Every finding on record at Denali Center

.Based on record review and interview, the facility failed to:1) Ensure an alleged violation involving possible neglect and serious bodily injury was reported immediately, but no later than 2 hours, to the State Survey Agency (SSA) for 1 resident (#1), out of 1 resident reviewed for reporting of alleged violations, before any investigation was initiated. Specifically, the facility did not report the unexpected death of Resident #1, who required intermittent supervision and strict aspiration precautions (measures used to reduce the risk of food, liquid, or other material entering the airway or lungs) during meals. Resident #1 was found cyanotic (bluish discoloration caused by insufficient oxygen), unresponsive, and pulseless during the evening meal, and after attempted emergency intervention, was pronounced deceased . The facility did not report this unexpected event at the time, prior to any investigation, as required by Federal regulations.2) Develop and implement an accurate reporting policy for allegations of abuse that aligned with regulatory requirements.This failed practice prevented timely SSA review and created the potential for continued neglect. Findings: Reporting an Alleged ViolationResident #1 Record review from 7/13-21/26 revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), traumatic brain injury (an injury to the brain caused by a violent blow or jolt to the head), aphasia (loss or impairment of the ability to communicate), and left-sided hemiplegia (paralysis of the left side of the body). Review of the Speech-Language Pathologist (SLP) evaluation, dated 2/15/22, revealed Resident #1 required intermittent supervision, optimal upright positioning, cues to follow strict aspiration precautions, and assistance as needed to promote safe oral intake. The evaluation directed staff to provide slow-paced feeding, small bites and sips, swallowing between bites, alternating liquids and solids, and upright positioning for 30 minutes following meals. Further review of the SLP evaluation revealed Resident #1 was evaluated while seated upright in a wheelchair in the common dining area. The SLP documented Resident #1 leaned to one side during the meal and required repositioning. The SLP recommended head-of-bed elevation greater than 45 degrees, with supports and repositioning as needed, for snacks and liquids consumed in the resident's room. The SLP separately recommended upright, supported wheelchair seating during all meals with continued intermittent supervision. Review of physician orders revealed an order, dated 3/8/22: .Intermittent supervision with strict aspiration precautions per speech therapy.Review of Resident #1's care plan revealed interventions for intermittent supervision and strict aspiration precautions, a modified-texture diet (altering the consistency of foods and liquids to make them safer and easier to chew, swallow, and digest, primarily for individuals with dysphagia or other swallowing difficulties), small portions, use of a specialized spoon, and use of a deep-dish plate. The care plan did not include the SLP's recommendations for upright, supported wheelchair seating during meals, positioning supports, repositioning, or a measurable frequency for intermittent supervision. Review of nursing notes, dated 7/6/26, revealed Resident #1 was found in bed, cyanotic, unresponsive, and without a pulse. Staff initiated cardiopulmonary resuscitation (CPR) and notified emergency medical services. Resident #1 was pronounced deceased on 7/6/26 at 6:41 PM. Review of the on-call physician's progress note, dated 7/6/26, revealed Resident #1 was found unresponsive in his/her room, received CPR, and was pronounced deceased . The note did not identify a cause of death or document that choking, aspiration, or a care-related cause had been ruled out. During an interview on 7/15/26 at 1:24 PM, Certified Nursing Assistant (CNA) #1 stated he/she positioned Resident #1 in bed at approximately 45 degrees and set up the resident's dinner tray. CNA #1 stated Resident #1 could not independently reposition himself/herself, if he/she slid or leaned while eating. CNA #1 stated he/she understood Resident #1 was to be checked approximately every 15 minutes while eating. CNA #1 stated he/she left Resident #1 to provide total feeding assistance to another resident and that the feeding generally required approximately 20 minutes. When asked how he/she could complete Resident #1's expected check while feeding the other resident, CNA #1 stated another staff member would have needed to check Resident #1. CNA #1 did not identify a specific communication or handoff assigning that responsibility to another staff member. During an interview on 7/15/26 at 9:02 AM, the Resident Care Coordinator (RCC) stated the SLP's specific positioning recommendations should have been included in Resident #1's care plan and CNA Kardex (a condensed resident-specific care guide used by CNAs to identify assigned care needs, safety precautions, and required interventions). The RCC stated the care plan did not contain specific instructions regarding Resident #1's actual position during meals and acknowledged the care plan probably did not provide staff with sufficient instructions to safely position and supervise the resident. The RCC stated he/she did not know whether the facility had a policy defining intermittent supervision and he/she generally instructed staff that intermittent supervision meant checking a resident every 15 to 30 minutes and using their own judgment. The RCC acknowledged different staff could interpret the supervision requirement differently. Facility's Reporting Neglect Policy Procedures Review of State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care [LTC] Facilities, Rev. 229; Issued 4/25/25, revealed the Code of Federal Regulations (CFR) 483.12(b) and (c) addressed the reporting requirements for LTC facilities when allegations of abuse are reported: - CFR 483.12(b): .The facility must develop and implement written policies and procedures that. - CFR 483.12(c): .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must. - 483.12(c)(1) .Ensure that all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the SSA and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.Further review revealed Alleged violations was defined in the regulation as: a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Record review revealed Resident #1 required intermittent supervision and strict aspiration precautions during meals due to dysphagia and aspiration risk. On 7/6/26, Resident #1 was found cyanotic, unresponsive, and pulseless after the evening meal and was subsequently pronounced deceased . At the time of the event, the cause of death had not been determined, choking or aspiration had not been ruled out, and the circumstances had not been investigated. These facts reasonably indicated possible neglect resulting in serious bodily injury and met the definition of an alleged violation requiring immediate reporting to the SSA before completion of the facility's internal investigation.During an interview on 7/21/26 at 10:00 AM, the Administrator stated the Director of Nursing (DON) was notified of Resident #1's death at approximately 7:00 PM on 7/6/26, and the Administrator was notified at 7:37 PM. The Administrator was out of state at the time and was not present within the facility.The Administrator further stated she was informed Resident #1 had been found unresponsive and pulseless in bed, had been eating supper, and had aspiration precautions. The Administrator stated food or stomach contents came up during CPR and staff filled a suction canister (a container used to collect material removed by suction) while suctioning Resident #1. The Administrator stated Resident #1 had been positioned at approximately 45 degrees and that little food remained on the meal tray. During the same interview, the Administrator stated a nurse manager interviewed staff, reviewed Resident #1's meal ticket, and other care information. The Administrator stated she spoke with the Chief Executive Officer (CEO) and Medical Director and told them she did not believe the incident was reportable. The Administrator stated: I did not at this point think that this was a reportable event, but I didn't have all the information. We were still doing an investigation. When asked what is reportable she further stated: What I would report would be neglect. During an interview on 7/9/26 at 3:00 PM, the Administrator stated she continued to believe the event was not reportable because she had not found neglect, although the investigation remained in progress. On 7/13/26, the Administrator presented findings of no abuse or neglect to the organizational quality committee and advised the committee that a root cause analysis (RCA - a structured process used to identify the underlying causes and contributing factors of an adverse event and develop corrective actions to prevent recurrence) was planned to determine whether additional system or process concerns existed. When asked whether she understood the initial report was required when facts reasonably indicated possible neglect and before any investigation was initiated, the Administrator stated: Yes, I understand that . I had not established that there had been neglect. During the interview, it was explained that the survey team had not determined whether neglect had occurred. Rather, the known circumstances, including the resident's need for aspiration precautions and intermittent supervision during meals, the unexpected death occurring during the meal period, the unknown cause of death, and the fact that aspiration or other care related factors had not been ruled out, reasonably established a possible allegation of neglect resulting in serious bodily injury. Under 42 CFR 483.12(c), these circumstances required immediate reporting to the SSA before completion of the facility's internal investigation to determine whether neglect had occurred.The Administrator stated she believed neglect had been ruled out because staff followed Resident #1's care plan and physician orders. However, the Administrator acknowledged the RCA remained pending and stated, There might be something that comes up in that that changes our mind. Develop and Implement an Accurate PolicyReview of the facility policy, Denali Center Abuse and Neglect, effective 7/7/26, revealed the policy did not accurately reflect the reporting requirements. Although the policy correctly defined an alleged violation, it directed staff to report concerns based upon reasonable cause to believe abuse, neglect, exploitation, or mistreatment had occurred and instructed the Administrator or DON to notify the SSA using reporting timeframes applicable to suspected crimes rather than alleged violations. The policy did not require all alleged violations involving possible abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property to be reported immediately, but no later than two hours, when the event involved abuse or resulted in serious bodily injury, or within 24 hours when serious bodily injury was not involved. As a result, the policy did not provide staff with accurate direction regarding the facility's regulatory reporting obligations.When reporting a crime, the regulation required an employee to have reasonable cause to believe that a crime occurred before reporting the concern internally for investigation and allowed up to 24 hours for the Administrator or the DON to notify the SSA.The facility's policy had no timeline documented to report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were to be reported immediately, but no later than 2 hours after the allegation was made if the event that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

.Based on record review and interview, the facility failed to develop and implement a comprehensive, person-centered care plan for 1 resident (#1), out of 1 resident reviewed, that included measurable objectives and timeframes to meet the resident's needs during meals.Specifically, the facility did not incorporate the Speech-Language Pathologist's (SLP) recommendations during meals to address Resident #1's dysphagia (difficulty swallowing), aspiration risk (when food, liquid, saliva, or other material was inhaled into the lungs), and positioning and supervision needs to include:1. upright, supported wheelchair seating during meals; 2. positioning supports and repositioning during oral intake in the resident's room; 3. safe-swallowing techniques; and 4. clear instructions defining the frequency and responsibility for intermittent supervision. The failed practice of an incomplete care plan created inconsistent implementation of swallowing precautions, positioning, supervision, and feeding assistance, increasing the likelihood Resident #1 would be improperly positioned or insufficiently supervised during meals, thereby increasing the risk of choking, aspiration, and respiratory compromise.Findings: Resident #1 Record review from 7/13-21/26 revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included dysphagia, traumatic brain injury (TBI- an injury to the brain caused by a violent blow or jolt to the head), aphasia (loss or impairment of the ability to communicate), and left-sided hemiplegia (paralysis of the left side of the body). Review of the facility policy Denali Center-Care Plan Process, last reviewed 7/26/23, revealed: .Purpose/Scope . assure all residents admitted and residing at Denali Center will have current care plans reflecting care received from all disciplines. Residents, families, and guardians will have input into care plan initially, and as needed on an on-going basis . Further review of the policy revealed: .must develop and implement a baseline (interim) care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .consistent with the resident rights . that includes measurable objectives and timeframes.Further review of the policy revealed interdisciplinary care plans were to: 1) Incorporate identified problem areas; 2) Incorporate risk factors associated with identified problems; 3) Reflect treatment goals and objectives in measurable outcomes; 4) Identify the professional services/team members that are responsible for each element of care; and 5) Prevent decline in the resident's functional status and/or functional levels. The policy stated Certified Nursing Assistant (CNAs) and Licensed Nurse (LN) task lists were developed from the resident's plan of care. The policy further directed that the Resident Care Coordinator (RCC) or Charge Nurse (CN) update the care plan as the resident's needs changed and review it during resident care conferences. The policy required the baseline care-plan summary to include the resident's needs, interventions, protective devices, associated risks and benefits, and dietary instructions. Review of Resident #1's SLP evaluation, dated 2/15/22, revealed Resident #1 required intermittent supervision, maintenance of optimal upright positioning, cues to follow strict aspiration precautions, and assistance as needed to increase safety during oral intake. The evaluation identified safe feeding and swallowing precautions that included: 1) Allowing additional time to swallow; 2) Maintaining a slow rate of intake; 3) Swallowing between bites; 4) Providing small bites of food; 5) Providing small sips of liquid; 6) Alternating solids and liquids; and 7) Remaining upright for 30 minutes after meals. Further review of the SLP evaluation revealed Resident #1 was evaluated while seated upright in a wheelchair in the common dining area. The SLP documented the resident leaned to one side during the meal and required repositioning. The SLP recommended the head of the bed be elevated greater than 45 degrees, with supports and repositioning as needed to maintain the resident's position, for oral intake in the resident's room, including snacks and thin liquids. The SLP separately recommended upright, supported wheelchair seating during all meals, with continued intermittent supervision to promote safety during oral intake. Review of physician orders revealed an order dated 3/8/22, for: Intermittent supervision with strict aspiration precautions per speech therapy. Review of Resident #1's comprehensive care plan revealed interventions for: 1) Intermittent supervision and strict aspiration precautions; 2) A modified-texture diet (altering the consistency of foods and liquids to make them safer and easier to chew, swallow, and digest, primarily for individuals with dysphagia or other swallowing difficulties); 3) Small portions; 4) Use of a specialized Munchkin spoon (a small, adaptive spoon used to provide smaller bites and support safer self-feeding); 5) Use of a deep-dish plate; 6) LN verification of the prescribed diet; and 7) Allowing Resident #1 to feed [himself/herself] or providing feeding assistance depending on the resident's mood. The care plan stated Resident #1 could feed himself/herself or might require staff to feed him/her depending on his/her mood. The care plan did not identify measurable criteria that staff were able to use to determine when Resident #1 required feeding assistance. Review of Resident #1's CNA Kardex (a condensed resident-specific care guide used by CNAs to identify assigned care needs, safety precautions, and required interventions), revealed the resident was at high risk for choking and was to be placed in a sitting, upright position for meals and was to be assisted by the CNA during feeding. The CNA Kardex did not define the resident's required body position, identify whether upright positioning required wheelchair seating or bed positioning, identify the positioning supports required, or define the frequency and responsibility for intermittent supervision. During an interview on 7/16/26 at 9:02 AM, the RCC stated SLP recommendations were generally communicated to care-planning staff through an email containing a brief overview of the recommendations. The RCC stated he/she updated Resident #1's care plan but did not recall communicating directly with the SLP regarding the resident. The RCC stated he/she relied upon a condensed SLP communication instead of reviewing the complete SLP evaluation. The RCC was unable to locate the communication or identify documentation of a subsequent SLP evaluation that supported care-plan entries dated in 2025. When asked what instructions the care plan provided regarding Resident #1's actual body position during meals, the RCC stated: It really doesn't say a lot. The RCC further acknowledged the care plan did not contain specific positioning instructions for meals.The RCC stated the SLP's positioning instructions should have been included in Resident #1's comprehensive care plan and CNA Kardex. The RCC stated he/she should have questioned or clarified the SLP recommendation when he/she believed Resident #1 could not tolerate a 90-degree position. The RCC stated he/she may have interpreted the phrase and/or as tolerated to mean staff should elevate Resident #1 only as high as the resident could tolerate. The RCC acknowledged he/she did not contact the SLP to clarify how Resident #1 was to be safely positioned for meals when the SLP-recommended position was believed to be unattainable. When asked whether the care plan provided staff with enough specific information to safely position and supervise Resident #1 during meals, the RCC stated, Probably not. When asked how the facility defined intermittent supervision, the RCC stated he/she did not know whether the facility had a policy defining the term. The RCC stated he/she generally instructed staff that intermittent supervision meant checking the residents every 15 to 30 minutes and using their judgment. The RCC acknowledged the intervention should have been individualized and that different staff members' judgments could differ. The RCC stated, I know that judgment's probably not a good answer, because other people's judgment may not be the same as my judgment. The RCC stated Resident #1's RR (resident representative) wanted the resident to retain the ability to feed himself/herself. The RCC stated the resident had lost function on his/her left side, frequently spilled food onto his/her chest, became tired later in the day, and required varying levels of feeding assistance. During an interview on 7/15/26 at 1:24 PM, CNA #1 stated he/she relied on the CNA Kardex to determine how to position and assist Resident #1 during meals. CNA #1 stated he/she understood intermittent supervision to mean checking Resident #1 approximately every 15 minutes while the resident ate. CNA #1 stated he/she positioned Resident #1 in bed, set up the dinner tray, and then left to provide total feeding assistance to another resident. CNA #1 stated the total-assist feeding ordinarily required approximately 20 minutes. CNA #1 stated he/she did not tell another staff member that Resident #1 needed to be checked while he/she was assisting the other resident and did not ask or assign another staff member to complete the check.During an interview on 7/15/26 at 8:30AM, SLP #1 reviewed the 2/15/22 SLP evaluation and stated the recommendations addressed two different oral-intake settings. SLP #1 stated oral intake in the resident's room required head-of-bed elevation greater than 45 degrees with positioning supports and repositioning as needed. SLP #1 stated full meals required upright, supported wheelchair seating with intermittent supervision. SLP #1 further stated aspiration precautions included safe and reliable positioning, use of wedges or other positioning supports when eating in bed and rechecking the resident throughout oral intake to ensure the resident had not slid, leaned, or lost the required position. SLP #1 stated the resident's actual body position was more important than the numerical angle of the bed because a resident could slide downward or lean despite an elevated head of bed. During an interview on 7/21/26 at 10:00AM, the Administrator stated the facility did not interpret the SLP evaluation to require Resident #1 to be seated in a wheelchair for all meals. Review of facility-provided nursing standards under [NAME], titled Impaired swallowing and aspiration precautions, last revised 4/20/26, revealed: .Patients with. dysphagia are at especially high risk for aspiration. Managing impaired swallowing.After the swallowing evaluation is complete, develop a multidisciplinary management plan that includes common swallowing strategies and that considers the patient's nutritional status and required supervision. Using common swallowing strategies. Place the patient in an upright seated position, at a 90-degree angle during meals to decrease the risk of aspiration. Otherwise, maintain the head of the patient's bed elevated 30 to 45 degrees. Using close supervision. check on the patient frequently during each meal. Spend 3 to 5 minutes each time providing cues and remind the patient to use swallowing strategies.

