Every finding on record at Providence Kodiak Island Med LTC

.Based on record review, observation, and interview, the facility failed to ensure a culture where residents were treated with dignity and respect for 2 residents (#'s 6 and 19), out of 13 sampled residents. Specifically, the facility failed to: 1) Respond appropriately to the toileting needs for Resident #6, which resulted in the resident being forced to defecate the bed; 2) Maintain Resident #6's dignity and privacy by allowing the resident's catheter urine collection bag to remain uncovered and visible to individuals passing by in the hallway; and 3) Ensure Resident #19's privacy, by way of closing the bedroom door, while providing personal care. These failed practices placed the residents at risk for diminished self-esteem and/or self-worth and the potential for a poor quality of life. Findings: Resident #6Toileting Needs Record review on 12/1-5/25 revealed Resident #6 was admitted to the facility with diagnoses that included a right parietal lobe mass (a brain mass that can affect sensory processing and spatial awareness), cirrhosis of the liver (scarring of the liver), anxiety disorder, bipolar disorder (a mental health condition characterized by extreme mood swings), and an unstageable pressure ulcer/injury. During an interview on 12/2/25 at 9:13 AM, Resident #6 stated the staff made him/her poop in bed. The resident stated the staff did not allow him/her out of bed to use the bathroom because he/she was weak, and the staff would not provide a bed pan. Instead, the staff encouraged the resident to defecate the bed on an absorbent pad, assuring that they would clean it up afterward. The resident expressed discomfort and embarrassment. When asked if the resident could tell if he/she needed to use the bathroom, the resident stated that he/she could. Random observations on 12/1-5/25 revealed Resident #6's door was open most of the time, and staff were sitting directly outside of the resident's room, or staff were sitting in the resident's room. During an interview on 12/2/25 at 9:20 AM, Certified Nursing Assistant (CNA) #2 stated Resident #6 did not leave his/her room and was not able to walk. CNA #2 further stated that Resident #6 was a fall risk who could be impulsive and tried to get out of bed. When asked about Resident #6's toileting routine, CNA #2 stated the resident, . just goes in [his/her] bed. During an interview on 12/4/25 at 4:21 PM, CNA #3 stated that he/she was not sure if Resident #6 knew when he/she had to go to the bathroom. The CNA further stated the resident knew when he/she had a bowel movement in his/her bed. When that happened, the resident would call out, and the CNAs would clean the resident up. When asked if the resident was offered a bed pan to use, CNA #3 reiterated that the resident just went in bed. Review of Resident #6's care plan, dated 10/30/25, revealed: . Problem: Fall Injury Risk. Intervention: Identify and Manage Contributors. Assess assistance level required for safe and effective self care; provide support as needed, such as toileting and mobilization. Problem: Palliative Care. Goal: Enhanced Quality of Life. Maximize comfort. Optimize Skin Protection. Minimize incontinence and moisture. Further review revealed no documentation of an identified mobility impairment or interventions to aid the resident with toileting. During an interview on 12/4/25 at 4:41 PM, the Director of Nursing (DON) stated Resident #6 had a wound on his/her bottom and it should be kept clean. CNAs should be using a fracture pan (a type of bedpan that is smaller and has a low flat design that makes it easier to slide under individuals with limited mobility) covered with absorbent disposable under pads when toileting Resident #6. The DON further stated the resident should not be going in the bed if it could be helped. Urine Collection Bag Random observations on 12/1-5/25 revealed Resident #6's room door open and a urinary catheter collection bag (a tube inserted through the urinary tract into the bladder, connected to a collection bag) containing varying amounts of yellow urine was observed hanging from Resident #6's bed. The collection bag was not covered and visible from the hallway for anyone walking by to see. During an interview on 12/04/25 at 11:42 AM, the DON stated staff should use urinary catheter collection bag covers and was not sure if the facility had them. The DON further stated that covering those collection bags was a dignity issue. Resident #19 Privacy Record review on 12/1-5/25 revealed Resident #19 was admitted to the facility with a diagnosis of non-Alzheimer's dementia. An observation on 12/4/25 at 7:50 AM, revealed Resident #19's room door was observed to be open. From the hallway, Resident #19 was visible lying on his/her left side while CNA #4 was at the bedside providing perineal care. During the provision of care, the resident's buttocks were exposed. Additionally, Resident #1 was present in the nearby common room, positioned in a manner that could have allowed a line of sight into Resident #19's room. During an interview on 12/4/25 at 8:27 AM, CNA #4 stated that Resident #19's room door had a tendency to swing open on its own. He/she further explained he/she typically placed a trash can behind the door to prevent it from opening unintentionally. CNA #4 acknowledged that the door should have been closed during the provision of personal care. During an interview on 12/04/25 at 11:42 AM, the DON stated CNAs should be shutting the door during cares. Review of the facility's 2025 My Rights & Responsibilities, updated 2/25/25, revealed: . I have the right. to be treated with respect and dignity by all my caregivers. Review of the facility's policy Standard of Care, dated 7/2024, revealed: . The standard of care are established as daily expectations in the care of the residents . refer to the attached PKIMC [Providence Kodiak Island Medical Center] Long Term Care, Standard of Care . Review of this policy's attached Standard of Care/Person-Centered Care form, last updated 3/22/22, revealed: . Ongoing care . Follow the person-centered plan of care . Use designated continence management products . Approaches . Attention to confidentiality and privacy. Actively listen to residents-affirm self-worth [and] dignity. Promote resident choice and personal preference whenever possible .

.Based on record review and interview, the facility failed to ensure adequate screening was conducted in accordance with the abuse and neglect policy. Specifically, the facility did not reference the State Nurse Aide Abuse & Neglect Registry for potential new Certified Nursing Assistant (CNA) hires. This failed practice placed all residents (based on a census of 21) at risk for exposure to abuse, neglect, exploitation, mistreatment, and misappropriation of their property. Findings: Review of the facility's HR Employee Personnel surveyor sheet, where the facility documented personnel credential/training information for a selected sample, revealed there was no documentation for checking the State nurse aide abuse registry prior to hire. During an interview on 12/4/25 at 3:50 PM, when asked if the facility checked the State nurse aide abuse registry prior to hiring CNAs, the Senior Human Resources (HR) Regulatory Assurance Analyst stated the HR department reviewed the State of Alaska Background Check system and checked potential hires to known variances (the process of adjusting or modifying a background check for certain conditions or offenses known as barriers to obtaining an eligible background check) in the system. When asked specifically about the State nurse aide abuse registry, the Senior HR Regulatory Assurance Analyst stated they did not check this registry. During an interview on 12/4/25 at 3:52 PM, the LTC Director of Nursing (DON) stated she was not familiar with the State nurse aide abuse registry and when shown where to go on the State website to view the registry, the LTC DON stated this had not been utilized in the past for screening CNA hires. Review of the facility's policy Resident Abuse, Neglect, and Exploitation, dated 4/2025, revealed: . Screening: All staff will be screened for records of reported abuse prior to hiring. Documentation will be kept in their personnel file.

.Based on record review, interview, and observation, the facility failed to develop and implement comprehensive, person-centered care plans for 6 Residents (#'s 1, 2, 12, 13, 16, and 17), out of 13 sampled residents. Specifically, the facility failed to: 1) Develop and maintain accurate care plans to meet the current needs of 5 Residents (#'s 1, 2, 13, 16, and 17); and 2) Carry forward previously identified needs, that were care planned for, when the facility initiated the use of a new electronic medical record (EMR) for 2 Residents (#'s 12 and 16). These failed practices placed the residents at risk of not receiving services that enable them to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings: Care Plan Development Resident #1 Record review on 12/1-5/25 revealed Resident #1 was admitted to the facility with diagnoses that included vascular dementia (a condition where decreased blood flow to the brain which may affect cognitive function) and hemiparesis (one sided muscle weakness) affecting the left side. Review of Resident #1's MDS assessment (Minimum Data Set - A federally required assessment), dated 9/23/25, revealed: . Section I: Active Diagnoses.Hemiplegia or Hemiparesis. Yes. Review of Resident #1's care plan, start date 10/9/25, revealed no personalized or individualized care plan interventions addressing the resident's left sided hemiparesis. During an interview on 12/4/25 at 4:12 PM, the MDS Coordinator stated that Resident #1's care plan should have included specific interventions related to Resident #1's left sided hemiparesis. Resident #2 Record review on 12/1-5/25 revealed Resident #2 was admitted to the facility with diagnoses that included cognitive impairment, paranoid schizophrenia (characterized by prominent paranoia and delusions), and speech impairment. Random observations on 12/1-5/25 revealed Resident #2 regularly walked independently with and without a cane in his/her room and out in the community area. The resident also was able to sit down and get up without staff help from various surfaces. Review of Resident #2's care plan, dated 7/31/25, revealed: . OK to have my bed height at my knee level as I stand up from my bed without assist. I use the upper half side rails to facilitate my turning & repositioning in bed independently to with 1 helper supervising or touching assistance. Review of Resident #2's most recent care plan, dated 10/30/25, revealed: . Mobility Impairment. Ensure effective use of devices such as. transfer board or orthosis. Intervention: Assist with repositioning. Position the patient for optimal performance, such as sitting in a chair for meals or performing hygiene at sink. During an interview on 12/4/25 at 4:12 PM, the MDS Coordinator stated that Resident #2's care plan could be more individualized and confirmed the resident was independent with his/her mobility. Resident #13 Record review on 12/1-5/25 revealed Resident #13 was admitted to the facility with diagnoses that included schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, like hallucinations and delusions, and a mood disorder, like depression), obsessive compulsive disorder (OCD - A disorder that causes unwanted thoughts, fears, and repetitive behaviors that interfere with daily life), and social anxiety (everyday nervousness that includes fear, anxiety, and avoidance that interferes with relationships, daily routines, work, and/or other activities). Review of Resident #13's care plan, dated 10/9/25, revealed: - Problem: Anxiety . Goal: Anxiety reduction or Resolution . Intervention: Promote Anxiety reduction . This identified care plan intervention started on 10/9/25; - Problem: Coping Ineffective . Goal: Effective Coping . Intervention: Support and Enhance Coping Strategies . This identified care plan intervention started on 10/9/25; - Problem: Fear . Goal: Self-Control of Fear Demonstrated . Intervention: Prevent or Minimize Fear . This identified care plan intervention started on 10/9/25; - Problem: Psychotropic Drug Use and Risk for Related Side Effects . This identified care plan intervention started on 10/9/25. Further review revealed schizoaffective disorder and OCD were not included in the care plan. During an interview on 12/4/25 at 5:12 PM, the MDS Coordinator stated that Resident #13's psychiatric diagnoses should be included in his/her care plan because it was something staff should address during care. During an interview on 12/5/25 at 8:40 AM, Resident #13's provider, LTC Provider #14, stated schizoaffective disorder and OCD should be care planned for, but care plans were nurse driven and he/she was not part of making them. Resident #16 Record review on 12/1-5/25 revealed Resident #16 was admitted to the facility with diagnoses that included stroke, hypertension (high blood pressure), and prediabetes. Review of Resident #16's electronic Medication Administration Record (eMAR), dated 12/2025, revealed the following medications ordered for constipation: 1. Senna (Senokot) Tablet 8.6mg (milligrams) every morning, which started on 10/1/25;2. Bisacodyl (Dulcolax) EC (enteric coated) tablet 10mg PRN (as needed) daily for constipation, which started on 10/1/25; and3. Polyethylene glycol (Miralax) powder 17g (grams) PRN daily for constipation, which started on 10/1/25. Review of Resident #16's care plan, dated 10/2025, revealed no identified problem for constipation. During an interview on 12/4/25 at 5:38 PM, the MDS Coordinator stated Resident #16's care plan should have included interventions for constipation. Resident #17 Record review on 12/1-5/25, revealed Resident #17 was admitted with diagnoses that included history of hemorrhagic cerebrovascular accident (CVA, a stroke, is when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel) with residual deficit and weakness. Review of Resident #17's MDS assessment, dated 9/19/25, revealed: Section B; Hearing, Speech, and Vision. Ability to see in adequate light (with glasses or other visual appliances). Impaired- sees large print, but not regular print in newspapers/books. Corrective Lenses. Yes. Review of Resident #17's care plan dated 10/7/25, revealed no personalized or individualized care plan interventions that addressed the resident's vision impairment or corrective lenses. Random observations on 12/1-5/25 revealed Resident #17 wore corrective lenses daily. During an interview on 12/2/25 at 10:10 AM, Resident #17 stated that he/she needed his/her glasses in order to see. During an interview on 12/4/25 at 4:39 PM, the MDS coordinator stated Resident #17's care plan should have included specific interventions related to Resident #17's vision impairment and the need for corrective lenses. Care Plans in New EMR During an interview on 12/2/25 at 8:30 AM, the LTC Director of Nursing (DON) stated on 10/1/25, the facility had transitioned from their old EMR system, called ECS, to their new EMR system called EPIC. The LTC DON stated all information that was in ECS was transcribed into EPIC's software formatting. Resident #12 Record review on 12/1-5/25 revealed Resident #12 was admitted to the facility with diagnoses that included transient ischemic attack (TIA - a brief blockage of blood flow to the brain that causes stroke-like symptoms), dementia, and blindness. During an interview on 12/2/25, Resident #12's family stated he/she had frequent urinary tract infections (UTIs) and had been on antibiotics in the past. Review of Resident #12's medical record revealed he/she had been treated for UTIs on 1/16/25 and 8/8/25. Further review revealed Resident #12 had an additional abnormal urinalysis (lab testing of urine to determine or rule out infection) on 8/14/25 that was not treated with antibiotics. During an interview on 12/4/25 at 6:37 PM, Resident #12's Provider stated the resident was chronically colonized, which indicated UTIs would be a recurring issue. Resident #12's Provider stated a urology consult was offered, however Resident #12 had refused. The appropriate treatment now was to assess and/or treat each UTI if they occurred. ECS Care Plan Review Review of Resident #12's ECS care plan, dated 8/2025, revealed: . I have a self-care deficit (toileting), am at risk for impaired skin integrity, at risk for infection . Because I have difficulty wiping after a bowel movement, get redness/irritation in my groin . recurrent UTIs . I need my nurses to . request a urinalysis to determine if I have a urinary tract infection . notify my physician for S/S [signs and/or symptoms] of UTI . EPIC Care Plan Review Review of Resident #12's EPIC care plan, dated 10/2025, revealed frequent UTIs was not documented in the care plan. During an interview on 12/4/25 at 5:06 AM, the MDS Coordinator stated Resident #12's history and plan for frequent UTIs should be documented in his/her EPIC care plan. Resident #16 Record review on 12/1-5/25 revealed Resident #16 was admitted to the facility with diagnoses that included stroke, hypertension (high blood pressure), and prediabetes. During an interview on 12/2/25 at 9:45 AM, Licensed Nurse (LN) #1 stated Resident #16 was hard of hearing and one had to yell so he/she could hear them. LN #1 stated Resident #16 had hearing aids, however, did not use them. During an interview on 12/2/25 at 9:55 AM, Resident #16 stated his/her hearing aid batteries were low and couldn't use them. ECS Care Plan Review Review of Resident #16's ECS care plan, dated 4/2025, revealed: I have impaired communication. I have disturbed sensory perception (auditory). I was provided with a SuperEar (personal sound amplification product) November 2024 to enhance my hearing [and] have a new hearing aid for left ear (February 2025) (also have a right hearing aid) . I show this by: difficulty understanding others when they are talking to me . I need my nurse to . encourage use of hearing aids daily, ensure that hearing aids are functioning properly, ensure that hearing aide(s) are being placed every AM [and] removed at HS . I need my aides to . encourage use of hearing aids daily . Check hearing aids for proper function prior to placing in ears . Place batter in the battery case . Cup your hand over the hearing aid; you should hear a whistle. If you do not hear a whistle, change the batteries. EPIC Care Plan Review Review of Resident #16's EPIC care plan, dated 10/2025, revealed hearing impairment was not documented in the care plan. During an interview on 12/4/25 at 5:35 PM, the MDS Coordinator stated Resident #16's hearing impairment should be documented in his/her EPIC care plan. Review of the facility's policy Resident Care Plans for Long Term Care, last revised on 11/2018, revealed: . The Social Worker determines specific Care Plan goals that are person-centered care after completing the initial assessment and asking the resident and the resident representative for their input. The Social Worker completes a Care Plan addressing the resident's psycho-social well-being, mood and behaviors, and transfer or discharge plan. Review of the facility's policy Resident Assessment and Comprehensive person-centered Care Plan, dated 6/2024, revealed: Care Plan . The comprehensive person-centered care plan includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychological needs as identified by a comprehensive assessment . Updates to the person-centered care plan will be initiated and dated as added or deleted . The comprehensive person-centered care plan is a working tool .

