Every finding on record at Heritage Place

. Based on observation and interview, the facility failed to ensure food products with damaged or compromised packaging were identified and removed from use for 37 residents who received meals from the facility kitchen. Specifically, the facility failed to identify and remove food products with damaged or compromised packaging from the dry food storage area. The products remained stored with other food inventory and were available for use in preparing meals for residents. This failed practice had the potential to place all residents who received meals from the facility kitchen at risk for exposure to food from damaged or compromised packaging, with the potential for contamination and foodborne illness. Findings: During an observation on 8/24/26 at 11:56 AM of the dry food storage area, the following food products were observed: One 3-kilogram can of Dole Tropical Fruit Salad with a dent in the top seal; andOne 680-gram cardboard cannister of Progresso Bread Crumbs with the manufacturer seal broken/open, exposing food product to the open-air environment. These products were not identified as damaged, segregated, or otherwise designated as unavailable for use. During an interview on 8/24/26 at 12:10 PM, the Kitchen Manager confirmed the identified food products should not have remained in the dry storage area and stated the products should have been returned to the supplier or discarded. Review of the facility policy Shelf Stable Food Safety, effective date 6/2025, revealed: Inspect cans for integrity, if bulging or dented, remove from use immediately. Review of the Food and Drug Administration (FDA), 2022 edition, section 3-202.15 Package Integrity, accessed on 9/9/26 at this link: https://www.fda.gov/media/164194/download?attachment , revealed, Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.

. Based on record review and interview, the facility failed to ensure 1 Resident (#5), out of 5 residents reviewed for unnecessary medications: 1) received a gradual dose reduction (GDR - a tapering of a dose to determine if symptoms or conditions could be managed by a lower dose, or if the dose or medication could be discontinued for an antipsychotic medication (a psychotropic medication primarily used to treat psychosis, including delusions, hallucinations, disorganized thinking or speech, and inappropriate behavior); or 2) had a documented clinical contraindication to attempt a GDR. This failed practice placed Resident #5 at risk for unnecessary antipsychotic medication use. Findings: Record review on 8/24-28/26 revealed Resident #5 was admitted to the facility with diagnoses that included vascular dementia, moderate, with anxiety (decline in memory and thinking ability caused by reduced blood flow to the brain), major depressive disorder, recurrent, moderate (repeated episodes of moderate depression affecting mood, energy, and daily functioning), delusional disorder (a condition involving one or more fixed, false beliefs that persist despite evidence to the contrary), and mental disorder, not otherwise specified (a mental health condition that does not fully meet the criteria for a more specific diagnosis). Review of Resident #5's physician's order, dated 11/14/24, revealed: .Quetiapine Fumarate (Seroquel) [An antipsychotic medication] Oral Tablet 25 mg [milligrams]. give 25 mg by mouth in the evening for Anxiety/Agitation, tearfulness, Hallucinations . Further review revealed the order directed staff to monitor for a decrease in anxiety/agitation and to monitor for adverse side effects including dry mouth, salivation, nasal congestion, nausea, vomiting, anorexia, fever, and flushed face. Review of Resident #5's Medication Administration Record (MAR), from 8/1/25 through 8/26/26, revealed continued administration of Quetiapine Fumarate 25 mg by mouth at 20:00 [8:00 PM] daily, as ordered on 11/14/24, with no evidence of a dose change, hold, or reduction documented at any point during this timeframe. Review of Resident #5's Care Plan, last revised 8/12/26, revealed: . [Resident #5] takes antidepressant and antipsychotic r/t [related to] depression/anxiety. [Resident #5] will be free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood through review date. Associated interventions included, .Administer medications as ordered. Monitor/document for side effects and effectiveness. Report to nursing decrease in Sadness, Withdrawal, Anxiety, Agitation, hallucinations, tearfulness . Sees [Physician #1] for anti-psychotic Rx [prescription] mgmt. [management]. Further review of Resident #5's Care Plan revealed no intervention or approach to attempt a gradual dose reduction (GDR) of Resident #5's Quetiapine medication. There were no parameters specific to a GDR attempt, evaluation, or contraindication documented. Review of the pharmacist's monthly Consultant Drug Regimen Reviews for Resident #5, from 7/24/25 through 7/31/26, revealed the following: On 7/24/25, under GDR Status, the review documented: See psychotropic assessment 12/4/24 for risk vs [versus] benefit . Under Summary, the review documented: Patients anxiety/hallucinations improved with the initiation of quetiapine . Under Recommendation to Physician, the review documented: None. Review of the pharmacist's drug regimen reviews, dated 8/29/25; 9/30/25; 10/31/25; 11/26/25; 12/18/25; 1/29/26; 2/26/26; 4/2/26; 4/28/26; 5/26/26; 6/26/26; and 7/31/26, revealed the GDR Status field documented: See psych [psychiatric] note 3/2025 [3/14/25], and the Summary field documented: Patients anxiety/hallucinations improved with the initiation of quetiapine. Dr [Doctor] may be open to trial without quetiapine. Under Recommendation to Physician, every review documented: None. Review of the Psychiatric Assessment, dated 3/14/25, revealed: Physician #1 [noted]. ongoing distorted perceptions in the form of paranoia and delusional thought content most likely due to neurocognitive decline, which can also be exacerbated during times of delirium AKA [also known as] 'sundowning.' [Resident #5] is otherwise not had behavioral disturbances, other disorganized behavior that could be a concern for [he/she's] safety or others. Discussed considerations of using second generation antipsychotic disorders in the context of neurocognitive disorders in regard to increased risk of mortality. If [he/she] continues to be stable may consider trial without Seroquel. Family is agreeable. Review of Resident #5's nursing assessment flowsheet titled Behavior Monitoring & Interventions Monitor for hallucinations, anxiety, agitation, tearfulness, dated 6/1/26 through 8/15/26, revealed 121 assessments. Of these, 115 assessments were documented as Response Not Required, indicating no behavior triggering a need for intervention was observed at the time of the check. The remaining assessments reflected an actual behavior requiring an intervention: 6/17/26 at 5:24 PM - Redirect [which indicated an intervention was used to help with an observed behavior or symptom]~Better (improved) [which indicated the resident's response to the intervention], Remove from Situation/Ensure Resident Safety~Better (improved) 7/11/26 at 4:24 AM - Redirect~Better (improved) 7/19/26 at 7:59 PM - Redirect~Same (unchanged), Provide Comfort (massage, reposition, heat/cold) ~Same (unchanged) 7/26/26 at 8:02 PM - Redirect~Same (unchanged), 1:1 [which indicated one staff was with this one resident for a time]~Same (unchanged) 7/30/26 at 5:59 PM - Meaningful Activity~Better (improved) 8/5/26 at 4:56 PM - 1:1~Better (improved) During an interview on 8/28/26 at 9:25 AM, the Assistant Director of Nursing (ADON #1) stated, while reviewing Resident #5's documented behaviors from 2024 forward, that she recognized documentation of anxiousness, restlessness, and false beliefs, and confirmed the hallucinations were well described in the 2024 records. ADON #1 further stated that this same pattern of behaviors was not reflected in the 2025 or 2026 records, showing few documented behaviors, with only a handful of entries reflecting agitation and persistent false beliefs. When asked what happened with the behavior assessments once collected, the ADON stated the information was .given to [Physician #1], if he's following that resident, and confirmed that when nurses were not available to give a verbal report, staff would .go back and print behaviors when he's here for his review in person. The ADON confirmed a Response Not Required notation on the monitoring form meant the resident did [not] have any behavior[s]. During an interview on 8/26/26 at 4:05 PM, the Medical Director (MD) stated he was aware of the requirement to attempt GDRs on psychotropic medications and confirmed his understanding that the requirement is to attempt [a GDR] unless clinically contraindicated, and that this has to be documented. He reviewed Resident #5's record and confirmed no GDR had been attempted or documented since the medication was originally ordered. He further stated, if a GDR is not attempted, we still have to see it in the chart that there is a contraindication and here's why it's not recommended, and acknowledged that no such documented rationale existed for Resident #5. During an interview on 8/27/26 at 1:00 PM, the consultant pharmacist (CP) stated that his monthly medication regimen reviews (MRRs or Drug Regimen Reviews) were intended to evaluate the continued necessity of psychotropic medications, including consideration of a GDR. He further stated that when a physician's psychotropic assessment stated no medication changes were wanted, .I'll just kind of defer to that. He acknowledged he could not identify any documented physician rationale, risk-benefit assessment, or clinical contraindication supporting the decision not to pursue a GDR for Resident #5, stating, in regard to this documentation, They [the physicians] didn't put it in. He further stated that his own monthly review summaries repeatedly documented that Resident #5's symptoms had improved and that the physician may be open to trial without [Seroquel], indicating a GDR was clinically appropriate to pursue, yet his formal recommendation stated none. When asked to reconcile this, the CP stated he had [dropped] the ball, following up at some point. Review of the facility policy Gradual Drug Dose Reduction, effective 6/2025, revealed: .Heritage Place, in compliance with state and federal regulations, along with a registered pharmacist performs regular review and monitoring of all medications in an effort to eliminate the use of unnecessary medications. The policy further stated: .All medications shall be considered for possible gradual dose reduction . Residents who use psychotropic medications shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. the pharmacist and practitioner will consider tapering of medications as one approach to finding an optimal dose or determining whether continued use of a medication is benefiting the resident. Review of the facility's policy Psychotropic Medication Monitoring Program, effective 4/2026, revealed: . all residents using psychotropic drugs will be reviewed by a HP [Heritage Place] interdisciplinary team. all medications are monitored monthly by a pharmacist. whose findings . are sent to the Medical Director, Director of Nursing and the appropriate physician, all sign off having reviewed the recommendations. Further review revealed: . When appropriate, as determined by the above review, in accordance with State and Federal Regulations, all residents receiving psychotropic drug(s) will be evaluated for a gradual dose reduction.

