Every finding on record at Centennial Post Acute

.Based on record review and interview, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, were provided for the treatment of pressure ulcers. Specifically, the facility failed to ensure a resident with a facility acquired pressure ulcer received appropriate treatment interventions, to include timely higher level of care, for 1 Resident (#110), out of 3 residents with pressure ulcers reviewed. These failed practices contributed to Resident #110 being hospitalized with sepsis and passed away from this complication Findings:Resident #110Record review on 12/14-24/25 revealed Resident #110 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and type 2 diabetes. Resident #110 required routine dialysis.Resident #110 was admitted to the facility for physical therapy (PT), occupational therapy (OT), and dialysis assistance.Resident #110's dialysis was converted to hemodialysis (filtration of the blood using a machine with a special filter called a dialyzer, acting like an artificial kidney. A port in the arm called a fistula, a connection between an artery and vein in the arm, was used during dialysis to filter waste products and excess fluid from the body) while at the facility. The facility transported the resident to a dialysis center every Monday, Wednesday, and Friday for treatment.Resident #110's skin assessment on admission, dated 3/10/25, revealed there was redness to his/her sacrum (central position of the hips directly below spine, at area above buttocks crease) that was blanchable (turns white when pressure applied, and returns to original color after pressure released which indicated good circulation), however had no wounds to his/her sacral area upon admission.Further record review revealed Resident #110 had a fall in the facility on 4/8/25 which caused a fracture of the right femur (thigh bone) at the neck, or top, of the bone. According to the notes, this required hospitalization and surgical repair.Review of Resident #110's Admission/re-admission Summary Note, dated 4/14/25, revealed: This resident is readmitted this afternoon following hip repair surgery. [His/her] ADL [activities of daily living] had declined since [his/her] discharge to the hospital, returning [he/she] has difficulty standing and transferring well as bed mobility and dressing.Review of Resident #110's nursing SBAR (situation, background, assessment, and recommendation) note, which was completed by nurses when a change in condition occurred with residents, dated 5/6/25, revealed: New pressure injury to the [left] [iliac] crest [the left hip bone's upper, outer edge]. Stage II [a shallow wound involving partial skin loss] . Further review revealed the wound measured 2.2 centimeters (cm) long by 1.5 cm wide by 0.1 cm deep. Further review revealed Provider #1 ordered for the facility's SNF (skilled nursing facility) wound care team assess the resident on 5/7/25.Review of Resident #110's first SNF Wound Care note was dated 5/14/25 (7 days after the order was written) and completed by Wound Care Physician Assistant (PA) #5. Review of this note revealed Resident #110 now had two diabetic wounds:1) A right sacral area (right side of lower back, to the right of the upper buttock crease) measuring 3.0 cm long by 1.0 cm wide by 0.2 cm deep. This wound was described as an open diabetic wound (a slow-healing open sore or lesion, that develops in people with diabetes due to nerve damage and poor circulation) that was not infected; and2) A left sacral area (left side of lower back, to the left of the upper buttock crease) measuring 2.0 cm long by 0.5 cm wide by 0.2 cm deep. This wound was described as an open diabetic wound that was not infected.Further review revealed: . Please change dressing after shower/bed bath/soilage to avoid leaving on wet/moist dressings. Change positions often to keep pressure off the wound, and spread body weight evenly with cushions, mattresses, pillows, foam wedges, or other pressure-relieving devices. Complicating factors include the patient's limited mobility status, nutritional status, and underlying medical conditions as noted and reviewed in Past Medical History.In addition, the SNF Wound Care note stated: Overall treatment goals include a decrease in wound size, preventing infection/inflammation, maceration, excessive drainage, malodor, and discomfort/pain for continued day-to-day activities of daily living. If the patient has any complications, please contact me or the office. I will be visiting this patient as needed every week until all wounds heal or are otherwise specified. This documentation for goals of treatment was the same on every SNF Wound Care note reviewed, 5/14/25 through 8/11/25, throughout the resident's admission.Review of Resident #110's provider/nursing progress notes, dated 5/6-14/25, revealed no documentation of the right sacral wound.Review of Resident #110's Treatment Administration Record (TAR), dated 5/2025, revealed a standing order was placed by nursing on 5/6/25: Left iliac crest Stage 2 pressure injury: Cleanse with normal saline/wound cleanser, pat dry, skin prep peri wound [a wipe or spray protective barrier on intact skin around a wound], apply [nickel] depth pluro gel [wound gel that creates a moist wound healing environment] and cover with optifoam [a multi-layered foam dressing with a silicone adhesive border that absorbs wound drainage] q [every] 3 days and PRN [as needed] if soiled or dislodged. One time a day every 3 days for wound care.Further review revealed this order remained in effect after the SNF wound care team assessed Resident #110 on 5/14/25.Further review of Resident #110's TAR, dated 5/2025, revealed no wound care treatment orders for the resident's right sacral wound assessed on 5/14/25.Review of Resident #110's second SNF Wound Care note, dated 5/21/25 and completed by Wound Care PA #5, revealed Resident #110's right sacral wound had improved in length measurement slightly, while the left sacral wound had markedly grown in size and was now infected:1) The right sacral wound measured 2.1 cm long by 1.2 cm wide by 0.3 cm deep and was not infected. The wound condition was assessed as stable. The wound care plan was documented as: Cleanse with wound cleanser, barrier cream to peri-wound, followed by honey and alginate to the wound bed, and cover with border foam daily or as needed for soilage.2) The left sacral wound now had maceration (where skin becomes softened, white, and wrinkly due to prolonged exposure to moisture) and measured 7.0 cm long by 6.9 cm wide by 0.1 cm deep and was now infected. The wound condition was assessed as stable despite its growth and decline. The wound care plan was documented as: Cleanse with wound cleanser, apply barrier cream for peri-wound, followed by fungal powder and as needed for soilage.Review of Resident #110's TAR, dated 5/2025, revealed the planned wound care treatment order for the right sacral wound documented in the 5/21/25 SNF Wound Care note was not ordered.Further review revealed the standing order for dressing changes for the left iliac crest remained unchanged and differed from the planned wound care treatment documented in the 5/21/25 SNF Wound Care note. No order for fungal powder was ordered.Review of Resident #110's Medication Administration Record (MAR), dated 5/2025, revealed no medications were ordered for the infected wound.An attempt to interview Wound Care PA #5 regarding these discrepancies was not possible as Wound Care PA #5 no longer worked for SNF Wound Care at the time of survey and was unavailable.No documentation could be found in Resident #110's medical record to determine if this was a planned alteration in care.Review of Resident #110's second SNF Wound Care note, dated 5/28/25 and completed by Wound Care PA #5, revealed Resident #110's right sacral wound was resolved, while the left sacral wound had improved in size, however remained infected and antibiotic treatment was initiated:1) . Wound 1: Right sacral area, diabetic wound. Resolved.2) The left sacral wound measured 2.5 cm long by 1.9 cm wide by 0.3 cm deep and had purulent (thick, often yellowish, greenish, or brownish pus) drainage. The wound care plan was documented as, Cleanse with wound cleanser, apply barrier cream for peri-wound, followed by fungal powder, then cover with border foam daily or as needed for soilage. Start doxycycline (an antibiotic) 100 milligrams (mg) twice daily for 28 doses.Review of Resident #110's TAR, dated 5/5025, revealed the standing order for dressing changes for the left iliac crest was discontinued on 5/28/25. Further review revealed the following order that started on 5/29/25: Right [should be left] posterior iliac crest: cleanse daily with normal saline/wound cleanser, pat dry, skin prep peri wound, apply Santyl [an ointment, helps remove necrotic tissue] to wound bed and cover with a foam dressing QD [every day]. One time a day for wound care.Further review revealed no fungal powder was ordered as documented in the SNF Wound Care note from 5/28/25.Review of Resident #110's MAR, dated 5/2025, revealed doxycycline started on 5/28/25: Doxycycline 100 mg. give 1 tablet by mouth at bedtime for wound cellulitis for 14 days until finished.This antibiotic was not ordered twice a day as documented in the SNF Wound Care note from 5/28/25.An attempt to interview Wound Care PA #5 regarding these discrepancies was not possible as noted prior.No documentation could be found in Resident #110's medical record to determine if this was a planned alteration in care.Further review of the 5/28/25 SNF Wound Care note revealed there were two more skin injuries being treated, a left forearm trauma wound (hit arm on the grab bar of bed on 5/22/25 causing a skin tear) and a left fifth toe diabetic wound.Continued Wound Evaluation HistoryReview of Resident #110's medical record revealed weekly documentation of continued wound evaluations, dated 6/4/25 - 8/11/25, showing little to no improvement with wound healing and multiple rounds of different antibiotics that had little effect, and at times ordered and administered at the inappropriate times for subtherapeutic effect:1. 6/4/25:Review of Resident #110's second SNF Wound Care note, dated 6/4/25 and completed by Wound Care PA #5, revealed the left sacral wound measured 4.0 cm long by 2.6 cm wide and was unable to determine depth. The wound remained infected. Further review revealed the wound care plan: Cleanse with wound cleanser, apply barrier cream for peri-wound, followed by santyl and alginate to the wound bed, then cover with border foam daily or as needed for soilage. Continue doxycycline 100 mg tab orally twice a day #28 pills.Review of Resident #110's TAR, dated 6/2025, revealed the following wound care order started on 6/5/25: Right [should be left] posterior iliac crest: cleanse daily with normal saline/wound cleanser, pat dry, skin prep peri wound, apply Santyl to wound bed and cover with calcium alginate with silver and cover with foam dressing QD. One time a day for wound care.Review of Resident #110's MAR, dated 6/2025, revealed the doxycycline remained at the same dose, 100mg by mouth at bedtime, and not twice a day as documented in the SNF Wound Care note dated 6/4/25.An attempt to interview Wound Care PA #5 regarding these discrepancies was not possible as noted prior.No documentation could be found in Resident #110's medical record to determine if this was a planned alteration in care.Further review of the 6/4/25 SNF Wound Care note revealed the left forearm trauma wound, now diagnosed as a diabetic wound, and the left fifth toe diabetic wound were still being treated.Review of Resident #110's care plan revealed it was originally initiated on 3/13/25, however additions for wound care interventions were not added until 6/4/25 (21 days after wounds were first identified):- FOCUS: ADL/Mobility: Resident is at risk for ADL/Mobility decline and requires assistance related to recent fall and surgery [initiated 3/13/25]. Interventions added on 6/4/25: Bed Mobility: Assist of (Substantial/maximal assistance). Monitor for changes in condition or declines in ability to participate in ADLs, decreased strength, increased weakness, or changes in cognition. Notify Physician if occurs. Toileting: Assist of (Partial or Moderate Assistance). Transfer: Assist of (Partial or Moderate Assistance).- FOCUS: Skin: Resident is at risk for skin breakdown related to immobility secondary to fall/recovery; surgery [initiated 3/13/25]. Intervention. Assist to turn and reposition as indicated/tolerated [initiated 3/13/25].- FOCUS: Skin: Resident has impaired skin integrity as evidenced by pressure ulcer to sacrum, scab to toe, redness to groin [initiated 6/4/25]. Interventions that were initiated 6/4/25. Administer treatments as ordered and monitor for effectiveness [6/4/25]. Educate resident on avoiding skin injuries. Encourage good nutrition and hydration to promote healthier skin. identify potential causative factors and eliminate/resolve when possible.2. 6/11/25:Review of Resident #110's second SNF Wound Care note, dated 6/11/25 and completed by Wound Care PA #5, revealed the left sacral wound measured 2.1 cm long by 1.3 cm wide and was unable to determine depth. The wound remained infected. Further review revealed the wound care plan: Cleanse with wound cleanser, apply barrier cream for peri-wound, continue antibiotics prescribed last week, doxycycline 100 mg orally twice a day for another week, and cover the wound with bordered foam daily or as needed for soilage.Review of Resident #110's TAR, dated 6/2025, revealed the wound treatment order that started on 6/5/25 had not changed to reflect the planned wound care treatment documented in the 6/11/25 SNF Wound Care note (different peri-wound order, no santyl or calcium alginate, different dressing).Review of Resident #110's MAR, dated 6/2025, revealed the doxycycline that started on 6/11/25 was not twice a day as documented in the 6/11/25 SNF Wound Care note: Doxycycline. 100 mg. Give 1 tablet by mouth at bedtime for wound cellulitis for 8 days until finished.An attempt to interview Wound Care PA #5 regarding these discrepancies was not possible as noted prior.No documentation could be found in Resident #110's medical record to determine if this was a planned alteration in care.3. 6/18/25:Review of Resident #110's second SNF Wound Care note, dated 6/18/25 and completed by Wound Care PA #5, revealed the left sacral wound measured 4.0 cm long by 2.7 cm wide and was unable to determine depth. This note documented the wound was not infected, however antibiotics continued for infection. Further review revealed the wound care plan: Cleanse with wound cleanser, apply barrier cream for peri-wound, followed by santyl and alginate, then cover with border foam daily or as needed for soilage. Continue doxycycline tablets. twice a day for another seven days.Review of Resident #110's TAR, dated 6/2025, revealed the wound treatment order that started on 6/5/25 had not changed to reflect the planned wound care treatment documented in the 6/18/25 SNF Wound Care note (different peri-wound order, different dressing).An attempt to interview Wound Care PA #5 regarding this discrepancy was not possible as noted prior.No documentation could be found in Resident #110's medical record to determine if this was a planned alteration in care.Review of Resident #110's MAR, dated 6/2025, revealed the order for doxycycline that started on 6/18/25 was now ordered for twice a day: Doxycycline. 100 mg. Give 1 tablet by mouth every morning and at bedtime for wound infection for 7 days.4. 6/25/25:Review of Resident #110's second SNF Wound Care note, dated 6/25/25 and completed by Wound Care PA #5, revealed the left sacral wound measured 3.5 cm long by 2.0 cm wide and was unable to determine depth. The wound remained infected and pain was now associated with wound care. Further review revealed the wound care plan remained unchanged from the last assessment: Cleanse with wound cleanser, apply barrier cream for peri-wound, followed by santyl and alginate to the wound bed, then cover with bordered foam daily. Continue the prescribed antibiotic.Further review revealed: . The patient is noncompliant, the patient is staying prolonged in one position and refusing to be changed, and for this condition, decline is inevitable.Review of Resident #110's TAR, dated 6/2025, revealed the wound treatment order that started on 6/5/25 had not changed to reflect the planned wound care treatment documented in the SNF Wound Care notes (different peri-wound order, different dressing).An attempt to interview Wound Care PA #5 regarding this discrepancy was not possible as noted prior.No documentation could be found in Resident #110's medical record to determine if this was a planned alteration in care.Review of Resident #110's TAR, dated 6/18-25/25, revealed the left iliac crest dressing change was completed every day with exception to 6/20/25 when it was documented the resident was unavailable.Review of Resident #110's MAR, dated 6/2025, revealed the order for doxycycline that started on 6/25/25 was ordered again: Doxycycline. 100 mg. Give 1 tablet by mouth every morning and at bedtime for wound infection for 7 days.Review of Resident #110's nursing progress notes, dated 6/12/25 - 6/25/25, revealed no documentation for non-compliance or refusal to be changed per the SNF Wound Care note, except for one dressing change refusal on 6/15/25.Further review of Resident #110's medical record revealed: - No documentation that Certified Nursing Assistants (CNAs) informed nurses that the resident had been noncompliant;- No Risk Versus Benefits form to document noncompliance and care planning needs; and- No additions or changes were made to the resident's care plan to reflect new interventions to assist with noncompliance.Review of the standard Lippincott Nursing Procedures ninth edition, dated 2023, revealed: . work with the patient and multidisciplinary team to implement regular repositioning routine. adapt position changes to the patient's situation. Emphasize the importance of position changes to the patient and family, and encourage their participation in the treatment and prevention of pressure injuries.5. 7/2/25:Review of Resident #110's second SNF Wound Care note, dated 7/2/25 and completed by Wound Care PA #5, revealed the left Sacral wound measured 3.9 cm long by 2.5 cm wide by 1.2 cm deep and now had tunneling (a deep channel that forms under the skin surface, extending from the main wound, creating dead space where infection can thrive) at 12 o'clock of 1.1 cm and 11 o'clock 1.9 cm. The wound's overall condition was assessed as stable despite this new development, as well as, remaining infected after several round of antibiotics. Further review revealed the wound care plan remained unchanged from the last two assessments: Cleanse with wound cleanser, apply barrier cream for peri-wound, followed by santyl and alginate, then cover with border dressing daily. Antibiotics were continued despite not being documented in the note.Further review revealed: .The patient is noncompliant. The patient is staying prolonged in one position in bed and refuses to be turned.Review of Resident #110's TAR, dated 6/2025, revealed the wound treatment order that started on 6/5/25 had not changed to reflect the planned wound care treatment documented in the SNF Wound Care notes (different peri-wound order, different dressing).Review of Resident #110's TAR, dated 6/26/25 through 7/2/25, revealed all left iliac crest dressing changes were completed with the exception of 6/26/25, which was documented as a refusal despite being documented in the 6/26/25 Daily Skilled Charting Form Summary as being completed due to being soiled.Review of Resident #110's MAR, dated 7/2025, revealed an order for doxycycline that started on 7/2/25 was ordered again: Doxycycline. 100 mg. Give 1 tablet by mouth every morning and at bedtime for wound infection for 7 days extend 7 more days.Review of Resident #110's nursing progress notes, dated 6/26/25 - 7/2/25, revealed no non-compliance or refusal to be turned per the SNF Wound Care note's documentation.Further review of Resident #110's medical record revealed:- No documentation that Certified Nursing Assistants (CNAs) informed nurses that the resident had been noncompliant;- No Risk Versus Benefits form to document noncompliance and care planning needs; and- No additions or changes were made to the resident's care plan to reflect new interventions to assist with noncompliance.6. 7/8/25:Review of Resident #110's second SNF Wound Care note, dated 7/8/25 and completed by Wound Care PA #5, revealed the left sacral wound measured 5.5 cm long by 4.6 cm wide, unable to determine depth and continued to have tunneling at 12 o'clock of 1.1 cm and 11 o'clock 1.9 cm. The wound remained infected. Further review revealed the wound care plan remained unchanged from the last three assessments: Cleanse with wound cleanser, apply barrier cream for peri-wound, followed by santyl and alginate, then cover with border foam daily. The patient is currently on oral antibiotics that were prescribed by his primary care.Further review revealed: .The patient is noncompliant.Review of Resident #110's TAR, dated 6/2025, revealed the wound treatment order that started on 6/5/25 had not changed to reflect the planned wound care treatment documented in the SNF Wound Care notes (different peri-wound order, different dressing).Review of Resident #110's TAR, dated 7/3-8/25, revealed all left iliac crest dressing changes were completed.Review of Resident #110's MAR, dated 7/2025, revealed the doxycycline order was discontinued early on 7/7/25 and he/she was started on a different antibiotic, Bactrim DS (double strength), on 7/7/25: Bactrim DS tablet 800-160 mg (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth every 12 hours for Wound infection for 7 days. This medication was given on 7/7/25 and 7/8/25.Review of Resident #110's nursing progress notes, dated 7/3/25 - 7/8/25, revealed no non-compliance per the SNF Wound Care note's documentation.Further review of Resident #110's medical record revealed:- No documentation that CNAs informed nurses that the resident had been noncompliant;- No Risk Versus Benefits form to document noncompliance and care planning needs; and- No additions or changes were made to the resident's care plan to reflect new interventions to assist with noncompliance.7. 7/15/25:Review of Resident #110's second SNF Wound Care note, dated 7/15/25 and completed by Wound Care PA #5, revealed the left sacral wound measured: 6.3 cm long by 2.8 cm wide by 1.5 cm deep and increase in tunneling at 12 o'clock of 1.3 cm, 3 o'clock 0.6 cm, 6 o'clock 2.0 cm, and 9 o'clock 1.8 cm. The wound's overall condition was assessed as stable despite the increase in size and tunneling. This assessment also documented that the wound was not infected although continuing to be treated with antibiotics for infection. Further review revealed the wound care plan remained unchanged from the last four assessments: Cleanse with wound cleanser, apply santyl followed by alginate on the wound bed and cover with border foam daily.Further review revealed: . The patient is noncompliant. The patient is staying in one position all the time and often refuses to be repositioned.Review of Resident #110's TAR, dated 6/2025, revealed the wound treatment order that started on 6/5/25 had not changed to reflect the planned wound care treatment documented in the SNF Wound Care notes (different peri-wound order, different dressing).Review of Resident #110's TAR, dated 7/9-15/25, revealed all left iliac crest dressing changes were completed with the exception of 7/14/25, where it was documented that resident was out at dialysis.Review of Resident #110's MAR, dated 7/2025, revealed on 7/9/25 the Bactrim DS antibiotic order was changed to regular strength Bactrim: Bactrim 400-80 mg (sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth one time [at 7:00 AM] a day for skin infection for 7 days.During an interview on 12/17/25 at 4:25 PM, Provider #1 stated a lot of medication could be given with dialysis, like doxycycline, and didn't require order changes, however it was recommended that Bactrim be given after dialysis. In reviewing Resident #110's records, Provider #1 stated it appeared the Bactrim order did not get ordered for after dialysis.Review of the facility-provided administration times for when the Bactrim doses were given to Resident #110 revealed:- 7/9/25 dose was given at 8:26 AM;- 7/10/25 at 10:18 AM;- 7/11/25 at 8:14 AM;- 7/12/25 at 7:53 AM;- 7/13/25 at 8:25 AM; and- 7/14/25 at 8:28 AM.Review of Resident #110's dialysis schedule revealed he/she received dialysis after 10:30 AM on 7/9/25, 7/11/25, 7/14/25. These three doses, out of the six doses given, would have been subtherapeutic due to being dialyzed out of the resident's blood, resulting in reduced effectiveness to treat infection.Review of Resident #110's nursing progress notes, and Nurse's Note notes, dated 7/9/25 - 7/15/25, revealed no non-compliance per the SNF Wound Care note's documentation.Further review of Resident #110's medical record revealed:- No documentation that CNAs informed nurses that the resident had been noncompliant;- No Risk Versus Benefits form to document noncompliance and care planning needs; and- No additions or changes were made to the resident's care plan to reflect new interventions to assist with noncompliance.Resident Fall at Dialysis on 7/16/25Review of Resident #110's Alert Charting, dated 7/16/25 at 5:10 PM, revealed: fall at dialysis and being sent to ER [emergency room].Review of Resident #110's Alert Charting, dated 7/16/25 at 7:43 PM, revealed: Nurse writer spoke with [Resident Representative (RR)] regarding bed hold. [RR] asked if [Resident #110] was on any antibiotics currently. Explained to [him/her] [Resident #110] was due to [his/her] wound culture results. [RR] said ok good I will let the ED [emergency department] know.During an interview on 12/16/25 at 1:25 PM, Resident #110's Resident Representative (RR) stated that on 7/16/25, Resident #110 was at dialysis and fell. The Dialysis center called for an ambulance and had the resident go to the E.R. for medical clearance prior to returning to the facility and the RR went to the E.R. The RR stated the E.R. Provider told him/her that Resident #110's wound care was not adequate, and he would like to refer the resident to outpatient wound care at Providence.Review of Resident #110's After Visit Summary from Providence Alaska Medical Center (PAMC), dated 7/16/25, revealed: The wound on the left buttock does appear to have mild infection superficially. CT scan was reassuring. I think it is reasonable to complete a course of antibiotics. In this case I spoke with the pharmacist and we agree Keflex would be a reasonable choice. This is 7 days of antibiotics. [He/she] takes it only once per day because of [his/her] renal failure. On days of dialysis please be sure and take it after dialysis has been completed. Please continue dialysis. I sent a referral for wound care here at Providence. Please return for worsening symptoms. Please plan to follow-up with primary care in 3 to 5 days. Further review revealed the discharge diagnosis for Resident #110 was cellulitis and Schedule an appointment with VA Clinic as soon as possible for a visit in 3 days (around 7/19/25).Review of Resident #110's Nurse's Note, dated 7/16/25 at 11:20 PM, revealed: [Resident #110] arrived to [facility] from PAMC via medical transport stretcher. Dressings C/D/I [clean/dry/intact]. ED placed a referral to outpatient WC [wound care] and [son/daughter-in-law] mentions several [appointments] needing transportation. States [he/she] will reach out to. RCM once [he/she] has the [appointments] scheduled. (Optometrist, AK heart, VA PCP [primary care provider]). New Rx [prescription]: Keflex 500mg capsule 'take 2 capsules by mouth daily for 7 days. On days that you have dialysis please take the ABX [antibiotics] AFTER dialysis.'.Review of Resident #110's medication orders revealed Provider #1 ordered: Cephalexin [Keflex] Oral Tablet 500mg Give 1000mg by mouth in the morning for superficial wound infection for 7 days.Review of Resident #110's MAR, dated 7/2025, revealed this order was transcribed and scheduled for 9:00 AM administration. There was no notation within the order to administer the antibiotic after dialysis.During an interview on 12/17/25 at 4:25 PM, Provider #1 stated Keflex would need to be given after dialysis. In reviewing Resident #110's records, Provider #1 stated it appeared the Keflex order did not get ordered for after dialysis. When asked if the referral to PAMC for outpatient wound care was reviewed and initiated, Provider #1 stated he didn't recall looking at the ED discharge summary and stated nursing staff would normally have initiated an SBAR to alert him to make the order for referral.Review of the facility-provided administration times for when the Keflex doses were given to Resident #110 revealed:- 7/17/25 dose was given at 4:17 PM;- 7/18/25 at 8:29 AM;- 7/19/25 at 8:36 AM;- 7/20/25 at 8:28 AM;- 7/21/25 at 8:07 AM;- 7/22/25 at 9:21AM; and- 7/23/25 at 8:58 AM.Review of Resident #110's dialysis schedule revealed he/she received dialysis on 7/18/25, 7/21/25, and 7/23/25. These three doses, out of the seven doses given, would have been subtherapeutic due to being dialyzed out of the resident's blood, resulting in reduced effectiveness to treat infection. This was the last round of antibiotics the resident received.Review of Resident #110's medical record revealed no SBAR documented for initiation of the referral for outpatient wound care at PAMC or the need for a VA follow up appointment.Further review revealed no documentation that the resident ever went out for wound care at PAMC, nor was the resident transported to any VA PCP follow-up appointment.During an interview on 12/16/25 at 1:25 PM, Resident #110's RR stated communication with the facility in an attempt to make the outpatient wound care at PAMC and the VA PCP follow up appointment was through phone conversations and did not get initiated. The RR stated the facility told him/her because Resident #110 was VA the family had to coordinate the appointment if the family wanted the VA to pay for it. The VA told the RR that the facility needed to put in the referral. The facility never did this despite the RR requesting them to do so. To the RR's knowledge, he/she stated Resident #110 was never taken to PAMC for outpatient wound care or the VA follow up appointment.Review of Resident #110's medical record revealed no documentation that the facility talked with the RR about the referrals, the steps the facility took to initiate referrals, or guidance/education the facility provided to the RR to initiate the referrals.8. 7/23/25:Review of Resident #110's second SNF Wound Care note, dated 7/23/25 and completed by Wound Care PA #5, revealed the left sacral wound measured 6.1 cm long by 3.8 cm wide by 1.3 cm deep and had tunneling at 12 o'clock of 1.2 cm, 3 o'clock 0.5 cm, 6 o'clock 2.0 cm, and 9 o'clock 2.1 cm. Further review revealed the wound care plan changed: Cleanse with wound cleanser, apply barrier cream to peri-wound, followed by pluro gel to the wound bed and wound VAC every three days. Continue the prescribed antibiotics as per primary care provider.Further review revealed: .The patient is noncompliant.Review of Resident #110's TAR, dated 6/2025, revealed the wound treatment order that started on 6/5/25 had not changed to reflect the planned wound care treatment documented in the 7/23/25 SNF Wound Care notes (different peri-wound order, changing from santyl and alginate to pluro gel, different dressing).Review of Resident #110's TAR, dated 7/16-23/25, revealed all left iliac crest dressing changes were documented as completed with the exception of 7/17/25 and 7/23/25 where it was documented Other/See Nurses Note and 7/22/25 whe

.Based on record review and interview, the facility failed to comply with PASRR Pre-admission Screening and Resident Review - requirements by not incorporating the PASRR Level II determination into the resident's assessment, care planning, and discharge planning for 1 Resident (#113), out of one resident reviewed for PASRR documentation. The PASRR Level II evaluation identified the need for continued nursing facility services and required specialized mental health services. The facility did not ensure the Level II report was available at admission, did not initiate specialized services during the stay, did not revise the care plan to reflect PASRR findings, and discharged the resident without addressing PASRR-identified needs or following recommended discharge options. This failure resulted in an untreated and escalating behavioral symptoms, increased psychotropic medication use, and discharge without appropriate mental health supports, constituting psychosocial harm by reasonable person concept .Findings:Record review on 12/14-24/25 revealed Resident #113 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance (cognitive decline affecting memory, thinking, and problem solving which did not include agitation or aggression), fracture of the right femur (thigh bone), infection to surgical site to fix the femur, metabolic encephalopathy (a brain disorder caused by a chemical imbalance from an underlying illness leading to impaired brain function, confusion, memory issues, and personality changes), and muscle weakness.Further review revealed Resident #113 also had diagnoses of depression and anxiety.Review of Resident #113's PASRR Level 1, which was in the resident's medical record and dated 9/4/25, revealed the resident had diagnoses of delirium, encephalopathy, anxiety, and depression. Further review revealed: . Based on the information reviewed. the following determination is made. If admission. for this individual is approved, all services as identified by PASRR Level II evaluation must be provided. to meet the individual's nursing and disability-specific needs. Level II PASRR evaluation needed. Date referred for Level II evaluation: 9/5/25. Date Level II report received: 9/18/25.Further review of Resident #113's medical record revealed no PASRR Level II report was present.During an interview on 12/17/25 at 12:03 PM, when asked to provide Resident #113's PASRR Level II report, the Director of Social Services (DSS) stated Resident #113's PASRR Level II report was not in the resident's medical record and was retrieved on 12/17/25 from the facility's PASRR Coordinator. The DSS stated this Level II report was not available during Resident #113's admission or reviewed during discharge planning.Review of Resident #113's Behavioral Health Level II Pre-admission Screening and Resident Review (PASRR) Assessment, dated 9/18/25, revealed: . Summary Narrative of Functional Assessment. [Resident's POA] stated [Resident #113] would need help performing all ADLs [Activities of Daily Living]. Per PASRR Level I request, [Resident #113] experiences challenges with practical skills, including occupational skills, safety, schedule/routines, mobility, travel, and transportation. experiences challenges with completion of tasks, needs assistance to complete tasks, lack persistence, and has difficulty concentrating. demonstrates socially inappropriate behaviors, including challenges with independent living. Self-monitoring of health status. [Resident #113] would need help with self-monitoring of [his/her] health status. Self-administering of medical treatment. [Resident #113] would need help tracking [his/her] appointments, making [his/her] appointments, as well as tracking, obtaining, and remembering to take [his/her] medication. Self-monitoring of nutritional status. [Resident #113] would need help with self-monitoring of [his/her] nutritional status. [Resident #113] wants to cook [his/her] own food but [his/her] cooking 'was becoming a safety concern'. Determination. Nursing facility services. are needed. Mental Illness. Individual has mental illness. Specialized services. are needed. [Resident #113] would benefit from continuing to receive medication management following discharge from Providence Alaska Medical Center.Further review revealed: Additional PASRR Determination Information. A level II evaluation was completed. on 9/18/25. The evaluator found that [Resident #113] would benefit from nursing facility services and required specialized services (SS) for mental health needs. If the LTC [long-term care] facility chooses to admit [Resident #113], but finds they can no longer safely meet [his/her] care needs, please consider the options listed below: The LTC facility can pursue placement at an ALH [assisted living home] that offers more mental health supports (may obtain list from the Division of Behavioral Health)[;] The LTC facility can issue a formal 30-day discharge notice to the client, stating they cannot safely meet the client's care needs. If this occurs, a copy of the discharge notice should be submitted to SDS [Senior and Disabilities Services] in Harmony [an electronic data base][;] The LTC facility can send the client to the emergency room for assessment, if interventions and PRN medications are not effective in managing behavioral concerns.Review of Resident #113's medical record revealed:1. No specialized services were ordered during his/her admission;2. Resident's care plan was initiated on 10/12/25. Interventions for anxiety, dementia, and depression were not initiated until 10/27/25 (15 days later). Interventions did not include specialized services;3. Resident was on daily doses of fluoxetine (Prozac - an antidepressant), which started on 10/9/25; Mirtazapine (Remeron - a second antidepressant), which started on 10/8/25; Quetiapine (Seroquel - an antipsychotic), which started on 10/8/25.Further review revealed the facility's Provider initiated further medications due to resident's increase in aggressive behaviors:- Depakote (a mood stabilizer), which started on 10/21/25; and- Olanzapine (Zyprexa - an antipsychotic) for an as needed, or PRN, medication for agitation and/or anxiety, which started on 10/14/25. This medication was stopped on 10/28/25, however it was restarted on 10/31/25 due to increase in behaviors.4. Review of resident #113's nursing progress notes, 10/17/25 through 11/6/25, revealed multiple episodes of aggression, combativeness, and non-compliance with staff and services being offered (showers, PT, wound care, etc.).Review of Resident #113's Discharge Summary and Post-Care Instructions V2.0, dated 11/3/25, revealed no documentation of the required need for specialized services for mental health treatment, as listed in the PASSR Level II report, nor did the discharge plan follow the recommended Level II discharge options for the resident. During an interview on 12/17/25 at 12:03 PM, after reviewing Resident #113's medical record, the DSS stated there was not adequate documentation in the record to show that the discharge planning was sufficient and there were concerns about how this resident was discharged . Regarding the PASRR Level II report, the DSS stated had they had this information and its recommendation for long-term care services, this would have affected the discharge planning for this resident.Review of the facility policy PASRR Process, dated 3/2025, revealed: Upon admission to the facility the Admissions Coordinator, Medical Records Director or designee will ensure that a PASRR Level I is included in the admission paperwork. The Social Service Director will ensure that a care plan is initiated related to the mental health diagnosis with initial, person centered approaches. Once a Level II Evaluation is complete, the Social Service Director will give to the Medical Records Director to be placed in the EHR [electronic health record]. Additionally, the Social Service Director will expand the care plan to include recommended approaches noted on the PASRR II evaluation as well as through observations and interviews by not only the Social Services Director but all member[s] of the IDT [interdisciplinary Team].

.Based on interview and record review, the facility failed to ensure that residents were discharged in a manner that protected health, safety, and psychosocial well-being, as required. The facility failed to develop and implement an effective discharge planning process for 2 residents (#'s 112 and 113) out of 2 residents reviewed for discharge, resulting in an unsafe and inappropriate discharges.Specifically, the facility failed to:1. Identify and address each resident's post-discharge care needs;2. Ensure required services, referrals, and equipment were arranged prior to discharge;3. Assess and confirm caregiver availability, capacity, and training;4. Involve resident representatives in discharge planning and decision-making;5. Incorporate PASRR (Pre-admission Screening and Resident Review - (a federally mandated pre-admission screening to ensure individuals placed in a long-term care facility had appropriate services) Level II findings and required specialized services;6. Reassess and resolve changes in condition prior to discharge; and7. Ensure discharge destinations met the residents' health and safety needs.These failures resulted in residents being discharged to unsafe environments without adequate support, services, or coordination, causing actual physical compromise and psychosocial harm, and placing residents at continued risk for injury, decline, and loss of dignity:This failed practice resulted in the discharge of Resident #112 to a known unsafe and inaccessible home environment without adequate caregiver support, without required services in place, and without safe access into the residence. As a result, the resident experienced distress and emotional harm, required fire department assistance to enter the home, he/she fell after discharge, lacked necessary wound care and nursing services, and relied on unplanned third parties for essential care. The resident's ability to maintain safety, dignity, and highest practicable physical and psychosocial well-being was compromised.This failed practice resulted in the discharge of Resident #113 despite unresolved acute behavioral changes, cognitive impairment, documented need for nursing facility level care, and required specialized mental health services identified through PASRR Level II. The discharge occurred without required referrals, without representative involvement, and without addressing a documented change of condition on the day of discharge. As a result, the resident experienced distress, confusion, and loss of security, and required the POA (Power of Attorney) to assume unplanned caregiving responsibilities to prevent harm.This citation utilizes the reasonable person concept for determination of psychosocial harm. A reasonable person in the position of either resident would experience fear, distress, and loss of dignity when discharged under these circumstances. These outcomes constitute actual psychosocial harm .Findings:During an interview on 12/16/25 at 1:00 PM, the Director of Social Services (DSS) and Social Service Coordinator (SSC) stated currently, the facility had no documented set of standards for their discharge planning process. The DSS stated that there were expectations, however they were only verbalized throughout the social service department (SSD).When asked to explain the standards used, the DSS and SSC stated that the SSD would have a care conference with new admissions, about two or three days from admission. This first care conference would be to identify needs of the admission and discharge goals when ready.Then, the SSD would have another care conference about two weeks prior to discharge. The DSS stated that, currently, these were the only care conferences conducted, however this was self-identified as a need to improve upon, and it was a goal to initiate more care conferences throughout a resident's admission in the future.When asked to describe how the facility prepared for a discharge, the DSS and SSC stated during the care conference prior to discharge, the facility would identify where the resident would discharge to, and which services would be needed upon discharge. Examples of needs and services that would be reviewed included, but not limited to:1. Durable medical equipment (DME - wheelchair, walker, hospital bed, or other equipment);2. PCA (Personal Care Assistant) services (where a certified nursing assistant, or CNA, would help in the house with ADLs, activities of daily living such as bathing);3. Primary Care Provider (PCP) follow-up (the goal would be to have a 2-week follow-up appointment made prior to leaving the facility);4. Home health services;5. Physical Therapy (PT), Occupational Therapy (OT), and/or Speech Therapy (SP);6. Wound Care;7. Skilled Nursing (where a Licensed Nurse, or LN, would come to the house for assistance); and/or8. Meals on Wheels.The DSS and SSC further stated the care conference would include the resident and resident representatives or family (if applicable), and referrals would be coordinated after the care conference for the identified discharge needs. The expectation would be to have the referrals ordered, by sending a fax to each referral, two to three days before the resident left the facility. For DME, it was the expectation that this would be available at the facility on the day of discharge. The DSS and SSC stated a Discharge Summary form would be completed after this care conference which showed what services were identified and when the services were ordered.When asked what would occur if resident or resident representative voiced concerns during this care conference about the discharge plan, the DSS and SSC state they would collaborate with the facility's leadership team and they would attempt to accommodate additional needs prior to discharge.When asked what would occur if concerns were voiced that the house wasn't wheelchair accessible or the house was not ready to accommodate the resident, the DSS and SSC stated they would re-review the discharge plan. When asked if home visits occurred prior to a resident discharging to a home, the DSS stated this had not been completed prior and was something that the facility had self-identified as a concern. Currently, they are in the process of looking into adding in-home visits to their discharge planning process.Resident #112Record review on 12/14-24/25 revealed Resident #112 was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, infection due to right hip prosthesis, and arthritis due to bacteria in the hip joint.During an interview on 12/16/25 at 1:44 PM, Resident #112's family member stated the resident had been hospitalized for quite a while, prior being admitted to the facility, for an infection in his/her hip replacement joint socket (an artificial hip). The resident had multiple surgeries while in the hospital and was being treated for a MRSA infection (Methicillin-resistant Staphylococcus aureus - a type of staph infection) with I.V. (intravenous) antibiotics (administered through a small catheter inserted in a blood vessel). Once out of the hospital, the resident was admitted to the facility for recovery, wound care, and continued antibiotic therapy. Resident #112's family member stated while at the facility, the resident had a fall on 7/31/25 which resulted in a fractured femur (thigh bone), which required surgery. The artificial joint needed to be removed from the resident's hip, and this was replaced with a spacer device to support the joint area until the resident was well enough to have another joint replacement procedure. Resident #112's family member stated once the resident returned to the facility (on 8/18/25), attempts were made to have the resident go to follow-up appointments with his/her surgeon to plan for the new hip replacement surgery, however those appointments were inconsistent, or for whatever reason would not be arranged (at one point the resident would go for an appointment to be told that there was no appointment).Resident #112's family member further stated as the resident's stay progressed, the Medicare benefits were starting to run out and the facility started contacting him/her to discharge the resident. Resident #112's family member explained that he/she was estranged from the resident and lived in a different state and only began to get involved in the resident's care due to the resident's need for support. Resident #112's family member began guardianship procedures and started attending care conference meetings. Resident #112's family member stated that a pastor from the resident's church was helping out as well and would also attend the care conference meetings. Resident #112's family member stated the resident lived alone in a house that had multiple stories, which was in disrepair, and full of rodents. The facility was made aware of the state of the house during the care conferences, but despite this information, the facility moved forward with a discharge plan to have the resident return home.Wound Care TreatmentReview of Resident #112's Treatment Administration Record (TAR), dated 11/2025, revealed the resident had two separate sacrum (tailbone) MASD (moisture associated skin disease) dressing treatment orders, which originally started on 10/28/25. These wound orders were changed on 11/7/25 and remained in effect up to discharge.Discharge DocumentationReview of Resident #112's Resident Centered Social History and Discharge Planning Assessment, dated 8/28/25, revealed: . This assessment supports the development of a comprehensive social history, goals of care, and includes information on the residents discharge plan. Most recent admission: [DATE]. Responsible Party/Legal Guardian: Not applicable, resident responsible for self. Other family and friend relationships: [Resident #112 family member] [and] [pastor from church]. Cognitive Patterns. BIMS [brief interview for mental status] score 13 [which indicated intact or normal thinking and memory]. Discharge Assessment, Goals, and Preferences. Prior living situation before admission to the facility: community without support/independent. Comments: lived at home alone. Does the resident prefer to involve any of the following in the decisions about their care and treatment. Family member(s) [was checked]. Resident or resident representative discharge goal/plan: return to community. Expected discharge timeframe: greater than 30 days[.] Does the resident have family or other support to provide assistance post-discharge? No.Review of Resident #112's Social Services Note, dated 9/9/25 - 11/19/25, revealed:- 9/9/25: Had a care conference today with resident and [his/her] [family member] and [his/her] Pastor. [family member] was speaking. about having a possible [second] hip surgery. it was unknown if [his/her] surgeon wanted [him/her] to come in for a [second] surgery. Talked about what discharge plans would look like if resident did not have [his/her] [second] surgery. Nothing is planned at this time. Awaiting further instructions from surgeon as to having a second surgery.- 11/11/25: Met with resident today to discuss [his/her] discharge options. Residents 100 Medicare Days will be exhausted 11/18/25. Resident is awaiting to see if [he/she] will be having a secondary surgery. Talked with Pastor. will send [him/her] PCA service information along with ADRC [aging and disability resource center] resources. Pastor. to build a ramp, [Resident] has 3 steps that leads into [his/her] home. [Resident] will need a small wheelchair, raised toilet seat and PT from Home Health.- 11/18/25: Patient is scheduled to DC [discharge] 11/19, transport set up for 2pm . Called pastor. for pick up time and [he/she] stated the patient needs too much help and should be in an assisted living facility or have 24 hour care. I explained private care giving does cost money out of pocket but we are setting up home healthcare which is covered by the insurance and [he/she] will have a wheelchair. I spoke with the patient afterthis and [he/she] was in tears saying pastor. has been telling [him/her] the whole time [he/she] has been here that [he/she] will get a ramp installed for [him/her] 2 steps into the house so [he/she] wouldn't have issues using the wheelchair. Patient also showed me a video of the inside of [his/her] house which is an open floor plan to maneuver a wheelchair easily. Patient is A&Ox4 [alert and oriented to person, place, time and situation], [his/her] own representative and is desiring to return home 11/19.- 11/19/25: Resident set to d/c [discharge] today. Spoke to Pastor. who will be at. residence upon [his/her] discharge. Pastor. will call the fire department for the lift assist. Resident is alert and oriented x 4 and wished to discharge home with the help of home health and PCA services. Social services to reach out to Bright Star for nursing and PCA services. Enhabit Home Health for PT, and ordered a wheelchair and bedside commode through Procare [transport service] is set to transport this resident to [his/her] home.Review of Resident #112's Provider Progress Note, dated 11/10/25, revealed: . found to have DVT [deep vein thrombosis, blood clot] RLE [right lower extremity, however documentation later in the note indicated left leg]. Had been more active, but said [he/she] had fallen some weeks back and had been laying in bed more. Reimplant/removal spacer was being planned. discussed unlikely to have surgery for 6 months now due to DVT. 11/11: note appear that ortho would like to take out spacer and do R THA [right total hip arthroplasty - hip replacement]. Assessment and Plan. Therapies: PT. Plan: discharge to home. Labs: weekly labs due to anemia/recent septic hip. LLE [lower left extremity] thrombus: Occlusive [blocking blood vessels] and nearly occlusive thrombus noted throughout entire left lower leg extremity, [blood thinner] started. 6 months end date. Right hip: spacer in place, able to participate in rehab. HOME HEALTH The patient will need continued home health/PT/OT for continued conditioning to maintain or improve on current level of functioning and mobility. For strengthening and reconditioning. Also, to prevent falls and further injury and debility. WHEELCHAIR The patient will need a wheelchair at home. The patient has mobility limitations that impair their ability to participate in toileting, feeding, dressing, grooming, and bathing. These mobility ADL issues cannot be resolved by an appropriately fitted cane or walker. Additionally, the patient is willing and able to use the wheelchair in the home and will have caregivers available, willing, and able to assist using the wheelchair. The home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair provided.Further review revealed of the Provider's note did not document the need for wound care.Review of Resident #112's REHAB - Functional Abilities V2.0, dated 11/18/25, revealed:1. Mobility: Resident #112 was independent with rolling left and right in bed; sit to lying; lying to sitting on side of bed, however, Resident #112 needed supervision or touching assistance to sit to stand and for chair-to-bed-to-chair transfer.Further review revealed car transfer; walk 10 feet; walk 50 feet with two turns; walk 150 feet; walking 10 feet on uneven surfaces; 1 step (curb); 4 steps; 12 steps; and picking up object from the floor were not attempted due to medical condition or safety concerns.Further review revealed the assessment identified the resident used a manual wheelchair and required supervision or touching assistance to wheel 50 feet with two turns and wheel 150 feet.2. Self-care: Resident #112 was independent with eating; oral hygiene; toileting hygiene and personal hygiene (excluding baths or showers).Further review revealed shower/bathe self and tub/shower transfer required partial/moderate assistance. Upper body dressing required setup or clean-up assistance and lower body dressing and putting on/taking off shoes and toilet transfer required supervision or touch assistance.Review of Resident #112's Notice of Proposed Transfer/Discharge - V4.0, dated 11/19/25 [day of discharge], revealed: Type of Assessment. Transfer [return expected]. Effective Date of. discharge: [DATE]. Reason for. Discharge. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. Comments: Resident has exhausted [his/her] Medicare benefit days. Resident would like to discharge home with the help of Home Health PT and the help of PCA services. [He/she] will have Meals on Wheels set up. Pastor. to assist with building a ramp to go over the 2 steps [he/she] has to get into [his/her] house with [his/her] wheelchair. Home Care will call to assist/set-up in care services for resident. Upon discharge to the home, resident and or family to call non-emergency dispatch line for Lift assist. Notifications . Resident Notification. [Resident #112]. Further review revealed the family member and the Pastor were not listed as being notified.Review of Resident #112's Discharge Summary and Post-Care Instructions V2.0, dated 11/19/25, revealed: . Discharge Information. Date. 11/19/25. Discharge location. Home/Community. Reason for Discharge. Resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.Further review of the Discharge Summary revealed the following post-discharge services, referrals, and equipment were listed: . Primary Care Physician Name. Resident does not have a Primary Care Provider. List of resources provided. [Facility Provider] for Centennial Post Acute will follow home health orders until resident is established with PCP. Home Health Services Agency Name and Contact Information. Bright Star Care - Nursing and PCA. Other Services and Referrals Ordered. Nursing and Physical Therapy. Enhabit Home Health. Durable Medical Equipment (DME). 3-in-1 commode (bedside toilet)[.] wheelchair. Procare. Community Support Services . In-home support services[.] Meal Service. Meals on Wheels[.] Bright Star Care.Further review of the Discharge Summary revealed the resident did not have access into or out of his/her residence placing him/her at risk of being trapped in the house: . Recapitulation of Stay. Social Services Summary. Resident is alert and oriented x 4, resident is upset that that ramp over [his/her] steps did not get built like promised. Additional Comments about Discharge. Pastor. to be at the house upon discharge and to call the fire dispatch in order to get a lift assist to get the resident inside [his/her] home.Further review of the Discharge Summary revealed the following nursing clinical summary which was inconsistent with the resident's current status: . Physical Function and Structural Problems. Physical Function - Activities of Daily Living (ADLs). requires some assistance. Is this an improvement from baseline? Yes. Physical Function: Mobility. requires some assistance. Is this an improvement from baseline? Yes. Functional Limitations. No limitation in ROM [range of motion]. Special Treatments, Devices and Procedures. fall risk[,] skin breakdown risk. Further review revealed no documentation for the need for continued wound care.Further review revealed this Discharge Summary stated the Pastor would be the resident's caregiver which was not accurate. Further review revealed there was no determination how often the Pastor would be available to help the resident: . Home Caregiver Training: Is a home caregiver available? Yes. Name and relationship: [Pastor]. Number of hours available to provide assistance each day: TBD [to be determined]. Has training been provided and verbalizes understanding with (as applicable) return demonstration? No. Is there any follow-up training needed? No.Further review of the Discharge Summary revealed no mention of resident's blood clot, the need for weekly labs, or the need to follow up with his/her surgeon on when hip surgery could be scheduled. Further review revealed there was no referral need for wound care.During an interview on 12/16/25 at 2:05 PM, Resident #112's Pastor stated he/she felt Centennial shouldn't have discharged the resident. The Pastor stated he/she told the discharge team the resident should not discharge, but they did it anyway and put him/her down as the resident's caregiver, but I am just a pastor, not [his/her] caregiver. The Pastor stated he/she was at the house when the facility transported the resident home because if he/she hadn't been there they would have left the resident on the sidewalk in the cold. The Pastor stated he/she had to call the fire department to get the resident lifted into his/her house because it was not wheelchair accessible.During an interview on 12/16/25 at 1:44 PM, Resident #112's family member stated that a member of the fire department, who showed up at the resident's house to assist him/her inside, saw the state of the resident's house and the inaccessibility of wheelchair access inside the house. The fireman and his wife (who were strangers prior) have been assisting the resident since the discharge due to the level of care the resident needed.During an interview on 12/18/25 at 2:20 PM, the Fireman's Wife stated they had been helping the resident since the day of discharge. The conditions of [his/her] home are horrible. The Fireman's Wife stated the house was a multilevel home and there was a rodent infestation within it. She described the house as being wheel chair inaccessible and the resident was now limited to one level of the house; the bathroom door needed to be removed so the resident's wheelchair could access the room; all of the rugs needed to be removed from the house so the resident could maneuver in the home; and there was no bed on the one level so the resident was sleeping in a recliner. The Fireman's Wife stated they had to use their own money to buy a new recliner for the resident because he/she was falling out of the old one. The Fireman's Wife stated the resident would not be able to survive alone in that house and required nursing home level care. They were doing the best they can, through the help of strangers and people from his/her church to assist whenever they can. They have tried to make the resident's kitchen accessible, however it was not possible with how the kitchen was structured. The Fireman's Wife stated the last person that was there during the day attempted to clear the paths of the house and put food within reach of the resident for the night, otherwise the resident would not be able to eat.The Fireman's Wife further stated the resident was not able to walk at all. She stated the resident could transfer to the wheelchair but had fallen in the home since discharging and this was a safety risk if alone in the house as the resident could not get off the floor independently. The Fireman's Wife stated they did what they can, but there was no one available to be in the house 24/7.Referral ReviewReview of Resident #112's medical record for referral documentation of services, referrals, and equipment listed in the Discharge Summary and Post-Care Instructions V2.0, dated 11/19/25, revealed:1. A referral for a wheelchair, through Procare, was completed on 11/13/25, prior to the resident's discharge;2. A referral was documented to Enhabit Home Health to provide PT services. This referral was made on the day of discharge, 11/19/25. Further review revealed nursing was not checked on the referral as a service that was needed as documented on the Discharge Summary;3. A referral was documented to Ancora Home Health to provide home health services (and not Bright Star Care as documented in the Discharge Summary). Further review revealed this referral was dated 11/13/25, but not faxed until 11/17/25.Further review of the Ancora referral revealed: Primary Physician: Anchorage Neighborhood Health. Follow-up [Appointment] Date/Time: Resident to Schedule. This information was not on the Discharge Summary for the resident to complete.4. A referral to Procare was completed on 11/21/25 (2 days after discharge) for a bedside commode.5. There was no referral to Bright Star Care for in-home services as documented on the Discharge Summary.6. There was no referral for wound care.During an interview on 12/16/25 at 1:44 PM, Resident #112's family member stated no referral information was provided when the resident discharged from the facility. The family member stated when he/she called the facility about the referrals, and he/she was told the facility had tried to call the referrals and doctors to attempt to get services set up, but they couldn't get a response.During an interview on 12/18/25 at 2:20 PM, the Fireman's Wife stated regarding in-home services, they only have PCA services setup for once a week so the resident could have a bath.During an interview on 12/17/25 at 12:03 PM, after reviewing Resident #112's medical record, the DSS stated the paperwork did indicate the stair ramp was not installed prior to the resident's discharge, but the resident wanted to go home so the fire department was contacted to assist the resident into the home. When asked if this was an appropriate discharge, the DSS agreed that despite the resident's wishes this was not a safe discharge.Resident #113Record review on 12/14-24/25 revealed Resident #113 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance (cognitive decline affecting memory, thinking, and problem solving which did not include agitation or aggression), fracture of the right femur (thigh bone), infection to surgical site to fix the femur, metabolic encephalopathy (a brain disorder caused by a chemical imbalance from an underlying illness leading to impaired brain function, confusion, memory issues, and personality changes), and muscle weakness.Review of Resident #113's hospital Discharge Summary, dated 10/8/25, revealed the resident had a lengthy hospitalization from a fall that resulted in the femur fracture requiring surgical repair. Further review revealed: Acute toxic/metabolic encephalopathy/delirium/[cognitive] impairment. [he/she] has marginal capacity to make medical decisions. [Resident #113] is discharging to Centennial SNF [skilled nursing facility].Further review of Resident #113's medical record revealed the resident had a Power of Attorney (POA). Review of the legal document, dated 9/3/25, revealed this document indicated the POA had the power to decide about insurance transactions, benefits from government programs, and all other matters.Resident #113's POA was documented as Resident #113's agent in his/her medical record.Review of Resident #113's 01. Nursing - Admission/readmission Evaluation/Assessment, dated 10/8/25, revealed: . Reason for admission: physical therapy and wound care. Orientation. Cognition. Confused. Short-term memory loss. Mood Behavior: Mood and behavior patterns. Disorganized thinking. Sad. resident upset and disoriented. Keeps saying [he/she] wants to go home. Summary Note. very anxious and upset to be here and not at home. needs reoriented frequently. Unable to make needs known.Physical Therapy admission Assessment\Review of Resident #113's Physical Therapy Medicare PT Evaluation [and] Plan of Treatment, dated 10/9/25, revealed restorative/rehabilitation exercises were planned for strengthening to improve in transfers, ambulating, and wheelchair use: Frequency: 5 time(s)/week. Duration: 4 weeks. Risk Factors: Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: increased pain, increased dependency upon caregivers, further decline in function and falls.Wound Care TreatmentReview of Resident #113's TAR, dated 10/2025, revealed the resident was receiving daily wound care to his/her right knee from 10/15/25 to 10/26/25, and to his/her right outer thigh which started on 10/29/25 and remained in effect up to discharge.Mental Health NeedsRecord review also revealed Resident #113 had diagnoses of depression and anxiety.Review of Resident #113's PASRR Level 1, which was in the resident's medical record and dated 9/4/25, revealed the resident had diagnoses of delirium, encephalopathy, anxiety, and depression. Further review revealed: . Based on the information reviewed. the following determination is made. If admission. for this individual is approved, all services as identified by PASRR Level II evaluation must be provided. to meet the individual's nursing and disability-specific needs. Level II PASRR evaluation needed. Date referred for Level II evaluation: 9/5/25. Date Level II report received: 9/18/25.Further review of Resident #113's medical record revealed no PASRR Level II report was present.During an interview on 12/17/25 at 12:03 PM, when asked to provide Resident #113's PASRR Level II report, the DSS stated Resident #113's PASRR Level II report was not in the resident's medical record and was retrieved on 12/17/25 from the facility's PASRR Coordinator. The DSS stated this Level II report was not available during Resident #113's admission or reviewed during discharge planning.Review of Resident #113's Behavioral Health Level II Pre-admission Screening and Resident Review (PASRR) Assessment, dated 9/18/25, revealed: . Summary Narrative of Functional Assessment. [Resident's POA] stated [Resident #113] would need help performing all ADLs. Per PASRR Level I request, [Resident #113] experiences challenges with practical skills, including occupational skills, safety, schedule/routines, mobility, travel, and transportation. experiences challenges with completion of tasks, needs assistance to complete tasks, lack persistence, and has difficulty concentrating. demonstrates socially inappropriate behaviors, including challenges with independent living. Self-monitoring of health status. [Resident #113] would need help with self-monitoring of [his/her] health status. Self-administering of medical treatment. [Resident #113] would need help tracking [his/her] appointments, making [his/her] appointments, as well as tracking, obtaining, and remembering to take [his/her] medication. Self-monitoring of nutritional status. [Resident #113] would need help with self-monitoring of [his/her] nutritional status. [Resident #113] wants to cook [his/her] own food but [his/her] cooking 'was becoming a safety concern'. Determination. Nursing facility services. are needed. Mental Illness. Individual has mental illness. Specialized services. are needed. [Resident #113] would benefit from continuing to receive medication management following discharge from Providence Alaska Medical Center.Further review revealed: Additional PASRR Determination Information. A level II evaluation was completed. on 9/18/25. The evaluator found that [Resident #113] would benefit from nursing facility services and required specialized services (SS) for mental health needs. If the LTC [long-term care] facility chooses to admit [Resident #113], but finds they can no longer safely meet [his/her] care needs, please consider the options listed below: The LTC facility can pursue placement at an ALH [assisted living home] that offers more mental health supports (may obtain list from the Division of Behavioral Health)[;] The LTC facility can issue a formal 30-day discharge notice to the client, stating they cannot safely meet the client's care needs. If this occurs, a copy of the discharge notice should be submitted to SDS [Senior and Disabilities Services] in Harmony [an electronic data base][;]

