Every finding on record at Cordova Community Med LTC

.Based on record review and interview, the facility failed to implement an abuse, neglect, and exploitation screening policy accordingly. Specifically, the facility failed to ensure individuals who had direct contact with residents, their medical or financial records, or control over or impact on the financial well-being of residents had a valid criminal history check conducted under 7 Alaska Administrative Code (AAC) 10.900-10.990. This resulted in 6 employees working at the facility without valid clearance from the Alaska Background Check program. This failed practice placed all residents (based on a census of 8) at risk for abuse and neglect. Findings:Infection Control Nurse (ICN) Review of the State of Alaska background check clearance letter for the ICN, dated 1/6/21, revealed: .The Background Check Program has completed the background check for [ICN] and the individual has been issued an Eligible Determination for association with Cordova Community Medical Center. The determination is valid from 01/06/2021 to 12/30/2025. Review of email correspondence sent from the State of Alaska Background Check Unit to the facility, sent on 11/30/25, revealed: The following individual(s) need a new background check within the next 30-60 days:. Provider: Cordova Community Medical Center Applicant Name:[ICN] Position: Nurse Aide New Background Check Needed by: 12/30/2025. Review of the New Alaska Background Check System (NABCS) website revealed that a new background check application for the ICN was started on 2/27/26 and their status was changed to provisionally hired (meaning allowed to work until the background check application was completed) on 3/10/26. Review of payroll records provided by the facility revealed that the ICN worked a total of 439.5 hours from 12/31/25 - 3/9/25 without a valid background check. Review of the facility-provided document Cordova Community Medical Center Job Description Infection Control Nurse, signed on 6/28/23 by the ICN, revealed: .POSITION SUMMARY. collects, prepares, and analyzes healthcare associated infection data. monitors employee compliance in use of barriers and infection prevention measures. implements programs to protect the healthcare workers, visitors, and others in the healthcare environment. ESSENTIAL RESPONSIBILITIES. Monitors infection control practices and employee compliance. Actively participates in facility-wide risk and utilization review activities. Provides direct patient care as needed. Certified Nursing Assistant (CNA) #4 Review of the State of Alaska background check clearance letter for CNA #4, dated 11/30/20, revealed: .The Background Check Program has completed the background check for [CNA #4] and the individual has been issued an Eligible Determination for association with Cordova Community Medical Center. The determination is valid from 11/30/2020 to 11/30/2025. Review of email correspondence sent from the State of Alaska Background Check Unit to the facility, sent on 10/30/25 and again on 11/30/25, revealed: The following individual(s) need a new background check within the next 30-60 days:. Provider: Cordova Community Medical Center Applicant Name:[CNA #4] Position: Nurse Aide New Background Check Needed by: 11/30/2025. Review of the NABCS website revealed that a new background check application for CNA #4 was started on 3/2/26 and their status was changed to provisionally hired on 3/10/26. Review of payroll records provided by the facility revealed that CNA #4 worked a total of 369 hours from 12/1/25 - 3/9/25 without a valid background check. Review of the document Cordova Community Medical Center Job Description Nursing Assistant, signed on 5/8/08 by CNA #4, revealed: POSITION SUMMARY. The primary purpose of your job position is to provide your assigned residents with routine daily nursing care in accordance with our established nursing care procedures, and as may be directed by your supervisors. ESSENTIAL RESPONSIBILITIES. Greet and escort residents to their room. Make the resident comfortable. Transport residents to new rooms or to the receiving area. Participate in and receive the nursing report upon reporting for duty. Assist residents with daily dental and mouth care. Give or assist residents with bath functions. Assist residents with dressing/undressing as necessary. Assist residents with bowel and bladder functions. Maintain intake and output records as instructed. Maintenance Technician (MT) #2 Review of the State of Alaska background check clearance letter for MT #2, dated 11/30/20, revealed: .The Background Check Program has completed the background check for [MT #2] and the individual has been issued an Eligible Determination for association with Cordova Community Medical Center. The determination is valid from 11/30/2020 to 11/27/2025. Review of email correspondence sent from the State of Alaska Background Check Unit to the facility, sent on 9/30/25 and again on 10/30/25, revealed: The following individual(s) need a new background check within the next 30-60 days:. Provider: Cordova Community Medical Center Applicant Name:[MT #2] Position: Other New Background Check Needed by: 11/27/2025. Review of the NABCS website revealed that a new background check application for MT #2 was started on 2/26/26 and their status was changed to provisionally hired on 3/10/26. Review of payroll records provided by the facility revealed that MT #2 worked a total of 568.5 hours from 11/28/25 - 3/9/25 without a valid background check. Review of the document Cordova Community Medical Center Job Description Maintenance Technician, signed on 4/9/12 by MT #2 revealed: POSITION SUMMARY. Under the direction of the BSM [Building Service Manager], this position requires the ability to maintain all property and equipment of the Cordova Community Medical Center to a good and ready condition in accordance with state and federal Health Care Facility and Life Safety codes, as well as the policies and procedures of Cordova Community Medical Center. ESSENTIAL RESPONSIBILITIES. Perform a complete walk around inspection of the entire facility looking for any lights that need replacing and any other damage to the building that will need to be repaired. Assist in fire safety and the security of the hospital and the people within. Receptionist #7 Review of the State of Alaska background check clearance letter for Receptionist #7, dated 1/6/21, revealed: .The Background Check Program has completed the background check for [Receptionist #7] and the individual has been issued an Eligible Determination for association with Cordova Community Medical Center. The determination is valid from 01/06/2021 to 12/30/2025. Review of email correspondence sent from the State of Alaska Background Check Unit to the facility, sent on 11/30/25, revealed: The following individual(s) need a new background check within the next 30-60 days:. Provider: Cordova Community Medical Center Applicant Name: [Receptionist #7] Position: Nurse Aide New Background Check Needed by: 12/30/2025. Review of the NABCS website revealed that a new background check application for Receptionist #7 was started on 3/1/26 and their status was changed to provisionally hired on 3/10/26. Review of payroll records provided by the facility revealed that Receptionist #7 worked a total of 253.75 hours from 12/31/25 - 3/9/25 without a valid background check. Review of the document Cordova Community Medical Center Job Description Receptionist, signed on 6/18/08 by Receptionist #7, revealed: POSTION SUMMARY. Under the direction of the Office Manager, this position requires the ability to greet and register new patients, perform data entry of patient information including form of payment, communicate hospital admissions and print related forms used for documenting patient care and service charges. ESSENTIAL RESPONSIBILITIES. Assist incoming patients with admissions paperwork and Insurance information. Make copy of insurance cards and updates insurance information. Create demographics, request patient charts from Medical Records. Call and remind patients about their appointments. Look up accounts and answer questions (billing). Housekeeper #5 Review of the State of Alaska background check clearance letter for Housekeeper #5, dated 12/2/20, revealed: .The Background Check Program has completed the background check for [Housekeeper #5] and the individual has been issued an Eligible Determination for association with Cordova Community Medical Center. The determination is valid from 12/02/2020 to 12/2/2025. Review of email correspondence sent from the State of Alaska Background Check Unit to the facility, sent on 10/30/25 and again on 11/30/25, revealed: The following individual(s) need a new background check within the next 30-60 days:. Provider: Cordova Community Medical Center Applicant Name:[Housekeeper #5] Position: Cleaner New Background Check Needed by: 12/2/2025. Review of the NABCS website revealed that a new background check application for Housekeeper #5 was started on 2/26/26, and had not yet been granted provisional status as of 3/17/26. During an interview on 3/13/26 at 8:51 AM, the Director of Support Services (DSS) stated that Housekeeper #5 had not yet submitted his/her fingerprints and his/her appointment would not be until the following Thursday (3/19/26). He/she would not be eligible for a provisional hire until after those were submitted. The DSS further stated that Housekeeper was currently on paid time off (PTO) because of this. Review of payroll records provided by the facility revealed that Housekeeper #5 worked a total of 485.25 hours from 12/3/25 - 3/11/26 without a valid background check. Further review revealed that Housekeeper #5 had been working until 3/11/26, and his/her first day of PTO was 3/12/26. Review of the document HOUSEKEEPER I JOB DESCRIPTION, signed on 6/25/00 by Housekeeper #5, revealed: PURPOSE OF YOUR JOB POSITION. Cleans and services wards, rooms, baths, laboratories, kitchen, and dining rooms, mental health clinic, and offices. MAJOR DUTIES AND RESPONSIBILITIES. Sweeps and mops all floors, dusts furniture and equipment, cleans window sills, washes windows and empties trash baskets. Ensures sanitary and safe hospital facilities. Assist Building Services Manager in building maintenance. Assistant Director of Nursing (ADON) Review of the State of Alaska background check clearance letter for the ADON, dated 1/27/21, revealed: .The Background Check Program has completed the background check for [ADON] and the individual has been issued an Eligible Determination for association with Cordova Community Medical Center. The determination is valid from 01/27/2021 to 1/27/2026. Review of email correspondence sent from the State of Alaska Background Check Unit to the facility, sent on 11/30/25, revealed: The following individual(s) need a new background check within the next 30-60 days: Provider: Cordova Community Medical Center Applicant Name:[ADON] Position: Registered Nurse New Background Check Needed by: 1/27/2026. Review of the NABCS website revealed that a new background check application for the ADON was started on 3/9/26, and had not yet been granted provisional status as of 3/17/26. Review of payroll records provided by the facility revealed that the ADON worked a total of 102.75 hours from 1/28/26 - 3/13/26 without a valid background check. During an interview on 3/17/36 at 12:17 PM, the Administrator stated that the ADON was not currently working for the facility because she was moving to another state and that she was a casual employee. During an interview on 3/10/26 at 2:53 PM, the ADON stated that her role was Assistant Director of Nursing and that part of her responsibilities at the facility were to update the resident's MDS (Minimum Data Set, a federally required assessment) assessments and other tasks to support the Director of Nursing. While updating the MDSs, she did a deep dive to review notes and progress notes in the resident's Electronic Medical Record (EMR) and spoke to floor staff about the residents. She also attended care conferences which include staff members and residents and/or their representatives as needed to clear up any questions she may have while finalizing the MDS assessments. During an interview on 3/12/26 at 2:34 PM, the Director of Support Services (DSS) stated it was revealed that the state background checks had lapsed for the Infection Control Nurse (ICN). When asked if other employees were also lapsed, the DSS stated that there were four other employees whose background check had lapsed, bringing the total to five. She stated that the ICN, CNA #4, MT #2, and Receptionist #7 all currently had provisional background check approval to work while their applications were in process. Housekeeper #5 did not have a provisional background check because he/she had not gotten their fingerprints taken yet and the DDS confirmed that he/she was not currently working. Further review of the NABCS website revealed that the ADON's background check had also lapsed which was not disclosed by the DSS during the interview. During email correspondence on 3/17/26, the Administrator stated that this was an oversite because the ADON was not an onsite employee. Review of the facility policy Background check, last reviewed 11/14/25, revealed: . Purpose and/or Policy Statement:. Background clearance must be maintained throughout each employee's employment with CCMC. Policy: Cordova Community Medical Center (CCMC) requires background checks on all employees. Review of the facility policy State of AK Provisional Background, effective 2/12/25, revealed: Policy Statement. Once a Provisional hire has been approved by the State of AK, then the new hire will be able to start work and must comply with supervision and access restrictions until they receive final background check approval. If the position is the CEO, directors, department managers or doctor, these positions will not start in these positions until a fully approved clearance on the background checked is done. Other employees can start employment when provisional background checked is completed so long as the hiring manager follows the policies outlined below. Requirements for Provisional Employees. Supervision 1. Continuous Supervision- Provisional employees must be directly supervised by an employee with full background check clearance at all times. 2. Restricted access- Provisional employees may not have unsupervised access to vulnerable patients, sensitive information, or high- security areas. 3. Electronic Medical Records (EMRs)- Access to EMRs will be limited based on role and subject to approval by the Compliance and HR departments. Responsibilities. Human Resources (HR)- Tracks background checks status, ensures timely fingerprint submission, and notifies departments of expiring provisional statuses. Department Supervisors- Ensure provisional employees are monitored, supervised, and do not exceed their 60-day provisional period. Compliance & Security Teams- Restrict access to sensitive areas and systems as needed for provisional employees. Review of the facility policy Abuse Prevention, Recognition and Reporting Under State Law and the Elder Justice Act, last reviewed 3/6/26, revealed: . Screening: All candidates for employment to CCMC will be screened, by contacting the appropriate state licensing registry and/or the previous employer, to ensure that candidates have not been convicted of abusing, neglecting, or mistreating residents by a court of law. CCMC will refrain from employing any individual prohibited from working in a long term care facility because of failure to report a suspicion of a crime against a resident or a long term care facility. Review of 7 AAC 10.900(b) at https://www.akleg.gov/basis/aac.asp#7.10.900, the 34th Legislature (2025-2026), revealed: . Each individual who is to be associated with a provider in a manner described in this subsection must have a valid background check conducted under 7 AAC 10.900 - 7 AAC 10.990 if that individual is 16 years or older and will be associated with the provider as (1) an administrator or operator; (2) an individual service provider; (3) An employee, an independent contractor, an apprentice, an unsupervised volunteer, or a board member if that individual as (A) regular contact with recipients of services; (B) access to personal or financial records maintained by the provider regarding recipients of services, including access to (i) personal identifying information, financial information, treatment information, or medical records .(4) an officer, a director, a partner, a member, or a principal of the business organization that owns an entity, if that individual has (A) regular contact with recipients of services; (B) access to personal or financial records maintained by the provider regarding recipients of services, including access to (i) personal identifying information, financial information, treatment information, or medical records .

