Every finding on record at Polaris Extended Care

.Based on record review and interview, the facility failed to ensure the transfer or discharge of 1 resident (#1), out of 4 residents reviewed for transfer and discharge requirements, met the requirements of 42 CFR S483.15(c). Specifically, after determining Resident #1 would not return to the facility following hospitalization, the facility failed to establish and document the basis for the discharge, identify the specific resident needs the facility could not meet, document the facility's attempts to meet those needs, and identify the services available at the receiving facility to meet the resident's needs. This deficient practice placed the resident at risk of inappropriate discharge and disruption in continuity of care necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being Findings:.Record review on 6/11/26 revealed Resident #1 was admitted to the facility with diagnoses that included pneumonia (an infection that inflames air sacs in one or both of the lungs) due to methicillin resistant staphylococcus aureus (MRSA - a type of antibiotic resistant bacteria), chronic obstructive pulmonary disease and acute and chronic respiratory failure with hypoxia (low level of oxygen in the body tissues). Review of the Physician Order, dated 4/30/26, revealed: Psychiatry: May see psychiatry prn [as needed] for psychiatric related issues. Status: Active. Review of Resident #1's ADVANCE DIRECTIVE ACKNOWLEDGMENT FORM, signed on 5/4/26, revealed the resident had no advance directive and no durable power of attorney for medical decisions. Review of Social Service Summary, dated 5/6/26, revealed: .BIMS [Brief Interview of Mental Status] is 14 indicating [Resident #1] is cognitively intact. Review of facility's N [Nursing] ADV[Advance] Skilled Evaluation, dated 5/20/26, revealed: .Mood and Behavior.Resident is currently experiencing unwanted behavior(s). Delusions: Chronic. Resists care: Chronic. Mood and Behavior Note: Resident verbally abusive when not getting what he/she wants and when staff follow rules. Review of Nurses Progress Notes, dated 5/21/26 at 3:16 PM, revealed: Social Worker. and PT [Physical therapist] . were present in resident's room talking about his/her transfer to PTC [Polaris Transitional Care]. This writer [nursing staff] walked up to the room in time to hear him/her telling them that he/she has 'shot someone before & [and] when they popped back up, he/she shot them 5 more times'. I walked away at that point with the ADON [Assistant Director of Nursing] to start his/her send out to the ED [Emergency Department]. Review of the Social Services Notes, dated 5/21/26 at 3:30 PM, revealed: .Resident [#1] reported severe pain, stating pain level 'over 20'. Nursing staff offered PRN [as needed] pain medication.resident refused.During [the] discussion about increasing therapy participation, resident expressed interest in 'doing more therapy.' As an accommodation [sic], I offered the option of relocating to a room closer to the therapy area to support his/her goal. Resident initially appeared agreeable; however, after a room was identified, resident became visibly irritated and escalated verbally. Resident stated: 'You're an idiot if you think I am doing this on your terms and your time.' 'You can't corner me like my mom did.' Staff reassure[d] resident that relocation was optional and intended to support his/her stated goals. Resident became increasingly agitated and made verbal threats, stating: 'I will kill you, you're lucky,' (repeated twice) . Resident also made suicidal statements, indicating to act on his/her own terms. Resident #1's Transfer to emergency room Review of the Nurse Practitioner (NP) #1's Order, dated 5/21/26 at 3:43 PM, revealed: Send to ER [Emergency Room] for evaluation and treatment for suicidal ideation/homicidal ideations (plan verbalized) and uncontrolled pain (20/10). During an interview on 6/11/26 at 1:04 PM, NP #1 stated the Director of Nursing (DON) called her about Resident #1's threats to harm himself/herself, and to other people. NP #1 further stated she came to see the resident before the decision was made to transfer Resident #1 to the emergency room. During the same interview, NP #1 stated Resident #1 was aggressive, and she felt there was an emergency need for psychiatric evaluation. When asked if the facility can take care of Resident #1's behavior, she answered: no way. The NP stated in her experience, people can be alert and oriented with silly psychotic at the same time and do things because their brain just gets to be way over overwhelmed. Review of IDT (interdisciplinary) Notes, dated 5/21/26 at 4:30 PM, revealed: IDT consisting of Assistant Administrator [AA], DON, ADON, and Social Services convened [the] following notification that resident verbalized uncontrolled pain rate '20/10,' along with statements indicating suicidal and homicidal ideation. Based on presentation and reported symptoms, the team determined that resident's current care needs exceeded the facility's capability to provide safe and appropriate management.ARNP [Advanced Registered Nurse Practitioner] was consulted and concurred with recommendation for transfer to a higher level of care, order obtained to transfer resident to the emergency department for further evaluation and management. Further review of the IDT notes revealed chart review was conducted by the Long Term Care (LTC). The review identified that personality, delusional and mood disorders were not disclosed at the time of admission on [DATE] from PAMC (Providence Alaska Medical Center). Transfer Notice Provided to Resident #1 Before the Emergency Visit Review of Nurses Progress Notes, dated 5/21/26 at 4:44 PM, revealed: . Resident declined to sign transfer notice and declined bed hold.Resident transferred to Providence ER [Emergency Room] at 1614 [4:14 PM] via EMS [Emergency Medical Service]. Review of the NOTICE OF PROPOSED TRANSFER/DISCHARGE, dated 5/21/26, revealed the facility provided the residents with a notice of transfer/discharge. The reasons for transfer/discharge were: .2) The transfer/discharge is necessary for your welfare and your needs cannot be met in the facility (a) the specific needs that cannot be met are care, behavior/safety, uncontrolled pain.3) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident (a) Reasons the safety of others in the Facility are endangered include: Resident threats to kill staff. Further review revealed Resident #1 declined to sign the notice on 5/21/26. Resident Not Accepted Back to Return to LTC After emergency room Visit During an interview on 6/11/26 at 12:16 PM, the Social Services Director (SSD) stated on 5/21/26, two hours after Resident #1 was transferred, that the hospital called her asking why the resident was not accepted back to the facility. The SSD explained that the Resident was unsafe to himself/herself and others. The SSD stated she documented the conversation with the hospital's mental health specialist (MHS) on the chart on 5/22/26. Review of the SSD's notes, dated 5/22/26, revealed: Spoke with. (Mental Health Specialist Providence) regarding concerns about [Resident #1] and Providence's inquiry about. [Resident #1's] discharge and potential return. [MHS] asked why [Resident #1] is not being accepted back to the facility. I explained that [Resident #1] is currently unsafe to himself/herself and others based on recent observed behaviors and direct statements. Specifically, he/she verbalized suicidal ideation, stating he/she intended to shoot himself/herself. He/she also made direct threats to staff.The facility has an obligation to ensure a safe environment for all residents and staff and to prevent abuse, neglect, or foreseeable harm. [Resident #1's] explicit threats toward staff and statements of self-harm represent credible safety risks requiring immediate intervention and exceed[ed] what can be safely managed within this setting. Retaining a resident whose needs cannot be met safely places the facility at risk of noncompliance with federal requirements related to resident safety, supervision, and quality of care. Further review of the SSD's notes revealed: Accurate and complete information at the time of admission is necessary to determine appropriate placement and develop an effective care plan. The absence of clearly communicated behavioral health history and the lack of alignment with PASRR [Pre-admission Screening and Resident Review] related screening raises concern regarding the adequacy of pre-admission evaluation and the appropriateness of placement in a non-psychiatric facility. Additionally, when a resident exhibits acute psychiatric instability, including threats of harm to self or others, transfer to a higher level of care for evaluation and stabilization is consistent with standards of care and federal expectations regarding appropriate placement and access to necessary medical and psychiatric services . Review of Resident #1's hospital medical record, dated 5/21/26, revealed Resident #1 was admitted on [DATE] in the emergency department [ED] with a chief complaint of suicidal thoughts. Review of the hospital's Care Management Initial Assessment notes, dated 5/22/26, revealed: Social work [SW #1] was consulted to see if pt [patient] can return to Polaris SNF [Skilled Nursing Facility] rather than being admitted to hospital. Per chart review, psych[psychiatric] ED clinician was initially consulted, who had cleared pt and had reached out to Polaris, which as of yesterday [5/21/26] declined to accept pt back. Pt was advised that LCSW [Licensed Clinical Social Worker] is working on trying to see if he can be discharged back to Polaris, though if this is not possible he/she will need to be admitted so care team can work on an alternative discharge plan. Message sent to psych clinician. [name of clinician], whose note from 5/21[/26] indicates pt needs further assessment, to confirm when pt will be cleared so social work can either call SNF to see if pt can return, possibly under a behavioural[sic] contract or needs to be admitted pending alternative placement. Per discussion with attending, it was clarified that pt has been cleared by psych and LCSW will now call Polaris to discuss this and if pt can return to its facility. Further review of the SW notes revealed: LCSW called Polaris and spoke with . [name of the head of nursing], who reported that pt has had an ongoing issue with behaviours[sic] at its SNF and as a result is not seeking to accept pt back. Social work asked if a 30[-]day notice had been given, however, per later discussion with leadership, this may not be needed for this facility. She states pt has had 'multiple incidents of SI[suicidal ideation]/HI [homicidal ideation]' and may have untreated borderline personality disorder, which is 'hard' on its staff. She is concerned that, were pt to be discharged , his/her behaviours[sic] would increase and he/she would 'boomerang' back to hospital. She acknowledged pt's concern for pain, which had initially been uncontrolled as he/she had been discharged to Polaris without this[sic] medications. She will discuss pt's case with other staff and will follow up with LCSW. The SW #1 notes also revealed: LCSW received call from .[name of social services director] and [name of assistant administrator (AA)] at Polaris.AA confirmed that facility is not prepared to accept pt back, indicating concern for possible undiagnosed bipolar disorder and would benefit mental health treatment for this. She was advised that psych ED clinician had ruled this out as a diagnosis. She also expressed concern that the PASS-R sent to Polaris prior to discharge had not identified pt's behavioural[sic] issues. Attending was advised of outcome of social work's conversation and will reach out to request that pt be admitted . During an interview on 6/11/26 at 12:16 PM, the SSD stated she was expecting the hospital to call her for an updated PASSR, but she did not hear anything from the hospital since their last conversation on 5/21/26. Record review on 6/11/26, revealed there was no other documented communication between the LTC and the hospital aside from the SSD notes on 5/22/26. During an interview on 6/12/26 at 12:56 PM, the Administrator stated the facility transferred Resident #1 to the hospital because staff believed the resident required a psychiatric evaluation and treatment beyond the facility's capabilities. The Administrator stated the facility attempted to obtain mental health services before the hospitalization and believed important information regarding the resident's psychiatric history had not been disclosed before admission. The Administrator stated that after the hospital informed the facility the resident had been evaluated and was ready for discharge, the facility did not believe it was safe for the resident to return because staff continued to have concerns regarding the resident's behaviors. The Administrator further stated the admission PASSR had not been completed correctly, diagnoses had been omitted, and the omitted information could have resulted in a Level II PASSR evaluation. The Administrator acknowledged the facility recognized significant psychiatric concerns as the resident's stay progressed but did not identify any attempt by the facility to complete a corrected PASSR screening or request a Level II PASSR evaluation after those concerns were identified. When asked about communication with the hospital after the facility declined to readmit Resident #1, the Administrator stated the facility did not follow up with the hospital and acknowledged communication between the facility and hospital essentially ceased. The Administrator stated she did not know why the facility failed to reestablish communication regarding the resident's disposition. Lack of Discharge Notice From LTC After Resident #1's emergency room Visit Record review on 6/11/26 revealed there was no documented second discharge notice provided to Resident #1 after the facility determined that the resident could not return to the facility due to facility's inability to manage Resident #1's aggressive behavior. During an interview on 6/11/26 at 3:43 PM, the Quality Director (QD) stated the facility issued a transfer notice before Resident #1's emergency room visit and that the LTC would not issue another discharge notice when the facility determined the resident could not return to the LTC after hospitalization. During a joint interview on 6/11/26 at 4:11 PM with the ADON and the QD, the ADON stated the transfer/discharge was initiated by the facility because they couldn't manage Resident #1's pain, suicidal ideation and aggressive behavior. The ADON stated the facility had no other transfer/discharge notice provided to the resident aside from the notice the facility had provided before the resident transferred to the hospital on 5/21/26. Review of the facility's Discharge or Transfer policy, dated 11/2019, revealed: It is the policy of this facility to provide the Resident with a safe organized structured transfer or discharge from the facility to include but not limited to hospital, another healthcare facility or home that will meet their highest practical level of medical, physical, and psychosocial well being. A transfer and or discharge shall be considered for the following reasons as regulated by Federal, State and other Regulatory Agencies .1. Transfer/discharge: Emergency, and 2. Transfer/discharge: Other Healthcare Facility (planned). Further review revealed both discharges required C. Complete transfer/discharge form.

.Based on record review and interview, the facility failed to provide and document a discharge notice to 1 resident (#1) out of 4 sampled residents after determining that Resident #1 would not be permitted to return to the facility following hospitalization. Specifically, after determining Resident #1 would not be permitted to return to the facility following hospitalization, the facility failed to provide a discharge notice that included the effective date of the discharge, the specific location to which the resident was to be discharged , an explanation of the resident's right to appeal the discharge, the name, mailing address, email address, and telephone number of the State entity that receives appeal requests, information on how to obtain an appeal form, information on obtaining assistance in completing and submitting an appeal request, and the name, mailing address, email address, and telephone number of the representative of the Office of the State Long Term Care Ombudsman (LTCO). The facility also failed to provide a copy of the discharge notice to the Office of the State LTCO. These failed practices deprived Resident #1 of the procedural protections required for an involuntary discharge, including timely written notice of the discharge decision, information regarding the right to appeal, and access to assistance from the Office of the State LTCO through timely notification of the discharge.Findings:.Record review on 6/11/26 revealed Resident #1 was admitted to the facility with diagnoses that included pneumonia (an infection that inflames air sacs in one or both of the lungs) due to methicillin resistant staphylococcus aureus (MRSA - a type of antibiotic resistant bacteria), chronic obstructive pulmonary disease and acute and chronic respiratory failure with hypoxia (low level of oxygen in the body tissues). Review of the Physician Order, dated 4/30/26, revealed: Psychiatry: May see psychiatry prn [as needed] for psychiatric related issues. Status: Active. Review of Resident #1's ADVANCE DIRECTIVE ACKNOWLEDGMENT FORM, signed on 5/4/26, revealed the resident had no advance directive and no durable power of attorney for medical decisions. Review of Social Service Summary, dated 5/6/26, revealed: .BIMS [Brief Interview of Mental Status] is 14 indicating [Resident #1] is cognitively intact. Review of facility's N [Nursing] ADV[Advance] Skilled Evaluation, dated 5/20/26, revealed: .Mood and Behavior.Resident is currently experiencing unwanted behavior(s). Delusions: Chronic. Resists care: Chronic. Mood and Behavior Note: Resident verbally abusive when not getting what he/she wants and when staff follow rules. Review of Nurses Progress Notes, dated 5/21/26 at 3:16 PM, revealed: Social Worker. and PT [Physical therapist] . were present in resident's room talking about his/her transfer to PTC [Polaris Transitional Care]. This writer [nursing staff] walked up to the room in time to hear him/her telling them that he/she has 'shot someone before & [and] when they popped back up, he/she shot them 5 more times'. I walked away at that point with the ADON [Assistant Director of Nursing] to start his/her send out to the ED [Emergency Department]. Review of the Social Services Notes, dated 5/21/26 at 3:30 PM, revealed: .Resident [#1] reported severe pain, stating pain level 'over 20'. Nursing staff offered PRN [as needed] pain medication.resident refused.During [the] discussion about increasing therapy participation, resident expressed interest in 'doing more therapy.' As an accommodation [sic], I offered the option of relocating to a room closer to the therapy area to support his/her goal. Resident initially appeared agreeable; however, after a room was identified, resident became visibly irritated and escalated verbally. Resident stated: 'You're an idiot if you think I am doing this on your terms and your time.' 'You can't corner me like my mom did.' Staff reassure[d] resident that relocation was optional and intended to support his/her stated goals. Resident became increasingly agitated and made verbal threats, stating: 'I will kill you, you're lucky,' (repeated twice) . Resident also made suicidal statements, indicating to act on his/her own terms. Resident #1's Transfer to emergency room Review of the Nurse Practitioner (NP) #1's Order, dated 5/21/26 at 3:43 PM, revealed: Send to ER [Emergency Room] for evaluation and treatment for suicidal ideation/homicidal ideations (plan verbalized) and uncontrolled pain (20/10). During an interview on 6/11/26 at 1:04 PM, NP #1 stated the Director of Nursing (DON) called her about Resident #1's threats to harm himself/herself, and to other people. NP #1 further stated she came to see the resident before the decision was made to transfer Resident #1 to the emergency room. During the same interview, NP #1 stated Resident #1 was aggressive, and she felt there was an emergency need for psychiatric evaluation. When asked if the facility can take care of Resident #1's behavior, she answered: no way. The NP stated in her experience, people can be alert and oriented with silly psychotic at the same time and do things because their brain just gets to be way over overwhelmed. Review of IDT (interdisciplinary) Notes, dated 5/21/26 at 4:30 PM, revealed: IDT consisting of Assistant Administrator [AA], DON, ADON, and Social Services convened [the] following notification that resident verbalized uncontrolled pain rate '20/10,' along with statements indicating suicidal and homicidal ideation. Based on presentation and reported symptoms, the team determined that resident's current care needs exceeded the facility's capability to provide safe and appropriate management.ARNP [Advanced Registered Nurse Practitioner] was consulted and concurred with recommendation for transfer to a higher level of care, order obtained to transfer resident to the emergency department for further evaluation and management. Further review of the IDT notes revealed chart review was conducted by the Long Term Care (LTC). The review identified that personality, delusional and mood disorders were not disclosed at the time of admission on [DATE] from PAMC (Providence Alaska Medical Center). Transfer Notice Provided to Resident #1 Before the Emergency Visit Review of Nurses Progress Notes, dated 5/21/26 at 4:44 PM, revealed: . Resident declined to sign transfer notice and declined bed hold.Resident transferred to Providence ER [Emergency Room] at 1614 [4:14 PM] via EMS [Emergency Medical Service]. Review of the NOTICE OF PROPOSED TRANSFER/DISCHARGE, dated 5/21/26, revealed the facility provided the residents with a notice of transfer/discharge. The reasons for transfer/discharge were: .2) The transfer/discharge is necessary for your welfare and your needs cannot be met in the facility (a) the specific needs that cannot be met are care, behavior/safety, uncontrolled pain.3) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident (a) Reasons the safety of others in the Facility are endangered include: Resident threats to kill staff. Further review revealed Resident #1 declined to sign the notice on 5/21/26. Resident Not Accepted Back to Return to LTC After emergency room Visit During an interview on 6/11/26 at 12:16 PM, the Social Services Director (SSD) stated on 5/21/26, two hours after Resident #1 was transferred, that the hospital called her asking why the resident was not accepted back to the facility. The SSD explained that the Resident was unsafe to himself/herself and others. The SSD stated she documented the conversation with the hospital's mental health specialist (MHS) on the chart on 5/22/26. Review of the SSD's notes, dated 5/22/26, revealed: Spoke with. (Mental Health Specialist Providence) regarding concerns about [Resident #1] and Providence's inquiry about. [Resident #1's] discharge and potential return. [MHS] asked why [Resident #1] is not being accepted back to the facility. I explained that [Resident #1] is currently unsafe to himself/herself and others based on recent observed behaviors and direct statements. Specifically, he/she verbalized suicidal ideation, stating he/she intended to shoot himself/herself. He/she also made direct threats to staff.The facility has an obligation to ensure a safe environment for all residents and staff and to prevent abuse, neglect, or foreseeable harm. [Resident #1's] explicit threats toward staff and statements of self-harm represent credible safety risks requiring immediate intervention and exceed[ed] what can be safely managed within this setting. Retaining a resident whose needs cannot be met safely places the facility at risk of noncompliance with federal requirements related to resident safety, supervision, and quality of care. Further review of the SSD's notes revealed: Accurate and complete information at the time of admission is necessary to determine appropriate placement and develop an effective care plan. The absence of clearly communicated behavioral health history and the lack of alignment with PASRR [Pre-admission Screening and Resident Review] related screening raises concern regarding the adequacy of pre-admission evaluation and the appropriateness of placement in a non-psychiatric facility. Additionally, when a resident exhibits acute psychiatric instability, including threats of harm to self or others, transfer to a higher level of care for evaluation and stabilization is consistent with standards of care and federal expectations regarding appropriate placement and access to necessary medical and psychiatric services . Review of Resident #1's hospital medical record, dated 5/21/26, revealed Resident #1 was admitted on [DATE] in the emergency department [ED] with a chief complaint of suicidal thoughts. Review of the hospital's Care Management Initial Assessment notes, dated 5/22/26, revealed: Social work [SW #1] was consulted to see if pt [patient] can return to Polaris SNF [Skilled Nursing Facility] rather than being admitted to hospital. Per chart review, psych[psychiatric] ED clinician was initially consulted, who had cleared pt and had reached out to Polaris, which as of yesterday [5/21/26] declined to accept pt back. Pt was advised that LCSW [Licensed Clinical Social Worker] is working on trying to see if he can be discharged back to Polaris, though if this is not possible he/she will need to be admitted so care team can work on an alternative discharge plan. Message sent to psych clinician. [name of clinician], whose note from 5/21[/26] indicates pt needs further assessment, to confirm when pt will be cleared so social work can either call SNF to see if pt can return, possibly under a behavioural[sic] contract or needs to be admitted pending alternative placement. Per discussion with attending, it was clarified that pt has been cleared by psych and LCSW will now call Polaris to discuss this and if pt can return to its facility. Further review of the SW notes revealed: LCSW called Polaris and spoke with . [name of the head of nursing], who reported that pt has had an ongoing issue with behaviours[sic] at its SNF and as a result is not seeking to accept pt back. Social work asked if a 30[-]day notice had been given, however, per later discussion with leadership, this may not be needed for this facility. She states pt has had 'multiple incidents of SI[suicidal ideation]/HI [homicidal ideation]' and may have untreated borderline personality disorder, which is 'hard' on its staff. She is concerned that, were pt to be discharged , his/her behaviours[sic] would increase and he/she would 'boomerang' back to hospital. She acknowledged pt's concern for pain, which had initially been uncontrolled as he/she had been discharged to Polaris without this[sic] medications. She will discuss pt's case with other staff and will follow up with LCSW. The SW #1 notes also revealed: LCSW received call from .[name of social services director] and [name of assistant administrator (AA)] at Polaris.AA confirmed that facility is not prepared to accept pt back, indicating concern for possible undiagnosed bipolar disorder and would benefit mental health treatment for this. She was advised that psych ED clinician had ruled this out as a diagnosis. She also expressed concern that the PASS-R sent to Polaris prior to discharge had not identified pt's behavioural[sic] issues. Attending was advised of outcome of social work's conversation and will reach out to request that pt be admitted . During an interview on 6/11/26 at 12:16 PM, the SSD stated she was expecting the hospital to call her for an updated PASSR, but she did not hear anything from the hospital since their last conversation on 5/21/26. Record review on 6/11/26, revealed there was no other documented communication between the LTC and the hospital aside from the SSD notes on 5/22/26. During an interview on 6/12/26 at 12:56 PM, the Administrator stated the facility transferred Resident #1 to the hospital because staff believed the resident required a psychiatric evaluation and treatment beyond the facility's capabilities. The Administrator stated the facility attempted to obtain mental health services before the hospitalization and believed important information regarding the resident's psychiatric history had not been disclosed before admission. The Administrator stated that after the hospital informed the facility the resident had been evaluated and was ready for discharge, the facility did not believe it was safe for the resident to return because staff continued to have concerns regarding the resident's behaviors. The Administrator further stated the admission PASSR had not been completed correctly, diagnoses had been omitted, and the omitted information could have resulted in a Level II PASSR evaluation. The Administrator acknowledged the facility recognized significant psychiatric concerns as the resident's stay progressed but did not identify any attempt by the facility to complete a corrected PASSR screening or request a Level II PASSR evaluation after those concerns were identified. When asked about communication with the hospital after the facility declined to readmit Resident #1, the Administrator stated the facility did not follow up with the hospital and acknowledged communication between the facility and hospital essentially ceased. The Administrator stated she did not know why the facility failed to reestablish communication regarding the resident's disposition. Lack of Discharge Notice From LTC After Resident #1's emergency room Visit Record review on 6/11/26 revealed there was no documented second discharge notice that contained the following:a. The effective date of the discharge;b. The specific location to which the resident is to be discharged ;c. An explanation of the right to appeal the discharge to the State;d. The name, address (mail and email), and telephone number of the State entity which receives such appeal hearing requests;e. Information on how to obtain an appeal form;f. Information on obtaining assistance in completing and submitting the appeal hearing request; andg. The name, address (mailing and email), and phone number of the representative of the Office of the State LTCO.provided to Resident #1 after the facility determined that the resident could not return to the facility due to facility's inability to manage Resident #1's aggressive behavior. During an interview on 6/11/26 at 3:43 PM, the Quality Director (QD) stated the facility issued a transfer notice before Resident #1's emergency room visit and that the LTC would not issue another discharge notice when the facility determined the resident could not return to the LTC after hospitalization. During a joint interview on 6/11/26 at 4:11 PM with the ADON and the QD, the ADON stated the transfer/discharge was initiated by the facility because they couldn't manage Resident #1's pain, suicidal ideation and aggressive behavior. The ADON stated the facility had no other transfer/discharge notice provided to the resident aside from the notice the facility had provided before the resident transferred to the hospital on 5/21/26. During an interview on 6/12/26 at 12:56 PM, the Administrator stated that after the hospital informed the facility, Resident #1 had been evaluated and was ready for discharge, the facility determined the resident could not safely return because of continued concerns regarding the resident's behaviors. The Administrator further stated the facility did not reestablish communication with the hospital regarding the resident's disposition after declining the resident's return. In addition, the Administrator confirmed no discharge notice was provided to the resident after the hospital's attempt to discharge the resident back to the long-term care facility. Review of the facility's Discharge or Transfer policy, dated 11/2019, revealed: It is the policy of this facility to provide the Resident with a safe organized structured transfer or discharge from the facility to include but not limited to hospital, another healthcare facility or home that will meet their highest practical level of medical, physical, and psychosocial well being. A transfer and or discharge shall be considered for the following reasons as regulated by Federal, State and other Regulatory Agencies .1. Transfer/discharge: Emergency, and 2. Transfer/discharge: Other Healthcare Facility (planned). Further review revealed both discharges required.C. Complete transfer/discharge form. Notification of the Long-Term Care Ombudsman's Office During an interview on 6/11/26 at 9:30 AM, the QD stated per the LTCO instruction, the facility should report discharge notice every month including an emergency transfer/discharge. Review of the facility's monthly discharge report to the LTCO, dated 5/2026, revealed Resident #1's transfer to the hospital on 5/21/26 was included. Record review on 6/11/26, revealed there was no other documented Resident #1's discharge notification of the LTCO after the facility determined the resident could not be accepted back to return to the LTC. Review of the facility's Discharge or Transfer policy, dated 11/2019, revealed the policy did not include the process of notifying the LTCO of resident's discharges

. Based on record review, interview, and observation the facility failed to ensure sufficient nursing staff to meet residents' needs, (based on a census of 93) as established by the facility assessment (a mandatory, comprehensive evaluation to understand the specific resident population's needs and match them with necessary staffing, equipment, and resources to meet those needs). Specifically: The facility assessment identified minimum staffing requirements; however, actual staffing schedules showed fewer certified nursing assistants (CNAs), and licensed nurses (LNs) than defined.Residents (#2 and #3) were not provided ADLs according to their care plans. These deficient practices resulted in delayed residents' care per comprehensive care plans, unmet needs and had the potential to negatively impact residents' health, safety, and quality of life. Findings: Staffing Review of the facility provided 2026 Polaris Extended Care Facility Assessment, undated, revealed: . Nurse staffing information (S483.35 - F732) is posted daily and includes the facility name, current date, census, total number, and actual hours worked per shift for registered nurses, licensed practical nurses, and certified nurse aides [CNAs]. The information is posted at the beginning of each shift and in a prominent location that is readily accessible to residents and visitors. The daily posted nurse staffing data is retained for a minimum of 18 months. Sample staffing charts are provided below and are a snapshot of staffing that flexes to meet census, resident acuity and needs. Further review of the assessment indicated staffing should include 6 to 8 licensed nurses (registered nurses and licensed practical nurses) on day shift, 5 to 7 licensed nurses on night shift, 8 to 10 CNAs on day shift and 7 to 8 CNAs on night shift. Record review on 1/5-6/26 of staffing schedules for December 2025 and January 2026 revealed staffing consistently fell below the facility assessment's established levels. Specifically, the facility failed to meet established staffing levels for 6 out of 10 weekend days reviewed: LNs- On Saturday, 1/3/26, five day shift LNs were scheduled. The established minimum for day shift LNs was 6-8 per facility assessment. On Friday, 12/19/25, four night shift LNs were scheduled.On Saturday, 1/3/26, four night shift LNs were scheduled; the Director of Nursing (DON) worked as a LN for med pass [medication administration] in Yukon cottage. The established minimum for night shift LNs was 5-8 per facility assessment. CNAsOn Sunday, 12/14/25, seven day shift CNAs were scheduled;On Friday, 12/19/25, six day shift CNAs were scheduled;On Saturday, 12/20/25, six day shift CNAs were scheduled; On Sunday,12/21/25, six day shift CNAs were scheduled; On Saturday, 12/27/25, seven day shift CNAs were scheduled; and On Saturday, 1/3/26, six day shift CNAs were scheduled. The established minimum for day shift CNAs was 8-10 per facility assessment. On Thursday, 12/18/25, 6 night shift CNAs were scheduled; [NAME] Sunday, 12/21/25, 5 night shift CNAs were scheduled. The established minimum for night shift CNAs was 7-8 per facility assessment: Further review of the staffing schedules for December 2025 and January 2026, revealed, LNs and CNAs picked-up residents assignment in other cottages that did not have assigned regular LNs and CNAs. During an interview on 1/5/26 at 2:21 PM, CNA #1 stated there was no nurse from Monday, Tuesday, Wednesday and Thursday in Aniak cottage, all nurses that worked in Aniak cottage were float nurses from other cottages. CNA #1 further stated LN #1 was a nurse of Polaris Transitional Care (PTCC), who was covering for Aniak cottage because they don't have a regular nurse assigned there. During the same interview, CNA #1 stated he/she felt not doing good quality of care because he/she was rushing the cares. He/she was worried that residents would fall because they only have one nurse and one CNA in the cottage. During an interview on 1/5/26 at 3:25 PM, LN #2 stated there was only one CNA that was taking care of the residents. He/she further stated if the CNA called in sick the other CNAs from other cottages would pick up resident assignment in the cottage. During an interview on 1/5/26 at 4:16 PM, an anonymous resident stated: Staff shortage is really a big problem here. He/she also stated they had shared nurses and shared CNAs. He/she further stated that in December 2025, he/she had to wait for a long time. They would end up getting bed baths instead of shower if the CNAs didn't have time. During an interview on 1/6/26 at 5:00 PM, the Administrator (ADM) stated there had been a lot of sick calls which contributed to low staffing around 12/21/25. The ADM further stated, the facility's goal was to schedule 8 nurses on day shift, 6 nurses at night, 12 CNAs on day shift, and 8 CNAs on night shift. Further review of the facility provided 2026 Polaris Extended Care Facility Assessment, undated, revealed: The facility considers the fluctuation in census, acuity levels, resident needs or preferences, staff competencies and skill set when determining staffing schedules and assignments and staffs accordingly. The facility has consistent assignments for direct care nursing staff (licensed nurses and nursing assistants) and therapists, to the extent possible, for the purpose of continuity of care. Nursing care staff are adjusted according to patient needs and acuity . Provision of Activities of Daily Living (ADL) Resident #2 Record review on 1/5-6/26 revealed Resident #2 was admitted to the facility with diagnoses that included quadriplegia (paralysis of all four limbs and the trunk, often resulting in severe limitations in movement, sensation, and respiratory function). Review of Resident #2's care plan, last revised 12/29/25, revealed: .Focus: ADL Self Care Performance Deficit r/t [related to] Limited Mobility . Interventions/Tasks: . PROVIDE SHOWER EVERY SUNDAY AND THURSDAY NIGHT.TOILETING DEVICE: Carendo [height adjustable and reclining shower] chair for shower . Further review of the care plan revealed no revisions to reflect reduced showers. Review of Resident #2's Minimum Data Set (MDS - a federally required assessment) significant change in status assessment, dated 12/16/25, revealed, under Section F-Preferences for Customary Routine and Activities, Resident #2 prefers receiving showers. Further review revealed, under Section GG-Functional Abilities, Resident #2 had an impairment of the upper and lower limbs on both sides and was dependent on staff for his/her showers. Review of the progress note, dated 12/21/25 at 8:32 PM, revealed: Confirm with CNA Shower EVERY SUNDAY AND THURSDAY NIGHT. and complete LN- Skin Evaluation - PRN [as needed] / Weekly every night shift every Thu, Sun.short staffed, needs 2 person assist Review of Resident #2's care plan, revealed: BATHING (SHOWER/BATHE SELF): 1 person providing dependent assistance using carendo chair. Review of Resident #2's December 2025 shower log revealed Resident #2 did not receive a shower from 12/18-28/25 (totaling 14 days in between showers) and instead received a bed bath on 12/18/25 and 12/21/25. Review of the progress note, dated 1/5/26 at 1:54 AM, revealed: Confirm with CNA Shower EVERY SUNDAY AND THURSDAY NIGHT. and complete LN- Skin Evaluation - PRN / Weekly every night shift every Thu, Sun .Helping CNA was not able to give shower to resident. Review of Resident #2's January 2026 shower log, revealed Resident #2 did not receive showers on scheduled shower days of 1/1/26 (Thursday) and 1/5/26 (Sunday). Documentation reflected a bed bath on 1/1/26, and no shower or bed bath documented on 1/5/26. During an interview on 1/6/26 at 12:47 PM, Resident #2 stated he/she was dependent on staff for activities of daily living such as showering. Resident #2 further stated staff did not shower him/her for three weeks last month (December 2025) and yesterday (1/5/26) because he/she was told there were not enough CNAs available. When asked about staff response to call lights, Resident #2 stated, I have to wait a long time most of the time, sometimes I wait a half hour to 40 minutes because they are helping someone shower or 1 CNA has two cottages. When I call for small things like water, they tell me they are too busy and turn around because they need to help someone else. I feel like they don't want to help me with things like turning my TV volume up or down even though they are in here, it only takes a second to do that, but they turn around and leave the room and just walk out. During an interview on 1/6/26 at 5:55 PM with the Director of Nursing (DON), the DON stated showers were audited twice a week and discussed during rounds. DON further stated if a resident did not get a shower, the CNA was supposed to notify the nurse or the supervisor. Resident #3 Record review on 1/5-6/26 revealed Resident #3 was admitted to the facility with diagnoses that included multiple sclerosis (chronic autoimmune disease in which the immune system attacks the protective covering of nerve fibers in the brain and spinal cord, disrupting communication between the nerves and the body), muscle weakness, and functional quadriplegia. Review of Resident #3's MDS quarterly assessment, dated 11/4/25, revealed, under Section GG-Functional Abilities, Resident #3 had an impairment of the upper and lower limbs on both sides. Further review revealed Resident #3 was dependent on staff for his/her chair/bed-to-chair transfers. Review of Resident #3's care plan, last revised, 11/14/25, revealed: .Focus: ADL Self Care Performance Deficit r/t Limited Mobility, Activity Intolerance . Interventions/Tasks: TRANSFER Requires supervision and physical assistance with transferring. 1 person using overhead lift . Review of the Social Service Summary note dated 5/8/25 at 2:57 PM revealed: [Resident #3] indicated interest in being transferred to [his/her] chair more than once a week. Resident identified staffing concerns being a primary factor in transfer assistance due to being a two (2) person transfer; however, [he/she] report a decrease in [his/her] typical enjoyed activities when [he/she] is left in [his/her] bed. Resident stated [he/she] would like to address issue during care conference. Review of the facility's resident grievance log revealed Resident #3 filed a grievance on 8/13/25. Review of the grievance revealed: Resident is concerned about not being able to get up out of bed more than one time per week. [He/she] has been told that [he/she] can only get up one time per week due to staffing. Would like to get up M [Monday], W [Wednesday], F [Friday] .SW [Social Worker] discussed with leadership team, DON. DON to address [with] staff and ensure resident is able to get up more frequently. Review of Resident #3's CNA Tasks revealed: Ensure resident is up every Monday, Wednesday, Friday. Further review of the task log, from 12/8/25-1/5/26, revealed: - The week of 12/14-20/25, Resident #3 got up once (12/19/25), - The week of 12/21-27/25, Resident #3 did not get up; and- The week of 12/28/25-1/3/26, Resident #3 got up once (1/2/26). - No was marked to the resident getting up on 12/17/25, 12/22/25, 12/24/25 and 12/31/25. During an interview on 1/5/26 at 11:37 AM, Resident #3 stated he/she did not get out of bed twice during the month of December (2025). Resident #3 further stated when I ask to get up they say well we will see, and that usually means no, they are either shorthanded or too many people getting up at once so they don't' have time. It is in my plan of care that I get up three times a week, but two times a week works fine for me. Review of the facility provided 2026 Polaris Extended Care Facility Assessment, undated, revealed: Based on our resident population and their care needs, we have made a good faith effort and approach to ensure we have sufficient and qualified staff to meet the needs of our residents at any given time. The facility periodically interviews residents for preferences on waking and sleep times, shower schedules, etc. Should an individual identify, or express preferences related to individual choice, cultural needs, or other factors, their plan of care is adjusted to meet their person-centered care preferences when able. If the facility is unable to meet a request, the resident is advised, and the facility will collaborate with the resident and/resident representative to achieve the best solution or compromise possible. Record review of the Payroll Based Journal (PBJ) for the facility, dated October 2024 through September 2025 accessed at https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission on 1/21/2026, revealed the facility triggered for low weekend staff for all four quarters of federal fiscal year 2025 establishing a history of low weekend staffing. Quarter 1 of federal fiscal year 2026 (October 2025 - December 2025) was not available at time of survey.

.Based on record review and interview, the facility failed to ensure the resident representative was informed of, and able to participate in, care decisions for 1 resident (#1) out of 15 residents sampled. Specifically, the facility failed to notify Resident #1's court appointed guardian of a scheduled psychiatric consultation, despite documentation confirming the guardian held full legal authority for medical and mental health treatment decisions. This failed practice prevented the guardian from exercising the right to be informed, to participate in planning of care, and to provide informed consent for mental health services .Findings:Record review on 1/5-6/26, revealed Resident #1 was admitted to the facility with diagnoses that included multiple sclerosis (a disease that causes breakdown of the protective covering of the nerves), renal tubule-interstitial disease (a kidney disease that affects the tubules and surrounding tissues), bipolar disorder (mental health condition characterized by extreme mood swings), delusional disorder (serious mental health condition characterized by persistent, false beliefs that are not based in reality) and anxiety disorder (mental health disorder characterized by uncontrollable feelings of anxiety and fear).Review of Resident #1's LETTER OF GUARDIANSHIP, dated 4/17/14, revealed: . the Office of Public Advocacy is hereby appointed as full guardian of the ward, [name of Resident #1] The duties and powers of the full guardian of the respondent shall be those provided in the Findings and Order of Guardianship. Further review of the document revealed .GUARDIANSHIP PLAN AS [Alaska Statute] 13.26.116 judicial determination has been that [name of Resident #1] is incapacitated and the services of a guardian are necessary.the guardian has full authority to provide for the ward's medical care, mental health treatment, and any necessary physical and mental examination including the power to approve administrations of any and all medications to be prescribed for the ward, and to approve medical procedures and administration of psychotropic medications.Review of Resident #1's Consultation Report, dated 10/22/25, revealed: .Consultation Report Requested Regarding: Behavioral health [.] Findings: Today['s] visit-pt [patient] unescorted.documentation at time of visit-stating guardian POA [Power of Attorney] pt unable to tell us why [he/she] is here.Recommendations: need more info-reason for visit [,] guardian contact.During an interview on 1/6/26 at 5:00 PM, the Administrator and the Director of Nursing (DON) stated there was no documented guardian notification.During a concurrent interview and document review on 1/6/25 at 5:36 PM, the DON stated that in the facility's staffing schedule, dated 10/22/25, there was a note that Resident #1 needs an escort, but cannot verify who the escort was.Review of an email from the facility's Assistant Administrator (AA) dated 1/7/26 at 11:27 AM, revealed: .Our driver provided transportation to and from the appointment and ensured the resident was checked in upon arrival. The resident's recent BIMS [Brief Interview for Mental Status] assessment indicates intact cognitive function, which typically does not require an escort for medical appointments. Further review of the email revealed: It is our standard practice to notify residents and their representatives of scheduled appointments. Our last communication with the resident's guardian indicated that [he/she] may have been notified but, due to a large caseload, cannot recall with certainty.Review of the follow-up email from the facility's AA, dated 1/7/26 at 1:11 PM, revealed: At this time, there is no documentation in the resident's chart indicating confirmation from the guardian. However, we did reach out to the resident's guardian yesterday [1/6/26] to confirm that [he/she] was aware of the resident's request for mental health services and the scheduling of a mental health appointment. The guardian responded stating: 'It is possible that I was made aware. I have a large caseload.'.

.Based on record review and interview, the facility failed to ensure 2 residents (#2 and #3) out of 15 sampled residents received activities of daily living (ADL) services in accordance with assessed needs, care plans, and stated preferences, resulting in unmet personal care needs and potential diminished quality of life. Specifically, the facility failed to provide scheduled showers to one resident (#2) who was fully dependent on staff for bathing and failed to assist another resident (#3) out of bed as required by the care plan. These failed practices resulted in unmet personal care needs and poor quality of life . Findings: Resident #2 Record review on 1/5-6/26 revealed Resident #2 was admitted to the facility with diagnoses that included quadriplegia (paralysis of all four limbs and the trunk, often resulting in severe limitations in movement, sensation, and respiratory function). Review of Resident #2's care plan, last revised 12/29/25, revealed: .Focus: ADL Self Care Performance Deficit r/t [related to] Limited Mobility . Interventions/Tasks: . PROVIDE SHOWER EVERY SUNDAY AND THURSDAY NIGHT.TOILETING DEVICE: Carendo [height adjustable and reclining shower] chair for shower . Further review of the care plan revealed no revisions to reflect reduced showers. Review of Resident #2's Minimum Data Set (MDS - a federally required assessment) significant change in status assessment, dated 12/16/25, revealed under Section F-Preferences for Customary Routine and Activities, Resident #2 prefers receiving showers. Further review revealed, under Section GG-Functional Abilities, Resident #2 had an impairment of the upper and lower limbs on both sides and was dependent on staff for his/her shower. Review of the progress note, dated 12/21/25 at 8:32 PM, revealed: Confirm with CNA Shower EVERY SUNDAY AND THURSDAY NIGHT. and complete LN [Licensed Nurse]- Skin Evaluation - PRN [as needed] / Weekly every night shift every Thu, Sun.short staffed, needs 2 person assist. Review of Resident #2's care plan, revealed: BATHING (SHOWER/BATHE SELF): 1 person providing dependent assistance using carendo chair. Review of Resident #2's December 2025 shower log revealed Resident #2 did not receive a shower from 12/18-28/25 (totaling 14 days in between showers) and instead received a bed bath on 12/18/25 and 12/21/25. Review of the progress note, dated 1/5/26 at 1:54 AM, revealed: Confirm with CNA Shower EVERY SUNDAY AND THURSDAY NIGHT. and complete LN- Skin Evaluation - PRN / Weekly every night shift every Thu, Sun .Helping CNA [certified nursing assistant] was not able to give shower to resident. Review of Resident #2's January 2026 shower log on 1/6/26 revealed Resident #2 did not receive showers on scheduled shower days of 1/1/26 (Thursday) and 1/5/26 (Sunday). Documentation reflected a bed bath on 1/1/26, but no shower or bed bath on 1/5/26. During an interview on 1/6/26 at 12:47 PM, Resident #2 stated he/she was dependent on staff for activities of daily living such as showering. Resident #2 further stated staff did not shower him/her for three weeks last month (December 2025) and yesterday (1/5/26) because he/she was told there were not enough CNAs available. When asked about staff response to call lights, Resident #2 stated, I have to wait a long time most of the time, sometimes I wait a half hour to 40 minutes because they are helping someone shower or 1 CNA has two cottages. When I call for small things like water, they tell me they are too busy and turn around because they need to help someone else. I feel like they don't want to help me with things like turning my TV volume up or down even though they are in here, it only takes a second to do that, but they turn around and leave the room and just walk out. During an interview on 1/6/26 at 5:55 PM with the Director of Nursing (DON), the DON stated showers were audited twice a week and discussed during rounds. DON further stated if a resident did not get a shower, the CNA was supposed to notify the nurse or the supervisor. Resident #3 Record review on 1/5-6/26 revealed Resident #3 was admitted to the facility with diagnoses that included multiple sclerosis (chronic autoimmune disease in which the immune system attacks the protective covering of nerve fibers in the brain and spinal cord, disrupting communication between the nerves and the body), muscle weakness, and functional quadriplegia. Review of Resident #3's MDS quarterly assessment, dated 11/4/25, revealed, under Section GG-Functional Abilities, Resident #3 had an impairment of the upper and lower limbs on both sides. Further review revealed Resident #3 was dependent on staff for his/her chair/bed-to-chair transfers. Review of Resident #3's care plan, last revised, 11/14/25, revealed: .Focus: ADL Self Care Performance Deficit r/t Limited Mobility, Activity Intolerance . Interventions/Tasks: TRANSFER Requires supervision and physical assistance with transferring. 1 person using overhead lift . Review of the Social Service Summary note dated 5/8/25 at 2:57 PM revealed: [Resident #3] indicated interest in being transferred to [his/her] chair more than once a week. Resident identified staffing concerns being a primary factor in transfer assistance due to being a two (2) person transfer; however, [he/she] report a decrease in [his/her] typical enjoyed activities when [he/she] is left in [his/her] bed. Resident stated [he/she] would like to address issue during care conference. Review of the facility's resident grievance log revealed Resident #3 filed a grievance on 8/13/25. Review of the grievance revealed: Resident is concerned about not being able to get up out of bed more than one time per week. [He/she] has been told that [he/she] can only get up one time per week due to staffing. Would like to get up M [Monday], W [Wednesday], F [Friday] .SW [Social Worker] discussed with leadership team, DON. DON to address [with] staff and ensure resident is able to get up more frequently. Review of Resident #3's CNA Tasks revealed: Ensure resident is up every Monday, Wednesday, Friday. Further review of the task log, from 12/8/25-1/5/26, revealed: The week of 12/14-20/25, Resident #3 got up once (12/19/25), The week of 12/21-27/25, Resident #3 did not get up; andThe week of 12/28/25-1/3/26, Resident #3 got up once (1/2/26). No was marked to the resident getting up on 12/17/25, 12/22/25, 12/24/25 and 12/31/25. During an interview on 1/5/26 at 11:37 AM, Resident #3 stated he/she did not get out of bed twice during the month of December (2025). Resident #3 further stated when I ask to get up they say well we will see, and that usually means no, they are either shorthanded or too many people getting up at once so they don't' have time. It is in my plan of care that I get up three times a week, but two times a week works fine for me. Review of the facility provided 2026 Polaris Extended Care Facility Assessment, undated, revealed: Based on our resident population and their care needs, we have made a good faith effort and approach to ensure we have sufficient and qualified staff to meet the needs of our residents at any given time. The facility periodically interviews residents for preferences on waking and sleep times, shower schedules, etc. Should an individual identify, or express preferences related to individual choice, cultural needs, or other factors, their plan of care is adjusted to meet their person-centered care preferences when able. If the facility is unable to meet a request, the resident is advised, and the facility will collaborate with the resident and/resident representative to achieve the best solution or compromise possible.