.Based on record review, interview, and observation, the facility failed to develop, implement, and maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, analyzed, and corrected systemic quality deficiencies. The facility failed to use available data to identify trends, failed to prioritize high-risk issues, and failed to implement and sustain corrective actions.Specifically, the facility failed to identify and/or address ongoing patterns of deficient practice related to staffing, grievance process, clinical care, activities, medication management, therapy services, discharge planning, environmental conditions, and care planning. These issues were evident through internal reports, resident council concerns, medical record documentation, staffing data, and direct observation, yet were not recognized and/or effectively acted upon through the QAPI process.These failed practices placed all residents (based on a census of 97) at risk of receiving less than optimal care and poor quality of life Findings:During an interview on 12/18/25 at 4:34 PM, the Regional Director of Clinical Nursing Services (RDCNS) and the Administrator stated the QAPI committee collected data from different metrics. When asked to clarify what metrics were used, the RDCNS stated for clinical metrics that they look into were electronic health record, corporate dashboard, HR (human resources) reporting work day, maintenance through TELS (a maintenance software) that track and document activities, sanitation rounding in the kitchen, activities, resident council minutes, feedback from residents and staff. The RDCNS stated data from the metrics were brought into the QAPI meeting. The RDCNS stated the committee prioritized patient safety, resident and staff satisfaction, maintenance, activities, impacts quality of life such as high risk, adverse events. They also had a quick review of accidents and events, and post incident interventions. The RDCNS also stated the team would come up with a plan based on the prioritized data.When asked about their monitoring process, the RDCNS stated a sub-committee would be assigned to look into the root cause of the issue then a PIP (Performance Improvement Project) would be created. She explained that the PIP lead would report to the QAPI committee, then the QAPI committee would give their feedback if the plan would be updated or sustained. She further stated that currently the QAPI committee had Infection control and skin integrity PIP.Low Weekend Staffing Review of the Payroll Based Journal (PBJ) Staffing Data Report (a mandatory electronic staffing data submission system created by the Centers for Medicare & Medicaid Services [CMS]) for the fourth quarter (7/1/25 to 9/30/25) revealed: Excessively Low Weekend Staffing was triggered.Review of the facility provided Centennial Post Acute Facility Assessment, updated on 11/25/25, revealed: . The facility is struggling with securing FT [full time] staff for nurses and CNAs. The assessment indicated staffing should include: . 6 nurses on day/eve[[NAME]] shift and minimum of 3 on NOC/night shift.12-15 CNAs on day shift/eve shift and 9-12 on NOC/night shift. 2 restorative aides daily.Review of 12 randomly selected weekend staffing schedules for the fourth quarter (7/1/25-9/30/25) revealed staffing consistently fell below the facility assessment's established levels. Specifically:- On 8/9/25, 2 LNs were scheduled, the established minimum was 3.Dayshift, CNAs, the established minimum was 12:- On 7/5/25, 10 day shift CNAs were scheduled;- On 7/6/25, 11 day shift CNAs were scheduled;- On 7/12/25,11 day shift CNAs were scheduled; and- On 7/13/25, 9 day shift CNAs were scheduled.Nightshift, CNAs, the established minimum was 9:- On 7/5/25, 7 night shift CNAs were scheduled;- On 7/6/25, 8 night shift CNAs were scheduled;- On 7/13/25,6 night shift CNAs were scheduled; and- On 9/6/25, 7 night shift CNAs were scheduled.Restorative Aides (RAs) - established minimum was 2 daily:- On 7/5/25, 1 RA was scheduled;- On 7/6/25, 0 RAs were scheduled;- On 7/12/25,1 RA was scheduled;- On 7/13/25,1 RA was scheduled;- On 8/9/25,1 RA was scheduled;- On 8/10/25,1 RA was scheduled;- On 8/23/25,1 RA was scheduled;- On 8/24/25,1 RA was scheduled;- On 9/6/25, 1 RA was scheduled;- On 9/7/25, 1 RA was scheduled;- On 9/27/25, 0 RAs were scheduled; and- On 9/28/25, 1 RA was scheduled.Resident #48Record review on 12/14-24/25 revealed Resident #48 was admitted to the facility with diagnoses that included quadriplegia (paralysis of all four limbs). The resident fully relied on staff to dress and get the resident up and out of bed.During an interview and concurrent observation on 12/14/25 at 11:11 AM, Resident #48 stated that he/she had called for staff around 9:00 a.m. to assist with getting out of bed and was still waiting. The resident remained in bed with a Hoyer lift positioned beside the bed and the wheelchair near the doorway. The resident stated that he/she had requested to be out of bed by 9:30 a.m. and reported that long waits had been common since admission, expressing concern that the facility seemed very short-staffed. Staff assisted Resident #48 out of bed at 11:23 a.m., a total wait time of 2 hours and 23 minutes. During an interview on 12/18/25 at 4:15PM CNA #2 stated residents who are wanting to get out of bed would have to wait longer if other residents need to use the restroom. CNA #2 stated there wasn't enough staff to be everywhere at the same time. Sometimes there would only be one CNA assigned to a court and there would be another staff assigned to float between several courts.Resident #77During an interview and concurrent observation on 12/14/25 at 9:19 AM, Resident #77's room had an odor of urine. The resident was in bed with an open urinal about one-quarter full hanging from the bed rail. When asked how long it had been there, the resident said about an hour. The resident explained staff were busy and would empty it eventually, noting they were always helpful but short-staffed.Further observation revealed Resident #77 was on enhanced barrier precautions (EBP, an infection control measure that requires staff to wear gowns and gloves during high-contact care activities for residents with wounds, indwelling devices, or multidrug-resistant organisms, to prevent the spread of infections). It was noted there were no gowns available to use for Resident #77's room.During an interview on 12/14/25 at 10:02 AM, when asked about EBP gowns for Resident #77, CNA #5 stated the night shift must have used them up and didn't have time to replace them. The CNA further stated the urinals would be taken care of when they rounded on the resident, however, if the CNA was helping other residents, it can be difficult to round regularly.Resident CouncilDuring an interview on 12/17/25 at 3:00 PM, with those who attended Resident Council meetings, Resident #95 reported long delays in staff response when residents needed help. They stated on weekends, only one CNA was assigned to a unit while another floated between units, causing further delays if both staff were occupied or if the float staff was in another unit. Resident #95 stated, There's just not enough people to help us. Resident #25 added that CNAs sometimes forgot to return after answering call lights. All seven attendees (Resident #'s 25, 35, 47, 69, 74, 95, and 102) agreed response times were slow due to not enough staff. When asked how the facility responded to the Resident Council's concern regarding staffing issues, the group stated they were told that the staff was being educated and that the facility was working on staffing, however, they did not see any improvement. Review of the Resident Council Meeting Minutes revealed:- Minutes from the 8/18/25 meeting: . Nursing: Concern: CNA's are leaving pee containers in rooms and they are starting to smell. Response from Manager: Nursing Staff will be educated. ;- Minutes from the 9/8/25 meeting: . Nursing: CNA's are clearing call lights and telling residents they'll get back to them and forgetting to get back with them. Concern Response from Manager: Nursing staff will be educated. ;- Minutes from the 10/13/25 meeting: . old business. CNA's are clearing call lights and telling residents they'll get back to them and forgetting to get back with them. There were no facility responses recorded in the minutes regarding this matter. ;- Minutes from the 11/10/25: . old business. CNA's call lights are not being answered in a timely manner. Nursing: Concern: Need more staff. Response from Manager: We are working on it. ;- Minutes from the 12/8/25 meeting: . old business. CNA's call lights are not being answered in a timely manner. There were no facility responses recorded in the minutes regarding this matter.During an interview on 12/17/25 at 1:07 PM, the Administrator stated he was not aware of the low weekend staffing, and that the staffing reports generated from their party vendor showed the facility was meeting their Patient Per Day (PPD) goals, which were based on the nursing union and California standards.Further review of the facility provided Centennial Post Acute Facility Assessment, updated on 11/25/25, revealed: . The facility assessment should drive staffing decisions. to carry out facility functions.During an interview on 12/18/25 at 4:34 PM, the Administrator stated the facility was adequately staffed in the weekend following the Patient Per Day (PPD) 4.0 and 5.0. He further stated the union guideline was 1 Certified Nurse Assistant (CNA) was to 9 residents (1:9) per night shift and 1:7 day shift. One nurse on each court and majority of nurses were RNs (Registered Nurse).He further stated the committee was not aware of the low weekend staffing. He stated their PBJ (Payroll Based Journal) report was directly reported from their clocking-in system. The Administrator further stated he would look deeper into the staffing issue.Grievance processDuring random observations from 12/14-18/25, the grievance procedure notice was observed posted throughout residents' courts. The notice indicated that residents and others could submit complaints or grievances anonymously, either orally or in writing, with grievance forms available in the Social Services Office. The notice stated that all concerns would be addressed within a reasonable timeframe and that the Grievance Officer should be notified immediately of any suspected resident abuse, neglect, misappropriation, or exploitation. The notice identified the designated Grievance Officer as Grievance Officer (GO) #1 and listed the following contact information: 9100 Centennial Circle, Anchorage, AK 99504; email: [name of GO#1]@centennialpa.com; phone number: [PHONE NUMBER]. The notice further stated that a copy of the Grievance Policy or a written grievance decision was available upon request.During an interview on 12/17/25 at 10:00 AM, the Social Services Director (SSD) stated that she currently serves as the facility's Grievance Officer (GO #2), a role she assumed upon starting her position in November 2025. The SSD was unsure of the exact departure date of the previous Grievance Officer (GO #1). She stated that residents were informed about the grievance process through admission packets, grievance forms located on each court and outside of the Social Services Office, and locked grievance boxes collected daily. Upon reviewing the admission packets, the SSD noted that they did not include written information identifying the Grievance Officer or providing contact details, and no additional written notification of her role had been provided to residents or their representatives. The SSD also stated that she had not yet introduced herself at Resident Council meetings, believing attendance requires an invitation, but she planned to introduce herself to residents when possible. Upon reviewing the grievance procedure notice posted throughout the facility, the SSD also noted that the contact information should no longer be for the GO #1, not accurately reflecting the change in grievance officers.During the Resident Council meeting on 12/17/25 at 3:08 PM, Residents (#25, #35, #47, #69, #74, #95, #102) stated they did not know who the new GO was. The council reported they were aware the former GO had left in September, but the new GO had not approached the council for an introduction.Record review of Resident Council meeting minutes, dated 9/8/25, revealed complaints regarding missing laundry, with the facility response documented as: .We will try and educate the staff.Record review of Resident Council meeting minutes, dated 10/13/25, revealed the introduction of the new Activities Director and Admissions Director. The minutes also documented discussion of old business related to missing laundry and Certified Nurse Assistants (CNA) clearing call lights and failing to return to residents.Record review of Resident Council meeting minutes dated 11/10/25, revealed discussion of new business noting many newly hired CNAs; there was no mention of a new Grievance Officer. Old business again included missing laundry and call light concerns.Record review of Resident Council meeting minutes, dated 12/8/25 revealed no discussion regarding a new Grievance Officer. Old business continued to include missing laundry and call light concerns.Review of RESIDENT GRIEVANCE FORM, undated, posted on each court's entrance board near a locked wooden box, revealed a structured document that included fields for the date and time of the grievance or concern, the resident's name and room number, and the name of the person completing the form. It provided a section to describe the nature of the grievance, followed by areas for investigation findings and interventions/action taken. The form also included a section for the date follow-up to resolution occurred, with signature lines and dates for the person conducting follow-up (by whom), the administrator, the grievance officer, and the resident. No additional instructions were provided regarding how or where to submit the completed form.Review of the policy and procedure titled Grievance, last revised 3/2015 revealed: .the facility will have a designated Grievance Officer who is responsible for overseeing the grievance process, receiving, investigating, tracking grievances through to their conclusion and maintain the confidentiality of all information associated with grievances.Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance. PROCEDURE: 1. The Social Services Director/Designee should assure that residents and/or their representative(s) receive a review of their rights and responsibilities upon admission. 2. The Activities Director/Designee should complete a grievance form when a global issue is raised at a Resident Council Meeting. 3. The Social Services Director/Designee or ANY staff member should assist concerned resident(s), resident representative(s), other family member(s), or advocate that have issues or concerns to complete a Grievance/Concern Form.Review of the posted document RESIDENT RIGHTS, undated, revealed: Choice, Medical Care, Privacy & Confidentiality, Free from Abuse & Restraint, Visitors & Association, Activities & Work, Personal Possessions, Grievances & Complaints, Financial Affairs, Transfer & Discharge. A detailed document of the above Resident Rights Summary is available from the admission Office or Social Worker.During an interview on 12/18/25 at 4:34 PM, the RDCNS stated the facility would provide the residents with a folder that contained the grievance process. She added that a signage was posted in the facility that would alert the residents of the information of the grievance officer. She further stated the Social Services Director (SSD) was the grievance officer (GO) #2.Activities not being provided for the residentsResident #12Record Review from 12/14-24/25 revealed Resident #12 was admitted to the facility with diagnoses that included a fracture of the left femur, and major depressive disorder (a mental disorder characterized by low moods, low self-esteem, and loss of interest in or pleasure in normally enjoyable activities).During an interview with Resident #12 on 12/15/25 at 9:34 AM, when asked about which activities the resident enjoyed at the facility, Resident #12 stated no one came to offer him/her activities.Review of Resident #12's ACTIVITY ASSESSMENT., dated 7/29/25, revealed the resident had interests that included cooking, birthday parties, happy hour and beauty days.Review of Resident #12's Care Plan Report, last reviewed 7/30/25, revealed: I know I have the right to do what I want. Will have daily socialization with staff or visitors as desires. cooking, birthday parties, happy hour, beauty days. Encourage autonomy and independence with preferred activity pursuits. Support choices for preferences regarding customary routine and activities.ActivitiesSeptember:Review of Resident #12's Activities Flowsheet, dated 9/1-30/25, revealed the activities staff interacted with Resident #12 twice for the month of September (9/12/25 and 9/30/25).November: Review of Resident #12's Activities Flowsheet dated 11/1-30/25, revealed the activities staff interacted with Resident #12 once for the month of November (11/4/25).December:Review of Resident #12's Activities Flowsheet dated 12/1-16/25 revealed the activities staff interacted with Resident #12 once for the month of December (12/2/25).Resident #27Record Review from 12/14-24/25 revealed Resident #27 was admitted to the facility with diagnoses that included weakness, mild cognitive impairment of uncertain or unknown etiology and osteoarthritis (chronic degenerative joint disease characterized by the progressive breakdown of joint cartilage and underlying bone).During an interview with Resident #27 on 12/14/25 at 10:30AM, when asked about the activities that had been offered, he/she stated: I've never been offered to participate in any activities, and I don't recall ever attending an activity. It would be nice if something like that existed.Review of Resident #27's ACTIVITY ASSESSMENT., dated 10/15/25, revealed the resident had interests that included walks, investment banking, and being with animals and pets.Review of Resident #27's Care Plan Report, last reviewed 10/14/25 revealed no activities care planning.ActivitiesOctober:Review of Resident #27's Activities Flowsheet dated 10/14-31/25 revealed the resident participated in activities on seven dates (10/15-16/25, 10/20-23/25, and 10/29/25), with no additional documentation indicating the resident was offered or participated in activities for the remaining 12 days.November:Review of Resident #27's Activities Flowsheet, dated 11/1-30/25 revealed the resident participated in activities on two dates (11/3-4/25), with no additional documentation indicating the resident was offered or participated in activities for the remaining 28 days.December: Review of Resident #27's Activities Flowsheet dated 12/1-16/25 revealed no documentation that the resident was offered or participated in any activities.Resident #67Record Review from 12/14-24/25 revealed Resident #67 was admitted to the facility with diagnoses that included depression and adult failure to thrive (condition characterized by a decline in overall health and function, marked by social and psychosocial withdrawal, reduced engagement in activities or interactions, decreased motivation, and diminished ability to meet basic physical and emotional needs, often accompanied by functional decline or poor nutritional intake).Review of Resident #67's Care Plan Report, last revised 12/12/25 revealed the following activities care planning: .Resident will maintain current cognitive-communication skills to delay further decline. Coordinate with activities staff for participation in cognitive stimulation activities. My preferred activities are arts/crafts (drawing, sewing, and coloring), education (jeopardy, wheel of fortune), cooking/baking, gardening, listening to country music, family visits, pet therapy, reading magazines, reminiscing, horse racing, taking naps, socializing with staff, and beauty break. Staff will continue to encourage resident to participate in activities of stated interest.ActivitiesJanuary:Review of Resident #67's Activities Flowsheet, dated 1/1-31/25 revealed the resident participated in activities on one date (1/1/25), with no additional documented activity participation or offers for the remaining 30 days.February:Review of Resident #67's Activities Flowsheet, dated 2/1-28/25 revealed the resident participated in activities on five dates (2/8/25, 2/15/25, 2/25/25, and 2/28/25), with no additional documentation indicating the resident was offered or participated in activities for the remaining 23 days.March:Review of Resident #67's Activities Flowsheet, dated 3/1-31/25 revealed the resident participated in activities on one date (3/6/25), with no additional documented activity participation or offers for the remaining 30 days. April:Review of Resident #67's Activities Flowsheet, dated 4/1-30/25 revealed the resident participated in activities on two dates (4/1/25 and 4/7/25), with no additional documented activity participation or offers for the remaining 28 days.May:Review of Resident #67's Activities Flowsheet dated, 5/1-31/25 revealed the resident participated in activities on one date (5/7/25) with no additional documented activity participation or offers for the remaining 30 days.June:Review of Resident #67's Activities Flowsheet, dated 6/1-30/25 revealed no documentation that the resident was offered or participated in any activities.July:Review of Resident #67's Activities Flowsheet, dated 7/1-31/25 revealed the resident participated in activities on one date (7/21/25), with no additional documented activity participation or offers for the remaining 30 days.August:Review of Resident #67's Activities Flowsheet, dated 8/1-31/25 revealed the resident participated in activities on two dates (8/23/25 and 8/27/25), with no additional documented activity participation or offers for the remaining 29 days.September:Review of Resident #67's Activities Flowsheet, dated 9/1-30/25 revealed the resident participated in activities on two dates (9/5-6/25), with no additional documented activity participation or offers for the remaining 28 days.October:Review of Resident #67's Activities Flowsheet, dated 10/1-31/25 revealed the resident participated in activities on two dates (10/16/25 and 10/18/25), with no additional documented activity participation or offers for the remaining 29 days.November: Review of Resident #67's Activities Flowsheet, dated 11/1-30/25 revealed the resident participated in activities on one date (11/3/25), with no additional documented activity participation or offers for the remaining 29 days.December:Review of Resident #67's Activities Flowsheet, dated 12/1-17/25 revealed the resident participated in activities on one date (12/15/25) with no additional documented activity participation or offers for the remaining 16 days.During an interview with the Activities Director on 12/16/25 at 1:30 PM, she stated that if a resident participated in an activity, or was offered to participate in an activity, it would be documented on the Activities Flowsheet. She further stated that if documentation was not present on the Activities Flowsheet, it meant the resident was not offered to participate in an activity. When asked how she tracked which residents had not participated in activities she stated that it was done by memory.Record review of the facility policy Activity Programs, last revised 6/2018 revealed: .2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 3. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. 6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. 9. Activities are documented in the resident's medical record. 13. Residents are encouraged, but not required, to participate in scheduled activities.During an interview on 12/18/25 at 4:34 PM, the RDCNS stated there were no complaints about the activities not being provided to the residents. This was something QAPI would look at.Review the facility's QAPI committee minutes of the meeting, dated 7/2025, revealed: .For the month of July, we aimed to focus the non-performing residents to address social isolation and distribute the minutes of the monthly resident council meeting in every department.outcome some of the feedback noted during one-on-one visits and resident council meeting are as follows: they are happy to have developed social interactions. It helped them cope up with loneliness and boredom.Review of the facility's QAPI committee minutes of the meeting, dated 10/2025, revealed activities department concerns and issues were not discussed.Narcotic reconciliationDuring an interview on 12/18/25 at 10:07 AM, Licensed Nurse (LN) #3 stated that during shift change, both the incoming and outgoing nurses were required to conduct a narcotic count together. LN #3 further stated this process was documented on the Shift Audit Record, located in the narcotic tracking books and required four total signatures:- Two signatures in the section labeled Signature of Nurse Leaving Shift, and- Two signatures in the section labeled Signature of Nurse Coming on Shift.Record review on 12/14-24/25 revealed that 3 out of 3 reviewed narcotic logbooks ([NAME] Court, Cedar Court, and Spruce Court) for the period October through December 2025 contained incomplete narcotic count documentation, evidenced by missing required signatures on the Shift Audit Record on the following days: [NAME] Court October 2025: 10/10, 10/19, 10/20, 10/22 November 2025: 11/1, 11/2, 11/3, 11/11, 11/12, 11/14, 11/15, 11/16, 11/19, 11/20, 11/24, 11/26, 11/27, 11/28, 11/29, 11/30 December 2025: 12/4, 12/5, 12/11, 12/13Cedar Court October 2025: 10/25, 10/26, 10/30 November 2025: 11/4, 11/17, 11/22, 11/23 December 2025: 12/1, 12/2, 12/9 Spruce Court October 2025: 10/1, 10/2, 10/5, 10/6, 10/8, 10/9, 10/10, 10/12, 10/13, 10/14, 10/18, 10/19, 10/20, 10/22, 10/27, 10/28, 10/31 November 2025: 11/2, 11/4, 11/6, 11/9, 11/10, 11/11, 11/13, 11/17, 11/18, 11/20, 11/21, 11/23, 11/24, 11/25, 11/26, 11/27, 11/28, 11/30 December 2025: 12/1, 12/3, 12/4, 12/5, 12/7, 12/9, 12/10, 12/11, 12/17 During an interview on 12/22/25 at 9:30 AM with the PharMerica (Centennial's contracted pharmacy services provider) Manager , when asked about the narcotic tracking books, she stated that PharMerica provided the narcotic tracking books, however it was the responsibility of the facility to handle all tracking and documentation in the books. Review of the facility provided Pharmacy Services Agreement, signed on 7/29/24, revealed: .Obligations of the client [Centennial]. Client shall, or require the Customer to, as the case may be . Store and handle all Medications in accordance with Applicable Law . Upon Client's request, Pharmacy shall provide the following and any other additional consulting services . Perform random quarterly audits of medication carts or audit medication storage areas for controlled and non-controlled medications . Perform on-site audits of Medical Records, contents of medication carts and/or Resident treatment charts, if provided by pharmacy. During an interview on 12/24/25 at 1:00 PM with the Director of Nursing (DON) , she stated that counting narcotics from each unit's medication cart was to occur each shift. She further stated: We have had a lot of turnover and maybe I just need to re-implant that policy and procedure to everyone. The DON further stated that the pharmacy came to the facility once a month to perform audits of narcotic tracking books, medication carts, and medication rooms, however she was not made aware of missed signatures in the narcotic tracking books. Review of the facility provided policy Pharmacy Services Overview, undated, revealed: .Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice . The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including (but not limited to) . (1) Receipt, labeling and storage of medications; (2) Reconciliation of medications from the pharmacy; (3) Control of medications from point of receipt to secured storage areas; (4) Facility staff roles and responsibilities during the receipt and storage of medication . d. Disposition of medications . f. Documentation of processes, as applicable.During an interview on 12/18/25 at 4:34 PM, the RDCNS stated narcotic reconciliation was a new concern.Review of the QAPI Minutes of the Meeting, dated 4/30/25, revealed: .Pharmacy/Nurse Report: Narcotics documentation issues: signed out in book but not documented in MAR [Medication Administration Record] (2 events were [where] nurse destroyed narcotics without second signature).Physical therapy (PT) not provided to the residentRecord review on 12/14-24/25 revealed Resident #111 was admitted to the facility on [DATE] with diagnoses that included radiculopathy (compression or irritation of a spinal nerve root, leading to pain, numbness, tingling, or weakness that radiates along the path of the affected nerve), spinal stenosis (spaces within the spine narrow, placing pressure on the spinal cord or nerves and causing pain, numbness, or weakness) and lumbosacral spinal fusion (surgical procedure that joins two or more vertebrae in the lower spine to stabilize the spine, reduce pain, and correct spinal instability or deformity).During an interview on 12/17/25 at 4:20 PM, Resident Representative (RR) stated Resident #111 was not making progress while he/she was at the facility because he/she was not receiving physical therapy (PT). RR further stated the physical therapist went on leave.Review of the Minimum Data Set (MDS- a federally required assessment), admission Assessment, dated 8/21/25, revealed, under Section GG-Functional Abilities, Resident #111 was coded as requiring substantial/maximal assistance for toileting hygiene, shower/bathe self and upper body dressing and dependent -where a helper does all the effort and the resident does none of the effort for lower body dressing and putting on/taking off footwear. Further review revealed Resident #111 was coded as requiring substantial/maximal assistance for sitting on side of bed to lying flat on the bed, lying on the back to sitting on the side of the bed with no back support, getting on and off a toilet and getting in and out of a tub/shower and dependent - where a helper does all the effort and the resident does none of the effort to complete the activities of coming to a standing position from sitting in a chair, wheelchair, or on the side of the bed and transferring to and from a bed to a chair.Review of Resident #111's Medicare PT Evaluation & Plan of Treatment, dated 8/16/25, revealed: Plan of Treatment.Frequency: 5/time(s)/week Duration 4 week(s) Intensity: Daily.Review of Resident #111's Physical Therapy Treatment Encounter Note(s) revealed Resident #111 had PT sessions on 8/16/25, 8/18/25 and 8/19/25 and no PT services for 12 [NAME]

.Based on record review and interview, the facility had failed to ensure the activities program was directed by a qualified professional. This failed practice placed all residents (based on a census of 97) at risk of not having an activities program directed by a qualified professional that met their physical, mental, and psychosocial needs Findings: Record review on 12/17/25 at 2:29 PM of the Activities Director (AD) appointment letter revealed the AD was hired into the director position on 9/3/25. During an interview on 12/16/25 at 1:20 PM, the AD stated she had been the AD for about a month, and she reported directly to the Human Resources Manager (HRM). The AD understood that the HRM had an AD certification but still needed to obtain her own certification once she had enough qualifying hours. During an interview on 12/17/25 at 2:33 PM, the HRM stated she held an Advanced Activity Professional board certification. During the same interview on 12/17/25 at 2:33 PM, when asked if the HRM was involved with directing the Activities program, the HRM stated: No. The HRM reported that beginning on 8/6/24, the AD had previously worked as a dietary aide and helped out with the activities program when she was available. Then sometime in 1/2024, the AD became the receptionist, where she occasionally assisted with the activities program. The HR Director added that the AD's prior program experience had never been full-time before assuming responsibility for directing the activities program. Review of the facility provided: Job Description: Activity Director, undated, revealed: . Qualification. Activity Director Certification.

Based on observation, interview, and record review, the facility failed to ensure:1) accurate grievance officer contact information was available to residents and representatives through required postings or individual notice, and2) to provide clear instructions on how to file and submit grievances, since grievance forms and admission information did not include submission instructions and the primary posted notice contained incorrect grievance officer information.These failed practices resulted in residents and resident representatives not having reliable access to the grievance process due to inaccurate grievance officer identification and unclear submission instructions, placing residents at risk for delayed reporting and resolution of concerns, creating a facility-wide system failure that limited residents' ability to access and use the grievance process Findings:During random observations from 12/14-18/25, the grievance procedure notice was observed posted throughout residents' courts. The notice indicated that residents and others could submit complaints or grievances anonymously, either orally or in writing, with grievance forms available in the Social Services Office. The notice stated that all concerns would be addressed within a reasonable timeframe and that the Grievance Officer should be notified immediately of any suspected resident abuse, neglect, misappropriation, or exploitation. The notice identified the designated Grievance Officer as Grievance Officer (GO) #1 and listed the following contact information: 9100 Centennial Circle, Anchorage, AK 99504; email: [name of GO#1]@centennialpa.com; phone number: [PHONE NUMBER]. The notice further stated that a copy of the Grievance Policy or a written grievance decision was available upon request.During an interview on 12/17/25 at 10:00 AM, the Social Services Director (SSD) stated that she currently serves as the facility's Grievance Officer (GO #2), a role she assumed upon starting her position in November 2025. The SSD was unsure of the exact departure date of the previous Grievance Officer (GO #1). She stated that residents were informed about the grievance process through admission packets, grievance forms located on each court and outside of the Social Services Office, and locked grievance boxes collected daily. Upon reviewing the admission packets, the SSD noted that they did not include written information identifying the Grievance Officer or providing contact details, and no additional written notification of her role had been provided to residents or their representatives. The SSD also stated that she had not yet introduced herself at Resident Council meetings, believing attendance requires an invitation, but she planned to introduce herself to residents when possible. Upon reviewing the grievance procedure notice posted throughout the facility, the SSD also noted that the contact information should no longer be for the GO #1, not accurately reflecting the change in grievance officers.During the Resident Council meeting on 12/17/25 at 3:08 PM, Residents (#25, #35, #47, #69, #74, #95, #102) stated they did not know who the new GO was. The council reported they were aware the former GO had left in September, but the new GO had not approached the council for an introduction.Record review of Resident Council meeting minutes, dated 9/8/25, revealed complaints regarding missing laundry, with the facility response documented as: .We will try and educate the staff.Record review of Resident Council meeting minutes, dated 10/13/25, revealed the introduction of the new Activities Director and Admissions Director. The minutes also documented discussion of old business related to missing laundry and Certified Nurse Assistants (CNA) clearing call lights and failing to return to residents.Record review of Resident Council meeting minutes dated 11/10/25, revealed discussion of new business noting many newly hired CNAs; there was no mention of a new Grievance Officer. Old business again included missing laundry and call light concerns.Record review of Resident Council meeting minutes, dated 12/8/25 revealed no discussion regarding a new Grievance Officer. Old business continued to include missing laundry and call light concerns.Review of RESIDENT GRIEVANCE FORM, undated, posted on each court's entrance board near a locked wooden box, revealed a structured document that included fields for the date and time of the grievance or concern, the resident's name and room number, and the name of the person completing the form. It provided a section to describe the nature of the grievance, followed by areas for investigation findings and interventions/action taken. The form also included a section for the date follow-up to resolution occurred, with signature lines and dates for the person conducting follow-up (by whom), the administrator, the grievance officer, and the resident. No additional instructions were provided regarding how or where to submit the completed form.Review of the policy and procedure titled Grievance, last revised 3/2015 revealed: .the facility will have a designated Grievance Officer who is responsible for overseeing the grievance process, receiving, investigating, tracking grievances through to their conclusion and maintain the confidentiality of all information associated with grievances.Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance. PROCEDURE: 1. The Social Services Director/Designee should assure that residents and/or their representative(s) receive a review of their rights and responsibilities upon admission. 2. The Activities Director/Designee should complete a grievance form when a global issue is raised at a Resident Council Meeting. 3. The Social Services Director/Designee or ANY staff member should assist concerned resident(s), resident representative(s), other family member(s), or advocate that have issues or concerns to complete a Grievance/Concern Form.Review of the posted document RESIDENT RIGHTS, undated, revealed: Choice, Medical Care, Privacy & Confidentiality, Free from Abuse & Restraint, Visitors & Association, Activities & Work, Personal Possessions, Grievances & Complaints, Financial Affairs, Transfer & Discharge. A detailed document of the above Resident Rights Summary is available from the admission Office or Social Worker.

.Based on record review, interview, and observation the facility failed to ensure sufficient nursing staff to meet residents' needs, (based on a census of 97) as established by the facility assessment (a mandatory, comprehensive evaluation to understand the specific resident population's needs and match them with necessary staffing, equipment, and resources to meet those needs). Specifically:The facility assessment identified minimum staffing requirements for weekends; however, actual staffing schedules showed fewer certified nursing assistants (CNAs), and licensed nurses (LNs) than defined.Residents reported dissatisfaction with care, including delays in call light response times and provision of hygiene.These deficient practices resulted in delays in care and unmet needs for residents and had the potential to negatively impact residents' health, safety, and quality of life.Findings:Review of the Payroll Based Journal (PBJ) Staffing Data Report (a mandatory electronic staffing data submission system created by the Centers for Medicare & Medicaid Services [CMS]) for the fourth quarter (7/1/25 to 9/30/25) revealed: Excessively Low Weekend Staffing was triggered.Review of the facility provided Centennial Post Acute Facility Assessment, updated on 11/25/25, revealed: . The facility is struggling with securing FT [full time] staff for nurses and CNAs. The assessment indicated staffing should include: . 6 nurses on day/eve[[NAME]] shift and minimum of 3 on NOC/night shift.12-15 CNAs on day shift/eve shift and 9-12 on NOC/night shift. 2 restorative aides daily.Review of 12 randomly selected weekend staffing schedules for the fourth quarter (7/1/25-9/30/25) revealed staffing consistently fell below the facility assessment's established levels. Specifically:On 8/9/25, 2 LNs were scheduled, the established minimum was 3.Dayshift, CNAs, the established minimum was 12:On 7/5/25, 10 day shift CNAs were scheduled;On 7/6/25, 11 day shift CNAs were scheduled;On 7/12/25,11 day shift CNAs were scheduled; [NAME] 7/13/25, 9 day shift CNAs were scheduled.Nightshift, CNAs, the established minimum was 9:On 7/5/25, 7 night shift CNAs were scheduled;On 7/6/25, 8 night shift CNAs were scheduled;On 7/13/25,6 night shift CNAs were scheduled; [NAME] 9/6/25, 7 night shift CNAs were scheduled.Restorative Aides (RAs) - established minimum was 2 daily:On 7/5/25, 1 RA was scheduled;On 7/6/25, 0 RAs were scheduled;On 7/12/25,1 RA was scheduled;On 7/13/25,1 RA was scheduled;On 8/9/25,1 RA was scheduled;On 8/10/25,1 RA was scheduled;On 8/23/25,1 RA was scheduled;On 8/24/25,1 RA was scheduled;On 9/6/25, 1 RA was scheduled;On 9/7/25, 1 RA was scheduled;On 9/27/25, 0 RAs were scheduled; [NAME] 9/28/25, 1 RA was scheduled.Resident #48Record review on 12/14-24/25 revealed Resident #48 was admitted to the facility with diagnoses that included quadriplegia (paralysis of all four limbs). The resident fully relied on staff to dress and get the resident up and out of bed.During an interview and concurrent observation on 12/14/25 at 11:11 AM, Resident #48 stated that he/she had called for staff around 9:00 a.m. to assist with getting out of bed and was still waiting. The resident remained in bed with a Hoyer lift positioned beside the bed and the wheelchair near the doorway. The resident stated that he/she had requested to be out of bed by 9:30 a.m. and reported that long waits had been common since admission, expressing concern that the facility seemed very short-staffed. Staff assisted Resident #48 out of bed at 11:23 a.m., a total wait time of 2 hours and 23 minutes.During an interview on 12/18/25 at 4:15PM CNA #2 stated residents who are wanting to get out of bed would have to wait longer if other residents need to use the restroom. CNA #2 stated there wasn't enough staff to be everywhere at the same time. Sometimes there would only be one CNA assigned to a court and there would be another staff assigned to float between several courts.Resident #77During an interview and concurrent observation on 12/14/25 at 9:19 AM, Resident #77's room had an odor of urine. The resident was in bed with an open urinal about one-quarter full hanging from the bed rail. When asked how long it had been there, the resident said about an hour. The resident explained staff were busy and would empty it eventually, noting they were always helpful but short-staffed.Further observation revealed Resident #77 was on enhanced barrier precautions (EBP, an infection control measure that requires staff to wear gowns and gloves during high-contact care activities for residents with wounds, indwelling devices, or multidrug-resistant organisms, to prevent the spread of infections). It was noted there were no gowns available to use for Resident #77's room.During an interview on 12/14/25 at 10:02 AM, when asked about EBP gowns for Resident #77, CNA #5 stated the night shift must have used them up and didn't have time to replace them. The CNA further stated the urinals would be taken care of when they rounded on the resident, however, if the CNA was helping other residents, it can be difficult to round regularly.Resident CouncilDuring an interview on 12/17/25 at 3:00 PM, with those who attended Resident Council meetings, Resident #95 reported long delays in staff response when residents needed help. They stated on weekends, only one CNA was assigned to a unit while another floated between units, causing further delays if both staff were occupied or if the float staff was in another unit. Resident #95 stated, There's just not enough people to help us. Resident #25 added that CNAs sometimes forgot to return after answering call lights. All seven attendees (Resident #'s 25, 35, 47, 69, 74, 95, and 102) agreed response times were slow due to not enough staff. When asked how the facility responded to the Resident Council's concern regarding staffing issues, the group stated they were told that the staff was being educated and that the facility was working on staffing, however, they did not see any improvement.Review of the Resident Council Meeting Minutes revealed:Minutes from the 8/18/25 meeting: . Nursing: Concern: CNA's are leaving pee containers in rooms and they are starting to smell. Response from Manager: Nursing Staff will be educated. ;Minutes from the 9/8/25 meeting: . Nursing: CNA's are clearing call lights and telling residents they'll get back to them and forgetting to get back with them. Concern Response from Manager: Nursing staff will be educated. ;Minutes from the 10/13/25 meeting: . old business. CNA's are clearing call lights and telling residents they'll get back to them and forgetting to get back with them. There were no facility responses recorded in the minutes regarding this matter. ;Minutes from the 11/10/25: . old business. CNA's call lights are not being answered in a timely manner. Nursing: Concern: Need more staff. Response from Manager: We are working on it. ;Minutes from the 12/8/25 meeting: . old business. CNA's call lights are not being answered in a timely manner. There were no facility responses recorded in the minutes regarding this matter.During an interview on 12/17/25 at 1:07 PM, the Administrator stated he was not aware of the low weekend staffing, and that the staffing reports generated from their party vendor showed the facility was meeting their Patient Per Day (PPD) goals, which were based on the nursing union and California standards.Further review of the facility provided Centennial Post Acute Facility Assessment, updated on 11/25/25, revealed: . The facility assessment should drive staffing decisions. to carry out facility functions.