.Based on record review and interview, the facility failed to ensure nursing staff had the appropriate competencies, skill sets, and techniques to care for resident's needs. Specifically, nursing staff did not receive Trauma-Informed Care specific training. This failed practice had the potential to 1) exacerbate past trauma for 1 resident (#3), out of 8 residents, and affect the resident's ability to attain the highest practicable mental and psychosocial well-being; and 2) affect all residents (based on a census of 8) with any newly identified trauma during the course of their residency in the facility. Findings:Trauma-Informed Care (TIC) training Review of the facility's Facility-Wide self assessment, dated [DATE], revealed: .Staff competencies and annual training requirements per regulatory and/or facility policy:. Further review revealed no TIC training listed with their staff competencies and annual training requirements. During an interview on [DATE] at 3:50 PM, the Director of Nursing (DON) stated that they did not have TIC training. During an interview on [DATE] at 8:33 AM, the Administrator stated that the facility's TIC training was done through other education courses which had portions of the TIC. Review of email correspondence, sent on [DATE] at 9:59 AM, from the facility Administrator to the state surveyors revealed: Please find the attached training transcripts/ course content. RN's get additional training in trauma care through staff meetings, care planning, and consult with our behavioral health professionals and social worker. Review of course content Preventing and De-escalating Crisis Situations, revealed two paragraphs that covered Promoting Trauma-Informed Care as follows: The trauma-informed care framework includes recognizing, understanding, and responding to the effects of trauma in the populations you serve. It emphasizes that symptoms and related diagnoses are adaptations to very stressful events or situations, rather than pathological or unhealthy responses. This empathic treatment approach meets clients where they are and can assist in reducing a person's feelings of agitation.Sometimes, the way a person adapts to trauma causes problems with their daily functioning. Even so, the adaptation is or has been helpful in some way to that person. Trauma-informed care (TIC) is considered a best practice. The correct treatment plan could help prevent dangerous incidents and produce better outcomes than without TIC. You can search the Relias [a learning management system] library for more offerings on trauma-informed care. These paragraphs did not include training for the implementation of Trauma-Informed Care to include accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident and how to include these interventions into care plans for accurate implementation. Review of course content Preventing, Identifying, and Responding to Neglect and Abuse, revealed no specific TIC training. Review of the course content The 3 D's: Delirium, Dementia, and Depression, revealed no specific TIC training. Review of the course content Cultural Awareness and Humility, revealed no specific TIC training. Review of email correspondence sent on [DATE] at 1:07 PM, from the facility Administrator to the state surveyors revealed: CCMC maintains multiple policies and staff training programs designed to support resident safety, dignity, and compliance with CMS regulations. Staff complete training modules that address recognizing and reporting abuse and neglect, behavioral crisis prevention and de-escalation, dementia and behavioral health awareness, and cultural awareness and humility in providing person-centered care. The curriculum in these as well as additional job level trainings assigned cover topics that include cultural awareness, trauma informed care, and make every effort to avoid triggers for patients. The program as a whole is not housed in one training program, but in a comprehensive plan. CCMC has written policies addressing abuse prevention, resident privacy and reporting requirements, and a facility-wide Trauma-Informed Practice policy that guides staff in providing services that avoid re-traumatization and support resident choice, safety, and empowerment. Resident #3 Record review on 3/9-13/26 revealed Resident #3 was admitted to the facility with diagnoses that included dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking) with behavioral disturbance, personality disorder (a mental health condition that involves long lasting, all-encompassing, disruptive patterns of thinking, behavior, mood, and relating to others), and insomnia (difficulty falling asleep, staying asleep, or waking up too early). Review of Resident #3's SOCIAL HISTORY/ Trauma and Cultural Assessment, dated [DATE], revealed: . Is there a history of physical, emotional, or sexual abuse (if Yes reference in Care Plan for trauma needs.) Trauma- son died at age of 21 in a motorcycle wreck. Resident had difficulty coping with loss. Resident states 1st husband was untruthful. Family describes a lot of arguing among her and spouse. Significant Life Experiences. Marital years. 1st marriage described as volatile. Review of Resident #3's Care Plan Report which included all active, cancelled, and resolved care plan items since admission, revealed no care plan items relating to the resident's history of trauma. Review of the facility policy Trauma Informed Practice, last reviewed [DATE], revealed: . Trauma Informed Care (TIC): 'Trauma-informed care is a strengths based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.'. Policy: CCMC [Cordova Community Medical Center] will create and maintain a safe, calm, and secure environment with supportive care, a system-wide understanding of trauma prevalence and impact, recovery and trauma specific services, and recovery-focused, client-driven services. Early Screening and Comprehensive Assessment of Trauma. The initial (first encounter with the agency) intake, assessment, and documentation process includes questions designed to sensitively and respectfully explore prior (including early childhood) and current trauma-related experiences. The screening and assessment process is sufficiently thorough and focused on trauma-related issues to allow for the determination of a diagnosis associated with trauma, such as PTSD [post-traumatic stress disorder]. The ongoing process allows for the gathering of new trauma related information leading to potential changes in diagnosis as well as appropriate treatment objectives, goals, and services. Sound Alternatives [The community behavioral health clinic] provides trauma-related information that will assist other service providers to develop a service plan that will promote effective care and reduce the likelihood of retraumatization.

.Based on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) food was stored under proper sanitation practices in the main kitchen; and 2) expired food items were discarded timely. These failed practices had the potential of causing or spreading foodborne illness to 6 out of 8 residents who receive food from the kitchen. Findings: An observation, during the initial main kitchen tour, on 3/9/26 at 3:08 PM, revealed: 1) Dry Storage/Pantry Area: - 1 30-ounce can of [NAME] Mexican Style Hominy, with a best by date of 4/13/25; and- 1 unopened box of microwave popcorn (6 bags in the box), with a best by date of 1/2/26. 2) Large Bin Container Closet: An observation of one metal bin labeled white rice 2 years + [good for more than 2 years] and sugar U.B. [use by] 11/10/26. Further observation revealed this label was not accurate. There were multiple bulk bags, of different food items in this bin, that were open to air placing the bags at risk of contamination (not rolled down and/or sealed to protect contents): - One opened 25 lbs. bag of Producers [NAME] Rice approximately 1/4 full;- One opened 20 lbs. bag of Monarch Lentils a little more than 1/4 full; and- One opened 50 lbs. bag of Monarch Granulated Sugar less than 1/4 full. 3) Walk-in Freezer: - One opened box of Simply Wheat Dinner Rolls, approximately 30 rolls in the box, with a use by date of 2/26/26;- One opened box of Salad Style Imitation Crabmeat, two unopened packages and one 1/2 bag in the box, with a use by date of 2/28/26;- One opened box of Patuxent Farms Breakfast Sausage Patty, four patties left in the box, with a use by date of 2/28/26;- One opened box of Mechanically Tenderized Beef Stk [steak] Cubed, one left in the box, with a use by date of 1/1/25; and- One opened box of Harvest Value Cooked Italian Style Pizza Topping Large Chuck, with a use by date of 3/1/26. During an interview on 3/9/26 at 3:42 PM, [NAME] #3 stated Use By dates on food items would be treated as an expiration date. [NAME] #3 further stated the two pantry items identified were expired and the freezer foods past their use by date should have been discarded. [NAME] #3 acknowledged the bulk bin finding upon discovery. Review of the facility policy Meal Times/Nourishments, last reviewed 1/24/25, revealed: . Nourishments prepared by the FNS Department will be covered, and labeled with a Use By Date. and will be monitored by FNS for outdates. Bulk nourishments are provided and stored in dining room. All individual and bulk nourishments are for the use of residents and patients only.

.Based on record review, interview and observation, the facility failed to ensure the MDS (Minimum Data Set- a federally required nursing assessment) assessment accurately represented the residents' status for 2 residents (#'s 1 and 3), out of 8 sampled residents. This failed practice placed the residents at risk for inadequate care planning and goals which could affect their overall health and wellbeing. Findings:Resident #1 Record review on 3/9-13/26 revealed Resident #1 was admitted to the facility with diagnoses that included adult failure to thrive, acquired absence of left leg below knee, and history of falling. Review of Resident #1's quarterly MDS assessment, dated 12/20/25, revealed: [Section] J1800. Has the resident had any falls since admission/entry or reentry or the prior assessment. whichever is more recent? 0 [No]. Review of Resident#1's ED Note, dated 10/7/25, revealed: [Resident #1] reports [he/she] was in [his/her] wheelchair tonight and leaned forward to pick up something. As [he/she] leaned, [he/she] slipped out of the wheelchair and landed on the floor, striking [his/her] left shoulder posteriorly on furniture as [he/she] fell. During an interview on 3/10/26 at 2:40 PM, Resident #1 stated that in October 2025 he/she had reached over to pick up a colored pencil that was on the floor and then fell out of his/her wheelchair but that he/she had not fallen since then. During an interview on 3/10/26 at 2:53 PM, the Assistant Director of Nursing (ADON) stated that she missed Resident #1's October fall during her review and that it should have been included in the 12/20/25 quarterly MDS assessment. Resident #3 Record review on 3/9-13/26 revealed Resident #3 was admitted to the facility with diagnoses that included Squamous cell carcinoma (a type of cancer) of skin of unspecified parts of face with an onset date of 11/7/25. Review of Resident #3's quarterly MDS assessment, dated 2/2/26, revealed: [Section] M1040. Other Ulcers, Wounds, and Skin Problems. Check all that apply. Z. None of the above were present [selected]. Review of Resident #3's Periodic Provider Assessment, dated 10/29/25 at 3:50 PM, revealed: . worsening R [right] temple lesion, s/p [status post] 5 FU [5- Fluoroucil, a medication used to treat cancer] injection with initial response and now worse. Had consult with oncology and waiting for plan. Injection will not cure but may slow progression. Random observations on 3/9-13/26, revealed Resident #3 was seen with a wound dressing on the right side of his/her face covering an area including his/her right temple and portions of his/her right cheek. During an interview on 3/11/26 at 8:43 AM, the ADON stated that Resident #1 did have a cancerous lesion on his/her face and that section M1040 box D of the 2/2/26 quarterly MDS assessment, Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion), should have been selected and that it was an oversight. During an interview on 3/10/26 at 2:53 PM, the ADON stated that her responsibilities at the facility included updating the resident's MDS assessments and other tasks to support the Director of Nursing. While updating the MDSs, she did a deep dive to review notes and progress notes in the resident's Electronic Medical Record (EMR) and spoke to floor staff about the residents. She also attended care conferences which included staff members and residents and/or their representatives as needed to clear up any questions she may have while finalizing the MDS. Review of the facility policy Minimum Data Set (MDS), last reviewed 6/27/25, revealed: . Minimum Data Set (MDS): is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. The Care Area Assessment will include, but is not limited to, the look back period, staff and resident interviews, quarterly or comprehensive assessments, and medication, chart, and care plan review.

.Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan for 1 resident (#3), out of 8 sampled residents. Specifically, the resident's identified trauma history was not care planned for to ensure trauma-informed care interventions were implemented. This failed practice had the potential to exacerbate past trauma and affect the resident's ability to attain the highest practicable mental and psychosocial well-being. Findings:Record review on 3/9-13/26 revealed Resident #3 was admitted to the facility with diagnoses that included dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking) with behavioral disturbance, personality disorder (a mental health condition that involves long lasting, all-encompassing, disruptive patterns of thinking, behavior, mood, and relating to others), and insomnia (difficulty falling asleep, staying asleep, or waking up too early). Review of Resident #3's SOCIAL HISTORY/ Trauma and Cultural Assessment, dated [DATE], revealed: . Is there a history of physical, emotional, or sexual abuse (if Yes reference in Care Plan for trauma needs.) Trauma- son died at age of 21 in a motorcycle wreck. Resident had difficulty coping with loss. Resident states 1st husband was untruthful. Family describes a lot of arguing among her and spouse. Significant Life Experiences. Marital years. 1st marriage described as volatile. During an interview on [DATE] at 10:44 AM, the Director of Nursing (DON) stated the social history/trauma and cultural assessment was the facility's trauma screening. It was done within 7 days of a Resident's admission to the facility by Case Manager #1, who worked in the behavioral health clinic. When asked about Resident #3's identified trauma history, the DON stated that Resident #3's trauma should have been included in his/her care plan but was unsure if it would continue to be on his/her care plan at this time. Review of Resident #3's Care Plan Report which included all active, cancelled, and resolved care plan items since admission, revealed no care plan items relating to the resident's history of trauma. Review of Resident #3's first Care Plan Conference Summary after admission, dated [DATE] at 10:00 AM, revealed no documentation regarding the resident's history of trauma. Review of the facility policy Assessments, Care Plans, and Care Conferences, last reviewed [DATE], revealed: . Each resident's care is based upon a comprehensive assessment with the utmost consideration of individual needs and preferences to ensure care is culturally-competent and trauma-informed. Review of the facility policy Trauma Informed Practice, last reviewed [DATE], revealed: . Trauma Informed Care (TIC): 'Trauma-informed care is a strengths based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.'. Policy: CCMC [Cordova Community Medical Center] will create and maintain a safe, calm, and secure environment with supportive care, a system-wide understanding of trauma prevalence and impact, recovery and trauma specific services, and recovery-focused, client-driven services. Early Screening and Comprehensive Assessment of Trauma. The initial (first encounter with the agency) intake, assessment, and documentation process includes questions designed to sensitively and respectfully explore prior (including early childhood) and current trauma-related experiences. The screening and assessment process is sufficiently thorough and focused on trauma-related issues to allow for the determination of a diagnosis associated with trauma, such as PTSD [post-traumatic stress disorder]. The ongoing process allows for the gathering of new trauma related information leading to potential changes in diagnosis as well as appropriate treatment objectives, goals, and services. Sound Alternatives [The community behavioral health clinic] provides trauma-related information that will assist other service providers to develop a service plan that will promote effective care and reduce the likelihood of retraumatization.

.Based on record review and interview, the facility failed to inform residents, in writing, before or at the time of admission, of the services available in the facility and the charges for those services, including services not covered under Medicaid or by the facility's per diem rate, for 7 of 8 Medicaid-eligible residents reviewed. This failed practice resulted in residents not receiving required information necessary to understand the cost of care and services, placing them at risk for unexpected financial liability. Findings:Review of the facility's Resident admission Agreement paperwork, undated, revealed: . Our responsibilities. We will provide you with the items and services set forth in Exhibit 'A' to this Agreement which are presently included in our daily rate. If you request any item(s) or service(s) not included in our daily rate, you agree and acknowledge that you will be billed directly for those services. Your responsibilities. You shall pay all fees and charges due under this Agreement. The Responsible Party shall ensure that all fees and charges due under this Agreement are timely paid from you income, assets, and resources. Review of Exhibit A of the Resident admission Agreement, revealed: - The daily rate includes. [a list of services and items provided]. Further review revealed no daily rate listed to show how much it cost to be in the facility per day. - Items no included in the daily rate include. [a list of services and items not covered in the daily rate]. Further review revealed no cost on items that could potentially have a flat rate, like hairdresser, transportation and escorts to appointments, rehabilitation services (physical therapy, occupational services, speech therapy), or x-rays. During an interview on 3/11/26 at 2:43 PM, the Director of Nursing (DON) stated the daily rate was not listed in the admission packet for the residents to receive at admission and acknowledged the services that may incur charges did not have fees listed for those services that could be associated with a flat rate. Review of the resident rights titled Your rights and Protections as a Nursing Home Resident, undated, revealed: . Get Information on Services and Fees: You have the right to be told in writing about all nursing home services and fees (those that are charged and not charged to you) before you move into the nursing home and at any time when services and fees change.

