Every finding on record at Polaris Transitional Care

.Based on record review and interview, the facility failed to ensure that 1 resident (Resident #11) out of 1 resident reviewed for dialysis care, received treatment and care in accordance with physician orders, the comprehensive person-centered care plan, and professional standards of practice. Specifically, the facility failed to:1. remove a post-dialysis dressing within the ordered timeframe;2. assess and accurately document the condition of the resident's dialysis access site; and3. monitor, evaluate, and communicate complications related to the resident's vascular access.These failed practices had the potential to result in clinically significant complications, including bleeding, infection, or vascular access compromise, and did not meet accepted standards of practice for post-dialysis care Resident #11Record review on 3/25-26/26 revealed Resident #11 was admitted to the facility with diagnoses that included dependence on renal dialysis (medical treatment that performs the function of the kidneys when they are no longer able to adequately filter waste products and excess fluid from the blood), end stage renal disease (ESRD - the final stage of kidney disease in which the kidneys have permanently lost the ability to function adequately to meet the body's needs), and peripheral vascular disease (PVD - impaired blood circulation in the extremities due to narrowed blood vessels).Failure to Remove Post-Dialysis Dressing Within the Ordered TimeframeRecord review of physician orders initiated 1/19/26 revealed, POST DIALYSIS: SHUNT CHECK BLEEDING - REMOVE PRESSURE DRESSING AFTER 3 HOURS. OBSERVE AND MAINTAIN NO PRESSURE ON RUE FISTULA OR DIALYSIS CATHETER.Review of the Medication Administration Record (MAR), dated 1/1-31/26, revealed the following order: .POST DIALYSIS: SHUNT CHECK BLEEDING - REMOVE PRESSURE DRESSING AFTER 3 HOURS -Order Date- 01/19/2026. Further review of the MAR did not indicate that the removal of the dressing. Review of nursing progress notes from 1/27-29/26 revealed no documentation to support that a dressing change was performed to Resident #11's arteriovenous (AV) fistula access site.During an interview on 3/25/26, dialysis staff reported that post-dialysis dressings should be removed within an appropriate timeframe and that delayed removal may increase the risk of complications.Review of the facility provided document Dialysis Communication, dated 1/29/26, revealed, .Communication FROM Dialysis Center for Polaris. [Resident #11's] fistula dressing must be removed [after] 4-6 hrs [hours] after HD [hemodialysis] to prevent clotting/narrowing of AV [arteriovenous] graft.Failure to Assess and Accurately Document the Condition of the Resident's Dialysis Access SiteReview of Resident #11's care plan, initiated on 1/21/26, revealed: .Will have no s/sx [signs and symptoms] of complications from dialysis. Check and change dressing daily at access site. Document. Monitor/document/report to MD PRN [Medical Doctor - as needed] for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock.Review of the TAR, dated 1/1-31/26, revealed an order: .ASSESS FISTULA SITE AND DOCUMENT: C=CLEAR, T=TENDERNESS, R=REDNESS, B=BLEEDING every shift - Order Date- 01/19/2026.During an interview on 3/26/26 at 11:00 AM, LN #3 reported that he/she provided post-dialysis care to Resident #11. LN #3 stated that upon the resident's return from dialysis on 1/27/26, the access site was bleeding, and a dressing change was performed. Review of LN #3's TAR documentation revealed that the assessment was charted as, clear.Review of nursing progress notes from 1/27-29/26 revealed no documentation to support that a dressing change was performed to Resident #11's arteriovenous (AV) fistula access site as indicated by LN #3.Review of the facility policy Dialysis (Renal), Pre- and Post-Care, last revised 3/2025, revealed: .It is the policy of this facility to. Assess and maintain. renal dialysis access. Further review revealed: .Post-Dialysis Care. Dialysis access should be assessed upon return to the facility for patency, any unusual redness, swelling, or bleeding. Post dialysis AV shunt access care as ordered. Any problems with a resident's access should be addressed immediately. Excessive bleeding from graft site, redness, swelling, pain, or a non-functioning graft requires medical attention. Documentation related to pre- and post-dialysis care will be placed in the clinical record and include. Resident assessments, interventions.Failure to Monitor, Evaluate, and Communicate Complications Related to the Resident's Vascular AccessReview of the facility policy Renal Dialysis, Care of Resident, Hemodialysis Access Site, Diet/Fluid Restrictions, Care Plan, last revised 11/2019, revealed requirements to monitor for signs of complications and call the physician immediately for bleeding.During an interview on 3/26/26 at 12:45 PM, the Administrator explained that the facility followed standard processes supported by training and order sets. She stated that staff received, in-services that we do.annually with the staff.Record review from 3/25-26/26 of Resident #11's medical record did not reveal any notifications to Resident #11's physician about the post-dialysis bleeding AV fistula on 1/29/26.Review of Centers for Disease Control and Prevention (CDC) dialysis safety guidelines on the Best Practices . in Dialysis Settings online page (www.cdc.gov/dialysis-safety/hcp/clinical-safety/index.html) shows that facilities are expected to assess staff adherence to aseptic technique . during dressing changes and to conduct ongoing observations of vascular access care and catheter accessing, Standards of care require reassessment of the access site after removal for bleeding, redness, or swelling, with accurate documentation and timely communication of findings.

. Based on observation, interview, and record review, the facility failed to ensure food was stored under proper sanitary conditions in the North Dining Room resident/family refrigerators. This failed practice placed all residents who were able to consume food by mouth (based on a census of 39) at risk for foodborne illness An observation on 11/18/25 at 1:00 PM, of the resident/family refrigerator revealed: - an unlabeled large yellow-lidded plastic food container holding a thick white liquid that had condensation/frost buildup. The container did not contain a date of preparation, resident identifier, or a discard date. The food container was stored directly on top of an unlabeled and undated clamshell container of grapes.An observation on 11/18/25 at 1:10 PM of the resident/family mini-refrigerator, revealed: - an undated and unlabeled white Styrofoam takeout container containing leftover food (rice with visible yellow residue/sauce). The container had no resident name, no date of preparation, and no discard date. The container lid was partially open, exposing the food to the refrigerator environment. - an unlabeled and undated plastic soup-type container containing a thick yellowish liquid or food product. The container showed no indication of the date it was placed in the refrigerator or when it should be discarded.During an interview on 11/19/25 at 10:00 AM, the Food Service Supervisor (FSS) stated every container in the resident/family refrigerators should have been labeled with a patient identifier, received date, and open date. The FSS also confirmed that the food items that were found presented a risk for contamination.Review of the facility provided policy Food and Nutrition Services, last reviewed on 3/2025, revealed: .food(s) brought to a resident by family/visitors must be. stored and served in accordance with food safety professional standards. All foods shall be labeled with the resident name, location and date.Review of an FDA article titled Food Code Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, accessed at: https://www.fda.gov/media/127796/download#:~:text=Section%203%2D501.17%20specifies%20ready,C%20(41%C2%B0F)%20or revealed: .Section 3-501.17 specifies ready-to-eat, time/temperature control for safety (TCS). and held longer than a 24 hour period shall be marked to indicate the date or day by which the food is to be consumed on the premises. or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. These time/temperature parameters are intended to help control for growth of Listeria monocytogenes.

.Based on record review, interview and observation, the facility failed to ensure care and services were provided in accordance with professional standards of practice and the comprehensive person-centered care plans for 3 residents (#12, #18, and #68) out of 43 residents (total census). Specifically, the facility failed to follow standards, care plan interventions, and physician's order directing staff not to obtain blood pressure measurements in the residents' compromised arms. This deficient practice resulted in the potential for compromised circulation, pain, and lymphedema Resident #12Record review from 11/17-21/25 revealed Resident #12 was admitted to the facility with diagnoses that included fracture of the right acetabulum (a break in the socket of the right hip joint where the head of the femur sits) and dependence on renal dialysis (medical treatment that filters waste, toxins, and excess fluid from the blood when the kidneys can no longer perform these functions effectively).Review of the physician's orders dated 10/14/25, revealed: AV SHUNT [surgical vascular access] OLD SITE: right upper arm- MONITOR FOR REDNESS, BLEEDING, SKIN BREAKDOWN, EDEMA every shift. [ORDER DATE] 10/14/2025.Further review of the orders revealed: NO NEEDLE STICKS, B/P [blood pressure], NO TIGHT CLOTHING OR JEWELRIES ON right arm old SHUNT. Can only take BP to left lower leg. Can do blood draw to left upper arm (s/p mastectomy [surgical removal of breast tissue]) every shift.[Order Date] 10/14/2025.Review of Resident 12's care plan, initiated on 10/14/25, revealed: NO BP to the right/left upper, take BP to left lower left only and blood draw only to left UE [upper extremity].Review of Resident #12's Blood Pressure Summary revealed blood pressures entries documented on the left arm on 10/19/25, 10/25/25, 10/26/25, 10/30/25, 11/4/25, 11/12/25, and 11/16/25. Further review revealed blood pressure entries documented on the right arm, where Resident #12 has his/her old AV fistula (surgically created connection between an artery and a vein that provides reliable access for dialysis) site on 10/17/25, 10/22/25, 10/24/25, 10/30/25, and 11/8/25.During an interview on 11/20/25 at 1:54 PM, Resident #12 stated sometimes his/her blood pressure was read falsely low when measured on the leg, so he/she had told staff to measure the blood pressure on his/her left wrist.An observation on 11/20/25 at 1:54 PM revealed a sign above Resident #12's head of bed that read: CAN ONLY DO BP TAKING TO LEFT LOWER. Only use left UE for Blood draw.Resident #18Record review on 11/17-21/25 revealed Resident #18 was admitted to the facility with diagnoses that included pulmonary fibrosis (lung-scarring disease), end-stage renal disease (kidneys permanently failed - dialyses required), dependence on renal dialysis, immunodeficiency associated with other specified major defects (severe immune deficiency), muscle weakness, difficulty walking and need for assistance with personal care.Review of the physician's orders last reviewed 10/30/25, revealed: .SHUNT/DIALYSIS SITE: Left AVF [arteriovenous fistula].Review of Resident #18's Kardex (used by Certified Nurse Assistants (CNAs)for a quick access to resident's care plan), revealed: . Do not draw blood or take B/P in left arm with graft.An observation on 11/18/25 at 2:07 PM of Resident 18's room revealed a sign attached to a wooden door that read: NO BP. NO BLOOD DRAWS TO LEFT UPPER ARM.Review of Resident #18's Blood Pressure Summary from 10/28/25-11/18/25, revealed one entry where staff documented a blood pressure reading obtained in the left arm on 11/17/25.Resident #68Record review on 11/17-21/25 revealed Resident #68 was admitted to the facility with diagnoses that included heart failure (a chronic condition in which the heart cannot pump blood effectively), insomnia, and pain.Review of the physician orders dated 9/27/25, revealed: NO BP'S, LABS, IV's (intravenous access) ON RUE (right upper extremity) - h/o (history of) RIGHT MASTECTOMY.An observation on 11/17/25 of Resident 68's room, revealed a sign posted at the head of the bed that read: NO BP. NO IV. NO LABS. ON THE RIGHT ARM.Review of Resident #68's Blood Pressure Summary from 9/26/25-11/14/25, revealed five separate entries where staff documented blood pressure readings obtained in the right arm on 10/3/25, 10/5/25, 10/17/25 (3:37 AM), 10/17/25 (8:50 AM) and 11/13/25.During interview on 11/21/25 at 8:50 AM, when asked how blood pressure readings should be assessed on Resident #68, Licensed Nurse (LN) #2 stated: Place the cuff on his/her arm and take the BP. you can use either arm, he/she doesn't have any restrictions.Review of the facility-provided standard used in resident care Lippincott Nursing Procedures Ninth Edition book, dated 2023, revealed: .Don't measure blood pressure in an extremity that's affected by. mastectomy. because doing so can compromise lymphatic circulation and worsen edema. Likewise, don't take a blood pressure measurement on the same arm as an arteriovenous fistula or hemodialysis shunt, because blood flow through the vascular device might become compromised.

.Based on record review and interview, the facility failed to obtain informed consent prior to the initiation and use of psychotropic medications for 1 resident (#47) out of 12 sampled residents. Specifically, the facility administered multiple psychotropic medications without documented informed consent from the resident or the resident representative. This failure denied the resident and/or resident representative the right to be informed of the risks, benefits, and alternatives of psychotropic medications and the right to participate in care planning and decision-making. Past Noncompliance: During a recertification, licensure and complaint survey conducted on 11/21/25 past noncompliance was identified at F552. The last standard recertification survey was conducted on 11/1/24. The state agency verified that the facility took appropriate corrective actions for noncompliance found at F552 with a correction date of 8/20/25 Record review on 11/17-21/25 revealed Resident #47 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (injury to the brain caused by a complete lack of oxygen, leading to the death of brain cells and potentially severe, long-lasting neurological impairments), bipolar disorder (mental health condition characterized by alternating periods of elevated and depressed mood, affecting energy, behavior, and daily functioning), and hemiplegia and hemiparesis following a cerebral infarction (weakness or inability to use one side of the body) affecting the left non-dominant side.Review of the current physician orders revealed the following:1. QUEtiapine Fumarate Oral Tablet 150 MG [milligram] (Quetiapine Fumarate) Give 1 tablet by mouth in the evening for TBI [traumatic brain injury], agitation, combativeness, yelling, aggression. [Start Date 8/20/25] [Quetiapine is an antipsychotic medication used to treat conditions such as schizophrenia, bipolar disorder, and depression by helping balance certain neurotransmitters in the brain.]2. LORazepam Oral Tablet 2 MG (Lorazepam) Give 2 mg by mouth three times a day for TBI, cognitive impairment with aggression, combativeness. [Start Date 8/20/25] [Lorazepam is a benzodiazepine medication used to reduce anxiety, treat seizures, and provide sedation by calming activity in the brain and nervous system].3. hydrOXYzine HCl [hydrochloride] Oral Tablet (Hydroxyzine HCl) Give 25 mg by mouth three times a day for anxiety. [Start Date 7/28/25] [Hydroxyzine is an antihistamine medication used to treat anxiety, allergies, nausea, and insomnia by reducing activity in the central nervous system and blocking histamine].Review of the facility's psychotropic consent form Psychotherapeutic Medications Facility Verification of Resident Informed Care, dated 8/1/25 revealed: .I have obtained informed consent from the resident/surrogate decision-maker for the use of: Hydroxyzine 25 mg PO [by mouth] 3x daily for anxiety.Lorazepam 2 mg PO BID [twice a day] for anxiety Lorazepam 1 mg PO [every] 4 as needed for anxiety. [signed by Resident Representative (RR)].Review of the facility's psychotropic consent form Psychotherapeutic Medications Facility Verification of Resident Informed Care, dated 8/20/25 revealed . I have obtained informed consent from the resident/surrogate decision-maker for the use of: Lorazepam 2 mg PO TID [three times a day] for anxiety Quetiapine 150 mg daily in the evening. [VERBAL CONSENT VIA PHONE].Psychotropic consents prior to 8/2025 were requested by the surveyor on 11/19/25. Review of the facility provided documents revealed: Consents for lorazepam 0.5 mg PRN [as needed] signed on 1/29/25 and 2/12/25. There were no informed consents for quetiapine, hydroxyzine, or olanzapine, despite these medications being administered prior to 8/2025.Review of Resident #47 's medication administration record (MAR) from 3/2025-8/2025 revealed the following psychotropics were administered without resident or the resident representative's consent: 1. hydrOXYzine HCl Oral Tablet 25MG (Hydroxyzine HCl) Give 1 tablet by mouth every 6 hours as needed for Anxiety -Order Date-03/06/2025 1551 -D/C [discontinued date] Date-07/28/2025 1254. The resident received a total of 122 doses from 3/12/25-7/28/25.2. QUEtiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for traumatic brain injury with behavioral disturbance attempted wean-Order Date-04/23/2025 0959-D/C Date-08/20/2025 1010. The resident received a total of 223 doses from 4/23/25 to 8/20/25.3. ZyPREXA Oral Tablet 5 MG (Olanzapine) Give 1 tablet by mouth every 12 hours as needed for agitations, [aggression][MT2] , combativeness -Order Date- 04/25/2025 1710 -D/C Date- 05/02/2025 1145. The resident received a total of 8 doses from 4/25/25-5/1/25.4. OLANZapine Oral Tablet 5 MG(Olanzapine) Give 5 mg by mouth every 8 hours as needed for agitation/aggression-Order Date-05/02/2025 1118-D/C Date-05/07/2025 1620. The resident received a total of 10 doses from 5/2-7/25.5. ZyPREXA Oral Tablet 5 MG(Olanzapine) Give 5 mg by mouth every 8 hours for TBI with aggression/agitation-Order Date-05/07/2025 1623-D/C Date-05/17/2025 0933. The resident received a total of 27 doses from 5/1-16/25.6. ZyPREXA Oral Tablet 5 MG (Olanzapine) Give 1 tablet by mouth three times a day for [aggression], agitation, combativeness, TBI, Korsakoff syndrome [chronic memory disorder, usually caused by severe thiamine (vitamin B1) deficiency often related to long-term alcohol misuse] -Order Date- 05/17/2025 0933 -D/C Date-06/23/2025 2021. The resident received a total of 111 doses from 5/17/25 to 6/23/25.Review of the LN [Licensed Nurse] Psychoactive Medication Evaluation, dated 3/27/25 at 2:25 PM revealed Enter the name and dose of the psychoactive medication(s) used within the last 7 days. LORazepam, traZODone HCL, Hydroxyzine HCl .V. Informed Consent Obtained a. 0. Yes.Review of the LN Psychoactive Medication Evaluation, dated 8/4/25 at 8:52 AM revealed Enter the name and dose of the psychoactive medication(s) used within the last 7 days. quetiapine 50 mg BID [Twice daily] Olanzapine 5 mg TID [3 times a day].V. Informed Consent Obtained a. 0. Yes.Review of the LN Psychoactive Medication Evaluation dated 5/5/25 at 4:30 PM revealed Enter the name and dose of the psychoactive medication(s) used within the last 7 days. LORazepam Tablet 0.5 MG *Controlled Drug* BID, LORazepam Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug*Give 2 tablet by mouth every 6 hours as needed for aggression, combativeness traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 50 mg TID QUEtiapine Fumarate Oral Tablet 50 MG Give 1 tablet BID OLANZapine Oral Tablet 5 MG Give 5 mg by mouth every 8 hours PRN.V. Informed Consent Obtained a. 9. Unable to Determine.During an interview on 11/21/25 at 11:30 AM, the Administrator stated that the psychotropic consents for lorazepam were the only consents on file prior to 8/2025.Review of facility policy Psychotropic Medication Management, dated 3/2025, revealed: 8. Upon initial comprehensive assessment, the SSD [social services director] designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physician's orders for psychotropic medications. The facility's Interdisciplinary Team (IDT) will review to ensure. Informed consent was obtained prior to medication use. 9. Upon change of condition or initiation of a new order for psychoactive medications, the facility will obtain consent prior to the initiation of the new medication or if the dosage of an existing psychoactive medication increases.Corrective ActionsThe facility has since corrected this noncompliance as of 8/20/25, implementing the following:On 8/1/25, the facility obtained psychotropic consent for Hydroxyzine 25 mg, Lorazepam 2 mg and Lorazepam 1 mg from the RR.On 8/20/25, the facility obtained psychotropic consent for Lorazepam 2 mg and Quetiapine 150 mg from the RR