.Based on observation, interview, and record review, the facility failed to develop, implement, and maintain a system to ensure licensed nursing staff were competent and practiced within their authorized scope of practice in accordance with the State Nurse Practice Act and professional standards. This deficient practice occurred for 4 of 6 licensed nurses reviewed and placed all residents (based on a census of 97) at risk for inaccurate assessment, inappropriate care planning, and delayed identification of changes in condition FindingsRecord review of Resident Care Manager [RCM] (LVN/LPN[Licensed vocational nurse/licensed practical nurse]) dated 8/2025, revealed: The Resident Care Manager (LVN/LPN) is responsible for overseeing the care and well-being of assigned residents, ensuring that care plans are properly implemented, and that residents receive high-quality, person-centered care in accordance with state and federal regulations. The Resident Care Manager serves as a liaison between residents, families, healthcare providers, and the interdisciplinary team. Essential duties: Care coordination & oversight: Develop, update, and monitor individualized resident care plans in collaboration with the interdisciplinary team. Ensure that care plans reflect the physical, emotional, and psychosocial needs of each resident. Conduct routine assessments and communicate changes in condition to the physician and appropriate staff. Supervise and support CNAs [Certified Nurse Assistant] and other nursing staff in the delivery of daily care. Provide training, guidance, and feedback to staff to ensure adherence to care standards and policies . Complete MDS [Minimun Data Set - a federally required assessment] information on residents as required Subsequent to Human Resources providing the above job description, facility administration provided surveyors with a second version of the RCM (LVN/LPN) job description, dated 9/2025, which contained the same duties and role expectations, except the terms develop and update were removed.Record review of the Resident Care Manager (RN[Registered Nurse]) job description, dated 9/2025, revealed the position contained the same title, role expectations, duties, and essential functions as the RCM (LVN/LPN) position, including responsibility for developing, updating, and monitoring resident care plans; conducting routine assessments; communicating changes in condition to physicians; supervising nursing staff; and completing MDS information, indicating the facility assigned identical job responsibilities to RN and LPN Resident Care Managers.Record review of facility staffing records and the current organizational chart , provided by the facility's Human Resources (HR) on 12/17/25, revealed the facility employed 6 Resident Care Managers (RCMs) at the time of survey, of which four were Licensed Practical Nurses (LPNs) and two were Registered Nurses (RNs) assigned to the RCM role; further review indicated all six RCMs shared equal responsibilities, identical essential duties, and functioned independently from one another in carrying out the role.Record review of Director of Staff Development (DSD) job description dated 2/2024, revealed: The Director of Staff Development (DSD) is responsible to plan and implement facility orientation, job skills training, in-service education and a Certification Training Program (if applicable) for the nursing assistants as required by regulations. Work with the Director of Nursing (DON) and Administrator to ensure that the highest degree of quality care is maintained at all times. The DSD also provides direct resident/patient care. Essential duties: Coordinate and participate in the recruiting and hiring of staff . Plan, conduct and document and/or coordinate all required Fire/Internal Disasters and External Mass Casualty Drills Utilize information from Licensing and Certification Surveys, Employee Evaluations, Facility Rounds, and recommendations from the Administrator and department heads to identify education needs. Organize In-Service education program for staff including assessment, planning, implementation and evaluation of education provided. Prepare and post a monthly In-Service calendar. Maintain records of In-Services as required by regulations. Plan and conduct meaningful In-Service education programs according to requirements for nursing personnel and all facility staff to assure competency in and new skills, and as directed by Administrator. Make rounds and observe delivery of patient care. Coordinate infection control surveillance program. Supervise staff, including taking or assisting with appropriate disciplinary measures. Complete all forms required by the Department of Health in relation to the In-Service and education programs . Provide direct resident/patient care. Assist with the overall supervision of and management of the staff.Record review of facility staffing records and the current organizational chart revealed the facility employed one Licensed Practical Nurse (LPN #1) who was assigned and functioning in the roles of DSD, Infection Control Preventionist and RCM. Further review confirmed the individual was not a Registered Nurse (RN) and was licensed through the State of Alaska to practice as an LPN.During an interview on 12/18/25 at 12:00 PM, RCM #2 stated he/she was responsible for completing treatment orders, wound care coordination, chart reviews, risk management activities, and updating resident plans of care. RCM #2 confirmed he/she independently developed plans of care as needed, stating he/she could go in and update them and was able to create new care plan focuses, goals, and interventions on their own. When asked if these care plan updates required RN review or co-signature, RCM #2 stated there was no sign-off required, explaining he/she did not sign care plans but independently entered updates without RN approval. RCM #2 further indicated that while the DON generally supervised the RCM role, the DON did not routinely review or approve the care plan updates, and he/she performed these duties independently in his/her role as RCM.During an interview on 12/18/25 at 8:30 AM, RN #1 stated he/she had recently completed orientation and indicated he/she did not receive separate classroom training or formal competency validation beyond unit-based orientation. RN #1 was unable to initially identify the nurse educator or infection preventionist but acknowledged that guidance related to training, competencies, and clinical practice was obtained through facility leadership.During an interview on 12/18/25 at 8:40 AM, RN #2 stated that LPN #1 functioned as the facility's primary nurse educator and infection prevention resource and was responsible for staff development, competency guidance, and infection control oversight. RN #2 further stated that LPN #1 assisted nursing staff with resident assessments, care planning development, and clinical decision-making, and was the individual he/she would consult for questions related to competencies, assessments, treatment plans, and changes in resident condition. During an interview on 12/18/25 at 8:50 AM, RN #3 stated that although there was some confusion regarding official titles, LPN #1 functioned as a key clinical resource for resident assessments, care plan development, and coordination of care, and that nursing staff felt comfortable seeking guidance from LPN #1 for assessment findings, care plan interventions, risk assessments, and competency-related questions. During an interview on 12/18/25 at 9:03 AM, RN #4 stated he/she routinely sought guidance from LPN #1 regarding resident assessments and care planning and identified LPN #1 as the primary point of contact for competency-related questions and clinical guidance. Collectively, the interviews indicated that RN staff relied on LPN #1 for guidance and support related to assessments, care planning, and nursing competencies, demonstrating that LPN #1 functioned in a role requiring RN-level clinical oversight and decision-making.During an interview on 12/17/25 at 4:30 PM, LPN #1 stated that in the role of RCM, he/she was able to enter and edit resident plans of care, explaining that his/her name appeared on care plans on its own because he/she updated them; LPN #1 further stated he/she had also assumed the role of Staff Development/Educator within the past few months and was responsible for conducting staff orientation, coordinating and providing in-service education, arranging external training programs, scheduling student experiences, and providing education in response to grievances or identified needs. LPN #1 reported he/she spent most of the scheduled time performing nurse management and administrative duties, and although he/she occasionally assisted on the floor, this rotated among nurse managers. LPN #1 stated he/she was frequently sought out to assist with blood draws, wound care, safety planning, infection control coordination, and data analysis related to education and infection prevention, and that nursing staff consulted him/her when making decisions about changes in resident condition and potential hospital transfers, at which time he/she would advise staff and contact or direct contact with the physician as appropriate. LPN #1 described functions he/she performed independently, including blood draws and wound dressings, stating he/she could not administer IV antibiotics or fluids without certification, could not stage wounds, and could not administer blood products. LPN #1 stated he/she routinely reviewed resident diagnoses, medications, treatments, and equipment needs when updating plans of care and that RN review occurred during new admissions and periodic reviews.During an interview on 12/18/25 at 2:30 PM, LPN #1 stated that in the role of Infection Preventionist (IP), he/she independently coordinated and carried out the core duties of the infection control program, including surveillance, assessment, data analysis, provider notification, and follow-up. LPN #1 explained that when a resident was started on antibiotics, he/she independently completed an infection evaluation, assessed reported and observed symptoms (such as fever, confusion, skin changes, or urinary symptoms), documented findings in the electronic system, and determined whether the information triggered a potential infection case. LPN #1 stated that he/she monitored residents 48-72 hours after antibiotic initiation to assess symptom improvement or persistence and contacted the physician regarding continuation, modification, or discontinuation of antibiotics based on findings. LPN #1 further stated that he/she analyzed infection data using automated reports and trend tools to identify infection patterns by unit or resident population, and used this analysis to determine the need for staff education, audits, or targeted interventions. LPN #1 stated that while infection control committee meetings included the Director of Nursing, RCMs, and other interdisciplinary members, he/she independently prepared reports, presented findings, and initiated follow-up actions. LPN #1 acknowledged consulting a regional infection prevention resource for guidance with the annual infection risk assessment due to being newly transitioned into the role; however, he/she otherwise described performing day-to-day infection surveillance, assessment, decision-making, and coordination of infection control activities independently, including staff exposure tracking, outbreak reporting, and communication with public health authorities.Review of the LPN Scope of Practice Advisory Opinion - Alaska Board of Nursing, 7/2016, revealed: The RN and LPN should recognize the level and depth of knowledge and decision making that various nursing activities demand. This accountability and responsibility exists regardless of directives, policies, protocols or staffing patterns implemented by employing agencies. The advisory opinion further states that When an RN is directing LPN practice, it is the RN who establishes the nursing regimen and communicates the nursing practice needs of the client. Highly complex and variable situations are most appropriately placed within the RN scope of practice and outside the scope of the LPN.This document further reveals that LPN practice is not independent, stating that the LPN contributes to the planning, implementation and evaluation of nursing care but does not independently develop or make changes to a plan of nursing care, and must consult with the RN or LIP [Licensed Independent Provider] to seek guidance in providing client care. The document explicitly identifies activities NOT appropriate for the LPN to perform, including 1. Comprehensive assessments of a client who has been admitted to an institution or unit, 2. Assimilation and analysis of objective and subjective data to formulate the plan of care,.6. Administer IV push medications other than saline to flush an intermittent infusion device. 7. Phlebotomy unless additional training and demonstration of competency has been documented.12. Administration of chemotherapy drugs.14. flushing [NAME] catheters or PICC [Peripherally Inserted Central Catheter] lines, . 16. Identify unlabeled medications.17. Complete physicals.18. Work independently.19. Triage patients.Review of Alaska Administrative Code12 AAC 44.137, Licensed Practical Nurse Scope of Practice, accessed at https://nalpn.org/wp-content/uploads/2023/06/NURSE-PRACTICE-STANDARDS05.30.2023.pdf states that The standards of practice set out in the Nurse Practice Standards for the Licensed Practical & Licensed Vocational Nurse, May 30, 2023 edition, of the National Association of Licensed Practical Nurses are adopted by reference as the authorized scope of practice for a practical nurse licensed under this chapter. The adopted standards establish that Licensed Practical Nurses (LPNs) practice under direction, contribute to-but do not independently perform-comprehensive assessments, nursing care plan development, or independent clinical decision-making

.Based on observation, interview, and record review, the facility failed to ensure food items were prepared, stored, and labeled in accordance with professional standards and/or manufacturer instructions for food service safety for 87 residents (#1, #2, #3, #5, #8, #9, #10, #11, #12, #13, #15, #17, #18, #19, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #33, #35, #36, #37, #38, #39, #40, #41, #43, #44, #45, #47, #48, #50, #51, #52, #53, #54, #55, #56, #58, #59, #60, #61, #62, #63, #64, #65, #67, #68, #69, #70, #71, #73, #74, #75, #76, #77, #78, #79, #80, #82, #83, #84, #85, #87, #88, #89, #90, #92, #94, #95, #96, #97, #102, #103, #104, #105, #106, #107, #108, #109) out of 97 residents that received meals from the kitchen.Specifically:1) the dry storage and kitchen area contained expired food items;2) sanitizing solution used was improperly diluted and produced out-of-range results; and3) hair restraints were improperly used.These failed practices placed the residents who received meals from the kitchen, at risk of receiving contaminated food and/or contracting foodborne illnesses .Findings:Expired ItemsDuring the initial kitchen tour on 12/14/25 at 8:15 AM, the following items were observed to be expired in the dry storage and kitchen area:4 boxes- Gold Medal Carrot Cake Mix 5 lb. (pound), expired 7/6/24;8 bags- Ruffles Original Potato Chip Foodservice package 16 oz. (ounce), expired 12/2/25;1 bottle- [NAME] [NAME] Style Cooking Wine 1 gallon, expired 11/26/24;1 bottle- [NAME] Fine Burgundy Cooking Wine 1 gallon, with faded and illegible expiration date;and 1 container- Monarch Baking Powder 5 lb. container, with a faded and illegible expiration date.During an interview on 12/14/25 at 9:20 AM, the Food and Nutrition Manager (FNM) stated food items were audited weekly in the pantry and expired items were to be discarded immediately to prevent further use. If an item was damaged, including items with illegible expiration dates, then the expectation would be to discard the items to prevent further consumption.Record review of the facility provided policy, Food Receiving and Storage, last revised 11/2022, revealed: 3. Dry foods are stored in buns are removed from original packaging, labeled and dated ( use by date). Such foods are rotated using a first in- first out system. 7.Foods are labeled, dated and monitored so they are used by their use-by date. or discarded.Sanitizing SolutionDuring an observation on 12/16/25 at 9:58 AM, Dietary Aide (DA) #3 was by the ice machine in the kitchen area with a rag and a red sanitizing bucket. DA #3 placed the rag inside the red sanitizing bucket, then used the rag to wipe the outer surface of the ice machine. DA #3 tested the red sanitizing bucket with the Ecolab test strips which revealed a reading of a light green color. DA #3 stated that the light green color would be in the recommended range and showed the Ecolab canister's color reference range. He/she further stated that the bucket being used to clean the ice machine was made approximately 20 minutes ago.During an interview on 12/16/25 at 10:17 AM, DA #3 stated the solution in the red bucket was called Ecolab Sink & Surface Sanitizer and was used to clean the surfaces in the kitchen. DA #3 demonstrated the process by going to the janitor closet and poured an unmeasured amount by the attached hose of the Ecolab Sink & Surface Sanitizer dispenser. DA #3 then went to the sink across the janitor closet and placed an unmeasured amount of hot water into the red sanitizing bucket. He/she then tested this new solution with a test strip and received the same reading of a light green color.During a follow-up interview on 12/16/25 at 10:30 AM, DA #3 stated, he/she clarified with the FNM what the recommended color range reading for the sanitizer test strips. DA #3 further stated he/she initially thought the light green color was within the recommended range however the correct reading indicated the appropriate range was dark green or teal.During an observation on 12/16/25 at 10:58 AM, FNM and DA #1 tested the red sanitizing bucket in the mini kitchen by the dining area where residents come out to eat their meals. DA #1 stated this bucket was used to clean the surfaces in the dining area. DA #1 tested the solution and received the test strip result indicated a light green color.During an interview on 12/16/25 at 11:00 AM, DA #1 stated he/she placed the Ecolab Sink & Surface Sanitizer solution in the red sanitizing bucket and mixed it with hot water. The FNM then told DA #1 to not further dilute the solution as it would not yield accurate results. DA #1 remade the solution as-is and received a teal color when he/she tested the second solution.Review of Ecolab Sink & Surface Cleaner Sanitizer FAQ [Frequently Asked Questions], accessed at https://www.ecolab.com/offerings/sink-surface-cleaner-sanitizer, dated 12/29/25, revealed: .What are the active ingredients? Dodecylbenzenesulfonic Acid (DDBSA, 272 - 700 ppm [parts per million]) and Lactic Acid (704 - 1875 ppm) . Are the ingredients approved for food-contact surface sanitizing.all ingredients in Sink & Surface Cleaner Sanitizer have been reviewed.for use in food-contact surface sanitizing solutions and are approved for use on food-contact surfaces.Review of the Ecolab Sink and Sanitizer poster, copyright dated 2020, .Sanitization Range Testing. Testing should be at or above room temperature 65 F [Fahrenheit]. Withdraw a test strip from a canister. Dip test strip for 5 seconds in test solution. Shake off excess solution.Compare colors after 10 seconds with colors on the test strip canister to determine concentration (oz[ounce]/gal[gallon]), ALWAYS COMPARE AGAINST CANISTER SCALE. Testing solution should be between 272-700 ppm DDBSA and [PHONE NUMBER] ppm Lactic Acid.Review on 12/16/25 of Sink & Surface Cleaner Sanitizer Test Strips, Item Number: 20318-01-11, revealed instructions: .Immerse the test strip in sample for 5 seconds. Excess sample should be shaken off of strip.Evaluate the color 10 seconds after removing the test strip from the sample.Match the center of the test strip pad to the color chart to determine concentration. Further review of the instructions indicated a blue box where the color of the test strip should fall within that is approved as an active range of Sink & Surface Cleaner Sanitizer. The blue box contained a dark green (700 ppm DDBSA, 1875 ppm Lactic Acid) and teal color range (272 DDBSA, 704 ppm Lactic Acid). The light green and yellow green color range was noted to be below the approved range.During an interview on 12/16/25 at 11:05 AM, the FNM stated the Ecolab Sink & Surface Sanitizer coming out of the dispenser was a pre-mixed solution that was already diluted as serviced by the manufacturer and did not indicate further additional dilution as it could prevent the solution from properly cleaning the surfaces as it is intended to do.Review of the facility-provided Job Description of Dietary Aide, prepared 2/2024, revealed: .Essential Duties. To leave the kitchen in a clean and sanitary manner. clean work surfaces and refrigerators.Review of the facility provided policy, Sanitization, dated 2023, revealed, .2. All surfaces, equipment, countertops, shelving, dishware and utensils are kept clean and maintained in good condition.3. All equipment, food contact surfaces, dishware, and utensils are properly cleaned and sanitized through heat or chemical sanitization.Hair RestraintsDuring a continuous observation on 12/16/25 at 11:17 AM-11:38 AM, DA #1 was at the other side of the steam table in the long-term care (LTC) kitchen serving the residents in the dining room as the food was being plated. DA #1 was observed to have no hairnet for the duration of this observation. DA #1 put on a hairnet at 11:39 AM.During a continuous observation on 12/16/25 at 11:17 AM-11:45 AM, DA #2 was at the other side of the steam table in the LTC kitchen serving the residents in the dining room as the food was being plated. DA #2 was observed to have approximately 1 inch width strands of hair sticking out from the left and right front side of the hairnet and strands of hair from the back side of the hairnet.During an interview on 12/16/25 at 1:08 PM, the FNM stated hair restraints such as a hairnet or a cap should cover the entirety of the worker's head, as loose hair would not be acceptable when working with food. FNM stated that there was no policy regarding hairnets but provided a handbook that was used as a curriculum for kitchen staff training.Review of the facility-provided document titled, Foodservice Employee Safety Handbook, copyright dated 2006, revealed: .Personal Hygiene. Most foodservice jobs require you to wear some type of protective equipment (PPE). This includes items such as hairnets, beard covers. PPE must be worn in a way that protects against the contamination of food and equipment. Wear hairnets, beard covers, caps, and other hair restraints that appropriately covers all visible hair. Loose hair can fall into food. Further review of the handbook revealed: Harmful bacteria can be found on your skin and in your hair can easily be transferred to food. Again, these bacteria can make people sick. It is your responsibility to wear a hair restraint effectively. Make sure your hair is completely under your hair restraint.

.Based on interview, observation, and record review, the facility failed to ensure a safe, comfortable and homelike environment was provided for all residents (based on a census of 97). Specifically, the facility failed to ensure: 1) the elevator flooring was properly installed; 2) windows were functional to keep wind and cold from entering resident bedrooms; and 3) room temperature level was within 71 degrees Fahrenheit (F) to 81 degrees F. These failed practices denied all residents the right to have a safe and comfortable homelike environment Findings: Elevator floorDuring random observations from 12/14-18/25, the elevator floor was observed to be composed of approximately 6-inch square sections of linoleum like material curling around the edges. Two of these sections were lifting and had been patched with sections of what appeared to be duct tape, though the sections remained uneven and were not fully adhered to the floor.During an interview on 12/18/25 at 4:11 PM, the Director of Life Safety and Maintenance (DLSM) stated that he had direct oversight of the elevator. The DLSM reported that the elevator floor contained loose pieces, which posed a potential hazard to residents. The DLSM further stated that he planned to purchase a one-piece, medical-grade flooring material to replace the existing flooring rather than continuing repairs using smaller pieces. The DLSM was unable to identify the specific flooring material that was deteriorating. Windows and Resident Room TemperatureDuring an interview on 12/14/25 at 10:22 AM, Resident #68 stated: It's been cold in this room since November [2025]. I have my windows taped up because there's a draft. My roommate's window also has the same issues. The furnace is not really working that well.During an interview on 12/14/25 at 11:31 AM, Resident #1 stated it was cold in here (referring to the bedroom) because the furnace was old. During an interview on 12/14/25 at 11:45 AM, Resident #35 stated, I get really cold easily. It's an old building. My windows are covered with pillows and a blanket to help from the room getting cold, especially since it's been windy. I have a space heater.During an interview and observation on 12/15/25 at 8:54 AM, Resident #40's Resident Representative (RR) stated that Resident #40 complained of his/her room being constantly cold in the winter. An observation of the Resident #40's window revealed it was encircled with multiple layers of black tape, creating a makeshift wind barrier. Further observation revealed three folded blankets placed at the base of Resident #40's window. Resident #40's RR stated that the facility used the blankets to block a cold draft which would enter Resident #40's room through the window, however the RR stated that the draft could still be felt despite this intervention.During an interview on 12/17/25 at 1:48 PM Certified Nursing Assistant (CNA) #1, stated when the residents would complain of their room being cold, he/she would assess the resident first then provide more blankets if it was cold. Then, report the issue to the Maintenance Department through TELS [the facility's maintenance reporting system].During an interview on 12/17/25 at 2:05 PM, the DLSM stated it was difficult to ensure that the temperature of the room was maintained at a comfortable level because of temperature changes. Whether it is cold or hot, it would take three days to bring the temperature to a comfortable level. The DLSM stated the maintenance staff had been checking the residents' room temperature weekly. The DLSM stated they didn't have a policy for checking the room temperature.During the same interview, the DLSM further stated that if there were residents' complaints about their room temperature, the staff would report to the DLSM through TELS system. The staff could also report any work order through band app (facility's messaging system), radio, his phone direct line and cellphone. The DLSM stated the maintenance department would response immediately or within 15 minutes even on off hours. The facility would provide heater/fan, and blankets according to residents' needs. When asked if there was a thermostat in the residents' room, he stated he didn't know.During the same interview, the DLSM stated the facility's plan was to replace the boiler in May 2026 and replace 50 windows to cut the drafting. DLSM further stated, comfort is very important to us.Review of the facility's Director of Life Safety and Maintenance room temperature reports, dated January to December 2025, revealed the room temperature standard at Centennial Post Acute was .71-81 degrees Fahrenheit per regulations. temperatures are taken weekly at two rooms per court. Temperatures are taken using an infrared temperature sensor at 3 wall locations in the room, with the average stated in the report.Review of the facility's maintenance department Work Orders, dated 12/1-17/25, revealed:- #11764 two residents complaining of their rooms being too cold that they can't sleep;- #11775 draft from window, could we get it taped please;- #11778 window is letting in air;- #11759 window blew open won't shut;- #11762 Resident stating his/her room is cold.- #11753 heater needed;- #11734 complaining its cold; and- #11708 window leaking.An observation on 12/18/25, between 9:08 AM to 9:25 AM, of random room temperature checks with the DLSM who took three readings of the room temperature using an infrared sensor, revealed two out of eight rooms checked, had the following average room temperature readings of:- room [ROOM NUMBER] - 67.7 degrees F and- room [ROOM NUMBER] - 69.3 degrees F.An observation on 12/18/25 at 2:00 PM, of the Birch Court rooms revealed room [ROOM NUMBER]'s window was sealed with duct tape.An observation on 12/18/25 at 2:14 PM, of the [NAME] Court rooms revealed there were six rooms where the windows were sealed with duct tape: Rooms 501, 502, 506B, 508, 509, and 510B.An observation on 12/18/25 at 2:36 PM, of [NAME] Court rooms revealed room [ROOM NUMBER] had towels around the base of the window.An observation on 12/18/25 at 2:40 PM, of Cedar Court rooms revealed eight rooms where windows were sealed with duct tape: Rooms 202, 204, 206B, 207, 210A, 210B, 211 (also had blankets around the base of the window), and 212.An observation on 12/18/25 at 3:01 PM, of [NAME] Court rooms revealed five rooms where windows were sealed with duct tape: Rooms 301, 303, 305A, 307, and 310A. room [ROOM NUMBER] had blankets at the base of the window.An observation on 12/18/25 at 3:11 PM, of Spruce Court rooms revealed 7 rooms where windows were sealed with duct tape: Rooms 103, 105, 106 (also had blankets at the base of the window), 108, 109, 111, and 112 (also had blankets at the base of the window). Common Area TemperatureRandom observations from 12/14-18/25 revealed group activities for all residents were held in the common area.Review of Centennial Activity Calendar, dated 12/16/25, revealed Bingo was held in the common area.Random observation on 12/16/25 revealed Bingo was held in the common area.Review of Centennial Activity Calendar, dated 12/17/25 revealed Craft Circle with Kevin and [NAME] sings were held in the common area.An observation on 12/18/25 at 9:25 AM, revealed the common area on the first floor had an average temperature reading of 66.6 degrees F.During an interview on 12/18/25 at 9:25 AM, DLSM stated the maintenance staff were checking the room temperature in rooms [ROOM NUMBERS] on each court. However, the room temperature in the common area on the first floor was not included in their weekly room temperature check.Review of the Quality Assurance and Performance Improvement (QAPI) minutes of the meeting, dated 10/2025, revealed an email from the Director of Nursing (DON) .QAPI Maintenance.boiler replacement is on track for Spring. Review of the facility's policy Maintenance Service, dated 2001, revealed: .The maintenance department is responsible for maintaining the buildings.maintaining the heat/cooling system.in good working order.

. Based on record review and interview, the facility failed to ensure pharmacy services met professional standards of practice and facility policy for the accountability and documentation of controlled substances. Specifically, the facility failed to ensure licensed nursing staff consistently completed required shift to shift narcotic count documentation, as evidenced by repeated missing required signatures in narcotic tracking books over a three-month period. This failed practice resulted in incomplete controlled substance records and compromised accountability for narcotic medications, placing 50 out of 97 residents (census) at risk for medication diversion and administration errors.Findings: During an interview on 12/18/25 at 10:07 AM, Licensed Nurse (LN) #3 stated that during shift change, both the incoming and outgoing nurses were required to conduct a narcotic count together. LN #3 further stated this process was documented on the Shift Audit Record, located in the narcotic tracking books and required four total signatures: - Two signatures in the section labeled Signature of Nurse Leaving Shift, and - Two signatures in the section labeled Signature of Nurse Coming on Shift. Record review on 12/14-24/25 revealed that 3 out of 3 reviewed narcotic logbooks ([NAME] Court, Cedar Court, and Spruce Court) for the period October through December 2025 contained incomplete narcotic count documentation, evidenced by missing required signatures on the Shift Audit Record on the following days: [NAME] Court October 2025: 10/10, 10/19, 10/20, 10/22 November 2025: 11/1, 11/2, 11/3, 11/11, 11/12, 11/14, 11/15, 11/16, 11/19, 11/20, 11/24, 11/26, 11/27, 11/28, 11/29, 11/30 December 2025: 12/4, 12/5, 12/11, 12/13 Cedar Court October 2025: 10/25, 10/26, 10/30 November 2025: 11/4, 11/17, 11/22, 11/23 December 2025: 12/1, 12/2, 12/9 Spruce Court October 2025: 10/1, 10/2, 10/5, 10/6, 10/8, 10/9, 10/10, 10/12, 10/13, 10/14, 10/18, 10/19, 10/20, 10/22, 10/27, 10/28, 10/31 November 2025: 11/2, 11/4, 11/6, 11/9, 11/10, 11/11, 11/13, 11/17, 11/18, 11/20, 11/21, 11/23, 11/24, 11/25, 11/26, 11/27, 11/28, 11/30 December 2025: 12/1, 12/3, 12/4, 12/5, 12/7, 12/9, 12/10, 12/11, 12/17 During an interview on 12/22/25 at 9:30 AM with the PharMerica (Centennial's contracted pharmacy services provider) Manager , when asked about the narcotic tracking books, she stated that PharMerica provided the narcotic tracking books, however it was the responsibility of the facility to handle all tracking and documentation in the books. Review of the facility provided Pharmacy Services Agreement, signed on 7/29/24, revealed: .Obligations of the client [Centennial]. Client shall, or require the Customer to, as the case may be . Store and handle all Medications in accordance with Applicable Law . Upon Client's request, Pharmacy shall provide the following and any other additional consulting services . Perform random quarterly audits of medication carts or audit medication storage areas for controlled and non-controlled medications . Perform on-site audits of Medical Records, contents of medication carts and/or Resident treatment charts, if provided by pharmacy. During an interview on 12/24/25 at 1:00 PM with the Director of Nursing (DON) , she stated that counting narcotics from each unit's medication cart was to occur each shift. She further stated: We have had a lot of turnover and maybe I just need to re-implant that policy and procedure to everyone. The DON further stated that the pharmacy came to the facility once a month to perform audits of narcotic tracking books, medication carts, and medication rooms, however she was not made aware of missed signatures in the narcotic tracking books. Review of the facility provided policy Pharmacy Services Overview, undated, revealed: .Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice . The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including (but not limited to) . (1) Receipt, labeling and storage of medications; (2) Reconciliation of medications from the pharmacy; (3) Control of medications from point of receipt to secured storage areas; (4) Facility staff roles and responsibilities during the receipt and storage of medication . d. Disposition of medications . f. Documentation of processes, as applicable.

.Based on record review and interview, the facility failed to review, revise, and implement comprehensive, person-centered care plans in accordance with resident needs. Specifically, the facility failed to:1. ensure residents or resident representatives participated in and that the facility conducted and documented required quarterly interdisciplinary care plan reviews for 3 residents (Residents #1, #3, and #64) of 20 sampled residents; and2. revise the comprehensive care plan to reflect a significant change in condition for 1 closed record (Resident #99), including the addition of appropriate interventions following the onset of a seizure disorder and initiation of anticonvulsant therapy.These failed practices demonstrated a pattern of deficient care planning practices and denied residents and resident representatives the opportunity to participate in care planning, make preferences and decisions known, and receive care and interventions aligned with current medical conditions and assessed needs Findings: Care ConferenceResident #1Record review on 12/14-24/25, revealed Resident #1 was admitted to the facility with diagnoses that included cervical disc disorder with myelopathy (impaired function of the spinal cord caused by degenerative changes of the discs and facets joint in the neck), intestinal obstruction, protein-calorie malnutrition, chronic respiratory failure and diabetes mellitus (chronic disease characterized by high levels of sugar in the blood).During an interview on 12/14/25 at 11:38 AM, when asked if he/she participated in a care planning meeting, Resident #1 stated he/she could not remember when the last time he/she participated in the care planning meeting.Record review of Resident #1's electronic health record (EHR) on 12/14-24/25, revealed, two admission assessment IDT (Interdisciplinary Team) conferences dated 8/12/25 and 8/28/25.Further review revealed there were no other documented IDT quarterly care conferences.During an interview on 12/16/25 at 12:43 PM, Resident Care Manager (RCM) #1 stated care planning meetings should have been conducted quarterly through an IDT care conference which were organized by Social Services (SS) staff, however, because the facility had no SS Director (SSD) since 9/2025, the SS Assistant (SSA) was the only one covering the care conferences. RCM #1 further stated there should have been one IDT meeting with Resident #1 on 11/2025.During an interview on 12/17/25 at 11:01 AM, the SSD confirmed there were no subsequent IDT care conferences conducted for Resident #1 after 8/2025. Resident #3Record review on 12/14-24/25, revealed Resident #3 was admitted to the facility with diagnoses that included amputation involving multiple toes and fingers, acquired absence of right and left fingers, type 2 diabetes mellitus and chronic obstructive pulmonary disease.During an interview on 12/14/25 at 1:14 PM, when asked if Resident #3 participated in his/her care planning meeting, Resident #3 stated he/she had not.During an interview on 12/16/25 at 12:43 PM, RCM #1stated there was no care conferences conducted for Resident #3, however, the SSA had talked to the resident about his/her discharge plan.During an interview on 12/17/25 at 11:01 AM, SSD stated there were no quarterly IDT care conferences conducted for Resident #3 within the past year. Resident #64Record review on 12/14-24/25, revealed Resident #64 was admitted to the facility with diagnoses that included sepsis (severe immune response to infection), acute cholecystitis (inflammation of the gallbladder), benign prostatic hyperplasia (enlarged prostate) with urinary tract symptoms.Record review on 12/14-24/25 revealed an IDT conference was conducted for Resident #64 on 7/1/25. Further review revealed there were no other documented IDT quarterly care conferences.During an interview on 12/17/25 at 11:01 AM, the SSD confirmed no subsequent IDT care conferences were conducted for Resident #64 after 7/1/25.During an interview on 12/17/25 at 11:01 AM, SSD and SSA stated quarterly IDT care conferences should have been conducted every three months. The SSD stated the facility recognized the issue and would ensure care conferences would be completed in the future.Review of the facility's Care Conference policy and procedure, last revised 2/2025, revealed: . It is the policy of this center to hold care conference to review care plans developed and discuss current care plan goals and interventions with the resident and /or resident representative. Procedure: 1) A care conference will be scheduled with the resident and/or representative to review care plan goals and interventions. Care conferences will be held upon admission, quarterly and with any significant change in condition in conjunction with MDS [Minimum Data Set] Assessment. The Initial Care Management Meeting does not replace the required care conference to review the Comprehensive Care Plan. Revision of Comprehensive Care PlanResident #99Record review from 12/14-24/25 revealed Resident #99 was admitted to the facility with diagnoses that included Parkison's disease (movement disorder of the nervous system), unspecified atrial fibrillation (irregular, rapid heart rhythm which can result to poor blood flow in the heart's lower chambers), type 2 diabetes mellitus without complications, and unspecified bipolar disorder (mood disorder characterized by significant mood fluctuations).Further review of the medical record revealed no seizure disorder diagnosis.Review of Resident #99's LTC (Long Term Care) Progress Notes, dated 11/10/25 revealed, .CNA [Certified Nursing Assistant] saw resident shaking, like having seizure during their rounds. Priority nurse was called. LN [Licensed Nurse] assessed resident, not shaking, but is unresponsive to verbal and painful stimuli. Vitals were taken: 194/80 [mmHg- millimeter of mercury, standard unit used for pressure measurement], pulse: 102. [temperature] 97.4 [Fahrenheit], 20 [respiratory rate], 98% on room air, BS [blood sugar]: 165. Called 911, paramedics came and assessed vitals. BP [blood pressure] went down to 70/35 [mmHg]. Resident became responsive but still not answering questions which is not [his/her] baseline. Paramedics took [him/her] and went to Alaska Regional Hospital and said that they're keeping [him/her] for observation.Review of Resident #99's [Hospital] History and Physical, dated 11/13/25 revealed, .Assessment and Plan.patient reported to have tonic clonic seizure [type of seizure involving sudden loss of consciousness, followed by muscle stiffening (tonic phase) and rhythmic jerking movements (clonic phase)] by EMS [Emergency Medical Services]. Has no known h/o [history of] seizure.minimize sedating medicines, frequent redirection, minimize external stimuli.seizure/fall precautions.Review of Resident #99's discharge summary from his/her hospitalization, dated 11/13/25 revealed, .Start taking these medications.levetiracetam [Levetiracetam (Keppra) is an anticonvulsant medication used to prevent and control seizures by stabilizing electrical activity in the brain] 250 MG [milligrams] tablet .commonly known as: KEPPRA. Instructions. Take 1 tablet (250 mg total) by mouth in the morning and 1 tablet (250 mg total) before bed time. For: Seizure disorder.Other Orders. admission Type: Readmission.Primary Diagnosis: Seizure disorder.Review of the Resident #99's LTC Order Recap Report on 12/18/25, revealed: .levetiracetam Oral Tablet 250 MG.Give 250 mg by mouth every morning and at bed time for Seizure Disorder. Start Date.11/13/25. End Date.11/20/25.LaMICtal Oral Tablet 25 MG (Lamotrigine) [Lamotrigine(Lamictal) is an anticonvulsant medication used to treat epilepsy and bipolar disorder by stabilizing electrical activity in the brain and helping regulate mood] Give 1 tablet by mouth two times a day for seizure d/o [disorder]. Start Date.11/21/2025.Review of the MDS (Minimum Data Set, a federally required nursing assessment), dated 11/19/25, revealed in Section I-Active Diagnosis, the response was unmarked for I5400. Seizure Disorder or Epilepsy.Review of the Care Plan Report, on 12/18/25, revealed no interventions/tasks were initiated for seizures.During an interview on 12/17/25 at 12:08 PM, RCM #3 stated he/she mostly focuses on the MDS portion and explained that active diagnoses were filled out in the MDS based off the diagnosis list in the EHR. He/she further stated when residents were admitted and/or were transferring back from a facility, the RCM would go over the documentation received such as a discharge summary or history and/or history and physical. RCM #3 stated the provider would then be contacted, and the respective information and/or orders would be placed in the EHR.During an interview on 12/17/25 at 11:46 AM, RCM #1 stated active diagnoses would be a part of the care plan to be able to lay out person-centered goals and interventions/tasks. He/she further stated the care plan was a working document and would be updated as necessary when a resident's condition changes. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, last revised 3/2022 revealed: .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem area and their causes and relevant clinical decision making. 11. Assessments of resident are ongoing and care plans are revised as information about the residents and the residents' conditions change.12. The interdisciplinary team revises and updates the care plan: a. when there has been a significant change in the resident's condition.c. when the resident has been readmitted to the facility from a hospital stay.

.Based on record review and interview, the facility failed to develop and implement an ongoing program of individualized, meaningful activities in accordance with resident assessments and care plans for 3 residents (#12, #27, and #67) of 20 sampled residents. Specifically, the facility failed to consistently offer activities aligned with each resident's identified interests and documented activity goals over extended periods of time, as evidenced by prolonged gaps in activity offerings and participation. This failed practice resulted in residents not being provided opportunities for socialization, engagement, and cognitive stimulation consistent with their assessed needs, placing the affected residents at risk for social isolation, decreased psychosocial well-being, and decline in quality of life Findings:Resident #12Record Review from 12/14-24/25 revealed Resident #12 was admitted to the facility with diagnoses that included a fracture of the left femur, and major depressive disorder (a mental disorder characterized by low moods, low self-esteem, and loss of interest in or pleasure in normally enjoyable activities).During an interview with Resident #12 on 12/15/25 at 9:34 AM, when asked about which activities the resident enjoyed at the facility, Resident #12 stated no one came to offer him/her activities.Review of Resident #12's ACTIVITY ASSESSMENT., dated 7/29/25, revealed the resident had interests that included cooking, birthday parties, happy hour and beauty days.Review of Resident #12's Care Plan Report, last reviewed 7/30/25, revealed: I know I have the right to do what I want. Will have daily socialization with staff or visitors as desires. cooking, birthday parties, happy hour, beauty days. Encourage autonomy and independence with preferred activity pursuits. Support choices for preferences regarding customary routine and activities. ActivitiesSeptember:Review of Resident #12's Activities Flowsheet, dated 9/1-30/25, revealed the activities staff interacted with Resident #12 twice for the month of September (9/12/25 and 9/30/25).November:Review of Resident #12's Activities Flowsheet dated 11/1-30/25, revealed the activities staff interacted with Resident #12 once for the month of November (11/4/25).December:Review of Resident #12's Activities Flowsheet dated 12/1-16/25 revealed the activities staff interacted with Resident #12 once for the month of December (12/2/25). Resident #27Record Review from 12/14-24/25 revealed Resident #27 was admitted to the facility with diagnoses that included weakness, mild cognitive impairment of uncertain or unknown etiology and osteoarthritis (chronic degenerative joint disease characterized by the progressive breakdown of joint cartilage and underlying bone).During an interview with Resident #27 on 12/14/25 at 10:30AM, when asked about the activities that had been offered, he/she stated: I've never been offered to participate in any activities, and I don't recall ever attending an activity. It would be nice if something like that existed.Review of Resident #27's ACTIVITY ASSESSMENT., dated 10/15/25, revealed the resident had interests that included walks, investment banking, and being with animals and pets.Review of Resident #27's Care Plan Report, last reviewed 10/14/25 revealed no activities care planning. ActivitiesOctober:Review of Resident #27's Activities Flowsheet dated 10/14-31/25 revealed the resident participated in activities on seven dates (10/15-16/25, 10/20-23/25, and 10/29/25), with no additional documentation indicating the resident was offered or participated in activities for the remaining 12 days.November:Review of Resident #27's Activities Flowsheet, dated 11/1-30/25 revealed the resident participated in activities on two dates (11/3-4/25), with no additional documentation indicating the resident was offered or participated in activities for the remaining 28 days.December:Review of Resident #27's Activities Flowsheet dated 12/1-16/25 revealed no documentation that the resident was offered or participated in any activities. Resident #67Record Review from 12/14-24/25 revealed Resident #67 was admitted to the facility with diagnoses that included depression and adult failure to thrive (condition characterized by a decline in overall health and function, marked by social and psychosocial withdrawal, reduced engagement in activities or interactions, decreased motivation, and diminished ability to meet basic physical and emotional needs, often accompanied by functional decline or poor nutritional intake).Review of Resident #67's Care Plan Report, last revised 12/12/25 revealed the following activities care planning: .Resident will maintain current cognitive-communication skills to delay further decline. Coordinate with activities staff for participation in cognitive stimulation activities. My preferred activities are arts/crafts (drawing, sewing, and coloring), education (jeopardy, wheel of fortune), cooking/baking, gardening, listening to country music, family visits, pet therapy, reading magazines, reminiscing, horse racing, taking naps, socializing with staff, and beauty break. Staff will continue to encourage resident to participate in activities of stated interest. ActivitiesJanuary:Review of Resident #67's Activities Flowsheet, dated 1/1-31/25 revealed the resident participated in activities on one date (1/1/25), with no additional documented activity participation or offers for the remaining 30 days.February:Review of Resident #67's Activities Flowsheet, dated 2/1-28/25 revealed the resident participated in activities on five dates (2/8/25, 2/15/25, 2/25/25, and 2/28/25), with no additional documentation indicating the resident was offered or participated in activities for the remaining 23 days.March:Review of Resident #67's Activities Flowsheet, dated 3/1-31/25 revealed the resident participated in activities on one date (3/6/25), with no additional documented activity participation or offers for the remaining 30 days.April:Review of Resident #67's Activities Flowsheet, dated 4/1-30/25 revealed the resident participated in activities on two dates (4/1/25 and 4/7/25), with no additional documented activity participation or offers for the remaining 28 days.May:Review of Resident #67's Activities Flowsheet dated, 5/1-31/25 revealed the resident participated in activities on one date (5/7/25) with no additional documented activity participation or offers for the remaining 30 days.June:Review of Resident #67's Activities Flowsheet, dated 6/1-30/25 revealed no documentation that the resident was offered or participated in any activities.July:Review of Resident #67's Activities Flowsheet, dated 7/1-31/25 revealed the resident participated in activities on one date (7/21/25), with no additional documented activity participation or offers for the remaining 30 days.August:Review of Resident #67's Activities Flowsheet, dated 8/1-31/25 revealed the resident participated in activities on two dates (8/23/25 and 8/27/25), with no additional documented activity participation or offers for the remaining 29 days.September:Review of Resident #67's Activities Flowsheet, dated 9/1-30/25 revealed the resident participated in activities on two dates (9/5-6/25), with no additional documented activity participation or offers for the remaining 28 days.October:Review of Resident #67's Activities Flowsheet, dated 10/1-31/25 revealed the resident participated in activities on two dates (10/16/25 and 10/18/25), with no additional documented activity participation or offers for the remaining 29 days.November:Review of Resident #67's Activities Flowsheet, dated 11/1-30/25 revealed the resident participated in activities on one date (11/3/25), with no additional documented activity participation or offers for the remaining 29 days.December:Review of Resident #67's Activities Flowsheet, dated 12/1-17/25 revealed the resident participated in activities on one date (12/15/25) with no additional documented activity participation or offers for the remaining 16 days.During an interview with the Activities Director on 12/16/25 at 1:30 PM, she stated that if a resident participated in an activity, or was offered to participate in an activity, it would be documented on the Activities Flowsheet. She further stated that if documentation was not present on the Activities Flowsheet, it meant the resident was not offered to participate in an activity. When asked how she tracked which residents had not participated in activities she stated that it was done by memory.Record review of the facility policy Activity Programs, last revised 6/2018 revealed: .2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 3. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. 6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. 9. Activities are documented in the resident's medical record. 13. Residents are encouraged, but not required, to participate in scheduled activities.

.Based on record review, interview, and observation, the facility failed to ensure treatment and care was provided, based on physician orders and comprehensive person-centered care plans, for 2 residents (#23 and #27), out of 20 sampled residents. This failed practice had the potential to diminish overall health and wellbeing, placing Resident #23 at risk for unrecognized blood pressure instability related to antihypertensive therapy and Resident #27 at risk for impaired skin integrity due to failure to implement ordered offloading and pressure reduction measures Findings: Resident #23Record Review on 12/14-24/25 revealed Resident #23 was admitted to the facility with diagnoses that included hypertension (elevated blood pressure), heart failure (condition in which the heart pumps ineffectively) and history of transient ischemic attack (stroke).Review of Resident #23's electronic health record (EHR) revealed a physician's order, dated 6/18/25: .Vital signs daily. Further review revealed an order for blood pressure medication, dated 9/12/25: .Coreg Oral Tablet 6.25 MG (Carvedilol). Give 1 tablet by mouth two times a day for HTN (hypertension - elevated blood pressure).Review of Resident #23's Care Plan Report, last reviewed 10/8/25, revealed: .Goal. Will exhibit a therapeutic effect related to the use of the medication. Interventions/Tasks. Vital signs as ordered.Review of Resident #23's vital signs flowsheets dated 6/18/25-12/14/25 revealed only two documented vital sign assessments (9/1/25 and 9/11/25), with no documentation of daily vital signs for the remaining 177 days.During an interview with the facility's acting Director of Nursing (DON) on 12/17/25 at 9:30 AM, the DON confirmed that the facility should have been checking vital signs daily on Resident #23.Review of the facility policy Vital Sign Monitoring, last revised 3/2025, revealed: .It is the policy of this facility to monitor the resident's vital signs. Vital signs will be monitored for residents receiving medications including but not limited to anti-hypertensives and psychotropics. Vital signs, to include temperature, blood pressure, pulse and respirations are done no less often than monthly, unless physician's orders or the plan of care specifies differently. Resident #27Record Review from 12/14-24/25 revealed Resident #27 was admitted to the facility with diagnoses that included weakness, mild cognitive impairment of uncertain or unknown etiology and osteoarthritis.An observation on 12/14/25 at 10:00 AM, revealed Resident #27 was laying supine (on back) in bed, with both heels of his/her feet on the mattress. Further observation revealed his/her feet and heels were covered by non-skid socks.Review of Resident #27's EHR revealed two wound care orders:1.Left heel (vascular). leave open to air. Start Date. 11/9/2025,2.offloading boots to LLE (left lower extremity). Start Date. 11/3/2025.Review of Resident #27's Care Plan Report, last reviewed 10/24/25, revealed: .Focus. Skin: Resident is at risk for skin breakdown related to immobility, and central cord syndrome, and malnutrition. Goal. Will prevent or delay skin breakdown to the extent possible given risk factors. Interventions. Keep skin clean and dry to the extent possible. Further review revealed no interventions to keep Resident #27's left heel open to air or for the use of offloading boots.During an interview on 12/14/25 at 1:00 PM, when asked if Resident #27 should have been wearing heel boots, Licensed Nurse (LN) #12 agreed that there was an order to have heel boots in place.Review of the facility provided policy Care Plans, Comprehensive Person-Centered, last revised 3/2022, revealed: .The comprehensive, person-centered care plan. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. reflects currently recognized standards of practice for problem areas and conditions.