.Based on record review, observation, and interview, the facility failed to adhere to professional standards for food safety. Specifically, the facility failed to ensure: 1) Food items stocked for residents had not expired; 3) Canned foods with damaged rims were removed from inventory; 4) Opened food items were properly labeled and stored; 5) The dishwasher on the Salmonberry unit had achieved proper temperature during the wash cycle; and 6) Safe food temperatures were maintained prior to serving. These failed practices placed all residents (based on a census of 21) at increased risk for foodborne illness. Findings: Expired Food An observation on 12/1/25 at 5:20 PM, inside the main kitchen's walk-in refrigerator, revealed: one 5 lb container of Minor's culinary cream. The lid of the container had a label that read . prepared date 11-9-25. use by 11-30-25. During an interview on 12/1/25 at 5:21 PM, the Dietary Manager (DM) confirmed that the cream should have been removed from the walk-in refrigerator and discarded. An observation on 12/1/25 at 5:24 PM, inside the main kitchen's walk-in freezer, revealed: one box of Safeway Marionberry pie 9 inch. packed on: Nov.20.25. sell thru: Nov.25.25. The box containing the pie did not have a facility supplied label or expiration date. During an interview on 12/1/25 at 5:25 PM, the DM confirmed that the pie should have a facility supplied label. An observation on 12/3/25 at 8:17 AM, of the Salmonberry unit kitchenette, revealed: 17 - 8 oz containers of Ensure Plus therapeutic nutrition, with an expiration date of 1DEC2025. During an interview on 12/3/25 at 10:35 AM, the DM confirmed the containers of Ensure were expired and should have been removed from the kitchen. Dented cans An observation on 12/1/25 at 4:57 PM, of the main kitchen, revealed: three - 6.56 lb cans of Arrezzio Marinara Sauce with dented rims on a storage rack. During an interview on 12/1/25 at 4:57 PM, the DM stated the expectation was that if cans were found to be dented, they are immediately removed from service. Food labeling and storage An observation on 12/1/25 at 4:41 PM, inside the main kitchen, revealed: - A produce bin of 15 russet potatoes. These potatoes were soft to the touch, and their skins were wrinkly in texture;- One open 5 lb. box of Krusteaz Tempura Batter labeled with an open date of 5/12/25. Further observation revealed the box was not closed and the bag inside, containing the batter powder, was not closed and open to air;- One open 1 gallon container of La [NAME] Canola Oil, half empty, no open date;- One open 2 quart container of Kikkoman Soy Sauce, more than 3/4 empty, no open date;- One open 1 gallon container of Great value Apple Cider Vinegar, 1/4 empty, no open date;- One open 23 fl. oz. container of Thai Kitchen premium fish sauce, 1/2 empty, no open date; An observation on 12/1/25 at 5:28 PM, inside the main kitchen's walk-in freezer, revealed: one 32 oz bag of Reliance cauliflower, opened and approximately half empty. There was no indication of the date the package was opened or when it would expire. During an interview on 12/1/25 at 5:28 PM, the DM stated that the bag of cauliflower should have an orange label, referring to a facility-used label that would have the open date and expiration date of the product. During an interview on 12/1/25 at 5:30 PM, the DM stated the potatoes should have been pulled from being used. An observation on 12/1/25 at 5:40 PM, of the Salmonberry unit kitchenette, revealed one open 1 gallon Great Value Vegetable Oil, more than 3/4 empty, no open date. An observation on 12/1/25 at 5:45 PM, of the Fireweed unit kitchenette, revealed: - One opened Smucker's Squeeze strawberry fruit spread, partially used, no open date;- One small ceramic bowl, uncovered and open to air, filled 2/3 of the way with salt and spices mixture, no label; - One clear ProKeeper airtight container labeled Sugar Cane with a brown sugar-like substance layered over a white powdery substance. During an interview on 12/1/25 at 5:50PM, [NAME] #1 stated that all food containers should be labeled with both an open date and a use-by date. The cook acknowledged that the strawberry fruit spread should have had such a label. Additionally, the cook stated the uncovered bowl of spices should have been properly covered and labeled. During an interview on 12/1/25 at 5:55PM the DM was asked about the container labeled Sugar Cane. The DM stated that she was unfamiliar with the item and did not know what it was, and it should be thrown out. She then took the container and emptied it into the trash. Dishwasher - Wash Cycle Temperature An observation on 12/5/25 at 8:27 AM, of the dishwasher in the Salmonberry unit kitchenette, revealed [NAME] #3 starting the dishwasher after loading a rack full of assorted dishes. When the wash cycle first started it displayed 155 F [Fahrenheit] and immediately displayed 148 F and ranged between 147-148 F for the remainder of the wash cycle. During the rinse cycle the machine displayed temperatures between 186-187 F. [NAME] #3 did not rerun the dishwasher again after the cycle was complete. During an interview on 12/5/25 at 11:57 AM, [NAME] #3 stated that he/she does not normally prime the dishwasher before running the dishes through. He/she also stated that normally he/she would run the dishwasher again since the temperature was low, but he/she felt nervous with the surveyors watching him/her. He/she further stated that he/she was unsure of the temperature that he/she should be recording on the log as the machine displayed different temperatures through the cycles and had another number on the display at the end. Review of the facility's policy Dish Machine Operation, last revised 2/2025, revealed: . Procedures. Prime the dish machine: Run 3 to 5 empty dish racks through a cycle to ensure wash and rinse temperatures reach their required minimum temperature. Wash cycle temperature will be between 150 F to 160 F, sanitize temperature at least 180 F or higher, and surface temperature at least 160 F. If wash and rinse temperatures fall below required minimum temperatures during wash cycles, dietary will stop machine and wait until machine heater resumes proper temperatures before continuing. If wash or rinse temperatures fail to reach the minimum required temperature following the priming process, dietary staff will contact the facilities department immediately and discontinue use of dish machine. Dish washing will resume using the 3-compartment sink procedure to wash and sanitize soiled dish-ware. Food Temperatures An observation on 12/2/25 from 11:25 AM to 11:40 AM, revealed [NAME] #3 on the Fireweed unit cooking lunch for the residents. Further observation revealed at 11:35 AM, [NAME] #3 started to serve meals without temperature checking the food. Further observation revealed at 11:42 AM, [NAME] #3 took a therapeutic meal out of a food warmer, which was covered in tin foil, and served it without temperature checking the food. Review of facility kitchen logs, dated 12/1-4/25, revealed each meal's food items met or exceeded safe cooking food temperatures, however the logs did not indicate when the temperatures were obtained. Further review of the kitchen log revealed: Any drop below 140 F requires reheating to 165 F . During an interview on 12/4/25 at 5:58 PM, the DM stated the Cooks temperature-checked the food while they were cooking the meal and this was the temperature documented on the temperature logs. When asked if the Cooks temperature-checked the food prior to serving, the DM stated there was a weekly check prior to serving a meal but this was not documented. The DM further stated the food log form had recently changed and on the older form there was a section to log temperatures of food prior to serving, however this was removed. An observation on 12/5/25 at 12:43 PM, of test trays that were requested (of a regular meal and a pureed meal), revealed temperatures of the foods were below the safe holding temperatures required: Regular Meal: - Salmon: 90 F;- [NAME] (pasta): 117 F; and- Veggie: 95 F.Pureed Meal: [NAME]: 91 F (this was the only food offered on the pureed test tray despite asking for all foods served) The DM acknowledged these low temperatures at time of discovery. During the survey, the facility was asked to provide policies and procedures on food storage. The facility provided one policy regarding resident owned food only. Review of the facility's policy Food Storage - Nursing Units, dated 7/2025, revealed: . Policy . to comply with standards for food storage, handling, and consumption . Purpose/Scope: To define the procedure for safe and sanitary storage, handling, and consumption of patient/resident foods . Food items must be discarded sooner than or according to the expiration date on the packaging .