.Based on record review, interview, and observation, the facility failed to ensure 1 resident (#18), out of 12 sampled residents, was given the opportunity to make choices about aspects of his/her life that were significant to him/her. Specifically, the facility failed to ensure the resident had the opportunity to receive a shower and/or a bath according to his/her preferences. This failed practice had the potential to affect the resident's quality of life and sense of well-being Resident #18Record review on 11/17-21/25 revealed Resident #18 was admitted to the facility with diagnoses that included pulmonary fibrosis (lung-scarring disease), end-stage renal disease (kidneys permanently failed - dialyses required), dependence on renal dialysis (Kidney failure requiring dialysis), immunodeficiency associated with other specified major defects (severe immune deficiency), muscle weakness, difficulty walking and need for assistance with personal care.During an interview on 11/18/25 at 9:26 AM, Resident #18 stated he/she would like to take a shower on Tuesdays or Wednesdays and/or weekends. The resident further stated that sometimes he/she asked for it but was told no by staff, who told Resident #18 that was not on his/her schedule. Resident #18 added: because of the dialysis days I am supposed to be resting the days staff wants me shower.Minimum Data SetReview of Resident #18's Minimum Data Set (MDS - a federally required assessment), dated 10/30/25, revealed Resident #18 needed assistance with bathing, dressing. Resident needed partial assistance from another person to complete any activities. E. Shower/bathe self. substantial/maximal assistance. Further review of this document under Section F - Preferences for Routine and Activities, dated 11/4/25, when asked How important is to you to choose between a tub bath, shower, bed bath, or sponge bath? Resident #18 answered Very important.During an interview on 11/19/25 at 11:30 AM, the MDS Nurse stated that resident preferences for showers or baths were documented in Section F of the MDS. She further explained that the activities department should have obtained these preferences at the time of the resident's admission. She also stated that these preferences should have been included in the care plan; however, for Resident #18, this information was not documented.Care Plan and Kardex (Resident Daily Care Plan)Review of Resident #18's IDT Care Plan Review - V 2, dated 10/30/25, revealed: .Dialysis M (Monday), W (Wednesday), F (Friday) .[he/she] has dialysis 3 times a week, prefers to rest when [he/she] comes back to facility.Further review of the care plan revealed Resident # 18's shower preference or schedule were not included.Review of the Kardex, dated 11/19/25 revealed Resident # 18's shower preference or schedule were not included.During an interview on 11/19/25 at 11:40 AM, Certified Nursing Assistant (CNA) #1 stated that the facility maintained a daily assignment schedule for resident showers, with each resident typically receiving two scheduled showers per week. CNA #1 explained that Resident #18, was assigned nighttime showers. When asked whether residents may independently choose their own shower times, CNA #1 clarified that the facility followed a set schedule for all residents.During an interview on 11/19/25 at 12:00 PM, CNA #2 stated that some residents refused their scheduled showers, and when refusals occur, CNAs documented them directly in the electronic record. CNA #2 further stated: residents cannot choose to shower on days outside their assigned schedule, as staffing levels and workload make it difficult to accommodate unscheduled showers. While this CNA tried to provide showers, when possible, he/she emphasized that it cannot be promised on a resident's preferred day, and the facility generally adhered strictly to the pre-established shower schedule.During an interview on 11/19/25 at 11:11 AM, the Director of Nursing (DON) stated that she had direct oversight of CNAs, managed their schedule, and coordinated competencies and staff education. DON also stated activity preferences were gathered by the activity staff, while shower preferences were expected to be obtained by the admitting nurse and added to the appropriate shift's shower schedule and care plan, with updates made if a resident requested changes. In reviewing the case of Resident #18, the DON stated that no documented shower preference could be found in the admission assessment, care plan, Kardex (staff reference sheet), or shower schedules.During the same interview, the DON further stated that she had not previously been informed of the resident's preference to avoid showers on dialysis days and agreed that this pattern should have prompted an adjustment to schedule showers on non-dialysis days to meet the facility's twice-weekly shower expectation.Review of the Treatment Administration Record (TAR) with the DON, on 11/19/25 at 11:11 AM, revealed Resident #18 had two showers marked, with multiple refusals recorded but without reasons consistently documented or supported by nurse progress notes.Review of Resident #18's Documentation Survey Report v2 [version] . Intervention/Task .Bathing ., revealed: period from 10/28/25 to 11/18/25, Resident #18 received a shower twice on 11/2/25 (Sunday) and 11/16/25 (Sunday). For the same period, Resident had 3 documented refusals respectively on 11/7/25 (Friday - dialysis day), 11/10/25 (Monday - dialysis day) and 11/14/25 (Friday - dialysis day).Random observations conducted from 11/17-21/25 of Resident #18's room revealed no signage of the resident's shower preference.Review of the facility's policy Routine Procedures - Residents' Bath, Shower, dated 2/2022, revealed: . It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relaxation. Residents will be assisted to have a shower or full bath at least 2x/week or resident preference.Review of the facility's policy PTC/PEC [Polaris Transitional Care/ Polaris Extended Care] STANDARDS OF CARE, updated 3/1/25, revealed: . AM CARE (EVERY MORNING)/ H.S. [bedtime] CARE (EVERY HS AT BEDTIME): Hands and face washed, Toileted & Peri Care. Maintain dignity. Oral Care. PERIODIC CARE: Shower/Bath as scheduled. Provide a complete bed bath and report to PCN [unknown] (.) . ONGOING CARE: . Provide peri care after voids .APPROACHES .listen to resident. Affirm self-worth and dignity. Avoid controlling, negative words such as No, Don't, You can't. Promote resident choice and right to express concerns .

.Based on record review and interview, the facility failed to ensure a resident's advance directive (AD) was obtained and maintained in the medical record and was readily accessible to staff for 1 resident (#47) of 12 sampled residents. Specifically, the facility did not obtain, verify, or properly file the resident's advance directive upon admission, resulting in staff being unaware of the resident's documented treatment preferences. This failure placed the resident at risk for receiving care or interventions inconsistent with the resident's expressed wishes and compromised the resident's right to request, refuse, and/or discontinue treatment Record review on 11/17-21/25 revealed Resident #47 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (injury to the brain caused by a complete lack of oxygen, leading to the death of brain cells and potentially severe, long-lasting neurological impairments), bipolar disorder (mental health condition characterized by alternating periods of elevated and depressed mood, affecting energy, behavior, and daily functioning), hemiplegia and hemiparesis following a cerebral infarction (weakness or inability to use one side of the body) affecting the left non-dominant side.Review of the Quarterly MDS (Minimum Data Set- a federally required assessment used in long-term care facilities to collect information about a resident's health, functional status, and care needs to support care planning), dated 11/10/25, revealed Resident #47 was not screened with the Brief Interview for Mental Status due to rarely or never understanding. Further review revealed a staff-assessed cognitive score of 3-severely impaired-indicating the resident never or rarely made decisions regarding tasks of daily life.Review of the electronic health record (EHR) on 11/18/25 at 10:01AM revealed Resident #47's code status was documented as DNR [Do Not Resuscitate]/ Do Not Attempt Resuscitation.Review of Resident #47's EHR on 11/18/25 at 10:03 AM, under Misc (Miscellaneous) section, revealed no advance directive was present.Review of the Contacts section revealed Resident #47 was listed as the Care Conference Person Legal Representative Resident/Self. Further review identified Resident Representative (RR) #1 listed as an emergency contact and resident representative.Review of Resident #47's AD provided by the facility revealed the facility did not have Resident #47's AD until after the surveyor requested a copy on 11/19/25.Review of the admission Notes revealed the following:1. [11/19/25 at 2:11 PM] Called ANMC [Alaska Native Medical Center] and spoke with CM [case manager] . regarding patient records at ANMC. Per [CM] there is no Advance Directive or POLST [Physician Orders for Life-Sustaining Treatment] on file at ANMC for [Resident #47].2. [11/19/25 at 2:22 PM] Spoke with. case manager at Alaska Regional Hospital, regarding records during recent hospitalization for [Resident #47] in January. They do have an Advance Directive on file for [him/her] and will fax to Polaris today for continuity of care.3. [11/19/2025 at 2:42 PM] Called [Resident #47's RR] and POA [Power of Attorney] .to arrange a time to sign admission [agreement], consent forms and Advance Directive Acknowledgement. Left a voice message for a return phone call.Review of the Advance Health Care Directive, faxed to the facility on [DATE] revealed the listed Health Care Agent did not match the name of RR #1. Further review revealed the document did not contain a signature, date, witness signature, or notary signature.During an interview on 11/19/25 at 4:15 PM, the Administrator stated the facility received Resident #47's advance directive via fax from Alaska Regional Hospital that day, and the facility did not have a copy of the advance directive prior to 11/19/25.During an interview on 11/21/25 at 9:24 AM, the Assistant Administrator (AA) stated the facility provided written information about advance directives upon admission and would document receipt of this information in the admission agreement. The AA further stated that the facility could not access the resident's original admission agreement.Review of the facility's policy Advance Directives and Associated Documentation, dated 3/2025 revealed: It is the policy of this facility that a residents' choice about advance directives will be recognized and respected. Further it is policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.It is policy of this facility to implement the resident decisions and directives that are in compliant [compliance] with State and/or Federal Law and the policies of this facility.Definitions:.Advance directive: A written instruction that related to the provision of health care when the individual is incapacitated, such as a Living Will, Durable Power of Attorney for Health Care or the Natural Death Act. These documents allow the individual to identify choices related to their medical treatment or designate someone to make treatment choices for them should they lose decision making capacity for themselves.Procedure: 1. Prior to, or immediately after admission, a facility staff member shall: a. Provide the resident/family or responsible agent written information, in a manner easily understood by the resident or resident representative, regarding the right to accept to refuse to formulate Advance Directives. 4. If the resident is incapacitated and not capable of independent decision-making at the time of admission: a. Inform the surrogate decision maker to document their desire to initiate an advance directive and their knowledge that this decision is in the resident's best interest or is to comply with resident's known desires, when this need arises. b. If the surrogate decision-maker is a family member, not identified on an Advanced Directive document, all members of the immediate family with equal relationship to the resident will need to agree and sign the document. i. In the event opinions differ among family members, the Advance Directives will not be implemented until a resolution is achieved.6. Obtain copy of the Advance Directive and conservatorship/guardianship documents and place in the resident health record.

.Based on record review and interview, the facility failed to report to the State Survey Agency (SSA) and Adult Protective Services (APS) an allegation of resident neglect no later than 24 hours after the allegation was made as required by 42 Code of Federal Regulation (CFR) S483.12(c)(1), for 1 resident (#69), out of 3 unsampled residents reviewed for compliance with reporting requirements. This failed practice placed Resident #69 at risk for ongoing neglect, unaddressed care concerns, and further exposure to mistreatment and/or mental anguish Record review on 11/17-21/25, revealed Resident #69 was admitted to the facility with diagnoses that included unspecified abnormalities of gait and mobility (gait and mobility impairment), wedge compression fracture of lumbar vertebra (vertebral collapse fracture), COPD (chronic obstructive pulmonary disease) and osteoporosis (bone-thinning disease). Resident #69 was also legally blind and had documented past medical history of frequent falls.Record review of the facility's Resident Concern & Feedback [Grievance] Form, dated 6/15/25, revealed an email from Resident #69's Representative, dated the same day, describing multiple incidents he/she believed constituted neglect.Further review of the grievance revealed the Representative reported that Resident #69 received high doses of narcotic pain medication during the early weeks of admission, despite documented cautions from two prior facilities regarding the resident's history of opioid-induced delirium. The Representative stated this resulted in significant delirium and confusion, which prevented Resident #69 from participating meaningfully in therapy. According to the grievance, skilled-nursing coverage was denied on 4/23/25 due to lack of progress, after which the resident became a private-pay resident.The Representative's communication further alleged multiple care concerns since the denial of coverage, including:- Repeated preventable falls, including one in early June 2025 after a recent kyphoplasty (surgical procedure with balloon-assisted vertebral cement augmentation). He/she stated that the fall occurred when call-light requests for toileting assistance were not addressed, resulting in a new acute L4 compression fracture.- Failure to notify family of the falls and of the newly sustained fracture.- Failure to provide an escort or pre-medication for diagnostic imaging appointments despite residents' pain and blindness.- Neglect of meal assistance, with meals reportedly being placed at the bedside without description, un-covering, or feeding assistance for a legally blind resident.- Pain-medication delays routinely exceeding one hour.- Repeated loss of personal laundry.- Refusal to release medical records to a receiving facility in anticipation of the resident's transfer.- Exposure to an aggressive co-resident who allegedly broke windows and yelled into other residents' rooms, creating an unsafe environment.- Minimal or absent communication from physicians, nurse practitioners, and nursing staff regarding the resident's condition, treatment, or care needs.The Representative stated he/she believed the environment was unsafe and neglectful, urging for an immediate transfer for Resident #69.Review of Resident #69's medical record from 11/17-21/25 revealed no documentation was found showing the facility reported these allegations of neglect to the SSA or APS, as required.During an interview on 11/21/25 at 11:00 AM, Quality Director (QD) stated that when she assumed her role, she reviewed all existing grievances and was surprised by several findings. She implemented staff re-education and began addressing systemic issues, recognizing that follow-up on grievances had not been handled appropriately prior to her arrival. QD explained that although previous staff had submitted a report of the resident's fall, the Resident Representative's four-page complaint had not been included in any documentation or in the final report, which suggested a communication breakdown within social services at that time.QD further stated regarding APS reporting, that she did not know whether the case had been reported at the time because no formal APS reporting system existed then; she later identified this as a deficiency and implemented a system for social services compliance, revised grievance forms, provided staff education, and reset expectations for grievance handling. She continued stating that prior to her arrival, grievances were not consistently captured, and that QD now reviews and signs every grievance, with final sign-off occurring only after resolution with the resident or family. She concluded: I would have erred on the side of caution and reported the allegation as possible neglect.Review of the facility's policy Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, last revised 3/2025, revealed: 1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: a. 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 involves abuse or results in serious bodily injury- Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury.2. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to:a. The Administrator of the Facility; b. The State Survey Agency; c. Adult Protective Services (as appropriate) .3. Ensure that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s). 4. Ensure that the results of all investigations are reported within five (5) working days of the incident to: a. The Administrator and b. The State Survey Agency 5. Ensure that, if the alleged violation is verified, appropriate corrective action is taken. 6. Guidelines for Facility Compliance: In order to comply with the Facility's obligations as set forth in 42 CFR 483.12, it will: a. Make all staff aware of the applicable reporting requirements upon hire and annually. b. Educate all staff on the definitions of abuse, neglect, mistreatment, exploitation, and misappropriation of resident property .Review of the facility's Policy/Procedure Grievances, last revised 11/23/21, revealed: 5. The Grievance Official will immediately report all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property to the Administrator; and as required by State law.