.Based on record review, observation, and interview, the facility failed to ensure a culture where residents were treated with dignity and respect for 2 residents (#'s 48 and 64), out of 20 sampled residents. Specifically, the facility failed to:1) provide Resident #48 a bed bath at a reasonable time of day;2) maintain Resident #48's dignity and privacy by leaving the catheter urine collection bag uncovered and visible in common areas; and3) maintain Resident #64's dignity and privacy by failing to cover the resident's buttocks while transporting the resident to the resident's room from the shower room through 2 separate courts on 2 separate floors.These failures subjected residents to distressing and undignified care practices and placed them at risk for emotional distress and reduced quality of life.Findings:Resident #48Record review on 12/14-24/25 revealed Resident #48 was admitted to the facility with diagnoses that included quadriplegia (paralysis of all four limbs), insomnia and neuromuscular dysfunction of the bladder ( a condition where nerve or muscle problems interfere with normal bladder control, leading to issues such as incomplete emptying, urinary retention, or incontinence) which resulted for the need of an indwelling urinary catheter, nightmare disorder (a sleep disorder characterized by repeated, vivid, and disturbing dreams that cause awakenings and significant distress or impairment in daytime functioning) and Post-Traumatic Stress Disorder (PTSD, a mental health condition that occurs after experiencing or witnessing a traumatic event). BathingDuring an interview on 12/14/25 at 10:55 AM, Resident #48 stated that staff woke him/her at 2:00 a.m. to provide a bed bath, which was very distressing due to frequent insomnia. The resident added that he/she experiences night terrors and was relieved not to have one when awakened. The resident stated it was very difficult to return to sleep after the bed bath.Review of Resident #48's Treatment Administration Record for bathing dated 12/13/25, revealed: . Was a shower or bath provided? . The record indicated a check mark under . Yes. and was time stamped at 2:22 AM, indicating Resident #48 was bathed at 2:22 AM on 12/13/25.Review of Resident #48's MDS (Minimum Data Set- A federally required assessment) comprehensive assessment, dated 11/25/25, revealed: . Section F:. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very Important. How important is it to you to choose your own bedtime? Very Important.Review of Resident #48's care plan, dated 11/18/25, revealed: . The resident experiences frequent distressing nightmares and symptoms of PTSD, including sleep disruption, anxiety, hypervigilance, and emotional distress. These symptoms may impact quality of life, rest, and participation in daily activities. Resident has episodes of Insomnia. Resident will sleep 6/8 hours per night. During an interview on 12/18/25 at 4:15 PM, Certified Nursing Assistant (CNA) #2 stated that it was not acceptable to wake residents for a bath or shower. CNA #3 added that if residents request a shower very late at night, staff will accommodate; however, showers should typically occur during the first four hours of the night shift if not completed during the day shift. CNA #3 further stated that Resident #48 usually went to bed around midnight.During an interview on 11/18/25 at 4:31 PM, the Infection Preventionist (IP) stated that staff were expected to perform showers during the day shift. She further stated that if residents requested showers late, staff could honor those requests, as it was not unusual for residents to want showers later in the evening. However, staff should not wake residents for showers or baths. Urine Collection [NAME] observation on 12/14/25 at 10:55 AM, revealed Resident #48 was seated in an electric powered wheelchair with a family member in a main floor sitting area near a side door. The resident's catheter collection bag hung on the left side of the wheelchair and was about one-quarter full of yellow urine. When asked about the bag, the resident stated that he/she did not like having the urine bag exposed to everyone to see. The family member stated that he/she wished the bag could be hidden but there was no good place to position it on the wheelchair.During an interview on 12/18/25 at 4:15 PM, CNA #2 stated urine collection bags should have been covered when residents were out of their rooms, however CNA #2 was unsure if Resident #48 had a urine collection bag cover.During an interview on 12/18/25 at 4:31 PM, IP stated when residents were out of their rooms and in the community the urine collection bag should have been covered.Review of Resident #48's care plan, dated 11/20/25, revealed: Bladder: At risk for complications with urinary system.Privacy cover to catheter bag as indicated to promote dignity. Resident #64Record review on 12/14-24/25 revealed Resident #64 was admitted to the facility with diagnoses that included dementia, and a history of transient ischemic attack (an episode of stroke like symptom that completely resolves), and cerebral infarction (occurs when a blood clot blocks a brain artery).Review of Resident #64's care plan, dated 10/8/25, revealed: . [Resident #64] has an ADL [activities of daily living] Performance Deficit r/t [related to] weakness, reduced mobility. Ambulation - does not walk. Assistive Devices - Wheelchair. Bathing Preference: Shower Sunday/Thursday Day shift.An observation on 12/14/25 at 8:48 AM, revealed Resident #64 was transported in a shower chair from his/her room to the elevator, passing through the Birch Court common area and hallway. The resident had no clothing on but was covered with a white blanket that concealed the front of the body. When CNA #4 turned the chair toward the elevator, the resident's buttocks were exposed through the opening between the seat and backrest, making the resident's buttocks visible to others in the court. Staff present at the time included LN #3 and this surveyor.During an interview 12/14/25 at 8:50 AM, LN #3 stated Resident #64 was going to the [NAME] Court shower room downstairs.An observation on 12/14/25 at 9:05 AM, revealed Resident #64 was transported in a shower chair from the [NAME] Court shower room to the elevator with a blanket covering the resident's front from shoulders to feet; however, Resident #64's buttocks were exposed from the back of the chair through the opening between the seat and backrest. To reach the elevator, the resident passed through a common area where Resident #31 was seated at a table. Resident #64, fresh from a shower, with buttocks exposed, passed directly in front of Resident #31 and a surveyor before boarding the elevator.During an interview 12/16/25 at 3:15 PM, CNA #4 stated he/she brought the resident to the first floor shower room because it was safe to transfer Resident #64 in that shower room. He/she further stated when transporting a resident, he would cover the resident with a blanket so no skin would peak through and to keep the resident warm.During an interview on 12/17/25 at 10:13 AM, Resident Care Manager (RCM) #2 and RCM #3 stated the CNAs were trained on ADL during their CNA training. Residents were supposed to be covered to protect privacy and dignity when going down to the shower room and going back to their room.Review of the facility's Resident Rights, undated, revealed: Centennial Post Acute acknowledged the rights accorded to everyone admitted to our care .Review of the facility's Nursing Home Resident Rights, undated, revealed: Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination. Right to a dignified existence. Be treated with consideration, respect, and dignity.

.Based on record review and interview, the facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC - an official notice, issued by Medicare-certified healthcare facilities to inform beneficiaries when their coverage will end, with appeal right information) was provided to and signed by the resident's legally authorized Power of Attorney (POA) for 1 Resident (#113), out of 2 discharged residents reviewed. The resident had a documented POA with authority over insurance and government benefit decisions. The facility obtained the resident's signature on the NOMNC but failed to include the POA's signature, did not document review of the notice with the POA, and did not ensure the POA was informed of appeal rights prior to discharge. This failure denied the POA the opportunity to exercise Medicare appeal rights, resulting in the loss of a protected procedural right .Findings:Resident #113Record review on 12/14-24/25 revealed Resident #113 was admitted to the facility with diagnoses that included dementia, without behavioral disturbance (cognitive decline affecting memory, thinking, and problem solving which did not include agitation or aggression), fracture of the right femur (thigh bone), infection following the surgical procedure to fix the femur, and muscle weakness. Resident #113 also had diagnoses with depression and anxiety.Further review Resident #113 had a Power of Attorney (POA) legal document, dated 9/3/25, and this document indicated the POA had the power to decide about insurance transactions, benefits from government programs, and all other matters.Resident #113's POA was documented as Resident #113's agent in his/her medical record.Review of Resident #113's NOMNC form, Form CMS-10123-NOMNC (Approved 12/31/2011) OMB approval 0938-0953, revealed: . Medicare A stay for Skilled Nursing Facility Services Will End: 11/5/25. Further review revealed that despite having documented dementia, the facility had Resident #113 signed this form on 11/3/25, however the resident did not sign with his/her legal name (last name was not correct). Resident #113's POA did not sign this NOMNC form.During an interview on 12/16/25 at 1:00 PM, the Director of Social Services (DSS) and the Social Services Coordinator (SSC) stated that the Social Services department at the facility would issue a NOMNC within 48 hours of a resident's last covered day. This NOMNC would be reviewed with a resident (if they were their own decision maker,) or with the family, POA, or guardian (if applicable). When asked how this was completed for a resident with a POA, the DSS and SSC stated they would have the POA come into the facility, if they were local, review the form to include the appeal rights, and have them sign it. If they were not local, they would conduct the review over the phone. The DSS and SSC stated if a resident had a POA, the resident would not sign the form.During an interview on 12/17/25 at 11:24 AM, Resident #113's POA stated the facility did not provide the NOMNC paperwork to him/her prior to the resident's discharge. The POA was not aware of appeal rights and would have considered this option as he/she felt the resident's discharge was not appropriate.During an interview on 12/17/25 at 12:03 PM, the DSS acknowledged that Resident #113's signature was on the NOMNC, dated 11/3/25, and not the POA. The DSS stated that the SSC had told her that the NOMNC was provided to the POA, but this was not documented.Review of the Centennial Post Acute. Notice of Medicare Non-Coverage document, dated 11/3/25, revealed: Your Right to Appeal This Decision. You have the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage of these services. Your services will continue during the appeal. If you choose to appeal, the independent reviewer will ask for your opinion. The reviewer also will look at your medical records and/or other relevant information. You do not have to prepare anything in writing, but you have the right to do so if you wish. How to Ask for an Immediate Appeal. You must make your request to your Quality Improvement Organization (also known as a QIO). A QIO is the independent reviewer authorized by Medicare to review the decision to end these services. Your request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above.

.Based on record review and interview, the facility failed to ensure comprehensive, person-centered care plans were developed and implemented to address identified needs for 2 residents (#'s 27 and 111) out of 2 residents reviewed for comprehensive care plans. Specifically, the facility failed to develop and implement dementia-related care plan interventions for Resident #27 and failed to develop and implement fall-risk-specific care plan interventions for Resident #111. These failed practices placed Resident #27 at risk for unmet cognitive and behavioral needs and placed Resident #111 at risk of injury Findings: Resident #27Record review on 12/14-24/25 revealed Resident #27 was admitted to the facility with diagnoses that included unspecified dementia, unspecified severity, with other behavioral disturbance (cognitive decline of unclear cause and severity, accompanied by behavioral symptoms), and mild cognitive impairment of uncertain or unknown etiology.Review of Resident #27's MDS (Minimum Data Set- a federally required assessment) Comprehensive Assessment, dated 10/24/25, revealed, under Section I-Active Diagnosis, Resident #27 was not coded for dementia. Review of the MDS's Section V - Care Area Assessment (CAA) Summary revealed the care area of cognitive loss/dementia had not been triggered and had not been addressed in the resident's care plan. Review of Resident #27's physician orders revealed: [Order Date 12/11/25 at 12:51 PM] RisperiDONE [atypical antipsychotic medication used to treat psychosis, mood disorders, and behavioral symptoms by helping balance neurotransmitters in the brain] Oral Tablet 1 MG (Risperidone) Give 2 mg by mouth at bedtime for Hallucinations F03.91: Unspecified dementia, unspecified severity, with behavioral disturbance.Review of the [Provider] Progress Note, dated 10/21/25, revealed: Chief Complaint: New admit.History of Presenting Illness: .pmh [primary medical history sig [significant] for dementia.Past Medical History: dementia.Review of the [Provider] Progress Note, dated 10/28/25, revealed: History of Presenting Illness: . sig for dementia. cognitive impairment: tests done in hospital M-ACE [Mini-Addenbrooke's Cognitive Examination]: 21/30 [suggests mild cognitive impairment] .MoCA [Montreal Cognitive Assessment] 18/22 [suggests mild cognitive impairment]. noted to have been rx'ed [prescribed] risperdal for dementia with behavioral disturbance.Review of Resident #27's care plan, last reviewed 10/24/25, revealed: Resident requires antipsychotic medication related to hallucinations as evidenced by auditory hallucinations. Further review revealed no care planning for dementia.During an interview on 12/17/25 at 10:13 AM, Resident Care Manager (RCM) #2 and RCM #3 stated Resident #27's diagnosis of dementia was added to the electronic health record (EHR) but not added to the MDS as it was not identified on admission. RCM #3 further stated Resident #27's diagnosis of dementia will be added to the next quarterly MDS.Review of the facility's Dementia-Clinical Protocol policy, revised 11/2018, revealed: Assessment and Recognition.5. The staff and physician will review the current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual's condition, related complications, and functional abilities and impairments.Treatment/Management.1. For the individual with confirmed dementia, the IDT [Interdisciplinary Team] will identify a resident-centered care plan to maximize remaining function and quality of life.5. The IDT will Identify and document the residence condition and level of support needed during care planning and review changing needs as they arise. A. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools) .Monitoring and Follow-Up.2. The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. Resident #111Record review on 12/14-24/25 revealed Resident #111 was admitted to the facility on [DATE] with diagnoses that included radiculopathy (compression or irritation of a spinal nerve root) and spinal stenosis (spaces within the spine narrow, placing pressure on the spinal cord or nerves) followed by a lumbosacral spinal fusion (surgical procedure that joins two or more vertebrae in the lower spine to stabilize the spine, reduce pain, and correct spinal instability or deformity).Review of Resident #111's Morse fall assessment [a standardized assessment tool used to evaluate a patient's risk of falling based on factors such as history of falls, mobility, mental status, and use of assistive devices], dated 8/14/25 at 1:50 PM, revealed: Description: Admission. Category: Moderate Risk of Falling.Gait.Impaired-difficulty rising from chair, uses chair arms to get up, bounces to rise- keeps head down when walking, watches the ground - grasps furniture, person or aid when ambulating. Cannot walk unassisted.Impaired.Review of Resident #111's 02. NURSING - FALL RISK OBSERVATION/ASSESSMENT - V [version] 2.0 dated 8/15/25 at 5:27 AM, revealed: Admission.Category: High Risk.Balance: Non-ambulatory / wheelchair for locomotion.Continence: 6. Dependent and Incontinent.Mobility: Non-ambulatory / wheelchair for locomotion. Confined to chair / geri-chair [padded reclining chair with wheeled bases to assist those with limited mobility] .Yes.Review of Resident #111's Medicare PT [Physical Therapy] Evaluation & Plan of Treatment dated 8/16/25, revealed: Sit [to] Stand. Total Dependence without attempts to initiate.Current Referral:.Patient referred to PT due to decline in decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced balance, reduced functional activity tolerance, increased need for assistance from others, reduced ADL [Activities of Daily Living] participation and pain.Precautions: Fall Risk.Risk Factors: Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: falls and further decline in function.Review of Resident #111's MDS admission Assessment, dated 8/21/25, revealed, under Section GG-Functional Abilities, Resident #111 was coded as requiring substantial/maximal assistance for toileting hygiene, shower/bathe self and upper body dressing. Further review revealed Resident #111 was coded as dependent - where a helper does all the effort and the resident does none of the effort to complete the activities such as lower body dressing and putting on/taking off footwear. Review of the MDS's Section V - Care Area Assessment (CAA) Summary revealed the care area of falls had triggered and had been addressed in the resident's care plan.Review of Resident #111's care plan revealed there was no documentation, to include interventions, for risk of falls.Review of Resident #111's Alert Note, dated 9/4/25 at 11:31 PM revealed: This LN [Licensed Nurse] and CNA [Certified Nursing Assistant] heard a bang coming from room.Resident found lying on floor next to bathroom door. I was trying to go to the bathroom. I tried walking backwards and missed my step. I didn't hit my head, but my right hip hurts radiating down my leg. Resident assessed per RN [Registered Nurse]. Resident able to move all extremities with pain to right hip noted. Resident assisted back to bed via hoyer lift. On call provider notified and received verbal order to send to ER [emergency room] for further evaluations and resident agreed.Review of the ED [Emergency Department] Provider Notes, dated 9/4/25 revealed: [Resident #111] presents today via ambulance from Centennial Extended Care with right hip and low back pain status post a mechanical fall from standing about 30 minutes ago. The medics report the patient has been cared for at Centennial since a lumbar spinal fusion . about a month ago. They state the patient was ambulating to the bathroom using a walker when [he/she] fell to the ground onto laminate flooring, landing on [his/her] right buttock and low back. The medics report 3.5/10 pain, and state they brought the patient in due to concern by [his/her] caregivers over [his/her] recent spinal surgery. Further review revealed: CT [Computed Tomography Scan] also shows right.impaction fracture of [thoracic] T11. [he/she] does not currently have focal tenderness at the site I do not suspect this is truly an acute fracture.Review of the facility's investigative final report, dated 9/10/25 at 11:44 AM, revealed: Resident Interview: [Resident #111] was interviewed at the time of the fall. [He/she] reported going to toilet [himself/herself] and fell. The resident was using a walker at the time and reported that [his/her daughter/son] had brought it in for [him/her] in preparation for [his/her] discharge the next day. The resident was asked if [he/she] is aware that [he/she] should have called for assistance and [he/she] reported [he/she] understood. Staff Interviews: The staff was interviewed who were working with the resident at the time of the incident. The staff said that they heard the resident fall. [He/she] was alert and let them know what happened. The staff had checked in on the resident throughout the shift and no concerns were noted. The resident was excited about [his/her] discharge home the next day . The staff did not see any environmental factors that could have resulted in the fall. Interventions: Upon return from the ER , the resident appeared comfortable. [He/she] was educated on calling for assistance with toileting. [He/she] was also evaluated for safety at the ER per providers call to the facility. The resident was asked to stay longer at the facility due to potential injury but [he/she] declined. The self-directed discharge happened as planned with a follow up with [his/her] surgeon and PCP [primary care provider].During an interview on 12/18/25 at 11:04 AM, RCM #2 stated every resident upon admission was assessed for fall risk using a Morse Fall Assessment. RCM #2 further stated if a resident was identified as a moderate fall risk they should be care planned for risk of falls. Review of the facility's Fall Risk and Neurological Assessment policy, revised 11/6/23, revealed: .It is the policy of the center that residents are evaluated for their risk of falls upon admission. A plan of prevention is initiated, as appropriate, for identified risks.PROCEDURE: 1. The Morse Fall Risk Scale is completed on admission. 2. The Kardex includes interventions based on the results identified in the Morse fall scale and includes specific interventions for fall prevention. 3. The MDS including Care Area Assessments (CAA) is utilized to further evaluate resident's risk of falls and development of the comprehensive care plan. 4. History and physicals are reviewed to identify fall history, if applicable, and contributing diagnosis and other factors this information is utilized to initiate individualized interventions to prevent or reduce risk of falls and identify need for referral to other disciplines, including but not limited to PT, OT, ST, pharmacist, optometrist . Review of the facility's Care Plans, Comprehensive Person- Centered policy, revised 3/2022, revealed: .A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan: .e. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are:.c. trauma informed.9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem and their causes, and relevant clinical decision making .

.Based on record review and interview, the facility failed to ensure a resident on wander guard elopement precautions received adequate supervision for 1 Resident (#90), out of 2 residents reviewed for wander guard supervision. This failed practice contributed to the resident's ability to leave the facility in a cab, become stranded at a local store, and returned to the facility by entering a stranger's privately owned vehicle, placing him/her at risk for abuse, exploitation, and/or death .Findings:Record review on 12/14-24/25 revealed Resident #90 was admitted to the facility on [DATE] with diagnoses that included a displaced fracture of medial wall of left acetabulum (a fracture in the socket part of the left hip joint where the bone fragments are moved out of their normal alignment), chronic kidney disease, schizophrenia (a mental disorder that disrupts how a person thinks, feels, and behaves, causing them to lose touch with reality), and anxiety.Further review revealed Resident #90 left the faciity on [DATE] by calling a cab around 3:00 PM. Facility personnel became aware that the resident was not in the facility around 5:30 PM (2 1/2 hours after the resident left). Once aware, facility personnel began to search the facility, notify leadership, and were about to call the police when the resident was returned to the facility by a man and woman who found the resident at [NAME] (a local grocery store six miles away from the facility).Elopement EvaluationReview of Resident #90's Elopement Risk Evaluation, dated 9/17/25, revealed: . Mental status. Is the resident cognitively impaired with poor decision making skills (i.e., poor decision cues, intermittent confusion, inattention, and disorganized thinking)?. Yes. Is the resident an elopement risk? . Yes.Further review revealed Resident #90 scored 15 on this evaluation, which indicated he/she was a high risk to wander.Review of Resident #90's physician orders, revealed an order dated 9/17/25: Wander guard [a discreet wearable tag that triggers an alarm at doors providing staff alerts that a resident has left through a door]: check placement every shift.Review of Resident #90's provider note, dated 9/23/25, revealed: . cannot make [his/her] own decisions. Elopement BehaviorsReview of Resident #90's progress notes, dated 9/28/25 through 11/15/25, revealed the following wander guard monitoring and elopement-type behaviors:- 9/17/25: . earlier part of the shift [he/she] wants to go home and smoke outside.- 9/28/25: . frequently asks for someone to take [him/her] shopping at Walmart.- 10/2/25: . [he/she] is fixated on leaving to go shopping today and is working on staff to call [him/her] a cab.- 10/13/25: . wander guard functioning well on Left wrist.- 10/19/25: [he/she] wishes to go to Walmart. Cab service ordered by another resident[,] refuses due to not being handicap ready. [Resident #90] transfers on [his/her] own.- 10/31/25: . Wander guard is intact on [his/her] wheelchair.During an interview on 12/16/26 at 4:10 PM, Licensed Nurse (LN) #3 stated he/she was the nurse working Resident #90's court on 11/15/25. LN #3 stated that Resident #90 had left through the front door of the facility that day, and the wander guard alarm did go off when he/she exited. LN #3 and others on the court questioned each other if that was an alarm, however LN #3 stated they did not respond to the alarm. LN #3 stated that apparently no one was at the front desk at that time, so the resident was able to leave. LN #3 stated he/she didn't realize Resident #90 was not on the unit when he/she attempted to deliver Resident #90's afternoon medications and meal. This was when a search started and leadership was notified. LN #3 stated he/she was about to call the police when Resident #90 was returned to the facility by a couple who happened to be at the store. LN #3 stated Resident #90 had told the staff that he/she went to see a friend at the store, however this friend left him/her at the store when the line he/she was in took too long, and the resident couldn't get back to the facility.Review of Resident #90's care plan, initiated on 9/18/25, revealed: . FOCUS: Elopement: Resident is at risk for elopement/exit seeking/wandering related to wanders aimlessly. GOAL: Resident's safety will not be endangered related to behaviors. Will have reduced episodes of exit-seeking behaviors. Will not leave the facility without a responsible person. Will not wander out of the facility. INTERVENTIONS: Administer medications as ordered. Allow wandering in safe areas within the facility. Approach in calm, non-threatening manner. Check exit, stairwell and door alarms on a routine schedule for operability. Check function of wander alarm per manufacturer recommendations. Check placement of wander alarm every shift. Document and notify physician if behavior interferes with daily functioning. Elopement risk assessment per facility policy.During an interview on 12/28/25 at 6:38 PM, when asked if the facility had made any changes to Resident #90's care plan after this elopement, LN #7 stated they added a goal for the resident to notify staff when he/she would like to go to the store.Review of Resident #90's revised care plan, dated 11/20/25, revealed the addition of this goal: resident will notify staff when [he/she] would like to go to the store. Further review revealed no other interventions were included to help mitigate future elopements.Review of the facility policy Wanderguards/Elopement Prevention Systems, dated 2/2025, revealed: It is the policy of this facility that residents will be safe and secure in their environment. Those residents, who have been identified as exit seeking, will have a wanderguard or similar device placed on their person, to assist in preventing them from wandering out of the facility and potentially being harmed. Risk for elopement will be placed on the care plan, along with interventions, to include wanderguard.Review of the facility policy Elopement/Wandering, dated 10/2025, revealed: . Upon return to the center, the licensed nurse completes the following. Review and update care plan and in room care plan/Kardex - Update interventions.Facility policies failed to define staff roles and required actions when a wander guard alarm activated, resulting in delayed response and resident elopement

.Based on record review and interview, the facility failed to ensure 3 residents (#'s 10, 68 and 88), out of 3 residents reviewed for dialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood), received the services consistent with professional standards of practice. Specifically, the facility failed to ensure blood pressure measurements were taken on the appropriate extremity. This failed practice placed the residents at risk for damage to their AV (arteriovenous) fistula (connection made between an artery and vein that is used for dialysis access) Findings: Resident #10Record review from 12/14-24/25 revealed Resident #10 was admitted to the facility with diagnoses that included Type 2 diabetes mellitus (DM- a chronic disease characterized by high levels of sugar in the blood) with diabetic chronic kidney disease (CKD- gradual loss of kidney function), dependence on renal dialysis, and end stage renal disease (ESRD- last stage of CKD).Review of Resident #10's Care Plan Report, initiated 11/18/25 revealed: .Dialysis: Resident Requires [dialysis] and has an AV fistula (shunt) and is at risk for complications related to treatment . Avoid taking blood pressure [BP], performing venipuncture, giving injections, strenuous activity, or applying restrictive clothing or restraints on the AV site extremity . Check AV Fistula (Left Arm) site dressing upon return from dialysis .Review of Resident #10's Blood Pressure Summary, dated from 11/7/25-12/15/25 revealed the facility measured Resident #10's blood pressure in his/her left arm on 5 occasions. Resident #68Record review from 12/14-24/25 revealed Resident #68 was admitted to the facility with diagnoses that included Type 2 DM, dependence on renal dialysis, and peripheral vascular disease (progressive disorder affecting blood vessels outside the heart leading to reduced blood flow and various symptoms).Review of Resident #68's Care Plan Report, initiated 10/4/25 revealed: .Dialysis: Resident requires Hemodialysis due to End Stage Renal Failure and has an AV Fistula (shunt) .Avoid taking blood pressure, performing venipuncture, giving injections, strenuous activity, or apply restrictive clothing or restraints on the AV site extremity .Review of Resident #68's Electronic Health Record (EHR) revealed a physician order dated 11/18/25: . No BP or venipuncture to Left arm due to dialysis fistula .Review of Resident #68's Blood Pressure Summary, dated 9/30/25-12/14/25 revealed the facility measured Resident #68's blood pressure in his/her left arm on 30 occasions. Resident #88Record review from 12/14-24/25 revealed Resident #88 was admitted to the facility with diagnoses that included dependence on renal dialysis, ESRD, and other complications of vascular dialysis catheter.Review of Resident #88's Care Plan Report, initiated on 11/20/25, revealed: .Dialysis: Resident Requires [X] Hemodialysis related to [X] End Stage Renal Failure and has an [X] AV Fistula (shunt) located (Left upper arm). Interventions/Tasks. Avoid taking blood pressure, performing venipuncture, giving injections, strenuous activity, or applying restrictive clothing or restraints on the AV site extremity.Review of Resident #88's EHR revealed a physician order dated 11/20/25: .Avoid taking blood pressure, performing venipuncture, giving injections, strenuous activity, or applying restrictive clothing or restraints on the AV site extremity.Review of Resident #88's Blood Pressure Summary, dated from 11/18/25-12/17/25 revealed the facility measured Resident #88's blood pressure in his/her left arm on 25 occasions.During an interview on 12/17/25 at 2:39 PM, the facility's Interim Director of Nursing (DON) stated the blood pressure measurements should not be obtained from an arm with an AV fistula when there was a physician's order that indicated such restriction.Review of the facility-provided standard used in resident care Lippincott Nursing Procedures, Eleventh Edition book, published in 2018, revealed the following education when caring for a resident with dialysis access: .Avoid taking blood pressure in an arm with an arteriovenous shunt or fistula.

.Based on record review and interview, the facility failed to ensure continuity of rehabilitative services for 1 resident (#111) reviewed for rehabilitative services. Specifically, the facility failed to ensure physical therapy services were provided as ordered when the facility's physical therapist went on leave. This failed practice resulted in an interruption of ordered rehabilitative services and placed the resident at risk of negative impacts to their functional status and rehabilitation outcomes Findings:Record review on 12/14-24/25 revealed Resident #111 was admitted to the facility on [DATE] with diagnoses that included radiculopathy (compression or irritation of a spinal nerve root, leading to pain, numbness, tingling, or weakness that radiates along the path of the affected nerve), spinal stenosis (spaces within the spine narrow, placing pressure on the spinal cord or nerves and causing pain, numbness, or weakness) and lumbosacral spinal fusion (surgical procedure that joins two or more vertebrae in the lower spine to stabilize the spine, reduce pain, and correct spinal instability or deformity).During an interview on 12/17/25 at 4:20 PM, Resident Representative (RR) stated Resident #111 was not making progress while he/she was at the facility because he/she was not receiving physical therapy (PT). RR further stated the physical therapist went on leave.Review of the Minimum Data Set (MDS- a federally required assessment), admission Assessment, dated 8/21/25, revealed, under Section GG-Functional Abilities, Resident #111 was coded as requiring substantial/maximal assistance for toileting hygiene, shower/bathe self and upper body dressing and dependent -where a helper does all the effort and the resident does none of the effort for lower body dressing and putting on/taking off footwear. Further review revealed Resident #111 was coded as requiring substantial/maximal assistance for sitting on side of bed to lying flat on the bed, lying on the back to sitting on the side of the bed with no back support, getting on and off a toilet and getting in and out of a tub/shower and dependent - where a helper does all the effort and the resident does none of the effort to complete the activities of coming to a standing position from sitting in a chair, wheelchair, or on the side of the bed and transferring to and from a bed to a chair.Review of Resident #111's Medicare PT Evaluation & Plan of Treatment, dated 8/16/25, revealed: Plan of Treatment.Frequency: 5/time(s)/week Duration 4 week(s) Intensity: Daily.Review of Resident #111's Physical Therapy Treatment Encounter Note(s) revealed Resident #111 had PT sessions on 8/16/25, 8/18/25 and 8/19/25 and no PT services for 12 calendar days (8 business days) until 9/1/25, 9/3/25 and 9/4/25.Review of the physician's orders revealed: PT Clarification: Continue skilled PT 5x [5 times] a week for 4 weeks: PLAN OF CARE may include: gait training 97116, ther ex [therapeutic exercise] 97110, ther act [therapeutic activity] 97530, neuro re-ed [neuromuscular reeducation] 97112, group therapy 97150, sensory integration 97533, manual therapy 97140. TXDX [Treatment Diagnosis] . muscle weakness. LTG [Long Term Goals]: Able to negotiate 8 stairs to return to split level home of [family member], safely and with CGA [contact guard assistance]. THE THERAPY CLARIFICATION ORDER SERVES AS THE PHYSICIAN CERTIFICATION FOR THE THERAPY PLAN OF CARE. [Start Date] 8/16/25. [End Date] 9/12/25. Further review of the medical record revealed no modifications, discontinuation, or suspension of the physical therapy orders during the lapse in services.During an interview on 12/16/25 at 2:00 PM, the Director of Rehabilitation (DOR) stated the facility's physical therapist went on leave on 8/20/25. DOR stated that, during that time, PT services were not provided, and the facility was attempting to secure replacement PT coverage. The DOR further stated PT services resumed on 9/1/25 after a temporary physical therapist was obtained. When asked how the lapse in PT services was communicated to residents, the DOR stated it may have been discussed with residents during care conferences, however no documentation was available to verify this. The DOR stated PT services were routinely provided on weekdays and were not offered on weekends. The DOR further stated he believed the physician was notified of the lapse in services but was not aware of any corresponding physician order changes or care plan revisions during the period PT services were not provided.During an interview on 12/16/25 at 4:00 PM, the Regional Director of Clinical Nursing Services (RDCNS) stated that during the lapse in PT services, the facility did not update care plans or modify physician orders for residents receiving PT services. The RDCNS further stated the facility discussed plans to hold Interdisciplinary Team (IDT) conferences to notify residents of service interruptions in the future. The Regional DON stated these discussions occurred during morning rounds; however, there was no documentation available to confirm the discussion during morning rounds.Review of the Centennial Post Acute Facility Assessment, updated 11/25/25, revealed: We provide long-term care and short-term care to include rehab. 2. Services we utilize to provide care for our residents include physical, occupational and speech therapies. Our rehab staff provide services in our facility in a manner to meet the needs of the residents and the facility. We are proficient with and continue to learn new telehealth platforms to utilize provider services to meet the needs of our residents.

Based on record review and interview, the facility failed to ensure provision of necessary care and services for one resident (#1) out of 20 sampled residents.Specifically, the facility failed to:1) monitor and evaluate the resident's response to the IV fluid bolus ordered on [DATE];2) educate and inform the resident of the risks and benefits after he/she declined vital sign measurements while in a life threatening condition;3) notify the attending provider of the resident's refusal of care, sustained hypotension and continued altered mental status; and4) ensure the resident was transferred to the emergency room for a higher level of care. These failed practices prevented Resident #1 from receiving care and services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and placed the resident at risk for serious harm and death due to unaddressed changes in condition. The resident passed away on [DATE]. A determination was made that the facility's noncompliance with one or more requirements of participation placed Resident #1 in immediate jeopardy beginning on [DATE]. This situation was brought to the attention of the facility's administration on [DATE] at 3:35 PM, at which time the facility was notified of the identified immediate jeopardy.The State Agency verified onsite on [DATE] at 12:35 PM that the immediacy was removed on [DATE] at 10:45 PM. The facility removed the immediacy by reviewing all current residents for any changes in conditions within the previous 48 hours. Any identified residents were assessed by the Director of Nursing or nursing manager and notified physicians of change in condition. Change of condition education was to be provided to licensed nurses and certified nurse aides. Following the removal of the immediacy, noncompliance remained at a scope and severity of D, no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings:Review on 6/11-13/25 revealed Resident #1 was admitted to the facility with diagnoses that included severe sepsis with septic shock (a life-threatening condition caused by the body's response to infection, leading to dangerously low blood pressure and organ dysfunction), essential hypertension, and atrial fibrillation (an irregular heart rhythm).Assessment of Resident #1's HypotensionReview of Resident #1's SBAR (Situation, Background, Assessment, Recommendation - a standardized communication tool used by healthcare staff to clearly and concisely report a resident's condition and facilitate physician notification), dated [DATE] at 12:00 PM, revealed: . Situation . Hypotensive [abnormally low blood pressure] & tachycardic [abnormally fast heart rate] . Background . 69 y/o [year old] [male/female], DNR [do not resuscitate] . Hx [history of] sepsis with shock . Assessment . 65/46 [mm/Hg (millimeters of mercury)] [BP], 107 [heart rate], increased confusion.During an interview on [DATE] at 12:23 PM, Resident #1's attending physician and Medical Director (MD), stated he was notified on [DATE], via SBAR, that Resident #1 had a critically low blood pressure and tachycardia. He assessed the resident and noted he/she was mildly obtunded (altered mental status characterized by decreased consciousness and responsiveness) with ongoing hypotension and elevated heart rate. He ordered a one-time 1000 mL (milliliter) IV (intravenous) bolus of normal saline for dehydration and hypotension. The MD stated he did not provide instructions or orders for follow-up monitoring, but expected nursing staff to notify him after shift change or upon completion of the fluids if the Resident had not improved.Review of Resident #1's Order Recap Report, revealed an order dated [DATE], Sodium Chloride Solution 0.9% Use 1000 ml IV one time only for dehydration, hypotension. Until [DATE] 23:59 bolus 1 L [liter] normal saline. This order did not include any parameters for reassessment or guidance for notifying the physician based on the resident's response to treatment.Further review revealed: Azithromycin Tablet 250 MG [milligram] Tablet Give 500 mg by mouth one time a day for infection for 1 day -Start Date- [DATE] 1230.Critical Hypotension Event - No Clinical ResponseReview of Resident #1's Progress Notes, dated [DATE] at 12:23 AM, revealed an entry by Licensed Nurse (LN) #5: Patient refused to allow staff to take vitals. Attempted 3 more times and [he/she] still refused. Further review revealed no documentation of physician and/or resident representative notification of the resident's refusal to allow staff to obtain vital signs.Review of Resident #1's Blood Pressure Summary, revealed a blood pressure reading of: . [DATE] 07:41 [AM] . 75/45 [mm/Hg].Record review on 6/11-13/25 revealed no documentation of physician and/or resident representative notification for Resident #1's blood pressure measurement of 75/45 mm/Hg.During an interview on [DATE] at 12:23 PM, the MD stated he was not informed when the resident's blood pressure remained critically low on [DATE]. The MD further stated Resident #1 would have been immediately transferred to the emergency room for possible sepsis had he been advised of Resident #1's condition and/or lack of improvement. The MD stated a blood pressure of 75/45 mm/Hg was not life-sustaining and required higher level of care. The MD stated he was unaware of Resident #1's clinical updates and considered his/her death as unexpected.During an interview on [DATE] at 3:15 PM, certified nurse aide (CNA) #4 stated after he/she obtained the blood pressure on [DATE] of 75/45 mm/Hg for Resident #1, that [he/she] appeared really out of it and was talking to [himself/herself]. CNA #4 further stated he/she reported the change in mental status to LN #2, who was assigned to the resident that shift. CNA #4 stated after he/she reported the low blood pressure and altered mental status, LN #2 responded without urgency, requested the blood pressure to be rechecked. CNA #4 stated that LN #2 kind of acted like it was nothing, and CNA #4 did not observe any further assessment or follow-up by LN #2.During an interview on [DATE] at 11:05 AM, when LN #5 was asked if vital signs would be obtained after the administration of IV fluids for hypotension, he/she stated yes. When asked if the physician would have been notified if the blood pressure remained low, he/she stated yes. LN #5 further stated when a resident refused vital sign measurements to be taken in critical situations, he/she would have notified the physician. LN #5 stated the facility had not provided specific training on how to respond to residents who refuse critical cares. LN #5 further stated the physician was not notified when Resident #1 refused to allow vital signs to be obtained.During an interview on [DATE] at 1:07 PM, LN #2 was asked how he/she would respond if a resident who presented with a blood pressure of 75/45 mm/Hg. LN #2 stated he/she would withhold blood pressure medications, notify the physician, and document the physician notification. LN #2 further stated altered mental status combined with hypotension would require physician notification, and if the resident refused to allow vital signs to have been taken, it would also warrant a physician notification. LN #2 stated Resident #1's blood pressure should have been reassessed following the administration of IV fluids to evaluate the resident's response.During an interview on [DATE] at 12:16 PM, the Resident Care Manager (RCM) revealed that on the morning of Resident #1's death, I really only got involved after [he/she] passed . I hadn't seen [him/her] that morning. The RCM further stated that the day prior, he had started an IV and administered a liter of fluids, stating, I was one of the few RNs [Registered Nurse] there that were able to do it . The nurse on the floor is the one watching the patient at all times.When asked what the nurse should have done when notified of a blood pressure of 75/45 mm/Hg, the RCM stated: Provider notification for assessment . no matter what, a provider notification. The RCM also revealed there was no specific follow-up order given after the prior day's IV fluids, stating, They [the physician] said to monitor closely and call on call if there were any issues.When asked about his/her responsibilities in supporting a new LN caring for Resident #1, the RCM stated: I would give support . but I was covering a couple of units. It varied how much attention I could give to a single nurse based on what was going on.The RCM also confirmed that if the nurse had failed to contact the provider after the fluid bolus, the provider would have had no way to know if the resident was improving or worsening.Finally, the RCM confirmed that while he/she assisted with the IV fluids and post-mortem care, he/she had not assessed the resident that morning and had no awareness of the LN's response to the low blood pressure reported by the CNA.Review of the facility's provided, Job Description: RN [registered nurse], dated 2/2024, revealed: .Monitor and adjust resident's status based on changing needs and conditions . Ensure that all nursing service personnel are in compliance with their respective job descriptions . Make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . Meet with your shift on a regularly scheduled basis to assist in identifying and correcting problem areas and/or to assist in the improvement of services . Notify the resident's attending physician and next-of-kin when there is a change in the resident's condition. Visit residents on a daily basis in order to observe and evaluate each resident's physical and emotional status .Review of the facility's provided, Job Description: LPN/LVN [licensed practical nurse/licensed vocational nurse], dated 2/2024, revealed: .The primary purpose of your job position is to provide direct nursing care to the residents . Nursing Care Functions . Consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary. Implement and maintain established nursing objectives and standards . Make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status . Notify the resident's attending physician and next-of-kin when there is a change in the resident's condition . Take and record . blood pressures, etc., as necessary . Monitor seriously ill residents as necessary . Ensure that resident's who are unable to call for help are checked frequently .Review of the facility's policy, Vital Signs, revised 12/2024, revealed: It is the policy of the facility to ensure the accurate and timely measurement, documentation, and monitoring of residents' vital signs to support their health, safety, and well-being in compliance with state and federal regulations . Vital signs shall be monitored according to the following guidelines: . Change in Condition - Vital signs shall be taken immediately when a resident exhibits signs of distress, deterioration, or any significant change in condition . 4. Report any abnormal findings to the charge nurse and physician as required. 5. Response to Abnormal Vital Signs . Significant Deviations - Notify the physician immediately and document the notification . Emergency Situations - Initiate emergency procedures (e.g., CPR, oxygen therapy) and call 911 if necessary.Review of the facility's policy, Fever/Septicemia - Clinical Protocol, last revised 3/2018, revealed: Assessment and Recognition .1. A nurse will assess a resident with a suspected infection and will document related findings . k. Description of any new or worsening decline in functional status, including confusion . decreased mobility . Assessment data will include: a. Vital signs . Management . The physician or provider will prescribe antibiotics judiciously, following CDC recommendations . Monitoring and Follow-Up . 1. The physician and nursing staff will evaluate the progress of individuals with fever and/or infection until the symptoms resolve. 2. Nursing staff and physician will monitor for other complications of infection, fever, or sepsis (for example . delirium). 3. The nurses will communicate with the physician or provider to identify whether the resident needs any special monitoring, precautions, or interventions.Review of the facility's policy, Change in a Resident's Condition or Status, last revised 2/2021, revealed: . 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): . d. significant change in the resident's physical/emotional/mental condition; . f. refusal of treatment . g. need to transfer the resident to a hospital/treatment center . 2. A significant change of condition is a major decline or improvement in the resident's status that . will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . b. there is a significant change in the resident's physical, mental, or psychosocial status .Review of the professional standard, Lippincott Nursing Procedures Ninth Edition book, dated 2023, revealed: . Blood Pressure Measurement . Frequent blood pressure measurement is critical . during any illness or condition that threatens cardiovascular stability . Frequent blood pressure measurement may also be necessary for unstable patients .