.Based on record review and interview, the facility failed to ensure necessary care and services were received to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 residents (#6 and #9), out 6 sampled residents. Specifically, the facility failed to: 1) Administer scheduled wound treatment and dressing change orders to Resident #6's right thigh and right buttock on 11/6/25 and 11/8/25; 2) Properly assess reports of increased right leg pain on 11/7-9/25 by Resident #6 and appropriately report this change in condition to providers; and 3) Ensure timely notification for Wound Care Team assessment and interventions for a change in condition of a surgical site for Resident #9's pacemaker (an artificial device surgically placed under the skin for stimulating the heart muscle and regulating its contractions). These failed practices resulted in harm as evidence by regression of Resident #6's right thigh and right buttock wounds, an infection of Resident #6's wounds which required painful wound cleansing treatments, and adverse effects of antibiotic therapy. Additionally, these failed practices resulted in Resident #9's hospitalization due to an infection of the surgical site which required extensive treatment to heal, necessary surgical intervention to relocate the resident's pacemaker, and a lengthy hospital stay for treatment. Findings:Resident #6 Record review on 11/25-26/25 revealed Resident #6 was admitted to the facility with diagnoses that included myasthenia gravis with acute exacerbation (a condition caused by a breakdown in communication between nerves and muscles, causes weakness and rapid fatigue of muscle control of the face, throat, arms, and legs), diffuse large B-cell lymphoma (most common form of non-Hodkins lymphoma, cancer of the B cells which are responsible for producing antibodies), immunodeficiency (failure of the immune system to protect the body adequately from infection), asthma, and chronic respiratory failure. Wound History Review of Resident #6's electronic Treatment Administration Record (eTAR), dated 9/1/25 through 11/26/25, revealed a history of treatment for right thigh skin related issues since 9/3/25, which initially started as a rash or blister and progressed to two furuncles (boils or abscesses) to the back of Resident #6's right thigh and right buttock. Further review revealed Resident #6's most recent wound treatment order started on 10/28/25: Two furuncles (boil, abscess) to posterior right thigh and right buttock: remove packing strip. Irrigate with NS [normal saline] or wound spray. Cleanse with wound cleanser, pat dry. Utilize a cotton tipped applicator (q-tip) to place 1/4 inch iodoform [a continuous strip of gauze impregnated with iodoform, iodine with antiseptic properties] loosely in one continuous strip into depth of wound; leave 1/2 inch or greater outside of wound, then secure in place with Mepilex Transfer [a thin and conformable wound dressing which draws moisture and drainage away from a wound] (cut to fit) or bordered foam [a specialized wound care product designed to manage moderate to heavy drainage from wounds]. Every day shift every Tue[sday], Thu[rsday], Sat[urday] for Furuncles on [RLE (right lower extremity)] for 30 days. Further review revealed Wound Care Nurse (WCN) #2 and Physician Assistant (PA) #11 completed this ordered wound treatment on Tuesday, 11/4/25. On 11/4/25, Resident #6's wound treatment orders were revised. These new orders were set to start on Thursday, 11/6/25: - Right buttock: Furuncle (boil, abscess) to posterior right buttock: remove packing strip. Irrigate with NS or wound spray. Cleanse with wound cleanser, pat dry. Utilize a cotton tipped applicator (q-tip) to place 1/4 inch iodoform loosely in one continuous strip into depth of wound; leave 1/2 inch or greater outside of wound, then secure in place with Mepilex Transfer (cut to fit) or bordered foam. Every day shift every Tue, Thu, Sat for Furuncles on [right] buttock for 30 days; and - Right thigh: Furuncle (boil, abscess) to . right posterior thigh: Cleanse/irrigate with NS or wound cleanser, pat dry. Place [AquacelAg] [a specialized, non-woven wound dressing, which contains ionic silver, that is designed to absorb wound fluid and bacteria, creating a moist environment that supports healing] over wound bed and secure with bordered foam. Every day shift every Tue, Thu, Sat for Furuncle on right posterior thigh for 30 days. Further review of these two new wound treatment orders revealed Licensed Nurse (LN) #8 signed the eTAR on Thursday, 11/6/25, and Saturday, 11/8/25, as having completed these dressing changes. During an interview on 11/25/25 at 11:59 AM, Resident #6 stated his/her thigh wound started in September 2025 and progressed to abscesses to his/her right thigh and right buttock. Wound treatments with dressing changes continued since then, and the wounds were improving. Resident #6 stated wound cleaning and dressing changes were usually painful, but the pain was improved as the wounds progressed, and he/she had not been using PRN pain medication during dressing changes for a while. Resident #6 stated WCN #2 and PA #11 completed the wound cleaning, assessment, and dressing change on Tuesday, 11/4/25, and they come every Tuesday to do this. Resident #6 then became tearful and stated the week of 11/4/25 the pain on the back of his/her right leg had started to increase and he/she reported this pain to the nurses who were working that week. Resident #6 stated the nurses would provide pain medication, but this was the only intervention they completed based on this reported increase of pain. Resident #6 stated after 11/4/25, his/her right abscess wounds were not visually inspected or assessed by any nurse during this week. When asked about the dressing changes on 11/6/25 and 11/8/25, Resident #6 state LN # 8 was supposed to do these dressing changes, however, did not do them. Pain Medication Review Review of Resident #6's electronic Medication Administration Record (eMAR), dated November 2025, revealed an as needed (or PRN) order for Morphine, an opioid pain reliever: Morphine Sulfate Oral Tablet 15mg. Give 7.5mg [1/2 tablet] by mouth every 6 hours . as needed for pain, which started on 5/28/25. Further review revealed Resident #6 had a significant increase in PRN Morphine medication use in November 2025, compared to the prior month. Resident #6 used the Morphine PRN only once in October 2025 (10/18/25). In November 2025, Resident #6 used the PRN Morphine on three consecutive days (11/7/25, 11/8/25, and 11/9/25). Nursing Note Documentation Review Review of Resident #6's Nursing Notes, dated 11/4/25 through 11/11/25, revealed the following notes for nursing assessments and Morphine PRN medication administrations: - WCN #2 Note, dated 11/4/25 at 3:34 PM: Skin issue: #001: Skin issue has been evaluated. Location: Rear right thigh. Laterality/Orientation: Distal . Issue type: Abscess. Progress: Improving: overall wound characteristics improved . Painful: Yes. Wound pain (frequency): Intermittent. Pain description: Sharp. Pain description: Stabbing. Wound Pain interventions: Change in position . Distraction techniques . Relaxation techniques . Resident declines medication prior to and after wound care [stating] that 'they don't work [too] well for pain, just makes [him/her] sleepy.' Relief from interventions: Yes . #002 . Right gluteus [buttock] Laterality/Orientation: Right . Issue type: Abscess. Progress: Improving: overall wound characteristics improved [wound pain assessment same as first wound] . [He/she] has success controlling pain with breathing techniques and relaxation techniques[.] Relief from interventions: Yes . Skin issues Note: Resident is followed by wound care for healing furuncles on posterior of [RLE]. [He/she] reports increased pain from wounds over last several days. Resident is able to tolerate assessment and wound care with the use of distraction/breathing/relaxation techniques. [He/she] declines medication for pain control. - LN #21 Nursing Note, dated 11/4/25 at 5:49 PM: Resident pain scale 4 [from 0 out of 10 pain scale], offered PRN pain medication but refused . - LN #13 Nursing Skin Check Note, dated 11/6/25 at 9:55 PM: . Skin Issue: #001: Skin issue has not been evaluated. Location: Rear right thigh . #002: Location: Right gluteus . Skin issue has not been evaluated . Reason for not evaluated: Skin issues evaluated by WCT [wound care team] 2 days prior . - LN #8 Nursing Note, dated 11/7/25 at 10:48 AM: Morphine Sulfate Oral Tablet 15mg Give 7.5mg by mouth every 6 hours . as needed for pain[.] right upper thigh pain. LN #8 documented this pain medication was effective 11/7/25 at 11:44 AM, with a pain scale of 0. - LN #8 Nursing Note, dated 11/8/25 at 11:28 AM: Morphine Sulfate Oral Tablet 15mg Give 7.5mg by mouth every 6 hours . as needed for pain[.] right thigh pain. LN #8 documented this pain medication was effective 11/8/25 at 12:28 AM, with a pain scale of 0. - LN #21 Nursing Note, dated 11/9/25 at 9:48 AM: Morphine Sulfate Oral Tablet 15mg Give 7.5mg by mouth every 6 hours . as needed for pain[.] Requested for pain in [his/her] right leg. LN #21 documented this pain medication was effective 11/9/25 at 2:24 PM, with a pain scale of 4. - LN # 25 Nursing Skin Check Note, dated 11/10/25 at 11:15 PM: . Skin Issue: #001: Skin issue has not been evaluated. Location: Rear right thigh . #002: Skin issue has not been evaluated . Right gluteus . Further review revealed no documentation for the reason why the skin evaluation was not completed. - LN #25 Nursing Long Term Care Evaluation Note, dated 11/10/25 at 11:17 PM: . Pain: Indicators of pain: None . Skin: Skin warm & dry, skin color WNL [within normal limits] and turgor [the normal state of tension in skin] is normal. Skin note: WCT seen resident last week. Skin Issue: #001: Skin issue has not been evaluated . #002: Skin issue has not been evaluated . Safety concerns: No. Comfort concerns: No . Further review revealed no nursing documentation that Resident #6's reports of increased pain to his/her right leg were visually assessed or reported to the WCT or Resident #6's provider. During the interview on 11/25/25 at 11:59 AM, Resident #6 stated when WCN #2 and PA #11 came to complete the Tuesday dressing change on 11/11/25, they discovered the right thigh and buttock abscesses and surrounding tissues were infected. Resident #6 tearfully stated they had to debride (remove damaged tissue and infected drainage) and clean the wounds, It was horrible. They had to squeeze all the infection out of the wounds and fill it with wound cleaner several times. I was screaming. PA #11 Note Review Review of Resident #6's SNF [Skilled Nursing Facility] Wound Care [at] Polaris Extended Care notes documented by PA #11, dated 11/4/25 and 11/11/25, revealed the following changes in the wounds to Resident #6's right thigh and right buttock: 1. Wound #1: Right thigh abscess: a. Measurements:- On 11/4/25: 0.6 cm long by 0.5 cm wide by 4.8 cm deep.- On 11/11/25: 1.0 cm long by 0.8 cm wide by 4.0 cm deep. b. Exudate (fluid released from a wound):- On 11/4/25: Moderate serosanguineous [thin, watery drainage that is pinkish or pale red] drainage.- On 11/11/25: Moderate serosanguineous and purulent [thick, often yellowish, greenish, or brownish pus] drainage. c. Infected:- On 11/4/25: No.- On 11/11/25: Yes. 2. Wound #2: Right buttock abscess: a. Measurements:- On 11/4/25: 0.6 cm long by 0.6 cm wide by 1.2 cm deep.- On 11/11/25: 7.0 cm long by 9.0 cm wide by 4.0 cm deep. b. Exudate:- On 11/4/25: Moderate serosanguineous drainage.- On 11/11/25: Heavy purulent and serosanguineous drainage. c. Infected:- On 11/4/25: No.- On 11/11/25: Yes. Further review of revealed Wound #2's overall condition had declined, due to infection and a procedure to drain the abscess was necessary: . Procedure: Incision and drainage of abscess . a sterile size 10 scalpel was used to make an incision, and the abscess was expressed and irrigated with normal saline . Further review of the PA #11 notes, dated 11/4/25 and 11/11/25, revealed: . Overall treatment goals include a decrease in wound size, preventing infection/inflammation, maceration [where skin becomes softened, white, and wrinkly due to prolonged exposure to moisture], excessive drainage, malodor [unpleasant or offensive body odor], and discomfort/pain . If the patient has any complications, please contact me . During an interview 11/25/25 at 12:50 PM, WCN #2 stated when he/she completed any wound dressing change, he/she signed and dated the dressing. When asked if he/she completed Resident #6's wound dressing change on 11/4/25, WCN #2 stated, yes. When asked if Resident #6's 11/4/25 dressing was still in place on 11/11/25, WCN #2 stated Resident #6's dressing, that he/she dated and signed on 11/4/25, was still in place on 11/11/25. WCN #2 stated when they removed the dressing on 11/11/25, it was quite messy because the 11/4/25 dressing had held in a lot of serosanguineous drainage the whole week. WCN #2 stated the abscess wounds had increased induration (the firmness or hardening of the tissue surrounding a wound) and Resident #6 was in a large amount of pain. Antibiotic Treatment During the interview on 11/25/25 at 11:59 AM, Resident #6 stated he/she had to start I.V. antibiotics due to the infected abscesses. He/she stated because of his/her myasthenia gravis diagnosis, the type of antibiotic used (Ceftriaxone) affected his/her ability to breathe and made his/her body ache which limited his/her mobility and ability to get out of bed. I feel like I was doing so well and because a couple of nurses didn't listen or do their job, I took several steps backward. Review of the eMAR, dated 11/11/25, revealed antibiotics were started: Ceftriaxone Sodium Injection solution . Use 1 gram intravenously [I.V.] every 12 hours for day for skin and soft tissue infection for 10 days . (medication was given 11/11/25 - 11/21/25). During an interview on 11/25/25 at 2:10 PM, the Director of Nursing (DON) stated she was notified by the WCT on 11/11/25 that dressing changes for Resident #6 were not completed over the weekend. The DON stated an investigation was conducted, and when LN #8 was interviewed he/she reported that he/she thought the dressing changes were PRN and this was the reason they were not completed. eMAR Program Design During the interview on 11/25/25 at 2:10 PM, when the eMAR Program design was reviewed, the DON acknowledged it was designed to alert nurses to scheduled medications or treatments by turning the order green. This program feature alerted nurses to scheduled medication or treatment due, which prompted them to complete and signed off the order. The DON stated PRN orders did not alert in this manner and were only signed off when completed (otherwise they were left unsigned, or blank in the program). The DON further acknowledged LN #8 initialed Resident #6's scheduled dressing change orders on 11/6/25 and 11/8/25 as if they were completed, and did not indicate they were held, refused, or not completed. Resident #9 Record review on 11/25-26/25 revealed Resident #9 was admitted with diagnoses that included disorder involving the immune system, cholangitis (infection of the biliary system), systolic (congestive) heart failure (a chronic condition that results when the heart muscle is unable to pump blood efficiently), complete atrioventricular block (a complete absence of electrical conduction between the atria and ventricles of the heart). Further review revealed Resident #9 had a pacemaker implanted on 6/22/15 just under his/her skin on the left side of his/her chest. Pacemaker Maintenance Review of Resident #9's medical record revealed he/she underwent a surgical procedure on 7/31/25 to replace the pacemaker's generator (the part of the pacemaker that sends electrical impulses to the heart and contains the battery). Review of Resident #9's nursing note, dated 8/1/25, revealed the 7/31/25 surgical dressing was removed as ordered: . no redness or signs of infection . Resident #9 was seen at Alaska Heart and Vascular Institute on 8/7/25 for follow up. A nursing note, dated 8/7/25 at 11:07 AM, documented that: . heart and vascular states no restrictions and encourage resident to lift and move [his/her] left arm as usual and continue to monitor for infection otherwise come back in a year. Surgical Site Assessment, Change in Condition (CIC) Review of Resident #9's medical record revealed a CIC note entered by LN #11, dated 10/20/25 at 2:12 PM, which documented: The Change In Condition/s reported on this CIC Evaluation are/were: Change in skin color or condition. Last week incision was closed with steri strips [thin adhesive bandages], CDI [clean, dry, and intact], pink. Today noted 2 large scab[s] at incision and erythema [redness of the skin]. Light rash in surrounding area. Clean area with wound cleanse, pat dry, apply skin prep to edges. Reported to supervisor, who updated provider. Additional Skin/Wound Assessments after this CIC Review of Resident #9's nursing notes after this CIC, dated 10/20-23/25, revealed multiple nurses documented no concerns for infection to surgical site: - Nursing note by LN #15, dated 10/20/25 at 11:30 PM: Noted wound to left chest incision, it was noted dry, no drainage, no signs of infection noted, no swelling. Cleansed with wound cleanser then edges skin prepped. - CIC note by LN #18, dated 10/21/25 at 6:47 PM: Noted wound to left chest incision, no sign of any infection. No swelling or any drainage noted. - Nursing note by LN #15, dated 10/21/25 at 10:07 PM: COC [change of condition] follow up for redness to left upper chest incision site, redness improving, no swelling nor drainage noted. Cleansed with WC [wound cleanser] then left open to air, applied skin prep to edges. - CIC note by LN #11, dated 10/22/25 at 6:49 PM: Left chest incision treatment completed as ordered. Gently washed with wound cleanser, pat dry, and applied wound prep on the edges. Tolerated well, denies pain. No drainage noted. No rash noted. Erythema noted at incision site. Temp 97.8 [Fahrenheit]. - CIC note by LN #28, dated 10/23/25 at 3:55 AM: Left chest incision site was washed with wound cleanser, pat dry and applied wound prep on the edges, no drainage noted no s/s [signs and symptoms] of infection. Continue POC [plan of care]. - Nursing note by LN #31, dated 10/23/25 at 11:23 PM: COC: Incision site to L upper chest, redness. Site cleansed with wound cleanser, patted dry, and skin prep applied to peri-wound [tissue surrounding wound]. No drainage or s/s of infection noted. Will continue to monitor. Wound Care Nurse Note Review of Resident #9's nursing note, by WCN #2, dated 10/24/25 at 5:37 PM, revealed: . Resident seen bedside by [wound care] RN at request of ADON [Assistant Director of Nursing] due to concern for skin damage observed over recent hardware replacement site (per report: Pacemaker battery surgically replaced 3-4 weeks ago). Resident is up in bed, alert and oriented, consents to assessment and treatment. There is an area of engorged eschar [layer of dead tissue usually black in appearance] surrounded by blanchable [skin that turns pale when pressure is applied, suggesting normal blood circulation] erythema and dry skin. Hardware [pacemaker] is palpable [able to be felt] below wound and periwound. Unstable eschar erupts with gentle mechanical action and purulent exudate spontaneously erupts from around edges. Unstable eschar and purulent drainage are cleansed away with soak, revealing wound bed that is 90% slough [layer of dead tissue usually yellow, tan, or white in appearance], 5% pink tissue, and 5% unstable epithelial [made of cells, a type of tissue that covers many internal and external surfaces of the body] tissue. Wound measures 1.4cm x 2.2cm x UTD [unable to determine depth]. No other s/sx of acute infection observed. Wound RN recommends initiating empirical [derived from observation] administration of abx [antibiotics] and referral to cardiology. Cottage RN, Nursing Supervisor, and MD are made aware of findings and family is subsequently notified. Family strongly advocates for transport to ED [Emergency Department] for evaluation; this RN does not disagree. MD recommendation to begin Bactrim DS [an oral antibiotic] and to refer to cardiology, but does not disagree with family desire for medical evaluation this evening at ED. Treatment is initiated: Wound is cleansed with Vashe wound cleanser, allowed to dwell for 10 minutes. Bacitracin [a topical antibiotic ointment] is applied to wound and periwound. Covered with bordered foam. During an interview on 11/25/25 at 1:25 PM, LN #11 stated that he/she had cared for the resident for approximately four months and had seen the wound around the time the resident had his/her pacemaker battery replaced. Initially Resident #9 had some tenderness and some slight redness but nothing abnormal. There were steri strips over the site and sometimes the resident would have to be redirected because he/she would touch the area. LN #11 stated he/she had returned to work after being off for three days and found that the steri strips previously in place over the area were no longer there. LN #11 stated the wound was dehisced (meaning the edges of the wound had separated and the wound was open) and two scabs had formed. He/she notified his/her supervisor who recommended the change in condition reporting. The provider and Resident #9's nephew were notified about the change in condition, and orders for wound care were entered based on facility standing orders. During an interview on 11/26/25 at 10:06 AM, the Administrator stated when LN #11 had reported the wound change in condition, it did not seem severe enough at the time for an immediate wound team evaluation. The change in condition monitoring was in place, and nurses were to be monitoring the change. The wound team was brought in on 10/24/25 when it was felt the wound was getting worse. During an interview on 11/26/25 at 3:18 PM, Resident #9's Cardiologist stated that he was Resident #9's consulting Cardiologist when he/she was brought to the ED on 10/24/25 and his/her subsequent admission. Resident #9's Cardiologist stated Resident #9 had a history of an ongoing gall bladder infection and had been on steroids previously, which made him/her at high risk for infection. The bacteria in Resident #9's infected left chest wound came from the gall bladder, not from the skin. Cultures revealed gram negative organisms, consistent with the gall bladder infection. If the infection had come from the skin, he would have expected to see gram positive organisms. Resident #9's Cardiologist further stated that when Resident #9's left chest surgical site CIC was noted, the facility should've contacted [his office, Alaska Heart and Vascular Institute] immediately since the wound was dehisced. He reiterated that with any signs of possible infection, [his office] needs to be contacted as soon as possible. Review of Resident #9's medical record revealed he/she was transferred to Providence Alaska Medical Center on 10/24/25 and admitted . Review of Resident #9's Providence Alaska Medical Center records, dated 10/24/25 - 11/21/25, revealed that due to the advancement of the infection in the left chest implant site, Resident #9 had to have a second procedure on 11/4/25 to implant a new pacemaker on the right side of the chest. During this hospital stay, Resident #9 was diagnosed with . infected and broken down pacemaker pocket . and required negative pressure wound therapy (known as a wound vac) to help heal the wound where the previous pacemaker had been. The resident was hospitalized for 28 days. Review of the facility policy Skin and Wound Assessment, last revised 3/2025, revealed: . A licensed nurse (which can be the facility Wound Nurse) must assess/evaluate at least weekly each wound, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include . Identifying any possible complications or signs/symptoms consistent with the possibility of infection. It is understood that a resident may experience pain associated with the presence of a wound and/or any form of skin compromise. Therefore, the nursing staff shall be responsible to assess the resident for complaints of pain on assessment, prior to treatment, and as appropriate . Complaints of pain shall be documented in the resident's clinical record . Clinical interventions designed to alleviate the complaints of pain shall be administered by the nursing staff . The resident's response to the intervention shall be promptly assessed following its administration to validate its effectiveness and confirm that the resident's pain has been adequately alleviated[.] Both the intervention and the response to the intervention shall be documented in the resident's clinical record . Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's Order . Review of the facility policy Change in Condition, last revised 3/2025, revealed: .It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychological well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. If, at any time, it is recognized by any of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): . Any signs or symptoms of infection . New complaints of pain or worsening pain. The nurse will perform and document an assessment of the resident and identify need for additional interventions. The nurse will communicate the change to other departments as appropriate. nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgement and shall contact the physician based on the urgency of the situation.

.Based on record review and interview, the facility failed to: 1) Document the reason for resident discharges in the medical record for 3 long-term Residents (#'s 1, 6, and 9), out of 3 resident's reviewed. Specifically, the three residents were discharged without any documentation that showed the residents' welfare and the residents' needs could not be met in the facility; and 2) Document sufficient preparation and orientation to residents and/or resident representatives to ensure safe and orderly discharge from the facility for 3 long-term Residents (#'s 1, 6, and 9), out of 3 resident's reviewed. This failed practice resulted in inappropriate discharges and displaced these residents from a familiar environment that had been their home for years and placed them at risk for the undue stress of an unfamiliar environment and unknown staff, which could affect their overall health and well-being. Findings:Resident #1 Record review on 7/29/25 revealed Resident #1 was admitted to the facility on 5/2010 with diagnoses that included anoxic brain damage (brain injury that occurs when the brain is deprived of oxygen), persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings), and chronic respiratory failure (not enough oxygen or too much carbon dioxide in the body). Further review revealed Resident #1 had a tracheostomy (a surgical procedure that creates an opening in the front of the neck into the trachea to facilitate breathing) and was non-communicative. Review of Resident #1's Post-Transfer Notice of Facility-Initiated Transfer, dated 6/10/25, revealed: . This letter serves as written documentation that you were transferred from Polaris Extended Care [PEC] to Polaris Transitional Care [PTC] on June 3, 2025. Although you agreed to the transfer March 7, 2025, it was initiated by the facility, and therefore we are required to issue this notice . Reason for Transfer: This transfer was made to support continuity of care within our organization [and] access to more appropriate services . Further review revealed no identification of what the more appropriate services were at PTC that was not available at PEC. Review of Resident #1's Social Services Note, dated 3/7/25, revealed: LCSW [licensed clinical social worker] spoke with resident's guardian, [Office of Public Advocacy, OPA, Guardian #3] via phone regarding option to move resident from PEC to PTC to provide 24/7 nursing care for resident's tracheostomy needs. [OPA Guardian #3] verbalized consent for resident to move from PEC to PTC. Aforementioned relayed to the care team for coordination of care. Review of Resident #1's physician orders revealed an order, dated 6/3/25, May discharge to Polaris Transitional Care Center, which was 88 days after it was discussed with the guardian. Review of Resident #1's Discharge Summary and Post-Discharge Plan of Care, dated 6/3/25, revealed: Recapitulation of Resident's Stay: Reason for admission: Custodial/Long-Term Care Services. Treatment Provided: Other. Explain Other: Resident was here at Polaris Extended Care as a long term resident. Progress (include any complications): No recent complications noted. Resident's health status has been stable. Reason for discharge: Other . Explain: Resident is moving to sister Facility, Polaris Transitional Care . Further review revealed no documentation identifying the reason for Resident #1's discharge. Review of Resident #1's medical record, on 7/29/25, revealed no assessment that indicated what needs could not be met at PEC. Further review revealed no nursing note to indicate any concerns of needs not being met, or any change in status that indicated the resident's health and wellbeing was affected by any needs not being met prior to the transfer to PTC. Further review revealed no physician/provider note that reflected the bases for the transfer, specific resident needs that could not be met, facility attempts to meet the resident's needs, or services available at the receiving facility to meet the resident's needs. Discharge Planning Record review on 7/29/25 for Residents #1 revealed no documentation of a resident-centered discharge planning process, that involved the residents and resident representatives, for orientation to the new facility or preparation of this transition to another facility. Resident #6 Record review on 7/29/25 revealed Resident #6 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness or paralysis of the left side of the body following a stroke) and chronic respiratory failure. Further review revealed Resident #6 had a tracheostomy and was non-communicative. Review of Resident #6's Post-Transfer Notice of Facility-Initiated Transfer, dated 6/10/25, revealed: . This letter serves as written documentation that you were transferred from Polaris Extended Care [PEC] to Polaris Transitional Care [PTC] on June 3, 2025. Although you agreed to the transfer March 10, 2025, it was initiated by the facility, and therefore we are required to issue this notice . Reason for Transfer: This transfer was made to support continuity of care within our organization [and] access to more appropriate services . Further review revealed no identification of what the more appropriate services were at PTC that was not available at PEC. Review of Resident #6's Social Services Note, dated 3/7/25, revealed: LCSW attempted phone contact with resident's daughters/co-guardians . regarding option to move resident from PEC to PTC to provide 24/7 nursing care for resident's tracheostomy needs. No answer . Review of Resident #6's Social Services Note, dated 3/10/25, revealed: LCSW spoke with resident's daughter/guardian . and discussed option of resident admitting to PTC for 24/7 nursing care of resident's tracheostomy. [daughter] verbalized consent for move to PTC. Aforementioned relayed to PEC admissions team for coordination of care. Review of Resident #6's physician orders revealed an order, dated 6/3/25, May discharge to Polaris Transitional Care Center, which was 85 days after it was discussed with the guardian. Review of Resident #6's Discharge Summary and Post-Discharge Plan of Care, dated 6/3/25, revealed: Recapitulation of Resident's Stay: Reason for admission: Custodial/Long-Term Care Services. Treatment Provided: Other. Explain Other: Resident was here at Polaris Extended Care as a long term resident. Progress (include any complications): Resident is not on rehab. Reason for discharge: Other . Explain: Resident is moving to Polaris Transitional Care, a sister facility . Further review revealed no identification for the reason to discharge Resident #6, what services could not be met, or what PTC services would be provided that were not available at PEC. Review of Resident #6's medical record, on 7/29/25, revealed no assessment that indicated what needs could not be met at PEC. Further review revealed no nursing note to indicate any concerns of needs not being met, or any change in status that indicated the resident's health and wellbeing was affected by any needs not being met prior to the transfer to PTC. Further review revealed no physician/provider note that reflected the bases for the transfer, specific resident needs that could not be met, facility attempts to meet the resident's needs, or services available at the receiving facility to meet the resident's needs. Discharge Planning Record review on 7/29/25 for Residents #6 revealed no documentation of a resident-centered discharge planning process, that involved the residents and resident representatives, for orientation to the new facility or preparation of this transition to another facility. Resident #9 Record review Resident #9 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and chronic respiratory failure. Further review revealed Resident #9 had a tracheostomy and was non-communicative. Review of Resident #9's Post-Transfer Notice of Facility-Initiated Transfer, dated 6/10/25, revealed: . This letter serves as written documentation that you were transferred from Polaris Extended Care [PEC] to Polaris Transitional Care [PTC] on June 3, 2025. Although you agreed to the transfer March 7, 2025, it was initiated by the facility, and therefore we are required to issue this notice . Reason for Transfer: This transfer was made to support continuity of care within our organization [and] access to more appropriate services . Further review revealed no identification of what the more appropriate services were at PTC that was not available at PEC. Review of Resident #9's Social Services Note, dated 3/7/25, revealed: LCSW spoke with resident's health care agent . regarding for resident to move from PEC to PTC to receive 24/7 nursing care for his tracheostomy needs. [health care agent] verbalized consent for resident to move from PEC to PTC. LCSW attempted to discuss possible room move with resident. Resident was unable to verbally or nonverbally communicate with LCSW during SW [social worker] visit. All aforementioned relayed to the care team for coordination of care. Further review of Resident #9's medical record revealed a physician's order, dated 4/3/25, Transfer to Polaris Transitional Care 4/3/25, which was 27 days after it was discussed with the guardian (and not accurately documented in the transfer notice). Review of Resident #9's medical record revealed no Discharge Summary and Post-Discharge Plan of Care was available for review. During an interview on 7/29/25 at 12:58 PM, the Director of Community Liaison stated a Discharge Summary and Post-Discharge Plan of Care assessment could not be located in Resident #9's medical record. Review of Resident #9's medical record, on 7/29/25, revealed no assessment that indicated what needs could not be met at PEC. Further review revealed no nursing note to indicate any concerns of needs not being met, or any change in status that indicated the resident's health and wellbeing was affected by any needs not being met prior to the transfer to PTC. Further review revealed no physician/provider note reflecting the bases for the transfer, specific resident needs that could not be met, facility attempts to meet the resident's needs, or services available at the receiving facility to meet the resident's needs. Discharge Planning Record review on 7/29/25 for Residents #9 revealed no documentation of a resident-centered discharge planning process, that involved the residents and resident representatives, for orientation to the new facility or preparation of this transition to another facility. Facility Decision to Transfer Residents During an interview on 7/29/25 at 10:30 AM, the Administrator stated that PEC was a skilled nursing facility, and within staffing parameters, any resident could be accepted into the facility, except for residents with ventilators, extreme bariatric (overweight) needs, acute substance abuse, or who required one-on-one care at time of admission. The Administrator stated there was no limit to admission length. The Administrator further stated that PTC was also a skilled nursing facility and had the same exceptions with accepting residents. However, PTC had some bariatric rooms available. The Administrator stated the average length of stay at PTC was 100 days and depending on the level of care needed, the facility would look for alternative placements, if continued care was required. The Administrator stated there were some residents who were admitted for long-term stays. When asked if both long-term care facilities offered 24/7 nursing care, the Administrator stated, yes. The Administrator stated that PTC offered a different staffing scenario than the cottage-style environment of PEC. She further stated, PEC limited and/or delayed staff's help availability because they were separated in the cottages. Staff would have to walk over to another cottage if help was needed, where the halls of PTC made it possible to have a more immediate availability of staff help, if it was needed. During an interview on 7/29/25 at 10:30 AM, when asked how it was decided to move Residents #1, #6, and #9 from PEC to PTC, the Director of Community Liaison stated the previous Administrator decided to move the residents with tracheostomies due to staffing concerns to offer more consistent care. When asked if there was any indication that appropriate care was being affected or disrupted due to these staffing concerns prior to the transfer of these three residents with tracheostomies, the Director of Community Liaison stated, no there was no proof care was not being provided. During an interview on 7/29/25 at 10:30 AM, the Assistant Director stated because PEC was having staffing concerns, there were times that cottages were split between nurses causing one nurse to cover more than one cottage. This caused nurses to have to leave their assigned cottage and go to another cottage for a time to care for other residents. The decision to move the residents with tracheostomies to PTC was for more consistent nursing availability. During an interview on 7/29/25 at 10:45 PM, Regional Representative (RR) #3 stated when he consulted with the previous Administrator about staffing concerns, they identified that the residents with tracheostomies were more medically acute and required more care. Splitting cottages due to staffing issues at PEC prompted discussion on how to provide for these more medically acute residents on a more consistent basis. RR #3 stated during these discussions, there was an idea to possibly move the more medically acute residents into one cottage for a higher level of care and staff that cottage accordingly, with two Certified Nursing Assistants (CNAs) and one Licensed Nurse (LN). He further stated, that was just an idea and was never attempted. RR #3 stated the facility's decision to move the residents with tracheostomies was based on a mitigation plan, to avoid any potential adverse reactions due to staffing concerns because of a potential risk of not being able to meet their needs. When asked if there was any indication that appropriate care was being affected or disrupted due to these staffing concerns prior to the transfer of these three residents with tracheostomies, RR #3 stated there was no indication that their care was not being provided. RR #3 stated the needs were being met but there was a potential for risk of adverse reactions and that was why they were transferred. During an interview on 7/29/25 at 2:25 PM, the Medical Director (MD) stated the Administrator's decision to move the residents with tracheostomies was to organize things better and get these residents all in one place for more consistent care. The MD stated it was the Administrator's decision, and he was not provided with the opportunity to have an input on the decision. When asked if there was any indication that appropriate care was being affected or disrupted prior to the transfer of these three residents with tracheostomies, the MD stated he had not heard of any concerns with care not being provided at PEC. Facility Assessments PEC Assessment Review of Polaris Extended Care Facility Assessment, dated 2025, revealed: 1. Facility Capacity and Census: - Capacity: Our facility is licensed to provide care for 96 residents. The actual maximum number of residents allowable may be less at times to accommodate for safety resident care needs. - Resident Population Profile: . We accept residents with or residents that may develop the following common diseases, conditions, physical and cognitive disabilities, or combination conditions that may require complex medical care and management . Conditions that are not able to be cared for or services that cannot be provided are identified as Exception in the sections below . Common Diseases and Conditions . Nervous System . altered mental status . traumatic or anoxic brain injury . hemiparesis/hemiplegia . Respiratory System . Acute and chronic respiratory failure . tracheostomy . Exception: new tracheostomy; ventilators . - Acuity: Our facility reviews our residents' acuity levels to understand potential implications regarding the intensity and complexity of care and services needed . Our facility assessment includes an evaluation of the overall number of facility staff needed to ensure enough qualified staff are available to meet each resident's needs as identified through resident assessments and care plans . 2. Services and Care We Offer Based on Residents' Needs: . Respiratory Treatments . Tracheostomy care . - Resident Support/Care Needs: Our facility cares or many different residents with various types of care needs. The list below identifies the most common or frequently provided services in these general categories . Activities of Daily Living; Mobility and Fall/Fall with Injury Prevention; Bowel/Bladder; Skin Integrity; Mental Health and Behavior; Medications; Pain Management; Infection Prevention and Control; Management of Medical Conditions; Other Special Care Needs . tracheostomy care . Nutrition; Provided Person Centered/Directed Care including Psycho/Social/Spiritual Support . 3. Facility Resources Needed: Day to Day and During Emergencies: - Facility Description: Our facility is a 116,460 square foot nursing facility consisting of 8 cottages, 8 courtyards, and common's building . - Facility Staff: . Below is a list of staff identified as needed to care for our resident population and provide services as full-time, part-time, or PRN [as needed] employees in the facility unless indicated as remote, a community partner, or contracted through an outside entity, or a community partner . Nursing . Certified Nursing Assistant; Hospitality Aide; Registered Nurse; Licensed Practical Nurse [LPN] . Therapy Services: Director of Therapy; Assistant Director of Therapy; Occupational Therapy . Physical Therapy . Speech Language Pathologist; Wellness Aides . Medical, Physician, and Advanced Roles . Medical Director (contracted); Attending Physician (contracted); Nurse Practitioner (contracted) . Pulmonologist (community partner) . PTC Assessment Review of Polaris Transitional Care Facility Assessment, dated 2025, revealed there were no additional services that were provided, which PEC did not offer. The facility assessment capabilities were identical in each facility. Quality Assurance and Performance Improvement (QAPI) Oversight During an interview on 7/29/25 at 10:30 AM, the Director of Community Liaison stated that the staffing concerns were being discussed in QAPI, and this prompted the discussion to move the residents with tracheostomies. Review of the facility's QAPI meeting PowerPoint presentations, dated 3/2025 and 6/2025, revealed no documentation of meeting minutes were associated, to indicate what was discussed concerning what was presented. Further review revealed on the PowerPoint presentations, dated 5/2025 and 6/2025, revealed an Area of Focus that documented: Acuity: Acuity-based room changes to ensure the safest, most effective care environment for all residents, supporting clinical needs & promoting quality outcomes. There was no documentation provided by the facility, or that could be found in the medical records, to show these room changes were attempted for more effective care, to attempt to meet their needs, prior to the transfer of the residents with tracheostomies. During an interview on 7/29/25 at 3:00 PM, the Administrator stated the QAPI meeting PowerPoint presentations reflected data collected from different departments of the facility for each meeting held. The Administrator stated there were copies of the PowerPoint presentations that were shown during the meetings. However, there were no meeting minutes that reflected what the facility was going to do with the data presented in the presentations. When asked to present any documentation from Leadership which documented any planning for staffing concerns, Leadership presented a QAPI Follow-Up Summary: Acuity Management - Trach [Tracheostomy] Resident Transfers from PEC to PTC, dated 3/28/25, which revealed: - . During recent QAPI discussions, it was noted that Polaris Extended Care (PEC) continues to experience challenges related to staffing coverage, particularly due to its cottage-style layout, which limits nursing accessibility across units. While PEC is fully equipped to provide skilled nursing care, the physical separation of its cottages contributes to increased strain on staff, especially when managing residents with complex respiratory needs such as tracheostomies. Polaris Transitional Care (PTC), by contrast, has a connected-unit layout that allows for easier nurse access, cross-coverage, and resource sharing. With stabilized staffing levels at PTC, there is an opportunity they are medically stable and meet appropriate criteria. - .Assessment: PEC currently houses several trach residents who require intermittent skilled respiratory care but are otherwise clinically stable. The physical layout of PEC creates delays in nurse response and limits efficiency in managing high-acuity residents during staffing shortages. PTC has available capacity, stable staffing, and physical infrastructure more suited for prompt clinical response and skilled oversight of trach residents. - .Recommendation: - Identify Candidates: Conduct a focused review of all PEC residents with tracheostomies to determine clinical stability and potential for safe transition. - Obtain Consent: Contact resident's families and/or legal guardians to obtain informed consent for transfer, ensuring transparency and inclusion in care decisions. - Clinical Approval: Ensure clinical approval from PTC nursing leadership prior to any transfer to verify unit readiness, appropriateness of placement, and to ensure safe handoff. - Coordinate Transfer: Collaborate with therapy, providers, social services, and the admission team to plan and document transfers appropriately. - Care Plan Updates: Revised care plans, respiratory protocols, and nursing assignments to reflect updates resident location and needs. - Reevaluation Plan: Reevaluate each resident's potential return to PEC if/when staffing rations stabilize and that setting and based on ongoing assessment of individual care needs and appropriate placement. During an interview on 7/29/25 at 3:50 PM, the Assistant Director stated this QAPI Follow-Up Summary, dated 3/28/25, was the only additional documentation leadership could find regarding the planning of staffing for the decision to transfer Residents #1, #6, and #9. Review of resident medical records and facility-provided documentation, on 7/29/25, revealed the following discrepancies with the a QAPI Follow-Up Summary: Acuity Management - Trach [Tracheostomy] Resident Transfers from PEC to PTC, dated 3/28/25, presented: 1. Identify Candidates: A focused review of all PEC residents with tracheostomies to determine clinical stability and potential for safe transition was not presented by the facility or found in the medical records. 2. Obtain consent: Consent for transferring the residents was obtained from guardians on 3/7/25 and 3/10/25, 18 days prior to the 3/28/25 Follow-Up summary was created. 3. Clinical Approval: This Ensure clinical approval from PTC nursing leadership prior to any transfer to verify unit readiness, appropriateness of placement, and to ensure safe handoff was not presented by the facility or found in the medical record. 4. Coordinate Transfer: The Collaborate with therapy, providers, social services, and the admission team to plan and document transfers appropriately was not presented by the facility or found in the medical records. 5. Care Plan Updates: Review of both facility's care plans and respiratory protocols revealed the following: Resident #1 PEC Review of the PEC physician orders revealed the following orders for tracheostomy care, date 3/1/25: - Provide trach [tracheostomy] care [every] shift.- Trach Care: Change trach ties daily. Every day shift for per protocol.- Trach Care: Check trach placement every 2 hours.- Trach Care: Trach suctioning PRN [as needed].- Trach Care: Change trach every 6 weeks.- Trach care: Take pulse TID [three times a day]. Review of the PEC physician orders revealed the following orders for tracheostomy care, date 3/3/25: - 03 Treatment: O2: O2 via [by] trach mask only. Apply PRN to keep O2 [oxygen] Sat [oxygen saturation - how much oxygen is in the blood] greater than 90%. Use 2 LPM [liters per minute]; may increase to 4 LPM if needed.- Treatment: Change Trach tubing every 2 weeks. Frequency: Duration: x 14 days. Review of Resident #1's PEC care plan, which was initiated on 2/20/25 with a next review date of 8/11/25, revealed there was a focus problem for Potential for alteration in respiratory function. Has tracheostomy r/t [related to] impaired breathing mechanics, anoxic brain damage, persistent vegetative state, chronic respiratory failure and had interventions of: - Administer oxygen as ordered;- Assess for [signs and symptoms] of hypoxia [low levels of oxygen in the body tissues]: altered level of consciousness, irritability, listlessness [having little or no interest in anything], cyanosis [bluish discoloration of the skin, lips, or nails due to a lack of oxygen in the blood];- Keep extra trach tube and obturator [an olive-tipped curved rod that is used to guide the outer trach cannula and prevent scraping of the tracheal walls while the tube is being inserted] at bedside. If tube is coughed out, notify RT [Respiratory Therapy] immediately. If tube cannot be reinserted, monitor for signs of respiratory distress. Use pediatric mask over stoma to ventilate. Elevate HOB [head of bed] 45 degrees and stay with resident - obtain medical help immediately;- Maintain spare trach at the bedside;- Monitor/document respiratory rate, depth and quality. Check and document [every] shift as ordered;- Monitor/document/report to MD PRN any [signs and symptoms] of: upper respiratory infection, pneumonia, atelectasis [collapse of a lung or part of a lung], decreased cardiac output [where the heart is unable to pump enough blood to meet the body's needs], pneumothorax [collapsed lung], SIADH [Syndrome of Inappropriate Antidiuretic Hormone - a condition characterized by the excessive secretion of antidiuretic hormone (ADH). Symptoms include confusion, seizures, and muscle cramps], decreased renal perfusion [low urine output], increased intracranial pressure [pressure that builds up inside the skull], hepatic congestion [diffuse venous congestion within the liver];- Tracheostomy care; and- Use Enhanced Barrier Precautions [a set of infection control practices designed to reduce the transmission of multi-drug resistant organisms (MDROs)]. PTC Review of the PTC physician orders revealed the following orders for tracheostomy care, date 6/3/25: - Provide trach care every shift.- Trach Care: Change trach ties daily and as needed.- Trach Care: Check trach placement every 2 hours.- Trach Care: Trach suctioning as needed.- Take pulse oximetry [O2 sats] every shift for trach care.- Use tracheostomy pad on back of neck every shift for wound prophylaxis [prevention].- Trach care info: Type: Bivona, Size: I.D. = 7.0- Treatment: O2: O2 via trach mask only. Apply PRN to keep O2 sat greater than 90%. Use 2 LPM. May increase to 4 LPM if needed. 6/4/25:- Trach care: Change trach every 6 weeks. (Type: Bivona Size: I.D. = 7.0). 6/5/25:- Humidified mist [moistened oxygen] to tracheostomy. Change tubing and chamber kit, trach mask, mask interface adapter and filter every month. Review of the PTC care plan, which was initiated on 6/3/25 with a next review date of 9/1/25, revealed there was a focus problem Has Tracheostomy [related to] late effects anoxic brain injury and had interventions of: - Administer oxygen as ordered;- Assess for [signs and symptoms] of hypoxia: altered level of consciousness, irritability, listlessness, cyanosis;- Ensure that trach ties are secured at all times;- Give humidified oxygen as prescribed;- Keep extra trach tube and obturator at bedside. If tube is coughed out, notify RT immediately. If tube cannot be reinserted, monitor for signs of respiratory distress. Use pediatric mask over stoma to ventilate. Elevate HOB [head of bed] 45 degrees and stay with resident - obtain medical help immediately;- Maintain spare trach at the bedside;- Monitor for changes in respiratory rate or depth. Observe/document for use of accessory muscles. Notify MD of significant changes;- Monitor/document for restlessness, agitation, confusion, increased heart rate (Tachycardia), and bradycardia [slow heart rate];- Monitor/document respiratory rate, depth, and quality. Check and document [every] shift/as ordered;- Monitor/document/report to MD PRN any [signs and symptoms] of: upper respiratory infection, pneumonia, atelectasis, decreased cardiac output, pneumothorax, SIADH, decreased renal perfusion, increased intracranial pressure, hepatic congestion;- Provide good oral care daily and PRN;- Reassure resident to decrease anxiety;- Suction as necessary;- Tracheostomy care;- Use Enhanced Barrier Precautions; and- Use standard precautions. Assist with coughing as needed. Further review of Resident #1's PTC care plan revealed no complex respiratory care needs, or intermittent skilled respiratory care, as documented on the QAPI Follow-Up summary provided by the facility, that was not being provided at PEC. Resident #6 PEC Review of the PEC physician orders revealed the following orders for tracheostomy care, date 2/26/25: - Trach Care; Routine trach care with suctioning per policy every shift. Every 8 hours and as needed.- Trach care: Check trach placement every 2 hours. Review of the PEC physician orders revealed the following orders for tracheostomy care, date 2/27/25: - Trach care: Change trach ties daily every shift.- Treatment: Change trach every 6 weeks.- Trach care: Take Pulse OX TID.- O2: Supplemental oxygen 2 LPM via trach, humidified[.] Frequency: O2 PRN for SOB, history of stroke, trach dependent, chronic respirator to maintain SPO2 above 92% and for SOB, Dyspnea.- Treatment: Change trach tubing every 2 weeks.- Treatment: Change [trach] inner cannula two times a day.- Trach care; Monitor aerosol waterbag [a container with a valve that allows water to be released for humidification] every shift; change [ever] 2 weeks (label with initials [and] sate opened). Review of Resident #6's PEC care plan, which was initiated on 1/24/25 with a next review date of 10/7/25, revealed there was a focus problem At risk for altered breathing pattern and Had Tracheostomy [related to] Impaired breathing mechanics. Other contributing factors may include [diagnosis] of CVA [Cerebrovascular Accident - stroke] with hemiplegia, Chronic Respiratory failure with interventions of: - Administer oxygen as ordered;- Assess for [signs and symptoms] of hypoxia: altered level of consciousness, irritability, listlessness, cyanosis;- Keep extra trach tube and obturator at bedside. If tube is coughed out, notify RT immediately. If tube cannot be reinserted, monitor for signs of respiratory distress. Use pediatric mask over stoma to ventilate. Elevate HOB [head of bed] 45 degrees and stay with resident - obtain medical help immediately;- Keep head of bed elevated above 30 degrees unless providing care or resident request;- Maintain spare trach at the bedside;- Monitor/document respiratory rate or depth. Observe/document for use of accessory muscles. Notify MD or significant changes.- Monitor/document/report to MD PRN any [signs and symptoms] of: upper respiratory infection, pneumonia, atelectasis, decreased cardiac output, pneumothorax, SIADH, decreased renal perfusion, increased intracranial pressure, hepatic congestion;- Provide good oral care daily and PRN;- Trach care as ordered; and- Use Enhanced Barrier Precautions. PTC Review of the PTC physician orders revealed the following orders for tracheostomy care, date 6/3/25: - Trach care: Routine trach care with suctioning every shift.- Trach care: Change trach ties daily every day shift for per facility policy.- Tr[TRUNCATED]

.Based on record review and interview, the facility failed to: 1) Provide a written notice of transfer/discharge, by the facility, at least 30 days before the resident was transferred or discharged for 3 Residents (#'s 1, 6 and 9), out of 3 residents reviewed for transfer/discharge; and 2) Ensure the contents of the notice of transfer/discharge followed regulation requirements. These failed practices denied the resident and/or resident representative appeal rights information that include: 1) The name, address (mailing and email), and telephone number of the entity which receives such requests; 2) Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; 3) The name, address (mailing and email) of the State Long-Term Care Ombudsman; and 4) the mailing and email address of the Alaska Disability Law Center responsible for the protection and advocacy of individuals with a mental disorders. Not providing all required information within the required timeframe violated the resident's right to appeal prior to the transfer/discharge if so desired. Findings:30-Day Timeline Requirement Resident #1 Record review on 7/29/25 revealed Resident #1 was admitted to the facility May 2010 with diagnoses that included anoxic brain damage (brain injury that occurs when the brain is deprived of oxygen), persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings), and chronic respiratory failure (not enough oxygen or too much carbon dioxide in the body). Further review revealed Resident #1 had a tracheostomy (a surgical procedure that creates an opening in the front of the neck into the trachea to facilitate breathing) and was non-communicative. Review of Resident #1's Post-Transfer Notice of Facility-Initiated Transfer, dated 6/10/25, revealed: . This letter serves as written documentation that you were transferred from Polaris Extended Care [PEC] to Polaris Transitional Care [PTC] on June 3, 2025. Although you agreed to the transfer March 7, 2025, it was initiated by the facility, and therefore we are required to issue this notice . While this letter is being provided after the transfer occurred, we are issuing it now to ensure accurate documentation and communication with you and the Long-Term Care Ombudsman. Reason for Transfer: This transfer was made to support continuity of care within our organization [and] access to more appropriate services. Your Rights: You retain the right to: Appeal the transfer decision. Contact the Long-Term Care Ombudsman (907-334-4480) or Alaska Disability Law Center (907-565-1002) for advocacy or concerns. We apologize for the delay in issuing this formal notice and remain committed to ensuring your rights and well-being are respected at every step of your care . Review of Resident #1's Social Services Note, dated 3/7/25, revealed: LCSW [licensed clinical social worker] spoke with resident's guardian, [Office of Public Advocacy, OPA, Guardian #3] via phone regarding option to move resident from PEC to PTC to provide 24/7 nursing care for resident's tracheostomy needs. [OPA Guardian #3] verbalized consent for resident to move from PEC to PTC. Aforementioned relayed to the care team for coordination of care. Review of Resident #1's physician orders revealed an order, dated 6/3/25, May discharge to Polaris Transitional Care Center, which was 88 days after it was discussed with the guardian. Resident #6 Record review on 7/29/25 revealed Resident #6 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness or paralysis of the left side of the body following a stroke) and chronic respiratory failure. Further review revealed Resident #6 had a tracheostomy and was non-communicative. Review of Resident #6's Post-Transfer Notice of Facility-Initiated Transfer, dated 6/10/25, revealed: . This letter serves as written documentation that you were transferred from Polaris Extended Care [PEC] to Polaris Transitional Care [PTC] on June 3, 2025. Although you agreed to the transfer March 10, 2025, it was initiated by the facility, and therefore we are required to issue this notice . While this letter is being provided after the transfer occurred, we are issuing it now to ensure accurate documentation and communication with you and the Long-Term Care Ombudsman. Reason for Transfer: This transfer was made to support continuity of care within our organization [and] access to more appropriate services. Your Rights: You retain the right to: Appeal the transfer decision. Contact the Long-Term Care Ombudsman (907-334-4480) or Alaska Disability Law Center (907-565-1002) for advocacy or concerns. We apologize for the delay in issuing this formal notice and remain committed to ensuring your rights and well-being are respected at every step of your care . Review of Resident #6's Social Services Note, dated 3/7/25, revealed: LCSW attempted phone contact with resident's daughters/co-guardians . regarding option to move resident from PEC to PTC to provide 24/7 nursing care for resident's tracheostomy needs. No answer . Review of Resident #6's Social Services Note, dated 3/10/25, revealed: LCSW spoke with resident's daughter/guardian . and discussed option of resident admitting to PTC for 24/7 nursing care of resident's tracheostomy. [daughter] verbalized consent for move to PTC. Aforementioned relayed to PEC admissions team for coordination of care. Review of Resident #6's physician orders revealed an order, dated 6/3/25, May discharge to Polaris Transitional Care Center, which was 85 days after it was discussed with the guardian. Resident #9 Record review Resident #9 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and chronic respiratory failure. Further review revealed Resident #9 had a tracheostomy and was non-communicative. Review of Resident #9's Post-Transfer Notice of Facility-Initiated Transfer, dated 6/10/25, revealed: . This letter serves as written documentation that you were transferred from Polaris Extended Care [PEC] to Polaris Transitional Care [PTC] on June 3, 2025. Although you agreed to the transfer March 7, 2025, it was initiated by the facility, and therefore we are required to issue this notice . While this letter is being provided after the transfer occurred, we are issuing it now to ensure accurate documentation and communication with you and the Long-Term Care Ombudsman. Reason for Transfer: This transfer was made to support continuity of care within our organization [and] access to more appropriate services. Your Rights: You retain the right to: Appeal the transfer decision. Contact the Long-Term Care Ombudsman (907-334-4480) or Alaska Disability Law Center (907-565-1002) for advocacy or concerns. We apologize for the delay in issuing this formal notice and remain committed to ensuring your rights and well-being are respected at every step of your care . Review of Resident #9's Social Services Note, dated 3/7/25, revealed: LCSW spoke with resident's health care agent . regarding for resident to move from PEC to PTC to receive 24/7 nursing care for his tracheostomy needs. [health care agent] verbalized consent for resident to move from PEC to PTC. LCSW attempted to discuss possible room move with resident. Resident was unable to verbally or nonverbally communicate with LCSW during SW [social worker] visit. All aforementioned relayed to the care team for coordination of care. Further review of Resident #9's medical record revealed a physician's order, dated 4/3/25, Transfer to Polaris Transitional Care 4/3/25, which was 27 days after it was discussed with the guardian (and not accurately documented in the transfer notice). Notice to The Long-Term Care Ombudsman Review of the Notification of Facility-Initiated Transfer Between Campuses letters, dated 6/10/25 and sent to the Long-Term Care Ombudsman's office, revealed: We are writing to notify you of a recent facility-initiated transfer involving [Resident #'s 1, 6, and 9 had a separate letter with the exact same verbiage]. The transfer occurred between two licensed units within our organization - Polaris Extended Care and Polaris Transitional Care . We acknowledge that per CMS regulations, a 30-day written notice is required for facility-initiated discharges and transfers. In this instance, that process was not completed in advance of the move. We recognize this oversight and want to affirm our commitment to adhering to all CMS and state requirements moving forward, including the timely issuance of proper notifications . Facility Correction During an interview on 7/29/25 at 10:45 AM, Regional Representative #3 stated that after Resident #'s 1, 6, and 9 were transferred to Polaris Transitional Care, facility leadership became aware that the 30-day notice to the residents and/or resident representatives did not get completed. On 6/10/25, notification letters were sent to the resident representatives and the State of Alaska Long-Term Care Ombudsman office was made aware of the oversight. Regional Representative #3 further stated that the previous facility Administrator was re-educated on the proper notification requirements so the oversight would not happen again. During an interview on 7/29/25 at 3:50 PM, when asked what the date of the Administrator's re-education was, the Director of Community Liaison stated it was completed on 6/10/25. Review of the facility policy Resident Rights and Responsibilities, revised on 4/2025, revealed: . The facility will inform the resident of their rights and responsibilities in a language that is both clear and understandable to the resident . Review of the facility-provided Nursing Home Residents' Rights, a hand-out that was in the facility's admission packet and undated, revealed: Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to ‘promote and protect the rights of each resident' . Rights During Discharge/Transfer: Right to appeal the proposed transfer or discharge and not be discharged while an appeal is pending. Receive 30-day written notice of discharge or transfer that includes: the reason; the effective date; the location going to; appeal rights and process for filing an appeal; and the name and contact information for the long-term care ombudsman . Review of the facility policy Criteria for Transfer and Discharge, revised on 4/2025, revealed: . When the Facility transfers or discharges a resident, the Facility shall ensure that the transfer or discharge is documented in the resident's medical record . Procedure .Prior to transfer or discharge, the Facility shall notify the resident and the resident's representative of the transfer or discharge and the reason for the transfer or discharge in writing in a language and manner they understand. The facility shall send a copy of the notice to the State Long-Term Care Ombudsman. The notice shall be made at least 30 days before the resident is transferred or discharged or as soon as practicable before the transfer or discharge when: The safety or health of individuals in the facility would be endangered; the resident's health improves to allow a more immediate transfer or discharge; An immediate transfer or discharge is required by the resident's urgent needs; or A resident has not resided in the facility for 30 days. Content of Transfer/Discharge Notice Record review on 7/29/25 revealed the Post-Transfer Notice of Facility-Initiated Transfer, dated 6/10/25 and sent to Resident #'s 1, 6, and 9 and their representatives, failed to include: 1) The name, address (mailing and email), and telephone number of the entity which receives such requests; 2) Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; 3) The name, address (mailing and email) of the State Long-Term Care Ombudsman; and 4) the mailing and email address of the Alaska Disability Law Center responsible for the protection and advocacy of individuals with a mental disorders. Review of the facility policy Criteria for Transfer and Discharge, revised 5/2025, revealed: . Prior to the transfer or discharge, the Facility shall notify the resident and the resident's representative of the transfer or discharge and the reason for the transfer or discharge in a language and manner they understand . The notice shall include the following: The reason for the transfer or discharge; The effective date of transfer or discharge; The location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and email), and entity which receives the requests; Information on how to obtain an appeal form and assistance in completing and submitting this hearing request; Name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; Provide the agency name, address (mailing and email) for residents with special needs (e.g., agency for protection/advocacy for individuals with intellectual and developmental disabilities or agency for protection/advocacy for individuals with mental disorders or related disabilities) .