.Based on record review and interview, the facility failed to address or include the staff competencies and skill sets that are necessary to provide the level and types of care needed for their resident population in their facility assessment. Specifically, trauma-informed care (TIC) training was not included in their annual facility-wide assessment. This failed practice: 1) placed 1 resident (#3), out of 8 resident's reviewed, at risk of having their past trauma exacerbated which had the potential to affect the resident's ability to attain the highest practicable mental and psychosocial well-being; and 2) placed all residents (based on a census of 8) at risk of not having newly identified trauma care planned for to mitigate retraumatization. Findings:Review of the facility's Facility-Wide self assessment, dated 11/10/25, revealed .Staff competencies and annual training requirements per regulatory and/or facility policy:. Further review revealed no TIC training listed with their staff competencies and annual training requirements. During an interview on 3/12/26 at 3:50 PM, the Director of Nursing (DON) stated that they do not have TIC training. During an interview on 3/12/26 at 9:15 AM, the DON stated TIC training was not listed in the facility assessment and should have been part of the assessment

Based on record review and interview, the facility failed to provide proof that the Alaska Nurse Aide Abuse Registry was checked before hiring Certified Nurse Aides (CNAs). This failed practice placed all residents, based on a census of eight, at potential risk of abuse by individuals who may have had a documented history of misconduct. Findings: Record review on 1/30/25 revealed the facility had 13 CNAs working at the Long-Term Care (LTC). Review of the CNA employee records revealed no documentation that the Alaska Nurse Aide Abuse Registry was checked, prior to the CNAs starting work with residents of the LTC. During the course of this survey, proof was requested that the Alaska Nurse Aide Abuse Registry was checked for all CNAs working at the LTC. Review of the facility-provided form,Nurse Aides Abuse Registry, revealed this form was dated 1/29/16. During an interview on 1/30/25 at 8:30 AM, the facility's Chief Executive Officer (CEO) stated the Human Resources (HR) staff took screenshots of the abuse registry to confirm that an employee was not listed and placed this documentation in the employee's file. The CEO further stated that no such screenshots were available for any CNA employed at the facility. Review of the facility policy, Background Check, last reviewed 11/14/24, revealed: . 3. Nurse Aide Abuse Registry: A. The HR director will perform a check on the Nurse Aide Abuse Registry on all CNA's prior to making an Offer of Employment. Review of the facility's Policy and Procedure, Abuse Prevention, Recognition, and Reporting, last revised on 5/31/23, revealed: all candidates for employment will be screened by checking the licensing registry prior to hiring. The policy further stated that, these steps will be documented and maintained. Review of the Alaska Nurse Abuse Registry at https://www.commerce.alaska.gov/web/Portals/5/pub/NUA_NurseAideAbuseRegistry.pdf on 2/5/25, revealed it was last updated on 5/1/24.

Based on record review and interview, the facility failed to provide written notice of the bed hold policy and provide the facility's bed hold form (policy of reserving a resident's bed for a specified period when the resident is temporarily transferred to a hospital or another healthcare setting) for two residents (#'s eight and nine), out of nine residents reviewed, who were transferred to the emergency department (ED) and/or hospital, for medical treatment. This failed practice had the potential for the residents and/or their resident representatives to not be informed of the facility's bed hold policy, placing these residents at risk for losing their beds at the facility due to an extended stay at another healthcare facility. Findings: Resident #8 Record review from 1/27- 31/25 revealed Resident #8 was admitted to the facility with diagnoses that included sequelae of central nervous system tuberculosis (long-term complications or residual effects that persist after an individual has recovered from tuberculosis infection) and gastrostomy (a surgical opening in the stomach that allows for the insertion of a feeding tube) status. Review of Resident #8's Discharge Assessment MDS (Minimal Data Assessment - a federally required nursing assessment), dated 10/6/24, revealed: Discharge assessment-return anticipated 10/6/24. This assessment showed the resident had been transferred out of the facility and was expected to return. Further review of Resident #8's Discharge Assessment MDS, dated [DATE], revealed: Discharge assessment-return anticipated 12/17/24. This assessment showed the resident had been transferred out of the facility and was expected to return. Further review revealed Resident #8 was transferred from the LTC (Long Term Care) facility and admitted to the hospital due to a dislodged gastrotomy tube (feeding tube) on 10/7/24 and discharged back to the facility on [DATE]. Resident #8 was also transferred to the hospital on 12/17/24 for another dislodged gastrotomy tube and discharged back to the facility on [DATE]. Further review revealed no documentation a bed hold policy or bed hold form was provided to the patient's representative for either of these transfers to the hospital. During an interview on 1/29/25 at 3:10 PM, the Director of Nursing (DON) stated, I do not see bed hold [forms] for [Resident #8] were sent to the POA [Power of Attorney] who we reach by email. The DON further stated .we give a bed hold letter with an emergency transfer. The bed hold form should be given to the POA. Resident #9 Closed record review on 1/28-30/25, revealed Resident #9 was admitted to the facility with diagnoses that included adult failure to thrive (condition characterized by unintentional weight loss, decreased appetite, poor nutrition, and inactivity); anemia (condition in which the blood lacks enough healthy red blood cells to carry adequate oxygen to the body's tissues); and heart failure (condition in which the heart is unable to pump blood effectively). Further review revealed no evidence that a bed hold notice was provided to Resident #9 when he/she was transferred to a hospital for a medical emergency on 1/26/25. During an interview on 1/29/25 at 3:10 PM, when asked about the process for providing bed hold notices to a resident upon transfer to another facility due to a medical emergency, the DON stated, Our policy is to give the resident a written letter. My guess is that it wasn't given to [Resident #9] because the transfer was an emergency. Review of the facility policy, Bed Hold, dated 5/24/23, revealed: Purpose and/or Policy statement: Cordova Community Medical Center will provide resident and/or legal representative written notice of the bed hold policy on admission and prior to transfer. Further plans for readmission are addressed after an absence of more than 10 days from the facility . Definitions: Bed-hold: Holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization . Policy: Cordova Community Medical Center will hold LTC beds for up to twelve (12) days for a therapeutic leave and up to fourteen (14) days for a transfer to an acute care facility. Procedure: The resident and/or their legal representative will be notified of the bed hold policy upon admission to the facility. If the resident has not returned to the facility by day (10), the Director of Nursing or LTC Coordinator will follow up with the resident/representative and reassess the situation. If it is apparent that the absence will be longer than fourteen (14) days, and the bed is needed for another resident, The Director of Nursing will notify the resident or their representative that the bed will not be held. Review of the facility document titled, Cordova Community Medical Center Bed Hold Letter, undated, revealed: Dear _______________ . A transfer to the hospital can be a stressful circumstance for people. Medicaid and Medicare will not pay for holding a bed during hospitalization of a resident. In order to alleviate some of the anxiety and stress to the residents of Cordova Community Medical Center [CCMC] we have listed basic guidelines that are intended to assist people in their decision-making and to provide a smoother transfer process. 1. We are able to hold a resident's room for up to fourteen [14] days. Residents have the option of hold the room indefinitely by arranging private payment on a daily basis. For more information, please contact the Business Office or the Director of Nursing . Your room will be held for fourteen (14) days. The last day the room will be held is _______________. If you have any questions, please contact the Director of Nursing. This form was to be signed by the Resident or Resident Representative and the Director of Nursing or Long Term Care Coordinator. . 51615

Based on observation, interview, and record review, the facility failed to: 1) ensure expired medical products were removed from the medical supply storage room; and 2) ensure the medication cart drawers were locked when unsupervised. These failed practices placed all residents (based on a census of 9) at risk for: 1) adverse effects or complications from use of expired products; and/or 2) potential loss, diversion, or accidental exposure to medications. Findings: Expired medical products: An observation on [DATE] at 3:27 PM, of the medical supply storage room, revealed the following expired medical supplies: 1- Copan eSWAB collection and preservation swab, expired on [DATE]; 3- BD Vacutainer Serum red top vials, expired on [DATE]; and 1- BD Vacutainer Serum green top vial, expired on [DATE]. During an interview on [DATE] at 3:27 PM, Licensed Nurse (LN) #2 stated the night shift LN was responsible to check the medical supply room for expiration dates but was unsure of the frequency it was checked. LN #2 was not aware of the expired items. During an interview on [DATE] at 3:47 PM, the orienting Director of Nursing (DON)/LN stated when items from the medical supply room were expired, the supplies should have been replaced. Medication cart drawers: An observation and concurrent interview on [DATE] at 3:27 PM, revealed LN #2 standing in front of the medication cart, located within the nurses station, with several medication cart drawers slightly pulled out. Without locking the cart, the LN went into the medical supply room with the surveyor. Upon returning to the medication cart after approximately 10 minutes, the LN was asked by the surveyor to demonstrate how to lock the medication cart. The LN demonstrated by flipping inward the vertical locking bars located on the corners of the cart and locking the cart with a key. The LN attempted to demonstrate the medication drawers were locked by pulling on several drawers, however, the final drawer opened. The drawer contained multiple daily medication packs for one resident. The LN then pushed the drawer back in, which locked it into place. Then the surveyor reached out and pulled open another drawer containing multiple daily medication packs belonging to a different resident. The drawer was then pushed back into the cart and locked into place by the surveyor. The LN stated that he/she always locked up the medication cart but did not regularly check to see if any drawers would open after the cart was locked and was not trained to do so. During an interview on [DATE] at 2:15 PM, the orienting DON/LN stated that LN's were trained to lock the medication cart every time the LNs walked away from the cart, and that medications should have been locked up at all times in the cart. Review of the facility's policy, Order Processing and Medication Administration in LTC [Long Term Care], revised [DATE], revealed All medications will be stored behind locked units.

Based on observation, interview, and record review, the facility failed to 1) store food under proper sanitary conditions; and 2) regularly maintain the ice machine based on manufacturer's instructions. This failed practice placed 6 residents (#s 1, 2, 5, 6, 7, and 8) out 6 residents who received meals from the kitchen, at risk for foodborne illnesses and communicable disease. Findings: Food Storage An observation, during the initial kitchen tour on [DATE] at 4:00 PM, revealed the following spoiled fruits and vegetables in the walk-in cooler: 1 open pack of Kale had yellow leaves; 1 tomato with a dime-sized black spot ; 3 whole cantaloupes containing multiple silver dollar sized black spots and several soft brown spots; and 7 whole cantaloupes containing multiple various sized soft brown spots. During an interview on [DATE] at 4:25 PM, Dietary Staff (DS) #1 stated he/she was responsible to check expired and spoiled items in the walk-in cooler. He/she stated the facility's process was to remove the spoiled and expired items from the cooler. For spoiled fruits, he/she stated they would cut out the rotten spots and serve the good parts of the fruit. DS #1 asked the Dietary Manager (DM) if he/she was supposed to discard the 3 spoiled cantaloupes. The DM stated he/she would show DS #1 how to take care of the cantaloupes later. The DM stated, they would still use the fruit if other parts of the fruit were ok. During an interview on [DATE] at 12:53 PM, the DM stated the fruits and vegetables with the black spots were thrown away. Review of the facility's policy Storage and Receiving Food Items, dated [DATE], revealed: .Fruits and vegetables are refrigerated . These items are sorted regularly, and damaged or spoiled pieces are discarded . Ice Machine Maintenance During an observation on [DATE] at 5:15 PM, Cook #1 filled the pitcher with ice from the ice machine, added water and delivered the iced water with the prepared meal trays to the long- term care unit. During an interview on [DATE] at 2:17 PM, when asked if he was responsible for the ice machine maintenance, the Maintenance Manager (MM) stated yes, but he only changed the ice machine filter every 6 months but did not keep an ice machine maintenance log. During an interview on [DATE] at 2:22 PM, the DM stated the ice machine was used for residents. During an interview on [DATE] at 9:00 AM, the DM stated the Dietary staff (DS) cleaned the outside surface of the ice machine weekly. When asked if the DS cleaned the interior compartment of the ice machine based on manufacturer's instruction, the DM stated he/she was not aware that there was a manufacturer's manual. He/she also stated he/she was not aware there was a need to clean the interior compartments of the ice machine. Review of the Scotsman Meridian ice machine manual revealed: Maintenance . the water and ice vending systems will need to be periodically sanitized and de-mineralized. The air-cooled condenser will also need to be kept clean, schedule the sanitation, cleaning, and de-mineralization on a regular basis to keep the ice clean and the machine operating efficiently.