Based on record review, observation, and interview, the facility failed to: 1) provide multiple doses of routine anticonvulsant medication to Resident #1 per physician's order, and 2) provide accurate acquiring, and receiving of medications for one resident (#1) out of three sampled residents. These failed practices resulted in: 1) untimely acquisition and administering of medication for Resident #1; 2) Resident #1 enduring multiple seizure episodes, decorticate posturing [a reflex pose that's a symptom of damage to or disruptions in brain activity. It causes your legs to become rigid and straight, while your arms flex upward and hold tensely to your chest.] with nonresponsiveness for several hours, and subsequent hospitalization ; and 3) a negative outcome that compromised the resident's ability to maintain and/or reach his/her highest practicable physical wellbeing, as a consequence of subtherapeutic levels of anticonvulsant medication and caused actual harm to the resident. Findings: Record review on 1/21-22/25, revealed Resident #1 was admitted to the facility with diagnoses that included hemiplegia (weakness or paralysis of one side of the body) and hemiparesis (partial paralysis of one side of the body), anoxic brain damage (lack of oxygen to the brain resulting in cognitive, physical and neurological impairments) and general epilepsy (seizures that involve both halves of the brain) and epileptic syndrome (seizures that are characterized based on symptoms, location or origin, and diagnostic tests). Further review revealed Resident #1 had a PEG-Tube (a surgically inserted feeding tube into the stomach bypassing the mouth and esophagus) . Omitted Medication: Review of the Physician's order, dated 11/14/24, revealed: Valproic Acid Oral Solution [medication for seizures] 250 MG/5ML (Valproate Sodium) Give 20 ml via PEG-Tube two times a day for Anoxic Brain Injury. Review of the Medication Administration Record Report dated 12/1-31/24, revealed valproic acid oral solution 250 mg/5ml was not administered on 12/23/24 at 3:00 PM, 12/24/24 at 7:00 AM and 12/24/24 at 3:00 PM. Dates of unadministered valproic acid oral solution were coded as 9 for Other/See Nurses Notes. Review of the nursing notes section eMAR (electronic medication administration record) Medication Administration Note, dated 12/23/24 at 4:20 PM, revealed: Valproic Acid Oral Solution 250 MG/ 5 ML Give 20 ml via PEG-Tube two times a day for anoxic Brain Injury awaiting pharmacy to deliver. Review of the nursing notes section eMAR Medication Administration Note, dated 12/24/24 at 10:09 AM, revealed: Valproic Acid Oral Solution 250 MG/ 5 ML . waiting for delivery. Review of the nursing notes section eMAR Medication Administration Note, dated 12/24/24 at 4:57 PM, revealed: Valproic Acid Oral Solution .medication not available. Record review on 1/21/25 of Resident #1's EHR (electronic health record), dated 12/23/24 through 12/24/24, revealed no evidence that the nurses contacted the physician or the pharmacist about the unavailability of valproic acid oral solution. During an interview on 1/21/25 at 12:52 PM, when asked what the procedure was when a medication was not available, the Director of Nursing (DON) stated the nurse would call the provider if the medication was not available in the Cubex (the facility's medication storage system). Review of the Progress notes Health Status Note, dated 12/25/24 at 1:48 AM, revealed: Note Text: Resident [#1] had seizure like activity lasting approximately between one to two minutes.On-call provider called regarding situation and was given the approval to send resident [#1] to ER [emergency room ].Paramedics arrived 10 minutes later.transferred to .PROV [Providence Alaska Medical Center] ER at 0120 [1:20 AM]. Family. notified of transfer. Review of the Providence Alaska Medical Center (PAMC) Admission History & Physical, dated 12/25/24 at 7:33 AM, revealed: [Resident #1] presented with 2 witnessed generalized tonic-clonic seizures [an event that causes a loss of consciousness and violent muscle contractions]. 1 witnessed by [emergency room ] staff which was aborted with IV [intravenous] Ativan [a benzodiazepine medication used to treat active seizures] administration. [He/She] has had ongoing decorticate [a reflex pose that's a symptom of damage to or disruptions in brain activity. It causes your legs to become rigid and straight, while your arms flex upward and hold tensely to your chest.] posturing and nonresponsiveness for several hours. Decorticate posturing improved with additional dose of IV Ativan. Reports from [Resident #1's] [facility] say that [he/she] was not receiving [his/her] Depakote [brand name of valproic acid] for the about the last 48 hours due to running out of it, however [his/her] Depakote level was undetectable today, per discussion with pharmacy given the half-life of Depakote this likely means that [he/she] has been off of it for longer than 2 days. Review of Resident #1's PAMC emergency room medical record, dated 12/25/24, revealed a lab result, dated 12/25/24 at 2:33 am, for valproic acid in the Resident's blood was at < [less than] 3.0. The record indicated that a therapeutic range for valproic acid was between 50 and 100 ug/mL (microgram per milliliter). Review of the Providence Alaska Medical Center Discharge Summary, dated 12/27/24 at 11:00 AM, revealed: COURSE IN HOSPITAL .Patient had been without [his/her] home Depakote for the past 48 hours prior to admission, subsequently leading to seizures .Depakote bolus initiated, levels subtherapeutic .PLAN FOR FOLLOW -UP .3. It is imperative that this patient not run out of [his/her] antiseizure medications, as this is what led to this hospitalization . Review of the SKILLED NURSING FACILITY TRANSFER ORDERS, dated 12/27/24 at 11:36 AM, revealed Resident #1 was admitted to the hospital on 12/25/24 and discharged on [DATE] with a principal problem of Breakthrough seizure. The medication orders section revealed valproic acid 250mg/5 ml liquid was included in the list. Further review of the medication orders section, revealed a handwritten note which read: Please do not run off seizure meds[medicine] again. Review of the Provider's Progress Notes, dated 12/29/24, revealed: .Chief Complaint: return from hospital.HPI [history of present illness]: [Resident #1's name] .seems to have breakthrough seizures related to not receiving [his/her] seizure meds [medications]. Valproic acid undetectable in ED [Emergency Department] Received a loading dose of Depakote and was admitted overnight. Review of the facility's Drug Record Book, dated 1/21/25 at 4:46 PM revealed: Valproic Acid Oral Solution 250 MG/5ML . Re/Ordered Date: 12/09/2024 .12/30/2024 . Review of the medication delivery Packing Slip, dated 12/9/24, from PharMerica [the facility's contracted pharmacy] revealed: . 473.00 [ML] VALPROIC ACD SOL 250/5ML for Resident #1 was delivered. The facility received the medication on 12/10/24. Due to the medication being received on 12/10/24, this would only allowed the Resident to have enough medication through 12/21/24 if no additional medication was available. Review of another Packing Slip, dated 12/30/24, revealed valproic acid was delivered to the facility and received on 12/31/24. There was no other valproic acid solution for Resident #1 delivered between 12/9/24 and 12/30/24. During an interview on 1/21/25 at 4:24 PM, the Administrator stated the facility did not have inventory of valproic acid. She stated Resident #1's valproic acid was a G-tube medication (medications administered through a gastrostomy tube). She added that PharMerica would deliver the valproic acid two weeks at a time. She further stated when the medication ran-out on 12/23/24, that would have been the end of the two weeks. An observation on 1/21/25 at 3:15 PM revealed Resident #1's Valproic Acid Oral Solution USP bottle was 473 ml in size. During an interview with the Pharmacist on 1/22/24 at 8:00 AM, he/she stated based off Resident #1's medication order of 40 ml per day, Resident #1 would receive only 11 full days of Valproic Acid from a 473 ml bottle. During an interview with Licensed Nurse (LN) #2 on 1/21/25 at 3:15 PM, he/she stated the way he/she knew when to reorder Resident #1's valproic acid bottle was to look at the bottle and reorder another bottle if it looked like the bottle was getting close to being empty. During an interview on 1/21/25 at 4:24 PM, when asked when the facility requested delivery of valproic acid on 12/23-24/24, the Administrator stated she was out at that time, she learned about the missed medication today [1/21/25]. When asked if the missed medication was discussed during the stand-up meeting [daily staff meeting], she stated there was no leadership team during Christmas so there was no stand-up meeting that day [12/25/24]. She stated, It got missed, she further stated it should have been reported to the State. During an interview on 1/21/25 at 5:04 PM with the Administrator, she confirmed that PharMerica did not receive a refill order for valproic acid solution from a nurse during the time when the medication was not available in the facility. Review of the facility's policy Medication Administration General Guidelines , dated 1/2023, revealed: .Documentation .2. If a dose of regularly scheduled medication is withheld .the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN [as needed] documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified . Review of the Food and Drug Administration (FDA) Medication Guide for Valproic Acid, accessed on 1/29/25 at https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/018081s070,018082s053lbl.pdf#page=41 revealed: Stopping Depakote or Depakene suddenly can cause serious problems. Review of the facility provided document Medication Guide Valproic Acid Oral Solution on 1/21/25, revealed: Do not stop Valproic Acid Oral Solution, USP . Stopping Valproic Acid Oral Solution, USP suddenly can cause serious problems. Stopping a seizure medicine suddenly in a patient who has epilepsy can cause seizures that will not stop (status epilepticus). Acquisition and receiving of medications: During an interview on 1/21/25 at 10:51 AM, LN #1 stated residents' medications were in the medication cart. If there was no available medication in the medication cart, the nurse would check the availability of the medication in the Cubex . If there was no available medication in the Cubex, the nurse would request for a refill. Review of the Anchorage Cubex [Medication Inventory] List, on 1/21/25 at 3:57 PM, revealed valproic acid was not listed. When asked about the requisition process, LN #1 stated if the medication was a new medication, then the nurse would have removed a strip from the medication's label and attached the strip to a fax form and send the fax to PharMerica for refill. During the same interview, LN #1 stated PharMerica had an automatic refill process in the pharmacy system for scheduled medications that the residents' had been receiving, so the nurses did not need to fax a refill order. During an interview on 1/21/25 at 12:52 PM, the Director of Nursing (DON) when asked about the expectation for the pharmacy delivery time, he stated if the medication order was placed at 2:00 PM then the medication would be delivered the next day. If the order was placed after 4:00 PM, the medication would be delivered not the next day but the following day. DON further stated if nurses were unable to administer a medication within the hour due to a missing dose, the expectation was to further notify the provider and document in the EHR. When asked if PharMerica would notify the facility if the medication was not available, the DON stated PharMerica would not notify the facility of the unavailability of the medication, but they would send a partial refill. He added that if PharMerica could not send the medication, PharMerica would call a satellite pharmacy locally (in Anchorage), then the local pharmacy will deliver the medication to the facility in a few hours. During an interview on 1/22/25 at 8:00 AM, the Pharmacist stated he was not a fulltime employee of the facility. He added that he was a local pharmacist that was hired by PharMerica to provide consultation. His role in the facility was to load medication in the Cubex on Tuesdays and Thursdays and conduct a monthly chart review including psychotropic medication review of all residents in the facility. He stated the nurses and providers could email, call or text him. During the same interview, the Pharmacist stated the Cubex had individual cubies that stored individual medication like tablets or inhalers which were not Resident specific medications. He added that when the medications were delivered, he would stock the Cubex. If the delivered pack contained a whole month supply for a resident , he stated he does not check those medications. He further stated he did not reconcile the medications received for the resident specific medications. The Pharmacist further stated if the medication was running low, or expired, PharMerica would send new supply. When asked if he kept a list of delivered medication for the Cubex, he stated no. He further stated a delivery invoice comes with the package. After loading the medication in the Cubex, he would then throw away the delivery invoice. When asked if he had a list of expired medications that were sent to PharMerica, he stated no, the expired medication was packed and returned to the pharmacy. Review of the Pharmacy Services Agreement, signed by the facility on 7/29/24 and signed by PharMerica on 8/2/24, revealed: .Pharmacy shall provide the services set forth in the agreement to Client and persons in care of the Customer (the 'Residents' or 'Patients') in accordance with the terms and conditions of this Agreement, and any Schedules, Exhibits or policies and procedures of the Manual (collectively, the 'Services'), which are incorporated into this Agreement by reference.OBLIGATIONS OF THE PHARMACY. A. Pharmacy shall provide to Client and deliver to the Customer prescription and non-prescription drugs. In accordance with the orders of the Resident's licensed prescribers as provided to Pharmacy by Customer, and the Customer's own orders.B. Pharmacy shall deliver Products in accordance with Pharmacy's routine delivery schedule. Delivery schedules and cut-off times will be at the sole discretion of Pharmacy. Pharmacy will make three (3) schedule deliveries per day. OBLIGATIONS OF THE CLIENT. Client shall, or require the Customer to, as the case may be.B. Use its reasonable effects to aggregate, organize and plan daily orders to Pharmacy to minimize Stat orders. H. Provide Pharmacy with access to the Customer, as necessary, to enable Pharmacy to carry out its obligations under the Agreement.J. Store and handle all Medications in accordance with Applicable Law. M. return to Pharmacy unused Medications.P. adopt Medication ordering processes that conform to the Pharmacy's dispensing procedures.

Based on record review, interview and observation, the facility failed to protect the resident's right to be free from deprivation of goods and services by facility staff. Specifically, the facility failed to ensure an anticonvulsant medication was available and administered per physician's order for one resident (#1) out of three sampled residents. This failed practice of deprivation of goods and services resulted in Resident #1 not receiving medication causing the resident to endure multiple seizure episodes, decorticate posturing [a reflex pose that's a symptom of damage to or disruptions in brain activity. It causes your legs to become rigid and straight, while your arms flex upward and hold tensely to your chest.] with nonresponsiveness for several hours, and subsequent hospitalization . This failed practice resulted in a negative outcome that compromised the resident's ability to maintain and/or reach his/her highest practicable physical wellbeing, as a consequence of subtherapeutic levels of anticonvulsant medication and caused actual harm to the resident. Findings: Record review on 1/21-22/25, revealed Resident #1 was admitted to the facility with diagnoses that included hemiplegia (weakness or paralysis of one side of the body) and hemiparesis (partial paralysis of one side of the body), anoxic brain damage (lack of oxygen to the brain resulting in cognitive, physical and neurological impairments) and general epilepsy (seizures that involve both halves of the brain) and epileptic syndrome (seizures that are characterized based on symptoms, location or origin, and diagnostic tests). Further review revealed Resident #1 had a PEG-Tube (a surgically inserted feeding tube into the stomach bypassing the mouth and esophagus). Omitted Medication: Review of the Physician's order, dated 11/14/24, revealed: Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) [medication for seizures] Give 20 ml via PEG-Tube two times a day for Anoxic Brain Injury. Review of the Medication Administration Record Report dated 12/1-31/24, revealed valproic acid oral solution 250 mg/5ml was not administered on 12/23/24 at 3:00 PM, 12/24/24 at 7:00 AM and 12/24/24 at 3:00 PM. Dates of unadministered valproic acid oral solution were coded as 9 for Other/See Nurses Notes. Review of the nursing notes section eMAR (electronic medication administration record) Medication Administration Note, dated 12/23/24 at 4:20 PM, revealed: Valproic Acid Oral Solution 250 MG/ 5 ML Give 20 ml via PEG-Tube two times a day for anoxic Brain Injury awaiting pharmacy to deliver. Review of the nursing notes section eMAR Medication Administration Note, dated 12/24/24 at 10:09 AM, revealed: Valproic Acid Oral Solution 250 MG/5 ML . waiting for delivery. Review of the nursing notes section eMAR Medication Administration Note, dated 12/24/24 at 4:57 PM, revealed: Valproic Acid Oral Solution .medication not available. Record review on 1/21/25 of Resident #1's EHR (electronic health record), dated 12/23/24 through 12/24/24, revealed no evidence that the nurses contacted the physician or the pharmacist about the unavailability of valproic acid oral solution. During an interview on 1/21/25 at 12:52 PM, when asked what the procedure was when a medication was not available, the Director of Nursing (DON) stated the nurse would call the provider if the medication was not available in the Cubex (the facility's medication storage system). Review of the Progress notes Health Status Note, dated 12/25/24 at 1:48 AM, revealed: Note Text: Resident [#1] had seizure like activity lasting approximately between one to two minutes.On-call provider called regarding situation and was given the approval to send resident [#1] to ER [emergency room ].Paramedics arrived 10 minutes later.transferred to .PROV [Providence Alaska Medical Center] ER at 0120. Family. notified of transfer. Review of the Providence Alaska Medical Center (PAMC) Admission History & Physical, dated 12/25/24 at 7:33 AM, revealed: [Resident #1] presented with 2 witnessed generalized tonic-clonic seizures [an event that causes a loss of consciousness and violent muscle contractions]. 1 witnessed by [emergency room ] staff which was aborted with IV [intravenous] Ativan [a benzodiazepine medication used to treat active seizures] administration. [He/She] has had ongoing decorticate posturing and nonresponsiveness for several hours. Decorticate posturing improved with additional dose of IV Ativan. Reports from [Resident #1's] [facility] say that [he/she] was not receiving [his/her] Depakote [brand name of valproic acid] for about the last 48 hours due to running out of it, however [his/her] Depakote level was undetectable today, per discussion with pharmacy given the half-life of Depakote this likely means that [he/she] has been off of it for longer than 2 days. Review of Resident #1's PAMC emergency room medical record, dated 12/25/24, revealed a lab result, dated 12/25/24 at 2:33 am, for valproic acid in the Resident's blood was at < [less than] 3.0. The record indicated that a therapeutic range for valproic acid was between 50 and 100 ug/mL (microgram per milliliter). Review of the Providence Alaska Medical Center Discharge Summary, dated 12/27/24 at 11:00 AM, revealed: COURSE IN HOSPITAL .Patient had been without [his/her] home Depakote for the past 48 hours prior to admission, subsequently leading to seizures .Depakote bolus initiated, levels subtherapeutic .I have significant concerns that patient ran out of [his/her] seizure medicine at skilled nursing. Case management and social worker are aware and will be further investigating. Family is also very concerned about patient care at this facility and I understand their concerns .PLAN FOR FOLLOW -UP .3. It is imperative that this patient not run out of [his/her] antiseizure medications, as this is what led to this hospitalization . Review of the SKILLED NURSING FACILITY TRANSFER ORDERS, dated 12/27/24 at 11:36 AM, revealed Resident #1 was admitted to the hospital on 12/25/24 and discharged on [DATE] with a principal problem of Breakthrough seizure. The medication orders section revealed valproic acid 250mg/5 ml liquid was included in the list. Further review of the medication orders section, revealed a handwritten note which read: Please do not run off seizure meds[medicine] again. Review of Progress notes Alert Notes on 12/27/24 at 7:51 PM revealed: Resident [sibling] came in around 19:30 [7:30 pm] this evening .This writer respectfully answered the [sibling] that the only person we can give [information] regarding the resident will be [his/her] POA [Power of Attorney]. As of this time, if you will be asking an in depth regarding resident cares and medications, it's better if you could talk to the POA or if management will be here. This [sibling] adamantly asking what medications are you giving at night and at days and they said to us in the hospital that my resident was neglected with [his/her] medications! This writer even verbalized as of this time, I cannot give you an in depth [information] about that. However, if you have concerns, just wait and talk to our Nursing management during office hours. Review of the Provider's Progress Notes, dated 12/29/24, revealed: .Chief Complaint: return from hospital.HPI [history of present illness]: [Resident #1's name] .seems to have breakthrough seizures related to not receiving [his/her] seizure meds[medications]. Valproic acid undetectable in ED [Emergency Department] Received a loading dose of Depakote and was admitted overnight. Review of the facility's Drug Record Book, dated 1/21/25 at 4:46 PM revealed: Valproic Acid Oral Solution 250 MG/5ML . Re/Ordered Date: 12/09/2024 .12/30/2024 . Review of the medication delivery Packing Slip, dated 12/9/24, from PharMerica [the facility's contracted pharmacy] revealed: . 473.00 [ML] VALPROIC ACD SOL 250/5ML for Resident #1 was delivered. The facility received the medication on 12/10/24. Review of another Packing Slip, dated 12/30/24, revealed valproic acid was delivered to the facility and received on 12/31/24. There was no other valproic acid solution for Resident #1 delivered between 12/9/24 and 12/30/24. During an interview on 1/21/25 at 4:24 PM, the Administrator stated the facility did not have inventory of valproic acid. She stated Resident #1's valproic acid was a G-tube medication (medications administered through a gastrostomy tube). She added that PharMerica would deliver the valproic acid two weeks at a time. She further stated when the medication ran-out on 12/23/24, that would have been the end of the two weeks. An observation on 1/21/25 at 3:15 PM revealed Resident #1's Valproic Acid Oral Solution USP bottle was 473 ml in size. During an interview with Licensed Nurse (LN) #2 on 1/21/25 at 3:15 PM, he/she stated the way he/she knew when to reorder Resident #1's valproic acid bottle was to look at the bottle and reorder another bottle if it looked like the bottle was getting close to being empty. During an interview with the Pharmacist on 1/22/24 at 8:00 AM, he/she stated based off Resident #1's medication order, Resident #1 would receive only 11 full days of valproic acid from a 473 ml bottle. During an interview with the Director of Nursing (DON) on 1/21/25 at 2:15 PM, DON stated the investigation for Resident #1's missed doses of valproic acid and subsequent hospitalization was ongoing and had not been completed. DON further stated that he was waiting to interview one nurse that was assigned to Resident #1 on the day Resident #1 did not receive scheduled valproic acid. DON stated he does not know the cause of valproic acid being unavailable. DON stated he opened the investigation the day after Resident #1 came back from the facility. When asked if missed medication was the reason for hospitalization , DON stated possibly, don't know for sure, the hospital paperwork isn't saying that. Review of the Providence Alaska Medical Center Discharge Summary, dated 12/27/24 at 11:00 AM, revealed: COURSE IN HOSPITAL .Patient had been without [his/her] home Depakote for the past 48 hours prior to admission, subsequently leading to seizures .PLAN FOR FOLLOW -UP .3. It is imperative that this patient not run out of [his/her] antiseizure medications, as this is what led to this hospitalization . During an interview on 1/21/25 at 4:24 PM, when asked when the facility requested delivery of valproic acid on 12/23-24/24, the Administrator stated she was out at that time, she learned about the missed medication today [1/21/25]. When asked if the missed medication was discussed during the stand-up meeting [daily staff meeting], she stated there was no leadership team during Christmas so there was no stand-up meeting that day [12/25/24]. She further stated that Resident #1 being in the hospital was discussed during the stand-up meeting the day after [12/26/24] and that the stand up was led by the DON. She stated, It got missed, she further stated it should have been reported to the State. During an interview on 1/21/25 at 5:04 PM with the Administrator, she confirmed that PharMerica did not receive a refill order for valproic acid solution from a nurse during the time when the medication was not available in the facility. Review of the stand up meeting minutes, dated 12/26/24 at 10:16 AM, revealed: Hospital .[Resident #1]-seizures . Review of the Incident Report, Medication Error, unknown creation date, revealed, [Resident #1] had a seizure at 0148 hours on 12/25/2024. After the seizure it was noted that the resident did not receive [his/her] Depakote medication on 12/23/24 at 100 hours, and both doses on 12/24/2024 .The resident was assessed by the unit nurse, the on-call provider was notified and the resident was sent to the emergency room for evaluation . Review of the facility's policy Medication Administration General Guidelines, dated 1/2023, revealed: .Documentation .2. If a dose of regularly scheduled medication is withheld .the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN [as needed] documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified . Review of the Food and Drug Administration (FDA) Medication Guide for Valproic Acid, accessed on 1/29/25 at https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/018081s070,018082s053lbl.pdf#page=41 revealed: Stopping Depakote or Depakene suddenly can cause serious problems. Review of the facility provided document Medication Guide Valproic Acid Oral Solution on 1/21/25, revealed: Do not stop Valproic Acid Oral Solution, USP . Stopping Valproic Acid Oral Solution, USP suddenly can cause serious problems. Stopping a seizure medicine suddenly in a patient who has epilepsy can cause seizures that will not stop (status epilepticus). Review of the facility's policy Unusual Occurrence Reporting, undated, revealed: As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare or our residents . 1. Our facility will report the following events to appropriate agencies: Allegations of abuse, neglect . and . Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents . Unusual occurrences shall be reported via telephone to appropriate agencies are required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations . Review of the facility's Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection policy, revised 1/2023 revealed: .6. Facility utilizes Incident/Accident Investigation policy and procedure to investigate concerns and incidents . All alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown sources . must be thoroughly investigated. The investigation is done to determine, as far as possible: i. What occurred; and ii. To make necessary changes to the provision of care and services to prevent reoccurrence. b. A thorough investigation is completed through a systemic collection and review of evidence/information that describes and explains an event or series of events. It seeks to determine if abuse, neglect . and how to prevent further occurrences .14. All staff members are considered mandatory reporters and as such are obligated to report using the state reporting mechanism 16 .If the allegation involves neglect . that does not involve abuse or serious injury, the incident is reported within 24 hours to local law enforcement and the state survey agency, as required . DEFINITIONS OF ABUSE: . Neglect: is the failure of the facility, its employees or service providers to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .

Based on record review, observation , and interview, the facility failed to ensure one resident (#1) out three sampled residents was free of a significant medication error. Specifically, the facility failed to provide multiple consistent doses of an anticonvulsant medication per physician's order. This failed practice resulted in: 1) a significant medication error due to the omission of administering multiple doses of anticonvulsant medication for Resident #1; 2) Resident #1 enduring multiple seizure episodes, decorticate posturing [a reflex pose that's a symptom of damage to or disruptions in brain activity. It causes your legs to become rigid and straight, while your arms flex upward and hold tensely to your chest.] with nonresponsiveness for several hours, and subsequent hospitalization ; and 3) a negative outcome that compromised the resident's ability to maintain and/or reach his/her highest practicable physical wellbeing, as a consequence of subtherapeutic levels of anticonvulsant medication and caused actual harm to the resident. Findings: Record review on 1/21-22/25, revealed Resident #1 was admitted to the facility with diagnoses that included hemiplegia (weakness or paralysis of one side of the body) and hemiparesis (partial paralysis of one side of the body), anoxic brain damage (lack of oxygen to the brain resulting in cognitive, physical and neurological impairments) and general epilepsy (seizures that involve both halves of the brain) and epileptic syndrome (seizures that are characterized based on symptoms, location or origin, and diagnostic tests). Further review revealed Resident #1 had a PEG-Tube (a surgically inserted feeding tube into the stomach bypassing the mouth and esophagus) . Omitted Medication: Review of the Physician's order, dated 11/14/24, revealed: Valproic Acid Oral Solution [medication for seizures] 250 MG/5ML (Valproate Sodium) Give 20 ml via PEG-Tube two times a day for Anoxic Brain Injury. Review of the Medication Administration Record Report dated 12/1-31/24, revealed valproic acid oral solution 250 mg/5ml was not administered on 12/23/24 at 3:00 PM, 12/24/24 at 7:00 AM and 12/24/24 at 3:00 PM. Dates of unadministered valproic acid oral solution were coded as 9 for Other/See Nurses Notes. Review of the nursing notes section eMAR (electronic medication administration record) Medication Administration Note, dated 12/23/24 at 4:20 PM, revealed: Valproic Acid Oral Solution 250 MG/ 5 ML Give 20 ml via PEG-Tube two times a day for anoxic Brain Injury awaiting pharmacy to deliver. Review of the nursing notes section eMAR Medication Administration Note, dated 12/24/24 at 10:09 AM, revealed: Valproic Acid Oral Solution 250 MG/ 5 ML . waiting for delivery. Review of the nursing notes section eMAR Medication Administration Note, dated 12/24/24 at 4:57 PM, revealed: Valproic Acid Oral Solution .medication not available. During an interview on 1/21/25 at 12:52 PM, when asked what the procedure was when a medication was not available, the Director of Nursing (DON) stated the nurse would call the provider if the medication was not available in the Cubex (the facility's medication storage system). During the same interview on 1/21/25 at 12:52 PM, when asked about the expectation for the pharmacy delivery time, the DON stated if the medication order was placed at 2:00 PM then the medication would be delivered the next day. If the order was placed after 4:00 PM, the medication would be delivered not the next day but the following day. DON further stated if nurses were unable to administer a medication within the hour due to a missing dose, the expectation was to further notify the provider and document in the EHR (electronic health record). Record review on 1/21/25 of Resident #1's EHR, dated 12/23/24 through 12/24/24, revealed no evidence that the nurses contacted the physician or the pharmacist about the unavailability of valproic acid oral solution. Review of the Progress notes Health Status Note, dated 12/25/24 at 1:48 AM, revealed: Note Text: Resident [#1] had seizure like activity lasting approximately between one to two minutes.On-call provider called regarding situation and was given the approval to send resident [#1] to ER [emergency room ].Paramedics arrived 10 minutes later.transferred to .PROV [Providence Alaska Medical Center] ER at 0120 [1:20 AM]. Family. notified of transfer. Review of the Providence Alaska Medical Center (PAMC) Admission History & Physical, dated 12/25/24 at 7:33 AM, revealed: [Resident #1] presented with 2 witnessed generalized tonic-clonic seizures [an event that causes a loss of consciousness and violent muscle contractions]. 1 witnessed by [emergency room ] staff which was aborted with IV [intravenous] Ativan [a benzodiazepine medication used to treat active seizures] administration. [He/She] has had ongoing decorticate posturing and nonresponsiveness for several hours. Decorticate posturing improved with additional dose of IV Ativan. Reports from [Resident #1's] [facility] say that [he/she] was not receiving [his/her] Depakote [brand name for valproic acid] for the about the last 48 hours due to running out of it, however [his/her] Depakote level was undetectable today, per discussion with pharmacy given the half-life of Depakote this likely means that [he/she] has been off of it for longer than 2 days. Review of Resident #1's PAMC emergency room medical record, dated 12/25/24, revealed a lab result, dated 12/25/24 at 2:33 am, for valproic acid in the Resident's blood was at < [less than] 3.0. The record indicated that a therapeutic range for valproic acid was between 50 and 100 ug/mL (microgram per milliliter). Review of the Providence Alaska Medical Center Discharge Summary, dated 12/27/24 at 11:00 AM, revealed: COURSE IN HOSPITAL .Patient had been without [his/her] home Depakote for the past 48 hours prior to admission, subsequently leading to seizures .Depakote bolus initiated, levels subtherapeutic .PLAN FOR FOLLOW -UP .3. It is imperative that this patient not run out of [his/her] antiseizure medications, as this is what led to this hospitalization . Review of the SKILLED NURSING FACILITY TRANSFER ORDERS, dated 12/27/24 at 11:36 AM, revealed Resident #1 was admitted to the hospital on 12/25/24 and discharged on [DATE] with a principal problem of Breakthrough seizure. The medication orders section revealed valproic acid 250mg/5 ml liquid was included in the list. Further review of the medication orders section, revealed a handwritten note which read: Please do not run off seizure meds[medicine] again. Review of the Provider's Progress Notes, dated 12/29/24, revealed: .Chief Complaint: return from hospital.HPI [history of present illness]: [Resident #1's name] .seems to have breakthrough seizures related to not receiving [his/her] seizure meds [medications]. Valproic acid undetectable in ED [Emergency Department] Received a loading dose of Depakote and was admitted overnight. Review of the facility's Drug Record Book, dated 1/21/25 at 4:46 PM revealed: Valproic Acid Oral Solution 250 MG/5ML . Re/Ordered Date: 12/09/2024 .12/30/2024 . Review of the medication delivery Packing Slip, dated 12/9/24, from PharMerica [the facility's contracted pharmacy] revealed: . 473.00 [ML] VALPROIC ACD SOL 250/5ML for Resident #1 was delivered. The facility received the medication on 12/10/24. Due to the medication being received on 12/10/24, this would only allow the Resident to have enough medication through 12/21/24 if no additional medication was available. Review of another Packing Slip, dated 12/30/24, revealed valproic acid was delivered to the facility and received on 12/31/24. There was no other valproic acid solution for Resident #1 delivered between 12/9/24 and 12/30/24. During an interview on 1/21/25 at 4:24 PM, the Administrator stated the facility did not have inventory of valproic acid. She stated Resident #1's valproic acid was a G-tube medication (medications administered through a gastrostomy tube). She added that PharMerica would deliver the valproic acid two weeks at a time. She further stated when the medication ran-out on 12/23/24, that would have been the end of the two weeks. An observation on 1/21/25 at 3:15 PM revealed Resident #1's Valproic Acid Oral Solution USP bottle was 473 ml in size. During an interview with the Pharmacist on 1/22/24 at 8:00 AM, he stated based off Resident #1's medication order of 40 ml per day, Resident #1 would receive only 11 full days of valproic acid from a 473 ml bottle. During an interview with Licensed Nurse (LN) #2 on 1/21/25 at 3:15 PM, he/she stated the way he/she knew when to reorder Resident #1's valproic acid bottle was to look at the bottle and reorder another bottle if it looked like the bottle was getting close to being empty. During an interview on 1/21/25 at 4:24 PM, when asked when the facility requested delivery of valproic acid on 12/23-24/24, the Administrator stated she was out at that time, she learned about the missed medication today [1/21/25]. When asked if the missed medication was discussed during the stand-up meeting [daily staff meeting], she stated there was no leadership team during Christmas so there was no stand-up meeting that day [12/25/24]. She stated, It got missed, she further stated it should have been reported to the State. During an interview on 1/21/25 at 5:04 PM with the Administrator, she confirmed that PharMerica did not receive a refill order for valproic acid oral solution from a nurse during the time when the medication was not available in the facility. Review of the facility's policy Medication Administration General Guidelines , dated 1/2023, revealed: .Documentation .2. If a dose of regularly scheduled medication is withheld .the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN [as needed] documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified . Review of the Food and Drug Administration (FDA) Medication Guide for Valproic Acid, accessed on 1/29/25 at https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/018081s070,018082s053lbl.pdf#page=41 revealed: Stopping Depakote or Depakene suddenly can cause serious problems. Review of the facility provided document Medication Guide Valproic Acid Oral Solution on 1/21/25, revealed: Do not stop Valproic Acid Oral Solution, USP . Stopping Valproic Acid Oral Solution, USP suddenly can cause serious problems. Stopping a seizure medicine suddenly in a patient who has epilepsy can cause seizures that will not stop (status epilepticus).

Based on record review and interview, the facility failed to ensure the care plan was followed for 1 resident (#6), for one record reviewed. Specially, Certified Nursing Assistant (CNA) (#12) failed to follow Resident #6's care plan for activities of daily living (ADLs) and the total number of staff needed for safe bed mobility and toileting. This failed practice resulted in a fall with serious physical injuries from the resident's bed, negatively impacting Resident #6 and potentially declining Resident's physical well-being. Findings: Record review on 6/3-5/24 revealed Resident #6 was admitted to the facility with diagnoses that include hemiplegia (weakness or paralysis of one side of the body), contractures (an abnormal and usually permanent shortening of a muscle, resulting in distortion or deformity; stiffness of the joints that causes deformity and prevents full extension), muscle weakness, adult failure to thrive, and below knee amputation. Review of Resident #6's Kardex (a quick reference sheet which outlines a resident's overall care needs, derived from the resident's care plan), dated as of 6/3/24, revealed: . ADL/Mobility . bed mobility - 2 person dependent [meaning two staff were required for safety] . Toileting . Toileting - 2 person extensive assist, incontinence care per protocol [meaning two staff were required for safety] . Review of the Corrective Action Form - Final Written Warning, dated 3/6/24, addressed to CNA #12 stated the following Facts: On 3/2/2024 at approximately 2230 hours, the CNA entered a resident's room to check on him/her. After determining that the resident was to require incontinence care . The CNA rolled the resident by himself/herself to provide care, and when rolling the resident, the resident fell to the ground from the bed. The resident care plan required that the resident have two person assist with any bed mobility. The CNA was aware of this fact but made the decision to provide the care without waiting for his/her partner. Unfortunately, the resident did fall during the care provided, and this resulted in at least one confirmed fracture with two more potential that will be confirmed or ruled out at his/her orthopedic follow up . Review of Alaska Regional Emergency Department Encounter Note, dated 3/3/24, revealed Resident #6 presented with traumatic left pain and swelling secondary to a mechanical fall . Per EMS [Emergency Medical Services] report [staff were] changing [his/her] [brief] . when patient fell out of the bed and landed on [his/her] left knee. Further review of this document revealed: Radiology . results: 1. Comminuted nondisplaced fracture of the patella. Question [of] a nondisplaced fracture of the lateral femoral condyle. 3. There is diffuse demineralization, which limits evaluation for presence of subtle nondisplaced fracture; correlate for presence of osteoporosis.; Final impression: 1. Closed nondisplaced comminuted fracture of left patella . 2. Contusion of left knee . 3. Closed nondisplaced fracture of the condyle of left femur.; Patient instructions . Non weightbearing on this joint. Follow up as an outpatient with Orthopedics. Continue to take pain medications as prescribed. During an interview via phone call on 6/4/24 at 10:00 AM, when asked what happen with Resident #6 on 2/3/24, CNA #12 stated, I made a mistake, I accidentally was changing him/her . my coworker was always going to the bathroom that night because he/she wasn't feeling well, so I changed [Resident #6] and he/she fell . I was on the left side and he/she fell on the right . he/she was holding the rails, and then don't know how it happen she/he let go and fell . immediately called the priority nurse and getting the vital signs and brought him/her back to bed. Review of the facility's policy Fall Risk and Neurological Assessment, last revised on 11/6/23, revealed: It is the policy of this center that residents are evaluated for their risk of falls upon admission. A plan of prevention is initiated, as appropriate, for identified risks . Procedure: 1) The Morse Fall Risk Scale is completed on admission. 2) The Kardex includes interventions based on the results identified in the Morse fall scale and includes specific interventions for fall prevention . The MDS, including Care Area Assessment (CAA) is utilized to further evaluate resident's risk of falls and development of the comprehensive care plan. During an interview on 6/4/24 at 12:00 PM, the Director of Nursing (DON) stated CNA #12 was re-trained on 3/4/24 on the Importance of Care Plan adherence and acknowledgement, pointing out how to review and where to find the Kardex, and action required where each member of the nursing staff shall thoroughly review the Kardex for every resident under their care. CNA #12 also received a final written warning letter on 3/6/24. The DON further stated: this is the first time this staff had an incident like this, and he/she has been working here for many years always with exemplar conduct. No further incidents have occurred since 3/2024, and CNA #12 has been performing his/her duties without further concern. .

Based on record review and interview the facility failed to ensure social services had identified, assessed, and took action for: 1) the need for a power of attorney (POA) and/or guardian and 2) the ability to give consent to sexual activity, for 1 resident (#1), out of 3 sampled residents. The failure to ensure the resident had protection to assist with decision making and/or ability to consent, allowed a situation in which the resident was removed from the facility and potentially exploited by a staff member. After the event the resident was hospitalized with hypertension (high blood pressure) and dehydration. Findings: Resident #1 Record review on 9/22/17 and 9/30/17 revealed Resident #1 had [DIAGNOSES REDACTED]. The Resident required extensive assistance with transfers and personal care and did not have a power of attorney (POA) or guardian to help make decisions. A POA is chosen by the individual to act in their behalf; a guardian is chosen by the courts. The Resident had an agency that paid his/her medical bills at the facility. Cognition Review of an Occupational Therapy OT Evaluation and Plan of Treatment dated 8/18/15, revealed Was SLUMS (St. Louis University Mental Status Examination-a screening exam for dementia to determine possible referral) Administered? =Yes .Slums=14/30, Dementia . A SLUMS score from 1-20 may indicate dementia. Review of the Minimum Data Set (MDS) annual assessment, dated 4/17/16, revealed the Resident's brief interview for mental status (BIMS) score was 9, which may indicate moderate memory impairment. Review of the most recent MDS assessment, dated 7/9/17, revealed the Resident's BIMS score was a 2 Review of a prior MDS assessment BIMS, dated 4/9/17 revealed the Resident's score was a 5. A BIMS of 0-7 indicates the individual's memory may be severally impaired. Review of the Care Area Assessment (CAA), dated 4/9/17, revealed Resident is alert with [DIAGNOSES REDACTED]. Noted problems with recalling during assessment. This places the resident at risk for social isolation and resident getting needs met. Review of Resident #1's care plan revealed the problem Resident has a memory/recall problem R/T (related to) CVA (cerebrovascular accident/ stroke), dated 3/15/16, revealed Alert physician if new onset of cognitive loss observed .Engage resident in conversation that is meaningful to the resident .Provided verbal and visual reminders as needed (e.g. directions, pictures, etc.) .Review photographs, memory books, keepsakes, etc. with the resident as needed. Further review of the care plan, updated by the Resident Care Manager (RCM) on 9/22/17, revealed there were no changes to this problem or the approaches related to the Resident's memory problem. Review of a social service note, dated 5/22/17, revealed Received notification that NP (Nurse Practitioner) would like POA (power of attorney) pursued for resident. Spoke with resident; he is not interested in having another person appointed to make his decisions. Resident continues to be alert and oriented to person, place, and situation. Does exhibit some disorientation to time, however resident does make consistent and reasonable decisions when in familiar environment. There was no information about further testing for cognitive impairment before or after the decline in the BIMS score. Review of a social service note, dated 5/30/17, revealed .made several attempts on varying days to administer BIMS and PHQ-9 assessments; resident became aggravated or dismissed social services on attempts. Review of the MDS assessment, dated 5/17/17, revealed Resident #1 had short and long term memory problems and was Moderately Impaired-decisions poor; cues/supervision required. Review of a providers note, dated 5/14/17, revealed .has no impulse control. Further review revealed Resident #1 had left the facility with certified nursing assistant (CNA) #2 on 9/16/17 at 4:15 pm, with plans to return later in the evening. At 12:00 am, when the Resident had not returned, Licensed Nurse (LN) #1 called the facility Administrator and reported him/her missing. The Resident was subsequently found, by administrative staff and local police, in a neighboring community with the CNA #2. The Resident was subsequently hospitalized with dehydration and a hypertensive crisis. Review of the Release of Responsibility for Leave of Absence revealed Authorization must be signed by the resident, or by the nearest relative on the case of a minor when resident is physically or mentally incompetent. Further review revealed the CNA had signed the Resident out on 8/26/17 at 12:55 pm and 2:00 pm and 9/16 at 4:15 pm. An interview was conducted with RCM #2 on 9/22/17 at 11:30 am. When asked about the process for reviewing the results of a BIMS score for a resident and if that resident would need a power of attorney or guardian based on that score the RCM stated Social Services does the BIMS interview. Social Services would look at the previous MDS and compare the BIMS scores. Then the RCM reviews the scores. The Interdisciplinary Team would review the BIMS if there were changes in the scoring. The RCM was asked what BIMS number would trigger the facility to initiate a power of attorney or guardian application for a resident. The RCM said there was no target number. The RCM review the quarterly MDS' for changes. The changes would be discussed at resident care conferences and a referral would be made to Social Services for power of attorney (POA) or guardianship. If there was no family there would be a referral to APS (Adult Protective Services). The RCM was asked about a BIMS score that progressively went down with every MDS. The RCM said there was a 14 day time frame to observe the resident to see if a significant change would be needed. We observe for any signs/symptoms of a urinary tract infection; review the diagnosis; possible referral for SLUM test; and look for early detection of dementia. During an interview on 9/22/17 at 11:30 am, when asked about Resident #1's ability to make decisions, LN #2 stated the Resident usually stated yes or no answers because of the aphasia. The LN stated the Resident knows who he/she is and where he/she is. During an interview with the Speech Language Pathologist (SLP) on 9/22/17 at 12:15 pm, when asked how Resident's cognition was assessed if they had a declining BIMS score, the SLP replied therapies could do the SLUMS assessment to assist in determining a dementia diagnosis. The SLP stated the facility would have to refer the Resident to the rehabilitation department for the test. During an interview on 9/22/17 at 3:40 pm, when asked about Resident #1's declining BIMS score and the need for a POA and/or guardian, the Social Service Director (SSD) stated he/she had spoken with Resident #1 who was adamant he/she did not want a POA. The SSD stated the Resident was able to make his/her own decisions. When asked about how the Resident was determined to be competent enough to make the decision about a POA, given his/her potential decline in cognitive status, the SSD replied the interdisciplinary team would make that decision. During an interview on 10/3/17 at 8:45 am, the Resident's emergency contact/friend stated he/she had known the Resident for a long time. The friend stated the Resident's long term memory was intact but his/her short term memory was impaired. Consent Review of the most recent comprehensive MDS annual assessment, dated 4/9/17, revealed the MDS coded the Resident for Psychosis: none of the above .Physical behav (behavior) symptoms directed at others .Behav symptoms interfere with resident care. Review of the CAA, dated 4/9/17, revealed Resident exhibits sexually inappropriate behavior by attempting to touch female staff in vulnerable places .This behavior occurs only when female staff are present. Review of the problem on the care plan, revised 9/22/17, revealed Behavioral Symptoms Resident has socially inappropriate/disruptive behavioral symptoms .grabbing at females. Resident at risk for victimization and isolation related to behaviors. An approach, dated 4/10/17, revealed cares in pairs. The care plan was revised to include .a male care giver will be provided to manage inappropriate behaviors with staff and protect resident. Another approach, dated 3/31/17, revealed Allow distance in seating other residents around resident. During an interview on 9/30/17 at 2:00 pm, when asked if the Resident's behaviors had made him/her vulnerable, RCM #1 stated he/she had been more worried about the Resident not receiving care. The RCM stated the Resident was to have 2 staff when providing cares because of his/her sexual behaviors. The RCM stated he/she had never screened Resident #1 for the ability to give informed consent. The RCM stated since the event one of the care givers needed to be male. During an interview on 9/30/17 at 3:30 pm, the SSD stated the Resident had never been evaluated for his/her ability to give consent to sexual activity. The SSD stated the facility was currently working on a policy regarding staff taking residents out of the facility. Review of the facility's policy abuse Screening, training, identification, investigation, reporting and protection-Alaska, reviewed 6/17, revealed 5. Residents with sexual behaviors will be assessed by social services or nursing to determine their ability to give informed consent related to sexual acts. 6. Residents assessment related to sexual behaviors will include the resident's cognitive status. What the resident verbalizes regarding sexual desires, a history of their prior sexual habits and value system related to sexuality . Review of Intimacy and Sexuality in Dementia Care, copyright 2014, from the Alzheimer's Association at www.alz.org, revealed Requirements for Consent .There are four basic requirements .1. The ability to voluntarily participate (free from coercion). 2. The ability to say 'no' (verbally or non-verbally). 3. The ability to be safe from harm 4. The ability to be free from exploitation or abuse. .

Based on record review, interview and observation the facility failed to ensure the environment was free from accidents and hazards for 1 resident (#2), out of 4 residents reviewed. Specifically, a hot beverage (coffee) provided to the resident was not within a safe temperature range for consumption. This failed practice caused the resident to receive a second degree burn (a second-degree burns affect both the outer and underlying layer of skin and causes pain, redness, swelling, and blistering) to his/her lap when the beverage was spilled and increased pain from the wounds which required an alteration in treatment. The facility had implemented corrective action prior to the survey conducted 9/5-6/17. Findings: Record review on 9/5-6/17 revealed Resident #2 had [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set annual assessment, dated 8/6/17 revealed the Resident had scored 4 out of 15 on the Brief Interview for Mental Status, indicating severe memory impairment, needed extensive assistance for transfers and dressing, and supervision with eating. Review of the most recent comprehensive care plan, start date of 2/15/16, and revised 9/3/17 revealed, the Resident was to have Supervision and cueing during meal times. During an interview on 9/5/17 with Certified Nursing Assistant (CNA) #1, who was on duty on the date of the accident (8/6/17), stated he/she went to the kitchen, retrieved two carafes of coffee and returned to his/her duty station. When asked if the CNA had checked the temperature of the coffee, CNA #1 replied, No, where I used to work, the machines did not get that hot. The CNA stated he/she then poured coffee into a mug and handed it to the Resident. CNA #1 then left the resident to answer a call light, once in the room; the CNA heard Resident #2 cry out and immediately went to investigate. Upon returning to the resident, the CNA realized the beverage had been spilled and Resident #1 had been injured. During an interview on 9/6/17 at 9:40 am with Licensed Nurse (LN) #1 who was on duty at the time of Resident #1's incident stated, when the Resident cried out, LN#1 and CNA#1 assisted Resident #1 back to his/her room, removed the Resident's clothing and applied cool compresses to the injured area. Left Thigh: Review of the Skin Grid for All 'Other' Skin Problems forms, initially dated 8/6/17, revealed: Burn to the left inner thigh was sized at 15.5 by 11.2 cm in diameter and pink. On 8/17/17, the nurse documented the burn to the left thigh was 11.5 by 17 cm, full thickness of the skin and Resident's burn progressed and developed blisters. Blisters have popped or reabsorbed treatment (with) Silvadine (burn cream) cream. Right Thigh: On 8/6/17 the nurse documented Burn to the right inner thigh was 15 by 9.7 cm and pink. On 8/17/17 the injury was documented as 8.5 by 20 cm, full thickness of skin and Resident had blisters that form and have popped open area is present and now being treated (with) Silvadine cream. Further review of the document revealed Resident #2 was experiencing pain. Review of physician's progress note, dated 8/21/17 at 2:31 pm revealed Extremities: Bilateral healing wounds to inner thighs. Mild sloughing is seen. Wounds are clean .Assessment: . with severe underlying dementia who is status [REDACTED]. These wounds are healing. Review of a discharge summary from a hospital stay on 8/28-31/17 revealed Taken from the admission (history and physical) .has been unable to tolerate the pain and is unable to take the prescribed Percocets (narcotic pain medication) . Discharge [DIAGNOSES REDACTED].Assessment/Impression .Pt will retain (his/her) Foley (indwelling urinary catheter) to assist in the healing of(his/her) burns since urine incontinence would be detrimental to wound healing at this time. Review of a physician's orders [REDACTED].#2 was to receive Narco (hydrocodone-acetaminophen-a narcotic pain medication) 1 tablet prior to a dressing changes. Observation in the facility kitchen on 9/5/17 revealed the facility used a Curtis RU-300 commercial grade automatic urn for brewing coffee. During an interview on 9/5/17 at 10:25 am, the Dietary Manager (DM) stated the temperature of the coffee from the coffee urn in the kitchen was 175 degree Fahrenheit (F). The DM stated the urn required high brew temperatures. When asked what the safe temperature was to serve coffee, the DM stated hot liquids were to be at 155 degrees F when leaving the kitchen. Review of the Wilber Curtis Co., Inc. Service Manual-RU Series Automatic Urns registered 2008, revealed Brew Temperature 200 (Degrees Fahrenheit) and WARNING: HOT LIQUID, Scalding MAY (NAME)CUR. Avoid splashing. According to the American Burn Association, accessed at www.ameriburn.org on 9/8/17, Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids . Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds .Sensory impairments can result in decreased sensation, especially to the hands and feet, so the person may not realize if something is too hot. Changes in a person's intellect, perception, memory, judgment or awareness may hinder the person's ability to recognize a dangerous situation. Review of Safety Tips and Info, by the Burn Institute, accessed at burninstitute.org, 9/19/17, revealed scalds are the leading cause of burn injuries, particularly to young children and senior adults. Hot liquids can cause first, second and third degree burns depending on temperature and length of exposure. At 155 degrees, a third degree burn can occur within 1 second. Corrective Action: Further record review, policy review and interviews revealed the facility had implemented corrective action prior to the survey conducted on 9/5-6/17. Review of Safety-PCI-Hot Beverage Risk Screening 1, dated 8/7/17 at 15:07 pm, revealed Resident #2 had risk factors that placed him/her at risk for burns from hot liquid consumption and .Should be screened by skilled Occupational Therapy/RCM designee and provided with supervision for consumption of hot beverages until such time a full assessment has been performed and interventions identified. During an interview on 9/5/17 at 12:10 pm with Resident Care Manager (RCM) #1 stated the facility had implemented the following facility wide interventions to prevent further thermal burns. Record review revealed nursing and dietary staff had attended educational in-services teaching about hot beverages from the kitchen. The topics of the in-service were to reiterate the appropriate temperature of drinking beverages at 155; if residents request a cup of coffee, the nursing staff is to call the kitchen and request the drinks; non-kitchen staff does not have the ability to self-serve beverages from the kitchen. Dietary staff are to check the temperature on all hot beverages that leave the kitchen. Further steps initiated to prevent accidents of this type were continued dialog between staff and supervisors reiterating the training at various scheduled monthly staff and daily meetings. Multiple interviews conducted on 9/5-6/17 confirmed facility dietary and nursing staff had been educated on the new policy. At the time of the exit on 9/6/17, the facility presented a draft copy of a hot beverage policy and stated it was in the process of development and implementation.