. Based on record review and interview, the facility failed to ensure the drug regimen for one resident (#41), out of 12 sampled residents, was free from unnecessary medication. Specifically, the facility failed to prevent duplicate drug therapy by continuing a maintenance dose concurrently with a high-dose of prednisone (corticosteroid medication used to reduce inflammation and suppress the immune system) without a documented clinical rationale confirming the benefits of maintaining both doses of the medication. This failed practice placed Resident #41 at risk for potential adverse effects from unnecessary medication administration related to excessive corticosteroid exposure. Record review on 11/17-21/25, revealed Resident #41 was admitted to the facility with diagnoses that included aftercare following joint replacement surgery and dislocation of the internal right hip prosthesis (artificial components of a right hip replacement move out of their normal position, causing loss of joint alignment, pain, and impaired mobility) and chronic obstructive pulmonary disease (COPD- a long-term lung condition that causes airflow blockage and breathing difficulties).Review of the physician progress notes, dated 10/17/25, revealed: [Resident #41] has been coughing since [he/she] got here with shortness of breath has had COPD exacerbations [sudden worsening of COPD symptoms-such as increased shortness of breath, coughing, and mucus production-often triggered by infection or environmental irritants] in the past [plus] sputum production . COPD: steroid burst [short course of high-dose corticosteroids such as prednisone used to quickly reduce inflammation during acute flare-ups of COPD] and taper.Review of Resident #41's Consultant Pharmacist's Medication Regimen Review [MRR] October 2025 revealed Resident [#41] has two orders for prednisone for COPD; one order is a 5 mg tablet dose once daily for COPD and the second order is for a 15-day taper using the 20 mg tablet. Please confirm if the once daily 5 mg tablet dose is to start after the conclusion of the taper (and is so annotate it as such) or if that order needs to be discontinued. Further review revealed a handwritten note signed by the ordering physician reading: Correct 5 mg is maintenance, kept so wouldn't get lost #1 Burst + Taper prednisone #2 Taper extended d/t [due to] severe COPD. [signature of MD] 11/5/25. Review of Resident #41's medication administration record (MAR) of October 2025 and November 2025 revealed the following:1. predniSONE Oral Tablet 5 MG (Prednisone) Give 1 tablet by mouth in the morning for copd. [Order Date] 10/08/2025. Administered since 10/9/25.2. predniSONE Oral Tablet 20 MG (Prednisone) Give 3 tablet by mouth one time only for COPD exacerbation for 1 Day [Order Date] 10/17/2025. Administered on 10/17/25.3. predniSONE Oral Tablet 20MG (Prednisone) Give 3 tablet by mouth in the morning for copd exacerbation for 2 Days. [Order Date] 10/17/2025. Administered on 10/18/25 and 10/19/25.4. predniSONE Oral Tablet 20 MG (Prednisone) Give 2 tablet by mouth in themorning for copd exacerbation for 3 Days [Order Date] 10/17/2025. Administered 10/20-22/25.5. predniSONE Oral Tablet 20 MG (Prednisone) Give 2 tablet by mouth one time [NAME] for copd exacerbation for 5 Days [Order Date] 10/22/2025. Administered 10/23-27/25.6. predniSONE Oral Tablet 20 MG (Prednisone) Give 1 tablet by mouth one time a day for copd exacerbation for 5 Days [Order Date] 10/22/2025. Administered 10/28/25-11/1/25.7. predniSONE Oral Tablet 20 MG (Prednisone) Give 0.5 tablet by mouth one time a day for copd exacerbation for 5 Days [Order Date] 10/22/2025. Administered 11/2-6/25.Further review of the MAR revealed between 10/18/25-11/6/25, a total of 19 days, Resident #41 received between 15 mg to 65 mg of prednisone daily, reflecting the addition of the 5 mg maintenance dose to the steroid burst and taper.During an interview on 11/19/25 at 7:10 AM with Pharmacist #1, he/she stated part of his/her duties at the facility was to conduct monthly medication regimen review for the entire facility. He/she further stated, he/she emailed the facility and documented in the facility's EHR (electronic health record) a recommendation to clarify the prednisone 5 mg dose after the prednisone burst and taper course. He/she stated when a physician prescribed a steroid burst and taper of prednisone, the maintenance dose of prednisone if prescribed, is typically discontinued during the duration of that burst and taper. Pharmacist #1 stated he/she did not verify the orders of prednisone when orders were entered by the physician but that the EHR alert system would have flagged for duplicate medication. Pharmacist #1 stated he/she would have double checked with the prescriber whether the maintenance dose of prednisone should be continued or not. Pharmacist #1 stated when medication orders were entered by the physician, the physician would be able to modify the medication administration start time if they wished, for example enter an order for Resident #41's maintenance dose of prednisone 5 mg with a future start time in one or two weeks.During an interview on 11/19/25 at 10:15 AM, the Administrator stated she would receive an email from Pharmacist #1 of all the monthly medication reviews then a printed copy of the recommendation would be handed to the physician. The physician would review the recommendations and acknowledged the pharmacist 's recommendation by affixing his signature.During an interview on 11/19/25 at 10:34 AM, when asked what the clinical rationale for maintaining maintenance dose and burst and taper dose, the Medical Director (MD) stated that he left the maintenance dose of prednisone 5mg on the MAR because he didn't want the maintenance dose to get lost as it has happened in the past. MD further stated he discussed keeping the maintenance dose with Resident #41 in which the resident consented. MD stated he may or may not have gotten a notification from the verifying pharmacist when entering orders for the prednisone burst and taper regarding whether to continue the maintenance dose.Record review of the facility's Pharmacy Service Agreement Review, undated, revealed (a) On a monthly basis, during the previously scheduled visit to the Customer, a Consultant Pharmacist shall perform a medication regimen review (MRR) for each Resident on active Customer census on the visit date (b) Within 48 hours after conducting the MRR, the Pharmacy or Consultant Pharmacist shall provide the MRR report to Client's Administrator/Executive Director and Director of Nursing. When irregularities are noted, the MRR report documenting such irregularities will be provided to Client's Administrator/Executive Director and Director of Nursing. Electronic delivery of the report is an appropriate alternative to hard copy.

.Based on observation, interview, and record review, the facility failed to ensure the electronic health record (EHR) of 1 resident (#3), out of 12 sampled residents, was maintained in a manner to ensure confidentiality from unauthorized access. Specifically, Licensed Nurse (LN) #1 left the medication cart computer screen unlocked and unattended in a hallway. This failed practice had the potential to place the resident's medical record at risk for unauthorized access and use An observation on 11/18/25 at 11:21 AM, revealed the nurse's medication cart for the Iliamna Hall was located in front of the clean utility room of the south hall unattended. Further observation revealed the cart's computer screen was not locked and access to resident records was available.During an interview on 11/18/25 at 11:21 AM, the Business Office Manager (BOM) stated the computer should not have been left open and accessible. The BOM located an LN (unidentified) and requested them to lock the computer.An observation on 11/19/25 at 9:03 AM, revealed LN #1 was preparing for medication administration for Resident #3. While preparing the medication, he/she checked the Medication Administration Report (MAR) in Point Click Care (PCC-facility's EHR). After the medication preparation, LN #1 minimized the PCC without locking the computer screen then proceeded to Resident #3's room and administered the medications to the resident. Further observation revealed the medication cart was left in the hallway unattended.During an interview on 11/19/25 at 9:30 AM, when asked if anybody can access resident's medical record when the computer screen was not locked, LN #1 stated, yes. The LN further stated that he/she would have locked the PCC screen by clicking the lock icon. However, that time he/she forgot to lock the screen.During the same interview, LN #1 stated he/she had been trained on how to lock the computer.Review of LN #1's HIPAA (Health Insurance Portability and Accountability Act) training certificate revealed he/she completed the training on 3/25/25.Review of the facility's New Hire HIPAA Training module, undated, revealed: .Securing Protected Health Information in HIPAA terms, secured means that Protected Health Information (PHI) is safeguarded from access by unauthorized individuals.We log off computers when not in use .During an interview on 11/20/25 at 1:13 PM, the Director of Staff Development (DSD) stated all nurses were trained in HIPAA. When asked how staff secure PHI, she stated the staff should keep the screen off or log-off and make sure the computer was locked. When informed about LN #1 not locking the computer screen during the medication administration, she stated [he/she] should not have done that. The DSD further stated the PCC MAR had a lock icon that the LN should have used to lock the computer screen.Review of the facility provided [NAME] (facility's service provider) HIPAA Compliance Policy and Procedure, revision date 3/24/16, revealed: . Accessing, using, and/or disclosing PHI will be limited to the minimum necessary to accomplish the intended purpose. the Privacy Rule generally requires covered entities to take reasonable steps to limit the use or disclose PHI.

.Based on record review and interview, the facility failed to maintain its Infection Prevention and Control Program (IPCP). Specifically, the facility failed to:Maintain a system for consistent preventing, identifying, reporting, investigating, and controlling infections, such as occupational bloodborne pathogen (infection spread in the blood) exposures.Maintain a system for recording occupational bloodborne pathogen exposures and documenting the corrective actions taken by the facility.Formalized reporting and communication of infection control issues across departments and committees, including Quality Assurance and Performance Improvement (QAPI) and Human Resources (HR), to monitor trends and implement preventive actions.These failed practices had the potential for ineffective Infection Control Program and increased the potential risk for development and transmission of disease and/or infection in all residents (based on a census of 43) and staff. Review of the facility document titled Infection Control Tracking Spreadsheet, (undated, modified 11/20/25), revealed the following entry:- On 8/3/25, Certified Nurse Assistant (CNA) #4 reported an occupational exposure while performing a blood-sugar finger stick. After pricking the resident's finger with a lancet and squeezing to obtain blood, blood splashed into CNA #4's right eye.- CNA #4 was wearing a face mask and gloves but no eye protection.- The CNA rinsed the eye with saline and notified the charge nurse the same day.- The Infection Preventionist (IP) was not notified until 8/5/25.- The record marked yes for completion of an employee injury report and receiving bloodborne pathogens education.Further review of the tracking sheet, revealed:- No details of the education provided were documented.- No follow-up treatment was recorded after the CNA declined initial medical evaluation.- and the employee's phone number was not recorded.Review of the Employee Statement of Accident, dated 8/6/25 revealed the employee later sought medical treatment on an undisclosed date, inconsistent with earlier documentation that no follow-up treatment was given. During an interview on 11/20/25 at 5:00 PM, the IP nurse stated that the only documentation the facility had for the blood-to-eye exposure involving CNA #4 was the employee's self-report form, the supervisor's accident/exposure form, and his/her own IP tracking spreadsheet. She further stated although CNA #4 initially refused treatment, CNA #4 later informed the charge nurse-not the IP-that he/she had gone to his/her primary care provider. The IP added that she reviewed the source resident's chart and found no documented history of HIV or hepatitis, noting that the facility usually checks history rather than drawing source labs unless there was a specific concern. The IP further described the facility's exposure-evaluation process, which includes first-aid guidance, collecting incident details, documenting the event, providing bloodborne pathogen education, and referring employees for initial and follow-up testing when indicated.During the same interview, the IP nurse further stated that root-cause analyses were typically reserved for more serious exposures, such as needle-stick injuries. Regarding the facility's corrective actions for the blood exposure incident, the IP counseled the employee on using appropriate PPE-such as a face shield-to prevent future splashes, documenting this only on her spreadsheet. The IP nurse stated she did not forward the incident to the QAPI committee but did verbally notify the administrator, noting that QAPI typically reviews resident infections, while Human Resources (HR) oversees most employee injuries unless they involve bloodborne pathogen exposure.During an interview on 11/21/25 at 10:30 AM, the Administrator stated that the facility managed infections and communicable diseases among staff through daily morning stand-up meetings where the IP would report any new illnesses, precautions, or potential outbreaks. She explained that communication was primarily verbal. She further stated the IP was supposed to maintain her own tracking log and providing written infection-control updates monthly during QAPI meetings.Regarding occupational exposures such as the blood-to-eye incident involving CNA #4, the Administrator explained that the process would begin with the supervisor completing an incident report, which would be sent to HR and workers' compensation. HR then would communicate the case to the IP, who was expected to track, investigate, and follow up with the employee, including maintaining written documentation. The Administrator stated she learned about this exposure during morning stand-up the day after it occurred but did not recall any further discussion with the IP about follow-up. She also verified that the exposure was not documented in QAPI minutes for neither August or September of 2025. The Administrator stated that there appeared to be a breakdown in communication between the IP, HR, administration, and QAPI.During the same interview, the Administrator further stated that she would oversee infection control through daily stand-up updates, monthly QAPI reports, and one-on-one meetings with leadership, including the IP: in this case, the system failed to ensure proper tracking, follow-up, or communication regarding the bloodborne pathogen exposure and that the facility lacked documentation of the IP's investigation or staff education.During an interview on 11/21/25 at 12:30 PM, the Medical Director (MD) stated: that although he was responsible for coordinating resident care and supporting infection-control processes, he was not aware of the bloodborne pathogen exposure in which CNA #4 received blood in his/her eye. After reviewing his messages, he confirmed he had not been notified of this incident and had not reviewed the source resident nor ordered any related labs. He explained that, in general, the IP nurse was supposed to consult with him regarding exposures, source-patient testing, and any needed post-exposure protocols. He added that he would meet formally with the IP nurse once a month, with occasional additional informal check-ins, but had no other routine oversight role beyond these interactions. Review of the facility-provided Bloodborne Pathogens Exposure Control Plan (ECP), undated, revealed: . Record keeping .In the event of an exposure incident, the following records will be kept in the employee's medical file:- The results of any examination, medical testing, and follow-up procedures.- A copy of the treating physician's written opinion to the employer.- A copy of all information provided by the employer to the health care professional regarding the exposure incident. Record every needlestick on the OSHA [Occupational Safety and Health Administration] 300 Log and/or the Sharps Injury Log. Record all other exposure incidents that result in medical treatment, (e.g., gamma globulin, hepatitis B immune globulin, hepatitis B vaccine, etc.) on the OSHA 300 log. Retain these records for five years.Plan evaluation and review the exposure control plan and update it at least annually.Review of the document Job Description- Infection Preventionist, signed on 3/1/25 revealed: Assist all departments in evaluating and classifying routine and job-related functions to ensure that tasks involving exposure to blood/body fluids are properly identified. Monitor infection control practices and procedures to ensure that personnel are implementing our standard operating procedures for tasks involving exposure to blood/body fluids. Further review of this document revealed: Prepare monthly summaries of all facility/resident/personnel infections, corrective action taken, and the results of the corrective action. Submit copies to the Administrator and Director of Nursing Services. Maintain a written record of all residents and employees who have nosocomial infections. Provide personnel with information concerning the facility's policies governing hepatitis B vaccinations. Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility's policies and procedures governing accidents and incidents.According to the Centers for Disease Control (CDC) and Prevention (https://www.cdc.gov), an effective infection prevention and control program includes systems to promptly identify, report, and investigate potential sources of infection, ensure proper use of personal protective equipment, manage exposures to blood and body fluids, and implement corrective measures to reduce transmission risks in healthcare settings

.Based on record review and interview, the facility failed to ensure their facility assessment was up to date and accurate. This failed practice had the potential to place all residents (based on a census of 49) at risk of not having the necessary care and resources from an accurate assessment. Findings:Record review on 7/29/25 of the facility's Polaris Transitional 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. Review of the facility's State of Alaska license, effective 3/1/25 through 3/1/26, revealed it was licensed for 50 beds. The facility assessment was not accurate. During an interview on 7/29/25 at 2:14 PM, the Director of Community Liaison stated the bed capacity for PTC was 50 beds. 2. 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 . Review of the facility's initial licensing application, dated 1/3/25, revealed this facility was one building, Type V (000) construction, with two wings, each having one 12 bed hallway and one 13 bed hallway. Each wing also had a common room with tables and chairs and a nurse's station. The facility assessment was not accurate. Review of the facility-provided Polaris Transitional Care Facility Assessment, dated 2025, revealed: . The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must review and update that assessment, as necessary, and at least annually .

