minute safety checks. An Interdisciplinary Team (IDT) note, dated 1/25/23 at 9:12 a.m., indicated the IDT met to discuss the resident occurrence. Initiated 30 minute safety checks while on Neuros (for 72 hours). Post Fall Evaluation notes on 1/26/23 at 7:08 a.m., indicated on 1/26/23 at 6:30 a.m., Resident 31 had an unwitnessed fall in her room, resident was in a hurry/rush at the time of the fall. The reason for the fall was not evident. The resident had current medical conditions that contributed to the fall. Unable to ambulate per self, a history of falls, and a history of falls at the facility. Resident had a similar fall when she slid out of her wheelchair the prior morning. An annual MDS assessment, completed on 10/21/22, assessed the resident as being cognitively intact. Limited assistance of one person physical assist for bed mobility and transfers. Independent with no set up or physical help for walking in the room, corridor, and locomotion off the unit. Supervision with no setup or physical help from staff for locomotion on the unit. Supervision and one person physical assist with toileting and personal hygiene. Assistive devices included a wc and walker. 1 fall without injury since admission/entry or reentry or the prior assessment. A fall care plan for Resident 31 indicated she was at risk for falling related to requiring assistance with ADL's (daily tasks related to resident care and hygiene), medication use, history of falls, and bowel and bladder incontinence. The goal was for the resident to be free of falls with injury. Interventions updates included on 1/6/23 encourage the resident to go to her room when she falls asleep in wc, and on 1/25/23 30 minute checks while on neuro's. During an interview on 1/27/23 at 10:00 a.m., UM 3 indicated, she had sent out a UA sample for the resident related to her falls in the past 2 days. She thought the root cause of the falls were related to the resident getting up to go to the bathroom on her own. She could not answer if the resident got up independently during off shifts. Indicated the resident would use her call light for assistance. Observation of the resident medical record with UM 3 indicated there was no MD order for a UA, and no documentation in the progress notes the MD or responsible party had been notified of both falls. Observation of the electronic communication system for the contracted laboratory with UM 3 indicated there was no documentation a UA sample had been received by the lab or was being processed. The facility provided no laboratory results dated [DATE]. During an interview on 1/27/23 at 10:06 a.m., Certified Nursing Assistants (CNA's) 16 and 17 indicated they routinely cared for Resident 31. She did not use her call light for assistance as she preferred to be independent. The resident would transfer out of bed to her wc then to the toilet, taking her clothing with her to dress. Staff would sometimes catch her in the middle of care and assist her with dressing and transfers. On 1/27/23 at 11:30 a.m., UM 3 presented a laboratory form for Resident 31, dated 1/26/23 at 5:54 p.m. indicated UA with culture, and a handwritten physician's order, dated 1/26/23, indicated UA C&S. UM 3 indicated, there was no MD order initially for the UA as the nurse yesterday did not know how to write the physician's order. A nurse on the rehabilitation hall later placed the lab order and wrote the handwritten MD order. UM 3 did not provide documentation the MD or resident representative had been notified of the falls, or a physician had given the order for the UA. 3. During the initial tour on 1/23/23 at 11:50 a.m., Resident 40 was observed putting together a jigsaw puzzle in her room on a desk located at the foot of her bed. She indicated, she could transfer and ambulate on her own but would call for assistance in the evening to toilet due to past falls with injury before her admission. She was concerned her call button reached her when she was in bed and in her recliner, but if she fell by the desk where she often sat putting together puzzles, or by her television she would have to crawl to get to the cord on her recliner. Resident 40 indicated she had reported her concerns to the Activity Director among peers during a resident council meeting, but she had never been given another cord. The resident call light was observed where she indicated clipped to the arm of her recliner, and when stretched would reach the end of the bed but was taut approximately 3 feet off the ground creating a hazard. An oxygen concentrator was also observed behind the resident bed attached to a 20+ foot oxygen tubing with nasal cannula the resident was wearing. When the resident stood up to sit on her rollator walker seat she was observed to step on and around the tubing which was laying haphazardly on the floor. The resident indicated she had tripped over her oxygen tubing on multiple occasions but caught herself by grabbing onto furniture before she fell. Resident 40's record was reviewed on 1/25/22 at 1:46 p.m. Diagnoses on Resident 40's profile included, but were not limited to, chronic obstructive pulmonary disease (COPD), difficulty walking, need for assistance with personal care, and weakness. A physician's order dated 1/8/23, indicated oxygen at 2 liters (L) via nasal cannula (NC), may titrate to keep oxygen saturations (sat) greater than 92% two times a day. Resident Council Minutes, dated September 6, 2022, indicated, a resident said she would rather have a call light that she could wear since her call light wasn't always within her