Every finding on record at Providence Valdez Medical Center

.Based on record review, observation, and interview, the facility failed to implement its abuse prevention screening process to ensure an employee with regular resident contact maintained a valid State of Alaska background check clearance before continuing to work in the facility. Specifically, the facility failed to ensure an individual who had direct contact with residents had a valid criminal history check conducted under 7 Alaska Administrative Code (AAC) 10.900-10.990. This resulted in 1 employee working (Assistant #3) at the facility without valid clearance from the Alaska Background Check program. This failed practice placed all residents (based on a census of 9) at risk for abuse, neglect or exploitation. Findings:Review of the State of Alaska background check clearance letter for Assistant #3, dated [DATE], revealed: .The Background Check Program has completed the background check for [Assistant #3] and the individual has been issued an Eligible Determination for association with Providence Health & Services Alaska (Main). The determination is valid from [DATE] to [DATE]. Review of two email correspondences sent from the State of Alaska Background Check Unit to the facility, sent on [DATE] and again on [DATE], revealed: The following individual(s) need a new background check within the next 0-60 days:. Provider: Providence Health & Services Alaska (Main). Applicant Name: [Assistant #3]. New Background Check Needed by: [DATE]. Review of the New Alaska Background Check System (NABCS) website revealed that a new background check application for Assistant #3 was started on [DATE], the day after Assistant #3's background check expired. The status of the application showed Assistant #3 was provisionally hired (meaning allowed to work until the background check application was completed) on [DATE]. Review of payroll records provided by the facility revealed that Assistant #3 worked a total of 164.38 hours from [DATE]- [DATE] without a valid background check. An observation on [DATE] at 5:02 PM, kitchen staff brought up the dinner meal from the facility's main kitchen to the Long-Term Care (LTC) unit for the LTC residents. Further observation revealed six residents (#'s 2, 4, 6, 7, 8, and 9) were at the dining room table for the meal. Three residents were in their rooms (#'s 1, 3, and 5). Further observation revealed the kitchen staff served meals to the residents at the table, as well as hand delivered trays of dinner to each resident who was in their room. An observation on [DATE] at 12: 35 PM, revealed kitchen staff hand delivered the lunch meal to Resident #1, who was in his/her room. During an interview on [DATE] at 11:33 AM, when asked what his/her job entailed, Assistant #3 stated that he/she helped prep and cook resident meals and also served lunch and dinner in person to the LTC residents on the unit. During an interview on [DATE] at 3:22 PM, the Human Resource Regulatory Assurance Analyst (HRRAA) stated that a system log was maintained with background check application numbers and expiration dates. Monthly audits were conducted to identify employees within 90 to 100 days of expiration. Renewal requests were then initiated for employees to complete new fingerprints, which were submitted to the state background check program. The Chief Administrative Officer added that the state background check process took a long time to complete. Review of the facility-provided policy Resident/Patient Abuse, Neglect and Exploitation, dated 12/2024, revealed: . All staff will be screened for records of reported abuse prior to hiring. Documentation will be kept in their personnel file. Review of the facility-provided policy Background Check Reverification and Fingerprints, undated, revealed: Caregivers who work in the state of Alaska. must have their background check renewed with the State of Alaska. In most cases, this occurs every five years. Caregivers can expect to start receiving notifications 90 days prior to their reverification deadline. After the fingerprints are submitted, RA [Regulatory Assurance] will monitor the State of Alaska site for results. Review of 7 AAC 10.900(b) at https://www.akleg.gov/basis/aac.asp#7.10.900, the 34th Legislature (2025-2026), revealed: . Each individual who is to be associated with a provider in a manner described in this subsection must have a valid background check conducted under 7 AAC 10.900 - 7 AAC 10.990 if that individual is 16 years or older and will be associated with the provider as (1) an administrator or operator; (2) an individual service provider; (3) An employee, an independent contractor, an apprentice, an unsupervised volunteer, or a board member if that individual as (A) regular contact with recipients of services; (B) access to personal or financial records maintained by the provider regarding recipients of services, including access to (i) personal identifying information, financial information, treatment information, or medical records .(4) an officer, a director, a partner, a member, or a principal of the business organization that owns an entity, if that individual has (A) regular contact with recipients of services; (B) access to personal or financial records maintained by the provider regarding recipients of services, including access to (i) personal identifying information, financial information, treatment information, or medical records .