Based on record review and interview, the facility's pharmacist failed to report medication irregularities to the attending physician, the facility's medical director, and director of nursing during monthly drug regimen reviews for 1 Resident (#5), out of 1 resident reviewed for unnecessary medications.Specifically, the pharmacist failed to recommend a gradual dose reduction (GDR - a tapering of a dose to determine if symptoms or conditions could be managed by a lower dose, or if the dose or medication could be discontinued) for an antipsychotic medication (a psychotropic medication primarily used to treat psychosis, including delusions, hallucinations, disorganized thinking or speech, and inappropriate behavior) when no GDR had been attempted, and no documentation indicating a clinical contraindication to attempt a GDR.This failed practice placed Resident #5 at risk for unnecessary antipsychotic medication use.Findings:.Record review on 8/24-28/26 revealed Resident #5 was admitted to the facility with diagnoses that included vascular dementia, moderate, with anxiety (decline in memory and thinking ability caused by reduced blood flow to the brain), major depressive disorder, recurrent, moderate (repeated episodes of moderate depression affecting mood, energy, and daily functioning), delusional disorder (a condition involving one or more fixed, false beliefs that persist despite evidence to the contrary), and mental disorder, not otherwise specified (a mental health condition that does not fully meet the criteria for a more specific diagnosis).Review of Resident #5's physician's order, dated 11/14/24, revealed: .Quetiapine Fumarate (Seroquel) [An antipsychotic medication] Oral Tablet 25 mg [milligrams]. give 25 mg by mouth in the evening for Anxiety/Agitation, tearfulness, Hallucinations . Further review revealed the order directed staff to monitor for a decrease in anxiety/agitation and to monitor for adverse side effects including dry mouth, salivation, nasal congestion, nausea, vomiting, anorexia, fever, and flushed face.Review of Resident #5's Medication Administration Record (MAR), from 8/1/25 through 8/26/26, revealed continued administration of Quetiapine Fumarate 25 mg by mouth at 20:00 [8:00 PM] daily, as ordered on 11/14/24, with no evidence of a dose change, hold, or reduction documented at any point during this timeframe.Review of Resident #5's Care Plan, last revised 8/12/26, revealed: . [Resident #5] takes antidepressant and antipsychotic r/t [related to] depression/anxiety. [Resident #5] will be free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood through review date. Associated interventions included, .Administer medications as ordered. Monitor/document for side effects and effectiveness. Report to nursing decrease in Sadness, Withdrawal, Anxiety, Agitation, hallucinations, tearfulness . Sees [Physician #1] for anti-psychotic Rx [prescription] mgmt. [management].Further review of Resident #5's Care Plan revealed no intervention or approach to attempt a gradual dose reduction (GDR) of Resident #5's Quetiapine medication. There were no parameters specific to a GDR attempt, evaluation, or contraindication documented.Review of the pharmacist's monthly Consultant Drug Regimen Reviews for Resident #5, from 7/24/25 through 7/31/26, revealed the following:On 7/24/25, under GDR Status, the review documented: See psychotropic assessment 12/4/24 for risk vs [versus] benefit . Under Summary, the review documented: Patients anxiety/hallucinations improved with the initiation of quetiapine . Under Recommendation to Physician, the review documented: None.Review of the pharmacist's drug regimen reviews, dated 8/29/25; 9/30/25; 10/31/25; 11/26/25; 12/18/25; 1/29/26; 2/26/26; 4/2/26; 4/28/26; 5/26/26; 6/26/26; and 7/31/26, revealed the GDR Status field documented: See psych [psychiatric] note 3/2025 [3/14/25], and the Summary field documented: Patients anxiety/hallucinations improved with the initiation of quetiapine. Dr [Doctor] may be open to trial without quetiapine. Under Recommendation to Physician, every review documented: None.Review of the Psychiatric Assessment, dated 3/14/25, revealed: Physician #1 [noted]. ongoing distorted perceptions in the form of paranoia and delusional thought content most likely due to neurocognitive decline, which can also be exacerbated during times of delirium AKA [also known as] 'sundowning.' [Resident #5] is otherwise not had behavioral disturbances, other disorganized behavior that could be a concern for [he/she's] safety or others. Discussed considerations of using second generation antipsychotic disorders in the context of neurocognitive disorders in regard to increased risk of mortality. If [he/she] continues to be stable may consider trial without Seroquel. Family is agreeable.Review of Resident #5's nursing assessment flowsheet titled Behavior Monitoring & Interventions Monitor for hallucinations, anxiety, agitation, tearfulness, dated 6/1/26 through 8/15/26, revealed 121 assessments. Of these, 115 assessments were documented as Response Not Required, indicating no behavior triggering a need for intervention was observed at the time of the check. The remaining assessments reflected an actual behavior requiring an intervention:6/17/26 at 17:24 - Redirect [which indicated an intervention was used to help with an observed behavior or symptom]~Better (improved) [which indicated the resident's response to the intervention], Remove from Situation/Ensure Resident Safety~Better (improved)7/11/26 at 4:24 - Redirect~Better (improved)7/19/26 at 19:59 - Redirect~Same (unchanged), Provide Comfort (massage, reposition, heat/cold) ~Same (unchanged)7/26/26 at 20:02 - Redirect~Same (unchanged), 1:1[which indicated one staff was with this one resident for a time]~Same (unchanged)7/30/26 at 17:59 - Meaningful Activity~Better (improved)8/5/26 at 16:56 - 1:1~Better (improved)During an interview on 8/28/26 at 9:25 AM, the Assistant Director of Nursing (ADON #1) stated, while reviewing Resident #5's documented behaviors from 2024 forward, that she recognized documentation of anxiousness, restlessness, and false beliefs, and confirmed the hallucinations were well described in the 2024 records. ADON #1 further stated that this same pattern of behaviors was not reflected in the 2025 or 2026 records, showing few documented behaviors, with only a handful of entries reflecting agitation and persistent false beliefs.When asked what happened with the behavior assessments once collected, the ADON stated the information was .given to [Physician #1], if he's following that resident, and confirmed that when nurses were not available to give a verbal report, staff would .go back and print behaviors when he's here for his review in person. The ADON confirmed a Response Not Required notation on the monitoring form meant the resident did [not] have any behavior[s].During an interview on 8/26/26 at 4:05 PM, the Medical Director (MD) stated he was aware of the requirement to attempt GDRs on psychotropic medications and confirmed his understanding that the requirement is to attempt [a GDR] unless clinically contraindicated, and that this has to be documented. He reviewed Resident #5's record and confirmed no GDR had been attempted or documented since the medication was originally ordered. He further stated, if a GDR is not attempted, we still have to see it in the chart that there is a contraindication and here's why it's not recommended, and acknowledged that no such documented rationale existed for Resident #5.During an interview on 8/27/26 at 1:00 PM, the consultant pharmacist (CP) stated that his monthly medication regimen reviews (MRRs or Drug Regimen Reviews) were intended to evaluate the continued necessity of psychotropic medications, including consideration of a GDR. He further stated that when a physician's psychotropic assessment stated no medication changes were wanted, .I'll just kind of defer to that. He acknowledged he could not identify any documented physician rationale, risk-benefit assessment, or clinical contraindication supporting the decision not to pursue a GDR for Resident #5, stating, in regards to this documentation, They [the physicians] didn't put it in. He further stated that his own monthly review summaries repeatedly documented that Resident #5's symptoms had improved and that the physician may be open to trial without [Seroquel], indicating a GDR was clinically appropriate to pursue, yet his formal recommendation stated none. When asked to reconcile this, the CP stated he had [dropped] the ball, following up at some point.Review of the facility policy Gradual Drug Dose Reduction, effective 6/2025, revealed: .Heritage Place, in compliance with state and federal regulations, along with a registered pharmacist performs regular review and monitoring of all medications in an effort to eliminate the use of unnecessary medications. The policy further stated: .All medications shall be considered for possible gradual dose reduction (GDR). Residents who use psychotropic medications shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. the pharmacist and practitioner will consider tapering of medications as one approach to finding an optimal dose or determining whether continued use of a medication is benefiting the resident.Review of the facility's policy Psychotropic Medication Monitoring Program, effective 4/2026, revealed: . all residents using psychotropic drugs will be reviewed by a HP [Heritage Place] interdisciplinary team. all medications are monitored monthly by a pharmacist. whose findings . are sent to the Medical Director, Director of Nursing and the appropriate physician, all sign off having reviewed the recommendations. Further review revealed: . When appropriate, as determined by the above review, in accordance with State and Federal Regulations, all residents receiving psychotropic drug(s) will be evaluated for a gradual dose reduction.

.Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were appropriately stored and that expired drugs and biologicals were removed from storage. Specifically, the facility failed to:1) remove expired menthol cough drops from 1 medication storage room, out of 2 observed; and2) secure Calmoseptine (a topical medication ordered for staff application), for 1 resident (#55), out of 1 resident reviewed for medication storage.These failed practices:1) had the potential to affect all residents, based on a census of 37, who could consume oral cough drop medication; and2) resulted in Resident #55 ingesting the ointment on 5/4/26, placing the resident at risk for adverse effects of the medication. Findings: Expired menthol cough drops:An observation of the Drug Store room on 8/26/26 at 3:15 PM revealed eight bags of Cardinal Health Menthol Cough Drops, containing 5.4 mg (milligrams) of menthol (the active ingredient acting as a cough suppressant and oral anesthetic) per lozenge/drop and packaged as 30 lozenges per bag. The cough drops had a manufacturer expiration date of 7/2026 and remained stored in the Drug Store room.During an interview on 8/27/26 at 1:00 PM, the Consultant's Pharmacist (CP) stated that the Cardinal Health Menthol Cough Drops were considered an over-the-counter (OTC) medication by the facility. The CP further stated that he considered the cough drops to be a medication and that these were supposed to be stored in the drug store room.During an interview on 8/26/26 at 3:30 PM, the Assistant Director of Nursing (ADON) #2 provided an overview of the facility's medication storage, medication carts, and processes for medication management. ADON #2 stated that the treatment nurse was responsible for auditing the medication room, stating the treatment nurse is supposed to be doing the audit of that room. When asked about the expired Cardinal Health cough drops, ADON #2 stated, we just destroyed it. ADON #2 stated that there had not been a consistent treatment nurse due to the facility's low census and stated, we're going to have to figure out another process to make sure that's going to be done. ADON #2 also stated that the night shift was responsible for checking medication expiration dates in the medication cabinets once per shift.During an interview on 8/25/26 at 12:25 PM, Licensed Nurse (LN) #9 stated if nurses found an expired item, they were expected to dispose of the item in the appropriate receptacle.Unsecured topical medication:Record review on 8/24-28/26 revealed Resident #55 was admitted to the facility with diagnoses that included cerebral infarction (stroke) and dysphagia (difficulty swallowing). Review of Resident #55's Treatment Administration Record (TAR), dated May 2026, revealed the resident was being treated for a moisture-associated skin disorder (MASD - skin inflammation or erosion caused by prolonged exposure to moisture): RA [Resident Attendant] to apply [C]almoseptine to areas of MASD to groin. Treatment nurse to monitor area daily until resolved. Further review revealed this order started on 4/12/26.Review of Resident #55's progress note, dated 5/4/26 at 9:54 AM, revealed: OT [Occupational Therapist] reported [Resident #55] was dipping [his/her] snack crackers in a cup of Calmoseptine that [he/she] had on [his/her] bedside. Further review revealed nursing staff assessed the resident, called Poison Control, and Assistant Director of Nursing (ADON) was contacted. Review of the facility reported incident initial report, dated 5/4/26, revealed: OT reported resident had Calmoseptine cream on [his/her] lips & [and] face upon entering [his/her] room. [He/she] stated [he/she] thought it was a 'dip'[food]. Review of Resident #55's TAR, dated May 2026, revealed the facility-initiated monitoring after speaking with Poison Control: Monitor for adverse side effects of possible consumption of Calmoseptine - morning of 5/4/26. Poison control stated to watch for CNS [Central Nervous System] depression -including decreased respiration and somnolence [excessive sleepiness], GI [gastrointestinal] upset -vomiting/diarrhea. Two times a day for Health Monitoring for 3 Days. Further review revealed this order started on 5/4/26 and ended 5/7/26. No adverse effects were noted.Review of the facility reported incident final report, dated 5/8/26, revealed the resident ingested approximately half of a 2 ounce cup of Calmoseptine.Review of an email from the Director of Nursing (DON) to State of Alaska (SOA) Health Facilities Licensing and Recertification (HFLC) Office, dated 5/12/26, revealed Resident #55 had not been assessed as capable of independently applying ointment. The DON documented the ointment . was in [his/her] room as part of [his/her] wound care program. During an interview on 8/28/26 at 11:00 AM, the ADON stated, [the Calmoseptine] should have been kept in a drawer. The ADON further stated .they're using it every day so it would have just been in the drawer staff just didn't put it back. She reported Resident #55's BIMS (Brief Interview for Mental Status - a short cognitive assessment used to evaluate memory and thinking) was 3 out of 15 (a score of 0 to 7 indicated severe cognitive impairment). Review of Resident #55's care plan, which was active in May 2026, revealed the facility added a problem addressing the resident's confusion and tendency to mistake one item for another on 5/8/25, four days after the incident regarding Calmoseptine. However, the facility did not add an intervention addressing the resident's access to medications or topical products. Review of the facility's policy Medication - ordering and receiving, effective 5/2026, revealed: .Nurses are responsible for checking the medication carts, storage cabinets and medication refrigerator on a monthly basis for expiring medications. Medications are removed prior to expiration date. Medications not being used are discontinued per standing order due to non-use. Random cart checks are performed by the DON or designee. Review of the facility's policy Safe Environment of Care (EOC), revised on 12/2024, revealed: Policy: All staff will pay constant attention to the EOC at Heritage Place and follow procedure. to ensure the safety of our residents.

. Based on record review and interview, the facility failed to ensure its written policies and procedures for abuse, neglect, exploitation, and misappropriation of resident property included all required components for all residents (based on a census of 39).Specifically, the Resident Abuse, Neglect or Misappropriation of Property policy contained procedures related to employee background screening, staff orientation, investigation, resident protection, and reporting; however, the facility's written procedures, considered together, did not establish comprehensive procedures for:1) directing staff training on injuries of unknown source and resident behavioral symptoms that increase the risk for abuse or neglect;2) preventing situations in which abuse, neglect, exploitation, or misappropriation were more likely to occur;3) directing the individuals responsible for investigations to determine the extent and cause of alleged violations and to take appropriate steps to safeguard evidence;4) assessing the alleged victim for psychosocial effects, protecting residents from retaliation, and continuing protective measures after an investigation when needed; and5) communicating and coordinating specific abuse, neglect, exploitation, and misappropriation concerns with the facility's Quality Assurance and Performance Improvement (QAPI) program.These written procedure gaps placed residents at risk of inconsistent prevention, investigation, protection, and follow-up when suspected abuse, neglect, exploitation, or misappropriation occurred Record review on 8/24-28/26 of the facility policy Resident Abuse, Neglect or Misappropriation of Property, effective 11/2024, revealed the policy applied to the Reporting, prevention, and investigation of resident abuse, neglect, or misappropriation of property. Review of the facility's Nursing Care Procedures policy, effective 11/2025, revealed that it directs wellness staff to use the Lippincott Nursing Procedural Manual for standard nursing care procedures unless another policy, procedure, or physician order indicates otherwise. Review of the Lippincott procedure Suspected resident abuse assessment, long-term care, revised 9/14/25, revealed instructions for identifying suspected abuse, including indicators staff may encounter when an event was not observed.TrainingFurther review of the abuse policy revealed: .All new HP employees will complete orientation per CPH/HP policy. All HP employees will complete mandatory, annual review. The policy identified orientation and annual review requirements but did not identify the required abuse training content or the assigned abuse training course. Review of the HealthStream SQ LTC: Abuse and Neglect storyboard, undated, revealed instruction on forms and warning signs of abuse, prompt reporting, protective actions, and some responses to upset persons. The written materials reviewed did not direct staff training on injuries of unknown source and resident behavioral symptoms that may increase abuse or neglect risk. PreventionThe abuse policy defined multiple forms of abuse, including verbal, sexual, physical, and mental abuse, as well as neglect, exploitation, and misappropriation of resident property. The policy also did not contain comprehensive prevention procedures addressing the assessment, care planning, intervention, and monitoring of residents whose behaviors or care needs could increase the risk of conflict, abuse, or neglect, or procedures addressing situations in which abuse, neglect, exploitation, or misappropriation were more likely to occur. Review of the HealthStream SQ LTC: Abuse and Neglect storyboard, undated, revealed discussion of staffing, staff stress, and calming upset persons. Review of the Lippincott procedure Suspected resident abuse assessment, long-term care, revised 9/14/25, revealed instructions to develop a safety plan after abuse is suspected. Neither document sets out the facility's ongoing process to identify, assess, care plan, intervene, and monitor resident-specific risk before an allegation occurs.InvestigationReview of the abuse policy revealed: .The investigation should include interviews with the alleged victim, roommate(s) of alleged victim, family members, other staff members, and other pertinent person(s). The policy also identified the Director of Clinical Services, Social Services Associate, or designee as responsible for conducting investigations. Review of the Lippincott procedure Forensic evidence collection, reviewed 12/14/25, revealed detailed nursing instructions for collecting, preserving, securing, and documenting evidence. The written materials reviewed did not identify a process directing the assigned abuse investigators to determine whether a violation occurred, its extent, and its cause, or to coordinate appropriate evidence safeguards for each allegation. The forensic procedure addresses clinical evidence collection but does not direct the full abuse investigation.ProtectionReview of the abuse policy revealed that .If an employee is suspected of abuse, neglect, or misappropriation of property.he/she would be suspended. during the investigation. The policy further stated: .If the alleged perpetrator is another resident, family member, visitor or volunteer the facility shall determine whether the incident occurred and take appropriate action to protect all residents. The policy identified possible protective actions including separation of the involved parties, resident transfer, or restricting an individual from further entry into the facility. Review of the Lippincott procedure Suspected resident abuse assessment, long-term care, revised 9/14/25, revealed instructions for nurses to assess injury and pain, monitor and assist the resident to safety, provide emotional support, and develop a safety plan with the care team. The written materials reviewed did not direct staff to assess the alleged victim for psychosocial effects, protect residents from retaliation, or maintain protective measures after the investigation as needed. Review of the HealthStream Compliance: Whistleblowing module, undated, revealed instruction on protection from retaliation for employees who report wrongdoing. It did not address retaliation against residents.QAPI CoordinationReview of the facility's Quality Assurance and Performance Improvement (QAPI) Plan, undated, revealed that staff document incidents in the electronic medical record, weekly leadership meetings review incidents, the Safety Committee reviews incident reports, and information goes to the Heritage Place Quality Management Committee. These provisions provide a general route for incident information. The written materials reviewed did not explain how staff identify and communicate specific abuse, neglect, exploitation, or misappropriation concerns to QAPI or how the program coordinates review and follow-up for those cases.During an interview on 8/27/26 at 3:22 PM, the Administrator Designee (AD) stated there were no additional abuse-related policies or documents beyond those provided to the survey agency. The AD stated she believed the required elements were contained within the existing policy but were not separately labeled. When informed of the specific required components that were not addressed by the written procedures, the AD stated the facility was not aware that the documents did not contain all required regulatory elements.