.Based on record review, observation, and interview, the facility failed to ensure a homelike environment was set up and maintained for 1 Resident (#1), out of 2 residents observed, who was admitted to the facility over a month ago. This failed practice denied the resident the right to a personalized homelike environment. Findings:During an interview on 7/28/25 at 4:06 PM, the Office of Public Advocacy (OPA) Guardian for Resident #1 stated she had been his/her Guardian since last year and she had visited Resident #1 at his/her prior facility (PEC - Polaris Extended Care) before he/she moved to Polaris Transitional Care (PTC) on 6/3/25. The OPA Guardian stated that when Resident #1 was at PEC, his/her room was beautifully set up with family pictures on the wall and personal belongings throughout his/her room. The OPA Guardian further stated she visited Resident #1 at PTC on 7/25/25 and his/her room was night and day compared to when he/she was at PEC. The OPA Guardian stated Resident #1 had been at PTC for over a month and his/her belongings were still in boxes in the corner of his/her room. The OPA Guardian stated Resident #1's room was not home-like at all, and it was disappointing that the facility had not personalized his/her room. Resident #1 Record review on 7/29/25 revealed Resident #1 was admitted to the facility on [DATE] 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), chronic respiratory failure (not enough oxygen or too much carbon dioxide in the body), and tracheostomy (a surgical procedure that creates an opening in the front of the neck into the trachea to facilitate breathing). An observation on 7/29/25 at 2:34 PM, of Resident #1's room, revealed 7 cardboard boxes containing personal items stacked along the wall that was directly across from the foot of Resident #1's bed. Further observation revealed the room had no personal items on the walls or situated around the room to create a home-like environment, except for about 7 to 8 pictures on a gray corkboard on the wall near the boxes. This corkboard was situated behind a TV that was mounted on the wall and approximately 5 feet away from the Resident's head, making it difficult to see clearly from across the room. During an interview on 7/29/25 at 1:50 PM, Nursing Supervisor (NS) #1 stated when a resident was admitted to a room, the CNA (Certified Nursing Assistant) assigned was responsible for inventorying personal items and putting personal items away in drawers, among their other tasks. He/she stated, it was the expectation that these tasks were done pretty much immediately. NS #1 added, they were unsure of what needed to be unpacked for this resident and family would usually help unpack. When asked if family was contacted to help unpack the boxes, he/she replied, I don't know. During an interview on 7/29/25 at 2:20 PM, Family Member (FM) #1 stated that he/she had been visiting the resident since 7/18/25 from out of state. When asked if staff had talked to him/her about the boxes of personal items in the resident's room, he/she replied no, and that he/she didn't know anything about the boxes or their contents. Record review on 7/29/25 was unable to find documentation that staff had contacted family or the representative for guidance or assistance in unpacking the resident's belongings or that the resident or representative had resisted the facilities attempts to facilitate a homelike environment. Review of the facility's policy Homelike Environment, dated 3/2025, revealed: . 3. The Social Service staff contact family, conservator, or responsible party and enlist their help in personalizing the resident's environment. A letter may be sent to encourage their cooperation in this process . 5. If a resident resists a homelike emphasis, the resident's wishes are honored and his/her resistance documented appropriately in the Social Services notes .

51614 . Based on observation, interview, and record review the facility failed to ensure foods were stored and labeled in accordance with professional standards for food safety for all residents (based on a census of 43). Specifically, the facility failed to ensure: 1) foods were labeled and dated; 2) foods were being stored at safe temperatures in the Northside and Southside dining room kitchens and 3) expired foods were discarded. These failed practices had the potential of causing or spreading foodborne illness to all residents, who received food from the affected kitchens. Findings: Main Kitchen: An observation, during the initial main kitchen tour, on [DATE] at 8:35 AM, revealed: 1) Dry Storage/Pantry area: - Two 7lbs cans of expired Monarch Pork & Beans cans labeled with Rec [Received], dated [DATE] and UB [Used By], dated [DATE]; 2) Walk-In Cooler: - Six 11-ounce container of expired Premier Protein Chocolate Shakes with a manufacture expiration date of [DATE]; - One plastic bag of green and red whole apples without Rec or UB dates labeled; - One large clear glass jar of unidentified contents without open date; Rec or UB dates labeled; 3) Walk-In Freezer: - One expired large clear plastic container labeled, Fries without Rec date; but had UB [DATE]; - Three expired aluminum containers labeled, Goat Meat with UB, [DATE]; An observation, during the main kitchen tour, on [DATE] at 8:32 AM, revealed: 1) Walk-In Cooler: - One expired small metal pan, labeled Ham UB [DATE]; - One expired medium metal pan, labeled Can Corn Open [ed] [DATE] UB [DATE]. North Side Dining Room Kitchen: An observation, during a North Side kitchen tour, on [DATE] at 9:30 AM, revealed: 1) Refrigerator: North Side temperature log had 6 temperatures missing for the following dates: ,d+[DATE]-,d+[DATE], [DATE], ,d+[DATE]-,d+[DATE] and [DATE]. 2) Freezer: North Side temperature log had 6 temperatures missing for the following dates: ,d+[DATE]-,d+[DATE], [DATE], ,d+[DATE]-,d+[DATE] and [DATE]. 3) Kitchen cabinet: - One half full 0.11-ounce package [NAME] Light Sugar Free Fruit Punch, without open date label; - One half full 60-ounce Ocean Spray 100% Apple Juice, without open date label. South Side Dining Room Kitchen: An observation, during a South Side kitchen tour, on [DATE] at 9:34 AM, revealed: 1) Refrigerator: South Side, temperature log had 4 temperatures missing for the following dates: [DATE], ,d+[DATE]-,d+[DATE], [DATE]. 2) Freezer: South Side, temperature log had 4 temperatures missing for the following dates: [DATE], ,d+[DATE]-,d+[DATE], [DATE]. 3) Small Refrigerator: - One half gallon of milk without open date and UB date label; - Six expired half Turkey sandwiches, labeled ,d+[DATE] [[DATE]]; - Two expired half Peanut Butter sandwiches, labeled ,d+[DATE] [[DATE]] During an interview on [DATE] at 9:20 AM, the Dietary Manager (DM) stated all containers should have been labeled with a received date, open date, and use by date. If the food was not used by the used by date, then the food should have been thrown away. The DM further stated the refrigerator and freezers required daily documentation of the temperature. Review of the facility's policy LABELING FOR RECEIVING AND STORAGE OF FOOD ITEMS, revised on ,d+[DATE], revealed: 1. All items received in the department will be labeled with a U. B. (use by) date . 2. Dry storage items will be discarded in following the shelf-life list from the use by date unless expiration date is noted on the item and the expiration date will be used as the date of discarding . 4. Items left in their original containers will have an opened date . The date will say Open Date . use by date . 7. Items repackaged or processed within the department will be labeled with a use by date for 3 days later. The Label will say use by . (example: Month/Day/Year must be written).

Based on record review and interview, the facility failed to obtain informed consent prior to administering psychotropic medications (medications in the class of either antipsychotics, antianxiety, or antidepressants that would have affected behavior, mood, thoughts, or perception). Specifically, the facility made changes to the medication orders for one resident (#8) out of 5 sampled residents for unnecessary medications. This failed practice denied the Resident and/or Resident's Representative the right to consent to medications and be informed of the risk and benefits for the medications use. Findings: Resident #8 Record review on 10/28/24-11/1/24 revealed Resident #8 was admitted to the facility with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety, agitation, and insomnia. Hydroxyzine (brand name: Vistaril) classified as an antihistamine medication: Review of Psychotropic R[isks] & B[enefits], dated 8/7/24, revealed: Psychotherapeutic Drug Started: 8/7/24 . Hydroxyzine, Diagnosis of resident, Anxiety, Dose of Drug: 25mg BID [twice daily] as needed, Route: po [by mouth], Risk & Benefits Explained to: [Resident Representative (RR) #1], To Give Drug: Approved. Review of Physician Orders, dated 10/22/24, revealed: .3) Stop Vistaril 25mg PO BID, 4) Vistaril 25 mg po TID [three times daily], DX: Anxiety. Review of Physician Orders, dated 10/23/24, revealed: Order Clarification, Hydroxyzine 25mg PO [by mouth] TID [three times a day] PRN [as needed] x 21 days, DX [diagnosis]: Anxiety. Review of medication administration record, dated 10/2024, revealed Hydroxyzine 25mg was given on 10/25/24 (3 doses) and 10/28/24 (3 doses) for a total of 6 doses for anxiety. Record review on 10/29/24 at 12:30 PM, revealed no documentation of a Psychotropic R & B for Resident #8's increased administration frequency of hydroxyzine 25mg to three times daily. Aripiprazole (brand name: Abilify) classfied as an antipsychotic medication: Review of Psychotropic R & B, dated 9/10/24, revealed: Psychotherapeutic Drug Started: 9/10/24 . Aripiprazole, Diagnosis of Resident: Schizophrenia, Dose of Drug: Aripiprazole increase to 25mg to 20mg daily, Route: by mouth, Risk & Benefits Explained to: [RR #1] To Give Drug: Approved. Review of Physician Orders, dated 10/22/24, revealed: 1) Stop Abilify 25mg daily, 2) Abilify 30 mg Q [every] am PO, DX: Schizophrenia . Review of medication administration record, dated 10/24/24 revealed, Abilify 30mg was given daily on 10/24-31/24 (8 total doses) for schizophrenia. Record review on 10/29/24, at 12:30 PM, revealed no documentation of Psychotropic R & B for Resident #8's increased dosage of Aripiprazole to 30mg daily. During an interview on 10/29/24 at 11:59 AM, RR #1, stated the facility did not inform him/her that Resident #8's Abilify had been increased to 30 mg daily. During an interview on 10/30/24 at 3:40 PM, Nursing Supervisor (NS) #2 stated when psychotropic medications were started or changed, residents or the representatives were given the risk and benefits of the medication so they could make an informed decision before the start of the medication. NS #2 stated the family had not been notified that Resident #8's Abilify was increased to 30mg daily on 10/22/24. Review of the facility's policy Psychotropic Medications, last approved 7/2024, revealed: . B. Definition (s) Psychotropic Medication- Any drug that affects brain activities associated with mental process and behavior. This includes antipsychotics . In, addition, other mediations that affect brain activity when used as a substitute for a psychotropic medication. This includes antihistamines . C. General Provisions .2. Residents or their representative are advised of potential risks versus benefits of psychotropic medication therapy.

Based on interview and record review, the facility failed to provide quarterly statements for personal fund accounts to one resident (#8's) Resident's Representative (RR), out of 1 sampled resident whose money was held by the facility. This failed practice placed the Resident and/or his/her RR at risk for not receiving a complete and accurate accounting of his/her personal funds entrusted to the facility. Findings: Record review on 10/28/24-11/1/24 revealed Resident #8 was admitted to the facility with diagnoses that included schizophrenia (serious mental illness that affects how a person thinks, feels and behaves). During an interview on 10/29/24 at 11:59 AM, Resident #8's Resident Representative (RR) #1stated that he/she had not received any bank statements from the facility. During an interview on 10/31/24 at 12:20 PM, LN #5 stated Resident #8 had a POA [RR #1] that was declared for financial obligations. LN #5 stated the resident's face sheet should identify who the financial POA was and not the resident. LN #5 stated that the financial POA should be receiving the resident's bank statements. During and interview on 10/31/24 at 12:57 PM, Business Officer (BO) #1 stated Resident #8 had a personal funds account with the facility. BO #1 stated quarterly statements were provided quarterly to the resident. When asked who the facility was sending the statements to, BO #1 stated the resident, we have been sending them to [his/her] home address in [NAME]. When asked if BO #1 was aware the resident had a POA for his financial obligations, BO #1 stated, No, we do not have that information. Review on 10/31/24 of Resident #8's Face Sheet, revealed: . Financial Responsible Party, [Resident #8] . Review on 10/31/24 of Resident #8's Power of Attorney, dated 11/13/19, revealed: . Name of individual you choose as your agent: [RR #1] . Section 3. [NAME] the boxes below to indicate the powers you want to give your agent or agents . (D) Banking transactions . Review of the facility's policy Resident Trust Account, dated 3/2023, revealed: . 7. Statements are provided to the resident or resident's representative quarterly and upon request. Review of the Providence Transitional Care Center, A Handbook for Residents and Families, dated 1/2024, revealed: . Bank statements showing all transactions, including interest earnings, are provided quarterly.