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control protocols were performed during food preparation, medication administration, and enteral feeding (receiving nutrition through a gastrostomy tube [a tube inserted through the stomach]). These failed practices had the potential to affect all residents (based on census of 9) for the development and/or transmission of communicable diseases and infections. Findings: Food Preparation During an observation on 12/13/23 between 4:30 PM to 5:15 PM, Cook #1 prepared dinner menu items such as sausage patties, gravy, waffles, and hot fruit compote. Cook #1 wore gloves when he/she started the food preparation. The cook removed the steam table tray lid and dished out one sausage patty. He/she covered the steam table with the lid then took milk from the walk-in cooler. The cook cut the sausage patty into chunks and with the same gloved hands, the cook placed the chunks into a blender. Cook #1 returned to the steam table, uncovered the sausage patty tray and measured the temperature of the patties. With the same gloved hands, he/she continued the puree process. He/she added gravy, milk, and thickener into the blender. He/she poured the pureed food into a small bowl then placed the bowl into the warmer. Next, Cook #1, rinsed the blender in the sink by holding the blender in his/her left hand while holding the spray nozzle with his/her right hand. With his/her wet gloved hands, he/she took a bowl of pears from the walk-in cooler, uncovered the bowl, placed the pears in the blender, sprinkled cinnamon, and returned the cinnamon bottle to the cabinet. He/she continued the puree process by adding milk to the pears . Cook #1 then placed the pureed pears into a small bowl then placed the bowl into the cooler. With the same gloved hands, Cook #1 rinsed the blender (in the same manner as mentioned above). The Cook then replaced his/her gloves without performing hand hygiene in between glove changes and continued preparing food. During an interview on 12/14/23 at 12:53 PM, Dietary Manager (DM) #1 stated the dietary staff were expected to wash their hands before putting on gloves. He/she also stated dietary staff should have changed gloves before starting a new task. Review of the Food Code 2022, 2-301.14 When to Wash., dated 1/18/23, revealed: .FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation . and . (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks . (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. Medication Administration During a Meal Resident #2 Record review on 12/11 - 15/23 revealed Resident #2 was admitted to the facility with diagnoses that included dementia, allergic rhinitis (allergic reactions that causes sneezing, congestion, runny and itchy nose), and dry eye syndrome. During an observation on 12/13/23 at 10:56 AM, while Resident #2 was eating breakfast, Licensed Nurse (LN) #2, with gloved hands, fed Resident #2 various crushed medications mixed in applesauce in between bites of bacon. LN #2 then offered Resident #2 his/her scheduled nose spray. The resident agreed to the administration, stopped eating, and the nose spray was administered by the LN using the same gloved hands. Then LN #2 adjusted the resident's clothing protector, which had a piece of bacon on it. Next, the LN asked the resident to remove his/her glasses so he/she could administer eye drops. The resident stated he/she wanted to eat some more. The LN offered Resident #2 eye drops again at 10:57 AM, where the resident declined because he/she was still eating, then again at 11:00 AM where the resident agreed to take the drops. With a piece of bacon in one hand, the resident removed his/her glasses with the other. Using the same gloved hands, the LN administered the eye drops. Without replacing his/her gloves or performing hand hygiene, the LN used a tissue to wipe away the excess drops from the resident's eyes. Medication administration/tube feeding Resident #9 Record review on 12/11-15/23 revealed Resident #9 was admitted to the facility with diagnoses the included miliary tuberculosis (a condition where tuberculosis bacteria enter the bloodstream and spread to different parts of the body), and tuberculosis meningitis (a form of tuberculosis that infects the membrane of the brain and spinal cord). Review of the Minimum Data Set (MDS- and federally required assessment for all long-term care residents) quarterly assessment, dated 9/23/23, revealed Resident #9 received enteral feeding. During an observation on 12/15/23 at 7:00 AM, LN #1 checked Resident #9's gastric residual volume (the amount of fluid remaining in the stomach after enteral feeding) with the use of a syringe (this syringe was kept at the bedside). Afterwards, the LN placed the syringe in a cup, removed his/her gloves but did not perform hand hygiene. Next, the LN placed a stethoscope around her neck and then put on new gloves. Then the LN checked the placement of the gastrostomy tube. The LN removed his/her gloves, sanitized his/her hands, and prepared the resident's medications. With new gloves on, the LN elevated the resident's bed and administered medication and water one at a time. The LN rinsed the syringe and the cup, then removed his/her gloves. While holding the used gloves, he/she covered Resident #9 with a blanket and lowered the resident's bed. He/she then recorded the medication administered in the computer. Without hand hygiene, the LN put on new gloves, hung a bag filled with 1000 ml of water, then hung the bag of parenteral nutrition. Next, the LN primed the tubing with water and parenteral nutrition, where the excess fluid flowed into the cup with a syringe in it. The LN did not rinse the cup and syringe after priming. The LN stated the syringe would be changed every Sunday night. Then, the LN left the room. Resident #3 Record review on 12/11-15/23 revealed Resident #3 was admitted to the facility with diagnoses the included anoxic brain damage (complete loss of oxygen flow to the brain) and dysphagia (difficulty swallowing). Review of the MDS quarterly assessment, dated 9/23/23, revealed Resident #3 received enteral feeding. During an observation on 12/15/23 at 7:27 AM, LN #1 rinsed a syringe and cup with gloves on after lowering the bed, then the LN checked the gastric residuals with wet gloves. After removing one glove, the LN checked the gastric tube placement with a stethoscope then removed his/her other glove. Without performing hand hygiene, the LN began preparing medications on the medication cart in the room. The LN removed the medications from a medication drawer and placed the medication into a medication cup and added water to dissolve it. While waiting for the pill to dissolve, the LN rinsed the syringe and cup, removed his/her gloves, and put on new gloves without performing hand hygiene. Next, the LN removed Resident #3's right arm splint and assessed the skin. The LN removed his/her gloves, performed hand hygiene, put on new gloves and gave the medications with water through the tube. Then LN reattached the tube feeding tubing, rinsed the syringe and cup, removed his/her gloves and without hand hygiene, he/she lowered the bed. During the same observation, Resident #3 coughed, which disconnected the tube feeding tubing from the gastric tube. The LN immediately closed the gastric tube, discontinued the tube feeding and wiped up the spilled fluid on Resident #3's bed. The LN then removed his/her gloves without performing hand hygiene. The CNAs were called to change the soiled absorbent pad under the resident's buttocks and pillowcase. With gloved hands, the LN prepared another tube feeding bag, connected and primed the tubing, where the excess fluid flowed from the tubing into a cup with a syringe in it. Next the LN attached the tube feeding to the resident's gastric tube and then he/she removed his/her gloves and performed hand hygiene. The LN did not rinse the cup and syringe. Then, the LN moved to the next resident in the room. Review of the facility's policy Hand Hygiene, dated 11/9/18, revealed: .indications .employees must wash their hands immediately or as soon as possible: before and after patient contact, after contact with inanimate objects and surfaces that are likely to be contaminated, after gloves are removed, between tasks and procedures on the same patient to prevent cross-contamination to different body sites . Review of Centers for Disease Control and Prevention Hand Hygiene Guidance, dated 1/30/20, found in this link: https://www.cdc.gov/handhygiene/providers/guideline.html, revealed: .Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal .

Based on record review and interview, the facility failed to ensure pneumococcal and influenza immunizations documentation (administered or declined) were completed for 1 resident (#5), of 5 residents sampled for pneumococcal and influenza immunizations. This failed practice denied the resident or resident representative the opportunity to receive education on the benefits and potential side effects, and to accept or decline the immunizations. Findings: Record review on 12/11-15/23 revealed Resident #5 was admitted to the facility with diagnoses that included cerebral infarction (where a cluster of brain cells do not receive enough blood supply and die), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that cause obstructed airflow in the lungs). Further record review revealed Resident #5 did not have any allergies listed for the pneumococcal and influenza immunizations. Review of Resident #5's immunization record on 12/14/23 at 8:12 AM, revealed the resident was overdue for pneumococcal and influenza immunizations. Further review of the immunization record revealed no documentation that the facility: offered the pneumococcal and influenza immunizations, provided education of the risks and benefits of receiving the immunizations, the resident or resident representative declined the immunizations, or administered the pneumococcal or influenza immunizations. During an interview on 12/14/23 at 12:13 PM, the orienting Director of Nursing/Licensed Nurse reviewed Resident #5's immunization record in the medical record with the surveyor, and found the immunizations and education were not up to date since Resident #5's admission in October 2023. She stated she was unable to locate the records where the facility educated and offered the pneumococcal and influenza immunizations to Resident #5 or his/her representative. She conferred with other colleagues who were also unable to locate the records. Review of the facility's policy Immunizations for LTC [Long Term Care] and Swing Bed Residents, revised on 5/25/23, revealed, .All residents admitted to Long-term care and skilled nursing facility will be screened within seven days of admission .Following providers orders any needed vaccines will be administered .after having been informed of the risks and benefits of each immunization .Refusals will be documented on the immunization record .Document the vaccination on the Medication administration Record (MAR), the immunization record, and online at Alaska Vactrak. Review of the Centers for Disease Control and Prevention (CDC) article, Who should get a flu vaccine this season?, dated 8/25/23, retrieved from: https://www.cdc.gov/flu/prevent/vaccinations.htm, revealed: Everyone 6 months and older should get a flu vaccine every season . Vaccination is particularly important for people who are at higher risk of serious complications from influenza . Review of the CDC article, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, dated 9/22/23, retrieved from: https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html#adults-19-64, revealed: . Adults 19 through [AGE] years old with certain risk conditions .Chronic lung disease, including chronic obstructive pulmonary disease .

Based on record review and interview, the facility failed to ensure COVID-19 vaccination documentation (administered or declined) was completed for 1 resident (#5), of 5 residents sampled for COVID-19 vaccinations. This failed practice denied the resident or resident representative the opportunity to receive education on the benefits and potential side effects, and to accept or decline the immunizations. Findings: Record review on 12/11-15/23 revealed Resident #5 was admitted to the facility with diagnoses that included cerebral infarction (where a cluster of brain cells do not receive enough blood supply and die), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that cause obstructed airflow in the lungs). Further record review revealed Resident #5 did not have an allergy listed for the COVID-19 vaccine. Review of Resident #5's immunization record on 12/14/23 at 8:12 AM, revealed the resident was overdue for the COVID-19 vaccine. Further review of the immunization record revealed no documentation that the facility: offered the COVID-19 vaccine, provided education of the risks and benefits of receiving the vaccine, the resident or resident representative declined the vaccine, or administered the COVID-19 vaccine. During an interview on 12/14/23 at 12:13 PM, the orienting Director of Nursing/Licensed Nurse reviewed Resident #5's immunization record in the medical record with the surveyor, and found the immunizations and education were not up to date since Resident #5's admission in October 2023. She stated she was unable to locate the records where the facility educated and offered the COVID-19 vaccine to Resident #5 or his/her representative. She conferred with other colleagues who were also unable to locate the records. Review of the facility's policy Immunizations for LTC [Long Term Care] and Swing Bed Residents, revised on 5/25/23, revealed, .All residents admitted to Long-term care and skilled nursing facility will be screened within seven days of admission .Following providers orders any needed vaccines will be administered .after having been informed of the risks and benefits of each immunization .Refusals will be documented on the immunization record .Document the vaccination on the Medication administration Record (MAR), the immunization record, and online at Alaska Vactrak.

Based on interview and record review the facility failed to ensure accurate staffing data for the 3rd quarter of 2023 (April - June 2023) was reported to Centers for Medicare and Medicaid (CMS) Payroll Based Journal (PBJ). This failed practice potentially denied residents and/or representatives (based on census of 9), and the public, accurate staffing data when accessing the Nursing Home Compare website. Findings: During an interview on 12/14/23 at 10:22 AM, Accounts Payable and Payroll staff stated the facility used an online service for payroll called ADP (Automatic Data Processing). She stated the facility coded the worked LN (licensed nurse) hours to specific departments (such as Long-Term Care, and other departments, etc.) in the ADP. She further stated all the LTC (Long Term Care) LN hours from ADP were then pulled out and submitted to the CMS PBJ every quarter. She confirmed that the reported PBJ LN hours were less than 24-hours on certain days during the 3rd quarter. Record review on 12/14/23 at 10:32 AM, of the facility's PBJ staffing report revealed the facility did not meet the LTC LN 24-hour staffing requirement for 19 days in the 2023 3rd quarter on the following dates: 4/8/23 20.5 hours reported worked; 4/15/23 13 hours reported worked; 4/23/23 12.5 hours reported worked; 4/30/23 16.75 hours reported worked; 5/6/23 20.5 hours reported worked; 5/13/23 12.75 hours reported worked; 5/14/23 13.5 hours reported worked; 5/23/23 21.75 hours reported worked, 5/24/23 12.25 hours reported worked; 5/25/23 0 hours reported worked; 5/26/23 12.5 hours reported worked; 5/27/23 12.5 hours reported worked; 5/28/23 12.5 hours reported worked; 6/4/23 12.5 hours reported worked; 6/8/23 13.5 hours reported worked; 6/14/23 0 hours reported worked; 6/18/23 12.5 hours reported worked; 6/23/23 12.5 hours reported worked and; 6/25/23 22 hours reported worked. During an interview on 12/14/23 at 3:55 PM, the Director of Nursing (DON) stated the LTC had 24 hours LN coverage each day. She stated that if there were no LN hours in the PBJ report, the hours could have been coded incorrectly. She also stated a travel LN who worked hours from May-June 2023 might have been missed in the report because the travel LN used a paper timecard, which was paid to the travelling nurse's company instead of through the ADP process. Record review of the facility's ADP 3rd quarter timesheet report, revealed multiple travel LN's paper timecards from May-June 2023, showed LNs worked in the LTC unit but were coded to another department on the following dates: 4/8/23, 4/15/23, 4/23/23, 4/30/23, and 5/6/23. Further review revealed, LNs, employed by the facility, worked in the LTC unit but were not coded to the LTC department or reported in the 3rd quarter timesheet report on the following dates: 5/13/23, 5/14/23, 5/23/23, 5/24/23, 5/25/23, 5/26/23, 5/27/23, 5/28/23, 6/4/23, 6/8/23, 6/14/23, 6/23/23, and 6/25/23. During a joint interview with the Administrator and DON on 12/14/23 at 4:22 PM, the Administrator stated the nurse leadership would provide LN coverage if there were staff who called-in[sick], but the coding for that coverage was not reported correctly. The DON stated the facility should change their timekeeping process. Review of the facility's untitled new nurse work hours report (no date) with a signed note (no date), provided by the Administrator on 12/15/23 at 11:00 AM (after the exit conference) revealed: PBJ reporting error identified. The report pulled from ADP time keeping system and submitted to PBJ only included nurses with their home department as LTC. A new report has been run that includes nurses with other home department, but time coded to LTC. It demonstrates 24/7 coverage for LTC. Review of the facility's employee handbook dated 6/22/23 revealed: Timekeeping .Time worked is all the time actually spent on the job performing assigned duties .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: 1) screen or identify visitors who may have a positive [CONDITION(S)] test for [CONDITION(S)] CoV-2, symptoms of COVID-19, or close contact with someone with [CONDITION(S)] CoV-2 infection when entering the facility according to CDC recommendations; and 2) use face masks and gloves appropriately. This failed practice placed all residents, based on a census of 10, at risk of contamination and development of COVID-19 infection. Findings: Review of the facility campus revealed the Long-Term Care (LTC) Center was housed inside the Critical Access Hospital building. Screening of visitors An observation on 9/24/22 at 4:00 PM when entering the facility, revealed Unit Clerk #1 asked the surveyors to write their names in the visitors' logbook at the nurse's station. Unit Clerk #1 took each surveyor's temperature, verbalized the temperature reading, and then asked the surveyors to write the temperature in the logbook. This same observation and instruction occurred on 9/25-28/22 when surveyors were screened by other Unit clerks. During an interview and concurrent record review on 9/27/22 at 10:25 AM, when asked the screening process for when a visitor comes in the facility, Unit Clerk #2 stated visitors were instructed to sign in the logbook, asked if the visitor had signs or symptoms of COVID-19, and had their temperature taken. When asked if the process was the same for visitors seeing a resident at the LTC unit, Unit Clerk #2 stated the LTC unit had a separate logbook for visitors. When asked where information for visitors experiencing signs and symptoms and possible exposure to people with COVID-19 infection would be placed in the logbook, Unit Clerk #2 stated he/she would assume the visitors would not come to visit if they have had signs and symptoms. The unit clerk further stated, if the visitor said he/she had signs and symptoms, follow-up questions would be asked (such as if he/she had recently tested positive for COVID-19 or was in close contact with someone with COVID-19 infection). When asked the reason for the surveyors not being questioned regarding COVID -19 signs and symptoms that morning, Unit Clerk #2 stated I assumed that surveyors would not come in if they had signs and symptoms. Unit Clerk #2 added he/she was supposed to screen the surveyors with the same process as visitors. On the same interview and concurrent record review, when asked to identify the LTC visitors who signed-in the logbook, Unit Clerk #2 showed the following: 9/24/22 Visitor #1 and Visitor #2 9/25/22 Visitor #3 9/26/22 Visitor #3 All visitors had temperature readings and no other screening questions entered in the logbook. Review of the facility's COVID-19 Transmission Mitigation policy, dated 6/30/22, revealed: .Screening: visitors shall be screened at check-in .Procedure .visitors .will be screened for current [CONDITION(S)]-CoV-2 infection; symptoms of COVID-19; Prolonged close contact .with someone with [CONDITION(S)]-CoV-2 infection in the prior 14 days or have otherwise met criteria for quarantine. During an interview on 9/27/22 at 10:35 AM, when asked the screening process for LTC visitors, Licensed Nurse (LN) #2 stated visitors were screened by taking their temperature and asked questions as indicated on the sign-in sheet at the emergency room nurses' station. LN #2 added there was also a sign-in sheet in the dining room. When asked if there was a separate sign-in sheet for the LTC visitors, LN #2 stated the LTC used the same questions as in the ER nurse's station sign-in sheet. The LN #2 further explained that if visitors were screened at the ER nurses' station there was no need to screen the visitors again at the LTC unit. During a joint interview with Chief Nursing Officer (CNO)/Quality Improvement Nurse/ Acting Infection Preventionist and LTC Director of Nursing (DON) on 9/27/22 at 12:59 PM, when asked the screening process, the CNO stated visitors were screened at the ER nurses' station or LTC. The Certified Nurse Aide (CNA) or LN would screen the visitors. According to Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 9/23/22, at this link https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Fnursing-home-long-term-care.html revealed: . Establish a Process to Identify . Individuals with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection . Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria: 1) a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2 2) symptoms of COVID-19, or 3) close contact with someone with [CONDITION(S)]-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP)). Use of Face Masks An observation on 9/24/22 at 4:10 PM, when entering the facility, revealed Housekeeper #1, as well as, LN #3 had their face masks down under their chins while they walked in the hallway. An observation on 9/25/22 at 11:49 AM, revealed CNA #3 had his/her mask pulled down on his/her chin while charting in the activity room. Further observation revealed, there were 2 residents in the room. An observation on 9/25/22 at 12:30 PM, revealed LN #1 talked with another surveyor with his/her mask pulled down and asked that surveyor to pull down his/her mask as well to hear better. Two other staff working at the front desk were also observed to be talking with their masks pulled down. During an interview on 9/25/22 at 1:30 PM, when asked how Resident #2 was doing, LN #1 pulled his/ her mask down and stated the Resident was ok. Then, LN #1 pulled his/her mask back up. An observation on 9/26/22 at 10:07 AM, revealed a front desk worker was throwing items away in the lobby area with his/her mask pulled down on his/her chin. Once the surveyor walked by, he/she put the mask back into place. An observation on 9/26/22 at 3:10 PM, revealed LN #1 was sitting at the LTC nurses' station without a mask. LN #1 put the mask back on when the surveyor entered the LTC unit. Observations throughout the survey period, 9/24-28/22, revealed laminated signs throughout the building, noted specifically near the elevator and report room that read, Please wear your face mask at all times. Review of the facility's COVID-19 Transmission Mitigation policy, dated 6/30/22, revealed: .Source control: use of cloth masks or facemasks to cover a person .mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing . During an interview on 9/27/22 at 10:12 AM, when asked what PPE (Personal Protective Equipment) were required to wear to prevent COVID-19 infection, CNA #3 stated the staff were required to wear a mask. CNA #3 further explained he/she took the mask off at his/her own discretion to take breaths. During a joint interview with Chief Nursing Officer (CNO)/Quality Improvement Nurse/ Acting Infection Preventionist and LTC Director of Nursing (DON) on 9/27/22 at 12:59 PM, the CNO and DON stated everyone should wear a mask during patient care and depending on the situation. The facility recommended that staff should wear mask in the residents' area and staff may remove mask whenever they were in the break room or offices. Glove Use An observation on 9/25/22 at 1:33 PM, revealed LN #1 took a pair of gloves from his/her pocket and put them on. LN #1 took a bar of chocolate, opened the wrapper then took a piece of chocolate and offered to Resident #9 by holding the piece of cholate in front of the resident's mouth. The Resident did not take it. LN #1 removed the gloves and threw them away in the trash can. Further observation revealed LN #1 offered the chocolate again that time with no gloves on. An observation on 9/25/22 at 1:41 PM, revealed LN #1 was at the nurse's station. LN #1 prepared dressing supplies such as gloves, scissors, bandage [sealed], gauze [sealed] and placed on top of the nurse's counter. LN #1 then gathered the supplies and entered Resident #8's room. LN #1 was observed to place the gloves and other supplies on top of a notebook and tv remote control on the bedside table. LN #1 then performed hand hygiene and put on the gloves. LN #1 placed the sealed gauze and extra gloves on top of the bed. LN #1 then removed the bandage around resident's head, opened the gauze and patted the wound on the left ear. LN #1 stated the wound was dry. After that, LN #1 removed the gloves, threw them in the trash can, washed hands, and put on two layers of gloves. The LN #1 went back to the nurse's station and grabbed [MEDICATION(S)] ointment. The LN #1 placed the sealed bandage, tape, and scissors on top of the bed. The LN #1 then applied the ointment to Resident #8's left ear and removed the first layer of gloves then threw them away. LN #1 then opened the bandage and wrapped it around Resident #8's ear and around the head and secured the bandage. During an interview on 9/25/22 at 2:05 PM, when asked if there was a need to use a pad to lay the dressing supplies on, LN #1 stated no because it was a clean wound dressing change. LN #1 further explained that if he/she would do a lot more wound care, he/she would use a padding. During an interview on 9/25/22 at 2:09 PM, LN #1 stated he/she put gloves in her pocket because there was something that came up. LN #1 further stated the gloves were put in his/her pocket just for one time use and that he/she usually would acquire them from the box. During a joint interview with Chief Nursing Officer (CNO)/Quality Improvement Nurse/Acting Infection Preventionist and LTC Director of Nursing (DON) on 9/27/22 at 12:59 PM, when asked if there was a need to use pads to lay dressing supplies during clean dressing change, the CNO stated there was no need if the wound was dry. When asked if gloves should be placed on top of a table or bed, the CNO stated the supplies including gloves must be placed on a clean area. According to Centers for Disease Control and Prevention (CDC) Hand Hygiene in health care settings, dated 1/8/21, accessed on 9/27/22 at this link: https://www.cdc.gov/handhygiene/providers/, revealed: .Glove use .wear gloves according to Standard Precautions, when it can be reasonably anticipated that contact with .other potentially infectious materials, mucous membrane, and .contaminated equipment .