Based on interview and record review, the facility failed to ensure the designated Director of Nursing (DON) worked 40 hours a week. This failed practice had the potential to place all residents (based on a census of 44) at risk of not receiving quality nursing services due to a lack of oversight. Findings: During the entrance conference interview on 6/9/25 at 10:45 AM, the DON stated she was designated as the DON and Administrator of the facility. She further stated she worked 35 hours per week as the DON and 5 hours per week as the Administrator. During a follow-up interview on 6/11/25 at 2:03 PM, the DON stated she did not complete a timecard because she was not required to clock-in. She stated she used Monday mornings to perform Administrator duties and the rest of the hours for DON time. During an interview on 6/13/25 at 9:30 AM, the DON stated she assumed the Administrator role since October 2024 after the previous Administrator retired. Record review on 6/11/25 at 2:35 PM, of the POSITION DESCRIPTION [PD], version 2024.04 Title: Administrative/Director, Heritage Place, revealed: POSITION SUMMARY: The Administrator/Director of Clinical Services provides leadership, and oversight to ensure the planning, organizing, and management of all aspects of the nursing home. Supervises and evaluates the care provided to residents to ensure the highest possible quality and compliance with state and federal regulations. In compliance with Long Term Care regulation F354, this position must include a minimum of 35 hours a week to be spent performing Director of Nursing (i.e., Director of Nursing duties). Further review revealed a handwritten note attached to the PD that read: no appoint [appointment] letters available. Org [organization] doesn't use. Another note attached read: 8-4:30 MF [Monday to Friday] 35 hours- wk [week] Focus on DON role 5 hr per wk focusing on Admin [administrator] role. .

Based on observation and interview, the facility failed to ensure medical supplies were labeled appropriately and removed from storage if expired. These failed practices placed all residents (based on a census of 44) at risk for adverse effects or complications from use of the expired products. Findings: Central Medical Supply Room: An observation on [DATE] at 10:05 AM, of the central medical supply room, revealed the following expired medical supplies: 1 - Bard 16 french (diameter size) urethral catheters with a coude tip (meaning, the tip is slightly bent, helping the catheter bypass obstructions within the urethra that would hinder a straight catheter's path), expired on [DATE]; and 2 - Bard 24 french urethral catheter, expired on [DATE]. Further observation revealed the following sterile suction catheters without documented expiration dates: 4 - AirLife Tri Flo 5/6 french suction catheters, with no expiration date; and 1 - AirLife Tri-Flo 14 french suction catheter, with no expiration date. During an interview on [DATE] at 12:30 PM, the Support Services Manager (SSM) stated he ordered and stocked the central supply room and that some medical supplies were sourced from the hospital. When asked what the process was for ensuring medical supplies had not expired, the SSM stated the expiration dates were checked once a week and medical supplies from the hospital were stocked weekly. When asked about the products lacking expiration dates, the SSM acknowledged there was no facility process for verifying expiration dates on supplies without a visible date and stated that lot numbers could be used as a reference. During a follow-up interview on [DATE] at 1:38 PM, the SSM stated the expired foley catheters and the suction catheters without expiration dates were stocked by the hospital. The SSM stated there was not a good process in place to verify expiration dates. During an interview on [DATE] at 10:25 AM, Licensed Nurse (LN) #1 stated if nurses found an expired item, they were expected to dispose of the item. LN#1 further stated if he/she found a product with no expiration date, he/she would notify the nurse manager. Review of the facility's policy Monitoring Supply Dates, last reviewed on 11/2024, revealed: Procedure .4. All department manager/supervisors are responsible [for] monitoring supplies stocked in their department. However, the Supports Services Manager will conduct spot inspections of storage areas during the bi-weekly Housekeeping inspection to ensure proper rotation of materials stocked in the Sitka storage area, and the Med-room [medication room] .5. During spot checks, items which will expire before next check are removed from inventory. .

Based on observation, interview, and record review, the facility failed to ensure food was stored under proper sanitary conditions in the main kitchen and in the Sitka [NAME] unit. This failed practice placed all residents (based on a census of 44), who received food from both kitchens at risk for foodborne illness and communicable disease. Findings: Main Kitchen An observation, during the initial kitchen tour, on 6/9/25 at 8:09 AM, revealed: 1) Dry Storage/Pantry: - 1 opened 25 ounce bottle of Traditional Style Rotisserie Seasoning, 3/4 full, received on 11/12/20, no open date; - 1 opened 16 ounce bottle of Whole Celery Seeds, 5/6 full, received on 10/12/20, no open date; - 1 opened 4 ounce bottle of Whole Tarragon Leaves, 3/4 full, received on 10/3/20, no open date, and; - 1 opened 18 ounce bottle of Mild Chili Powder, 5/6 full, received on 10/11/21, no open date. 2) Food Preparation area: - 1 opened 25 ounce bottle of Traditional Style Rotisserie Seasoning, 1/2 full, received on 11/12/20, no open date; - 1 opened 5 ounce bottle of Dill Weed, 3/4 full, received on 10/5[no year], no open date; - 1 opened 16 ounce bottle of Whole Celery Seeds, 1/4 full, received on 10/12/20, no open date; - 1 opened 16 ounce bottle of Whole Caraway Seed, 1/4 full, received on 10/5/21, no open date; - 1 opened 12 ounce bottle of Crushed Red Pepper, 1/3 full, received on 9/18/22, no open date; - 1 opened 14 ounce bottle of Whole Fennel Seed, 3/4 full, received date was smudged and unreadable, no open date; - 1 opened 20 ounce bottle of Poppy Seed, 1/3 full, received date was smudged and unreadable, no open date; - 1 opened 18 ounce bottle of Whole Sesame Seeds, 2/3 full, received on 4/7/25, no open date; - 1 opened 6 ounce bottle of Ground Cloves, received on 1/10/19, no open date; - 1 opened 16 ounce bottle of Ground Nutmeg, 3/4 full, received on 12/21/23, no open date; - 1 opened 16 ounce bottle of Ground Cayenne Pepper, 1/2 full, received on 6/25 [no year], no open date; - 1 opened 15 ounce bottle of Ground Ginger, 1/2 full, received on 2/12[no year], no open date; - 1 opened 14 ounce bottle of Ground Coriander, 1/4 full, received on 9/10/21, no open date; - 1 opened 6 ounce bottle of Rubbed Sage, 1/4 full, received on 10/9[no year] no open date; and, - 1 opened 1 pound box of Corn Starch, 1/2 full, received on 4/1/24, no open date. 3) Resident/Family Refrigerator - 1 opened 22 ounce bottle of Hershey's Syrup, received on 11/1/24, no open date; and, - A 1/2 loaf of white bread, no open date. During an interview on 6/9/25 at 8:46 AM, the Food Service Supervisor (FSS) stated every container should be labeled with a received date and open date. When asked how staff determined when to replace items without expiration dates, the FSS explained that staff would notify her if the item looked close to being empty. Sitka [NAME] Unit An observation of the Sitka [NAME] unit's kitchenette on 6/9/25 at 2:30 PM, revealed: Refrigerator: - A 1/2 loaf of cinnamon raisin bread, with torn packaging exposing the bread, opened on 6/3/25. Review of the facility's policy Food Labeling and Dating, effective date 11/2024, revealed: . All food items are dated before they are stored. The manufacturer's date of expiration or use by will be the date to dispose the product Items opened and stored in their original container will have the letters OP on them, with the date that the product was opened . Review of the facility's policy Monitoring Supply Dates, effective date 11/2024, revealed: . Food Service will monitor all groceries in the Dietary department storeroom, cabinets, refrigerators, and freezers (including Sitka Rose). The Dietary Supervisor will perform weekly inspections of all areas where food is stored to ensure proper rotation and fresh dates are maintained During spot-checks, items which will expire before next check are removed from inventory . Review of the facility's policy Shelf Stable Food Safety, effective date 6/2025, revealed: Heritage Place Kitchen follows the USDA [United States Department of Agriculture] recommendations of food storage and recommended shelf life . Spices remain in original manufacturer's container and are clearly labeled with the name of the spice, the receiving date and the opened date to track freshness . .

Based on record review, observation, and interview the facility failed to ensure pureed food was prepared to the appropriate consistency to meet 3 resident's (#6, #15, and #19 ) individual needs out of 3 residents on a pureed diet. This failed practice had the potential to place the residents at risk for aspiration and compromised nutritional intake. Findings: Record review on 6/9-13/25 revealed Resident #6 was admitted to the facility with diagnoses that included multiple sclerosis (a disease of the central nervous system marked by numbness, weakness, loss of muscle coordination, and problems with vision, speech, and bladder control), Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), and dysphagia (difficulty swallowing). Further review revealed Resident #6 was on a pureed/level four texture diet (foods that are blended to a smooth, thick consistency without lumps, making them safe and easy to swallow for individuals with chewing or swallowing difficulties). Record review on 6/9-13/25 revealed Resident #15 was admitted to the facility with diagnoses that included dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking) and anxiety. Further review revealed Resident #15 was on a pureed/level four texture diet. Record review on 6/9-13/25 revealed Resident #19 was admitted to the facility with diagnoses that included dementia, depression and dysphagia. Further review revealed Resident #19 was on a pureed/level four texture gluten free diet. An observation and concurrent interview in the main kitchen on 6/11/25 at 3:05 PM, [NAME] #2 prepared pureed ham and pureed tomato soup. [NAME] #2 blended diced ham with an unmeasured amount of chicken broth in a blender and stated the mixture was pureed ham. The ham had a runny, pourable consistency; when a serving spoon was inserted and stirred, the mixture ran off the spoon like a thin sauce. [NAME] #2 then blended an unmeasured amount of tomato soup with mashed potatoes and stated the mixture was pureed tomato soup. The tomato soup also exhibited a runny, pourable consistency, running off the spoon like a thin sauce. When asked how he/she determined if the correct puree consistency had been achieved, [NAME] #2 stated he/she eyeballs the mixture and did not use any tests or tools to ensure proper puree consistency. During an interview on 6/11/25 at 4:15 PM, the Food Services Supervisor (FSS) stated IDDSI (International Dysphagia Diet Standardization Initiative) guidelines should have been followed when preparing pureed food. The FSS further stated cooks were supposed to follow recipes to make pureed food. Review of the facility's recipe book revealed: P.[Puree]Ham Breakfast .Combine ¾ Gravy with prepared Meat in blender or food processor. Continue blending until pudding-like consistency is reached. Further review revealed no recipe for pureed tomato soup. During an observation in the Sitka [NAME] unit on 6/12/25 at 4:27 PM, pureed corn, served for dinner, did not hold its shape on the spoon and did not fall off the spoon in one shape when it was tilted. Further observation revealed the pureed corn dripped continuously through fork prongs. Review of the facility's IDDSI handouts, dated 1/2019, revealed: Level 4-Pureed Food [should] Hold shape on a spoon .Fall off a spoon in a single spoonful when tilted .Liquid (like sauces) must not separate from solids . How do I test my food to make sure it is Level 4 Pureed? It is safest to test Pureed Food using the IDDSI Fork Drip Test and the IDDSI Spoon Tilt Test . IDDSI Fork Drip Test Liquid does not dollop, or drip continuously through the fork prongs . IDDSI Spoon Tilt Test Sample holds its shape on the spoon and falls off fairly easily if the spoon is tilted or lightly flicked .Pureed foods must pass both tests! Review of the facility's policy, Therapeutic Diets, effective date 12/2024 revealed: Food is cut, chopped, ground, pureed, or liquidized according to individual's resident needs . For diets ordered with a Dysphagia Diet, the IDDSI guidelines will be followed: . 4- Pureed Foods & Extremely Thick Liquids. .