Based on record review and interview, the facility failed to investigate and resolve a grievance for 1 resident (#18), out of 12 sampled residents. This failed practice violated the Resident's right to have a grievance investigated and resolved. Findings: During an interview on 10/28/24 at 12:00 PM, Resident #18 stated, I have been upset with cares . I was put into a sling [lift to transport resident to bathroom or transfer to a wheelchair from bed or chair] and given drugs . I was violated. The resident stated recalling waking up on a ceiling lift sling in February 2024 with a pain in the vaginal area and realized he/she was being catheterized without his/her permission or knowledge. Licensed Nurse (LN) #3 was the nurse. Resident #18 stated further, I was not hurt in the catheterization incident. Resident #18 stated his/her complaints were not always investigated and resolved. Review of the Resident Concern and Feedback Communication, dated 4/10/24, revealed the facility failed to show a grievance was fully investigated and the facility failed to document the resident was informed of the outcome of the facility's investigation. The complaint centered around the resident's complaint about being catheterized in a ceiling lift sling. There was no evidence that the complaint was investigated in the documentation provided by the facility. Review of the Notes, dated 2/25/24 revealed: Late Entry: 2/24/24, Purpose of Note: New or Sudden Onset/change in condition: somnolence [excessive sleepiness] . Noted patient somnolent also as per NOC [night] RN who was passing meds at 2000 [8:00 PM] . [Resident #18] said . needed to pee. Used the lift and took patient to bathroom with assistance. Patient tend to fall back asleep, reminded that [he/she] needed to void. Patient unable to void after staying with patient for almost 15 minutes. Patient placed back in bed . Encouraged patient to void, urinal provided with CNA [Certified Nursing Assistant] at bedside. Patient unable to void, explained to patient that [he/she] needs to be bladder scanned as [he/she] hasn't voided since last shift. Patient agreed. Bladder scanned performed on patient, obtained 590 mls [milliliter] . Patient still disoriented, saying [he/she] was saying [he/she] was seeing a 'tool' by the wall, told [him/her] it was the wall clock. Notified hospitalist of patient's change in condition, scanned of 590 ml. Obtained order for straight cath [catheter- a flexible tube inserted into the bladder to drain urine or collect a sample]1. Informed patient with CNA at bedside will need to straight cath to empty [his/her] bladder. Explained to patient that it is a one-time straight cath order. With CNA assisting, attempted to straight cath patient, unable to cath patient as patient felt uncomfortable and told us to stop. Informed patient that we will try to get [him/her] to the bathroom again which this RN and CNA did using the lift. Patient still not able to void after staying with patient in bathroom about 10-15 minutes. Patient was put back in bed, placed attends [incontinence briefs] on, kept [him/her] comfortable and [he/she] went back to sleep. Reported to incoming day RN that [he/she] wasn't able to void [urinate] just yet. This was signed by LN #3. A physician order dated 2/25/24 signed by the physician revealed: Straight cath patient X1. Further review of the Notes, dated 2/25/24 at 2:37 PM, revealed: Late entry 2/25/24 12:01 PM . Patient verbally requested to the Anchorage Fire Department with staff present to be sent via Anchorage Fire Department to the emergency room . The fire department assisted the patient in transferring to the gurney and transported patient leaving the facility at 12:40 PM. This was completed by LN #7. Further review of the Notes dated 2/25/24 at 5:07 PM, revealed: [Resident #18] returned to floor with EMTs [Emergency Medical Technicians] 5:11 PM While in ER [emergency room ], they drew labs, labs came out good. They also tested [his/her] urine. No UTI [urinary tract infection]. They gave [him/her] a dose of Prednisone. This was completed by LN #6. Review of the Grievance Log for 2024 included a Resident Concern and Feedback Communication Form dated 4/11/24. Under the My Concern section on this form was written: [Resident #18] shared a concern that [he/she] was upset with LN #5 that [LN#5] wanted to put a cath [catheter] in [him/her] while [he/she] is a sling. [Resident #18] called APD [Anchorage Police Department] to report [LN #5]. This was signed by the prior administrator. The Follow Up . section was left blank in: Situation. Background. Assessment. Recommendation. Initial Contact with Person submitting concern: Date/Time/Name and 5 Day contact with person submitting concern: Date/Time/Name. Further review of the grievance log revealed: the prior administrator had completed a narrative describing the complaint: On April 10th I was notified that [Resident #18] wanted to speak with me . I met with [Resident #18] where [he/she] began to tell me [he/she] was upset with 4 caregivers, primarily [LN #5]. Before [Resident #18] could explain . concerns were the APD officer arrived to speak with [Resident #18]. [Resident #18] asked me to leave so [he/she] could talk to the officer. After the officer met with [Resident #18], [he/she] came out and stated that [he/she] took [his/her] concern and will be passing it off to a detective . [The officer] also stated that 'this was not a police matter' and [he/she] did not believe the detectives would have much to do with it. I went back to the conference room to talk with [Resident #18]. The conversation with [Resident #18] was all over the place, [he/she] was jumping from one topic to another and at times I had a challenging time following what [his/her] actual concern was. What [Resident #18] wanted to share with me was that [LN#5] and three other caregivers wanted to put a catheter in [him/her] while [he/she] was in a lift sling. I could not get any specific details about the event just that [he/she] was focused on [LN#5]. I met with [Resident #18] for an hour. After meeting with [Resident #18], I followed up with [the Director of Nursing (DON).] [The DON] shared that the event [Resident #18] is referring was in February and had already been followed up on. The ombudsman had been part of the follow up. I submitted a resident concern form on [his/her] behalf on the issue again and have forwarded it to our grievance official. Signed [prior administrator]. During an interview on 11/1/24 at 10:00 AM, the DON stated that he/she had explained to the patient that the catheterization was not done in the sling and the bed was the place for catheterization. The DON added that he/she had not documented anything on the follow up to the ombudsman or Resident #18. The DON stated the complaint was not thorough with its documented investigation and follow-up. During an interview on 11/1/24 at 1:24 PM, when asked the grievance process, the Director of Quality (DOQ) stated, the resident would bring the concern to the nursing department and then the nursing department addressed the issue and then formed a complaint. There were five days to address the complaint and update the complainant about the resolution. Sometimes a letter will be sent. Some complaints were addressed immediately like lost dentures or a missing phone. The DOQ further stated significant complaints would take significant work. The prior administrator asked the DOQ to follow up after APD visited Resident #18. APD informed the resident there was no crime, which concluded the police investigation. The DOQ stated her interaction with Resident #18 was limited because of a previous encounters between the DOQ and the resident. The DOQ agreed that the documented investigation and resident follow-up in the grievance log were not complete. Review of the Resident Concerns and Grievances, dated 5/2024, revealed, All residents have the right to file concerns and prompt resolution . 2. Grievance Officer or Designee a. Oversees the grievance process .b. Monitors for completeness and timeline for completion when receives notification c. leads and supports investigations d. reviews concern and investigation with Administrator and Director of Nursing as appropriate; determines any need for further follow-up . f. ensures written follow-up of decisions when appropriate. Written response to a grievance must include 1. The date the grievance was received; 2. A summary of pertinent findings or conclusions; 3. A statement as to whether the grievance was confirmed or not; 4. The steps taken to resolve the grievance 6. The date the written decision was issued . PEC Cottage Manager/designee or PTCC Nurse manager/ shift supervisor . in coordination with the grievance officer . b. contacts the individual lodging concern within 24 hours to acknowledge receipt and pending investigation, c. investigates the concern; d. prevents potential violations of resident's rights during investigation; e. contacts the individual lodging the concern to report findings and outcome of the issue within 5 days f. completes written response g. sends copy to the director of nursing within 5 days .

Based on record review and interview, the facility failed to ensure a comprehensive care plan was updated according to the resident's current dental status for 1 resident (#3), out of 12 sampled residents. This failed practice placed the resident at risk of not receiving appropriate care. Findings: Record review on 10/28/24 -11/1/24, revealed Resident #3 was admitted to the facility with diagnoses that included fracture of the femur (thigh bone), facial weakness and dysphagia (difficulty swallowing). During an interview on 10/28/24 at 2:30 PM, Resident #3 stated he/she lost his/her dentures in his/her room. Resident #3 stated he/she reported it to the staff. The facility staff including the Director of Nursing (DON) searched for the missing dentures but were not found. Review of the ST [Speech Therapy] NOTES (all), dated 9/17/24, revealed: . [Resident #3] reporting lost dentures Friday afternoon, increased difficulty [and] effectively chewing foods. Nurse supervisor[unknown] downgrading [Resident] to soft and bite size diet textures. Review of the Nutrition Notes, dated 10/9/24, revealed: .Nutrition Consult: re: dental soft diet, . [Resident #3] edentulous (lack of teeth), unable to chew. Status/Assessment: Staff reports . [Resident #3] lost [his/her] dentures. [Resident] states [he/she] is unable to eat this (pointing to [his/her] soft and bite sized lunch), provided . [Resident] with [his/her] request for lunch of mashed potatoes with gravy and ranch dressing, cream of wheat with brown sugar . Review of the Minimum Data Set (MDS) Note, dated 10/29/24 at 12:46 PM, revealed: . [Resident #3] states [his/her] dentures were lost, making it difficult for others to understand [him/her] and to chew [his/her] food. [He/she] states because [he/she] lost [his/her] dentures, [he/she] has to be on 'soft diet that really sucks.' [he/she] is aware [he/she] has a dental appointment . [on] December 31st [2024] . Review of Resident #3's Care Plan, on 10/30/24 at 11:54 AM, revealed the care plan was dated 9/6/24 . I need to wear dentures because I have problem swallowing, have lost all my teeth I show this by having easy to chew consistency diet, having upper dentures. I need my aides to take care of my dentures as needed, help me wear my dentures comfortably, I need my Dietary staff to mechanically altered food so I can eat without choking, I need everyone to .make sure I'm wearing my dentures. During an interview on 10/30/24 at 1:55 PM, the DON stated the facility investigated Resident #3's dental concern. The facility was not able to find the missing dentures so the facility set-up the Resident's dental appointment in November 2024 and the Resident would get his/her dentures in December 2024. During an interview on 11/1/24 at 11:55 AM, when asked if the Resident #3's comprehensive care plan should have been updated according to his/her current dental status, the DON stated the care plan should have indicated no dentures. She further stated the MDS nurse or nursing staff should have changed the care plan. The DON confirmed on 11/1/24 at 1:09 PM that the comprehensive care plan was not updated according to Resident #3's current dental status and the MDS nurse would update the care plan. Review of the facility's policy Individualized Care Plan, dated 2/2024, revealed: . The Plan of Care is kept up to date every 90 days and as changes happen.

Based on observation, interview, and record review, the facility failed to ensure inappropriately labeled medications and supplies were not used for wound care for one resident (#17) out of 1 resident observed for wound care. This failed practice placed the resident at risk for receiving expired medications and expired wound cleansing solution. Findings: An observation, during Resident #17's wound care, on 10/31/24 at 2:45 PM, revealed Licensed Nurse (LN) #2 and LN #1 placed wound care dressing supplies onto a bedside table with a clean field draped over the table. LN #2 placed an opened tube of Triamcinolone Acetonide Ointment with a manufacturer's expiration date of 1/2027 onto this field. This tube had a black handwritten ink letter, B and no other labeled identification of the initials of who opened the tube or date of when the tube had been opened. LN #2 also placed two opened bottles of Vashe wound cleansing solution with the same manufacturer's expiration date of 8/31/25 onto this clean field. These bottles of Vashe wound cleansing solution had no label of when the bottles were opened or initials of whom opened these bottles. LN #2 with the assistance of LN #1 completed the wound care on the Resident's buttocks area using the Vashe wound cleansing solution placed on gauze to cleanse the wound, applied of the ointment onto the wound, and covered the wound with a Mepilex dressing. During an interview on 10/31/24 at 3:00 PM, LN #2 stated, when asked if the ointment and wound cleanser were labeled with the initials of who opened the bottles of wound cleanser and tube of ointment and date when the items were opened, he/she stated that the items had not been labeled with an open date or the complete initials of who opened the wound care cleanser bottles and the ointment tube and should have been appropriately labeled. Review of Providence Anchorage Long Term Care Nursing Protocol Medication Labeling, dated 3/2024, revealed, This protocol promotes labeling medications that have defined expiration periods with open and expiration dates . Nursing will place a label on the medication once opened that has an open date, expiration date and initials.

Based on record review and interview, the facility failed to implement pharmaceutical services that included procedures to ensure the accurate dispensing and administration of medications for 2 residents (#s 1 and 2), out of 2 sampled residents. Specifically, the facility failed to ensure the pharmaceutical service processes included the receiving and interpretation of prescriber's original hand-written medication orders to confirm the Five Rights (right patient, right medication, right dose, right route, and right time) were accurately followed during the transcription of the orders into the resident's electronic Medication Administration Record (eMAR). This failed practice resulted in Resident #1 requiring hospitalization for an anemic crisis, did not respond to blood transfusions, and later died , which constituted an immediate jeopardy at, which constituted an immediate jeopardy at CFR 483.45(a) Pharmacy Services. This situation was brought to the attention of the facility's administration on [DATE] at 4:45 PM, at which time the facility was notified of identified immediate jeopardy. The facility submitted an acceptable removal plan on [DATE] at 2:30 PM. The State Survey Agency verified onsite that the immediacy was removed on [DATE] at 2:00 AM. The situation that constituted the immediate jeopardy started on [DATE] at 9:32 AM. Findings: Record review on [DATE] and [DATE] revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included an abscess of the liver, chronic kidney disease, acute cholecystitis (inflammation of the gall bladder), and long term/current use of an anticoagulant (Heparin - a blood thinner medication that decreases the blood's ability to clot). Review of Resident #1's medication orders, dated [DATE], revealed an order for the anticoagulant, Heparin Sodium (Porcine) 5000 Unit/ml solution (1 ml/5000unit) SubQ [injection beneath the skin, but not muscle] every 8 hours ([6:00 AM], [2:00 PM], and [10:00 PM]) x 14 days. This medication was ordered for venous thromboembolism prophylaxis (VTE - a condition that occurs when blood clots form in veins, used as a preventative measure to prevent further clots). Medication Error Synopsis Record review revealed on [DATE], Physician #3 placed a hand-written ordered for LMWH [Low Molecular Weight Heparin: Enoxaparin, also called Lovenox] 80mg subQ BID [twice a day] [DATE]-[DATE] for atrial fibrillation in Resident #2's medical record. Further review revealed Licensed Nurse (LN) #4 signed off this medication order on [DATE], in Resident #2's paper hard chart, however transcribed the order into Resident #1's ECS (Electronic Medication Administration Record [eMAR]) record in error. Review of the ECS system data base, dated [DATE], revealed this transcribed order was electronically sent to the pharmacy on [DATE] at 10:37 PM under Resident #1's name. Review of the pharmacy's PrimeCare system data base, dated [DATE], revealed this transcribed order was reviewed and cleared by the pharmacy at 9:32 AM. Resident #1 was administered seven doses of Lovenox, from [DATE] to [DATE], in addition to Resident #1's regular Heparin therapy, before this error was discovered and discontinued. Effects of Medication Error Resident #1 Lab History Review of Resident #1's lab work, dated [DATE], revealed Resident #1's blood values were at below normal ranges: - [NAME] Blood Cells: 3.36 K/ul (normal value: 4.0 - 11.0 K/ul) - Red Blood Cells: 3.81 M/ul (normal value: 3.9 - 5.0 M/ul) - Hemoglobin (the protein contained in red blood cells, responsible for delivery of oxygen): 9.9 g/dl (normal value: 12.0 - 16.0 g/dl) - Hematocrit (percentage by volume of red blood cells in blood): 32.2 % (normal value: 36.0 - 46.0 %) - Platelets: 75 K/ul (normal value: 140 - 440 K/ul) Review of Resident #1's lab work, dated [DATE], revealed Resident #1's blood values continued to decrease: - [NAME] Blood Cells: 3.00 K/ul - Red Blood Cells: 3.38 M/ul - Hemoglobin: 8.9 g/dl - Hematocrit: 28.4 % - Platelets: 53 K/ul Review of Resident #1's next labs drawn, dated [DATE] (4 days after the start of the medication error, and 1 day after the error was discontinued), revealed Resident #1's blood values were at a critically low level: - [NAME] Blood Cells: 7.37 K/ul (normal level) - Red blood Cells: 2.34 M/ul - Hemoglobin: 6.1 g/dl - Hematocrit: 18.9 % (Critical result: laboratory called the unit for a read back and acknowledgement) - Platelets: 35 K/ul Record review of Resident #1's Progress Note, dated [DATE], revealed: Notified by Nursing supervisor this [morning] of critical hemoglobin of 5.8 . concern for hemolysis [the breakdown of red blood cells] so lab was resent and repeated at 8:50 AM was 6.1 mg/dL. Subsequently also learned that patient has had medication error - was started on Lovenox 80 mg SQ [SubQ] BID ,d+[DATE]-,d+[DATE] in spite of already receiving heparin SQ 5000 units TID [three times a day] when a large volume of orders occurred last week .Today, on chart review noted blood pressure on ,d+[DATE] (below patient baseline) and axial temperature of 94.2 F . On bedside assessment, [he/she] is lethargic and opens eyes to voice but does not answer any questions. [He/she] does spontaneously speak however speech is unintelligible and does not appear to be an attempt to engage in conversation/answer provider questions, which is not patient's baseline. Further review of the Progress Note revealed: . Assessment [and] Plan: . chronic baseline anemia. On follow up ,d+[DATE], noted 3 gm drop in hgb [hemoglobin] following 3 days of administration of supratherapeutic [amounts of a drug that are greater than the therapeutic concentration or maximum dose in a medical treatment] LMWH dosing to patient with baseline CKD [chronic kidney disease]. Hypotension and mental status changes noted on ,d+[DATE] provider exam with hgb 6.1 and PLT [platelets] 35,000 . Received lovenox 80 mg BID SQ ,d+[DATE] - ,d+[DATE] in error was also receiving SQ heparin - discontinue ,d+[DATE] (had been resumed ,d+[DATE]) warrants emergent ER [emergency room ] evaluation for acute on chronic symptomatic anemia (presume acute blood loss due to supratherapeutic anticoagulation though also concern for hemolysis per prior charting) . Review of Resident #1's Resident Transfer Form Emergency Department revealed Resident #1 left for the Emergency Department (ED) on [DATE]. Review of Resident #1's medical record revealed the resident was transported to Alaska Regional Hospital and admitted on [DATE]. Further review revealed the following course through that hospitalization : [DATE]: admitted through ED, transfused 1 unit of packed red blood cells (prbc), repeated 2 more units. No improvement to blood values. [DATE]: An additional 2 units of prbc's transfused. No improvement to blood values. No further transfusions recommended. [DATE]: Resident #1 unresponsive. No urine output, placed on comfort care. [DATE]: admitted to inpatient hospice. [DATE]: Resident #1 passed away. Resident #2 Record review conducted on [DATE] and [DATE] revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Atrial Fibrillation (A-fib - a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure, and other complications) and fractures. Review of Resident #2's ECS record revealed he/she had a delay in Lovenox administration, due to the transcription error, and was not started until [DATE]. Facility's Medication Order Processing Procedure During an interview on [DATE] at 2:48 PM, the Director of Nursing (DON) stated the physicians placed orders for medication by handwriting the orders into the residents' paper hard charts. The DON further stated these hand-written orders were reviewed, signed off, and transcribed into the residents' eMAR (called ECS) by the nursing supervisors of the units. Once the order had been transcribed into ECS, the ECS system alerted the pharmacy electronically of the new order. The DON further stated that the original hand-written order remained in the chart and was never sent to the pharmacy. During an interview on [DATE] at 12:00 PM, the Pharmacy Supervisor stated that the pharmacy never received copies of the hand-written medication orders, unless they were a narcotic or a controlled substance. The Pharmacy Supervisor further stated that the pharmacy would be alerted through the ECS system when a nurse transcribed a new order. This transcribed order would then be reviewed by a pharmacist and processed electronically through the pharmacy's separate computer system (called PrimeCare). The Pharmacy Supervisor stated the pharmacy lacked control of orders for new medications and how they were put into ECS to ensure it was done correctly. The Pharmacy Supervisor further stated that the pharmacy could not hold or stop medication orders in the ECS system, they were only able to look in the system at transcribed orders. When asked about the addition of Lovenox to Resident #1's medication regimen, that already included Heparin, the Pharmacy Supervisor stated it was assumed that Lovenox was replacing Heparin, but acknowledged an order to discontinue Heparin was not received. The Pharmacy Supervisor stated that Heparin and Lovenox should not be used together as a risk of increased bleeding could result. The Pharmacy Supervisor further stated the pharmacy did not have control over the facility's medication as all the medications used were stored in a Pyxis Medstation and were not directly dispensed from the pharmacy. Review of the facility's policy Medication Order Processing and Delivery, dated ,d+[DATE], revealed: .The licensed nurse or designee enters new orders into the ECS system. Orders are transmitted electronically to the pharmacy. Orders for controlled substances are printed from ECS and faxed to the Pharmacy . Medications are obtained from the Pyxis Medstation. Bulk items (ointments, inhalers, etc.) are dispensed from the Pharmacy . A pharmacist is responsible for reviewing all medication orders . Further review revealed no process for the pharmacist to receive or review the original hand-written medication orders to ensure they were transcribed correctly into the ECS system. Review of the facility's policy Medication Order Initiation and Discontinuation, dated ,d+[DATE], revealed: .The licensed nurse or pharmacist is responsible to receive medication orders . The PCN [primary care nurse] enters the medication order into ECS. When indicated by ECS the order is to be printed from ECS and faxed to the Pharmacy. All other orders should transmit electronically. Pharmacy staff processes the electronic prescriptions from ECS into the pharmacy system . Further review revealed no process for the pharmacist to receive or review the original hand-written medication order to ensure it was transcribed correctly into the ECS system.

