Every finding on record at Ketchikan Med CTR New Horizons Transitional Care

.Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed. Specifically, the facility failed to ensure: 1. The concentration of sanitizer, in their red sanitation buckets, met manufacturer's recommended concentration levels for effective sanitation on kitchen surfaces; 2. Food items, stocked for resident meals, had not expired; and 3. Opened packages of food items were properly labeled. These failed practices placed 22 residents who received food from the kitchen, out of 23 residents, at risk for foodborne illness and communicable disease. Findings: 1) Sanitizer concentration An observation on 4/8/26 at 11:10 AM, of the main kitchen, revealed four red sanitizer buckets at various locations in the kitchen. One of the red buckets was tested with a QT-10 Hydrion test strip for ten seconds in the solution, which revealed no color change on the strip. When compared to the color change guide on the test strip packaging, the color corresponded to a reading of 0 parts per million (ppm) of sanitizer concentration in use. This was checked again and confirmed by the Food Services Manager (FSM). The red sanitizer buckets were immediately removed from service. Random observations on 4/6-10/26, revealed no manufacturer's information regarding the sanitizer or acceptable sanitizer ppm concentration posted in the kitchen/dishwasher area. Review of the manufacturer representative's emailed document, Ecolab Smartpower Sanitizer, copyright 2017, revealed: . Testing [sanitizer] solution should be between 150 - 400 ppm. During an interview on 4/8/26 at 11:10 AM, the FSM stated the red sanitizer buckets contained a solution dispensed from a dispenser labeled ECOLAB APEX Solid Quat Broad Range Sanitizer. This dispenser was located by the dishwasher. She further stated the solution should have been tested as soon as it was made to ensure the concentration of sanitizer in the solution was within the range recommended by the manufacturer before being placed into service. Record review on 4/8/26 at 11:24 AM, of the Sanitizer Bucket Log, dated 4/2026, revealed no entries for ppm testing on: - 4/6/26 at 5:30 PM; - 4/7/26 at 1:30 PM and 5:30 PM; and- 4/8/26 at 9:30 AM. An observation on 4/8/26 at 1:19 PM, of the main kitchen, revealed follow up testing of the red sanitizer buckets showed the sanitizer concentration at 200 ppm. During an interview on 4/8/26 at 1:29 PM, the FSM explained that when the dry sanitizer powder was changed out, some powder may have become wet before the system was closed, causing it to clump which prevented proper mixing and dispensing at the correct concentration. The FSM further stated that the dispenser was now fixed. An observation on 4/9/26 at 9:27 AM, of the main kitchen, revealed a total of four red sanitizer buckets. One bucket that was tested resulted at 100 ppm. This was confirmed with the Executive Chef. The other three sanitation buckets in the kitchen were emptied by staff before they were tested. During an interview on 4/9/26 at 9:35 AM, the FSM stated she thought they had fixed the problem the previous day. She again stated that the buckets should be tested before they were placed into service. She further stated that she had a call into the Ecolab representative for them to come out and look at the sanitizer dispenser. An observation in the main kitchen on 4/9/26 at 1:05 PM, revealed red sanitizer buckets tested between 200-300 ppm. Review of the Ecolab sanitizer dispenser maintenance document, Regular Service Call, dated 3/23/26 at 6:16 PM, revealed: . Dispensers: Good. Inspecting dispenser health for optimal chemistry consumption. 2) Expired food An observation on 4/6/26 at 2:23 PM, of the main kitchen's dry storage area, revealed three expired unopened packages of flour tortillas, labeled Use By 4/5/26. An observation on 4/6/26 at 2:47 PM, of the main kitchen's walk-in refrigerator, revealed the following expired items: - Approximately 3 liters of liquid egg substitute in a plastic container, labeled: . Product: Liquid Egg Sub. Today's Date: 03/31/26. Good Thru: 04/03/26.; - Five unopened loaves of bread, labeled: Use By 3/30; and - One unopened loaf of bread labeled: . Product: Bread. Todays Date: 04/02/26. Good Thru: 04/05/26. The FSM acknowledged that the tortillas, egg substitute, and bread were expired and discarded the items. An observation on 4/6/26 at 3:21 PM, of the LTC unit kitchen, revealed one expired 1.2 liter Kikkoman soy sauce bottle, partially used, labeled: BEST BY: 08FEB2026. The Activities Director (AD) acknowledged the soy sauce was expired and discarded it. 3) Food Labeling An observation on 4/6/26 at 2:47 PM, of the main kitchen's walk-in refrigerator, revealed: - One unopened loaf of bread, no expiration label; and - One opened bag of shredded lettuce and carrots, approximately half full, no label indicating when it was opened or when it was to expire. The FSM acknowledged that the loaf of bread and the bag of lettuce and carrots should have been labeled with expiration dates and discarded the items. An observation on 4/6/26 at 3:21 PM, of the LTC unit kitchen, revealed: - One resealable bag of white rice, about a quarter full, without a label indicating when it was opened or when it would expire; and - One unopened bag of Ball Park 8 count hot dog buns, with no label indicating when it would expire. The AD acknowledged that the rice and hot dog buns should have been labeled with expiration dates and discarded the items. During an interview on 4/6/26 at 3:24 PM, the AD confirmed that he was responsible for supervising the storage of foods in the LTC unit kitchen. Foods that were stored in the kitchen would normally get labeled with the name of the resident it belonged to and the use by date. During an interview on 4/6/26 at 2:30 PM, the FSM stated on Monday's, kitchen personnel checked expiration dates as they put away freight. Personnel also checked for expired foods on Fridays as well. She further stated that beginning on 4/1/26 the kitchen had been under a new company, Compass, and that they were still integrating their processes, including their new labeling system. Review of the facility's policy Storage of Food and Supplies Procedure, last approved on 7/9/25, revealed: . All Products:. 4. All goods are checked on a continuing basis for expiration dates and outdated products disposed of or returned to the Food Service Manager for proper credit. 5. All items produced or packaged in the kitchen contain proper production and/or expiration date.

.Based on observation, interview and record review, the facility failed to maintain patient care equipment in a safe operating manner. Specifically, the facility failed to ensure a shower chair, which was used by 8 residents (#'s 4, 5, 6, 8, 10, 15, 23, and 24), out of 23 residents reviewed, was free of cracks and/or tears. A shower chair with a compromised surface exposed residents to the padding within, which had the potential to be contaminated with bodily fluids and diseases. A compromised surface created the inability to completely sanitize the surface between resident use, which placed all 8 residents at risk for the development and transmission of communicable diseases and infections. Findings: During an observation and concurrent interview on [DATE] at 8:49 AM, Certified Nursing Assistant (CNA) #1 removed a purple ARJO-brand shower chair from Resident #6's room and placed it across the hallway into the damp community shower room. The shower room had a strong odor of urine. When asked about the urine odor, CNA #1 stated Resident #6, who was incontinent, had just completed a shower in that room and that he/she was going to sanitize the shower chair. Further observation of the shower chair revealed the gray seat cushion was observed to have an approximately two inch tear, creating a flap along the front edge of the seat which exposed the padding within. The location of the tear was in the area where a resident's thigh, near the left knee, would have rested when seated in the chair. The CNA further stated there were two resident showers that day that would have utilized the purple shower chair. CNA #1 further stated the tear in the shower seat cushion would be reported to the nurse. During an interview on [DATE] at 8:16 AM, CNA #1 stated four resident showers were planned for the day and that the purple shower chair would be used for those showers. An observation on [DATE] at 10:15 AM, revealed the community shower room was in use. Further observation at 10:58 AM, revealed the purple shower chair with the torn seat cushion was drying in the community shower room. During an interview on [DATE] at 1:30 PM, the Infection Preventionist (IP) stated the purple shower chair with the torn seat cushion should not be used to bathe residents. The IP further stated that if it could not be cleaned, then it should not be used. During an interview and concurrent observation on [DATE] at 4:55 PM, CNA #2 stated Resident #8 had just finished bathing with staff assistance. The purple shower chair with the torn seat cushion, which was damp, was observed in Resident #8's bathroom. During an interview on [DATE] at 4:30 PM, Licensed Nurse (LN) #1 confirmed that eight residents (#'s 4, 5, 6, 8, 10, 15, 23, and 24) utilized the purple shower chair when they bathed. This was based upon review of the DAILY BATHS SCHEDULE AS OF [DATE] sheet. During an interview on [DATE] at 5:00 PM, the Director of Nursing (DON) stated that she had ordered a replacement seat cushion for the purple shower chair. When informed that the torn seat cushion was still in use and the purple shower chair was currently located in Resident #8's bathroom, the DON stated that the torn seat cushion should not have been in use. Review of the ARJO shower chair manual titled INSTRUCTIONS FOR USE, undated, revealed: . Action Before Every Use. Check accessories and parts for damage. If any part is missing or damaged - do NOT use the product. Every week. Visually check all exposed parts, especially where personal contact is made by either the patient or caregiver. Make sure no cracks or sharp edges have developed. Review of the facility provided policy Managing Malfunctioning or Defective Equipment and Supplies Policy, effective date [DATE], revealed: It is the policy of PeaceHealth that broken, expired, contaminated or defective products be managed in a consistent manner. These products. will be: Fixed to bring the product into conformance. Caregiver Responsibilities. Remove the device from the patient care area.

.Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored to maintain medication identity and control. This failed practice placed all residents, based on a census of 23, at risk for medication error, misidentification, and drug diversion. Findings:.An observation on 3/4/26 at 3:00 PM, revealed the following during an inspection of a medication cart: 1. Drawer 231 contained an opened individual blister pack of metoprolol succinate (medication used to treat high blood pressure, heart failure, and other heart-related conditions by slowing the heart rate and reducing cardiac workload), which held one half of a medication tablet. 2. Drawer 230 contained an opened individual blister pack of Sertraline (an antidepressant medication classified as a selective serotonin reuptake inhibitor, used to treat depression, anxiety, and other mood disorders), which held one half of a medication tablet. 3. Drawer 227 contained opened individual blister packs of Baclofen (a muscle relaxant used to treat muscle spasms, commonly associated with neurological conditions); Metoclopramide (medication used to treat gastroesophageal reflux disease and diabetic gastroparesis by increasing stomach motility and accelerating stomach emptying); and Vitamin B-12. Each of these opened blister packs held one half of a medication tablet. 4. Drawer 240 contained an opened individual blister pack of gabapentin (a medication used for siezures and nerve pain), which held one half of a medication tablet. Also in the drawer were two medication inhalers with no patient identifier labels: Spiriva (a long-acting bronchodilator used to treat chronic obstructive pulmonary disease by relaxing airway muscles and improving airflow);and fluticasone propionate and salmeterol (a combination inhaled medication containing a corticosteroid [reduces airway inflammation] and a long-acting bronchodilator [relaxes airway muscles], used to treat asthma and chronic obstructive pulmonary disease). The Spiriva inhaler had a pouch opened date that was unreadable and was missing a use by date. The fluticasone propionate and salmeterol inhaler was missing a discard date. During an interview on 4/9/26 at 1:00 PM, the Director of Nursing (DON) confirmed that nursing staff had been returning partial doses (e.g., half tablets) to the medication cart rather than disposing of them after medication administration. The DON stated that the medication administration procedure was not consistent with best practice and acknowledged that medications should have been disposed of after completion of the medication pass to reduce risk. The DON also confirmed that inhalers should have patient-specific labels and agreed the observed inhalers should have been labeled accordingly. Review of the facility policy Medication Administration Policy, last updated 11/2/25, revealed: 11. Labeling Medications. Label all medication or solution that is transferred from the original packaging to another container. Medications/Solutions not immediately administered will be labeled. Labels include the drug name, concentration, amount (if not apparent from the container), expiration date (when not used within 24 hours), time, when expiration occurs in less than 24 hours, and initials of person preparing. Any medications or solutions found unlabeled are immediately discarded. All original containers used in the procedure are discarded at the end of the procedure. Review of the facility policy LTC: Medication Administration in New Horizons Policy, last modified 4/8/26, revealed: Medication Labeling: All multi-use medications for specific residents will be labeled by pharmacy or with resident name label whichever indicated as well as date opened (when required) and discard date (when applicable) before being placed in the tower or the WOW [workstation on wheels] for storage.

.Based on interview and record review, the facility failed to allow resident-invited visitors and/or guests to attend a resident council meeting. This failed practice denied the resident's right to invite visitors to the resident council meeting, which denied all residents (based on a census of 26) the right and opportunity to advocate for themselves and placed them at risk for decreased feelings of self-worth and had the potential to affect their mood and overall wellbeing. Findings:During an interview on 9/2/25 at 1:45 PM, Resident #12 stated that he/she invited his/her family member, who was his/her resident representative, to the resident council meeting that occurred on 7/23/25. Resident #12 further stated that his/her family member invited the Mayor and a City Council member, along with a previous member, to the meeting on his/her behalf. Resident #12 wanted his/her family member and local officials in the meeting to hear of program concerns that had been happening in the facility lately, such as limited activities and low staffing. Resident #12 stated that when the family member and local officials arrived for the meeting, the facility Administrator removed them from the meeting. Resident #12 stated he/she told the Administrator his/her family member was his/her advocate, and the other visitors were there because he/she wanted them there. Resident #12 stated the Administrator still had them vacate the meeting. This upset him/her because he/she wanted their support on resident concerns. During an interview on 9/2/25 at 4:10 PM, Resident #20 stated he/she was happy to see the Mayor and City Council member at the Resident Council meeting on 7/23/25, but the Administrator ordered them to leave. Resident #20 stated he/she was the President of the Resident Council, and he/she told the Administrator he/she couldn't have them leave, but the Administrator said, no way and had them removed anyway. That upset Resident #20 because he/she would have liked them to have stayed for the meeting to hear what the residents had to say. During an interview on 9/3/25 at 10:37 AM, Resident #18 stated he/she was at the 7/23/25 resident council meeting and was happy to see the presence of the Mayor and City Council representative. Resident #18 stated that when the Administrator said they were not allowed to stay, he/she heard other residents tell the Administrator they wanted the visitors to stay. Resident #18 stated he/she would have liked to have had them present in the meeting to hear from the residents. During an interview on 9/3/25 at 12:43 PM, the Resident Representative for Resident #12 stated the resident invited him/her to the 7/23/25 resident council meeting. After hearing the concerns, the residents had planned to address in the meeting, the Resident Representative invited a City Council member, a previous City Council member, and the Mayor to the meeting to hear what the residents had to say. The Resident Representative stated Resident #12 approved of him/her inviting the local officials to the meeting. The Resident Representative stated that when they got to the unit for the meeting, the Administrator met him/her at the activities room door and told him/her that the resident council meeting was for residents only. The Administrator stated they could not attend the meeting. The Resident Representative stated that the City Council member, previous City Council member, and him/her went into the meeting anyway, however the Administrator would not let the meeting start until the resident invited visitors left the room. During an interview on 9/4/25 at 10:04 AM, the Administrator stated that at the time of the meeting, she had a conversation with Resident #12's family member and told him/her that resident council meetings were not a public meeting, was a closed meeting, and that family and visitors couldn't be there. The Administrator stated she thought the resident council meeting was an internal meeting to talk about activities and resident rights and that if any resident wanted a visitor to a meeting, they would have to vote on that at the meeting prior to the visit. When asked if she recalled residents telling her they wanted the visitors to stay for the resident council meeting, the Administrator stated she did not remember hearing that. During an interview on 9/4/25 at 1:14 PM, the Chief Nursing Officer (CNO) stated she was in the 7/23/25 resident council meeting and confirmed the Administrator told the visitors they could not stay for the meeting. The CNO further stated that she witnessed several resident state that they wanted the visitors to stay for the meeting. During an interview on 9/8/25 at 10:45 AM, Visitor #3 stated he/she was invited to the resident council meeting because he/she had heard some of the residents had concerns they wanted to voice, namely about activities. Visitor #3 stated when he/she got there, the Administrator stated she didn't want the meeting to turn political, and Visitor #3 stated the Administrator asked him/her several times to not attend the meeting. Visitor #3 stated he/she left because he/she didn't want to disrupt the resident council meeting or cause a problem. Review of the facility's policy LTC [Long Term Care]: Patient Rights and Responsibilities Policy, dated 1/10/25, revealed: It is the policy of PeaceHealth to define, recognize, protect and promote the rights and responsibilities of the patients and their legal, authorized or designated representatives . Review of the facility's Resident Rights and Responsibilities form, undated, which was available to all residents, revealed: . You have the right to dignity, respect and compassion. This includes your right to: Be treated with consideration, respect and dignity, recognizing each resident's individuality . Exercise rights without interference, coercion, discrimination, or reprisal; You have the right to self-determination. This includes your right to . choice about designating a representative to exercise your rights; Organize and participate in resident and family group . You have the right to access to: Individuals, services, community members, and activities inside and outside the facility; Visitors of your choosing, at any time . Review of the facility policy LTC: Visitation Policy, dated 1/3/25, revealed: . The purpose of this policy is to define how the facility develops, implements, monitors, and evaluates visitation rights for applicable residents. The facility promotes visitation for all residents subject to the resident's wishes . Residents are permitted to have visitors of their choosing at the time of their choosing . Visitation will be resident-centered . Residents are permitted to visit with representatives from federal and state survey agencies, resident advocates . space and privacy are provided as needed for such visits . Review of the facility's policy LTC: Resident Council Meetings Policy, dated 1/10/25, revealed: The purpose of this policy is to promote empowerment of the residents and to provide opportunity for residents to have a voice regarding the Long Term Care Unit and the care that is being provided to them . Further review revealed no documentation that residents were permitted to invite visitors to the meetings as is their resident right.