.Based on record review and interview, the facility failed to report an allegation of abuse to the State Agency as required under CFR 483.12(c)(1). Not reporting 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 at risk for future exposure to potential abuse. Findings:A review of a report, that was received from The Office of Long-Term Care Ombudsman (OLTCO) on 6/12/25, revealed the facility submitted a report of alleged abuse to Adult Protective Services (APS) involving Certified Nursing Assistant (CNA) #4 against Resident #10 on 5/24/25. Further review of the APS report revealed the incident occurred on 4/15/25. However, the facility leadership was only made aware of the incident on 5/24/25, who submitted the initial report to APS without notifying the State Agency. During an interview on 7/15/25 at 9:37 AM, the Director of Nursing (DON) stated on 5/24/25 CNA #9 informed leadership about an incident on 4/15/25 that he/she witnessed. The DON state CNA #9 stated he/she witnessed CNA #4 strike Resident #10 on the shoulder telling the resident he/she should not have peed [his/her] pants. When leadership questioned why CNA #9 didn't report this on the day of the incident, the DON stated CNA #9 stated he/she reported it to the nurse working day shift that day, which he/she identified as LN #6. When asked who the DON reported the incident to, the DON stated he reported it to APS. The DON stated he did not send the initial report to the State Agency on 5/24/25, however, he did send the final report to the State Agency on 5/29/25 at 4:20 PM using the email complaintcoordinator@alaska.gov. Review of the email sent to the State Agency, dated 5/29/25 at 4:21 PM, revealed: Initial and final report attached. APS report submitted on 5/24 within two-hour timeframe. Further review of the State Agency email complaintcoordinator@alaska.gov revealed no email from the facility with the initial report was sent on 5/24/25. The State Agency was only made aware of this allegation on 6/12/25 when the OLTCO report was received because the complaintcoordinator@alaska.gov email was the incorrect email for the facility to use for reporting and was not monitored for reports. Review of the State of Alaska, Department of Health Complaint Form - Instructions for Filing a Complaint, at https://health.alaska.gov/en/division-of-health-care-services/health-facilities-licensing/ revealed the correct email address to send complaints was listed as DHCS.HFLC@hss.soa.direct.net. Review of the facility policy, Reporting Alleged Violations of Abuse, Neglect, Exploitation, or Mistreatment, dated 4/2025, revealed: . Procedure: In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: Not later than two (2) hours after the allegation is made if the events that cause the allegation involved abuse or results in serious bodily injury . Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: The Administrator of the Facility, The State Survey Agency; Adult Protective Services (as appropriate) . Ensure that the results of all investigations are reported within five (5) working days of the incident to: The Administrator and The State Survey Agency .

Based on record review, interview, and observation, the facility failed to protect the residents right to be from neglect for 3 sampled resident (#'s 40, 47, and 70), out of 21 sampled residents, and 1 unsampled resident (#56). Specifically, the facility failed to ensure provisions of goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress were provided: 1) Activities of Daily Living (ADLs - the skills of bathing, dressing, toileting, transferring, bed mobility, and eating) were completed and/or completed in a timely manner to meet the needs of 1 resident (#40); 2) Medications were available for administration as ordered 2 residents (#47 and #56); and 3) Appropriate, timely treatment for a possible urinary tract infection (UTI) for 1 resident (#70). This failed practice: 1) placed Resident #40 at risk for psychological harm and/or physical harm and a less-than-optimal environment that ensured the resident was able to maintain their highest practical well-being; 2) placed Residents #47 and #56 at risk of possible serious complications and hospitalization; and 3) left Resident #70 with UTI symptoms for over a month despite repeated requests for answers and possible treatment from the resident which resulted in continued pain and discomfort. Findings: Activities of Daily Living Resident #40 Record review on 5/18-22/25 revealed Resident #40 was admitted to the facility with diagnoses that included morbid obesity, coronary artery disease, heart failure, hypertension, end stage renal disease and diabetes mellitus. Review of Resident #40's Minimum Data Set (MDS - a federally required nursing assessment) annual assessment, dated 6/27/24, revealed showering, bed bath, or sponge bath were very important to Resident #40. Resident #40 required setup or clean-up assistance during oral care. Review of Resident #40's MDS quarterly assessment, dated 3/11/25, revealed Resident #40 had an impairment of the lower limbs and required wheelchair transportation, always incontinent of bladder and bowel, and at risk for pressure ulcers. Resident #40 required assistance for his/her shower transfers. Review of Resident #40's Care Plan Report, dated 4/15/25, revealed .MY GOAL IS TO: . feel comfortable and safe, give me time to do tasks. ADL Self Care Performance r/t [related to] Cognitive deficit, Limited Mobility. Interventions/Tasks. TOILET USE (TOILET TRANSFER, TOLIET HYGIENE): Requires 1 person providing more than half the effort . BED MOBILITY. Requires 1-2 people providing more than half the effort.BATHING. Shower days: Tuesday day and Friday evening. PERSONAL HYGIENE/ORAL CARE (ORAL HYGIENE): SET UP ASSIST . I need my aides to help me brush.I HAVE: the potential to feel anxious, scared/fearful. WHEN I FEEL THIS WAY I: . feel down or depressed. MY GOAL IS TO: feel. safe and secure, participate in my care, make decisions about my daily routine. Offer me choices ask me how I am feeling today. During an interview on 5/18/25 at 8:35 AM, Certified Nurse Assistant (CNA) #2 stated he/she was the only CNA scheduled in the Deshka cottage. CNA #2 further stated from 3:30 PM to 7:00 PM on 5/18/25, he/she had to cover the Kenai cottage while covering the Deshka cottage because there was not enough staff. CNA #2 stated he/she was concerned how all residents would be cared for. CNA #2 stated there were two residents in the Deshka cottage that required feeding assistance and would be required to wait longer than normal. During an interview on 5/18/25 at 1:06 PM, Resident #40 stated he/she was unable to brush his/her teeth when requested. Resident #40 stated staff was not available to gather his/her supplies. Resident #40 further stated that he/she could not get to the toilet independently so he/she would often have episodes of incontinence. Resident #40 stated that he/she had to wait 1 hour and 45 minutes for staff to come and provide perineal care after he/she pressed the call light. Resident #40 further stated he/she had not received a shower for 1 ½ months due to not enough staff. Resident #40 stated it required two CNAs to transfer him/her out of bed. During an interview on 5/19/25 at 8:20 AM, CNA #2 stated Resident #40 was last showered about 2 months ago. CNA #2 further stated Resident #40 was transferred to the shower by the ceiling lift and required two staff members to complete a safe transfer. CNA #2 stated he/she does not always have a second staff member to assist. During an interview on 5/20/25 at 1:40 PM, the MDS Coordinator (MC) reviewed Resident #40's care plan. The MC stated Resident #40 required one or two staff to complete the transfer with the use of the ceiling lift based on their comfort level and ability. The MC further stated Resident #40's current weight on 5/13/25 was 278 pounds. Review of Resident #40's Documentation Survey Report. Task Only, dated March 2025, revealed from 3/1/25 to 3/31/25; - No showers were documented as successfully completed; - Oral Hygiene- was only documented on three days: 3/3/25, 3/17/25 and 3/19/25, and; - Personal Hygiene- was only documented on the following days: 3/3/25, 3/11/25, 3/16-19/25. Review of Resident #40's Documentation Survey Report . Task Only, dated April 2025, revealed from 4/1-30/25;Tub/shower transfer occurred on two occasions. Review of Resident #40's Task: Bathing, dated 5/1-20/25, revealed . 5/17/25 [at] 00:01. Shower. No other showers were documented as successfully completed. During an interview on 5/22/25 at 2:15 PM, Resident #40 smiled and stated he/she received a shower two days ago. Resident #40 stated when he/she did not receive a shower over the past 2 months, he/she felt uncomfortable. Resident #40 further stated he/she felt down because there was not enough help and I just cry and go to sleep. During an interview on 5/22/25 at 3:30 PM, Physical Therapist (PT) #1 stated when operating a ceiling lift, one to two staff members were required. When PT #1 was asked how many staff members were required to transfer Resident #40 out of bed, PT #1 stated if Resident #40 requested two staff members or the staff member operating the lift did not feel comfortable alone, then the transfer required two staff members. Review of the facility's policy PEC/PTCC [Polaris Extended Care/Polaris Transitional Care Center] Anchorage Long Term Care STANDARDS OF CARE, dated 12/2024, revealed: . AM CARE (EVERY MORNING): Hands and face washed, Toilet & Peri Care. Oral Care. H.S. [bedtime] CARE (EVERY HS AT BEDTIME): Hands and face washed, Toilet & Peri Care. Oral Care. BEFORE MEAL CARE: Toileting and Peri care. PERIODIC CARE: Shower/Bath as scheduled. Provide a complete bed bath if scheduled shower cannot be given. ONGOING CARE: . Call lights: work as team to meet the goal of answering regular within 5-10 minutes. Provide peri care after voids . Promote resident choice and personal preference . Lack of Medication Availability Resident #47 Record review on 5/18-22/25 revealed Resident #47 was admitted to the facility with diagnoses that included type 1 diabetes mellitus (insulin-dependent diabetes), chronic kidney disease stage IIIb (CKD - moderate to severe kidney function loss) and vascular insufficiency (impaired blood flow). During an interview on 5/19/25 at 8:33 AM, Resident #47 stated he/she had issues with not receiving his/her medication on 3/25/25. Resident #47 further stated his/her medication, Sodium Bicarbonate, was ordered three times per day and sometimes he/she would go days without receiving the medication due to staff not being able to locate it in the medication administration cart. During an observation and concurrent interview on 5/20/25 at 10:30 AM, LN #1 opened the medication administration cart in the Deshka cottage and removed a large white bottle with a pharmacy label for Resident #47's Sodium Bicarbonate medication. The pharmacy label documented that the medication was: .filled 2/25/25 . expires 8/24/25 . LN #1 further stated he/she was unsure why the medication was not available on 3/25/25. Review of Resident #47's Medication Administration Record (MAR), for March 2025, revealed: . Sodium Bicarbonate oral tablet 650 mg . Give 1 tablet by mouth three times a day for Metabolic Acidosis Associated with CKD-Order Date-11/17/2022. Further review revealed the following doses of Sodium Bicarbonate were not given: 3/19/25 at 1:00 PM; 3/23/25 at 9:00PM; 3/24/25 at 9:00 PM; 3/25/25 at 9:00 PM; 3/26/25 at 9:00 AM; 1:00 PM; and 9:00 PM. Further review revealed all missed doses were documented as 2=Hold/See Nurse Notes or 7=Other/See Nurse Notes. Review of Resident #47's Provider Progress Note, dated 3/19/25 at 11:48 AM, revealed: . CKD stage IIIB . NaBicarb [Sodium Bicarbonate] 650mg TID . Review of Resident #47's eMAR [electronic MAR] Medication Administration Note, dated 3/19/25 at 12:37 PM, revealed: . Morning dose was given at 1240 skipping noon dose. Review of Resident #47's eMAR Medication Administration Note, dated 3/23/25 at 9:27 PM, revealed: Sodium Bicarb missing. Review of Resident #47's eMAR Medication Administration Note, dated 3/25/25 at 8:51 AM, revealed: not available. Review of Resident #47's eMAR Medication Administration Note, dated 3/26/25 at 9:02 AM, revealed: not available. Review of Resident #47's eMAR Medication Administration Note, dated 3/26/25 at 9:39 PM, revealed: not in stock. Review of the National Kidney Foundation, dated 2025, retrieved from: https://www.kidney.org/kidney-failure-risk-factor-serum-bicarbonate, revealed . sodium bicarbonate. can help keep kidney disease from getting worse . Resident #56 Record review on 5/18-22/25 revealed Resident #56 was admitted to the facility with diagnoses that included absence epileptic syndrome, not intractable, without status epilepticus, other sequelae of cerebral infarction (stroke), hemiplegia (weakness or paralysis of one side of the body) following cerebral infarction, long term (current) use of anticoagulants (blood-thinning medication) and unspecified hearing loss, bilateral. During an interview on 5/20/25 at 10:27 AM, Resident #56 stated he/she had epilepsy and missed several doses of Celotin (anti-seizure medication) medication. Resident #56 stated the facility ordered his/her medications and had run out multiple times. Resident #56 further stated, I cannot miss any doses as it is my lifeline. Resident #56 stated he/she reported the concern about the missed doses of Celotin but was not sure which member of staff was reported to. During an interview on 5/20/25 at 10:45 AM, LN #1 stated Resident #56's monthly medications were automatically filled by an out of state pharmacy contracted by the facility. LN #1 stated the medications were received and checked in by the nursing supervisors. LN #1 further stated if a medication was missing for administration, he/she would contact the nursing supervisor, and then the pharmacy would be notified. LN #1 stated that if the medication was needed right away, the facility would request the pharmacy to send a prescription to the local satellite pharmacy, so the patient could receive it that day. LN #1 further stated if a medication was ordered and not administered, then the resident, the resident's POA (Power of Attorney) and the provider must be notified. Review of Resident #56's Care Plan Report, dated 2/25/25, revealed: . Because I: History of . seizure disorder . Interventions/Tasks. I need my nurses to . give me my medications as ordered . notify MD [Medical Doctor] as needed . Review of Resident #56's MAR, dated March 2025, revealed Resident #56 missed: Celotin 300mg capsule BID for Seizure Disorder on 3/20-25/25. All missed doses documented as 2=Hold/See Nurse Notes or 7=Other/See Nurse Notes. Review of Resident #56's eMAR Medication Administration Note, dated 3/20/25 at 5:50 AM, revealed: Medication not available. Review of Resident #56's eMAR Medication Administration Note, dated 3/20/25 at 1:28 PM, revealed: Med was ordered 3/19/2025 in the NOC [night] shift. Has not been delivered yet. Review of Resident #56's eMAR Medication Administration Note, dated 3/21/25 at 5:08 AM, revealed: unavailable, ordered from pharmacy. Review of Resident #56's eMAR Medication Administration Note, dated 3/21/25 at 1:58 PM, revealed: unavailable. Review of Resident #56's Progress Note, dated 3/22/25 at 5:18 AM, revealed: RX [Celotin] unavailable, pharmacy contacted 3/20/25. Review of Resident #56's Progress Note, dated 3/22/25 at 6:10 AM, revealed: Resident POA called and upset that [his/her] [sibling] was not getting [his/her] seizure medication and why it has not been delivered . Review of Resident #56's Progress Note, dated 3/22/25 at 10:00 AM, revealed: Dilantin 100mg TID initiated until Celotin is available. Review of Resident #56's Provider Progress Note, dated 3/24/25 at 5:03 PM, revealed: . Chief Complaint: Nursing reports missing Celotin, pt [patient] started on Dilantin .Seizure. Celotin 300mg BID . Review of Resident #56's Progress Note, dated 3/26/25, revealed Celotin was restarted. Review of Resident #56's MAR, dated May 2025, revealed missed administrations of the following ordered doses for Celotin 300 mg: 5/1/25 at 6:00 AM, 5/5/25 at 6:00 AM, 5/7/25 at 2:00 PM, 5/8/25 at 6:00 AM, 5/10/25 at 6:00 AM, 5/11/25 at 6:00 AM, 5/14/25 at 2:00 PM and 5/17/25 at 6:00 AM. All missed doses were documented 2=Hold/See Nurse Notes. Review of Resident #56's Provider Progress Note, dated 5/1/25 at 9:53 AM, revealed . being seen today for f/u care . Seizure-Nonintractable absence epilepsy without status epilepsy-Methsuximide (Celotin) 300mg BID. Further review revealed there was no documentation noted regarding the unavailable Celotin medication. Review of Resident #56's eMAR Medication Administration Note, dated 5/5/25 at 5:05 AM, revealed Celotin 300mg capsule not available, reordered, given Ethosuximide [Zarontin - an antiseizure medicaiton]. This was the only documentation noted for any of the missed administrations of Celotin on 5/25. Review of Resident #56's Order Summary Report, dated 5/20/25, revealed . Celotin Oral Capsule 300MG Give 1 capsule by mouth two times a day for Seizure Disorder. Order Date 10/1/22 Start Date 3/1/25 . Ethosuximide Oral Capsule 250 MG Give 1 capsule by mouth as needed for Absence Seizures related to ABSENCE EPILEPTIC SYNDROME, NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUS (G40.A09) Give if resident runs out of Celotin. order date 5/2/25 start date 5/3/25. Review of the Epilepsy Foundation, dated 2024, retrieved from https://www.epilepsy.com/what-is-epilepsy/seizure-triggers/missed-medicines, revealed: . Missing doses of seizure medication is the most common cause of breakthrough seizures. Missed medicines can trigger seizures in people with both well-controlled and poorly controlled epilepsy. Missing doses of medicine can also lead to falls, injuries and other problems from seizures and changes in medicine levels . stopping seizure medication . suddenly, a person can have withdrawal symptoms. You could also have long seizures, cluster of seizures or status epilepticus, even if you've never had these problems before. If you're taking more than one seizure medicine, stopping one of the medicines could change the level or amount of another seizure medicine in your body. These sudden changes in drug levels can trigger seizures . During an interview on 5/22/25 at 1:50 PM, the Director of Nursing (DON) stated if a nurse was unable to locate an ordered medication, the nurse should check the emergency kit (ekit) for a dose. The nurse should contact the pharmacy for to the medication to be dispensed from the ekit. If the medication was not in the ekit, the pharmacy would send a prescription to the local satellite pharmacy to be dispensed right away. The DON further stated if a medication was omitted, the nurse should contact the physician, document in the medical record why the medication was not given, the steps taken to obtain the medication, the discussion held with the physician and if there was any harm to the resident. Review of the facility job description Licensed Vocational Nurse/Licensed Practical Nurse, dated 12/17/21, revealed .Prepare and administer medications as ordered by the physician . Chart nurses' notes in professional and appropriate manner that timely, accurately and thoroughly reflects the care provided to the resident . Review of the facility job description Registered Nurse, dated 12/17/21, revealed .Prepare and administer medications as ordered by the physician . Chart nurses' notes in professional and appropriate manner that timely, accurately and thoroughly reflects the care provided to the resident . Review of the facility policy Medication Administration, dated 3/25, revealed: . If a dose of regularly scheduled medication is withheld . the nurse shall document either in the Electronic Medication Administration Record . and enter an explanatory note. Review of the facility-provided standard used in resident care Lippincott Nursing Procedures Ninth Edition, book, published 2023, revealed: . To promote a culture of safety and to prevent medication errors, nurses must . adhere to the five rights of medication administration: .administer the medication by the right route . Safe Medication, Administration Practices . If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. Delay in UTI Treatment Resident #70 During an interview on 5/18/25 at 10:45 AM, Resident #70 stated he/she requested a urine analysis (UA- a lab test to see if there were any abnormalities in a urine sample) to be completed back in April for symptoms of a UTI he/she was having, mainly bladder pain and painful urination. Resident #70 stated there was a huge delay in getting a UA successfully completed, Once the nurse forgot to order the UA, the second time the UA was never sent to the lab, the third time the UA was contaminated, and the fourth sample is still at the lab. Resident #70 stated, currently, he/she continued to have UTI symptoms of flank pain (pain over the kidney area, near lower back) and painful urination, and has had no doctor come and talk to him/her about them. Resident #70 further stated that he/she usually used a purewick catheter (a flexible external catheter that used low pressure suction to wick urine away from the patient), however it was currently broken because a Certified Nursing Assistant (CNA) accidently threw a part away during cares and the facility had ordered the part but was waiting for its delivery to continuing using the catheter. Review of Resident #70's medical record, dated 4/16/25 to 5/22/25, revealed: 1) An order for a UA was written on 4/16/25 and documented it was completed, however a review of Resident #70's lab reports revealed this UA was never received or analyzed by the lab vendor. A review of Resident #70's progress notes revealed: - 4/20/25 at 6:48 PM: Resident #70 inquired about the results of last UA. - 4/27/25 at 4:51 PM: Ibuprofen (pain medication) was given resident complained of back pain. - 4/28/25 at 4:33 PM: Ibuprofen was given pain scale 5 (on a scale of 0 to 10), requested for back pain. - 4/29/25 at 8:31 AM: Ibuprofen was given complained of low back pain. - 4/29/25 at 12:03: Documentation of Phenazopyridine HCL [a pain reliever for the lower urinary tract, but not for UTIs] Oral Tablet 95mg . Give 2 tablet by mouth every 8 hours as needed for Urinary tract/Badder discomfort until [5/1/25 11:59 PM] three times a day. - 4/29/25 at 6:28 PM: Resident complaint of back pain, offered Morphine but refused. Requested Ibuprofen PRN [as needed], given and was effective. Pain scale was down to 3 [at] 1:44 PM . Resident wants to know last urine test result, will send message to ANP [advanced nurse practitioner]. - 5/1/25 at 12:00 AM: Provider progress note from ANP #3, Chief Complaint: urine/flank pain . [He/she] states [he/she] is generally not feeling well with urethral pain/burning/lack of urinary frequency . Labs/Radiology/Tests: Labs: Labs and imaging reviewed on Epic [electronic medical record] . Assessment and Plan: Urethral Pain. U/A C&S [urine analysis with culture and sensitivity - analyze the urine, culture it to determine sensitivity to antibiotics if indicated] . ICD [International Classification of Disease] Codes . N39.0 urinary tract infection, site not specified . 2) An order for a UA was written on 5/1/25 and documented it was completed, however a review of Resident #70's lab reports revealed this UA was never received or analyzed by the lab vendor. Further review of Resident #70's progress notes revealed: - 5/5/25 at 10:32 AM: Resident stated that [he/she] is having bladder pain . wanted to know [his/her] last urine test result . Message to [ANP #3] about the result, waiting . - 5/5/25 at 6:12 PM: Change of Condition: Symptoms or signs noted of condition change . pain in urination . Reported to primary care clinician [ANP #3] Date and time of clinician notification: [5/5/25] 1:00 PM. - 5/5/25 at 7:33 PM: Order from [ANP #3] for U/A, C&S if indicated transcribed . - 5/6/25 at 10:06 AM: Resident stated complained of bladder pain . Resident is waiting for the lab result of [his/her] urine, informed [him/her] it was sent by [night] nurse this morning . - 5/6/25 at 6:57 PM: At [3:04 PM] Resident check [his/her] lab result [through] MyChart wants result. Writer message [ANP #3] said she will order antibiotics. Waiting for actual [antibiotic] order . 3) An order for a UA was written on 5/6/25 and documented it was completed. A review of Resident #70's UA lab report from 5/6/25 revealed the following abnormalities: - Clarity: Turbid (cloudy or hazy urine, can be caused by bacteria, cells, or mucus) - Leukocyte Esterase: Moderate (increased number of leukocytes in urine, could indicate UTI) - [NAME] Blood Cells: 26-50 (normal range is 0-5, could indicate serious medical conditions like inflammation or infection) - [NAME] Blood Cell Clumps: Rare (could indicate an infection or inflammation) Further review revealed: Culture results: 10,000-50,000 CFU/ml mixed flora (multiple morphologies present) suggestive of superficial contamination/colonization. Suggest appropriate recollection with timely delivery to the laboratory, if clinically indicated. Further review of Resident #70's medical record revealed no re-order or re-collection of another UA took place after this report was received by the facility. Further review of Resident #70's progress notes revealed: - 5/6/25 at 7:47 PM: Diagnosis or Condition(s) being monitored: Pain in Urination . Pain originates from during urination located at bladder described as sharp nonpharmaceutical interventions include repositioning as tolerated . Genitourinary and renal: Urine is slightly darker yellow urine Active [symptoms] difficult/painful urination . offered pain medication was refused . encouraged to drink fluids. - 5/9/25 at 4:09 PM: Resident is requesting for another U/A C&S to be done due to [his/her] back pain 3-5/10 [3 to 5 out of 10]. Pain medication was offered. Resident refused. Resident's recent U/A C&S was reviewed by [ANP #3]. Per NP, [Resident #70's] UA C&S came back normal but if [he/she] would like to have another test then that's okay. Ordered noted and carried out. Resident aware . - 5/9/25 at 4:54 PM: Received a phone call from [Resident #70's] POA [Power of Attorney], at [1:55 PM] today. She was concerned about ongoing complaints to her from [Resident #70] about a UTI that was not being treated. This writer [Licensed Nurse (LN) #14] called [ANP #3] and learned that the UA C&S microscopic that resulted on 5/6/25 was [negative] for nitrates and growth, with moderate leukocytes. Electrolytes WNL [within normal limits]. The Macrobid [an antibiotic] that had been ordered prophylactically was withdrawn. After speaking with [Resident #70], I believe the results had not been explained to [him/her]. The current problem is the resident still has complaints of intermittent kidney pain. I called the Provider again who said to get a new UA with C&S and microscopic if indicated if the resident was good with that plan. [Resident #70] agreed & the order was entered. The [Registered Nurse] in Matanuska will obtain the sample via sterile straight cath. Just before the time of this note, this writer called the POA back to update her on the above events. Will continue to monitor. 4) An order for a UA was written on 5/9/25 and documented it was completed, however a review of Resident #70's lab reported revealed this UA was never received or analyzed by the lab vendor. - 5/14/25 at 8:34 AM: Received new order from [ANP #3] to resume the order for Phenazopyridine HCL oral tablet 95mg PRN for bladder discomfort . - 5/14/25 at 4:40 PM: Writer [LN #15] spoke with [Resident #70] and updated [him/her] of an order for a Urology consult obtained from yesterday . also I asked [him/her] if [he/she] has any urinary difficulties and would like to have a UA done, 'I still have random discomfort after peeing, yes, I would like to have it done.' UA C&S with micro if indicated was entered in PCC [Point Click Care - electronic medical record] for tomorrow's collection at [6:00 AM]. POA is aware that UA will be done tomorrow. - 5/14/25 at 5:12 PM: Spoke with [Resident #70] and let [him/her] know that [night] nurse will collect urine from [him/her] tomorrow early morning and [he/she] agreed . - 5/15/25 at 7:02 AM: UA C&S with micro [microscope analysis] if indicated. One time only for 1 day collected at [6:50 AM]. 5) An order for a UA was written on 5/15/25 and documented it was completed. A review of Resident #70's UA lab report from 5/15/25 revealed the following abnormalities: - Specific Gravity: high at 1.031 - Protein: 20mg/dL (normal range is 0-14mg/dL. Could be indicative of kidney disease or dehydration) - Leukocyte Esterase: Small - [NAME] Blood Cells: 11-15 Further review of Resident #70's progress notes revealed: - 5/18/25 at 2:13 AM: Phenazopyridine was administered. With an effective reassessment at 2:41 AM. - 5/18/25 at 12:24 PM: Phenazopyridine was administered, resident requested for bladder pain and discomfort. Stated [his/her] pain scale was 7. Had an effective reassessment at 6:42 PM (over 6 hours after having administered it). - 5/18/25 at 7:50 PM: . Resident complain of [bladder] pain and symptoms. Pain scale of 7. Check on Resident went down to 2 as stated . - 5/21/25 at 9:34 AM: Phenazopyridine was administered, per requested for urinary pain. During an interview on 5/21/25 at 10:21 AM, after reviewing Resident #70's UA lab reports from 5/6/25 and 5/15/25, the Medical Director stated there were some abnormalities to both lab reports. When asked to review Resident #70's medical record to see if any provider had assessed Resident #70 after these samples were received, the Medical Director stated no one had seen him/her for these concerns. The Medical Director stated he was taking over resident care this week and would assess Resident #70. Further review of Resident #70's progress notes revealed antibiotics were started after the Medical Director's assessment. - 5/21/25 at 1:47 PM: . Nitrofurantoin Macrocrystal Capsule 100mg give 1 capsule by mouth two times a day for cystitis [An inflammation of the urinary bladder, often caused by a bacterial infection. It's a common type of UTI] for 7 days . - 5/22/25 at 1:24 PM: . Received order to change [Nitrofurantoin Macrocrystal] to Macrobid BID [for] 7 days . During an interview on 5/22/25 at 5:30 PM, after having reviewed Resident #70's medical record, the Director of Nursing and Infection Preventionist both stated they could not find documentation that a Provider followed up with Resident #70's symptoms of UTI and they could not explain why three of the five UAs obtained did not make it to the lab for analysis. Review of the facility's policy Patient Rights, undated, revealed: . Receive adequate and appropriate care . Be informed of all changes in medical condition . participate in their own assessment, care-planning, treatment, and discharge . To be treated with consideration, respect, and dignity . Reasonable accommodation of one's needs and preferences . Review of the facility's policy ADL, Services to carry out, reviewed on 3/2025, revealed: Residents who are unable to carry out activities of daily living (ADL) will receive necessary services, on a daily and on as needed basis, to maintain . Personal Hygiene include . Toileting . among others. Review of the facility's policy titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, dated 3/2025, revealed, It is the policy of this Facility that each resident has the right to be free from abuse, neglect . Neglect is the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Neglect includes cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress . .

Based on interview and record review, the facility failed to provide appropriate, timely treatment for a possible urinary tract infection (UTI) for 1 resident (#70), out of 21 sampled residents. This failed practice left the resident with UTI symptoms for over a month despite repeated requests for answers and possible treatment from the resident which resulted in continued pain and discomfort. Findings: Record review of 5/18-22/25 revealed Resident #70 was admitted to the facility with diagnoses that included large B-cell lymphoma, unspecified cite (an aggressive, fast-growing form of non-Hodgkin lymphoma that originates in B cells), mysthenia gravis with (Acute) excerbation (a weakness and rapid fatigue of muscles under voluntary control), and other polyuria (excessive urination). During an interview on 5/18/25 at 10:45 AM, Resident #70 stated he/she requested a urine analysis (UA- a lab test to see if there were any abnormalities in a urine sample) to be completed back in April for symptoms of a UTI he/she was having, mainly bladder pain and painful urination. Resident #70 stated there was a huge delay in getting a UA successfully completed, Once the nurse forgot to order the UA, the second time the UA was never sent to the lab, the third time the UA was contaminated, and the fourth sample is still at the lab. Resident #70 stated, currently, he/she continued to have UTI symptoms of flank pain (pain over the kidney area, near lower back) and painful urination, and has had no doctor come and talk to him/her about them. Resident #70 further stated that he/she usually used a purewick catheter (a flexible external catheter that used low pressure suction to wick urine away from the patient), however it was currently broken because a Certified Nursing Assistant (CNA) accidently threw a part away during cares and the facility had ordered the part but was waiting for its delivery to continuing using the catheter. Review of Resident #70's medical record, dated 4/16/25 to 5/22/25, revealed: 1) An order for a UA was written on 4/16/25 and documented it was completed, however a review of Resident #70's lab reports revealed this UA was never received or analyzed by the lab vendor. A review of Resident #70's progress notes revealed: - 4/20/25 at 6:48 PM: Resident #70 inquired about the results of last UA. - 4/27/25 at 4:51 PM: Ibuprofen (pain medication) was given resident complained of back pain. - 4/28/25 at 4:33 PM: Ibuprofen was given pain scale 5 (on a scale of 0 to 10), requested for back pain. - 4/29/25 at 8:31 AM: Ibuprofen was given complained of low back pain. - 4/29/25 at 12:03: Documentation of Phenazopyridine HCL [a pain reliever for the lower urinary tract, but not for UTIs] Oral Tablet 95mg . Give 2 tablet by mouth every 8 hours as needed for Urinary tract/Badder discomfort until [5/1/25 11:59 PM] three times a day. - 4/29/25 at 6:28 PM: Resident complaint of back pain, offered Morphine but refused. Requested Ibuprofen PRN [as needed], given and was effective. Pain scale was down to 3 [at] 1:44 PM . Resident wants to know last urine test result, will send message to ANP [advanced nurse practitioner]. - 5/1/25 at 12:00 AM: Provider progress note from ANP #3, Chief Complaint: urine/flank pain . [He/she] states [he/she] is generally not feeling well with urethral pain/burning/lack of urinary frequency . Labs/Radiology/Tests: Labs: Labs and imaging reviewed on Epic [electronic medical record] . Assessment and Plan: Urethral Pain. U/A C&S [urine analysis with culture and sensitivity - analyze the urine, culture it to determine sensitivity to antibiotics if indicated] . ICD [International Classification of Disease] Codes . N39.0 urinary tract infection, site not specified . 2) An order for a UA was written on 5/1/25 and documented it was completed, however a review of Resident #70's lab reports revealed this UA was never received or analyzed by the lab vendor. Further review of Resident #70's progress notes revealed: - 5/5/25 at 10:32 AM: Resident stated that [he/she] is having bladder pain . wanted to know [his/her] last urine test result . Message to [ANP #3] about the result, waiting . - 5/5/25 at 6:12 PM: Change of Condition: Symptoms or signs noted of condition change . pain in urination . Reported to primary care clinician [ANP #3] Date and time of clinician notification: [5/5/25] 1:00 PM. - 5/5/25 at 7:33 PM: Order from [ANP #3] for U/A, C&S if indicated transcribed . - 5/6/25 at 10:06 AM: Resident stated complained of bladder pain . Resident is waiting for the lab result of [his/her] urine, informed [him/her] it was sent by [night] nurse this morning . - 5/6/25 at 6:57 PM: At [3:04 PM] Resident check [his/her] lab result [through] MyChart wants result. Writer message [ANP #3] said she will order antibiotics. Waiting for actual [antibiotic] order . 3) An order for a UA was written on 5/6/25 and documented it was completed. A review of Resident #70's UA lab report from 5/6/25 revealed the following abnormalities: - Clarity: Turbid (cloudy or hazy urine, can be caused by bacteria, cells, or mucus) - Leukocyte Esterase: Moderate (increased number of leukocytes in urine, could indicate UTI) - [NAME] Blood Cells: 26-50 (normal range is 0-5, could indicate serious medical conditions like inflammation or infection) - [NAME] Blood Cell Clumps: Rare (could indicate an infection or inflammation) Further review revealed: Culture results: 10,000-50,000 CFU/ml mixed flora (multiple morphologies present) suggestive of superficial contamination/colonization. Suggest appropriate recollection with timely delivery to the laboratory, if clinically indicated. Further review of Resident #70's medical record revealed no re-order or re-collection of another UA took place after this report was received by the facility. Further review of Resident #70's progress notes revealed: - 5/6/25 at 7:47 PM: Diagnosis or Condition(s) being monitored: Pain in Urination . Pain originates from during urination located at bladder described as sharp nonpharmaceutical interventions include repositioning as tolerated . Genitourinary and renal: Urine is slightly darker yellow urine Active [symptoms] difficult/painful urination . offered pain medication was refused . encouraged to drink fluids. - 5/9/25 at 4:09 PM: Resident is requesting for another U/A C&S to be done due to [his/her] back pain 3-5/10 [3 to 5 out of 10]. Pain medication was offered. Resident refused. Resident's recent U/A C&S was reviewed by [ANP #3]. Per NP, [Resident #70's] UA C&S came back normal but if [he/she] would like to have another test then that's okay. Ordered noted and carried out. Resident aware . - 5/9/25 at 4:54 PM: Received a phone call from [Resident #70's] POA [Power of Attorney], at [1:55 PM] today. She was concerned about ongoing complaints to her from [Resident #70] about a UTI that was not being treated. This writer [Licensed Nurse (LN) #14] called [ANP #3] and learned that the UA C&S microscopic that resulted on 5/6/25 was [negative] for nitrates and growth, with moderate leukocytes. Electrolytes WNL [within normal limits]. The Macrobid [an antibiotic] that had been ordered prophylactically was withdrawn. After speaking with [Resident #70], I believe the results had not been explained to [him/her]. The current problem is the resident still has complaints of intermittent kidney pain. I called the Provider again who said to get a new UA with C&S and microscopic if indicated if the resident was good with that plan. [Resident #70] agreed & the order was entered. The [Registered Nurse] in Matanuska will obtain the sample via sterile straight cath. Just before the time of this note, this writer called the POA back to update her on the above events. Will continue to monitor. 4) An order for a UA was written on 5/9/25 and documented it was completed, however a review of Resident #70's lab reported revealed this UA was never received or analyzed by the lab vendor. - 5/14/25 at 8:34 AM: Received new order from [ANP #3] to resume the order for Phenazopyridine HCL oral tablet 95mg PRN for bladder discomfort . - 5/14/25 at 4:40 PM: Writer [LN #15] spoke with [Resident #70] and updated [him/her] of an order for a Urology consult obtained from yesterday . also I asked [him/her] if [he/she] has any urinary difficulties and would like to have a UA done, 'I still have random discomfort after peeing, yes, I would like to have it done.' UA C&S with micro if indicated was entered in PCC [Point Click Care - electronic medical record] for tomorrow's collection at [6:00 AM]. POA is aware that UA will be done tomorrow. - 5/14/25 at 5:12 PM: Spoke with [Resident #70] and let [him/her] know that [night] nurse will collect urine from [him/her] tomorrow early morning and [he/she] agreed . - 5/15/25 at 7:02 AM: UA C&S with micro [microscope analysis] if indicated. One time only for 1 day collected at [6:50 AM]. 5) An order for a UA was written on 5/15/25 and documented it was completed. A review of Resident #70's UA lab report from 5/15/25 revealed the following abnormalities: - Specific Gravity: high at 1.031 - Protein: 20mg/dL (normal range is 0-14mg/dL. Could be indicative of kidney disease or dehydration) - Leukocyte Esterase: Small - [NAME] Blood Cells: 11-15 Further review of Resident #70's progress notes revealed: - 5/18/25 at 2:13 AM: Phenazopyridine was administered. With an effective reassessment at 2:41 AM. - 5/18/25 at 12:24 PM: Phenazopyridine was administered, resident requested for bladder pain and discomfort. Stated [his/her] pain scale was 7. Had an effective reassessment at 6:42 PM (over 6 hours after having administered it). - 5/18/25 at 7:50 PM: . Resident complain of [bladder] pain and symptoms. Pain scale of 7. Check on Resident went down to 2 as stated . - 5/21/25 at 9:34 AM: Phenazopyridine was administered, per requested for urinary pain. During an interview on 5/21/25 at 10:21 AM, after reviewing Resident #70's UA lab reports from 5/6/25 and 5/15/25, the Medical Director stated there were some abnormalities to both lab reports. When asked to review Resident #70's medical record to see if any provider had assessed Resident #70 after these samples were received, the Medical Director stated no one had seen him/her for these concerns. The Medical Director stated he was taking over resident care this week and would assess Resident #70. Further review of Resident #70's progress notes revealed antibiotics were started after the Medical Director's assessment. - 5/21/25 at 1:47 PM: . Nitrofurantoin Macrocrystal Capsule 100mg give 1 capsule by mouth two times a day for cystitis [An inflammation of the urinary bladder, often caused by a bacterial infection. It's a common type of UTI] for 7 days . - 5/22/25 at 1:24 PM: . Received order to change [Nitrofurantoin Macrocrystal] to Macrobid BID [for] 7 days . During an interview on 5/22/25 at 5:30 PM, after having reviewed Resident #70's medical record, the Director of Nursing and Infection Preventionist both stated they could not find documentation that a Provider followed up with Resident #70's symptoms of UTI and they could not explain why three of the five UAs obtained did not make it to the lab for analysis. Review of the facility's policy Patient Rights, undated, revealed: . Receive adequate and appropriate care . Be informed of all changes in medical condition . participate in their own assessment, care-planning, treatment, and discharge . To be treated with consideration, respect, and dignity . Reasonable accommodation of one's needs and preferences . .

Based on interview, observation, and record review, the facility failed to ensure: 1) Residents were provided with clear instructions on how to file a grievance; and 2) Consistent and accurate information about the grievance officer's identity was provided. This failed practice denied all residents (based on a census of 91) and their representatives the ability to exercise their rights to file grievances correctly and receive written resolutions of the investigation by the grievance officer. Findings: During an interview on 5/21/25 at 2:01 PM, members of the Resident Council (Residents #'s 18; 20; 28; 34; 35; 47; 48; 68; and 87) shared their concerns about grievances, they highlighted a lack of transparency and clarity in the process. They noted that under the new management (Polaris), Residents were unaware of the grievance official's identity or the procedure for filing complaints, leading to a lack of confidence that issues were being addressed. When told by the surveyors of the identity of the Grievance Officer (GO), resident council unanimously stated, we've never heard of such person, never seen him or her . we have no idea who you are talking about. Additionally, they expressed fears of retaliation for raising concerns, perceiving the administration as unprofessional and lacking accountability, a situation worsened by the transition to Polaris, with no resident input or ongoing dialogue with Polaris' administration to address these systemic issues. Resident #28 stated the only grievance officer he/she has ever seen was the state long-term care ombudsman. Resident #47 further added, we don't even know if the grievance official is a he or she, it [the grievance officer] is non-existent. When surveyors informed the resident council of the name of the grievance officer, Resident #47 stated he/she did come around the other day [to Resident #47's room] asking how things are going, but they didn't tell me who they were .so this [grievance official] is news to all of us. Random observations on 5/18-22/25 in all cottages revealed the existence of a framed sign on the counter next to the entryway of the cottages, featuring a wooden frame with a Suggestions label on the bottom left. The sign had a blue and orange header with the text caring reliably in white. Below the header, it read: Thank you for your feedback. If you have any concerns or feedback about your care, please fill out a concern/feedback form and either give it to a caregiver or drop it here [referring to a locked wooden box nearby]. You may also call the grievance official at 212.9250 or e-mail pec_grievance_official@providence.org. Note: you may submit a concern anonymously, however, we will not be able to follow up with you directly if you do. Further follow up on the email address pec_grievance_official@providence.org led to an incorrect address, and the phone number 212.9250, aside from being incomplete, when called, connected to the Assistant Administrator (AA), who confirmed the email was inaccurate and stated the phone number should instead lead to the grievance officer. During an interview on 5/20/25 at 8:25 AM, the AA also added that they (the Grievance Officer and the Assistant Administrator) worked together on addressing grievances, but the sign needed to be changed. Review of the document titled Meet our grievance officer, undated, introduced Grievance Officer #1 as the grievance officer, noting their over 35 years of experience in long-term care, their advocacy for residents and families, and their dedication to addressing concerns with respect and care. It provided contact information for Grievance Officer #1, including an email (GrievanceOfficial1@ensignservices.net) and a phone number (907-212-9237), encouraging individuals to reach out with any concerns. These documents were discovered throughout the cottages in various locations. The email and phone number listed in this form contained inaccurate and inconsistent information when compared to the instructions provided in the wooden framed sign described above. Record review of the Resident admission Agreement, undated, revealed the following grievance procedure: (A). Generally. If the Resident or Resident Representative believes that the Resident is being mistreated in any way or the Resident's rights have been or are being violated by staff or another resident, the Resident or Resident Representative shall make his/her complaint known to the Facility's Director of Nursing or Administrator. The Facility will review and investigate the complaint and provide a response to the Resident or Resident Representative. A copy of the Facility's grievance policy and procedure regarding any complaints about Facility practices is attached to this Agreement and available upon request. During an interview on 5/21/25 at 6:16 PM, the Director of Nursing (DON) stated that he was not the grievance officer, and that the admission paperwork was incorrect, as it should specify DON or designee as the point of contact for grievances. During a separate interview on 5/22/25 at 3:25 PM, the DON reported recently having addressed a grievance submitted via the facility's complaint hotline by Resident #19. The grievance concern was of insufficient shower frequency for Resident #19 and other residents. The DON stated that he neither documented nor logged the grievance officially. The DON pointed out the Hotline number as the way to file a complaint and provided surveyors with a copy of the Hotline grievance process form. The DON further stated, Flyers with the Grievance Officer's picture and grievance information were posted, and staff were informed to share this with residents. I'm not sure if every resident received this directly Addressing fear of retaliation is tough-if residents don't voice it, it's hard to address, but we can discuss it at the next council meeting. Record review of the document titled Accountability, undated, revealed a notice that emphasized accountability and standards of care. It prominently featured a hotline phone number, [PHONE NUMBER], encouraging reporting of grievances or concerns to this number, which was available 24 hours a day, 7 days a week. Record review of the Resident admission Agreement, undated, revealed the following: (A). Retaliation. The Facility shall not retaliate or discriminate against a Resident, a family member, or guardian or any other person because the Resident, the resident's family member or guardian, or any other person: (1) makes a complaint or files a grievance concerning the Facility; (2) reports a violation of law, including a violation of laws or regulations regarding nursing facilities; or (3) initiates or cooperates in an investigation or proceeding of a governmental entity relating to care, services, or conditions at the Facility. During an interview on 5/22/25 at 3:25 PM, when asked about what training do staff receive to support resident council rights and handle grievances, the DON stated the grievance officer role was discussed in staff meetings, Either I or the Administrator reviews every grievance to ensure compliance. The grievance officer, doesn't directly report to me, so I'd need to confirm their oversight structure. During an interview on 5/21/25 at 3:05 PM, Grievance Officer #1 stated they do not have an official process to track grievances and that not all grievances would be found in the grievance log, because they would rather have their staff verbally inform them of the grievances. She explained that this informal approach allows for quicker communication and resolution. During a separate interview on 5/22/25 at 4:30 PM, Grievance Officer #1 who is also the Quality Assurance Coordinator stated resident concerns brought up during resident council have not been identified in Quality Assurance and Performance Improvement (QAPI) meetings. Review of the policy and procedure Resident Rights - Grievances, revised 11/23/21, revealed the framework for addressing resident concerns in a facility. The policy emphasizes the facility's commitment to establishing a grievance process that addresses concerns without fear of discrimination or reprisal. It encourages residents to make prompt efforts to resolve grievances, ensuring their rights are protected. The procedure detailed steps such as the role of a grievance officer in overseeing the process, residents' rights to file grievances anonymously or in writing, and the use of specific Grievance Resolution Forms. It also highlighted concerns can be raised at meetings, with the grievance officer tasked with investigating, taking action, and resolving issues within three working days while reporting any severe violations as required by state law. A notable gap in the policy and procedure is the absence of the grievance official's name, despite a designated field for it under the procedure section. The document also lacked the official's business address, phone number, and email. .

Based on record review and interview, the facility failed to implement their abuse, neglect, and exploitation screening policy accordingly. Specifically, the facility failed to ensure individuals who had direct contact with residents, their medical or financial records, or control over or impact on the financial well-being of residents had a valid criminal history check conducted under 7 Alaska Administrative Code (AAC) 10.900-10.990. This resulted in 37 employees and 18 contracted staff working in the facility without valid clearance from the Alaska Background Check program. This failed practice placed all residents (based on a census of 91) at risk for abuse and neglect. Findings: New Employees During an interview on [DATE] at 1:03 PM, the HR (Human Resources) Manager stated the hiring process of new employees included the completion of a State of Alaska background check application, that included fingerprinting after the employee accepted the job. The HR Manager further stated the facility waited for the receipt of an eligible background check before the facility started the onboarding process, which included orientation training, shadow time on the floor, and then starting work independently. Record review on 5/18-22/25 of the facility-provided active employee list, undated, revealed the following new hire employees started their orientation/training, and/or direct resident care without a valid and/or appropriately associated State of Alaska background check: 1) Licensed Nurse (LN) #100 LN #100 started orientation on [DATE] and the first day working directly with residents was [DATE]. LN #100's eligible background check was not obtained until [DATE] (31 days after work was already started). 2) LN #101 LN #101 started orientation on [DATE] and the first day working directly with residents was [DATE]. LN #101's eligible background check was not obtained until [DATE] (29 days after work was already started). 3) Social Worker #1 Social Worker #1's first day of employment was [DATE]. The Social Worker's eligible background check was not obtained until [DATE] (24 days after work was already started). 4) LN #102 LN #102 started orientation on [DATE] and the first day working directly with residents was [DATE]. LN #102's eligible background check was not obtained until [DATE] (27 days after work was already started). 5) LN #103 LN #103 started orientation on [DATE]. LN #103's eligible background check was not obtained until [DATE] (24 days after work was already started). 6) Business Office Staff #1 Business Office Staff #1's first day of employment was [DATE]. Business Office Staff #1's eligible background check was not obtained until [DATE] (22 days after work was already started). 7) LN #106 LN #106 started orientation on [DATE]. LN #106's eligible background check was not obtained until [DATE] (18 days after work was already started). 8) Certified Nursing Assistant (CNA) #202 CNA #202 started orientation on [DATE]. CNA #202's eligible background check was not obtained until [DATE] (25 days after work was already started). 9) LN #110 LN #110 started orientation on [DATE] and the first day working directly with residents was [DATE]. LN #110's eligible background check was not obtained until [DATE] (58 days after work was already started). 10) Physical Therapy (PT) Tech #1 PT Tech #1 started orientation on [DATE]. PT Tech #1's eligible background check was not obtained until [DATE] (50 days after work was already started). 11) LN #111 LN #111 started orientation on [DATE]. LN #111's eligible background check was not obtained until [DATE] (54 days after work was already started). 12) LN #112 LN #112 started orientation on [DATE] and the first day working directly with residents was [DATE]. LN #112's eligible background check was not obtained until [DATE] (36 days after work was already started). 13) Hospitality Aide #90 Hospitality Aide #90 started orientation on [DATE] and the first day working directly with residents was [DATE]. Hospitality Aide #90's eligible background check was not obtained until [DATE] (36 days after work was already started). 14) Maintenance Staff #40 Maintenance Staff #40 started orientation on [DATE]. Maintenance Staff #40's eligible background check was not obtained until [DATE] (50 days after work was already started). 15) HR Payroll Representative The HR Payroll Representative started orientation on [DATE]. The HR Payroll Representative's eligible background check was not obtained until [DATE] (64 days after work was already started). 16) Dietician #8 Dietician #8 started employment on [DATE]. Dietician #8 had no eligible background check for the facility during time of the survey. Further review revealed Dietician #8 had a background check for another LTC (Long Term Care) facility associated with the owner, dated [DATE], but this was not associated with the current facility at time of the survey. 17) LN #116 LN #116 started orientation on [DATE] and the first day working directly with residents was [DATE]. LN #116 had no eligible background check for the facility at time of the survey. Further review revealed LN #116 had a background check for another LTC facility associated with the owner, dated [DATE], but this was not associated with the current facility at time of the survey. 18) Hospitality Aide #91 Hospitality Aide #91 started orientation on [DATE] and the first day working directly with residents was [DATE]. Hospitality Aide's eligible background check was not obtained until [DATE] (34 days after work was already started). 19) LN #117 LN #117 started orientation on [DATE] and the first day working directly with residents was [DATE]. LN #117's eligible background check was not obtained until [DATE] (38 days after work was already started). 20) Hospitality Aide #92 Hospitality Aide #92 started orientation on [DATE] and the first day working directly with residents was [DATE]. Hospitality Aide #92's eligible background check was not obtained until [DATE] (31 days after work was already started). 21) CNA #207 CNA #207 started orientation on [DATE] and the first day working directly with residents was [DATE]. CNA #207 had no eligible background check for the facility during the survey. Further review revealed CNA #207 had a background check for another LTC facility associated with the owner, dated [DATE], but this was not associated with the current facility at time of the survey. 22) LN #118 LN #118 started orientation on [DATE] and the first day working directly with residents was [DATE]. LN #118's eligible background check was not obtained until [DATE] (31 days after work was already started). Established Employees During an interview on [DATE] at 1:03 PM, the HR Manager stated when the new owner took over, on [DATE], the facility attempted to get the old background check eligibility letters that were associated with the old owner and facility name, for employees who remained through the change in ownership. The letters for these established employees were never obtained. The HR Director further stated, due to not having the old eligibility letters, the new owners assumed all established employees had a valid background check to continue working until their new eligibility letters, under the new owners and facility name, were obtained. Record review on 5/18-22/25 of the facility-provided active employee list, undated, revealed the following established employees worked without a valid and/or appropriately associated State of Alaska background check: 1) Administrator During an interview on [DATE] at 1:03 PM, the HR Manager stated the Administrator was working under the old owner and name prior to the change of ownership. Review of the State of Alaska Background Check database revealed the Administrator never had an eligible background check under the old owner and name. The Administrator took on the full-time duties of this role when the new owner took over the facility on [DATE]. A background check application was only first submitted for the Administrator on [DATE] (72 days after assuming the role) and an eligible background check was obtained on [DATE]. (A total of 80 days without an eligible background check). 2) Director of Nursing (DON) The DON's prior eligible background check for the old owner expired on [DATE]. The DON was hired for the role on [DATE]. A background check application was only first submitted for the DON on [DATE] (72 days after assuming the role) and an eligible background check was obtained on [DATE]. (A total of 81 days without an eligible background check). 3) HR Manager The HR Manager's prior eligible background check for the old owner expired on [DATE]. No background check application was submitted for the HR Manager until [DATE] (during the survey) and it was determined eligible on that date. (A total of 82 days without an eligible background check). 4) Director of Community Liaison The Director of Community Liaison's prior eligible background check for the old owner expired on [DATE]. An eligible background check, under the new owner and name, was obtained on [DATE]. (A total of 70 days without an eligible background check). 5) Infection Preventionist The Infection Preventionist's prior eligible background check for the old owner expired on [DATE]. An eligible background check, under the new owner and name, was obtained on [DATE]. (A total of 82 days without an eligible background check). 6) LN #105 LN #105's prior eligible background check for the old owner expired on [DATE]. Further review revealed LN #105's background check application, under the new owner and name, was still in process at time of survey. LN #105 was working without an eligible background check. 7) LN #113 LN #113's prior eligible background check for the old owner expired on [DATE]. Further review revealed that LN #113's background check application, under the new owner and name, was still in process at time of survey. LN #113 was working without an eligible background check. 8) [NAME] #30 Cook #30's prior eligible background check for the old owner expired on [DATE]. Further review revealed that [NAME] #30's background check application, under the new owner and name, was still in process at time of survey. [NAME] #30 was working without an eligible background check. 9) LN #114 LN #114's prior eligible background check for the old owner expired on [DATE]. Further review revealed that LN #114's background check application, under the new owner and name, was still in process at time of survey. LN #114 was working without an eligible background check. 10) [NAME] #31 Cook #31's prior eligible background check for the old owner expired on [DATE]. Further review revealed that [NAME] #31's background check application, under the new owner and name, was still in process at time of survey. [NAME] #31 was working without an eligible background check. 11) [NAME] #32 Cook #32 was a past employee prior to when the new owner took over the facility on [DATE]. [NAME] #31 had no eligible background check for the facility during time of the survey. Further review revealed [NAME] #32 had a background check for another LTC facility associated with the owner, dated [DATE], but this background check was not associated with the current facility at time of the survey. 12) [NAME] #33 Cook #33's prior eligible background check for the old owner expired on [DATE]. Further review revealed that [NAME] #33's background check application, under the new owner and name, was still in process at time of survey. [NAME] #33 was working without an eligible background check. 13) Laundry Staff #20 Laundry Staff #20's prior eligible background check for the old owner expired on [DATE]. Further review revealed that Laundry Staff #20's background check application, under the new owner and name, was still in process at time of survey. Laundry Staff #20 was working without an eligible background check. 14) Clergy #6 Clergy #6's prior eligible background check for the old owner expired on [DATE]. Further review revealed that Clergy #6's background check application, under the new owner and name, was still in process at time of survey. Clergy #6 was working without an eligible background check. 15) CNA #211 CNA #211's prior eligible background check for the old owner expired on [DATE]. An eligible background check was obtained on [DATE]. (A total of 76 days without an eligible background check). Travel Staff During an interview on [DATE] at 1:03 PM, the HR Manager stated that travel employees were hired and processed through The [NAME] Group, Inc. (the new owner) and not the facility. The HR Manager stated that she informed The [NAME] Group, Inc. that travel staff required an Alaska State background check prior to working at the facility, but currently, there were no travel staff that had a State of Alaska eligible background check. When asked for a list of all active travel staff currently working for the facility, the following list was provided: 1) LN #104: Started contract for employment on [DATE]. The contract ends on [DATE]. 2) LN #107: Started contract for employment was not listed. The contract ends on [DATE]. 3) LN #108: Started contract for employment on [DATE]. The contract ends on [DATE]. 4) LN #115: Started contract for employment on [DATE]. The contract end date was not listed, however LN #115 was still on the active employee list provided by the facility. 5) CNA #201: Started contract for employment on [DATE]. The contract ends on [DATE]. 6) CNA #203: Started contract for employment was not listed. The contract ends on [DATE]. 7) CNA #204: Started contract for employment [DATE]. The contract ends on [DATE]. 8) CNA #205: Started contract for employment on [DATE]. The contract ends on [DATE]. 9) CNA #206: Started contract for employment on [DATE]. The contract ends on [DATE], however CNA #206 was still on the active employee list provided by the facility. 10) CNA #208: Started contract for employment on [DATE]. The contract ends on [DATE]. 11) CNA #209: Started contract for employment was not listed. The contract ends on [DATE]. 12) CNA #210: Started contract for employment on [DATE]. The contract ends on [DATE]. 13) Speech/Language Pathologist #1: Started contract for employment on [DATE]. The contract ends on [DATE]. 14) Speech/Language Pathologist #2: Started contract for employment on [DATE]. There was no end date listed for his/her contract. 15) Occupational Therapist (OT) #2: Started contract for employment on [DATE]. The contract ends on [DATE]. 16) OT #3: Started contract for employment on [DATE]. There was no end date listed for his/her contract. 17) OT #4: Started contract for employment on [DATE]. The contract ends on [DATE]. 18) Physical Therapist (PT) #7: Started contract for employment on [DATE]. There was no end dated listed for his/her contract. Review of 7 AAC 10.900(b) at https://www.akleg.gov/basis/aac.asp#7.10.900, the 34th Legislature (2025-2026), revealed: . Each individual who is to be associated with a provider in a manner described in this subsection must have a valid background check conducted under 7 AAC 10.900 - 7 AAC 10.990 if that individual is 16 years or older and will be associated with the provider as (1) an administrator or operator; (2) an individual service provider; (3) An employee, an independent contractor, an apprentice, an unsupervised volunteer, or a board member if that individual as (A) regular contact with recipients of services; (B) access to personal or financial records maintained by the provider regarding recipients of services, including access to (i) personal identifying information, financial information, treatment information, or medical records .(4) an officer, a director, a partner, a member, or a principal of the business organization that owns an entity, if that individual has (A) regular contact with recipients of services; (B) access to personal or financial records maintained by the provider regarding recipients of services, including access to (i) personal identifying information, financial information, treatment information, or medical records . .