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors for 2 resident (#s 1 and 2), out of 2 sampled residents. The facility failed to implement and maintain processes and procedures to ensure accurate transcription of physician orders for medications. The facility administered seven doses of an anticoagulant medication (a blood thinning medication that decreases the blood's ability to clot) without a valid physician order which resulted in concurrent administration of two different anticoagulants. This failed practice resulted in Resident #1 requiring hospitalization for an anemic crisis, did not respond to blood transfusions, and later died , which constituted an immediate jeopardy at CFR 483.45(f)(2) Significant Medication Errors. This situation was brought to the attention of the facility's administration on [DATE] at 4:45 PM, at which time the facility was notified of identified immediate jeopardy. The facility submitted an acceptable removal plan on [DATE] at 6:40 PM. The State Survey Agency verified onsite that the immediacy was removed on [DATE] at 7:30 AM. The situation that constituted the immediate jeopardy started on [DATE] at 10:37 PM. Findings: Resident #1 Record review conducted on [DATE] and [DATE] revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included abscess of liver, chronic kidney disease, acute cholecystitis (inflammation of the gall bladder), and long term/current use of an anticoagulant (Heparin - a blood thinner medication that decreases the blood's ability to clot). Review of Resident #1's medication orders, dated [DATE], revealed an order for the anticoagulant, Heparin Sodium (Porcine) 5000 Unit/ml solution (1 ml/5000unit) SubQ [injection beneath the skin, but not muscle] every 8 hours ([6:00 AM], [2:00 PM], and [10:00 PM]) x 14 days. This medication was ordered for venous thromboembolism prophylaxis (VTE - a condition that occurs when blood clots form in veins, used as a preventative measure to prevent further clots). Medication Error Synopsis Record review revealed, on [DATE] at 6:30 PM, Physician #3 placed a hand-written ordered for LMWH [Low Molecular Weight Heparin: Enoxaparin, also called Lovenox] 80mg subQ BID [twice a day] [DATE]-[DATE] for atrial fibrillation in Resident #2's medical record. Further review revealed Licensed Nurse (LN) #4 signed off this medication order on [DATE] at 10:00 PM, in Resident #2's paper hard chart, however transcribed the order into Resident #1's ECS (Electronic Medication Administration Record [eMAR]) record in error. Review of Resident #2's Physician Orders form, for the [DATE] order, revealed that the 24-hour chart check was signed off and completed by LN #5 on [DATE] at 6:48 AM. Review of Resident #1' ECS record revealed seven doses of Lovenox was administered, from [DATE] to [DATE], in addition to Resident #1's 13 doses of his/her regular Heparin therapy, before this error was discovered and discontinued. Effects of Medication Error Resident #1 Lab History Review of Resident #1's lab work, dated [DATE], revealed Resident #1's blood values were at below normal ranges: - [NAME] Blood Cells: 3.36 K/ul (normal value: 4.0 - 11.0 K/ul) - Red Blood Cells: 3.81 M/ul (normal value: 3.9 - 5.0 M/ul) - Hemoglobin (the protein contained in red blood cells, responsible for delivery of oxygen): 9.9 g/dl (normal value: 12.0 - 16.0 g/dl) - Hematocrit (percentage by volume of red blood cells in blood): 32.2 % (normal value: 36.0 - 46.0 %) - Platelets: 75 K/ul (normal value: 140 - 440 K/ul) Review of Resident #1's lab work, dated [DATE], revealed Resident #1's blood values continued to decrease: - [NAME] Blood Cells: 3.00 K/ul - Red Blood Cells: 3.38 M/ul - Hemoglobin: 8.9 g/dl - Hematocrit: 28.4 % - Platelets: 53 K/ul Review of Resident #1's next labs drawn, dated [DATE] (results after the additional seven doses of Lovenox were given in error), revealed Resident #1's blood values were at a critically low level: - [NAME] Blood Cells: 7.37 K/ul (normal level) - Red blood Cells: 2.34 M/ul - Hemoglobin: 6.1 g/dl - Hematocrit: 18.9 % (Critical result: laboratory called the unit for a read back and acknowledgement) - Platelets: 35 K/ul Record review of Resident #1's Progress Note, dated [DATE], revealed: Notified by Nursing supervisor this [morning] of critical hemoglobin of 5.8 . concern for hemolysis [the breakdown of red blood cells] so lab was resent and repeated at 8:50 AM was 6.1 mg/dL. Subsequently also learned that patient has had medication error - was started on Lovenox 80 mg SQ [SubQ] BID ,d+[DATE]-,d+[DATE] in spite of already receiving heparin SQ 5000 units TID [three times a day] when a large volume of orders occurred last week .Today, on chart review noted blood pressure on ,d+[DATE] (below patient baseline) and axial temperature of 94.2 F . On bedside assessment, [he/she] is lethargic and opens eyes to voice but does not answer any questions. [He/she] does spontaneously speak however speech is unintelligible and does not appear to be an attempt to engage in conversation/answer provider questions, which is not patient's baseline. Further review of the Progress Note revealed: . Assessment [and] Plan: . chronic baseline anemia. On follow up ,d+[DATE], noted 3 gm drop in hgb [hemoglobin] following 3 days of administration of supratherapeutic [amounts of a drug that are greater than the therapeutic concentration or maximum dose in a medical treatment] LMWH dosing to patient with baseline CKD [chronic kidney disease]. Hypotension and mental status changes noted on ,d+[DATE] provider exam with hgb 6.1 and PLT [platelets] 35,000 . Received lovenox 80 mg BID SQ ,d+[DATE] - ,d+[DATE] in error was also receiving SQ heparin - discontinue ,d+[DATE] (had been resumed ,d+[DATE]) warrants emergent ER [emergency room ] evaluation for acute on chronic symptomatic anemia (presume acute blood loss due to supratherapeutic anticoagulation though also concern for hemolysis per prior charting) . Review of Resident #1's Resident Transfer Form Emergency Department revealed Resident #1 left for the Emergency Department (ED) on [DATE]. Review of Resident #1's medical record revealed the resident was transported to Alaska Regional Hospital and admitted on [DATE]. Further review revealed the following course through that hospitalization : [DATE]: admitted through ED, transfused 1 unit of packed red blood cells (prbc), repeated 2 more units. No improvement to blood values. [DATE]: An additional 2 units of prbc's transfused. No improvement to blood values. No further transfusions recommended. [DATE]: Resident #1 unresponsive. No urine output, placed on comfort care. [DATE]: admitted to inpatient hospice. [DATE]: Resident #1 passed away. Resident #2 Record review conducted on [DATE] and [DATE] revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Atrial Fibrillation (A-fib - a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure, and other complications) and fractures. Review of Resident #2's ECS record revealed he/she had a delay in Lovenox administration, due to the transcription error, and was not started until [DATE]. Facility's Medication Order Processing Procedure During an interview on [DATE] at 2:48 PM, the Director of Nursing (DON) stated the physicians placed orders for medication by handwriting the orders into the residents' paper hard charts. The DON further stated these hand-written orders were reviewed, signed off, and transcribed into the residents' eMAR (called ECS) by the nursing supervisors of the units. Once the order had been transcribed into ECS, the ECS system alerted the pharmacy electronically of the new order. The DON further stated that the original hand-written order remained in the chart and was never sent to the pharmacy. When asked about the facility's auditing process for medication orders, the DON stated there was a 24-hour chart check that was completed nightly for all new orders written in the hard charts. These written orders were compared to the orders in the ECS system to ensure the orders were transcribed correctly. Facility Training on 24-hour Chart Checks During an interview on [DATE] at 3:05 PM, the Senior Manager of Clinical Education (SMCE) stated the 24-hour chart check was solely looking at the residents' hard paper chart for new orders, and ensuring those orders were transcribed correctly into the ECS system and to ensure proper notifications were completed. The SMCE further stated the 24-hour chart check did not involve reviewing all residents' ECS records to ensure orders transcribed had written orders in the hard paper charts. Facility Investigation of Medication Error During an interview on [DATE] at 3:10 PM, the Quality Director stated an investigation into the medication error occurred. All nurses involved were interviewed and the following was determined: - LN #4 stated when he/she was placing the orders written for Resident #2 when another nurse interrupted the transcription to ask for help in Resident #1's ECS record. LN #4 stopped his/her order entry and opened Resident #1's ECS record to assist the nurse. LN #4 did not switch back into Resident #2's ECS record before completing Resident #2's transcriptions and inadvertently placed Resident #2's Lovenox order into Resident #1's ECS record. - LN #5 stated when he/she performed the 24-hour chart check, he/she found no discrepancies for Resident #1, but did notice Resident #2's Lovenox order was not transcribed onto his/her ECS record. LN #5 spoke with LN #4, who signed off the orders in Resident #2's hard paper chart. LN #5 stated LN #4 wrote down the discrepancy and stated he/she would look at it later. LN #5 signed off Resident #2's chart check as completed, assuming LN #4 would go back and fix the discrepancy. LN #5 admitted that he/she did not follow the 24-hour chart check protocol. Review of the facility's policy Order Management, dated ,d+[DATE], revealed: .Every Chart will be checked every night by a licensed nurse to ensure that all orders have been transcribed accurately and no orders have been missed. This is a second check on all orders . Review of the facility's protocol 24-Hour Check of Each Chart, dated ,d+[DATE], revealed: The assigned night shift nurse and/or rover nurse will review all orders and is responsible to ensure that the order is clearly written, transcribed correctly into eMAR and that all communications via fax and email were done (Pharmacy is faxed all controlled substance orders . If an order is found during the 24-hour check that had not been previously processed by nursing, the assigned night shift nurse will ensure that the order is processed . Further review revealed no process to ensure all orders transcribed into the ECS system were audited to ensure it had a written order in the resident's hard chart.