.Based on record review and interview, the facility failed to: 1) Ensure their facility assessment (a mandatory, comprehensive evaluation to understand the specific resident population's needs and match them with necessary staffing, equipment, and resources to meet those needs) was up to date and accurate; and 2) Establish an accurate competency training program for Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) to ensure all nursing staff had the specific competencies and skill sets necessary to care for resident's needs as identified in the facility's facility assessment. This failed practice had the potential to place all residents (based on a census of 21) at risk of: 1) not having the necessary care and resources required for day-to-day operations (including nights and weekends) and emergencies; and 2) not receiving services that enable them to attain or maintain their highest practicable physical, mental, and psychosocial well-being Findings: Assessment Accuracy Record review on 12/1-5/25 revealed the facility's Facility Assessment was last updated on 10/23/24 (408 days). During an interview on 12/5/25 at 12:14 PM, the Hospital Director of Nursing (DON) stated the 10/23/24 Facility Assessment was the most current assessment and acknowledged it had not been updated. Nursing Competency and Skill Sets During an interview on 12/4/25 at 3:19 PM, the LTC Director of Nursing (LDON) and Hospital DON (HDON) stated LNs and CNAs were provided with new hire competency training and also completed competency training annually. The LDON and HDON further stated that the online training platforms HealthStream and QStream were also used to train nursing staff. New Hire Competency Training When asked for the facility's new hire competency training for LNs, the facility provided the checklist Form 3B Competency Plan/Tracking Form - New/Transfer Staff form along with individual competency check-off sheets for each competency listed. Review of the facility-provided Form 3B Competency Plan/Tracking Form - New/Transfer Staff LN competency checklist, dated 2024, revealed the following competencies were listed: - Department orientation;- Hemoccult;- Glucometer;- Abuse and Neglect Reporting;- Pyxis Access/ECS Access/Epic Access (medication storage and electronic medical records);- Policy 905.003 Standard of Care;- Age Related Care - Elder;- Oxygen Concentrators;- Crash Cart [NAME] AED (external defibrillator machine);- Safe Handling of O2 [oxygen] Tanks and Regulators;- [NAME]-Port Gastrostomy Tube Replacement (feeding tube directly implanted through the abdomen into the stomach);- Jejunostomy Tube Replacement (feeding tube directly implanted through the abdomen into the jejunum, small intestines); and- Ostomy Appliance Care (an opening in the abdomen to reroute waste (stool or urine) from the digestive or urinary system). When asked for the facility's new hire competency training for CNAs, the facility provided the checklist Form 3B Competency Plan/Tracking: New CNA Staff form along with individual competency check-off sheets for each competency listed. Review of the facility-provided Form 3B Competency Plan/Tracking: New CNA Staff competency checklist, undated, revealed the following competencies were listed: - Department orientation;- Abuse and Neglect Reporting at Nurse Aide Level;- Age Related Care - Elder;- ARJO Maxi Move (a battery operated floor lift for safe patient handling);- ARJO MaxiSky (Ceiling lift);- ARJO Sara Steady (a non-powered, manual sit-to-stand transfer aid);- Basic Transfer Techniques;- Change of Condition;- Gait Belt;- Hemoccult;- Safe feeding and swallowing technique;- Sage Handling of O2 tanks and Regulators;- Safe Patient handling: universal principles and practices; - Slide Tubes; and- Weighing residents. Annual Competency Training During an interview on 12/5/25 at 1:21 PM, the LTC Director of Nursing stated the facility could not provide annual competency training proof for the LNs and CNAs of the facility. Resident Competency Needs Review of the facility's Facility Assessment, dated 10/23/24, revealed the following lists of nursing staff competencies were identified as required to meet the needs of residents: 1. A.1 Function - Care Requirements . Competencies for this section: CNA: dining assistance, meal textures, lifts, peri care [cleaning of residents after incontinence episodes] (male and female, with/without catheter), positioning, ROM [range of motion], weights, oral care, catheter care, proper use of specialty surfaces including mattresses and cushions, nail care, bladder training, hydration, aspiration prevention. NURSES: specialty surfaces, Foley and straight catheter insertion and care, bladder scan, enteral feeding and gastrostomy care, skin care under devices, safe patient handling, swallowing difficulty, ROM, use of care for splints and braces, end of life care, bladder training and scanning, hydration, medication administration, aspiration precautions, dining assistance, physical assessments . 2. B.2 Acuity - Care Requirements: ALL: Infection control best practices (hand hygiene, proper use of PPE [personal protective equipment] CNA: Equipment cleaning, dining assist, speech, weights, oral care, catheter care, proper use of specialty surfaces including mattresses and cushions, vital signs, care planning, dementia, skin care, bowel and bladder training, hydration. NURSES: Blood glucose monitoring, phlebotomy, specialty surfaces, infection control and PPE, equipment cleaning, straight catheters, Foley catheter care and insertion, bladder scan, enteral feedings and gastrostomy care to include placement of device, wounds and wound care, skin care under devices, swallowing difficulty, ROM, use of and care for splints and braces, medication policies, psychotropic medications, sepsis, standards of care, end of life care, order entry, heart failure, bladder training, hydration, BLS [basic life support], food handling, blood borne pathogens, pacemakers, bone stimulator, dementia and dementia-related disorders, care planning . restraint management, O2 handling, external fixator . Competencies/Trainings Not Provided by Facility Review of the facility's training/competency requirements listed in the Facility Assessment and compared to the facility's training offered (Competency Checklists, HealthStream, and QStream) revealed the following: 1. Standards of Care: Review of the LN competency training Policy 905.003 Standard of Care, dated 2016, revealed this policy contained standards of care and person-centered daily care for residents to include: 1) morning and evening routine care; 2) periodic care to include showers, nail care, and weights; 3) care before and after meals; 4) frequency of ongoing cares for all shifts to include monitoring of residents, ROM, incontinence care, catheter care, turning/positioning, safety precautions, and physical environment cleaning; and 5) reporting of changes in condition. It was not documented that CNAs were offered this Policy 905.003 Standard of Care training. 2. Competency training for the facility's lift devices (i.e., ARJO Maxi Move, ARJO MaxiSky ceiling lift, and ARJO Sara Steady), basic transfer techniques, and safe feeding and swallowing techniques were not offered to LNs. 3. There was no competency and/or training documentation identified for standards and/or expectations for peri care, catheter insertion or catheter care, vital signs, bladder scanning, ROM, or specialty surfaces. Review of the facility's Facility Assessment, revealed: . Staffing plan. Staffing Plan Purpose. The purpose of this staffing plan is to provide our residents with the highest quality of life, care, and services as possible. We utilize standardized staffing guidelines to ensure proper staffing on each shift in order to provide quality care services to our residents on a day-to-day basis and in the event of an emergency. Guidelines. The staffing plan shall take into consideration: An evidenced based MDS [Minimum Data Set - a federally required assessment] Resident Population Profile to review the types of resident stays based on functional, acuity, cognitive and cultural data collected and analyzed within 12 months of the creation date of the Facility Assessment. Staff training/competencies/skill sets required to ensure appropriate care and services are delivered 24/7 [24 hours a day, 7 days a week] .

.Based on record review and interview, the facility failed to implement federally required in-service training for Certified Nursing Assistants (CNAs), ensuring continuing competencies of no less than 12 hours per year that included dementia management, cognitive impairment, and resident abuse prevention training. This failed practice placed all residents (based on a census of 21) at risk of not receiving services that enable them to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings: Review of the facility's HR Employee Personnel surveyor sheet, where the facility documented personnel credential/training information for a selected sample, revealed there was no annual 12-hour CNA training listed for 3 of 3 sampled CNAs (CNA #'s 1, 2 and 5). During an interview on 12/4/25 at 4:00 PM, the LTC Director of Nursing (LTC) stated she was the facility's educator prior to taking the DON role, and there had never been a 12-hour CNA in-service training program for the facility

.Based on record review and interview, the facility failed to have an active restorative program (an exercise program focused on maximizing resident independence and function through individualized plans) for appropriate treatment and services to maintain or improve a resident's ability to carry out the activities of daily living (including but not limited to hygiene, mobility, elimination, dining, and/or communication) for 4 Resident (#'s 1, 7, 13, and 16), out of 13 samples residents. This failed practice placed the residents at risk of not receiving services to enable them to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings: Resident #1 Record review on 12/1-5/25 revealed Resident #1 was admitted to the facility with diagnoses that included vascular dementia (a condition where decreased blood flow to the brain, which may affect cognitive function) and hemiparesis (one sided muscle weakness) affecting the left side. During an interview on 12/2/25 at 3:23 PM, Resident #1's resident representative (RR) was concerned that the resident was losing mobility. The RR stated Resident #1 should be getting some form of physical therapy on a regular basis but felt that the resident was not receiving the therapy. Review of Resident #1's most recent Minimum Data Set (MDS - a federally required assessment) quarterly assessment, dated 9/23/25, revealed the Resident was coded for extensive assistance and completely dependent on staff for activities of daily living, bed mobility, and transfers. Review of Resident #1's care plan, with a start date of 10/9/25, revealed: . Problem: Mobility Impairment. Goal. Optimal Mobility. Provide mobility and gait interventions with therapeutic interventions. Review of Resident #1's care plan, dated 9/30/25, revealed: . I:HAVE A MOBILITY DEFICIT. I need my aides to cue/assist me with ROM [Range Of Motion] during care. I need my restorative aides to. provide restorative program/exercise per rehab recommendations. Review of the Occupational Therapy Annual Evaluation, dated 7/18/25, revealed: . Plan. Skilled Occupational Therapy not recommended at this time. Continue restorative aide program. Review of the [Elder House] Restorative Log revealed Resident #1 was supposed to receive restorative aide three to five times a week. Resident #1 had no sessions logged for 9/2025. Record review on 12/2-5/25 revealed the restorative aide had worked with Resident #1 four times since 10/1/25 through the date of the survey. Those dates were 10/1/25, 10/3/25, 10/10/25, and 11/11/25. Resident #7 Record review on 12/1-5/25 revealed Resident #7 was admitted to the facility with diagnoses that included cerebral vascular accident (CVA, a stroke, when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel), depression, and epilepsy (seizures). Review of Resident #7's care plan, dated 10/1/25, revealed: . Problem: Fall Injury Risk . I am at risk for falls/injury. I have the potential to lose my balance and stumble, fall down and hurt myself . Goal: Absence of Fall and Fall-Related Injury . Because I have had a stroke - Have left sided weakness [and] neglect . I need restorative aide to . assist me with restorative exercise program per rehab recommendations (improve left extremity strength [and] endurance), report changes in my abilities to my nurse [and] rehab staff . Review of the facility's [Elder House] Restorative Log, dated 9/2025, revealed Resident #7 was to have restorative aide twice a week and his/her last restorative exercises were performed on 9/12/25. Further review of the restorative log revealed no restorative exercises were offered after 9/29/25. Review of Resident #7's personal restorative program log, dated 9/2025, revealed Resident #7 was to complete the following exercises every session: Active range of motion (activating one's muscles to complete exercises), with 2 sets of 10 repetitions each: - Knee extensions (to restore knee range: the straightening of the knee joint);- Heel slides (to strengthen the knee and hip muscles: while lying on back, sliding one knee up towards the buttocks while keeping the other leg straight, then sliding back down);- Ankle pumps (to engage calf muscles to help improve circulation and reduce swelling: pointing the toes up toward your head then pointing them down);- Hip flexion (to strengthen hip flexion muscles that run under the abdominal muscles and connect to the spine: leg raises while on lying on back, raise legs of the mattress/floor); and- Hip extension (to strengthen glute and hamstring muscles: lifting hips off mattress/floor, or while standing and supported kick leg back). Further review of Resident #7's log revealed there were no exercises offered after 9/29/25. Resident #13 Record review on 12/1-5/25 revealed Resident #13 was admitted to the facility with diagnoses that included stroke, hypertension (high blood pressure), and seizures. During an interview on 12/2/25 at 9:48 AM, Resident #13 stated he/she would like to have more physical therapy. Review of Resident #13's Occupational Therapy (OT) note written by OT #1, dated 10/16/25, revealed: . [Resident #13] reported [he/she] is interested in gaining strength for increased mobility and time in main living space. Reported [he/she] is interested in working with the Sara Steady [a non-powered, manual sit-to-stand transfer aid] again. Goals: [Resident #13] is interested in therapy or restorative aid to gain strength. [His/her] long term goal is to get strong enough to take steps again. Plan to resume use of restorative program including Sara Steady for up for meals and socializing. See patient care plan for frequency of Sara Steady use . Review of Resident #13's care plan, dated 10/2025, revealed no documentation about use of Sara Steady or a restorative aide program. Review of the facility's [Elder House] Restorative Log revealed there was no active log for 10/2025. Resident #13 was not on the restorative log. During an interview on 12/5/25 at 8:56 AM, OT #1 stated he/she has not talked to Restorative Aide #8 about initiating a restorative program for Resident #13 because the restorative program was on hold at the time of the 10/16/25 note and currently was still on hold. Resident #16 Record review on 12/1-5/25 revealed Resident #16 was admitted to the facility with diagnoses that included stroke, hypertension (high blood pressure), and prediabetes. Review of Resident #16's care plan, dated 4/2025, revealed: . I have mobility deficit help transferring, help walking, restorative exercise. I need my restorative aides to provide restorative program/exercise per rehab recommendations - see restorative exercise book. Review of Resident #16's care plan, dated 10/2025, revealed: . Fall Injury Risk. Goal: Absence of Fall and Fall-Related Injury. Intervention: Identify and Manage Contributors. Encourage physical activity, such as performance of mobility and self-care at highest level of patient ability, multicomponent exercise program. Mobility Impairment. Goal: Optimal Mobility Independence and Safety. Intervention: Support Mobility Independence and Safety. Schedule mobility activities. Provide mobility and gait training with therapeutic interventions. Review of the facility's [Elder House] Restorative Log, dated 9/2025, revealed Resident #16 was to have restorative two to three times a week and his/her last restorative exercises were performed on 9/12/25. Further review of the restorative log revealed no restorative exercises were offered after 9/29/25. Review of Resident #16's personal restorative program log, dated 9/2025, revealed Resident #16 was to complete the following exercises every session: 1) 10 to 20 sit to stand transfers as tolerated; and 2) active range of motion, (with an undocumented number per sets, with an undocumented number of repetitions each): - Shoulder elevations (to strengthen deltoid, or shoulder muscle. Standing with dumbbells in hands, raise arms out to the side and up to level height of shoulder)- Knee extensions;- Heel slides;- Ankle pumps;- Hip flexions;- Hip extensions;- Hip Abductions (to strengthen the glutes and help tighten that area. Standing, raise leg sideways/lying on side, raise leg up); and- Hip Adductions (to strengthen groin muscles. Standing, bring leg out and then inward crossing leg across the other and holding inward, lying on side, raising lower leg upward) Further review of Resident #16's log revealed there were no exercises offered after 9/29/25. During an interview on 12/5/25 at 11:31 AM, Restorative Aide #8 stated the restorative program was usually initiated when the OT verbally reviewed a resident's exercise plan with him/her and they were placed in the restorative binder. Restorative Aide #8 stated all restorative exercises were documented in the restorative binder on the restorative log and a resident exercise sheet. When asked when the restorative program was last offered, Restorative Aide #8 stated it had not been offered in the facility since the beginning of October 2025. Review of the facility's restorative program binder revealed 9/2025 was the last month exercises were documented as being completed or offered. At that time, 14 residents were listed as receiving an individualized restorative aide program at the facility. Review of the facility's policy CBEH [Chiniak Bay Elder House] Restorative Nursing Program, dated 8/2025, revealed: . CBEH will provide resident with restorative nursing services that maintains a resident's ability to function at their highest level and maintain range of motion according to plan of care written by therapy or nursing professionals. Resident who may benefit from the restorative nursing program include, but are not limited to: A resident recently discharged from rehabilitation services, A resident at risk for functional decline, A resident with [an] identified deficit or decline, and has an established need. A CNA, Restorative Aide or designated nursing professional will: Implement the plan of care under the supervision of a licensed nurse. Document each session.