.Based on interview and record review, the facility failed to ensure residents were free from abuse. Specifically, the Administrator's conduct towards residents was construed, by residents and staff, as verbally abusive. This failed practice placed all residents (based on a census of 26) at risk for continued exposure to verbal abuse and mental anguish which had the potential to affect their overall health and well-being.Findings:Resident #12 During an interview on 9/2/25 at 1:45 PM, Resident #12 stated she felt verbally abused by negative comments the Administrator had said to him/her, and this made him/her very sad, and he/she was now hopeless, like I'll never get out of here. It was observed that Resident #12 was physically shaking when he/she told this story, wringing his/her hands and his/her voice was cracking with emotion. Resident #20 During an interview on 9/2/25 at 4:10 PM, Resident #20 stated the Administrator, scares me, [he/she] is really bossy and is mean to me. When asked to elaborate on anything the Administrator may have said, Resident #20 couldn't recall a specific conversation, it's how [he/she] talks, its loud and speaks meanly. During an interview on 9/3/25 at 11:45 AM, Staff #76 stated residents have reported to him/her that they didn't feel safe on the unit because the Administrator's interactions were rough with a lack of respect. During an interview on 9/4/25 at 1:14 PM, when asked if she had ever been informed that the Administrator's behavior towards residents was a concern, the Chief Nursing Officer (CNO) stated some things were said and she had started to receive feedback around the time of a staff meeting on 6/25/25. The CNO stated that during this time the information that was shared did not always appear accurate and was different than what the Administrator was sharing with her, so nothing really made her concerned, until almost a month later at the 7/23/25 resident council meeting and she witnessed the Administrator's behavior that day. The CNO stated that when the Administrator addressed the residents in the meeting, the Administrator's voice was raised, and her arm/hand movements were very animated as she talked and the CNO stated she was concerned with the Administrator's presentation. The CNO stated that the way the Administrator addressed the residents made her feel anxious and the conversation had become uncomfortable, and from her perception she felt that the group was not being heard or seen. When asked if the Administrator's oral and gestured language may have been frightening or intimidating to the residents, the CNO stated, Absolutely. The CNO stated she stood up, during this meeting, to nonverbally cue the Administrator that the conversation was veering onto an uncomfortable path, however the Administrator did not stop the behavior. During an interview on 9/4/25 at 4:55 PM, Staff #83 stated that the Administrator's tone of voice was very rude when she talked to residents and the Administrator would often willfully cut them off in conversations. Review of the facility's abuse allegation investigation documentation of the resident interviews, that occurred during the investigation surrounding the concerns identified during the 7/23/25 resident council meeting, revealed an additional resident (#25), had felt verbally abused by the Administrator. Review of the facility's policy LTC [Long Term Care]: Abuse, Neglect, Exploitation and Misappropriation of Residents Property Policy, dated 3/6/25, revealed: Definitions . Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident or their families, or within hearing distance . Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident . Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment . The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property . Review of the facility's Resident Rights and Responsibilities, undated, revealed: . You have the right to dignity, respect, and compassion. This includes your right to . Freedom from abuse, neglect, exploitation and misappropriation of property .

.Based on record review and interview, the facility failed to implement written policies and procedures to investigate an allegation of abuse for 1 Resident (#12), out of 1 allegation of abuse investigation reviewed. Specifically, the facility's HR Department and Risk Management Department failed to: 1) adequately monitor the investigation process to ensure all steps of the investigation procedure were completed appropriately; 2) ensure all investigations processes were adequately documented; and 3) ensure additional investigations from the results of the investigation process were appropriately carried out 2 residents (#'s 20 and 25), out of 5 residents interviewed during the investigation. This failed practice resulted in an inadequate grievance investigation which placed all residents (based on a census of 26) at risk for suboptimal investigations of any resident complaints and grievances. Findings:Incident Reported A facility reported incident (FRI) was submitted to the State Agency for an allegation of verbal abuse, dated 7/23/25, by the Chief Nursing Officer (CNO). Investigation by CNO During an interview on 9/3/25 at 1:34 PM, the CNO stated during the resident council meeting on 7/23/25, in the middle of the meeting, Resident #12 stated he/she felt the Administrator had verbally abused him/her. After the meeting, the facility team decided to file a State report regarding Resident #12's comment and initiate an investigation. The CNO stated the report was sent to the State Agency on 7/23/25. The CNO further stated that she contacted the HR Director for PeaceHealth on 7/23/25 about the investigation and placed the Administrator on administrative leave pending the conclusion of the investigation. The CNO further stated she completed an interview with Resident #12 on 7/23/25 about the comments in the meeting, however Resident #12 did not comment on what the verbal abuse was. When asked to see the documentation for the interview with Resident #12, the CNO stated no documentation for the interview was completed. The CNO stated she also submitted this incident in the facility's electronic incident reporting system Safe2Share. When asked if the CNO interviewed the Administrator during the investigation, the CNO stated she and the Administrator had talked but this was not documented. When asked if the CNO contacted Resident #12's provider to inform them of the reported allegation of abuse, the CNO stated she did not contact the provider. When asked what other steps occurred during the investigation, the CNO stated she had a Minimum Data Set (MDS - a nationally mandated routine assessment) Nurse interview five other residents to ensure no other residents had any concerns. The CNO stated she drafted questions for the MDS Nurse to use. From these interviews, she determined these residents felt safe. When asked what the investigation's determination was, the CNO stated that because Resident #12 retracted his/her statement and because it was determined it was mainly about the Administrator's approach to communicating with others, she determined the abuse allegation as retracted and concluded the investigation on 7/28/25. The CNO stated the Administrator returned to work on 7/29/25. Review of the facility's documentation of the five other resident interviews that occurred during this investigation, undated, revealed two resident's, Resident #20 and #25, interviews revealed they had felt verbally abused by the Administrator. During an interview on 9/3/25 at 1:34 PM, when asked if these comments were investigated, the CNO stated, no. Facility Policy about Abuse Investigations Review of the facility policy Allegation of Abuse Policy, dated 12/15/24, revealed: . It is the policy of PeaceHealth that any allegation of abuse by a patient against a caregiver will be responded to immediately. An investigation of the facts will be coordinated . Caregiver - Patient Present . Risk Management and Human Resources; - Risk Management and Human Resources, working with the department manager will outline an action plan for investigating the incident using the steps listed here as a guide; - The Risk Manager will review the patient components of the event while human resources will direct their focus on the caregiver . ; - Human Resources (HR) Meet with manager and place caregiver on administrative leave (if appropriate). Meet with and lead caregiver interview. Conduct review of evidence and report findings to HR leadership. Maintain caregiver related documentation in HR records; - Risk Manager. Risk Management [facilitates] the investigation. Obtain lists of involved parties and witnesses. Review CareConnect to learn purpose of admission/encounter, medical history and general information about care that is underway. Lead interviews with patient/legal representative and witnesses. Secure evidence and maintain documentation of the event. Assist with law enforcement reporting. Following discussion with human resources and manager, will close case and identify lessons learned and any process improvement opportunities. Maintain documentation (for the patient) of this event in Safe2Share - Feedback . Risk Management During an interview on 9/5/25 at 9:00 AM, the Clinical Risk Manager and the PeaceHealth Director of Quality, the Clinical Risk Manager stated one of his daily duties was to monitor the facility's variance (or grievance) reporting system Safe2Share; assign correct clinical leaders to complete investigations to grievances submitted, and to ensure compliance with State and Federal regulations. The Clinical Risk Manager also stated he was available for clinical consultation and was a resource for clinical leaders. When asked about the 7/23/25 Safe2Share report submitted by the facility's CNO, the Clinical Risk Manager stated he did receive notice that a report was submitted, and he did contact the CNO. The Clinical Risk Manager stated the CNO reported that the resident retracted her complaint and the CNO stated the HR Department at the facility was assisting her through the investigation. Based on this information, the Clinical Risk Manager stated he was satisfied that he didn't need to be involved in this investigation. When asked if the Risk Management team oversaw the CNO and HR Department's handling of the 7/23/25 investigation, the Clinical Risk Manager stated, no because Risk Management team and the HR Department maintain their own files and Risk Management never sees the HR Department's files. When asked what the expectation would be for an investigation for an allegation of abuse would be, the Clinical Risk Manager stated that at a minimum it should include, but is not limited to: 1) making sure the resident is safe; 2) interview the resident; 3) make sure the alleged perpetrator is interviewed; and see if there were any witnesses. When asked if the Safe2Share report was reviewed by Risk Management to ensure the minimum was completed once the report was closed, the Clinical Risk Manager stated he had a verbal conversation with the CNO on the investigation results. The Clinical Risk Manager stated the CNO reported that she interviewed the resident, talked to several other residents to see if any other residents had concerns which concluded that they didn't like how the Administrator talked to them but didn't feel abused or unsafe, and that she planned to follow up with HR and the Administrator to talk to her about the way to interact with residents. The Clinical Risk Manager stated from this conversation he felt the CNO's investigation was adequate. When asked if he reviewed the investigation documentation, the Clinical Risk Manager stated he did not. When this surveyor reviewed the investigation documentation with the Clinical Risk Manager and the PeaceHealth Director of Quality, areas of incomplete steps in the investigations were identified. The PeaceHealth Director of Quality stated it appeared that the CNO may not have asked the right questions during the investigation. When asked who was responsible for the overall quality of a grievance investigation to ensure all grievance investigations were thoroughly completed and the investigation documentation met the facility's requirements, the Clinical Risk Manager stated the leadership assigned to the investigation was responsible for the quality. The Clinical Risk Manager stated, The Risk Management team was responsible for completeness, but not quality of the Safe2Share report investigations submitted. When asked if the facility had a grievance committee as stated in the facility's policy Patient Complaint and Grievance Policy, the Clinical Risk Manager stated that currently the facility did not have a grievance committee and that all grievances were being addressed in the Quality Assurance and Performance Improvement (QAPI) committee. The Clinical Risk Manager stated that they were in the process of revamping the grievance committee, for a more robust and effective plan moving forward, and recognized there was room for improvement in this area. HR Department During an interview on 9/5/25 at 10:52 AM, the HR Director for PeaceHealth stated she was part of the 7/23/25 investigative process for the allegation of abuse by Resident #12. The HR Director for PeaceHealth stated the CNO had contacted her by phone, as she was out of state at the time, and the HR Director for PeaceHealth stated she provided verbal guidance and help to assist in placing the Administrator on administrative leave pending the investigation. When asked if to describe the guidance she provided, the HR Director for PeaceHealth stated she wasn't involved in the investigation itself but did go over the CNO's findings after. When asked to explain what was discussed, the HR Director for PeaceHealth stated the CNO said she talked to the Administrator, talked with the residents and residents. When asked if the CNO went over the additional resident interviews during the discussion, the HR Director for PeaceHealth couldn't remember. When asked what the expectation would be for an investigation for an allegation of abuse would be, the HR Director for PeaceHealth stated she would expect documentation that included: 1) talk to any witnesses; 2) get to the bottom of what actually transpired; 3) interview the resident; 4) and interview the alleged perpetrator. When the investigation documentation was reviewed with the HR Director for PeaceHealth, and what was not completed during the investigation, she acknowledged items were missing from the investigation. When asked if the CNO included her investigation documentation in the Safe2Share file, as indicated in the Safe2Share Electronic Reporting Policy, the Clinical Risk Manager stated, no. When asked who was responsible for the overall quality of a grievance investigation to ensure all grievance investigations were thoroughly completed and the investigation documentation met the facility's requirements, the HR Director for PeaceHealth stated they do not have any access to the Safe2Share system, and it was the department head who would be the leader of the investigation and not HR. The HR Director for PeaceHealth further stated they were not part of the QAPI committee. Review of the facility's policy Safe2Share Electronic Reporting Policy, dated 12/15/23, revealed: . It is the policy of PeaceHealth that caregivers and credentialed providers complete a Safe2Share report under the following circumstances: Upon any occurrence or event that involves a) an unsafe condition, b) an unanticipated outcome with respect to a patient care, c) a potential or actual unexpected or adverse outcome . Safe2Share is an important tool to support Clinical Excellence and Risk Management to help improve the provision of health care services[.] It is an integral part of that commitment is to maintain an awareness and improve situations that may present a risk of harm . Leadership Responsibility. Leaders of the primary department/unit named in the Safe2Share file are expected to review and investigate the submitted event, and document the investigation in the Safe2Share file . Network leadership is responsible to provide appropriate steps are taken to mitigate the harm or risk of harm, prevent further such events, to maintain patient safety, and respond to patient grievances . Risk Team members reviews Safe2Share files for completeness and additional routing .

.Based on record review and interview, the facility failed to report the results of an investigation of an allegation of abuse to the State Agency within 5 working days as required under CFR 483.12(c)(4). The lack reporting investigation results concerning an allegation of abuse in an appropriate and timely manner inhibited the State Agency from accurately assessing and investigating this allegation, which placed all residents (based on a census of 26) at risk for future exposure to potential abuse. Findings:A facility reported incident (FRI) was submitted to the State Agency for an allegation of verbal abuse, dated 7/23/25, by the Chief Nursing Officer (CNO). During an interview on 9/3/25 at 1:34 PM, the CNO stated she faxed the final report to the State Agency on 8/4/25. When asked to show proof of this fax, the CNO stated she could not provide this proof. A review of the State Agency's fax line and email revealed no final report received from the facility for the 7/23/25 incident. Review of an email received on 9/7/25, from the CNO, revealed: I was talking to . our HR Director Friday [9/5/25] after you guys headed to the airport. She triggered my brain to remember something regarding the final report that I could not prove that I had submitted. I did fax it to the state because on 7/28 I received a phone call from the state asking me to fill out the paperwork electronically for my final report. I am attaching the final report I saved because I wanted to ensure that I had proof of it . Review of the email attachment revealed the report was an Adult Protective Services Intake Report. This report was dated 7/28/25 and labeled initial report. Further review revealed the detailed statement was identical to the initial report and contained no results from the investigation. Review of the facility policy LTC [Long Term Care]: State Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy, dated 2/18/25, revealed: . Reporting: In accordance with Alaska state law, 42CFR483.13(b)(c), all suspected cases of abuse and/or neglect will be reported as outlined below: Health Facilities Licensing and Certification (HFL&C): The initial reporting of the incident must be faxed or phoned immediately. Fax is the preferred method of contact; please fax (907) [PHONE NUMBER] or call (907) [PHONE NUMBER] for allegations including that involving nursing aide abuse. The results of the investigation must be followed up through a written report within five days of the initial reporting of the incident . Further review of the facility policy revealed the facility was also required to submit the initial report to the Division of Senior Services, which was where the Adult Protective Services Intake Reports would be generated. The policy stated: . it is not required to follow up with the Division of Senior Services with the results of the investigation .