.Based on record review and interview, the facility failed to: 1) Report an allegation of verbal intimidation/harassment, involving inappropriate sexual comments made by Certified Nursing Assistant (CNA) #4 to 1 Resident (#9), to the State Survey Agency immediately, or not later than 2 hours after the allegation was made/reported; and 2) Develop and implement an accurate reporting policy for allegations of abuse that aligned with regulatory requirements. Not reporting an allegation of abuse in an appropriate and timely manner placed all residents (based on a census of 9) at risk for future exposure to potential abuse. Findings:Resident #9 Record review on 5/11-15/26 revealed Resident #9 was admitted to the facility with diagnoses that included Alzheimer's disease with behavioral disturbance, decreased functional mobility, and anxiety. Review of Resident #9's Resident Daily Care Plan, last updated 4/23/26, revealed Resident #9 required a two-person assist with brief changes every two to three hours and staff were to provide personal hygiene. Review of Resident #9's Occupational Therapy Initial Assessment Addendum for POC [Plan of Care] Submission, dated 2/11/22, revealed: . [Resident #9] is not able to follow simple commands or participate in an interview. During interactions with [Resident #9], it was noted that [he/she] becomes agitation when removed from the group setting. with concerns from staff that [he/she] has a past history of trauma which impacts the provision of care during ADLs [activities of daily living, to include brief changes and personal hygiene]. 1) Allegation Reporting Staff Incident Report to Facility Leadership Review of an internal staff-submitted incident report, dated Tuesday, 10/28/25 at 12:00 AM, revealed the following report was submitted by a Licensed Nurse (LN) #2: . Describe the event in your own words: After shift change last night in LTC [long term care], a conversation was relayed to me by [CNA #8]. I was not a witness to the conversation and have no way to verifying its accuracy. [He/she] stated that one time while changing [Resident #9], [CNA #4] was staring at [Resident #9] and [CNA #4 made sexually explicit remarks directed toward Resident #9 during cares. The reported remarks included an implied sexual proposition and a personal statement by CNA #4 about sexual activity.] Further review of the occurrence report revealed the incident was categorized under workplace violence for verbal intimidation/harassment/bullying, and the type of verbal intimidation/harassment was Other bias/discriminatory language, unwanted sexual comments/gestures. It was documented that this incident occurred on Monday, 10/27/25 at 8:00 AM. Facility Initial Report to State Survey Agency Review of a Facility Reported Incident (FRI), received by the State Survey Agency on Thursday, 10/30/25 at 12:17 PM, revealed the facility's initial report regarding the incident between CNA #4 and Resident #9: . Caregiver working with another co worker, reported a disturbing conversation: '. while conducting personal care and changing [Resident #9], [CNA #4] was staring at [Resident #9] and [CNA #4 made sexually explicit remarks directed toward Resident #9 during cares. The reported remarks included an implied sexual proposition and a personal statement by CNA #4 about sexual activity.]' . Initial Action: [CNA #8], made sure that the resident's needs were met, and the rest of the day carried on with [CNA #4] as if the conversation never happened. [CNA #8] indicated that Sunday there was no further conversation or incident. [CNA #8] was still disturbed by what was stated and decided on Monday evening when [he/she] came back to work, to speak with the Team Leader, who immediately submitted an Incident Report and Administration was notified. This initial FRI report documented that this incident actually occurred on Sunday, 10/26/25 at 11:00 AM. Further review of the FRI initial report revealed this report was completed by the facility's Chief Administrative Officer (CAO), who documented the date of notification to leadership of the allegation was Tuesday, 10/28/25. This initial report was sent to the State Survey Agency two days after leadership was made aware of the allegation. Further review revealed the CAO documented the incident as not abuse, No abuse, but reporting disturbing conversation under investigation. Review of the facility-provided policy Resident/Patient Abuse, Neglect and Exploitation, effective 12/2024, revealed the facility defined abuse as: . 'Abuse' means the willful infliction of. intimidation. including a caretaker of goods and services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents/patients, even those in a coma, due to willful, intentional, or reckless non accidental, or non-therapeutic infliction of. mental distress that can cause. mental anguish. 