.Based on record review, observation, and interview, the facility failed to ensure the resident environment was free from accident hazards by failing to monitor and control the temperature of hot beverages provided to 1 resident (#29), out of 18 sampled residents. Specifically, staff served hot coffee from a staff designated coffee pot to a cognitively impaired resident without verifying safe temperature parameters, resulting in burns that required nursing assessment and treatment. This failed practice caused the resident to endure second degree burns and constituted actual harm to the resident. Findings:Record review from 1/11-15/26, revealed Resident #29 was admitted to the facility with diagnoses that included dementia, Alzheimer's disease (a progressive, irreversible brain disorder that causes memory loss, cognitive decline, and behavioral changes due to the degeneration of nerve cells and brain tissue), and chronic pain. Resident #29 also had a history of falling and impaired skin integrity. An observation on 1/13/26 at 2:45 PM, revealed Resident #29 had multiple irregularly shaped red areas of skin on his/her left flank (lower to mid left side of back). The red patches of skin were of varying sizes and degrees of redness. The largest area was about palm-sized around the back of the rib cage, with slightly smaller red patches that reached down and stopped above the Resident's hip. The red area closest to the hip was observed to be covered in dry flakes of skin. During an interview on 1/13/26 at 2:45 PM, when asked what caused the red patches of Resident #29's skin, Licensed Nurse (L)N #1 stated they were a burn from when the resident spilled coffee. Review of Resident #29's Nursing Narrative Note, dated 10/27/25 at 5:18 PM and written by LN #1, revealed: . Notified by unit nurse and CNA [Certified Nursing Assistant] that resident had reddened, fluid filled blisters on left flank. notified [Provider #3] of new skin issue. Received new orders for cool compress to area for 20 minutes on q4h [every 4 hours] and [provider] will assess in morning. Burn. at lunch time, resident had spilled coffee or tea. but did not realize it had burned [his/her] skin. Review of the facility provided Foundation Health - Event Form, entry date 10/28/25, revealed: CNA notified unit nurse and RCC [Resident Care Coordinator] that resident had a large red, blanchable fluid filled blisters on left flank. Origins are unknown by CNA and Nurse, RCC spoke with [Resident Representative, RR] and [RR] stated that when [he/she] came in to see [him/her] for lunch, it appeared [he/she] had spilled something on [him/her] that looked like coffee or tea. Further review revealed follow up notes were entered on this event form, 79 days later, on 1/14/26 at 5:56 PM (during the survey) that revealed: Investigation revealed resident was given a cup of hot coffee from staff coffee pot and placed on a table. Resident bumped table and coffee, resulting in spill on left side of body where shirt was visible with coffee stain. Wound care initiated. How preventable was the event? Likely could have been prevented. Recommendation for system improvement. Temperature check of hot liquids to assure temperatures are in CMS regulation for resident consumption. Sign on staff coffee [pot] stating 'Staff Only'. During an interview on 1/14/26 at 11:06 AM, CNA #3 stated he/she was not sure of how hot resident coffee should be and that it arrived hot enough for them from the kitchen. CNA #3 stated that he/she would get coffee for residents from whichever coffee pot had coffee in it. When asked if he/she received education on not serving residents from staff coffee pots, the CNA stated that he/she could not remember. During an interview on 1/14/26 at 2:43 PM, LN #4 stated there was not a Staff Only sign on the staff coffee pot prior to Resident #29's burn, and it was likely that staff poured Resident #29 a cup of coffee from the staff coffee pot because they were out of coffee at the nursing station. An observation on 1/14/26 at 2:47 PM, revealed the staff coffee pot was in a secure area accessible only by door code. The coffee pot had a sign posted on it that stated: . Caution. Coffee is Very Hot To Be Used by Staff Only. During an interview and concurrent observation on 1/15/26 at 9:40 AM, the Administrator stated staff were educated about not serving residents hot coffee from staff coffee pots after Resident #29's burn incident. It was communicated during shift huddle, and the burn was placed on their huddle process board. The Administrator further stated the entire team reviewed the board going on and off their shifts. The education was also entered on the CNA worksheet for rounding. It was observed there was nothing noted on the board regarding Resident #29's burn during the conversation. The Administrator stated that it currently was not on the board, since it happened months ago. Review of the article from the Alzheimer's Association, Late-Stage Alzheimer's & Dementia Caregiving, undated, retrieved from https://www.alz.org/help-support/caregiving/stages-behaviors/late-stage, revealed: . Foods and fluids. Always check the temperature of warm or hot liquids before serving them.

.Based on observation, interview, and record review, the facility failed to ensure potentially hazardous foods were stored and labeled in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) expired foods were discarded; 2) foods were labeled and dated; and 3) foods were stored at safe temperatures in the Fireweed Cafe (Long-Term [LTC] Care Dining Room) refrigerators. These failed practices had the potential of causing or spreading foodborne illnesses to residents (based on a census of 73 out of 77) who received food from the kitchen Findings:An observation on 1/11/26 at 2:50 PM, of the Fireweed Cafe and the facility's hospital kitchen, revealed: 1) Dry Storage in Fireweed Cafe - Four Newman's Own French Dressing salad dressing packets, 1.5 ounces each, expired on 11/12/25. During an interview on 1/11/26 at 3:25 PM, the Food and Nutrition Manager (FNM) stated the packets were expired and should have been discarded. 2) Fireweed Cafe Freezer -One untied and torn unlabeled clear plastic bag containing food without an open date (appeared to be approximately seven pretzel sticks), with no use-by or expiration date. Further observation revealed one of the pretzel stick was uncovered and directly exposed to the freezer's cold environment; -One opened and unlabeled clear plastic bag containing food without an open date (appeared to be 11 bread rolls), without a use-by or expiration date. During an interview on 1/11/26 at 3:25 PM, the FNM stated the bag of pretzel sticks should have been sealed. FNM further stated the products stored in the freezer did not require open, use-by or expiration labels and that the facility followed Food and Drug Administration (FDA) guidelines regarding food storage. During an interview on 1/13/26 at 11:17 AM, the Culinary Supervisor (CS) stated the bag of bread rolls had ice crystals forming on the corners and should have been thrown out. The CS further stated the bread rolls were leftovers from a previous meal. The CS stated he/she checked expiration dates twice a week in the Fireweed Cafe. 3) Main Kitchen Walk-in Refrigerator: -One box of lettuce, without a lid;-One tray of tiramisu stored uncovered. During an interview on 1/11/26 at 3:35 PM, FNM stated the box of lettuce should have been covered with a lid. During a follow-up observation on 1/13/26 at 11:17 AM, of the Fireweed Cafe kitchen, revealed:- One Kikkoman Less Sodium Soy Sauce-2-quart bottle-with no lid;- One [NAME] Pure Maple Syrup, 2-quart bottle, approximately 2/3 full, stored unrefrigerated, with manufacturer instructions that stated: Refrigerate After Opening. During an interview on 1/13/26 at 11:17 AM, the CS stated the bottle of soy sauce should have a lid. The CS further stated syrups were not refrigerated. Refrigerator Temperatures Fireweed Cafe Upright Refrigerator Random observations on 1/11-15/26 revealed the Fireweed Cafe Upright Refrigerator stored lettuce and cherry tomatoes. Review of the temperature log, from 10/13/25-1/13/26, revealed the accepted temperature range listed for the refrigerator was between 33 degrees F (Fahrenheit) to 41 degrees F. Further review revealed the following dates and times the refrigerator was above 41 degrees F: 1. From 12/3/25 at 2:50 PM until 12/4/25 3:20:52 AM (12 hours and 30 minutes), temperatures ranged from 41.22 F to 42.10 F; 2. On 12/4/25, from 4:20 AM until 9:50 AM (5 hours and 30 minutes), temperatures ranged from 41.05 F to 43.49 F; and 3. On 1/8/26 at 9:19 AM until 2:04 PM (4 hours and 45 minutes), temperatures ranged from 41.05 F to 42.27 F; Fireweed Cafe Kitchen 3-Door Refrigerator Random observations on 1/11-15/26 revealed the Fireweed Cafe Kitchen 3-Door Refrigerator stored tomatoes, boiled eggs, oranges, strawberries, egg salad, smoked ham, mozzarella cheese slices, Swiss cheese slices, and previously frozen beef that was thawing. Review of the temperature log, from 10/13/25-1/13/26, revealed the accepted temperature range listed for the refrigerator was between 33 degrees F to 41 degrees F. Further review revealed the following dates and times the refrigerator was above 41 degrees F: 1. On 10/15/25, from 8:40 AM until 4:00 PM (7 hours and 20 minutes) temperatures ranged from 41.22 F to 45.2 F; 2. On 10/16/25, from 10:20 AM until 2:25 PM (4 hours and 5 minutes), temperatures ranged from 41.4 F to 44.34 F; 3. On 10/17/25, from 8:15 AM until 2:25 PM (6 hours and 10 minutes), temperatures ranged from 41.22F to 45.03 F; 4. On 10/19/25, from 9:19 AM until 4:00 PM (6 hours and 41 minutes), temperatures ranged from 41.4 F to 47.9 F; 5. On 10/20/25, from 9:55 AM until 3:40 PM (5 hours and 45 minutes), temperatures ranged from 41.22 F to 44 F; 6. On 10/21/25, from 9:00 AM until 7:20 PM (10 hours and 20 minutes), temperatures ranged from 41.22 F to 49.07 F; 7. On 10/22/25, from 8:25 AM until 7:40 PM (11 hours and 15 minutes), temperatures ranged from 41.22 F to 54.63 F; 8. On 10/23/25, from 8:20 AM until 7:20 PM (11 hours), temperatures ranged from 41.05 F to 47.4 F; 9. On 10/24/25, from 10:24 AM until 3:05 PM (4 hours and 41 minutes), temperatures ranged from 41.05 F to 43.66 F; 10. On 10/24/25, from 3:14 PM until 7:50 PM (4 hours and 36 minutes), temperatures ranged from 41.4 F to 45.03 F; 11. On 10/26/25, from 8:20 AM until 6:10 PM (9 hours and 50 minutes), temperatures ranged from 41.05 F to 45.54 F; 12. On 10/27/25, from 9:54 AM until 3:55 PM (6 hours and 1 minute), temperatures ranged from 41.05 F to 44.52 F; 13. On 10/29/25, from 9:45 AM until 7:40 PM (9 hours and 55 minutes), temperatures ranged from 41.4 F to 53.82 F; 14. On 11/3/25, from 8:50 AM until 4:10 PM (7 hours and 20 minutes), temperatures ranged from 41.4 F to 46.72 F; 15. On 11/4/25, from 9:03 AM until 7:00 PM (9 hours and 57 minutes), temperatures ranged from 41.22 F to 46.89 F; 16. On 11/19/25, from 10:19 AM until 6:54 PM (8 hours and 35 minutes), temperatures ranged from 41.05 F to 54.63 F; 17. On 11/22/25, from 2:33 PM until 6:43 PM (4 hours and 10 minutes), temperatures ranged from 41.05 F to 46.56 F; 18. On 12/18/25, from 10:37 AM until 6:49 PM (8 hours and 12 minutes), temperatures ranged from 41.57 F to 44.52 F; and 19. On 12/24/25, from 12:59 PM until 5:04 PM (4 hours and 5 minutes), temperatures ranged from 41.57 F to 47.73 F. During an interview on 1/14/26 at 10:57 AM, the FNM stated that refrigerator temperatures were centrally monitored and the engineering department would notify the FNM if the refrigerator temperatures were out of range. The FNM further stated foods from the refrigerators in Fireweed Cafe had not been thrown out in the past three months when temperatures were out of range. During an interview on 1/15/26 at 11:00 AM, the Plant Ops Supervisor (POS) stated that the kitchen was responsible for checking the alarms. The POS further stated the FNM had an alarm above his office door, and this alarm would light up if temperatures were out of range. Review of the facility provided FDA Food Code 2022, revealed: 3-302.11 Packaged and Unpackaged Food - Protection Separation, Packaging, and Segregation. Food that is inadequately packaged or contained in damaged packaging could become contaminated by microbes, dust, or chemicals introduced by products or equipment stored in close proximity or by persons delivering, stocking, or opening packages or overwraps. Packaging must be appropriate for preventing the entry of microbes and other contaminants such as chemicals. These contaminants may be present on the outside of containers and may contaminate food if the packaging is inadequate or damaged, or when the packaging is opened. The removal of food product overwraps may also damage the package integrity of foods under the overwraps if proper care is not taken. Review of the facility policy Food Safey and Sanitization, updated 5/28/24, revealed: .4) Food Storage.2. Refrigerated foods are stored at or below 41 F (5 C [Celsius].4. Foods are protected from contamination (dust, flies, rodents, and other vermin) .8. All leftovers are labeled, covered and dated when stored. They are used following the guidelines of the Discard Dates attachments or discarded. 11. Opened containers and prepped foods are used or discarded within the time frame of the Discard Dates form, developed by management. Review of the facility policy Denali Center: Use of Leftovers, effective date 2/4/25, revealed: .2. All opened food items in coolers, freezers and dry storage must be covered and labeled as indicated in the State of Alaska Food Code. 3. To suppress bacteria growth, foods are to be stored at or below 5 C (41 F) or above 57.2 C (135 F). No food should be in the Danger Zone between 5 - 57.2 C (41 F to 135 F). If a food temperature falls into the danger zone, the food must be reheated to 165 F or above. If the food temperature is in the danger zone for more than two hours, the food must be discarded.