Based on interview and record review, the facility failed to develop, implement, and ensure appropriate oversight supervisor of the activity program to support residents in their choice of activities. Specifically, the facility failed to: 1) Ensure activities admission evaluations were completed per established activities program policy for 4 sampled residents (#'s 13; 22; 70; and 292), and 3 unsampled residents (#'s 192, 193, and 293), out of 11 residents reviewed who were admitted since 3/1/25; 2) Ensure the activity director developed, implemented and supervised the activity program which included scheduling of activities, both individual and groups, monitoring the response or reviewing/evaluating the response to the programs to determine if the activities meet the assessed needs of the resident; and 3) Develop and implement methods of ongoing evaluation of activities offered under the activities program. Specifically, the facility did not have a method to document specific resident activity participation in residents' medical records to evaluate effectiveness of the program. These failed practices placed all residents (based on a census of 91) at risk for: 1) not having activity preferences be known, which could affect their overall involvement in activities; and 2) not having their activities participation documented to show engagement, or lack of participation. Findings: Activity admission Evaluations During an interview on 5/22/25 at 9:04 AM, when asked how newly admitted residents were assessed for activity preferences, the Activities Supervisor stated there was a paper assessment completed in the residents' room and then that information would be put into the Resident's Minimum Data Set (MDS - a federally required assessment). When asked if the activity preferences were documented anywhere else in the medical record, the Activity Supervisor was not sure. When asked who completed the activity admission assessments, the Activity Supervisor stated she would do some, but the Activity Staff completed most of them for the facility's new admissions. During an interview on 5/22/25 at 9:14 AM, the Assistant Administrator stated new admission activity assessments were a document on a form called Activity - admission Evaluation which was to be completed for each resident admitted to the facility. The normal process would be to print off the evaluation and go to the resident's room and work with the resident to fill out the form. The Activity - admission Evaluation form in the medical record would then be completed. When asked to review resident records to show where this information was documented, the Assistant Administrator stated after his review it appeared that activity information was mostly documented was in the MDS and not on the Activity - admission Evaluation form in the medical record. The Assistant Administrator further stated that these Evaluation forms needed to be completed so the Certified Nurse Assistants (CNAs) and Licensed Nurses (LNs) could view them and implement activity choices. During an interview on 5/22/25 at 9:34 AM, Activities Staff #2 stated he/she mostly charted the activities admission evaluations for newly admitted residents in MDS assessments. Review of resident medical records for 11 residents admitted to the facility, from 3/1/25 to 5/22/25, revealed: Sampled Residents - Resident #13 was admitted on [DATE] and had no Activity - admission Evaluation form completed. - Resident #22 had an Activity - admission Evaluation form, dated 3/24/25, in his/her medical record, however this evaluation was completely blank. - Resident #70 was admitted on [DATE] and had no Activity - admission Evaluation form completed. - Resident #292 was admitted on [DATE] and had no Activity - admission Evaluation form completed. Unsampled Residents - Resident #192 was admitted on [DATE] and had no Activity - admission Evaluation form completed. - Resident #193 was admitted on [DATE] and had no Activity - admission Evaluation form completed. - Resident #293 was admitted on [DATE] and had no Activity - admission Evaluation form completed. Activities Supervisor Responsibilities During an interview on 5/22/25 at 9:04 AM, the Activities Supervisor stated her role as the Activities Supervisor was to oversee the activity programs for two different Long Term Care (LTC) facilities that were housed on the same property. There were two Activity Staff who assisted her in the implementation of the activities program for this facility and one for the other. When asked who created the monthly activity calendar for the facility, the Activities Supervisor stated the Activities Staff created and implemented the calendar. When asked to describe how she oversaw the activity program for the facility, the Activities Supervisor stated she really didn't oversee the activity program for this facility, as she was usually implementing the activity program for the other LTC on the property. The Activities Supervisor stated the activity calendar had not changed since the new owner took over the facility on 3/1/25. Review of the facility-provided job description for Activities Supervisor, dated 12/27/21, revealed the Essential Duties and Responsibilities included: . Plan, develop, organize, implement, and direct the activities programs of this facility. Develops and implements activities calendars. Review of the facility-provided job description for Activities Staff, dated 12/27/21, revealed the Essential Duties and Responsibilities included: . Assist in planning, developing, organizing, implementing, supervising, and evaluating the activities program of this facility. Further review revealed creating the activities program calendar was not within their scope of duties. Activity Participation Documentation During an interview on 5/22/24 at 9:34 AM, Activities Staff #2 stated he/she mostly documented resident participation with activities offered in the medical record's Point of Care (POC) charting section. Review of the POC charting section of resident medical records revealed there was no way to document on each specific activity offered on a given day or to show which of these activities a resident participated in. It only provided a once-a-day notation for a creative activity; entertainment activity; independent activity; mental activity; one on one activity; religious activity; social activity; or trip activity. During an interview on 5/22/25 at 4:47 PM, the Assistant Director and Medical Records Supervisor stated after reviewing the electronic medical record there was no place for activity staff to document resident participation of each specific activity offered at this time. Review of the facility policy Activities Programming, dated 3/2025, revealed: . It is the policy of this facility to ensure that activities are available to meet resident needs and interests that support the physical, mental, and psychosocial well-being of the resident . An Activity - admission Evaluation will be conducted at the time of admission to determine resident preferences and interests . Attempts will be made to accommodate resident preferences, when safe to do so, for planning activities programs and calendars. Program considerations may include group offerings, independent offerings, or religious/spiritual offerings . Some activities can be adapted to accommodate the resident's change in functioning dur to physical or cognitive limitations . Calendars will include a variety of activities designed to meet resident preferences and requests as much as possible . .

Based on record review, observation, and interview, the facility failed to ensure their medication error rate was below 5% for 2 sampled residents (#4 and #36) and 2 unsampled residents (#49 and #55), out of 5 residents observed for medication administration. The facility's overall medication error rate was 23.08%. This failed practice placed the residents at risk for adverse medication outcomes. Findings: Resident #4 Record review on 5/18-22/25 revealed Resident #4 was admitted to the facility with diagnoses that included dysphagia (difficulty swallowing), rheumatoid arthritis (autoimmune disorder that affects the joints), and depression. An observation on 5/19/25 from 10:20 AM to 11:24 AM, revealed Licensed Nurse (LN) #2 prepared and administered medications for Resident #4. LN #2 administered the medications through the resident's G-tube (gastrotomy tube: a tube inserted through the belly that gives direct access to the stomach). Review of the physician orders for the medications LN #2 administered revealed two medications were to be administered by mouth: - DULoxetine [an antidepressant that can also treat pain] .Give 1 capsule by mouth . Administer PO [by mouth] with apple sauce . Order Date: 03/28/2025; and -Ferrous Sulfate [iron supplement] .Give 1 tablet by mouth .Order Date: 05/01/2025. During an interview on 5/19/25 at 10:30 AM, LN #2 stated the medications were written as a route of oral but explained, the resident only preferred to take [his/her] medications by the tube because [he/she] can't swallow very well. The only time I have seen [him/her] take medications by mouth are TUMS [brand name of antacids]. During an interview on 5/19/25 at 4:02 PM, Resident #4 stated he/she took all his/her prescribed medications via G-tube. He/she further stated, It's hard for me to be able to swallow. During a follow-up interview on 5/19/25 at 4:13 PM, LN #2 stated the eMAR (electronic medication administration record) was utilized during medication administration and LNs were to use the 5 rights. The 5 rights of medication administration included right drug, right patient, right dose, right route, and right time. He/she further added if there was a discrepancy or an issue with an order, the supervisor should be notified, who would then notify the provider and/or the pharmacy. When asked if LNs on the floor could contact the provider to verify orders prior to administration, he/she stated, yes. During an interview on 5/22/25 at 2:30 PM, the Director of Nursing (DON) was asked if LNs were able to administer Residents' medications via a different route than what was ordered, he stated LNs were to follow the orders as its prescribed, and if the order needed to be changed, LNs are expected to call the doctor to make that decision before LNs administer. Resident #36 Record review on 5/18-22/25 revealed Resident #36 was admitted to the facility with diagnoses that included unspecified dementia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side (paralysis on one side of the body due to a stroke), and type 2 diabetes (insulin dependent diabetes). Review of Resident #36's insulin orders revealed Lantus Solostar Subcutaneous [placing the needle between the skin and muscle, injecting medication into the fatty layer between the muscle and skin] Solution Pen-injector 100 unit/mL [milliliters] - Inject 14 unit[s] subcutaneously one time a day Diabetes Mellitus. This order was started on 3/19/25. An observation on 5/19/25 at 9:23 AM, revealed LN #16 prepared to administer Resident #36's Lantus insulin. He/she applied an insulin needle (a BD AutoShield Duo 30-gauge needle, 5mm long) to the insulin pen, primed the needle by injecting some insulin from the pen into the needle (to eliminate any air within the needle) and then turned the dial to14 units on the pen. LN #16 then entered Resident #36's room, checked Resident #36's blood sugar reading on his/her dexcom sensor (a sensor device worn to continuously monitor blood sugar which displayed the readings on a small electronic device close by), which was 268, and then approached Resident #36. LN #16 introduced himself/herself, told the Resident what he/she was doing, then swabbed Resident #36's left deltoid muscle (shoulder muscle) with an alcohol pad. LN #16 injected the Lantus insulin at a 90-degree angle into the area of the deltoid muscle, counted to 10 while the needle was still in place (to ensure all insulin was administered), then removed the needle. Further observation of Resident #36's shoulder area at the deltoid muscle, revealed no adipose, or fatty, tissue layer that would allow for safe injection of medication between the skin and deltoid muscle. During an interview on 5/19/25 at 10:21 AM, when asked to define a subcutaneous injection, LN #16 stated the injection would be between the skin tissue and muscle. When asked about the observation of Resident #36's Lantus insulin injection, and it being administered in the observed method of the deltoid muscle area, LN #16 stated he/she would not agree with that observation of injection over the deltoid area and that being a pediatric nurse for years, knew how to administer a subcutaneous injection. During an interview on 5/19/25 at 2:33 PM, when asked where a subcutaneous injection should be administered, the Nursing Supervisor #1 showed the back of his/her arm and stated, in nursing school we are instructed to use the back of the arm. Review of the facility-provided standard used in resident care Lippincott Nursing Procedures Ninth Edition book, dated 2023, revealed: . Subcutaneous Injection: Subcutaneous injection delivers a drug into the adipose (fatty) tissue beneath the skin . When compared with intramuscular injection, subcutaneous injection provides slower, more sustained drug delivery . The most common sites are the outer aspect of the upper arm [above the elbow and below the shoulder], anterior [outer] thigh, loose tissue of the lower abdomen, upper hips, buttocks, and upper back . Review of the DB AutoShield Duo insulin pen needle guideline BD Autoshield Duo Safety Pen Needle with Dual Automatic Protective Shields, dated 2023, at https://go.bd.com/rs/565-YXD-236/images/EMBC%20ASD%20How-to-Use%20Leaflet_23-023_HI.pdf, revealed: How to inject insulin with AutoShield Duo 5mm Safety Pen Needle . Step 7: Choose the injection site and disinfect the skin. Rotate injections between and within sites [body diagram on step seven showed injection sites on back of arms, outer aspects of hips, outer aspects of thighs, and abdomen] . Step 8 Inject into the skin at a 90-degree angle . Resident #49 Record review on 5/18-22/25 revealed Resident #49 was admitted to the facility with diagnoses that included hypertrophic cardiomyopathy (thickening of the heart muscle), vascular dementia (a decline in cognitive functioning due to reduced blood flow to the brain), and hemiplegia following cerebral infarction affecting the left non-dominant side (paralysis on one side of the body due to a stroke). An observation on 5/20/25 at 8:24 AM, revealed LN #6 prepared the following medications, whole in applesauce, for Resident #49: - Acetaminophen (Tylenol - pain reliever) Oral Tablet 500 mg - 2 tablets - Carvedilol (medication used to treat high blood pressure and heart failure by lowering heart rate and reducing the heart's workload) Oral Tablet 3.125 mg - 1 tablet - Eliquis (medication used to thin the blood) Oral Tablet 5 mg - 1 tablet - Oyster Calcium Oral Tablet 500 mg - 1 tablet - Vitamin D3 Oral Tablet 25 mcg - 1 tablet Review of Resident #49's Physician Orders revealed: Carvedilol Oral Tablet 3.125 MG (Carvedilol) . Directions . Give 1 tablet by mouth two times a day for Hypertension[.] Hold if SBP [systolic blood pressure] is less than 110, Hold if Pulse is less than 60. This medication order was started on 2/25/25. Review of Resident #49's Clinical Weights and Vitals documentation for 5/20/25 at 8:31 AM, revealed Resident #49's blood pressure (BP) was 109/63 and pulse was 82. Further observation on 5/20/25 at 8:24 AM, revealed LN #6 mixed all the whole tablets in a small clear cup of applesauce. When asked if LN #6 planned to administer the Carvedilol, LN #6 responded yes, stating Resident #49's heart rate was 82. When shown the ordered parameter to hold the medication if the Resident's systolic blood pressure (SBP) was less than 110, LN #6 agreed to hold the medication, then scooped out a medium sized, white round tablet from the applesauce, claimed it was the Carvedilol tablet, and discarded it in the Resident's trash bin. He/she then administered the remaining medications to Resident #49. The surveyor then retrieved the discarded tablet from the Resident's trash bin, and noted it was 2-3 times larger than the Carvedilol tablet and did not resemble the visual characteristics of Carvedilol. At 12:45 PM, a blood pressure reading showed Resident #49's blood pressure (BP) was 93/50, and the Resident was observed to be arousable only to painful stimuli. An observation on 5/20/25 at 1:10 PM, revealed Resident #49's BP was taken using the facility's provided vital signs machine, and measured 89/48. With the DON present, a manual BP reading was performed which resulted in a BP reading of 105/44. The DON instructed LN #6 to notify the Resident's physician of the continued low BP readings. During an interview on 5/22/25 at 3:25 PM, when asked if it was appropriate for LN #6 to discard a medication that he/she could not determine was the correct medication, the Assistant Director of Nursing (ADON) replied, No, and if it was me, I would have thrown them all out and started again. Resident #55 Resident #55 was admitted to the facility with diagnoses of gastritis with bleeding (inflammation of the stomach lining accompanied by bleeding), gastrostomy status (presence of a feeding tube), and long-term use of aspirin (a medication used to reduce inflammation and prevent blood clots). Review of Resident #55's Physician Orders revealed: - Aspirin Oral Tablet Chewable 81MG (Aspirin) Give 1 tablet by mouth one time a day for CAD [coronary artery disease]. This medication was started on 2/27/25; and - Calcium Carbonate Tablet Chewable 500 MG Give 1 tablet by mouth one time a day for gastric distress. This medication was started on 2/27/25. An observation on 5/20/25 at 8:19 AM, revealed LN #6 administered the chewable medications to Resident #55, without instructing him/her to chew the medications. Resident #55 swallowed the medications whole. An interview on 5/21/25 at 5:37 PM, the DON was asked how nurses should instruct residents to take chewable medications. The DON stated, They would instruct the resident to chew them. Review of the facility-provided standard used in resident care Lippincott Nursing Procedures Ninth Edition book, published in 2023, revealed: . To promote a culture of safety and to prevent medication errors, nurses must . adhere to the five rights of medication administration: . the right medication . administer the medication by the right route . Review of the facility's policy Medication Administration General Guidelines, dated 3/2025, revealed: .Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record . Medications are administered in accordance with .orders of the prescribed .If necessary, the nurse contacts the prescriber for clarification . .

Based on interview and record review, the facility failed to ensure all staff involved in food preparation, distribution, and service maintained current food handling licenses, called food handler cards, for 24 Night Shift (NOC) staff (#'s 2; 3; 5; 6; 7; 8; 9; 10; 13; 19; 20; 24; 25; 28; 29; 30; 31; 32; 34; 35; 36; 37; 41; and 43), out of 44 NOC staff, and 3 Cooks (#'s 32; 33; and 35), out of 11 Cooks. This failed practice put all 75 residents, who receive food from the kitchen, at risk of health and safety issues due to receiving food prepared and served by unqualified individuals. Findings: Food Handler Cards During an interview on 5/21/25 at 5:15 PM, the Kitchen Manager (KM) stated all staff including housekeepers, cooks, Licensed Nurses (LNs), and Certified Nursing Assistants (CNAs) who handled food must have current food handler cards: all staff are trained during orientation about snack availability, and all are supposed to hold current food handler cards, allowing them to prepare snacks. Review of the facility-provided document Food handler cards for After-hours staff, undated, revealed a total of 44 Night Shift (NOC) staff members listed. Further review revealed 10 NOC staff with expired food handler cards: 1) NOC Staff #3 - expired 1/13/25; 2) NOC Staff #5 - expired 3/10/25; 3) NOC Staff #7 - expired 2/9/25; 4) NOC Staff #8 - expired 11/8/24; 5) NOC Staff #9 - expired 12/31/24; 6) NOC Staff #13 - expired 11/23/07; 7) NOC Staff #19 - expired 10/28/24; 8) NOC Staff #20 - expired 1/26/25; 9) NOC Staff #41 - expired 2/2025; and 10) NOC Staff #43 - expired 1/14/25. Further review revealed the facility was unable to provide proof that 14 NOC Staff (NOC Staff #'s 2; 6; 10; 24; 25; 28; 29; 30; 31; 32; 34; 35; 36; and 37) had food handler cards. Review of the facility Cook's Food Handler cards documentation, for 11 Cooks, revealed Cooks #32 and #33 had no proof of a food handler cards and [NAME] #35's food handler care expired on 11/19/24. During an interview on 5/22/25 at 4:50 PM, the KM stated, during the Providence period [old owner], staff development sent out notices for card renewals and managed the process, but now I'm unsure who's responsible for keeping these cards current. The KM further stated they were unaware of these expired cards. When asked what to do when a staff member with an expired food handler card is on the schedule, the KM replied, they won't be able to work until they get the card. Review of the evening and night shift schedule for the CNA's on 5/18/25 revealed: 3 current, 2 expired and 3 with unknown status of their food handler cards. Review of the evening and night shift schedule for the nurses on 5/18/25, revealed 2 current, 2 expired and 4 with unknown status of their food handler cards. During an interview on 5/21/25 at 5:15 PM, the KM initially stated no written policies exist for late-night or after-hours snacks, relying instead on verbal communication amongst staff. The KM retrieved a policy from the previous owner's stock titled Dietary: Snacks, and hand wrote the date 5/28/25 at the top of the policy and stated the 03/2025 date at the bottom of the policy was an error and wrote error. Copied by mistake [KM's name]. Review of this policy, Dietary: Snacks revealed: It is the policy of this facility to provide the residents with snacks between meals and HS [night] as indicated. Procedure . Snacks will be delivered from the kitchen with breakfast, lunch and dinner trays if indicated. Snacks will be offered to residents following throughout the day and at HS by dietary, activities and/or nursing staff. Staff will deliver the snacks according to their diet and restrictions . The KM hand wrote Staff have food handler cards on the policy as well. .

Based on interview, record review, and observation, the facility failed to: 1) Ensure residents received meals at times and in a manner consistent with their needs, preferences, and requests; and 2) Consistently offer access to suitable snacks or alternative meals outside of scheduled mealtimes to prevent prolonged periods without nourishment. These failed practices placed all 75 residents, who received food from the kitchen, at risk of less-than-optimal nutritional intake and decreased quality of life. Findings: During an interview on 5/21/25 at 2:01 PM, members of the Resident Council (Residents #'s 18; 20; 28; 34; 35; 47; 48; 68; and 87) shared their concerns about how close mealtimes were scheduled and the 15-hour gap between dinner (between 4:15 and 5:00 PM) and breakfast (8:00 AM). Residents stated snacks must be requested before cooks left at 6:00 PM, or they would go without food until breakfast. Some residents resorted to ordering food from outside the facility due to lack of consistent access to after-hours snacks. The cooks worked from 7:30 AM to 6:00 PM, leaving Licensed Nurses (LNs) or Certified Nurse Assiatants (CNAs) to handle snack preparation after hours. During an interview on 5/21/25 at 5:15 PM, the Kitchen Manager (KM) acknowledged resident complaints about meal timing and cook availability. The KM stated they were open to adjusting the meal schedules based on resident preferences. The KM added resident satisfaction was informally assessed through verbal check-ins by housekeepers, the KM, or the dietitian during quarterly reviews, but currently there was no formal or written process to consistently document preferences or satisfaction. The KM confirmed snacks were available between meals and after hours via a pre-order with the cooks, or snacks could be prepared by LNs, CNAs, or housekeepers who were aware of residents' dietary needs, but noted some residents preferred ordering DoorDash. She further stated residents could access snacks from cottage refrigerators, though many residents were unaware of this option. Random observations on 5/18-22/25, revealed residents did not have access to snacks without staff assistance. The kitchen area, where the refrigerators were located, and dry storage areas with snack items, were off-limits to residents. There were no indications posted on how to obtain food after hours. Residents were also observed with food stored in their rooms. During an interview on 5/21/25 at 5:15 PM, the KM stated all staff received training on snack availability, including CNAs and LNs. The KM further stated dietary was constantly addressing communication gaps by having housekeepers verify snack needs daily with residents. While a tracking system for snacks existed, it was not consistently used, and they were working on improvements. The KM also added, no formal grievances about food were reported in the past year. During an interview on 5/21/25 at 5:15 PM, the KM initially stated no written policies exist for late-night or after-hours snacks, relying instead on verbal communication amongst staff. The KM retrieved a policy from the previous owner's stock titled Dietary: Snacks, and hand wrote the date 5/28/25 at the top of the policy and stated the 03/2025 date at the bottom of the policy was an error and wrote error. Copied by mistake [KM's name]. Review of this policy, Dietary: Snacks revealed: It is the policy of this facility to provide the residents with snacks between meals and HS [night] as indicated. Procedure . Snacks will be delivered from the kitchen with breakfast, lunch and dinner trays if indicated. Snacks will be offered to residents following throughout the day and at HS by dietary, activities and/or nursing staff. Staff will deliver the snacks according to their diet and restrictions . The KM hand wrote Staff have food handler cards on the policy as well. .

Based on interview, observation, and record review, the facility failed to ensure staff were appropriately trained, or with competencies up to date, for direct resident care in 2 cottages, Susitna and Nenana. This failed practice had the potential to create diminished resident care for 23 residents (Susitna Cottage: #'s 2; 3; 24; 26; 33; 45; 46; 52; 60; 68; 71; and 193; Nenana Cottage: #'s 5; 20; 35; 38; 49; 50; 51; 55; 77; 83; and 492) which could affect their overall quality of care and quality of life. Findings: Nenana Cottage During an interview on 5/20/25 at 8:30 AM, Rehabilitation Aide (RA) #1 stated, I'm working in Nenana Cottage today because I was asked to help because surveyors are here. Normally I work in the Rehab department, I haven't worked as a CNA [Certified Nursing Assistant] in the cottages for over three years. During an interview on 5/21/25 at 1:03 PM, when asked to review RA #1's training and competencies for CNA duties, the Director of Community Liaison stated RA #1's last training for safe patient handling occurred during the 7/27/23 annual skills fair and last training for peri care was 5/30/23. The Director of Community Liaison further stated there was no current CNA training or competencies for RA #1. Susitna Cottage An observation on 5/20/25 at 12:53 PM, revealed the Minimum Data Set (MDS - a federally required assessment) Nurse was providing incontinence care to Resident #71. During an interview on 5/20/25 at 1:39 PM, the MDS Nurse stated, I've never worked as a CNA before so [the Director of Staff Development] is here to support me because there is no CNA available. The MDS Nurse further stated, I have been an MDS nurse for 15 years, so I haven't provided patient care in a long time. During an interview on 5/21/25 at 1:03 PM, when asked to show the MDS Nurse's training and competencies for peri care, the Director of Community Liaison could not provide this after reviewing the MDS Nurse's training records. During an interview on 5/21/25 at 1:03 PM, when asked if Licensed Nurses (LNs) were provided training and competencies for peri care, the Director of Staff Development stated since being in the position, no nurse had been trained in peri care. Review of the facility-provided 2025 Polaris Extended Care Facility Assessment, revealed: Staff training/education and competencies: Polaris Extended Care ensures that all staff receive training and demonstrate competencies necessary to provide the appropriate level and type of care required for our resident population. Training is tailored to the acuity and specialized need of our residents . Competency evaluations are conducted during orientation and annually thereafter, and include direct observation, skills validation, and knowledge-based testing . Training records and competency validations are maintained by the staff development coordinator and reviewed by department heads and the Quality Assurance & Performance Improvement (QAPI) committee . .

Based on record review, interview, and observation, the facility failed to ensure 4 residents (#s 4, 19, 40, and 48), out of 21 sampled residents, were given the opportunity to make choices about aspects of his/her life that were significant to them. Specifically, the facility failed to ensure residents had the opportunity to: 1) receive a shower and/or a bath; 2) be transferred in and out of bed when requested; and 3) go outside and participate in activities as specified in the plan of care. These failed practices had the potential to affect the resident's quality of life and increase feelings of frustration. Findings: Resident #4 Record review on 5/18-22/25 revealed Resident #4 was admitted to the facility with diagnoses that included dysphagia (difficulty swallowing), rheumatoid arthritis (autoimmune disorder that affected the joints), and depression. During an interview on 5/18/25 at 12:45 PM, Resident #4 stated the facility was so short-staffed that he/she only received 1 shower a week, instead of the two scheduled showers that was care planned for. During an interview on 5/19/25 at 3:57 PM, Certified Nursing Assistant (CNA) #1 stated that due to being short-staffed, residents were unable to get the care that they deserve. He/she confirmed that Resident #4 was scheduled for showers on Wednesdays and Saturdays but added that if staff was unable to give showers on the scheduled days, .they would have to wait until the next shower day . During an interview on 5/21/25 at 10:36 AM, Resident #4's POA (Power of Attorney) stated he/she was concerned due to the resident's reports of inadequate showers. Review of Resident #4's Documentation Survey Report v2 [version] . Intervention/Task .Bathing ., revealed: -During the month of March, the resident received a shower twice on 3/19 and 3/26; -During the month of April, the resident received a shower twice on 4/9 and 4/30 and; -Between 5/01-21/25, he/she received a shower on 5/7, 5/14, and 5/21. Review of Resident #4's Minimum Data Set (MDS - a federally required assessment) quarterly assessment, dated 1/7/25, revealed Resident #4 had an impairment of the upper limbs. Resident #4 was dependent on staff for his/her shower transfers. Review of Resident #4's Care Plan Report, initiated 3/15/25, revealed: .Focus: ADL Self Care Performance Deficit r/t [related to] Limited Mobility, Fatigue . Goal: Will maintain current level of function in .Grooming, Toilet Use and Personal Hygiene . Interventions/Tasks: . BATHING (SHOWER/BATHE SELF): help of 1 person providing all the effort. Shower days: Wednesday and Saturday . Resident #19 Record review on 5/18-22/25 revealed Resident #19 was admitted to the facility with diagnoses that included multiple sclerosis (chronic autoimmune disease where the immune system attacks the protective covering of nerve cells), type 2 diabetes mellitus with diabetic polyneuropathy (Type 2 DM: non-insulin-dependent diabetes, with nerve damage complications), neuromuscular dysfunction of the bladder (condition where the bladder lacks control due to nerve or muscle problems), and major depressive disorder (MDD: mood disorder characterized by persistent feeling of sadness and loss of interest in activities). During an interview on 5/18/25 at 8:42 AM, Resident #19 stated he/she would only get showers once a month, and . maybe sometimes two if I guilt them into doing it . During an interview on 5/19/25 at 3:58 PM, CNA #1 confirmed Resident #19 is scheduled for showers on Tuesday and Friday. Record review of Resident #19's Documentation Survey Report v2 [version] . Intervention/Task .Bathing ., revealed: -During the month of March, the resident received a shower five times on 3/7, 3/11, 3/18, 3/25, and 3/31; -During the month of April, the resident received a shower four times on 4/11, 4/15, 4/22, and 4/28, and; -Between 5/01-21/25, the resident received a shower four times on 5/6, 5/13, 5/14 and 5/20. Review of Resident #19's MDS quarterly assessment, dated 1/31/25, revealed Resident #19 had an impairment on one side of the upper and lower limbs. Resident #19 was dependent for his/her shower transfers. Review of Resident #19's Care Plan Report, initiated 3/15/25, revealed: .Focus: ADL Self Care Performance Deficit r/t [related to] Limited Mobility, Activity Intolerance . Goal: Will maintain current level of function in .Grooming, Toilet Use and Personal Hygiene . Interventions/Tasks: .BATHING(SHOWER/BATHE SELF): help of 1 person providing all the effort. Shower days: Tuesday and Friday . Resident #40 Record review on 5/18-22/25 revealed Resident #40 was admitted to the facility with diagnoses that included coronary artery disease, morbid obesity (disease characterized by a BMI [Body Mass Inde] of 40 or higher), heart failure, hypertension, end stage renal disease (ESRD - a condition in which kidney function is less than 10% of normal; the kidneys can no longer remove wastes, concentrate urine, and regulate electrolytes), and diabetes mellitus. During an interview on 5/18/25 at 1:06 PM, Resident #40 stated he/she was unable to brush his/her teeth when requested. Resident #40 stated staff was not available to gather his/her supplies. Resident #40 further stated that he/she could not get to the toilet independently so he/she would often have episodes of incontinence. Resident #40 stated that he/she had to wait 1 hour and 45 minutes for staff to come and provide perineal care after he/she pressed the call light. Resident #40 further stated he/she had not received a shower for 1 ½ months due to not enough staff. Resident #40 stated it required two CNAs to transfer him/her out of bed. During an interview on 5/19/25 at 8:20 AM, CNA #2 stated Resident #40 was showered about 2 months ago. CNA #2 further stated Resident #40 was transferred to the shower by the ceiling lift and required two staff members to complete a safe transfer. CNA #2 stated he/she did not always have a second staff member to assist. During an interview on 5/20/25 at 1:40 PM, the MDS Coordinator (MC) reviewed Resident #40's care plan. She stated that the number of staff required for a ceiling lift transfer depended on the staff member's comfort level. Review of Resident #40's Documentation Survey Report. Task Only, dated March 2025, revealed from 3/1/25 -3/31/25; - No showers were documented as successfully completed; - Oral Hygiene- was only documented on three days: 3/3/25, 3/17/25 and 3/19/25, and; - Personal Hygiene- was only documented on the following days: 3/3/25, 3/11/25, 3/16-19/25. Review of Resident #40's Documentation Survey Report . Task Only, dated April 2025, revealed from 4/1-30/25, tub/shower transfer occurred on two occasions. Review of Resident #40's Task: Bathing, dated 5/1-20/25, revealed . 5/17/25 . Shower. No other showers were documented as successfully completed. During an interview on 5/20/25 at 3:10 PM, CNA #2 stated he/she provided Resident #40 a shower with the assistance of a hospitality aide. CNA #2 stated the hospitality aide was able to assist with the transfer of Resident #40 out of bed to the shower. During an interview on 5/22/25 at 2:15 PM, Resident #40 smiled and stated he/she received a shower two days ago. Resident #40 stated when he/she did not receive a shower over the past 2 months, he/she felt uncomfortable. Resident #40 further stated he/she felt down because there was not enough help and I just cry and go to sleep. During an interview on 5/22/25 at 3:30 PM, Physical Therapist (PT) #1 stated when operating a ceiling lift, one to two staff members were required. When PT #1 was asked how many staff members were required to transfer Resident #40 out of bed, PT #1 stated one to two staff members. PT #1 stated if Resident #40 requested two staff members or the staff member operating the lift did not feel comfortable operating the lift alone, then the transfer required an assist of two staff members. Review of Resident #40's MDS quarterly assessment, dated 3/11/25, revealed Resident #40 had an impairment of the lower limbs and required wheelchair transportation. Resident #40 was dependent for his/her shower transfers. Review of Resident #40's Care Plan Report, dated 4/15/25, revealed . BED MOBILITY (ROLL LEFT AND RIGHT, SIT TO LYING, LYING TO SITTING ON SIDE OF BED): Requires 1-2 people providing more than half the effort. PERSONAL HYGIENE/ORAL CARE (ORAL HYGIENE): SET UP ASSIST . I need my aides to help me brush . Resident #48 Record review on 5/18-22/25 revealed Resident #48 was admitted to the facility with diagnoses that included, Type 2 DM, ESRD, hemiplegia (a condition in which half of the body is paralyzed) and hemiparesis (partial paralysis of one side of the body) following unspecified cerebrovascular disease (damage to the blood vessels in the brain) affecting right dominant side, MDD and post-traumatic stress disorder (PTSD - a mental health condition caused by a traumatic event that affects the ability to function daily). During an interview on 5/18/25 at 12:53 PM, Resident #48 stated that he/she cannot get transferred in and out of bed when requested. Resident #48 further stated he/she had to make the decision to get out of bed or just stay in bed because there were not enough CNAs available. Resident #48 stated he/she had missed frequent activity events because he/she was not able to get out of bed or staff did not wake him/her up. Resident #48 stated he/she was frustrated. Resident #48 further stated, Staffing is an issue every day and has gotten worse. You get a good one [CNA], and the facility burns them out and they leave. During an interview on 5/22/25 at 9:05 AM, the Activity Coordinator (AC) stated the only documentation for activity participation was completed in the MDS upon admission, quarterly, and the annual assessments. During an interview on 5/22/25 at 2:39 PM, the Director of Nursing (DON) stated if a resident requested to be transferred out of bed, the resident should be transferred out of bed. The DON further stated a resident should receive requested care as soon as possible. Random observations from 5/18-22/25 of Resident #48's bedroom door revealed a sign that advised staff to wake up Resident if sleeping. Review of Resident #48's MDS annual assessment, dated 9/20/24, revealed it was very important for Resident #48 to go outside to get fresh air when the weather was good, to attend activities, do things with groups of people and to be able to do his/her favorite activities. Resident #48 had an impairment on one side with limited range of motion and was dependent for his/her transfers. During an interview on 5/18/25 at 8:35 AM, CNA #2 stated he/she was the only CNA in the Deshka cottage. CNA #2 further stated from 3:30 PM to 7:00 PM on 5/18/25, he/she had to cover the Kenai cottage while covering the Deshka cottage, because there was not enough staff. CNA #2 stated he/she was concerned about how all residents would be cared for timely. CNA #2 stated there were two residents in the Deshka cottage that required feeding assistance and would be required to wait longer for assistance. Review of the facility's policy PEC/PTCC [Polaris Extended Care/Polaris Transitional Care Center] Anchorage Long Term Care STANDARDS OF CARE, dated 12/2024, revealed . AM CARE (EVERY MORNING): Hands and face washed, Toilet & Peri Care. Oral Care. H.S. [bedtime] CARE (EVERY HS AT BEDTIME): Hands and face washed, Toilet & Peri Care. Oral Care. BEFORE MEAL CARE: Toileting and Peri care. PERIODIC CARE: Shower/Bath as scheduled. Provide a complete bed bath if scheduled shower cannot be given. ONGOING CARE: . Call lights: work as team to meet the goal of answering regular within 5-10 minutes. Provide peri care after voids . Promote resident choice and personal preference . Review of the facility's policy Services to carry out ADL [Activity of Daily Living], dated 3/2025, revealed: . 2. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services, on a daily and on as needed basis, to maintain: Good nutrition, Grooming, Personal hygiene, Oral hygiene, Bathing, Showering, Toileting . Review of the facility's policy Safe Transfer of a Resident, dated 3/2025, revealed: .Mechanical lift transfers are usually used for resident who are very large or extremely dependent .Safe and secure mechanical lift transfers may require the help of one, two, or three caregivers depending on the resident's condition . Review of the facility's policy Comprehensive Resident Centered Care Plan, dated 3/2025, revealed: . Resident's Goal-refers to the resident's desired outcomes and preferences for admission, which guide decision-making during care planning . Person-centered care- means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives . Review of the facility's policy Adequate Staffing, dated 3/2025, revealed: . 2. The facility maintains adequate staff on each shift to assure that the resident's needs are met . Review of the facility's policy Patient Rights, undated, revealed: . Receive adequate and appropriate care. To be free from mental . abuse . Reasonable accommodation of one's needs and preferences . Right to Dignity, Respect, and Freedom. To be treated with consideration, respect, and dignity . .

Based on record review, interview, and observation, the facility failed to develop and/or implement a comprehensive care plan for 6 Residents (#s 4; 19; 51; 60; 89; and 492), out of 21 sampled residents. Specifically, the facility failed to: 1) implement showers scheduled as care planned; 2) provide adequate supervision and/or assistance to a resident who utilized a ceiling lift; 3) reposition residents and maintain skin integrity as care planned; and 4) develop a care plan for a resident's diagnosis of chronic obstructive pulmonary disease (COPD). These failed practices placed the residents at risk of not receiving necessary care and services to address the individual's needs. Findings: Shower Schedule Resident #4 Record review on 5/18-22/25 revealed Resident #4 was admitted to the facility with diagnoses that included dysphagia (difficulty swallowing), rheumatoid arthritis (autoimmune disorder that affected the joints), and depression. During an interview on [DATE] at 12:45 PM, Resident #4 stated the facility was so short-staffed that he/she only received one shower a week, instead of the two scheduled showers that was care planned for him/her. During an interview on [DATE] at 10:36 AM, Resident #4's POA (Power of Attorney) stated he/she was concerned due to the resident's reports of inadequate showers. During an interview on [DATE] at 3:57 PM, Certified Nurse Assistant (CNA) #1 stated that due to being short-staffed, residents were unable to get the care that they deserve. He/she confirmed that Resident #4 was scheduled for showers on Wednesdays and Saturdays but added that if staff was unable to give showers on the scheduled days, .they would have to wait until the next shower day . Review of Resident #4's Documentation Survey Report v2 [version] . Intervention/Task .Bathing ., reviewed on [DATE], revealed: -During the month of [DATE], the resident received a shower twice on 3/19 and 3/26; -During the month of [DATE] , the resident received a shower twice on 4/9 and 4/30 and; -Between 5/1-21/25, he/she received a shower on 5/7, 5/14, and 5/21. Review of Resident #4's Minimum Data Set (MDS - A federally required assessment) quarterly assessment, dated [DATE], revealed Resident #4 had an impairment of the upper limbs. Resident #4 was dependent on staff for his/her shower transfers. Review of Resident #4's Care Plan Report, initiated on [DATE], revealed: .Focus: ADL Self Care Performance Deficit r/t [related to] Limited Mobility, Fatigue . Goal: Will maintain current level of function in .Grooming, Toilet Use and Personal Hygiene . Interventions/Tasks: . BATHING(SHOWER/BATHE SELF): help of 1 person providing all the effort. Shower days: Wednesday and Saturday . Resident #19 Record review on 5/18-22/25 revealed Resident #19 was admitted to the facility with diagnoses that included multiple sclerosis (chronic autoimmune disease where the immune system attacks the protective covering of nerve cells), type 2 diabetes mellitus with diabetic polyneuropathy (non-insulin-dependent diabetes with nerve damage complications), neuromuscular dysfunction of the bladder (condition where the bladder lacks control due to nerve or muscle problems), and major depressive disorder (mood disorder characterized by persistent feeling of sadness and loss of interest in activities). During an interview on [DATE] at 8:42 AM, Resident #19 stated he/she would only get showers once a month, and .maybe sometimes two if I guilt them into doing it . During an interview on [DATE] at 3:58 PM, CNA #1 confirmed Resident #19 was scheduled for showers on Tuesday and Friday. Record review of Resident #19's Documentation Survey Report v2 [version] . Intervention/Task .Bathing ., reviewed on [DATE], revealed: -During the month of [DATE], the resident received a shower five times on 3/7, 3/11, 3/18, 3/25, and 3/31; -During the month of [DATE], the resident received a shower four times on 4/11, 4/15, 4/22, and 4/28, and; -Between 5/1-21/25, the resident received a shower four times on 5/6, 5/13, 5/14 and 5/20. Review of Resident #19's MDS quarterly assessment, dated [DATE], revealed Resident #19 had an impairment on one side of the upper and lower limbs. Resident #19 was dependent for his/her shower transfers. Review of Resident #19's Care Plan Report, initiated on [DATE], revealed: .Focus: ADL Self Care Performance Deficit r/t [related to] Limited Mobility, Activity Intolerance . Goal: Will maintain current level of function in .Grooming, Toilet Use and Personal Hygiene . Interventions/Tasks: .BATHING(SHOWER/BATHE SELF): help of 1 person providing all the effort. Shower days: Tuesday and Friday . During an interview on [DATE] at 2:55 PM, the Director of Nursing (DON) stated it was the expectation for staff to follow the resident's care plan, including showers. Supervision and/or Assistance for Ceiling Lift Resident #60 Record review on 5/18-22/25 revealed Resident #60 was admitted to the facility with diagnoses that included non-traumatic subarachnoid (the space in the brain where cerebrospinal fluid circulates) hemorrhage, hemiplegia (paralysis of one side of the body), and hemiparesis (one sided muscle weakness). Review of Resident #60's Care Plan Report, initiated on [DATE], revealed Resident #60 Requires assistance . for transferring from one position to another r/t [related to]: Cognitive deficit, Decreased strength Provide two persons for supervision/physical assist with mechanical aid or transfer belt. An observation on [DATE] at 11:05 AM, revealed Resident #60 was lying in bed. CNA #7 provided Resident #60's personal care. During the cares, CNA #7 inserted a ceiling lift sling behind the Resident. After the sling was placed, CNA #7 hooked the sling to the ceiling lift. Then, the CNA pressed the lift button to transfer the Resident from the bed to the wheelchair. While the ceiling lift moved from bed to wheelchair, the ceiling lift stopped working. The CNA stated the cord was pulled out, pointing at the red button (emergency button) with a cord hanging from the ceiling lift. During the same observation, CNA #7 continued to point at the red button while the Resident was suspended in the ceiling lift sling. Then, the CNA pushed the call light. While waiting for help, the CNA rushed towards the door leaving the Resident suspended in the air, alone and out of sight of the CNA. As CNA #7 opened the door, Licensed Nurse (LN) #12 went inside the room followed by Hospitality Aide (HA) #1. LN #12 reached and pushed the red button back while HA #1 and CNA #7 were guarding the Resident. Then, CNA #7 continued to lower the Resident into the wheelchair. During an interview on [DATE] at 10:00 AM, when asked what was meant if the resident's care plan stated two-person physical assist, mechanical lift or transfer, the Nurse Supervisor (NS) stated it should be two-person assist. During a follow-up interview on [DATE] at 8:55 AM, the Dirctor of Nursing DON stated the CNA should have used a radio transmitter to ask for help. The DON stated there should have been somebody else in the room and to not leave the Resident suspended in the air alone. DON stated CNAs will be educated. Review of the facility's policy Transfer of a Resident, Safe, dated 3/2025, revealed: .safe and efficient transfers are combination of resident's ability and perceptual capacity, proper equipment and proper techniques and good planning.transfers may involve.mechanical lift. Review of the Maxi Sky 2 (the ceiling lift used by the certified nurse aide to transfer a resident from bed to wheelchair), INSTRUCTIONS FOR USE, revised date 6/2024, revealed: .Actions Before Every Use Note: The need for a second attendant to support the patient must be assessed in each individual case. WARNING: Before an attempt is made to attempt to move a patient, a clinical assessment of the patient's suitability for transfer must be carried out by a qualified professional considering that, among other things, the transfer may include substantial pressure on the patient's body. Repositioning and Skin Integrity Resident #51 Record review on 5/18-22/25 revealed Resident #51 was admitted to the facility with diagnoses that included atrial fibrillation (an irregular heart rhythm), dementia (a decline in cognitive functioning affecting daily living), and hemiplegia. A continuous observation on [DATE], from 9:00 AM to 12:00 PM, revealed Resident #51 was positioned on his/her back with a slight left-sided tilt. During this time, Resident #51 remained in the same position without any repositioning interventions for a total of three hours. Review of Resident #51's Resident Daily Care Plan (RDCP), dated [DATE], revealed: Reposition me every 2 hours. Review of Resident #51's Care Plan Report, initiated on [DATE], revealed: . help me reposition at least every 1-2 hours while I'm in bed . Review of Resident #51's, Turns and Repositions log, for [DATE], revealed the resident was repositioned two times during that day, once at 2:01 PM and at 8:35 PM. During an interview on [DATE] at 2:31 PM, when asked about the repositioning log indicating only two repositioning interventions on [DATE] for Resident #51, LN #6 stated, From the charting that is correct. It's not realistic to expect the residents to be turned every two hours when you only have one nurse and one CNA working . It's an organization problem. An observation on [DATE] at 10:34 AM, revealed Resident #51's left hip had an oval shaped, 1.5 inch x 1 inch, bright-red wound with a shiny appearance. The resident's incontinence brief was observed rubbing directly against the wound. No dressing or protective intervention was in place for friction prevention. Review of Resident #51's Care Plan Report, initiated on [DATE], revealed: .MY GOAL IS TO: keep my skin healthy and intact . My nurses to reduce pressure and friction between myself and my bed . Review of Resident #51's Order Summary Report, dated [DATE], revealed: Left hip blister: cleanse with NS [normal saline], pat dry, cover with a dry dressing . Review of the facility-provided standard used in resident care Lippincott Nursing Procedures Ninth Edition book, dated 2023, revealed: . Tailoring wound care to wound color . Cover a red wound, keep it moist and clean, and protect it from trauma . During an interview on [DATE] at 10:40 AM, when discussing interventions for wound healing, LN #6 stated, I leave it [the wound] open to air. When discussing the ordered intervention to cover the wound with a dry dressing, LN #6 stated, There should be a dry dressing in place. Resident #492 Record review on 5/18-22/25 revealed Resident #492 was admitted to the facility with diagnoses that included depression, bipolar disorder (mental health condition characterized by alternating episodes of emotional highs and lows, significantly affecting mood, energy, and daily functioning), and atrial fibrillation. A continuous observation on [DATE], from 8:20 AM to 12:00 PM, revealed Resident #492 remained positioned supine (lying face up) in bed, without any staff entering the room to reposition the resident for a total of 3 hours and 40 minutes. Record review of Resident #492's Care Plan Report, initiated on [DATE], revealed: . Has the potential for pressure ulcer development r/t [related to] Generalized body weakness and impaired mobility . Out of bed unless contraindicated . Needs monitoring/reminding/assistance to turn/reposition. Review of the Resident #492's Turns and Repositions, log, dated [DATE], revealed the resident was turned or repositioned two times during that day, at 1:06 PM and 3:30 PM. Review of the facility-provided standard used in resident care Lippincott Nursing Procedures Ninth Edition book, dated 2023, revealed: . Pressure Injury Prevention .Turn and reposition the patient regularly and frequently . During an interview on [DATE] at 3:25 PM, when asked about the facility's policy for turning and repositioning of residents with impaired mobility, the Assistant Director of Nursing (ADON) stated, We expect the staff to turn [residents] every two hours and as needed. Developing a Care Plan for a Diagnosis Resident #89 Record review on 5/18-22/25 revealed Resident #89 was admitted to the facility with a diagnosis of COPD, unspecified (Chronic Obstructive Pulmonary Disease - a long-term lung condition that causes breathing difficulties due to airflow obstruction, without specific details provided about the type such as emphysema or chronic bronchitis, or severity). Record review on 5/18-22/25 revealed Resident #89 died on [DATE]. Review of the Resident #89's provider's orders revealed: -Drug: [Trelegy Ellipta] Fluticasone-Umeclidin-Vilant [a once daily inhalant medication used for the maintenance treatment of COPD] 100MCG [micrograms]/ACT [actuation, or per puff]-62.5MCG/ACT 25MCG/ACT Aerosol Powder Breath Activated Dose: (1 puff) Route: inhalation Frequency: daily Time: AM First Date: [DATE] Administration Instructions: Give 1 puff using inhaler once a day For: asthma/ Chronic Obstructive Pulmonary Disease . - Drug: Albuterol Sulfate (2.5 MG [milligrams]/3ML [milliliter]) 0.083% Nebulization Solution [nebulizer treatment: given through breathing in a mist of moisturized air and medication] Dose: (3 ml) Route: inhalation PRN Frequency: every 4 hours as needed First Date: [DATE] For: Chronic Obstructive Pulmonary Disease . Review of resident #89's last Care Plan Report, dated [DATE], did not include COPD. During an interview on [DATE] at 1:30 PM, when asked if a care plan for COPD should have been implemented for a resident with a COPD diagnosis, the DON stated, yes, they should. Review of the facility's policy Comprehensive Resident Centered Care Plan, dated 3/2025, revealed: . Resident's Goal-refers to the resident's desired outcomes and preferences for admission, which guide decision-making during care planning . Person-centered care- means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives . Review of the facility's policy Safe Transfer of a Resident, dated 3/2025, revealed: .Mechanical lift transfers are usually used for resident who are very large or extremely dependent .Safe and secure mechanical lift transfers may require the help of one, two, or three caregivers depending on the resident's condition . Review of the facility's policy, Patient Rights, undated, revealed: . Receive adequate and appropriate care. To be free from mental . abuse . Reasonable accommodation of one's needs and preferences . Right to Dignity, Respect, and Freedom. To be treated with consideration, respect, and dignity . .