Based on observations, interviews, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure: 1) the use of professional standards of manual washing and sanitizing using the 3-sink method; 2) concentrations of sanitizing solution buckets were prepared using non expired test strips; 3) dating refrigerated and frozen foods to monitor for growth of microorganisms; 4) rotation of stock for dry storage, and 5) professional temperatures of prepared foods to be served. These failed practices placed 8 residents that received meals from the kitchen at risk of foodborne illness. Findings: Manual Washing- 3-sink method An observation on [DATE] at 12:25 PM, revealed dishes submerged in the first sink. A laminated sign above the sinks read Dishwashing- 1. Pre-Rinse, scrape or soak to remove large food particles 2. Wash in a clean hot (110 [degrees Fahrenheit (F)]) detergent solution 3. Rinse in another compartment with warm clear water 4. Sanitize. For household bleach use 1 tablespoon per 5 gallons water. Check solution with appropriate test strips. 5. Air Dry to prevent contamination from towels or hands. During an interview on [DATE] at 12:27 PM, Dietary Personnel (DP) #3 was asked about the temperatures of the 3 sinks. DP #3 obtained a facility thermometer and tested the first sink of soapy water that revealed a temperature of 102 degrees F. The second sink, which DP #3 stated was rinse water, revealed a temperature of 90 degrees F. The third sink, which DP #3 stated was bleach water, revealed a temperature of 82 degrees F. DP #3 stated these temperatures appeared to be low. During an interview on [DATE] at 12:41 PM, when asked about the 3-sink method, DP #1 stated the sinks were usually drained and refilled after lunch and before more dishes were processed but that task was not completed today. DP #1 was made aware of the observed temperatures for the individual sinks and agreed they were not at standard temperatures. Review on [DATE] of the Food Code 2017 Recommendations of the United States Public Health Service Food and Drug Administration, accessed from https://www.fda.gov/media/ 2/download revealed, ,d+[DATE].19 Manual Warewashing Equipment, Wash Solution Temperature. The temperature of the wash solution in manual WAREWASHING EQUIPMENT shall be maintained at not less than 43oC (110oF) or the temperature specified on the cleaning agent manufacturer's label instructions. Sanitation buckets During an interview and concurrent observation on [DATE] at 5:18 PM, DP #2 tested the sanitation bucket with a Chlorine Test Paper. It revealed a 200 PPM (parts per million) reading. Also observed at this time, was the expiration date of the Chlorine Test Papers being ,d+[DATE]. DP #2 obtained three other containers of Chlorine Test Papers that were all expired. These strips were used to test the sanitation buckets as well as the sanitation sink of the 3-sink method. During an interview on [DATE] at 12:27 PM, DP #3 was asked about the concentration of the sanitation bucket. DP #3 obtained a facility Chlorine Test Paper [expired ,d+[DATE]] and tested the sanitation bucket. The paper came out of the solution the same color and revealed no purple coloring [indicative of a chemical reaction]. An observation on [DATE] at 12:29 PM, of the Sink Sanitizing Log, revealed the sink and sanitation bucket were last changed at 9:30 AM that morning. During an interview on [DATE] at 12:41 PM, DP #1 stated the sanitation bucket needed to be changed every 2 hours and that it was not done since 9:30 AM. During at interview on [DATE] at 12:08 PM, DP #1 stated non expired Chlorine Testing Strips were obtained and put into use. Review of the facility policy Sanitation & Safety-Appropriate Food and Equipment Handling, revised [DATE], revealed Sanitation- . The dietary manager is responsible for supervising all sanitation and housekeeping procedures within the dietary department. The dietary manager develops a cleaning schedule and is responsible for seeing that it is followed satisfactorily . Review of facility policy Food Services Work Responsibilities, revised [DATE], revealed Procedure- . Follow the cleaning schedule and accomplish the task(s) assigned . Change sanitizing solution bucket every 2 hours or as needed. Check with a test strip and document . Labeling of items in the walk-in refrigerator and walk-in freezer An observation on [DATE] at 4:30 PM revealed: Sour Cream 24 oz, opened and undated Extra Heavy Mayonnaise 1 gallon, opened and undated Most open items revealed only use by dates, no open dates and no expiration dates. Hash browns quantity 10, in plastic bag with zip tie, undated Hot dogs quantity 14, in a zip lock bag, use by date of [DATE], had built up ice all around the hot dogs Saranwrap bundle of dozens of meat chunks with an illegible date Tray of three individually wrapped ham steaks, undated Large storage container of individually zip locked bags of black cod that was donated from Fish and Game, no use by date During an interview and concurrent observation on [DATE] at 4:40 PM, DP #2 stated items should be properly labeled and that leftovers were not kept longer than 3 days. DP #2 removed the sour cream, mayonnaise, hash browns and hot dogs. During an interview on [DATE] at 12:08 PM DP #1 stated a use by date was researched and put on the black cod in the walk-in freezer. Review on [DATE] of the Food Code 2017 Recommendations of the United States Public Health Service Food and Drug Administration, accessed from https://www.fda.gov/media/ 2/download revealed, S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Pf commercially processed food o open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf Dry Storage An observation on [DATE] at 4:30 PM of the dry storage goods, revealed multiple large, canned goods as well as large plastic containers with no labeled expiration dates and only codes. During an interview on [DATE] at 4:35 PM, DP #2 was not able to provide exact expiration dates of these items and would further investigate these dates. DP #2 further stated that when new items arrived a taped marking of the received date was placed in front of those items. During an interview on [DATE] at 12:41 PM, DP #1 also stated the same as above for the process of rotating dry goods. DP #1 followed up with this writer on [DATE] at 12:08 PM, stating he/she was in contact with US Foods trying to get the expiration dates of all those items in the dry storage area. By end of this survey those dates were not provided. Review of facility policy Storage and Receiving Food Items, revised [DATE], revealed Procedure- . The stock is rotated on a first in, first out (FIFO) basis. The FIFO system will be used every time stocking occurs. Food items already stored will be moved forward and the new items will be placed behind the already stored foods. All foods being moved in the FIFO manner will be checked for expiration dates. Expired foods will be discarded . All food items in refrigerators are properly dated, labeled, and placed in containers with lids, or are loosely wrapped. All frozen food is dated, labeled, and wrapped. Moisture-proof, tight-fitting materials are used to prevent freezer burn . Review of policy Use of Traditional Game Foods in Public Facilities, revised [DATE] revealed Handling- . The food will be labeled with type of food and Use By date . Temperatures of prepared foods An observation on [DATE] at 11:35 AM, of the plating of lunch revealed a menu of orange chicken, fluffy rice, and Asian vegetable mix. DP #1 took temperatures of the orange chicken but not the vegetables or rice. An observation on [DATE] at 11:59 AM, revealed lunch had arrived on the Long-Term Care (LTC) Unit. CNA #1 then went around to all the residents in the dining room and washed their hands with warm washcloths. No temperatures of food items were taken before being served. During an interview on [DATE] at 12:41 PM, DP #1 confirmed that temperatures were not taken of the vegetables or rice. DP #1 further stated the process was to temp just the meats and that everything else went into the warmer. When asked about a log to document temperatures it revealed only the meat temperature documented. During an interview on [DATE] at 8:30 AM, the Director of Nursing stated breakfast used to be buffet style on the LTC in which staff took temperatures of the food items, but this had been changed months ago giving that responsibility back to the kitchen as far as food items being tempted. Review of the facility policy Infection Control in Food Preparation, revised [DATE], revealed Procedure- All food is cooked to the standard temperature of required internal temperature . Adequate thermometers are available to check the internal temperature of food items . All food is served as soon after preparation as possible. Hot foods are held at 140 degrees F. Or above; cold foods, at 45 degrees. Or below. Food is not held at room temperature .

Based on record review, observation, and interview, the facility failed to provide respect and dignity during dining for 1 resident (#5), out of 4 residents observed while eating in the dining room. Specifically, the facility failed to provide the resident with a small plate for a baked potato during dinner, rather than placing it directly on the table. This failed practice placed the resident at risk of not receiving care that promotes dignity, respect, and quality of life. Findings: Record review on 9/24-28/22 revealed Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 9/24/22 at 5:09 PM, revealed Resident #5 was eating dinner in the dining room. Resident #5 had steak, carrots, baked potato, pears, and a cup of coffee. Further observation revealed, a whole piece of steak and pieces of carrots were served on a small plate. The carrots filled half of the plate up to the rim of the plate. The baked potato was open resting on the foil it was cooked in directly on the table. Half of the potato was cut into big chunks. The Resident was observed cutting the potato into smaller pieces and ate one piece at a time. The Resident was also observed cutting the steak on a small plate. Further observation revealed there was not enough space on the plate for the resident to work on the steak. CNA #1 approached the resident and asked if Resident #5 needed help to cut the steak in which the Resident agreed. During an interview on 9/24/22 at 5:33 PM, when asked the reason Resident #5's baked potato was on the table, CNA #1 stated the kitchen staff delivered dinner on a tray. CNA #1 showed the sample of trays inside the cart. CNA #1 described that the food was on a small plate with a cover and that the baked potato was wrapped in foil placed on the tray but not on a plate. When asked if the dinner plate was too small to hold the food, CNA #1 stated yes. Record review of Resident #5's Care Plan, dated 7/6/22, revealed: Focus: [Resident #5] has an ADL self-care performance deficit . weakness, needing assistance in all ADLS r/t [related to] Dementia, Left Wrist OA[[CONDITION(S)]]. Goal: [Resident #5] will maintain current level of function and participation with . ADLs on a daily basis through review date (supervision with eating .). Intervention: [Resident #5 requires staff to setup . meal and cut .food into small bites.[Res] is able to feed .himself/herself with staff supervision/encouragement . Further review of the care plan interventions on nutritional problem, dated 8/1/22, revealed: .[Res] will be provided diet as ordered . w/ food cut up by Nursing . small portions for . dinner on a small plate. During an interview on 9/27/22 at 2:05 PM, Dietary Personnel #4 stated the baked potato was wrapped in foil and placed on the tray. The baked potato was delivered to the dining room without a plate. During an interview on 9/27/22 at 2:07 PM, CNA #4 stated the baked potato was wrapped in foil when delivered to the dining room. CNA #4 added that the CNAs should have gotten a plate from the Long-Term Care (LTC) kitchenette [small kitchen in the dining room], removed the foil, placed the baked potato on a plate, and then cut the potato into pieces so that it was ready to eat. During a joint interview with the LTC Director of Nursing (DON) and Chief Nursing Officer (CNO)/Quality Improvement Nurse ([NAME]) on 9/28/22 at 8:45 AM, when asked if a baked potato should have been served in foil on the table. [NAME] stated it depends on the resident's preference or choice, but a plate should have been offered. Review of the admission packet on 9/28/22 at 9:30 AM, revealed the facility had .adopted the following statement of patient rights .to be treated with respect, dignity and recognition .of individuality and personal needs, and sensitivity to .psychosocial needs .