. Based on record review and interview, the facility failed to ensure float nursing staff (NS) and travel NS, had the job specific competencies and skill sets necessary to care for long-term care (LTC) residents' needs. Specifically, the facility failed to ensure: 1) float/travel NS had current LTC training for ADL (activities of daily living) Coding and Definitions;2) float/travel NS had current LTC training for Behavioral Health (BH);3) float/travel NS had current LTC training for QAPI (quality assurance performance improvement);4) float/travel NS had current LTC training for Dementia for LTC; and5) float/travel NS had current LTC training for Trauma Informed Care. This failed practice had the potential to place all residents (based on a census of 26) at risk of not receiving the necessary specific treatment and care needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being .Findings: Record review on 9/2-5/25 of the float NS training records revealed: 1) 17 NS (NS #'s 1, 2, 3, 4, 5, 6, 8, 9,10, 11, 12, 13, 14, 16, 17, 19, 20), out of 20 NS personnel files reviewed, did not have current training for ADL Coding and Definitions; 2) 17 NS (NS #'s 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 16, 17, 19, 20), out of 20 NS personnel files reviewed, did not have current training for BH; 3) 17 NS (NS #'s 1, 2, 3, 4, 5, 6, 8, 9, 10, 11,12,13, 14, 16, 17, 19, 20), out of 20 NS personnel files reviewed, did not have current training for QAPI; 4) 11 NS (NS #'s 3, 4, 5, 6, 8, 9, 12, 14, 17, 19, 20), out of 20 NS personnel files reviewed, did not have current training for Dementia for LTC; and 5) 17 NS (NS #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 16, 17, 19, 20), out of 20 NS personnel files reviewed, did not have current training for Trauma Informed Care. During an interview with the Clinical Nurse Educator on 9/4/25 at 11:00 AM, she stated that she was only aware of abuse and neglect training being required for staff who floated to the LTC. She also stated that she did not know about dementia specific modules being required and therefore the float staff did not complete the same training as the core staff. When asked if she thought a staff member floating to the LTC without this specific job training could impact resident care, she stated: I think they are still giving good care, but it's possible the lack of LTC specific training could have an impact. Review of the document Facility Assessment - staff training and competencies, dated 5/2024, revealed: .The Nurse Educator keeps records of all training and skill fair documents. The Nurse Educator and Facility Administration education department ensure all areas are included. These training programs are also reviewed by PeaceHealth System education department. Evaluation of the facility's training program and effectiveness in ensuring training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. During an interview on 9/4/25 at 1:00 PM, NS #20 stated that he/she had not received any LTC specific education prior to working in the LTC unit. He/she stated: .I only had general orientation. He/she further stated that no education was provided for dementia care, trauma-informed care, and cultural competency. During an interview on 9/4/25 at 12:23 PM, House Supervisor #1 stated that to float nursing staff to the LTC unit, staff must have completed an online module that provided education on abuse and neglect. When asked if the module educated on dementia care or trauma-informed care, House Supervisor #1 stated that abuse and neglect was the only education being tracked. Review of the facility provided policy Trauma Informed Care Policy, dated 9/3/2025, revealed: .Health Care organizations often train their clinical staff in trauma-specific treatment approaches. Facility Environment: train all staff to be sensitive to individuals (residents or staff) who are responding to a situation due to past trauma and understand how to support them. Review of the facility training module LTC ADL Coding and Definitions, updated in 2023 revealed that the module focuses on educating caregivers about accurately coding ADL's such as bathing, dressing, eating, and toileting, which are critical for assessing a resident's functional status and support needs in LTC. It outlines objectives to define self-performance and support required for ADLs, code them correctly on the MDS (Minimum Data Set - federally mandated assessment tool used in long-term care). Review of the facility training module Care of the Resident with Mental Disorders, updated in 5/2023 revealed that the module aims to enhance caregivers' ability to support residents with behavioral health issues, focusing on identifying signs, symptoms, and triggers of these conditions, as well as specific strategies for improved communication with residents who have experienced trauma. It emphasizes the importance of trauma-informed care to mitigate triggers and ensure culturally competent care, aligning with regulatory standards that mandate facilities should eliminate or reduce abuse and provide care in accordance with residents' preferences and professional standards. Review of the facility training module QAPI Training for Caregivers, updated in 2023, revealed that the module aims to equip caregivers with the knowledge to contribute to QAPI by discussing how caregivers can participate, describing QAPI elements and tools, identifying regulatory mandates, and informing about available resources and supports. It emphasizes the importance of caregivers in all post-acute care settings in enhancing care quality through systematic improvement processes. Review of the facility training module Dementia-related Conditions - Resident Care - PeaceHealth's Long Term Care Education, updated 5/2023, revealed that caregivers are encouraged to adopt a person-centered approach, recognizing stress triggers (physical, psychosocial, environmental) and using a four-step behavioral model (Prevent, Gather, A.C.T. [Ask, Collect, Treat], Redirect) to manage behaviors effectively. The module further trains caregivers with job specific behavioral models that include specific strategies such as preventing escalation with calm interactions, gathering information on resident preferences, and triggers. Review of the document Facility Assessment - Ketchikan Med [Center] New Horizons Transitional Care, dated 5/2024 indicated that total number of beds for the facility at the time of the assessment was 29. From this assessment, the residents that required assistance with ADLs, with specific needs included: bathing (20 residents), dressing (21), transferring (20 residents), toilet use (20 residents), and eating (20 residents). Behavioral health conditions or diagnoses were also identified in the facility assessment. The summary showed the most common conditions, and combinations of conditions that the facility may accept, such as dementia/impaired cognition (12 residents), depression (8 residents), anxiety disorders (4 residents), and others like schizophrenia (1 residents) and Post-traumatic stress disorder (1 residents)

.Based on record review and interview, the facility failed to ensure their facility assessment was reviewed and updated annually. This failed practice had the potential to place all residents (based on a census of 26) at risk of not having the necessary care and resources from an accurate assessment. Findings:Review of the facility's Proactive LTC Consulting Facility Assessment revealed this assessment was last updated on 5/21/24. The Chief Nursing Officer (CNO) acknowledged this finding and stated the facility assessment needed to be updated

.Based on record review and interview, the facility failed to ensure four float Certified Nurse Assistants (CNAs) out of four float CNAs chosen for review, received the required 12 hours of annual in-service training, specifically including education on dementia care and abuse/neglect prevention. This failed practice placed all residents (based on a census of 26) at risk for substandard care due to staff not being provided with the education necessary to ensure continuing competence in the care of long-term care (LTC) residents .Findings: Record review on 9/2-5/25 of CNA training records revealed:CNA #52 - 12 Hour Annual CNA Training with Dementia/Abuse/Neglect, expired on [DATE];CNA #53 - 12 Hour Annual CNA Training with Dementia/Abuse/Neglect, not completed;CNA #54 - 12 Hour Annual CNA Training with Dementia/Abuse/Neglect, not completed;CNA #55 - 12 Hour Annual CNA Training with Dementia/Abuse/Neglect, expired on [DATE]. Review of the facility provided schedule document Charge Back - Non Home Employee Detail, dated [DATE]-[DATE], revealed the following CNAs worked without the required 12 hours of annual in-service training on the following dates:CNA #52 worked in the LTC on [DATE] and [DATE];CNA #53 worked in the LTC on [DATE];CNA #54 worked in the LTC on [DATE];CNA #55 worked in the LTC on [DATE]. During an interview with the Director of Nursing (DON) on [DATE] at 9:30 AM, she stated that she was unaware that float staff needed LTC specific training to care for LTC residents, other than the abuse and neglect module. During an interview on [DATE] at 11:00 AM, CNA #55 stated that he/she had worked as a float in the LTC and had not received any education on dementia care or abuse/neglect within the past year. During an interview on [DATE] at 12:23 PM with the House Supervisor #1, he/she stated that to float a CNA to the LTC unit, they must have completed an online module that provided education on abuse and neglect. When asked if the module educated on dementia care, the House Supervisor stated that abuse and neglect was the only education being tracked. During an interview on [DATE] at 11:30 AM with the Clinical Nurse Educator, she stated that float CNAs working in LTC do not attend the annual educational retreats provided to the LTC CNAs to meet the 12-hour requirement. She further stated, There's a program for float CNAs, an article that they do for their Continuing Education Units (CEUs) to renew their license, but it does not provide education for dementia care or abuse and neglect in the LTC residents. Review of the document Facility Assessment - staff training and competencies, dated 5/2024, revealed: .The Nurse Educator keeps records of all training and skill fair documents. The Nurse Educator and Facility Administration education department ensures all areas are included. These training programs are also reviewed by PeaceHealth System education department. Evaluation of the facility's training program and effectiveness in ensuring training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Review of the facility adopted training module Dementia-related Conditions - Resident Care - PeaceHealth's Long Term Care Education, updated 5/2023, revealed that caregivers like CNAs are encouraged to adopt a person-centered approach, recognizing stress triggers (physical, psychosocial, environmental) and using a four-step behavioral model (Prevent, Gather, A.C.T. [Ask, Collect, Treat], Redirect) to manage behaviors effectively. The module further trains caregivers with job specific behavioral models that include specific strategies such as preventing escalation with calm interactions, gathering information on resident preferences, and triggers. Review of the facility adopted training module Abuse, Neglect, and Exploitation in the Elder Care Setting, updated in 6/2022, revealed the module aimed to educate caregivers on recognizing and reporting abuse, neglect, and exploitation in elder care settings, covering types such as physical, verbal, mental, and financial abuse, as well as neglect and exploitation

.Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 resident (#12), out of 1 allegation of abuse investigation reviewed. Specifically, the facility failed to: 1) Accurately interview Resident #12 to determine the nature and timing of the allegation of abuse; 2) Have evidence of the Administrator's interview conducted during the investigation; 3) Contact the Resident's Provider regarding the allegation of abuse; and 3) Investigate reports of intimidation and verbal abuse received from 2 residents (#'s 20 and 25), out of 5 residents interviewed during the investigation. These failed practices: 1) caused a misinterpretation of what the allegation of abuse was and when it occurred; 2) resulted in the investigation being incomplete; and 3) denied Residents #20 and #25 the right to potentially submit a complaint for an allegation of abuse and placed them at risk for continued emotional upset from the experiences reported. Findings:Incident Reported A facility reported incident (FRI) was submitted to the State Agency for an allegation of verbal abuse, dated 7/23/25, by the Chief Nursing Officer (CNO). Incident Description During an interview on 9/2/25 at 1:45 PM, Resident #12 stated he/she had been asking about going to therapy to help strengthen his/her legs so he/she could walk again. Resident #12 stated the Administrator came to him/her one day while he/she was looking out a window in the activities room and said, You are never going to get out of that chair [meaning wheelchair]. You are a failure, and you are going to die here. Resident #12 stated this comment made him/her very sad and he/she was now hopeless, like I'll never get out of here. It was observed that Resident #12 was physically shaking when he/she told this story, wringing his/her hands and his/her voice was cracking with emotion. When asked when this conversation occurred, Resident #12 stated he/she couldn't remember the exact date, but it was before the 7/23/25 resident council meeting. Investigation by CNO During an interview on 9/3/25 at 1:34 PM, the CNO stated during the resident council meeting on 7/23/25, in the middle of the meeting, Resident #12 stated he/she felt the Administrator had verbally abused him/her. After the meeting, the facility team decided to file a State report regarding Resident #12's comment and initiate an investigation. The CNO stated the report was sent to the State Agency on 7/23/25. The CNO further stated that she contacted the HR Director for PeaceHealth on 7/23/25 about the investigation and placed the Administrator on administrative leave pending the conclusion of the investigation. The CNO further stated she completed an interview with Resident #12 on 7/23/25 about the comments in the meeting, however Resident #12 did not comment on what the verbal abuse was. When asked to see the documentation for the interview with Resident #12, the CNO stated no documentation for the interview was completed. The CNO further stated that Resident #12 stated he/she was just mad and didn't want to file a report, but the CNO felt it was her responsibility to file the report anyhow to make sure an abundance of caution was made. The CNO stated she also submitted this incident in the facility's electronic incident reporting system Safe2Share. When asked if the CNO was aware that when Resident #12 spoke of the verbal abuse in the resident council meeting, the resident was speaking about an incident that had occurred before the resident council meeting, and not about a comment made at the meeting, the CNO stated she was not aware of this and had assumed it was about a comment made in the resident council meeting on 7/23/25. When asked if the CNO interviewed the Administrator during the investigation, the CNO stated she and the Administrator had talked but this was not documented. When asked if the CNO contacted Resident #12's provider to inform them of the reported allegation of abuse, the CNO stated she did not contact the provider. When asked what other steps occurred during the investigation, the CNO stated she had a Minimum Data Set (MDS - a nationally mandated routine assessment) Nurse interview five other residents to ensure no other residents had any concerns. The CNO stated she drafted questions for the MDS Nurse to use. From these interviews, she determined these residents felt safe. When asked what the investigation's determination was, the CNO stated that because Resident #12 retracted his/her statement and because it was determined it was mainly about the Administrator's approach to communicating with others, she determined the abuse allegation as retracted and concluded the investigation on 7/28/25. The CNO stated the Administrator returned to work on 7/29/25. Review of the facility's documentation of the resident interviews that occurred during this investigation, undated, revealed two resident's, Resident #20 and #25, interviews revealed they had felt verbally abused by the Administrator. During an interview on 9/3/25 at 1:34 PM, when asked if these comments were investigated, the CNO stated, no. Review of the facility policy Allegation of Abuse Policy, dated 12/15/24, revealed: . It is the policy of PeaceHealth that any allegation of abuse by a patient against a caregiver will be responded to immediately. An investigation of the facts will be coordinated . Caregiver - Patient Present. An allegation is made against a caregiver by a patient or another party for a patient currently in the hospital or in an ambulatory setting. Receiving Party. Any caregiver or provider who observes or who receives a report that anyone is being abusive, either physically, sexually, or verbally or in any way behaving in a manner harmful or disrespectful to any patient who is under the care of PeaceHealth, must immediately report this behavior to their manager/designee . Responding Leader. Visit the patient to ensure they are safe and to advise the patient their concern is under review and who will be the point of contact for the review going forward . Contact the risk manager on call . Contact their human resources partner to determine next steps with caregiver under review . the caregiver under review may be placed on administrative leave until the conclusion of the investigation . Contact the patient's provider . Review of the facility policy Patient Complaint and Grievance Policy, dated 2/14/25, revealed: . This policy and procedure establishes a mechanism and the procedures to respond, review, and resolve patient grievances and complaints . Definitions . Grievance . Allegation of a patient rights violation, such as abuse, discrimination or violation of privacy rise to the level of a grievance . The process for responding to patient grievances according to federal regulations and regulatory guidelines is outlined in the Patient Complaint and Grievance Procedure . Patient Grievance Procedure . Leadership over the area where the grievance originated is responsible to initiate an immediate review, determine appropriate actions, and communicate findings in a timely manner investigation process will include . Interview all available witnesses identified by any sources as having personal knowledge of relevant to the complaint . Written report which includes the investigator's personal observation . A summary of all witness statements; and a statement of the basis for the finding . Review of the facility's policy LTC [Long Term Care]: State Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy, dated 2/18/25, revealed: Procedure . Charge Nurse or 1st Responder . Immediately review the initial information. Determine immediately if the resident is in any danger of harm or further abuse . If the person alleged to be the abuser is a caregiver . immediately relieves them of duty . Begin preliminary investigation by speaking to the reporting person, addressing who did what when and, if known, why. When appropriate, briefly ask the resident/family what their thoughts are about the incident. Document findings on Investigation Report form .