Based on record review, observation and interview the facility failed to prevent medical device pressure injuries for 1 resident (#3) out of 2 residents reviewed with indwelling urinary catheters. The failure to implement preventative measures in a timely manner caused the resident to obtain two stage II pressure injuries. As a result, this placed the resident at risk for infection, delayed healing and less than optimum medical outcome. Findings: Record review of Resident #3's medical record from 5/2-4/17 revealed the Resident had [DIAGNOSES REDACTED]. Review of Resident #3's medical record revealed the Resident had a Braden Score (number indicating risk for skin breakdown) of 15 indicating he was at mild risk for skin breakdown. Further review revealed the Resident had an indwelling urinary catheter placed on 4/25/17. Observation on 5/2/17 at 9:10 am during morning cares revealed the Resident had an indwelling urinary catheter. The catheter was secured in place by an adhesive device located on his upper left inner thigh. The tubing was placed in such a way the penis would only stay on the Resident's right side. Certified Nursing Assistant (CNA) #1 began to provide peri-care to the genital area with waterless soap. There was very limited movement of the penis due tension of the tubing from the penis to the adhesive securing device. During the observation, two open areas located next to the meatus (an opening at the beginning of the urethra) were observed. One area was located on the Resident's right side of the meatus. The area was slightly concaved with red borders and a white center. Further observation of the peri-care revealed an open area located on the underside of the penis. Specifically, the skin was vertically separated approximately 1 from bottom of the meatus down the underside of the penis's shaft. The catheter tubing was resting at the bottom of the wound. The area was purple-red and inflamed. The CNA began to dress the Resident. During an interview on 5/2/17 at 9:22 am CNA #1 stated he/she was unaware of the wounds located on the Resident's penis. The CNA observed the area again for any wounds. When asked if the wounds observed are reportable to the nurse, the CNA stated he/she wasn't sure but would report it anyway. During an interview on 5/2/17 at 9:23 am Resident #3 stated he was not able to feel much sensation, including pain, in his lower extremities due [MEDICAL CONDITION] located in his spine. The Resident wasn't able to feel if the catheter was too tight, nor pain or discomfort at the site. During an interview on 5/2/17 at 11:00 am, the Nurse Practitioner (NP) stated he/she was consulted for the skin concerns and pressure wounds on the Resident's penis that day (5/2/17). When asked if he/she had been notified of the wound on Resident #3's penis prior to 5/2/17 the NP stated No. When asked what stage the wounds were, the NP stated he/she doesn't stage wounds and the Surveyor would have to refer the questions to the Resident Care Managers (RCM). During an interview on 5/3/17 at 8:00 am the Administrator (former Director of Nursing) stated the Resident didn't report the concern because he was unable to feel discomfort in his lower extremities. The Administrator stated she was unaware of any wounds on Resident #3 prior to 5/2/17. In addition, the Administrator stated the CNAs should report any break in skin integrity to the floor nurses. During an interview on 5/3/17 at 8:55 am RCM #1 stated the area was caused by pressure from the catheter tubing. When asked if the RCMs stage wounds, the RCM stated the floor nurses were responsible for staging wounds. During an interview on 5/3/17 at 8:57 am the Director of Nursing (DON) stated the two wounds located on Resident #3's penis were most likely caused by pressure and pulling of the catheter tubing. Record review on 5/3/17 of a Provider Progress Note/New Order Form, dated 5/2/17, revealed the NP documented the urethral channel was red and inflamed, sphincter cuff was split forward and the area was dark and purple with a slight yellow discharge. During an interview on 5/3/17 at 9:00 am the NP stated it was a very good possibility the cause of the catheter associated urethra erosion was pressure from the catheter tubing. Record review revealed two Skin Grid for Pressure, Venous, Arterial & Diabetic Ulcers forms, dated 5/3/17, that indicated the Resident had two Stage II wounds, located on the penis, with yellow & tan (drainage), red wound bed and foul odor. Both forms indicated the probable cause for the two Stage II wounds as pressure. Record review of Resident #3's Care Plan, last updated 4/20/17 prior to survey, revealed no concerns with pressure ulcers. Record review of Resident #3's Care Plan, last updated 5/3/17 during the survey, revealed Pressure Ulcer Acutally pressure ulcer on penile area (related to) use of foley cath. Review of the Ostomy Wound Management Volume 56, Issue 12 article Severe Indwelling Urinary Catheter-Associated Urethral Erosion in Four Elderly Men, dated 12/2010 revealed Medical devices may be an overlooked cause of pressure ulcers in the LTC (Long Term Care) setting. Severe erosive urethral injury can occur with indwelling urinary catheters over a short time period. Unlike many other pressure ulcers, no topical therapy will heal the defect caused by tissue erosion .Education is key to recognizing the risk of indwelling catheters on pressure ulcer development in vulnerable populations. This should include education on proper securement of indwelling catheters and subsequent monitoring of the insertion site.

Based on record review and interview the facility failed to ensure 2 residents (#s 1 and 2) out of 3 sampled residents had not experienced a significant medication error that negatively impacted the residents' health and well-being. Specifically, resident #1 did not receive a medication necessary to prevent blood clotting and experienced a stroke as a likely response, and resident #2 experienced increased pain from not receiving medications ordered for arthritic pain management. Findings: Resident #1 Record review on 2/15-16/17 revealed Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Resident was on the medication [MEDICATION NAME] (also known as [MEDICATION NAME], a medication that thins the blood to prevent clotting). Review of the hospital discharge summary dated 2/2/17 at 10:59 am, revealed, . Patient does have a history of [MEDICAL CONDITION] and is chronically on [MEDICATION NAME] . INR (The international normalized ratio) 1.95 . Review of the Skilled Nursing Facility Transfer Orders dated 2/2/17, revealed, . DX: (diagnosis) Afib Goal INR: 2-3 .Unchanged Medications . [MEDICATION NAME] ([MEDICATION NAME]) 5mg tablet .take 2.5 mg every Mon, Wed, Fri, Sat. Take 5 mg every Tues, Thurs, Sun . Review of the facility's Resident Progress Notes dated 2/2/17 at 19:25 pm, revealed Resident arrived via providence transportation . Review of the eMAR (electronic medication administration record) revealed, the Resident had not received the ordered [MEDICATION NAME] dose on the evening of 2/2/17, the date of admission. During an interview on 2/16/17 at 11:15 am when asked about the missed [MEDICATION NAME] doses, the Resident Care Manager (RCM) #1 stated, the [MEDICATION NAME] orders were not entered into the eMAR when Resident #1 was admitted to the facility on [DATE] and had not been given. The RCM stated the medication orders were entered it the eMAR on 2/3/17 and an INR was done. Review of the progress notes, dated 2/3/17 at 4:22 pm revealed, PT/INT checked this morning 1.7. There was no information in the medical record the Resident's physician was immediately notified of the sub-therapeutic level of the INR (below the ordered range of 2-3). Review of the facility's policy Medication and Treatment Orders-eMAR, most recent review date, 01/16 revealed, . PROCEDURE: 1. Physician orders will be received and entered into software by a licensed nurse expeditiously and exactly as ordered . In addition, further review of Medication Administration History revealed, the Resident had not received the ordered [MEDICATION NAME] doses on 2/3/17 because the medication was unavailable and on 2/4/17 because the Resident had refused. There was no documentation in the medical record the Resident's provider had been immediately notified of the further missed [MEDICATION NAME] doses. Review of facility progress notes, dated 2/5/17 at 1:19 pm, revealed at 8:00 am . Arousable, Lethargic, speech garbled, unable to swallow oatmeal, let it ooz out .Left side of mouth dropped . 0920 (9:20 am) transported to . for evaluation and treat . Review of a progress note, dated 2/5/17 at 2:38 pm, revealed, Resident was admitted to Regional Hospital . diagnosis - [MEDICAL CONDITION]. Review of Hospital Admission history and physical dated 2/5/17 revealed, . presents with left-sided weakness . This morning (s/he) woke up and was noted to have change in mental status as well as left-sided weakness . Patient has no known history of stroke . INR 1.2 . MRI consistent with small right cortical stroke . (S/He) is somewhat subtheraputic on (his/her) [MEDICATION NAME] in the setting of chronic [MEDICAL CONDITION] which is likely the source of the stroke . 2. Chronic [MEDICAL CONDITION] . Titrate [MEDICATION NAME] to achieve therapeutic goal between 2 and 3 . Review of hospital discharge summary, dated 2/14/17, revealed . Patient underwent repeat imaging at this admission which demonstrated small right cortical stroke. Of note patient was sub therapeutic on (his/her) [MEDICATION NAME] that he takes for chronic [MEDICAL CONDITION] . During the same interview on 2/16/17 at 11:15 am RCM #1 stated the nurse is to get the medication needed from the E Kit (an emergency supply of medications with in the facility to be used by staff for residents when their medications aren't available), for the residents. The RCM stated, [MEDICATION NAME] was available in the emergency kit. The RMC further stated, [MEDICATION NAME] is a significant medication and the physician should have been notified of the missed doses. According to the Food and Drug Administration, accessed at fda.gov, [MEDICATION NAME] has a narrow therapeutic range (index), and its action may be affected by factors such as other drugs and dietary vitamin K. Therefore, anticoagulation must be carefully monitored during [MEDICATION NAME] therapy . Missed Dose The anticoagulant effect of [MEDICATION NAME] persists beyond 24 hours. If a patient misses a dose of [MEDICATION NAME] at the intended time of day, the patient should take the dose as soon as possible on the same day. The patient should not double the dose the next day to make up for a missed dose. Review of the facility's policy Medication ordering and receiving from the Pharmacy . Emergency Pharmacy Service and Emergency Kits . Procedures . The ordered medication is obtained either from the emergency box or from the provider pharmacy . G. When an emergency or starter dose of a medication is needed, the nurse unlocks the container and removes the required medication . Review of the facility's policy Medication Administration-Errors most recent review date, 1/16 revealed, POLICY: It is the policy of this facility that practices will be in place to ensure . 2) Residents are free of any significant medication errors . Resident #2 Record review from 1/15-16/17 revealed, Resident #2 was admitted to the facility for rehabilitation after an extended hospitalization for an infection. Record review of the Resident's eMAR from 1/1 - 2/16/17 revealed the medication Xeljanz XR (used for treatment of [REDACTED]. The eMAR documentation revealed each day, either the Xeljanz XR was Not administered: Item unavailable or Not administered: waiting for auth (authorization). Further review of the eMAR revealed additional information on the following dates: 1/6/17, waiting for MD authorization; 1/8/17, awaiting pharmacy; 1/10/17, Propac contacted, waiting on insurance approval; 1/17/17, Propac contacted, waiting on insurance approval; 1/24/17, will contact Propac pharmacy again; 1/31/17, will follow up with OPA for PA form and script. During an interview on 2/15/17 at 1:55 pm, Resident #2 stated, because s/he had not been reviving the medication s/he had experienced increased arthritic pain. During an interview on 2/16/17 at 7:00 am, RCM #2 was asked why the medication Xeljanz XR was not available for 30 days after the medication ran out. The RCM stated, it was missed communication between all persons involved for getting authorization to fill the medication. Review of email communication to the RCM from the Director of Nursing on 1/23/17 revealed . re-send Xeljanz XR. Review of the facility policy Fax Orders reviewed 1/16, revealed If the physician has not responded to the fax within 24 hours, the nurse will telephone to receive orders . If the fax has not been returned, contact the physician office for . orders needed.

Based on interview and record review the facility's Governing Body (GB) failed to provide sustainable and/or consistent support to facility staff in order to influence change. As a result the facility experienced repeated deficiencies, some of which resulted in harm and immediate jeopardy (IJ). The failure to ensure effective appropriation of the facility resources constituted an IJ and placed all the residents at risk for immediate serious injury, harm, impairment, and/or death (based on a census of 98). The facility was notified of the IJ on 5/12/15 at 2:00 pm. The IJ was not abated before the exit: Findings during the survey revealed repeated deficiencies in the past 12 months (from prior surveys) in the following areas: Pharmacy Services-the facility failed to ensure appropriate storage of medications, as a result staff were administering expired medications, not disposing of discharged residents medications, and was not accurately monitoring medication errors. Dignity-the facility failed to ensure staff responded to residents needs and provided care in a dignified manner by: 1) doing invasive procedures in common areas 2) not ensuring catheter bags filled with urine were covered 3) residents were no exposed when personal care was being provided. Infection Control-the facility failed to: 1) ensure contact precautions were followed for 1 resident which placed all residents residing in the facility at risk for contracting a highly infectious disease 2) have an effective control program that tracked and trended infections and failed to ensure antibiotic stewardship 3) failed to monitor the hand hygiene of staff. Supplies and Medications-the facility failed to ensure needed supplies and medications were available. Some of the medications, available at a local drug store, would be out for weeks at a time. Supplies that were unavailable included a specific solution for [MEDICAL TREATMENT], and Daikon solution (bleach and water). Assessments/Care Planning-failed to accurate assessments and care plans were completed and implemented. The facility failed to reassess after a significant change for Residents #s 7, 8, and 12. This caused actual harm for Resident #s 7 and 12 due to: 1) a significant decline in ADL function and unrecognized weight gain for Resident #7. 2) Unrecognized weight loss and the development of pressure ulcers for Resident #12. 3) Inaccurate assessment and care planning for several residents. Social Services-the facility failed to ensure Resident #13's PASRR had been sent to the state for approval and failed to ensure special services were offered. In addition, the resident did not have a behavior health plan to guide staff in managing behaviors that harmed 1 resident and placed other residents at risk for harm. In addition the facility failed to: provide support to Resident #s 3 and 9 after episodes of sexual assault by other residents in the facility. Wound Care-the facility failed to ensure: 1) skin assessment was completed in a timely manner. 2) Ensure wound care was completed. 2) Ensure interventions and treatments were implemented. 3) Resident #12 had necessary interventions to help prevent a facility acquired pressure ulcer. This resulted in harm for Resident #12. Investigation and Reporting Abuse and Neglect- the facility failed to ensure resident #30 was free of physical abuse by anyone including other residents and the facility failed to take action to prevent repeated incidents of abuse. This failure resulted in actual harm for Resident #30. The facility also failed to: 1) Ensure suspected abuse was reported to the State agency in 24 hours; 2) thoroughly investigate bruising of unknown origin; and report the bruising of unknown origin to the State agency. The failure to thoroughly investigate and report incidents creates the potential for unchecked abuse or neglect. Accidents and Supervision- the facility failed to: 1) Ensure water temperatures were closely monitored, despite a history of fluctuating temperatures. As a result the facility had water temperatures near or above 120 degrees Fahrenheit, which created a risk for thermal injuries. 2) Monitor Resident #13's behaviors in the dining room and have a process that guided staff in recognizing the risks. 3) Ensure keys to unlock doors in resident rooms and bathrooms were accessible and all staff had knowledge on how to unlock the doors. Quality of Care-failed to 1) ensure resident receive appropriate treatment per care plan for wounds, interventions to prevent falls, and the care necessary to help the resident receive their highest practicable level of well-being. Random observations during the survey, from 5/3-12/15, revealed the DON also functioned as the wound nurse and the ADON functioned as the infection control nurse and was also responsible for employee education. Further review revealed the facility had abolished the day shift supervisor and was utilizing the RCMs in that role. Further observations during the survey revealed nurse staffing was insufficient to implement the care plans of the residents. See F353 for further information. During an interview on 5/4/15 at 3:15 pm the DON stated even though the facility had identified they had an issue with staffing. The facility had to keep the census base up (resident numbers) as a result the facility was taking residents that had a higher acuity level and did not have the staffing numbers or training needed to meet the current level of care required by the residents residing in the facility. During an interview on 5/4/15 at 2:30 pm, MD #1 stated it was more tricky working here and it was harder to get things done. The MD stated it had taken the facility several months to implement wound vac (a type of treatment used on wounds) education for the nurses. In addition, the MD stated the facility was so anxious to fill beds they accepted the residents from the hospital without required documents in place. During an interview on 5/5/15 at 12:00 pm the Administrator, CS #2, and CS #3, stated they had assisted the facility with performing a mock survey and had identified many of the same issues identified during the survey. See F502 and F520 for further detail. Review of the Actions Taken By the Directors of Care Center (Anchorage) Inc. Without a Meeting, undated, revealed any action which may be taking at a meeting without a meeting provided that the directors unanimously consent in writing to such action. No other GB meeting minutes were provided by the Administrator during the survey despite multiple requests.

Based on observations, interview and record review the facility failed to: 1. Ensure safe water temperatures in resident care areas. Testing of water temperatures revealed water temperatures that ranged from 112.6-121.1 degrees Fahrenheit (F) on 5/3/15 from 9:30-11:45 am. a result, all the residents residing in the facility were placed at risk for serious harm from thermal injuries. This deficient practice constituted Immediate Jeopardy (IJ) to the residents' health and safety. The facility was notified on the IJ on 5/3/15 at 11:00 am and took steps to mitigate the risks to the residents. The immediacy was abated by the facility on 5/7/15 at 9:15 am, before the end of the survey. 2. Provide 1 resident (#13) with volatile (lost his temper and became physically aggressive quickly) behaviors, adequate supervision to ensure a safe environment in the dining room. Although staff witnessed resident #13 hit and chase resident #30 throughout the dining room, no staff intervened. Staff failure to identify, evaluate, and respond to these behaviors resulted in an unsafe environment for all 10 residents (#s 8; 27; 29; 30; 31; 32; 33; 34; 35; and 36) in the dining room which placed the residents in immediate jeopard for safety. The facility was notified of the IJ on 5/4/15 at 3:00 pm and abated the immediacy of the IJ by placing Resident #13 on a 1:1 supervision on 5/4/15 at 4:48 pm. 3. Ensure locked resident room doors and bathroom doors were accessible in the event of an emergency. After the doors locked and multiple staff were unaware of how to unlock the doors . The resident room entry doors had locking mechanisms that when locked from the inside required a key to unlock. The key was kept on the nurse's key ring. Many staff members were unaware that the doors had locks and/or did not know where the keys were located or which staff had the keys. The keys were not easily available when the nurse was off the court or at night when the nurse covered 3 courts. The residents' bathroom doors also had a locking mechanism. The bathroom doors' locking mechanisms required a person to first pop off a plastic cap and use an allen wrench inserted into the lock to open the door. Multiple staff were unaware that the bathroom doors could even be locked. The staff were also unaware where the wrenches were located and/or unable to locate the wrench on all courts. In addition, some of the room locks had putty over the key hole/wrench hole on the door , which staff did not know how to remove. The caps and putty plugs made the unlocking mechanism inaccessible. This failed practice placed all residents in the facility at immediate risk for harm or injury due to the potential delayed access to the locked resident rooms or bathrooms by facility staff in the event of an emergency (based on a census of 98). The facility was notified of the IJ on 5/8/15 at 3:00 and took steps to mitigate the risk to the residents. The immediacy was abated by the facility on 5/11/15 at 2:00 pm before the end of the survey. 4. Ensure potentially harmful chemicals were kept in a secure manner when a closet was left unlocked. This failed practice placed 1 non-sampled resident (#43) of 16 residents and any other residents who wandered at risk for injury from accidental exposure or ingestion of toxic materials. 5.Ensure safe fluid consumption for 1 (#40) non-sampled resident out of 13 sampled residents when facility staff failed to supervise the positioning of the resident appropriately while providing thickened liquids to the resident after facility had determined the resident was at risk for aspiration (entry of material into the lungs via the trachea). This failed practice placed the resident at risk for injury or harm from choking and aspiration pneumonia, which could lead to death. Findings: Water Temperatures: During the initial tour observations on Alder Court on 5/3/15 at 9:30 am, the water at the sink was too hot for the surveyor to wash his hands. After obtaining a calibrated thermometer from the facility, water temperatures tested throughout the facility revealed the following: Alder Court Observations on 5/3/15 at 9:40 am revealed water temperatures on Alder Court included: Room 204 bathroom sink - 114.3 F; Room 205 bathroom sink - 115.3 F; Room 208 bathroom sink - 115.3 F; Room 208 room sink - 114.4 F; and Room 211 bathroom sink - 114.4 F; Cedar: Observations on 5/3/15 at 10:00 am revealed water temperatures on Cedar Court included: Room 108 bathroom sink - 113.0 F; and Room 111 bathroom sink - 112.6 F; Observation on 5/3/15 at 11:25 am revealed water temperatures on Cedar Court included: Shower Room shower - 117.8 F; and Shower Room sink - 119.4 F; Review of the Logbook Report provided by the facility on 5/3/15 revealed Cedar Court had documented temperatures as follows: 5/2/15: Room 203 - 115.3; 4/25/15: Room 203 - 115.2; Popular Court: Observation on 5/3/15 at 9:45 am revealed water temperatures on Popular Court tested at: Room 212 bathroom sink - 118.2 F; Room 211 bathroom sink - 118.4 F; and Room 204 bathroom sink - 119.1 F. Willow Court: Observation on 5/3/15 at 11:35 am revealed water temperatures on Willow Court tested : Shower Room shower - 73.4 F; and Shower Room sink - 116.6 F; Spruce Court: Observation on 5/3/15 at 10:20 am revealed water temperatures on Spruce Court were: Room 103 bathroom sink - 117.1 F; Room 107 bathroom sink - 117.3 F; Room 108 bathroom sink - 117.1 F; and Shower Room shower - 116.2 F. A second observation on 5/3/15 at 11:39 am revealed water temperatures on Spruce Court had risen to: Shower Room shower - 120.5 F; and Shower Room sink - 121.1 F During an interview on 5/3/15 at 10:22 CNA # 2 stated the water temperatures frequently fluctuated between hot and cold. During an interview on 5/3/15 at 11:43 CNA #26 stated sometimes water can be hot, too hot.for the independent residents, I worry. During an interview on 5/3/15 at 11:44 the Administrator stated that she had just adjusted the water temperature to a lower temperature in response to the surveyors' findings. The Administrator stated they have known of the water temperature issues for six months and that the facility had been working with a plumbing contractor to resolve the issues. In addition, the Administrator stated the facility currently did not have a procedure in place for giving baths and shower if water is too hot. In addition the Administrator disclosed the facility does have issues with fluctuating water temperatures and stated It's not a perfect system. The Administrator added, the water temperatures have been the Biggest issue the past few months. During an interview on 5/3/15 at 12:12 pm the Maintenance Director stated We have had issues. with the water tempatures. The Maintenance Director stated there are cross connections that were installed wrong and resulted in water being too hot. During an interview on 5/3/15 at 1:01 pm Contractor #1 stated cross connections may be effecting the fluctuations in water temperatures. During the group interview on 5/5/15 at 2:00 pm Resident #28 stated the water will go from freezing cold: to blistering hot. Additionally, the Resident stated the staff will tell him the water temperature is too hot and they were unable to provide a shower and this is a chronic problem. During the group interview on 5/5/15 at 2:00 pm Resident #42 stated concern with the water temperatures due to temperatures fluctuating. Additionally, the Resident stated the water can become too hot. During the group interview on 5/5/15 at 2:00 pm Resident #22 stated concern with water temperatures fluctuating from being too cold to being too hot. On 5/6/15 at 3:15 pm, RCM #4 turned the hot spigot on in Resident #12's bathroom sink. After running the water for several minutes, the RCM indicated that the water was still cold. After observing cares this Surveyor went to wash her hands. The hot water spigot was turned on and the Surveyor placed her hands in the water. The water was so hot the Surveyor had to quickly remove her hands due to the temperature of the water. During an interview on 5/6/15 at 4:20 pm, with the Administrator and CS #s 2 and 3, the survey team shared concerns regarding continued sudden fluctuations in water temperatures. During an interview on 5/7/15 at 9:15 am CS #2 confirmed the facility Should not have fluctuations issues. In addition, she stated we don't want to have fluctuating temperatures.we are seeing fluctuating temperatures. During an interview on 5/7/15 at 9:28 am the Administrator stated the facility has been working on the issue for six months and confirmed the facility had experienced fluctuating temperatures. According to the American Burn Association, accessed at www.ameriburn.org on 5/21/15, Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids. Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds.Sensory impairments can result in decreased sensation, especially to the hands and feet, so the person may not realize if something is too hot. Changes in a person's intellect, perception, memory, judgment or awareness may hinder the person's ability to recognize a dangerous situation (such as a tub filled with scalding water) or respond appropriately to remove themselves from danger. A water temperature 120 degrees F is hot enough for a 3rd degree burn in 5 minutes. According to the U.S. National Library of Medicine, accessed on 5/21/15 at www.nlm.nih.gov, There are three levels of burns: First-degree burns affect only the outer layer of the skin. They cause pain, redness, and swelling. Second-degree burns affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. They are also called partial thickness burns. Third-degree burns affect the deep layers of skin. They are also called full thickness burns. They cause white or blackened, burned skin. The skin may be numb. Abusive Behavior Breakfast in Dining Room On 5/4/15 from 7:15-8:30 am two surveyors observed the morning meal located in the main dining room (DR). Resident #13 and Resident #30 sat at a small table located next to the window. Resident #13 actively took all of the table items (coffee condiments, menu, napkins, and cups) and put them on his side of the table. When Resident #30 attempted to look at the menu Resident #13 pointed a finger at him and shook it from side to side (indicating Resident #30 was not to touch the rearranged items). When Resident #30 tried to retrieve his coffee cup, Resident #13 appeared visibly agitated at him and gritted his teeth with a tense face, shook his fist and kicked at Resident #30 under the table. For several minutes Resident #13 continued to angrily shake his fist at Resident #30 as he became more agitated. As the kitchen staff began to pass out the breakfast, Resident #30 attempted to retrieve a napkin from Resident #13's side of the table. Resident #13 jumped up, walked around the end of the table and threw a punch at Resident #30's face. Resident #30 raised his arm to block the blow. Resident #13's blow made firm contact with Resident #30's left forearm. Resident #13 sat back down at the table and continued to aggressively shake his fists at Resident #30. Resident #30 got up and walked over to the area where extra napkins were kept on the other side of the room. When he got to the other side, and picked up a napkin, Resident #13 jumped up and ran across the room attempting to take the napkin away from Resident #30. Resident #30 started running and Resident #13 was chased after him. They raced around the tables where CNA staff were assisting other residents with their meals. The chase ended at the Residents' own table. Resident #30 sat down and attempted to hide a napkin, but Resident #13 stood next to him and aggressively snatched the napkin away from Resident #30 and then sat back down on his side of the table. Resident #13 continued to shake his fist at Resident #30. The kitchen staff then gave both Residents their meals and Resident #13's attention became focused on eating. There were 9 other residents eating their breakfast in the dining room that morning residents (#8; 27; 29; 31; 32; 33; 34; 35 and #36). During the Residents' interactions none of the several dietary staff or 3 CNA staff that were present in the dining room attempted to intervene. During the two Residents' interactions the Surveyor observed Resident #30's facial expressions and when Resident #13 acted aggressive toward him, Resident #30 would not make direct eye contact, but looked from side to side. It appeared that Resident #30 was aware of Residents #13's escalation and attempted to avoid a conflict. Resident #8, who sat directly behind Resident #13 and Resident #30 called CNA #2 over and told the CNA to keep an eye on them because Resident #13 was trying to hurt Resident #30. The CNA said to Resident #8 in a humorous manner, Well you had better stay away from people like that so you don't get hurt. Lunch in Dining Room Observations on 5/4/15 from 11:40 am - 12:20 pm in the main dining room, during the lunch meal, revealed Resident #13 and Resident #30 sitting at their table located against the window. Resident #30 placed a napkin out of Resident #13's reach on the window sill next to him. Resident #13 stood up and reached over the table and grabbed the napkin out of the window sill where Resident #30 had placed it. Resident #13 then sat back down and repeatedly kicked at Resident #30 under the table. Resident #13 came in contact with Resident #30's legs two times. When Resident #30 picked up the paper menu, Resident #13 grabbed it from Resident #30's hand. Resident #13 clenched his fist at Resident #30 and jabbed a finger out at Resident #30 several times firmly. Resident #13's teeth were clenched and face was tense. Then, Resident #13 grabbed the paper menu off the table and pointed at Resident #30 with a clenched fist. Resident #13 then stood and tried to get the kitchen staffs' attention while pointing down at the table and motioned for food. Resident #13 was visibly agitated and his behavior was escalating. The kitchen staff served both Residents two small bowls with cottage cheese and Resident #30 quickly put his cottage cheese down on his chair on the wall side. The kitchen staff then placed pudding on the table. Resident #30 held it between his hands. Resident #13 reached over and slapped Resident #30's hands in an attempt to take the pudding away from him. Resident #30 was able to keep the pudding in his hand until Resident #13 soundly slapped him a second time on the top of his hands and Resident #30 allowed Resident #13 to jerk it out of his hands. The slap was loud enough to be heard across the room. Resident #13 then stood up and walked around to Resident #30 and slapped him on the top of the head hard enough to be heard across the room. When Resident #13 slapped Resident #30 on top of the head a staff member sitting at the far end of the dining room heard it and stood up and gasped, then sat back down and began assisting a resident with her meal. Resident #27 sitting two tables behind Resident #13 and Resident #30 called over to one of the kitchen staff and informed her that two Surveyors were watching what was going on with Resident #13 and Resident #30. During an interview on 5/4/15 at 1:00 pm, Dietary Aide #1 stated she had reported Resident #13 had struck Resident #30 on 5/4/15 to the Dietary Manager and CNA #3. Dietary Aide #1 also stated Resident #13 had struck Resident #30 in the past and altercations between the two Residents had occurred about 1 time per month for the past year. The Dietary Aide had previously reported the incidents to the Dietary Manager but had not received a response. During an interview on 5/4/15 at 1:15 pm Dietary Aide #3 stated Resident #13 hit Resident #30 on the head and stole the Resident's food while the two were in the dining room for lunch on 5/4/15. During an interview on 5/5/15 at 1:00 pm, the Dietary Manager stated the Dietary Aides had reported Resident #13 had struck Resident #30 on 5/4/15 and that he had reported the incident to the RCM. The Dietary Manager stated no previous incidents had been reported to him. During an interview on 5/4/15 at 2:30 pm Resident #8 confirmed, that she saw Resident #13 hit Resident #30 on the arm during the morning meal. The Resident further disclosed both Resident #13 and Resident #30 teased each other. Resident #8 stated that when that kind of behavior went on between those 2 Residents that she would tell the staff that they needed to keep an eye out for them, so that no one would get hurt. When asked if she was afraid of Resident #13 striking out at her Resident #8 said No, there are too many people around here and they wouldn't let him hit her. Resident #8 went on to say that she had gone on an outing with Resident #13 and stated he sometimes had a jerky nerve. Resident #8 then stated (Resident #13) is a dangerous lad. Door Locks in Resident Rooms and Bathrooms Birch Court Observation on 5/8/14 at 2:50 pm revealed Resident rooms 201-213 (all rooms) on Birch Court had resident entry doors and bathroom doors that were able to be locked from the inside. During an interview on 5/18/15 at 2:10 pm, when asked how the doors could be unlocked, RCM #1 stated the nurse has a key on the med key ring. The RCM stated she did not keep the keys on the unit when the nurse left the floor so keys were not available on the unit during that time. After a few minutes, LN #2 returned to the medication cart from a residents room. The LN showed the surveyor the door key and claimed she never left the Court. During an interview on 5/18/15 at 2:15 pm CNA #18 stated she did not know how to open the bathroom doors if they were locked. During an interview on 5/8/15 at 2:40 pm, LN #2 stated the charge nurse for each court carried a key that would unlock the Resident room doors if they were locked. When asked to demonstrate unlocking the bathroom doors, the LN stated there was a tool kept in the treatment cart that was used to unlock the bathroom doors. The LN retrieved a straight edge screwdriver and peeled the cover off the lock on the room side of the bathroom door and then attempted to use a multi-headed Allen wrench tool on the lock. The LN was unable to unlock the bathroom door. When asked what would be done if the LN was unable to unlock the door of a Resident that had locked themselves in their room or bathroom and needed assistance, LN #2 stated the supervisor carried keys to open the doors and a set was hanging in the supervisor's office. The LN confirmed there was no day shift supervisor. During an interview on 5/8/15 at 2:45 pm, CNA #4 stated if a Resident locked their doors and needed assistance, he would call the LN or the Supervisor for a key. During an interview on 5/8/15 at 3:00 pm, the ADON stated the supervisors office was locked so the supervisor would have to be located to be able to get to the keys that would unlock the Resident room doors Willow Court During an interview on 5/8/15 at 2:45 pm, when asked how to get the doors to the rooms and bathrooms opened in the event they were locked, CNA #19 stated the nurses had the key to the doors, The CNA stated the bathroom doors had an Allen wrench that was kept on a hook by the unit kitchenette. However, the CNA was unable to locate the wrench. During an interview on 5/8/15 at 3:00 pm, LN #10 pulled out the key ring and attempted to locate the correct key to unlock the bathroom door. The LN acknowledged that she did not know how to unlock the Bathroom door in the event of an emergency. The LN then called maintenance staff to come up to the court to unlock the bathroom door. At 2:55 pm Maintenance Staff #1 arrived on the court and stated the Allen wrench should be kept in the assigned location on the unit, but was unable to locate one. During an interview on 5/8/15 at 2:55 pm SS #1 confirmed she had a master key to the room doors. After looking around the office for a few minutes the SS was able to locate it. Alder Court: Observations of Alder Court on 5/8/15 from 2:30-3:00 pm revealed the following Residents' room entry doors had locking mechanisms: 201; 202; 204; 205; 207; 208; 209; 212; and 213. The following bathrooms had a locking mechanism on the door: 202; 203; 204; 207; 208; 209; 210; 211; 212; and 213. During an interview on 5/8/15 at 2:20 pm, CNA #2 stated she thought there may be keys on the unit but was not sure what key to use to open the Residents' entry doors. The CNA further stated she was unaware the bathroom doors were able to be locked and did know how to unlock them. During an interview on 5/8/15 at 2:45 pm with LN #11, when asked what she would do if a Resident was locked in a bathroom that was on fire, she replied I guess they would have to wait on the fire department because she didn't know how to open the doors. During an interview on 5/8/15 at 2:45 pm CNA #20 stated she was not aware the bathroom doors locked and she did not know how to unlocked them from the outside. During an interview on 5/8/15 at 3:00 pm CNA #21 stated the nurses or supervisor had a master key for all the doors. Additionally, the CNA stated it could take a while to get a supervisor to unlock the door. During an interview on 5/8/15 at 3:15 pm the Administrator stated each court should have a key to the bathrooms and residents' rooms located on a hook next to the janitor's closet. In addition, the Administrator stated every nurse on the court should have a key to the residents' rooms and bathrooms and the keys should be hanging on the wall near the refrigerator. Cedar Court: Observations of Cedar Court on 5/8/15 from 2:30-3:00 pm revealed the following Residents' room entry door had locking mechanisms on the door: 101; 102; 103; 104; 105; and 106. The following bathrooms had a locking mechanism on the door: 102; 103; 104; 105; and 106. During an interview on 5/8/15 at 2:32 pm CNA #22 stated she was not aware of how to unlock the residents' entry doors or bathrooms. During an interview on 5/8/15 at 2:32 pm CNA #23 stated the nurse is the only staff member with keys. The CNA was unaware of the location of the nurse at this time and stated she would have to have her paged overhead. During an interview on 5/8/15 at 2:32 pm CNA #24 stated there may have been a key to unlock the doors located on the hook next to the janitor's closet. When the CNA went to look for the keys, she confirmed the keys were not present. The CNA stated an attempt to locate the nurse would have been the next option. When the CNA attempted to located the nurse, she confirmed she could not locate the nurse. The CNA stated an attempt to contact the nurse could be made on the ipod messenger system, but the CNA did not have an ipod. When asked what she would do in the event of an emergency involving unlocking a resident's room or bathroom, the CNA replied I don't know. During an interview on 5/8/15 at 2:36 pm CNA #22, CNA #23 and CNA #24 stated the tools and devices used to unlock the bathroom doors and entry doors were not readily accessible to all staff. During an interview on 5/8/15 at 2:43 pm LN #3 stated she was not aware the residents' entry room doors and bathroom door locks were different. Observation on Cedar Court on 5/8/15 at 2:43 pm revealed Resident room #101 had a unique locking mechanism that was different from the other rooms in the court. During an interview on 5/8/15 at 2:45 pm LN #7 stated she had a large set of keys. The LN disclosed she divided the set up into two smaller sets because of the weight. Additionally, the LN stated she kept one set locked in the medication cart during the shift. The LN confirmed a circular metallic piecelocated on the key set (that was locked in the medication cart) could be used to open Resident room #101 but not the remaining doors on the unit. In addition, the LN stated she was not always present on the unit because the evening nurse covers more than one unit. During an interview on 5/8/15 at 2:48 pm LN #7 and LN #3 stated the tools and devices use to unlock the bathroom doors and entry doors were not readily accessible to all staff. During an interview on 5/8/15 at 2:50 pm LN # 7 stated she was unaware the bathroom doors locked and confirmed she was not able to unlock the bathroom doors. Poplar Court Observations of Poplar Court on 5/8/15 from 2:30-3:00 pm revealed the following Residents' room entry door had locking mechanisms on the door: 201; 202; 203; 204; 205; 204; 207; 208; 209; 210; 211; and 212; and 213. The following bathroom doors had locking mechanisms: 201; 202; 203; 206; 208; 210; and 211. During an interview on 5 /8/15 at 2:15 pm, when asked how to get in the locked door in the event of an emergency, LN #5 stated she did not know where the keys were located to unlock the residents' rooms to the locks to the residents door was located. The LN then left the unit for a few minutes. After the LN returned MS #1 asked the LN to check the nurse's key ring for the key to unlock the residents' room door, the LN was able to locate the key. When questioned by the surveyor on 5/8/15 at 2:15 pm, RCM #4 stated she did not know where the keys were located for the locks to the residents' doors On 5/8/15 at 2:15 pm when asked about keys for the locks, CNA #31 stated I don't know where they are but they should be around here somewhere. He looked around for a few minutes and eventually found keys hanging on the wall. Spruce Court Observations of Spruce Court on 5/8/15 from 2:30-3:00 pm revealed the following Residents' room entry door had locking mechanisms on the door: 101; 103; 104; 105; 106; 107; 108; 109; 111; 212; and 113 (Empty). The following bathroom doors had locking mechanisms: 101; 102; 103; 104; 105; 106; 107; 108; 109; 110; 111; 112; and 113. In addition the entry door to room 101's key hole had been puttied over rendering the room inaccessible if the door was locked. During an interview on 5/8/15 at 2:30 pm CNA #13 stated the nurse kept the key to unlock the door to the residents' rooms. During an interview on 5/8/15 at 2:45 pm, LN #12 stated she kept the keys to the residents' rooms on her because the ring also had the key to the medication cart. The LN stated she would call the supervisor to get into the bathroom in the event it was locked. LN #16, who was present during the interview, stated she would call maintenance staff to unlock the bathroom door. Unlocked Housekeeping Closet: Record review on 5/3/15 revealed Resident #44 had a [DIAGNOSES REDACTED]. At various times on 5/3/15 the Resident was observed wandering aimlessly around the Alder Court. Observation of Alder court on 5/3/15 at 8:48 am revealed an unlocked housekeeping closet, with keys left in the lock, located next to the kitchenette. The closet contents included bottles of: alkaline bathroom cleaner and disinfectant; peroxide multi surface cleaner and disinfectant; glass cleaner and one unlabeled bottle of green solution. In addition, the wall contained storage devices for chemicals to be diluted and used in smaller quantities. The device contained alkaline bathroom cleaner, peroxide multi surface cleaner and disinfectant, glass cleaner; and odor eliminator. During an interview on 5/3/15 at 8:48 am CNA #5 stated the keys should not be in the door and under normal circumstances the door remains locked and the keys are placed out of reach of the residents. Random observations of Alder Court on 5/4/15 from 4:30 to 5:15 am revealed keys in the lock mechanism of the housekeeping closet next to the kitchenette. During an interview on 5/7/15 at 1:25 pm, the Maintenance Director confirmed the door should be locked at all times. In addition, the Maintenance Director identified the green solution as Laundry Fresh odor eliminator. During an interview on 5/8/15 at 3:25 pm the Administrator confirmed the housekeeping closet on Alder Court should be locked at all times and keys placed out of residents' reach. Review of the manufacturer's material safety data sheet, dated 6/16/14, for the alkaline bathroom cleaner and disinfectant revealed Harmful if swallowed or in contact with skin. Causes severe skin burns and eye damage. Review of the manufacturer's material safety data sheet, dated 10/22/14, for peroxide multi surface cleaner and disinfectant revealed Harmful if swallowed or in contact with skin. Causes severe skin burns and eye damage. May cause an allergic skin reaction. Review of the manufacturer's material safety data sheet, dated 11/14/14, for the glass cleaner revealed Get medical attention if symptoms occur after contact with eyes, skin or ingestion. Review of the manufacturer's material safety data sheet, dated 10/23/13, for the laundry fresh room refresher revealed Avoid contact with eyes, skin and clothing and indicated the being exposed to the solution could cause temporary incapacitation or possible residual injury. Aspiration Precautions Record review on 5/3-8/15 revealed Resident #40 was admitted to the facility with [DIAGNOSES REDACTED]. The Record review of the CNA Care plan, dated 5/1/15, revealed that the resident HOB (head of bead) (up) 90 degrees during meals and fluid via teaspoon; high risk for aspiration. Observation on 5/4/15 at 6:53 am CNA's #10 took a glass of thickened water to the Resident. The Resident took a drink from the glass and started coughing and choking immediately as the CNA left the room and continued with her other duties. The Resident was observed in bed on his back and the head of the bed was at a 45 degree angle. At 6:58 am, seeing the Resident was in distress, and hearing the Resident state he could not breathe, the Surveyors called for LN #1. Both the LN and CNA #6 went to the Resident's bedside. It was not until after the Resident began choking and Surveyor intervention that the staff raised the head of the bed. Record review for Resident #10 revealed a Speech Therapy swallows evaluation completed on 5/1/15, which indicated the following: IMPRESSIONS:.This (Resident) will require skilled SLP services for determination of least restrictive diet as well as training of staff and patient in use of compensatory/positioning strategies to reduce risk of aspiration; RISK FACTORS: Aspiration .; SHORT TERM GOALS: In order to safely consume highest level of oral intake, patient and staff will use.bolus size modifications, rate modifications and secondary dry swallow and upright posture during meals and upright posture for >30 minutes after meal. A Speech Therapy Treatment Encounter Note(s) on 5/1/15, revealed: Recommendations: Honey thick liquids, liquids by teaspoon; Supervision for oral intake = Progressive self-feeding program/restorative dining; Swallow strategies/positons: To facilitate safety and efficiency, it is recommended the patient and or caregiver uses the following strategies and / or maneuvers during oral intake: secondary swallow and upright posture during meals and upright posture for > 30 minutes after meals,

Based on observation, interview, and record review the facility was not administered in a manner that enabled the facility to use its resources effectively and efficiently. Failure of the facility to provide oversight, supervision, and support of nursing staff resulted immediate jeopardy in 5 citations under federal regulations: 483.25 Free of Accidents Hazards/ Supervision/ Devices, CFR 483.13 Abuse, and CFR 483.65 Infection Control, Prevent Spread, Linens. Without adequate oversight and support the facility placed all the facility residents residing in the facility (census of 98) in immediate jeopardy for potential serious injury; harm; impairment; and/or death. The Administration failed to ensure: · Policies and procedures related to reporting and investigation of abuse and neglect were understood by staff and effectively sustained over time. As a result the residents remained at risk for abuse and neglect. · Oversight of care issues that caused harm to residents such as prevention, identification, intervention, investigation of pressure sores (bed sores) and weight loss. · Adequate staffing to meet the needs of the residents per their care plans. · Effective and sustainable PoC for prior citations in the areas of infection control; pharmacy services; accidents and supervision; lack of supplies and medications; care planning; treatment of [REDACTED]. The facility's administration was notified of the IJ in Administration 483.75 on 5/8/15 at 3:00 pm. The IJ had not been abated at the end of the survey. Findings: Observations, interviews, and record review during the survey revealed Resident #12 developed a facility acquired pressure ulcer due the facility's failure to implement measures to prevent pressure wounds and suffered a significant unrecognized weight loss. See F325 and F314 for details of deficient practice. Although the facility staff was aware of Resident #13's behaviors the facility did not plan and implement adequate interventions to promote the safety of all the residents eating in the dining room. See F223 and F 323 for details of the deficient practice. Administration had direct oversight of the Neighborhood Helpers that functioned as paid feeding assistants. During the survey there was no evidence the paid feeding assistants had completed the State authorized training program and were functioning within the confines of that role. Review of facility policies revealed the many of the current provided policies did not match the electronic records currently used related to the documentation of resident refusals, behavior monitoring, and mobility physical restraint assessments. The facility Administration did not ensure it had the resources for an infection control program during the months they were without an ICP. See F441 for details of the deficient practice. Facility administration failed to ensure all education needs and implemented changes were monitored to ensure compliance by facility staff. There was no oversight of the Dietitian's contract that ensured professional dietary standards were followed in the areas of therapeutic diets and monitoring weight changes. See F309 and F367 for extent of details of deficient practice. There was no oversight of the medical social services provided by the facility. See F250 for extent of deficient practice. During an interview on 5/4/15 at 3:15 pm the DON stated even though the facility had identified they had an issue with staffing. The facility had to keep the census base up (resident numbers) as a result the facility was taking residents that had a higher acuity level and did not have the staffing numbers or training needed to meet the current level of care required by the residents residing in the facility.