Based on record review, observation, and interview the facility failed to ensure comprehensive care plans were revised to meet the changing needs of 3 residents (#'s 26, 31, and 33), out of 12 sampled residents. Specifically, the facility failed to revise care plans to reflect: 1) the use of a foot cradle for Resident #26; 2) a change in cognition and activities of daily living (ADLs) for Resident #31, and; 3) the use of enhanced barrier precautions (EBP) for Resident #33. This failed practice placed the residents at risk for less than the highest practicable mental, physical, and psychosocial well-being. Findings: Resident #26 Record review on 6/9-13/25 revealed Resident #26 was admitted to the facility with diagnoses that included vascular dementia (reduced blood flow to the brain affecting cognition and brain function), major depressive disorder, delusional disorder (a condition in which a person has one or more fixed persistent beliefs that are not based on reality), and disorders of bone density and structure. Random observations on 6/9-11/25 revealed Resident #26's feet were in a foot cradle (frame installed at the end of the bed to keep sheets/ blankets off the legs/feet), covered with a blanket. Review of Resident #26's Care Plan, revised on 5/13/25, revealed: [Resident #26] has an arterial ulcer of the Left middle Toe r/t[related to] poor circulation . Interventions Monitor/document/report PRN [as needed] any s/sx[signs and symptoms] of infection . The use of the foot cradle was not in the care plan. During an interview on 6/9/25 at 2:25 PM, Resident #26 stated he/she had hammertoes [a foot condition where an imbalance of the muscles and ligaments around the toe joint causes the toes to bend in a downward position], the foot cradle was protecting his/her toes from touching the blanket. During an interview on 6/11/25 at 1:44 PM, Certified Nursing Assistant (CNA) #1 stated the foot cradle was in place for at least three weeks to protect Resident #26's left toes from touching the blanket. During an interview on 6/13/25 at 11:26 AM, the Director of Nursing (DON) stated there was no need for a physician's order for the use of the foot cradle because that was a nursing intervention. When asked if the use of foot cradle should be care planned, she stated it should be. Resident #31 Record review on 6/9-13/25 revealed Resident #31 was admitted to the facility with diagnoses that included dementia (a decline in cognitive function), congestive heart failure (a long term condition where the heart is unable to pump blood efficiently), and ischemic cardiomyopathy (a condition where the heart muscle is weakened as a result of a heart attack or coronary artery disease). During a joint interview with Resident #31 and Resident #31's Resident Representative (RR) on 6/9/25 at 2:25 PM, Resident #31 would begin to speak but would stop mid-sentence. The RR stated Resident #31 had experienced a decline in cognition and ability to perform activities of daily living (ADLs) beginning around 5/26/25. The RR further stated the change had affected Resident #31's dexterity, eating, and mobility which resulted in increased dependence on staff to perform oral hygiene, feeding, dressing, amongst other ADLs. The RR added Resident #31 had used a walker but was not able to since his/her decline. The RR stated he/she was concerned Resident #31 was not receiving oral care on a regular basis. Review of Resident #31's care plan, focus last revised on 11/12/24, revealed, . [Resident #31 is independent for meeting emotional, intellectual, physical, and social needs . is independent for most activities of daily living . There were no interventions listed on the care plan regarding the resident's oral hygiene needs, or the resident's new needs for additional assistance with cognition or ADLs. Review of the MDS (Minimum Data Set, a federally required nursing assessment), dated 5/9/25, revealed the resident used a walker or a manual wheelchair for mobility. Further review of the assessment revealed: - . Eating .Setup or clean-up [staff] assistance .resident completes the activity .; - . Oral Hygiene . Setup or clean-up [staff] assistance .resident completes the activity .; - . Toileting Hygiene . Partial/moderate [staff] assistance .Helper does LESS THAN HALF the effort .; - . Upper body dressing . [staff] provides VERBAL CUES or TOUCHING/STEADYING assistance as resident completes activity .; - . Lower body dressing . Partial/moderate [staff] assistance .Helper does LESS THAN HALF the effort .; - . Personal hygiene . [staff] provides VERBAL CUES or TOUCHING/STEADYING assistance as resident completes activity .; - . Walk 10 feet . supervision or touching assistance .; - . Walk 50 feet . Walk 150 feet . [staff] provides VERBAL CUES or TOUCHING/STEADYING assistance as resident completes activity .; During an interview on 6/12/25, at 4:15 PM, the MDS nurse stated he/she was aware the resident had a decline in functionality and the last interdisciplinary team (IDT) meeting held for Resident #31 was on 6/9/25. The MDS nurse further stated a significant change would have been decided during the IDT meeting but no significant change assessment was completed. Review of Resident #31's progress note, dated 6/9/25, revealed an IDT Collaboration regarding Resident #31's, . global decline and now has a physician prognosis of 6 months or less . The note further spoke about discontinuing the resident's thyroid medication, but did not mention completing a significant change assessment or updating the care plan to comprehensively reflect the resident's new needs. During an interview on 6/13/25 at 10:52 AM, the DON confirmed Resident #31's health decline and stated Resident #31 was not currently independent with ADLs or mobility, and that the care plan should have been updated to reflect the resident's changes. Resident #33 Record review on 6/9-13/25 revealed Resident #33 was admitted to the facility with diagnoses that included cellulitis (a bacterial infection of the skin and soft tissues underneath), peripheral vascular disease (a condition where blood circulation is reduced to body parts outside of the brain and heart), and was under palliative care (a treatment approach for individuals living with a life-limiting illness). During an interview and concurrent observation on 6/9/25 at 12:28 PM, Resident #33 stated he/she had a bad infection, but it was getting better. The resident was sitting on the side of the bed with both feet on a cushioned pad on the floor. Both feet and lower legs were red and swollen, with areas of flaky broken skin that wept an odorous opaque tan fluid. An observation and concurrent interview on 6/9/25 at 12:53 PM, revealed Resident #33 had his/her name on the outside of his/her room with a small square picture of fireworks underneath. CNA #5 stated the fireworks meant the resident was on enhanced barrier precautions (EBP), meaning that staff would need to put on a gown and gloves if they were going to come in direct contact with the resident or the resident's body fluids. Review of Resident' #33's care plan, dated 4/7/25, revealed the EBP were not included in the care plan. During an interview on 6/12/25 at 2:23 PM, the Assistant Director of Nursing (ADON) stated EBP was active in Resident #33's electronic medical record. The ADON further stated EBP was not reflected in the care plan but should have been. Review of the facility's policy, Care Plans - Comprehensive Person-Centered [CPCCP], reviewed on 5/2025, revealed: The CPCCP will: . describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing . Incorporate identified problem areas . Assessments of residents are ongoing and care plans are revised as information about the resident and residents' condition change . .

Based on record review, interview, and observation, the facility failed to ensure consistent oral care was provided to 1 resident (# 31), out of 12 residents sampled. This failed practice had the potential to place the resident at risk of poor oral health outcomes. Findings: Record review on 6/9-13/25 revealed Resident #31 was admitted to the facility with diagnoses that included dementia (a decline in cognitive function), congestive heart failure (a long term condition where the heart is unable to pump blood efficiently), and ischemic cardiomyopathy (a condition where the heart muscle is weakened as a result of a heart attack or coronary artery disease). During an interview and concurrent observation on 6/9/25 at 2:25 PM, Resident #31's Resident Representative (RR) stated he/she was concerned Resident #31 was not receiving oral care on a regular basis. The RR also stated Resident #31 had experienced a health decline during the last two weeks, which affected the resident's cognition and activities of daily living, such as his/her dexterity. The change had resulted in the resident relying on staff to perform oral hygiene amongst other regular daily activities. During the interview, it was noted that Resident #31 had bad breath that was very notable. Review of Resident #31's Task Description list, undated, revealed: . Oral Hygiene . Frequency . Every Shift [twice a day] . Review of Resident #31's Oral Hygiene Task sheet, dated 5/15/25 through 6/12/25 (28 days), revealed Resident #31 only received oral care once daily on ten occasions (out of 56 opportunities per orders of twice daily). Review of Resident #31's Kardex sheet (a summary of a resident's care plan used by certified nursing assistants to provide care), dated 6/12/25, revealed no instructions regarding assistance with oral hygiene. Review of Resident #31's care plan, last revised on 11/12/24, revealed there were no interventions listed on the care plan regarding the resident's oral hygiene needs. During an interview on 6/13/25 at 10:52 AM, the Director of Nursing (DON) stated oral care was to be performed at least once per 12-hour shift and as needed. The care plan should have been updated to reflect Resident #31's current needs. .

Based on record review and interview, the facility failed to ensure medical records were complete for 1 sampled resident (#33), out of 12 sampled residents. Specifically, physician signatures on written orders were not dated. This failed practice created incomplete medical records which placed the resident at risk for inconsistencies in treatment and care provided. Findings: Record review on 6/9-13/25 revealed Resident #33 was admitted to the facility with diagnoses that included cellulitis (a bacterial infection of the skin and soft tissues underneath), peripheral vascular disease (a condition where blood circulation is reduced to body parts outside of the brain and heart), and was under palliative care (a treatment approach for individuals living with a life-limiting illness). Review of Resident #33's physician telephone/verbal order sheets, from 1/3/25 to 5/8/25, revealed the following: A telephone/verbal order slip, dated 1/3/25, was written to: Hold KCl [potassium chloride - a mineral supplement] Repeat BMP [lab work: basic metabolic panel] in 1 wk [week] . The handwritten orders contained a physician's signature with no date or time associated with the signature; A telephone/verbal order slip, dated 1/6/25, was written to: Stop: Hydromorphone [an opioid medication used to treat pain] 2mg Tablet . Start: Hydromorphone 4mg Tablet . The handwritten orders contained a physician's signature with no date or time associated with the signature; A telephone/verbal order slip, dated 1/6/25, was written for the following: Prognosis [less than or equal to] 6 months to live . The handwritten order contained a physician's signature with no date or time associated with the signature; A telephone/verbal order slip, dated 1/13/25, was written to: Stop: Potassium. The handwritten order contained a physician's signature with no date or time associated with the signature; A telephone/verbal order slip, dated 4/9/25, was written to: Stop: lactulose [a medication used to treat constipation] 15 ml [milliliters] .; miralax [a medication used to treat constipation] .; sertraline [an antidepressant] 100 mg .; tizanidine [a muscle relaxer] 2mg .; torsemide [a diuretic medication used to treat edema] 20mg . The handwritten orders contained a physician's signature with no date or time associated with the signature; and A telephone/verbal order slip, dated 5/8/25, revealed two medication orders for: Cephalexin [an antibiotic] 1gram . [and] Doxycycline [an antibiotic] 100 mg [milligrams] . The handwritten orders contained a physician's signature with no date or time associated with the signature. Review of Resident #33's electronic orders revealed all the above orders were entered into the resident's electronic medical record (EMR) by the facility's Resident Care Coordinator (RCC). The different ordering physicians for all the above orders were Ordered By: GROUP, THE ALASKA HOSPITALIST . There were no individual electronic physician signatures with a designated time or date stamp on any of the orders. During an interview on 6/13/25 at 8:50 AM, the RCC stated when physicians gave verbal orders, she would fill out a telephone/verbal order slip and then enter the order in the EMR. She further stated the physicians signed the telephone order slips when they rotated through for their weekly visits to the facility. The RCC stated that she would check the order slips to ensure completeness after the physician signed the slip. During an interview on 6/13/25 at 11:20 AM, the Director of Nursing (DON) stated all physician signatures on verbal orders should have a date and time. The DON further explained the facility's physicians do not enter orders or physician progress notes directly into the facility's EMR but wrote their notes into another EMR associated with the hospital. Review of The American Health Information Management Association (AHIMA)'s article Ethical Standards of Clinical Documentation Integrity (CDI) Professionals, dated 2020, at https://www.ahima.org/media/r2gmhlop/ethical-standards-for-clinical-documentation-integrity-cdi-professionals-2020.pdf?oid=301868 revealed: . Facilitate accurate, complete, and consistent clinical documentation within the health record to demonstrate quality care, support coding, and reporting to high-quality healthcare data used for both individual patients and aggregate reporting . .