.Based on record review, interview, and observation, the facility failed to provide an ongoing, resident-centered activity program, aligned with individual care plans, for 17 Residents (#'s 4, 5, 7, 9, 12, 13, 18, 20, 21, 23, 25, 27, 28, 31, 33, 34, and 36), out of 26 residents who enjoyed activities outside of their rooms. Specifically, the facility failed to: 1) Consistently provide activities as documented on the facility's monthly activity calendar for the months of July, August, and September 2025; 2) Provide scheduled outings with the use of the facility's transportation van; and 3) Allow residents with the diagnosis of dementia from participating in scheduled outings. These failed practices placed these residents at risk for loneliness, isolation, boredom and decreased their quality of life, which had the potential to affect their overall physical, mental, and psychosocial well-being .Findings: Resident Activities Preferences Resident #4 Record review on 9/2-6/25 revealed Resident #4 was admitted to the facility with diagnoses that included Type 2 diabetes mellitus (DM-disorder characterized by persistent high blood sugar levels and inability to use insulin properly), senile dementia with behavioral disturbance (age-related memory loss or confusion in older adults) and hypertension (high blood pressure). Review of Resident #4's care plan, start date of 3/13/25, revealed an identified problem [Resident #4's POA] has voiced [Resident #4's] activity preferences as conversing, cooking group, religious events/clergy, books on tape, visits from family/friends, watching TV . [Resident #4] likes [NAME] movies. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 3/13/25 through 10/31/25. Resident #5 Record review on 9/2-6/25 revealed that Resident #5 was admitted to the facility with diagnoses that included gastroesophageal reflux disease (GERD- a chronic condition where stomach acid flows back into the esophagus, causing symptoms like heartburn and acid reflux), late onset Alzheimer disease (characterized as when the disease develops in individuals aged 65 and older) without behavioral disturbance, and anxiety. Review of Resident #5's care plan, start date of 10/16/24, revealed an identified problem [Resident #5's] participation in activities can be sporadic due to [his/her] short attention span r/t [related to] Alzheimer's Dementia. [He/she] enjoys [his/her] baby doll 'Bridget, ', family visits, ambulating on unit, listening to music, sorting items, and watching movies with dancing. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 10/16/24 through 11/30/25. Resident #7 Record review on 9/2-6/25 revealed Resident #7 was admitted to the facility with diagnoses that included hypertension, dementia, and anxiety disorder. Review of Resident #7's care plan, start date of 11/14/24, revealed an identified problem [Resident #7's POA] has voices [his/her] activity preferences as having special events in room, listening to music, watching tv, 1:1 visits with family, family outings, van rides, visits from [NAME] (unit support dog), and going outside for fresh air. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 11/14/24 through 10/31/25. Resident #9 Record review on 9/2-6/25 revealed Resident #9 was admitted to the facility with diagnoses that included hypertension, Type 2 DM, and severe late onset Alzheimer's dementia without behavioral disturbance. Review of Resident #9's care plan, start date of 1/22/25, revealed an identified problem [Resident #9's daughter] has voiced [Resident #9's] activity preferences as group activities such as board games, manicures, cooking, making floral arrangements, arts and crafts, watching television, picture books, listening to religious music and folding/stacking. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 1/22/25 through 9/30/25. Resident #12 Record review on 9/2-6/25 revealed Resident #12 was admitted to the facility with diagnoses that included depression, hypertension, and cerebrovascular accident (CVA- also known as a stroke, is when blood flow to a part of the brain is stopped either by a blockage or rupture of a blood vessel). Review of Resident #12's care plan, start date of 12/27/24, revealed an identified problem [Resident #12] had voiced [his/her] activity preferences as coloring, books on tape, writing, painting, cooking, [playing] cards, resident council, pet therapy, watching tv, games, out on patio, sports, conversing, hair, current events and music. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 12/27/24 through 9/30/25. During an interview on 9/2/25 at 1:45 PM, Resident #12 stated the facility used to have a monthly outing to Walmart for residents. Resident #12 stated they would use the facility van to take the residents, but this hasn't happened in a while. Resident #12 stated, Residents just want to get out and look around. It's nice to leave the facility and just go out. Resident # 13 Record review on 9/2-6/25 revealed Resident #13 was admitted to the facility with diagnoses that included aphasia (disorder that affects communication due to select brain damage), stroke, and hypertension. Review of Resident #13's care plan, start date of 10/8/24, revealed an identified problem [Resident #13] has listed [his/her] activity preferences as not liking large group activities. [He/she] likes [to] attend special events and enjoys haircuts . The goal for this problem was [Resident #13] will be provided activity choices of interest that will enhance quality of life through next review. This goal was dated 10/8/24 through 11/30/25. Resident #18 Record review on 9/2-6/25 revealed Resident #18 was admitted to the facility with diagnoses that included CVA, dementia, and hemiplegia (one-sided paralysis). Review of Resident #18's care plan, start date of 2/27/25, revealed the identified problem [Resident #18] stated [his/her] activity preferences to be located in activity room with other residents. [He/she] enjoys watching tv, games, and socializing with others . [He/she] enjoys occasional outings. The goal for this problem was provide activity choices of interest that will enhance quality of life through next review. This goal was dated 2/17/25 through 11/30/25. During an interview on 9/3/25 at 10:37 AM, Resident #18 stated the residents haven't had activities for a couple of weeks now. Resident #18 stated he/she personally missed the balloon toss very much because it got us moving. Resident #18 further stated, this is what we need. He/she stated the residents looked forward to going out to the fourth of July parade every year and going the [NAME] Lake picnic, but the residents didn't go this year. When asked how not having as many activities as usual made him/her feel, Resident #18 stated, We get discouraged, I'm sadder now. Resident #20 Record review on 9/2-6/25 revealed Resident #20 was admitted to the facility with diagnoses that included hypertension, neurogenic bladder (condition that affects the bladder function due to nervous system issues), and DM. Review of Resident #20's care plan, start date of 10/17/24, revealed the identified problem [Resident #20] has voiced [his/her] activity preferences as participation in group activities and self-imitated activities in [his/her] room. [He/she] enjoys board games, cards, conversing, dominoes, BINGO, visiting with friends, arts, crafts, tv, and attending resident council. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 10/17/24 through 9/30/25. Resident #21 Record review on 9/2-6/25 revealed Resident #21 was admitted to the facility with diagnoses that included severe dementia without behavioral disturbance, chronic pain syndrome, and reactive depression. Review of Resident #21's care plan, start date of 3/5/25, revealed an identified problem [Resident #21] has voiced [his/her] activity preferences as Bingo, conversing, clergy visits, holding/playing with baby doll, drumming, singing, playing with sensory blanket, and van rides. The goal for this problem was provide activity choices of interest that will enhance quality of life through next review. This goal was dated 3/5/25 through 11/30/25. Resident #23 Record review on 9/2-6/25 revealed Resident #23 was admitted to the facility with diagnoses that included hemiparesis (one-sided muscle weakness) affecting the left side as late effect of CVA, major depressive disorder (MDD- mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension. Review of Resident #23's care plan, start date of 10/8/24, revealed an identified problem [Resident #23] has voiced [his/her] activity preferences as watching television, laptop, phone, and ipad in [his/her] room. [He/she] enjoys trips to Wal-Mart, local events, and small group activities such as special events . The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 10/8/24 through 11/30/25. Resident #25 Record review on 9/2-6/25 revealed Resident #25 was admitted to the facility with diagnoses that included hemiparesis of left non dominant side as late effect of cerebral infarction, generalized anxiety disorder (GAD- a mental health condition characterized by excessive worry), and MDD. Review of Resident #25's care plan, start date of 6/10/25, revealed an identified problem [Resident #25] is at increased risk for decreased activity participation related to health complications. See description for preferences . do group activities or to be offered group activities, wanted to be able to do some of [his/her] favorite activities as able, to go outside when the weather is nice, watch TV, play cards, van rides, and shopping . The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 6/10/25 through 11/30/25. Resident #27 Record review on 9/2-6/25 revealed Resident #27 was admitted to the facility with diagnoses that included Type 1 DM (a chronic autoimmune condition where the pancreas produces little or no insulin), Parkinson's disease (a neurodegenerative disease primarily of the central nervous system, affecting both motor and non-motor systems) and hypertension. Review of Resident #27's care plan, start date of 3/3/25, revealed an identified problem [Resident #27] has voiced [his/her] activity preferences as listening to music, visits, clergy visits, family outings, community events and van rides. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 3/3/25 through 10/31/25. Resident #28 Record review on 9/2-6/25 revealed Resident #28 was admitted to the facility with diagnoses that included MDD, GAD, and Type 1 DM. Review of Resident #28's care plan, start date of 8/20/25, revealed an identified problem [Resident #28] has voiced [his/her] activity [preferences] as coloring books, play cards, listen to books on tape, crafts, play games, knitting, getting hair done, listening to music, getting nails done, sit on patio, paint, pet therapy, planning, puzzles, reading, watch tv. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 8/20/25 through 11/30/25. Resident #31 Record review on 9/2-6/25 revealed Resident #31 was admitted to the facility with diagnoses that included hypertension, alcohol use disorder, and expressive aphasia. Review of Resident #31's care plan, start date of 7/22/25, revealed the identified problem [Resident #31] has voiced [his/her] preferences as Bingo, out on patio, puzzles, watching TV, hair, and reading . The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 7/22/25 through 10/31/25. Resident #33 Record review on 9/2-6/25 revealed Resident #33 was admitted to the facility with diagnoses that included Alzheimer's disease, schizophrenia (mental health condition that affects how people think, feel, and behave. It is characterized by a range of symptoms, including hallucinations, delusions, and disorganized thinking), and GAD. Review of Resident #33's care plan, start date of 1/24/25, revealed the identified problem [Resident #33] has voiced [his/her] activity preferences as coloring, crafts, cooking group, exercise group, listening to music, out on patio, painting, pet therapy, and 1:1 visits. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 1/24/25 through 10/31/25. Resident #34 Record review on 9/2-6/25 revealed Resident #34 was admitted to the facility with diagnoses that included dementia, CVA, and chronic kidney disease (CKD- progressive condition characterized by the gradual loss of kidney function over time) stage 2 due to DM. Review of Resident #34's care plan, start date of 10/29/24, revealed the identified problem [Resident #34] has voiced [his/her] activity preferences as watching television, movies, listening to music, reading, outside events (Senior picnic, plays, community events), 1:1 visits with family, friends, caregivers. [He/she] likes to attend special events on the unit. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 10/29/24 through 9/30/25. Resident #36 Record review on 9/2-6/25 revealed Resident #36 was admitted to the facility with diagnoses that included dementia and unspecified malnutrition. Review of Resident #36's care plan, start date of 11/20/24, revealed the identified problem [Resident #36] has voiced [his/her] activity preferences as Bingo, nails, watch tv, games, cards, hair, listening to music, play music, and 1:1 visits. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 11/20/24 through 11/30/25. Lack of Activities During an interview on 8/27/25 at 3:48 PM, Staff #40 stated the Administrator cancelled the Fourth of July parade outing. Staff #40 stated there had been multiple days in which activities were closed, that even the activity room doors were closed, because staff were pulled out of activities to work on the floor for direct resident care. During an interview on 9/2/25 at 4:10 PM, Resident #20 stated the facility have hardly had activities now. When asked about the activity calendar and if those activities were being offered, Resident #20 smiled and stated, the calendar is just for looks. They don't do them. I'd like more activities. When asked how that has made him/her feel, Resident #20 stated, I've given up. I just watch TV now. We are not happy, no one smiles anymore. There is no happiness here anymore. During an interview on 9/3/25 at 9:00 AM, Staff #84 stated he/she was pulled to the floor on this day to assist with resident cares. He/she further added, this does happen often due to short-staffing and providing cares would be more of a priority. He/she stated the activities department would need to be closed for the whole day or partially, if necessary. Staff #84 stated that the department used to have more staff to help implement the activities listed in the calendar and/or outings. Record review of the facility's activities calendar, September 2025, revealed for date 9/4/25: .Thursday. [9/4/25] Football Season Begin .1:1 Visits. Coffee/Newspaper 8:30 AM. Chair Yoga 11:00 AM. Table Games 2:00 PM. Snack Cart 2:30 PM. Afternoon TV/Movie 3:00 PM Random observations on 9/4/25 from 11:00 AM-12:00 PM, revealed the Chair Yoga, activity did not ensue. During an interview on 9/4/25 at 11:30 AM, Staff #86 stated the Activities CNA (Certified Nursing Assistant) had called out and that he/she was pulled to the floor to assist with resident cares and the scheduled 11:00 AM chair yoga was cancelled. During an interview on 9/4/25 at 11:53 AM, the Director of Nursing (DON), when asked if the scheduled activity of Chair Yoga was offered and/or provided to the residents, she verified that the staff member thought that he/she was not going to be able to do it and cancelled the activity. The DON further stated that she would educate the staff that activities still needed to be offered to residents when listed in the calendar. Record review of a facility-provided list of dates from 7/2025 through 9/2025 when the activities department were closed and/or partially closed, revealed:-7/4 open 7:00 AM-1:30 PM;-7 /6 closed;-7/18 1:00 PM-7:30 PM;-7/19 closed;-7/20 closed at 4:00 PM;-7/21 closed;-7/22 closed;-7/27 closed;-7/28 opened from 8:00 AM-1:00 PM;-7/29 closed;-8/2 opened for bingo, 3:00 PM-5:00 PM;-8/4 opened 7:00 AM- 11:30 AM;-8/11 closed;-8/12 7:00 AM-1:00 PM;-8/17 closed-8/24 closed During an interview on 9/3/25 at 4:16 PM, the Chief Nursing Officer (CNO) stated the facility has had staffing shortages since December 2024 and this had caused problems maintaining enough staff on the floor for direct resident care. When asked how this had affected the activities department, the CNO stated that there had been times when staff were pulled from activities to work the floor, and this had caused activities to be closed at times. The CNO stated the overall goal was to have activities offered every day, however this was not always possible. Outings During an interview on 8/27/25 at 3:48 PM, Staff #40 stated that the Administrator also would not let the staff utilize the facility van for outings.During an interview on 9/2/25 at 1:45 PM, Resident #12 stated the facility used to have a monthly outing to Walmart for residents. Resident #12 stated they would use the facility van to take the residents, but this hasn't happened in a while. Resident #12 stated, Residents just want to get out and look around. It's nice to leave the facility and just go out. During an interview on 9/3/25 at 9:00 AM, Staff #84 stated that the department used to have more staff to help implement the activities listed in the calendar and/or outings. During an interview on 9/3/25 at 11:00 AM, Staff #68 stated the Administrator said that staff could not use the facility van anymore for outings because there were no drivers and it was not financially feasible. Record review of facility-provided document Ticket to Ride, dated 6/25/25, revealed only 3 residents went to a Walmart outing. Record review of facility-provided document Events.Walmart.Date.8/12.Time.9:30 AM. revealed the activity has been postponed to 8/14/25. 5 residents went to the outing on 8/14/25. During an interview on 9/3/25 at 1:18 PM, Staff #90 stated the last outing offered to residents was on 8/14/25 and the next outing date offered was unknown. During an interview on 9/3/25 at 4:16 PM, when asked if the facility was adhering to the activity calendar, the CNO stated that the indoor activities were easier to offer, however the outdoor activities were harder. The CNO stated that the facility had lost drivers for the facility van, which had affected the facility's ability to offer scheduled outings, like trips to Wal-Mart. The CNO stated historically, the facility usually offered two trips a month to Wal-Mart but this had been hard to offer lately. The CNO stated that currently there were three staff that could drive the van. During an interview on 9/4/25 at 12:18 PM, Staff #71 stated that the Administrator also told staff that you all don't need to use the van this much! when discussing outings for residents. Cancelled Cooking Groups During an interview on 9/3/25 at 11:00 AM, Staff #68 stated that the Administrator told staff they were not able to offer cooking groups to the residents anymore because it was too much food. Staff #68 stated the Administrator said if the residents wanted to cook a meal, then they would have to eliminate a meal from the central kitchen. During an interview on 9/3/25 at 4:16 PM, when asked about why the cooking group was stopped, the CNO stated she was not sure, but never confirmed with the Administrator as to why this activity was cancelled. During an interview on 9/4/25 at 12:18 PM, Staff #71 stated that the Administrator told staff you guys cook too much! when planning for cooking groups. The Administrator told staff that if residents wanted to cook, they would have to eliminate a meal if you cook this much. Dementia Residents and Outings Record review revealed Resident #5 and #9 was admitted to the facility with the diagnosis of dementia. During an interview on 9/4/25 at 10:04 AM, the Administrator stated that she had concerns for two residents with dementia, Resident #5 and #9, attending the [NAME] Lake picnic. The Administrator stated she felt it was unsafe because the residents can wander, and they didn't have enough staff for a 1:1 (one staff to one resident). When asked if there was an order that stated these residents must be on a 1:1 if on an outing, the Administrator stated no 1:1 order was needed, that it would be in the care plan and a nurse could have the authority to make that decision. Review of Resident #5's and #9's care plans revealed that no 1:1 was needed for outings. During an interview on 9/4/25 at 12:18 PM, Staff #71 stated that when floor and activities staff were talking about the 7/18/25 [NAME] Lake picnic outing, and how they would plan to bring Resident #5 and #9, who were diagnosed with dementia, Staff #71 stated the Administrator came out of her office and joined the conversation. The Administrator stated, Absolutely not and that these residents will never leave the unit. Staff #71 attempted to explain to the Administrator that these residents had routinely gone on outings, and done so safely, and it would not be appropriate to exclude them, however the Administrator would not agree. Staff #71 stated the residents could not go to the outing. During an interview on 9/4/25 at 1:14 PM, when asked if she had heard that residents with dementia diagnoses were not allowed to go on outings, the CNO stated she had heard this was a concern from staff, however, did not know enough about the federal regulations at the time. During an interview on 9/9/25 at 2:53 PM, the Medical Director stated that Resident #5 and #9 did have a history of wandering, however they had attended many outings in the past without concern, and they would not need a 1:1 on outings. The Medical Director stated that caution was always needed, but there was no rule that these residents couldn't attend outings. Review of the facility's policy LTC [Long Term Care]: Activities Therapy Scope of Service, revised on 3/6/25, revealed: .Purpose. to provide appropriate daily activities for each resident. To comply with State and Federal regulations. Goals/Objectives. to provide meaningful and age appropriate activities that engage each resident while promoting dignity, respect and the well-being of each resident. Provide one on one and group activities, special events, in house and outings to community events. Types of Residents. Early to advanced dementia including Alzheimer', illnesses of all body systems, end of life care, and wound care. Operation. Sunday-Saturday, open as needed to meet the needs of events for residents. Review of the facility's policy LTC: Resident Dignity Policy, revised 2/18/25, revealed: .The purpose of this policy is to provide the following, though not all inclusive, examples of maintaining resident dignity. In this context it means that in their interactions with residents, staff carries out activities that assist the resident to maintain and enhance his/her self-esteem and self-worth.c. Assist resident to attend activities of their choosing.