Based on interview and record review the facility failed to ensure the QAPI, used to identify and implement change for improvement, failed to evaluate areas, implement improvement, and effect sustainable change as identified in prior surveys and in areas that had been or should have been identified by the facility. In addition the QAPI was not receiving accurate data from facility staff and was unable to accurately evaluate the effectiveness of any changes. These deficient practices placed all residents residing in the facility at immediate risk for serious injury, harm, impairment or death and constituted an Immediate Jeopardy (IJ) to the residents' future well-being and safety. These findings resulted in Immediate Jeopardy to the well-being and safety of all the residents ' residing in the facility (based on census of 98). The facility's Administrator was notified of the Immediate Jeopardy at the exit briefing on 5/12/15 at 2:00 pm. The Immediate Jeopardy had not been abated by the end of the survey. Findings: During an interview on 5/4/15 at 2:30 pm, MD #1 stated QAPI had a lot of projects to say the least. During an interview on 5/5/15 at 12:00 pm, the facility's Administrator and Corporate Staff #1 and 2 stated the QAPI met monthly and monitored wounds; falls; infections; quality measures; hospitalization rates; prior surveys; medication errors; and supply issues as current and ongoing problems. Corporate Staff # 2 stated the corporate team (from Washington) had conducted a mock survey at the facility a few months ago. During the interview Corporate Staff #1 stated they had not been monitoring OTC medication errors and had been utilizing the MACC meeting (attended by facility managers) to determine if compliance had been achieved. When asked about unplanned discharges to the hospital she stated the DON was supposed to audit charts to determine the cause. During the interview the Administrator stated the facility used learning circles to identify issues the staff wanted to work on and confirmed that approach takes longer to fix. Review of the facility's action plan for January 2015 revealed the facility was to form a Performance Improvement Team (PIT) that addressed skin, [MEDICAL CONDITION] behavior monitoring, incident reports, NARC E-kit (medications for emergencies) and the MACC meetings. The plan stated the DON was responsible. Further review of the PIT teams revealed there was no PIT that addressed pain. During an interview on 5/6/15 at 11:55 am, when discussing concerns about pain management, the DON stated that nurses should be obtaining a numerical rating of 0 to 10 (indicating a quantitative and qualitative measurement of effectiveness) both before and after the administration of PRN pain medication. In addition, the DON stated the use of a plus and minus sign is not an acceptable and effective measure of pain. When asked how the facility monitored pain, the DON stated during quarterly assessments and MACC meetings. The DON stated MACC meetings attempted to find different interventions to lower pain levels. The DON then stated neither the Pharmacist nor the Physicians attended the MACC meetings. Furthermore, according to the DON, the facility did not have any form of a quality assurance subcommittee reviewing pain and corporate mandated quality assurance projects. When asked about Residents using PRN pain medications frequently, the DON stated a review should be conducted on medication and a different approach should be considered. During the interview the DON confirmed the facility had not been tracing OTC medication errors and in addition had no knowledge of the medications errors identified by the survey team. During an interview with CS #s 2 and 3 on 5/7/15 at 5:30 pm, Corporate #3 stated We don't like it when the system breaks down- like you guys have seen during this survey- but we are working on fixing it. During the same interview Corporate Staff #2 stated we did a mock survey in February and we found the same concerns you guys are finding with infection control and wounds. We are trying to make a change but Rome wasn't built in a day- it takes time. Findings during the survey revealed repeated deficient practices in: Pharmacy Services-the facility failed to ensure appropriate storage of medications as a result staff were administering expired medications, not disposing of discharged residents medications, and was not accurately monitoring medication errors. Dignity-the facility failed to ensure staff responded to residents needs and provided care in a dignified manner by: 1) doing invasive procedures in common area 2) not ensuring catheter bags filled with urine were covered 3) residents were covered when personal care was being provided. Infection Control-the facility failed to: 1) ensure contact precautions were followed for 1 resident which placed all residents residing in the facility at risk for contracting a highly infectious disease 2) have an effective control program that tracked and trended infections and failed to ensure antibiotic stewardship 3) failed to monitor the hand hygiene of staff. Supplies and Medications-the facility failed to ensure needed supplies and medications were available. Some of the medications, available at a local drug store, would be out for weeks at a time. Supplies that were unavailable included a specific solution for [MEDICAL TREATMENT], and Daikon solution (bleach and water). Assessments/Care Planning-failed to accurate assessments and care plans were completed and implemented. The facility failed to reassess after a sigifigent change for Residents #s 7, 8, and 12. This caused actual harm for Resident #s 7 and 12 due to: 1) a sigifigent decline in ADL function and unrecognized weight gain for Resident #7. 2) Unrecognized weight loss and the development of pressure ulcers for Resident #12. 3) Inaccurate assessment and care planning for several residents. Social Services-the facility failed to ensure Resident #13's PASSR had been sent to the state for approval and failed to ensure special services were offered. In addition, the resident did not have a behavior health plan to guide staff in managing behaviors that harmed 1 resident and placed other residents at risk for harm. In addition the facility failed to: provide support to Resident #s 3 and 9 after episodes of sexual assault by other residents in the facility. Wound Care-the facility failed to ensure: 1) skin assessment was completed in a timely manner. 2) Ensure wound care was completed. 2) Ensure interventions and treatments were implemented. 3) Resident #12 had necessary interventions to help prevent a facility acquired pressure ulcer. This resulted in harm for Resident #12. Investigation and Reporting Abuse and Neglect- the facility failed to ensure resident #30 was free of physical abuse by anyone including other residents and the facility failed to take action to prevent repeated incidents of abuse. This failure resulted in actual harm for Resident #30. The facility also failed to: 1) Ensure suspected abuse was reported to the State agency in 24 hours; 2) thoroughly investigate bruising of unknown origin; and report the bruising of unknown origin to the State agency. The failure to thoroughly investigate and report incidents creates the potential for unchecked abuse or neglect. Accidents and Supervision- the facility failed to: 1) Ensure water temperatures where closely monitored, despite a history of fluctuating temperatures. As a result the facility had water temperatures near or above 120 Fahrenheit, which created a risk for thermal injuries. 2) Monitor Resident #13's behaviors in the dining room and have a process that guided staff in recognizing the risks. 3) Ensure keys to unlock doors in resident rooms and bathrooms were accessible and all staff had knowledge on how to unlock the doors. Quality of Care-failed to 1) ensure resident receive appropriate treatment per care plan for wounds, interventions to prevent falls, and the care necessary to help the resident receive their highest practicable level of well-being. See 2567 report for extent of deficient practices.

Based on record review, observations and interview the facility failed to ensure staff implemented ordered contact precautions to prevent potential transmission of [DIAGNOSES REDACTED]icile (bacteria that can cause inflammation of the colon and can cause a life-threatening diarrhea) for 1 sampled resident (#12) on contact precautions for a [DIAGNOSES REDACTED]icile infection. These failed practices placed all the residents living on the Pod ( Poplar and Spruce Courts) at risk for acquiring the disease and constituted an Immediate Jeopardy (IJ) to their health and well-being. The situation was brought to the attention of the facility's administration on 5/5/15 at 4:40 pm at which time the facility was told of specific examples of the failed contact precautions and hand hygiene. On 5/7/15 at 9:15 am, it was determined the facility had abated the IJ through the facility's implementation of an action plan that addressed staff education, equipment, and supervision in infection control processes. In addition, the facility failed to: 1) ensure staff performed appropriate hand hygiene; 2) maintain resident equipment in a clean manner for 2 residents (#'s 2 and non-sampled #27); 3) monitor TB screening for 3 residents (#'s 5, 7, and 11); and 4) maintain an infection control program that tracked and trended infections, provided antibiotic stewardship, and documented any actions plans. These failed practices placed all the residents in the facility at risk for infections (based on the census of 98 at the time of the survey). Findings: Contact Precautions Record review from 5/3-8/15 revealed Resident #12 had been admitted to the facility with [DIAGNOSES REDACTED]. The Resident's medication regime included [MEDICATION NAME] (antibiotic) used to treat [DIAGNOSES REDACTED]icile infections. Review of the Resident #12's most recent comprehensive care plan and CNA care plan revealed the Resident was on contact precautions (use of PPE and hand hygiene protocol) for a [DIAGNOSES REDACTED]icile infection. Review of the CDC guidelines at www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html accessed 5/18/15, revealed, Clostridium difficile (C. difficile) is a bacterium that causes inflammation of the colon, known as colitis. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. Clostridium difficile can live for long periods on surfaces. Since spores may be difficult to remove from hands even with hand washing, adherence to glove use, and Contact Precautions in general, should be emphasized for preventing [DIAGNOSES REDACTED]icile transmission via the hands of healthcare personnel. Observations on 5/3/15 at 8:30 am, revealed a small chest of drawers outside of Resident #12 and Resident #39 rooms. The drawers contained gloves, gowns, masks and a blood pressure cuff. A sign lying on top of the chests stated See nurse before entering. An observation on 5/3/15 from 8:15-09:30 am, revealed CNA's #6 and #14 entered and exited multiple residents' rooms including residents on contact precautions, without performing hand hygiene. Further observations revealed CNA's #6 and #14 retrieved food trays from the food cart and delivered the food to residents without sanitizing or washing their hands when they entered and exited resident's rooms. An observation on 5/3/15 at 3:30 pm, revealed CNA #34 entered Resident #12's contact precaution room. The CNA did not perform hand hygiene, put on gloves or use PPE before providing cares to the Resident. Observations on 5/4/15 at 4:15 am, revealed CNA #12 providing bedside personal cares to Resident #12. The CNA did not have on PPE and did not perform hand hygiene upon exit of the room. Observations on 5/4/15 at 5:15 am, revealed LN #8 entered Resident #12's contact precaution room without performing hand hygiene, putting on gloves or using PPE. The LN assisted the Resident with his morning medications. The LN adjusted the bed, touched the bedside table and bed sheets. The LN did not perform hand hygiene upon exiting the room. Observations on 5/4/15 at 8:00 am, revealed CNA #6 assisted Resident # 39, who required contact precautions, with ADLs and transferring the Resident to a wheel chair. The CNA was not wearing any PPE. The CNA did not perform hand hygiene after assisting the Resident to the dining room table. Further observation revealed the CNA used a portable vital sign unit to take the Resident's blood pressure, measure the oxygen saturation and pulse, and take a temperature. The portable vital sign unit was not cleaned prior to it being moved to the alcove for storage. Observations on 5/4/15 at 8:13 am, revealed the SSC entered Resident #12's contact precaution room without performing hand hygiene or donning a protective gown. The SSC went to the Resident's bedside, pulled the curtain, touched the bed linens, and spoke with the Resident. The SSC did not perform hand hygiene upon exit of the room. The SSC then proceeded to enter 4 other rooms to see residents. The SSC did not perform hand hygiene when entering or exiting any of the rooms. During an observation on 5/4/15 at 8:15 am, CNA #6 adjusted the bed linens for Resident #12. The CNA was not wearing PPE. The CNA then proceeded to remove a breakfast tray from the food cart and deliver it to another resident. The CNA did not perform hand hygiene between the two resident's rooms. During an interview on 5/4/15 at 8:37 am, the DON was asked how staff would know if a Resident required contact precautions. The DON stated chests are placed outside resident rooms with infectious diseases. The chests have the PPE that staff should use before room entry. Each chest contained individual, designated blood pressure cuff, gowns, gloves, and masks. These items were to be kept in the chest outside the room. Staff should not use the portable blood pressure machine. In addition the DON stated visitors were alerted to contact precautions by the signage lying on the cart that stated see Nurse before entering. During an observation on 5/4/15 at 8:38 am, CNA #10 was heard asking RCM #4 if Resident #12 was on contact precautions. The RCM stated yes and pointed to the sign and the drawers. The CNA then replied, Oh, I didn't know he was on precautions. During an interview on 5/4/15 at 8:42 am, RCM #4 confirmed Resident #12 was on contact precautions. RCM #4 stated staff and visitors were to wear PPE (protective gown, gloves, and mask) prior to entering the resident's room. Staff should wash their hands after PPE is removed. In addition, the RCM stated the sign kept falling on the floor. The RCM then taped the See Nurse before entering sign to the door frame. Observations on 5/5/15 at 9:10 am, revealed CNA #6 providing incontinence care for Resident #12. After cleaning the perineum (genitals and buttocks) of stool and throwing the soiled brief away the CNA removed the soiled gloves, pulled a pair of gloves out of her uniform pocket, and put them on. The CNA then continued to provide care to the Resident and touch other items in the room. The CNA did not perform hand hygiene when going from dirty to clean tasks. The CNA then removed the protective gown and gloves and assisted the Resident up in the bed. After completing cares the CNA removed the trash bag containing the soiled brief and tossed it in the open refuse can outside the room. Observation on 5/5/15 at 10:05 am, revealed LN #5 enter Resident #12's room, and without donning PPE or performing hand hygiene, administered the Resident's medications. Upon exiting the room, the LN used the hand sanitizer but not soap and water. LN #5 then went to the med cart and gathered another resident's medication. On 5/5/15 at 10:13 am, CNA #6 entered Resident #12's room without donning PPE, took Resident #12's vital signs using the portable vital sign unit (on wheels) and without cleaning the equipment the CNA rolled the unit to 7 other resident's rooms on the court and took residents vital signs. The CNA did not perform hand hygiene or clean the equipment between residents. During an interview on 5/5/15 at 11:47 am, RCM #4 stated the portable vital sign unit was not to be used on residents requiring contact precautions. An observation on 5/6/15 at 3:00 pm, revealed CNA #6 in Resident #12's room taking vital signs with the portable vital sign unit. The CNA did not use the designated vital sign equipment located in the cabinet outside the Resident's door. Record review of the facility policy Transmission Based Precautions, dated 11/09, revealed .Personnel having contact with the infected resident should wear gloves and a gown.prior to leaving the resident's room.hand hygiene (is) performed.Indirect transmission of infections agents can occur through contact with resident care equipment.resident care items like thermometers, stethoscopes blood pressure cuffs or commodes with be designated for use but the resident needed contact isolation. Record review of the facility policy Hand Hygiene, dated 10/2011, revealed It is the policy of this facility to require staff wash their hands.before and after entering isolation precaution settings. During an interview on 5/5/15 at 1:30 pm, MD #1 confirmed Resident #12 should be on contact precautions. The MD stated the Resident had tested positive last week and was still considered infectious. Hand Hygiene Observation on 5/3/15 at 8:30 am, revealed CNA #6 entered a resident's room to help the resident to the toilet. The CNA did not perform hand hygiene before entering the room or upon exiting. At 8:35 am the CNA returned to the room and assisted the Resident off the toilet and into a chair. The CNA did not perform hand hygiene when exiting the room. The CNA then removed a breakfast tray from the food cart and delivered it to another resident in their room. Observation on 5/3/15 at 9:06 am, revealed CNA #14 entered a resident's room without performing hand hygiene and repositioned the Resident. The CNA then exited the room and did not perform hand hygiene. Observation at 9:10 am, revealed CNA #6 exited a resident's room, did not perform hand hygiene, walked to the dining table and began feeding breakfast to Resident #'s 41 and 29. Observation on 5/6/15 at 11:55 am, revealed CNA #s 6 and 10 exited a residents room after providing Resident care. Neither CNA performed hand hygiene when exiting the room. LN #5 was observed facing the medication cart nearby with their back to the CNA's exiting the room behind. During an interview on 5/6/15 at 11:55 am, LN #5 was informed about the CNA's exiting the resident's room without sanitizing their hands, she replied, we only sanitize our hands for rooms with precautions. Record review of the facility policy Transmission Based Precautions, dated 11/09, revealed .Personnel having contact with the infected resident should wear gloves and a gown . prior to leaving the resident's room.hand hygiene (is) performed. Resident Care Equipment Resident #2 Record review on 5/4-8/15 revealed Resident #2 had a [DIAGNOSES REDACTED]. Random observations from 5/3-7/15 revealed oxygen tubing on the floor and an unlabeled nebulizer mask with large amounts of opaque white debris. During one random observation on 5/4/15 at 7:28 am CNA #5 stepped on the oxygen tubing multiple times while assisting the Resident. Indwelling Urinary Catheter Random observations on 5/5/15 revealed Resident #27 seated in a wheelchair. While propelling self around the facility the Resident's indwelling urinary catheter tubing was dragging on the ground beneath the wheelchair. TB Screening Resident # 5 Record review on 5/3-8/15 revealed Resident #5 on 4/12/200 and had a history of [REDACTED]. Resident #7 Record review on 5/3-8/15 revealed Resident #7 was admitted to the facility on [DATE] and had had a [DIAGNOSES REDACTED]. Further review of Resident #7's medical record revealed no record of annual TB screening. Resident #11 Record review on 5/3-8/15 revealed Resident #11 was admitted to the facility 12/3/13 and had [DIAGNOSES REDACTED]. Further review of Resident #11's medical record revealed no record of annual TB screening. During an interview on 5/8/15 at 12:30 pm, RCM #3 stated TB testing was done only on admission for residents. During an interview on 5/8/15 at 2:15 pm, the DON stated TB screening for Residents was only done on admission and if the Resident was returning to the facility after a discharge to the community. When the Surveyor requested the policy and procedure for Resident TB screening, the DON stated the policy was not correct because it was for Washington State standards, not Alaska. Review on 5/8/15 of the policy TB Testing, Resident & Employee, dated 8/12, revealed no mention of annual TB screening for Residents. Review on 5/15/15 of [DIAGNOSES REDACTED] in Alaska 2013 Annual Report, accessed at www.epi.hss.state, revealed In 2013, 71 cases of [DIAGNOSES REDACTED] (TB) were reported to the Alaska [DIAGNOSES REDACTED] Program for an incidence of 9.6 cases per 100,000 population. This was a 7.6% increase in the number of cases and a 6.7% increase in the incidence of [DIAGNOSES REDACTED] when compared to 2012. The report also identified an increase in number of TB cases specifically in the Anchorage/Mat-Su area from 10 cases per 100,000 people (or 2.5%) in 2012 to 25 cases per 100,000 people (or 6.3%) in 2013. Antibiotic stewardship and surveillance Resident #7 Record review on 5/3-8/15 revealed Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Progress Notes, dated 4/16/15, revealed .Cloudy colored urine in leg bag. Alerted shift supervisor of urine color and resident's current VS (vital signs). MD was called. There is an order for [REDACTED]. The VS listed in the progress notes for that day were BP 180/67, pulse 75, respirations 18, and temperature 96.7 degrees F. Review of Resident #7's lab report Urine Culture, collected date 4/17/15, revealed Susceptibility test results verified Car(b)apenem - intermediate or resistant organism.Isolates may become resistant to all cephalosporins (group of antibiotics) after initiation of therapy. Further review of Labs Flowsheet, dated 4/1/15 - 4/30/15, revealed an order for [REDACTED]. According the to Nursing 2014 Drug Handbook [MEDICATION NAME] can be toxic to the sensory cells of the ear, can cause ringing in the ears, balance difficulty, and is a nephrotoxic (damaging to the kidneys) particularly in the elderly. During an interview on 5/7/15 at 3:45 pm the IC Nurse stated based on facility protocols Resident #7 would not have had the urinalysis that led to the Resident being given [MEDICATION NAME] (a strong antibiotic that can be damaging to the kidneys) if cloudy urine was the only sign and symptom. The IC Nurse stated she would research the reasons for the urinalysis and supply the supporting documentation. No further information was supplied by the end of the survey. Infection Prevention and Control Committee During an interview on 5/5/15 at 13:55 pm with the ADON, acting as the ICP stated she had been at the facility less than 2 months, which was confirmed the Corporate Nursing Consultant. In addition, the ADON stated the facility had not filled the ICP position for at least 4 months prior to her taking the position. When asked who was responsible for performing surveillance prior to the last two months the ADON and Corporate Nurse Consultant did not respond. Record review of the facility policy Infection Reporting and Tracking dated 11/09, revealed, It is the policy of this facility to investigate, control, and prevent infections; .the (ICC)will maintain a record of infections and corrective actions related to infections; .the (ICC) will monitor residents with infections to evaluate effectiveness of treatment; .a facility lay-out map will be used to document types of infections by location.each month.(with) a new map each month; .Infection incidence will be calculated monthly.and presented at the Infection Control Committee/Quality Assurance Committee; .the (ICC) will complete periodic facility rounds to determine if staff practices related to infection control meet professional standards; .the (ICC) will analyze data collected and implement corrective action as needed; .the (ICC) will request and review monthly print-outs of antibiotic use each month;.the (ICC) will request and review quarterly print-out of antibiogram from the lab; .the (ICC) will report outcomes of facility rounds, trending, analysis and corrective action related to facility infections and staff education., to the Infection Control Committee as part of the quarterly Quality Assurance committee meeting. During the survey, as early as 5/4/15, the facility was asked multiple times, each day for the Infection Control Committee minutes; Tracking and trending of infections; documentation of how the antibiotic stewardship was implemented, documentation of action plans for any identified trends, and what Infection Prevention and Control information was reporting to the Quality Performance Improvement Committee for the previous 12 months. No documentation of surveillance trending or action plan was provided. In addition, no documentation to support an active infection prevention program was provided.

Based on observation, interview, and record review the facility failed to ensure resident #30 was free of physical abuse by anyone, including other residents. The facility failed to take action to prevent repeated incidents of abuse. Although staff witnessed resident #13 hit and pursue resident #30 in the dining room, no staff intervened. Staff failure to identify physical abuse and failure to implement measures to prevent recurrence or repeated incidents of abuse resulted in a second incident of physical abuse within four hours. Staff were present in the dining room and witnessed resident #13 hit resident #30 multiple times but staff again failed to recognize the abuse and failed to take immediate measures to protect resident #30 from physical abuse by resident #13. The facility failed to ensure staff had been properly trained to respond to escalating aggressive resident behaviors; recognize abuse, and intervene to protect residents. These failures placed all residents in the dining room, (#s 8; 27; 29;30; 31; 32; 33; 34; 35 and #36), in immediate jeopardy from harm or injury. The facility was notified of the IJ on 5/4/15 at 3:25 pm. The facility provided a plan that abated the immediacy of the IJ. by placing Resident #13 on a 1:1 supervision. on 5/4/14 at 4:38 pm. Findings: During observations Breakfast meal On 5/4/15 from 7:15 - 8:30 am two surveyors observed the morning meal located in the main dining room (DR). Resident #13 and Resident #30 sat at a small table located next to the window. Resident #13 actively took all of the table items (coffee condiments, menu, napkins, and cups) and put them on his side of the table. When Resident #30 attempted to look at the menu Resident #13 pointed a finger at him and shook it from side to side (indicating Resident #30 was not to touch the rearranged items). When Resident #30 tried to retrieve his coffee cup, Resident #13 appeared visibly agitated at him and gritted his teeth with a tense face, shook his fist and kicked at Resident #30 under the table. For several minutes Resident #13 continued to angrily shake his fist at Resident #30 as he became more agitated. As the kitchen staff began to pass out the breakfast, Resident #30 attempted to retrieve a napkin from Resident #13's side of the table. Resident #13 jumped up, walked around the end of the table and threw a punch at Resident #30's face. Resident #30 raised his arm to block the blow. Resident #13's blow made firm contact with Resident #30's left forearm. Resident #13 sat back down at the table and continued to aggressively shake his fists at Resident #30. Resident #30 got up and walked over to the area where extra napkins were kept on the other side of the room. When he got to the other side, and picked up a napkin, Resident #13 jumped up and ran across the room attempting to take the napkin away from Resident #30. Resident #30 started running and Resident #13 chased after him. They raced around the tables where CNA staff were assisting other residents with their meals. The chase ended at the Residents' own table. Resident #30 sat down and attempted to hide a napkin, but Resident #13 stood next to him and aggressively snatched the napkin away from Resident #30 and then sat back down on his side of the table. Resident #13 continued to shake his fist at Resident #30. The kitchen staff then gave both Residents their meals and Resident #13's attention became focused on eating. There were 9 other residents eating their breakfast in the dining room that morning residents (#8; 27; 29; 31; 32; 33; 34; 35 and #36). During the Residents' interactions none of the kitchen staff or CNA staff attempted to intervene. During the two Residents' interactions the Surveyor observed Resident #30's facial expressions and when Resident #13 acted aggressive toward him, Resident #30 would not make direct eye contact, but looked from side to side. It appeared that Resident #30 was aware of Resident #13's escalation and he attempted to avoid conflict. Resident #8, who sat directly behind Resident #13 and Resident #30 called CNA #2 over and told the CNA to keep an eye on them because Resident #13 was trying to hurt Resident #30. The CNA said to Resident #8 in a humorous manner, Well you had better stay away from people like that so you don't get hurt. Dining observation lunch meal Observations on 5/4/15 from 11:40 am - 12:20 pm in the main dining room, during the lunch meal, revealed Resident #13 and Resident #30 sitting at their table located against the window. Resident #30 placed a napkin out of Resident #13's reach on the window sill next to him. Resident #13 stood up and reached over the table and grabbed the napkin out of the window sill where Resident #30 had placed it. Resident #13 then sat back down and repeatedly kicked at Resident #30 under the table. Resident #13 came in contact with Resident #30's legs two times. When Resident #30 picked up the paper menu, Resident #13 grabbed it from Resident #30's hand. Resident #13 clenched his fist at Resident #30 and jabbed a finger out at Resident #30 several times firmly. Resident #13's teeth were clenched and face was tense. Then, Resident #13 grabbed the paper menu off the table and pointed at Resident #30 with a clenched fist. Resident #13 then stood and tried to get the kitchen staffs' attention while pointing down at the table and motioned for food. Resident #13 was visibly agitated and his behavior was escalating. The kitchen staff served both Residents two small bowls with cottage cheese and Resident #30 quickly put his cottage cheese down on his chair on the wall side. The kitchen staff then placed pudding on the table. Resident #30 held it between his hands. Resident #13 reached over and slapped Resident #30's hands in an attempt to take the pudding away from him. Resident #30 was able to keep the pudding in his hand until Resident #13 soundly slapped him a second time on the top of his hands and Resident #30 allowed Resident #13 to jerk it out of his hands. The slap was loud enough to be heard across the room. Resident #13 then stood up and walked around to Resident #30 and slapped him on the top of the head hard enough to be heard across the room. When Resident #13 slapped Resident #30 on top of the head a staff member sitting at the far end of the dining room heard it and stood up and gasped, then sat back down again and continued assisting a resident with her meal. Resident #27 sitting two tables behind Resident #13 and Resident #30 called over to one of the kitchen staff and informed her that two Surveyors were watching what was going on with Resident #13 and Resident #30. During an interview on 5/4/15 at 1:00 pm, Dietary Aide (DA) #1 stated she had reported Resident #13 had struck Resident #30 on 5/4/15 to the Dietary Manager and CNA #3. DA #1 also stated Resident #13 had struck Resident #30 in the past and altercations between the two Residents had occurred about 1 time per month for the past year. The Dietary Aide had previously reported the incidents to the Dietary Manager but had not received a response. During an interview on 5/4/15 at 1:15 pm DA #3 stated Resident #13 hit Resident #30 on the head and stole the Resident's food while the two were in the dining room for lunch on 5/4/15. During an interview on 5/5/15 at 1:00 pm, the Dietary Manager stated the Dietary Aides had reported Resident #13 had struck Resident #30 on 5/4/15 and that he had reported the incident to the RCM. The Dietary Manager stated no previous incidents had been reported to him. During an interview on 5/4/15 at 2:30 pm Resident #8 confirmed, that she saw Resident #13 hit Resident #30 on the arm during the morning meal. The Resident further disclosed both Resident #13 and Resident #30 teased each other. Resident #8 stated that when that kind of behavior went on between those 2 Residents that she would tell the staff that they needed to keep an eye out for them, so that no one would get hurt. When asked if she was afraid of Resident #13 striking out at her Resident #8 said No, there are too many people around here and they wouldn't let him hit me. Resident #8 went on to say that she had gone on an outing with Resident #13 and stated he sometimes had a jerky nerve. Resident #8 then stated (Resident #13) is a dangerous lad. Record review from 5/4-8/15 revealed the following issues concerning Resident #13 A typed, undated letter found in the Resident's medical record which came from Resident #13's mother revealed.I know that on Monday you got very mad and hit someone. That made Mom very upset because you know we do not hit. Sometimes we have to wait to do things and that is ok. I want you to remember to always be good, not hit and do not get so angry or mad when you have to wait I want you to write to the lady you hit and tell her you are very sorry and you will not hit again. On 5/8/15, the Surveyor requested from RCM #1, overseeing Resident #13's care, more information on the incident referenced in the letter. No other information was provided during the survey. Review of the Resident's most recent daily care plan, undated, located in the direct care staffs Care Plan Book, revealed no direction on what to do if Resident #13 became angry or volatile toward others; or inform the direct care staff to monitor and/or intervene when teasing between Resident #13 and Resident #30 escalated to the point of potential harm. The facility had also not directed the dietary staff on what to do if Resident #13 became volatile. As a result of no supervision; lack of adequate training for direct care staff and dietary staff on when the teasing was developing into inappropriate physical contact; and a lack of comprehensive care planning on how to intervene; Resident #30 was physically abused on two separate occasions by Resident #13 while in the dining room.

Based on record review, observation, and interview the facility failed to ensure interventions were identified and implemented to prevent weight loss for 1 resident (#12) of 13 residents reviewed. As a result, the resident suffered a significant weight loss. Findings: Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Resident's MAR indicated [REDACTED]. Record review on 5/3-8/15 of the Weight Variance Report for Resident #12 revealed the following dates and weights documented: · 1/29/15 147 pounds · 3/4/15 *139.6 pounds · 3/26/15 136.7 pounds · 4/2/15 134.4 pounds · 4/9/15 135 pounds The * weight documented on 3/4/15 indicated a weight loss of 5.0%. According to the Weight Variance Report this indicates a Significant Weight Change. Review on 5/3-8/15 of the Observation Report Nutrition-PCI-Medical Nutrition Therapy Re-Assessment-PCI, a report completed by the registered dietician, dated 3/12/15, revealed a 5.7% weight loss in 30 days. Review on 5/3-8/15 of the Interdisciplinary Progress Notes, dated 1/24/15-5/6/15 revealed no documentation regarding Resident #12's weight loss. Review on 5/3-8/15 of the comprehensive nursing care plan, edited 4/20/15, revealed no documentation of weight as a problem and no goal or approach for the Resident's continued weight loss. Further review of MDS assessments dated 1/30/15 revealed the Resident was coded as needing Setup help only with eating. The MDS on 4/20/15 revealed the Resident coded as needing 1 person assist with eating. Observation on 5/5/15 at 9:00 am, revealed Resident #12's breakfast tray being removed from the bedside table and placed in the tray cart. Observation of the food tray revealed 100% of the breakfast meal had not been eaten. The paper band was still wrapped around the silverware and paper napkin. Multiple random meal observations from 5/3/15 to 5/8/15 revealed staff would put the Resident's meal trays on the bedside table, place the table over the bed and then leave the room without offering assistance to the Resident. The observations revealed the staff did not attempt to assist the Resident in anyway with meal setup or assistance. During an interview on 5/6/15 at 3:40 pm, RCM #4 was asked when the physician was notified of Resident #12's weight loss. The RCM was unable to confirm the physician had been notified of the weight loss. Continuing with the interview, RCM #4 reported CNA #31 weighed each resident weekly and reported a weight loss of 2 or more pounds to me. She further stated that she documented residents' weight loss in the Progress Notes or RD Nutritional Summary and considered a significant weight loss to be 5% or more. Review on 5/3-8/15 of the physician progress notes [REDACTED].#12's weight loss. Review on 5/3-8-15 of the facility policy Nutrition Risk Review, dated 1/15, revealed A weekly NAR (Nutrition At Risk) meeting consisting of the DNS, RCM, RD and other disciplines as indicated will occur to discuss resident status, make referrals to other health professionals and plan appropriate, individualized interventions.An assessment will be completed for residents who are identified as having nutritional risk, including but not limited to: a. significant/patterned weight changes.The RCM or designee will be responsible to review the resident's medical record prior to meeting with the team. Review to include but not limited to.weights.current nutrition interventions. There was no documentation of Resident #12's progressive weight loss, and the significant weight loss of greater than 5% was not discussed at a meeting nor was there any interventions documented.

Based on record review, observation and interview, the facility failed to ensure a functional system or process was in place to ensure timely skin assessments and the provision of wound care. As a result, 4 residents (#s 6, 7, 11, and 12) out of 13 sampled residents did not receive adequate skin assessment for identified skin issues and/or did not receive wound care. These failed practices placed residents with skin problems at risk of developing new skin issues (pressure ulcer or other skin breakdown); and placed those residents with identified skin issues at risk of experiencing a delayed healing or worsening of pressure ulcers (bed sores-localized injury the skin and/or underlying tissue resulting from pressure or in combination with friction and/or shear). Resident #12, who developed facility-acquired pressure ulcers, sustained harm due to facility failure to put appropriate preventative measures in place or initiate sufficient ongoing assessment and treatment after the ulcers were identified. Findings: Resident #12 Record review on 5/3-8/15 revealed Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the 2 most recent MDS assessments, dated 1/30/15, and 4/20/15, revealed the Resident was identified as being high risk for pressure ulcers. The Resident was coded as not having any unhealed pressure ulcers in both assessments. Record review on 5/3-8/15 also revealed: Admission Nursing Database 1, recorded date 1/23/15, Skin Condition.no evidence of skin breakdown; OT Evaluation & Plan of Treatment.Certification Period 1/23/2015-2/6/2015.Risk Factors.decrease in level of mobility.decreased skin integrity.increased dependency upon caregivers and limited out-of-bed activity; Nutrition-PCI-Medical Nutrition Therapy Re-Assessment-PCI, with an observation date 5/3/15, the No box was checked under Skin Issues, indicating the Resident did not have any skin breakdown; The most recent comprehensive nursing care plan, edited on 4/20/15, identified Problem.At risk for skin impairment R/T decreased strength and mobility due to recent [MEDICAL CONDITION]; A physicians order, dated 5/1-31/15, of [MEDICATION NAME] ointment; Apply to buttocks at every attend change.and.Please get patient up in wheelchair every day; Treatment Flowsheet, dated 5/1-31/15, with Weekly Skin Checks. Document: (-) No Skin impairment present. (+) Skin impairment present. Follow Skin at Risk policy. Once a Day on Sun. The flowsheet had a + on Sunday, 5/3/15, indicating skin impairment was present.; and Review of Nurse Progress Notes, dated 5/5/15, revealed Resident #12's right buttock wound was documented both as a skin tear and an open area by RCM #4 and as a laceration by LN #5. An observation on 5/5/15 at 9:10 am revealed Resident #12 being assisted with care. The Resident's heels were not floating on pillows to relieve pressure when CNA #6 pulled the covers down to turn the Resident on his side. When the CNA removed the Resident's attend, dried stool was caked to the Resident's buttocks. CNA #6 completed peri care for the Resident but did not apply ointment to the Resident's buttocks. While observing the care, the Surveyor noted an opened Stage II wound (Approximately 1 x 1 inch in size about the size of a nickel) on the Resident's right buttock. Continued observation revealed the Resident also had excoriation along the crack of the buttocks and on the scrotum. The CNA did not say anything about the wounds and further observation and review revealed CNA #6 did not report the wounds to a nurse. During an interview on 5/5/15 at 3:30 pm, when asked about Resident #12's skin integrity, RCM #4 stated Resident #12 had no skin impairments and no pressure sores. And stated As far as I know (Resident #12) does not have a wound. The plus sign on the TAR dated 5/3/15 may be a mistake. After cueing from the surveyors, RCM #4 said she would do a head to toe assessment of Resident #12 that day (5/5/15) and if the resident had a wound she would start the wound mapping and skin grid process. RCM #4 stated wounds should be documented in the MACC Book, Skin Grid Book, and the Progress Notes. Record review on 5/5/15 revealed the MACC book, Skin Grid book, Progress Notes, and April's MAR and TAR revealed no wound entry for Resident #12, indicating the Resident did not have any documentation of wounds. During an interview on 5/6/15 at 3:00 pm RCM #4 was asked if she seen Resident #12's wound she replied, yes I did and I'm going to do a dressing change soon. An observation on 5/6/15 at 3:20 pm revealed RCM #4 and the ADON assessed Resident #12's skin. Resident #12 was lying in the supine position, in a regular bed and not on an air bed,with his heels against the mattress and not floating to relieve pressure. When the Residents attends was removed, dried stool was caked on the Residents buttocks. Peri care had to be done before the RCM was able to assess the skin. 2 Surveyors observed the Resident had a Stage II wound on the right buttock, excoriation along the crack of the buttocks and the scrotum, and a wound on the left heel. The RCM said, Oh, the dressing is not here. The RCM did not identify or address the approximate 1x1 inch size circular reddened area on the Resident's left heel, until the Surveyors pointed it out to her. Further observation revealed the wound on the Resident's left heel was mushy and boggy. During an interview on 5/7/15 at 11:40 am RCM #4 explained the process for reporting resident wounds by CNAs. RCM #4 stated CNAs should report any skin concerns to me. The CNAs are my eyes and ears; I rely on them to keep me informed. RCM #4 was asked if Resident #12's wound were reported to her and she confirmed they had not. The RCM was further asked if she noticed the Resident's left heel when she did her head to toe assessment on 5/5/15. She stated there was nothing on his heels; no skin issues as of 5/5/15. During the interview, when asked what treatments would be done for the wound, RCM #4 replied, I haven't done anything with his heel yet. I will look at it later. When asked why the pressure sore had been documented as a skin tear on the skin grid and a open area on the MACC book, the RCM stated the terms skin tear and open area to be interchangeable. When asked about the measuring the size of the wound, the RCM replied I forgot to document the measurements. I would document the measurements in the nurse progress notes. When asked what interventions residents should receive to prevent skin breakdown, RCM #4 replied the residents should be turned every 2 hours and heels should be floated with pillows. CNA's would be expected to turn residents every 2 hours. When asked what type of mattress Resident #12 was supposed to have, RCM #4 replied I'm not sure what type of mattress (Resident #12) has. She stated the Resident should have an air mattress or overlay on his bed and he used to have an air mattress but the RCM didn't know what had happened to it. During an interview on 5/7/15 at 1:40 pm, 2 days after notification of the wound, RCM #4 stated Resident #12's left heel wound was a Stage 1 pressure ulcer. She confirmed the heel wound was very soft under the skin. I'm going to let (MD #1) know and get the treatment started. Random continuous observations from 5/3-8/15 revealed the Resident lying in bed on his back with his heels directly on the bed. The Resident's heels had not been floated off the bed with pillows, he was not on an air mattress or overlay and the Resident was not turned every 2 hours, or encouraged to reposition every two hours. During observation on 5/8/15 at 12:00 pm, an air overlay mattress was folded and lying on top of Resident #12 cabinet which was located outside of his door. During an interview on 5/8/15 at 12:48 pm CNA #31 confirmed the CNA's did not have a sheet or place to document a residents wound. The CNA stated they were supposed to report wounds to the nurse. During an interview on 5/8/15 at 2:30 pm, 3 days after the wounds were identified, when asked if she was aware of Resident's #12 pressure wounds, MD #1 replied I am now and stated she was just recently informed of the Resident's wounds. Record review from 5/3-5/15 revealed no documentation Resident #12 had any skin impairments except for the + on the Weekly Skin Checks of 5/3/15 until after the Surveyors notified RCM #4 on 5/5-6/15 of the 3 new areas of skin impairments; including 2 of the impairments being Stage I and II wounds. The following documentation was done after the Surveyor notified the RCM: · Review on 5/7/15 of the SKIN GRID FOR ALL 'OTHER' SKIN PROBLEMS, dated 5/5/15, revealed documentation Resident #12 had a Skin Tear on the right buttocks. · Review on 5/7/15 of the RESIDENT PROGRESS NOTES, dated 5/5/15, Resident has an open area on (Resident #12) right buttock area. 1 by 1 cm. and · Review on 5/7/15 of the MACC , dated 5/5/15, revealed Resident #12 had open area (right) Buttock new treatment orders. Record review from 5/3-8/15 revealed there was no documentation for treatment of [REDACTED]. and crack of buttocks. A policy on skin assessment and skin at risk was requested. No policy was provided by the end of the survey. Resident #6 Record review on 5/4-8/15 revealed Resident #6 had [DIAGNOSES REDACTED]. Review of the Skin Grid for Pressure, Venous, Arterial & Diabetic Ulcers, dated 4/12/15, revealed the Resident had developed a pressure wound on the right buttock. Review of the Treatment Flowsheet, dated 5/1/15 - 5/31/15, revealed the Resident was to have the treatment Cleanse with wound cleanser, pat dry, apply foam dressing.every 3 days and PRN.until healed. The square for 5/3/15 was left blank which identified the wound care had not been done. An observation on 5/4/15 at 10:15 am, revealed Resident #6's right buttock wound did not have the foam dressing on it prior to LN #9 performing wound care. During an interview on 5/4/15 at 10:30 am, when asked why Resident #6's foam dressing had not been intact, LN #9 replied the wound care hadn't been done on 5/3/15. Resident #7 Record review on 5/3-8/15 revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Braden Scale for Prediction of Pressure Sore Risk, dated 2/4/15, revealed Resident #7 was At Risk for skin breakdown. Review of both the most recent MDS comprehensive assessment, an annual assessment dated [DATE], and the most recent quarterly assessment, dated 3/1/15, revealed Resident #7 was coded as increased from no pressure ulcers on the 6/5/14 assessment to having one Stage 2 pressure ulcer with eschar (a hard crust or scab) in the wound bed on the 3/1/15 assessment. Review of the RAI Version 3.0 Manual, Chapter 3 Page M-6, revealed unstageable pressure ulcers have .eschar tissue present such that the tissue layers involved with the pressure ulcer cannot be determined, should be classified as unstageable. March Skin Grid Review of Skin Grid for Pressure, Venous, Arterial & diabetic Ulcers revealed: On 3/3/15 Highest Stage - Stage II.Appearance of Wound 100% tan scab intact. On 3/17/15, Highest Stage - Stage II.Appearance of Wound dark brown scab intact; On 3/25/15, Highest Stage - Stage II.Appearance of Wound dark brown scab with lighter edges.Currently being TX for ABLE cellulite (bacterial skin infection) causing drainage from bottom of wound. Review of the TAR dated 3/1/15 - 3/31/15 revealed: 1. Apply Coban compression stocking to BLE after shower on Mon (Monday) + Thur (Thursday) leaving (Resident #7) L heel exposed. The treatments were circled as not done on March 9, 17, 23, and 26. Additionally, the March 16 treatment was blank. On the back of the form was noted 3/18/15 1400 hours (2:00 pm) Stage II Coban system not avail(able). Wrapped in Aces. 2. Prevalon boot LLE when in bed and sitting to (decrease) pressure on L heel with 19 opportunities left blank on the TAR that identified the boot was not put on the Resident's left foot as ordered. 3. Monitor L heel blister daily for S&S of infection until healed was left blank for 7 days that identified this treatment was not completed on those days. 4. Weekly Skin Checks. Document: (-) No Skin Breakdown present. (+) Skin Breakdown present.Once A Day on Sun. March 1, 8, and 15 were marked with a (+) that identified Resident #7 had skin breakdown. March 22 and 29 were marked with (-) that identified the Resident did not have any skin breakdown. Review of MAR, dated 3/1/15 - 3/31/15, revealed Resident #7 was given Keflex (an antibiotic) for [MEDICAL CONDITION] in the lower extremities for seven days beginning 3/23/15. April Skin Grid Review of Skin Grid for Pressure, Venous, Arterial & diabetic Ulcers revealed: On 4/2/15, Highest Stage - Stage II.Appearance of Wound brown scab intact. April TAR Review of the TAR dated 4/1/15 - 4/30/15 revealed: 1. Weekly Skin Checks. Document: (-) No Skin Breakdown present. (+) Skin Breakdown present.Once A Day on Sun. April 5 was marked with a (-) that identified Resident #7 did not have any skin breakdown. April 12, 19, and 26 were marked with (+) that identified the Resident had skin breakdown. 2. Apply Ace Wrap to bilateral lower extremities daily was left blank on 9 days and circled on 4 days which identified the wraps were not applied a total of 13 days in April. 3. Off loading boot to L foot was blank on all days in the month of April. May TAR Record review on 5/4/15 of the TAR dated 5/1/15 - 5/31/15 revealed: 1. R and L offloading boot was left blank that signified the boots were not put on the Resident on: 5/1/15 evening and night; 5/2/15 day and evening; and 5/3/15 evening. 2. Apply Ace wrap to bilateral lower extremities daily was left blank on 5/2/15 that signified the wraps were not put on the Resident. An observation on 5/3/15 at 3:50 pm revealed Resident was sitting in his wheelchair in his room. The Resident had a blue boot half on and half off his left foot. The Resident did not have a boot on his right foot or wraps on either lower leg. An observation on 5/4/15 at 11:02 am revealed Resident #7 was sitting in his/her chair in his room. The Resident had a blue boot on his left foot. The boot was not on the right foot and wraps were on neither lower leg. There was also a black crusty spot on the top of the first remaining toe of the left foot. An observation on 5/7/15 at 7:45 am revealed Resident #7 was asleep in bed without any wraps on either leg. Untreated Wound to Toe Review of the Resident's medical record on 5/3-4/15 revealed Refer patient to podiatry for left great toenail injury - eval &treat. dated 3/26/15. During an interview on 5/4/15 at 11:20 am, RCM #2 stated there wasn't any documentation in the medical record to show that the Resident's order for a podiatry evaluation and treatment of [REDACTED]. During an interview on 5/4/15 at 2:45 pm, Medical Records Staff #1 stated the evaluation had been done on 4/6/15 but the report was not available because the Podiatrist did not know to send a note for the medical record until the Medical Records Staff had asked about the evaluation. The report was provided to the Surveyor and put in the file for MD #2. Review on 5/4/15 of the Podiatrist report, dated 4/6/15, revealed Assessment/Plan 1. [MEDICAL CONDITION] 2. Onychomycosis (fungal infection that can cause interference with standing, walking, and exercising and cause pain).May benefit from unna boots (wraps that are used to decrease [MEDICAL CONDITION] and and skin breakdown in the lower legs) if cardiac status stable. During an interview on 5/6/15 at 4:40 pm, MD #2 confirmed she had not been aware of the black spot on Resident #7's toe, I just got the report today. The MD was also not aware that the Resident had not had the ordered Coban 2 wraps applied due to missing supplies. The MD stated I only get information from the RCMs. If they don't tell me, I don't know. Resident #11 Record review on 5/3-8/15 revealed Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of Observation Report.Braden Scale for Prediction of Pressure Sore Risk, dated 9/11/14, revealed Resident #11's score was an 11 (high risk for pressure sores). Review of the annual MDS dated [DATE], revealed the Resident's assessment was coded as not at risk for developing pressure ulcers. Review of the quarterly MDS assessment dated [DATE] revealed the Resident was at risk for pressure ulcers and had one Stage 2 pressure ulcer. An observation of morning cares on 5/7/15 at 7:15 am revealed a red area on Resident #11's right great toe and right 2nd toe. During an interview on 5/8/15 at 12:00 pm, CNA #13 stated she had identified and reported Resident #11's skin breakdown on the Resident's right foot to the Charge Nurse on 5/6/15 and on 5/7/15. During an interview on 5/8/15 at 12:10 pm, RCM #3 confirmed staff had not written a note or filled out a form detailing the skin breakdown on Resident #11's toes. The RCM reported she had received a verbal report from the CNA just that day. Review of Position Statement: Pressure Ulcer Staging, accessed at www.wocn.org on 5/26/15, revealed a Stage 1 pressure ulcer is intact skin with non-blanchable redness of a localized area usually over a bony prominence. A Stage II pressure ulcer is characterized by partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough.This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration, or excoriation. Review of NPUAP (National Pressure Ulcer Advisory Panel)Pressure Ulcer Stages/Categories, accessed on 5/19/15 at www.npuap.org, revealed Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV.