Based on record review, interviews, and observation the facility failed to identify and implement safety interventions to prevent thermal injuries from hot liquids for 1 sampled resident (Resident #5) out of 1 observed having hot coffee. This failed practice placed 8 residents, out of census of 10, at risk for burn injury. Findings: Record review on 9/24/22-9/28/22 revealed Resident #5 was admitted to the facility with diagnoses that included dementia (impairment of brain function), dysphagia (difficulty swallowing), and age-related physical debility. Review of the MDS quarterly assessment (Minimum Data Set- a federally required nursing assessment) dated 6/25/22, revealed: Section G. Functional Status, ADL [activities of daily living] Assistance H. EATING 1- Supervision- oversight, encouragement or cuing 1- setup help only. Review of Resident #5's Care Plan, revised on 7/6/22, revealed [Resident #5 (R5)] requires staff to setup [R5's] meal and cut [R5's] food into small bites. [Resident #5] is able to feed self with staff supervision/encouragement. Staff will remind [R5] to sit up straight, tuck [R5's] chin, and keep [R5's] feet on the footrests when eating. Distractions will be kept to a minimum or removed. Review of Resident #5's Physician/Dietary Orders, revised 7/30/21, revealed Regular diet, Regular texture, Regular consistency. During an interview on 9/25/22 at 10:05 AM, Certified Nursing Assistant (CNA) #3 stated that the temperature of the coffee did not need to be checked as it came from the kitchen downstairs, and they made sure all the temperatures were good. CNA #3 further stated that if food and drinks were microwaved on the Long-Term Care (LTC) unit, the CNAs would then take the temperature before serving the item. During an interview on 9/25/22 at 1:50 PM, CNA #1 stated that he/she did not ever heat up coffee in the microwave and that a new cup of coffee was just ordered from the kitchen. CNA #1 further stated that if food and drinks were microwaved, he/she would take the temperature of the item before serving to the resident. An observation on 9/27/22 at 3:40 PM, revealed Resident #5 sitting in the activity room working on a puzzle with a cup of coffee on the table that visibly had steam rising from the cup. During an interview and concurrent observation on 9/28/22 at 8:16 AM, CNA #4 was asked the process of how coffee was made and served. CNA #4 stated that it was made in the coffee pot of the kitchenette on the LTC unit. When asked to prepare a cup of black coffee for this surveyor as if he/she were a resident, CNA #4 poured a cup from the pot and handed it to this surveyor. When asked to get a temperature of the coffee, CNA #4 could not find a facility thermometer in the kitchenette and had to have the kitchen staff send one up. After a new cup of coffee was poured and handed to this surveyor, CNA #4 took a temperature that revealed 169 degrees Fahrenheit. When asked if the coffee would be served like that to a resident, CNA #4 said no and that CNAs would use their best judgement before serving hot items. During an interview on 9/28/22 at 8:30 AM, the Director of Nursing (DON) stated the facility did not have a policy for hot liquid preparation and that the temperature of hot drinks made on the unit were not taken before being served. The DON further stated that the facility had not had any issues from hot drinks but could see how that could be an issue. According to the American Burn Association, accessed at www.ameriburn.org, revealed Thinner skin of older adults burn faster and deeper. Preventing a burn injury is always better than the pain and trauma of medical treatment afterward.

Based on record review and interview, the facility failed to establish an infection prevention and control program (IPCP) that includes an Antibiotic Stewardship Program (ASP) for the Long-Term Care (LTC) Unit. Specifically, the facility failed to have its own long-term care-based ASP. This failed practice had the potential to place all residents, based on a census of 10, at risk of adverse events, including the development of antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use. Findings: Record review of the facility's Antibiotic Stewardship Program, dated 11/11/18, revealed: .Policy: The CDC reports 20-50% of antibiotics in acute care hospitals are either unnecessary, appropriate, or used for too long. This policy is designed to help prevent avoidable side effects and complications arising from antibiotic overuse .prevent growing antibiotic resistance. Member: Medical Director (MD) will serve as Head .make a report quarterly to the Infection Control Committee, QA (Quality Assurance) committee and CEO (Chief Executive Officer) on hospital antibiotic usage .The Pharmacist will review all hospital antibiotic prescriptions .Lab Director .report the results of all hospital cultures and resistance patterns to the MD . Further review of the same document revealed: Requirements: Meet quarterly as part of the Infection Control Committee meeting to assess hospital antibiotic usage data and progress of process improvement develop, implement, and review the progress of the current action plans for improving hospital antibiotic usage. During a joint interview with Chief Nursing Officer (CNO)/Quality Improvement Nurse/ Acting Infection Preventionist and LTC Director of Nursing (DON) on 9/27/22 at 12:59 PM, when the surveyor verified a copy of the antibiotic stewardship program was hospital-based and asked if the facility had a LTC-based antibiotic stewardship program, the CNO stated No.

Based on record review, observation, and interview the facility failed to ensure safe liquid consumption for 1 (#2) resident out of a sample of 3 residents. Specifically, facility staff failed to implement the physician's order for thickened liquids after the facility had determined the resident was at risk for aspiration (entry of material into the lungs via the windpipe). This failed practice placed the resident at risk for injury or harm from choking and aspiration pneumonia, which can lead to death. This situation constituted an immediate jeopardy and was brought to the attention of the facility's administration on 3/24/14 at 6:35 pm. The immediate jeopardy was abated onsite. Findings: Based on record review, observation, and interview the facility failed to: 1) ensure manufactures guidelines were followed for the use of a feeding cup for 1 resident (#2) out of 3 sampled residents; 2) ensure equipment was stored/maintained in a manner to prevent accidental injury; 3) ensure 1 resident (#4) was smoking safely as identified in assessment and care plan, In addition, the facility failed to ensure the resident had received education about the safe use of the smoking area; and 4) ensure the facility doors were alarmed to notify staff of people entering or exiting the facility at night. These failed practices placed all residents at risk for harm from injury. Findings: Thickened Liquids Record review on 3/24-27/14 revealed Resident #2 had [DIAGNOSES REDACTED]. Review of the March 2014 physician's orders revealed "Consistency [DATE]: Pureed, Add thick-it to all liquids to nectar consistency." Review of the "Nurse Aide's Information Sheet", undated, revealed "Thickened Liquids Type Honey-Thick." Thick-It is a cornstarch based thickening agent used to thicken hot or cold liquids from nectar to pudding consistency. Thickened liquids are used for people with swallowing disorders; the thicker liquid reduces the risk of aspiration during consumption. Review of the most recent Minimum Data Set (MDS) quarterly assessment, dated 1/8/14, revealed the Resident had signs and symptoms of a swallowing disorder as indicated by "Loss of liquids/solids from mouth when eating or drinking", "Holding food in mouth cheeks or residual food in mouth after meals", and "Coughing or choking during meals or when swallowing medications." Observation on 3/24/14 at 5:30 pm revealed Certified Nurse's Assistant (CNA) #1 assisting Resident #2 with her evening meal. After rinsing out the feeder cup used to give the Resident her pureed meal, the CNA poured the milk provided on the meal tray directly into the feeder cup, and without adding the thickener, positioned the nozzle into the Resident's mouth and pressed down on the plunger, squirting the milk into the Resident's mouth. The Resident began to cough and a trickle of milk ran out of her mouth. During an interview, on 3/24/14 at 5:32 pm, when asked what consistency the liquids were supposed to be, CNA #1 replied, "The kitchen sends the food pureed and thickened." Review of the dietary card provided on the Resident's meal tray revealed there was no information about the thickened liquids. At 5:35 pm, the surveyor intervened and immediately informed Licensed nurse (LN) #3 that staff used the feeder cup to feed Resident #1 unthickened liquids. The LN confirmed Resident #1 required thickened liquids. LN #1 went directly to the dining room and provided education to the staff regarding the need for thickened liquids. This situation constituted immediate jeopardy with risk for aspiration. The surveyor informed the facility administration of the immediate jeopardy at 6:35 pm. During an interview on 3/24/14 at 6:00 pm, when asked what instructions the CNAs received about thickening fluids, LN #2 replied it would just be ordered and in the Resident's care plan. During the interview, the LN confirmed the facility did not have a policy on thickened liquids. During an interview on 3/25/14 at 1:20 pm, the Dietary Manager confirmed the kitchen staff do not ever add thickening to a Resident's food, it would be up to the nursing staff to add the thickener to obtain the ordered consistency. Feeding Cup Record review on 3/24-27/14 revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the "Nurse Aide's Information Sheet", undated, revealed under meals, the box "feeder" marked with "*asp (aspiration) prec (Precautions)*" written in. Review of the "Daily Care Plan" for Resident #2, revealed "Aspiration Risk...Dietary Pureed diet-Regular foods. Total assist with feeder cup. Needs cues to chew or take a bite. Use thicket (Thick-it) to thicken liquids. Spits food out she has had enough to eat." Observations on 3/24/14 at 2:00 pm, CNA #2 was observed assisting Resident #2 with lunch. During the observation, the CNA spooned the pureed food into a feeder cup with a flexible feeding nozzle on the side of the cup and a plunger on the top, used to force the food through the nozzle. During the meal, the CNA would intermittently press the plunger forcing the food through the nozzle into the Resident's mouth and stated, "Swallow" and asked, "Did you swallow?" The CNA occasionally pulled up on the plunger, allowing air to get into food. Occasionally, the Resident was still chewing the last bite when the CNA placed the nozzle back onto the Resident's mouth and delivered more food. The CNA fed the Resident the pureed meal that consisted of a Stromboli sandwich, soup, and strawberries and cream in 25 minutes. During an interview on 3/24/14 at 2:05 pm, when asked how they know how much food the Resident was receiving at one time the CNA replied the Resident was supposed to get about 10 cc at a time. When asked about the training using the feeder cup the CNA replied they had been using it a long time and that she would show whoever was working during the day, the travel CNAs how to use the device. The CNA confirmed there were no written instructions on how to use the feeder cup. Observation on 3/24/14 from 5:00 pm revealed CNA #1 using the feeder cup to feed the Resident her evening meal. After placing the feeding nozzle into the Resident's mouth, the CNA would press on the plunger to deliver the pureed meal into the Residents mouth. During the meal, the Resident chewed continuously to keep up with the amount of food being delivered. The CNA fed the Resident pureed soup, quiche, and pie in 20 minutes. During an interview on 3/24/14 at 5:20 pm, when asked what training the staff had received to use the feeder, CNA #1 replied, "We just give her a little bit so we won't choke (the Resident). " During an observation of the morning meal on 3/26/14 at 8:28 am, CNA #5 was observed using the feeder cup to give Resident #2 her morning meal. During the observation the CNA placed the nozzle into the Resident's mouth and delivered the food by pressing on the plunger while stating, "Here's your food" and "Did you swallow?" The Resident grimaced while being fed. When the CNA attempted to force some prune juice into the Resident's mouth, the Resident pulled away, at which the CNA exclaimed "Is that sour?" In addition "too sour" while continuing to press on the plunger and force the prune juice into the Resident's mouth. The Director of Nursing (DON) entered the room with medications crushed in a medication cup and mixed the contents with some of the Resident's food and thick-it. When the DON attempted to give the Resident the medications, Resident #2 pushed the DON away, exclaiming "ouch!" The Resident continued to grimace while receiving the medications. The DON then attempted to get the Resident to drink 30 ml of a green liquid medication. The Resident began to cough, grimaced, stated "No!", and pushed the DON away. When the CNA continued to feed the Resident with the feeder cup the DON asked the CNA "What are you going to watch for signs of swallowing?" The CNA responded, "Coughing, face get red" and continued to push on the plunger to force the food through the nozzle into the Resident's mouth. The Don then stated, "So just little bites." The Resident continued to grimace, pushed staff away, and refused to open her mouth. The DON fed the Resident the remainder of her meal using a spoon. Review of the Resident's Comprehensive Care Plan, updated 3/12/14, revealed "Offer food slowly and allow her to swallow" and Patiently attempt to feed (Resident #2) with a spoon." During an interview on 3/25/14 at 12:59 pm, when asked for information about the feeder cups, the Occupational Therapist confirmed it was the same device as the "Ableware People Feeder" in his catalog. Review of the manufactures instructions for the People Feeder, provided by the facility on 3/27/14 revealed "Feed the person by squeezing the food out of the nozzle into the mouth" and "Do not feed only by pushing the piston (plunger) down." During the meal observations on 3/24-27/14, the facility staff did not attempt to use a spoon first nor did they squeeze the nozzle of the Feeder to deliver the food into the Resident's mouth. Hazardous Equipment Resident #1 Record review of 3/24-27/14 revealed Resident #1 had [DIAGNOSES REDACTED]. "Comprehensive Care Plan...Problem 6: Safety - at risk for falls Related to: Fall history, cognitive impairment, gait and balance, non compliance with safety needs...Check the environment for fall risk factors and institute corrective action. Hot coffee burner and sharp blades Random observations on 3/24-27/14 of the kitchenette located off the residents' dining room revealed a coffee pot on a burner ring. The burner was very hot to the touch, and the Surveyor was only able to place their hand there for a second. This area was open and accessible to residents. Random observations in the kitchenette on 3/24/14 revealed a blender blade with 4 sharp blades drying on the counter. Random observations on 3/24-27/14 Resident #1 was unaccompanied in a wheelchair and had self-propelled towards the area. Foot pedals on the floor Observations in the activity room on 3/24/14 at 12:40 pm, revealed 2 wheelchair foot pedals on the floor at the end of the couch creating a potential tripping hazard for all Residents and staff. Nourishment room Random observations throughout the survey on 3/24-27/14 revealed a small kitchen area with the sign "Nourishment Room" The door to the room was unlocked and propped open. Two "Ferno" electric burners were located inside the room. Resident #8 was frequently observed in the room getting ice from the icemaker located in the room. During an interview on 3/26/14 at 7:20 am, when asked about the unlocked "nourishment room", LN #4 confirmed Resident #4 and Resident #8 used the room to get ice. When asked about the stove burners, the LN replied the burners were not functional. During the interview, the Surveyor turned the burners on to show they were functional and heated up. Smoking Record review on 3/26-27/14 revealed Resident #4 had [DIAGNOSES REDACTED]. Observation of the smoking area on 3/27/14 at 8:10 am revealed it was located in the active ambulance bay with wet tire marks on the floor in close proximity to the smoking chair. Cords and chains were attached to the ambulance bay door, which moved when the door opening. During an interview on 3/26/14 at 10:10 am, LN #2 confirmed Resident #4 went to the smoking area, located inside the ambulance bay, to smoke without any assistance from staff. The LN also confirmed the smoking assessment identified the resident needed "minimal assistance." During an interview on 3/26/14 at 10:15 am, Resident #4 confirmed he went to the ambulance bay to smoke independently and did not notify the staff when he was going to the smoking area. The Resident confirmed he kept his cigarettes and lighter in his pocket. During an interview on 3/27/14 at 8:10 am, when asked about the risk of the Resident being in the ambulance bay when an ambulance came in, LN #1 confirmed it had happened but stated it was a rare event. During the interview, the LN confirmed the Resident smoked independently. Review of Resident #4's record revealed there was no information the Resident had been educated about the danger of smoking in a active ambulance bay. Record review of Resident #4's "Resident Smoking Assessment", dated 4/3/13, revealed "The resident must be able to perform all of the physical tasks assessed to be permitted to smoke with supervision...Minimal Assistance: Resident exhibits physical ability to smoke with minimal assistance as evidenced by the evaluation of motor skills..." Review of the Resident's "Comprehensive Care Plan", dated 3/6/14, revealed, "(Resident #4) will be assessed using the 'Resident Smoking Assessment 'initially then yearly or after a change of status. The last assessment was done April 2013... (Resident #4) will exhibit physical ability to light a cigarette, smoke a cigarette...with minimal assistance..." Review of the facility policy "Smoking for Long Term Care Residents", dated 6/28/2012, revealed "...3. A safe-smoking assessment will be completed by nursing staff before resident will be able to smoke independently. 4. A smoking assessment will be completed at admission, with each periodic assessment and with any significant change..." Exit Door Alarms Observation on 3/26/14 from 5-7 am revealed lights located on the Simplex 2001 board located above the nurse's station were all simultaneously flashing. During an interview on 3/26/14 at 6:05 am, when asked about the flashing lights LN #s 4 and 5 replied it meant the multiple exterior door alarms were engaged so staff would be alerted when someone entered or exited the building at night. LN #4 switched the light identified as "Kennel" so it was a solid green and stated that identified the "Kennel" door was not alarmed. Both LNs confirmed not all exit doors were in line of sight of the nurse's station and without the door alarms Residents or community members could enter or leave the facility unannounced. During an observation on 3/26/14 at 6:05 am, after the confirmation by staff that opening the exit door identified as the "Kennel" would not set off the alarm, the surveyor opened the door. The exit door alarm sounded. During an interview on 3/27/14 at 11:30 am, when asked about the flashing lights on the Simplex 2001 board at the nurse's station, the Maintenance Manager replied if the lights were flashing, the door alarms were on bypass, which meant the staff would not be notified if someone exited or entered the building by that door. The Maintenance Manager demonstrated the lights would be solid colored if the door alarms were engaged. .