.Based on interview and record review, the facility failed to treat one resident (#16), out of 26 residents reviewed, with dignity and respect. Specifically, the facility's Administrator took the resident's personal checkbook, against the resident's wishes, and kept this item in her personal desk without communicating an appropriate rationale for the restriction. This failed practice violated the resident's right to be treated with dignity and respect and placed undue stress on the resident which had the potential to affect the resident's overall health and well-being. Findings:During an interview on 9/2/25 at 2:35 PM, Resident #16 stated the Administrator confiscated my checkbook and said if I didn't give it to [him/her] I would be kicked out of the hospital. Resident #16 stated, I was so angry. Resident #16 state the Administrator took the checkbook and wouldn't give it back, she held it over the weekend. Resident #16 could not identify the date this occurred. During an interview on 9/4/25 at 10:04 AM, the Administrator stated Resident #16 was having difficulty with insurance and needed an application for Medicaid completed. The Administrator stated the Power of Attorney (POA) had requested assistance in getting the checkbook because Resident #16 was writing checks and the POA couldn't have the resident writing checks he/she wasn't aware of. When asked to describe her encounter with Resident #16, the Administrator stated she took a nurse with her to Resident #16's room and told the resident he/she had not been on Medicaid since December. The Administrator stated she told Resident #16 she didn't want to initiate a discharge for him/her, but that the facility needed to get a payor source for his/her continued stay. For that reason, the Administrator stated she told Resident #16 she needed to take the checkbook so your POA can apply for Medicaid for you. The Administrator stated Resident #16 initially said no, that he/she did not want anyone to take his/her check book and asked, What are you going to do with it? The Administrator stated after conversing for a while, and only after the Administrator agreed to tell the resident if any checks were written while the checkbook was in her possession, did the resident surrender the checkbook to her. When asked what the Administrator did with the checkbook, the Administrator stated she put it in her personal desk in her office. When asked why she didn't put the checkbook in the facility's resident safe, the Administrator stated she didn't know the process for using the safe. When asked about the timeline of this event, the Administrator stated it was a day or two prior to going on remote status (returning to home out of state but continuing to work), which was the first weekend of August. When asked if she usually took personal belongings from residents, the Administrator stated it was not usual practice. When asked why the POA didn't come with the Administrator to discuss the situation with the resident prior to taking the checkbook, the Administrator stated she could have and probably should have done that. When asked why the Administrator did not give the checkbook to the POA after obtaining it, the Administrator stated she had to leave for a family emergency and switched to remote status before the checkbook could be transferred to the POA. When asked if she informed anyone that Resident #16's checkbook was in her personal desk, the Administrator stated she couldn't remember. During an interview on 9/4/25 at 10:04 AM, the Director of Nursing stated it was not common practice to take personal belongings of residents and put them in staff desks. During an interview on 9/4/25 at 10:04 AM, the Chief Nursing Officer (CNO) stated she knew that the Administrator took Resident #16's checkbook and placed it in her desk, but she was not aware of how long the Administrator had the checkbook. The CNO stated it was not usual practice to keep personal belongings in personal desks. The CNO stated once she had heard Resident #16 was inquiring about his/her checkbook, she went into the Administrator's office and retrieved the checkbook from the Administrator's desk and it was returned to the resident. During an interview on 9/4/25 at 12:18 PM, Staff #45 stated he/she witnessed an interaction between the Administrator and Resident #16, after the Administrator had possession of the checkbook, where Resident #16 said, I want my checkbook! The Administrator dismissed Staff #45 saying, you don't need to be here for this, I got this. Staff #45 left the room. During an interview on 9/4/25 at 12:54 PM, Staff #62 stated he/she witnessed the initial interaction between the Administrator and Resident #16 concerning the checkbook. Staff #62 stated his/her perspective of the conversation was that the Administrator was forcing Resident #16 to give up his/her checkbook and the words used by the Administrator were threatening saying, you don't really have a choice, you need to give me the checkbook. Staff #62 stated Resident #16 was mad. Staff #62 stated the Administrator dismissed him/her from the room prior to the conversation ending, and prior to the Administrator taking possession of the checkbook. Staff #62 was unaware of what transpired after being dismissed. During an interview on 9/4/25 at 12:58 PM, Resident #12's POA stated the Administrator called him/her about getting Resident #16's finances worked out for a payor source. The POA stated Resident #16's struggled with giving up control of his/her finances. The POA told the Administrator that he/she didn't force finances on residents, but if the facility wanted to help back him/her up, he/she felt it was in the resident's best interest to not have control of the finances. The POA further added, the Administrator stated she had no problem backing him/her up. Review of Resident #16's medical record revealed no notes regarding the Administrator's discussion with the POA, her interaction with Resident #16 to get the checkbook, that she stored the checkbook in her personal desk, or what the plan was going to be once she had the checkbook. Review of Resident #16's POA paperwork, dated 2/20/25, revealed the POA was named as Resident #16's agent with power under the category banking transactions. Review of the facility's policy LTC [Long Term Care]: Patient Rights and Responsibilities Policy, dated 1/10/25, revealed: It is the policy of PeaceHealth to define, recognize, protect and promote the rights and responsibilities of the patients and their legal, authorized or designated representatives . Review of the facility's Resident Rights and Responsibilities form, undated, which was available to all residents, revealed: . You have the right to dignity, respect and compassion. This includes your right to: Be treated with consideration, respect and dignity, recognizing reach resident's individuality . Exercise rights without interference, coercion,, discrimination, or reprisal; a homelike environment, and use personal belongings when possible . Keep personal belongings as space permits and have those possessions be kept safe .

Based on interview and record review, the facility failed to update and revise the care plan for two residents (#s 1 and 19), out of 13 sampled residents. Specifically, the facility failed to update and revise the care plans to reflect: 1) anticoagulant medication use for Resident #1; and 2) chronic right shoulder pain for Resident #19. Failure to assess and revise care plan problems, goals, and interventions placed the residents at risk for not receiving appropriate and/or necessary care and services. Findings: Resident #1 Record review on 2/24-28/25 revealed Resident #1 was admitted to the facility with diagnoses that included atrial fibrillation (an abnormal heart rhythm originating in the atria that reduces the atrium's efficiency and can lead to blood clots forming in the atrium), heart failure (inability of the heart to maintain adequate blood circulation), and diabetes. Review of Resident #1's medications, on 2/26/25, revealed he/she was taking Apixaban (Eliquis, an anticoagulant medication to reduce clot formation) 5 milligrams (mg) twice a day. Further review revealed this medication started on 12/17/24. Review of Resident #1's care plan, on 2/27/25, revealed Apixaban was not on his/her care plan to alert staff to be aware the Resident was on this high-risk medication, so they were aware of potential risks and side effects associated with being on an anticoagulant. Review of Resident #1's care plan event log (a log that showed all changes made to the care plan since admission), revealed: - 12/17/24: the anticoagulant medication was added to the care plan, [Resident #1] is at risk for side effects and/or adverse reactions related to use of diuretics [,] anticoagulant medications. - 1/28/25: the anticoagulant medication was removed from the care plan, [Resident #1] will be free from side effects and/or adverse reactions related to diuretic medication through next review. Anticoagulant medication was never put back on the care plan. Review of Resident #1's medication history revealed he/she was still taking Apixaban on 1/28/25 and was not held any time prior to this date since admission. Further review revealed the only time Resident #1's anticoagulant medication was held was on 2/13/25 (for both doses that day) and 2/14/25 (for only one dose in the morning and resumed that evening) for bleeding associated with a tooth extraction that occurred on 2/12/25. During an interview on 2/27/25 at 10:36 AM, the MDS Coordinator stated that Resident #1's anticoagulant medication was not on his/her care plan and needed to be added. Resident #19 Record review on 2/24-28/25 revealed Resident #19 was admitted to the facility with diagnoses that included a subdural hematoma (a collection of blood between the dura mater, outer covering of the brain's membrane, and the arachnoid layer, inner layer of the brain's membrane, usually caused by head trauma) and a fracture of the right tibial plateau (break in the upper part of the shin bone near the knee joint) requiring a right total knee replacement (surgical procedure in which the damaged or worn-down knee joint is replaced with an artificial implant). During an interview on 2/24/25 at 4:04 PM, Resident #19 stated he/she had been having right shoulder pain. Resident #19 further stated he/she had hardly been able to move his/her right shoulder, and tasks such as putting on a jacket was very painful. He/she further stated the right shoulder pain had been an issue since admission. Review of the Physical Therapy Progress Note, dated 1/23/25 at 2:49 PM, revealed: Pt [Patient] c/o [complained of] pain right hip. Bilateral feet ankle and right shoulder, at varying times during evaluation . Review of the Physical Therapy Progress Note, dated 1/30/25 at 3:42 PM, revealed: Pain/Discomfort Assessment . Pain Type Chronic pain (ankle/foot, knee RLE [right lower extremity], right shoulder) Intervention(s) to Relieve Pain/Discomfort Medicated for pain (prior per RN [Registered Nurse]. RN notified of shoulder pain) . Review of the Nursing Note, dated 2/1/25 at 12:46 AM, revealed: [He/she] was given Oxycodone [prescription opioid pain medication used to treat moderate to severe pain] for [his/her] pain in right shoulder and right knee to shin. [He/she] reported that [he/she] wants the Vicks Vaporub [a topical ointment used as a cough suppressant but also used to relieve aches and pains in muscles and joints. It contains menthol and camphor which works by stimulating sensory receptors to provide cooling pain relief] for [his/her] right shoulder pain . Review of the Nursing Note, dated 2/2/25 at 12:30 AM, revealed: [Resident #19] requested only Vick's for [his/her] right shoulder discomfort . Review of the Nursing Note, dated 2/7/25 at 1:29 AM, revealed: [Resident #19] only complaint was pain: a HA [headache] and pain in the right leg to foot and then later also in the right shoulder . Review of the Nursing Note, dated 2/8/25 at 11:21 PM, revealed: [His/her] only complaint was pain in right thigh to foot, right shoulder and HA. [He/she] was given oxycodone vicks vaporub on right shoulder and ice on leg . Review of the Physical Therapy Progress Note, dated 2/10/25 at 4:40 PM, revealed: Patient attempted to transfer from bed to wheelchair required mod assist [moderate assistance] due to reports of pain in RLE and R [right] shoulder . Review of the Nursing Note, dated 2/11/25 at 1:59 AM, revealed: [Resident #19] only complaint was pain: a HA and pain both legs (right leg to foot was the majority of the pain) and also in the right shoulder. [He/she] was given Oxycodone with night meds[medications] for 9/10 pain, and Vicks applied to right shoulder pain. Review of the Nursing Note, dated 2/20/25 at 12:32 PM, revealed: [Resident #19] reported continued pain in [his/her] right shoulder area. [He/she] states this has been ongoing since admission. Currently receiving Vick's vapor rub with ease. [He/she] asks if [he/she] could have imaging. Message sent to [provider] regarding this and the resident notified of the above . Review of the Nursing Note, dated 2/20/25 at 1:35 PM, revealed: Complaints of right shoulder pain during morning rounds, vicks vapo rub applied as per resident request. [He/she] verbalized a little bit of relief upon assessment. [He/she] asked this writer if [he/she] could have imaging on [his/her] right shoulder since [the right shoulder pain] has been ongoing pain since admission. Charge [Nurse] notified and Provider notified . At [4:00 PM] resident was sitting on the edge of the bed appears to not be in pain but when I approach [him/her] [he/she] [complained] of pain and was about to cry . Review of the Physical Therapy Progress Note, dated 2/20/25 at 1:40 PM, revealed: [Resident #19] reported [he/she] was not feeling well today and when asked in what way [he/she] reported that [his/her] right shoulder is in significant pain . Review of the Speech and Language Pathologist Progress Note, dated 2/24/25 at 3:44 PM, revealed: [Resident #19] complained of leg and shoulder pain and was expecting some medication which was administered by the RN during the session. [Resident #19] reported [he/she] feels [he/she] can't concentrate very well when [he/she] has things on [his/her] mind or when [he/she] is hurting but [he/she] endorsed it is getting better. Review of the Baseline Care Plan, effective from 1/22/25 to 1/30/25, revealed: [Resident #19] is at risk for Pain related Total knee replacement Goal: Pain will be controlled through next review Interventions: Assess for pain q[every] shift, administer pain medications as ordered, notify Provider of any non-relieved pain . Further review revealed no documentation in Resident #19's care plan about his/her right shoulder pain. During an interview on 2/26/25 at 8:53 AM, MDS Coordinator stated he/she and the Director of Nursing (DON) are the only ones that updated the care plans. The MDS Coordinator further stated he/she reads all the notes daily in the residents' chart and nurse communications to ensure updates are completed. During an interview on 2/26/25 at 10:50 AM, when asked when he/she became aware of Resident #19's right shoulder pain, the MDS Coordinator stated he/she became aware on Monday 2/24/25. During a follow up interview on 2/26/25 at 2:10 PM, when asked if Resident #19's right shoulder pain should have been included in the care plan, the MDS Coordinator stated yes, it should have been included. Later in the day, Resident #19's care plan was updated to reflect his/her right shoulder pain. Review of the facility's policy LTC [Long Term Care]: Care Planning Policy, effective date 3/2/24 revealed: Purpose .To provide a multi-disciplinary approach to patient care demonstrated by a care plan that is generated, updated and followed by each discipline caring for any individual resident and to maximize communication between discipline members so that all team members are aware of, and supportive of, each discipline's resident goals and interventions .The Care Plan is to be considered a dynamic document. It is to [be] updated on a continual basis and is based on the assessed needs of the individual resident. The MDS RN-Coordinator is in charge of and responsible for completing, reevaluating and revision of the Resident Care Plan. The MDS RN-Coordinator reports directly to the Director of Nurses for all aspects of the care planning process and works very closely with the charge nurse when developing, evaluating and revising care plans .As indicated above the care plan is to be a dynamic document that is to be updated often. To that end, the MDS Coordinator or the Charge will update the Care Plan as necessary. The expectation is, that this care plan will become more refined overtime and, as a result, become more resident specific and more inclusive, as time goes on . When reviewing and updating the Plan of Care there are several areas to consider and assess the residents need relative to these areas they include but are not limited to the following: . the specific indication for which any PRN type medication is to be given.