.Based on record review and interview, the facility failed to establish an accurate competency training program for travel Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) to ensure all travel nursing staff had the specific competencies and skill sets necessary to care for resident's needs as identified in the facility's facility assessment. This failed practice had the potential to place all residents (based on a census of 77) at risk of: 1) not having the necessary care and resources required for day-to-day operations (including nights and weekends) and emergencies; and 2) not receiving services that enable them to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings:Review of the facility-provided Denali Center Facility Assessment 2026, dated 12/15/25, revealed: 1.Diseases/conditions, physical and cognitive disabilities treated in the organization: - Psychiatric/Mood Disorders. Impaired Cognition, Post-Traumatic Stress Disorder, Anxiety Disorder, Behaviors that Needs Interventions; - Neurological System. Parkinson's Disease, Hemiparesis, Hemiplegia, Paraplegia, Quadriplegia, Multiple Sclerosis, Alzheimer's Disease, Non-Alzheimer's Dementia. Stroke, Traumatic Brain Injuries, Neuropathy. Huntington's Disease, Aphasia. 2. Services and Care we offer based on our Resident's Needs: - Activities of Daily living. Bathing, showers. eating. - Mental health and behavior. Managing the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD. - Pain management. Assessment of pain, pharmacologic and nonpharmacological pain management. 3. Staff training/education and competencies. Denali center utilizes competencies from the [NAME] Organization of Nurse Leaders. The organization utilizes HealthStream [web-based learning management system used by healthcare facilities to assign, deliver, track, and document staff education, training, and competency validation, including required in-service training and compliance modules] for BLS [basic life support] and annual mandatory education. Topics include. Nutrition/Hydration/Dining with Dignity. safety/Good Catch program/rounding/Falls, Substance abuse/mental health, resident rights. Orientation and competencies cover: Communication. Abuse, Neglect, and exploitation. Other competencies may include. Activities of daily living - bathing (e.g. tub, shower, sitz, bed). Resident assessment and examinations. Caring for person's with Alzheimer's or other dementia. Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, and implementing nonpharmacological interventions. During an interview on 1/14/26 at 2:57 PM, the Senior Manager of Human Resources (HR) and the Education Systems Analysist stated the facility utilized travel nurses (registered nurses [RNs] and licensed practical nurses [LPNs]) and travel CNAs for resident care. Review of the facility provided employee roster revealed the facility currently had one travel RN (#10), one travel LPN (#12), and four travel CNAs (#'s 2, 13, 14, and 15) working with residents at the time of the survey. Review of the facility-provided education record for current staff, received on 1/20/26, revealed the following annual trainings, through HealthStream, were assigned to the current travel nursing staff to be completed in 2025: - DC (Denali Center) dining with dignity;- Meaningful care;- Dementia Care I: mental decline and caregiver challenges;- Dementia Care II: physical decline and caregiver challenges;- Dementia Care III: understanding and managing difficult behaviors;- Understanding neglect;- Elder abuse: preventing;- Controlling violence in healthcare & preventing elder abuse;- Resident rights & responsibilities; and- Patient or resident safety basics. Further review revealed the travel nursing staff did not complete trainings as assigned: 1. Travel LPN #12 - had not completed any of the trainings assigned in HealthStream; 2. Travel CNA #2 - had not completed the following trainings:- DC (Denali Center) dining with dignity;- Meaningful care;- Dementia Care I: mental decline and caregiver challenges;- Dementia Care II: physical decline and caregiver challenges;- Dementia Care III: understanding and managing difficult behaviors;- Understanding neglect; and- Elder abuse: preventing. 3. Travel CNA #13 - had not completed the following trainings:- DC (Denali Center) dining with dignity;- Meaningful care;- Dementia Care I: mental decline and caregiver challenges;- Dementia Care II: physical decline and caregiver challenges;- Dementia Care III: understanding and managing difficult behaviors;- Understanding neglect;- Elder abuse: preventing; and- Controlling violence in healthcare & preventing elder abuse. 4. Travel CNA #14 - had not completed the following trainings:- Meaningful care;- Dementia Care I: mental decline and caregiver challenges;- Dementia Care II: physical decline and caregiver challenges;- Dementia Care III: understanding and managing difficult behaviors;- Understanding neglect;- Resident rights & responsibilities; and- Patient or resident safety basics. 5. Travel CNA #15 - had not completed the following trainings:- DC (Denali Center) dining with dignity;- Meaningful care;- Dementia Care I: mental decline and caregiver challenges;- Dementia Care II: physical decline and caregiver challenges;- Dementia Care III: understanding and managing difficult behaviors;- Understanding neglect; and- Elder abuse: preventing. During an interview on 1/20/26 at 9:53 AM, after reviewing the education record, the Administrator stated there was opportunity for improvement with tracking the traveler's completion of assigned trainings

.Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program to provide a safe and sanitary environment. Specifically, the facility failed to: 1. Ensure enteral feeding equipment was properly labeled in accordance with infection prevention practices; and 2. Ensure clean linens were protected from environmental contamination during transport. These failed practices placed residents (based on a census of 77) at risk for the development of communicable diseases and/or infections. Findings:Enteral Feeding Equipment Labeling Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Traumatic Brain Injury (TBI), gastrostomy (A surgically created opening through the abdominal wall into the stomach used for the administration of nutrition, fluids, and medications directly into the gastrointestinal tract when oral intake is inadequate or not possible), and tracheostomy (A surgically created opening through the neck into the trachea to maintain an airway and support breathing, often requiring ongoing airway care and infection prevention measures). Resident #4 had a gastrostomy tube (g-tube) in place for enteral nutrition (liquid nutrition delivered directly to the stomach through a tube). An observation on 1/14/26 at 9:25 AM, revealed Resident #4 was being fed with enteral nutrition. Further observation revealed: 1) the enteral nutrition bottle was not dated and labeled when the feeding was initiated;2) the enteral tubing was not labeled with the date and time its use began; and3) the water flush used for hydration was also not labeled with a date and time. During an interview on 1/14/26 at 12:00 PM, when asked if Resident #4's enteral formula container and administration set should be labeled with dates and times, Licensed Nurse (LN) #2 stated that it should have been labeled. Review of the facility provided policy Enteral tube feeding, intermittent, gastronomy and jejunostomy, last revised 12/14/25, revealed: .Make sure that the enteral formula container is labeled with. date and time of formula preparation; date and time that the formula was hung. Label the enteral administration set with the date and time that it was first hung. Change the enteral administration set according to the manufacturer's instructions to prevent bacterial growth. Clean Linen Protection during Transport An observation on 1/12/26 at 2:44 PM, revealed laundry personnel brought clean clothes on a wheeled cart to the long-term care (LTC) units from the laundry room. Further observation revealed there was a cart cover attached to the top of the cart, however it was not pulled down completely to cover the clean clothes. The bottom half of hung clothes was visible as the laundry personnel moved through the different units delivering the laundry. An observation on 1/14/26 at 2:34 PM, revealed laundry personnel brought clean clothes on a wheeled cart to the LTC units from laundry room again. Further observation revealed the cart's cover was not pulled down completely to cover the clean clothes. The bottom half of hung clothes was visible as the laundry personnel moved through the different units delivering the laundry. During an interview on 1/14/26 at 2:00 PM, when asked about clean laundry being delivered to the units, the Administrator stated that it was the expectation that the clean laundry be covered when being delivered. Review of the facility provided policy Foundation Health Partners Infection Prevention Plan, dated 2/15/23, revealed: . The infection prevention program is responsible for: Developing and implementing policies governing control of infections and communicable diseases. Reduce risk of infections related to procedures, medical equipment, and devices. Assure clean and sanitary environment. Reduce potential transmission of organisms to patients, staff and others.

.Based on record review and interview, the facility failed to ensure Long-Term Care (LTC) travel nursing staff (licensed nurses and certified nursing assistants [CNAs]) completed assigned trauma-informed care training. This failed practice placed 2 sampled residents (#'s 3 and 39), out of 18 sampled residents, and one unsampled resident (#66), with a documented trauma history, at risk of not receiving appropriate care for trauma-related needs. Findings:Record review on 1/11-15/26, revealed the facility-provided CMS-802 Matrix for Providers, completed on 1/12/26, revealed residents #'s 3, 39, and 66 were identified as being assessed as having a history of Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress) and/or traumatic events in their life. During an interview on 1/14/26 at 2:57 PM, the Education Coordinator for the LTC stated trauma informed care training was assigned annually for all staff, to include travel nursing staff, having contact with residents. Review of the facility provided employee roster revealed the facility currently had one travel Registered Nurse (RN)(#10), one travel Licensed Practical Nurse (LPN) (#12), and four travel CNAs (#'s 2, 13, 14, and 15) working with residents at the time of the survey. Review of the facility-provided education record for current staff, received on 1/20/26, revealed LTC travel nursing staff were assigned two trauma informed care trainings: 1) Medicare required trauma informed care education; and 2) Trauma Informed care for healthcare staff education, through HealthStream, to be completed in 2025. Further review revealed the travel nursing staff did not complete trainings as assigned: 1. Medicare required trauma informed care education training was not completed by any travel nursing staff (RN #10, LPN #12, CNA #'s 2, 13, 14, and 15). 2. Trauma Informed care for healthcare staff training was not completed by LPN #12, CNA #'s 2, 13, 14, and 15. During an interview on 1/20/26 at 9:53 AM, the Administrator stated there was an opportunity for improvement to ensure all travel nursing staff completed their assigned trauma informed care training annually. Review of the facility-provided Denali Center Facility Assessment 2026, dated 12/15/25, revealed: . Staff training/education and competencies. Denali Center utilizes competencies from the [NAME] Organization for Nurse Leaders. The organization utilizes HealthStream for BLS [basic life support] and annual mandatory education. Topics include. Trauma informed care.

.Based on record review and interview, the facility failed to ensure timely notification to the State's Senior Disability Services that a resident's stay would exceed 90 days and to request a Level II Preadmission Screening and Resident Review (PASRR - a federally required process to determine whether individuals with mental illness or intellectual disabilities need specialized services) evaluation for 1 resident (#3), out of 18 sampled residents. This failed practice delayed the required assessment and placed the resident at risk of not receiving necessary services and care to meet their individualized disability-specific needs. Findings:Record review on 1/11-15/26, 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), schizophrenia (a severe mental disorder characterized by delusions [false beliefs], hallucinations [perception of sights, sounds, etc. that are not actually present]), and post-traumatic stress disorder (PTSD - a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress). Review of Resident #3's Pre-admission Screening and Resident Review Level I form, dated 10/15/24, revealed: . PASRR Categorical Determinations (certain circumstances that are time-limited that require an abbreviated PASRR Level II evaluation report) [checked] Convalescent care for a period of 90 days or less, as certified by the physician. If the individual stays beyond 90 days, an individualized PASRR Level II evaluation must be completed. The facility shall notify SDS [Senior Disability Services, a State of Alaska, Department of Health Division] on day 85 that it anticipates the resident will need services more than 90 days. Day 85 is: 01/09/25. During an interview on 1/14/26 at 2:00 PM, the Social Worker (SW) stated that Resident #3's PASRR Level I had a directive to call the Senior Disability Services on 1/9/25 to initiate a Level II assessment. When asked if this was done, the SW stated it was not completed because it was missed and at this time, Resident #3 did not have a PASRR Level II. During the survey, a facility policy on PASRR evaluations was requested. The facility provided a policy titled LTC [Long Term Care] Authorizations and Re-Authorization Forms. Review of the facility provided policy, LTC Authorizations and Re-Authorization Forms, originally dated 1/1/17, revealed no information about ensuring Level II PASRRs were requested, implemented, and completed timely to ensure residents receive necessary services if determined necessary