reach. Unit Manager (UM) 3 let the resident know that she had an idea about her call light since she sits on both sides of the room. She would let maintenance know about her idea to see if it would work. Resident Council Minutes dated October 2022 - January 2023 lacked documentation the call light request was followed up. A quarterly MDS assessment completed on 1/23/23 assessed the resident was cognitively intact. Independent with set up help only for bed mobility, and locomotion off the unit. Supervision and one person physical assist for transfers. Supervision and set up only for walking in room and corridor, locomotion on the unit. Mobility devices included a walker. Oxygen while a resident. A care plan for Resident 40, dated 4/26/22, indicated she had a diagnosis of Congestive Heart Failure. The goal was for her to have clear lung sounds and her heart rate and rhythm to be within normal limits. Interventions included oxygen therapy as ordered. A fall care plan for Resident 40, dated 5/5/22, indicated the resident was at risk for falls related to requiring assistance for ADL's, bladder, and incontinence. The goal was for the resident to be free of falls with injury. The intervention was to encourage call light was within reach while in room and encourage her to use it. Promptly respond to all requests for assistance. During an interview on 1/26/23 at 10:54 a.m., the AD indicated, during a resident council meeting in September 2022, Resident 40 had reported when doing puzzles, the call light was not long enough to go from one side of the room to the other. UM 3 indicated she had an idea already so she would go to maintenance to get a double headed call cord. During an interview on 1/26/23 at 11:15 a.m., the Maintenance Supervisor indicated, he did not recall getting a request to provide Resident 40 with a longer or split call cord, and observation of repair request cards, dated 2022, indicated there was no request card found. During an interview on 1/26/23 at 11:34 a.m., the Administrator (ADM) indicated, she had never heard about Resident 40 requesting a different call cord. During an interview on 1/26/23 at 11:42 a.m., Respiratory Therapist (RT) 14 indicated, Resident 40 received breathing treatments per the nursing staff. The RTs went out weekly to change out oxygen tubing and oxygen equipment. To her knowledge no fall concerns related to the oxygen tubing had been identified or documented. 4. Resident 35's clinical record was reviewed on 1/27/23 at 1:16 p.m. The resident was admitted to the facility, on 4/20/21, with diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a mini stroke caused by a temporary disruption in the blood supply to part of the brain), hypertension (high blood pressure), anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life), insomnia (difficulty sleeping or staying asleep), and heart failure. An annual Minimum Data Set (MDS) assessment, dated 12/29/22, indicated the resident had a moderate cognitive impairment, had no behaviors or wandering, required limited assistance of one person for bed mobility, transfer, walking in the room, dressing and personal hygiene, required extensive assistance of one person for toilet use, and was occasionally incontinent of bladder, received scheduled and prn (as needed) pain medication, utilized a walker and wheelchair for mobility, had two or more falls with injury since her admission into the facility, and received oxygen therapy. A fall risk assessment, completed on 10/13/22, indicated the resident was a high risk for falls and a fall risk assessment, completed on 10/18/22, indicated the resident was a moderate risk for falls. A care plan, initiated on 4/21/21, indicated the resident had the potential for pain and received pain medications. Interventions included, but were not limited to, observe for side effects of pain medication. Observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness, and falls. Report occurrences to the physician. A care plan, initiated on 4/21/21 and revision on 10/18/22, indicated the resident was at risk for falls related to requiring assistance with Activities of Daily Living (ADL) (daily tasks related to resident care and hygiene), medication use, bladder and bowel incontinence, and a history of falls. Intervention on the care plan included, but were not limited to, anticipate and meet her needs, ensure the call light was within reach while in her room and encourage her to use it, and to promptly respond to all requests for assistance. A post fall evaluation progress note, dated 10/18/22 at 10:45 p.m., indicated Resident 35 had an unwitnessed fall in the bathroom when the resident attempted to transfer herself from the toilet to a wheeled walker. A skin tear, measuring 5.08 centimeters (cm) by 3.81 cm, injury to the right outer calf was noted with the fall. The resident's call light was on when the resident was found by staff on the bathroom floor. On 1/27/23 at 11:05 a.m. the Administrator (ADM) provided a grievance log, dated September 2022 to January 2023, and indicated Resident 35's daughter had contacted the facility and had a grievance about the call light times taking too long for staff to answer for her mother, due to a fall from the toilet Resident 35 had sustained with a skin tear on 10/18/22. The ADM provided a call light log, titled Past Calls 10/18/22, and indicated Resident 35 had pressed her call light, on 10/18/22 at 7:15 p.m., and waited fifty minutes for the call light to be answered, had pressed her call light, on 10/18/22 at 10:11 p.m. and waited seven minutes