.Based on record review and interview, the facility failed to ensure gradual dose reductions (GDRs), or contraindications for GDRs, were clearly documented for 1 Resident (#13) who used psychotropic medications (medications that affect behavior, thoughts, or perception), out of 13 sampled residents. This failed practice placed the resident at risk for unnecessary medications. Findings: Resident #13 Record review on 12/1-5/25 revealed Resident #13 was admitted to the facility with diagnoses that included schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, like hallucinations and delusions, and a mood disorder, like depression), obsessive compulsive disorder (OCD - a disorder that causes unwanted thoughts, fears, and repetitive behaviors that interfere with daily life), and social anxiety (everyday nervousness that includes fear, anxiety, and avoidance that interferes with relationships, daily routines, work, and/or other activities). Medication Review Review of Resident #13's medication administration record, dated 9/2025 through 12/2025, revealed he/she was on the following psychotropic medications: 1. Fluoxetine (Prozac - an antidepressant) 80mg (milligrams) by mouth daily in the morning for schizoaffective disorder, social anxiety disorder, and OCD. Further review revealed this medication was started on 11/29/18 and remained at this dose when admitted to the facility on [DATE]. 2. Risperdal (Risperidone - an antipsychotic) 1.5mg by mouth daily at night for schizoaffective disorder, social anxiety disorder, and OCD. Further review revealed this medication dose was started on 10/28/19. Care Plan Review Review of Resident #13's care plan, dated 10/9/25, revealed: . Problem: Psychotropic Drug Use and Risk for Related Side Effects . Goal: GDR (as indicated per psychotropic classification: quarterly, or every six months) . Intervention: Attempt gradual order reduction of antipsychotic as least once per quarter . Quarterly pharmacy review of psychotropic medications for possible dose reduction . Gradual Dose Reduction Review Review of Resident #13's Antipsychotic/[Psychopharmacological] Medication Dose Reduction History form, undated, revealed: 1. Fluoxetine: There was no documentation indicating that a gradual dose reduction had been attempted. Further review of the form revealed: . GDR clinically contraindicated - Complete Determination of Clinical Contraindication Form . Further review of Resident #13's medical record revealed no contraindication form. 2. Risperdal: On 10/28/19, a dose reduction was completed, reducing Resident #13's Risperdal dose from 2.5mg to 1.5mg. Further review of the history form revealed this reduction was assessed as successful. No other reductions were documented on the history form. Further review of Resident #13's medical records revealed no contraindication form. Medication Regimen Reviews (MRRs) Review of Resident #13's MMR completed by Pharmacist #10, dated 10/2/25, revealed: . Psychotropic medication dose changes: The resident is seen quarterly by Psychiatry for medication management. Assessment for fluoxetine dose reduction declined in July 2020, due to ongoing depression and COVID-19 stressors. Suggested again on April 2021 and declined (see April 2021 MMR findings), physician documented in chart that medication remained medically necessary at current dose. Assessment for psychotropic medications dose reduction recommended again in March 2022. Risperidone dose had been decreased to 1.5mg daily on 10/29/19. Further GDR considered clinically contraindicated (see October 2020 and November 2020 MMR findings). Addressed again on October 2021 (clinically contraindicated by [psychiatrist #2], see Note from 5/10/2022 and, more recently, on 12/6/2023). [Psychiatrist #5], psychiatry, currently following [him/her] periodically for medication management. [He/she] has been assessing the appropriateness of GDR and deeming it clinically contraindicated on 10/24/2024 and recently at 4/15/25 (see Notes in Epic [electronic medical record]) . Review of the psychiatry notes documented in this MMR, dated 5/10/22 - 4/15/25, revealed: - 5/10/22 Note: . Plan: Follow-up in 3 months for ongoing medication management. Continue Prozac 80 mg qam [every morning]. Continue Risperdal 1.5 mg qhs [every night]. Medication regimen discussed, understood and accepted. Review of potential medication side effects, medication benefits and alternatives of medication treatment . Further review revealed no documentation for GDR attempts, plans for GDRs, or contraindications for GDRs. - 12/6/23 Note: (review of this note revealed the time of service was on 11/2/23, but documented on 12/6/23) . Plan: Follow-up in 3 months for ongoing medication management. Continue Prozac 80 mg qam. Continue Risperdal 1.5 mg qhs. Medication regimen discussed, understood and accepted. Review of potential medication side effects, medication benefits and alternatives of medication treatment . Further review revealed no documentation for GDR attempts, plans for GDRs, or contraindications for GDRs. - 10/24/24 Note: . Treatment Plan: Medication Initiation/Changes . continue Prozac 80mg daily and Risperidone 1.5mg nightly . Psychotherapy Recommended . Future considerations - as [he/she] gets older consider going down on [his/her] fluoxetine and risperidone as [his/her] risk of SE [side effects] will increase with age . Further review revealed no documentation for GDR attempts, plans for GDRs, or contraindications for GDRs. - 4/15/25 Note: . Treatment Plan: Medication Initiation/Changes . continue Prozac 80mg daily and Risperidone 1.5mg nightly . Psychotherapy Recommended . Future considerations - as [he/she] gets older consider going down on [his/her] fluoxetine and risperidone as [his/her] risk of SE will increase with age . Further review revealed no documentation for GDR attempts, plans for GDRs, or contraindications for GDRs. LTC Provider Note Review Record review of Resident #13's LTC provider note written by Provider #14, dated 11/18/25, revealed: . Stable mood and behavior, improved over the past couple years . Continue Prozac 80mg daily and Risperdal, per psych recommendations . Follow up as needed with [Psychiatrist #5]. Further review revealed no documentation for GDR attempts, plans for GDRs, or contraindications for GDRs. During an interview on 12/4/25 at 5:12 PM, the MDS (Minimum Data Set - a federally required assessment) Coordinator stated the Antipsychotic/[Psychopharmacological] Medication Dose Reduction History forms were not used anymore and all GDR information, to include GDR contraindications, would be documented in provider notes. When asked to review Resident #13's provider notes to locate GDR information, to include GDR contraindications, the MDS Coordinator stated she could not locate any documentation. During an interview on 12/5/25 at 8:40 AM, LTC Provider #14 stated that GDRs for Resident #13's Fluoxetine and Risperdal would be contraindicated due to successful control of Resident #13's symptoms on the current regimen. When asked about documentation for these GDR contraindications, LTC Provider #14 stated he/she was not aware that verbiage for GDR contraindications was required in the medical record. LTC Provider #14 made an amendment to Resident #13's most recent provider note to reflect this contraindication. During an interview on 12/5/25 at 9:18 AM, Pharmacist #10 stated that the 10/2/25 MRR's narrative about psychotropic medication dose changes was a collection of multiple pharmacists, and he/she personally did not make any of the narratives documented. Pharmacist #10 stated there were several Pharmacists who shared the responsibility of completing MMRs for the LTC residents. When asked to review the psychiatry notes, dated 5/10/22, 12/6/23, 10/24/24, and 4/15/25, to show where the GDR contraindications were documented, Pharmacist #10 reviewed the 4/15/25 note and stated he/she interpreted the documentation to continue current doses as the contraindication. Pharmacist #10 was not familiar with GDR documentation regulatory requirements and could not speak to how GDRs were monitored or suggested to LTC providers for consideration. Review of the facility policy Elder House Pharmaceutical Services, dated 11/2024, revealed: .The pharmaceutical services provided shall be sufficient to meet the needs of the residents of the Elder House . including . A Medication Regimen Review (MRR) conducted monthly by a licensed pharmacist . This review will ensure that each resident's drug regimen is free from unnecessary drugs and that psychotropic drugs are used appropriately . Review of the facility policy Elder House Psychotropic Medication Monitoring, dated 9/2025, revealed: . Residents who use psychotropic drugs will periodically receive gradual dose reductions unless contraindicated in effort to discontinue these drugs . Assessment/Monitoring . Psychotropic Medication Gradual Dose Reduction (GDR) history will be tracked by the CBEH [Chiniak Bay Elder House] nurse manager, CBEH quality nurse or designee and reported to Quality meetings . The attending physician will . Attempt gradual dose reduction (GDR), unless clinically contraindicated, within the first year in two separate quarters (at least one month between attempts) then annually . If gradual dose reductions (GDRs) are clinically contraindicated, the reason why must be documented in the medical record .

.Based on interview and record review, the facility failed to ensure neurological (neuro) checks (assessments to determine if any neurological changes/symptoms arose from a potential head injury) were performed after an unwitnessed fall with head injuries per resident care polices for 1 Resident (#7), out of 13 sampled residents. This failed practice placed the resident at risk for delay in treatment from any potential changes in neuro status. Findings: Record review on 12/1-5/25 revealed Resident #7 was admitted to the facility with diagnoses that included cerebral vascular accident (CVA, a stroke, when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel), depression, and epilepsy (seizures). During an interview on 12/02/2025 at 11:18 AM, Resident #7 stated he/she had fallen last month, he/she landed on his/her face, and had cuts to his/her forehead and over his/her left eyebrow. When asked, Resident #7 stated he/she did not go to hospital. Review of Resident #7's MORSE Fall scale (a clinical tool used to assess an older adult's risk of falling) score, dated 10/5/25, revealed a score of 80 (on a scale of 0 to 125: A score of 45 - 125 indicated a high risk for falls). Further review revealed Resident #7's MORSE fall score was also 80 on 11/4/25. Review of Resident #7's care plan, dated 10/1/25, revealed: Problem: Fall Injury Risk . I am at risk for falls/injury. I have the potential to lose my balance and stumble, fall down and hurt myself . Review of Resident #7's Nursing Note, dated 11/4/25, revealed: Resident stated [he/she] got up from the bed then [he/she] stood up . Then all of a sudden . [he/she] tipped and lost [his/her] balance. [He/she] was found on the floor by CNA [certified nursing assistant] near the footboard . Unwitnessed fall at [4:10 AM]. Assisted back to bed . Vital signs obtained . Neuro check alert, awake and oriented . Noted swelling on left eyebrow with minimal bleeding and abrasions on left forehead and left knee . Notified [provider] and no new order made . Further review of Resident #7's medical record revealed no documentation of post fall neuro checks. During an interview on 12/3/25 at 3:01 PM, the MDS Coordinator stated neuro checks would be documented in the electronic medical record (EMR), called EPIC, in the flowsheet section or the nurse's notes. When asked to locate Resident #7's post fall neuro checks from his/her 11/4/25 fall, the MDS Coordinator stated she could not locate any documentation of post fall neuro checks other than the initial check when the fall occurred. Review of the facility's policy . Falls Management Prevention, dated 5/2025, revealed: . Post-Fall Management . Implement the following interventions . For unwitnessed falls . perform a neurological check with attention to level of consciousness, neck pain, or deficits in the extremities. Any patient with a known or suspected head injury or intracranial bleed, notify the provider and continue neuro checks: every hour x [times] 4[,] every 4 hours x 6 .

.Based on record review and interview, the facility failed to ensure Long-Term Care (LTC) staff were sufficiently and consistently trained for trauma-informed care. This failed practice placed 2 residents (#'s 3 and 5), out of 13 sampled residents, with documented trauma history, at risk of not receiving appropriate care for trauma-related needs. Findings: Review of the facility's HR Employee Personnel surveyor sheet, where the facility documented personnel credential/training information for a selected sample, revealed Licensed Nurse (LN) #1 had no trauma informed care training. Review of the staffing schedule, dated 12/1-5/25, revealed LN #1 worked dayshift on 12/1/25 and 12/2/25. LN #1 was the only nurse working dayshift on 12/1/25 for all Long-Term Care (LTC) residents. During an interview on 12/4/25 at 3:19 PM, the hospital Director of Nursing (DON) stated trauma-informed care training was not consistently offered to nursing staff of the LTC. The hospital DON further stated this had been identified and the facility was in the process of improving the training's implementation. During an interview on 12/5/25 at 1:21 PM, the LTC DON stated they could not provide proof that trauma-informed care training had been offered and completed by all nursing staff of the LTC. Resident #3 During an interview on 12/2/25 at 2:50 PM, Resident #3 stated that he/she only wanted female staff to help him/her. This came from past trauma with men. The resident further stated that some men just have that something that scares him/her. Resident #5 Record review on 12/1-5/25 revealed Resident #5 had diagnoses that included PTSD (Post Traumatic Stress Disorder) and major depression. Review of Resident #5's care plan's Need/Preference, dated 9/2/24, revealed: I HAVE: A history of trauma: sexual and physical abuse as a child. I prefer to have female aides whenever possible. Review of the CMS-802 Matrix for Providers form, which was completed by the facility on 12/2/25, revealed the facility inaccurately documented no residents were identified with PTSD (post-traumatic stress disorder - a mental health condition that's caused by an extremely stress or terrifying event) or trauma. Review of the CNA job description, dated 9/1/09, revealed: . Essential functions. Resident Care: Provides personal care and emotional support under the supervision of the Registered Nurse and or Physician. Performs basic patient/resident observation skills and reports significant changes in patient condition to the appropriate team members. Review of the Acute Care RN job description, that was provided by the facility for LTC LNs, dated 1/1/17, revealed: . General summary. Accountable for the delivery of coordinated safe, compassionate, therapeutic, evidence-based quality care to patients and families, based on individual physical, emotional, and spiritual needs. Review of the facility's Facility Assessment, dated 10/23/24, revealed: . Cognitive, Mental, [and] Behavioral Status. Cognitive care requirements. Staff competencies required. CNA. trauma-informed care. Nurse. Trauma-informed care.