Based on interview and record review, the facility failed to provide routine drugs for 1 resident (#24), out of 15 sampled residents. Specifically, the facility failed to ensure Morphine (an opioid pain medication) was readily available for the relief of pain. This failed practice caused the resident to be in physical pain, and psychosocial distress, for over eight hours without the ability of pain relief. Findings: Review of the facility campus revealed eight separate cottage buildings, with 12 resident bedrooms in each cottage, for a total of 96 resident beds. Facility Medication Availability Random interviews on 3/14/25 and 3/17/25 with the Administrator, Director of Nursing (DON), Clinical Coordinator, Licensed Nurse (LN) #5 and LN #6 revealed that the facility was under new ownership effective 3/1/25. The prior owner and in-house pharmacy pulled all their medication stock prior to the new owners' acquisition. However, the prior owner did provide 2 weeks of scheduled medications for the resident's continuity of care. On 3/1/25, the new owner did take over the facility and had an off-site pharmacy, called PharMerica, contracted to take over the pharmaceutical needs of the facility's residents. In addition to PharMerica, the facility also provided plastic organizer cases that contained controlled medications, called E-kits (emergency kits), for immediate medication needs, that were secured with breakaway seals, and which were double locked. The E-kits were located in 4 out of 8 cottages, for all 8 cottages to use. During the same interview, it was explained that the protocol for using these E-kits was to call PharMerica, inform them of the need to access the E-kit for immediate medication needs. PharMerica would review the request and then provide a pull code which allowed the LNs to break the seal and get the requested medication, then re-seal the box with another seal. The LNs would then document the medications pulled on a Emergency Box slip and fax it to PharMerica. Then, the LNs would document what was taken from the box, the pull code, and the seal numbers before opening the box. After reclosing the E-kit, the LNs would also document the new seal number. During the same interview, it was explained that the protocol to request routine scheduled medications was to fax medication requests to PharMerica, who would fill the requests and ship the medications from their home-base business, out of Washington State. The LNs were responsible for faxing the medication requests timely to ensure the residents did not run out of medications. Resident #24 Record review on 3/14/25 and 3/17/25 revealed Resident #24 was admitted to the facility with diagnoses that included myasthenia gravis with acute exacerbation (a condition caused by a breakdown in communication between nerves and muscles, causes weakness and rapid fatigue of muscles), diffuse large B-cell lymphoma (cancer of B cells, a type of lymphocyte that is responsible for producing antibodies), chronic respiratory failure, and heart failure. Resident #24 was also on hospice to assist with his/her diagnosis of myasthenia gravis and pain control. The hospice agency did not supply medications for the resident, and the facility was responsible for providing all medications. During an interview on 3/14/25 at 4:50 PM, Resident #24 stated it had become a frequent occurrence where his/her cottage ran out of medications, and the LNs were having to search other cottages for medications. During the same interview, Resident #24 began crying and further stated that he/she received his/her scheduled dose of Morphine at 2:00 AM this morning, Friday 3/14/25. However, this dose wasn't giving him/her relief from pain so he/she requested an additional dose at 5:00 AM. Resident #24 stated the LNs told him/her they did not have any more Morphine to give him/her, and they were trying to find some to help him/her with his/her pain. Resident #24 further stated they were only able to give him/her an additional dose of Morphine later in the day at 1:30 PM. Resident #24 waited 8 hours and 30 minutes after he/she had originally asked for the pain medication. When asked what it was like waiting for that pain medication, Resident #24 began to cry harder and stated his/her pain was about 5 out of 10 (pain scale 0 to 10 - 0 being no pain, 10 being worst pain) if he/she didn't use his/her abdominal muscles (by staying as still as he/she could) but increased to 8 out of 10 when he/she moved at all. Resident #24 further stated that in addition to his/her muscle pain, he/she had been attempting to pass a kidney stone for more than a week and this kidney pain also increased without the Morphine. Review of Resident #24's electronic Medication Administration Record (eMAR), for March 2025, revealed: Morphine Sulfate (Concentrate) Solution (liquid Morphine) 20 milligram [mg] [per] milliliter [ml] - Give 0.5 ml by mouth four times a day for [Severe] Pain. This medication was scheduled to be given at 2:00 AM, 8:00 AM, 2:00 PM, 8:00 PM. Further review revealed this medication started on 3/1/25. Further review of the eMAR for March 2025, revealed Morphine Sulfate Oral Solution 10 MG/5ML (Morphine Sulfate) Give 0.5 ml by mouth every 3 hours as needed for Severe [Pain] During an interview on 3/14/25 at 6:00 PM, LN #5 stated the LNs were responsible for faxing medication requests to PharMerica and on Wednesday, 3/12/25, the LNs did request routine medications (including additional Morphine for Resident #24). What the LNs did not know, was there was a fax error occurring on the PharMerica side and the transmission had not gone through. This was not known to the LNs until Thursday 3/13/25. LN #5 stated he/she re-faxed the request; however, this caused a shortage of medication supplies available. LN #5 stated he/she attempted to call PharMerica to obtain a pull code to open the facility's E-kit that contained the Morphine supply when Resident #24 requested additional Morphine for pain early morning, Friday 3/14/25. However, PharMerica would not authorize it because they required a hard copy script with the physician's wet signature (real time signature) for the controlled medication. LN #5 stated it took all day to get the required script to PharMerica before they would authorize a pull code, but once received, LN #5 was able to administer a dose of Morphine to Resident #24 at 1:32 PM As a result, this further delayed the facility's ability to manage Resident #24's pain. An observation on 3/14/25 at 6:15 PM revealed a multi-dose bottle of liquid Morphine, which was pulled from the E-lit, was now available to cover Resident #24's administration until PharMerica's shipment of medication arrived. During an interview on 3/14/25 at 6:43 PM, the Administrator stated when faxed medication requests were completed, PharMerica was able to deliver the medications to the facility within 24 to 48 hours. The Administrator stated the E-kits were designed to be used if medication supplies ran out or a new medication was needed immediately. The Administrator further stated they were aware that timely ordering of scheduled medication was a concern; and that LNs were ordering the medications late, and medications supplies were running out. There was also a faxing communication error, where all communication from PharMerica was going to a fax machine that the new owner did not have access to. The Administrator stated re-education was being implemented with the nurses, the fax errors have been corrected, and a plan to mitigate these occurrences was being established. Review of the facility-provided policy Care and Treatment: Six Rights of Medication Administration, reviewed 3/2025, revealed: It is the policy of this facility to ensure that the six rights of medication administration are followed in order to ensure safety and accuracy of administration .Right Time - Medication are administered within prescribed time frames to be given an hour before or up to an hour after . Right Documentation - Document administration or refusal of the medication after the administration or attempt and note any concerns.

Based on interview and record review, the facility failed to ensure 1 resident (#24), out of 15 sampled residents, was free from significant medication errors. This failed practice caused the resident to be in pain and in physical respiratory distress due to a delay and inconsistency in medication administration. Findings: Resident #24 Record review on 3/14/25 and 3/17/25 revealed Resident #24 was admitted to the facility with diagnoses that included myasthenia gravis with acute exacerbation (a condition caused by a breakdown in communication between nerves and muscles, causes weakness and rapid fatigue of muscles), diffuse large B-cell lymphoma (cancer of B cells, a type of lymphocyte that is responsible for producing antibodies), chronic respiratory failure, and heart failure. Further review revealed Resident #24 was also on hospice to assist with his/her diagnosis of myasthenia gravis and pain control. The hospice agency did not supply medications for the resident, and the facility was responsible for providing all medications. Pain Control During an interview on 3/14/25 at 4:50 PM, Resident #24 stated it has become a frequent occurrence where his/her cottage (the facility had a total of 8 cottages on campus, with each having a 12 bed/resident capacity) was running out medications and the Licensed Nurses (LNs) were having to search other cottages for medications. During the same interview, Resident #24 began crying and further stated that he/she received his/her scheduled dose of Morphine at 2:00 AM this morning, Friday 3/14/25. However, this dose wasn't giving him/her relief from pain so he/she requested an additional dose at 5:00 AM. Resident #24 stated the LNs told him/her they did not have any more Morphine to give him/her, and they were trying to find some to help him/her with his/her pain. Resident #24 further stated they were only able to give him/her an additional dose of Morphine later in the day at 1:30 PM. Resident #24 waited 8 hours and 30 minutes after he/she had originally asked for the pain medication. When asked what it was like waiting for that pain medication, Resident #24 began to cry harder and stated his/her pain was about 5 out of 10 (pain scale 0 to 10 - 0 being no pain, 10 being worst pain) if he/she didn't use his/her abdominal muscles (by staying as still as he/she could) but increased to 8 out of 10 when he/she moved his/her muscles. Resident #24 further stated that in addition to his/her muscle pain, he/she had been attempting to pass a kidney stone for more than a week and this kidney pain also increased without the Morphine. Review of Resident #24's electronic Medication Administration Record (eMAR), for March 2025, revealed: Morphine Sulfate (Concentrate) Solution (liquid Morphine) 20 milligram [mg] [per] milliliter [ml] - Give 0.5 ml by mouth four times a day for [Severe] Pain. This medication was scheduled to be given at 2:00 AM, 8:00 AM, 2:00 PM, 8:00 PM. Further review revealed this medication started on 3/1/15. Review of the administration details in the eMAR, for Morphine, revealed: 1) 3/14/25, 8:00 AM dose - documented, by LN signature, as being given at 1:32 PM (5 hours, 32 minutes late) During an interview on 3/14/25 at 6:15 PM, LN #5 stated he/she did document the 1:32 PM dose of Morphine given to Resident #24 in the eMAR on the 8:00 AM segment of the Morphine order. Review of Resident #24's Nurse Notes, dated 3/14/25, revealed no documentation related to not having Morphine on hand to meet Resident #24's need for pain relief, nor was there documentation of signing off the 8:00 AM dose of medication later in the day. 2) 3/14/25, 2:00 PM dose - documented, by LN signature, as being given at 6:05 PM (4 hours and 5 minutes late). Review of Resident #24's Nurse Notes, dated 3/14/25, revealed there was no documentation of signing off the 2:00 PM dose of medication later in the day. Further review revealed Resident #24's next scheduled dose, at 8:00 PM, was given at 8:05 PM, 2 hours after this late dose was given. Muscle Control During an interview on 3/14/25 at 4:50 PM, Resident #24 stated it has been a struggle lately to get his/her medications on time because LNs were having to cover more than one cottage, and this had delayed their ability to be prompt with residents' needs. Resident #24 further stated that one of his/her medications, called Pyridostigmine (Mestinon - treats myasthenia gravis by helping the muscles work) is time sensitive and if he/she does not get this medication on time it affected his/her muscles ability to work and caused him/her to have difficulty breathing. Resident #24 began to cry and stated, I sit and wait [for the Pyridostigmine] and the longer I wait my muscles get weaker and the harder it is to breathe. Resident #24 stated Pyridostigmine was to be administered every 4 hours, and this medication has been administered hours late. Review of Resident #24's eMAR, for March 2025, revealed: Pyridostigmine Bromide Oral Tablet 60 milligrams (mg) - give 2 tablets by mouth every 4 hours for Myasthenia Gravis. This medication was scheduled to be given at 2:00 AM, 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM. Further review revealed this medication started on 2/27/25. Review of the administration details in the eMAR, for Pyridostigmine, revealed the following times this medication was given late: 1) 3/5/25, 2:00 PM dose - documented, by LN signature, as being given at 5:06 PM (3 hours, 6 minutes late) Further review revealed Resident #24's next scheduled dose, at 6:00 PM, was given at 6:03 PM, 1 hour and 3 minutes after the previous dose was given, which was outside of the ordered parameters of every 4 hours. 2) 3/5/25, 10:00 PM dose - documented, by LN signature, as being given at 11:02 PM (1 hour, 2 minutes late) 3) 3/9/25, 2:00 AM dose - documented, by LN signature, as being given at 3:54 AM (1 hour, 54 minutes late) Further review revealed Resident #24's next scheduled dose, at 6:00 AM, was given at 5:47 AM, 1 hour and 53 minutes after the previous dose was given, which was outside of the ordered parameters of every 4 hours. 4) 3/9/25, 10:00 AM dose - documented, by LN signature, as being given at 12:02 PM (2 hours, 2 minutes late) Further review revealed Resident #24's next scheduled dose, at 2:00 PM, was given at 1:43 PM, 1 hour and 41 minutes after the previous dose was given, which was outside of the ordered parameters of every 4 hours. 5) 3/14/25, 10:00 AM dose - documented, by LN signature, as being given at 12:32 PM (2 hours, 23 minutes late) Further review revealed Resident #24's next scheduled dose, at 2:00 PM, was given at 2:07 PM, 1 hour and 35 minutes after the previous dose was given, which was outside of the ordered parameters of every 4 hours. 6) 3/16/25, 10:00 AM dose - documented, by LN signature, as being given at 11:07 AM (1 hour, 7 minutes late) Review of the facility-provided policy Care and Treatment: Six Rights of Medication Administration, reviewed 3/2025, revealed: It is the policy of this facility to ensure that the six rights of medication administration are followed in order to ensure safety and accuracy of administration .Right Time - Medication are administered within prescribed time frames to be given an hour before or up to an hour after . Right Documentation - Document administration or refusal of the medication after the administration or attempt and note any concerns.

Based on record review, interview, and observation, the facility failed to ensure sufficient Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) were available to provide care to all residents, based on a census of 93, as determined by resident acuity (acuity is a measurement of the level of care a resident needs, based on the severity of either an illness or mental condition). This failed practice, to ensure sufficient staff to provide basic nursing care such as turning and repositioning and getting residents out of bed, resulted in harm to residents who developed Stage III, IV, unstageable pressure ulcers and deep tissue injuries. These failed practices caused actual harm due to the of deterioration of pressure ulcers. In addition, failure to ensure adequate staffing to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident caused psychosocial harm. Findings: Review of the facility campus revealed eight separate cottage buildings, with 12 resident bedrooms in each cottage, for a total of 96 resident beds. The facility's total census at the time of this survey was 93 residents. Resident Acuity Review of the facility-provided ADL [Activities of Daily Living] assistance documentation from resident's medical records, received 7/16-17/24, revealed the following need for assistance from staff: 1) Bed Mobility (Turning or adjusting): - Independent: 4 residents - One-person assist: 62 residents - One to two person assist: 9 residents - Two-person assist: 15 residents - Information not provided: 3 residents (#'s 8, 28, and 60) 2) Transfer (from bed to wheelchair): - Independent: 2 residents - One-person assist: 62 residents - One to two person assist: 11 residents - Two-person assist: 15 residents - Information not provided: 3 residents (#'s 8, 62, and 87) 3) Bathing: - Independent: 2 residents - One-person assist: 74 residents - One to two person assist: 6 residents - Two person assist: 8 residents - Information not provided: 3 residents (#'s 8, 33, and 76) 4) Eating: - Independent: 5 residents - Set Up Assistance: 40 residents - Dependent: 23 residents - Intermittent Supervision: 4 residents - Enteral feeding: 9 residents - Information not provided: 12 residents (#'s 8, 12, 33, 49, 51, 57, 66, 76, 77, 79, 82, and 91) 5) Toileting: - Independent: 2 residents - One-person assist: 65 residents - One to two person assist: 13 residents - Two-person assist: 10 residents - Information not provided: 3 residents (#'s 8, 61, and 76) Nursing Management/Supervision During an interview on 7/10/24 at 3:26 PM, the Administrator stated the Director of Nursing's (DON's) last full-time day was 6/21/24 and went to a schedule of coming to the facility Monday through Friday, 4:00 AM to 6:00 AM and then coming back in the afternoon if needed. Also, the DON would work Saturday and Sunday 6:00 AM to 12:00 PM as needed. The Administrator stated a new DON was hired and his/her start date was 7/29/24. When asked to describe the nursing supervisor staffing, the Administrator stated there were two manager positions, one of those positions was filled 6/17/24 and the other was still open, and four nursing supervisor positions that were filled. When asked if the nursing supervisors documented their activities during their shifts, to include providing support in the cottages, the Administrator stated there was no documentation to account for what the nursing supervisors did during their shifts. When asked to describe the current staffing situation in the cottages, the Administrator stated the facility traditionally would have had one nurse in every cottage (12 residents per cottage), and 16 CNAs (2 CNAs per cottage) scheduled on the dayshift, however since COVID they had not been able to meet that staffing level. The Administrator stated that the facility was currently running at crisis staffing level where there was one nurse for every 18 resident (one nurse per 1 and a half cottages) and one CNA for every 12 residents (one CNA per cottage), and there was a goal of having 4 support CNAs (1 support CNA per two cottages) to provide support and complete showers. However, when staff call out of work, the facility had only been able to provide about 3 support CNAs a day. When asked what other measures the facility had attempted to help support the cottages to meet the needs of the residents, the Administrator stated they increased training with home keepers (cooks), housekeepers, and activity staff to help with assisting CNAs when needed in bed mobility and transfers, as well, as assist with dining for residents who required minimal support. These staff were trained in safe patient handling and dining assistance but are not considered nursing staff. When asked if the facility had received any calls or grievances about the staffing shortages, the Administrator stated there had been grievances from families, and that the facility had explained the goals of the change in staffing. During an interview on 7/11/24 at 1:25 PM, when asked if staff had voiced any concerns about the staffing levels, the DON stated nurses had expressed concerns on having to pick up extra residents in a second cottage. The CNAs had expressed concerns that the home keepers, housekeepers, and activity staff weren't supporting them during the day because they were unsure on what they could or couldn't do. When asked specifically what the home keepers, housekeepers, and activity staff could do to support the CNAs, the DON stated they could assist only with bed mobility or transfers of resident when the CNAs were present, however they could not assist by themselves, and they could not assist with toileting. Also, for dining assistance, they could help with cuing and support resident's hands or arms to allow the residents to feed themselves, however they could not feed residents. Random observations on 7/8-10/24 and 7/15-18/24 revealed no home keepers, housekeepers, or activity staff assisted CNAs in any fashion with bed mobility, transfers, or dining assistance. During an interview on 7/11/24 at 2:26 PM, when asked who was designated the DON of the facility when she was not physically present during business hours, the DON stated she was the only DON and could be contacted through teams messaging and phone calls anytime. During an interview on 7/12/24 at 10:29 AM, the Lead CNA (LCNA) stated the support CNA was provided an assignment sheet every morning with a list of showers, vital signs, and weights that needed to be obtained for the shift. The support CNA's first priority was ensuring showers were completed for their assigned cottages, then they would complete vitals and weights if they had time. After the assignments were completed, the support CNA would then be available to assist in other regular CNA duties. When asked how the staffing shortage and crisis level staffing had affected resident care, the LCNA stated it was a challenge to meet the needs of residents as swiftly as they could have with a full complement of staff, and that staff were not able to give the residents the level of attention they used to. The LCNA stated it was hard to meet the needs of the residents, and residents had voiced that their care had been delayed, to include not getting showers, and they didn't like the new staffing schedule. The LCNA further stated that if there weren't enough support CNAs, residents would get bed baths instead of showers because there were not enough staff to provide showers. The LCNA further stated that having only one CNA per cottage now meant that residents had to wait longer for their needs to be met and it may have impacted pressure ulcers because the CNAs were having trouble meeting the turning schedule of every 2 hours. During an interview on 7/18/24 at 9:46 AM, Nurse Educator #3, who had been a nursing supervisor for years and covered the position from time to time, stated the nursing supervisor ensured that staffing was handled, managed requests for provider orders or guidance, communicated with providers on those requests every morning and input orders if needed. Nurse Educator #3 stated nursing supervisors also managed and adjusted resident appointments and addressed any concerns from residents and staff. When asked if there was any documentation a nursing supervisor completed that showed what they did during their shift, Nurse Educator #3 stated no, there was not. Pressure Wounds Assessment Review of the facility's Matrix for Providers, CMS-802 (a document used to identify pertinent care categories) documentation, completed on 7/8-9/24, revealed an overall pressure ulcer rate of 19% [18 residents total]. - 3 residents had stage III pressure ulcers (involves the full thickness of the skin and may extend into the subcutaneous tissue layer) - 7 residents had stage IV pressure ulcers (the deepest, extending into the muscle, tendon, ligament, cartilage or even bone) - 6 residents had unstageable pressure ulcers (full thickness skin and tissue loss, but unable to stage the wound due to obscured visualization due to extent of tissue damage) - 3 residents had deep tissue injuries (an injury to a resident's underlying tissue below the skin's surface that results from prolonged pressure). Review of the facility provided CASPER report (a document that calculates quality measures that are included in the Centers for Medicare & Medicaid Services (CMS) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)), dated June 2024, revealed the facility's Pressure Ulcers facility adjusted percentage was 16.1% (compared to the comparison group national average of 7.4%). The July report was unavailable as it was too early in the month for that final report. During an interview on 7/12/24 at 2:30 PM, Wound Care Nurse (WRN) #1 stated there were currently 18 residents with pressure ulcers. When asked if limited staffing concerns contributed to the pressure ulcer numbers, the WRN #1 stated residents needed to be turned every 2 hours to relieve pressure. When asked if she felt residents were being turned every 2 hours, the WRN #1 stated, no. When asked if she felt this contributed the deterioration of the resident's pressure ulcers, WRN #1 stated, yes. During an interview on 7/18/24 at 11:27 AM, when asked if the Quality Assurance and Performance Improvement (QAPI) committee had implemented any performance action plans due to the high rate of pressure ulcers at the facility, the Quality Director stated she felt that the lack of staffing, and their inability to provide more one on one attention to residents, had attributed to this increase, and QAPI's focus had been to help boost staff numbers. The Quality Director further stated a performance improvement plan was in effect for pressure ulcers. When asked if the pressure ulcer rates had been discussed with the Governing Body (GB), the Quality Director stated the increase in pressure ulcer rates and the residents had been discussed. GB had been informed of low staffing levels. GB had discussed funding solutions, such as bringing in travelers, and leadership meetings had been held to possibly plan for this. Resident/Family Interviews and Observations Resident #26 During an interview on 7/8/24 at 4:01 PM, Resident #26 stated he/she had requested . no male caregivers for changing and showering. Resident #26 stated males providing hygiene to him/her bothered his/her spouse as well. Resident #26 further stated CNA #3 told him/her, . If your husband doesn't know it will be ok. Resident #26 stated . But it bothers me. During an interview on 7/15/24 at 11:10 AM, CNA #6 stated Resident #26 refused CNA #6 to provide personal cares because Resident # 26's spouse does not like it. CNA #6 stated a male CNA on nights showered resident. During an interview on 7/15/24 at 3:20 PM, LN #7 stated Resident #26 did not want male caregivers providing personal/pericare [cleaning of the genitalia and buttock area]. LN #7 stated, .It is more his/her [spouse] and his/her culture. I have talked to his/her [spouse] many times and explained we do not always have a [female] CNA . Review of the facility-provided ADL assistance documentation from resident's medical records, received 7/16-17/24, revealed Resident #26: I BATHE with 1 helper providing all of the effort. I use the shower chair. I prefer showers . Resident #34 During an observation and interview on 7/8/24 at 12:04 PM, Resident #34 was sitting in his/her room, at his/her bedside table with a disposable Styrofoam clamshell food container containing the resident's lunch. Resident #34 stated that the food was cold, but it was no use to call someone to warm it up as it might be forgotten in the microwave, or the staff would take a long time to come get it to heat it up. The resident stated that he/she might as well eat it cold than bother the staff. Resident #34 stated he/she had been eating out of Styrofoam containers all weekend as well as that day. His/her meals were served this way when a cook would not come into work. When this happened, their meals would be prepared in another cottage and brought over. He/she stated the meals felt like he/she was eating take out and would rather eat off real dishes. During an interview on 7/8/24 at 1:50 PM, Resident #34 stated that he/she was at the mercy of the staff. He/she stated that he/she would like to shower every night before bed, but he/she was told the facility policy was to shower twice a week. The resident stated that his/her shower days were Wednesdays and Saturdays. The resident expressed concerns that he/she would not be able to get a shower if he/she had a bad episode of bowel incontinence. Review of Resident #34's MDS (Minimum Data Set - A federally required nursing assessment) annual assessment dated [DATE], revealed: . Section F0400. Interview for Daily Preferences: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very important . During an interview on 7/15/24 at 11:43 AM, Resident #34 stated twice last week, he/she was not able to get out of bed until dinner time. He/she further stated he/she usually liked to be up and dressed by 8:00 AM daily. The resident expressed that it was very lonely waiting for the staff to come assist with getting him/her out of bed. The resident was unsure what activities he/she missed on those days and expressed that he/she felt that dining at the dining table with other residents at least once a week was important. Review of Resident #34's MDS annual assessment dated [DATE], revealed: . Section F0500. Interview for Daily Preferences: How important is it to you to do things with groups of people? Very important. How important is it to you to do your favorite activities? Very important . Resident #39 During an interview on 7/8/24 at 10:58 AM, Resident #39 stated that his/her biggest complaint with the facility was the lack of staffing due to a new system which was one CNA per cottage. There were times when there was no cook, no nurse, or CNA. Resident #39 stated that the lack of staffing consequence was that he/she did not always get his/her shower. Resident #39 stated, when questioned about the lack of showers, stated, This is unacceptable. Resident #39 had concerns that his/her exercises were not always completed. Resident #39 stated, If we lack staff, the replacement has to come from a different cottage. The lack of CNAs has always a problem. The doctors are gone too. The [administrative leadership] are aware of this. We can't take care of ourselves. One CNA with 12 people is a lot. Review of Resident #39's Baseline Care Plan, printed on 7/17/24, revealed: Special Precautions . Assist me with ROM exercises to all extremities, 3-5 rep, BID [twice a day] with care as tolerated . I bathe with the help of 1-2 people doing 100% of the care, using the Carendo shower chair. Transfer me with the ceiling lift and blue sling. No Male CNAs during shower. Nails to be trimmed by PCN. Bath/shower: Tuesday (day); Friday (day). During an interview on 7/9/24 at 9:01 AM, Resident #39 stated he/she was not being able to choose more showers when she/he wished. Showers were scheduled two days a week. Resident #39 stated, I often miss showers due to there not being enough staff here. Review of Resident #39's MDS annual assessment, dated 3/14/24, revealed: . Section F0400. Interview for Daily Preferences: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very important . Resident #47 During an observation on 7/15/24 at 12:45 PM, Resident #47 was sitting at dining table and asked staff for help to the bathroom. Occupational Therapist (OT) #1 told Resident #47 that he/she would have to wait for staff. The Dietary Manager was serving food to residents at the dining table. It was observed that Licensed Nurse (LN) #4 was going room to room passing medications. Resident #47 started independently propelling his/her wheelchair (wc) with his/her feet to the nurse. LN #4 told Resident #47 he/she was trying to locate the CNA. It was observed CNA #7 came out of room [ROOM NUMBER] and went immediately towards room [ROOM NUMBER] as Resident #47 was looking towards CNA #7 saying he/she needed to go to the bathroom. CNA #7 ignored Resident #47 and entered room [ROOM NUMBER]. At 1:05 PM, Resident #47 continued to request help to the bathroom propelling himself/herself in his/her wc throughout the common space in cottage. OT #1 told Resident #47 he/she would try and find staff to assist him/her. At 1:15 PM, CNA #7 told Resident #47 I have one more person to change first. CNA #7 then entered room [ROOM NUMBER]. At 1:27 PM, it was observed that CNA #7 walk up to the kitchen as OT #1 ask CNA #7 about another resident's meal. Resident #47 noted CNA #7 and started propelling him/herself toward the kitchen from the hallway and tried to get CNA #7's attention. Resident #47 stopped propelling and stopped trying to call out to CNA #7. Resident #47 started to frown and put his/her head down. During an interview on 7/15/24 at 1:28 PM, when asked if he/she still required assistance to the bathroom, Resident #47 frowned putting his/her head down stating they required assistance of toileting hygiene (because the resident had an accident). At 1:29 PM, CNA #7 took Resident #47 to his/her room. Resident #56 During an observation and interview on 7/15/24 at 1:48 PM, no CNA, LN, or cook were visibly present in the Yukon cottage. Further observation in Resident #56's room revealed his/her had a breakfast tray to be picked up. Resident #59 used the call light and stated, They won't come, I always wait. Resident #59 stated the breakfast had been delivered around 11:00 AM. The breakfast tray was on his/her lap and the resident was in bed with the head of the bed raised 45 degrees. Observation of the open common areas of the cottage revealed no staff visible. CNA #8 arrived at 2:09 PM and asked Resident #56 what he/she wanted. When asked, why the call light had been delayed and no staff were present in the dayroom, CNA #8 stated he/she did not hear the call light because he/she was in the office charting since the other computer out on the floor did not work. Resident #61 During an interview on 7/16/24 at 3:30 PM, Resident #61 stated he/she had to stay in bed for days because there is only one CNA, and they don't have time to get me up. Resident #61 stated he/she missed activities because [of] not enough staff. missed BINGO today . Review of the facility-provided ADL assistance documentation from resident's medical records, received 7/16-17/24, revealed Resident #61: I TRANSFER with the dependent assistance of 1 person, using the ceiling lift with green-trimmed bariatric sling . Resident #77 During an interview on 7/10/24 at 9:30 AM, Resident #77's family stated the facility had reduced their CNAs dramatically. This family member stated he/she had witnessed residents in Deskha cottage crying out saying they needed help, however there was no one in the Deshka cottage to help because the CNA was busy with someone else. The family member further stated he/she had called and filed a grievance, however never received a response about it. The family member stated he/she turned the grievance into LN #14 on 6/13/24 and he/she had a copy of the grievance. Resident #78 During an interview on 7/15/24 at 11:53 AM, Resident #78 stated that the nursing staff do not ask her when she wants to get up, they just let her sleep. The resident stated that he/she is on a diuretic (a drug that helps remove excess water, salts, and other accumulated metabolic products from the body through urine), which increases his/her need to urinate. The resident stated he/she cannot wait long periods of time for staff to answer the call light, which resulted in the resident urinating in bed. This had happened regularly and as recent as two days ago. Review of Resident #78's Baseline Care Plan, printed on 7/12/24, revealed: I USE THE BATHROOM: with the help of 1 person doing less than half the effort. I am continent of bladder and bowel, but wear incontinence briefs in case I have an accident. Resident #86 During an interview on 7/12/24 at 1:09 PM, Resident #86 stated since the staffing change there has been a big problem getting showers because he/she required assistance. Resident #86 stated he/she rarely received a shower, unless he/she felt brave enough to try and take a shower by himself/herself. Resident #86 also stated there had been delays in obtaining a bedpan when needed because there were no staff to answer the request, and he/she had to wait 3 hours once just to relieve himself/herself. Review of the facility-provided ADL assistance documentation from resident's medical records, received 7/16-17/24, revealed Resident #86: I BATHE with 1 helper providing more than half the effort. I sit on the shower chair. I prefer showers . Review of Resident #86's MDS annual assessment, dated 1/23/24, revealed: . Section F0400. Interview for Daily Preferences: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very important . Resident #86 further stated because nurses must go to other cottages now to help other residents, he/she has had to wait hours for as needed medications for shortness of breath. This had happened so often that he/she had resorted to calling the nurse supervisors for help when nurses weren't in the cottage. Resident #92 During an observation and interview on 7/15/24 at 11:49 AM, Resident #92 was in bed and had just finished his/her breakfast of pancakes and peanut butter. The resident said that he/she had waited to be served breakfast since 7:00 AM and had received it about an hour ago. He/she was going to skip lunch because it was so late in the day. The resident pressed his/her call light because he/she wanted nicotine gum. The surveyor left the resident's room. Continued observation on 7/15/24 at 12:38 PM, 46 min later, this surveyor walked over to the call light monitoring system in the common area and saw that Resident #92's call light had been on for 46 minutes. Further observation revealed Resident #92 called out from his/her room to [NAME] #2 in the kitchen. The cook was busy and stated that someone would be in shortly. This surveyor asked Resident #92 if anyone had been in to help, the resident stated no one had come. During an interview while continuing the observation on 7/15/24 at 12:39 PM, CNA #11 stated he/she was the only CNA in the cottage. CNA #11 then went into Resident #92's room and the call light was turned off. Resident #92 waited approximately 51 minutes for staff. At 1:17 PM Resident #92 was observed coming out of his/her room in his/her wheelchair. When asked if he/she received his/her nicotine gum, the resident stated, No and that he/she was headed out to go smoke. Resident Council Meeting Minute Review Review of Resident Council meeting minutes, dated 1/17/24, revealed: . Resident shared concerns of the night CNA's leaving the cottage for an extended amount of time and not available to help with their own resident[s]. Resident believes it is a safety concern. Resident shared concerns that his call light is not being answered at nights due to caregivers not being available in the cottages. He feels this is escalating and not being addressed. Review of Resident Council meeting minutes, dated 4/17/24, revealed: . [DON] shared with group that staffing situation for C.N.A's and the ability to fill the 17 open positions which led to the leadership team to be creative and revamp the staffing structure . Staffing will be as follows: 1 C.N.A. per cottage during the day with a 4-person support team responsible for showers and weights, meal assist, transferring/transporting to activities etc. and on call as needed when C.N.A's need assistance in the cottages . Resident asked for clarification on toileting assistance with 1 C.N.A. in each cottage. Residents concern is waiting for assistance at night to get help to the toilet and will that also be a problem during the day? [DON] acknowledged and assured resident the scheduled C.N.A. in the cottage will be available to assist and if need of further support, they are to contact the support team. If the new staffing structure does not work [DON] will revisit the process . Review of Resident Council meeting minutes, dated 6/20/24, revealed: [DON] shared with the group the new C.N.A. process that started this week. Process is structured with 1 C.N.A. in the cottage and a 4 person C.N.A. support team each supporting 2 cottages . [Home keepers] and Housekeepers are currently in orientation for more extensive training to assist in the cottages . As this is the first week of the new process we are hoping to see a positive outcome . We will be evaluating the process by asking for feedback from our residents . Residents' concerns as follows: Will we have someone on the weekends helping us get out of bed and help with getting ready for the day including church services on Sundays? Per [Administrator] this concern was part of the reason we created the new process . Yes there will be more caregivers available to assist with getting out of bed. What happened if our C.N.A. calls out? Per [DON] if your C.N.A. calls our one of the support team caregivers will jump in while we start calling for someone to come in. Resident shared she has not been getting up daily as she should and having to wait to be put back to bed causing her pain on the weekend. [DON] acknowledged residents' complaint and explained that the weekend was very challenged with caregivers calling out and staffing being extremely short, but nursing leadership did step in and assisted as needed . [Administrator] shared with group the new process which went live on Tuesday. To reiterate the support team of 4 C.N.A.s will be doing the showers and vitals and as needed assists. Any concerns please reach out to [DON] and/or [RN Manager] . Direct Care Staff Interviews During an interview on 7/8/24 at 9:27 AM, CNA #10 stated the Aniak cottage did not have a home keeper (cook) that day for the cottage. When the cooks were short staffed, the meals for the cottage were prepared in another cottage, placed in separate disposable Styrofoam clamshell food containers labeled with the resident's room number, and brought over. The CNA and LN would serve the meals. During an interview on 7/8/24 at 1:20 PM, LN #3 stated the lack of staff was a problem. Whenever a CNA was missing, that was a problem. If the cottage's cook was not working that day, the food came from a different cottage. LN #3 stated the housekeepers are often short staffed too. During an interview on 7/9/24 at 9:07 AM, [NAME] #2 stated that the Aniak cottage did not have a cook for the last three days (7/6-8/24), and other cooks in the other cottages would rotate preparing meals for the day. [NAME] #2 stated that meals were served in the disposable Styrofoam clamshell food containers because when a cook was covering another cottage, there was no time to wash dishes for both cottages and complete other duties. If another cottage did not have a cook available for the day, [NAME] #2 would prepare meals for the other cottage first before working on the meals for his/her assigned cottage. During an interview on 7/10/24 at 4:39 PM, the Dietary Manager stated serving meals from disposable Styrofoam clamshell food containers was not ideal and needed to ask dietary why they were delivering food like that. She stated that it did not happen very often and did not know why the food could not be plated. During an interview on 7/15/24 at 12:39 PM, CNA #11 stated there were no limits on the frequency a resident can get up out of bed or have a shower but depended on the availability of staff. Most of the time the staff were busy, and it was much harder to give showers outside of the resident's schedule. During an interview on 7/16/24 at 4:35 PM, LN #8 stated staff shortages had affected the ability to spend time with the residents. LN #8 stated it was a struggle to complete turns every 2 hours and showers. When properly staffed it used to be enjoyable and staff could spend time with residents to put on lotion, however staff are now rushed due to the increased workload that resulted in the staff being less available. LN #8 further stated quality time with residents wasn't possible anymore. During an interview on 7/17/24 at 3:28 PM, CNA #11 stated the 4 person CNA support teams doesn't work and cottage CNAs end up doing everything on their own. CNA #11 further stated nurses would help, when they are available, but it wasn't easy for the nurses because they now had to cover other cottages. Administration During an interview on 7/17/24 at 8:17 AM, when asked if the concerns with low staffing had impacted the resident's care, the Medical Director stated residents did talk to her about how staff needed help. The Medical Director further stated low staffing was affecting the residents with higher acuity, who required heavier assistance in cares, more than the residents who were more independent. When asked if she was involved with any leadership meetings that would discuss staffing levels and resident care, the Medical Director stated she was only at the facility every other week and when she was here was only at the facility for three days that week. The Medical Director further stated staffing was not something she would be involved with and didn't think it was her lane to get involved in, If turning residents isn't getting completed, I would say we need to find avenues to get it done. During an interview on 7/17/24, the Administrator stated she had the overall responsibility of the campus, and that she set the expectation and goals. When asked what kind of involvement in leadership oversight the Medical Director should have, the Administrator stated the Medical Director was supposed to be involved in quality and infection control, but that she had just started the position in May 2024 and was still learning the role. When asked how many open nursing positions the facility had, the Administrator stated there were currently 10 CNA positions and 5 nursing positions posted, however there were more that needed to be filled. When asked if the number of staff currently working, based on the bed capacity of 96, was able to meet the needs of the resident acuity levels, the Administrator stated she felt they were able to meet the needs, but not at the standard we would want to meet them. When asked if they facility had considered lowering the census numbers, to help ease the staffing strain and better meet the resident's needs, the Administrator stated they would consider lowering the census if the facility could not meet the staffing crisis level for 4 consecutive da [TRUNCATED]

Based on interview, observation, and record review, the facility administration failed to ensure effective and efficient use of resources to provide for resident safety and to ensure the highest practicable physical, mental, and psychosocial well-being. This placed all residents (based on a census of 93) at risk for physical and/or psychosocial harm. The facility administration failed to maintain the facility in substantial compliance with regulatory requirements which resulted in substandard quality of care in which residents experienced actual physical harm including development of Stage III, IV, and unstageable pressure ulcers and deep tissue injuries. These failed practices caused actual harm due to the of deterioration of pressure ulcers. In addition, failure to ensure adequate staffing to provide for residents' physical, social, and emotional needs caused psychosocial harm. The facility administration was aware of the concerns but failed to identify or implement effective corrective measures. Findings: Review of the facility campus revealed eight separate cottage buildings, with 12 resident bedrooms in each cottage, for a total of 96 resident beds. Facility administrative and support staff (e.g. pharmacist, laundry, therapies) were located at the commons building. The facility's total census at the time of this survey was 93 residents. During an interview on 7/10/24 at 3:26 PM, the Administrator stated the Director of Nursing's (DON's) last full-time day was 6/21/24 and went to a schedule of coming to the facility Monday through Friday, 4:00 AM to 6:00 AM and then coming back in the afternoon if needed. Also, the DON would work Saturday and Sunday 6:00 AM to 12:00 PM if needed. The Administrator stated a new DON was hired and his/her start date was 7/29/24. See F727 for additional information regarding not having a full-time DON. During an interview on 7/17/24, the Administrator stated she had the overall responsibility of the campus, and that she set the expectations and goals. Staffing During an interview on 7/10/24 at 3:26 PM, when asked to describe the current staffing situation in the cottages, the Administrator stated the facility traditionally would have had one nurse in every cottage, and 16 CNAs (2 CNAs per cottage) scheduled on the dayshift, however since COVID they had not been able to meet that staffing level. The Administrator stated that the facility was currently running at crisis staffing level where there was one nurse for every 18 resident (one nurse per 1 and a half cottages) and one CNA for every 12 residents (one CNA per cottage), and there was a goal of having 4 support CNAs (1 support CNA per two cottages) to provide support and complete showers. This had been a challenge to attain, however, due call outs, and currently had been able to only provide about 3 support CNAs a day. When asked if the facility had received any calls or grievances about the staffing shortages, the Administrator stated there had been grievances from family. During an interview on 7/11/24 at 1:25 PM, when asked if staff had voiced any concerns about the staffing levels, the DON stated nurses had expressed concerns on having to pick up extra residents in a second cottage. During an interview on 7/12/24 at 10:29 AM, when asked how the staffing shortage and crisis level staffing had affected resident care, the Lead CNA (LCNA) stated it was a challenge to meet the needs of residents as swiftly as they could have with a full complement of staff, that staff able to give the residents the attention as they used to. The LCNA stated it was hard to meet the needs of the residents, and residents had voiced that their care had been delayed, to include not getting showers, and they didn't like the new staffing schedule. The LCNA further stated that if there weren't enough support CNAs, residents would get bed baths instead of showers because there weren't enough staff to provide showers. The LCNA further stated that having only one CNA per cottage now meant that residents had to wait longer for their needs to be met and it may have been impacting pressure ulcers because the CNAs were having trouble meeting the turning schedule of every 2 hours. See F676 for additional information regarding Activities of Daily Living (ADLs). During an interview on 7/17/24, when asked if the number of staff currently working, and based on the bed capacity of 96, was affecting the facility's able to meet the needs of the resident acuity levels, the Administrator stated she felt they were able to meet the needs, but not at the standard we would want to meet them. When asked how many open nursing positions the facility had, the Administrator there were currently 10 CNA positions and 5 nursing positions posted, however there were more that needed to be filled. Home Keepers/Housekeepers/Activity Staff During an interview on 7/10/24 at 3:26 PM, when asked what other measures the facility had attempted to help support the cottages to meet the needs of the residents, the Administrator stated they increased training with home keepers (cooks), housekeepers, and activity staff to help with assisting CNAs when needed in bed mobility and transfers, as well, as assist with dining for residents who required minimal support. These staff were trained in safe patient handling and dining assistance. During an interview on 7/11/24 at 1:25 PM, when asked if staff had voiced any concerns about the staffing levels, the DON stated the CNAs had expressed concerns that the home keepers, housekeepers, and activity staff weren't supporting them during the day because they were unsure on what they could or couldn't do. Random observations on 7/8-10/24 and 7/15-18/24 revealed no home keeper, housekeeper, or activity staff assisted CNAs with bed mobility, transfers, or dining assistance. See F725 for additional information regarding Sufficient Staffing and F675 for additional information regarding Quality of Life. Pressure Ulcers Review of the facility provided CASPER report, dated June 2024, revealed the facility's Pressure Ulcers facility adjusted percentage was 16.1% (compared to the comparison group national average of 7.4%). The July report was unavailable as it was too early in the month for that final report. Review of the facility's Matrix for Providers, CMS-802 [a document used to identify pertinent care categories] documentation, completed on 7/8-9/24, revealed an overall pressure ulcer rate of 19% [18 residents total]. During an interview on 7/12/24 at 2:30 PM, Wound Care Nurse (WRN) #1 stated there were currently 18 residents with pressure ulcers. When asked if limited staffing concerns contributed to the pressure ulcer numbers, the WRN #1 stated residents needed to be turned every 2 hours to relieve pressure. When asked if she felt residents were being turned every 2 hours, the WRN #1 stated, no. When asked if she felt this contributed the deterioration of the resident's pressure ulcers, WRN #1 stated, yes. During an interview on 7/17/24 at 8:17 AM, the Medical Director stated, If turning residents isn't getting completed, I would say we need to find avenues to get it done. During an interview on 7/18/24 at 11:27 AM, when asked if the Quality Assurance and Performance Improvement (QAPI) committee had implemented any performance action plans due to the high rate of pressure ulcers at the facility, the Quality Director stated she felt that the lack of staffing, and their inability to provide more one on one attention to residents, had attributed to this increase, and QAPI's focus had been to help boost staff numbers. The Quality Director further stated a performance improvement plan was in effect for pressure ulcers. When asked if the pressure ulcer rates had been discussed with the Governing Body (GB), the Quality Director stated the increase in pressure ulcer rates and the residents had been discussed. GB had been informed of low staffing levels. GB had discussed funding solutions, such as bringing in travelers, and leadership meetings had been held to possibly plan for this. See F725 for additional information regarding sufficient staffing. Quality of Life During an interview on 7/17/24 at 8:17 AM, when asked if the concerns with low staffing had impacted the resident's care, the Medical Director stated residents talked to her about how staff needed help. The Medical Director further stated low staffing was affecting the residents with higher acuity, who required heavier assistance in cares, more than the residents who were more independent. Review of the Resident Council Meeting Minutes, dated 1/17/24, 4/17/24, and 6/20/24, the DON noted a decrease in staffing had been occurring. During the 6/20/24 meeting the [Administrator] shared with group the new process [staffing restructure] which went live on Tuesday [6/23/24]. During an interview on 7/11/24 at 1:25 PM, when asked if staff had voiced any concerns about the staffing levels, the DON stated nurses had expressed concerns on having to pick up residents in a second cottage. The CNAs had expressed concerns that the home keepers, housekeepers, and activity staff weren't supporting them during the day because they were unsure on what they could or couldn't do. During an interview on 7/16/24 at 4:35 PM, LN #8 stated staff shortages had affected the ability to spend time with the residents. LN #8 stated it was a struggle to complete turns every 2 hours and showers. When properly staff showers used to be enjoyable and staff could spend time with residents to put on lotion, however staff are now rushed due to the increased workload that resulted in the staff being less available. LN #8 further stated quality time with residents wasn't possible anymore. During random interviews and observations, 7/8-10/24 and 7/15-18/24, revealed multiple residents expressed feelings of hopelessness, had sad-tones verbal expressions, tearfulness, and shared they experienced apathy, humiliation, frustration, and/or feelings of helplessness about the current staffing situation and how it had affected their livelihood at the facility. See F725 for additional information regarding sufficient staffing and F675 for additional information regarding quality of life. Review of the facility's policy SNF [skilled nursing facility]/AL [assisted living] Abuse Prohibition and Prevention, revised 1/2024, revealed: . The purpose of this policy is to set forth the . policy regarding the prohibition and prevention of resident . neglect . Definitions . Neglect . means 'the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .

Based on record review, interview, and observation, the facility failed to ensure residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, the facility's failed to create and sustain an environment that humanizes and individualizes each resident's quality of life and ensuring that the care and services provided were person-centered, and honored and supported each resident's preferences, choices, and values. This failed practice resulted in psychosocial harm for 10 residents (#s 26, 34, 39, 47, 56, 61, 77, 78, 86, and 92). In addition, these failed practices placed the remaining 83 residents at risk for living and receiving care in a less that optimal environment. Findings: Resident Quality of Life During random interviews and observations, 7/8-10/24 and 7/15-18/24, revealed multiple residents expressed feelings of hopelessness, had sad-toned verbal expressions, tearfulness, and shared they experienced apathy, humiliation, frustration, and feelings of helplessness about the current staffing situation and how it has affected their livelihood at the facility. Resident #26 During an interview on 7/8/24 at 4:01 PM, Resident #26 stated he/she had requested . no male caregivers for changing and showering. Resident #26 stated males providing hygiene to him/her bothered his/her spouse as well. Resident #26 further stated CNA #3 told him/her, . If your husband doesn't know it will be ok. Resident #26 stated . But it bothers me. During an interview on 7/15/24 at 11:10 AM, CNA #6 stated Resident #26 refused CNA #6 to provide personal cares because Resident # 26's spouse does not like it. CNA #6 stated a male CNA on nights showered resident. During an interview on 7/15/24 at 3:20 PM, LN #7 stated Resident #26 did not want male caregivers providing personal/pericare [cleaning of the genitalia and buttock area]. LN #7 stated, .It is more his/her [spouse] and his/her culture. I have talked to his/her [spouse] many times and explained we do not always have a [female] CNA . Review of the facility-provided ADL assistance documentation from resident's medical records, received 7/16-17/24, revealed Resident #26: I BATHE with 1 helper providing all of the effort. I use the shower chair. I prefer showers . Resident #34 During an observation and interview on 7/8/24 at 12:04 PM, Resident #34 was sitting in his/her room, at his/her bedside table with a disposable Styrofoam clamshell food container containing the resident's lunch. Resident #34 stated that the food was cold, but it was no use to call someone to warm it up as it might be forgotten in the microwave, or the staff would take a long time to come get it to heat it up. The resident stated that he/she might as well eat it cold than bother the staff. Resident #34 stated he/she had been eating out of Styrofoam containers all weekend as well as that day. His/her meals were served this way when a cook would not come into work. When this happened, their meals would be prepared in another cottage and brought over. He/she stated the meals felt like he/she was eating take out and would rather eat off real dishes. During an interview on 7/8/24 at 1:50 PM, Resident #34 stated that he/she was at the mercy of the staff. He/she stated that he/she would like to shower every night before bed, but he/she was told the facility policy was to shower twice a week. The resident stated that his/her shower days were Wednesdays and Saturdays. The resident expressed concerns that he/she would not be able to get a shower if he/she had a bad episode of bowel incontinence. Review of Resident #34's MDS (Minimum Data Set - A federally required nursing assessment) annual assessment dated [DATE], revealed: . Section F0400. Interview for Daily Preferences: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very important . During an interview on 7/15/24 at 11:43 AM, Resident #34 stated twice last week, he/she was not able to get out of bed until dinner time. He/she further stated he/she usually liked to be up and dressed by 8:00 AM daily. The resident expressed that it was very lonely waiting for the staff to come assist with getting him/her out of bed. The resident was unsure what activities he/she missed on those days and expressed that he/she felt that dining at the dining table with other residents at least once a week was important. Review of Resident #34's MDS annual assessment dated [DATE], revealed: . Section F0500. Interview for Daily Preferences: How important is it to you to do things with groups of people? Very important. How important is it to you to do your favorite activities? Very important . Resident #39 During an interview on 7/8/24 at 10:58 AM, Resident #39 stated that his/her biggest complaint with the facility was the lack of staffing due to a new system which was one CNA per cottage. There were times when there was no cook, no nurse, or CNA. Resident #39 stated that the lack of staffing consequence was that he/she did not always get his/her shower. Resident #39 stated, when questioned about the lack of showers, stated, This is unacceptable. Resident #39 had concerns that his/her exercises were not always completed. Resident #39 stated, If we lack staff, the replacement has to come from a different cottage. The lack of CNAs has always a problem. The doctors are gone too. The [administrative leadership] are aware of this. We can't take care of ourselves. One CNA with 12 people is a lot. Review of Resident #39's Baseline Care Plan, printed on 7/17/24, revealed: Special Precautions . Assist me with ROM exercises to all extremities, 3-5 rep, BID [twice a day] with care as tolerated . I bathe with the help of 1-2 people doing 100% of the care, using the Carendo shower chair. Transfer me with the ceiling lift and blue sling. No Male CNAs during shower. Nails to be trimmed by PCN. Bath/shower: Tuesday (day); Friday (day). During an interview on 7/9/24 at 9:01 AM, Resident #39 stated he/she was not being able to choose more showers when she/he wished. Showers were scheduled two days a week. Resident #39 stated, I often miss showers due to there not being enough staff here. Review of Resident #39's MDS annual assessment, dated 3/14/24, revealed: . Section F0400. Interview for Daily Preferences: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very important . Resident #47 During an observation on 7/15/24 at 12:45 PM, Resident #47 was sitting at dining table and asked staff for help to the bathroom. Occupational Therapist (OT) #1 told Resident #47 that he/she would have to wait for staff. The Dietary Manager was serving food to residents at the dining table. It was observed that Licensed Nurse (LN) #4 was going room to room passing medications. Resident #47 started independently propelling his/her wheelchair (wc) with his/her feet to the nurse. LN #4 told Resident #47 he/she was trying to locate the CNA. It was observed CNA #7 came out of room [ROOM NUMBER] and went immediately towards room [ROOM NUMBER] as Resident #47 was looking towards CNA #7 saying he/she needed to go to the bathroom. CNA #7 ignored Resident #47 and entered room [ROOM NUMBER]. At 1:05 PM, Resident #47 continued to request help to the bathroom propelling himself/herself in his/her wc throughout the common space in cottage. OT #1 told Resident #47 he/she would try and find staff to assist him/her. At 1:15 PM, CNA #7 told Resident #47 I have one more person to change first. CNA #7 then entered room [ROOM NUMBER]. At 1:27 PM, it was observed that CNA #7 walk up to the kitchen as OT #1 ask CNA #7 about another resident's meal. Resident #47 noted CNA #7 and started propelling him/herself toward the kitchen from the hallway and tried to get CNA #7's attention. Resident #47 stopped propelling and stopped trying to call out to CNA #7. Resident #47 started to frown and put his/her head down. During an interview on 7/15/24 at 1:28 PM, when asked if he/she still required assistance to the bathroom, Resident #47 frowned putting his/her head down stating they required assistance of toileting hygiene (because the resident had an accident). At 1:29 PM, CNA #7 took Resident #47 to his/her room. Resident #56 During an observation and interview on 7/15/24 at 1:48 PM, no CNA, LN, or cook were visibly present in the Yukon cottage. Further observation in Resident #56's room revealed his/her had a breakfast tray to be picked up. Resident #59 used the call light and stated, They won't come, I always wait. Resident #59 stated the breakfast had been delivered around 11:00 AM. The breakfast tray was on his/her lap and the resident was in bed with the head of the bed raised 45 degrees. Observation of the open common areas of the cottage revealed no staff visible. CNA #8 arrived at 2:09 PM and asked Resident #56 what he/she wanted. When asked, why the call light had been delayed and no staff were present in the dayroom, CNA #8 stated he/she did not hear the call light because he/she was in the office charting since the other computer out on the floor did not work. Resident #61 During an interview on 7/16/24 at 3:30 PM, Resident #61 stated he/she had to stay in bed for days because there is only one CNA, and they don't have time to get me up. Resident #61 stated he/she missed activities because [of] not enough staff. missed BINGO today . Review of the facility-provided ADL assistance documentation from resident's medical records, received 7/16-17/24, revealed Resident #61: I TRANSFER with the dependent assistance of 1 person, using the ceiling lift with green-trimmed bariatric sling . Resident #77 During an interview on 7/10/24 at 9:30 AM, Resident #77's family stated the facility had reduced their CNAs dramatically. This family member stated he/she had witnessed residents in Deskha cottage crying out saying they needed help, however there was no one in the Deshka cottage to help because the CNA was busy with someone else. The family member further stated he/she had called and filed a grievance, however never received a response about it. The family member stated he/she turned the grievance into LN #14 on 6/13/24 and he/she had a copy of the grievance Resident #78 During an interview on 7/15/24 at 11:53 AM, Resident #78 stated that the nursing staff do not ask her when she wants to get up, they just let her sleep. The resident stated that he/she is on a diuretic (a drug that helps remove excess water, salts, and other accumulated metabolic products from the body through urine), which increases his/her need to urinate. The resident stated he/she cannot wait long periods of time for staff to answer the call light, which resulted in the resident urinating in bed. This had happened regularly and as recent as two days ago. Review of Resident #78's Baseline Care Plan, printed on 7/12/24, revealed: I USE THE BATHROOM: with the help of 1 person doing less than half the effort. I am continent of bladder and bowel, but wear incontinence briefs in case I have an accident. Resident #86 During an interview on 7/12/24 at 1:09 PM, Resident #86 stated since the staffing change there has been a big problem getting showers because he/she required assistance. Resident #86 stated he/she rarely received a shower, unless he/she felt brave enough to try and take a shower by himself/herself. Resident #86 also stated there had been delays in obtaining a bedpan when needed because there were no staff to answer the request, and he/she had to wait 3 hours once just to relieve himself/herself. Review of the facility-provided ADL assistance documentation from resident's medical records, received 7/16-17/24, revealed Resident #86: I BATHE with 1 helper providing more than half the effort. I sit on the shower chair. I prefer showers . Review of Resident #86's MDS annual assessment, dated 1/23/24, revealed: . Section F0400. Interview for Daily Preferences: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very important . Resident #86 further stated because nurses must go to other cottages now to help other residents, he/she has had to wait hours for as needed medications for shortness of breath. This had happened so often that he/she had resorted to calling the nurse supervisors for help when nurses weren't in the cottage. Resident #92 During an observation and interview on 7/15/24 at 11:49 AM, Resident #92 was in bed and had just finished his/her breakfast of pancakes and peanut butter. The resident said that he/she had waited to be served breakfast since 7:00 AM and had received it about an hour ago. He/she was going to skip lunch because it was so late in the day. The resident pressed his/her call light because he/she wanted nicotine gum. The surveyor left the resident's room. Continued observation on 7/15/24 at 12:38 PM, 46 min later, this surveyor walked over to the call light monitoring system in the common area and saw that Resident #92's call light had been on for 46 minutes. Further observation revealed Resident #92 called out from his/her room to [NAME] #2 in the kitchen. The cook was busy and stated that someone would be in shortly. This surveyor asked Resident #92 if anyone had been in to help, the resident stated no one had come. During an interview while continuing the observation on 7/15/24 at 12:39 PM, CNA #11 stated he/she was the only CNA in the cottage. CNA #11 then went into Resident #92's room and the call light was turned off. Resident #92 waited approximately 51 minutes for staff. At 1:17 PM Resident #92 was observed coming out of his/her room in his/her wheelchair. When asked if he/she received his/her nicotine gum, the resident stated, No and that he/she was headed out to go smoke. Resident Council Meeting Minute Review Review of Resident Council meeting minutes, dated 1/17/24, revealed: . Resident shared concerns of the night CNA's leaving the cottage for an extended amount of time and not available to help with their own resident[s]. Resident believes it is a safety concern. Resident shared concerns that his call light is not being answered at nights due to caregivers not being available in the cottages. He feels this is escalating and not being addressed. Review of Resident Council meeting minutes, dated 4/17/24, revealed: . Resident asked for clarification on toileting assistance with 1 C.N.A. in each cottage. Residents concern is waiting for assistance at night to get help to the toilet and will that also be a problem during the day?. Review of Resident Council meeting minutes, dated 6/20/24, revealed: . Residents' concerns as follows: Will we have someone on the weekends helping us get out of bed and help with getting ready for the day including church services on Sundays? Resident shared she has not been getting up daily as she should and having to wait to be put back to bed causing her pain on the weekend. [DON] acknowledged residents' complaint and explained that the weekend was very challenged with caregivers calling out and staffing being extremely short. Food/Dining During an interview on 7/8/24 at 9:27 AM, CNA #10 stated the Aniak cottage did not have a home keeper (cook) that day for the cottage. When the cooks were short staffed, the meals for the cottage were prepared in another cottage, placed in separate disposable Styrofoam clamshell food containers labeled with the resident's room number, and brought over. The CNA and LN would serve the meals. During an interview on 7/8/24 at 1:20 PM, LN #3 stated the lack of staff was a problem. Whenever a CNA was missing, that was a problem. If the cottage's cook was not working that day, the food came from a different cottage. LN #3 stated the housekeepers are often short staffed too. During an interview on 7/9/24 at 9:07 AM, [NAME] #2 stated that the Aniak cottage did not have a cook for the last three days (7/6-8/24), and other cooks in the other cottages would rotate preparing meals for the day. [NAME] #2 stated that meals were served in the disposable Styrofoam clamshell food containers because when a cook was covering another cottage, there was no time to wash dishes for both cottages and complete other duties. If another cottage did not have a cook available for the day, [NAME] #2 would prepare meals for the other cottage first before working on the meals for his/her assigned cottage. During an interview on 7/10/24 at 4:39 PM, the Dietary Manager stated serving meals from disposable Styrofoam clamshell food containers was not ideal and needed to ask dietary why they were delivering food like that. Staffing/Care Deficits During an interview on 7/10/24 at 3:26 PM, when asked to describe the current staffing situation in the cottages, the Administrator stated the facility traditionally would have had one nurse in every cottage (12 residents per cottage), and 16 CNAs (2 CNAs per cottage) scheduled on the dayshift, however since COVID they had not been able to meet that staffing level. The Administrator stated that the facility was currently running at crisis staffing level where there was one nurse for every 18 resident (one nurse per 1 and a half cottages) and one CNA for every 12 residents (one CNA per cottage), and there was a goal of having 4 support CNAs (1 support CNA per two cottages) to provide support and complete showers. However, when staff call out of work, the facility had only been able to provide about 3 support CNAs a day. During the same interview, when asked if the facility had received any calls or grievances about the staffing shortages, the Administrator stated there had been grievances from families. During an interview on 7/11/24 at 1:25 PM, when asked if staff had voiced any concerns about the staffing levels, the Director of Nursing (DON) stated nurses had expressed concerns on having to pick up extra residents in a second cottage. The CNAs had expressed concerns that the home keepers, housekeepers, and activity staff weren't supporting them during the day because they were unsure on what they could or couldn't do. During an interview on 7/12/24 at 10:29 AM, the Lead CNA (LCNA) stated staffing shortage and crisis level staffing had affected resident care, the LCNA stated it was a challenge to meet the needs of residents as swiftly as they could have with a full complement of staff, and that staff were not able to give the residents the level of attention they used to. During the same interview the LCNA stated it was hard to meet the needs of the residents, and residents had voiced that their care had been delayed, to include not getting showers, and they didn't like the new staffing schedule. The LCNA further stated that if there weren't enough support CNAs, residents would get bed baths instead of showers because there were not enough staff to provide showers. The LCNA further stated that having only one CNA per cottage now meant that residents had to wait longer for their needs to be met and it may have impacted pressure ulcers because the CNAs were having trouble meeting the turning schedule of every 2 hours. During an interview on 7/16/24 at 4:35 PM, LN #8 stated staff shortages had affected the ability to spend time with the residents. LN #8 stated it was a struggle to complete turns every 2 hours and showers. When properly staffed it used to be enjoyable and staff could spend time with residents to put on lotion, however staff are now rushed due to the increased workload that resulted in the staff being less available. LN #8 further stated quality time with residents wasn't possible anymore. During an interview on 7/17/24 at 3:28 PM, CNA #11 stated the 4 person CNA support teams doesn't work and cottage CNAs end up doing everything on their own. CNA #11 further stated nurses would help, when they are available, but it wasn't easy for the nurses because they now had to cover other cottages. During an interview on 7/18/24 at 11:27 AM, the Quality Director stated she felt that the lack of staffing, and their inability to provide more one on one attention to residents, had attributed to and increase in pressure related injuries. During an interview on 7/17/24 at 8:17 AM, when asked if the concerns with low staffing had impacted the resident's care, the Medical Director stated residents did talk to her about how staff needed help. The Medical Director further stated low staffing was affecting the residents with higher acuity, who required heavier assistance in cares, more than the residents who were more independent. During an interview on 7/17/24, when asked if the number of staff currently working, based on the bed capacity of 96, was able to meet the needs of the resident acuity levels, the Administrator stated she felt they were able to meet the needs, but not at the standard we would want to meet them. Review of the facility's policy SNF [skilled nursing facility]/AL [assisted living] Abuse Prohibition and Prevention, revised 1/2024, revealed: . The purpose of this policy is to set forth the . policy regarding the prohibition and prevention of resident . neglect . Definitions . Neglect . means 'the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .

Based on record review, interview, and observation, the facility failed to ensure appropriate treatment and services that includes all care provided to residents to maximize the resident's functional abilities. Specifically, the facility failed to ensure Activities of Daily Living (ADLs - the skills of bathing, dressing, toileting, transferring, bed mobility, and eating) were completed to meet the needs of 8 Residents (#s 26, 34, 39, 47, 61, 78, 86, and 92), out of 20 sampled residents, as determined by resident acuity [acuity is a measurement of the level of care a patient need based on the severity of either an illness or mental condition]. This failed practice resulted in psychosocial harm of these residents. In addition, this failed practice also resulted in two residents (#s 56 and 77) not having ADL needs met. The overall inability to provided ADL care had the potential to affect the other 83 residents placing them at risk for not receiving servicers to maintain the highest practicable physical, mental, and psychosocial wellbeing. Findings: Review of the facility-provided ADL [Activities of Daily Living] assistance documentation from resident's medical records, received 7/16-17/24, revealed the following need for assistance from staff: 1) Bed Mobility (Turning or adjusting): - Independent: 4 residents - One-person assist: 62 residents - One to two person assist: 9 residents - Two-person assist: 15 residents - Information not provided: 3 residents (#'s 8, 28, and 60) 2) Transfer (from bed to wheelchair): - Independent: 2 residents - One-person assist: 62 residents - One to two person assist: 11 residents - Two-person assist: 15 residents - Information not provided: 3 residents (#'s 8, 62, and 87) 3) Bathing: - Independent: 2 residents - One-person assist: 74 residents - One to two person assist: 6 residents - Two person assist: 8 residents - Information not provided: 3 residents (#'s 8, 33, and 76) 4) Eating: - Independent: 5 residents - Set Up Assistance: 40 residents - Dependent: 23 residents - Intermittent Supervision: 4 residents - Enteral feeding: 9 residents - Information not provided: 12 residents (#'s 8, 12, 33, 49, 51, 57, 66, 76, 77, 79, 82, and 91) 5) Toileting: - Independent: 2 residents - One-person assist: 65 residents - One to two person assist: 13 residents - Two-person assist: 10 residents - Information not provided: 3 residents (#'s 8, 61, and 76) Staffing: During an interview on 7/11/24 at 1:25 PM, when asked if staff had voiced any concerns about the staffing levels, the DON stated nurses had expressed concerns on having to pick up extra residents in a second cottage. The CNAs had expressed concerns that the home keepers, housekeepers, and activity staff weren't supporting them during the day because they were unsure on what they could or couldn't do. When asked specifically what the home keepers, housekeepers, and activity staff could do to support the CNAs, the DON stated they could assist only with bed mobility or transfers of resident when the CNAs were present, however they could not assist by themselves, and they could not assist with toileting. Also, for dining assistance, they could help with cuing and support resident's hands or arms to allow the residents to feed themselves, however they could not feed residents. Random observations on 7/8-10/24 and 7/15-18/24 revealed no home keepers, housekeepers, or activity staff assisted CNAs with bed mobility, transfers, or dining assistance. During an interview on 7/12/24 at 10:29 AM, when asked how the staffing shortage and crisis level staffing had affected resident care, the Lead CNA (LCNA) stated it was a challenge to meet the needs of residents as swiftly as they could have with a full complement of staff, and that staff were not able to give the residents the level of attention they used to. The LCNA stated it was hard to meet the needs of the residents, and residents had voiced that their care had been delayed, to include not getting showers, and they didn't like the new staffing schedule. The LCNA further stated that if there weren't enough support CNAs, residents would get bed baths instead of showers because there were not enough staff to provide showers. Resident Review Resident #26 During an interview on 7/8/24 at 4:01 PM, Resident #26 stated he/she had requested . no male caregivers for changing and showering. Resident #26 stated males providing hygiene to him/her bothered his/her spouse as well. Resident #26 further stated CNA #3 told him/her, . If your husband doesn't know it will be ok. Resident #26 stated . But it bothers me. During an interview on 7/15/24 at 11:10 AM, CNA #6 stated Resident #26 refused CNA #6 to provide personal cares because Resident # 26's spouse does not like it. CNA #6 stated a male CNA on nights showered resident. During an interview on 7/15/24 at 3:20 PM, LN #7 stated Resident #26 did not want male caregivers providing personal/pericare [cleaning of the genitalia and buttock area]. LN #7 stated, .It is more his/her [spouse] and his/her culture. I have talked to his/her [spouse] many times and explained we do not always have a [female] CNA . Review of the facility-provided ADL assistance documentation from resident's medical records, received 7/16-17/24, revealed Resident #26: I BATHE with 1 helper providing all of the effort. I use the shower chair. I prefer showers . The LCNA further stated that having only one CNA per cottage now meant that residents had to wait longer for their needs to be met and it may have impacted pressure ulcers because the CNAs were having trouble meeting the turning schedule of every 2 hours. Resident #34 During an interview on 7/8/24 at 1:50 PM, Resident #34 stated that he/she was at the mercy of the staff. He/she stated that he/she would like to shower every night before bed, but he/she was told the facility policy was to shower twice a week. The resident stated that his/her shower days were Wednesdays and Saturdays. The resident expressed concerns that he/she would not be able to get a shower if he/she had a bad episode of bowel incontinence. Review of Resident #34's MDS (Minimum Data Set - A federally required nursing assessment) annual assessment dated [DATE], revealed: . Section F0400. Interview for Daily Preferences: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very important . During an interview on 7/15/24 at 11:43 AM, Resident #34 stated twice last week, he/she was not able to get out of bed until dinner time. He/she further stated he/she usually liked to be up and dressed by 8:00 AM daily. The resident expressed that it was very lonely waiting for the staff to come assist with getting him/her out of bed. The resident was unsure what activities he/she missed on those days and expressed that he/she felt that dining at the dining table with other residents at least once a week was important. Review of Resident #34's MDS annual assessment dated [DATE], revealed: . Section F0500. Interview for Daily Preferences: How important is it to you to do things with groups of people? Very important. How important is it to you to do your favorite activities? Very important . Resident #39 During an interview on 7/8/24 at 10:58 AM, Resident #39 stated that his/her biggest complaint with the facility was the lack of staffing due to a new system which was one CNA per cottage. There were times when there was no cook, no nurse, or CNA. Resident #39 stated that the lack of staffing consequence was that he/she did not always get his/her shower. Resident #39 stated, when questioned about the lack of showers, stated, This is unacceptable. Resident #39 had concerns that his/her exercises were not always completed. Resident #39 stated, If we lack staff, the replacement has to come from a different cottage. The lack of CNAs has always a problem. The doctors are gone too. The [administrative leadership] are aware of this. We can't take care of ourselves. One CNA with 12 people is a lot. Review of Resident #39's Baseline Care Plan, printed on 7/17/24, revealed: Special Precautions . Assist me with ROM exercises to all extremities, 3-5 rep, BID [twice a day] with care as tolerated . I bathe with the help of 1-2 people doing 100% of the care, using the Carendo shower chair. Transfer me with the ceiling lift and blue sling. No Male CNAs during shower. Nails to be trimmed by PCN. Bath/shower: Tuesday (day); Friday (day). During an interview on 7/9/24 at 9:01 AM, Resident #39 stated he/she was not being able to choose more showers when she/he wished. Showers were scheduled two days a week. Resident #39 stated, I often miss showers due to there not being enough staff here. Review of Resident #39's MDS annual assessment, dated 3/14/24, revealed: . Section F0400. Interview for Daily Preferences: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very important . Resident #47 During an observation on 7/15/24 at 12:45 PM, Resident #47 was sitting at dining table and asked staff for help to the bathroom. Occupational Therapist (OT) #1 told Resident #47 that he/she would have to wait for staff. The Dietary Manager was serving food to residents at the dining table. It was observed that Licensed Nurse (LN) #4 was going room to room passing medications. Resident #47 started independently propelling his/her wheelchair (wc) with his/her feet to the nurse. LN #4 told Resident #47 he/she was trying to locate the CNA. It was observed CNA #7 came out of room [ROOM NUMBER] and went immediately towards room [ROOM NUMBER] as Resident #47 was looking towards CNA #7 saying he/she needed to go to the bathroom. CNA #7 ignored Resident #47 and entered room [ROOM NUMBER]. At 1:05 PM, Resident #47 continued to request help to the bathroom propelling himself/herself in his/her wc throughout the common space in cottage. OT #1 told Resident #47 he/she would try and find staff to assist him/her. At 1:15 PM, CNA #7 told Resident #47 I have one more person to change first. CNA #7 then entered room [ROOM NUMBER]. At 1:27 PM, it was observed that CNA #7 walk up to the kitchen as OT #1 ask CNA #7 about another resident's meal. Resident #47 noted CNA #7 and started propelling him/herself toward the kitchen from the hallway and tried to get CNA #7's attention. Resident #47 stopped propelling and stopped trying to call out to CNA #7. Resident #47 started to frown and put his/her head down. During an interview on 7/15/24 at 1:28 PM, when asked if he/she still required assistance to the bathroom, Resident #47 frowned putting his/her head down stating they required assistance of toileting hygiene (because the resident had an accident). At 1:29 PM, CNA #7 took Resident #47 to his/her room. Resident #56 During an observation and interview on 7/15/24 at 1:48 PM, no CNA, LN, or cook were visibly present in the Yukon cottage. Further observation in Resident #56's room revealed his/her had a breakfast tray to be picked up. Resident #59 used the call light and stated, They won't come, I always wait. Resident #59 stated the breakfast had been delivered around 11:00 AM. The breakfast tray was on his/her lap and the resident was in bed with the head of the bed raised 45 degrees. Observation of the open common areas of the cottage revealed no staff visible. CNA #8 arrived at 2:09 PM and asked Resident #56 what he/she wanted. When asked, why the call light had been delayed and no staff were present in the dayroom, CNA #8 stated he/she did not hear the call light because he/she was in the office charting since the other computer out on the floor did not work. Resident #61 During an interview on 7/16/24 at 3:30 PM, Resident #61 stated he/she had to stay in bed for days because there is only one CNA, and they don't have time to get me up. Resident #61 stated he/she missed activities because [of] not enough staff. missed BINGO today . Review of the facility-provided ADL assistance documentation from resident's medical records, received 7/16-17/24, revealed Resident #61: I TRANSFER with the dependent assistance of 1 person, using the ceiling lift with green-trimmed bariatric sling . Resident #77 During an interview on 7/10/24 at 9:30 AM, Resident #77's family stated the facility had reduced their CNAs dramatically. This family member stated he/she had witnessed residents in Deskha cottage crying out saying they needed help, however there was no one in the Deshka cottage to help because the CNA was busy with someone else. Resident #78 During an interview on 7/15/24 at 11:53 AM, Resident #78 stated that the nursing staff do not ask her when she wants to get up, they just let her sleep. The resident stated that he/she is on a diuretic (a drug that helps remove excess water, salts, and other accumulated metabolic products from the body through urine), which increases his/her need to urinate. The resident stated he/she cannot wait long periods of time for staff to answer the call light, which resulted in the resident urinating in bed. This had happened regularly and as recent as two days ago. Review of Resident #78's Baseline Care Plan, printed on 7/12/24, revealed: I USE THE BATHROOM: with the help of 1 person doing less than half the effort. I am continent of bladder and bowel, but wear incontinence briefs in case I have an accident. Resident #86 During an interview on 7/12/24 at 1:09 PM, Resident #86 stated since the staffing change there has been a big problem getting showers because he/she required assistance. Resident #86 stated he/she rarely received a shower, unless he/she felt brave enough to try and take a shower by himself/herself. Resident #86 also stated there had been delays in obtaining a bedpan when needed because there were no staff to answer the request, and he/she had to wait 3 hours once just to relieve himself/herself. Review of the facility-provided ADL assistance documentation from resident's medical records, received 7/16-17/24, revealed Resident #86: I BATHE with 1 helper providing more than half the effort. I sit on the shower chair. I prefer showers . Review of Resident #86's MDS annual assessment, dated 1/23/24, revealed: . Section F0400. Interview for Daily Preferences: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very important . Resident #86 further stated because nurses must go to other cottages now to help other residents, he/she has had to wait hours for as needed medications for shortness of breath. This had happened so often that he/she had resorted to calling the nurse supervisors for help when nurses weren't in the cottage. Resident #92 During an observation and interview on 7/15/24 at 11:49 AM, Resident #92 was in bed and had just finished his/her breakfast of pancakes and peanut butter. The resident said that he/she had waited to be served breakfast since 7:00 AM and had received it about an hour ago. He/she was going to skip lunch because it was so late in the day. The resident pressed his/her call light because he/she wanted nicotine gum. The surveyor left the resident's room. Continued observation on 7/15/24 at 12:38 PM, 46 min later, this surveyor walked over to the call light monitoring system in the common area and saw that Resident #92's call light had been on for 46 minutes. Further observation revealed Resident #92 called out from his/her room to [NAME] #2 in the kitchen. The cook was busy and stated that someone would be in shortly. This surveyor asked Resident #92 if anyone had been in to help, the resident stated no one had come. During an interview while continuing the observation on 7/15/24 at 12:39 PM, CNA #11 stated he/she was the only CNA in the cottage. CNA #11 then went into Resident #92's room and the call light was turned off. Resident #92 waited approximately 51 minutes for staff. At 1:17 PM Resident #92 was observed coming out of his/her room in his/her wheelchair. When asked if he/she received his/her nicotine gum, the resident stated, No and that he/she was headed out to go smoke. Staff Interview During an interview on 7/15/24 at 12:39 PM, CNA #11 stated there were no limits on the frequency a resident can get up out of bed or have a shower but depended on the availability of staff. Most of the time the staff were busy, and it was much harder to give showers outside of the residents' schedule. During an interview on 7/16/24 at 4:35 PM, LN #8 stated staff shortages had affected the ability to spend time with the residents. LN #8 stated it was a struggle to complete turns every 2 hours and showers. When properly staffed it used to be enjoyable and staff could spend time with residents to put on lotion, however staff are now rushed due to the increased workload that resulted in the staff being less available. LN #8 further stated quality time with residents wasn't possible anymore. During an interview on 7/17/24 at 3:28 PM, CNA #11 stated the 4 person CNA support teams doesn't work and cottage CNAs end up doing everything on their own. CNA #11 further stated nurses would help, when they are available, but it wasn't easy for the nurses because they now had to cover other cottages. Administration During an interview on 7/17/24 at 8:17 AM, when asked if the concerns with low staffing had impacted the resident's care, the Medical Director stated residents did talk to her about how staff needed help. The Medical Director further stated low staffing was affecting the residents with higher acuity, who required heavier assistance in cares, more than the residents who were more independent. The Medical Director further stated If turning residents isn't getting completed, I would say we need to find avenues to get it done. During an interview on 7/17/24, the Administrator stated she felt they were able to meet the needs, but not at the standard we would want to meet them. Review of the facility's Providence Anchorage Long Term Care Standards of Care, revised 5/2023, revealed: . These standards are established as daily expectations for care of resident unless otherwise directed on the plan of care. The RDCP [baseline care plan] builds on this standard of care . -A.M. Care (every morning) . Toilet [and] pericare . completely groomed and dressed . ROM [range of motion] as per care plan with 3-5 reps [repetitions] or to tolerance . - H.S. [nighttime] Care (every HS at bedtime) . Toileted [and] peri care . ROM as per care plan with 3-5 reps or to tolerance . - Periodic Care: shower/bath as scheduled. Provide complete bed bath if scheduled shower cannot be given . - Ongoing Care: call lights: work as team to meet the goal of answering regular within 5-10 minutes . Provide peri care after voids, BM [bowel movement] . Turning/reposition [ever] 2 hours for residents with dependent mobility . Follow toileting schedules ([every] 2 hours means even hours) . - Approaches: Listen to resident - affirm self-worth [and] dignity . Promote resident choice and personal preference whenever possible. Review of the facility's policy SNF [skilled nursing facility]/AL [assisted living] Abuse Prohibition and Prevention, revised 1/2024, revealed: . The purpose of this policy is to set forth the . policy regarding the prohibition and prevention of resident . neglect . Definitions . Neglect . means 'the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .

Based on interview and record review, the facility failed to protect residents in response to allegations of abuse. Specifically, the facility failed to: 1) ensure an alleged perpetrator, Licensed Nurse (LN) #6, was immediately removed from resident care, to prevent further potential abuse, while an active abuse investigation was in progress for 1 sampled resident (#83), out of 1 active abuse investigation reviewed; and 2) ensure an alleged perpetrator, Certified Nurse Assistant (CNA) #2, was kept from 1 unsampled resident (#86), out of 1 past abuse investigation reviewed, after an investigation of abuse was completed. These failed practices caused psychosocial harm to Residents #'s 83 and 86; and placed all residents of the Susitna Cottage (based on a census of 12), and all residents of the Deshka Cottage (based on a census of 11) at risk for further potential abuse. Findings: Resident #83 During an interview on 7/17/24 at 9:10 AM, Resident #83, who was a resident of the Susitna Cottage, stated that on 7/14/24 at 6:00 PM he/she was sitting in his/her wheelchair and felt short of breath. He/she wanted the fan on, and also felt the need for oxygen. Resident #83 stated he/she used his/her call light to call for assistance. Resident #83 stated he/she waited 3 1/2 hours, and since no one came, he/she began to yell for help. Resident #83 stated LN #6 arrived and placed oxygen on him/her. Resident #83 asked LN #6, .when will I get transferred to the bed . Resident #83 stated LN #6 got really out of control screaming. [LN #6] got behind me and hit me like a hammer on top of my head. It hurt really bad. Resident #83 further stated he/she asked LN #6, 'Why are you hitting me?' and [LN #6] was screaming loud. [LN #6] left and left me in my chair. Resident #83 further stated that Resident #32 arrived at Resident #83's room to check on him/her. Resident #83 further stated he/she reported the incident to CNA #9 and then Supervisor Long Term Care Nurse (SRN) #1 arrived in the resident's room on 7/14/24. Resident #83 stated he/she provided his/her report of the incident to SRN #1. Resident #83 further stated that after SRN #1 left, LN #6 remained in the cottage and completed his/her shift on 7/14/24. Resident #83 stated that the next day, 7/15/24, he/she had a headache and was dizzy. Resident #83 stated his/her head was still tender to the touch. Resident #83 stated, I don't want to see [LN #6] again, I am afraid, like a killer they won't stop. [He/She] will do this again. I can't control [him/her], [LN #6] is very strong, powerful. During an interview on 7/17/24 at 10:30 AM, Resident #32 stated he/she, . heard people fussing and raising hell. Yelling voices loud enough to disturb and upset me. By the time I got to [Resident #83's] room, [LN #6] took off.I asked [Resident #83] what was going on? [Resident #83] stated '[LN #6] hit me on my head.' Resident #32 further stated . I don't want [LN #6] to know I am talking because I am afraid [LN #6] may poison me. Review of Resident #83's base line care plan, undated, revealed: . transfers . I need staff to do 100% of the effort using the overhead lift . Review of Resident #83's care plan, dated 6/11/24, revealed: . I am weak . tell my nurse when I am short of breath . Review of the facility's initial report, completed by SRN #1 on 7/14/24, revealed it was documented that SRN #1 was made aware of the incident at 6:50 PM, and the report was completed at 7:25 PM. Review of the LN #6's hours worked on 7/14/24, from the facility's kronos system (time keeping system that tracked working hours of an employee), revealed LN #6 remained on the clock and worked on the Susitna Cottage until 7:30 PM. LN #6 was allowed to work for 40 minutes after SRN #1 was made aware of the allegation of abuse. During an interview on 7/17/24 at 9:50 AM, SRN #1 stated on the evening of 7/14/24, he/she was informed by CNA #9 that Resident #83 wanted to talk to him/her right away. SRN #1 stated he/she went to the resident's room and Resident #83 reported the allegation of abuse. SRN #1 stated he/she completed the initial report and contacted the Administrator and Director of Nursing (DON) about the incident on 7/14/24 at 7:00 PM. When asked if he/she was aware of the facility's policy to remove staff from the facility, for resident safety, when a report of alleged abuse was given until the investigation was completed, SRN #1 stated he/she was aware of this policy however stated shift change was occurring and LN #6 stayed because he/she was leaving soon. SRN #1 stated he/she did report this incident to the nightshift nursing supervisor prior to him/her leaving for the night. When asked if LN #6 was taken off the schedule until the investigation was over, SRN #1 stated the DON had told him/her, when he/she made contact about the incident, that the Operations Director would intercept LN #6 in the morning to prevent him/her from working on 7/15/24. Review of the facility's staff schedule for 7/15/24, the day after this incident, revealed LN #6 was scheduled to work a full shift on the Deshka Cottage. Review of the LN #6's hours worked on 7/15/24, from the facility's kronos system, revealed LN #6 worked a full shift (7:00 AM to 7:30 PM) on the Deshka Cottage. During an interview on 7/18/24 at 11:15 AM, the Quality Director stated she was only informed of the allegation of abuse concerning LN #6 later in the day on 7/15/24, and LN #6 continued to work through 7/15/24. When told of the DON's plan to have the Operations Director to intercept LN #6 in the morning, the Quality Director stated there was a miscommunication, and that the Operations Director was on vacation on 7/15/24. The Quality Manager stated that LN #6 should have been placed on administrative leave as soon as the report of allegation was received, and the investigation was completed. Resident #86 During an interview on 7/12/24 at 1:09 PM, Resident #86 stated he/she was involved in an incident with CNA #2 where Resident #86 requested assistance after having a urine incontinence accident which resulted in the need for his/her bedding and clothing be changed. Resident #86 stated CNA #2 came into the room frustrated over the situation. At one point, Resident #86 requested another nightshirt. Resident #86 stated CNA #2 retrieved a fresh nightshirt from Resident #86's dresser and threw it in Resident #86's face. Resident #86 stated it was thrown with force, which caused the nightshirt to strike Resident #86's open eyes. Resident #86 further stated that he/she did report the incident and the facility did investigate. The result of the investigation concluded that everyone was having a bad day and it was decided that CNA #2 would not work in Resident #86's Cottage anymore, which Resident #86 was satisfied with and felt the incident was addressed and concluded. Resident #86 stated that a couple of weeks later, CNA #2 returned to the cottage to work, despite the agreement that CNA #2 would no longer work in his/her cottage. As Resident #86 began to cry during the interview, he/she stated he/she felt fearful and reported the incident to a supervisor, although could not remember who it was. Resident #86 stated the supervisor stated CNA #2 had to work the cottage due to staffing shortages. Resident #86 tearfully stated he/she felt so unsafe, he/she didn't leave his/her room the entire day. Review of the facility's investigation of this incident revealed the date of incident was 2/25/24, and the final investigation concluded on 2/28/24. Further review revealed a corrective action plan of [CNA #2] is being moved to another cottage and there is to be no interaction between [CNA #2] and the resident [Resident #86]. Review of the CNA #2's hours worked from the facility's kronos system, dated 2/25/24 to 4/30/24, revealed CNA #2 worked a full day in Resident #86's cottage on 3/3/24. During an interview on 7/18/24 at 11:15 AM, the Quality Director stated she could not speak to this incident, the investigation, or the outcome as the Director of Nursing (DON) handled this incident. The DON was not available to interview. Review of the facility's policy SNF [Skilled Nursing Facility]/AL [Assisted Living] Abuse Prohibition and Prevention, last revised 1/2024, revealed: . Protection: Resident will be protected from physical and psychological harm during and after the investigation. Protection measures include, but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation . increased supervision of the alleged victim and other residents at risk; room or staffing changes, if necessary, to protect the resident(s) from the accused; protect from retaliation .

Based on observation, interview, and record review the facility administration failed to ensure effective and efficient use of resources to provide for resident safety and to ensure the highest practicable physical, mental, and psychosocial well-being of all residents, based on a census of 94. The facility administration failed to maintain the facility in substantial compliance with regulatory requirements which resulted in substandard quality of care in which residents experienced actual physical harm including development of Stage II, III, and IV pressure ulcers and psychosocial harm to residents affected by prolonged isolation and inadequate care to meet physical, social, and emotional needs due to staffing shortages and facility directed room-based care (RBC) (residents cannot leave their room and the resident receives care, treatment, and meals in their room). The facility administration was aware of the concerns but failed to identify or implement effective corrective measures. The concerns were ongoing at the time of survey. Administration's failure to address the known concerns and the lack of administration involvement over the past 12 months resulted in immediate jeopardy with all residents (based on a census of 94 residents, in a 96-bed facility) at risk for serious harm. On 12/22/21 at 2:50 PM, the facility Administrator was informed in person of the determination of immediate jeopardy related to administration of the facility. The facility submitted an acceptable removal plan on 12/29/21 at 4:20 PM. Implementation of the removal plan was verified on 12/30/31. The immediacy was removed on 12/30/21 at 12:50 PM. Following the removal of the immediacy, noncompliance remained at widespread with actual harm that is not immediate. Findings: Observation of the facility campus revealed eight separate cottage buildings, with 12 resident bedrooms in each cottage, for a total of 96 resident beds. Facility adminstrative and support staff (e.g. pharmasist, laundry, therpies) was located at the commons building. The facility's total census at the time of this survey was 94 residents. During an interview on 12/17/21 at 2:55 PM, the Director of Nursing (DON) stated the facility had operated with a shortage of nursing staff, including Primary Care Nurses (PCNs) and Certified Nursing Assistants (CNAs), since the COVID-19 pandemic began two years ago. The DON further stated that in January 2021 the facility experienced an additional significant loss of nursing staff which resulted in shortages of direct-care staff to provide resident care in the cottages. The DON stated that currently the facility had 19 open CNA positions, 5 open Registered Nurse positions, 3 open Licensed Practitioner Nurse positions, and 4 temporary Nursing Aide positions. The DON further stated that the staffing shortages and the restrictions of RBC made it difficult for the facility to meet the psychosocial and physical care needs of the residents. The DON further stated that RBC resulted in resident isolation in their rooms and/or within each cottage. The social isolation resulting from RBC affected the resident's moods. The DON stated the residents were sad, they were not getting out of bed, and they were not wanting to eat. The DON further stated that RBC restrictions also limited other staff from entering those cottages to meet resident needs, such as Physical Therapy, Occupational Therapy, Rehab, and Activity. RBC resulted in a decrease in physical activity; the DON stated that while on RBC, residents could not leave their room to use the exercise bicycle in the common area (living room). During an interview on 12/20/21 at 3:00 PM, the Operations Director stated that at this time, the Activity Department could not meet the needs of the residents, based on RBC and the Activity Department being short staffed, and it was evident this had affected the Resident's moods as they seem sadder. During an interview on 12/22/21 at 9:03 AM, the Quality Director stated the facility's optimal staffing pattern would be to have 2 CNAs and 1 PCN per cottage for days and evenings, as well as 2 Supervisors during the day and 1 Supervisor for evenings and nights. Night shift would have 1 CNA and 1 PCN per cottage. Weekend supervision would include 1 Supervisor on days and 1 Supervisor on nights. The Quality Director further stated that the facility was not currently meeting this goal, and this affected resident care. The Quality Director stated it was a daily challenge to get residents up from bed, consistently perform resident turning schedules, and perform regular activities of daily living. This inability had increased the facility-acquired pressure ulcer rate. During an interview on 12/22/21 at 10:01 AM, the Staff Development Manager stated there was not sufficient staff at the facility at this time to meet the needs of the resident's needs, as identified through resident assessment and the individual plans of care. See F725 for additional information regarding sufficient staffing. During an interview on 12/22/21 at 10:10 AM, the Administrator, when asked who was involved in the facility's administration, stated that beside her, the Regional Office in Washington State, the Quality Director, the Director of Nursing (DON), the Operations Director (who oversaw Rehab/Physical Therapy/Occupational Therapy/Speech Therapy and Activity Department), Social Services, and Environmental Services (laundry, dietary, plant operations) all were involved with the administration of the facility. The Administrator further stated that staff shortages was a concern and affected what the facility was able to provide the residents and impacted residents' daily life. The Administrator stated that due to staffing shortages, resident care was not to the highest level she would have wanted it to be. The Administrator acknowledged that the current nursing staff shortages had resulted in a lack of basic care for residents, such as turning and repositioning residents in chairs and beds, which resulted in actual physical harm of facility-acquired pressure ulcers and associated complications. The facility operated under a declared public health emergency related to the COVID-19 pandemic. The facility administration did not ensure a qualified Infection Preventionist worked at least part time in the facility. See F882 for additional information on Infection Prevention support. The facility Administrator and Quality Director were regular members of the QAPI (Quality Assurance and Process Improvement) committee. The Administrator stated that the facility had stopped admissions from July to August of this year (2021), however received pressure and complaints from local hospitals to admit. The Administrator stated that stopping admissions again was considered, but not initiated. During an interview on 12/22/21 at 1:10 PM, the Medical Director stated staffing had been affected due to the COVID pandemic. She stated at this time, the main concern was how the facility could meet the needs of the residents. The Medical Director further stated it was very hard to maintain enough staff to offset the risk of RBC precautions. Review of the facility's Matrix for Provider form, dated 12/14/21, revealed a facility-wide overall pressure ulcer rate of 19%, 12.7% of those were facility-acquired. See F686 for additional information regarding facility acquired pressure ulcers. The Quality Director stated the QAPI Committee conducted root cause analyses (RCA), for pressure ulcers and resident depression, and created Performance Improvement Plans (PIPs) to address these concerns. Review of these PIPs revealed: 1) High Risk/Unstageable PuR [Pressure Ulcer] QM [Quality Measure], start date June 2021, summary RCA: We continue to use all the best practices to prevent high risk residents from acquiring a [pressure ulcer], but our current staffing constraints prevent the necessary frequency of turning and repositioning. During an interview on 12/18/21 at 4:11 PM, when asked if there were any official QAPI Committee meeting minutes or PIP Team meeting minutes, since the last meeting on 10/14/21, to show progression of this PIP, the PIP Coordinator stated the staffing constraints of the facility made it hard to build a PIP team, therefore no further meetings had taken place on the pressure ulcer PIP. Review of the facility's [NAME] report MDS 3.0 Facility Level Quality Measure Report, report period 7/1/21 - 12/31/21, revealed the facility's Hi-risk/Unstageable Pres [Pressure] Ulcer facility adjusted percentage was 21.8% (compared to the comparison group national average of 8.9%). 2) Managing Depression, start date September 2021, summary RCA: Depression rates have increased due to residents being isolated under RBC and limitations on visitations, activities, socialization, and interactions with caregivers. Loneliness, helplessness, and boredom have increased and are the possible adverse effects of RBC practices. During an interview on 12/28/21 at 4:11 PM, the PIP Coordinator stated there was no current documentation to provide for the Managing Depression PIP and the last meeting held for this PIP was in October 2021. Review of the facility's [NAME] report MDS 3.0 Facility Level Quality Measure Report, report period 7/1/21 - 12/31/21, revealed the facility's Depress [Depression] Sx [Symptoms] facility adjusted percentages was 9.2% (compared to the comparison group national average of 7.6%). During an interview on 12/22/21 at 9:03 AM, the Quality Director acknowledged that staffing shortages and RBC precautions were identified by the PIPs as contributing or causative factors for pressure ulcers and depression in residents. The Quality Director could not provide evidence of QAPI interventions for effective plans to mitigate the risks to the residents. See F856 and F867 for additional information related to the QAPI program and the QAPI improvement activities. The Quality Director further stated that a PIP concerning how staffing shortages were affecting resident care had not been initiated. During an interview on 12/22/21 at 10:10 AM, the Administrator stated the facility's regional oversight transitioned in January 2021 to a regional office in Washington state. This regional office supported the facility's administration through the collaboration with the Regional Chief of SNFs (Skilled Nursing Facilities) and ALFs (Assisted Living Facilities). The Administrator stated she collaborated directly with the Regional Director of SNF/ALF, who in turn reported to the facility's Governing Body (GB) on behalf of the facility. The Administrator further stated the facility did not interact directly with the GB. During an interview on 12/22/21 at 11:45 AM, the Regional Chief of Skilled Nursing Facilities (SNFs) and Assisted Living Facilities (ALFs) stated that the GB did not drill down to the facility level to oversee PIPs or ongoing issues, unless specifically asked to. During an interview on 12/28/21 at 9:19 AM, the Regional Director of Rehab and Quality (RDRQ) stated she helped to lead the Regional GB along with the Regional Chief Medical Officer and that the GB oversaw a multitude of facility types, called service lines, and SNFs and ALFs were just one service line the GB oversaw. The RDRQ stated that the GB reviewed specific facility data at each quarterly meeting consisting of quarterly reports provided by the Regional Chief of SNFs/ALFs. The RDRQ stated if there were outcomes outside of the national benchmarks, the GB would want to get more information on what was being done to improve those outcomes. The RDRQ stated the facility had only come under the regional office's supervisory umbrella in January 2021. In March 2021, the GB did review the facility's 2020 data during the GB's Annual QAPI report meeting, in preparation for taking over the facility's oversight. When asked if the GB addressed any of the identified facility outcomes that were outside of the national benchmarks at that time, the RDRQ stated the GB had not. The RDRQ further could not identify any action the GB had taken since March 2021 to address those outcomes. Review of the GB's 2021 QAPI SNF and ALF annual report PowerPoint, provided by the Regional Chief SNFs/ALFs, revealed the facility's [NAME] report, dated 1/1/20 - 12/31/20, that listed several outcomes outside of the national benchmarks: 1) High Risk/Unstageable Pressure Ulcers: facility: 15.7% (comparison group national average: 9.1%); 2) Physical Restraints: facility: 3.7% (comparison group national average: 0.2%); 3) Behaviors Symptoms Affecting Others: facility: 53.8% (comparison group national average: 20.6%); and 4) Move Independence Worsening: facility: 41.0% (comparison group national average: 27.2%). The RDRQ acknowledged that the GB was unaware of the current facility QAPI PIPs for pressure ulcers and managing depression, or the fact that these PIPs had no evidence of active engagement, since October 2021, to meet their targeted goals. The RDRQ further stated the GB was not aware of the facility's current pressure ulcer rate. See F837 for additional information related to the Governing Body.

Based on interview and record review the facility failed to maintain a Governing Body (GB) that ensured it was accountable for the Quality Assurance and Process Improvement (QAPI) program that: 1) consistently identified areas for performance improvement; 2) developed and implemented appropriate Performance Improvement Plans (PIPs) for identified deficiencies; 3) evaluated results; and 4) monitored and measured outcomes. This failed practice, to ensure accountability of QAPI oversight, resulted in: 1) physical harm to residents who developed stage II, III, and IV pressure ulcers and 2) psychosocial harm to residents affected by isolation and inadequate care to meet physical, social, and emotional needs, due to staffing shortages, during room-based care (RBC) (residents cannot leave room and the resident receives care, treatment, and meals in their room) which constituted an immediate jeopardy at 483.70(d)(3) Governing Body. This situation was brought to the attention of the facility's administration on 12/22/21 at 2:50 PM, at which time the facility was notified of identified physical and psychosocial harm and immediate jeopardy. The facility submitted an acceptable removal plan on 12/29/21 at 11:55 AM. The State Agency verified onsite that the immediacy was removed on 12/29/21 at 11:55 AM. Following the removal of the immediacy, noncompliance remained at widespread with actual harm that is not immediate. Findings: During an interview on 12/22/21 at 10:10 AM, the Administrator stated the facility's regional oversight transitioned in January 2021 to a regional office in Washington State. This regional office suppored the administration through the collaboration with the Regional Chief of Skilled Nursing Facilities (SNFs) and Assisted Living Facilities (ALFs). The Administrator stated she collaborated directly with the Regional Director of SNFs/ALFs, who in turn reported to the GB on behalf of the facility. The Administrator stated the information that they must report to the GB was quarterly and annual reports consisting of the facility's MDS (Minimum Data Set - a federally mandated nursing assessment) data and [NAME] (Computer-based Assessment for Sampling Personal Characteristics) scores, as well as the facility's star rating. The Administrator further stated that to her knowledge, the facility's PIPs were not reported to the GB. The Administrator could not identify how the GB engaged, in the form of support or resources for the facility, other than providing bonus money for retention and recruitment due to identified staffing shortages. The Administrator stated the facility did not interact directly with the GB. During an interview on 12/22/21 at 11:45 AM, the Regional Chief of SNFs /ALFs stated her role was to work with Administrators of SNFs and ALFs to allow the leaders to come together and collaborate for facility operations. The Regional Chief of SNFs/ALFs stated this centralized hub allowed for Administrator support and to collectively work more comprehensively together. When asked what level of involvement she had in the facility's operation and resident care, the Regional Chief of SNFs/ALFs stated the Administrator of the facility was responsible for their own facility's operation and the implementation of facility management. When asked what level of involvement she had in the facility's QAPI program, the Regional Chief of SNFs/ALFs stated this was delegated to the administrative level of the facility, but the Regional QA [Quality Assurance] did collaborate with the facility's Quality Director. When asked what level of involvement she had with the GB, the Regional Chief of SNFs/ALFs stated she provided the GB quarterly and annual reports that consisted of the facility's QAPI data, to include MDS data and [NAME] reports, goals around QAPI effectiveness, and the facility's star rating, and the GB reviewed this data during their quarterly meetings. The Regional Chief of SNFs/ALFs further stated the GB was not involved the development or monitoring of the facility's Facility Assessment, unless asked to. When asked what support and resources the GB provided the facility, the Regional Chief of SNFs/ALFs stated they were leveraging through governing to improve staffing. She further stated that the GB did not drill down to the facility level to oversee PIPs or ongoing issues, unless specifically asked to. During an interview on 12/28/21 at 9:19 AM, the Regional Director of Rehab and Quality (RDRQ) stated she helped to lead the Regional GB along with the Regional Chief Medical Officer and that the GB oversaw a multitude of facility types, called service lines, and SNFs and ALFs were just one service line the GB oversaw. The RDRQ stated that the GB reviewed specific facility data at each quarterly meeting consisting of quarterly reports provided by the Regional Chief of SNFs/ALFs. The RDRQ stated if there were outcomes outside of the national benchmarks, the GB would want to get more information on what was being done to improve those outcomes. The RDRQ stated the facility had only come under the regional office's supervisory umbrella in January 2021. In March 2021, the GB did review the facility's 2020 data during the GB's Annual QAPI report meeting, in preparation for taking over the facility's oversight. When asked if the GB addressed any of the identified facility outcomes that were outside of the national benchmarks at that time, the RDRQ stated the GB had not. The RDRQ further could not identify any action the GB had taken since March 2021 to address those outcomes. Review of the GB's 2021 QAPI SNF and ALF annual report PowerPoint, provided by the Regional Chief SNFs/ALFs, revealed the facility's [NAME] report, dated 1/1/20 - 12/31/20, that listed several outcomes outside of the national benchmarks: 1) High Risk/Unstageable Pressure Ulcers: facility: 15.7% (comparison group national average: 9.1%); 2) Physical Restraints: facility: 3.7% (comparison group national average: 0.2%); 3) Behaviors Symptoms Affecting Others: facility: 53.8% (comparison group national average: 20.6%); and 4) Move Independence Worsening: facility: 41.0% (comparison group national average: 27.2%). During the interview, when asked what additional steps the GB had taken to provide support and supervision of the facility's QAPI program, other than the GB meetings, the Chief Nursing Officer stated trips to the facility had been planned, however COVID had reduced GB visits, and this had not taken place yet. There was an attempt by the GB to get an understanding of the quality and services offered at the facility, prior to the facility's transition to their supervisory umbrella, and this was facilitated by the Regional Chief of SNFs and ALFs through a meeting in September 2020 with the former state regional office. That regional office's GB meeting minutes were obtained, and a meeting was scheduled in September 2021 to review them, however that was cancelled due to COVID. The RDRQ further stated that the GB's expectation of facility oversight would be to delegate the management of the facility to the Regional Chief of SNFs/ALFs, and she would in turn bring forward any concerns to the GB and get the GBs input. When asked if the GB had knowledge of the facility's PIPs currently being addressed, namely: 1) High Risk/Unstageable PuR [Pressure Ulcer] QM [Quality Measure], with a start date June 2021, where the QAPI committee identified: We continue to use all the best practices to prevent high risk residents from acquiring a [pressure ulcer], but our current staffing constraints prevent the necessary frequency of turning and repositioning, and that this PIP had no documentation of PIP monitoring, evaluation, or measuring since 10/14/21; and 2) Managing Depression, with a start date September 2021, where the QAPI committee identified: Depression rates have increased due to residents being isolated under RBC [room-based care] and limitations on visitations, activities, socialization, and interactions with caregivers. Loneliness, helplessness, and boredom have increased and are the possible adverse effects of RBC practices, and that this PIP had no documentation of PIP monitoring, evaluation, or measuring since 10/22/21, The RDRQ stated the GB was unaware of these concerns at the facility. See F856 and F867 for additional information related to the QAPI program and the QAPI improvement activities and F725 for additional information on insufficient staffing. When the RDRQ was informed that the current overall facility-wide pressure ulcer rate was 19% and 12.7% of that was facility acquired, she stated the GB was unaware of this concern. See F686 for additional information regarding facility acquired pressure ulcers. Review of the facility's Corporate QAPI Plan: [Facility's Name] QAPI Plan, dated 1/20/21, revealed: The Governing Body is responsible for the development and implementation of the QAPI program. The Governing Body is responsible for: 1) Identifying and prioritizing problems based on performance indicator data; 2) Incorporating resident and staff input that reflects organizational processes, functions, and services provided to residents; 3) Ensuring that corrective actions address gaps in the system and are evaluated for effectiveness; 4) Setting clear expectations for safety, quality, right, choice, and respect; 5) Ensuring adequate resources exist to conduct QAPI efforts . With Abaqis, the Governing Body and QA&A [Quality Assurance] Committee have access to and visibility into virtually all of an organization's QAPI activity including quality assessments, facility QAPI Self Assessments, Care Area investigations, PIPs, and detailed reporting . Review of the facility's policy Quality Assurance and Process Improvement (QAPI), last revised 5/2021, revealed: The responsibility for the oversight of the QAPI program ultimately resides with the [regional office] governing board. The duties of the governing board include, but are not limited to: a) Ensuring adequate resources exist to conduct QAPI efforts; b) Setting clear expectations for safety, quality, rights, and choice; c) Designate leadership to oversee the operations of [facility name] leadership will establish policies consistent with the [regional office] Mission, Vision, Promise, and Core Values, and will follow external regulations, laws and guidelines outlined by The Centers for Medicare and Medicaid Services (CMS), the Department of Health; and the State of Alaska Administrative code. The facility Quality Director stated there was no Governing Body policy, at the facility-level, that could be provided during this survey. A regional-level Governing Body policy was not provided during this survey.