Based on observation, interview and record review, the facility failed to ensure infection control procedures were properly implemented in the facility. Specifically, the Certified Nurse Assistants (CNAs) failed to change gloves and perform hand hygiene while providing personal cares, for 2 residents (#s 26 and 35), out of 2 residents observed for personal cares. This failed practice had the potential to place all residents at risk of contamination and transmission of infections. Findings: Resident #26 An observation on 6/10/25 at 9:04 AM, revealed both CNAs were wearing gloves. CNA #1 and CNA #2 began to assist the resident put on brief and pants up to Resident #26's lower legs while the resident was on lying position. Next, CNA #1 inserted an absorbent pad liner in between the resident's legs. Then the CNAs helped the resident change into a clean shirt. Next, CNA #1 wiped Resident #26's abdominal skin folds with wet wipes and applied cream on the skin and then inserted dry wipes in between the skin folds. Afterwards, CNA #1 and CNA #2 turned the resident onto his/her right side, then CNA #1 wiped Resident #26's perianal area. Next, CNA #1 pulled out a soiled absorbent pad liner and inserted a Hoyer lift (a mobility tool to assist individuals with limited mobility to safely transfer) sling under the Resident's back. While still wearing the same soiled gloves, CNA #1 and CNA #2, pulled the resident's pants and brief up. Both CNAs repositioned the Resident to the center of the bed, then pulled the brief and pants up more ensuring a good fit. Then CNA #1 and CNA #2 turned the resident onto his/her left side and secured placement of the Hoyer lift sling under the resident and positioned the resident to a lying position. CNA #1 removed his/her soiled gloves, sanitized his/her hands, put on new gloves, then continued to transfer the resident to his/her wheelchair. Resident #35 An observation on 6/11/25 at 9:15 AM, revealed CNA #3 provided Resident #35's perineal care. CNA #3 started by sanitizing his/her hands and put on gloves. Resident #35 was lying on bed. Then, while a soiled brief was still on the resident, CNA #3 assisted the resident with putting on his/her socks, placed a new brief around the resident's thighs, and placed clean pants onto the resident lower legs. Next, CNA #3 removed a pillow from resident's right side and placed a clean absorbent pad liner onto the bed. Then, CNA #3 removed Resident #35's soiled absorbent pad liner and wiped Resident #35's peri-area. While still wearing the same soiled gloves, CNA #3 removed Resident #35's eyeglasses and set them aside, repositioned the resident's head, then, repositioned the resident's arms towards his/her body. Afterwards, the CNA turned Resident #35 onto his/her left side, then CNA #3 cleaned Resident #35's anal area, wiped off the zinc oxide from the skin, applied new zinc oxide onto resident's skin, and then removed the soiled bed pad and turned Resident #35 to his/her back. While still wearing the same soiled gloves, CNA #3 placed a new absorbent pad liner over the resident's peri-area and pulled the new brief and pants up. CNA #3 continued to wear the same soiled gloves until Resident #35 was ready to be transferred through a Hoyer lift. While still wearing the same soiled gloves, CNA #3 brought the resident's wheelchair over to the bedside. Then the CNA removed his/her soiled gloves, wiped his/her hands with a sanitizing wipe, and continued to transfer the Resident into his/her wheelchair. During a joint interview on 6/12/25 at 1:58 PM, the Resident Care Coordinator (RCC) stated hand hygiene should be performed based on the facility's policy and procedures and Centers for Disease Control and Prevention (CDC). She stated hand hygiene should be performed after contact with the residents, after removal of gloves, and after a task was completed. The Director of Nursing (DON) and RCC were asked if the CNAs were expected to change gloves and wash hands after providing residents perineal care and before touching the resident, both DON and RCC replied, Yes. Review of the facility's policy, Hand Hygiene, dated 11/2024, revealed: . Use alcohol- based hand rub containing at least 62% alcohol.for the following situations.before moving from a contaminated body site to a clean body site during resident care.after contact with a resident's skin.after contact with blood or bodily fluids. Review of CDC's guidelines on clean hands Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, accessed on this link: https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, revealed: . know when to clean your hands . Before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, After contact with blood, body fluids, or contaminated surfaces, immediately after glove removal. .

Based on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) food was stored under proper sanitation and food handling practices in the main kitchen; 2) food was stored under proper sanitation and food handling practices on the Sitka [NAME] unit; and 3) the dishwasher water temperature was at appropriate temperature range, prior to washing dishes, for proper sanitation of all dishware and food service equipment. These failed practices had the potential of causing or spreading foodborne illness to all residents, based on a census of 43. Findings: Main Kitchen An observation, during the initial kitchen tour, on 5/13/24 at 11:05 AM, revealed: 1) Dry Storage/Pantry area: - 4- 28-ounce containers of Danish Orchards Blackberry Fruit Preserves, manufacture expiration date was 4/9/24; - Penne Noodles loose, in Rubbermaid bin, no packaging and no open date on bin; and - Fettuccine Noodles loose, in Rubbermaid bin, no packaging and no open date on bin. 2) Refrigerator: - 1- 16-ounce container of Roseli Parmesan Cheese - 1/2 full - no open date; - 1- 1 quart container of [NAME] Horseradish - 1/2 full - no open date; - 1- 48-ounce container of Real Lemon Juice - 1/3 full - no open date; - 1- 1-gallon container of Sliced Pepperoncini - 3/4 full - no open date; - 1- 5-pound container of Sour Cream - 1/2 full - no open date; - 1- 4.5-pound container of Minors Sweet and Sour Sauce - 1/2 full - no open date; - 1- 1-gallon container of Monarch 3/16-inch Crinkle Cut Dill Pickles - 1/4 full - no open date; and - 1- 1-gallon container of Monarch Sweet Pickle Relish - 1/4 full - no open date. 3) Freezer: - 1- Ziploc bag of one brown meat roast, labeled Roast Beef, dated 3/17; - 1- clear plastic bag with frozen slices of garlic bread labeled Garlic Bread - use first - no open date. 3) Central Kitchen area: - 1 Large rolling white container with clear lid labeled Peas - contained a mix of open individual bags marked: pearl barley, great northern beans, pinto beans, and navy beans, no open dates. - 1 Large rolling white container with clear lid labeled Pancake Mix - contained a large plastic bag with loose white powder, no packaging, no label, no open date. - 1 Large rolling white container with clear lid that did not close and not labeled - contained a mix of open individual bags marked: powdered sugar, granulated sugar, and cinnamon sugar, no open dates. - 1 Pan of cooked food, set on top of a pan filled with ice, on kitchen prep table. No lid on pan, open to air, filled with contents of orange, white, brown chunks with brownish liquid (gravy like) with spoon in the contents. An observation on 5/13/24 at 11:44 AM, revealed Food Service Assistant (FSA) #1 was preparing food-filled plastic cups labeled egg salad and tuna salad in the kitchen. FSA #1 was not wearing a hairnet. During an interview on 5/13/24 at 11:46 AM, the Dietary Manager stated every container should be labeled with an open date when the container was opened. The Dietary Manger further stated all personnel in the kitchen and preparing food were required to wear a hairnet. Sitka [NAME] Unit An observation of the Sitka [NAME] unit kitchenette on 5/15/24 at 2:10 PM, revealed: 1) Cupboards and Countertop: - 1- opened box of Pedialyte electrolyte powder (6 individual packets in a box) with a manufacture use by date of 01 [DATE]; - 1- unopened box of Pedialyte electrolyte powder (6 individual packets in a box) with a manufacture use by date of 01 [DATE]; - 1- opened box of [NAME] Microwave Popcorn Movie Theatre Butter (1 package in box) with a manufacture expiration date of 11/30/21; - 1- 5-fluid ounce container of Kikkoman Soy Sauce - 1/2 full - No open date; - 1- 12-ounce container of [NAME] Bee Pure Honey Clover - 1/4 full - No open date; and - 1- container of Local Raw Unfiltered Honey - 1/4 full - No open date. 2) Refrigerator: - 1- 20-ounce container of ketchup - 1/2 full - no open date; - 1- 13-ounce container of mustard - 3/4 full - no open date; - 1- 20-ounce container of mayonnaise - 1/2 full - open date not readable (smudged); - 1- 12-ounce container of tabasco sauce - 1/4 full - dated 11/10/22. 3) Freezer: - 1 Ziploc bag with 13 blueberry muffins - dated 7/10. Review of the facility's policy Food Labeling and Dating, effective date November 2023, revealed: .All food items are dated before they are stored. The manufacturer's date of expiration or use by will be the date to dispose the product. Items opened and stored in their original container. will have the letters OP on them, with the date that the product was opened. Once foods have been cooked to the proper temperature, held, and properly cooled; they may be labeled, dated, and may be frozen. Review of the facility's policy Monitoring Supply Dates, effective date November 2023, revealed: . the food services will monitor all groceries in the dietary department storeroom, cabinets, refrigerators, and freezers (including Sitka Rose). The dietary supervisor will perform weekly inspections of all areas where food is stored to ensure proper rotation and fresh dates are maintained. During spot-checks, items which will expire before next check are removed from inventory. Review of the facility's policy Safety in Food Service, effective date November 2023, revealed: General Precautions. Keep clean. Wash hands thoroughly before handling food or dishes. Food service personnel must wear hairnets while on duty. Dishwasher An observation and concurrent record review on 5/13/24 at 11:45 AM, revealed a May 2024 temperature log posted in the main kitchen near the dishwasher. A review of the log revealed the dishwasher temperatures for each cycle (wash, rinse, and sanitize) were documented for each meal of the day (breakfast, lunch, and dinner). Further review revealed a temperature target range of 120 degrees Fahrenheit (F) was under each cycle name on the log, however many of the temperatures logged for May 2024 were below this target temperature. An observation on 5/15/24 at 9:43 AM, revealed the label on the facility's dishwasher identified it as an American Dish Service dishwasher, model series AFC-3D-S. Further review of the label revealed: wash temperature 120 degree F minimum and rinse temperature 120 degree F minimum. An observation on 5/15/24 at 9:44 AM, FSA #4 demonstrated the steps of a dishwasher cycle: rinse off the dishes of any food particles, place dishes in a standard dish rack and put into the dishwasher, and then lower the dishwasher cover which initiated the wash, rinse, and sanitize cycles. Further observation revealed the wash cycle water temperature was 113 degrees F and the rinse cycle was 117 degrees F. During an interview on 5/15/24 at 9:44 AM, when asked if he/she knew the target temperature range for the dishwasher to properly clean and sanitize the dishes, FSA #4 stated he/she did not know what the target temperature should be. Record review of the facility kitchen's temperature logs for the dishwasher, dated 1/1/24 through breakfast of 5/17/24, revealed the number of times a dishwasher cycle was below 120 degrees for each meal: 1) January 2024: (93 total opportunities) - Breakfast: Wash cycle - 24 out of 31 times; Rinse cycle - 25 out of 31 times; Sanitization cycle - 15 out of 31 times. - Lunch (three days were not documented): Wash cycle - 22 out of 28 times; Rinse cycle - 20 out of 28 times; Sanitization cycle - 13 out of 28 times. - Dinner: Wash cycle - 16 out of 31 times; Rinse cycle - 16 out of 31 times; Sanitization cycle 8 out of 31 times. 2) February 2024 (87 total opportunities): - Breakfast: Wash cycle - 24 out of 29 times; Rinse cycle - 25 out of 29 times; Sanitization cycle - 19 out of 29 times. - Lunch: Wash cycle - 22 out of 29 times; Rinse cycle - 21 out of 29 times; Sanitization cycle - 10 out of 29 times. - Dinner (one day was not documented): Wash cycle - 23 out of 28 times; Rinse cycle - 16 out of 28 times; Sanitization cycle - 6 out of 28 times. 3) March 2024 (93 total opportunities): - Breakfast: Wash cycle - 30 out of 31 times; Rinse cycle - 25 out of 31 times; Sanitization cycle - 16 out of 31 times. - Lunch: Wash cycle - 23 out of 31 times; Rinse cycle - 20 out of 31 times; Sanitization cycle - 10 out of 31 times. - Dinner (two days were not documented): Wash cycle - 19 out of 29 times; Rinse cycle - 15 out of 29 times; Sanitization cycle - 6 out of 29 times. 4) April 2024 (90 total opportunities): - Breakfast: Wash cycle - 27 out of 30 times; Rinse cycle - 30 out of 30 times; Sanitization cycle - 19 out of 30 times. - Lunch (one day was not documented): Wash cycle - 23 out of 29 times; Rinse cycle - 19 out of 29 times; Sanitization cycle - 13 out of 29 times. - Dinner (one day was not documented): Wash cycle - 21 out of 29 times; Rinse cycle - 22 out of 29 times; Sanitization cycle - 5 out of 29 times. 5) May 2024 (49 total opportunities): - Breakfast: Wash cycle - 15 out of 17 times; Rinse cycle - 11 out of 17 times; Sanitization cycle - 4 out of 17 times. - Lunch: Wash cycle - 11 out of 16 times; Rinse cycle - 10 out of 16 times; Sanitization cycle - 3 out of 16 times. - Dinner: Wash cycle - 10 out of 16 times; Rinse cycle - 4 out of 16 times; Sanitization cycle - 2 out of 16 times. During an interview and concurrnet observation on 5/15/24 at 10:10 AM, the Support Services Manager (SSM) stated the dishwasher was a chemical sanitizing dishwasher machine. An observation revealed the SSM ran the dishwasher and monitored the temperature with a facility maintenance temperature gauge. The first wash cycle revealed the wash temperature to be 112.4 degrees F and the rinse temperature to be 124.4 degrees F. The second wash cycle revealed the wash temperature to be 129 degrees F and the rinse temperature to be 130.2 degrees F. The third wash cycle revealed the wash temperature to be 126.6 degrees F and the rinse temperature to be 132.2 degrees F. The SSM stated he would like to see the dishwasher temperature reach 130 degrees F for proper washing and sanitation of dishes. The SSM further stated the food service staff needed to run the dishwasher a couple of times to get the water temperature up to the target temperature range prior to using it to wash dishes. An observation on 5/15/24 at 3:32 PM, revealed FSA #8 was preparing to wash dishes. FSA #8 ran an empty cycle which revealed a wash temperature of 104 degrees F and a rinse temperature of 113 degrees F. Further observation revealed FSA #8 ran the dishwasher 3 times in a row before preparing to wash a set of dishes. The next cycle with dishes, which was the fourth time the dishwasher was run in a row, revealed a wash temperature of 118 degrees F and a rinse temperature of 122 degrees F. During an interview on 5/15/24 at 4:08 PM, FSA #8 stated, I have to run them [meaning dishes] through multiple times if I step away to get more dishes. If I keep running the dishwasher it holds the temperature, if I stop, it drops. Review of the latest provided, facility dishwasher routine service report from Ecolab, dated 1/9/24, revealed the dishwasher was working well and sanitizing effectively at a documented wash temperature of 130 degrees F. Review of the facility's owner's manual for the American Dish Service, Upright Dishwashers. AF/AFC-3DS. , dated 10/1/22, revealed: . General. The chemical sanitizing agent provides comparable germ killing ability in 140 degree rinse water as in the conventional machines with 180 degree rinse. If water temperature gauge has not reached 120 [degrees] F. when the water level is just below overflow, drain water from the machine and continue to fill until proper temperature is attained. Review of the facility's General Operating Instructions for the American Dish Service dishwasher, undated, revealed: . It is recommended that 140 [degrees] water be used. Report to your supervisor if it is lower than 120 [degrees] or higher than 160 [degrees]. Review of the facility's policy Dish Room Procedures [and] Sanitation Regulations, effective date November 2023, revealed: . Serving ware and utensils will be sanitized according to the procedures outlines below. Low Temp. Dish Machines minimum requirements: Wash cycle - 120 [degrees] F.