Based on record review, observation, and interview, the facility failed to ensure that Certified Nursing Assistants (CNAs) were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the care plan for 1 Resident (#17), out of 12 sampled residents. Specifically, the facility failed to ensure CNAs had appropriate competency for the use of suction toothbrushes (toothbrushes with suction to quickly remove excess fluids from the mouth to prevent choking) and appropriate training and competency for the use of yaunker suctions (a hard plastic oral suctioning tool). This failed practice placed 2 of 42 residents, at risk for inappropriate use of suction devices that could lead to choking, mouth/throat tissue damage that could result in swelling and inhibit breathing, and/or death which constituted an immediate jeopardy at 483.35(c) Proficiency of Nurse Aides. This situation was brought to the attention of the facility's administration on 5/6/22 at 3:20 PM, at which time the facility was notified of identified potential physical harm and immediate jeopardy. The facility submitted an acceptable immediacy removal plan on 5/6/22 at 5:15 PM. The State Agency verified, onsite, that the immediacy was removed on 5/8/22 at 3:16 PM. Findings: Record review on 5/2-6/22 revealed Resident #17 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #17's Comprehensive Care Plan, dated 3/31/22, revealed: I need: extra oral care Because I: have lost all my teeth, I have dysphagia and am aphasic [inability to comprehend or formulate language due to brain damage] . I need my aides to- help me brush .use a suction toothbrush . Record review of Resident #17's Baseline Care Plan (a working care plan in the resident's rooms and used during daily cares), printed on 5/4/22, revealed: Oral care: with the help of 1 person. Provide mouth care twice daily in AM [morning] and HS [evening]. Use yaunker suction as needed. During an observation/interview on 5/4/22 at 3:46 PM, when asked about Resident #17's oral cares, CNA #1 read from the resident's Baseline Care Plan and stated yaunker suctioning was used. During an interview on 5/5/22 at 4:06 PM, CNA #2 stated he/she used an oral care sponge with mouth wash and used a yaunker suction during Resident #17's oral care. During an observation on 5/6/22 at 10:46 AM, CNA #4 used the suction toothbrush, with the assistance of CNA #2, during Resident #17's oral care. CNA #4 then used the Yaunker suction around Resident's gums and in the back of the mouth, and lastly used a sponge and washcloth to clean and dry resident's face and lips. During an interview on 5/6/22 at 12:17 PM, when asked what training was provided for the suction toothbrush and the yaunker suction, CNA #3 stated he/she only observed a brief demonstration for both suction devices during orientation. CNA #3 stated he/she did not get to repeat back demonstration nor was there a competency checkoff for the suction devices completed during training. During an interview on 5/6/22 at 12:20 PM, when asked what training was provided for the suction toothbrush and the yaunker suctioning, CNA #4 stated he/she had worked at the facility for years and could not remember the orientation training for suction devices. He/she stated there was no competency checkoff completed for the suction devices during training. CNA #4 stated he/she would appreciate a refresher as suctioning was rarely used because he/she forgot how to do them. During an interview on 5/6/22 at 1:26 PM, the Staff Development Manager stated the Staff Educator provided education on the suction toothbrush at orientation for CNAs. The Staff Development Manager stated the training consisted of a demonstration using the suction toothbrush after reviewing a handout on steps taken to use the suction toothbrush. The Staff Development Manager further stated that there was a facility competency check off document entitled Using the Plak-Vak Suction Toothbrush, but the Staff Educator did not use this competency check off at training. In addition, the Staff Development Manager stated that CNAs do no use the yaunker suction and the Staff Educator did not train CNAs on the yaunker suction. During an interview on 5/6/22 at 1:46 PM, the Director of Nursing (DON) stated that CNAs were able do oral (mouth) suctioning on residents and could operate the yaunker suction equipment. During an interview on 5/6/22 at 2:32 PM, the DON and Staff Development Manager, stated there was the potential for harm to residents if the CNAs did not perform appropriate and correct yaunker suction technique. During an interview on 5/6/22 at 2:52 PM, Provider #1 stated suctioning with a yaunker suction would be considered a nursing task. He/she further stated that there was a risk of damage to the mouth and throat tissues if suctioning was completed incorrectly or inappropriately, which could affect breathing. Record Review of the facility's Certified Nursing Assistant (CNA) Job Description, revised on 9/5/19 revealed, . General Summary: The Certified Nursing Assistant performs basic routine nursing duties/tasks which do not require professional training and education. These duties/tasks center around the resident by assisting them in all activities of daily living. The CNA performs under the supervision of a licensed nurse (RN or LPN) at all times . Essential Functions . For direct patient care roles: Performs and maintains currency of essential competencies as required by specific area of hire and populations served . Resident Care: Demonstrates understanding of and carries out individual resident's care according to Standards of Care and Residents Daily Care Plan. Uses techniques as taught in facility orientation . Review of the facility's Facility Assessment, dated 2022, revealed: . Function - Care Requirements . 4. Staff Competencies required . CNA: safe patient handling, dining/speech . oral care . Care Plan . aspirations precautions. Further review revealed no indication for suctioning care. Further review revealed: . Nursing . swallowing difficulty . safe patient handling, physical assessment, aspiration precautions . Further review of the Facility Assessment revealed: . B. Acuity-Diseases, Conditions, [and] Treatments . Conditions . Swallowing Difficulty . Frequency Related to Benchmark: Very High . Treatments . Suctioning . Frequency Related to Benchmark: High . B.2. Acuity - Care Requirements . Staff Competencies required . CNA . feeding/speech . oral care . Care Plan . Nurse . swallowing difficulty . cough assist . Review of the State of Alaska Statutes and Regulations: Nursing, dated January 2022, revealed: 12 AAC 44.950. Standards for delegation of nursing duties to other persons . A nurse licensed under AS 08.68 may delegate the performance of nursing duties to other persons, including unlicensed assistive personnel [which includes the CNAs], if the following conditions are met: . (4) the person to whom the nursing duty is to be delegated has received the training needed to safely perform the delegated duty, and this training has been documented;(5) the nurse determines that the person to whom a nursing duty is to be delegated is competent to perform the delegated duty correctly and safely . Further review revealed: . 12 AAC 44.960. Delegation of Specialized Nursing Duties . Specialized nursing duties are those duties that do not require professional nursing education to correctly perform, but require more training and skill than routine nursing duties. Specialized nursing duties may be delegated to another person under the standard set out in 12 AAC 44.950 . Specialized nursing tasks that may be delegated include . suctioning of the oral pharynx . Review of the facility's policies concerning suction devices revealed only two policies: Suction Machines Cleaning and Disinfecting, last revised 7/2019, and Replacement of Suction Canister and Tubing, last revised 8/2017. The Quality Director stated the facility had no other policies or protocol for suction devices.

Based on record review, interview and policy review, the facility failed to ensure that 1 resident (#3) out of 4 sampled received the necessary care and services to prevent the development of a new pressure injury (a localized injury to the skin and/or underlying tissue that usually occurs over a bony prominence as a result of pressure; also known as pressure sore, wound, or decubitus ulcer). Specifically, 1) The facility failed to accurately and consistently assess and monitor for device acquired pressure wounds; and 2) the facility relied on Certified Nursing Assistants (CNAs) instead of licensed nurses, to remove PRAFO boots (pressure relief ankle foot orthosis) and report any skin issues found. The failure to accurately assess the skin under the boots caused an avoidable pressure injury on the left heel. Findings: Record review on 8/30-31/16 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, an admission assessment dated [DATE], revealed the resident was coded as not having any pressure injuries. Review of the provider's note dated 7/8/16 at 1:22 pm revealed .seen for new bruise on left heel .warm dry, new pressure injury to left heel .wound number 22, provider Diagnosis: [REDACTED].suspected deep tissue injury (SDTI) to left heel due to PRAFO device. Further documentation on 7/18/16 revealed .[DIAGNOSES REDACTED].granulating 10% and slough 90% .wound debrided today with scissors and debrisoft . Review of the treatment administration record (TAR) dated 6/23/16, revealed Adaptive device # 1: PRAFO .bilateral ankles .on at all times, 1) Remove twice daily, inspect site, clean & dry (unless MD orders prohibit removal) AM PM .If resident refuses removal, document & notify resident of risks and notify MD of refusal. During an interview on 8/31/16 at 7:30 am, LN #2 stated the CNAs do the hands on care which included removing the boots and inspecting the skin. The CNAs then would report any new skin issues to the nurses. LN #2 also stated that nurses do a regular skin integrity assessment weekly. If there is a new skin issue, a skin integrity assessment is filled out and forwarded to the wound team. She also stated, daily morning and evening removal of the PRAFO boots are done by the CNA's during resident care. During an interview on 8/31/16 at 8:30 am Resident #3 stated that the facility told her/him that the boots should stay on at all times. Furthermore, the Resident stated they did not remove the boots during the night the first week I was here, you see, I am paralyzed and cannot feel anything below my waist. During an interview on 8/31/16 at 12:00 pm, the Director of Nursing (DON) stated the heel wound was first noticed on 7/6/16. Additionally, the DON stated the new wound was large and obvious enough for the staff to easily notice. The DON confirmed the pressure injury was due to the PRAFO device and the heels should have been inspected daily by the nurse per orders. During an interview on 8/31/16 at 12:45 pm, the Director of Staff Development stated that the CNA's are trained to do skin checks morning and night and is part of the Standards of Care for each resident at admission. Review on 9/2/16 of POWELL, an orthotics and prosthetics facility in(NAME) VA at www.powellondp.com revealed, Risk and Benefits of the orthosis PRAFO device May cause skin breakdown such as scratching, bruising, or blistering, which can cause serious complications if skin is not checked regularly or if device is not applied as directed. Review on 8/31/16, of the facility's protocol, Standards of Patient Care for Nursing revealed .Skin Care: monitor skin when providing care, paying special attention to pressure areas such as heels, sacrum .Monitor patient's skin for redness, irritation, breakdown, dryness, etc. and notify the PCN .