.Based on record review, observation, and interview, the facility failed to ensure 1 resident (#29), out of 18 sampled residents, received treatment and care, in accordance with the professional standards of practice based on manufacture's recommendations. Specifically, the facility failed to use an appropriately sized lift sling while using a mechanical lift (a device designed to assist in the safe lifting and transferring a resident with limited mobility) during transfer. This failed practice placed the resident at risk for discomfort/pain during a transfer which had the potential to negatively impact the resident's physical health and/or psychosocial well-being. Findings:Record review from 1/11-15/26, revealed Resident #29 was admitted to the facility with diagnoses that included dementia, Alzheimer's disease (a progressive, irreversible brain disorder that causes memory loss, cognitive decline, and behavioral changes due to the degeneration of nerve cells and brain tissue), and chronic pain. Resident #29 also had a history of falling and impaired skin integrity. An observation on 1/13/26 at 2:39 PM, revealed Resident #29 was seated in his/her wheelchair beside his/her bed with a mechanical lift sling tucked behind his/her back. The sling wings were draped over the wheelchair arms, and another set was positioned between his/her legs. Licensed Nurse (LN) #1 pushed the mechanical lift (a Liko brand) so that the sling bar (part of the mechanical lift where the sling would be attached) was positioned in front of the resident. Certified Nursing Assistant (CNA) #2 and LN #1 latched the sling wings to the lift bar; the wings from between the resident's legs were crossed before the wings were attached to the bar. CNA #2 stood behind the wheelchair while LN #1 began slowly lifting Resident #29 out of his/her wheelchair. The resident began crying out loudly. As the resident was lifted, the resident started to tilt backward but remained in the sitting position. Resident #29 continued to cry out. Further observation revealed his/her buttocks were suspended out of the bottom of the sling and the sling wings were tightly compressed into the resident's inner thighs. A significant portion of the sling's back panel extended high over the resident's head. It was noted that the panel hanging over the resident's head had a yellow stripe running down the middle of it. CNA #2 then moved the wheelchair from under the resident and placed it on the other side of the room so that LN #1 could maneuver Resident #29 over to the bed. Resident #29 continued to loudly cry out until he/she was placed onto his/her back, with his/her knees bent and feet flat on the bed, in the middle of the bed. During an interview and concurrent observation on 1/13/26 at 3:01 PM, when asked about the sling's size, CNA #2 stated that the sling used during Resident #29's transfer had a yellow stripe, which correlated to the sling size. LN #1 confirmed the sling used was not a toileting sling (which had a large cut out in the seat area to allow toileting without removing the sling) but was a normal sling (which provided full body support with no cut out features) and was used to transfer Resident #29 every day. When asked why Resident #29 was loudly crying out during the transfer, LN#1 said that it was how the resident normally behaved. When asked if the resident was positioned properly in the sling, LN #1 only stated it was best to get the Resident over into bed as quickly as possible where the resident could be more comfortable. Further observation of the sling used with Resident #29 revealed the tag on the sling indicated that it was a Liko Soft Original HighBack Sling in a medium size. LN #1 stated lift sling sizes were based on weight. Review of Resident #29's care plan, last evaluated on 1/7/26, revealed: .LTC [Long-Term Care] Skin Integrity. Decrease friction and [Shearing] With any Transfers and Repositioning. LTC ADL [activities of daily living] Function Rehab. Assist Resident with Transfers. Further review of the care plan revealed no further documentation for guidance on mechanical lift assistance or sling size information for Resident #29. Review of the CNA report sheet, undated, revealed Resident #29 transferred with a: Mechanical Lift x2 [staff]; blue sling. Further review revealed Resident #29's roommate did not require transfer assistance, which indicated that the yellow sling in the room was designated solely for Resident #29. Review of the facility provided Liko Color Coded Sling Size Chart, for the Liko Original HighBack Sling, undated, revealed: . Medium. Patient's Weight. (88-176 lbs) [pounds]. The sizing guide chart for the medium size sling was yellow, which correlated to the colored stripe located on the sling that was used during Resident #29's transfer. Further review revealed the sizing guide for a large, which was the next size up, revealed: . Large. Patient's Weight. (154-264 lbs). The sizing guide chart for the large size was blue (to indicate the sling would have a blue stripe). Review of Resident #29's most recent weight, dated 1/1/26, was 182.98 lbs. Review of the facility provided Liko Color Coded Sling Size Chart, for the Liko Original HighBack Sling, undated, indicated a large size with a blue stripe should have been used based on the resident's weight. During an interview on 1/14/26 at 11:06 AM, CNA #3 stated he/she was unsure who would ensure correct sling sizes for residents but would go ask a charge nurse. During an interview on 1/14/26 at 11:19 AM, the Administrator stated that nursing staff had been trained on mechanical lifts and that she trusted the judgement of staff. The Administrator further stated that it was typical behavior for Resident #29 to cry out because of the Resident's dementia. During an interview on 1/14/26 at 11:19 AM, LN #1 stated that CNAs would choose the appropriate sling size for residents since they weighed the residents twice a month. Review of the Liko Original HighBack Sling. Instructions for Use, dated 2019, revealed: - . Lifting from a Sitting Position. Place the sling behind the patient's back. Fold up the lower edge of the sling around your finger tips to facilitate guiding the sling into place. Using the palm of your hand, push the lower edge of the sling down to the level of the patient's coccyx [tailbone] - this is very important. Tip: Correct positioning is facilitated if the patient leans/is leaned forward slightly. Pull the sling's leg supports forward along outside of the patient's thighs. Simultaneously, pull the leg support forward with the other hand to stretch it. Pull the leg supports forward to smooth out any creases in the back. Check that both leg supports protrude the same distance. Insert one leg support under each thigh. Make sure the fabric lies flat and that it reaches properly around the leg. Tip: The application of the leg supports is facilitated if the patient's legs are slightly raised from the seat. The Patient does not Sit Well in the Sling - Why is This? . Wrong! [a picture of a resident in a sling with their buttocks hanging out of the bottom of the sling was depicted] Risk of sliding out. The buttocks hang down. It can also be due to the fact that the sling has not been pulled down the patient's back sufficiently. Right! [picture of a resident in the sling without buttocks hanging out of the bottom of the sling was depicted] The lower edge of the sling is at the same level as the coccyx. The leg supports are properly positioned under the legs. Review of the facility provided training slide, titled, LIFT AND E-Z STAND, undated, revealed: . Liko Lift - Use the right [size] of. sling for safety. The sling needs to. cover the head and the bottom of patients/residents. Review of the facility provided policy CNA Expectations and Standards of Care, last reviewed 5/6/25, revealed: . Provide safe and appropriate assistance for all transfers.

.Based on record review and interview, the facility's provider failed to: 1) write, sign, and date progress notes at each visit; and 2) review the residents total program of care, including treatment for a burn, at each visit for 1 resident (#29), out of 18 sampled residents. This failed practice resulted in inconsistent medical record documentation which placed the resident at risk of diminished continuity of care. Findings:Record review from 1/11-15/26 revealed Resident #29 was admitted to the facility with diagnoses that included dementia, Alzheimer's disease (a progressive, irreversible brain disorder that causes memory loss, cognitive decline, and behavioral changes due to the degeneration of nerve cells and brain tissue), and chronic pain. While at the facility, the resident acquired a second degree burn on the left flank (lower to mid left side of back). An observation on 1/13/26 at 2:45 PM, revealed Resident #29 had multiple irregularly shaped red areas of skin on his/her left flank. The red patches of skin were of varying sizes and degrees of redness. The largest area was about palm-sized around the back of the rib cage, with slightly smaller red patches that reached down and stopped above the Resident's hip. The red area closest to the hip was observed to be covered in dry flakes of skin. During an interview on 1/13/26 at 2:45 PM, when asked what caused the red patches of Resident #29's skin, LN #1 stated they were a burn from when the resident spilled coffee. Progress Notes Review of Resident #29's Nursing Narrative Note, dated 10/27/25 at 5:18 PM, written by LN #1, revealed: . Notified by unit nurse and CNA [Certified Nursing Assistant] that resident had reddened, fluid filled blisters on left flank. notified [Provider #3] of new skin issue. Received new orders for cool compress to area for 20 minutes on q4h [every 4 hours] and [provider] will assess in morning. Burn. at lunch time, resident had spilled coffee or tea. but did not realize it had burned [his/her] skin. During an interview on 1/15/26 at 1:14 PM, LN #1 stated Provider #3 was overseeing the wound care for Resident # 29's burn. LN #1 stated Provider #3 saw Resident #29 on 10/28/25, 11/3/25, 11/17/25, 12/1/25, 12/22/25, and on 1/14/25. The resident's burn treatment orders were created from those visits. LN #1 also stated the resident's burn had healed to the point where Provider #3 discharged Resident #29 on 1/14/25 from wound care services, turning care of the burn over to nursing services. A review of Resident #29's medical record showed no progress notes from Provider #3, except for a late entry note dated 1/14/26 for a 10/27/25 date of service. Review of Resident #29's Denali Center Progress Note, dated 1/14/26, Late entry, written by Provider #3, revealed: . On October 27, 2025, I was notified by nursing that resident had a large reddened area to [his/her] left flank that was not present that am [morning] during [his/her] shower. On exam, the area is red, warm and very painful to touch. There was one blister present. Advised nursing is a burn and we need to treat with cool compress every 4 hours as tolerated by the resident. The following day, we stopped the cold compresses and started bacitracin and Allevyn dressings [waterproof foam wound dressing]. Wound responded accordingly to treatment and was healed. Wound Treatments Review of Resident #29's order titled Skin Care TAR [Treatment Administration Record], dated 10/27/25, revealed: . Q4h, Left Flank, Burn - Apply cool compress q4h for 20 minutes to LEFT FLANK. Review of Resident #29's order titled Skin Care TAR, dated 10/28/25 at 4:00 PM, revealed: . DAILY, Left Flank, Burn on Left Flank - gently cleanse and pat dry an apply layer of bacitracin. Review of Resident #29's order titled Skin Care TAR, dated 10/28/25 at 8:00 PM, revealed: . Q12H [every 12 hours], Left Flank, Burn on Left Flank - gently cleanse and pat dry an apply layer of bacitracin. Review of Resident #29's order titled Wound Care TAR, dated 11/3/25 at 9:00 AM, revealed: . Burn, Flank, Left, Posterior, Q48H, Cleanse and pat dry gently. Cover with long mepilex [dressing] and small 4x4 mepilex on blister towards upper back. Notify RCC or charge of any changes. Review of Resident #29's order titled Wound Care TAR, dated 11/17/25 at 9:00 AM, revealed: . Burn, Flank, Left, Outer, DAILY, Cleanse and pat dry gently. Apply bacitracin to middle and upper wound areas. follow separate wound tar for lower portion of wound. Review of Resident #29's order titled Wound Care TAR, dated 11/17/25 at 9:00 AM, revealed: . Burn, Flank, Left, Left, Posterior, Q-M-R- [every Monday and Thursday], Cleanse and pat dry gently. Cover bottom open area with small 4x4 mepilex on blister towards upper back. Notify RCC or charge of any changes. Review of Resident #29's order titled Wound Care TAR, dated 12/1/25 at 9:00 PM, revealed: . Burn, Flank, Left, Outer, DAILY, Cleanse and pat dry gently. Apply bacitracin to middle all wound area and leave open to air. Notify RCC of any changes. During an interview, on 1/20/26 at 9:43 AM, Provider #3 stated that additional notes should have been written to document his/her provider visits for the burn treatments throughout the healing process. Provider #3 further stated the burn was discontinued from wound care on 1/14/26, and ongoing care would continue under nursing services using A&D ointment. When asked if a new order had been placed for nursing to monitor and treat the burn, Provider #3 reviewed the medical record and confirmed that no such order had been entered. Existing Provider Progress Notes: Review of Resident #29's Denali Center Progress Note, dated 11/6/25, written by Provider #1, revealed: . Physical Exam. Skin: no rashes or lesions on open skin. REVIEW OF SYSTEMS. SKIN: no concerns noted. This was the first provider note in Resident #29's medical record since the burn episode on 10/27/25. Further review revealed no documentation for the resident's burn. Review of Resident #29's Denali Center Progress Note, dated 11/10/25, written by Provider #2, revealed: . Patient has a skin irritation on [his/her] back treated with bacitracin. Further review revealed no documentation for the resident's burn. Review of Resident #29's Denali Center Progress Note, dated 12/30/25, written by Provider #1, revealed: . Physical Exam. Skin: no rashes or lesions on open skin. REVIEW OF SYSTEMS. SKIN: no concerns noted. Further review revealed no documentation for the resident's burn. During an interview on 1/15/26 at 12:43 PM, when asked if he was able to follow the provider visits and assessments for Resident #29's burn, the Medical Director stated, after reviewing the provider's notes, that Resident #29's burn should have been documented better. Review of the facility provided policy Physician Practices/Clinics: Documentation for Coding Quality, Compliance, and Timelines of Documentation Completion, effective date 1/29/25, revealed: . To support services rendered, must be complete, and added to the medical record in a timely manner. All medical record documentation. Must reflect the Chief Complaint. Should specifically address the care being provided by each respective physician. Documentation in the medical record must be specific to each patient encounter. Cloned/Copied/Pasted documentation may be considered a misrepresentation of the patient condition and can lead to potential patient safety concerns. All documentation includes. Medically appropriate history.

.Based on record review and interview, the facility's pharmacy services failed to ensure medication administration orders were accurate to meet resident needs for 2 residents (#'s 29 and 53), out of 18 sampled residents. This failed practice, of potentially having medications administered incorrectly, placed the residents at risk of choking and/or aspiration which could affect their overall health and wellbeing. Findings:Resident #29 Record review on 1/11-15/26, revealed Resident #29 was admitted to the facility with diagnoses that included Alzheimer's disease (a progressive, irreversible brain disorder that causes memory loss, cognitive decline, and behavioral changes due to the degeneration of nerve cells and brain tissue), dementia, and chronic pain. During an observation and concurrent interview on 1/13/26 at 9:01 AM, Licensed Nurse (LN) #4 crushed and mixed the following medications in pudding for Resident #29: 1. Acetaminophen (a pain reliever) 325 MG (milligrams) oral tablet;2. Citalopram (an antidepressant) 40 MG oral tablet;3. Famotidine (decreases stomach acid) 20 MG oral tablet;4. Furosemide (a diuretic medication - to help eliminate excessive fluid in the body) 40 MG oral tablet;5. Potassium chloride (a medication used to prevent and treat low potassium levels) 20 MEQ (milliequivalent) oral tablet; and6. Quetiapine (Seroquel - an antipsychotic) 25 MG Oral Tablet. None of these medications had special instructions on the orders to crush the medications. When asked how he/she knew these medications for Resident #29 needed to be crushed, LN #4 stated that it was just known. The LN further stated the information would be passed on during report to the next nurse. LN #4 confirmed that there were no orders to crush any of the administered medications. Review of Resident #29's most recent Minimum Data Set (MDS - a federally required assessment), a quarterly assessment dated [DATE], revealed the resident was not identified as coughing or choking during meals or when swallowing medications. Resident #53 Record review on 1/11-15/26 revealed Resident #53 was admitted to the facility with diagnoses that included malignant neoplasm of the tongue (cancer of the tongue); aftercare following surgery for neoplasm (removal of cancer); and dysphagia (difficulty swallowing). Further review revealed Resident #53 had an order for NPO (nothing by mouth) and had a jejunostomy (J-tube - a medical device, surgically placed through the abdomen, used to provide nutrition and medication directly to the small intestine, or jejunum). Review of Resident #53's medication orders revealed several medications that were ordered to be administered by mouth: 1. Glycopyrrolate [a medication to help reduce excessive stomach acid production] 1mg oral tablet - Give 1 tablet ORAL TID [three times a day] for excessive secretions. The order start date was 1/2/26; 2. Glycopyrrolate 1mg oral tablet - Give 1 tablet ORAL nightly for excessive secretions. The order start date was 1/5/26; 3. Polyethylene glycol [Miralax - a medication for constipation] 3350 Oral powder - Give 17gm [grams] ORAL powder daily PRN [as needed] constipation. The order start date was 1/12/26; 4. Acetaminophen-hydrocodone [an opioid pain medication] 325mg-5mg oral tablet - Give 2 tablets ORAL Q4HRS [every 4 hours] PRN pain. The order start date was 1/12/26; and 5. Senna [a medication for constipation] 8.6mg oral tablet - Give 8.6mg ORAL daily PRN for constipation. The order start date was 1/2/26. During an interview on 1/13/26 at 3:53 PM, LN #5 stated Resident #53's medication should all be administered through his/her J-tube. When asked to review Resident #53's medications with orders for oral administration, LN #5 stated the medication's oral routes would not be correct and needed to be fixed to reflect J-tube as a route. During an interview on 1/15/26 at 11:35 AM, the Senior Operations Manager for the Denali Pharmacy (SOM) stated medication orders should specifically state the correct route. Orders to crush a medication would have an order comment indicating that a medication could be crushed. When asked to review Resident #53's medication orders to confirm if the correct route, via J-tube, was indicated on the orders, the SOM stated that they were written to be administered orally, and they were working on correcting the orders. When asked to review Resident #29's medication orders to confirm if the resident's medications should be crushed, the SOM stated there was not an order comment indicating the medications could be crushed. Review of the facility provided policy Denali Center - Medication Administration, effective date 8/8/24, revealed: . Before administering a medication, the licensed caregiver has the responsibility to. Verify the 6 rights (right resident, drug, dose, route, time, documentation) for each medication administered. Before crushing an oral solid for delivery, the licensed caregiver ensures that this dosage form can be safely crushed and administered. If a resident is receiving a medication through a tube or line (i.e. IV line, nasogastric tube, etc.) the use of the correct line is verified. Check the compatibility of the medications if more than one medication is to be administered via the same line. The medication dose, time and route will be documented on the Medication Administration Record immediately at the time of administration.