.Based on observation, record review, and interview, the facility failed to ensure the posted nurse staffing information included the actual hours worked by nursing staff. This failed practice had the potential to provide limited transparency regarding staffing levels, affecting all residents (based on a census of 21) and visitors' ability to evaluate the adequacy of nursing care provided. Findings: Random observations of the facility during the survey on 12/1-5/25, revealed the facility had two resident care units: the Fireweed Unit and the Salmonberry Unit. Each unit displayed a dry erase board listing the names of staff assigned to each shift, as well as a separate board showing the daily meal items. Below the meal board, a paper containing nurse staffing data was posted in a plastic sleeve titled: Daily Assignment Sheets. Review of the facility's Daily Assignment Sheet forms, dated 12/1-5/25, revealed that while staff names, assigned units, and scheduled shift times were documented, the sheets did not clearly reflect the actual hours worked by each category of nursing staff per shift. For example, while some entries included total hours ( 8HRS or 12HRS), these were not clearly distinguished as actual hours worked versus scheduled hours, and there was no indication that the posted staffing data was updated to reflect changes such as call-outs, overtime, or shift adjustments. During an interview on 12/5/25 at 12:31 PM, the Hospital Directory of Nursing (HDON) confirmed the posted nurse staffing information reflected the staff who were scheduled to work, but did not account for staff who had called out or were otherwise absent. The HDON stated that staffing changes due to call-outs or shift adjustments could not be determined or updated on the posting until the end of the day. Review of the facility's policy CBEH Daily Nurse Staffing Information, last revised 8/2024, revealed: . On a daily basis, at the beginning of the shift, PKIMC-Chiniak Bay Elder House must post the following data.Actual time worked for each of nursing staff, including split shifts.

Based on interview and record review the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Specifically, from 11/13-22/24 there was no full-time DON. This failed practice, of not having a full-time DON to provide oversight of nursing staff, daily management, direction and support, had the potential to place all residents (based on census of 21) at substantial risk for subquality of care. Findings: During an entrance conference on 11/18/24 at 4:20 PM, the Providence Kodiak Island Medical Center (PKIMC) Chief Executive Officer (CEO) stated Licensed Nurse (LN) #2, who was a nursing supervisor, was designated as DON since the DON was on leave. Review of the email from DON, dated 11/13/24, revealed the DON would be out and return on 12/2/24. Further review of the email revealed the points of contact for assistance were: . -First point of contact . [ name of Support Manager (SM)] -Second point of contact . [name of LN #2] - If you need additional support or escalation, please contact . [name of PKIMC Executive Director of Nursing (EDON)] or . [name of CEO]. Additionally . [name of Long-Term Care (LTC) Administrator] will be in the office next week if you need in-person support. Review of the facility's staff 2024 Schedule, dated 11/2024, revealed the DON was on Personal Time Off (PTO) from 11/13-22/24. LN #2: During an interview on 11/19/24 at 8:15 AM, LN #2 stated he/she was only available until 10:00 AM, then after 2:00 PM due to responsibilities of another position outside the facility. LN #2 stated had been in his/her position since 8/21/24. LN #2 stated, I am not much of a resource to staff since he/she was still new to the position and still learning the role as the nursing supervisor. During the same interview, LN #2 stated he/she was covering for the DON. However, he/she explained he/she was covering for some DON tasks because he/she did not know all the DON tasks. Further review of the facility's staff 2024 Schedule, dated 11/2024, revealed LN #2 was not on schedule on 11/14-15/24 and 11/18/24. On 11/22/24, he/she was scheduled only for 3 hours. Review of LN #2's Current Pay Period, dated 11/2024, revealed the following hours in the Daily column: On 11/14/24 3.28 hours On 11/15/24 1 hour On 11/18/24 it was blank, no hours recorded and on 11/22/24 it was blank, no hours recorded EDON: Review of the Executive Director of Nursing Kodiak Providence work schedule, undated, revealed: .Nursing Leader On-Call while LTC DON is on [leave] November 13-27/24. Review of the EDON's Previous Pay Period, dated 11/2024, revealed the EDON had regular 8 hours/day on 11/14-15/24 and 11/18-22/24. During an interview on 11/22/24 at 9:14 AM, the EDON confirmed her work hours was from 8:00-4:30 PM Monday to Friday at PKIMC as oversight of all clinical areas in the hospital. When asked what her role as EDON in the LTC, she stated she served as a resource for the LTC DON for anything about leadership. During an interview on 11/22/24 at 9:15 AM, EDON stated the LTC DON was out on leave and currently LN #2 had stepped in to handle the day-to-day needs. LN #2 would only consult with EDON if needed. EDON stated she had not come to the LTC facility over the last 2 weeks. LTC Administrator: During an interview on 11/21/24 at 4:47 PM, when asked if LN #2 covered for the DON, the LTC Administrator stated LN #2 was a LTC Manager. The LTC Administrator stated LN #2 would call the EDON or the CEO if something came up. During the same interview, the LTC Administrator [who was based out of town] stated she would report to the facility on e week a month and when she was not in the facility, she was on-call and could fly to Kodiak if needed. The LTC Administrator clarified that the EDON and the LTC Administrator covered for the DON while the DON was out. Nursing Staff: During an interview on 11/19/24 at 9:38 AM, LN #3 stated [LN #2] goes back and forth but if I need [ed] to reach [him/her], I have [him/her] on my phone. [He/she]'s new in this higher position. During an interview on 11/21/24 at 2:47 PM, when asked if LN #2 covered for DON while the DON was out, LN #1, stated LN #2 was a nursing supervisor. LN #1 stated: [I] don't know what [LN #2] does, [LN #2] might support. LN #1 stated the EDON covered for the DON. Review of the facility's Director Long Term Care RN [Registered Nurse] Job Description, dated 6/1/08, revealed: .GENERAL SUMMARY The Director LTC RN provides clinical leadership, day to day clinical management and direction at the Chiniak Bay Elder House [Providence Kodiak Island Medical LTC].

Based on observation, interview, and record review, the facility failed to ensure foods were prepared, stored and labeled in accordance with professional standards for food safety for all residents (based on a census of 21). Specifically, the facility failed to ensure: 1) foods were labeled and dated; 2) expired foods were discarded; 3) proper sanitization of food surfaces; and 4) proper sanitizing of dishes and cookware. 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 1) Dry Storage: An observation, during the initial main kitchen tour on [DATE] at 4:30 PM, revealed: -Two- 20-ounce packages of [NAME] Family Size 5 Cheese Tortellini with a use or freeze by dated [DATE]; -One- 1 gallon container of Four [NAME] Wine Vinegar with a best if used by dated [DATE]; -Six- 13-ounce packages of Monarch Classic [NAME] Gravy Mix, dated 101824; -Three- 1-gallon containers of [NAME] Mayo Light Mayonnaise, no expiration date; -Four- 13-ounce packages of Pioneer Low Sodium Roast Beef Flavored Gravy Mix, no expiration date; -Three- 12-ounce packages of Custom Culinary Pan Roast Gravy Low Sodium [NAME] Gravy Mix, no expiration date; -One clear tub containing 3 separate clear bags, with a taped piece of paper on the side of the clear tub, Thick & Easy Texture Modified Bread & Dessert Mix 9LB 9 LB [Alternate ID: 48862] with a weight of 19.70,no expiration date. 2) Kitchen Shelves: An observation, during a subsequent main kitchen tour on [DATE] at 12:13 PM, revealed: -One- 1 fluid ounce container of Spice Islands Pure Lemon Extract best by dated [DATE]; -One- 1 fluid ounce container of [NAME] Pure Orange Extract best by dated Jun 23 19; -One- 8 fluid ounce containers of Baker's Imitation Vanilla Flavor with a written opened dated [DATE]; -One- 1 fluid ounce container of [NAME] Coconut Flavor best by dated [DATE]; -One- 1 fluid ounce container of [NAME] Food Color best by dated [DATE]; -One- 16-ounce package of Great Value Baking Soda opened dated [DATE]. 3) Salmonberry Kitchenette: An observation, during the initial Salmonberry kitchenette tour on [DATE] at 6:02 PM, revealed: a) Refrigerator: - Two- 18 fluid ounce containers of Boost Balanced Nutritional Drink dated 22OCT2024; - 13- 8.45 fluid ounce containers of Katefarms Vanilla Glucose Support dated [DATE]. b) Cupboard: - Three- 18 fluid ounce containers of Boost Balanced Nutritional Drink dated 22OCT2024. During an interview on [DATE] at 2:04 PM, Kitchen Manager (KM) #1 stated all containers should have been labeled with an expiration date. KM #1 also stated the staff should have labeled all containers with a used by date, if no manufacture date was on the label. KM #1 stated further, staff were to be using the Food Labeling Guidelines. Sanitizing Buckets: Upon observation, during the initial Fireweed kitchenette tour on [DATE] at 5:45 PM, CNA #6 tested the red sanitizing bucket with a QAR QC Test Strips (chemical test strips). CNA #6 stated the results was 50 PPM (parts per million). CNA #6 was not aware of what the recommended PPM level should be. CNA #6 stated the kitchen staff tested the buckets. During a simultaneous interview and observation on [DATE] at 5:58 PM, CNA #7 stated the Salmonberry kitchenette's red bucket was the rinse bucket and the green bucket was for washing. CNA # 7 tested the red bucket with a QAR QC Test Strips and stated the results was yellow. CNA #7 was not aware of what the recommended PPM level should be. QAR QC Test Strips dated [DATE]. During an interview on [DATE] at 11:10 AM, Food Service Staff (FSS) #1 stated FSS took the red and green buckets to the units four times per day and changed the kitchen bucket every 4 hours. The PPM results should have been between ,d+[DATE] PPM to be acceptable sanitation levels. When asked what the process was if the results were 50 PPM, FSS #1 stated that indicated the solution needed to be changed. During an interview on [DATE] at 2:04 PM, KM #1 stated that the sanitizing buckets were prepared by the kitchen staff and provided to the Fireweed and Salmonberry kitchenettes three times daily. When asked what the sanitizing PPM levels should have been, KM #1 stated it should have been ,d+[DATE] PPM. KM #1 further stated if the sanitizing results were less than 200 PPM, the buckets should have been changed with new sanitizing solution and retested prior use. Dishwasher: During an interview on [DATE] at 2:05 PM, KM #1 stated the Ecolab reader mounted on the wall next to the dishwasher read the temperatures incorrectly. KM #1 stated the Ecolab technician evaluated the reader last week and determined it was malfunctioning. KM #1 stated the Ecolab Technician verified the dishwasher gauge located on the lower portion of the dishwasher was reading accurately. KM #1 stated on the Communication Board located out in the kitchen area stated what gauge the dishwashing staff were to have been using. When asked what dishwashing temperature was sanitizing, KM #1 stated 180 degrees. When asked regarding the Dish Machine Sanitizing Log Month/Year: [DATE], rinse temperature results on ,d+[DATE]-,d+[DATE] and ,d+[DATE]-,d+[DATE] of below 180 degrees, KM #1 stated, I think the staff are confused what temperature from what gauge to write down. KM #1 further stated, staff needs education. Record review of facility's Dish Machine Sanitizing Log Month/Year: [DATE], - [DATE] at 8:00, Rinse Temp. 100, - [DATE] at 2:00, Rinse Temp. 102, - [DATE] at 10:00, Rinse Temp. 100, - [DATE] at 1:50, Rinse Temp. 98, - [DATE] at 11:00, Rinse Temp. 104, - [DATE] at 1:10, Rinse Temp. 103, - [DATE] at 10:30, Rinse Temp. 100, - [DATE] at 2:00, Rinse Temp. 101, - [DATE] at 9:40, Rinse Temp. 102, - [DATE] at 2:30, Rinse Temp. [no recorded number], - [DATE] at 11:30, Rinse Temp. 102, - [DATE] at 2:00, Rinse Temp. 102, - [DATE] at 7:30, Rinse Temp. 102, - [DATE] at 2:30, Rinse Temp. 102, - [DATE] at 8:00, Rinse Temp. 103, - [DATE] at 2:00, Rinse Temp. 102, - [DATE] at 10:50, Rinse Temp. 110, - [DATE] at 1:35, Rinse Temp. 102, - [DATE] at 7:50, Rinse Temp. 102, - [DATE] at 2:30, Rinse Temp. 104, - [DATE] at 10:10, Rinse Temp. 100, - [DATE] at 3:00, Rinse Temp. 102, - [DATE] at 11:10, Rinse Temp. 110, - [DATE] at 1:20, Rinse Temp. 101, - [DATE] at 9:55, Rinse Temp. 101, - [DATE] at 1:00, Rinse Temp. 100, - [DATE] at 2:00, Rinse Temp. 102, - [DATE] at 11:05, Rinse Temp. 103, - [DATE] at 2:00, Rinse Temp. 100. Record review on [DATE] at 6:00 PM, SALMONBERRY Dish Machine Sanitizer Log located in the Salmonberry Kitchenette revealed: Wash Temperature must reach ,d+[DATE] degrees, and rinse must reach 180 degrees. Record review on [DATE] at 6:00 PM, SALMONBERRY Dish Machine Sanitizer Log located in the Salmonberry Kitchenette revealed missing and incomplete entries dated: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Record Review on [DATE] at 6:00 PM, revealed that SALMONBERRY Dish Machine Sanitizer Log located in the Salmonberry Kitchenette contained Wash Temp log entries that were below 160 F (Fahrenheit) dated: - [DATE] at 5:30 PM: 156 F, - [DATE] at 7:00 AM: 156 F and 12:00 PM: 156 F, - [DATE] at 8:00 AM: 156 F and 1:00 PM: 156 F, - [DATE] at 8:30 AM: 155 F, 12:15 PM: 156 F, and 6:00 PM: 156 F, - [DATE] at 8:30 AM: 154 F, 1:00 PM: 156 F, and 6:30 PM: 157 F, - [DATE] at 8:30 AM: 157 F, 12:30 PM: 156 F, and 6:30 PM: 156 F, - [DATE] at 8:30 AM: 157 F, 12:30 PM: 156 F, and 6:00 PM: 156 F, - [DATE] at 6:00 PM: 156 F, - [DATE] at 8:30 AM: 156 F, 12:30 PM: 150 F, and 6:30 PM: 155 F, - [DATE] at 8:30 AM: 155 F, and 6:30 PM: 157 F, - [DATE] at 7:00 AM: 156 F, 12:00 PM: 156 F, and 5:30 PM: 157 F, - [DATE] at 5:30 PM: 157 F, - [DATE] at 8:00 AM: 154 F, - [DATE] at 7:00 AM: 154 F, 12:00 PM: 157 F, and 6:00 PM: 157 F, - [DATE] at 8:30 AM: 157 F, and 12:30 PM: 149 F, - [DATE] at 8:30 AM: 143 F, and 12:38 PM: 142 F, - [DATE] at 6:30 PM: 157 F, - [DATE] at 6:50 PM: 157 F, - [DATE] at 8:30 AM: 157 F, 1:30 PM: 150 F, and 6:30 PM: 157 F, - [DATE] at 6:30 PM: 151 F, - [DATE] at 7:05 PM: 156 F, - [DATE] at 6:00 PM: 157 F, - [DATE] at 6:45 PM: 156 F, - [DATE] at 8:00 AM: 152 F, and 12:30 PM: 157 F, - [DATE] at 7:00 AM: 157 F, 12:00 PM: 157 F, and 6:00 PM: 156 F, - [DATE] at 5:00 PM: 157 F, - [DATE] at 5:15 PM: 156 F, - [DATE] at 8:30 AM: 148 F, - [DATE] at 8:41 AM: 156 F, - [DATE] at 8:30 AM: 156 F, 12:30 PM: 157 F, and 5:30 PM: 152 F, - [DATE] at 5:00 PM: 151 F, - [DATE] at 6:00 PM: 156 F, - [DATE] at 6:00 PM: 157 F, - [DATE] at 8:00 AM: 157 F, 12:15 PM: 157 F, and 6:35 PM: 157 F, - [DATE] at 6:15 PM: 156 F, - [DATE] at 12:00 PM: 154 F, and 6:30 PM: 157 F. Record Review on [DATE] at 6:00 PM, revealed that SALMONBERRY Dish Machine Sanitizer Log located in the Salmonberry Kitchenette contained Rinse Temp log entries dated [DATE] was 172 F . Review of the facility's policy Dish Machine Operation, last revised on ,d+[DATE], revealed: .Wash cycle temperature will be 160F, rinse temperature at least 180F or higher, and surface temperature at least 160F ., and .Temperature Recording: The FNS [Food Nutrition Staff] staff loading the dish machine will be responsible for checking and logging temperatures on the dish washing temperature log sheet throughout the use of the machine, at least 3 times a day .