Based on record review and interview, the facility failed to provide a program of meaningful activities for 1 resident (#44), out of 13 sampled residents based on an individualized assessment and care plan. This failed practice denied the resident opportunities that contributed to quality of life and placed the resident at risk for depression, loneliness, and boredom. Findings: Record review on 3/11-15/24 revealed Resident #44 was admitted to the facility with diagnoses that included pressure injury of the left heel, post-surgical left hip fracture repair, anxiety disorder, schizoaffective disorder bipolar type (a chronic mental health disorder that sometimes included episodes of mania and major depression), and moderate Alzheimer's dementia. During an interview on 3/11/24 at 5:03 PM, Resident #44 stated the activities in the facility did not appeal to him/her. The resident stated he/she preferred to listen to music, go to the store of his/her preference, and avoid large loud crowds. He/she further stated that his/her major interest was shooting. The resident also stated no one at the facility had discussed what he/she liked to do. During an interview on 3/14/24 at 9:34 AM, the Activity Coordinator (AC) stated a resident centered activities program for each newly admitted resident was developed from an initial activity assessment form. This assessment was normally completed within 1-2 weeks after admission. When asked if an activities program was developed for Resident #44, the AC stated it was not. When asked if activities that were offered to residents were documented, the AC stated they were not. The AC stated she kept all resident assessments on paper in her assessment folder. Review of the AC's activity assessment folder revealed a resident list titled: Daily Resident Attendance List .assessments we have [handwritten at the top of the page], not dated. Resident #44 was not included on this list. During an interview on 3/15/24 at 10:48 AM, the Long-Term Care (LTC) Administrator stated the AC determined residents' activity preferences in order to develop an activities program, then those preferences were included in the care plan. The LTC Administrator located one activity related to service dog visits on Resident #44's care plan. The LTC Administrator further stated that Resident #44 was to have an activities program created by the end of the day. The AC presented Resident #44's Activity Initial Assessment form, dated 3/15/24 at 2:14 PM, the last day of the survey. Review of the policy LTC: Activities Therapy Scope of Service, dated 3/2/24, revealed: Assessment .Complete Activity Initial Assessment upon admission .Assist with development of initial care plan. Reassess at any time when change in level of care .Assess each resident upon admission to ensure appropriate level of activities. Implement activities for each resident. Provide individual, group, and/or one on one in room activities.

Based on record review and interview, the facility failed to ensure 1 resident (#9), out of 13 sampled residents, received ordered restorative exercises. This failed practice placed the resident at risk of not maintaining or decreasing his/her highest level of range of motion and mobility. Findings: Record review on 3/11-15/24 revealed Resident #9 was admitted to the facility with diagnoses that included primary osteoarthritis (a degenerative joint and bone disease) of both knees, leg swelling bilateral, and weakness of both lower extremities. During an interview on 3/12/24 at 10:34 AM, Resident #9 stated he/she did not remember when the last time he/she had physical therapy. Review of Active Order, dated 2/9/24, revealed: Nursing Communication RA (Restorative Aide) Goal: To promote lower extremity circulation and maintain flexibility. Exercise: Ankle pumps 20, hip reduction 5R[right] 5L[left] . Priority: Routine. Review of Resident #9's Care plan' with start date on 3/22/21, revealed: .Problem: Impaired strength and mobility as evidenced by need for extensive assist with ADL cares. Goal: To maximize resident's own strength and mobility by end of the restorative program . Intervention . Document . [Resident #9's] participation in RA program . During an interview on 3/14/24 at 11:47 AM, when asked how he/she provided restorative exercises to the resident based on the order, the RA stated ankle pumps were the only exercise that popped-up in his/her documentation so he/she provided ankle pumps only. Review of the Restorative Aide Plan of Care, with a written note: verified [on] 1/9/23, revealed: .Exercises: 1. Ankle pumps x 20 . During an interview on 3/14/24 at 12:20 PM, when asked if there was a new restorative order for Resident #9 other than the order on 2/9/24, the RA stated the order on 2/9/24 was the current order but did not make it through smartphrase (a facility's electronic messaging). Interview and concurrent review on 3/14/24 at 3:36 PM, of RA's documentations in the electronic health record, revealed the RA provided ankle pumps only to Resident #9 since 2/9/24. When asked if another restorative aide had provided exercises to the resident, the RA stated no. This surveyor requested the RA to provide a copy of RA's documentation since 2/9/24 to 3/14/24. Review of the RA's documentation from 2/9/24-3/7/24, revealed: Goal: Maintain strength and mobility .Plan: supervise/assist .with the following three to six times per week .ROM [range of motion] active or active assist exercises performed by resident, with cueing, supervision, or physical assist by staff .Ankle pumps 20 . Further review of the document revealed the RA provided ankle pumps only on the following dates: 2/9/24, 2/12/24, 2/14/24, 2/15/24, 2/16/24, 2/19/24, 2/20/24, 2/22/24, 2/23/24, 2/26/24, 2/27/24, 2/29/24, 3/01/24, 3/4/24, 3/5/24, 3/6/24, 3/7/24. Hip reduction 5R[right] 5L[left] was not provided and no restorative exercises provided from 3/7-14/24. During an interview on 3/15/24 at 9:13 AM, the Administrator stated the facility had no policy regarding restorative exercises.

Based on observation, interview, and record review, the facility failed to post the total number and the actual hours worked by Certified Nurse Assistants (CNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs) per shift. This failed practice provided inaccurate information to the residents and their representatives. Findings: An observation on 3/15/24 at 9:20 AM, of the Direct staffing hours posted, dated 3/15/24, on the bulletin board along the hallway, revealed information which included the facility's census and the nursing staff (CNA, LPN, RN and other staff) scheduled for the day. Further review of the posting revealed the total number and actual work hours of nursing staff per shift was not documented. During an interview on 3/15/24 at 9:25 AM, when asked about the staffing hours poster, the Unit Clerk (UC) stated the total staffing hours of CNAs, LPNs, RNs and other staff were posted per day. The UC stated the total work hours per day was the same as actual work hours because the facility provided coverage as needed. The UC also stated she was not aware that the actual and total hours per shift was required to be posted. Review of the Daily Staffing Sheet provided by the UC from 3/11-14/24, the actual and total hours per shift were not documented.

Based on record review and interview, the facility failed to ensure residents were able to exercise their rights as residents of the facility. Specifically, the facility: 1) Failed to honor the resident's right to discontinue, or refuse continued, peri cares (the cleansing of a resident's genital/anal area) for 1 resident (#12), out of 11 sampled residents; and 2) Made it a stipulation for all residents, based on a census of 17, to be COVID-19 vaccinated as a requirement of admission to the facility. This failed practice violated the resident's right to: 1) stop a treatment or intervention, which resulted in psychosocial harm; and 2) choose to be immunized. Findings: The Right to Refuse and/or Discontinue Treatment Record review on 11/28/22 - 12/2/22 and 12/5/22 revealed Resident #12 was admitted to the facility with diagnoses that included Parkinson's disease and chronic pain. A review of Resident #12's most recent Annual MDS (Minimum Data Set - a federally required assessment), dated 9/19/22, revealed a BIMS (Brief Interview for Mental Status - to determine cognition) score of 15 (which indicated the resident was cognitively intact) and was able to understand others and make himself/herself understood with clear speech. Further review revealed Resident #12 required extensive assistance (2+ person physical assist) for toileting. Record review revealed that on 12/26/21, Licensed Nurse (LN) #4 and LN #5 entered Resident #12's room to perform peri cares due to the resident having a large bowel movement which had soiled the resident from the front of his/her genitals to the back anal region. During the course of the peri cares, as LN #4 held Resident #12's leg and while LN #5 performed the cleaning, Resident #12 requested that the LNs stop. Despite Resident #12's request, the LNs did not stop cares and continued to perform peri cares. An investigation into this incident was initiated due to Resident #12 becoming upset and told the LNs he/she did not want them to care to him/her again. Review of Resident #12's interview from the investigation, dated 12/26/21, revealed: [Resident #12] said the 2 nurses came to clean [him/her] up and they were rough with [him/her] and [he/she] got very upset with them and said, 'God Damn it - stop it.' [He/She] said 'they rubbed too hard' and when I told them they said, 'I have to clean it.' [Resident #12] said I begged them to not hurt me. [Resident #12] said [he/she] cried afterwards, and [LN #2] came to talk to me. Review of Resident #12's Nursing Note, dated 12/26/21 and written by LN #2, revealed: Informed by RN who was acting as a CNA that patient was upset and did not want RN in [his/her] room again. Writer spoke briefly with RN and found that the patient was upset because peri area cleaning after a BM [bowel movement] was painful. Writer spoke with the patient and got [his/her] account of what happened. [He/She] was very upset and tearful. [He/She] complained of rough wiping during a brief change that continued even after the [patient] requested they stop several times . Further review of the investigation revealed LN #6, who was assigned to Resident #12 on 12/26/21, stated Resident #12 was upset with LN #4 and LN #5 and continued to talk about the event throughout the remainder of the shift. During an interview on 12/1/22 at 4:37 PM, the Director of Nursing (DON) stated it was the expectation of every staff that when a resident says to stop cares, the staff should immediately stop. The DON agreed that LN #4 and LN #5 did not stop when Resident #12 prompted them to do so. The DON further stated Resident #12 did not like his/her leg lifted during cares. Also, Resident #12 did not like to be physically rolled in bed for cares and would rather roll himself/herself. During an interview on 12/2/22 at 10:38 AM, LN #2 stated that when he/she went to interview Resident #12, the resident was tearful and upset. When LN #2 stated that when he/she asked LN #5 why he/she did not stop cares when Resident #12 told staff to stop, LN #5 stated he/she was trying to complete the cleaning prior to stopping. LN #2 further stated Resident #12 had a bad history of sexual abuse and anything to do with peri cares was very upsetting to the resident. Review of Resident #12's care plan revealed the following identified problems: - Anxiety related to fear of people/groups as evidenced by staying in room, start date undated, and identified interventions: 1) Spend time with [Resident #12] and allow [him/her] to express thoughts and feelings. Be reassuring, start dated 4/26/21; and 2) Prepare [Resident #12] for care or appointments by notifying [him/her] prior, start date 4/26/21. - Incontinence related to decreased sensation as evidenced by [Resident #12] is unable to tell when [he/she] needs to use the bathroom, start date 4/26/21, and an identified intervention: Follow [Resident #12's] directions to how [he/she] wants to be specifically cleaned with peri-care, otherwise [he/she] will become upset. - Alteration in ADLs related to impaired mobility as evidenced by need for extensive assistance with ADLs, start date 7/3/22, and identified interventions: 1) Encourage [Resident #12] to participate in [his/her] own care as much as [he/she] is able . Toilet Use: Varies from Extensive to Total depending how much the resident participates. [He/She] requires 1-2 staff assist, start dated 7/3/22; 2) Encourage resident to assist with bed turning, start dated 7/3/22; and 3) Let [Resident #12] know what you are doing and when. Always be gentle with care. [He/She] has chronic pain with lower extremities and areas are sensitive to touch. If LE [lower extremity] lift too high or too quickly, [he/she] will become upset, start date 7/3/22. The Right to Refuse Immunizations Review of the facility's policy LTC [Long Term Care] Immunization Program for Residents of New Horizons, dated 5/24/22, revealed: COVID-19 Vaccine: Only COVID-19 vaccinated residents will be admitted to the New Horizon Long Term Care, refer to LTC COVID-19 policy. For extenuating circumstances such as comfort care admits the LTC interdisciplinary team will review the case. First vaccine must be administered prior to admission, new admit residents will agree to stay up to date on all future COVID-19 vaccines as per CDC guidance. Review of the Facility Assessment FY [fiscal year] 22 revealed: . Potential admissions must be up to date with COVID vaccinations, special situations that may not warrant COVID vaccines such as end of life care will be reviewed by the LTC Medical Director . During an interview on 12/5/22 at 12:55 PM, the Director of Nursing stated it was a requirement to be COVID-19 vaccinated to be admitted to the LTC facility, unless medically contraindicated. Review of the facility's policy LTC Patient Rights and Responsibilities Policy, dated 11/30/22, revealed: . It is the policy of PeaceHealth to define, recognize, protect and promote the rights and responsibilities of patients and their legal, authorized or designated representatives . We comply with applicable Federal civil rights laws and do not discriminate on the basis of . religion .Residents have the right to a dignified existence . Exercise rights without interference, coercion, discrimination, or reprisal . equal access to quality care . Right to self determination: Choice of activities, schedules, health care, care assessment and planning . personal and cultural preferences . request, refuse, and/or discontinue treatment or medication . .