.Based on observation, interview and record review, the facility failed to ensure medication and medical supplies were labeled appropriately, and removed from service if expired, in 1 medication cart, out of 7 medication carts inspected, and 1 unit medical supply storage area, out of 3 unit medical supply storage areas inspected. These failed practices had the potential to place the residents of the Tamarack unit (based on a census of 24) at risk of receiving expired medications and supplies which could cause adverse reactions and/or complications. Findings:An observation on 1/14/26 at 9:40 AM, of the Tamarac Unit, revealed a medication cart which had the following: - Four Monoject Needless Med Prep Cannula, expired on 4/30/2025;- One BARD Powerloc Safety Infusion Set (needle to access ports) 20G (gauge) x 0.75 in (inches), expired on 1/19/25;- One 3M Tegaderm transparent film dressing 4 in x 4 3/4 in, expired on 1/31/25; - Two 3M Tegaderm transparent film dressing 2 3/8 in x 2 3/4 in, expired on 11/7/23;- One Replicare dressing 1 1/2 in x 2 1/2 in, expired on 7/28/23; and- One bottle of Rugby Children's Chewable Multivitamins, unreadable expiration date, no handwritten date. An observation on 1/14/26 at 9:40 AM, of the Tamarac Unit, revealed the unit medical supply storage which had the following: - One Mepilex Border 4 x 12 in dressing, expired on 8/28/24;- One Mepilex Border 4 x 12 in dressing, expired on 5/28/25; During an interview on 1/14/26 at 8:39 AM, Licensed Nurse (LN) #1 stated medication was checked for expiration dates during medication pass. Each unit's Resident Care Coordinators (RCCs) would be assigned to audit the medication carts and supplies for expired items. If any were found, those items were replaced. The shared supply chain department for long-term care (LTC) and the hospital also monitored expiration dates. During an interview on 1/14/26 at 9:40 AM, LN #3, stated expired items should be thrown out and if an expiration date was unreadable, then it should be discarded and replaced. During an interview on 1/15/26 at 1:53 PM, the Administrator stated at the beginning of the month, nurses (RCC - Resident Care Coordinators) will go through the medication carts and supply carts and check expiration dates. The Administrator further stated when expired items were found, staff should throw the items away. Review of the facility provided Floor Stock Inspections, effective on 10/2/25, revealed: . Manufacturer's expiration dates or other pharmacy labeled dates will be used as a basis for removal of outdated items. Products without manufacturer dating. or without a handwritten date will also be removed.

Based on interview, observation and record review, the facility failed to ensure residents were provided with clear instructions on how to file a grievance while units were quarantined and segregated due to an Influenza outbreak, along with easy access to the grievance box during this time. This failed practice denied all residents and/or their representatives based on a census of 71, the right to submit grievances without fear of discrimination or reprisal. Findings: During a meeting with the Resident Council on 1/8/25 at 2:05 PM, when asked if they knew how to file a grievance, Resident #48 stated: there is one by the Administrator's office, the problem is that we are on full lockdown that started 10 days ago, and we are stuck in our wings [Units] so we cannot go get it, we cannot file a grievance. Resident #27, Resident #25 and Resident #51 also expressed confusion regarding the process of who handled the grievances and how to access the grievance forms and the grievance box. When asked if residents can file a grievance without fear of retaliation, Resident #25, and Resident #27, both stated they fear retaliation if they complained about their care. During observations from 1/6-10/25, all units were quarantined and segregated due to an Influenza outbreak, with doors to all the units closed. The units did not have any indications on how to file a grievance. Further observation revealed the grievance drop box was located next to the entry door of the Administrator's office. The Administrator's office was located by the front entrance of the facility, away from where the units were located. Review of the document Denali Center Grievance Procedure, date unknown, revealed the Denali Center Grievance Official was the Administrator. During an interview with Resident Care Coordinator #1 (RCC) on 1/10/25 at 8:17 AM, when asked how residents were able to file grievances, the RCC stated: Most of the time they [the residents] come find me or tell a nurse and I do an investigation and then take it to the Director of Nursing [DON], depending on what it is and its severity. The RCC further stated they did not have a grievance box on the units and that the grievance box was located away from all the resident rooms, outside the administrator's office. During an interview on 1/10/25 at 8:20 AM, regarding how to file a grievance, RCC #3 stated: there is a board near the cafeteria with a form they can fill out and there is a box by the administrator's office, but normally what happens is that they [the residents] come to me and either myself or the social worker fills out a formal grievance. They can also call Ombudsman and fill out an anonymous grievance that way. During random observations from 1/6-10/25, both the Denali Center Grievance Procedure and Denali Concern Form were located on the bulletin board near the common Dining Room (room [ROOM NUMBER]) in the Mall area of the facility, outside the care units. No other instructions were available on the bulletin board to indicate where the physical location of the grievance box or where to deposit the Denali Concern Form. During an interview on 1/8/25 at 4:35 PM, the Administrator confirmed that the box used for grievances was a wooden box located outside of her office, which was by the Long-Term Care entrance of the building, away from the care units. The Administrator further stated she did not want to take the risk of spreading Influenza A to the vulnerable residents, which was the reason why the facility was on lockdown. She stated the measures implemented were like COVID-19 measures, where resident interactions were kept minimal. She further stated the residents were able to access the grievance box despite this lockdown measure. When informed of the Resident Council concerns, she stated: What am I supposed to do, move a box to the units for 5- or 6-days' worth of a lockdown? She further added that residents can go through their social worker to submit the form or that residents can still come out to submit their grievances. When asked about the confidentiality aspect of the grievance process due to the location of the box, the Administrator said that confidentiality was maintained despite of the box being in front of her office. She further added that there would not be a difference whether the box was on the units or in front of her office. She further stated they can still be seen dropping a form. She further stated, she was concerned the forms would be missed if there were multiple boxes in different areas of the facility and she may not have time to check multiple places daily. Review of the document Denali Center Grievance Procedure, date unknown, revealed: . to assist you [Residents] when a problem does arise, we have prepared the following guide. In following the steps indicated, we will be able to provide a timely response to your concerns. It is our preference to resolve issues with our internal process, but we have included steps to contact outside agencies should you feel it appropriate . Step 1. We encourage you to speak up about the things that concern you. Step 2. If you have a concern or complaints, ask to see the charge nurse or social worker. Step 3. You may voice your concerns to any staff member you wish. They will help you by first remedying the problem if they can and notifying the charge nurse or social worker for follow up. Step 4. You have the right to file grievances anonymously. Step 5. You should expect a visit from the Charge Nurse/RCC [Resident Care Coordinator] or social worker within 1 hour of voicing your concerns. Step 6. We will discuss your concerns and begin a process to investigate and correct or make changes to resolve any problems identified. Your concern will be reported to our administrator and any departments involved. Step 7. Within seven (7) working days you can expect to receive a follow up about the concerns you have raised. Step 8. Within fourteen (14) working days you will receive a written or a verbal response from our administrator/nurse/manager/case manager with the findings of our investigation about your complaint. Further review of this document, there were no clear instructions on how to file a grievance and where to deposit the grievance form. Review of the document Denali Concern Form, revised on 5/2019, revealed the following: Reporter's name (may be anonymous); Date; Contact Information (address/telephone); Location [options to select the location] (Aspen, Birch, Tamarack, Willow, Spruce, Court Mall, Lobby or Other; Department (Nursing, Environmental .); Summary of Statement; List of Any Witnesses; Date Received by Grievance Officer; Name of the person completing the form if different; Steps to investigate; Summary of Findings; Formal grievance confirmed [checkboxes for Yes/ No]. Review of the Denali Center Concern Form and the Denali Center Grievances Procedure documents did not provide details on how to turn in a grievance form, or where the location of the grievance box was. Review of the policy and procedure titled Denali Center: Grievance Process dated 3/5/24, revealed: A. All residents have the right to voice grievances without decriminalization or reprisal or fear of discrimination or reprisal .E. Residents are notified through postings of the right to file grievances orally or in writing: the right to file grievances anonymously; the contact of information of the grievance official with who a grievance can be filed and a reasonable time frame for completing the review of the grievance: the right to obtain a written decision regarding his or her grievance, and the contact information of independence [independent] entities with whom grievances may be filed.

Based on observation, interview, and record review, the facility failed to properly store drugs and medical supplies. These failed practices had the potential to place all residents (based on a census of 71) at risk of receiving expired and non-sterile medications and supplies and subsequent adverse effects. Findings: Tamarack and [NAME] Medication Shared Room: An observation on 1/8/25 at 6:15 PM, revealed the following medical supplies were expired: - One box of 1.5 mL BD [[NAME], [NAME] and Company] ChloraPrep FREPP Clear applicators, expired on 10/24; - One quart bottle of Distilled [NAME] Vinegar in the ear irrigation tray, expired on 10/24. During an interview on 1/8/25 at 6:15 PM, Resident Care Coordinator (RCC) #3 confirmed expired supplies should have been discarded. Tamarack Medication Room: An observation on 1/8/25 at 6:28 PM, revealed the following medical supplies and medications were expired: - Two boxes of Nicotrol Inhaler 10 mg cartridges (smoking cessation aid), expired on 5/24; - One bottle of Children's Chewable Multivitamin, expired on 3/24; - One Stat Strip Xpress Glu Control Level 3, expired on 12/26/24; - Two Protexis PI Surgical Gloves, expired on 8/31/24 and 9/30/24; - Five 4 in. by 12 in. Mepilex Border AG dressings, expired 8/25/24; - One 4 in. by 4 in. Replicare Ultra dressing, expired on 10/22. During an interview on 1/8/25 at 6:28 PM, RCC #3 confirmed expired medications should have been returned to the pharmacy and the expired medical supplies should have been discarded. During an interview, on 1/9/25 at 10:05 AM, Pharmacist #1 stated the Nicotrol Inhalers were home medications of a current resident. He/she further stated home medications stored in medication carts were not monitored by the pharmacy department. Pharmacist #1 confirmed expired home medications were typically returned to and discarded by the pharmacy department. The pharmacist added Nicotrol had not yet been discarded as Nicotrol cartridges were expensive and difficult to obtain as they were no longer produced. Pharmacist #1 stated the facility follows the retail pharmacy's provided label for expiration dates. Denali Center BLS (Basic Life Support) Cart: An observation on 1/9/25 at 7:49 AM, revealed the following expired medical supply: One 4-1/2 x 4-1/8 yd Kerlix bandage roll expired on 8/22. Record review on 1/9/25 at 7:49 AM, of the facility's Emergency Equipment Cart log revealed the following: Check Weekly .Restock when expired & After Use . 1-Drawer of dressing supplies . [last checked] 12/22/24. During an interview on 1/9/25 at 7:49 AM, RCC #1 stated night shift charge nurses were responsible for inspections of the crash (BLS) cart weekly. Review on 1/9/25 at 3:00 PM, of the facility's Night Charge Nurse Duties, undated, revealed: Check the Crash cart every Wednesday. Document in the notebook marked weekly checks located in [RCC's] office on the Emergency cart. Review on 1/9/25 at 3:00 PM, of the facility's 12 HOUR NIGHT CHARGE procedures, undated, revealed: CHECK CRASH CART ON WEDNESDAY. Birch Medication Room: An observation on 1/9/25 at 8:01 AM, revealed the following opened and expired medical supplies: - One 1000 ml 0.9% Sodium Chloride Injection USP bag not in original packaging; - One I.V. (Intravenous) dressing kit not in the original packaging; - One 1.5 mL BD Chloraprep FREPP Clear applicator, expired on 10/24; - One Adult Pulse Oximeter Adhesive Sensor, expired 11/1/21. During an interview on 1/9/25 at 8:01 AM, RCC #2 stated expired and opened supplies should have been discarded. He/she further stated nurses should have been responsible for ensuring no expired medications and/or expired medical supplies were stored in the medication rooms. During a follow up interview on 1/9/25 at 1:15 PM, RCC #2 stated, based on the LPN( Licensed Practical Nurse) manager job description, the RCCs were responsible for ensuring medications storage rooms do not have expired supplies. Review of the facility's job description of LPN Mgr [Manager], undated, revealed Essential Functions .provides daily operational resource management including . supplies Aspen and Birch Medical Supply Room: An observation on 1/9/25 at 8:20 AM revealed the following expired products: - Seven .81 oz of Juven Therapeutic Nutrition Powder packets, expired on 8/1/24; - One .81 oz of Juven Therapeutic Nutrition Powder packets, expired on 3/1/24; - 32 .81 oz of Juven Therapeutic Nutrition Powder packets, expired on 11/1/24; - 43 0.14 oz Nutrisource fiber supplement packets, expired on 07/11/24. During an interview on 1/9/25 at 8:20 AM, RCC #2 stated expired nutritional supplements should have been discarded however it was the responsibility of Nutrition Services (NS) to ensure supplements stored in the storage rooms were not expired. During an interview on 1/9/25 at 2:59 PM, NS #3 confirmed NS were responsible for ensuring dietary products such as tube feeding formulas and nutritional supplements stored in the medical supplies room were not expired. He/she further stated, NS typically rounded every day to check the stock in the facility, but expired products were either missed or packaging was not checked for expiration dates. When asked about written policies and procedures regarding storage of dietary products, NS #3 stated there were none.