Based on record review and interview, the facility failed to ensure emergency care equipment was maintained. Specifically, the facility failed to complete the Automated External Defibrillator (AED) regular maintenance per manufacturer's recommendation. This failed practice had the potential to place all residents (based on a census of 21) at risk of not receiving emergency care. Findings: Record review of the facility's 2024 [NAME] AED Plus Monthly Inspection Log, dated from 1/2024 to 12/2024, revealed five steps to inspect the AED as: Step 1 press and hold the On/Off button; Step 2 AED Status Indicator Test Red X or [NAME] as check mark; Step 3 Defibrillator unit is clean, no spills, clear of objects on top, & casing intact with response choices of Yes or No; Step 4 Cables and Connectors are secured, and not damaged (cracks, broken wires, etc.) with response choices of Yes or No; and Step 5 AED unit supplies have two pads. One for Adult and Pediatric. Further review of the inspection log revealed: Step 2 was not marked either X or check marked from 1/2024 to 11/2024, with a total of 11 months. Step 3 was not marked yes or no from 6/2024 to 9/2024 and 11/2024, with a total of 5 months. Step 4 was not marked yes or no from 2/2024 to 11/2024, with a total of 10 months. During an interview on 11/22/24 at 11:35 AM, the Administrator stated that the incomplete responses in the inspection log would mean that the staff forgot to encircle the responses. When asked for clarification, the Administrator clarified that it meant that the staff would encircle the responses if the staff had checked the AED if it was clean and the cables were secured and not damaged. Review of the [NAME]'s Ensure AED Readiness with Regular Maintenance, dated 2024, accessed at this link: https://www.[NAME].com/en-GB/Other%20Resources%20and%20Links/how-to-maintain-aed, on 11/22/24, revealed: .AEDs are sophisticated medical device that are designed for years of service, but they require regular inspections and basic care to remain in proper working condition. This includes visually inspecting the AED regularly to confirm its readiness status, storing it in an temperature controlled area, and replacing consumables such as batteries and electrode pads to comply with expiration dates . Routine Inspection and Maintenance Checklist. Follow our simple maintenance checklist to ensure that your AED will be ready when you need it: The unit is clean, undamaged, and free of excessive wear. The green status indicator shows that the AED has passed its most recent self-test. The housing has no cracks or loose parts. The electrodes are present, sealed in their package, and within their expiration date. All cables are free of cracks, cuts, and exposed or broken wires. The battery is within its expiration date.

Based on observation, interview, and record review, the facility failed to ensure: 1) Informed consent was obtained prior to the use of bed rails for 16 residents (#'s 1, 2, 4, 5, 6, 10, 11, 12, 13, 15, 16, 18, 19, 72, 122, and 172), out of 21 residents reviewed; and 2) Assessments for the risk and benefits of the use of bedrails, prior to the use of bedrails, for 5 residents (#'s 4, 13, 16, 18 and 19), out of 21 residents reviewed. This failed practice had the potential to place residents at risk of falls, entrapment, and other preventable accidents. Findings: Random observations on 11/18-22/24 revealed Resident #'s 1, 2, 4, 5, 6, 10, 11, 12, 13, 15, 16, 18, 19, 72, 122, and 172 all had raised upper side rails on his/her beds. During an interview on 11/21/24 at 12:15 PM, Licensed Nurse (LN) #4 stated nurses completed a weekly nursing summary about bedrails. When asked if any consents or assessments were required with the use of bedrails, LN #4 stated he/she was not aware. LN #4 further stated that LN #7 took care of bedrail assessments. During an interview on 11/21/24 at 12:16 PM, LN #7 stated he/she had noticed some beds had the siderails up and was not aware siderails were up. LN #7 further stated the residents must have a siderail assessment completed in the electronic health record (EHR), but no resident or resident representative consent was needed, and no physician order was necessary. Resident #1 Record review on 11/18-22/24 revealed Resident #1 was admitted to the facility with diagnoses that included dementia (a condition that affects memory and thinking) and COPD (Chronic Obstructive Pulmonary Disease) (lung disease that blocks air flow and make it difficult to breathe). Review of Resident #1's medical record revealed the resident had side rail assessments completed on 10/30/23, 1/25/24, 7/16/24, and 10/14/24. Further review of Resident #1's medical record revealed no informed consent regarding the use of bed rails was found. Resident #2 Record review on 11/18-22/24 revealed Resident #2 was admitted to the facility with diagnoses that included dementia, stroke, and hemiplegia (partial or complete paralysis on one side of the body). Review of Resident #2's medical record revealed the resident had side rail assessments completed on 1/18/24, 4/15/24, 7/10/24, and 10/7/24. Further review of Resident #2's medical record revealed no informed consent regarding the use of bed rails was found. Resident #4 Record review on 11/18-22/24 revealed Resident #4 was admitted to the facility with diagnoses that included dementia and Parkinson's Disease (disorder that affects movement, often including tremors). Review of Resident #4's medical record revealed no side rail assessments or informed consent regarding the use of bed rails was found. Prior exiting from the facility, requested side rail assessments were not provided for Resident #4. Resident #5 Record review on 11/18-22/24 revealed Resident #5 was admitted to the facility with diagnoses that included Schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), hemiplegia, and seizure. Review of Resident #5's medical record revealed the resident had side rail assessments completed on 1/29/24, 4/23/24, 7/20/24, and 10/16/24. Further review of Resident #5's medical record revealed no informed consent regarding the use of bed rails was found. Resident #6 Record review on 11/18-22/24 revealed Resident #6 was admitted to the facility with diagnoses that included COPD and vision loss both eyes. Review of Resident #6's medical record revealed the resident had side rail assessments completed on 2/8/24, 8/5/24, and 10/30/24. Further review of Resident #6's medical record revealed no informed consent regarding the use of bed rails was found. Resident #10 Record review on 11/18-22/24 revealed Resident #10 was admitted to the facility with diagnoses that included heart failure, seizure disorder, diabetes mellitus, and generalized weakness. Review of the Resident #10's medical record revealed the resident had side rail assessments completed on 1/12/24, 4/8/24, 7/2/24, and 9/30/24. Further review of Resident #10's medical record revealed no informed consent regarding the use of bed rails was found. Resident #11 Record review on 11/18-22/24 revealed Resident #11 was admitted to the facility with diagnosis that included dementia. Review of the Resident #11's medical record revealed the resident had side rail assessments completed on 11/21/23, 2/15/24, 8/12/24, and 11/6/24. Further review of Resident #11's medical record revealed no informed consent regarding the use of bed rails was found. Resident #12 Record review on 11/18-22/24 revealed Resident #12 was admitted to the facility with diagnosis that included dementia. Review of Resident #12's medical record revealed the resident had side rail assessments completed on 1/9/24, 4/4/24, 7/1/24, and 9/26/24. Further review of Resident #12's medical record revealed no informed consent regarding the use of bed rails was found. Resident #13 Record review on 11/18-22/24 revealed Resident #13 was admitted to the facility with diagnoses that included dementia and depression. Review of Resident #13's medical record revealed no side rail assessments or informed consent regarding the use of bed rails was found. Prior exiting from the facility, requested side rail assessments were not provided for Resident #13. Resident #15 Record review on 11/18-22/24 revealed Resident #15 was admitted to the facility with diagnosis that included dementia. Review of Resident #15's medical record revealed the resident had side rail assessments completed on 2/12/24, 5/9/24, 8/6/24, and 11/4/24. Review of Resident #15's medical record revealed no side rail assessments or informed consent regarding the use of bed rails was found. Resident #16 Record review on 11/18-22/24 revealed Resident #16 was admitted to the facility with diagnoses that included seizure disorder, unspecified ataxia (medical problem that causes problems with movement) and reduced mobility. Review of Resident #16's medical record revealed no side rail assessments or informed consent regarding the use of bed rails was found. Prior exiting from the facility, requested side rail assessments were not provided for Resident #16. Resident #18 Record review on 11/18-22/24 revealed Resident #18 was admitted to the facility with diagnosis that included Schizophrenia. Review of Resident #18's medical record revealed no side rail assessments or informed consent regarding the use of bed rails was found. Prior exiting from the facility, requested side rail assessments were not provided for Resident #18. Resident #19 Record review on 11/18-22/24 revealed Resident #19 was admitted to the facility with diagnoses that included renal disease and depression. Review of Resident #19's medical record revealed no side rail assessments or informed consent regarding the use of bed rails was found. Prior exiting from the facility, requested side rail assessments were not provided for Resident #19. Resident #72 Record review on 11/18-22/24 revealed Resident #72 was admitted to the facility with diagnosis of dementia. Review of Resident #72's medical record revealed the resident had side rail assessment completed on 10/31/24. Further review of Resident #72's medical record revealed no informed consent regarding the use of bed rails was found. Resident #122 Record review on 11/18-22/24 revealed Resident #122 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, gout, and COPD. Review of Resident #122's medical record revealed the resident had side rail assessment completed on 11/7/24. Further review of Resident #122's medical record revealed no informed consent regarding the use of bed rails was found. Resident #172 Record review on 11/18-22/24 revealed Resident #172 was admitted to the facility on [DATE] with diagnoses that included CVA (cerebrovascular accident), hemiplegia, and unspecified dementia. Review of Resident #172's medical record revealed the resident had side rail assessment completed on 11/21/24. Further review of Resident #172's medical record revealed no informed consent regarding the use of bed rails was found. Surveyors requested the facility's Bedrail Policy on 11/22/24 from Administration. Bedrail policy not provided prior to the exit from the facility.