Based on record review and interview the facility failed to ensure residents were protected from mistreatment and abuse and failed to put interventions in place to prevent further incidents of abuse by 1 resident (#3) who had 14 documented incidents of sexually inappropriate behavior and/or sexual abuse. Findings: Resident #3 Record review on 6/13-16/11 revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as having short and long term memory problems, and was moderately impaired in cognitive skills for daily decision making ("decisions poor; cues/supervision required"). Further review revealed the Resident was not coded as exhibiting physical behavioral symptoms directed towards others ("grabbing, abusing others sexually"). Review of Nurse's Notes revealed the following: 2/27/11 at 4:30 am, "sexually inappropriate"; 3/4/11 at 4:00 am, was "sexually aggressive even (after) his scheduled [MEDICATION NAME] (antianxiety medication) and prn (as needed) [MEDICATION NAME]"; 3/8/11 at 5:40 pm, "a female Res (resident) told a CNA that as (Resident name) passed by her in the hallway he... pinched her nipple"; 3/19/11 at 8 pm, "sexually inappropriate (with) another resident, (grabbed her breast), witnessed by RN"; 3/23/11 at 8:15 am, "staff notified RN that she observed (Resident name) grabbing another female Res while he thought he was unsupervised"; 3/26/11 at 4 pm, "sexual aggression toward other residents"; 3/27/11 at 3 am, "continued to have sexual aggression toward female peers on the unit"; 3/29/11 at 3:40 am, "(Resident name) also continues to prey on female peers with inappropriate sexual advances & he requires supervision when (with) female peers"; 4/5/11 at 12:15 am, "he's had 3 episodes of exposing himself to staff & other (residents) and I also witnessed him trying to grope another resident"; 4/12/11 at 8:30 pm, "Grabbed (another Resident's) crotch 2-3 times"; and 4/26/11 at 4:30 am, "sexually inappropriate". Review of the Long-Term Care Bimonthly Exam, dated 4/5/11, revealed, "(Resident name) is a patient with severe dementia whose agitation, sexually inappropriate behavior and profanity outbursts have been increasing since January 2011." On 6/15/11 at 12:55 pm, the Director of Nursing provided the facility's Incident and Accident reports for 2011. Although nurses documented multiple reportable incidents involving Resident #3's sexual advances towards female residents, none were included in the Incident and Accident reports. Review of the State incident log revealed the facility had not reported any of these instances to the State Agency. Review of the current care plan, dated 4/14/11, revealed no problem, goal, or interventions documented for Resident #3's inappropriate sexual behavior. In addition, no interventions were identified for keeping Resident #3 away from female residents. Review of Family/Resident Care Conference Summary, dated 5/12/11, revealed no documentation that Resident #3's behavior was discussed. "Continue with the current plan of care" was recommended. During an interview on 6/15/11 at 9:20 am, the Director of Nursing (DON) stated, "Nurses are not updating care plans as they should be" and that was the reason the care plans were not being updated with resident's behavior. The Director of Nursing and the Nurse Manager stated that for the last 6 months or more the Resident's inappropriate behaviors had decreased, and that they did not think his sexual behavior was an issue. .

Based on interview and record review the facility failed to ensure resident-to-resident incidences of sexual abuse were reported to the State Agency within 24 hours and failed to conduct a thorough investigation and report the findings to the State Agency within 5 working days for 1 resident (#3) out of 7 sampled residents. Failure to thoroughly investigate and report incidents creates the potential for unchecked abuse or neglect. This placed residents at risk for physical and psychological harm. Findings: Resident #3 Record review on 6/13-16/11 revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as having short and long term memory problems, and was moderately impaired in cognitive skills for daily decision making ("decisions poor; cues/supervision required"). Further review revealed the Resident was not coded as exhibiting physical behavioral symptoms directed towards others ("grabbing, abusing others sexually"). Review of Nurse's Notes revealed 14 documented incidents that included sexually inappropriate behavior, sexual aggression, and sexual abuse. (Refer to F223) On 6/15/11 at 12:55 pm, the Director of Nursing provided the facility's Incident and Accident reports for 2011. Although nurses documented multiple reportable incidents involving Resident #3's sexual advances towards female residents, none were included in the Incident and Accident reports. Review of the State incident log revealed the facility had not reported any of these instances to the State Agency. During an interview with the Director of Nursing and the Nurse Manager on 6/15/11 at 9:20 am, they stated that for the last 6 months or more the Resident's inappropriate behaviors had decreased, and that they did not think his sexual behavior was an issue. Review of the facility policy "Long Term Care Resident Abuse", most recent review dated 6/4/11, revealed it included "Mandated to Report: Any employee of CCMC (Cordova Community Medical Center) who has knowledge of the abuse or neglect of a resident, has reasonable cause that a resident is being or has been abused or neglected ..." Review of the facility policy "Facility Reporting Requirements", dated June 19, 2008, revealed it included, "How to report: a. Complete the 'Initial report of Alleged Mistreatment, Abuse, or Neglect of a Resident' within 24 hours. b. Fax the completed report to the State Agency at [PHONE NUMBER]. This fax number is available 24 hrs/day, 7 days/week." .

Based on record review and interview, the facility failed to review, revise and implement adequate care plan interventions that addressed one Resident's (#5's) known verbalizations of wanting to die and attempts at suicide. Failure to revise and implement care plan approaches for depression and suicidal ideation resulted in actual harm to the resident. Findings: Review on 6/15-16/11 revealed the Resident had 3 previous attempts of suicide and 2 attempts of self mutilation between 7/09-12/10. Record review on 6/15-16/11 revealed the Resident was readmitted to the facility on [DATE] after a brief stay in a hospital for psychiatric care. His [DIAGNOSES REDACTED]. The Resident was taking [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (anti-depression medication) and Ativian (anti-anxiety medication). Further record review revealed the Resident's self destructive behaviors were preceded by verbalizations of wanting to die, thoughts that he was going to die and unstable mood swings. Review of nursing progress notes from 3/1/11-4/15/11 revealed: 3/17/11 at 2 pm the Resident told a nurse "My throat is closing off, this is how I am going to die tomorrow." A short time later the nurse documented, "pt is requesting (name) presence for his last rites"; 3/22/11 at 11:35 pm "(Name) was notified tonight of (Resident name's) desire to have him visit and he has agreed to visit (Resident name) in the am. (Resident name) has verbalized his feelings of 'disappointing God (with) past deeds he has done'. He also states he feels very close to death and thinks he will die soon. (Name omitted) seems to be in spiritual distress tonight, seeking spiritual assistance and comfort, regarding his illness as punishment for his past life, 'Don't mess with God'"; 3/23/11 at 10:40 pm, "somber mood ...low speech, very apologetic for unknown reason"; 3/29/11 at 4 am, "(Name omitted) had high anxiety level at change of shift, (stated) 'I can't swallow, I'm going to die tonight, call the doctor in right now. Nurse offered [MEDICATION NAME] for the Resident's throat concerns and the Resident refused by stating, 'I'm going to die'"; 3/30/11 at 5 pm, "Resident has been very up and down today, very demanding of the staff and then apologetic quickly afterwards"; 3/31/11, between 12:45-1:05 pm, the nurse documented the Resident made multiple statements that people were following him. "Why are you always watching me...Why are the monks following me ...Why am I being followed"; 4/3/11 "(Resident name) labile mood fluctuating from cheerfully walking laps greeting everyone he passes to soft spoken 'good-byes' because he won't be alive much longer"; 4/4/11 at 3:30 pm the nurse documented "...soft spoken voice barely audible (and) noted to state...'I'm dying' in a phone conversation to his POA (Power of Attorney)"; 4/4/11 at 5:15 pm the nurse documented the Resident stated, "I'll be dead by morning"; 4/5/11 at 12:05 am, "(Resident name's) behavior this shift has been at times inappropriate (and) bizarre. At start of shift he kept saying 'I'm going home to be with God,' I questioned him about [MEDICAL CONDITION] (and) he denied such a thing (and) stated he was making a 'scrapbook for a friend.' Later in shift I witnessed him moving frantically around his room to the point to where he spilled his ice water (and) dropped all the paper he was shuffling. I assisted him (with) clean up (and) instructed him to calm down. He responded (with) speech so fast I could not understand what he was saying ... His affect is very happy at one moment (and) flat withdrawn (and) sorrowful the next"; 4/6/11 at 12:55 am, "(Resident name) continues to have high (and) low mood swings this HS (evening) shift. He appeared anxious and distraught, rambling his speech, stuttering (and) speaking in whispers (and) talking very rapidly ... (Resident name) states he is fearful of dying tonight"; 4/8/11 at 9:45 am, "Resident not in room or activity rooms. Found to be in Ilanka Clinic after extensive search by the staff. (Resident name) was found in the neighboring medical clinic where he had gone in search of an appt (with) a provider. (Resident name) is currently in (with) (Physician name) at Ilanka Clinic". The Director of Nurses disclosed on 6/16/11 at 9:30 am the Resident had gone over to the clinic to get some help for his depression. 4/8/11 at 11:30 am, "Resident in bed states 'I'm ok, when are they sending me to API (Alaska Psychiatric Institute)?' Resident was reminded that he will remain here (and) he has an appt (with) mental health next week..."; 4/8/11 at 4:30 pm, "Resident up in room asks 'when do I leave for API?' Resident reminded again of his appt next week (with) mental health ..."; 4/8/11 at 7 pm, "(Resident Name) made a verbal contract to come find me or another staff member if he has thought or wants to act on feelings of self harm"; 4/11/11 at 10:02 am, "Bathroom call light sounded, this RN found pt. upright and leaning into the shower stall (with) the call light cord looped (and) snug around his neck, pt. was alert (and) airway was clear. Pt required immediate assist per he was (zero) wt. bearing (with) cord tight around his neck ...assisted to his bed, alert, (slightly) pale in coloring (and) (slight) tremulous bodily"; 4/11/11 at 11:25 am, "reddened around neck where string was wrapped around. Talked (with) pt. (and) he stated 'I don't deserve to live'; 4/11/11 at 12 noon, "RN informed aides to stay (with) pt even in BR (bathroom) an aide allowed him into the BR by himself without her presence"; 4/12/11 at 8:30 am nurse documented Resident "makes reference to 'not coming back so you won't have to look at me'"; 4/12/11 at 11 am, "(Resident Name) at nurses station in recliner states 'If anything happens to me make sure they bury me at sea'"; 4/12/11 at 7:30 pm, "CNA (certified nursing assistant) reported (Resident Name) had hid his bottle of Old Spice in his pants, had gone into the bathroom and attempted to drink his cologne"; and 4/13/11 at 6:55 am, "Pt. awake, escorted to shower. RN went through Res (Resident's) belongings (and) removed razor blade x 3, mouth wash (and) aftershave, objects placed in zip lock bag (and) put in med cart. Old spice cologne open (with) no lid (and) spilled RN threw away." Review of the care plan in place during the 3/17/11 - 4/13/11 episode of care revealed, "risk for self-directed violence R/T (related to) depression, past attempt at suicide and use of antidepressants." Care plan interventions that were developed on 1/25/11 included: "Assess whether (Resident Name) has considered suicide recently, thought about it or has a plan. Observe carefully for behavior indicative of suicide and remove dangerous items that could be used to injure (Resident Name)." The facility did not check the Resident's room for potentially dangerous items that could be used to injure him. Even after the Resident attempted to harm himself, the facility failed to search for and remove hazardous items until after he attempted to harm himself a second time. Review on 6/15/11 of physician progress notes [REDACTED]. The facility did not have a social worker available to provide the Resident consultation regarding his recent comments about death and dying.The social worker only came to the facility every 3 months. The last time the Social Worker had seen the Resident was in 2/4/11. Updates to the 1/25/11 care plan during the 3/17/11 - 4/13/11 care episode revealed the following: On 3/27/11, "See behavior monitoring form, note all dose of [MEDICATION NAME]"; On 3/28/11, "See notes per care conferences today, he needs an escort out of facility and to lunch downstairs. Please refer nurses' notes in pt. chart. Pt. noted (increase) in freezing episodes (with) pt. (PT, Physical Therapy) staff is rounding on pt. frequently to offer pt. assistance, cont NCP (nursing care plan). Assure of his safety"; and On 4/7/11 "[MEDICATION NAME] (and) [MEDICATION NAME] increased r/t increased thoughts of self harm as reported by (Dr. Name)." The updated care plan did not reflect the physician's orders [REDACTED]. is all the time, voices thoughts of self-harm." In addition, the updated care plan also did not reflect the physician's orders [REDACTED]. During an interview with RN #8 on 6/13/11 from 2:30-2:36 pm, she confirmed she had found Resident #5 attempting to hang himself in the bathroom on 4/11/11. She disclosed she was surprised the Resident attempted to hang himself, that she thought he had been better for months and thought he was kind of "evening out". She said that at the time she hadn't been told there had been any recent issues.When asked where she would look for any changes in behaviors she said she usually got that information in report. During interviews with the DON (Director of Nurses) and the Nursing Supervisor on 6/16/11 at 9:30 am, they confirmed the staff at the facility were well aware of the Resident's past history of attempted self-harm. The Surveyor asked how the staff had been trained to recognize when Resident #5 was having an increase in his desire to attempt self-harm. The DON said after the last State Agency complaint investigation they had trained staff on how to recognize depression and suicide ideation. When the Surveyor asked to see the training syllabus, the DON provided a pamphlet titled "Depression & Suicide in Long Term Care", dated 12/17/10. Upon reviewing the training pamphlet the Surveyor asked where the information on suicide was located. The DON reviewed the pamphlet and then said, "I thought the training pamphlet covered how to recognize suicide in the elderly." She then said, "Well maybe we just covered the suicide policy." When the Surveyor asked to see the staff sign-in sheet for the training the DON was unable to locate a staff sign-in sheet. When the Surveyor asked her what would be some signs and symptoms of potential suicide ideation she verbally listed the following: Verbally making statements about wanting to hurt themselves; refusing to eat; refusing to take medications; not sleeping; increase in mood changes from happy to sad; talking about dying or how they deserve to die; and making plans on how they are going to kill themselves. The Surveyor asked the DON if she agreed the Resident had expressed many of the signs of suicide ideation she had just verbalized, she confirmed, "Yes, he did." The Surveyor reviewed the facility's policy "Suicide Awareness and Suicide Precautions", dated 1/24/08, with the DON and asked if the staff instructions to "Check clothing and belongings for safety as often as necessary. Remove those items with which the patient could harm him/herself or others ...Personal belongings, which could be used as objects for self-harm ...(i.e. glass, matches, lighter, razor, belt, pop can with pull-tab, or other sharp objects)" were still to be followed. The DON confirmed staff was to follow the instructions in the policy. The Surveyor then asked why, after Resident #5 attempted to harm himself by wrapping the call light cord around his neck on 4/11/11 and after he tried to harm himself by drinking his cologne on 4/12/11, did the nursing staff wait until 4/13/11 to check the Resident's room for additional hazardous items. The DON did not know why the facility policy was not followed. The DON said "We just dropped the ball" concerning the Resident's safety.