Based on observation, interview and record review the facility failed to ensure potentially hazardous foods were stored, labeled and prepared foods in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) foods were labeled and dated; 2) expired foods were discarded; 3) Nutrition Services staff performed hand hygiene with glove changes and during the cooking and the preparation of foods. These failed practices had the potential of causing or spreading foodborne illnesses to residents, based on a census of 70, who received food from the kitchen. Findings: An observation, during the initial main kitchen tour, on [DATE] at 10:50 AM, revealed: 1) Dry Storage in Fireweed Cafe: - 30 expired Alpine Spiced Apple Cider Original- single serving packets- with manufacture best by date of [DATE]; - 44 expired [NAME] Sweet & Sour Sauce- 1- ounce single serve containers-with a manufacture used by date of [DATE]; - One expired Kikkoman Less Sodium Soy Sauce-5-ounce bottle-with manufacture best by date of [DATE]; -One expired Monarch Mandarina Segmentos Enteros-6-pound 10 ounce can- received on [DATE] and expired on [DATE]; -One-expired Monarch California Sliced Yellow Cling Peaches-6-pound 9 ounce can- received on [DATE] and expired on [DATE]; -One-expired [NAME] Ploy Sweet Chili Sauce- 25-ounce bottle-with manufacture expiration date [DATE]; -16-expired Nutri Grain Apple Cinnamon Soft Baked Breakfast Bars-1.3-ounce packages, with manufacture expiration date [DATE]; -One-box Heinz Tartar Sauce- open box [full box quantity 200 count] ,d+[DATE] full box- 0.12-gram single serve packages, with manufacture expiration date [DATE]; -One-clear plastic bag [containing multiple] Kikkoman Soy Sauce ,d+[DATE] full- single served packets [size of packet unknown], with manufacture best by date [DATE]; -One- box [NAME] Fat Free Classic Ranch Dressing open box [full box quantity 200] ,d+[DATE] full- 12.4-gram single served packet, with no best used by date or expiration date; -Two-boxes [NAME] Golden Italian Dressing open box [full box quantity 200] ,d+[DATE] full box-12.4- gram single served packet, no best used by date or expiration date; -One plastic container Chef's Pride Canola Oil-1 gallon bottle- no best used by date or expiration date; -One plastic container [NAME] Mayo Light-1 gallon container, no best used by date or expiration date; -One box Herb Ox Sodium Free Granulated Chicken Bouillon - single serving packets- half full box, no used by date or expiration date; -One box Monarch Non-Dairy Creamer open box [full box quantity 2000] ,d+[DATE] full-2.5-gram packet, no best used by date or expiration date; During an interview on [DATE] at 10:57 AM, the Culinary Director (CD) stated after the food arrived the products were taken through the hospital kitchen for processing. He stated that the food products were dated with a sticker gun and to be used within 6 months from the received date. When asked about food products that were not dated, and products that did not have a best used by date or expiration date, the CD did not provide an answer. 2) Fireweed Cafe Dining Refrigerator: -One- expired Chobani Blueberry Greek Yogurt individual container-4 ounces, with manufacture expiration date [DATE]; -One plastic container labeled G. Macaroni, no best used by date or expiration date; -One-plastic container labeled P. Macaroni, no best used by date or expiration date; -Two-disposable containers, labeled apple containing light yellow liquid with the sliced apples, no best used by date or expiration date; During an interview on [DATE] at 11:33 AM, Nutrition Service (NS ) #3 stated the macaroni containers contained ground and pureed macaroni salad. NS #3 stated they were not dated since they were prepared to be used that day. NS #3 further stated the liquid in apples was apple juice and were going to be used later that day. An observation during the hospital kitchen [a kitchen that stored food and prepared meals for residents in the long-term care] tour, on [DATE] at 9:30 AM, revealed: 3) Walk-in Freezer: -One- open box Plant-Based Smashed Patty in open plastic bag- ,d+[DATE] full- 2.6-ounce patty, no best used by date or expiration date; -One- clear plastic bag, food not identified [appeared to be large shell pasta noodles], not labeled, no best used by date or expiration date; -One- clear plastic bag, food not identified [appeared to be hotdog buns], 11 buns, not labeled, no best used by date or expiration date; -One- clear plastic bag, food not identified [appeared to be biscuits], quantity unknown, not labeled, no best used by date or expiration date; -Two- clear plastic bags, food not identified [appeared to be angel food cake], both containing ,d+[DATE] cake, not labeled, no best used by date or expiration date; -One- open box Hilltop Hearth Blueberry Muffins, 5 muffins, no best used by date or expiration date; -One- open box [NAME] Blueberry, in open plastic bag- ,d+[DATE] full, no best used by date or expiration date; -One- metal cart with three shelves- containing metal trays appeared to be chicken strips, French fries, and chicken wings not covered, not labeled, no best used by date or expiration date; -One-open box Grimmway Farms Carrots individual packets- 1.6 ounce- best if used by [DATE]; -One-open box US Foods Cheese loaf of white cheese wrapped in plastic, no best used by date or expiration date; -One-open box Cubed Cheese -5-pound packages- 2 opened bags, wrapped in plastic, both ,d+[DATE] full, no open date, no best used by date or expiration date. 4) Main Kitchen Food Preparation: -One- open box Quacker Quick Creamy Wheat-28-ounce box, contents not sealed opened to air; -One- open box [NAME] Enriched Hominy Quick Grits-20-ounce box, contents not sealed opened to air; -One- ,d+[DATE] loaf [NAME] Wheat Sandwich Bread- 24-ounce bag, with manufacture best by date [DATE]; -One- clear plastic bag [NAME] English Muffin -6 muffins, no best used by date or expiration date; -One- clear plastic bag [NAME] Bagel -6 bagels, no best used by date or expiration date; -One-clear plastic bag [NAME] bread -full bag, appears unopened, no label, no best used by date or expiration date. During a simultaneous interview on [DATE] at 9:40 AM, reviewed items found in the walk-in freezer and food preparation area of the kitchen, CD stated food products were not dated in the freezer since it is frozen and safe, only the quality goes down. NS #4 stated the carrots are good as long as they are kept frozen, we take out what we need and use, they can last for years. NS #4 further stated as products come in we just rotate the food, use older stuff first, we go through it quick. 5) Food Preparation and Plating Observation: An observation on [DATE] at 6:30 AM, food was prepared in the hospital kitchen and placed in metal containers with plastic wrap over the containers. Containers were placed in a warming cart for transport to the LTC. An observation on [DATE] at 7:00 AM, NS #2 placed metal containers in the steam table with gloved hands. Using the same gloved hands, NS #2 then made pancakes and French toast, placed the food in a metal container and moved it into the steam table. Continuing the observation on [DATE] at 7:25 AM, NS #2, still using the same gloved hands, measured the food temperatures for all food on the steam table. An observation on [DATE] at 7:43 AM, NS #1 was wearing gloves, while preparing supplemental shakes, pureed bananas, and was going in and out of the refrigerators. NS #1 changed his/her gloves without performing hand hygiene. During an interview on [DATE] at 7:43 AM, the CD stated staff was to perform hand hygiene between glove changes. An observation on [DATE] at 7:51 AM, NS #1 removed his/her gloves in the main kitchen, walked into Fireweed dining room to retrieve supplies, returned and, without performing hand hygiene, and put on a new pair of gloves. During a continuous observation on [DATE] at 7:53 AM through 9:08 AM, NS #2 cooked and prepared food with gloved hands. NS #2 wiped his/her gloved hands on a towel placed next to steam table. Next, NS #2 cracked raw eggs into a container, then whisked, and then poured the whisked eggs into a pan to cook. Next, NS #2 placed shredded cheddar cheese on top with the same gloved hands and then placed the cooked cheesy eggs onto a resident plate. Next, NS #2 returned to the steam table, which contained sausage gravy, turkey sausage, bacon, scrambled eggs, cream of wheat cereal, oatmeal, hashbrowns, pancakes, blueberry muffins and French toast, and prepped several resident's plates with cooked food from the steam table. While NS #2 prepared another resident plate, he/she touched the cooked eggs and bacon with same gloved hands used to handle raw eggs from earlier in the observation. NS #2 continued creating additional resident plates with food from the steam table while using the same gloved hands. NS #2 did not perform hand hygiene after he/she prepared raw food and served cooked food. During a follow-up observation of the dry storage in Fireweed Cafe on [DATE] at 9:50 AM, revealed: -One expired Kikkoman Less Sodium Soy Sauce-5-ounce bottle-with manufacture best by date of [DATE]; - 30 expired Alpine Spiced Apple Cider Original- single serving packets- with manufacture best by date of [DATE]. Review of the facility's policy Food Safety and Sanitization, last reviewed [DATE], revealed: 2) Employees . will hand all foods safely. 4. All staff will wash their hands just before they start to work in the kitchen and when they have used their hands in an unsanitary way.4) Food Storage . 4. Foods are protected from contamination . 8. All leftovers are labeled, covered, and dated when stored . 9. Foods with expiration dates and best by dates are used prior to the date on the package . 10. Canned and dry foods without expiration dates are used within six months of delivery or according to the manufacture's guidelines . Review of the facility's policy Food Preparation, effective date [DATE], revealed: . k. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods . Review of the facility's Food Service Worker- Job Code: 3304, undated, revealed: . Requires the ability to follow . and maintaining sanitation standard. This position requires the ability to learn and follow established policy and procedures . Must be able to learn food handling regulations . Review of the facility's Cook- Job Code: 3298, undated, revealed: . Must be able to learn and follow established policies and procedures . Must be able to learn food handling regulations . Review of the Food and Drug Administration (FDA) guidelines (Food labeling 2020), accessed at this link: https://www.FDA.gov, revealed: . concerning food storage and labeling, while the FDA does not mandate expiration dates, it encourages to use best by, use by, or sell by dates to indicate peak quality and safety as well as practices of inventory management such as First In, First Out (FIFO), inventory management practice that helps ensuring that older stock is used before newer stock, reducing waste and spoilage.

Based on observation, interview and record review the facility failed to ensure staff followed hand hygiene practices. Specifically, nutrition service staff did not performed hand hygiene and/or glove changes during the cooking and the preparation of the food. This failed practice placed all residents who receive food from the kitchen, based on a census of 70, at risk for cross contamination and spread of infectious disease; Findings: Dietary Hygiene: An observation on 1/9/25 at 7:43 AM, NS #1 was wearing gloves, while preparing supplemental shakes, pureed bananas, and was going in and out of the refrigerators. NS #1 changed his/her gloves without performing hand hygiene. An observation on 1/9/25 at 7:51 AM, NS #1 removed his/her gloves in the main kitchen, walked into the Fireweed dining room to retrieve supplies, returned and, without performing hand hygiene, and put on a new pair of gloves. During a continuous observation on 1/9/25 at 7:53 AM through 9:08 AM, NS #2 cooked and prepared food with gloved hands. NS #2 wiped his/her gloved hands on a towel placed next to steam table. Next, NS #2 cracked raw eggs into a container, then whisked, and then poured the whisked eggs into a pan to cook. Next, NS #2 placed shredded cheddar cheese on top with the same gloved hands and then placed the cooked cheesy eggs onto a resident plate. Next, NS #2 returned to the steam table, which contained sausage gravy, turkey sausage, bacon, scrambled eggs, cream of wheat cereal, oatmeal, hashbrowns, pancakes, blueberry muffins and French toast, and prepped several resident's plates with cooked food from the steam table. While NS #2 prepared another resident plate, he/she touched the cooked eggs and bacon with same gloved hands used to handle raw eggs from earlier in the observation. NS #2 continued creating additional resident plates with food from the steam table while using the same gloved hands. NS #2 did not perform hand hygiene after he/she prepared raw food and served cooked food. During an interview on 1/9/25 at 7:43 AM, the Culinary Director stated staff were to perform hand hygiene between glove changes. Review of the facility's policy, Food Safety and Sanitization, last reviewed 5/28/24, revealed: . 2) Employees . will handle all foods safely. 4. All staff will wash their hands just before they start to work in the kitchen and when they have used their hands in an unsanitary way. Review of the facility's policy, Food Preparation, effective date 10/28/22, revealed: . k. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods . Review of the facility's Food Service Worker- Job Code: 3304, undated, revealed: . Requires the ability to follow . and maintaining sanitation standard. This position requires the ability to learn and follow established policy and procedures . Must be able to learn food handling regulations . Review of the facility's Cook- Job Code: 3298, undated, revealed: . Must be able to learn and follow established policies and procedures . Must be able to learn food handling regulations . Review of the U.S. Food and Drug Administration (2022) FDA Food Code 2022 (FDA Publication No. 2022) U.S. Department of Health and Human Services, accessed on 1/22/25 at https://www.fda.gov/media/153455/download, revealed 2-301.14 . 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 including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES 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 . (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD . (H) Before donning gloves to initiate a task that involves working with FOOD . (I) After engaging in other activities that contaminate the hands. Further review of Review of the U.S. Food and Drug Administration (2022) FDA Food Code 2022 (FDA Publication No. 2022) U.S. Department of Health and Human Services, accessed on 1/22/25 at https://www.fda.gov/media/153455/download, revealed 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.

51613 Based on observation, interviews and record review, the facility failed to ensure three residents (#s 19, 22, 25) out of 20 sampled residents were given the opportunity to make choices about aspects of their lives that were significant to them. Specifically, the facility failed to ensure residents' rights to choose and participate in activities consistent with his/her interest. This failed practice had the potential to affect residents' quality of life. Findings: Activities participation: An observation on 1/6/25 at 1:14 PM revealed a white board by the Activity Room, stated, January 6th, 2025. Happy New Year! No group activities today, sorry for inconvenience . Resident #19 Record review on 1/6-10/25, revealed Resident #19 was admitted to the facility with diagnoses that included morbid obesity (a complex chronic disease that is characterized by a Body Mass Index [BMI] of 40 or higher), major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest), anxiety, and hemiplegia (neurological condition that involves paralysis of one side of the body). During an interview on 1/6/25 at 11:46 AM, Resident #19 stated he/she did not like how they are on lockdown and stated that, he/she enjoys bingo and socializing with others. Furthermore, he/she added that bingo hasn't happened since this lockdown. Review of the resident's care plan, undated, revealed: . Participate in Activity of Choice Daily . Encourage Active participation for Social Interaction Needs . Activities will Post Calendar in room . Remind Resident of Upcoming Activities of Interest . Resident #22 Resident #22 was diagnosed with anxiety, aphasia (impairment in a person's ability to comprehend or formulate language because of damage to specific brain regions), hemiplegia, and major depressive disorder. During an interview on 1/6/25 at 2:19 PM, the Resident stated that he/she was not able to go to activities due to being on lockdown. Furthermore, he/she added that there were no alternative activities offered for church. Review of the resident's care plan, undated, revealed: .Encourage Active Participation for Social Interaction Needs . Encourage Active Participation for Religious Spiritual Needs . Invite and Assist to Group Activities of Interest . Resident #25 Resident #25 was diagnosed with morbid obesity, chronic obstructive pulmonary disease (lung obstruction), hypertensive heart disease with heart failure (high-pressure heart), type 2 diabetes mellitus (insulin resistance), and major depressive disorder. During an interview on 1/7/25 at 11:24 AM, Resident #25 stated: Upper management are the ones making the rules. We are not allowed to go to church. We were told we couldn't go, not even with a mask. Visitors can come in and have a mask. We are not allowed to visit out there [referring to the common areas] anymore. This affects activities too, because if everyone wanted to play Bingo there is not enough room in the sunroom to have things as they should. During a meeting with the Resident Council on 1/8/25 at 2:05 PM, Resident #25 further stated they closed down our store, church and we can't walk around freely. During the same meeting, all residents in attendance confirmed that the option of Church [religious services] happening via Zoom (an online video conferencing tool) was not presented to them. During an interview with the Medical Director on 1/10/25 at 11:00 AM, he stated suspending activities just happens by default . the point is to not have people near each other. During an interview with Activities Assistant #1 on 1/9/25 at 12:00 PM, he/she stated that church was cancelled on two different days due to the lockdown. He/she further stated the facility had not considered Church activity via Zoom as an option. Review of the resident's care plan, undated, revealed: .involve in activities of choice and interest . adapt care and environment to optimize independence .engage in daily independent activities.