Based on record review and interview the facility failed to maintain a Quality Assurance and Process Improvement (QAPI) committee that developed and implemented appropriate plans of action to correct quality deficiencies they identified or should have identified. Without sufficiently identifying or adequately addressing and communicating about areas of deficient practice, systematic correction could not be achieved and maintained throughout the facility. This failed practice, to achieve or maintain corrective action, resulted in: 1) physical harm to residents who developed stage II, III, and IV pressure ulcers and 2) psychosocial harm to residents affected by isolation and inadequate care to meet physical, social, and emotional needs, due to staffing shortages, during room-based care (RBC) (residents cannot leave their room and the resident receives care, treatment, and meals in their room) which constituted an immediate jeopardy at 483.75(a) QAPI Program and 483.75(b) Program Design and Scope. This situation was brought to the attention of the facility's administration on 12/22/21 at 2:50 PM, at which time the facility was notified of identified physical and psychosocial harm and immediate jeopardy. The facility submitted an acceptable removal plan on 12/29/21 at 4:20 PM. The State Agency verified onsite that the immediacy was removed on 12/29/21 at 5:00 PM. Following the removal of the immediacy, noncompliance remained at widespread with actual harm that is not immediate. Findings: Review of the Facility Assessment, dated 2021-2022, revealed the following indicators: II. Staffing, Training, Services, and Personnel: A. Function, Mobility, and Physical Disabilities: - A.1 Function - Sufficiency Analysis Summary: 1. Staffing has been very challenging due to COVID-19. We continue to and work on scheduling recruitment to meet core staffing levels . and adjusting staffing as indicated by resident needs . 2. Staff training and competency program: We have noted an increase in gero-psych [the mental and physical health of individuals in the later stages of life] needs in our population . We monitor UORs [Unusual Occurrence Reports - reports of incidents or concerns] for behavior-related incidents and we have noted an increase in behavior-related incidents. There has been an increase in staff requests for support and resources to care for these residents . - A.2 Function - QAPI Action/Plan Summary: CNA: We have adjusted the pay schedule to help with recruitment and offered sign on bonuses. We have given CNAs a $2.00 raise to assist with retention . We have requested for travelers to augment our staffing. We are working with CNAs to change [half] of the CNAs to 12 [hour] shifts for retention and job satisfaction . Nurses: . We are in the process of adjusting the nurses pay scale. Nurses have also been offered sign on bonuses and referral bonuses . Therapy: we are working with rehab team to float therapists from [sister facility name] but this has been challenging due to COVID concerns . For all positions we have increased communication with their managers prior to starting and during the on boarding process . Further review revealed no active QAPI plan of action focused on ensuring resident safety or staff requests for support and resources to care for residents. B. Acuity - Diseases, Conditions, and Treatments: - B.1 Acuity - Sufficiency Analysis Summary: SEE A.1 - B.2. Acuity - QAPI Action/Plan Summary: SEE A.2. Crisis plans related to Covid-19 work shortages Further review revealed no active QAPI plan of action to address work shortages or to ensure resident safety and adequate care was provided to the residents. During an interview on 12/22/21 at 9:03 AM, when asked if the QAPI committee was monitoring the facility assessment indicators, the Quality Director state the facility assessment was not discussed in QAPI meetings. The Quality Director stated there was an electronic platform called Abaqis that the facility used to upload the facility's PIPs, MDS (Minimum Data Set - a federally mandated nursing assessment) data, and track and trend other facility data like the [NAME] (Computer-based Assessment for Sampling Personal Characteristics) report with benchmark goals (such as pressure ulcer rates, catheters, weight loss, and depression numbers), and it was this information that was the focus of the QAPI meetings. The Quality Director further stated the facility's optimal staffing pattern would be to have 2 CNAs and 1 PCN per cottage for days and evenings, as well as 2 Supervisors during the day and 1 Supervisor for evenings and nights. Night shift would have 1 CNA and 1 PCN per cottage. Weekend supervision would include 1 Supervisor on days and 1 Supervisor on nights. The Quality Director further stated that the facility was not currently meeting this goal, and this affected resident care. The Quality Director stated it was a daily challenge to get residents up from bed, consistently perform resident turning schedules, and perform regular activities of daily living (bathing, personal care, turning, transfers, and dressing). This inability had increased the facility-acquired pressure ulcer rate. The Quality Director further stated there was a shortage in the Activity and Therapy Departments as well. The Quality Director identified the following QAPI PIPs, and their summary root cause analysis (RCA) reasons for initiation, that the QAPI committee were currently engaged in: 1) High Risk/Unstageable PuR [Pressure Ulcer] QM [Quality Measure], start date June 2021, summary RCA: We continue to use all the best practices to prevent high risk residents from acquiring a [pressure ulcer], but our current staffing constraints prevent the necessary frequency of turning and repositioning. During an interview on 12/18/21 at 4:11 PM, the PIP Coordinator stated weekly skin integrity meeting were to be counted as the PIP meetings, however as time progressed, it became apparent the skin integrity meetings did not fit into the PIP's goal of addressing improvement. When asked if there was a change to the PIP interventions once this was realized, the PIP Coordinator stated nothing was documented. When asked if there were any official QAPI Committee meeting minutes or PIP Team meeting minutes, since the last meeting on 10/14/21, to show progression of this PIP, the PIP Coordinator stated the staffing constraints of the facility made it hard to build a PIP team, therefore no further meetings had taken place on the pressure ulcer PIP. Review of the facility's Matrix for Provider form, dated 12/14/21, revealed a facility-wide overall pressure ulcer rate of 19%, 12.7% of those were facility-acquired. See F686 for additional information regarding facility acquired pressure ulcers. Review of the facility's [NAME] report MDS 3.0 Facility Level Quality Measure Report, report period 7/1/21 - 12/31/21, revealed the facility's Hi-risk/Unstageable Pres [Pressure] Ulcer percentages were: facility percentage: 21.8% (compared to the comparison group national average of 8.9%). 2) Managing Depression, start date September 2021, summary RCA: Depression rates have increased due to residents being isolated under RBC and limitations on visitations, activities, socialization, and interactions with caregivers. Loneliness, helplessness, and boredom have increased and are the possible adverse effects of RBC practices. During an interview on 12/28/21 at 4:11 PM, the PIP Coordinator stated there was no current documentation to provide for the Managing Depression PIP and the last meeting held for this PIP was in October 2021. The PIP Coordinator further stated that the interventions for this PIP were placed on hold when visitors were opened up within the facility. She stated that the individually assigned tasks of the PIP team were completed, but due to staffing constraints, the PIP team had not reconvened to discuss them. See F867 for additional information related to the QAPI improvement activities and F725 for additional information on insufficient staffing. Review of the facility's [NAME] report MDS 3.0 Facility Level Quality Measure Report, report period 7/1/21 - 12/31/21, revealed the facility's Depress [Depression] Sx [Symptoms] percentages were: facility percentage: 9.2% (compared to the comparison group national average of 7.6%). During an interview on 12/22/21 at 9:03 AM, The Quality Director acknowledged that staffing shortages and RBC precautions were a contributing or causative factor for the PIPs listed above. The Quality Director could not provide proof of any implemented effective plans to mitigate the risk to the residents during this survey. The Quality Director further stated that a PIP concerning how staffing shortages were affecting resident care had not been initiated. Review of the facility's Corporate QAPI Plan: [Facility's Name] QAPI Plan, dated 1/20/21, revealed: - Addressing Care and Services: The QAPI program will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice, and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action . The scope of the QAPI program encompasses all types and segments of care and services that impact clinical care, quality of life, resident choice, and care transitions. - Identifying a Working QAPI Plan: On at least an annual basis, or as needed, the QAPI Self Assessment will be conducted. This will be completed with the input from the entire QAPI team and organizational leadership. The results of this assessment will direct use to areas we need to work on in order to establish and improve QAPI programs and processes in our organization. We will also conduct an annual facility assessment to identify gaps in care and service delivery in order to provide necessary services. These items will be considered in the development and implementation of the QAPI plan. Revies of the facility's policy Quality Assurance and Process Improvement (QAPI), last revised 5/2021, revealed: - Definitions: QAPI is the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive and data-driven approach to maintaining and improving safety and quality while involving all caregivers in practical and creative problem solving. - General Provisions: . The functions of the QAPI program include: 1. Address all systems of care and management practices; 2. Include clinical care, quality of life and resident choices; 3. Utilize the best available evidence to define and measure indicators of quality and facility goals . 7. The [Facility's Name] QAPI Committee guides the following: a. The QAPI process is focused on high risk, high volume, problem prone areas identified through data collection and analysis at least annually. b. Prioritizes and reviews performance improvement plans based on data analysis from available resources. Evaluating the effectiveness of performance improvement plans (PIPs), analyzing cause and implementing preventive actions that include feedback and learning. c. Ensures the frequency, scope, and complexity of PIPs reflect the services and available resources. d. Develops and implements appropriate plans of action to correct identified quality deficiencies; and maintain compliance with external regulations, laws, and quality best practice guidelines . 8. QAPI Committee Meetings: Occurs at least quarterly .

Based on interview and record review the facility failed to maintain a Quality Assurance and Process Improvement (QAPI) program that: 1) consistently identified areas for performance improvement; 2) developed and implemented appropriate Performance Improvement Plans (PIPs) for identified deficiencies; 3) evaluated results; and 4) monitored and measured outcomes. This failed practice, to achieve or maintain corrective action, resulted in 1) physical harm to residents who developed stage II, III, and IV pressure ulcers and 2) a potential for psychosocial harm to residents affected by isolation and inadequate care to meet physical, social, and emotional needs, due to staffing shortages, during room-based care (RBC) (residents cannot leave room and the resident receives care, treatment, and meals in their room) which constituted an immediate jeopardy at 483.75(d)(1) Program Systemic Analysis and Systemic Action. This situation was brought to the attention of the facility's administration on 12/22/21 at 2:50 PM, at which time the facility was notified of identified physical and psychosocial harm and immediate jeopardy. The facility submitted an acceptable removal plan on 12/29/21 at 4:20 PM. The State Agency verified onsite that the immediacy was removed on 12/29/21 at 5:00 PM. Following the removal of the immediacy, noncompliance remained at a widespread with actual harm that was not immediate. Findings: During an interview on 12/22/21 at 9:03 PM, the Quality Director stated the facility used am electronic platform called Abaqis to upload the facility's QAPI PIPs. The Quality Director stated the PIP template from Abaqis was used when developing a facility PIP and it outlined the information from the facility's PIPs action plans, interventions, and measurements data. During an interview on 12/28/21 at 4:11 PM, the Quality Director stated the QAPI committee would create PIPs when resident safety or quality of life concerns arose, or when the facility's [NAME] (Computer-based Assessment for Sampling Personal Characteristics) Report showed a characteristic concerning resident safety or quality of care was above the national average. The Quality Director further stated that when a PIP was initiated, a PIP team was assigned, and an action plan was developed for the PIPs implementation. The Quality Director identified 2 PIPs the facility's QAPI committee was currently working as: 1) pressure ulcers and 2) managing depression. A review of these PIPs revealed: Pressure Ulcer PIP Review of the facility's PIP High Risk/Unstageable PuR [Pressure Ulcer] QM [Quality Measure], start date June 2021, revealed a summary analysis of the Root Cause Analysis (RCA): We continue to use all the best practices to prevent high risk residents from acquiring a PuR, but our current staffing constraints prevent the necessary frequency of turning and repositioning. PIP Structure Review of the PIP's plan of action revealed the PIP team would meet weekly with a documented targeted end date of 7/1/21 and an overall goal of Residents will receive appropriate care to prevent and minimize pressure ulcers. Reduce the rate of pressure ulcers within the current constraints. PIP Interventions Review of the PIP's interventions revealed: - Weekly IDT [Interdisciplinary Team] Skin Integrity Meetings: Review of existing [pressure ulcers] and adjust interventions based on relevant factors; review of non-healing wounds or those progressively deteriorating, start date 6/1/21; end date of 3/31/22, was documented with a result of In Progress. Further review of this intervention revealed notations on 9/17/21: Work with [Staff Development Manager] to determine which residents are H/M/L [high/medium/low] risk and the association with those currently experiencing issues; and 10/21/21: Meetings are consistently being held and active participation from IDT [Interdisciplinary Team] is occurring weekly. This week our PDSA [Plan-Do-Study-Act] was to review each cottage new, WCT [Wound Care Team], and then other skin issues and that worked well. Our next step is to transition the meeting facilitation to nursing leaders for the next few weeks, and then make any adjustments in the tracker and ECS [facility's electronic medical record system] Skin Integrity Reporting, and then finally to transition the final facilitation format and tracker to [sister Facility Name]. - Resident Care Processes: Review [NAME] Resident report and address issues that influence or contribute to the development or healing of [pressure ulcers], start date 7/1/21; end date 3/31/22, was documented with a result of In Progress. - Recognition/Assessment: Inspect/evaluate and document skin conditions initially and periodically for risk factor for developing or healing [pressure ulcers], start date 7/1/21; end date 3/31/22, was documented with a result of In Progress. Further review of this intervention revealed a notation on 10/21/21: Braden Scale is only performed by the manager or MDS - goal is to move some of this to the supervisors under new R&R. - Pressure Reduction: Determine ways to turn and reposition high risk resident based on the individualized plan; i.e., tracking tool to prioritize resident care, start date 10/1/21; end date 12/31/21, was documented with a result of In Progress. Further review of the PIP's interventions revealed no documentation after 10/24/21 of the PIP's intervention progress. PIP measurement Review of the PIP's target measurement goal revealed the PIP team identified a goal of less than 75%, which was documented as the State and National Averages. Further review revealed no measurements were documented for this PIP, and the templated form indicated You still need to record you baseline measurement. PIP Meetings Review of the PIP's meeting minutes revealed only two meeting were held for this PIP, on 8/27/21 and 10/21/21. Further review revealed no other documentation from the PIP team within the PIP to indicate active engagement or participation. During an interview on 12/22/21 at 9:03 AM, the Quality Director stated due to staffing shortages, it was a daily challenge to get residents up from bed, consistently perform resident turning schedules, and perform regular activities of daily living (bathing, personal care, turning, transfers, and dressing). This inability had increased the facility-acquired pressure ulcer rate. During an interview on 12/28/21 at 4:11 PM, the PIP Coordinator stated the facility's weekly skin integrity meetings were to be counted as the weekly PIP meetings, and therefore those meeting minutes did not get uploaded into the Abaqis system to track on the PIP. The PIP Coordinator further stated it became apparent, as the weekly skin integrity meetings progressed, that they did not fit into the PIP's goal of addressing improvement. When asked if there was a change to the PIP interventions once this was realized, the PIP Coordinator stated nothing was documented. When asked if there were any further official QAPI Committee meeting minutes or PIP Team meeting minutes to show progression of this PIP after 10/14/21, the PIP Coordinator stated the staffing constraints of the facility made it hard to build a PIP team, therefore no further meetings had taken place on the pressure ulcer PIP. The PIP Coordinator confirmed a baseline measurement was not added to the PIP. When asked if there was any current data about the Pressure Reduction intervention added in October 2021, the PIP Coordinator stated they were unable to initiate that intervention due to the staffing constraints of the facility. The facility was unable to provide any documentation that showed this PIP was actively being worked to reach its goal. Review of the facility's Matrix for Provider form (which was filled out and supplied to the survey team during this survey), dated 12/14/21, revealed an individual, facility-wide overall pressure ulcer rate of 19%, 12.7% of those were facility-acquired. See F686 for additional information regarding facility acquired pressure ulcers. Review of the facility's [NAME] report MDS 3.0 Facility Level Quality Measure Report, report period 7/1/21 - 12/31/21, revealed the facility's Hi-risk/Unstageable Pres [Pressure] Ulcer percentages were: facility percentage: 21.8% (compared to the comparison group national average of 8.9%). Managing Depression PIP Review of the facility's PIP Managing Depression, start date September 2021, revealed a summary analysis of the RCA: Depression rates have increased due to residents being isolated under RBC [room-based care] and limitations on visitations, activities, socialization, and interactions with caregivers. Loneliness, helplessness, and boredom have increased and are the possible adverse effects of RBC practices. PIP Structure Review of the PIP's plan of action revealed the PIP team would meet monthly with a targeted end date of 1/19/22 and an overall goal to Reduce percent of Residents who have symptoms of Depression to at or below the national percentile. PIP Interventions Review of the PIP's interventions revealed: - Build Connections/Companionship/Community: Establish criteria and availability of Non-DCW [non-direct care workers] caregivers available to do visits and provide companionship/activities, start date 10/19/21; end dated 1/19/22, was documented with a result of In Progress. Further review of this intervention revealed a notation on 11/30/21: Visitations are now allowed and will help alleviate some of the isolation issues for some residents. Still need to review residents triggering on this measure to ensure those who do not have visitors receive other support. Further review of the PIP's interventions revealed no documentation after 11/30/21 of the PIP's intervention progress. PIP measurement Review of the PIP's target measurement goal revealed the PIP team identified a goal of at or below 7.4%, which was documented as the National Percentile Comparison. Further review revealed only one documented measurement score within the PIP was 11%, dated 10/19/21. PIP Meetings Review of the PIP's meeting minutes revealed 2 meetings were held for this PIP, on 9/28/21, 10/22/21, and one notation on 11/30/21 which documented information of action plan items, but no interventions towards acting on those action items was documented. Further review revealed no other documentation from the QAPI committee within the PIP to indicate active engagement or participation. During an interview on 12/28/21 at 4:11 PM, the PIP Coordinator stated there was no current documentation to provide for the Managing Depression PIP and the last meeting held for this PIP was in October 2021. The PIP Coordinator further stated that the interventions for this PIP were placed on hold when visitation opened up within the facility. She stated that the individually assigned tasks of the PIP team were completed, but due to staffing constraints, the PIP team had not reconvened to discuss them. See F725 for additional information on insufficient staffing. Review of the facility's [NAME] report MDS 3.0 Facility Level Quality Measure Report, report period 7/1/21 - 12/31/21, revealed the facility's Depress [Depression] Sx [Symptoms] percentages were: facility percentage: 9.2% (compared to the comparison group national average of 7.6%). During an interview on 12/22/21 at 9:03 AM, The Quality Director acknowledged that staffing shortages and RBC precautions were a contributing or causative factor for the PIPs listed above. The Quality Director could not provide proof of any implemented effective plans to mitigate the risk to the residents during this survey. The Quality Director further stated that a PIP concerning how staffing shortages were affecting resident care had not been initiated. Review of the facility's Corporate QAPI Plan: [Facility's Name] QAPI Plan, dated 1/20/21, revealed: - Overall PIP Plan: Performance Improvement Projects will be a concentrated effort on a particular problem in one area of the nursing center or on a facility-wide basis. They will involve gathering information systematically to clarify issues or problems and intervening for improvements. The nursing center will conduct PIPs to examine and improve care or services in area that the nursing center identifies as needing attention. - PIP Determination Process: Areas of improvement are identified by routinely and systematically assessing quality of care and service, and include high risk, high volume, and problem prone areas. Consideration will be given to the incidence, prevalence, and severity of problems, especially those that affect health outcomes, resident safety, autonomy, choice, quality of life, and care coordination. All staff are responsible for assisting in the identification of opportunities for improvement and are subject to selection for participation in PIPs. - Documenting PIPs: PIPs will be documented continuously during execution. The documentation will include the overall goals for the project and will identify team members, define appropriate measures, root cause analysis findings, interventions, PDSA cycle findings, meeting minutes, target dates, and overall conclusions. Abaquis provides an electronic platform for developing a PIP charter and for continuous PIP documentation in a structured format. Abaquis also allows for PIP team collaboration and visibility into PIP activity for team management and coordination of PIP efforts; provides a method of tracking PIP progress and documentation of findings for widespread and systemic improvement efforts; and allows for retaining and updating information related to ongoing projects for potential reference and future submission for survey compliance. - Identifying Change as an Improvement: Changes will be implemented using an organized and systematic process . Measures will be established that will monitor progress and change during PDSA cycles for PIPs and widespread improvement activities. Revies of the facility's policy Quality Assurance and Process Improvement (QAPI), last revised 5/2021, revealed: - Definitions: QAPI is the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive and data-driven approach to maintaining and improving safety and quality while involving all caregivers in practical and creative problem solving. - General Provisions: . The functions of the QAPI program include: 1. Address all systems of care and management practices; 2. Include clinical care, quality of life and resident choices; 3. Utilize the best available evidence to define and measure indicators of quality and facility goals . 7. The [Facility's Name] QAPI Committee guides the following: a. The QAPI process is focused on high risk, high volume, problem prone areas identified through data collection and analysis at least annually. b. Prioritizes and reviews performance improvement plans based on data analysis from available resources. Evaluating the effectiveness of performance improvement plans (PIPs), analyzing cause, and implementing preventive actions that include feedback and learning. c. Ensures the frequency, scope, and complexity of PIPs reflect the services and available resources. d. Develops and implements appropriate plans of action to correct identified quality deficiencies; and maintain compliance with external regulations, laws, and quality best practice guidelines . 8. QAPI Committee Meetings: Occurs at least quarterly . - Procedure: A. Data Sources - Quality, safety, resident and caregiver satisfaction and other stat are collected continuously for the purpose of identifying areas in which the ministries are doing well, areas for which more data are needed and those where a need for improvement is clear . Data sources include but are not limited to: Quality and care transitions . Safety . Quality of life, resident autonomy and choice .Other. B. Data analysis - Data are reviewed and analyzed the Director of Quality, Infection Preventionist, and others. Based on the data analysis, next steps are determined and may include, but are not limited to: 1. No follow-up required . 2. Acquire additional data . 3. Performance Improvement Plan (PIP) is indicated . 4. PIP Deployment: [Performance] Improvement Projects (PIP) will be developed and prioritized on the following criteria: a. single or multiple events that caused, or had potential to cause harm to residents; b. Trends in clinical or infection control data that indicate process review or change is needed; c. Concerns identified by external audience, such as the PHCC Quality Board, contracted care providers and partners, surveyors and others .

Based on interview, record review, and observation, the facility failed to ensure that residents received the necessary care and services to prevent the development of new pressure ulcers in 4 residents (#s 7, 12, 42, and 43), out of 28 sampled residents. Failure to accurately and consistently assess and monitor for wounds, provide appropriate interventions, and revise interventions on a timely basis resulted in physical harm to residents who developed deep tissue injuries and stage II, III, and IV pressure ulcers, with 2 resident developing medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . This situation was brought to the attention of the facility's administration on 12/17/21 at 4:30 PM, at which time the facility was notified of identified physical harm and immediate jeopardy. The facility submitted an acceptable removal plan on 12/20/21 at 9:30 AM. The State Agency verified onsite that the immediacy was removed on 12/21/21 at 10:24 AM. Following the removal of the immediacy, noncompliance remained at a pattern with actual harm that is not immediate. Findings: Skin Assessment Facility Expectations During an interview on 12/16/21 at 2:34 PM, the Director of Nursing (DON) stated Primary Care Nurses (PCNs) completed a head-to-toe skin assessment upon every admission. PCNs would have then completed a skin assessment weekly during the resident's showers and Certified Nursing Assistants (CNAs) would have completed daily skin assessment, also known as skin checks during cares. The DON stated no documentation would be present if no skin concerns were observed during skin evaluations. If a skin concern arose, the PCN would have completed a skin integrity report that was reviewed by the Nurse Practitioner (NP) on the Wound Care Team (WCT). An assessment of the resident would have been completed by the WCT and they would have been responsible to diagnose the skin concern. If a pressure ulcer was diagnosed , the WCT Nurse Practitioner would have measured, staged, and placed orders for treatment. During an interview on 12/16/21 at 4:00 PM, the Staff Development Manager stated PCN skin assessments were documented in the eMAR/eTAR (electronic Medication Administration Record/electronic Treatment Administration Record) under the Summary Charting order. During an interview on 12/21/21 at 10:11 AM, the Staff Educator stated all CNAs were educated at new hire orientation that daily skin checks should be completed during positioning/repositioning of residents and during hygiene cares. The Staff Educator stated the CNAs were educated to check heels (the expectation was to remove the socks to check each time), elbows, hips, and other bony prominences of the body during daily skin checks. The Staff Educator further stated the expectation would have been for the CNAs to report any skin concerns they saw to the PCN for follow up. Resident # 7 Record review on 12/21-22/21 revealed Resident #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident was nonverbal, received nutrition by gastric tube (tube surgically implanted into the stomach), and had a trachea (surgical hole in the windpipe). The Resident required total assistance with all activities of daily living. Review of Resident #7's MDS (Minimum Data Set - A federally mandated nursing assessment) assessment, an annual assessment dated [DATE], revealed Resident #7 was coded as high-risk for pressure ulcers with no pressure ulcers. Under section M1200. Skin and Ulcer Treatments A. Pressure reducing device for chair, B. Pressure reducing device for bed, C. Turning and reposition program, D. Nutrition, and hydration to manage problems, G. Application of nonsurgical dressings (with or without topical medications) other than to feet, and H. Application of ointments/medications other than to feet. The MDS further coded the Resident as needing total assistance with all activities of daily living (bathing, personal care, turning, transfers, and dressing) and that the resident was nonverbal. Review of Resident #7's CAAs (care area assessments), completed 9/8/21, revealed: Skin Status Braden Scale [a tool used to assess risk for pressure ulcers] reviewed and total was 13-moderate risk for skin breakdown. Noted no skin integrity concerns in nursing documentation. Review of Resident #7's Summary Charting orders, from 1/1/21 to 12/17/21, revealed one completed skin assessment was conducted on 8/19/21. Review of this head to toe Skin Assessment, dated 8/19/21, revealed Skin Assessment-No wounds, abrasions, rashes, or skin conditions of concern. Existing ingrown toenail right great toe. Review of a nursing Skin Integrity Report dated 11/20/21, revealed: Issue: Reddened area- Dry purple red area Wound Location: Inner and lower right great toe at the upper toe ball area Length (cm):1 Width: 1.5 Evaluated Comfort: Pain Identified? No Contributing Factors: Cognitive impairment, diabetes, Initial Skin Treatment: Non-Pressure Area: moisturizer BID [twice daily]. Resident/ Legal Rep Notification: Discussed Issue/Care with (who) [Resident's family] Other I-Team Notifications: Discussed issue/care [Resident's family] [Medical Director] MD, Nursing Supervisor [Name] and incoming staff . 11/20/21 Nursing Orders Written. [follow up] skin charting implemented. Review of Resident #7's provider note Wound Check dated 11/22/21, revealed [Resident #7] is being seen today for a wound check . nursing also filed a skin report regarding a reddened area to the right great toe that was thought to be caused by pressure. At last WC [wound care] visit I treated a torn 4th toenail that nursing reports had has been gradually improving with dried sanguineous [watery pink or clear drainage] discharge remaining under the nail bed . Assessment and Plan: DTI [Deep Tissue Injury- an injury to a resident's underlying tissue below the skin's surface that results from prolonged pressure] of the right great toe [Resident #7] has a new pressure injury to the right great toe that may have been caused by [his/her] contracture of [his/her] right leg and the pressure relieving boots which are in direct contact with the area. We will treat the eschar [a dry, dark scab or falling away of dead skin] with [MEDICATION(S)] [a topical antiseptic that provides infection protection] and attempt to keep dry . Plan: -hold Prevalon [a heel protector boot] boot to right foot -off load right heel and toes with pillow placing behind knee vertically to under heel - paint with [MEDICATION(S)] daily - continue to offload and position is care planned Torn toenail: Today I clipped toenails and the right 4th toenail attached to the nail bed. Review of Resident #7's Physical Therapy (PT) note, dated 3/30/21 at 4:22 PM, revealed: Daily Progress Note: This therapist was notified on 3/29/2021 that resident had reddened area to dorsal [back of] aspect of L [left] foot possibly from dorsal ankle splints. Splints held overnight and PCN rechecked this day, redness has resolved orders updated to reflect nighttime wear, ensure socks donned under splints and straps not too tight. No further skilled PT needs at this time. Review of Resident #7's PT note, dated 4/07/21 at 4:59 PM, revealed: Daily Progress Note: additional redness/ pressure identified by PCN on this day. PCN also expressed concern for resident skin integrity on heels and that [he/she] is not able to use the heel elevating cushion. This therapist discussed with wound care ANP [advanced nurse practitioner] and updated orders for discontinuing ankle splits and ordering pressure relieving boots. No further skilled PT needs. Review of Resident #7's PT note, dated 12/21/21 at 1:59 PM, revealed: Daily Progress Note: Screen 12/21/21 Resident is being screened for skin integrity. Resident presents with unstageable wound [You must be able to visualize the wound bed in order to stage the wound. If you cannot see the wound bed, the wound is considered not able to be staged] to rt [right] first hallux [big toe]. Braden score 13 [a score of 13-14 indicated moderate risk for pressure injuries]. Resident was previously screened by PT on 4/7/2021. At time of previous screen ankle splints were discharged and soft boots were ordered for improved skin integrity. Resident is dep [dependent] overhead lift transfer to standard wheelchair with bilateral leg rests. At this time skilled PT is not indicated. Recommend continued adherence to turning schedule Q [every] 2 hours in bed with heel protector boots dawn for skin integrity. An observation on 12/28/21 at 9:00 AM, revealed Resident #7 was on his/her back in bed. The Resident was wearing large black protective boots on both feet. During an interview on 12/28/21 at 9:00 AM, PCN #11 stated the wound team checks the wound and the dressing is done 3 times a week. PCN #11 further stated the dressing could be done as needed if it became soiled or fell off. He/she stated the treatment orders were for a honey gel followed by a foam dressing. An observation of the dressing on the Resident's right great toe revealed it was coming off. PCN #11 stated he/she was going to perform a dressing change. Observation of the wound during the dressing change revealed the toe had no open areas or ulcerations. Resident #12 Record reviews from 12/13-17/21, 12/20-22/21, and 12/28-29/21 revealed Resident #12 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/15/21 at 10:44 AM, Resident #12 stated he/she developed a pressure sore on his/her buttock due to being in bed and on room-base care (RBC) (residents cannot leave room and the resident receives care, treatment, and meals in their room) a lot because of COVID-19. Review of Resident #12's annual MDS assessment, dated 3/9/21, revealed Resident #12 was coded as high-risk for pressure ulcers and had no unhealed pressure ulcers. Under section M1200. Skin and Ulcer Treatments A. Pressure reducing device for chair, B. Pressure reducing device for bed, C. Turning and reposition program, G. Application of nonsurgical dressings (with or without topical medications) other than to feet, and H. Application of ointments/medications other than to feet. Review of Resident #12's MDS assessment, a quarterly assessment dated [DATE], revealed Resident #12 was coded as high-risk for pressure ulcers with a stage 3 pressure ulcer (involves the full thickness of the skin and may extend into the subcutaneous tissue layer; granulation tissue [new connective tissue that forms on a wound during the healing process] and epibole [rolled wound edges] are often present). Under section M1200. Skin and Ulcer Treatments A. Pressure reducing device for chair, B. Pressure reducing device for bed, C. Turning and reposition program, E. Pressure Ulcer care, G. Application of nonsurgical dressings (with or without topical medications) other than to feet, and H. Application of ointments/medications other than to feet. The MDS further coded the Resident as needing extensive assistance (2 or more persons physical assist) with all activities of daily living. Review of Resident #12's Braden Scale, documented in a Quarterly Nutrition assessment dated [DATE], revealed a score of 14 - moderate risk for skin breakdown. Review of Resident #12's Summary Charting orders in the eMAR, to be completed every other Monday, from 1/11/21 to 12/13/21, revealed 25 Mondays PCNs were to document skin assessments. 12 Mondays had no PCN initials on the eMAR, 6 Mondays had PCN initials but no documentation, and 7 Mondays had PCN initials with some documentation, but no skin assessment was documented. No PCN skin assessments were documented for Resident #12 for the entire year. Review of Resident #12's Skin Integrity Report, dated 6/18/21, revealed: Issue: Reddened Area - Moist; Wound Location: right buttock, close to perinium. Review of Resident #12's provider notes, Wound Check NP notes, on 12/17/21 at 10:54 AM, revealed: - 6/18/21: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed a notation that spoke to the bony prominence to Resident's sacral region (bony area of the back of the pelvis, just above the tailbone) that was high risk to breakdown: There is no current breakdown or [CONDITION(S)], but the area is firm and tender to palpation. We will continue to treat prophylactic and continue offloading. - 7/21/21: Today I am seeing [Resident #12] for nursing concerns related to open skin on [his/her] right ischium [the lower, outer portion of the back part of the pelvis bone, near the bottom outer portion of the buttock] .Wound Demographics: Provider Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Wound Assessment: Wound Measurements: Length: 1.5cm, Width: 1cm, Depth: 0.2cm .Assessment and Plan: Stage 2 Pressure Injury - Open area on patients right ischium thought to be friction on initial impression: however, given the location it appears that it is pressure related. Orders for treatment provided . Plan: - Cleanse wound with wound cleanser or NS [normal saline] - Apply honey gel to open or red areas - Cover with Allevyn (a non-adhesive dressing with a non-adhesive wound contact layer for use on fragile skin) foam border dressing - Change every 48 hours and PRN [if] soiled or soaked - Upgrade specialty mattress if needed - WCT following - 7/27/21: .Today, nursing reports worsening of the wound . Further review revealed: . Wound Assessment: Wound Measurements: 1.6cm x 2.2cm x 0.1cm . Wound Bed (specify %, character, and color): 20% black necrotic tissue [dead tissue], 20% loosely adhered yellow slough [a mass of dead tissue separating from an ulcer], 60% red to pink granulating tissue [new connective tissue that forms on a wound during the healing process] .Drainage (amount and type): small-serosanguinous [discharge that contains both blood and a clear yellow liquid known as blood serum]; Signs of Bio Burden [the number of bacteria living on a surface] or Infection: Bio burden suspected due to necrotic tissue and slough in wound base . Assessment and Plan: Pressure injury of right ischium, stage 3 - [Resident #12]'s pressure injury to the right ischium has worsened to a stage 3. No signs of infection at this time . Plan: - Cleanse with wound cleanser or NS, apply honey gel to wound base, cover with border foam dressing, change dressing every 48 hours - or sooner as needed - Position patient supine or on left side, no right side lying - Hold use of transfer board until wound heals - Continue pressure relieving mattress and roho cushion (a pressure relief cushion) for wheelchair - Consider nutritionist consult if wounds worsen, or others develop - WCT to follow up in 2 weeks . - 8/12/21: Review of this documentation revealed the stage 3 pressure injury was improving and treatment continued. Further review revealed: ROS [Review of Systems] (obtained from nursing staff, chart review, and [Resident #12]) .DERM [skin assessment]: No rashes or new skin integrity concerns . - 8/26/21: Review of this documentation revealed the stage 3 pressure injury continued to improve and treatment continued. Further review revealed: ROS (obtained from nursing staff, chart review, and [Resident #12] .DERM: No rashes or new skin integrity concerns . - 9/17/21: [Resident #12] is being seen today for wound care follow up for pressure injury to the right ischium. [He/She] was last seen for wound care by the author on 8-26, where I found an improving pressure injury. There were no signs of infection at that time. Today, nursing reports stable wound . ROS (obtained from nursing staff, chart review, and [Resident #12] .DERM: No rashes or new skin integrity concerns .Physical Exam . Skin: blanchable [CONDITION(S)] to the sacrum [wound discussed in 6/18/21 WCT note], stage 3 pressure injury to the right ischium, reopened pressure injury to the sacrum . Further review revealed: Wound Demographics: Provider Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .Wound Location: Sacrum; Date of Origin: 4/1/16 - closed on 5/24/[16] Reopened 9/17/21, Origination: [Facility Name]. Wound Assessment: Wound Measurements: 1.5cm x 1cm x 0 cm .Assessment and Plan: Pressure injury of right ischium, stage 3 .slight improvement in size. No signs of infection and wound base continues to be covered with slough. Delayed healing suspected related to multiple factors including immobility .Pressure ulcer of sacral region, stage 4 (the deepest, extending into the muscle, tendon, ligament, cartilage or even bone) . Reopened. Date of origin was before [facility] admission 4/1/16. At that time bone was showing and [CONDITION(S)] was suspected, but not worked up. The wound closed on 5/24/16. The wound currently has a crust over top, but the boney deformity persists on palpation and puts wound at high risk for rapid breakdown . Plan: - Cleanse wound with wound cleanser or NS, apply honey gel to wound base, cover with border foam dressing - Change dressing and apply topical every 48 hours, or sooner as needed - Continue pressure relieving mattress and roho cushion for wheelchair - WCT to follow up in 2 weeks - 10/1/21: Review of this documentation revealed the Stage 3 ischial pressure injury was improving and treatment continued, with follow up in 2 weeks. The Stage 4 sacral pressure ulcer had no signs of infection, with follow up in two weeks. - 10/12/21: Review of this documentation revealed the Stage 3 ischial pressure injury was improving and treatment continued, with follow up in 2 weeks. The Stage 4 sacral pressure ulcer appearing stable .It was found to have a crust on 9/17 and continues to have crust today on examination. Boney deformity persists on palpation and puts wound at high risk for rapid breakdown. No signs of infection today and we will not attempt removing the crust as this could expose bone .Plan .[treatment orders the same as 9/17/21] WCT to follow up in 2 weeks . -11/18/21: [Resident #12] is being seen today for wound care follow up for pressure injury to the right ischium. She was last seen for wound care by [NP #1] on 11/2, where she assessed and treated a pressure injury [stage 1] to the thigh related to urinary catheter. At that time her ischial wound was not assessed. Today, nursing reports improved pressure injury to the right ischium and thigh .ROS: (obtained from nursing staff, chart review, and [Resident #12] . DERM: No rashes or new skin integrity concerns. Closed pressure injury to the right ischium and sacrum followed by WCT. Further review revealed the stage 3 pressure injury to Resident's right ischium and the stage 1 pressure injury to Resident's left thigh were resolved. Further review revealed Resident #12's sacral pressure ulcer was not assessed on 11/18/21. Further review revealed no further Wound Check notes from the WCT to follow up or treat Resident #12's sacral pressure ulcer after 11/18/21. Review of Resident #12's Nutrition Notes, dated 6/1/21 to 12/21/21, revealed no nutrition consult was placed for wound care nutrition assessment. During an interview on 12/21/21 at 3:52 PM, NP #2 stated he/she did not write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/21/21 at 4:09 PM, the Resident Assessment Coordinator (RAC) #1 stated there was no documentation that resolved the sacral pressure ulcer in Resident #12 medical record. He/she further stated there were no active orders to treat this pressure injury in the eMAR/eTAR until 12/17/21, when a new skin assessment was completed, as a result of the facility's Immediate Jeopardy abatement plan. During an interview on 12/21/21 at 4:46 PM, the RAC #2 stated NP #2 informed him/her that Resident #12's sacral pressure ulcer reopened on 9/17/21 and was last assessed by the WCT on 10/12/21. NP #2 told RAC #2 that the orders for care was dropped by him/her or nursing by accident. New orders were reestablished on 12/17/21. Review of Resident #12's Care Plan, dated 9/14/21, revealed: Identified need: I have developed a stage 3 pressure sore on my right ischium tuberosity .Approaches for this need: I need my nurses to reduce pressure and friction between myself and my bed or chair, limit the head of my bed being elevated to 30 degrees and encourage me to use a 30-degree side lying position when in bed; keep me off my hips .I need my aides to help me with hygiene and general skin care; remind me to reposition in bed every 2 hours except during the night until 0600 per my request, help me reposition at least every 1 hour when I'm in a chair . reduce pressure and friction between myself and my bed or chair . Notify my nurse if I have further signs of skin breakdown . Further review revealed no documentation for the stage 4 pressure ulcer to Resident's sacral area. Resident #42 Record review on 12/22/21 revealed Resident #42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident's MDS assessment, annual review dated 7/01/21, revealed Resident #42 was coded M0300. Current Number of Unhealed Pressure Ulcers at Each Stage. D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough [yellow/white material in wound bed] or eschar [dead tissue] may be present on some parts of the wound bed. Often includes undermining and tunneling 1. Number of stage 4 pressure ulcers 1. The M1200. Skin and Ulcer Treatments coded included A. Pressure Reducing Device For Chair., B. Pressure Reducing Device for Bed., C. Turning and Reportioning Program., D. Nutrition or hydration intervention to manage skin problems., E. Pressure Ulcer care., G. Applications of Nonsurgical Dressings (with or without topical medications) Other Than to Feet., and H. Application of Ointments/Medications Other Than to Feet. Section G-Functional Status coded the Resident as needing total assistance with the activities of daily living for Bed Mobility, Transfers, Dressing, Eating, Toilet Use, and Personal Hygiene. The Resident had Total Dependence in Bathing performance. Review of a Braden Scale [a tool used to assess risk for pressure ulcers], dated 7/01/21, revealed Resident #42's result Score:14 Risk Category: 13-14=Moderate risk for skin breakdown. Review of Resident #42's electronic medical record [EMR] revealed a history of reoccurring pressure injuries to his/her coccyx [area over the tailbone] since 12/6/2013. A Skin Integrity Report dated 8/28/20, revealed the Resident had a Skin Tear to his/her coccyx that was 2.5 cm in length. Contributing Factors: Decreased Sensation, Moisture Perspiration Reviewed with Staff: Care Plan/Updates .Other I-Team Notifications: Provider .Nurse Manager .and Incoming Staff. Review of a provider note Wound Check, dated 2/15/21, revealed: Today I am seeing [Resident #42] for a wound check. We are currently following [Resident #42] weekly. It appears [Resident #42]'s measurements vary depending on staff. However, improved since last visit. Due to critical nursing shortage, there have been difficulties changing dressings as ordered three times a week still continues to be difficult to accomplish. There appears to be some erosion note from overlap of black foam .#1 Stage 4 Pressure Injury to coccyx-Patient continues Vera Flo wound vac [vacuum-assisted drainage and controlled delivery of topical cleansing solutions wound treatment system] with slow improvement . Review of a provider note dated 5/20/21, revealed [Resident #42] is being seen today for a wound check. [Resident #42] has a stage 4 pressure injury to [his/her] coccyx that has been present since 8-28-20. [He/she] was placed on a wound vac on 12-04-21 [12-04-20]. On 12-18-21 [12-04-20] [he/she] developed systemic symptoms of a suspected wound infection with fever, [CONDITION(S)] and AMS. [he/she] was subsequently put on IV [intravenous] [MEDICATION(S)] [antibiotic] for x 5 days with improvement of symptoms and appearance of wound. [His/her] wound progressed to the point where [he/she] had [his/her] NPWT [negative pressure wound therapy-wound vac] stopped on 3-31-21. On 5-4 [his/her] wound reopened and on 5-11 NPWT was restarted. [He/she] continues to be followed weekly by WCT [wound care team]. [He/she] was last seen by [provider name] for a wound check on 5-11-21 . [he/she] was found to have worsening stage 4 pressure injury and NPWT was restarted. Wound Measurements: 1.5 cm [length] x 0.7 cm [width] x 0.5 cm [depth] Review of a provider note dated 6/15/21, revealed [Resident #42] is being seen for a wound check. Please see previous notes for wound history. [Resident #42] has had a Stage 4 pressure injury to [his/her] coccyx with recent signs of near closure. NPWT was subsequently discontinued for the second time on 5-25-21, However it has reopened again, during dressing change today it was noted that the black foam intended for wound vac only, was being used to pack the wound and then covered with a foam dressing. Wound measurements: 1.5 cm [length] x 0.8 cm [width] x 1cm [depth]. Review of a provider note dated 7/26/21, revealed Wound check, [Resident #42] is being seen for a wound check. Compared to photos from last visit it appears [his/her] pressure wound on [his/her] coccyx has worsened over the last week. Nursing is unable to offer any reason as to why it appears so much larger than previous photos on such a short time but could be related to the current critical nursing shortage. Additional review of the 7/26/21 Wound Check revealed wound Measurements: 7/14/21 Length 1.5 [cm] Width 1.2 [cm] Depth 0.8 [cm] 7/26/21 Length 3 [cm] Width 1.8 [cm] Depth 1 9cm] Review of a provider note dated 8/20/21, revealed Wound Check I am seeing [Resident #42] for follow up of [his/her] chronic coccyx wound. Since last visit, it appears it has become larger and deeper. [He/she] has been on a wound vac twice before for this wound already. We are able to get it small enough to discontinue NPWT and then it reopened. Moisture doesn't seem to be an issue since starting the Purwick [external female catheter system] and [his/her] care plan includes frequent repositioning. Wound Measurements 3 cm [length] x 2 cm [width] x 2.3 cm [depth]. Review of the Resident's comprehensive care plan dated 10/13/21, revealed and identified need: I have a skin injury. I: have the potential to have further skin breakdown/ injury. Because I: decreased mobility, incontinence, multiple [CONDITION(S)], can't move around well on my own .have pressure injury, [CONDITION(S)] [paralysis of all four limbs], muscle [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], obesity. flexion contracture of hands and feet [permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff], vitamin D deficiency, dementia, cognitive defects [memory loss], history of weight loss and hypoalbuminemia [low type of protein] . I show this by: Braden score of 14, bed mobility dependent, urinary bowel incontinence, chair fast, have stage four pressure injury on my coccyx gluteal cleft. Approaches for this need were: I need my nurses to---reduce pressure and friction between myself and my bed or chair, elevate my heels when I'm lying in bed, monitor my nutrition or hydration intake, monitor my turning and repositioning, check my skin with cares, check my skin weekly, provide me with wound treatment as order, limit my time in wheelchair for no longer than two hours at a time, apply enter dry dressing underneath breast as needed from moist visitor, give me nutritional supplement as ordered, apply [MEDICATION(S)] [barrier cream] ointment as ordered . I need my aides to---help me with hygiene and general skin care; avoid using hot water for washing and use moisturizer on my skin, ensure that I am repositioned as scheduled. Offer me fluids when I change position, ensure my air mattress (KCI Barri Maxxair) is always on and in good working condition. Provide ROM exercises to my bilateral upper and lower extremities 3 to 5 reps, BID [twice daily] with care as tolerated. Apply splint left palm protector . use GREEN WEDGE for side-lying .Apply pillows under both shoulders when I am in bed. Apply barrier cream to my buttocks and peri area with each peri-care. Notify my nurse if I have signs of skin breakdown or increased pain or bruising .keep my head-of-bed No greater than 30 degrees .position me off wound at all times as much as possible. Let my nurse know if my wound dressing has come off or soiled. During an interview on 12/28/21 at 9:30 AM, Resident #42, when asked about his/her treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident stated he/she does not get out of bed anymore because there is nothing to get up for. Review of Resident #42's current treatment orders, dated 12/22-29/21, revealed Info: Remain off wound at all times Frequency: Daily . Supportive Device Bed, see my orders for the type. Berrimax [with] Maxxair .Indication: Stage 3 pressure ulcer . Order Type: Wound Dx: stage 4 Pressure wound Location: Coccyx Cleanse With: wound cleaner or NS. Apply to open or red areas: Honey gel Cover Wound With: Foam dressing (Alevin Life) Border .Change Dressing: Q [every] 48 hours. Resident #43 A record review from 12/13-17/21, 12/20-22/21, and 12/28-29/21 revealed Resident #43 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/14/21 at 1:58 PM, Resident #43 stated he/she had pressure sores on both of his/her heels that required every other day dressing changes. Review of Resident #43's MDS assessment, a significant change assessment dated [DATE], revealed Resident #43 was coded as high-risk for pressure ulcers and has a stage 4 pressure ulcer. Under section M1200. Skin and Ulcer Treatments A. Pressure reducing device for chair, B. Pressure reducing device for bed, C. Turning and reposition program, E. Pressure Ulcer care, G. Application of nonsurgical dressings (with or without topical medications) other than to feet, H. Application of ointments/medications other than to feet, and I. Application of dressings to feet (with or without topical medications). The MDS further coded the Resident as needing extensive assistance (2 or more persons physical assist) with all activities of daily living. Review of Resident #43's Braden Scale, completed 9/22/21, revealed a score of 15-moderate risk for skin breakdown. Review of Resident #43's Summary Charting orders in the eMAR, to be completed every other Saturday, from 1/2/21 to 12/4/21, revealed 26 Saturdays PCNs were to document skin assessments. 21 Saturdays had no PCN initials on the eMAR, 2 Saturdays had initials but no documentation, 1 Saturday had initials with documentation of basic needs are being met, and 2 Saturdays had a skin assessment documented, 1/16/21 and 3/27/21, I have examined the Resident's skin from head to toe and have noticed not wounds, abrasions, rashes, or skin conditions o [TRUNCATED]