The facility failed to 1) recognize, assess and monitor a decline in a resident's condition and 2) failed to notify the on-call physician of the continued deterioration in the resident's condition in accordance with physician orders [REDACTED]. This resulted in actual harm due to insufficient assessment and monitoring which resulted in delayed emergency room evaluation and treatment. Findings: Resident #1, a [AGE] year-old female, was admitted [DATE] with a [MEDICAL CONDITION] following a motor vehicle accident. Physician documentation from a [DATE] visit revealed the Resident's [DIAGNOSES REDACTED]. The Resident had multiple wounds and was receiving wound care. In addition, the Resident had a Foley catheter (catheter inserted in the bladder used for continuous drainage of the bladder) and a gastrostomy tube (a tube surgically inserted into the stomach through the abdominal wall) and received nutrition via the gastrostomy tube. Review on [DATE] of "CNA Charting" revealed the following vital signs (VS; T - body temperature, P - pulse rate, R - respiratory rate, and BP - blood pressure) documented for Resident #1: ("An armpit (axillary) temperature is usually 0.5? F to 1? F lower than an oral temperature", per an article by Jan Nissl, RN, BS [DATE]: (<http://www.revolutionhealth.com/articles/rectal-ear-oral-and-axillary-temperature-comparison>)) CNA #1, on [DATE] at 6:10 pm: T 103.5 Ax (equivalent to 103XXX,[DATE].5 orally) P 135, R 32, and BP ,[DATE]; CNA #2, on [DATE] at 11:20 pm: T 101.8 Ax (equivalent to 102.3 - 102.8 orally), P 153, R 39, and BP ,[DATE]; CNA #2, on [DATE]: - at 1:05 am: T 101.3 Ax (equivalent to 101.8 - 102.3 orally), P 151, R 42, and BP ,[DATE]; - at 2:25 am T 103.3 Ax (equivalent to 103.8 - 104.3 orally), no other VS recorded; - at 4:20 am: T 101.3 Ax (equivalent to 101.8 - 102.3 orally), P recorded as 34, R recorded as 128, and BP ,[DATE]; and - at 6:21 am: T 99.5 (equivalent to 100 - 100.5 orally), P 148, R 30, and BP ,[DATE]. The article by Jan Nissl, RN, BS continued with "A fever usually means your body is responding to a [MEDICAL CONDITION] or bacterial infection. For an adult, a fever usually isn't dangerous unless it reaches 103 F or higher. High fevers between 103 F and 106 F may cause: hallucinations; confusion; irritability; and convulsions." References Related to Vital Signs: Temperature Per "Vital Signs (Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure)": (<http://www.health.uab.edu/ />) "Body temperature may be abnormal due to fever (high temperature) or hypothermia (low temperature). A fever is indicated when body temperature rises above 98.6? orally...according to the American Medical Association...", and Respiration "Respiration rates may increase with fever, illness, and with other medical conditions. When checking respiration, it is important to also note whether a person has any difficulty breathing. Normal respiration rates for an adult person at rest range from 15 to 20 breaths per minute. Respiration rates over 25 breaths per minute or under 12 breaths per minute (when at rest) may be considered abnormal." Pulse The normal pulse for healthy adults ranges from 60 to 100 beats per minute. [MEDICAL CONDITION] a heart rate greater than 100 beats/minute and normally occurs in response to emotional or physical stress, such as excitement, exercise, pain, anxiety, and fever. [MEDICAL CONDITION] be an early sign of a life-threatening disorder, such as cardiogenic ([MEDICAL CONDITION] by a weak, thready pulse), hypovolemic (mild [MEDICAL CONDITION] by increased respiration, restlessness, thirst, and pale, cool skin. As shock progresses the pulse becomes increasingly rapid and thready), or septic shock (caused by decreased tissue perfusion (decrease in oxygen-rich arterial blood flow) and oxygen delivery as a result of severe infection [MEDICAL CONDITION]). ([MEDICAL CONDITION] Excerpt from Nursing: Interpreting Signs and Symptoms Lippincott Williams & Wilkins 2007). A rapid heartbeat does not allow enough time for the heart to fill before it contracts so blood flow to the rest of the body is compromised. (<http://www.heart.org>) Blood Pressure A blood pressure reading of 90 millimeters of mercury (mm Hg) or less systolic (the top number in a blood pressure reading) or 60 mm Hg or less diastolic (the bottom number) is generally considered low blood pressure. Current guidelines identify normal blood pressure as equal to or lower than ,[DATE]. Some medical conditions can cause low blood pressure including dehydration and severe infection ([MEDICAL CONDITION]). (<http://www.mayoclinic.com/health/hypoxemia>) Oxygen Saturation (O2 Sats) "Hypoxemia (low blood oxygen)" (<http://www.mayoclinic.com/health/hypoxemia>) "An approximate blood oxygen level can also be determined using a pulse oximeter - a small device that clips on your finger. Though the pulse oximeter actually measures the saturation of oxygen in your blood, the results are often used as an estimate of blood oxygen levels. Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low." Review on [DATE] of "Nursing Notes" revealed the following documentation: LPN #1, PCN (Primary Care Nurse) evening shift: On [DATE] at 12:17 am, LPN #1 documented that at 6:20 pm the CNA reported that the Resident complained of not feeling well; she took her vital signs. Documentation of VS revealed the Resident's blood pressure was ,[DATE], temperature (temp) 104 Ax (equivalent to 104.5 - 105 orally), pulse 135, and respirations 32. The LPN did a follow-up temperature and documented the temp as 103.6 Ax (equivalent to 104.1 - 104.6 orally). The LPN noted respirations were 22 when resting and 32 when the Resident started to moan. LPN #1 gave the Resident PRN Tylenol 650 mg suppository at 6:30 pm. At 7:20 pm LPN #1 did another follow-up temp and the temp was 99.8 Ax (equivalent to 100.3 - 100.8 orally). The LPN notified the evening shift supervisor and paged the on-call physician. The physician ordered blood work (CBC, or complete blood count and BMP, or basal metabolic panel). The physician told the LPN to give the Resident Tylenol #3 one tab q (every) 6 hours on-going for severe pain/fever and ordered a nasal swab to test for influenza A and B. In addition, the physician gave the LPN an order to call the covering physician if the Resident's condition worsened. The specimens were sent to the Providence Hospital lab at 8:40 pm. At 10:05 pm lab staff called the LPN to let her know the CBC was clotted and requested another specimen. He also told her that the influenza A and B preliminary report was negative but it needed to be sent to the state lab. At the change of shift LPN #1 told LPN #2 that the blood specimen would need to be obtained. LPN #2, PCN night shift: On [DATE] at 7:54 am LPN #2 documented that at 11:30 pm T was 101.8 Ax (equivalent to 102.3 - 102.8 orally), P 152, R 39, BP ,[DATE], and O2 Sats ",[DATE] 5 at R.A. (room air). Called R.T. (respiratory therapy) Started O2 at 6 liters O2 Sats were ,[DATE]% Cooling Measures Started" At 1 am - T 101.3 Ax (equivalent to 101.8 - 102.3 orally), P 151, R 42, and BP ,[DATE]. "Cooling Measures continued. O2 Sats 94% at 4 Liters." At 2:30 am - T 103.3.Ax (equivalent to 103.8 - 104.3 orally), no other VS documented. "Tyl.3 Given For Temp." At 4:20 am - T 101.3 Ax (equivalent to 101.8 - 102.3 orally); "2128 34" B.PXXX,[DATE] "Cooling Measures Continued." At 6:20 am - T 99.5 Ax (equivalent to 100 - 100.5 orally), P 148, R 30, BP ,[DATE] "Supervisor Updated Through Out The Night On Residents Condition." RN #1, day shift: On [DATE] at 3:58 pm RN #1 documented that the Resident's physician was paged at 7:15 am. At 8:00 am the RN updated the physician on the Resident's condition. Documentation noted the physician had reviewed the blood specimen results and was going to call the family to see what their wishes were for hospitalization /emergency room evaluation. At 8:15 am the physician called and gave the RN orders to start an IV infusion and make arrangements to send the Resident to the emergency room . Interviews During an interview on [DATE] at 3:55 pm, CNA #1 stated that at the beginning of the shift the Resident "did not respond to me. I didn't think she was 100%. I knew she was not okay. I noticed she was sweating a lot and she wasn't breathing right." When asked to describe the Resident's breathing she replied, "Panting, then stopped, like not breathing. I told the nurse. I kept an eye on her. Her respirations stayed the same and she was not responding like she normally would." CNA #1 also stated "with her temp and her breathing like that I assumed she would be sent to the hospital. She didn't get better and I kept an eye on her all night. I felt like she stayed the same. When night shift came on I gave report to the CNA and said she's not ok. She immediately got her vital signs. I believe her respirations were 42." Interview on [DATE] with CNA #2 at 7:30 am revealed CNA #2 received report from CNA #1 who told her that the Resident "wasn't feeling up to par" and was running a temp. After taking the Resident's vital signs, CNA #2 reported them to the nurse, LPN #2. The CNA stated that the Resident "was one of my favorites" and said that it was unusual for the Resident to have a fever and that the Resident "didn't look too hot." CNA #2 further stated "Normally she jokes and talks and is really chipper. She wasn't responding to me when I walked into the room." When asked to describe the Resident's breathing she stated "She was breathing really funny; kind of like panting, short breaths; like when you are crying." Interview with LPN #1 on [DATE] at 3:05 pm revealed CNA #1 notified her of the Resident's vital signs. LPN #1 stated she did a follow-up temp and gave the Resident a suppository for the fever. She called the evening shift supervisor. The next temp was 99.8 axillary (equivalent to 100XXX,[DATE].8 orally). The LPN stated "99.8 was still high 'cause the (oral) temp is 1 point higher." The physician was notified and he gave the LPN orders that included calling the physician on-call if the Resident's condition worsened. LPN #1 confirmed she wrote the verbal order on the physician orders [REDACTED]. In addition, she confirmed that during report she told the oncoming nurse, LPN #2, that there was an order to call the physician if the Resident's condition worsened. Review on [DATE] of the physician orders, the [DATE] MAR and the 24-hour chart check revealed: "If resident condition worsen call covering MD (physician name)" was written as a verbal order on [DATE] at 7:30 pm by LPN #1; the [DATE] MAR included "If resident condition worsen call covering MD (physician name) [DATE]; and documented below the physician order [REDACTED].? (check)", which was initialed. During an interview with LPN #2 on [DATE] at 7:45 am the LPN stated he had gotten report from the evening shift nurse and was told that the Resident was running a high temp. He stated that he gave the Resident Tylenol #3. When asked if he felt the Resident's pulse was unusually high he replied "it was but not for that high of temp. I was more concerned about getting the temp down and the pulse would come down with the temp." He also stated that at 1 am the Resident still had a fever and he also thought the pulse was still up. LPN #2 referred to his notes and confirmed the pulse was 151 at 1 am. When asked if this was unusual he stated the Resident's pulse was "usually in the 80s" and agreed that a pulse of 151 was high. When asked if the physician was notified that the Resident's pulse was that high he stated "No, I did not call". LPN #2 stated he got the blood work results about 5 am and "the supervisor said to just pass it on to days". When asked what the lab results looked like he stated "I don't remember" and added "it didn't stick out in my mind". Asked if he himself had checked to see if the lab results were posted he said "somebody pulled it up for me." When asked about the Resident's respirations he stated "they were slightly labored". LPN #2 also stated that when he began his shift the Resident's O2 Sats were ",[DATE]%" and that he called respiratory therapy and confirmed that he was in the room when the respiratory therapist came in. According to LPN #2, the respiratory therapist started the Resident on oxygen. When asked about the Resident's urine he stated "It was normal; amber". When the surveyors asked LPN #2 if the supervisor (an RN) had assessed the Resident he replied "She came a couple of times; just observed her." LPN #2 also stated that the Resident "wasn't responding when we first came on. She was sick." When asked about signs and symptoms of dehydration he stated the Resident's tongue was "fine; normal". The surveyors asked LPN #2 if there was an order to call the doctor if the Resident's condition got worse and he replied "No; I waited until the blood work came back and since it was so late she (supervisor) said to pass on to days". During an interview on [DATE] at 7:20 am with the night supervisor, RN #2, she stated LPN #2 had called her to come and take a look at the Resident. She stated that R.T. started oxygen via nasal cannula. When asked if she looked at the urine in the Resident's Foley bag, she stated she did not look at the urine. When asked if she was concerned about the Resident's pulse she stated "I didn't concentrate on her pulse, was it elevated?" The surveyor told RN #2 that the Resident's pulse was 153. When asked if there was any reason to call the physician she replied "No, and we were waiting on labs." She also confirmed that she had instructed staff to tell the day shift to notify the physician about the blood work results. Review on [DATE] of the "24 Hour Report", used by shift supervisors during report, revealed RN #2 documented that the Resident's pulse was 153 at 11:30 pm and 151 at 1:00 am. In addition, the temperatures, respirations of 39 and 42 as well as O2 Sats were documented on the 24 Hour Report. Review of "[MEDICAL CONDITION] (bacterial infection in the bloodstream or body tissues) in the Adult Patient" AJN, American Journal of Nursing: [DATE] - Volume 109 - Issue 3 (<http://journals.1ww.com/ajnonline/>) revealed the following: The increasing incidence [MEDICAL CONDITION], especially among older adults, its high mortality rate, and its subtle and rapid progression make prompt recognition and treatment imperative...Improving outcomes in patients [MEDICAL CONDITION] depends on every nurse involved in their care...Early recognition and rapid response are essential in the successful treatment of [REDACTED]. Stage 1 - systemic [MEDICAL CONDITION] response syndrome (SIRS) when two or more of the following are present: - a temperature higher than 100.4 ?F or lower than 96.8?F, - a heart rate greater than 90 beats per minute, - a respiratory rate greater than 20 breaths per minute, or - a white blood cell (WBC) count higher than 12. Interview on [DATE] with the Providence lab director revealed the Resident's lab results would most likely have been posted by 3 am on [DATE]. Review of the Resident's CBC revealed the WBC count was 21.8, which was identified as high by the lab. In addition, the BUN, creatinine, sodium, and chloride values were also identified by the lab as higher than normal. Per "Deciphering Diagnostic Tests", from the publishers of "Nursing" journal, 2008: WBC (white blood cell) - An elevated WBC count commonly signals infection. BUN (blood urea nitrogen) - An elevated BUN reflects renal (kidney) excretory capacity; high levels can indicate reduced renal blood flow (from hydration, for example), urinary tract obstruction, or GI (gastrointestinal) bleed. Creatinine - High levels usually indicate [MEDICAL CONDITION]. Analysis of serum creatinine levels provides a more sensitive measure of renal damage than BUN levels. Sodium and Chloride - Elevated levels may be due to dehydration. Review of both the Resident's clinical record and the electronic medical record revealed there was no respiratory therapy documentation for ,[DATE]-,[DATE]. On [DATE] at 7:45 am the Respiratory Therapist on duty was unable to find any documented evidence that the Resident had been seen, assessed, and treated by RT. During a phone interview on [DATE] at 8:07 am with the therapist who was on duty the morning of [DATE], he stated he didn't think he was called but that he didn't remember. When asked if nursing staff had called him to see the Resident, would he have documented it, he replied "yes, I would". During a phone interview with the respiratory therapy supervisor on [DATE] at 7:59 am he stated that therapists typically look at the residents' history; determine oxygen saturation level; listen to breath sounds; observe extremities for [MEDICAL CONDITION]; and initiate and monitor oxygen therapy. When asked if his expectation as a supervisor was that any assessment and treatment would be documented he replied "That would be my expectation." References Review of Providence Extended Care Center Protocols/Care Plans, used by nursing staff for specific identified issues, revealed they included the following: "Acute Onset of Fever" Problem: Any temperature ? 101 (O) or 102 (O) at any time. Nursing Interventions & Monitoring: When temperature is elevated, continue to monitor for cause of fever and document findings: Auscultate (listen to) lung sounds every shift. Monitor for changes in urinary pattern and odor, etc. Monitor for dehydration. Further review on [DATE] of "Nursing Notes" revealed no documented evidence nursing staff monitored for cause of the Resident's fever, assessed lung sounds, monitored urine for changes or monitored for dehydration. "Signs & Symptoms Urinary Tract Infection" Problem: Symptoms of urinary tract infection are present. Nursing Interventions & Monitoring: Determine current intake and output, complaints of urgency, frequency or burning, color, concentration and odor of urine, bladder distention, flank pain, or change in mental status. Further review on [DATE] of "Nursing Notes" revealed no documented evidence nursing staff monitored the Resident for decreased urinary output, assessed the concentration and odor of the urine, or monitored the Resident's mental status. "Resident Change of Condition/Treatment" 1. Any staff person who notices a resident's change in condition reports immediately to the licensed nurse (This includes mental as well as physical changes in condition). 2. The licensed nurse observes the resident and notes signs and symptoms. 5. Serious or life-threatening situations may warrant immediate transfer to the hospital and may preclude awaiting response by the physician. 8. The licensed nurse documents all pertinent information regarding change in condition in the resident's medical record and places on 24-hour report. Further review on [DATE] of "Nursing Notes" revealed no documented evidence that nursing staff assessed and consistently monitored the Resident's status for signs and symptoms indicating a change in condition which may have warranted transfer to the hospital. "Guidelines Twenty-Four Hour Report" 1. The 24-hour report is an internal tool to facilitate reporting and follow up of problems. Please bear in mind that the resident's individual record is the only legal proof of follow up of a problem. The 24-hour report is never a substitute for documentation in the chart but rather a prompting of problems to be followed and documented thoroughly in the resident's record. Further review on [DATE] of "Nursing Notes" revealed no documented evidence of any follow up for the Resident's elevated temperature, pulse, and respirations and decreased oxygen saturation documented by RN #2 in the 24 Hour Report. "Documentation" 1. Documentation in Medical Record Progress Notes Organize and integrate data to include nursing knowledge and experience. Include information in a progress note demonstrating nursing process: 1) Subjective: What the resident/patient says, other information that is not verified by facts but is pertinent to the issue. 2) Objective: Objective facts. Factual description of what you could see, hear, smell, measure, and what you did. 3) Assessment: Based on the subjective and objective data above, what is your Conclusion? Name the problem, strength or need. The assessment may also be a statement regarding the status of the issue (improved, declining, stable). 4) Plan: An appropriate plan of care or treatment based on the data assessment. Further review on [DATE] of "Nursing Notes" revealed no documented evidence of subjective or objective findings or assessment of the Resident's status. LPN #2's documentation included only vital signs, O2 Sats, cooling measures and that he kept the night supervisor, RN #2, updated. There was no documented evidence RN #2 conducted an assessment of the Resident's condition or evaluated breath sounds; signs/symptoms of dehydration; determination of intake and output; color, concentration and odor of urine; pulse rate that included pulse strength (e.g. bounding, weak) and any alterations in rhythm, such as [MEDICAL CONDITION] change in mental status; lab work results; signs of infection at Foley and Peg sites; and skin color and temperature. During an interview with RN #3 on [DATE] at 3:50 pm he stated that on [DATE] he was working as the evening shift supervisor and LPN #1 had called him because the Resident had a high fever, ,[DATE]. He stated that he told her to call the doctor right away. The doctor gave the LPN orders for blood work plus influenza testing. RN #3 was asked about oxygen saturations levels and at what point he would call the physician. He replied "when it is 85 and below". RN #3 was uncertain if he was informed about the Resident's pulse and stated that he would consider a high pulse as 80 and above. When asked when he would call the physician regarding an elevated pulse rate, he replied "If more than 100." When asked what he would do if the pulse rate was in the 150s he stated "I would definitely call the doctor and ask if we could send the resident to the hospital". When asked what a supervisor's expectation is if a resident gets worse, he stated "Would be sure the PCN assessed the resident. If the resident had gotten worse we would definitely call the doctor, especially if there is an order that says that." He further stated if oxygen Sats were really low and the resident needed more than 2 liters he would usually call the doctor also and ask respiratory therapy to assess. RN #3 stated that if he was working as a supervisor and it was important to do an assessment, he would do the assessment himself and chart it. During an interview with RN #1 on [DATE] at 8:45 am he stated that he reviewed the Resident's labs and her condition when he came to work on the day shift on [DATE], and he thought she should be evaluated at the hospital. RN #1 stated he called the physician at 7:15 am. Review on [DATE] of the facility's "Resident Transfer Form Emergency Department", signed by RN #1, revealed the Resident was transferred via EMS (Emergency Medical Services-Anchorage Fire Department) at 8:47 am with chief complaints of escalated temperature, decreased oxygen saturation, and possible dehydration. Review of EMS documentation revealed that at 8:35 am, upon arrival at the facility, the Resident's skin was hot and diaphoretic (secretion of sweat, especially the profuse secretion associated with an elevated body temperature). Documentation noted rhonchi (a rattling sound, somewhat like snoring heard on auscultation of the chest when there is a partial [MEDICATION NAME] obstruction) on expiration and grunting on inspiration. The urine in the Foley catheter bag was described as cloudy with particulates (particles or fragments of a substance or material) in the urine. The Resident's blood pressure was ,[DATE], pulse 135, respirations 22. The oxygen saturation level was 84% on room air and the Resident's temp was 101.3. EMS staff administered oxygen at 15L (liters), started an IV, and transported the Resident to the hospital. emergency room physician documentation revealed the medics found the Resident to be very [MEDICAL CONDITION] in the 140s to 150s. Physical exam revealed the Resident's temp was 103.2 (equivalent to 103XXX,[DATE].2 orally); pulse 149 and respirations 36. The Resident's gastrostomy tube was noted to be leaking yellowish-green fluid. During the emergency room course the Resident remained extremely [MEDICAL CONDITION] in the 140s and 150s. She was hypoxic (pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen <http://en.wikipedia.org/wiki/Oxygen> supply) and 15L of oxygen was needed to maintain the oxygen saturation at 91%. The Foley catheter tubing was coated with a thick mucoid substance and a new catheter was inserted. Diagnostic tests revealed bilateral pneumonia, urinary tract infection,[MEDICAL CONDITION] syndrome (an adverse systemic response to infection that includes fever, rapid heartbeat and respiration, low blood pressure and organ dysfunction associated with compromised circulation), and [DIAGNOSES REDACTED] (low levels of calcium in the body; low levels of calcium can cause arrhythmias or decreased cardiac output). Antibiotics were administered IV. During an interview on [DATE] at 12:50 pm, emergency room Staff #1 stated that the Resident's urine was very dark (darker than amber), thick, cloudy and very foul smelling and stated the peg tube was draining copious amounts of yellowish fluid. In addition, Staff #1 noted the Resident's mouth (lips and tongue) to be extremely dry, cracked and coated with a dried substance that would need to be soaked several times before it could be scraped off the tongue. The Resident was admitted to a medical floor with a temp of 103.2, pulse of 156 and respiratory rate of 28. Review of the medical record revealed admitting [DIAGNOSES REDACTED]. During interviews on [DATE] from 12:06 to 1 pm with Staff #s 2 and 3, they revealed the Resident's mouth was very dry and the tongue was cracked and covered in what looked like dried secretions. Staff stated they used a wet gauze and said it was hard to clean the Resident's tongue. Interview with Staff #4 on [DATE] at 12:30 pm revealed that on [DATE] the Resident's gastrostomy tube was changed due to issues with leakage. During an interview with Staff #5 on [DATE] at 12:01 pm, Staff #5 described the Resident's tongue as being caked with a brown, crusty-like substance that looked like scales. In addition Staff #1 stated the Resident's skin was pasty-colored and she was diaphoretic. Further record review revealed the Resident expired on [DATE]. Discharge [DIAGNOSES REDACTED]. As a result of insufficient assessment and monitoring, the facility failed to recognize the Resident's continued decline. This deficient practice led to the facility's failure to address the Resident's worsened condition by immediately notifying the physician as ordered, or by sending the Resident to the emergency room for evaluation. Per the Board of Nursing Statutes and Regulations, 12 AAC 44.970, Nursing Duties That May Not Be Delegated, "Nursing duties that require the exercise of professional nursing knowledge or judgment or complex nursing skills may not be delegated. Nursing duties that may not be delegated include (1) The comprehensive assessment of the patient by a registered nurse, and referral and follow-up."