47929 Based on record review, interview, and observation, the facility failed to ensure: 1) a properly sized sling was used in transfers for 1 resident (#195), out of 12 sampled residents; and 2) neurological (or neuro) checks (assessments to determine if any neurological symptoms arose from potential head injuries) were performed after unwitnessed falls for 2 residents (#'s 18 and 20), out of 4 sampled residents for falls. These failed practices had the potential to: 1) cause pain and distress to the resident; and 2) delay treatment if the resident had a change in neurological status. Findings: Transfer Sling Record review from 5/13-17/24 revealed Resident #195 was admitted to the facility with diagnoses that included lung cancer, chronic obstructive pulmonary disease (COPD, a disease making breathing difficult, which involves impaired gas exchange in the lungs), peripheral vascular disease (a condition that cause blood vessels to narrow, block or spasm), and atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart). Review of Resident #195's progress note, dated 5/14/24 at 6:03 PM, revealed: . [Resident #195] stayed in bed all shift. [He/she] requested a shower today but stated [he/she] is 'petrified to get out of the bed using the lift', several attempts made to help [him/her] shower and reassurance given about getting up using the lift but [he/she] refused every offer, will attempt shower tomorrow. Review of Resident #195's progress notes, dated 5/15/24 at 4:43 PM, revealed: .[Resident #195] expressed anxiety [with] transferring using the lift again this morning, MD [physician] notified and PRN [as needed] Ativan order received. During an interview 5/15/24 at 11:29 AM, Resident #195 stated he/she had to work on getting used to how the staff transferred him/her. When he/she first arrived, the staff used a lift to assist with getting him/her out of bed that hurt his/her breasts. The resident stated, It was an awful experience. During an observation and concurrent interview on 5/15/24 at 3:19 PM, Licensed Nurse (LN) #2 and Resident Assistant (RA) #2 used a Sara3000 (sit to stand lift) to transfer Resident #195 from the resident's bed to his/her wheelchair. From a sitting position on the edge of the bed, LN #2 and RA #2 placed a light blue sling with a green border (the green border indicated the sling size was large) around the torso of Resident #195. The staff placed the resident closer to edge of bed, where his/her lower legs were buckled to the standing platform on the lift. The staff then attached the sling to the lift with clips built into the sling. With the resident holding onto the handles, RA #2 advised the resident to lean forward, as the lift assisted the resident into a standing position. In doing so, the sling pulled up the resident's shirt, exposing the entire midsection of the resident and bunched up the shirt in the underarm area. While being lifted, Resident #195 said, Ouch. While LN #2 handled the oxygen tubing, the resident was turned around to align with his/her wheelchair and was lowered down into the wheelchair's seat. The resident was unbuckled, and the sling was removed. When asked how they knew what sling to use, RA#2 stated they use the sling compatible with the lift, which was placed in the room. During an interview on 5/15/24 at 3:44 PM, RA Supervisor #1 stated the RA Supervisors would choose an appropriate lift sling for residents after physical therapy evaluated the residents for the type of lift to be used. The facility had two different types of lifts, the full body lift (called a Hoyer) and the sit to stand lifts. RA Supervisors #1 and #2 would choose the sling size based on the resident's weight as soon as possible after admission, however, the sling sizes were not documented in the medical record. Staff would use what was placed in the room. When asked if a resident weighed 143.6 lbs. (pounds) which sit to stand sling would be selected, RA Supervisor #1 stated a yellow sling should be utilized, according to the sizing guide. Review of the facility's Sling Color Guide, no date, revealed: .Clip style hoyer and [NAME] sling sizes. Trim Color . M [medium] .Yellow . 121-165 lbs (55-75 kg [kilograms]) . L [large] . [NAME] . 154-264 lbs (75-120 kg) . Record review from 5/13-17/24 revealed Resident #195's weight on 5/14/24 (date of admission) was 143.6 lbs. During an interview on 5/16/24 at 12:35 PM, the Director of Nursing (DON) stated it was the expectation of the RA Supervisors to size residents for lift slings when they were admitted . If the resident did not like the sling, staff would work with the resident to find something that would work. The DON further stated that Resident #195 developed anxiety over lifts when he/she was in the hospital, and it continued here at the facility. The DON stated that the reason a sit to stand sling bunched up into Resident #195's armpits was because the resident was not engaging his/her legs. Review of Lippincott procedures - Transfer with a mechanical lift, long-term care, revised 5/21/23, revealed: .Preparation of Equipment .Check the size of the sling before applying it to the resident because improper sizing could result in injury. Neuro Checks Resident #18 Record review from 5/13-17/24 revealed Resident #18 was admitted to the facility with diagnoses that included cerebral infarction (a brain lesion in which a cluster of brain cells die when they don't get enough blood flow), aphasia (impaired speech due to damage in the brain), atrial fibrillation, and unspecified symptoms and signs involving cognitive functions and awareness. Further review of the Resident #18's medical record revealed the resident had seven falls in the facility since 10/29/23. Four of these falls were unwitnessed, dated 11/7/23; 12/9/23; 1/4/24; and 1/7/24. Review of Resident #18's Minimum Data Set (MDS - a federally mandated nursing assessment) assessment, an admission assessment dated [DATE] (and prior to any unwitnessed falls), revealed Resident #18 was not able to verbally speak, rarely or never made self understood, and rarely or never understood others. Fall Incident on 11/7/23 A review of Resident #18's Incident Audit Report, dated 11/7/23 at 11:30 PM, revealed: Staff alerted this nurse to resident being noted on floor laying flat on back with [his/her] [wheelchair] behind [him/her]. [He/she] was laying in doorway of double doors leading out into hallway from Town Square. Doors were closed previously. This nurse assessed. no injuries noted nor indicated from resident. Does not appear to have hit [his/her] head as no injuries were noted there either. A review of Resident #18's #683 Un-witnessed Fall Incident report, dated 11/7/23 at 11:30 PM, revealed: Resident Description: Resident Unable to give Description. A review of Resident #18's Post Fall Charting, dated 11/8/23 at 12:19 AM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 11/8/23 at 3:21 PM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 11/9/23 at 12:28 PM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. Further review of the medical record revealed no neuro checks were documented for this unwitnessed fall. Fall Incident on 12/9/23 A review of Resident #18's Incident Audit Report, dated 12/9/23 at 9:05 AM, revealed: At approximately [9:05 AM] [Resident #18] was found on the floor near the far end of Sunset; we examined [him/her]; took [his/her] vitals, and lifted [him/her] back into [his/her] wheelchair; [he/she] has a small skin tear on [his/her] left hand and a minor abrasion on [his/her] right knee. Factors. Cognitively impaired; [he/she] must have either tried to walk or leaned forward and fell . A review of Resident #18's #694 Un-witnessed Fall Incident report, dated 12/9/23, revealed: the Resident Description section of the report was left blank. A review of Resident #18's Post Fall Charting, dated 12/9/23 at 12:56 PM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 12/10/23 at 3:29 AM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 12/11/23 at 5:22 PM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. Further review of the medical record revealed no neuro checks were documented for this unwitnessed fall. Review of Resident #18's MDS assessment, a quarterly assessment dated [DATE], revealed Resident #18 was not able to verbally speak, rarely or never made self understood, and sometimes understood others. Fall Incident on 1/4/24 A review of Resident #18's Incident Audit Report, dated 1/4/24 at 9:33 AM, revealed: The RA [Resident Assistant] found [Resident #18] on the floor next to [his/her] bed looking toward the door with [his/her] feet straight out in front of [him/her]. A review of Resident #18's #705 Un-witnessed Fall Incident report, dated 1/4/24, revealed: Resident Description: Resident Unable to give Description. Review of Resident #18's Progress Note, dated 1/4/24 at 9:47 AM, revealed: [Resident #18] was found on the floor sitting with [his/her] back at [his/her] bed and feet stretched out in front of [him/her]. No demonstration of pain noted with active and passive ROM [range of motion]. [He/she] is resistant to care and combative during skin check, [morning] care, and toileting. No new bruise, redness, or apparent injury is found. A review of Resident #18's Post Fall Charting, dated 1/4/24 at 10:06 AM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 1/5/24 at 4:00 AM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 1/5/24 at 10:08 AM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. Further review of the medical record revealed no neuro checks were documented for this unwitnessed fall. Fall Incident on 1/7/24 A review of Resident #18's Incident Audit Report, dated 1/7/24 at 2:48 AM, revealed: Resident was noted to be sitting on buttocks [with] legs spread out in front of [him/her]. [He/she] was assessed but no injuries nor [signs/symptoms] of pain/discomfort noted. Head was not hit. [Wheelchair] was not far behind [him/her]. A review of Resident #18's #706 Un-witnessed Fall Incident report, dated 1/7/24 at 2:48 AM, revealed: Resident Description: Resident Unable to give Description. A review of Resident #18's Post Fall Charting, dated 1/7/24 at 2:54 AM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 1/7/24 at 12:42 PM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 1/8/24 at 3:36 AM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 1/8/24 at 3:11 PM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 1/9/24 at 3:08 AM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 1/9/24 at 3:51 PM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. Further review of the medical record revealed no neuro checks were documented for this unwitnessed fall. Review of Resident #18's care plan revealed an identified focus of ADL [Activities of Daily Living] Function/Risk for Falls, dated 9/6/23. Further review of the interventions for this identified problem revealed no intervention to follow fall protocols. During an interview on 5/17/24 at 8:52 AM, when asked what he/she would do if a resident was rarely or never understood, and there was a fall, LN #4 stated he/she would ask what happened, assess the resident for injuries, and for unwitnessed falls he/she would do neuro checks because you didn't know if the person could even remember if they hit their head. Resident #20 Record review from 5/13-17/24 revealed Resident #20 was admitted to the facility with diagnoses that included dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking). Further review of the Resident #20's medical record revealed the resident had three falls in the facility since 3/30/23. One of these falls was unwitnessed, dated 2/16/24. Review of Resident #20's MDS assessment, a quarterly assessment dated [DATE] (prior to the unwitnessed fall), revealed Resident #20's speech was unclear, rarely or never made self understood, and rarely or never understood others. Fall Incident on 2/16/24 A review of Resident #20's Incident Audit Report, dated 2/16/24 at 2:48 AM, revealed: [Resident #20] had an unwitnessed fall after awakening from [his/her] nap. A loud thud was heard in [his/her] room. [Resident #20] was found sitting quietly on the floor of [his/her] room. [He/she] was wearing grippy socks and there was nothing in the environment that could have caused the fall. [Resident #20] was assisted to [his/her] feet and returned to bed. [He/she] was assessed for pain and injury. A minor abrasion and a 3.9cm [centimeter] [by] 1.8cm contusion was noted on [his/her] right elbow. [He/she] had no complaint of pain and no non-verbal complaint of pain until the contusion was palpated. A review of Resident #20's #721 Un-witnessed Fall Incident report, dated 2/16/24 at 5:42 PM, revealed: Resident Description: Resident Unable to give Description. A review of Resident #20's Post Fall Charting, dated 2/16/24 at 6:19 PM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 2/17/24 at 5:52 PM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 2/18/24 at 4:20 AM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 2/18/24 at 5:57 PM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 2/19/24 at 4:37 AM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. A review of Resident #18's Post Fall Charting, dated 2/19/24 at 5:23 PM, revealed vital signs were taken. Further review revealed: . Did the resident hit their head? Answer, No. Review of Resident #18's care plan revealed an identified focus of Falls. Further review of the interventions revealed follow facility fall protocols. During an interview on 5/16/24 at 3:02 PM, the Assistant Director of Nursing (ADON) stated there were no neuro checks completed with Resident #20's unwitnessed fall on 2/16/24. Fall Protocol During an interview on 5/15/24 at 2:20 PM, LN #3 stated when a resident falls, there was a risk evaluation, in the occurrence reporting system, that was completed. This would allow the LN to document the details of the incident, including injuries; factors; witnesses; action; notes; and sign off. LN #3 further stated there was a huddle form, located in the main nursing room, that was filled out as well. From this huddle form, a huddle meeting occurred to review the incident and discuss the situation and what could be improved. During an interview on 5/15/24 at 2:40 PM, LN #1 stated there was a checklist in a binder at the main nurses' station to help nurses follow called, PCC [point click care] workflow: Risk Management/Resident Fall. For unwitnessed falls, LN #1 stated nurses would assess the resident, call 911 if needed, call the physician, and completed three days of vitals, neuro checks, and skin checks. LN #1 further stated that an order for neuro checks could be placed in the electronic records as an order. Review of the facility's Fall Action Lesson Learned (Huddle Form) form, undated, revealed this blank form had a section to check off interventions completed due to a fall: Huddle Form, Accident/Injury Report; Fall Risk Assessment; 48[hour]/72[hour] monitoring nurse order; faxed MD; called family; care plan. Further review revealed no neuro check option to select. Review of the facility's PCC [point click care] workflow: Risk Management/Resident Fall, dated 1/29/19, revealed steps taken when a fall occurred: . Under the Clinical tab go to Care Management and choose Risk Management. Click Activate and New. Fill out the incident box-Resident name, date and time, type of incident and incident location. Save. Fill out the information in each tab section across the top of the screen. complete the Morse Fall Scale and initial Post Fall Charting assessment. Review care plan. If serious injury occurred [fracture] or head injury, notify the state. fill out fall huddle form. add order for post fall charting. Further review revealed no guidance for unwitnessed falls, or any time neuro checks would be initiated. Review of the facility's policy Falls Assessment and Intervention, effective September 2023, revealed: . Applies To: Identify residents at risk for falls, establishing the plan of care for those residents and following up on any incidents of falling.Policy: Residents will be assessed for fall risk. Interventions will be used and monitored as appropriate. Evaluation. The Falls Huddle Form will be used within 30 minutes of the fall, whenever possible, to evaluate causes and initiate interventions. Post-Fall Assessment. The incident will be entered into incidents in EMR [electronic medical record] by staff involved. Notification of physician and family will be completed. The Falls Huddle will be held and the completed form will be submitted to the Director of Clinical Services. Orders for follow up assessment will be entered in the EMR. The administrator will be the only one to click the finalize button in the EMR. Further review revealed no guidance for unwitnessed falls, or any time neuro checks would be initiated. Review of the facility's policy Neurological Assessment, effective April 2024, revealed: Applies to: Resident care guidelines for a neurological assessment of a resident when a head trauma or change in neurological status is suspected or confirmed. Policy: A neurological assessment is completed by a licensed nurse when clinically indicated, including but not limited to post-unwitnessed fall. Completed neuro checks Q [every] 15min [minutes] x[times] 2, Q30minx2 and Q60minx2 UNLESS otherwise indicated by provider.