Based on record review, observations, and staff interviews the facility failed to ensure abilities in bed mobility, personal hygiene, range of motion, and urinary continence did not diminish for 1 resident (#7) out of 13 sampled residents. This failed practice caused the resident harm by leading to a decrease in his abilities in all these areas. Findings: Resident #7 Record review on 5/3-8/15 revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of both the most recent MDS comprehensive assessment dated [DATE], and the most recent quarterly assessment, dated 3/1/15, revealed Resident #7 was coded as having significant changes in numerous areas. The changes were as follows: The Resident was coded as needing 1 person assistance for bed mobility on the 6/5/14 assessment and needing extensive assistance in bed mobility on the 3/1/15 assessment; The Resident was coded as needing 1 person assistance for personal hygiene on the 6/5/14 assessment and needing extensive assistance personal hygiene on the 3/1/15 assessment; The Resident was coded as no range of motion impairment on the 6/5/14 assessment and impairment on both sides of the lower extremities on the 3/1/15 assessment; and The Resident was coded as occasionally incontinent on the 6/5/14 assessment and frequently incontinent on the 3/1/15 assessment. Restorative Program Review of Resident #7's CCP revealed the Restorative Nursing Program had been discontinued on 12/9/14. Review on 5/3-8/15 of Therapy RA (Restorative Aide) Referral Form dated 2/17/15, revealed Resident #7 had a current Restorative Nursing Plan prepared by PT #1 and signed by RCM #2. The plan included goals to Maintain Strength and Maintain Ambulation. Review on 5/3-8/15 of Point of Care History, dated 4/5/15 - 5/5/15, revealed: AROM was not performed on any day of the time period. The various reasons noted were Could not Assess, No Information, and Not Observed. Of the 27 opportunities reported, only 2 dates documented Refused as a reason for not performing the task; Transferring was Not Performed 25 times from 4/5/15 - 5/5/15 with only one of those times identified as Refused; Walking was listed only once and that opportunity was Not Performed; and Other rehabilitation activity was Not Performed 1 out of 4 opportunities. During an interview on 5/6/15 at 3:15 pm, RCM #2 confirmed not performing the restorative nursing plan for Resident #7 could have contributed to his decreased ROM. Interviews - ROM During an interview on 5/3/15 at 9:30 am CNA/RA #1 disclosed that usually she worked as the restorative aide, but since the facility had been short staffed she was not available to provide that service. During an interview on 5/6/15 at 2:50 pm, CNA #30 stated CNAs did not do any ROM. The CNA further stated the three Restorative Aides did all the ROM for the Residents. During an interview on 5/6/15 at 12:30 pm, RCM #1 disclosed if the Restorative Aide was not available, the restorative services were not provided. She further clarified, that regular floor CNAs did not perform ROM for the Residents. During an interview on 5/7/15 at 3:30 pm, RA #1 stated there were only 3 Restorative Aides to take care of all Residents' Restorative Plans. The RA stated they were often pulled to cover other duties throughout the facility such as to be a Resident escort or to work on the floor as a CNA. If we are pulled, then the exercises don't get done. Review on 5/3-8/15 of Restorative Exercise Group, dated 1/15, revealed It is the policy of this facility to ensure that a resident's strength and range of motion does not deteriorate unless the deterioration was unavoidable. Residents assessed with [REDACTED]. Urinary Continence Review on 5/3-8/15 of the CNA care plan, unclear date, revealed Toilet Resident before meals.wants res(ident) to have urinal by trash can at night was the only guidance to voiding patterns for Resident #7. Review of the CCP, dated 2/4/15, revealed no guidance or plan to restore Resident #7's bladder function. Incontinence was not included on the Resident's CCP. During an interview on 5/7/15 at 2:30 pm, the DON stated Resident #7 fell on [DATE] trying to get to the bathroom and the Resident should have been put on a toileting program at that time. The DON further stated the facility did not have any toileting or bowel and bladder training programs available for the residents. Review on 5/8/15 of Bladder Incontinence, dated 1/15, revealed It is the policy of this facility that a resident who is incontinent of bladder receives appropriate treatment and services to restore as much normal bladder function as possible.Interventions will ensure the resident attains his/her highest practical level of bladder continence and may include but not be limited to: Bladder Retraining Program, Scheduled Toileting Plan based on individualized voiding pattern or Incontinence Management.

Based on record review, interview, and observation the facility failed to ensure 1 resident (#1) out of 5 sampled residents received necessary medical social services and failed to: 1) provide a discharge plan prior to a discharge, 2) provide information regarding transfer and discharge rights, and 3) ensure the resident had a provider that continued to provide services to the resident until a replacement could be found and failed to assist the resident with finding a new provider. This failed practice resulted in the resident suddenly being discharged from the facility without prior any knowledge, homeless without recourse or possessions, and suddenly without a provider to manage care in the facility. Findings: Unplanned Discharge Record review on 10/9-10/14 revealed Resident #1 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident #1's recent pre-op History and Physical completed by the Medical Director revealed the Resident also had a history of [REDACTED]. Review of the last physician progress notes [REDACTED]. Further record review revealed the Resident was transferred to a local hospital for a pre-arranged procedure on 10/6/14 and was scheduled for discharge from the hospital back to the facility 10/8/14. During a telephone interview on 10/9/14 at 9:40 am, hospital SW #1, where the Resident was currently a patient, confirmed the Resident was to be discharged back the facility on 10/8/14. During the interview SW #1 stated the facility had refused to allow the Resident to return to the facility. The SW stated the facility Administrator and SS had stated the Resident no longer had a physician and could not return to the facility. SW#1 stated the Administrator at the facility called and stated they need to speak with corporate about the Resident's readmission. The SW stated the facility had not called back and had not returned further calls. During an observation of the Resident's room in the facility on 10/9/14 at 12:30 pm, CNA #1 and Maintenance Staff #1 were observed packing up the Resident's belongings. A cat was seen huddled in the open closet of the room. Bowls of cat food and water sat nearby on the floor. During an interview with CNA #1 on 10/9/14 at 12:30 pm, the Surveyor asked if the Resident was returning, the CNA responded, "No". The CNA stated they had just found out the Resident would not be returning to the facility a couple days ago. When asked who the cat belonged to, the CNA stated the facility had given the cat to the Resident. During an interview on 10/9/14 at 12:35 pm, LN #1 stated he/she had prepared the Resident to go to the hospital the morning of 10/6/14 for the procedure. During the interview the LN stated "I was only notified today (the Resident) was not going to return." During an interview on 10/9/14 at 2:30 pm, the SS stated the Resident was not being allowed back to the facility because the Resident no longer had a provider. During the interview, the SS stated "(Resident #1) doesn't want to be here and is looking for a new place". The SS confirmed there was no discharge plan in place for the Resident. During an interview on 10/9/14 at 3:30 pm the Administrator confirmed the Resident was not being allowed to return to the facility. When asked why the Resident had not been notified of (his/her) discharge form the facility, the Administrator did not respond. A review of the annual and last quarterly Minimum Data Set (a federally required assessment tool), dated 5/24/14 and 7/27/14 revealed there was not an active discharge plan in place for the resident to return to the community. In addition a discharge tracking form had not been completed. Review of most recent "Social Service Quarterly Review", dated 7/26/14, revealed ...psychosocial functioning fluctuates...deciding to have surgery...No discharge plan...does well in a stable secure environment that medically monitors him...no identified ancillary services needed at this time..." Review of a social services progress note, dated 9/13/14, revealed "working on moving out...will let me know when (he/she) finds a place." There was no further information about the Resident moving to another facility in the record. During an interview on 10/9/14 at 2:30 pm, the Medical Director stated he/she had continued to treat Resident #1 until another physician could be found. The Medical Director he/she had performed the Resident's physical for the procedure. The Medical Director confirmed no discharge orders had been written for the Resident. An observation on 10/10/14 at 2:30 pm revealed a new Resident had been moved into the Resident's room. Resident #1's belongings had been removed from the room. During an interview with the Resident on 10/13/14 at 1:10 pm, the Resident stated he/she was unaware the facility was "Not letting me come back" until after the procedure when it was time to be discharged from the hospital. The Resident stated "I was going to come here and have my surgery and go back (to the facility)". The Resident stated "A while back (SS) had looked for a new place for me but nothing ever came of that." When asked if there was a plan to go to another facility, the Resident replied "I don't know, I am worried about my cat...I don't know where I am going to go." Review of the facilities "Resident Rights" located in the admission packet given to residents revealed "The right of residence...they may not be discharged without timely and proper notification to both the resident and the family or guardian." Required Notice review of the resident's medical record revealed [REDACTED]. During an interview on 10/9/14 at 12:35 pm, when asked if Resident #1 had received any discharge orders or instructions, information about rights regarding discharges and transfers, or the facility's bed hold information, the LN replied, "I'm assuming (he/she) didn't". During an interview on 10/9/14 at 2:30 pm, when asked if the Resident had receive a notice of discharge that contained information about the Resident's rights and advocacy information, discharge instructions, or information about the bed hold policy, SS stated "No." During an interview on 10/9/14 at 3:30 pm, the Administrator confirmed the Resident had not been provided with any information about the discharge. Review of nursing progress notes revealed the last 3 entries, dated 10/6/14, were in regards to the Resident's surgery. The entries contained no documentation regarding discharge teaching or information about a discharge from facility. Review of the facility policy "Notice of Transfer or Discharge", review date 1/2014, revealed "notice of transfer/discharge shall be made in witting 30 days prior to transfer discharge...Physicians orders is required prior to the transfer discharge...Assist the resident...in preparing safe transportation, preparation of belongings, and orientation of receiving facility to residents patterns to minimize risk of adjustment difficulties." Review of Facility policy "Bed Hold", review date 11/2010, revealed "It is the policy of this facility upon transfer to offer the resident and responsible party the option to hold the bed...if unable to provide at time of transfer or discharge the policy will be provided within 24 hours". "Procedure...2) upon transfer or discharge the nursing department will provide the resident and responsible party a copy of the bed hold polic ...5) if nursing is unable to provide notification at time of transfer or discharge the Social Services Director will contact the responsible party to notify them of the facility policy and obtain decision..." Without Medical Provider During the interview on 10/9/14 at 2:30 pm, SS stated the Resident was not being allowed back in the facility because "he doesn't have a provider". When asked about the order regarding assisting the Resident with finding another provider, SS replied "Yes, I saw it" When asked what had been done to assist the Resident the SS stated "I gave (him/her) a list of doctors and places that take Medicaid." SS added, "(Resident #1) is capable; (he/she) set up the surgery without any help...I can't make (him/her) call a doctor and I can't make a doctor take (him/her)." During the interview the SS stated "(Resident #1) apparently thought Dr. (orthopedic surgeon) was (his/her) doctor." When asked if the orthopedic surgeon could write orders for the Resident to return to the facility, SS did not reply. During an interview on 10/9/14 at 2:30 pm, the Medical Director confirmed he /she had been Resident #1's provider for 4 years. During the interview the Medical Director stated Resident #1 had fired him/her "several times." The Medical Director stated "first time (he/she) fired me was end of July beginning of August, I did not take this to heart, and (he/she) was upset over a recent event." In addition, the Resident "...did not want me to care for (him/her), did not want (his/her) meds...I finally wrote an order for [REDACTED].#1) find another doctor." During the interview the Medical Director stated he/she had continued to write orders for the Resident including the pre-operative physical for the surgery the Resident needed until another provider could be found. During an interview on 10/9/14 at 3:30 pm the facility Administrator stated they were not letting the Resident return to the facility because the Resident did not have a medical provider and the Resident had been discharged . Record review from 10/9-10/14 of the medical record revealed a physician order was written on 9/29/14 "RCM or SW to assist resident with finding a new PCP". Further review revealed a Pre-operative history and physical had been completed by the Medical Director. The medical record did not contain a note or order transferring care to another provider. Record review of the progress notes revealed there were no social service progress notes after 9/3/14. There was no documentation anyone had attempted to assist the Resident with finding a new provider. During an interview on 10/13/14 at 1:10 pm, when asked if anyone at the facility had helped him/her find a new provider, Resident #1 stated "No, no one has." The Resident stated his/her provider was "the one at the (facility)." When asked if SS had supplied a list of providers the Resident stated "No, I never got any names." .

Based on record review and interview the facility failed to provide a written notice of discharge that stated reason for discharge; the effective date of the discharge; where the resident would be discharged to; Ombudsman contact information and the resident's right to appeal the discharge action to the State for 1 resident (#1) out of 5 residents reviewed. As a result, the resident was unaware of being discharged and was suddenly without a home, left homeless and without the benefit of his/her belongings and pet after the facility refused to allow the resident to return to the facility after a planned procedure at a local hospital. Findings: Resident #1 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The Residents' recent pre-op History and Physical, completed by the Medical Director, revealed the Resident also had a history of [REDACTED]. During a telephone interview on 10/9/14 at 9:40 am, hospital SW #1, where the Resident was currently a patient, confirmed the Resident was to be discharged back the facility on 10/8/14. During the interview SW #1 stated the facility had refused to allow the Resident to return to the facility. The SW stated the facility Administrator and SS had told her the Resident no longer had a physician and could not return to the facility. SW #1 stated she asked the facility to come speak to the Resident regarding his/her non-readmission to the facility and was told by the Administrator at the facility they need to speak with corporate before they could talk to the Resident. The SW stated the facility had not called back and had not returned further calls. SW #1 stated she spoke with Resident #1 about the issue and was told by the Resident that there had "been a lot of tension" between the Administrator and him. The SW stated the Resident had planned to return to the facility and did not know they were not going to let him/her come back; stating "it's my home; my things are there, my artwork". SW #1 further stated that the facility did not provide any discharge paperwork for the Resident regarding a non-readmission status. SW #1 further expressed "I'm shocked that they would do this to a resident without having talked to (Resident)". During an interview on 10/9/14 at 12:30 pm, CNA #1 from Court #1, the court where the Resident was living, was asked if the Resident #1 was returning to the facility, CNA #1 stated "No". The CNA stated he/she did not know about the Resident being discharged and was told about it "Just within the past 2 days. There was some uncertainty about him/her coming back". During an interview on 10/9/14 at 12:35 pm, LN #1 on Court #1 disclosed he/she prepared the Resident to go to the hospital the morning of 10/6/14 for surgery. LN #1 stated "I was only notified today that Resident #1 was not going to return ". The LN was asked if the Resident was given any discharge paperwork or notice or a bed-hold notice. LN stated "I'm assuming (he/she) didn't". A review of the annual and last quarterly Minimum Data Set (a federally required assessment tool), dated 5/24/14 and 7/27/14 revealed there was not an active discharge plan in place for the Resident to return to the community. Record review of Resident #1's medical record on 10/9-10/14 revealed there was no documentation regarding discharge planning or that the Resident was being discharged from the facility on 10/6/14. Further review revealed there were no physician orders for a discharge from the facility, nor were there any discharge instructions. There was no documentation in the medical record that contact information for the Ombudsman had been given to the Resident prior to the pre-arranged surgery or that he/she had been informed regarding rights to appeal a discharge to the State. During an interview on 10/9/14 at 2:30 pm when asked if Social Services had given any notice of discharge to the Resident prior to leaving for the pre-arranged surgery, SS stated "No". During an interview on 10/9/14 at 2:30 pm, the Medical Director was asked if she had written discharge orders for Resident #1. The MD stated "No". During an interview on 10/9/14 at 3:30 pm, the Administrator confirmed the facility was not letting the Resident return stating it was because the Resident did not have a provider and (he/she) had been discharged . The Administrator did not reply when asked why the Resident had not been notified of a discharge prior to leaving for the scheduled surgery. During an interview with Resident #1 on 10/13/14 at 1:10 pm, at a local hospital, the Resident confirmed that he/she did not know the facility was discharging him/her and "not letting me come back". The Resident stated "(Administrator) don't like me, (Administrator) had it out for me". When asked if anyone from the facility had given him/her notice of being discharged from the facility or not being allowed to come back the Resident stated "No, I was going to come here and have my surgery and then go back". When asked where he/she was going to go, the Resident stated "I don't know, I'm worried about my cat...I don't know where I'm going to go" . Review of the facility policy "Notice of Transfer or Discharge", review date of 1/2014, revealed "Policy...Notice of transfer/discharge shall be made in writing 30 days prior to transfer/discharge...", "Procedure...2.Physician's order is required prior to the transfer/discharge ...5.Assist the resident...in preparing safe transportation, preparations of belongings, and orientation of receiving facility to resident's patterns to minimize risk of adjustment difficulties...6.Discharge plan of care shall be completed and sent with the resident at time of transfer/discharge". .

F309 Based on record review and interview the facility failed to provide necessary care and services during physical assessments to maintain the highest practicable well-being for 1 resident (#5) out of 12 sampled residents and 1 non-sampled resident. This failed practice resulted in actual harm due to insufficient assessment and response to the resident's deteriorating health which resulted in delayed emergency room evaluation and treatment. Findings: Resident #5 Record review on 9/2-4/14 revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record indicated the Resident was a FULL CODE (FULL CODE means if a person goes into respiratory or [MEDICAL CONDITION] every possible measure available will be used to resuscitate them). Record review on 9/2-4/14 of the Resident's care plan revealed "...High risk for aspiration (inhalation of foreign materials into the lungs) ..." Review of the nursing assessment progress notes for 8/17/14 revealed: At 2:38 am the Resident displayed the following: "Resident ...had occasional moist cough but unable to expectorate...VS 122/76 mmHg Pulse 118 Respirations 20 Temp 98.8 O2 sat 93%..."; 11 hours later, at 1:27 pm, the nursing assessment revealed the following: "Resident ...continues to be [MEDICAL CONDITION] with pulse at 151 ..." The nursing assessment did not include a lung function evaluation and the Resident's O2 saturation was not done; At 3:13 pm, the nursing assessment included the following: "Res (Resident) tachypnic (rapid breathing), [MEDICAL CONDITION] (rapid heart rate), hypoxemic (when oxygen concentrations fall below the level necessary to sustain life). Dr. called, res (resident) tx (treated) to Prov (Providence) ..."; and At 8:55 pm, the nursing assessment revealed, "Received call from Nurse (name omitted) @ PAMC (Providence Alaska Medical Center) - 1850 (6:50 pm) stated (resident name omitted) will be admitted to hosp (hospital) (possibly ICU) for aspiration pneumonia, electrolyte imbalance, UTI (urinary tract infection)." During an interview on 9/4/14 at 7:05 am the day Shift Supervisor (SS) #1 revealed that part of the SS job duties was to review nurses' notes to ensure adequate care is being provided to residents. The Surveyors asked the SS to read the nurses' documentation concerning the Resident condition on 8/17/14 prior to being transported to the hospital ER; the SS said from the documentation it looked as if the nursing staff "acted too slow" in sending the Resident to the ER. The Surveyors asked if it would have been the facility's expectation that the nurse who worked the day shift to have read the Resident's night shift nursing assessment. SS #1 said "Yes" that was the facility's expectation. The Surveyor asked if the facility would have expected the day shift nurse to have assessed the Resident's lung status more thoroughly since the Resident's heart rate had significantly increased from 118 to 151. The SS stated "Yes". The Surveyors asked SS #1 if this incident should have been evaluated as possible neglect on the part of the nurse's inadequate nursing assessment, which ultimately ended in the Resident being sent to the emergency room . SS #1 confirmed it at least should have been investigated as a possible lack of sufficient nursing services. During an interview on 9/4/14 at 12:35 pm, the Interim Director of Nursing (DON) stated the facility did not have a specific policy regarding nursing assessments. The DON further stated since a facility nursing policy was not in place, the facility would use the nursing manual, Lippincott Manual of Nursing Practice 10th Edition, for nursing assessments. Review on 9/4/14 of the nursing manual, Lippincott Manual of Nursing Practice 10th Edition, revealed "Adult Physical Assessment ...Many major therapeutic decisions are based on the vital signs ..." Review on 9/4/14 of Lippincott Manual of Nursing Practice seventh edition's "Standards of Care Guidelines for Respiratory Compromise" revealed, "Be aware of the status of the patient when assuming care so comparison can be made with subsequent assessments; perform thorough systematic assessment including mental status, vital signs, respiratory status, and cardiovascular status ..." Review on 9/9/14 of the 2010 edition of "Nursing Scope and Standards of Practice" by the American Nurse Association revealed, "Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the [DIAGNOSES REDACTED]. .

Based on observation, record review, and interview the facility failed to provide care and services necessary to prevent physical harm for 1 resident (#5) of 12 sampled residents. Specifically, the facility failed to prevent a pressure sore which developed after staff left the resident on a bedpan for an extended period of time. In addition, the facility failed to: 1) assess the resident's pressure sore and provide wound care for 5 days, and 2) develop interventions and strategies to prevent similar occurrences from happening with all residents in the facility at risk for pressure sores. These failed practices constituted immediate jeopardy to resident health and safety. This situation was brought to the attention of the facility's administration on 7/26/12 at 2:15 pm. On 7/26/12 at 4:30 pm it was determined the immediacy of the jeopardy had been abated. Findings: Record review on 7/23-28/12 revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent comprehensive annual MDS (Minimum Data Set) assessment, dated 7/8/12, revealed the Resident was coded as "at risk of developing pressure ulcers". During an observation on 7/24/12 at 10:55 am, Licensed Nurse (LN) #5 was preparing to do a dressing change. When the Resident moaned with movement, the LN asked Resident #5 if it would be helpful to be turned to the side. Resident #5 said "It doesn't help when you are on the bedpan all night" and added "Oh, my gosh, the sore is really bad". Review of the facility-provided incident/accident report, dated 7/13/12, revealed the "incident occurred 7/9/12 and reported 7/13/12" and "likely bedpan was contributory"; "Bedpan was left under resident for a long period of time"; and "Resident needed to use bedpan and was offer bedpan by Staff and bedpan was left for a long period of time". The investigation was signed by the Wound Nurse (WN) on 7/19/12. Further observation during the dressing change on 7/24/12, 16 days after the incident, revealed a round, dark purple ring, in the shape of a bedpan, on the Resident's buttocks. The Resident had 3 wound areas. Review of the wound assessment form, dated 7/26/12, revealed 4 wound areas, described as follows: 1. Unstageable, suspected deep tissue injury, red/purple, 7 cm x 3 cm, and "Tissue boggy. Part of larger ring shaped area surrounding almost entire sacral area"; 2. Stage II, red, 1 cm x 1 cm, "Superficial depth, Beefy red"; 3. Stage II, 1 cm x 0.8 cm, "Beefy red, Superficial depth"; and 4. Unstageable, 1.4 cm x 2.3 cm, yellow, "Wound bed 100% yellow slough". Review of documentation of the staff interviews in the incident/accident report, dated 7/19/12, revealed the following: ? CNA #1 stated, "check and change resident (every) 2 hrs (hours) and last check and change was (at) 1930 (7:30 pm) and no bedpan was use during care"; ? CNA #8 stated, "came into resident room around 1200 midnight and noted bedpan left under resident and immediately reported to charge nurse"; and ? LN #8 stated, "Charge Nurse stated CNA reported bedpan left under resident and left mark. Per nurse It was reported at 1200 midnight, but did not assess wound, because did not know it was a wound." During an interview on 7/25/12 at 5:00 pm, Resident Care Manager (RCM) #1 said she was notified of Resident #5's "bedpan incident" a few days after it happened. RCM #1 stated "the type of bedpan and the length of time the Resident was on the bedpan" was what caused the sores. When RCM #1 was asked why was Resident #5 left on the bedpan so long she said, "They (staff) forgot about it". She further said it would take longer than 1 hour to make marks on the Resident. RCM #1 added that when she did find out about the incident, she and the Wound Nurse went to assess Resident #5. During an interview on 7/26/12 at 9:00 am, Resident #5 was asked about the pressure sores on her buttocks. Resident #5 said two nurses came in to look at the sores. She said she knew it was bad because "the girls' voices told me it was bad". Review of a Resident Progress Note, dated 7/13/12 at 4:20 am, revealed "...At 2410 (12:10 am) while assisting CNA for incontinent care and repositioning. CN (charge nurse) noted a large brownish black abrasion on her right buttocks. The shape turned up to down. Painful to touch. Her left side bottom had a medium size abrasion reddish brown..." Review of a Resident Progress Note, written by the WN on 7/13/12 at 1:22 pm, revealed "Call to resident room. Wound is circular in shape, red to some area and blue to other areas with a part of wound as stage II...Also noted a stage II wound to resident coccyx..." Review of the Resident's current nursing care plan, dated 7/13/12, revealed "weekly wound assessment by wound nurse". During an interview on 7/26/12 at 12:20 pm the WN was asked about her involvement in wounds. The WN stated she did an initial measurement on all residents' wounds but that she did not continue with measurements and treatment of [REDACTED]. The WN explained that "I go by the type of wounds." I follow wounds that are "diabetic, on a bony prominence, ischemic, or vascular." The WN confirmed she was not involved in Resident #5's wound care and said the Resident's pressure sores were being treated by the nursing staff. When asked how she could tell if wounds changed if they were not followed, she responded, "That is a very good question." She confirmed that if the WN doesn't measure the wounds then no one does. When asked how Resident #5 got the pressure sores, the WN said, "I was told by the nurse that the Resident got sores by the bedpan..." During an interview on 7/26/12 at 10:00 am, when the Dietitian was asked about her involvement with residents' pressure sores, she said that she did a nutrition evaluation for all pressure sores. When asked when she was notified of Resident #5's pressure sores, she said she hadn't received any notification; the Dietitian said she had not even been aware of Resident #5's pressure sores until it was brought to her attention by the surveyor. .

Based on observation, interview, and record review the facility failed to 1) provide adequate oversight and supervision of care issues that caused harm to residents such as prevention of pressure sores, medication administration according to physician orders [REDACTED]. As a result the residents remained at risk for abuse and neglect and 3) provide oversight to ensure facility policies regarding food safety were consistently implemented regarding egg purchasing and use which required only pasteurized shelled eggs for requests for "runny" or "sunny side up" eggs. Without oversight the facility staff did not know how to identify pasteurized eggs and served undercooked unpasteurized eggs which placed residents at risk for potentially life threatening food borne illness and constituted immediate jeopardy. These failures led to the facility's inability to maintain substantial compliance with regulatory requirements, and resulted in immediate jeopardy in 4 citations under federal regulations: Immediate Jeopardy at 483.13 (c) Abuse; Immediate Jeopardy at 483.35 (i)(2) Prepare and serve food; and Immediate Jeopardy at 483.25 Quality of Care. These failed practices constituted an immediate jeopardy at 483.75 Administration. This situation was brought to the attention of the facility's administration on 7/27/12 at 10:45 am and was not abated by the end of the survey. Findings: Failure to administer the facility in a manner in which its resources were effective and efficiently used resulted in substandard quality of care in the following regulatory areas: i. 483.13(c) Abuse, Developing and Implementing Policy & Procedures; ii. 483.15(h) Housekeeping and Maintenance Services; iii. 483.25 Each Resident Reach Highest, Practicable, Physical, Mental and Psychosocial Well Being; iv. 483.25(c) Pressure Sores, Not Develop, Receive Treatment; and v. 483.25(h) Accidents, Supervision.

Based on observation, interview, and policy review, the facility failed to ensure unpasteurized eggs (eggs that have not been through a process to ensure destruction of potentially harmful bacteria) were served in a manner to prevent the risk of food borne illness for 2 sampled residents (#s 1 and 9) and 6 non-sampled residents (#s 20; 21; 22; 23; 24; and 25) out of 8 residents who were served fried eggs for breakfast. This failed practice constituted immediate jeopardy to resident health and safety. This situation was brought to the attention of the facility's administration on 7/27/12 at 12:00 pm, at which time the facility was notified of the risk of serving undercooked, unpasteurized eggs to residents. On 7/27/12, it was determined the immediacy of the jeopardy had been abated. Findings: Undercooked Unpasteurized Eggs Observation during breakfast preparation on 7/27/12 at 8:15 am revealed the Dietary Manager (DM) frying eggs. While preparing Resident # 24's tray, the DM placed an egg cooked over-easy onto the plate. The DM was then asked to check the egg to see if it had been cooked until the yolk was congealed. When the DM stuck a knife into the egg, the yolk ran out onto the plate. The DM discarded the runny eggs and prepared a second plate of eggs, which were thoroughly cooked, for Resident #24. Inspection of the uncooked eggs in a metal pan next to the stove revealed the eggs did not have the patented "P" stamp that would have identified them as pasteurized. When asked if the eggs were pasteurized, the DM replied that they were. When asked about the remainder of the eggs, the DM opened the cook's refrigerator, which contained several trays of eggs. Observation of these eggs revealed none of them had the "P" stamp. Review of the instructions on the egg delivery box revealed "Safe handling instructions, cook until yolks are firm" and "Cook foods containing eggs thoroughly". Observation on the courts on 7/27/12 from 8:15-8:20 am revealed the breakfast trays for Resident #s 1; 9; 20; 21; 22; 23; and 25 included fried eggs. Resident #s 1 and 21 were already eating their eggs, which were runny, and refused to give them up. Surveyors asked staff to check the other trays to see if the eggs had been cooked until the yolks were congealed. All the eggs on the other trays were runny; the yolks ran out onto the plates. The eggs were not served. Review of the facility's policy, "Egg Purchasing and Use", review date 1/2012, revealed "Only pasteurized shelled eggs will be served to individual residents per their cooking style request including 'runny' or 'sunny side up'." According the most recent Federal Food Code's "Special Requirements for Highly Susceptible Populations", 3-801.11, "The following foods may not be served...(2) A partially cooked animal food such as...soft cooked eggs that are made from raw eggs..." During an interview on 7/27/12 at 9:25 am, the Director of Nursing (DON) was asked if staff had called her about issues or concerns in the facility. The DON said she had been at the facility since 7:00 am and no staff had called her about any concerns. During an interview on 7/27/12 at 9:27 am, the Administrator was asked if staff had notified her of any concerns, specifically the unpasteurized eggs in the kitchen being runny. She said, "No"; she had not been notified of anything. As a result of the facility's lack of communication, neither the DON nor the Administrator was aware there had been a serious issue identified in the kitchen. Based on observation, interview and policy review the facility failed to ensure: 1) ensure chemical sanitation levels were within acceptable parameters; 2) staff covered hair during food preparation; 3) staff did not eat in the kitchen; and 4) maintenance activities were not performed near food preparation. These failed practices created a risk for food borne illness in a vulnerable population and placed all residents who received food from the kitchen at risk for food borne illness. Findings: Sanitizing Solution Observation of the kitchen on 7/27/12 at 9:00 am revealed thermometers used to check food temperatures were stored in a sanitizing solution in a plastic container located on the tray line shelf. In addition, there were two buckets of sanitizing solution containing wiping cloths, one located under a counter and another in the sink in the dishwashing area. During an interview, on 7/27/12 at 9:10 am, Dietary Aide (DA) #4 was asked about the solution in the bucket in the sink. He stated it was a quat sanitizing solution (quarternary compounds, or quats, are common sanitation solutions used in commercial kitchens). When asked to test the solution strength, DA #4 picked up a small dispenser, removed a strip and dipped it into the sanitizing solution. Observation of the strip revealed that the sanitizing solution measured zero. Closer examination of the dispenser revealed it was labeled for use with "chlorine". When asked how a chlorine strip could measure a quat solution, DA #4 responded he did not know. During an interview on 7/27/12 at 9:15 am the DM confirmed the facility used a quat sanitizer. When asked to measure the strength of the solution in the other containers, he picked up a small package labeled "pHydron" (pH) and used the strips to check the sanitation level of the solution where the food thermometers were stored and the solution in the bucket under the counter that contained wiping cloths. Although these were the correct strips to measure quat sanitizer strength, closer examination of the package revealed it had an expiration date of 8/15/11, over 11 months ago. The DM confirmed staff should be using the pH strips to check the quat levels and confirmed the test strips should not be expired. Review of an undated Dietary Policy and Procedure on 7/27/12 at 9:30 am, revealed "Manual warewashing, Procedure: Important Tips check the concentration of the sanitizer." During a telephone interview on 7/31/12 at 1:44 pm, an Ecolab (manufacturer of the pHydrion test strips) representative confirmed the strips were no longer effective after the expiration date. Hair Net During an observation on 7/24/12 at 11:08 am, DA #1 was preparing the lunch meal and was not wearing a hair net. When asked if he should be wearing a hair net, he replied "yes". Review of Dietary Policy and Procedure: Infection Control in Dietary Dress Code (undated) revealed "Procedure 1. The following DRESS CODE procedures will be maintained: f) Hair will be neatly arranged with a hairnet or cap, or other coverings that are designed to prevent hair from contacting food, clean food service equipment, utensils, and linens effectively while on duty." Eating in Kitchen During an observation on 7/26/12 at 1:45 pm maintanence worker #2 was in the kitchen standing next to a rolling tool cart eating a plate of chicken and rice. When asked about eating in the kitchen he replied "next time, I won't do it". Review of the facility policy "Infection Control in Dietary Personal Cleanliness", undated, revealed "Eating, drinking, and gum chewing are not permitted in the dietary services department." Maintenance Activities in Kitchen During an observation on 7/26/12 at 1:50 pm, maintanence worker #2 was working under a sink directly adjacent to a food preparation area. At the time this plumbing work was being done, DA #2 was preparing plates of cottage cheese and lettuce on the adjacent counter. During an interview on 7/26/12 at 1:55 pm, maintanence worker #2 was asked if it was ok to do the plumbing work so close to the food being prepared and he replied, "I think so". During an interview on 7/28/12 at 8:50 am, when informed that maintanence worker #2 had been performing plumbing work in the kitchen when food was being prepared, the DM responded that he should not have done that. .

Based on observation, interview, and record review the facility failed to assess, and provide timely interventions and monitoring for 1 resident (#19) whose impaired bowel function resulted in fecal impaction. This failed practice constituted an immediate jeopardy to the resident health and safety. This situation was brought to the attention of the facility's administration on 7/27/12 at 9:15 pm. The immediate jeopardy was abated onsite. Findings: Record review on 7/27/12 revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview with the Resident and his daughter on 7/27/12 at 5:10 pm, the Resident stated "they are not listening to me, things move too slowly around this place". He stated he had "been here for one week before I never took a[***]. The daughter stated it "took a week before anything was done about him not having a bowel movement, none of the meds he was given were helping". The daughter stated "dad had to go back to the hospital twice for his constipation and he's still waiting to get something (the facility physician) ordered". They both expressed concern that the lack of care would continue and his health would deteriorate. Review of the hospital discharge summary, dated 7/11/12, revealed the Resident was transferred to the facility on [DATE] following a 2 week hospitalization for amputation of his right foot. Prior to his transfer to the facility, he was successfully disimpacted (manual removal of feces) by the nursing staff. His discharge [DIAGNOSES REDACTED]. Review of the Admission Nursing Database, dated 7/11/12, and the History and Physical written by the physician, dated 7/12/12, revealed the Resident's history of constipation and fecal impaction was documented in both assessments. The Resident's drug regimen included [MEDICATION NAME] (medication for pain), [MEDICATION NAME] (antibiotic), [MEDICATION NAME] (antifungal),[MEDICATION NAME](sleep aid). Per PubMed Health, all of these medications have a known side effect of constipation. Although the drug regimen included [MEDICATION NAME], and [MEDICATION NAME] (medications used to treat constipation), review of documentation for bowel movements revealed the Resident did not have a bowel movement (BM) until 7/17/12, a total of 6 days after admission. Review of Progress Notes from 7/11/12 -7/17/12 revealed there was no documentation regarding the Resident's bowel movements until 7/16/12, 5 days after admission. A progress note, dated 7/16/12 at 2:37 am, documented "...without BM at present." There was no documented evidence that a physician was notified regarding the Resident not having a bowel movement for 5 days. Further review revealed a progress note entry, dated 7/17/12 at 2:51 pm, that documented "Gave resident [MEDICATION NAME] suppository for no BM (for more than) 4 days at 1345 (1:45 pm)". Another entry written at 11:09 pm documented "At around 14:45 hrs (2:45 pm) resident c/o (complained of) constipation and having hard time to get bowel moved. Requested [MEDICATION NAME] 17 gm with water, with no relief. MD notified and ordered to administer fleet enema with no relief and MD ordered warm water enema with relief. Resident had XL/F (extra large, firm) BM and voided x3 and expressed feeling better". This 7/17/12 Progress note, written 6 days after admission, was the first documentation that noted the effectiveness of interventions used to treat the Resident's constipation. The facility's MACC (Managing Acute Condition Change, a charting process used by the facility to monitor any change in a resident's condition that necessitates frequent observation and recording) contained no documentation of the Resident's constipation problem. Review of the facility's Bowel Protocol, revision date 12/10, revealed "it is the policy of the facility to monitor and provide interventions to ensure routine bowel elimination by residents of this facility..." Eight procedures were listed that included: monitoring bowel records daily; MOM (Milk of Magnesia) to be given if no BM in 3 days; suppository to be given on the morning of the 4th day if no BM followed by an enema the afternoon of the 4th day; and if a resident exceeds 4 days without a BM, the physician was to be notified for further orders. Review of the MAR (Medication Administration Record) revealed the Resident was not given MOM, a suppository, or an enema until 7/17/12, a total of 6 days since the Resident's last BM. During an interview on 7/27/12 at 6:30 pm LN #4 confirmed he was aware of the facility's Bowel Protocol. When asked if the protocol was followed for the Resident he stated it had not been. Per the Resident and review of hospital records, the Resident went to theER on [DATE] with complaints of abdominal and anal pain. An x-ray was done in the ER, which showed "marked constipation and probable fecal impaction..." An ER summary was not in the Residents medical record at the facility. The Resident stated he received an enema and manual disimpaction. Further record review revealed the Resident was again sent to the ER per his request 2 days later, on 7/25/12, due to constipation and pain. Review of records from the hospital revealed the Resident had an x-ray. The x-ray report documented "persistent extensive residual colonic stool consistent with the clinical [DIAGNOSES REDACTED]. The Resident was given a soap suds enema and discharge instructions that included "[MEDICATION NAME] (stool softener)..., magnesium [MEDICATION NAME] to achieve a BM and a diet rich in uncooked fruits and vegetables". The facility MD wrote a new order on 7/26/12 for "magnesium [MEDICATION NAME] 150 ml po (by mouth) tonight and po qd (each day)". Review of the MAR indicated [REDACTED]. On 7/27/12 at 6:30 pm, LN #4 was asked about the magnesium [MEDICATION NAME] and whether the Resident had received it. The LN stated the Resident had not received any magnesium [MEDICATION NAME] yet as the facility did not have any. The LN added that the order had been sent to the ProPac pharmacy (located out of state). When asked if the physician had been notified that the Resident had not yet received the ordered magnesium [MEDICATION NAME], he stated he didn't know. Further review of records on 7/27/12 at 6:45 pm revealed no documented evidence the physician was notified that magnesium [MEDICATION NAME] was not available and had not been given to Resident #19. Based on observation, record review, and interview the facility failed to ensure the care plan was implemented for 2 residents (#s 7 and 9) out of 12 sampled residents whose care plans were reviewed. This failed practice placed residents at risk for not receiving the necessary and/or appropriate care and services. Findings: Resident #9 Record review on 7/23-28/12 revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed the Resident had fallen on 7/21/12. The staff found the Resident on the floor in the bathroom shower. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE] revealed the Resident was coded as needing extensive assistance for toileting and walking in room. Review of the most recent care plan, dated 1/16/12, revealed "Don't leave (Resident Name) unattended in the bathroom. (Resident Name) tends to get up by herself if nobody is available to help her." During an interview at 12:00 pm on 7/25/12, RCM (Resident Care Manager) #2 stated the Resident had been left unattended on the toilet and was later found on the floor. Resident #7 Record review on 7/23-28/12 revealed Resident #7 was admitted to the facility on [DATE]. The Resident's [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. During an interview on 7/23/12 at 1:05 pm, Resident #7 stated she had not been up in a chair since admission and added that it would be nice to get out of bed and sit in a chair. During an interview on 7/23/12 at 8:30 am, CNA #12 stated Resident #7 had not been up in a chair since admission because of her wounds. During an interview on 7/24/12 at 12:30, RCM #2 stated the Wound Nurse told her the Resident could not be in a chair because of the pressure ulcers. During an interview on 7/26/12 at 8:45 am the Wound Nurse stated that having a pressure ulcer would not be a contraindication for a resident to get up in a chair. During an interview on 7/27/12 at 9:00 am the Physician stated Resident #7 had no contraindications for being up in a chair. In addition, the Physician stated he/she was not aware the Resident had not been up in the chair. .

Based on observation, interview, and record review, the facility failed to ensure that residents received the necessary care and services to prevent the development of pressure ulcers for 3 residents (#s 2, 5, and 7) out of 3 sampled residents with pressure ulcers. Resident #5, who developed a facility-acquired pressure ulcer, sustained harm due to facility failure to put appropriate preventive measures into place or initiate sufficient ongoing assessment and treatment after the ulcers were identified. Findings: Resident #5 Record review on 7/23-28/12 revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent comprehensive MDS (Minimum Data Set) assessment, an annual assessment dated [DATE], revealed the Resident was not coded as having pressure ulcers, but was coded as "at risk of developing pressure ulcers". An observation on 7/24/12 at 10:55 am, revealed Licensed Nurse (LN) #5 preparing to do a dressing change. When the Resident moaned with movement, the LN asked Resident #5 if it would be helpful to be turned to the side. Resident #5 said "It doesn't help when you are on the bedpan all night" and added "Oh, my gosh, the sore is really bad". Review of the facility-provided incident/accident report, dated 7/13/12, revealed the "incident occurred 7/9/12 and reported 7/13/12" and "likely bedpan was contributory"; "Bedpan was left under resident for a long period of time"; and "Resident needed to use bedpan and was offer bedpan by Staff and bedpan was left for a long period of time". The investigation was signed by the Wound Nurse (WN) on 7/19/12. Further observation during the dressing change on 7/24/12, 16 days after the incident, revealed a round, dark purple ring, in the shape of a bedpan, on the Resident's buttocks. The Resident had 3 wound areas. Review of the wound assessment form, dated 7/26/12, revealed 4 wound areas, described as follows: 1. Unstageable, suspected deep tissue injury, red/purple, 7 cm x 3 cm, and "Tissue boggy. Part of larger ring shaped area surrounding almost entire sacral area"; 2. Stage II, red, 1 cm x 1 cm, "Superficial depth, Beefy red"; 3. Stage II, 1 cm x 0.8 cm, " Beefy red, Superficial depth " ; and 4. Unstageable, 1.4 cm x 2.3 cm, yellow, "Wound bed 100% yellow slough". Review of documentation of the staff interviews in the incident/accident report, dated 7/19/12, revealed the following: ? CNA #8 stated, "came into resident room around 1200 midnight and noted bedpan left under resident and immediately reported to charge nurse"; and ? LN #8 stated, "Charge Nurse stated CNA reported bedpan left under resident and left mark. Per nurse It was reported at 1200 midnight, but did not assess wound, because did not know it was a wound." During an interview on 7/25/12 at 5:00 pm, Resident Care Manager (RCM) #1 said she was notified of Resident #5's "bedpan incident" a few days after it happened. RCM #1 stated "the type of bedpan and the length of time the Resident was on the bedpan" was what caused the sores. When RCM #1 was asked why was Resident #5 left on the bedpan so long she said, "They (staff) forgot about it". She further said it would take longer than 1 hour to make marks on the Resident. Review of a Resident Progress Note, dated 7/13/12 at 4:20 am, revealed "...At 2410 (12:10 am) while assisting CNA for incontinent care and repositioning. CN (charge nurse) noted a large brownish black abrasion on her right buttocks. The shape turned up to down. Painful to touch. Her left side bottom had a medium size abrasion reddish brown..." Review of a Resident Progress Note, written by the Wound Nurse on 7/13/12 at 1:22 pm, revealed "Call to resident room. Wound is circular in shape, red to some area and blue to other areas with a part of wound as stage II...Also noted a stage II wound to resident coccyx..." Resident #7 Record review on 7/23-28/12 revealed Resident #7 was admitted to the facility on [DATE]. The Resident's [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 3/30/12, revealed the Resident had 3 pressure ulcers on admission: one Stage II, one Stage III, and one Stage IV. Review of Resident #7's Pressure Ulcer Assessment forms revealed the following documentation of new pressure ulcers: ? Stage II pressure ulcer on the right small toe, dated 6/21/12, and ? Stage II pressure ulcer on "Right center of Right thigh", dated 7/19/12. During an interview on 7/26/12 at 8:30 am the Wound Nurse stated these two new pressure ulcers were preventable. Further record review revealed Resident #7's [DIAGNOSES REDACTED]. Review of the MAR (Medication Administration Record) for the timeframe of 7/1-26/12 revealed the Resident's 4:30 pm and 8:00 pm blood sugar levels ranged from 301 to 577 on 24 of the 26 days. During an interview on 7/27/12 at 9:00 am, the Resident' physician stated the high blood sugars may have contributed to the development of new pressure ulcers. Additional record review revealed the Resident received a CCHO (complex carbohydrate diet) diabetic diet. During an observation on 7/25/12 at 8:15 am, Resident #7 was served a large cake donut with powdered sugar for breakfast. Observation during the lunch meal, at 12:25 pm, revealed the Resident was served glazed ham. During an interview on 7/25/12 at 8:15 am, Resident #7 stated that she often was served foods that she would not normally eat because of their high carbohydrate or sugar content. In addition, she stated she had ordered toast for breakfast, and not a donut. During an interview on 7/26/12 at 3:40 pm the Dietary Manager (DM) stated the donut and glazed ham should not have been given to a diabetic resident. During a second interview, on 7/28/12 at 9:30 am, the DM stated he does not consult with the dietitian when substitutes are made. During an interview on 7/26/12 at 1:30 pm, the Dietitian stated she attended a weekly "Nutritional Risk Review Committee" meeting, along with the Director of Nursing, Wound Nurse, Administrator, and Resident Care Managers. The Dietitian explained that the purpose of the meeting is to review high risk residents' clinical progress and address any concerns, including nutrition or wound healing. Review of documentation from the 5/25/12 Nutritional Risk Review Committee meeting revealed neither Resident #7's high blood sugars nor the increase in size of the sacral pressure ulcer was addressed. Review of documentation from the 7/12/12 meeting revealed the Resident's high blood sugars were still not addressed, nor was the development of a new right small toe pressure ulcer on 6/21/12. Resident #2 Record review on 7/23-28/12 revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 7/27/11, revealed the Resident was coded as not being at risk for development of pressure ulcers. Review of skin assessment forms, dated 6/11/12, revealed a Stage II pressure ulcer on both the left and right heel. Further review of the skin assessments revealed the pressure ulcer on the right heel was closed on 7/9/12. However, the 7/24/12 documentation indicated the left heel ulcer was not healed; measurement was 2.0cm x 2.0cm. During an interview on 7/28/12 at 10:00 am, the Wound Care Nurse was asked about the Resident's left heel pressure ulcer. The Wound Care Nurse stated the pressure ulcer was unavoidable due to the Resident's propelling self with left foot when up in the wheelchair. Review of the facility policy "Skin at Risk/Skin Breakdown", dated 12/10, revealed that "a resident who enters the facility does not develop pressure sores" and "receives necessary treatment and services" to "prevent new sores from developing". .

Based on observation, interview and record review the facility failed to notify the physician of the following: 1) high blood sugar levels for 1 resident (#7); 2) pressure sores caused when left on a bedpan for an extended period of time for 1 resident (#5); 3) persistent constipation that resulted in hospitalization for 1 resident (#19); and 4) unavailability of ordered medication for 1 resident (#19); out of 16 residents. Without timely notification, physicians lacked information necessary to order initial treatment or revise treatment orders. Findings: High blood sugars Resident #7 Record review on 7/23-28/12 revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MAR (Medication Administration Record) for the timeframe of 7/1-26/12 revealed the Resident's 4:30 pm and 8:00 pm blood sugar levels ranged from 301 to 577 on 24 of the 26 days. During an interview on 7/27/12 at 9:00 am Physician #1 reviewed the blood sugar levels documented on the MAR and stated he/she would expect nurses to call for blood sugars over 301. Physician #1 stated he/she had not been notified when the Resident's blood sugars were over 301. During an interview at 2:35 pm on 7/27/12, Licensed Nurse (LN) #2 was asked if she had notified the physician when the Resident's blood sugars were greater than 301. She confirmed she had not. Pressure sores Resident #5 Record review on 7/23-28/12 revealed Resident #5 was admitted to the facility on [DATE]. During an observation on 7/24/12 at 10:55 am, revealed (LN) #5 preparing to do a dressing change. When the Resident moaned with movement, the LN asked Resident #5 if it would be helpful to be turned to the side. Resident #5 said "It doesn't help when you are on the bedpan all night" and added "Oh, my gosh, the sore is really bad". Review of the facility-provided incident/accident report, dated 7/13/12, revealed the "incident occurred 7/9/12 and reported 7/13/12" and "likely bedpan was contributory"; "Bedpan was left under resident for a long period of time"; and "Resident needed to use bedpan and was offer bedpan by Staff and bedpan was left for a long period of time". The investigation was signed by the Wound Nurse (WN) on 7/19/12. Further review of the incident/accident report revealed no documentation the physician had been notified of the incident. Constipation Resident #19 Record review on 7/27/12 revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Although the Resident's drug regimen included [MEDICATION NAME], and [MEDICATION NAME] (medications used to treat constipation), review of documentation for bowel movements revealed the Resident did not have a bowel movement (BM) until 7/17/12, a total of 6 days after admission. There was no documented evidence that a physician was notified regarding the Resident not having a bowel movement for 6 days. Medication not available On 7/26/12 the physician wrote an order for [REDACTED]. Review of the MAR revealed the Resident did not receive magnesium [MEDICATION NAME] on either 7/26/12 or 7/27/12. Further review of records on 7/27/12 at 6:45 pm, revealed no documented evidence that the physician had been notified that the ordered medication, magnesium [MEDICATION NAME], was not available and had not been given. .