Based on record review and interview, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility failed to ensure the facility's abuse and neglect policy included: 1) screening of potential employees; 2) training on prohibiting and preventing, as well as, recognizing signs/symptoms of all types of abuse, neglect, exploitation, and misappropriation; 3) prevention/prohibition of all types of abuse, neglect, exploitation, and misappropriation; and 4) identification of different types of abuse. These failed practices had the potential to place all residents (based on a census of 17) at risk for abuse, neglect, exploitation, and misappropriation of resident property. Findings: During an interview on 12/2/22 at 12:24 PM, the Director of Nursing stated that the only policy the facility had for abuse and neglect was the LTC [Long Term Care] Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy. Policy Review: 1) Screening Review of the facility's policy LTC Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy, dated 11/4/21, revealed: . Unit Responsibilities . Refrain from employing any individual who had been prohibited from working in a long term care facility because of failure to report a suspicion of a crime against a resident of a long term care facility . Further review of the facility's policy revealed no written procedure for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property, to include attempting to obtain information from previous and/or current employers and/or checking with the appropriate licensing boards and registries. Further review reveals no written procedure to screen prospective consultants, contractors, volunteers, and students. 2) Training Review of the facility's policy LTC Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy, dated 11/4/21, revealed: New employees will receive a thorough orientation through Human Resources, PHKMC [PeaceHealth Ketchikan Medical Center] Long Term Care, and clinically, by being assigned to work with experienced primary staff for a period of time determined using level of education, role, and previous experience. The PeachHealth Mission Statement, State Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act policy, and other policies and procedures on how to recognize signs of burnout, frustration, and stress that may lead to abuse will be presented and explained . Further review of the policy revealed no written policies or procedures that include training new and existing staff and in-service training for nurse aides to include: - Prohibiting and preventing all forms of abuse, neglect, exploitation, and misappropriation of resident property; - Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; - Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical and psychosocial factors; and - Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. 3) Prevention Review of the facility's policy LTC Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy, dated 11/4/21, revealed no written policies or procedures to prevent and prohibit all types of abuse, neglect, exploitation, and misappropriation of resident property. 4) Identification Review of the facility's policy LTC Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy, dated 11/4/21, revealed no written procedures to assist staff in identifying abuse, neglect, exploitation of residents, and misappropriation of resident property. Further review revealed no identification of the different types of abuse: 1) mental/verbal abuse; 2) sexual abuse; 3) physical abuse; and 4) deprivation by an individual of goods and services.

Based on observation, interview, and record review, the facility failed to ensure food was stored under proper sanitary conditions. This failed practice placed all residents (based on a census of 17) at risk for foodborne illness. Findings: An observation and interview in the kitchen on 11/28/22 at 2:42 PM, revealed 2 loaves of raisin bread and a package of ciabatta bread rolls found in the walk-in freezer were not dated. The Food Service Supervisor agreed the bread and rolls were not dated. Further observation revealed a box of frozen cod was opened and was not rewrapped. The box was undated. The Food Service Manager stated, I am not sure how long the cod has been here. Further interview and observation at 2:47 PM, revealed that a plastic tub, used to hold smaller items, had ice buildup. In the tub, resting on the ice buildup, were corn tortillas and potato wedges in plastic packaging. The Food Service Manager agreed that there was an ice buildup in the tub, and the tortillas and potato wedges should be removed. An observation and interview on 11/28/22 at 2:48 PM, in the dry storage area, revealed there were 3, 4-pound bags of spaghetti sauce in vacuum bags, undated, and 1 package of spinach tortilla wraps, undated, in a plastic wrapper. The Food Service Manager stated that the spaghetti sauce and tortilla wraps should have been dated with an expiration date. Review of the facility's policy Storage and Food and Supplies Procedure, effective 12/10/21, revealed: All goods are checked on a continuing bases for expiration dates.

Based on record review, interview and policy review, the facility failed to ensure Residents were free from abuse and neglect and failed to take actions to prevent further incidents for 2 Residents (#s 1 and 3) of 4 sampled residents. Specifically, Resident #1 experienced neglect when he was forced to stay up late at night past his preferred time of sleep for staff convenience; and Resident #3 experienced a potential for mental abuse, verbal abuse and/or neglect when a nurse did not allow the resident his right to refuse care, despite the resident's clear refusal. Findings: Resident #1 Record review from 11/24-26/13 revealed Resident #1 was an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Multiple Data Set (MDS- a federally required assessment tool) quarterly assessment dated [DATE] identified the Resident required extensive assistance from staff to transfer and needed a walker to ambulate, had no falls since admission, and was at risk for developing decubitus (bedsore from sitting or lying in one position for an extended time). The Resident's care plan dated 8/15/13 revealed interventions including: "Allow/encourage patient (resident #1) to make independent decisions...Watch resident for non-verbal cues of need to take a nap...Preferred hour of sleep: 2200 (10:00 pm)." During an interview on 11/24/13 at 8:45 pm, when asked if he/she had concerns about Resident #1, Licensed Nurse (LN) #1 disclosed multiple staff had expressed concerns that LN #16 made Resident #1 stay up so late the Resident would fall asleep while sitting in the Merry Walker (enclosed rolling walker with a seat). During an interview on 11/24/13 at 9:30 pm when asked if he/she had concerns that Resident #1 was being abused or neglected by staff, Certified Nursing Assistant (CNA) #1 disclosed LN #16 kept Resident #1 up late sitting and sleeping in his Merry Walker. During an interview on 11/25/13 at 4:30 am, when asked if he/she had concerns that Resident #1 was being abused or neglected by staff, CNA #2 disclosed he/she had concerns about Resident #1 because LN #16 would not allow the CNA staff put the Resident to bed until after 11:00 pm. The CNA staff would ask LN #16 if they could put the Resident to bed because he was sleeping, LN #16 would say "No, not yet." During an interview on 11/25/13 at 6:30 am when asked if he/she had any concerns that Resident #1 was being abused or neglected CNA #5 stated LN #16 would not let staff put him to bed. During an interview on 11/26/13 at 6:40 am, CNA #3 was asked if he/she had any concerns with abuse or neglect with Resident #1. CNA #3 stated, Yes, Resident #1 was being kept up late even when he was falling asleep. During the interviews CNAs #1, 2, 5, 6, 7, & 9 stated they had been called into the Director of Nursing (DON) office individually about a month ago to discuss this concern and other concerns about cares with LN #16. In addition, CNAs #6 and 7 stated that following the meetings with the DON, the LN's interactions had improved, however the changes only lasted for the week of the intervention. Resident #3 Record review on 11/24-26/13 revealed Resident #3 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the Resident received nutrition, fluids, and medications through a tube that was surgically placed in his stomach (gastric tube). The admission MDS assessment dated [DATE] indicated the Resident: had unclear speech; sometimes understood others; sometimes was able to express needs; required extensive assistance for bed mobility; and was totally dependent on staff for transferring, dressing, bathing, and eating. The Resident's November "Worker Flowsheet" revealed instructions including: "Give resident time to process questions and instructions before repeating. He needs extra time...Resident will communicate when he has reached his limit by saying "Enough" or "No more." Review of the Resident's most current medication order revealed he was prescribed [MEDICATION NAME] 1 mg per PEG tube b.i.d. (two times a day) prn (as needed) for anxiety. During an interview on 11/24/13 at 6:45 pm, when asked if he/she had any concerns or if any staff concerns had been reported of resident abuse or neglect toward Resident #3, LN #1 disclosed Resident #3 was agitated around certain staff, stating specifically LN #16. During an interview on 11/25/13 at 4:30 am, CNA #2 stated that over the last few weeks he/she had reported to the DON he/she had heard LN #16 tell Resident #3 to "Knock it off " when trying to give the Resident a tube feeding. The CNA also stated when staff were in the room helping Resident #3, LN #16 came into the Resident's room and tell the staff to leave the room while he/she gave the Resident his tube feeding. CNA #2 said the Resident frequently became angry with LN #16 and yelled at him/her. During an individual interview on 11/25/13 at 6:30 am, CNA #5 stated he/she heard LN #16 tell Resident #3 to "STOP IT." Review of the incident logs provided by the facility revealed no evidence either incident was reported to Administration or the State Agency. During a telephone interview on 11/30/13, CNA #9 stated on 11/16/13 at approximately 12:00 am, he/she was standing outside Resident #3's room while LN #16 was in the room giving the Resident some medication through his gastric tube. The CNA heard the Resident yelling, "Don't give me that, you're just trying to drug me!" LN #16 came out of room and stated to CNA #9, "He's mad." During the interview, CNA #9 stated although they had not reported the incident to the DON, they had reported the incident to a nurse on day shift. Further review of the incident logs provided by the facility, revealed the incident had not been recorded as reported or investigated. During an interview on 11/26/13 at 11:35 am, when asked if any allegations of abuse or neglect had been reported, the DON replied, there had been none. The DON then stated if there had been a report of abuse, he would investigate the concern(s) and write an investigative report only if, because of the investigation, a change needed to be implemented. During an interview on 11/26/13 at 12:30 pm, when asked if any of the staff's concerns had been reported to her, the Vice President (VP) of Patient Care Services replied, "No staff member had spoken to her and used the term abuse, and was she not aware of any investigations of abuse or neglect in the Long Term Care." During a second interview with the DON and VP of Patient Care Services on 11/26/13 at 1:25 pm, the DON stated he had conducted a group intervention with the night shift CNAs and LN #16 due to them "not getting along." The DON did not provide any evidence of the education or interventions conducted. Record review on 11/26/13 of the Risk Management report provided by the DON, dated from 9/1/13-11/16/13 revealed no abuse/neglect reports. Record review on 11/24-26/13 of the facility policy "Suspected Abuse and/or Neglect of Patient/Resident", last reviewed 3/4/2013 revealed definition for "Involuntary Seclusion - refers to separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will...Mental Abuse- refers to humiliation, harassment, threats of punishment or deprivation, malicious teasing, not reasonably considering a resident's wishes, unreasonably restricting contact with family, friends, or other residents, or ignoring residents' needs for verbal and emotional contact...Neglect-refers to failure to provide goods and services necessary to avoid physical harm, or mental illness...Physical Abuse- refers to hitting, slapping, pinching, kicking, controlling behavior through corporal punishment, physical contact intentionally or through carelessness that results in or is likely to result in death, physical injury, pain or psychological harm to the resident, the use of any restraints, involuntary seclusion, or isolation of resident as a method of punishment, the use of any restraint in an unreasonable manner, such as tying the hand or legs together, the use of physical restraints for a prolonged period of time and/or acts of physical retaliation, even in response to a physical attack, constitute abuse." Record review on 11/24-26/13 of the facility policy "Reporting and Investigating Suspected Abuse/Neglect of Patient and/or Resident", dated 4/1/2007, last review 3/4/2013 revealed the scope of the policy was for the Long Term Care Unit caregivers, the procedure for reporting suspected abuse and/or neglect included...1) Individual reporting suspected abuse and/or neglect ... included immediately report suspicions to the LTCU Manager, Social Worker and/or Nursing Supervisor (1st Responder)...Immediately begin an Investigation Report form, filling our initial information, deliver form to 1st responder...2) 1st Responder (LTC Unit Manager, Social Worker or Nursing Supervisor) ...Determine immediately if the patient is in in any danger of harm or further abuse, if so, make provisions for the safety and well-being of the patient ...Interview staff members as soon as possible, documenting the interview or instructing staff persons to write down their recollection of events...Document initial findings on Investigation Report form and fax immediately to Health Facilities Licensing and Certification (HFL&C) per instructions on form ...Notify concerned persons (physician, family, guardian, and Administrator) of initial findings...3) Long Term Care Manager of Designee...review initial information...assuring initial reports have been made to the appropriate agencies...Conduct further investigation of suspected abuse and/or neglect as necessary ...Document the review and investigation...Report all cases of abuse and/or neglect to the appropriate authorities in accordance with Alaska statutes..." .