Based on record review and interview, the facility failed to adequately monitor the functional status of wander guard tags (a safety assistance device placed on a resident at risk for wandering and possible elopement. This device would trigger an alarm at any exit equipped with a wander guard sensor, alerting staff to a possible elopement attempt). Specifically, the facility used an outdated, obsolete tag battery tester, incapable of accurately indicating battery level status, for 1 Resident's (#30) tag device, out of 3 residents reviewed with wander guards, and which resulted in an elopement from the facility. This failed practice placed all residents with wander guard safety precautions (based on a census of 6) at risk for wander guard tag failure and possible elopement. Findings: Resident #30 Record review on ,d+[DATE]-,d+[DATE] revealed Resident #30 was admitted to the facility with a diagnosis of dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking). Review of Resident #30's care plan revealed an identified focus for Behavior. [Resident #30] has history of wandering related to dementia, dated [DATE]. Further review revealed interventions that included, [Resident #30] has a wander guard on [his/her] [left] ankle. Ensure the device is in place [every] shift. RA [Resident Aide] supervisor to check function weekly. Review of Resident #30's medical record revealed two separate elopement attempts and two successful elopements: - [DATE] at 5:40 PM, Incident Note: [Resident #30] exited out the alarmed sunset door. was immediately escorted back in the same doorway. was wearing [his/her] wander guard during [his/her] elopement. - [DATE] at 6:32 PM, Behavior Note: Resident intended to leave out the front door but the wander guard alarmed and staff was able to redirect [him/her]. - [DATE] at 8:34 PM, Behavior Note: Attempted to lead another resident out the front doors this evening. Alarms alerted staff and was able to redirect without issue. - [DATE] at 6:01 PM, Communication with Physician: [Resident #30] was found to have eloped and was found walking in the parking lot ambulating with wheeled walker by staff member and was easily escorted back into building. Wander guard battery was not working, so door did not alarm. Review of Resident #30's wander guard tag testing log, revealed his/her tag was tested the day prior, on [DATE], and passed the test as being functional. Review of the facility's Incident Audit Report, dated [DATE] through [DATE], revealed: Description of Action Taken: [Resident #30] was helped back into building and [Resident #30's] [wander guard] was in place on [his/her] left ankle. The battery in [his/her] [wander guard] was found to be not working so that is why the front door alarm did not go off. [RA Supervisor #1] said [he/she] had checked the battery on [his/her] [wander guard] yesterday and it was working. Wander Guard Battery Tester During an interview on [DATE] at 3:18 PM, the Assistant Director of Nursing (ADON) stated the wander guard tag batteries were not rechargeable and the whole tag device must be replaced if the battery died . The ADON further stated that RA Supervisors checked the batteries for all wander guard tags weekly to ensure they were functioning. During an interview on [DATE] at 3:21 PM, when asked how the wander guard tag batteries were tested , RA Supervisor #1 stated he/she used an Accutech Tag Activator/Deactivator device to check all wander guard tags weekly every Wednesday. After turning the device on, RA Supervisor #1 held the wander guard tag to the back of the device and pressed a button labeled TAD and waited for the Signal Strength lights to appear. There were two lights under the Signal Strength label, one labeled Tag is very near and one labeled Tag in Area. If the two lights activated, RA Supervisor #1 interpreted the tags as functioning. RA Supervisor #1 further stated he/she also looked for a light labeled Active Band Removal or Low Battery on Tag. If this light activated, RA Supervisor #1 interpreted the tag as having a low battery and replaced it. Record review on [DATE] at 4:08 PM, revealed the facility used an Accutech wander guard system. Further review revealed the device to check the wander guard tag batteries was an Accutech Tag Activator/Deactivator, FCC ID: JM7-IGWT-6660021. During an interview on [DATE] at 9:02 AM, Accutech Representative #1 stated the Accutech Tag Activator/Deactivator model the facility was using was [AGE] years old and obsolete. It was not recommended to be used anymore, as there had been 3 or 4 revisions since that particular model was in use. Accutech Representative #1 further stated that the model the facility was using was limited and would not give an accurate determination of the tag's battery status, the device will tell you the light is flashing and currently working but does not tell you how low the battery currently is. If the tag is weak or close to shutting down due to low battery, the device won't tell you that. It will tell you it is functioning, but the tag [could] shut down an hour later. Accutech Representative #1 further stated, when the tag goes weak it may not accurately trip the wander guard system at the door. During an interview on [DATE] at 10:10 AM, the Support Services Manager stated the wander guard system in the facility was about [AGE] years old and it was very expensive to update. Review of the facility's policy Resident Elopement Prevention, effective [DATE], revealed: . Proper functioning of the device is checked weekly and the results are recorded. Maintenance is notified of the need for any repair/replacement of the device.

Based on observation, interview, and record review, the facility failed to ensure expired medical products were removed from the medical supply storage areas. This failed practice placed all residents (based on a census of 43) at risk for adverse effects or complications from use of the expired products. Findings: Central Medical Supply Room: An observation and concurrent interview on [DATE] at 9:09 AM, revealed the following expired medical supplies: 5 - Bard Urethral Catheterization trays (contains a flexible tube that is inserted through the urethra to help drain urine from the bladder) with preconnected drain bag, 15 french (size of the tube), expired on [DATE]; 3 - Bard 14 french urethral catheters with a coude tip (meaning, the tip is slightly bent, helping the catheter bypass obstructions within the urethra that would hinder a straight catheter's path), expired on [DATE]; and 1 - Bard 14 french urethral catheter with a coude tip, expired on [DATE]. Licensed Nurse (LN) #1 stated the maintenance department was responsible for stocking the central supply room, however, the nurses checked the expiration dates as they gathered their supplies to stock the nurses' stations. LN #1 further stated the nurses stocked the main nurses' station/med room and the Sitka [NAME] Unit medication/supply corner. If the nurses found an expired item, they were expected to properly dispose of the item. Sitka [NAME] Unit Medication/Supply Corner: An observation and concurrent interview on [DATE] at 10:10 AM, revealed the following expired medical supplies: 1 - BD 5 ml (milliliter) syringe, expired on [DATE]; and 1 - Bard Urethral Catheterization tray with preconnected drain bag, 15 french, expired [DATE]. LN #3 stated the staff would have checked the expiration date as the supplies were stocked. The supplies were gathered from the central medical supply room. During an interview on [DATE] at 9:23 AM, the Support Services Manager (SSM), stated he ordered and stocked the central supply room and staff stocked their work area. When asked what the process was for ensuring products for the facility had not expired, the SSM stated the expiration dates were checked while he ordered the supplies twice a week. When asked about the multiple expired Bard Urethral Catheterization tray with preconnected drain bags, the SSM stated they must have received an expired case. Review of the facility's policy Monitoring Supply Dates, last reviewed on ,d+[DATE], revealed: Procedure .All department manager/supervisors are responsible [for] monitoring supplies stocked in their department. However, the Supports Services Manager will conduct spot inspections of storage areas during the bi-weekly Housekeeping inspection to ensure proper rotation of materials stocked in the Sitka storage area, and the Med-room [medication room] .During spot checks, items which will expire before next check are removed from inventory.

Based on observation, interview, and record review, the facility failed to ensure appropriate competencies and skills sets were properly established for Resident Aides (RAs), Licensed Nurses (LNs), and Food Service Staff who prepared modified diets for Sitka [NAME] residents. Specifically, the facility failed to ensure: 1) the RAs and LNs, as well as food service staff, were trained to operate a Cuisinart chopper/grinder food processor used on the Sitka [NAME] unit for preparing modified diets; and 2) RAs and LNs had food worker cards to certify they were appropriately trained to prepare modified diets. These failed practices placed 3 unsampled Sitka [NAME] residents (#s 15, 21, and 38) who were on modified diets, and potentially future residents placed on modified diets, at risk for improper food preparation and food borne illnesses. Findings: Food Processor Training and Operation During an interview on 5/13/24 at 11:46 AM, the Dietary Manager stated all personnel in the kitchen preparing food were required to wear a hairnet. An observation on 5/13/24 at 3:32 PM, revealed RA #1 prepared a minced and moist modified diet for Resident #15 on the Sitka [NAME] unit. Further observation revealed RA #1 placed approximately 3/8-inch by 1 1/2-inch round pieces of sausage into a Cuisinart chopper/grinder food processor and started the appliance by pushing a button. After the food processor automatically stopped, RA #1 then opened the processor's lid and pulled out and discarded larger pieces of sausage, that did not chop or grind down, and sausage casein out of the bowl with his/her gloved fingers. RA #1 was not wearing a hair net during this meal preparation. RA #1 then plated the rest of the meal and served the resident. During an interview and simultaneous observation on 5/14/24 at 10:46 AM, RA #1 stated the food processor appliance was used for residents with modified diets. He/she demonstrated the chopper/grinder process by placing one full-link sausage, during the breakfast meal, in the Cuisinart appliance. He/she stated the sausage was for a resident on a modified diet of minced and moist. RA #1 stated the texture of food was determined and gauged by the order and knowing their residents well and what they could handle. Further observation revealed RA #1 was not wearing a hair net during this meal preparation. During an interview on 5/16/24 at 11:03 AM, the Dietician initially stated that modified diets were to be completed by kitchen staff in the kitchen. When told of the observations from 5/13/24 and 5/14/24 of the RAs on Sitka [NAME] preparing minced and moist diets with a Cuisinart food processor, the Dietician stated she had never seen a food processor used on the unit before. The Dietician further stated that the International Dysphagia Diet Standardisation Initiative (IDDSI) training the RAs and LNs received would have prepared them to make modified diets. During an interview on 5/16/24 at 11:03 AM, the Administrator stated that RAs and LNs were trained on the consistencies of modified diets. During an interview on 5/16/24 at 11:49 AM, LN #3 stated 3 residents (#s 15, 21, and 38) had minced and moist diets. LN #3 further stated that staff used a food processor for minced and moist diets and food was ground in the processor till it stopped and staff would add gravy or broth for moisture if needed. When asked how RAs and LNs were trained to use the food processor, LN #3 stated RAs taught each other. Record review of Resident #15's provider diet order, dated 6/14/22, revealed: Resident choice/texture as tolerated diet. Easy to Chew/Level 7 texture. Further review revealed: finger foods. There was no minced and moist diet ordered for Resident #15. Record review of Resident #21's provider diet order, dated 8/19/19, revealed: Minced and Moist/Level 5 texture. Further review revealed: . texture as tolerated ranging mechanical soft to puree. Record review of Resident #38's provider diet order, dated 5/2/24, revealed: Minced and Moist level 5 texture. Further review revealed: . Resident choice/texture as tolerated. Diet is MM5 [minced and moist, level 5]/PU4 [pureed, level 4] depending on [resident's] alertness and abilities. An observation on 5/16/24 at 2:14 PM, of Sitka Rose's Cuisinart chopper/grinder food processor revealed there were two buttons on the processor, one labeled chop and one labeled grind. The opening of the processor bowl was wide, allowing for contact with blades of the processor with fingers. During an interview on 5/16/24 at 2:15 PM, when asked about the Cuisinart food processor and what level of diet the processor made, the Dietary Manager stated level 3 (IDDSI level 3 - liquidized diets). The Dietary Manager stated the staff would add gravy or broth and push the processor's button for 3 to 4 minutes until you reach grind level. When asked if the food processor would make level 5 minced and moist modified diets, the Dietary Manager stated, yes, you would add gravy or broth and process for 10 minutes. Review of the Cuisinart Instruction [and] Recipe Booklet, dated 2015, revealed: . - Important Safeguards: When using an electrical appliance, basic safety precautions should always be adhered to. Read all instructions. - Tips for Processing Food. Size. Always cut large pieces of food into smaller pieces for even size - about 1/2 inch. or as specified under Operation/Technique. if you don't start with pieces that are small and uniform, you will not get an even chop. Selecting the Right Operating Control. Use the Chop function for chopping, pureeing and mixing. It is the right choice, for example, for chopping soft, fragile food. Pulse action is best when you are using the Chop function. Two or three pulses are often enough. Use the Grind function for grinding spices, and for chopping hard food. Continuous-hold action is best when you are using Grind function. Never operate the. Chopper/Grinder continuously for longer than 1 minute at a time. - The Cuisinart Elite Collection Chopper/Grinder is intended for HOUSEHOLD USE ONLY. - Operation/Technique Chart: Meats. Chop. Pulse to chop, or process continuously to puree. Cooked meat. cut up to 8 ounces into 1/2-inch pieces. Review of the facility's policy Safety in Food Service, effective date November 2023, revealed: . Equipment Hazards. Never use machinery you have not been [trained] to use. Food Grinders. Food grinders should be equipped with narrow necks to make it impossible to reach the cutters with the fingers. General Precautions. Keep clean. Wash hands thoroughly before handling food or dishes. Food service personnel must wear hairnets while on duty. Food Worker Cards During an interview on 5/16/24 at 11:03 AM, when asked if RAs and/or LNs who prepared modified diets had food worker cards, the Administrator stated no RAs or LNs had food worker cards. Review of the State of Alaska web site for food worker cards, accessed on 5/16/24 at https://dec.alaska.gov/eh/fss/food-worker-card#about, revealed: . The Alaska Food Code requires food workers to obtain a food worker card. About the Food Worker Card Program. The goal of the Food Worker Card program is to educate food workers in Alaska about safe food practices and verify they have the essential knowledge needed to protect public health in food facilities. Food Worker Card is Required. Any person working with unpackaged food, potentially hazardous food, or food-contact surfaces is considered a food worker and needs a food worker card.