Based on record review and interview the facility failed to ensure sufficient Primary Care Nurses (PCNs), Certified Nursing Assistants (CNAs), and related service staff, such as Activities and Rehabilitation therapies, were available to provide care to all residents, based on a census of 94, as determined by resident assessment and individual plans of care. Additionally, the facility failed to identify and modify or implement adequate staffing to mitigate the effects of physical and/or social isolation resulting from room-based care (RBC) (residents cannot leave room and the resident receives care, treatment, and meals in their room) restrictions. This failed practice, to ensure sufficient staffing to provide basic nursing care such as turning and repositioning, resulted in harm to residents who developed Stage II, III, and IV pressure ulcers. In addition, failure to ensure adequate staffing to mitigate the effects of isolation and to provide for residents' physical, social, and emotional needs during RBC contributed to psychosocial harm to residents. Findings: Review of the facility campus revealed eight separate cottage buildings, with 12 resident bedrooms in each cottage, for a total of 96 resident beds. The facility's total census at the time of this survey was 94 residents. Resident Acuity Review of the CMS-672 form, Resident Census and Conditions of Residents, dated [DATE], revealed a facility-wide assessment of staff support required for basic activities of daily living (ADL) cares: - Bathing: Independent: 2 residents; Assist of one or two staff: 17 residents; Dependent: 75 residents - Dressing: Independent: 3 residents; Assist of one or two staff: 72 residents; Dependent: 19 residents - Transferring: Independent: 2 residents; Assist of one or two staff: 23 residents; Dependent: 69 residents - Toilet Use: Independent: 2 residents; Assist of one or two staff: 49 residents; Dependent: 43 residents - Eating: Independent: 53 residents; Assist of one or two staff: 18 residents; Dependent: 23 residents Further review revealed 58 residents were incontinent of bladder, 80 were incontinent of bowel. Of these, 25 residents had urinary catheters. For mobility, 19 residents were bedfast, 67 residents required wheelchairs, and 7 residents required assistance or assistive devices for ambulation. 8 residents required [CONDITION(S)] care (care to keep [CONDITION(S)] tube clean and clear from clogs, to prevent risk of infection), 9 residents required suctioning , 5 residents required ostomy (an artificial opening in the abdomen where the intestine is attached to allow for bowel elimination) care (care to change ostomy bag and keep area clean), and 20 residents required tube feedings (a medical device used to provide nutrition to residents [by way of a tube from the nose or mouth to the stomach or a tube surgically placed in the abdomen directly into the stomach] who cannot obtain nutrition by mouth, are unable to swallow safely). Nursing Management/Supervision During an interview on [DATE] at 8:30 AM, the Director of Nursing (DON) stated the facility had no COVID-19 positive residents, however in 4 of the 8 cottages, residents were restricted to their rooms and staff provided RBC due to a possible exposure from a staff member who tested positive for COVID-19. During an interview on [DATE] at 2:55 PM, the DON stated the facility operated with a shortage of nursing staff, including PCNs and CNAs, since the COVID-19 pandemic began two years ago. The DON further stated that in [DATE] the facility experienced an additional significant loss of nursing staff which resulted in shortages of direct-care staff to provide resident care in the cottages. The DON stated that currently the facility had 19 open CNA positions, 5 open Registered Nurse positions, 3 open Licensed Practitioner Nurse positions, and 4 temporary Nursing Aide positions. The DON further stated that the staffing shortages and the restrictions of RBC made it difficult for the facility to meet the psychosocial and physical care needs of the residents. The DON further stated that RBC resulted in resident isolation in their rooms and/or within each cottage. The social isolation resulting from RBC affected the resident's moods. The DON stated the residents were sad, they were not getting out of bed, and they were not wanting to eat. The DON further stated that RBC restrictions also limited other staff from entering those cottages to meet resident needs, such as Physical Therapy, Occupational Therapy, Rehab, and Activity. RBC resulted in a decrease in physical activity; the DON stated that while on RBC, residents could not leave their room to use the exercise bicycle in the common area. The DON further stated that staff allowed in RBC cottage(s) was limited to direct-resident care nursing staff only, which included PCNs, CNAs, and Cooks. The DON stated nursing management could go to the front door and into the foyer area but could not enter the cottage. As the DON of the facility, she was not allowed into the RBC cottages unless it was an emergency. The DON stated if she had to go into a cottage, she was not allowed to enter any other cottage for 7 days. This restriction also involved Nursing Supervisors and Managers, unless they had to work the floor due to nursing shortages. RBC resulted in decreased direct supervision of care provided in the cottage and currently, supervision of RBC cottages was completed through 3 safety huddles every day, via virtual meetings such as ZOOM or Facebook, and phone calls. Infection Prevention and Control During an interview on [DATE] at 11:57 AM, the Infection Preventionist (IP) stated cottage(s) were placed on RBC when an exposure occurred. The cottage(s) would remain on RBC, where all residents would stay in their rooms at all times, until a complete round of COVID testing occurred and 100% of a testing cycle's results were returned as negative. Once the negative results were confirmed, the cottage(s) transitioned to a modified room-base care (MRBC) status until the 14-day quarantine period was completed. On MRBC, residents who were vaccinated, and could wear a mask, would be allowed to come out of their rooms into the common areas if the mask remained in place. Those residents who were not vaccinated, or who could not wear a mask due to not being able to tolerate the mask due to medical reasons, would remain in their rooms for the full 14 days of quarantine. The IP further stated that while a cottage was on RBC, co-mingling of staff was limited. This meant that staff not performing direct-resident care would not be allowed in the cottage(s). Activity Therapy During an interview on [DATE] at 3:00 PM, the Operations Director stated the current Activity Department staff consisted of one Activity Therapy (AT) Assistant. The Operations Director further stated the AT Assistant was only allowed to go into open cottages (cottages not on RBC). He stated that when a cottage was restricted to RBC, the nursing staff were expected to provide resident activities, which at this time was difficult due to nursing staff shortages. The Operation Director stated the facility was aware RBC restrictions affected the residents' ability to participate in activities. The residents complained about lack of activities during Resident Council meetings and these concerns and complaints were documented in the Resident Council meeting minutes. The Operations Director further stated that prior to the COVID-19 pandemic, the Activity Department would provide residents with an Activity Calendar which showed the available activities for the week or month, however this stopped in [DATE]. Now, Residents are informed of available activities upon admission. Currently, the Activity Department offered Bingo on Tuesdays at 2:00 PM and Thursdays at 10:00 AM, and when the cottage was open the AT Assistant would perform one-on-one visits with residents. For RBC cottages, 3 iPads were available in each cottage for residents who wanted to join Bingo virtually. The Operations Director agreed this limited participation to only 3 residents, based on a 12-resident capacity per cottage, however stated some residents had their own devices to join if they wanted. The Operations Director stated that at this time, the Activity Department could not meet the needs of the residents and it was evident this had affected the Resident's moods as they seem sadder. Rehabilitation During an interview on [DATE] at 8:23 AM, the Rehab Therapy Aide stated that when a cottage was on RBC he/she could not enter that cottage until his/her last day of his/her work scheduled for the week. For this reason, residents in RBC cottages could only receive in-room rehab once a week despite having rehab orders for twice a week. Review of the rehab schedule for the facility, provided on [DATE], revealed 25 residents were receiving rehab therapy. Of those 25, 9 residents were in RBC cottages with limited rehab services. After [DATE], an additional cottage was placed on RBC which affected 4 additional residents for timely rehab therapy. Resident Psychosocial Assessment Review of the CMS-672 form, Resident Census and Conditions of Residents, dated [DATE], revealed a facility-wide assessment of mental status of residents: - Documented signs and symptoms of depression: 51 residents - Documented psychiatric diagnosis (excluding dementias or depression): 31 residents - Behavioral healthcare needs: 25 residents Further review revealed a facility-wide assessment for the use of [CONDITION(S)] medication (medications used to treat mental health disorders) use: - Antipsychotic medications (medications used to treat [CONDITION(S)], like hallucinations or delusions): 14 residents - Antianxiety medications (medications used to treat anxiety): 13 residents - Antidepressant medications (medications used to treat depression): 53 residents Resident Interviews During an interview on [DATE] at 12:42 PM, Resident #54 (who was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she further stated he/she would like to attend activities and socialize. During an interview on [DATE] at 12:47 PM, Resident #16 (who was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #16 stated the facility was unable to accommodate the request because there was not enough staff. Resident stated he/she was disappointed and upset because this is supposed to be our home .we are supposed to be able to have a say in our own care. Resident #16 further stated Bingo on Tuesdays and Thursdays was the only activities offered. He/she stated an activity aide occasionally came around to offer to paint the residents' nails about once per month. Resident #16 stated there was not much to do and was looking forward to when more activities were provided. Resident #16 stated he/she mostly watched television or used his/her cell phone. Resident #16 stated there were no activities posted anywhere. During an interview on [DATE] at 1:06 PM, Resident #54 stated the Certified Nursing Assistants (CNAs) only offered him/her a toothbrush and toothpaste during shower times, I only get to brush my teeth twice a week. During an interview on [DATE] at 2:07 PM, Resident #43 (who was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #43 stated he/she would be interested in attending activities, but staff did not tell him/her when they happened, nor do they invite him/her to go. During an interview on [DATE] at 12:47 PM, when asked what activities were available, Resident #49 (was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident stated, I have my own activity. When asked if the facility provided or helped him/her obtain supplies for activities, the Resident replied, he/she washed the paper plates the meals came in, dried them and colored on them. Resident #49 stated he/she got art out of his/her coloring books and glued it on to tin cans, he/she had recycled. Resident #49 stated he/she wanted the facility to provide more activities because the residents were on RBC, the residents do not get any activities. We are doing Zoom Bingo at the moment, that is the only group activity. When asked if he/she could leave the room, Resident #49 replied, No, we are room based. I need to go to the First National Bank, and they are not letting me do that. The Resident stated he/she was vaccinated, but as not allowed to eat in the dining room, sit at the windows and look at the flowers. Resident #49 stated he/she had only been off room-based care a couple of days since he/she had lived here. The Resident wanted to visit his/her friend who lived in another cottage and has not been able to do an in-person visit since coming here. During an interview on [DATE] at 10:44 AM, Resident #12 (who was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 10:49 AM, Resident #83 (who was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . We have not had an activity person for maybe as long as a year. The Resident stated they did not have enough staff to put an activity person in each cottage. The Resident stated the facility did have Bingo via Zoom, and she/he had played for years before COVID but had lost interest. Resident #83 further stated that he/she no longer got out of bed and had not left his/her room in 2 years, while saying There is nowhere to go and nothing to do. The Resident said he/she did have one of the CNAs take a picture of the Christmas tree because he/she was unable to see it from his/her room. The Resident said, I spent a lot of time studying that tree. The Resident stated he/she had celebrated Christmas with his/her family via zoom. Resident #83 stated he/she would like to be able to watch the [NAME] channel on his/her iPad, but the app would not load. He/she stated no one was to be able to fix it. During an interview on [DATE] at 4:01 PM, Resident #60 (who was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she stated he/she got a little bored sometimes. Resident #60 stated that he/she enjoyed listening to music and audio books. During an interview on [DATE] at 4:11 PM, Resident #8 said there was not enough staff to take care of resident needs, he/she stated the staff were on their best behavior the first week of this survey period, but now it's back to normal and nothing is going to change. Direct Patient Care Staff Interviews During an interview on [DATE] at 1:13 PM, CNA #11 stated staff try to honor requests made to change bathing times, but it was not always possible if there was not enough staff. During an interview on [DATE] at 10:17 AM CNA #1 stated being consistently short staffed made it very difficult to complete the ROM exercises with residents because it was time consuming, therefore they did not get completed. During an interview on [DATE] at 2:23 PM, Nurse Practitioner #1 stated when COVID hit pressure injuries increased and room-based care could be a contributing factor to the increase in pressure injuries. Administration Review of the facility's Admission and Discharge Report, from [DATE] to [DATE], revealed: - January: 7 admissions (1 has since expired, 1 was discharged ) - February: 4 admissions (1 has since expired, 1 was discharged ) - March: 4 admissions (2 has since expired) - April: 4 admissions - May: 8 admissions (2 have since expired, 1 was discharged ) - June: 3 admissions - July: 2 admissions - August: 1 admission - September: 3 admissions (1 has since expired, 1 was discharge) - October: 8 admissions (2 have since expired, 1 discharge) - November: 3 admissions - December: 6 admissions During an interview on [DATE] at 10:10 AM, the Administrator stated that staff shortages was a concern and affected what the facility was able to provide residents and impacted daily life. The Administrator stated that due to staffing shortages, resident care was not to the highest level she would have wanted it to be. The Administrator acknowledged that the current nursing staff shortages have resulted in a lack of basic care for residents, such as turning and repositioning residents in chairs and beds, which had resulted in actual physical harm of facility-acquired pressure ulcers and associated complications. The Administrator further stated that the facility had stopped admissions from July to August of this year (2021), however received pressure and complaints from local hospitals to admit. The Administrator stated that stopping admissions again was considered, but not initiated. During an interview on [DATE] at 1:10 PM, the Medical Director stated staffing had been affected due to the COVID pandemic. She stated at this time, the main concern was how the facility could meet the needs of the residents. The Medical Director further stated it was very hard to maintain enough staff to offset the risk of RBC precautions. During an interview on [DATE] at 10:01 AM, the Staff Development Manager stated there was not sufficient staff at the facility at this time to meet the needs of the resident's needs, as identified through resident assessment and the individual plans of care. Quality Assurance and Performance Improvement (QAPI) During an interview on [DATE] at 9:03 AM, the Quality Director stated the facility's optimal staffing pattern would be to have 2 CNAs and 1 PCN per cottage for days and evenings, as well as 2 Supervisors during the day and 1 Supervisor for evenings and nights. Night shift would have 1 CNA and 1 PCN per cottage. Weekend supervision would include 1 Supervisor on days and 1 Supervisor on nights. The Quality Director further stated that the facility was not currently meeting this goal, and this affected resident care. The Quality Director stated it was a daily challenge to get residents up from bed, consistently perform resident turning schedules, and perform regular activities of daily living. This inability had increased the facility-acquired pressure ulcer rate. The Quality Director further stated there was a shortage in the Activity and Therapy Departments as well. The Quality Director identified the following QAPI PIPs, and their summary root cause analysis (RCA)reasons for initiation, that the QAPI committee were engaged in: - High Risk/Unstageable PuRs (Pressure Ulcers) QM (Quality Measure): RCA analysis: We continue to use all the best practices to prevent high risk residents from acquiring a PuR [pressure ulcer], but our current staffing constraints prevent the necessary frequency of turning and repositioning. - Managing Depression: RCA analysis: Depression rates have increased due to residents being isolated under RBC and limitations on visitations, activities, socialization, and interactions with caregivers. Loneliness, helplessness, and boredom have increased and are the possible adverse effects of RBC practices. The Quality Director acknowledged that staffing shortages and RBC precautions were a contributing or causative factor for the PIPs listed above. The Quality Director could not provide proof of any implemented effective plans to mitigate the risk to the residents during this survey. The Quality Director further stated that a PIP concerning the staffing shortages had not been initiated. Pressure Ulcer Wound Care Documentation Review of Resident #42's provider note, Wound Check, dated [DATE], revealed: It appears [Resident #42]'s measurements vary depending on staff .Due to critical nursing shortage, there have been difficulties changing dressings as ordered three times a week still continues to be difficult to accomplish. Further review of a provider note, Wound check, dated [DATE], revealed: [Resident #42] is being seen for a wound check. Compared to photos from last visit it appears [his/her] pressure wound on [his/her] coccyx has worsened over the last week. Nursing is unable to offer any reason as to why it appears so much larger than previous photos on such a short time but could be related to the current critical nursing shortage. Review of the facility's Matrix for Provider form, dated [DATE], revealed a facility-wide overall pressure ulcer rate of 19%, 12.7% of those were facility-acquired. Review of the facility's [NAME] report MDS 3.0 Facility Level Quality Measure Report, report period [DATE] - [DATE], revealed: - The facility's Hi-risk/Unstageable Pres [Pressure] Ulcer percentages were: facility percentage: 21.8% (compared to the comparison group national average of 8.9%). - The facility's Depress [Depression] Sx [Symptoms] percentages were: facility percentage: 9.2% (compared to the comparison group national average of 7.6%). Governing Body (GB) During an interview on [DATE] at 9:19 AM, the Regional Director of Rehab and Quality (RDRQ) stated she helped to lead the Regional GB along with the Regional Chief Medical Officer and that the GB oversaw a multitude of facility types, called service lines, and Skilled Nursing Facilities (SNFs) and Assisted Living Facilities (ALFs) were just one service line. The RDRQ stated that the GB reviewed specific facility data at each quarterly meeting consisting of quarterly reports provided by the Regional Chief of SNFs/ALFs. The RDRQ stated if there were outcomes outside of the national benchmarks, the GB would want to get more information on what was being done to improve those outcomes. The RDRQ stated the facility had only come under the regional office's supervisory umbrella in [DATE]. In [DATE], the GB did review the facility's 2020 data during the GB's Annual QAPI report meeting, in preparation for taking over the facility's oversight. When asked if the GB addressed any of the identified facility outcomes that were outside of the national benchmarks at that time, the RDRQ stated the GB had not. The RDRQ further could not identify any action the GB had taken since [DATE] to address those outcomes. Review of the GB's 2021 QAPI SNF and ALF annual report PowerPoint, provided by the Regional Chief SNFs/ALFs, revealed the facility's [NAME] report, dated [DATE] - [DATE], that listed several outcomes outside of the national benchmarks: 1) High Risk/Unstageable Pressure Ulcers: facility: 15.7% (comparison group national average: 9.1%); 2) Physical Restraints: facility: 3.7% (comparison group national average: 0.2%); 3) Behaviors Symptoms Affecting Others: facility: 53.8% (comparison group national average: 20.6%); and 4) Move Independence Worsening: facility: 41.0% (comparison group national average: 27.2%). When asked if the GB had knowledge of the facility's PIPs currently being addressed, namely: Pressure Ulcers PIP, where the QAPI committee identified: We continue to use all the best practices to prevent high risk residents from acquiring a [pressure ulcer], but our current staffing constraints prevent the necessary frequency of turning and repositioning and that this PIP had no documentation of PIP monitoring, evaluation, or measuring since [DATE]; and 2) Managing Depression PIP, where the QAPI committee identified: Depression rates have increased due to residents being isolated under RBC [room-based care] and limitations on visitations, activities, socialization, and interactions with caregivers. Loneliness, helplessness, and boredom have increased and are the possible adverse effects of RBC practices, and that this PIP had no documentation of PIP monitoring, evaluation, or measuring since [DATE], The RDRQ stated the GB was unaware of these concerns at the facility. When the RDRQ was informed that the current overall facility-wide pressure ulcer rate was 19% and 12.7% of that was facility acquired, she stated the GB was unaware of this concern.

Based on record review, interview and observation the facility failed to implement visual supervision (1:1 supervision) for 1 resident (#12) with identified swallowing difficulties, out of 26 residents that required 1:1 supervision and/or supervised dining. Specifically, the resident was observed to be coughing and gurgling while attempting to chew bacon during a meal. Nursing staff were not providing 1:1 supervision and/or continuous visual observation during the meal. In addition, facility staff had varying levels of understanding about the difference between 1:1 supervision; supervision during meals; supervised dining; and 1:1 assistance for the residents during mealtimes. Facility staff had different levels of understanding regarding the homekeepers (HMK-that had completed a paid feeding assistants program) role and the level of supervision they could provide during meals for the various residents. This failed practice placed the resident in immediate jeopardy of harm from injury and/or death from aspiration of food. The immediate jeopardy situation for Resident #12 was brought to the attention of the facility's administration on 12/13/16 at 3:15 pm. The facility initiated a plan to abate the immediate risk for injury and/or harm to the Resident on 12/15/16 at 12:42 pm. Findings: During an interview on 12/13/16 at 7:50 am HMK #3 was asked what the homemaker role was with assisting residents to eat. The HMK stated he/she helped with feeding residents that are low risk and normal certified nursing assistants (CNA's) feed residents that need more help. The HMK stated the residents the homekeeper could assist were identified by a sticker on their diet sheet. Continuous observation on 12/13/16 from 8:47 am to 9:20 am revealed Resident #12 seated at the dining table, facing the kitchen area and eating a morning meal which contained whole bacon, cut-up eggs and whole toast. Resident #12 fed him/her-self. The Resident's tongue thrusted out of his/her mouth, frequently moving side to side and protruding outward during the meal. During the observation Licensed Nurse (LN) #1 and CNA #'s 1 and 2 were in and out of the dining area providing care and assistance to other residents. At 9:05 am, LN #1 approached the Resident to assess his/her vital signs. When the Resident refused, the LN left the dining area. In order to get a bite of the bacon the Resident had to pull on it to tear off manageable bite size pieces. The bacon appeared to be stretchy and thin and the Resident had difficulty pulling it apart. Resident #12 continued to eat and drink fluids while simultaneously gurgling, coughing and attempting to clear his/her throat. At 9:10 am Resident #12 spontaneously started to cough and gurgle while s/he stated, I have a swallowing problem and I have false teeth, but I don't wear them. HMK #2 was observed moving throughout the nearby open kitchen and at times leaving the area. The HMK did not provide 1:1 supervision of the Resident during the meal. During the observation, the Resident continued to feed him/herself with no staff providing 1:1 supervsion (visual supervision) in the dining area until 9:20 am when CNA #1 entered the dining area. Record review on 12/13/16 revealed Resident # 12 had [DIAGNOSES REDACTED]. Review of the most recent MDS, (Minimum Data Set- a federally required nursing assessment), dated 11/14/16, revealed Resident #12 was coded as being on a mechanically altered diet and had no swallowing difficulties. Review of Nutrition Notes, dated 11/15/16, revealed Resident #12 had Swallowing difficulty .dysphagia secondary to history of CVA (Cerebrovascular accident - stroke) resident reported intermittent difficulty with swallowing. Need for mechanically altered diet/fluids .Resident eats supervised after set-up as needed. Review of the Resident's diet sheet, located in a binder in the cottage kitchen, undated, revealed Dining assistance Instructions: SUPERVISION: requires 1:1 supervision during all meals and p.o. (by mouth) intake. The Resident did not have a sticker that indicated homekeeper staff could provide the supervision. Record review on 12/13/16 of Speech Therapy notes, dated 11/15/16, revealed, .Additional pertinent information from the hospital stay includes: Modified Barium Swallow Study was administered on 9/08/2016; the results indicated .Resident has dysphagia that has been managed with mechanically altered diet textured .Foods need to be modified to: chopped. A thin liquid .requires the following supervision: 1:1 supervision .Reported coughing on chopped/ground with scrambled eggs, bacon, coffee cake and thin liquids. Res (Resident) open to changing to ground with added moisture as (s/he) agrees that chopped is not safe at this time .Res (Resident) provided with nectar consistency liquids which resulted in a dry voice after swallow. Res (Resident) stated 'that is smoother' and (s/he) was open to thickening to nectar . During an interview on 12/13/16 at 11:00 am, HMK #2 when asked about the chopping food for residents, the HMK stated he/she was allowed to have cut the food to dice/cube size so residents do not choke when they swallow. The HMK further stated 1:1 supervision and supervision are the same, in regards to residents who could feed themselves. The HMK stated staff needed to be in the room looking at the residents at all times or sitting with them. During an interview on 12/13/16 at 11:05 am the Registered Dietitian (RD) #2 stated s/he allowed bacon to be kept whole but required it to be well cooked and not chewy for residents on a chopped diet. The RD added, Speech Therapy trained the homekeepers on how to feed residents. Eligible residents would have a sticker on their diet sheet that indicated a homekeeper could aide in feeding a low risk resident. The RD stated only licensed nurses and CNA's were allowed to feed and monitor high risk residents. During an interview on 12/13/16 at 1:25 pm CNA #5 was asked what supervision of a resident during meal time meant. The CNA said supervision means to be in the area, take food to the resident and stay around until they are finished eating. The CNA also stated 1:1 supervision was the same as total assistance further explaining it meant to actually feed a resident. During an interview on 12/13/16 at 1:30 pm, when asked what texture the bacon should be cooked at, for Resident #12, Speech Language Pathologist (SLP) #1 stated the bacon should have been cooked crisp and not chewy. When asked what 1:1 supervision during meals meant, SLP #1 stated the caregiver needed to be sitting with the Resident while consuming meals. The SLP stated the homekeepers (that had completed a paid feeding assistance program) could not provide the 1:1 supervision. During an interview on 12/13/16 at 1:35 pm, when asked what the 1:1 supervision meant, the Therapy Manager stated the staff had to be sitting with the resident being supervised. When asked if the homekeepers, trained as paid feeding assistants, could supervise residents that were deemed high risk for choking or aspiration, the Therapy Manager replied they could, if the task had been delegated to them by the SLP. During an interview on 12/13/16 at 1:44 pm, CNA #6 stated 1:1 supervision meant you were to stay with the resident and observe them. During an interview on 12/13/16 at 2:35 pm, CNA #7 stated 1:1 supervision meant the resident needed assistance to eat. During an interview on 12/13/16 at 2:00 pm, LN #3 in Cottage #7 stated 1:1 supervision meant constant monitoring of the resident while they were eating. When asked if a homekeeper could provide 1:1 supervision, the LN stated only the CNA's could provide 1:1 supervision of the high risk residents while they were eating. During an interview on 12/15/16 at 12:40 pm, SLP #2 stated 1:1 supervision meant staff were to keep a close eye on a resident. When asked about Resident #12 the SLP stated the initial swallowing study indicted the Resident was high risk for aspiration. When asked about the 1:1 supervision, SLP #2 stated the Resident needed to be in line of sight and staff needed to be close enough to talk to the Resident so they could provide cueing during meals. Protocol review of the facility protocol Monitoring Guide for Dining Room, revision date 4/22/16, revealed Review meal slip (diet sheet) for diet .correct food texture and special instructions .Staff are remaining at table if any resident still requires monitoring/cueing.

Based on record review, interview and observation the facility failed to prevent unavoidable pressure injuries for 5 (#'s 1; 2; 6; 8 and 9) of 5 residents reviewed with new, worsened, and/or high risk pressure injuries. The failure to implement preventative measures in a timely manner caused residents to obtain preventable pressure injuries (1 - Unstageable pressure injury; 2 - Stage 2 pressure injuries; and 3 - Stage 3 pressure injuries) and resulted in pain for 2 residents with an increased risk for infection, delayed healing, and poor medical outcome. Findings: Pressure Injury: According to the National Pressure Ulcer Advisory Panel, accessed 12/22/16 at www.nouap.org <http://www.nouap.org> A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. According to Mountain-Pacific Quality Health, a quality improvement organization, Stage 1 pressure injury is a non-blanchable [DIAGNOSES REDACTED] of intact skin; Stage 2 is partial thickness skin loss with exposed dermis; Stage 3 is full thickness skin loss in which fat is visible; a deep tissue injury is intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation; and an Unstageable pressure injury is a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed due to slough or eschar (dead tissue). Resident #1 Record review from 12/13-15/16 revealed Resident #1 had [DIAGNOSES REDACTED]. Further review revealed Resident #1 had an order for [REDACTED]. Review of the most recent MDS (Minimum Data Set-a federally required nursing assessment), a quarterly assessment dated [DATE], revealed the Resident was coded as having a risk for pressure injuries and had a Stage 2 pressure injury. Further review of the provider's note, dated 11/17/16, revealed a [DIAGNOSES REDACTED]. The provider's note also stated the wound resolved on 11/17/16. During an interview on 12/14/16 at 10:15 am Cottage Manager (CM) #2 stated the injury to the septum was caused by the nasal cannula and the Resident now used a silicone nasal cannula. The CM stated the pressure injury resolved on 11/17/16. Further review revealed the Resident used the nasal cannula at night instead of the [MEDICAL CONDITION] (Bi-level Positive Airway Pressure- delivers positive pressured air via mask) at night, thus wearing the nasal cannula for longer periods. The facility did not switch to a soft tip nasal cannula until after the Stage 2 pressure injury was discovered. Resident #2 Record review from 12/13-15/16 revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The Resident had an SP catheter (suprapubic catheter-a tube surgically implanted into the bladder to drain urine) and a GT (gastric tube-a tube surgically implanted into the stomach for feeding). Review of the most recent MDS comprehensive assessment, dated 12/6/16, and the most recent quarterly assessment, dated 9/15/16, revealed both assessments coded the Resident with memory impairment; decision impairment; needing extensive to total assist with activities of daily living; had functional limitations in range of motion; and was at risk for pressure ulcers. Record review of Resident #2's Comprehensive Care Plan (CCP), dated 12/8/16, revealed the Resident was at risk for skin breakdown, pressure ulcers and decreased mobility. The plan's goal included the Resident's skin would be intact and free from redness, irritation, injury. The CCP revealed the Certified Nursing Assistants (CNA) were to report any skin breakdown to the nurse and manage moisture conditions of the skins surface. Record review on 12/13/16 at 8:00 am of Resident #2's Daily Care Plan (DCP), dated 12/8/16, revealed Skin integrity check during care and notify PCN PRN (Primary Care Nurse as needed) .Ensure suprapubic catheter tubing is not resting on skin to prevent irritation and/or pressure areas. Suprapubic (SP) Catheter Wound: Observation on 12/13/16 at 9:20 am during morning cares revealed Resident #2's with an abdominal binder protecting a GT feeding tube site. The SP catheter tubing was also partially covered by the abdominal binder. The SP catheter exited the Residents lower abdomen thus forming a clockwise loop above the SP catheter site. The tube was lying in the creases of the lower abdomen, looped up and was secured by the lower portion of the abdominal binder. During the observation, CNA #2 began to provide SP catheter care. The CNA stated there was a large amount of clear fluid over the Resident's peri-area. The CNA then began to clean in the superficial depths of the lower abdomen fold containing the SP catheter. When the Surveyor requested to see the area around the SP catheter, CNA #2 gently pushed back the abdomen fold and revealed the opening for the SP catheter. This observation revealed a wound around the SP catheter site that measured approximately 3 cm by 2 cm with bright red granulated tissue and serosanguinous fluid. Record review of the Resident's Nursing Order Skin Integrity/TAR (Treatment Administration Record), dated 12/2016, revealed no documentation or management of a wound related to the SP catheter area. During an interview on 12/13/16 at 9:26 am the CNA stated s/he had not been aware of the wound located around the SP catheter site. In addition, the CNA confirmed the wound was not on the Resident's Care Plan. During an interview on 12/13/16 at 10:08 am CM #1 and Licensed Nurse (LN) #1 both stated they were not aware of the wound located around the SP catheter opening. Furthermore, CM #1 stated the area appeared to be a stage 3 pressure related wound and considered the observation a significant finding. During an interview on 12/13/16 at 1:15 pm the Wound Care Nurse (WCN) stated the area around the SP catheter was caused by trauma from the (SP catheter) tube. The WCN further stated the resident had a history of [REDACTED]. During an observation of the wound care on 12/13/16 at 1:15 pm, the Resident began to scream when the WCN began to clean around the wound. Record review of a progress note, dated 12/13/16, revealed Provider #1 documented the Resident had a Stage 3 pressure injury adjacent to the SP catheter insertion site. The document further revealed the pressure injury was likely from pressure of catheter against skin in skin fold .The wound is full thickness, painful. During an interview on 12/14/16 at 6:13 pm Provider #1 stated the Stage 3 pressure injury was a result of pressure from catheter tubing and associated the wound with the tubing being looped under lower abdominal fold with added pressure from the abdominal binder. Record review of the progress notes, dated 1/1/16 to 12/13/16, revealed Resident #2 had a prior pressure related ulcer at the SP catheter. Urethra Erosion: Record review of a physician's visit note, dated 11/10/15, revealed the SP catheter was surgically implanted into Resident #2's bladder as a result of penile erosion from an indwelling urinary catheter. During an interview on 12/14/16 at 6:13 pm Provider #1 stated the cause of the catheter associated urethra erosion was pressure from the catheter tubing which resulted in the reduction of skin integrity causing parts of the genitalia to split open. Resident #6 Record review from 12/13-15/16 revealed Resident #6 had [DIAGNOSES REDACTED]. Further review revealed Resident #6 had a feeding tube (tube surgically implanted into the stomach to deliver food), [MEDICAL CONDITION] (surgical construction of an opening in the trachea for the insertion of a catheter or tube to facilitate breathing) and was on comfort care. Record review on 12/13-15/16 of the most recent MDS annual assessment, dated 11/2/16, revealed the Resident was coded as a high risk for pressure injuries. Review of a nursing order, dated 11/15/16 revealed, Monitor bruise on L (left) second toe daily until resolved. Review of the provider's note, dated 12/2/16, revealed Resident #6 was identified with an unstageable pressure injury on the top of the left second toe; and a healed Stage 3 pressure injury on the top of the right second toe. Review of the WOUND/SKIN CARE ORDERS, dated 12/2/16, revealed a treatment order that included applying gauze between toes 1 and 2 of both feet. During an interview on 12/15/16 at 2:30 pm, CM #1 stated the pressure injuries on the toes were caused by the great toes overlapping the 2nd toes. The CM further stated the pressure injuries could have been avoided, had interventions been implemented that prevented the toes from rubbing together. Resident #8 Record review on 12/13-15/16 revealed Resident #8 had [DIAGNOSES REDACTED]. Further review revealed Resident #8 wore a controlled ankle movement (CAM) boot while the fracture was healing. Additional record review on 12/13-15/16 revealed Resident #8 acquired a Stage 2 pressure injury on the left lateral lower leg that was identified on 6/1/16. Review of the provider's note, dated 6/1/16, revealed, last night, nursing noted a red area on (the Resident's) lateral left calf when checking (his/her) skin under the boot. Review of the provider's notes, dated 7/15/16, revealed, Pressure ulcer (injury) of left leg, stage 2 .continues to require CAM boot, which likely caused the ulcer. Careful attention to wrapping leg with padding to protect from boot, and careful position to avoid further wound . During an interview on 12/15/16 at 9:55 am, CM #2 stated the pressure injury on Resident #8's leg was caused by the CAM boot. The CM stated the padding from the boot had wadded up causing the pressure injury. Resident #9 Record review on 12/13-15/16 revealed Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. Review of a significant change MDS assessment, dated 8/12/16, revealed the Resident was at high risk for pressure wounds, had experienced a decline in mobility, and had acquired a Stage 1 pressure ulcer and an unstageable pressure ulcer while a resident in the facility. Review of a significant change MDS, dated [DATE], revealed the Resident had acquired a Stage 3 pressure wound. Observation during morning care on 12/13/16 at 9:00 am, revealed Resident #9 had a pressure injury to the inner left heel. During the observation CNA #4 applied lotion to the lower legs and stated the nurse usually puts something on the injury. The CNA stated the pressure injury was healing. Review on 12/13-15/16 of the Nursing Notes revealed: 8/1/16 at 2:33 pm, Resident stayed mostly in bed, resting and sleeping for the day .Went and lifted using ceiling lift for the bathroom.; 8/3/16 at 2:12 pm, Resident's sleep pattern: stayed in bed for a few days to keep legs elevated; on and off naps during days.; and 8/7/16 at 2:00 pm, Ulcer/Wound-full/[MEDICAL CONDITION] thickness closed bluish round wound Location (left) heel length (cm): 2.5 cm Width (cm): 2.5 cm . Review of the wound nurse's Progress Note, dated 8/8/16 at 2:17 pm, revealed (Resident #9) has been staying in bed more .Per nursing report (Resident) spent a good part of the weekend in bed. Review of the skin revealed Left heel .is suspected deep tissue injury, purple ecchymotic blister cap over medial heel measures 4 x 3 cm, very tender to touch .Right heel .stage 1 pressure injury is a small non-blanching red area of intact skin without ulceration, minimal pain when palpitated . The wound nurse's plan included Prevalon boots when in bed if he allows (and) Upgrade mattress to P500 or similar. Further review of the nurses Progress Notes revealed: 10/31/16 at 11:58 am, .recurrent wound on left heel . and 10/31/16 at 2:02 pm, .recurrent left heel redness with scab, stage 3, per Resident 'hurtful' . Review of the physician orders, dated 10/31/16, revealed Please notify wound care team of recurrent wound on (left) heel. During an interview on 12/15/16 at 2:20 pm, Provider #s 1 and 2, who were on the wound care team, stated Resident #9 had experienced an increase in behaviors and a decline in his/her health which resulted in bilateral lower leg [MEDICAL CONDITION] and stasis wounds. According to Provider #1 after the Resident's behavior had improved, the Resident began to stay in bed 24 hours a day, not moving much, and required transfers in and out of bed with a mechanical lift. Provider #2 stated when s/he first observed the pressure injuries to the heels staff were ineffective at attempting to keep the Resident's heels elevated with pillow. The Provider stated s/he had ordered the Prevalon boots and the air mattress at that time. During the interview Provider #1, stated the pressure injuries could have been avoidable. Review of a provider's visit, dated 10/31/16, revealed (Resident #9) notes the heel of (his/her) left foot has been hurting for the past week .Unstageable pressure ulcer to left heel. Review of the Nursing Notes, dated 11/2/16, revealed the Resident rated his/her pain at 5 on a scale of 0 to 10 with 10 being the worst pain. The location of the pain was the left heel and pain worse when foot in contact with foot board .Resident has a stage 3 pressure injury .New wound near location of previous unstageable left heel ulcer. Review of the Resident's Braden scale (an assessment tool that helps predict pressure injury risk) revealed: On 6/28/16 a score of 12 (score of 10-12 indicated high risk for pressure injuries) and On 8/24/16 a score of 16 (score of 15-18 indicted mild risk for pressure injuries). According to the Wound, Ostomy, and Continence Nurses Society, accessed at www.wocn.org on 12/20/16, a Braden score at or below a 16 a preventative supportive surface (specialized mattress) should be considered.

Based on record review and interview the facility failed to ensure: 1) the physician for resident (#16) was notified of a change in condition in a timely manner, and 2) the guardians for resident #s 6 and 10 were notified of a change in medication regime. These failed practices caused resident #16 severe pain from a delay in medical treatment and denied the residents' guardians the information needed to make informed decisions about the residents care. Findings: Record review on 12/15/16 of the facility pain scale revealed a scale of 0 - 10. With 0 being pain free; 5 moderate pain; and 10 the worst possible pain. Resident #16 Closed record review on 12/15/16 revealed Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. Additional review revealed the resident sustained [REDACTED]. Review of the Resident's medication regime, dated 11/13/16, included [MEDICATION NAME] (Tylenol) . every 4 hours as needed for pain . [MEDICATION NAME] (a narcotic pain medication) by mouth 2 times daily in the morning and at bedtime and every four hours as needed for pain. Review of the Nursing Notes revealed: 11/12/16 at 10:57 pm Fall Report . Fall with injury . Time of fall (5:40 pm) Were you in pain? Yes . Other resident comments: 'I hit my head . my head doesn't hurt, my left leg hurts from the hip all the way down .' Acute care plan initiated . Physician notification: Notified via email . 11/12/16 at 10:20 pm PRN (as needed) med (medication) given: [MEDICATION NAME] . Pain Level before med 9/10 Location left hip (s) Follow up after 1 Hour . 11/13/16 at 2:25 am PRN med given: [MEDICATION NAME] .; Pain Level before med 10/10 .; Pain Level after med 9/10 . Location left upper lower leg(s) . 11/13/16 at 4:14 am, 2 hours after the pain medication was given, PRN med result . pain reduced; Pain Level after med: 9/10 . 11/13/16 at 4:59 am PRN med given: [MEDICATION NAME] . Pain Level before med: 10/10 . Follow up after 30 Minutes . Location left upper lower leg(s) . No follow up was documented for pain relief. 11/13/16 at 9:26 am F/U (follow up) Fall note: Resident is alert and oriented . Resident complained of pain scale 10/10 of upper left leg, going down to his/her legs, [MEDICATION NAME] .given at (2:22 am) after 1 hour of assessment pain goes down to a 9, Apap (Tylenol) given at (4:58 am) . Resident is able to stand up with 2 person pivot using a gait belt, with weight bearing on both legs but complaining of pain and radiating to (his/her) hips . Resident placed on 24 hrs. (hours) report, MD notified page (Medical Director's Name) . called the Supervisor with orders to send to PAMC ER (Providence Alaska Medical Center emergency room ) . Per Dr. Order 911 non emergent was called . Resident was picked up by paramedics around (6:30 am) via stretcher . As a result the Resident was sent to the hospital for evaluation almost 13 hours after the initial incident. The Resident experienced pain throughout the night that was not relived by his/her ordered pain regime at the time. Review of the facilities policy on .Acute Care Plan dated 5/16, revealed Acute Change of Condition Definition: A sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. 'Clinically important' means a deviation that, without intervention, may result in complications or death . Nursing Interventions & Monitoring . notify physician and document. During an interview on 12/15/16 at 4:30 pm the Resident's Physician confirmed she should have been immediately notified of the Resident's change in condition by phone call due to the Resident's increased pain post fall. The Physician stated email was not an appropriate form of communication when the Resident had experienced a significant change in condition. Resident #6 Record review from 12/13-15/16 revealed Resident #6 had [DIAGNOSES REDACTED]. Further review revealed the Resident was on comfort care. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Convulsions. The side effects to monitor for [MEDICATION NAME] included Sudden Death, Severe [MEDICAL CONDITION] (low blood pressure) . [MEDICAL CONDITION], [DIAGNOSES REDACTED] (a life-threatening, neurological disorder), Severe Extrapyramidal Reaction (abnormal body movements caused by antipsychotic medications), and Severe Respiratory Depression (slowing of breathing) . Severe Sedation. Review of the medical record revealed no documentation the guardian had been informed of risk and benefits for [MEDICAL CONDITION] medications. During an interview on 12/14/16 at 10:45 am, Cottage Manager (CM) #1 stated a risk and benefit consent for the [MEDICAL CONDITION] medications should have been reviewed and signed by the guardian. During an interview on 12/14/16 at 11:00 am, the Director of Quality Improvement stated the guardian had not been notified of the new [MEDICAL CONDITION] medications. Resident #10 Record review on 12/13-15/16 revealed Resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].Start duloxetine (medication used to treat depression, anxiety, and nerve pain . According to Medline Plus, accessed at www.medlineplus.gov on 12/20/16, duloxetine can cause high blood pressure; dizziness; increased bleeding; muscle cramps; weakness; difficulty urinating; [MEDICAL CONDITION], and eye pain. During an interview on 12/15/16 at 4:25 pm, CM #1 and the Director of Nursing confirmed there was no documentation Resident #10's Guardian was notified of the risk and benefits of the duloxetine.

Based on observation, interview, and record review the facility failed to ensure one resident (#20) received effective CPR after choking during a meal, which resulted in delayed emergency services and compromised resident #20's (life) outcome from the event. In addition, the facility failed to ensure nursing staff had adequate knowledge of CPR/BLS procedures, which placed all residents who were at risk for choking and all residents that were full code (initiation of emergency procedures if the heart stops beating), at immediate risk for not receiving effective emergency procedures during an event. This failed practice constituted an Immediate Jeopardy to Resident #20 and had the potential to effect the health and safety of 29 other residents eating with diet consistency modifications in the facility (Residents #s 3; 4; 5; 6; 8; 9; 10; 11; 14; 21; 22; 23; 24; 30; 31; 32; 33; 38; 39; 40; 41; 42; 43; 44; 45; 46; 49; 50; and 51) and 24 other residents with a designation of full code (Residents #s 4; 12; 14; 15; 16; 21; 23; 25; 26; 28; 34; 35; 36; 37; 40; 42; 43; 46; 47; 48; 52; 53; 54; and 55). Findings: This situation was brought to the attention of the facility's administration on [DATE] at 4:30 pm. The Immediate Jeopardy was abated onsite. On [DATE] at 11:30 am a Code Blue was called at Cottage #4. Upon arriving at the cottage at 11:35 am the Surveyor observed a code in progress in Resident #20's room. A facility staff was performing chest compressions on Resident #20. The Resident was lying in bed at a 15 degree incline on a 10 inch thick foam mattress. At 11:37 am EMTs came into the room and took over the code. The Resident's physician was in the room as well as a respiratory therapist. Standing just outside of the Resident's room was a person who was identified as the Resident's POA (Power of Attorney). The Surveyor asked the POA if he knew what happened. The POA said "Yes, I was sitting in the Resident's room watching TV while the Resident ate lunch". The POA said the Resident started choking and the POA saw that the Resident had a large piece of ham and cheese sandwich in his mouth which he was choking on. The POA said he started to go over to the Resident, but the Resident took a deep breath and sucked the large piece of sandwich down his throat and was not able to breath. The Surveyor asked if the Resident had teeth. The POA said "No", that he had his teeth pulled out a few months ago and he was in the process of getting new dentures, but they were not available yet. During an interview on [DATE] at 11:48 am Cook #1 disclosed the Resident had been given a regular whole meat sandwich. Review of the Resident's dietary orders revealed "Consistent Carbohydrates, ,[DATE] grams NA, Ground Meat with Soft Bread" The Surveyor confirmed with Cook #1 that these were the correct dietary orders for the Resident. The Surveyor asked why the Cook had not followed the physician orders [REDACTED]. The Cook said the Resident did not like his food ground and he gave him what he liked. The Cook said he prepared all of the residents' foods the way they wanted it. Review on [DATE] of the Facility job description for "Cook (Cottages)" revealed "Position Summary: ...this position is primarily responsible for planning, preparing, and serving meals and snacks according to resident dietary plan of care guidelines..." and under "Job Duties: ...2.Prepares foods for therapeutic menus according to dietetic specifications..." At approximately 11:50 am the Resident's Physician, who was also the facility's Medical Director, came out of the room and told the POA the Resident was breathing on his own and had a good heart rhythm. At 11:52 am an EMT came out and told the POA that they had to intubate (place a breathing tube in the throat), the Resident and they were supporting his breathing because the Resident was not breathing on his own. Shortly thereafter the EMT team transported the Resident to the local hospital. At approximately 12:10 pm during the post-code debriefing, the staff were talking about issues that arose during the code. One of the issues talked about was that the Resident's primary nurse had felt there was something wrong with the AED machine. The nurse said they sent a staff person over to another cottage to get another AED machine. There was also discussion concerning the difficulty in calling the code blue. The primary nurse had Cook #1 call over to the main administration building 3 times to let them know about the code. Then he physically ran over to the front desk, in a different building, to let them know. There was some discussion about a concern the primary nurse had about not being able to make the phone work. The facility staff also discussed as a group the fact that a backboard was not used when the CPR was initially started. During an interview on [DATE] at 1:05 pm CNA #5, who started the CPR compressions, was asked by the Surveyor to explain what happened during the incident with Resident #20. CNA #5 said she went into the room and saw that the Resident was not breathing. She started doing chest compressions and she thought he took a breath, so she continued until she was told to stop. I asked her when the back board was put under the Resident; she said she couldn't remember that she was "just trying to keep him alive". The Surveyor asked how long she did chest compressions before other staff came and relieved her. CNA #5 said about 10 minutes. During an interview on [DATE] at 1:15 pm LN #3 disclosed that when CPR was first started that neither she nor CNA #5 used the backboard under the Resident's back. LN #3 confirmed the Resident was in the bed with the 15 degree elevation and that the bed was a 10 inch thick foam mattress. When the Surveyor asked how long the chest compressions went on before the backboard was put behind the Resident's back, LN #3 said it was a while because it was when the Respiratory Therapist and the Physician got there and helped roll the Resident over that the backboard was first put under the Resident. The Surveyor asked LN #3 if she was trained on how to use a backboard during the annual BLS training; She said, "No". The Surveyor asked if the facility ever had mock code training, she said, "No," they were required to do an on-line training ever year and that this was her first code. When the surveyor asked if there was an issue with the AED machine not working right, she said she wasn't sure, and that was why they sent someone to go and get a second one. When asked if she had a problem getting the phone to work to call the administration building, she said she wasn't sure if it was working and that was why she had the cook run over and tell them in person. During an interview on [DATE] at 1:05 pm LN #4 at Cottage #6 was not able to open and operate the AED when asked to demonstrate the use. LN #4 stated the AED looked different than the one they trained on every year. When the surveyor asked if the facility ever had mock code training LN #4 said she did not recall ever participating in a mock code. In addition, LN #4 was not able to locate the backboard or operate the suction equipment on the emergency code cart. During an interview on [DATE] at 1:30 pm LN #5 at Cottage #7 was asked where to find a backboard should it be needed in an emergency. LN #4 stated, after looking in the supply room, that there was no backboard and she would have to ask the Manager. In addition, LN #5 stated the facility reviewed AED operation annually but that she had never participated in a mock code. During an interview on [DATE] at 4:30 pm the Medical Director disclosed the AED machine was not registering the chest compressions when the CPR was started because the backboard was not under the Resident. The Medical Director further stated after the backboard was put under the Resident the AED worked. The Medical Director also confirmed the Resident was on a ground meat diet and that the Cook had "taken liberties" when he gave the Resident a sandwich with whole sliced meat. When the Surveyor mentioned the Resident did not have teeth the Medical Director said, yes he did, that during the code when the EMTs were suctioning him that she saw the Resident's dentures come out with part of a sandwich. During an interview on [DATE] at 8:30 am, concerning the Resident's dental issues, when asked if the resident had his new dentures yet LN #6 stated no. During a second interview on [DATE] at 12:05 pm the Medical Director disclosed that the use of the backboard during a code was not on the BLS training. The Surveyor asked if putting a patient on a hard surface was necessary, and the Medical Director agreed it was. The Medical Director said the staff did not perform the Heimlich on the Resident because he was "already down" when they went into the room. The Medical Director stated the nurses that work at their long term care facility weren't at the same level of experience as nurses that worked at the hospital. When asked if nurses in long term care should know how to do effective CPR and use of the emergency equipment(AED/Suction/backboard), the Medical Director agreed their nursing staff should know how to do effective CPR and have the knowledge and skills to carry out emergency procedures. The Medical Director further stated that it could have been a "fatal flaw" . The Medical Director went on to say she did not think that the texture of food was the problem; She said that type of sliced meat should probably not have been served to any resident due to the potential of choking. The Medical Director did confirm that serving residents the wrong diet texture was placing the residents at risk. .

Based on observation, record review, interview, and policy review, the facility failed to ensure residents were provided therapeutic diets as ordered by their physicians for 1 sampled resident (#8) of 19 sampled residents and for 1 (#20) of 5 non-sampled residents. As a result, one resident was served food which caused the resident harm due to choking and subsequent [MEDICAL CONDITION] and placed the other resident at risk for choking. In addition, there were 4 residents (#s 21, 22, 23, and 24) that potentially could have been served food that was not in accordance with their dietary orders. Findings: The facility's failed practice caused an Immediate Jeopardy (IJ) for Resident #20. The IJ was called on 11/4/14 at 4:30 pm and the facility abated the IJ while the Surveyors were onsite. Observation on 11/4/14 from 11:35 am -12:00 noon revealed Resident #20 having CPR performed on him by nurses and EMTs due to the Resident choking on a meat sandwich that was given to the Resident as part of the noon meal. Standing just outside the Resident's room was a person that identified himself as the Resident's POA. The Surveyor asked the POA if he knew what happened. The POA said "Yes, I was sitting in the Resident's room watching TV while the Resident ate lunch". The POA stated the Resident started choking on a large piece of ham and cheese sandwich. The POA said he started to go over to the Resident, but the Resident took a deep breath and sucked the large piece of sandwich down his throat and was not able to breath. The Surveyor asked if the Resident had teeth. The POA said "No," that the Resident had his teeth pulled out a few months ago and was in the process of getting new dentures, but they were not available yet. At 11:52 am an EMT came out and told the POA that they had to intubate the Resident and they were supporting his breathing because the Resident was not breathing on his own. Shortly thereafter the EMT team transported the Resident to the local hospital. During an interview on 11/4/14 at 11:48 am Cook #1 disclosed the Resident had been given a regular whole meat sandwich. Review of the Resident's dietary orders revealed "Consistent Carbohydrates, 2-4 grams NA, Ground Meat with Soft Bread". The Surveyor confirmed with Cook #1 that these were the correct dietary orders for the Resident. The Surveyor asked why the Cook had not followed the physician orders [REDACTED]. The Cook said the Resident did not like his food ground and he gave the Resident what he liked. The Cook further stated he prepared all of the residents' foods the way they wanted it. Record review revealed there were 5 residents in Cottage #4 that had altered consistency diets. These were non-sampled residents #s 20; 21; 22; 23; and 24. During an interview on 11/4/14 at 4:30 pm the Resident's Physician/Medical Director disclosed the Resident had teeth extractions and his gums had healed very slowly due to the fact that the Resident was required to take [MEDICATION NAME] (a blood thinner). The Physician said clinically the Resident may have been able to eat the meat sandwich, but because it would have been an upgrade in his diet orders he should not have gotten the regular meat sandwich for lunch. The Medical Director said the Cook had taken dietary liberties that he should not have. During a second interview on 11/5/14 at 12:02 pm the Medical Director said the type of sliced meat in the sandwich probably would have been a choking hazard for all residents. Record review on 11/4-7/14 revealed Resident #20 was admitted to the facility with [DIAGNOSES REDACTED]. In addition, the Resident had his teeth removed and was in the process of having dentures fitted. Additional record review revealed the Resident was taking [MEDICATION NAME] on a daily basis. Record review of the MAR, dated 11/2014, revealed the Resident was not to have his dietary order upgraded to a different food texture unless the SLP (Speech Language Pathologist) first did an evaluation. Review of hospital reports, dated 11/4/14, after the Resident's choking incident revealed the Resident "brought in by EMS from (facility's name omitted) after an episode of choking followed by [MEDICAL CONDITION]. When paramedic arrived he had a heartbeat of 80, was in distress, heartbeat slowed down, or intermittently he went into asystole (no heart beat). Medics performed CPR for four minutes and pulled a piece of meat from his airway...He was...intubated prior to ED arrival." Additional hospital report review stated the Resident was initially unresponsive to painful stimuli and was put on a ventilator for several days before he could breathe on his own. Resident #8 Record review on 11/4-7/14 revealed Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 11/4-7/14 of the Resident's "Physician Orders" dated 10/6/14, revealed "...chopped with ground meat." Record review on 11/4-7/14 of the Resident's dietary card revealed, "Chopped with ground meat." Observation on 11/5/14 at 4:30 pm at Cottage #6 revealed Resident #8 eating a pork chop for dinner that had been chopped but had not been ground. When asked if that was the appropriate diet for the Resident, Cook #2 confirmed it was the wrong diet. During an interview on 11/5/14 at 12:05 pm the Medical Director said the SLP had to complete an evaluation before a resident could have his/her diet texture changed. Nursing could not upgrade a diet, but they could downgrade a diet; (i.e., upgrading a diet would be where a staff changed a resident's diet/food texture from ground meats to whole meats) (i.e., downgrading a diet would be where a staff changed a resident's diet/food texture from whole meats to ground meats). During an interview on 11/6/14 at 9:45 am, when asked if cooks were assigned to work in one cottage only, Cook #3 stated that each cook has a main cottage assignment, but they do cover other cottages when needed. Cook #3 further stated that he/she works 3 days in Cottage #1 and 2 days in Cottage #3. Review on 11/6/14 of the Facility job description for "Cook (Cottages)" revealed "Position Summary: ...this position is primarily responsible for planning, preparing, and serving meals and snacks according to resident dietary plan of care guidelines..."and under "Job Duties: ...2.Prepares foods for therapeutic menus according to dietetic specifications..." Review of the facility's policy and procedure for "SLP (Speech Language Pathologist) ordering Diet Texture Changes", not dated, revealed "Based on therapy performance, screening, or evaluation results, the SLP will determine the safest and least restrictive diet texture safely tolerated by the resident..." .

Based on record review and interview the facility failed to: 1) monitor and implement interventions to prevent injury for 1 resident (#5) out of 11 sampled residents. Because of this failed practice, resident #5 did not have nessesary interverventions in place and experienced a fall that resulted in a hip fracture ; and 2) assess 2 residents (#s 2 and 28) for being safe to smoke and to keep cigarettes and lighters in their rooms where oxygen was being used (resident #2). This failed practice caused harm for resident #5, and placed residents at risk for injury. Findings: Resident #5 Review of the clinical record on 12/9-12/13 revealed Resident was admitted to the facility with [DIAGNOSES REDACTED]. n 11/16/13, he experienced a witnessed controlled fall resulting in fracture. Surgical intervention, hemi-arthroplasty (total hip replacement), was performed on 11/17/13. The Resident was readmitted to the facility on [DATE]. Record review revealed the following history of falls: On 8/7/2013; 8/26/13; 10/4/13 (that resulted in a left elbow fracture); and 11/16/13. The witnessed controlled fall on 11/16/13 resulted in a hip fracture that required a total hip replacement. Review of the most recent MDS (Minimum Data Set), an annual assessment, dated 01/16/13, revealed the Resident had short-term memory loss, and mood and behavior problems. The most recent quarterly MDS, completed 9/12/13, revealed the Resident's cognitive skills for decision making were moderately impaired-decisions poor; cues/supervision required. Further review of a quarterly assessment dated [DATE] revealed the Resident was indentified for having 2 falls with no injury and again on 6/25/13, 2 falls with no injury. Resident was identified on the quarterly review, dated 9/12/13, for having had 2 falls with injury. Review of the "All Care Plan" (comprehensive care plan), dated 9/16/13, revealed the following: "Problem, potential for falls, potential for injury, related to cognitive loss/dementia, physical mobility impairment, visual/sensory impairment, fatigue (e.g. wandering), and altered balance/gait. Goal, I will wear my hip protectors (rigid shield of durable plastic that are sewn or inserted into hip protector underwear) daily." Review of the nurses' notes, dated 11/25/13 ("late entry for controlled fall on 11/16/13"), revealed on 11/16/13 at 6:30 pm the Resident "stood up from his wheelchair to try to transfer independently to another chair in the hearth area. The PCN (Primary Care Nurse) wasn't able to support his weight and assisted (Resident #5) to sit on the floor." "The TABs alarm (wheel chair alarm) alerted the PCN that (Resident #5) needed assistance, but she wasn't able to support his weight and had to assist him to the floor." Record review of the Resident Daily Care Plan (RDCP), dated 9/16/13, revealed the resident was to wear "hip protectors" as part of the "protective and adaptive devices." During an interview on 12/10/13 at 12:55 pm, when asked if Resident #5 had been wearing his hip protectors when he fell , Nurse Manager #2 replied, "No". During an interview on 12/12/13 at 1:00 pm, when asked about the fall, Physician #1 confirmed the right hip fracture had been caused by the fall. The Physician further stated the "hip protectors should have been in use; he was not wearing them, they were in the laundry. He needs to start wearing the hip protectors again when he starts moving and they are getting a second pair." Review of the editorial "Hip protectors: Prevent fractures but adherence is a problem" revealed: "...Hip protectors should be used at all times when the person is at risk of falling. For many older people this will mean use both during the day and night, and this requires strong commitment from the user or the person providing care for them ..." (BMJ 2002;324:375-376 (16 February). Smoking Assessments Resident #2 Review of the most recent MDS assessment, a significant change assessment, dated 11/29/13, revealed the assessment coded the Resident as a current tobacco user. Review of the admission paperwork, dated 3/18/13, revealed no documentation of the Resident being a smoker. Random observations from 12/9-12/13 revealed the Resident used oxygen in her room. Review of the Leave of Absence (LOA) binder for Resident #2 for the last 6 months revealed the Resident frequently went out to smoke. During an interview on 12/10/13 at 12:10 pm, Certified Nursing Assistant (CNA) #18 was asked if Resident #2 smoked. The CNA said the Resident went outside off campus to smoke after signing herself out in the LOA binder. CNA further stated the Resident kept her lighter and cigarettes in her room. When asked how the CNA would know if the Resident was independent to smoke, she said it was on her in-room care plan, which she confirmed the CNAs use for resident care. The CNA reviewed the in-room care plan and did not find any documentation that the Resident was independent to smoke or that the Resident was able to keep cigarettes and a lighter in her room with oxygen being used. During an interview on 12/10/13 at 12:30 pm, when asked if Resident #2 had a smoking assessment done. Nurse Manager (NM)#3 replied "No", and confirmed no smoking assessment was done. The NM stated there was nothing in writing regarding the resident's responsibility with smoking. Resident #28 Record review on 12/11/13 for Resident # 28 revealed when the Resident was first admitted to the facility the Resident's Power of Attorney (POA) had signed a patient rights packet on 2/26/13. The patient rights packet had a general statement that the campus was a "Smoke Free Campuses". During an interview on 12/12/13 at 1:00 pm, Licensed Nurse (LN) #27 disclosed the facility did not keep track of residents who smoked and that they were supposed to sign out in the LOA binder when they left the facility. LN #27 was asked if the facility completed a smoking safety assessment on residents when they came to the facility as a smoker. LN #27 said no smoking safety assessment was completed. LN #27 also disclosed Resident #28's care plan did not have any intervention that addressed the fact that the Resident smoked. When the LN was asked where the Resident kept his cigarette lighter and cigarettes the LN said she did not know where the Resident kept them. During an interview on 12/12/13 at 4:25 pm Resident #28 confirmed he did smoke and that he kept his lighter and cigarettes in one of his room table drawers. Review of the Resident's care plan and assessments revealed the facility had not assessed the Resident's ability to smoke safely and independently nor did the care plan include any mention that the Resident smoked. The Resident's record also did not mention if allowing the Resident to carry around his own lighter and cigarettes had been assessed for safety. Review of the most recent policy "Smoking", dated 1/1/13, revealed"...Residents will be assessed for safe tobacco...use and advised of the risks and benefits..." .