and fifty-two seconds, and pressed her call light for assistance, on 10/18/22 at 10:57 p.m., and waited thirteen minutes when she fell off of the toilet due to trying to get up by herself without staff assistance. The ADM had completed and provided a document, titled Providence Health Care, INC. Concern/Suggestion Report, which indicated, Resident 35's daughter had a concern about Resident 35's fall, on 10/18/22, after having waited too long on the toilet for staff assistance after pressing the call light. Action taken and results indicated follow up on 10/24/22 would investigate the fall and call light time responsiveness. ADM documented on the concern grievance, the daughter was called on 10/24/22 to discuss and left a message. No additional follow up documentation was noted with a grievance resolution for the call light time responsiveness. On 1/31/23 at 11:16 a.m., the Director of Nursing (DON) indicated, Resident 35 should not have been left on the toilet by herself, because she was a high fall risk. On 1/30/23 at 10:21 a.m., the Director of Nursing provided a Fall Prevention Program policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, it was the policy of the facility, to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls, and implementation of appropriate interventions to provided necessary supervision and assistive devices are utilized as necessary .Care Plan incorporates: a. Identification of all risk/issue, b. Addresses each fall, c. Interventions are changed for each fall as appropriate, d. Preventative measures .2. At the time of admission and in accordance with the plan of care the resident will be oriented to use the nurse call device. The nurse call device will be placed within the resident's reach at all times .6. The resident's environment will be kept clear of clutter which would affect ambulation and remove hazards .8. Call lights are answered promptly .Residents at moderate risk of falling will be assisted with toileting needs in accordance with voiding patterns identified during the assessment process and as addressed on the plan of care . 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview, observation, and record review, the facility failed to ensure the temperature and palatability of food served, for 1 of 1 test tray reviewed for temperature and palatability. This had the potential to effect 59 of 59 residents who received food from the kitchen. Findings include: During an interview, on 1/23/23 at 12:10 p.m., Resident 27 indicated she ate meals in her room and the food was often not hot enough. During an interview, on 1/24/23 at 10:50 a.m., Resident 111 indicated she ate meals in her room and the food was cold when she received the meal tray. During an interview, on 1/24/23 at 10:49 a.m., Resident 25 indicated he ate meals in his room and the food was not as warm as it could be. Resident Council minutes were provided by the Activity Director (AD) on 1/24/23 at 10:28 a.m. The minutes indicated the resident group had voiced multiple concerns of cold food temperatures of the residents' meals. During an interview with the Activities Director (AD), on 1/26/23 at 10:12 a.m., she indicated she took minutes for the Resident Council meetings and then spoke with the Administrator (ADM), who was the facility's grievance officer, the department heads, and staff about the Resident Council's concerns. The cold food temperature concerns had been brought up at several of the Resident Council meetings. There was not a written follow-up for the Resident Council's concerns. On 1/31/23 at 11:20 a.m., a lunch meal test tray was requested from the Dietary Manager (DM) in the kitchen. Dietary Aide (DA) 25 temped the food on the steam table, while the DM wrote onto a food temperature log the temperatures of: green beans at 153.3 Fahrenheit (F), salmon at 188.4 F, and rice at 173.4 F. DA 25 then began plating the food onto a plate with a warming pellet underneath the plate and a plastic cover on top of the plate. She placed the plate onto a tray and placed the tray into a tray cart. The last four plates did not have a warming pellet underneath, only the plastic cover on top of the plate. On 1/31/23 at 12:43 p.m., DM observed the four meal trays without warming pellets underneath the plates and indicated the kitchen was short on four warming pellets for the residents' lunches. When the staff do not bring back the warming pellets after a meal, the kitchen was short on the warming pellets for the next meal. The test tray food temperatures were green beans at 114.8 F, rice at 120.7 F, and salmon at 113.9 F. The DM indicated the test tray food temperatures were cold and should have been at least 125 F. On 1/27/23 at 10:25 a.m., ADM indicated the dietary department had completed test trays and have requested the residents to notify the staff immediately if they had a concern with their meal being cold. We have told the Resident Council verbally resolutions to the concerns of the cold food, but the facility had not provided the Resident Council a written follow-up response to the residents' concerns. On 1/27/23 at 10:05 a.m., the Director of Dining Services (DD) provided and identified a document as a current facility policy, titled Resident Food Services, dated 1/22. The policy indicated, .Subject: Meal Quality and Temperature .Policies: .Food and drinks are palatable, attractive, and served at a safe and appetizing temperature to ensure residents' satisfaction and to meet nutrition and hydration needs .Productive Kitchen: .All menu items will be temped with an