Based on record review and staff interview, the facility failed to ensure injuries of unknown origin were thoroughly investigated and reported to the State survey agency for 1 resident (#1) who had a history of [REDACTED]. Findings: Record review on 11/10/10 revealed Resident #1 was originally admitted to the facility 10/25/07 with [DIAGNOSES REDACTED]. Review of physician progress notes [REDACTED]. The facility did not report the incident to the State agency. The facility could not find documented evidence an initial or final report had been sent to the State agency. Further review revealed from June - September, 2009, the Resident had made comments about wanting to die. Documentation also revealed the Resident had attempted suicide 3 times (See F 309). The Resident was transferred to another hospital and was readmitted on [DATE] to a Cordova Medical Center swing bed. On 2/1/10 the Resident was admitted to the long term care unit. On 2/1/10 at 10:00 pm, the Resident was found on the floor in his room next to his bed. An initial and final investigative report was sent to the State agency. Review of the final report, dated 2/2/10, revealed "...spoke to resident - he does not remember falling, stated he was sleeping. 2-2-10- 1730 nurse stated she found resident on floor next to his bed with a bump and cut noted above left eye". Follow-up actions included: "Will remind resident to use his walker at all times, use call light when needs help, staff will increase bed checks, Keep floor mats next to bed". During the investigation the administrator gave the surveyors copies of the initial and final report as well as pictures of the injury. In addition there was an additional initial report completed by the RN who found the Resident. Documentation in the report included: "pt on floor, laying on R side on his blanket with 3 pillows under his head with 1.5 cm lac (laceration) over L eyebrow. Wire clothes hanger laying beside pt with sm. Blood noted on sharp hook end of hanger...Follow-up actions will include: apply side rail to L side of bed, padded floor mat to both sides of bed, All wire hangers removed from room." The initial and final report sent to the State agency did not include the information about the coat hanger. There was no mention in the report of pictures being taken. Nursing documentation on 2/1/10 at 11 pm revealed there was another RN and 2 CNAs that came into the Resident's room to assist the RN who found the Resident. During an interview on 11/10/10 at 3 pm, with the nurse who sent the initial and final report to the State agency, she was asked why the coat hanger was not mentioned in the report and investigated as possible self-mutilation. She stated that she felt the Resident was using it to retrieve a piece of paper from under his bed. She also confirmed that she had not taken any photos, did not see any photos in the Resident's record, and had not interviewed the 4 witnesses to the incident. As a result, a thorough investigation of an incident involving a Resident with a history of self-mutilation, was not conducted.

Based on record review and interview, the facility failed to review and revise one resident's (#1) care plan to address changes in the resident's mental and emotional status. Interventions for changes in the resident's mental and emotional condition, including suicide attempts, were not included in the resident's care plan. In addition, the facility failed to ensure a comprehensive interdisciplinary care plan was developed based on an admission assessment. Failure to develop a comprehensive care plan and failure to review and revise care plan interventions placed the resident at risk for not receiving the necessary and/or appropriate care and services. Findings: Record review on 11/10/10 revealed Resident #1 was originally admitted to the facility 10/25/07 with [DIAGNOSES REDACTED]. Further record review revealed the following documentation. 6/1/09 Suicidal ideation 6/3/09 Asked to be placed in psych hospital Review of the 4/24/09 care plan revealed entries/updates/revisions were made 6/10; 6/12; 6/17; and 6/26/09. None of the additions addressed the change in the Resident's mental/emotional condition. 7/25/09 Resident thinks he is going to die 8/7/09 Resident stated he wanted to die; tried to choke himself with a phone cord 8/26/09 Suicide attempt - transferred to another hospital 9/3/09 Returned to the facility 9/9/09 Found trying to wrap electrical cord around his neck 9/26/09 Resident stated "I gotta die" 9/28/09 Documentation of a self-mutilation incident; transferred to another hospital Review of documentation on the 9/24/09 "Interdisciplinary Team Progress Report" included "Not suicidal anymore". Review of the 7/1/09 care plan revealed entries for 7/9/09; 9/9/09; and 9/16/09. One of the 9/16/09 entries included documentation of 3 suicide attempts. The care plan did not include any interventions that addressed the Resident's verbalizations of death and attempts of suicide. The Resident was transferred to another hospital and was readmitted on [DATE] to a Cordova Medical Center swing bed. Documentation on the Care Plan Conference Summary, dated 1/21/10 revealed "...Pt. continues to be restless, ambulating constantly and looking for a way out of hospital. Pt. continues to hallucinate ...Pt needs careful looking after, continuously." On 2/1/10 the Resident was admitted to the long term care unit. A comprehensive admission assessment (MDS) was completed on 2/1/10. Review of the Resident Assessment Summary Report revealed the following areas triggered and "Care Plan" was marked: Cognitive Loss/Dementia; Communication/ ADL Functional/Rehabilitation Potential; Psychosocial Well-Being; Mood State; Behavioral Symptoms; and Falls. A comprehensive care plan had not been developed. On 11/10/10 at 3:30 pm the Director of Nursing confirmed a comprehensive care plan had not been completed for the 2/1/10 admission to the long term care unit.

Based on record review and interview the facility failed to implement their written policies and procedures for the protection of resident funds for 1 resident (#1) who had been identified as having impaired decision making skills. Specifically, the facility failed to 1) maintain a separate interest-beating account for resident funds; 2) failed to keep a complete and accurate record of financial transactions; 3) failed to give the resident and/or legal representative a copy of the receipt for monies received; 4) failed to ensure the safe storage of resident funds so that only authorized individuals had access to the funds; and 5) failed to have written authorization to hold resident funds for more than a couple of days. This resulted in misappropriation of resident funds. Findings: Review of the facility's final investigative report, dated 9/9/10, revealed the [AGE] year-old Resident had [DIAGNOSES REDACTED]." Review of the Resident's annual MDS (Minimum Data Set) comprehensive assessment, dated 5/7/10, revealed the Resident was coded as having short and long-term memory problems. Cognitive skills for daily decision making were coded as moderately impaired - decisions poor; cues/supervision required. Review of the assessment summary included: "(Resident name) has dementia and both her long and short term memory is very poor. Her decision making ability is very poor as well." Nursing documentation on 9/7/10 revealed "...(Resident name) quite confused earlier this evening..." The facility's final investigative report was reviewed with the Administrator and the Director of Nursing (DON) on 9/23/10 at 9:25 am. According to the report, Nurse #1 planned to take the Resident on a trip, via ferry, to Wasilla, Alaska. The DON and Administrator confirmed they were unaware of these plans. The DON discovered that Nurse #1 had signed out money out of the Resident's fund for the trip. According to the facility's report, on September 4, 2010 Staff #1 overhead Nurse #1 and the Resident talking about their trip. Staff #1 reported Nurse #1 went to the drug room to get the Resident's money. Nurse #1 counted the money in front of the Resident and Staff #1 and told the Resident she was taking $500 for the ferry ticket. Staff #1 reported the Resident told her she was not sure if she still wanted to go as it cost a lot of money. Nurse #1 took the money home with her on September 4th. On 9/8/10, 4 days later, Nurse #2 brought the Resident's money back and indicated that she was Nurse #1's neighbor and because Nurse #1 had a doctor's appointment that day, she was asked to being the money back for her. During an interview on 9/23/10 at 3:35 pm with the Social Worker she stated Nurse #1 had for some months been talking about taking the Resident on a trip. She stated that in July and August Nurse #1 became a little more serious about the trip. The Social Worker said she called the guardian prior to going on vacation and mentioned that one of the nurses was interested in taking the Resident on a trip; however, no details of the trip were discussed. During a phone interview with the Resident's Guardian on 9/22/10 she stated the Social Worker had called her in August and mentioned that one of the nurses wanted to take the Resident on a trip to Wasilla but said she did not hear anything about the trip after that. Further interview with the Social Worker revealed "before the end of June" the Resident had "about $1,000 here; I counted it." She stated that two staff in administration had voiced concerns about the money being kept in a grey filing cabinet in the administration area. She stated the filing cabinet was not locked during regular hours. She further stated that she thought the money had been in the filing cabinet since December or January. The Social Worker said she and Staff #2 "counted the money together; it was $1,000 or over." She confirmed the money was transferred to the narcotic cabinet in the drug room, where it would be more secure. During an interview on 9/23/10 at 9:25 am with the Administrator and DON, the surveyor asked who authorized the money being put in the narcotics cabinet. The DON stated "It's never been authorized." She stated the Resident's guardian put $20.00 into a savings account for taxes; sent the facility $1004.00 a month, and sent the Resident $55.00 a month. The DON said the Resident had "accumulated approximately $800.00". The Administrator confirmed the money had been transferred to her office about "2 weeks ago". The Administrator stated she was not aware of any account records or policies and procedures that addressed resident accounts. She said they were currently working on policies to address this issue. The Resident's money was kept in a white envelope in the narcotic cabinet in the drug room. Per the Social Worker, approximately $1,000 was in the grey filing cabinet when it was moved to the narcotic cabinet before the end of June. The following was documented on the outside of the envelope: $623.00 - signature of Nurse #3 and the Social Worker. It was not dated. There was no documentation of $1,000 being placed in the cabinet. Therefore, there was $377.00 unaccounted for. 6/28/10 "total = 583; $40 spent on Polygrip" - signature of Nurse #4 and the Activity Aide. 8/2/10 - $773.00 - signature of Nurse #5. There was no accounting for an increase of $190.00 from the last entry. 9/4/10 - "took 512.00 for ferry tickets. 303.00 remaining." Signature of Nurse #1 and Nurse # 2. Balance should have been $261.00 according to last entry. There was no accounting for a difference of $42.00. During an interview on 9/23/10 at 9:25 am with the Administrator, she confirmed the Resident's money should have been in an interest bearing account; receipts should have been given to the Resident or Guardian for monies received; an accurate account of monies should have been maintained; staff should not have had access to the Resident's money; and confirmed there was no written authorization from the Resident or the Guardian to manage the Resident's funds. Review of the facility's "Resident Trust Accounts", effective date 6/10/2004, included "...1. Cordova Community Medical Center maintains a separate interest-bearing checking account for the residents who want their monies to be managed by a Trust Account representative. 2. These funds will not be co-mingled with any other funds. 3. Accurate records will be kept of residents' monies and a statement of financial transactions will be provided within thirty (30) days following the end of the quarter and at any time upon request. 4. A copy of the receipt given to the resident or authorized representative for monies received shall be kept with Trust Account records ...11. Upon resident request, an amount up to $75.00 will be held in the facility safe for immediate resident needs." Review the facility's "Resident Rights" policy and procedure included the following: "...7. The facility must furnish a written description of legal rights which includes 1. A description of the manner of protecting personal funds, under paragraph (c) of the section; ...A. Protection of resident funds. 1. The resident has the right to manage his or her financial affairs, and the facility may not require residents to deposit their personal funds with the facility. 2. Management of personal funds. Upon written authorization of a resident, the facility must hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in paragraphs (c) 93)-(8) of this section. 3. Deposit of funds. i. Funds in excess of $50. The facility must deposit any residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account ...4. Accounting and records. The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf...ii. the individual financial record must be available through quarterly statements and on request to the resident or his or her legal representative..." Review of the "Cordova Community Medical Center Employee Handbook January 2009" revealed "6. Discipline and Dismissal: The following non-inclusive list describes examples of conduct or activities which are unacceptable:...Failure to comply with departmental or Medical Center policies or procedures..." As a result of this deficient practice, the Resident's funds were not maintained in a separate interest-beating account; there were no complete and accurate records of financial transactions; the Resident and/or legal guardian were not given a copy of the receipt for monies received; the Resident's funds were not safely stored and unauthorized individuals had access to the funds; and there was no written authorization to hold resident funds for more than a couple of days.