Based on record review, observation and interview, the facility failed to ensure residents' right to dignity and respect was honored for three residents (#'s4, 13, and 15), out of 21 residents (total census). Specifically, Certified Nurse Assistants (CNAs) used a cloth protector to wipe the residents' nose and mouth after dining. Additionally, a CNA transferred a resident in an ARJO lift (transfer lift device) from the resident's room to a chair in the living room. These failed practices placed the residents not being valued as a person with dignity and respect. Findings: Dining Experience: Resident #4 Record review on 11/18-22/24, revealed Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement) and dementia (a condition that affects memory and thinking). Review of Resident #4's Care Plan, dated 9/27/24, revealed: .assist me with food/fluid intake to promote adequate nutrition/hydration. During a dining observation on 11/18/24 at 4:57 PM at Salmonberry Unit, Resident #s 2, 4, 7, & 15 were at the long table having dinner. CNA #1 was feeding Resident #4. During an observation on 11/18/24 at 5:53 PM, CNA #1 was sitting next to Resident #4 and was observed to wipe Resident #4's nose with a cloth protector after dining. Then, the CNA wiped Resident's nose again with a paper napkin. After which, the CNA walked away carrying used plate and utensils and returned with a washcloth and wiped Resident's face and hands. Resident #15 Record review on 11/18-22/24, revealed Resident #15 was admitted to the facility with diagnoses that included palliative care and dementia. Review of Resident #15's Care Plan, dated 11/12/24, revealed: .I NEED: help with all my ADLs [Activities of Daily Living] .I EAT: with 1 helper providing more than half the effort.MY GOAL IS: participate in my ADLs as much as possible .maintain my dignity. During an observation on 11/21/24 at 8:47 AM at Salmonberry Unit, Resident #s 2, 4, 7, & 15 were at the long table and Resident #s 10, 18, and 72 were sitting at separate tables respectively. Further observation revealed, CNA #5 was observed to wipe Resident #15's mouth with a cloth protector after dining, then CNA #5 wheeled resident to the living room. During an interview on 11/21/24 at 10:00 AM, CNA #2 explained how the CNAs should prepare and help residents during dining. He/she stated the CNAs should bring the residents in the dining area, provide the residents with hand hygiene, place a cloth protector, and serve drinks and meals. When asked how they should wipe the residents' mouth if there were food crumbs around residents' mouth and after residents eat, CNA stated they should have used a washcloth to wipe residents' mouth or face after dining. Review of the facility's Standard of Care, dated 7/2024, revealed: . After Meal Care: Respectfully offer warm washcloth to clean hands and face. Assist as needed, Remove clothing protector. Transfer of a Resident: Record review on 11/18-22/24, revealed Resident #13 was admitted to the facility with diagnosis of a stroke. During an observation on 11/20/24 at 8:47 AM, Resident #13 was in an ARJO sling (resident elevated in the air) while CNA #2 was transferring resident from his/her room to the living room recliner. Only one CNA was operating the lift. No observation of another CNA was assisting with the transfer. During an interview on 11/19/24 at 2:10 PM, CNA #2 stated Resident #13 requires two-person assistance for care and one person assist for feeding at times. During an interview on 11/21/24 at 10:05 AM, CNA #4 stated Resident #13 requires assistance of a lift device for transfers from bed to chair or chair to bed. CNA #4 stated Resident #13 had been transferred in the ARJO lift from the resident's bed then to the living room chair in the community space because it provides less transferring of the resident. During an interview on 11/21/24 at 1:00 PM, Administrator was asked for the facilities policy for the ARJO transfer device and the manual for the equipment. ARJO, Maxi Move, Maintenance and Repair Manual, dated 7/2008 copy was provided. No policy for transfer devices or transferring of a resident was provided prior to the exit of survey. Review of ARJO Maxi Move Maintenance and Repair Manual, dated 9/2008, revealed: . The Maxi Move is a mobile patient lifter and is used for transferring patients from bed or chair to the toilet or bath . Review of the facility's My Rights and Responsibilities, undated, revealed: . I have the right. to be treated with respect and dignity by all my caregivers.

Based on observation, interview and record review the facility failed to ensure infection control procedures were properly implemented. Specifically, the facility failed to ensure staff contained linen during transportation. This failed practice had the potential to affect all residents (based on census of 21) for risk of the spread of infectious disease. Findings: During an observation on 11/19/24 at 9:50 AM, Certified Nursing Assistant (CNA) #2 with gloves on was transporting unbagged linen from Resident #172's room passing through the community area to the dirty linen cart. During an interview on 11/21/24 at 10:05 AM, CNA #4 stated all linens brought from a resident's room should be placed into a plastic bag before leaving the room and taken to the dirty linen cart in the hall of the community area. During an interview on 11/21/24 at 2:50 PM, Infection Control Preventionist (ICP) stated all linens should be bagged inside the resident's room before transporting. ICP stated no PPE (personal protective equipment) was required when placing bags into the dirty linen cart. Record review of the facility's 2023-2024 Chiniak Bay Elder House, Infection Prevention Program revealed: . Protecting caregivers, visitors and the healthcare environment. Limiting unprotected exposure to pathogens by using . barrier precautions including personal protective equipment .

Based on observation and interview, the facility failed to post the daily total number and the actual hours worked for all residents (based on census of 21) care per shift worked by the Certified Nurse Assistants (CNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). This failed practice provided inaccurate information to the all residents and their families. Findings: Random observation from 9/18-22/23 in the Fireweed and Salmonberry units' common area, revealed staff postings displaying the name of the facility, names of staff (RN and CNA) on duty per shift per day, and resident census were written on the whiteboard. Further review of the posting revealed the total number of staff and actual hours worked of nursing staff per shift was not documented. During an interview on 9/22/23 at 10:45 AM, the Director of Nursing (DON) stated the whiteboard had daily nurse staffing information for the residents and family. When asked if the total number and actual hours of nursing staff who provided direct resident care should have been included in the posting, she stated the time range for each shift was provided day shift 7:00 AM-3:30 PM, evening shift 3:00-11:30 PM, and night shift 11:00 PM-7:00 AM. No further comment was made regarding posting the total number or actual hours worked.

Based on observation, interview and document review, the facility failed to ensure: 1) food was stored under proper sanitary conditions; and 2) concentrations of sanitizing solutions were tested correctly to assure the solutions were maintained within acceptable parameters. These failed practices placed all residents (based on a census of 21) at risk for foodborne illness and/or communicable disease. Findings: Walk-in freezer During the initial tour of the kitchen on [DATE] at 9:00 AM, the walk-in freezer was observed. In the middle of the freezer were 4 boxes of frozen food placed on top of a milk crate. Behind these boxes were 2 Sterilite brand plastic containers stacked on top of one another, the bottom container was placed directly on the floor. Inside the container located on the floor were 10 bags of frozen fresh cut green beans. During an interview on [DATE] at 12:19 PM, the Food Service Manager (FSM) stated the plastic containers containing food should not have been stored on the floor. The FSM further stated the containers should have been placed 6 inches off the floor. At the conclusion of the interview, the FSM was asked to provide the facility policy for storage of food in the main kitchen. By close of survey, the policy had not been provided. Sanitation buckets During the initial tour of the kitchen on [DATE] at 9:35 AM, a sanitation bucket was observed in the 3rd sink. A poster was located above the sink with instructions for the Apex Solid Quat Broad Range Sanitizer [brand used by the facility] using the Hydrion QT-40 test strips. Further observation of the poster revealed Testing solution should be at room temperature- 65 degree F-75 degree F .Dip paper for 10 seconds. Don't shake. Cook #1 was asked to demonstrate the method to check the concentration of the sanitation solution. Cook #1 retrieved the QT-40 HYDRION test strips, placed the strip in the sanitation bucket, and immediately compared the color of the test strip (from the bucket) to the color on the QT-40 HYDRION test strip control. An observation of the QT-40 HYDRION test strips revealed an expiration date of [DATE]. Cook #1 stated he/she was not aware the test strips had expired and explained he/she could not see the expiration date because the writing was too small. Then, Dietary Aide (DA) #1 arrived with a second vial of test strips labeled as QAC QR /TEST STRIPS and stated these were the new test strips the facility would have been using. When asked for instructions for these test strips, the DA #1 stated he/she thought the procedure was the same. An observation and review of the package insert of the QAC QR /TEST STRIPS, with expiration date ,d+[DATE], revealed Hold strip level for 5 seconds. Shake off excess water from pad .Sample must be at room temperature (above 75 degree F). During an interview on [DATE] at 12:19 PM, the FSM stated the facility changed the sanitation buckets 3 times per day and had a log to document the tests. When asked for the policy, the FSM stated there was no policy, but the instructions for testing were located on the log sheets. Review on [DATE] at 4:00 PM of the facility's Hospital Sanitizer Bucket Log sheets, dated [DATE] and [DATE], both revealed Testing solution should be between ,d+[DATE] degrees. Dip paper in solution .for 10 seconds. Don't shake . Further review revealed no documentation of the type of test strip used. Review on [DATE] at 5:00 PM of the Providence Chiniak Bay Elder House Procedure Sanitizer Buckets, dated [DATE], revealed The dietary aides will fill and refill sanitizer buckets for the kitchenettes, however if the liquid is visible dirty, anyone may change it out immediately. LTC [long term care] cooks must help change buckets for kitchenettes at these times: Sat/Sun: 10[am], every day at 5:15 pm. Further review revealed no instructions for testing the sanitation bucket solution.

Based on record review, observation, and interview, the facility failed to have an antibiotic stewardship program (ASP), a program that monitors antibiotic usage and effectiveness. This failed practice had the potential, for all residents (based on a census of 21), to receive an ineffective and inaccurate implementation of antibiotic protocols for antibiotic use. Findings: Record review on 9/18-22/23 of the electronic health record (EHR) revealed Resident #13 was admitted to the facility with diagnoses that included bronchiectasis (a condition in which the airways of the lungs remain permanently damaged and widened due to persistent infection) and chronic obstructive pulmonary disease. Review on 9/19/23 at 1:40 PM of Resident #13's electronic medication administration record (eMAR), revealed an order for Azithromycin (antibiotic) 250 MG Tablet (1 tablet/250 mg) to be administered in the morning three times a week on Monday, Wednesday, and Friday for bronchiectasis with an entry date on 10/20/20. An observation on 9/20/23 at 10:15 AM of the medication administration, revealed LN #1 administered Azithromycin to Resident #13. During an interview on 9/21/23 at 1:15 PM, when asked if the facility had an ASP, the Pharmacist stated the facility piggybacked the ASP with Providence in Anchorage, Alaska. He stated the Long-term Care facility had no ASP and no ASP committee who would have reviewed the residents' antibiotic use. He stated the facility was working on developing and implementing an ASP. During an interview with the Infection Preventionist (IP) on 9/21/23 at 3:36 PM, the IP stated the Pharmacist led the ASP. She stated her role as an IP was to track the type of infections, type of antibiotic, dosage, and frequency. She stated that any discrepancies found would have been reported to the Pharmacist. When asked if the facility had ASP, she stated ASP was a work in progress. During an interview on 9/22/23 at 8:50 AM, when asked the facility's process for antibiotic use, LN #1 stated if the resident exhibited signs and symptoms, the CNAs (Certified Nurse Assistants) would have taken the vital signs and reported to the nurse on duty. The nurse on duty would have assessed the resident, then informed the physician . During the same interview, when asked about the tool used to communicate the signs and symptoms to the physician, LN #1 stated they do not have a tool. The Infection Preventionist (IP) stated they have had McGreer criteria (an infection surveillance criteria) in the electronic health record (EHR). LN #1 stated he/she was not aware of the criteria and was unable to locate the McGreer criteria in the EHR. The IP directed the LN where to find the tool. The LN stated he/she had not used the McGreer criteria. The LN explained he/she would have only verbalized the resident's signs and symptoms to the physician, the physician would then prescribed the antibiotic based on laboratory and culture results. When asked if they would have reassessed the resident after few days on antibiotic use (also called a time-out), the LN stated he/she did not know about it. The IP stated the facility did not have a time-out. LN #1 stated the Pharmacist reviewed antibiotic use during the monthly medication regimen review (MRR). He/she stated Resident #13 was the only resident who received antibiotic for bronchiectasis. During an interview on 9/20/23 at 10:18 AM, Physician #1 stated Resident #13 was prescribed the antibiotic (Azithromycin) for prophylaxis ( action taken to prevent disease, especially by specified means or against a specified disease) that would have been recommended by a pulmonologist. Review of the facility's Infection Control Program for 2022-2023, revealed ASP was not included.