Based on record review, interview and observation, the facility failed to monitor, evaluate, and determine the use of assistive devices as physical restraints for two residents (#31and #61) out of 20 sampled residents. This failed practice placed residents at an increased risk for unnecessary physical restraints, inadequate monitoring of devices, and physical injury. Findings: Resident #31 Record review on 1/6-10/25, revealed Resident #31 was admitted to the facility with diagnoses that included dementia (a condition that affects memory and thinking) and Parkinson's disease (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination). During an observation and simultaneous interview on 1/7/25 at 11:56 AM, Resident #31 was wearing a belt around his/her waist that was attached to the wheelchair. In the center of the belt was a plastic piece that resembled a belt buckle. When resident was asked if he/she could remove the belt, he/she said no. Resident #31 further stated maintenance personnel or clinical staff were the only ones that could remove the belt. When asked what the belt was for, Resident #31 stated it keeps me from falling out. During an interview on 1/9/25 at 4:39 PM, Resident Care Coordinator (RCC) #2 stated Resident #31 started wearing the seat belt on 6/19/24 after a fall. When asked if Resident #31 was able to remove the belt, RCC #2 stated he/she was not aware. RCC #2 was unable to locate in the EHR (electronic health record) if Resident #31 was able to remove his/her seat belt. RCC #2 stated Resident #31 transfers with one person assist. RCC #2 further stated Resident #31 transfers with the use of a sit to stand device. RCC #2 explained residents must have strength to use a sit to stand device being able to hang on and bear weight with their legs. During an interview on 1/9/25 at 5:01 PM, when the Director of Nursing (DON) was asked if Resident #31 could remove his/her wheelchair seat belt, she stated I think so, he/she can paint. When further asked if there was an evaluation completed to verify that the resident was assessed, she stated I sure hope so, it would be if I was on the floor. Review of the facility's, Quarterly Assessment, dated 12/2/24, revealed: . Other: tremors . Mobility Braden: Very limited . Can resident appropriately call for assistance?: Yes . Morse Mental Status . Orientated to own ability .Does the resident have a hx [history] of falls?: Yes . Is resident able to communicate needs?: Yes . Free of restraints . Review of the MDS (Minimum Data Set, a federally required nursing assessment) OBRA Quarterly Review Assessment, dated 12/4/24, revealed: P0100. Physical Restraints, Physical restraints are any manual method or physical or mechanical device, mater or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . Used in Chair or Out of Bed. G. Chair prevents rising. 0 = Not used. H. Other. 0 = Not used. P0200. Alarms. An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected . F. Other alarm. 0 = Not used. Review of the Care Plan Summary, dated 1/9/25, revealed: . Interventions . Ensure Resident Can Remove Velcro Seatbelt Independently. Resident #61 Record review on 1/6-10/25, revealed Resident #61 was admitted to the facility with diagnoses that included failure to thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction, and low cholesterol) and Schizophrenia (a severe mental disorder characterized by delusions [false beliefs], hallucinations [perception of sights, sounds, etc. that are not actually present], incoherence and physical agitation). During an observation and simultaneous interview on 1/6/25 at 2:48 PM, Resident #61 was sitting in a manual wheelchair in his/her room. Resident #61 had a belt around his/her waist that was attached to the wheelchair. In the center of the belt was a plastic piece that resembled a belt buckle, which would alarm when it was released. When the Resident was asked if he/she could remove the belt, he/she stated no and was shaking his/her head back in forth. Resident #61 was observed with upper extremity tremors when trying to grab the belt to demonstrate the inability to remove it. Certified Nursing Assistant (CNA ) #2 walked into Resident #61's room during the conversation and stated, the strap is to prevent a fall, if the Resident tries to stand up, it alarms. CNA #2 stated to Resident #61, I am going to set off the alarm and then pulled the hook and loop belt apart, which set off the alarm. When asked if Resident #61 was able to remove the seat belt, CNA #2 stated he/she did not know. During an interview on 1/9/25 at 4:30 PM, RCC #2 stated Resident #61's seat belt alarm was initiated on 10/28/24 after a fall. RCC #2 stated residents must be able to open the belt independently or it was a restraint. RCC #2 stated there were no documented seat belt evaluations for Resident #61. RCC #2 further stated he/she was not aware who verified that the resident was able to physically remove the belt. During an interview on 1/9/25 at 4:54 PM, the Administrator stated residents must be able to remove seat belts prior to the initiation of the device. She further stated if the resident was unable to remove the seat belt, a seat alarm [chair pad alarm] should be used. Review of the Post Fall Evaluation Long Term Care, dated 1/6/25, revealed: . Mechanism of Fall: . resident found by staff in [his/her] room .and [his/her] w/c [wheelchair] which was tipped over. Orientation Assessment: Disoriented x 4. Record review of the MDS OBRA Quarterly Review Assessment, dated 10/23/24, revealed: . Section P - Restraints . P0200. Alarms. An alarm is a physical or electronic device that monitors resident movement and alerts the staff when movement is detected. D. Motion sensor alarm. 1 = used less than daily. No other documentation for alarms reviewed. Review of the facility's Quarterly Assessment LTC, dated 10/23/24, revealed: . Ambulates with 1 person assist, . Free of restraints, Other: ez stand [sit to stand lift] . Review of the facility's policy, Restraints/Resident Behavior and Practices, effective date 10/15/24, revealed: Purpose/Expected Outcome: A. This facility believes that each resident has the right to be free from any physical restraints imposed. for purposes of discipline or convenience. If physical restraints . are utilized, they must treat the resident's medical symptoms. Definitions: A. Physical Restraints: any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety belts, and geri-chairs can be physical restraints. 2. A seat belt is a restraint when: a. When the resident can move self from sitting position to standing and is unable to remove the seat belt.

Based on record review, interviews, and observations, the facility failed to ensure activities of daily living (ADLs) were provided to two residents (#s 19 and 67), out of 20 sampled residents. Specifically, showers or baths were not provided to the residents as specified in their individualized plans of care. This failed practice resulted in residents not receiving ADLs to maintain personal care and hygiene . Findings: Resident #19 Record review on 1/6-10/25, revealed Resident #19 was admitted to the facility with diagnoses that included morbid obesity (a complex chronic disease characterized by a Body Mass Index [BMI] of 40 or higher), and hemiplegia (neurological condition that involves paralysis of one side of the body). Review of the facility's .Bath/Shower Schedule, dated 12/12/24, revealed Resident #19 was noted to have scheduled shower days on Tuesdays and Saturdays. During an interview on 1/6/25 at 11:15 AM, Licensed Nurse (LN) #2 stated the Bath/Shower schedule was the most recent version. During an interview on 1/6/25 at 11:20 AM, when asked if he/she was provided with a shower or bath, Resident #19 stated, I can't remember when the last time was . During an interview on 1/9/25 at 8:31 AM, LN #4 stated that when ADL cares were completed it would be documented in the Electronic Health Record (EHR). Review of the MDS (Minimum Data Set, a federally required nursing assessment) Quarterly Assessment, dated 11/14/24, revealed Resident #19 was assessed as dependent in Section GG. GG0130. Self-Care E. Shower/bathe self. Review of the Resident #19's Care Plan, undated, revealed: .Goals Functions at Optimal Level with ADLs, Interventions .Provide Total Assistance x2 with Maxi Lift Transfers .Provide Bath/Shower- 2 times a Week .Resident needs extensive assist .may use shower gurney . Review on 1/9/25, of the facility's Resident Bathing Chart, dated 11/11/24 to 1/9/25, revealed no shower or bath was provided for Resident #19 since 12/31/24 (9 days prior). Further review of the Resident #19's Bathing Chart, revealed no documentation for a tub bath, bed bath, whirlpool bath, and other form of bathing provided. During an interview on 1/9/25 at 8:42 AM, the Administrator acknowledged that the resident had no documented shower from 1/1-9/25. Resident #67 Record review on 1/6-10/25, revealed Resident #67 was admitted to the facility with diagnoses that included atherosclerotic heart disease (hardening of the arteries from plaque), cerebral edema (swelling of the brain) and compression of brain. During an interview on 1/7/25 at 10:33 AM, when asked if he/she was provided with shower or bath, Resident #67 stated no, Review of the MDS Admission Assessment, dated 12/2/24, revealed Resident #67 was assessed as dependent in Section GG. GG0130. Self-Care E. Shower/bathe self. Review of the Resident #67's Care Plan, undated, revealed: .Goals Functions at Optimal Level with ADLs, Interventions .Provide Bath/Shower- 2 times a Week . Review of the facility's Resident Bathing Chart from 11/29/24 -1/8/25, revealed no shower or bath provided on the following periods: 12/2-7/24- 6 days had passed since last shower on 12/1/24 12/11-14/24- 4 days had passed since last shower on 12/10/24 12/16-23/24- 8 days had passed since last shower on 12/15/24 12/25/24-1/6/25 - 13 days had passed since last shower on 12/24/24 Further review of the Resident #67's Bathing Chart, revealed no documentation for a tub, bed bath, whirlpool, and other form of bathing provided. During an interview on 1/8/25 at 1:46 PM, the Administrator stated the staff provided a bed bath to Resident #67 when the resident was unable to shower but was not documented. During a joint interview on 1/8/25 at 3:22 PM, Certified Nurse Assistant (CNA) #1, stated the residents were provided with a shower . When asked what the process was if the resident was unable to take a shower, LN #5 stated, the CNAs would provide a bed bath. When asked if the CNAs documented once the bed bath was provided to the residents, CNA #1 stated he/she would document it. Review of the facility's policy, CNA Expectations and Standards of Care, last updated 5/6/24 revealed: .2. Bathing/Personal Hygiene . a. bath/shower 2x a week, or as care planned .

50078 Based on record review, observation and interview the facility failed to obtain residents' consent for bedrails use and conduct accurate risks and benefits assessments for four residents (#'s 4, 8, 31 and 61) out of 20 sampled residents and one unsampled resident (#11) reviewed for bedrails use. This failed practice had the potential to place residents at risk of falls, entrapment, and other preventable accidents and potentially place residents at risk of feelings of isolation and helplessness . Findings: Resident #4 Record review on 1/6-10/25, revealed Resident #4 was admitted to the facility with diagnosis that included cerebral palsy (congenital disorder of movement, muscle tone, or posture). During an observation and simultaneous interview on 1/7/25 at 11:12 AM, Resident #4 had right upper extremity (RUE) contractions. Resident #4's bed had both upper side rails, and the right lower side rail raised. The raised and uncovered upper bed rails began at the top of the bed and ended by Resident #4's lower chest and the raised right lower side rail began at his/her right hip and ended by his/her right knee. Resident #4's bedside table was placed along the opened left lower side of bed. When asked if he/she could lower the bed rails, Resident #4 stated he/she did not think so. When asked why the bed rails were raised, Resident #4 stated staff put the rails up and not sure why they are up. Review of the most recent Quarterly Assessment LTC [Long Term Care], dated 5/21/24, revealed: . Has resident requested to have side rails up for use of bed controls?: No, Has the resident requested to have side rails up for comfort or security?: No . Bed Safety PT/OT Recommend Side Rails: No . Does resident have a hx [history] of falls from the bed?: yes . Bed Safety Side Rail Use: Left Upper side rail, Left Lower side rail, Right Upper side rail, Right Lower side rail . Bed Safety Review W [with] Resident/Legal Rep: No . Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment), OBRA Quarterly Review Assessment, dated 11/20/24, revealed: . Section P - Restraints, P0100 . Used in Bed. A. Bed rail. 0 = Not used. Review of the Care Plan Summary, dated 1/9/25, revealed: . LTC Falls . Intervene for Unsafe Behaviors Effecting Fall Risk . Keep bed controls out of reach and locked when in bed . upper side rails up with seizure pads . Further review of Resident #4's medical record revealed no physician order and/or informed consent regarding the use of bed rails was found. During an interview on 1/9/25 at 4:06 PM, Resident Care Coordinator (RCC) #2 stated Resident #4 should only have both upper side rails raised. RCC #2 was asked if Resident #4 had a bed rail assessment. RCC #2 was unable to locate a bed rail assessment in the medical record. Resident #8 Record review on 1/6-10/25, revealed Resident #8 was admitted to the facility with diagnoses that included a fracture of the lower end of the left tibia (shin bone) and diabetes mellitus. During an observation and simultaneous interview on 1/10/25 at 9:00 AM, revealed Resident #8 had four side rails raised on his/her bed. Resident #8 stated he/she was not sure why all side rails were raised. Record review of the most recent MDS OBRA Quarterly Review Assessment, dated 11/27/24, revealed: . Section P- Restraints, P0100 . Used in Bed. A. Bed Rail. 0 = Not used . Further review of Resident #8's medical record revealed no physician order and/or informed consent regarding the use of bed rails was found. Resident #11 Record review on 1/6-10/25 revealed Resident #11 was admitted to the facility with diagnoses that included pressure ulcer (bed sore) of the sacral (end of spine) region and diabetes mellitus. An observation on 1/10/25 at 9:15 AM, revealed Resident #11 had three side rails raised on his/her bed. Resident #11 stated he/she was not sure why the side rails were raised. Record review of the most recent MDS OBRA Quarterly Review assessment dated [DATE], revealed: .Section P- Restraints, P0100 . Used in Bed. A. Bed Rail. 0 = Not used . Further review of Resident #11's medical record revealed no physician order and/or informed consent regarding the use of bed rails was found. Resident #31 Record review on 1/6-10/25, revealed Resident #31 was admitted to the facility with diagnoses that included dementia (a condition that affects memory and thinking) and Parkinson's disease (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination). During an observation and simultaneous interview on 1/7/25 at 11:56 AM, Resident #31 had both upper side rails raised. The raised upper side rails began at the top of the bed and ended by Resident #31's lower chest. When asked if he/she could lower the side rails, Resident #31 stated: No but staff can. Review of Resident #31's Quarterly Assessment LTC, dated 12/2/24, revealed: . Bed Safety Assessment . Has resident requested to have side rails up for use of bed controls?: No Has resident requested to have side rails for comfort or security?: No . Bed Safety PT/OT Recommend Side Rails: No . Bed Safety Side Rail Use: Left Upper side rail, Left Lower side rail, Right Upper side rail, Right Lower side rail . Bed Safety Review w/ Resident/Legal Rep: No . Record review of the most recent MDS OBRA Quarterly Review Assessment, dated 12/4/24, revealed: . Section P- Restraints, P0100 . Used in Bed. A. Bed Rail. 0 = Not used. Review of Resident #31's Care Plan Summary, dated 1/9/25, revealed: . LTC ADL [Activities of Daily Living] Function Rehab [rehabilitation] . Assist Resident With Transfers . Staff Will Not Leave Resident Alone Sitting on Bed . LTC Falls . Use High Low Bed. Keep in Low Position . During an interview on 1/9/25 at 4:06 PM, when asked RCC #2 if Resident #31 had a bed rail assessment. RCC #2 was unable to locate a bed rail assessment in the medical record. Further review of Resident #31's medical record revealed no physician order and/or informed consent regarding the use of bed rails was found. Resident #61 Record review on 1/6-10/25, revealed Resident #61 was admitted to the facility with diagnoses that included failure to thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction, and low cholesterol) and Schizophrenia (a severe mental disorder characterized by delusions [false beliefs], hallucinations [perception of sights, sounds, etc. that are not actually present], incoherence and physical agitation). During an observation and simultaneous interview on 1/6/25 at 2:48 PM, Resident #61 had both upper side rails raised, and a right lower side rail raised. The raised upper bed rails began by the top of the bed and extended down the side of the bed and ended by Resident #61's lower chest, and the raised right lower side rail started by the resident's right hip and extended down the side of the bed ending by his/her right knee. When asked if he/she could lower the side rails, Resident #61stated: No. Review of Resident #61's PT [physical therapy] Evaluation LTC II dated 10/22/24 revealed: . answers questions limited to yes/no or short phrases . been found out of bed sitting in a chair in [his/her] room with all 4 bed rails up, self-transferring unwitnessed . Bed Mobility: . did not use rails . Review of the most recent MDS, OBRA Admission Assessment, dated 10/23/24, revealed: . Section P- Restraints, P0100 . Used in Bed. A. Bed Rail. 0 = Not used . Review of Resident #61's Quarterly Assessment LTC, dated 1/9/25, revealed: . Orientation Assessment: Disorientated x 4 . Is resident able to state preferences about side rail use?: No Has resident requested to have side rails up for use of bed controls?: No Has resident requested to have side rails for comfort or security?: No . Is resident able to change position in bed without using side rails?: Yes . Bed Safety PT/OT Recommend Side Rails: No . Bed Safety Side Rail Use: Left Upper side rail, Right Upper side rail. Bed Safety Review W Resident/Legal Rep: No . Review of Resident #61's Care Plan Summary, dated 1/9/25, revealed: . LTC Delirium . Interventions . Adapt Care and Environment to Optimize Comfort and Safety . LTC ADL Function Rehab. Assist Resident With Transfers . Staff Will Not Leave Resident Alone Sitting on Bed . LTC Falls . Use High Low Bed. Keep in Low Position . Further review of Resident #61's medical record revealed no physician order and/or informed consent regarding the use of bed rails was found. During an interview on 1/9/25 at 12:25 PM, surveyors requested individual resident assessments to include bed safety from the Director of Nursing (DON). The DON stated there were no bed rail assessments completed. During an interview on 1/9/25 at 4:06 PM, when asked RCC #2 if Resident #61 had a bed rail assessment. RCC #2 was unable to locate a bed rail assessment in the medical record. Review of the facility's policy Bed Safety Assessment Process, effective date 10/11/24, revealed: . 1. Side rails present an inherent safety risk, particularly when the patient is elderly or disoriented . patients may become trapped between the mattress or bed frame and the side rail. Disoriented patients may view a raised side rail as a barrier to climb over, may slide between raised, segmented side rails, or may scoot to the end of the bed to get around a raised side rail. When attempting to exit the bed by any of these routes, the patient is at risk for entrapment, entanglement, or falling from a greater height posed by the raised side rail, with a possibility for sustaining greater injury or death . Policy, A. Registered Nurse, with resident/family, and interdisciplinary (social work, rehab) participation, will complete an individual resident assessment to include bed safety . B. No resident will be placed with all four side rails unless it is clearly demonstrated and documented in the assessment . C. risks and benefits will be presented to the resident and/or responsible party . D. The Resident Care Coordinator/LPN[Licensed Practical Nurse]Manager will review all bed safety assessments. E. The Interdisciplinary Care Plan will be completed by day 21 of admission and the Registered Nurse will develop the plan for bed safety . Review of the facility's A Guide to Bed Safety [a pamphlet provided in residents' admission packet], undated, revealed: The Benefits and Risks of Bed Rails . more serious injuries from falls when patients climb over rails. inducing agitated behavior when bed rails are used as a restraint. Feeling isolated or unnecessarily restricted . Meeting Patients' Needs for Safety, Most patients can be in bed safely without bed rails. Consider the following: Use beds that can be raised and lowered close to the floor to accommodate both patient and health care worker needs. Keep the bed in the lowest position with wheels locked . When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitoring high-risk patients. .