Based on observation, interview, and policy review, the facility failed to ensure infection control procedures were properly implemented. Specifically, the facility failed to: 1) ensure staff removed soiled gloves and performed hand hygiene after completing dirty tasks to clean tasks for 1 unsampled resident (#10), out of 3 residents (1 unsampled and 2 sampled) observed for residents' care; and 2) ensure soiled personal protective equipment (PPE) were disposed of safely for 1 unsampled resident (#44), out of 2 residents (1 unsampled and 1 sampled) observed for transmission-based precautions (TBP). These failed practices had the potential to affect all residents, based on a census of 51, for risk of the spread of the Covid-19 virus and other infectious diseases. Findings: Hand Hygiene An observation on 3/6/23 at 1:34 PM, revealed Resident #10 was sitting in a wheelchair. A Hoyer sling was behind and under the Resident. CNA #1 (Certified Nursing Assistant) placed the sling's straps onto the hooks of the hanger bar on the Hoyer lift (an assistive device used by caregivers to safely transfer patients) and raised the Resident from the wheelchair approximately 1 ft to 1 1/2 ft above the wheelchair. The CNA then placed the peri-care supplies onto the wheelchair seat. The CNA wiped Resident #10's anal area with wet wipes and then dry wipes. The CNA rolled up the brief and discarded it in the trash can. While wearing the soiled gloves, the CNA removed the peri-care supplies from the wheelchair seat. He/she then placed a new brief on the wheelchair seat. Wearing the same soiled gloves, the CNA then pressed the Hoyer lift button to bring down the resident onto the wheelchair. The CNA secured the brief. While still wearing the same soiled gloves, the CNA unhooked the sling from the Hoyer lift. The CNA pulled and straightened the resident's shirt down. Then, the CNA tucked the Hoyer sling down each side of the resident and then resident's sides and then placed 2 blankets, one pillow, and a lap board on the resident's lap and legs. The CNA placed a pen onto the board for the resident to use with a puzzle book that was already on the lap board. During the same observation, while wearing the same soiled gloves, CNA #1 moved the Hoyer lift away from the Resident and then moved the wheelchair by holding the wheelchair's handles. After completing the tasks, the CNA removed the soiled gloves and discarded those gloves in the trash can. The CNA was not observed to perform hand hygiene after removing the soiled gloves. With his/her bare hands, the CNA tied the trash bag and placed a new trash bag in the trash can. Then, the CNA performed hand hygiene. During an interview on 3/9/23 at 1:00 PM, when asked about hand hygiene procedures during peri-care, the IP #1 (Infection Preventionist) stated the staff would perform hand hygiene when coming into the Residents' room and put on gloves prior to assisting the residents with toileting. The IP explained the staff would remove the gloves and perform hand hygiene when going out of the bathroom [to provide the resident time for toileting.] Before going back into the bathroom, the staff would perform hand hygiene and put gloves on, clean the Resident, and then perform hand hygiene after removal of the gloves. Review of the facility's Hand Hygiene policy, dated 11/2022, revealed: .[facility] follows CDC guidelines related to hand hygiene. [facility] considers hand hygiene the primary means to prevent the spread of infection .use .ABHR for the following situations .before and after direct contact with the Resident .before moving from the contaminated body sites to a clean body site during resident care .after contact with objects .in the vicinity of the Resident .after removing gloves . Review of the Centers for Disease Control and Prevention (CDC) website: https://www.cdc.gov/handhygiene/providers/index.html,revealed the policy / procedure dated 1/8/21 Hand hygiene in Healthcare Settings revealed .use an alcohol-based hand sanitizer .before moving from work on a soiled body site to a clean body site on the same patient . after touching a patient or the patient's immediate environment .immediately after glove removal. Personal Protective Equipment (PPE) During an interview with concurrent observation on 3/9/23 at 8:02 AM, CNA #2 stated Resident #44 had tested positive for COVID-19. Observation revealed a contact and airborne precautions sign was posted on the resident's door. Further observation revealed an uncovered trash can and an uncovered laundry hamper lined with a plastic bag placed just outside of the outlined blue taped square area. The hamper had a sign indicating dirty cloth gown. The CNA stated he/she would discard the used gown into the hamper. During an observation on 3/9/23 at 8:25 AM, IP #1 was rearranging the table and the uncovered hamper outside Resident #44's room. IP #1 moved the uncovered dirty cloth gown hamper in between Resident #44 and Residents #12 and #19's room (both of whom were COVID-19 negative residents). An observation on 3/9/23 at 12:00 PM, revealed LN #1 removed his/her gown in the hallway outside Resident #44's room and placed the used cloth gown into the uncovered hamper. During an interview on 3/9/23 at 1:00 PM, when asked about guidelines for the use of PPE when caring for Residents on transmission-based precautions (TBP), IP #1 stated the staff would put on gowns, change the surgical mask to N95 face mask or powered air purifying respirators (PAPR) before entering resident's room. The staff would remove PPE outside of the residents' rooms. The staff were also expected to perform hand hygiene after removal of used gloves, after removal of face shields and masks, and after removal of gowns. On the same interview, when asked about the hamper outside Resident #44's room, the IP stated the used cloth gown would be discarded into the hamper. He/she explained the hamper would be emptied when full or at the end of each shift. An observation on 3/9/23 at 2:00 PM, revealed a portion [approximately 6 inches] of used cloth gown was hanging out of the uncovered hamper. The gown was hanging out towards Residents #12 and #19's room. An observation on 3/9/23 at 2:41 PM, revealed Resident #52's room had a TBP sign on the door. A PPE cart, uncovered trash can, and uncovered hamper were placed in the hallway outside the Resident's room. An observation on 3/9/23 at 2:42 PM, revealed outside Resident #44's room, a portion of a used cloth gown was hanging out of the hamper. An observation on 3/10/23 at 9:27 AM revealed a cuff of a discarded cloth gown was hanging out of the uncovered hamper outside Resident #44's room. According to Centers for Disease Control and Prevention (CDC), Isolation Precautions, dated 7/22/19. Accessed at https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html, revealed .Remove gown and perform hand hygiene before leaving the patient's environment .

Based on record review and interview the facility failed to ensure the discharge status of resident (#55), out of 3 closed records reviewed, was updated. Specifically, the facility failed to update the discharge location of the resident. This failed practice provided inaccurate discharge information. Findings: Resident #55 Record review on 3/6-10/23 revealed Resident #55 was admitted to the facility with diagnoses that included dementia (loss of cognitive functioning), psychotic disturbance (a severe mental disorder that causes abnormal thinking and perceptions), and heart failure. Review of the resident's Care Plan, dated 1/1/23, revealed: .Discharge to another care setting Assisted living facility [ALF] when bed/room available . Review of the Discharge Summary, dated 1/31/23, revealed Resident #55 will transfer to an ALF. Review of the Progress notes, dated 2/1/23, revealed: . [Resident # 55's representative] decided to have [Resident #55] sent to the ER [emergency room ] for evaluation prior to discharge to [Assisted Living Facility]. Review of Resident #55's Minimum Data Set (MDS -a federally required nursing assessment) discharged Assessment, dated 2/1/23, revealed: A2100. Discharge Status .Acute hospital was marked. During an interview on 3/9/23 at 11:27 AM, when asked about the MDS discharge assessment for Resident #55, the MDS Coordinator (MC) stated the Resident was discharged and his/her return to the nursing home facility was not anticipated. The initial plan was that the Resident would discharge to an ALF. The MC further stated that the Resident was sent to the ER so the MDS discharge status was marked discharged to the hospital. During the interview, the (MC) referred the issue to the Administrator. The Administrator stated the resident was discharged to the hospital then transferred to the ALF. The administrator further explained the discharge summary indicated transfer to the ALF because the plan was to discharge the Resident to ALF but there was a last-minute change because the Resident needed to go the hospital. Review of the facility's Discharge Due to Transfer or Discharge Home policy, dated 3/2020, revealed: .Prior to discharge or transfer, the Discharge Planning review will be completed. The form is intended to document what the facility has done in anticipation of discharge, as well as providing information for the family, the Resident or the new facility for follow-up care.

Based on record review, observation, and interview the facility failed to: Initiate pain medication management ordered by a surgeon after a medical procedure for 1 resident (#19) out of 14 sampled residents. This failed practice caused the resident increased suffering from ineffective pain management and from severe pain following oral surgery. Findings: Resident #19 Record review from 8/13-17/18 revealed Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. Further review revealed Resident #19 went out of the State recently to have laser surgery to remove mouth [MEDICAL CONDITION]. He/she returned to facility on 8/11/18. During an observation of medication administration on 8/14/18 at 8:35 am, Resident #19 came into the nurse's station holding his/her mouth and asked, Did you get an order for [REDACTED].#2 stated, No, the doctor hasn't written the order yet. Resident reported mouth pain and described this pain as It's like someone threw a box of matches in my mouth and set them on fire. During an interview on 8/14/18 at 8:45 am, LN #2 stated when Resident #19 returned from out of State, the spouse brought in a prescription bottle of pain medication over the weekend. LN #2 stated this medication cannot be given in the facility without a written order from the facility physician. He/she was not certain if the weekend nurses contacted the physician for an order. LN #2 stated that at the time of this interview, he/she had not contacted the physician in an attempt to get an order. During an interview on 8/14/18 at 08:50 am, the Registered Nurse (RN) Supervisor stated they cannot give the medication at the facility because 1) there was no paperwork from the surgeon recommending its use and 2) there was no order from the facility physician to use it. He/she did not agree that the prescription bottle of pain medication from the surgeon constituted a recommendation for its use. Observation of the prescription bottle of pain medication revealed this prescription was filled on 8/9/18. Order on the bottle reads: [MEDICATION NAME] 1-3 tabs by mouth every 4-6 hours (as needed) pain. During an interview on 8/14/18 at 10:28 am, Resident #19 stated he/she has asked for this pain medication every day since returning to the facility. The Resident stated Tylenol offered does not relieve his/her pain. During an interview on 8/14/18 at 11:59 am, the Director of Nursing (DON) stated there is no daily nurse's note to document routine shift assessments, nor is there a daily nursing assessment for pain unless the resident complains of pain. During an interview on 8/14/18 at 1:20 pm, the RN Supervisor stated if he/she was the weekend nurse who received this kind of prescription, he/she would attempt to contact the doctor to get an order. The RN Supervisor further stated the surgeon faxed the procedure paperwork to the community doctor and that doctor uploaded it into the electronic record system EPIC. During an interview on 8/14/18 at 2:40 pm, Resident #19 stated he/she has reported to the nurses that Tylenol medication does not help his/her mouth pain. Record review on 8/15/18 at 9:40 am, revealed an order for [REDACTED]. Record review of Resident #19's Medication Administration Record [REDACTED] - 8/13/18: Tylenol 650 milligram (mg) given at 10:14 am for pain of 7 (based on a pain scale of 0-10 with 10 being severe pain). This medication was documented as not effective to treat pain. - 8/14/18: Tylenol 650 mg given at 8:34 am for pain of 7. This medication was documented as effective. - 8/14/18: Tylenol given at 8:05 pm with no pain assessment completed. This medication was documented as effective. - 8/15/18: [MEDICATION NAME] 5 mg given at 12:37 pm for pain of 5. This medication was documented as effective. Record review of nurses documentation weekly observations for Resident #19, dated 8/16/18 at 11:04 am, revealed no pain assessment completed on the pain scale within the assessment. It did not document mouth pain. .