Based on observations, interview, record review, and policy review the facility failed to protect 1 resident with known behaviors of wandering, and intrusive behaviors, from altercations with another resident who had known mental and physical acts of aggression toward the resident. Specifically, the facility failed to recognize that the wandering and intrusive behaviors of resident (#1) placed the resident at risk for abuse and harm by another resident (#13) or by other residents that may become angered or frustrated with resident (#1) entering their room and taking their personal belongings. The failure of the facility to provide reasonable precautions placed resident (#1) at risk for further abuse and harm and constituted an Immediate Jeopardy (IJ) for the safety of the resident. The facility was notified of the Immediate Jeopardy (IJ) on 3/16/17 at 10:50 am and abated the immediacy on 3/16/17 at 10:55 am. Findings: Random observations on 3/13-16/17 during the survey revealed Resident #1 wandered freely and frequently throughout the unit. Resident #1 was observed sitting for short amounts of time and then got up and move to another part of the unit or wander to his/her bedroom or sunroom. Random observations on 3/16/17 from 8:00 am to 10:00 am revealed Resident #1 wandering in and out of a Surveyor and Plant Operations meeting held in the Sunroom on Unit #2. The Resident sat in the meeting for approximately 20-30 minutes at a time. During the observation no staff attempted to distract or provide 1:1 care to Resident #1. No staffs were visualized checking on Resident #1's location and status during the random observations. During a group interview on 3/15/17 at 2:15 pm - 3:15 pm, Resident #13 expressed concerns regarding Resident #1 wandering into his/her room. Resident #13 stated he/she had knives and hammers in his/her room that he/she locked up. What if I (forgot and) left a knife out? During an interview on 3/16/17 at 9:55 am Resident #13 stated Resident #1 had entered his/her room hundreds of times over the past year and attempted to take items. In addition, Resident #13 stated he/she often had to .get up, grab a hold (of Resident #1) and escort Resident #1 out of his/her room. Resident #13 further stated he/she gets so aggravated that he/she often feels like going into Resident #1's personal room to take stuff from him/her. During the interview Resident #13 raised his/her voice and became agitated when discussing the events regarding another resident entering his/her room. During an interview on 3/16/17 at 9:55 am, Resident #9 stated, Resident #1 sometimes will open his/her door and wander into his/her room. Resident #9 stated that Resident #1 doesn't take anything. Resident #1 Record review on 3/14-16/17 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Further review revealed Resident #1 was identified with behaviors that included wandering throughout the unit including in and out of other Residents rooms. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed the Resident was scored as 8, moderately impaired, on the Brief Interview for Mental Status (BIMS) screening. Additionally, review of the previous MDS assessment, an annual assessment dated [DATE], revealed the Resident was scored as 7, severe impairment, on the BIMS screening. Further review of the most recent MDS quarterly assessment dated [DATE], revealed the Resident was coded with behaviors that occurred daily, were not directed toward others and a daily occurrence of wandering. Review on 3/14-16/17 of Resident #1's care plan, dated 2/1/17, revealed the Resident was care planned for the PROBLEM (BEHAVIOR): Identified wandering Disruptive behavior Easily distracted, difficulty sitting still, fidgety . Approaches included: .Provide one-to-one for restlessness, anxiety, & agitation. The care plan did not identify that the known wandering/disruptive behaviors placed the Resident at risk for injury from other Residents and there were no goals or approaches in the care plan to prevent Resident to Resident abuse. Additionally, the Resident was care planned for the PROBLEM (FALLS): Potential for Trauma-Falls. Behavior and Mood Record: Review on 3/14-16/17 of Resident #1's Behavior and Mood Record, from 10/1/16 to 3/15/17 revealed frequent behaviors that included: - Pacing/Rummaging; - Going into other Resident's rooms and occasionally taking others belongings; - Taking food from other Residents; - Wandering; - Disruptive behavior; - Entering the unit kitchen; - Exit seeking behavior. Nurses Notes: Review on 3/16/17 of Resident #1's nurses notes dated 2/24/17 revealed Resident #1 .took another patients medications. Monitoring B/P (blood pressure) . Resident to Resident Altercations: During an interview on 3/15/17 from 12:17 pm to 12:40 pm with the Social Services Manager (SSM) and the Director of Nursing (DON), the DON stated there was an incident between Resident #1 and Resident #13 that occurred around Halloween. The DON stated Resident #1 had wandered into Resident #13's room. Resident #13 donned a scary Halloween mask when Resident #1 came into his/her room. The DON stated Resident #1 was visibly frightened from the incident. Review on 3/16/17 of Resident #1's Behavior Record dated 10/2/16 at 8:28 am, revealed Screaming/Cursing at Others .Stated. That [***] scared Me! Is swinging (his/her) arms and screaming on top of (his/her) lungs. Review on 3/16/17 of Resident #1's nursing notes dated 10/5/16 at 4:06 pm, revealed .increase in agitation, also notification of this Resident being startled/frightened by another Resident . Review on 3/14-16/17 of a Resident Incident Report dated 12/2/16 revealed an incident between Resident #1 and #13 that occurred on 11/28/16 at approximately 4:45 pm: - 6:10 pm Resident #13 stated 'snatched the cookies away from (Resident #1) .I knocked (Resident #1's) hand away .it was instinctive, I was not trying to hurt (Resident #1) .' - 5:50 pm Licensed Nurse (LN) staff statement: (Resident #13) yelled at (Resident #1) to stay out of (his/her) room . Resident (#13) told (LN) that (s/he) slapped (his/her) hand away . - 6:05 pm Certified Nursing Staff (CNA) statement: Resident #13 .proceeded to snatch out of (Resident #1's) hand and pushed (him/her) away . - 5:32 pm LN staff statement: .heard Resident (#13) say in a loud voice to Resident (#1) 'Stay out of my room'. - Resident has a history of violence per (SSM) report. Details re: this will be provided in follow-up . Review of Resident #13's care plan dated 11/9/16, revealed no care planning related to Resident #13's aggression towards Resident #1. An addition to the care plan, dated 12/2/16 stated, Encourage resident to seek staff assistance when another resident has an item belonging to (him/her) versus trying to retrieve. Staff to reduce number of times when other resident(s) enter (his/her) room uninvited. Laser alarm at foot entrance to door of room to reduce entrance/alert staff. The care plan did not identify Resident #13 with aggressive behaviors and therefore there was no problem or approaches on the care plan to guide staff in protecting Resident #1 or other residents with similar behaviors from abuse. Review on 3/13-16/17 of the facility's policy Abuse Prevention and Protection from Abuse and Neglect in the Vulnerable Adult in the PKIMC LTC Center last revised 11/2016, revealed Physical Abuse: Includes hitting, slapping, pinching kicking .Mental Abuse: Includes, but is not limited to, humiliation, harassment .Residents with increased risk of conflict or neglect such as aggressive behavior, wandering .will be monitored and have concerns addressed in the resident's plan of care .In all instances an assessment of safety for the resident will be done and a plan of care will be implemented immediately .In the event a resident is admitted with known abusive history toward others .a care plan will be planned .to ensure safety of the LTC population . Following the survey on 3/20/17, the facility shared documentation that further revealed an awareness that Resident to Resident altercations occurred prior to or around 10/15/16. The documentation included incident reports with dates of incidents as 10/2/16 and 10/15/16, and mood and behavior logs of Residents #s 1 and 13.

Based on observation and interview the facility failed to ensure staff followed accepted infection control practices in the areas of medication administration and in the cleaning of the medication refrigerator, used to store resident medications. These failed practices placed residents at risk for cross contamination and transmission of infection in a vulnerable population (based on a census of 20). Findings: This situation constituted an immediate jeopardy and was brought to the attention of the facility's administration on 1/28/16 at 1:05 pm. The immediate jeopardy was abated on 1/28/16 at 1:10 pm. Based on record review and interview the facility failed to operationalize an effective Infection Control Program (ICP). Specifically, the facility failed to: 1) report ongoing infection prevention surveillance; 2) trend surveillance data; and 3) develop actions plans for trends identified. Failure to maintain an effective ICP and antibiotic stewardship placed vulnerable residents at risk for infection transmission. Findings: Medication Administration and Storage: Observation on 1/27/16 from 8:30 am - 9:30 am during a medication administration, Licensed Nurse (LN) #2 moved a trash container that was located in front of the medication refrigerator by placing the four fingers on the inner rim and the thumb on the outside rim. The LN then proceeded to use his/her samed gloved hand to prepare a resident medications. During this same observation the LN, using the same one gloved hand, grabbed the door of the medication refrigerator rubbing his/her fingers across the gasket seal, opened the refrigerator door and removed medications. Further observation of the refrigerator gasket seal revealed it appeared cracked along the top of the refrigerator edge. A thick black sticky substance mixed with debris was encrusted within the gasket's seal crevices. The same black substance lined the four sides of the gasket seal along the edge which included the bottom edge. Another substance, which was sticky and pink, was noted within the same refrigerator gasket seal and a thick white powdery substance coated the entire floor ledge inside the refrigerator. During the same observation of 1/27/16 from 8:30 am - 9:30 am LN #2, after touching the contaminated seal on the refrigerator with his/her gloved hand, prepped an oral syringe & mouthwash obtained from the PYXIS system (storage system used to stock medications). LN #2 did not remove the contaminated gloves or wash hands, before administering the medications to Resident # 12. During an interview on 1/28/16 at 11:02 am the DON (Director of Nursing) was asked who was responsible for cleaning the medication refrigerator. The DON stated the nurses were to clean it and they also were to keep a log of the cleaning; however, no log had been maintained. Observation on 1/28/16 from 11:02 am-12:30 pm revealed the Pharmacist opened the medication refrigerator and ran his bare hand along the refrigerator's gasket seal; wiped his bare hand along the floor of the refrigerator and showed the DON his hand was covered with white powder. The Pharmacist informed the DON the refrigerator was contaminated and the medications needed to be thrown away. The Pharmacist further stated the refrigerator was to be removed from service immediately. During an interview on 1/28/16 from 11:02 am-12:30 pm the Pharmacist instructed staff to discard the medications and had the refrigerator removed from the facility. In addition, the Pharmacist stated the refrigerator was bacteria ridden but was not sure if the black substance was mold. The Pharmacist further stated he could not guarantee the safety of the refrigerator medications. During the same interview the DON stated multiple times the refrigerator had to be removed and the refrigerator should not have been in this kind of condition. Infection Control Program: Record review on 1/29/16 at 9:15 am of the Infection Prevention Committee minutes: Dated 2/25/15, revealed Zero infection control deficiencies from CMS (Centers for Medicaid/Medicare Services). No documentation of infection prevention surveillance discussion or of antibiotic review. Dated 5/20/15, revealed Have had pneumonia and UTIs (urinary tract infections), however no trending. No documentation of antibiotic review. Dated 8/19/15; 10/20/15; and 12/11/15, revealed no infection surveillance discussion or antibiotic review. Further review of LTC (Long Term Care) dashboard report, provided by the Infection Preventionist on 1/29/16 at 10:15 am revealed, 2 urinary tract infections and 1 lower respiratory infection for the 1st quarter and 1 lower respiratory infection for 2nd quarter. No data had been documented for 3rd or 4th quarter. Review of the line list of antibiotics dispensed to LTC residents for 2015 revealed only 5 of the 21 residents treated for [REDACTED]. During an interview on 1/29/16 at 10:30 am the Infection Preventionist confirmed the infection committee minutes had no documentation of any action plans, and had no documentation and antibiotic concerns. Review of the Quality Data provided revealed no trending report of infections to the committee or action plans for the number antibiotics dispensed for residents who did not meet infection surveillance criteria. Review of the 2015 Chiniak Bay Elder House Infection Prevention Program Plan revealed, the principle functions include .to obtain and manage critical data and information, including surveillance for infections . The plan did not include trending of data to determine if an action plan was appropriate and did not include antimicrobial stewardship. During an interview on 1/29/16 at 10:45 am the Infection Preventionist stated she was new to the position, as of September 2015 and could not speak to the lack of data prior to that date. .

Based on observations, interview and record review the facility failed to ensure 2 electrical wash cloth heating units, located in an area accessible to residents, were maintained in a safe manner. This failed practice placed 2 residents with dementia (#s 4 and 10) out of 20 residents residing in the facility at immediate risk for serious injury from thermal burns. This deficient practice constituted Immediate Jeopardy (IJ) to the residents' health and safety. The facility was notified of the IJ on 1/28/16 at 1:05 pm. The immediacy was abated by the facility on 1/28/15 at 1:10 pm. Observation on 1/28/16 at 12:45 pm revealed electrical wash cloth heating units on both the Fireweed and Salmonberry units. The heating units were located on the open serving bar of the kitchenettes and contained several wet washcloths. The areas were accessible to the residents. The Surveyor opened the heating unit on Fireweed and inspected the inner functioning and felt the wash cloths. During the inspection the Surveyor had to quickly remove his/her hand due to the temperature of the inner liner and metal grating that housed the heated moist wash cloths. During an additional observation on 1/28/16 at 12:48 pm, a facility thermometer was obtained and the electrical wash cloth heating unit on Fireweed measured 151.3 degrees F (Fahrenheit). Resident #4: Record review on 1/26-29/16 revealed Resident #4 was admitted to the facility with a [DIAGNOSES REDACTED]. The Resident resided on Fireweed. Review of the most recent Minimum Data Set (MDS) comprehensive assessment, an annual assessment, dated 4/30/15, and the most recent quarterly assessment, dated 1/25/16, revealed both assessments coded the Resident as having: memory problems; disorganized thinking and wandering behaviors. Record review of Resident #4's Daily Care Plan, revision 12/11/15, revealed the Resident needed supervision while ambulating. Random observations from 1/26-28/16 revealed Resident #4 displaying wandering behaviors and pacing around the unit without the accompaniment of staff or visitors. Additional observations revealed the unsupervised Resident picked up and moved objects near the electrical wash cloth heating unit. During an interview on 1/28/16 at 12:49 pm a family member of Resident #4 stated the wash cloths are hot and he/she had to cool them down before giving it to Resident #4. Resident # 10: Record review on 1/26-29/16 revealed Resident #10 was admitted to the facility with a [DIAGNOSES REDACTED]. The Resident resided on Salmonberry. Review of the most recent MDS comprehensive assessment, an annual assessment dated [DATE], and the most recent quarterly assessment, dated 8/3/15, revealed the Resident was coded as having cognitive impairment and required supervision. Review of Resident #10's CNA Assignment Card, dated 10/27/15, revealed Problem (Behavior): Identified wanderer . Random observations from 1/26-28/16 revealed Resident #10 displaying wandering behaviors and pacing around the unit without the accompaniment of staff. The Resident stood next to the electrical wash cloth heating unit multiple times during the observations. Review of the facility's policy Resident's Needing Assistance with Eating, revised 1/2016, revealed .Use washcloth to clean face and hands. (Standard of care 905.003 .) During an interview on 1/28/15 at 1:00 pm CNA #6 stated the electrical wash cloth heating units were used to aide residents in washing their hands before and after meals. In addition, the CNA stated the wash cloths were extremely warm to the touch. During an interview on 1/28/16 at 4:00 pm the Director of Nursing (DON) stated the electrical wash cloth heating units have two settings: 1) low is 150 degrees F and 2) high is 175 degrees F. The DON further stated the devices were set on the low setting. Review of the facility's policy Standard of Care, revised 1/2016, revealed Before Meal Care: Respectfully offer Resident to wash hands .After Meal Care: Respectfully offer warm washcloth to clean hands and face. Review of the American Burn Association article Scald Injury Prevention Educator's Guide, accessed on 2/3/16 at www.ameriburn.org, revealed High risk groups .Older Adults .have thinner skin .can cause deeper burns with even brief exposure .Additional review revealed Time and Temperature Relationship to Severe Burns can cause intense burns at 148 degrees F to 155 degrees F in 1-2 seconds. Review of the American Burn Association articleScald Injury Prevention Educator's Guide,accessed on 2/3/16 at www.ameriburn.org, revealed elderly people are considered a high risk group for burns. Additional review revealed Special Care: Nursing Home .majority of residents in these facilities are older adults .with limited ability to recognize and avoid other burn injury hazards, administrators of these facilities must consider .burn prevention as part of their plan of care.