accurate thermometer and documented on the log .If hot or cold food temperatures do not meet standards, corrective actions are implemented and documented on log .Dining Room Service: .When bulk food is transported to a dining serving location, temperatures are taken and recorded in the kitchen before transport as well as at the final serving location .If temperatures are not optimal at the receiving location, corrective action is taken and documented in the notes section At the same time, DD provided and identified another document as a current facility policy, titled MenuWorks Daily Service Patient/Resident Taste and Temperature Log, dated 7/12/21. DD indicated the holding temperatures on the policy were hot entrees, vegetables, hot soup, sauces, gravies, and hot beverages holding temperatures should be at least 140 F. 1.3-21 (a)(1)(2)

Based on observation, record review, and interview, the facility failed to ensure fall care plans were revised and/or developed for 2 of 3 residents reviewed for accidents (Resident B and Resident D). Findings include: 1. Resident B was observed on 11/9/22 at 12:30 p.m. sitting in a wheelchair in the dining room wearing tube socks without shoes. On 11/9/22 at 11:30 a.m., Resident B's medical record was reviewed. Resident B's progress notes indicated that Resident B experienced a fall on the following dates: 9/27/22, 10/1/22, 10/5/22, 10/10/22, 10/24/22, 10/27/22 and 10/29/22. A review of the fall care plan indicated as an intervention that the facility was to ensure Resident B was wearing proper footwear, dated 12/14/21. The care plan did not include interventions for the falls from 9/27/22, 10/01/22, 10/5/22, 10/10/22, 10/27/22 or 10/29/22. On 11/10/22 at 9:10a.m., during an interview the Administrator indicated that the care plans had not been updated due to a vacancy in the facility staff and the care plan should have been updated with an intervention after each fall.2. Resident D's record was reviewed on 11/9/22 at 2:13 p.m. Resident D was admitted to the facility, on 10/5/22, with the diagnoses included, but were not limited to fracture of second lumbar vertebra subsequent encounter for fracture with routine healing (spinal fracture), other displaced fracture of upper end of right humerus subsequent encounter for fracture with routine healing (right arm fracture), muscle weakness, and difficulty in walking. An admission Minimum Data Set (MDS) assessment, dated 10/12/22, indicated the resident had a moderate cognitive impairment, required physical help in part of bathing of one person, had an upper extremity impairment on one side, and had a fall with a fracture in the last month prior to admission to the facility. An ADL (activities of daily living) care plan, dated 10/13/22, indicated Resident D needed assistance of one staff member when providing patient care. A progress note, dated 10/18/22 at 1:30 p.m., indicated Resident D was bathing in the shower room and assisted by a Certified Nursing Assistant (CNA). Resident D had requested privacy, so the curtain in the shower room was pulled closed. CNA indicated to Resident D to let her know when she was finished bathing. When Resident D indicated she was finished, the CNA reached for a towel and went to open the shower curtain and heard a thump. When the shower curtain was pulled back, the CNA observed Resident D had fallen onto the shower floor with a skin tear on the right shin area. A post fall risk assessment, dated 10/18/22, indicated Resident D was a moderate risk for falls. The medical record lacked documentation an at risk for falls care plan was developed for Resident D. On 11/10/22 at 10:49 a.m., the Administrator (ADM) indicated, Resident D was at risk for falls and should have had a fall care plan developed. On 11/9/22 at 3:00 p.m., the ADM provided and identified an undated document as a current facility policy, titled RESIDENT CARE PLAN POLICY. The policy indicated, .Purpose: To provide an individualized plan of care for each resident .Policy: It is the policy of Providence Health Care that a comprehensive plan of care will be provided for each resident the includes measurable objectives and time frames to meet the medical, nursing, mental and psychosocial needs that are identified in the interdisciplinary assessments .Standards: .2. Resident care services provided or arranged by the facility must meet professional standards of practice and be provided by qualified persons in accordance with the resident's care plan .9. The care plan is initiated following admission assessments and shall be completed within twenty-one (21) days of admission or within seven (7) days of the completion of a Comprehensive MDS Assessment. The goals shall be specific and relative to the resident's current condition, measurable and related to specific time frames .10. Additions and modifications will be made by each disciplinary team member to assist facility personnel in meeting the needs of the resident. Plans will be reviewed at least quarterly and revised at any time the condition of the resident changes or the resident exercises rights including the right to refuse treatment or after each assessment or assessment review where change has occurred which would alter the plan of care. Nurses on each shift are responsible for revising and updating the resident care plan whenever the resident's condition changes. All disciplines are responsible for updating the plan of care to assure the plan represents the resident's current status This Federal tag relates to Complaint IN00393738. 3.1-35(c)(1) 3.1-35(c)(2)