Based on record review, observation, and interview the facility failed to ensure 1 resident (#31), out of 8 residents reviewed on modified texture diet, received food in a form designed to meet the resident's needs. Specifically, the facility provided food not concurrent with the resident's mechanically altered diet order. This failed practice placed the resident at risk for choking and/or aspiration (the inhalation of food partials or fluid into the lungs that can lead to pneumonia and/or death), which could lead to serious illness and/or death. This failed practice placed the health and safety of the resident in immediate jeopardy. The surveyor interceded in the care being provided and notified the facility of the deficient practice and the risk of serious harm to the resident on 3/6/19 at 2:51 pm. The facility submitted a plan to mitigate the risk of serious harm and/or death to facility residents on 3/6/19 at 4:19 pm. Findings: Resident #31 Record review on 2/4-8/19 revealed Resident #31 had [DIAGNOSES REDACTED]. Record review of the most recent MDS (Minimum Data Set- a Federally required assessment) assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as receiving a mechanical altered therapeutic diet; requiring supervision of meals with encouragement and/cueing. Further review revealed the Resident was coded as having a BIMS (Brief Interview for Mental Status) of five (indicated the resident had severe cognitive impairment). Record review from 3/6-8/19 of Resident #31's care plan, latest revision date of 3/6/19, revealed a problem of being at risk for nutritional deficiency less than body requirements with approaches to monitor intake and dietary needs, provide soft food that were chopped/diced. Additional review of the Resident's care plan revealed no problem, intervention or goals related to dysphagia, aspiration precautions or risk. Review of the Resident #31's lunch diet card, dated 3/6/19, revealed the Resident was to have received diced mandarin oranges, diced paprika pork, diced linguine, and diced carrots. After dietary staff delivered the noon meal to the steam table on the Willow Run nursing unit, the certified nursing assistants (CNAs) plated the food and served it to the residents. During the lunch observation on 3/6/19 at 12:00 pm, CNA #6 plated a vegetable serving, meat serving and a serving of linguine noodles (characterized by long, flat strands). The CNA, chopped the vegetables and meat into pieces ranging from ½ x ½ to 1 x 1 and left the linguine noodles whole. At 12:08 pm, CNA #3 took the prepared lunch plate from the Willow Unit dining area to the common area located at the other end of the unit. At 12:11 pm, after he/she placed the plate in front of Resident #31 and uncovered the dish with the whole linguine noodles, the Surveyor stopped the CNA and inquired about the Resident's diet order. The CNA stated noodles were not usually served to the Resident. When asked if the noodles should be chopped like the other food items, the CNA stated the noodles should not have been served whole and should have been chopped or pureed. During an interview on 3/6/19 at 12:12 pm, CNA #6 stated the linguine noodles should have been chopped per diet order. Record review of Resident #31's medical record revealed a document entitled a Speech Therapy Module, dated 3/1/18 by Speech Language Pathologist (SLP) #1. SLP #1 had evaluated the Resident for dysphagia (difficulty swallowing) and increased coughing while eating. The evaluation revealed the Resident presented with moderate to severe oral pharyngeal dysphagia with likely mild aspiration of liquids and difficulty with efficient chewing of solid foods. Further review revealed, Given resident's advanced [MEDICAL CONDITION] and dementia prognosis for improvement in swallowing function is poor and (his/her) aspiration risk is high . Recommend texture modification recommendations (soft foods - diced) and adherence to aspiration precautions . and caregiver training . Further record review revealed a document entitled Nursing Concerns and MD (Doctor of Medicine) Orders, dated 3/1/18, that stated a diet texture modification was ordered to soft foods chopped/diced due to dysphagia and dementia as a result of recommendations following the clinical swallowing assessment completed by SLP #1. During an interview on 3/6/19 at 12:35 pm, SLP #1 stated the CNAs that serve food on Willow Unit should follow the diet card as provided by the dietary department. During the interview it was revealed the Resident has history of weight loss, dementia and esophagitis (inflammation of the lining of the esophagus, the tube that connects the throat to the stomach), and [MEDICAL CONDITION] which effect his/her swallowing. When presented with the observation from lunch meal the SLP stated the staff were not compliant with the diet order. The SLP stated the food should have been chopped into ¼ x ¼ pieces with sauce due to the Resident's diet order for chopped food. During an interview on 3/6/18 at 1:15 pm, the Dietitian stated diet cards were based on the residents' diet order and nutritional needs. During an interview on 3/6/19 at 2:45 pm, CNA #6 stated he/she was not provided with any specific training on how to plate food for the residents on the Willow Unit. The CNA further stated he/she was a fill-in CNA from another unit in the facility. Review of the facility's policy Denali Center - Nutritional Care, dated 12/20/18, revealed the Registered Dietitian Nutritionist works closely with Nutrition Service staff to ensure residents receive the appropriate diet. Review of the facility's policy Modification of Food Texture, dated 1/26/18, revealed the expected outcome was to provide a diet that meets the food texture needs of the resident while ensuring resident safety. Review of the facility provided document entitled Mechanically Altered Food Appendix #4, undated, revealed dysphagia chopped foods should be cut into ¼ x ¼ x ¼ pieces and served moist. The document indicated Ditalini Pasta (characterized by small tubular shape approximately 0.19 x 0.18) could be use whole. Further review revealed the facility was to refer to current, prescribed therapeutic diet plan as a guide when planning the menu and alteration will be care planned.

Based on observation, interview and record review the facility failed to ensure safety of smoking for 1 (#7) of 1 resident reviewed who smoked, out of a sample of 10 residents. Specifically, the facility failed to adequately reassess for safe smoking after the resident sustained [REDACTED]. and were unsuccessful; and failed to replace a smoking apron when its integrity was compromised due to multiple holes in the fabric. As a result, the resident was placed at risk for further, potentially serious, burn injury. This failed practice constituted an immediate jeopardy to resident health and safety. This situation was brought to the attention of the facility's administration on 12/2/10 at 10:20 am. The immediate jeopardy was abated onsite. Findings: Record review from 11/29-12/2/10 revealed Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Random observations throughout the survey, from 11/29-12/1/10, revealed the Resident spent a lot of time in the smoking room, watching movies or television, and smoking independently. Resident #7 was able to use a motorized wheelchair to travel to and from the smoking room. The Resident wore a protective smoking apron, which was noted to have several holes in it. Review of nursing documentation, dated 6/21/10, revealed the resident sustained [REDACTED]. On 6/23/10 Resident #7 was seen by the physician for an unrelated issue, shortness of breath. The physician's notes included the following: "the patient burned his right thumb due to holding a cigarette for too long. Because of [DIAGNOSES REDACTED], he has no real sensation in his hands. The cigarette burned out without his awareness." The physician recommended the use of a glove and noted that "Nursing is trying to look into a fire-resistant glove of some sort that the patient can use to avoid this." The most recent "Unattended Smoking Privilege Assessment", dated 6/23/10, was provided by the Director of Nursing (DON). The assessment was completed 2 days after the Resident's smoking-related burn, and included the following documentation: "Uses smoking apron. Needs to protect right hand between thumb/pointer. Has had burns. Educated him to be mindful and not get burned." Review of the Resident's current care plan, last reviewed on 11/11/10, revealed the following interventions were identified for the problem "Potential for injury/falls/safety": "I need assist from staff to light my cigarette but I am able to hold and extinguish cigarette. I do not need someone to supervise my smoking" and "Re-evaluate smoking assessment as needed". There was no documentation in the care plan regarding the use of a fire-resistant glove, as recommended by the physician subsequent to the Resident's smoking-related burn. Review of the facility policy "Smoking", provided by the DON, revealed the last review date was 5/2007. The policy included the following information regarding smoking assessments: "To determine whether or not a resident has the physical and cognitive abilities to smoke safely while unattended in the resident smoking lounge, an assessment will be completed on admission and with significant change. The assessment will be a documented observation that the resident: safely lights and holds their own cigarette, cigar or pipe, appropriately uses an ash tray, does not allow ashes to fall on clothing, maintains wakefulness while smoking, properly extinguishes the cigarette, cigar or pipe, and can appropriately call for assist while smoking in the lounge." During an interview on 11/30/10 at 1:40 pm, when the DON was asked why the Resident was not assessed as outlined in the Smoking policy, she stated that when the facility became smoke free on 8/1/07 a new tobacco-free policy was put into place. She explained that at that time Resident #7 was "grandfathered-in and allowed to continue smoking in a designated smoking room", The DON stated that the original smoking policy was "forgotten about when the facility became smoke-free" and that Resident #7, who still smoked, "fell through the cracks". During an interview on 11/30/10 at 2:15 pm, Resident #7 was accompanied into the smoking room by CNA #3. The Resident positioned himself in the center of the room, facing the television and next to an ashtray which was located on a table. The Resident was wearing a smoking apron that had a minimum of 5 holes in the area over his lap; the holes went all the way through the fabric. Resident #7 placed a cigarette between the 2nd and 3rd fingers of his right hand, supporting the cigarette with his thumb. CNA #3 lit the cigarette for him and left the room. As Resident #7 smoked his cigarette, the Surveyor asked if he was able to call for help if he needed assistance. The Resident replied that he used to have a call button on the left armrest of his wheelchair but it had broken and was not replaced. When asked how he would call for help now, he looked towards the door and said "the call button is on the wall over there". The doorbell style call button was located on the wall by the door, near the light switch. When asked if he felt he could quickly maneuver himself across the room to call for help in the event he burned himself, he stated that "it would be no big deal. If I burned myself I wouldn't feel it anyway". When the Surveyor asked about the incident several months ago, when he burned his thumb while smoking, the Resident stated "Yes, the cigarette burned down to my skin but I didn't know it because I couldn't feel it". Review of the Multidisciplinary Skin Injury Care Conference notes, dated 7/8/10, revealed "ordered fireproof gloves". Review of nursing notes for 8/10/10 revealed "Smoking glove attempted - not an easy fit over fingers, when applied he is unable to hold his cigarette. RCC (Resident Care Coordinator) notified". During an interview on 12/2/10 at11:15 am, the DON stated that, although it was not documented, the facility had provided Resident #7 with a forceps to use while smoking. She explained that when the cigarette was clamped with the forceps, the Resident was able to hold the forceps handles and smoke without having to hold the cigarette in his hand. She further stated the forceps had been lost and was not replaced. Although Resident #7 had been assessed 2 days after his smoking-related 2nd degree burn, the assessment did not identify the Resident's increased risk for injury related to decreased sensation in his hands due to [DIAGNOSES REDACTED]. When the use of a fire-resistant glove and utilizing a forceps to hold the cigarette had been trialed and were unsuccessful, no other interventions were put into place. Although the Resident wore a fire-resistant smoking apron, its integrity was compromised due to multiple holes in the fabric. As a result, the Resident continued to be at increased risk for serious injury or impairment. .