1. Based on observation, interview, and record review the Facility failed to ensure that the Facility operated in a safe and sanitary manner and failed to ensure potentially hazardous food from the Facility's kitchen were stored and prepared in a manner to prevent the risk of food borne illness in a vulnerable population. All residents who received food (based on a census of 22) from the kitchen were at immediate risk for serious harm or death and constituted immediate jeopardy to the residents' health and well-being. This situation was brought to the attention of the Facility's administration on 7/8/13 at 4:00 pm. On 7/8/13 at 7:07 pm, it was determined that the immediacy of the jeopardy had been abated through the Facility's implementation of an initial plan of action. Findings of issues that constituted Immediate Jeopardy: A black substance, identified as "mold" by the Dietary Manager (DM), was around the sink where seafood was being rinsed and drained; Potentially hazardous foods had been thawed in the same bin in the refrigerator and out dated for use; The sanitation solution was sitting in a sink which was being used to clean food service counters had turned a blackish color and had a large amount of food debrie floating around in it; Multiple dishes and utensils had been stored in drawers and on counters with standing water present in the bowl/scoops of the items, and dried food on utensils that were in the drawers ready for use; Previously used deep fry oil was stored in 2 - 5 gallon containers near the stove and adjacent to an egress from the kitchen should a fire occur; and Multiple kitchen surfaces and floors were covered with a layer of grease, food grime, and dirt. Potential Contamination of Fish Observations in the Facility's kitchen on 7/8/13 between 1:35 pm - 3:25 pm revealed a black substance in the grout around the "chefs" sink, in the dirty dish counter (adjacent to the dishwasher), and on the wall above the 3 compartment sink. When asked what the black substance was the DM responded, "its just mold". At 3:30 pm, a colander of fish fillets was observed sitting in a colander inside the chefs sink directly under the identified "mold". Meat storage Observation on 7/8/13 between 1:35 pm - 3:25 pm of the walk-in refrigerator revealed a plastic tote contained a thawing turkey breast and a ham roast together. The plastic tote had sticker with a removal date of 7/1/13. During an interview on 7/8/13 at 3:25 pm, the DM confirmed the meats should not have been thawed together and were past the expiration date. The DM then tossed the meat away. Sanitation solution Observation on 7/8/13 between 1:35 pm - 3:25 pm revealed a plastic bucket, used for the sanitizing solution and the wiping cloths for cleaning the counters, sitting in a food preparation sink. The solution in the bucket had turned a blackish color and had a large amount of food debrie floating around in it. During an interview on 7/8/13 at 1:45 pm, Kitchen Staff (KS) #5 confirmed staff used the wiping cloths in the bucket to clean the kitchen counters. During a second observation, a different bucket containing sanitizing solution, was observed sitting in the sink where food was prepared. The DM confirmed the bucket should not have been in there. Dishes Observation on 7/8/13 between 1:35 pm and 3:25 pm revealed a clean blender sitting with water in the bottom of the bowl. Multiple utensils, measuring, cups, and spoons were stored on shelves and in drawers, which contained water in the bowl of the items. During an interview on 7/8/13 between 1:35 pm and 3:25 pm, the DM confirmed the items should not have been put away wet or soiled. Hazardous waste storage Observation on 7/8/13 at 3:15 pm revealed 2 5-gallon buckets of previously used cooking oil stored under the sink adjacent to the stove and the deep fat fryer and adjacent to the egress from the kitchen. During an interview on 7/8/13 at 3:05 pm, the DM confirmed the oil had been stored there at least 3 weeks and stated it should not have been stored in the kitchen. Cleanliness of kitchen Further observations during the kitchen tour on 7/8/13 between 1:35 pm - 3:25 pm, revealed grime and dust buildup on nearly all horizontal surfaces in the kitchen except for the counter were the food was prepared. In addition, the tile floor, the edge of the tile cove base, and floor corners were visibly dirty with a thick layer of grease and grime that extended away from the wall several inches. 2. Based on observations, interviews, and record review, in addition to the findings constituting the immediate jeopardy, the facility failed to ensure: 1) a clean and sanitary environment; 2) items that were stored as clean were clean and free of water and debris; 3) thawing meats were dated and removed when outdated; 4) expired foods were from the cooking areas; 5) food was refrigerated after opening; 6) open foods were properly labeled. All residents who received food from the kitchen were at risk for food borne illness. Findings: Clean and sanitary Ceiling tiles and intake fan on the clean side of the dishwasher were covered in thick dust; All floor drains under the sinks had thick grime around the frame of the drain and in the cup of the drains; Walk-in freezer had ice build up on the fan unit and had ice build up on the shelving below the fan; Multiple storage racks had debris and fluid rings being used to store clean dishes, pans and pots; 2 large colanders, stored on a clean shelf, appeared rusty brown and had pitting corrosion; Multiple stainless steel cooking trays appeared to have grime on the inner edges; 2 trays of clean dishes on the right side (clean side) of the dishwashing counter had food particles present; Multiple spice containers, stored on a shelf below cooking utensils had a thick grime, and the cooking utensils were in contact with those spice containers; Multiple ovens, large cooking equipment was covered with fluid stains, and grime mixed with dust; Clean cooking utensils that were hanging from a rack were touching the cooking spice containers that were covered in grime; A dirty label maker that had a clean utensils placed in front of it was hanging on the clean storage rack for cooking utinsils; Walls in the dish room had dried food splatter and grime throughout. Dirty utensils and equipment stored on counters stored in drawers Egg slicer in clean utensil bin with dried egg on the inside of slicer; Dried food on clean storage trays; 1 mixer with red colored dried stain on the base under the bowl; Meat slicer with layer of dust; Manual can opener with dirty tip; Knifes in storage rack with food on blades; 2 knife sharpeners in rack with rust or food present on blade; Knife and potato peeler in drawer of prep counter in a bag, both dirty; White hard plastic spoon with scratches and discolored; Multiple drawers with cooking utensils had crumbs in them; and Floors dirty with papers, dust and debris. Undated meats 1 tote with 2 bags of thawed chicken without a date, the Dietary Manager stated they were pulled yesterday; 1 tote of thawed chicken with a pull date of 6/28; 1 tote of pre-cooked chicken for the salad bar without a date; 1 tote of thawed pork with a pull date of 7/1; and Expired foods stored on shelves 1 bottle Worcestershire sauce, expired dated 1/13; 1 bottle vinegar (best used by date 10/14/12); 1 opened oriental noodles dated 7/1/13 (toss date 7/8/13); 1 opened bag of vanilla wafers dated 7/1/13 (toss date 7/8/13); and 1 bottle Karo syrup (best use by date 4/1/13). Refrigeration after opening These items were not refrigerated. 1 quart jar of Kiokkmans soy sauce; 2 1 gallon containers of soy sauce; 1 bottle Hershey syrup; 1 bottle Strawberry syrup; 2 containers of cake frosting; and 1 bottle of hickory smoke liquid. Opened food items without dates and/or labels 1 can Ben a Protein; 2 cans thick and easy; 1 bin flour; 1 bin rice; 1 bin legumes; 1 bin sugar; 1 bag cornmeal; 1 spritzer bottle, the staff stated was oil; 1 baggie of wheat bran, no date; and 1 bag marshmallows. Dry storage crumbs present on floor and shelves; paper debris and dirt on floor; broken box of bread crumbs; and floors dirty with papers, dust and debris. Kitchen freezer Multiple open unlabeled bags of vegetables and fruits; and Multiple undated cups of pre-made Nepro (a nutritional supplement ) shakes in the freezer. Kitchen refrigerator Multiple, greater than 12 small cups of power pudding without dates or labels. Documentation Review Record review on 7/8/13 at 3:05 pm of the "Cleaning Schedule & Documentation" log provided by the DM revealed the schedule for cleaning specific areas either weekly, bi- monthly, or monthly. For the month of July there was no documentation of cleaning. Further review of the cleaning schedule from April through June 2013 revealed the last documented dates of cleaning of the following areas were: Kitchen drawers 6/4/13; Kitchen walls 6/5/13; Tray line shelves 6/26/13; Catering shelves, no documented dates for April, May, June, or July; Kitchen floor drains, 6/7/13; Walk-in freezer, 5/30/13; Pot and pan rack, 6/12/13; Dish storage racks, 6/19/13; Dry storage floors and shelves 6/4/13; Dish sinks 5/7/13; Dish machine, no documented dates for April, May, June, or July; Dish room walls 4/11/13; Dish room baseboards, no documented dates for April, May, June, or July; Delime dish machine monthly, 5/17/13; Dish machine curtains, no documented dates for April, May, June, or July; Cooler floors, 6/4/13; Polish stove hood 5/26/13; Beneath oven and grill sides 6/5/13; Beneath chef freezer and cooler 6/5/13; Holding ovens 5/18/13; Cooks station 6/5/13; and Knife holders 6/5/13. During the tour of the kitchen areas with the DM on 7/8/13 at 3:15 pm, the DM was asked if the Infection Preventionist made rounds in the kitchen he stated yes, but not very often. He also stated he did not report to the Infection Prevention and Control committee or to the Quality Assurance Committee and did not keep a sanitation log to reflect appropriate ph testing upon mixing or at intervals throughout the day. Review on 7/12/13 of the facility food services policy "Cleaning" dated 9/12/13, revealed "Clean all kitchen equipment on a regular schedule." Review on 7/12/13 of the food services policy "Food Handling" dated 4/12/13, revealed "Dish and utensil cleaning and sanitizing areas shall be separated from the preparation area." Review on 7/12/13 of the food services policy "Food Handling" dated 4/12/13, revealed "All food is covered or wrapped, labeled, and dated in storage." Review on 7/12/13 of the facility food services policy "Cleaning" dated 9/12/12, revealed "Buckets of sanitizer will be placed in each work area daily and will be changed as need (solution becomes cloudy, visibly dirty or falls below 150ppm with QT-40 test strips)." According to the "U.S. Public Health Service Food Code" dated 2009, revealed: 3-305.11 Food storage "Food shall be protected from contamination by storing the food (2) where it is not exposed to splash, dust, or other contaminations." 3-302.11 Mixing meat together "Food shall be protected from cross contamination... (2) Except when combining as ingredients, separation types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: (a) using separate equipment for each type (b) arranging each type of food in equipment so cross contamination of one type with another is prevented..." 3-201.11 Food labeling "Except for containers holding food that can be readily and unmistakable recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment... shall be identified with the common name of the food." Food Dating 3-501.17 Ready-to-Eat Potentially Hazardous Food (Time/Temperature Control for Safety Food) date Marking: "Except when packaging food using a reduced oxygen packaging method as specified ....refrigerated, ready to eat, potentially hazardous food ...prepared and help in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of (41oF) or less for a maximum of 7 days." 4-601.11 Food Contact Surfaces "Equipment Food-Contact Surfaces, nonfood Surfaces, and Utensils. (a) Equipments food-contact surfaces and utensils shall be clean to sight and touch. (b) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (c) Nonfood-contact surfaces or equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris." 4-901.00 Equipment and utensils, Air-drying required: "After cleaning and sanitizing, equipment and utensils: (a) shall be air-dried or used after adequate draining ..." .

1) Based on observations, record review, and interview, the facility failed to ensure a safe environment free from accident's and hazards. This failed practice specifically jeopardized the health and safety of 3 residents (#s 3, 6 & 7) of 9 sampled residents and had the potential to affect the health and safety of all mentally compromised residents capable of independent ambulation through walking; or through the use of self propelled wheel chairs and walkers. The failed practice constituted an Immediate Jeopardy situation to the health and safety the facility's residents. The Immediate Jeopardy was abated on 7/8/13 at 5:10 pm. 2) Based on observations, interview, and record review, the facility failed to ensure staff used heated gel packs according to the manufacturers directions, which placed all residents at risk for harm and potentially death resulting from burns. (Based on a census of 22) This failed practice constituted an Immediate Jeopardy situation. The Immediate Jeopardy was abated on 7/10/13 at 8:30 am. 3) Based on observations and interview the facility failed to ensure equipment was stored and maintained to prevent residents from potential harm. (Based on a census of 22). As a result, residents were placed at risk of harm from an unsecured oxygen tank and a jetted tub with a sharp edge. Findings; Immediate Jeopardy #1 Observation in the kitchen on the Long Term Care (LTC) unit on 7/8/13 at 4:45 pm, revealed knives in an unlocked drawer closest to the stove: 1 - 12" serrated knife; 1 - 10" butcher knife; 1 - 10" butcher knife; 2 - 7" serrated steak knives; and 1 - 4" paring knife. In an unlocked drawer next to the kitchen dish sink revealed: 1 - 12" butcher knife; and 1 - 4" paring knife. All the knives were readily accessible to anyone who would enter the LTC kitchen area. In addition, it was also noted the LTC kitchen's stove used for cooking which was operational, had burner control knobs which were readily accessible and located on the front of the stove at waist level. Medical record review during the 7/8-12/13 survey revealed Resident #3 diagnosed with [REDACTED].#6 diagnosed with [REDACTED].#7 diagnosed with [REDACTED]. Review of these residents' current care plans revealed Resident #3 had a care plan that said "...pt (Patient) can propel herself in the W/C (wheelchair)." Resident #6 care plan identified the Resident as ambulatory and having periods of delirium, agitation, and hallucinations. Resident #7 was care planned to independently use a Merry Walker (4-wheeled walker with a seat). Random observations from 7/8-12/13 of Resident #s 6 & 7 revealed both residents were unattended and found in the LTC kitchen area on multiple occasions. On 7/8/13 at 1:30 pm, Resident #6 was standing in front of the LTC kitchen stove. When the surveyors introduced themselves, the Resident told the surveyors she worked at the facility as a cook. Initially, when the surveyors first met the Resident, she was alone, unattended in the LTC kitchen area. Resident #7 was also sitting nearby in a Merry Walker unsupervised. Immediate Jeopardy #2 Observations on 7/10/13 at 5:30 am in the residents' tub room revealed a blanket warmer that had 3 gel packs lying in the bottom of the unit. The blanket warmer's temperature gauge read 162 degrees. The surveyor picked one of the gel packs up and attempted to hold it in her hands. The gel pack was too hot to hold even after being out of the warmer for 5 minutes. During an interview on 7/10/13 at 5:35 am, Certified Nursing Assistant (CNA) #2 was asked about how she used gel packs. She stated the nurse would tell her when to put one on a resident. She said she would wrap a gel pack in a towel; put the towel in a pillowcase; and then put it on the resident. When asked how she would know if the gel pack was too hot, she replied that she would put it next to her wrist. In addition, she said she did not know the temperature of the gel packs prior to putting them on residents. During an interview on 7/10/13 at 6:15 am, CNA #1 was asked about how she used gel packs. She said she would take one out of the blanket warmer and put it in a pillowcase. She further said if the gel pack had cooled down, she specifically emphasized she would put the gel pack in the microwave for 1 minute and 30 seconds. During an interview on 7/10/13 at 5:55 am, CNA #9 was asked about how to prep the gel packs before use. CNA #9 said a gel pack would be removed from the blanket warmer and wrapped in a pillowcase or just applied directly to the intended resident's area of discomfort. When asked how it was determined the gel pack was not too hot, CNA #9 said it was placed against the forearm. When asked what temperature would be considered too hot, the CNA did not know. When asked if training had ever been provided concerning the use of the gel packs, the CNA said, "No". During an interview on 7/10/13 at 6:40 am, LN #1 was asked about the usage of gel packs. LN #1 said Resident #2 used gel packs for abdomen pain, and in fact, he put a "hot" gel pack on her abdomen last night; after he wrapped it in a towel and checked the temperature against his forearm. He was asked and confirmed the temperature of the hot gel packs were not checked prior to being used on residents. He said he has told staff not to microwave gel packs, but to throw them away. During an interview on 7/10/13 at 8:10 am, the Long Term Care Manager said the staff used the microwave to heat gel packs when they needed a warm pack right away and there was not one in the blanket warmer. When asked if the facility had a process for heating the gel packs in the microwave the manager disclosed they did not have a written process specifically for the gel packs, that the CNAs were to ensure the gel packs were not too hot by holding them up against their wrists. Review of the manufacturers instructions located on the back of the gel packs, revealed the packs were to be heated in a 750 watt microwave for 55 seconds with the option to extend the heating time to a maximum of 65 seconds. The instructions then said to wrap the gel pack in a towel before use. Inspection of the facility's 2 microwaves, used to warm the gel packs, revealed they were 1000 watt microwaves. When the surveyor placed an unused gel pack into the 1000 watt microwave for 55 seconds and then placed it directly on her forearm for 3 minutes it left a dark red area on her skin that remained visible for 30 minutes. In addition, a gel pack was removed from the blanket warmer and after 10 minutes was wrapped in a pillowcase and was placed behind a surveyor's back on the outer layers of her clothes. Within 2 minutes the surveyor removed the gel packs because it felt too hot. In Summary 1) Review of the manufacturers instructions revealed the facility failed to follow the instructions for heating and using gel packs on an older population of residents with compromised skin integrity; 2) review of the facility's current Roster Matrix revealed there were 20 residents with moderate/severe pain who could potentially use the gel packs for relief; that the facility did not have a safe process for heating the gel packs; 3) the staff were not trained specifically on how to use the gel packs; and 4) the staff were inconsistent in their individual preparations of the gel packs. These failed practices resulted in an Immediate Jeopardy to the health and safety of the facility's resident population. Review of the facility's policy and procedures revealed the facility did not have a policy that addressed the use of the gel packs. "Heating Devices: How to Avoid Burns By Joan Ferlo Todd, RN, BSN Nurse-ConsultantFood and Drug Administration Center for Devices and Radiological Health, Rockville, Md. Orginially Published:1/10/1997 A patient with arthritis suffered a second-degree burn to the hip after receiving treatment with a heating pad for pain. Set at low, the heating pad was left on for less than 20 minutes with the patient lying on top of the pad. Later testing showed that the pad was working properly and met the manufacturer's specifications. What went wrong? Therapeutic heating devices, such as heating pads, microwavable hot packs, and hot-water bottles, although generally safe, can cause bums. Most burns result from improper use or use with inappropriate patients, such as infants and elderly patients. The severity of the burn is influenced by factors such as heat intensity, length of application, and the patient's age, medical history, and ability to sense pain. What precautions can you take? Follow these do's and don'ts to keep your patient safe when using heating devices: DO inspect the device before each use to ensure it's in proper condition. DO read directions and contraindications for use. DO use a protective cover. DO place the pad or pack on top of, not underneath, the patient. DO assess skin integrity frequently and adjust the therapy interval according to the patient's skin tolerance-no longer than 15 to 20 minutes. DON'T use the device on someone who's sleeping or unconscious, an infant, or a patient with altered mental status or decreased skin sensation (such as people with diabetes or compromised skin circulation). DON'T use pins to fasten the device in place. DON'T use with ointments or salve preparations containing heat-producing ingredients. DON'T use electrical heating devices in an oxygen-enriched environment or near oxygen-emitting equipment." Miscellaneous Accident Potentials Arjo Tub An observation during the initial facility tour on 7/8/13 at 1:35 pm of the Resident's tub room revealed 1 dime size chipped area in the bottom of the Residents' Arjo tub. The chipped area had a raised edge that could be felt when rubbing your hand along the tub's surface. During an observations on 7/10 at 5:46 am revealed an unsecured portable oxygen tank hanging off the side of the oxygen tank storage rack. During an interview with the Long Term Care Manager at 11:00 am, he confirmed the oxygen tanks were suppose to be stored in the rack not hanging off the outside of the rack. .