'Sexual abuse' includes but is not limited to sexual harassment. During an interview on 5/15/26 at 12:21 PM, when asked why the report of intimidation/harassment, involving inappropriate sexual comments, made by CNA #4 to Resident #9 was not interpreted as intimidation or sexual harassment, a form of abuse per the facility policy, the CAO stated at the time she didn't interpret the comment as harassment, but in retrospect she could see how it could be interpreted as such, but we didn't see it that way. When asked why the report was not submitted immediately, but no later than two hours after leadership became aware of the allegation, the CAO stated she was trying to investigate the allegation prior to sending the initial report and understood now that she should have submitted the report and then initiated the investigation after. 2) Facility's Reporting Abuse Policy Procedures Review of State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Rev. 232; Issued 7/23/25, revealed the Code of Federal Regulations (CFR) 483.12(b) and (c) addressed the reporting requirements for LTC facilities when allegations of abuse are reported: - CFR 483.12(b): The facility must develop and implement written policies and procedures that: - CFR 483.12(c): In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: - 483.12(c)(1): Ensure that all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, - or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Review of the facility-provided policy Resident/Patient Abuse, Neglect and Exploitation, effective 12/2024, revealed: . Reporting. The following is notified, as required by law, in the event that abuse occurs in the Long Term Care. Notification of the reportable event results in serious bodily injury, the staff member shall report the suspicion to the State Survey Agency and at least one local law enforcement entity, immediately, but no later than 2 hours after forming the suspicion. If the reportable event does not result in serious bodily injury but it is unclear as to the origin of injury, the staff member shall report the suspicion immediately to the LTC Team Leader/LTC Manager or LTC Administrator. A written report will be faxed to the State Survey Agency no later than 24 hours from time of knowledge of the injury. The facility's policy's verbiage does not align with CFR 483.12(c) and 483.12(c)(1) regulatory requirements to report allegations of abuse, neglect, exploitation or mistreatment immediately, but no later than two hours after the allegation was made, but instead, focused on reporting only abuse which resulted in serious bodily injuries within that required regulatory timeframe

.Based on record review, interview, and observation, the facility failed to clearly designate one registered nurse to serve as the full-time Director of Nursing (DON) for the long-term care (LTC) unit. Specifically, the facility's leadership documents, Human Resources (HR) records, payroll records, staff identification, and administrative interviews identified conflicting roles for the Director of Clinical Services (DCS), the LTC Manager, and the newly hired DON. As a result, the facility could not demonstrate that one RN was consistently designated to serve as the full-time DON responsible for LTC nursing leadership and oversight. This deficient practice placed all residents (based on a census of 9) at risk for more than minimal harm due to unclear nursing leadership accountability, including risk for delayed clinical oversight, delayed resident assessment, and failure to ensure consistent implementation of nursing services. Findings:Record review on 5/11-15/26, of the facility provided list of leadership personnel, undated, revealed the Key Contacts list identified the DCS as the LTC DON, RN/MDS [minimum data set - a federally required assessment], however the LTC Contact Resources list identified her as the LTC Manager (RN). During an interview on 5/14/26 at 1:35 PM, Licensed Nurse (LN) #1 stated the DCS was the LTC Manager and had always been the LTC Manager. LN #1 further stated that another person will be transitioned into the DON role soon. When asked if the DCS was ever the LTC DON, LN #1 stated, No. An observation on 5/14/26 at 1:48 PM, revealed the DCS wore a name badge that identified her as the Manager Long Term Care. The DCS's office door title and business card identified her as the Director of Clinical Services. Review of the facility provided LTC Quality Committee members list, undated, revealed the DCS attended this committee in the DCS role's capacity. Another staff member attended the meetings identified as the RN LTC DON. HR Review During an interview on 5/14/26 at 2:10 PM, personnel and staffing records were reviewed with facility administration and HR staff. Review of personnel records revealed the DCS was officially designated in the HR system as the DCS effective 4/6/26. The DCS held the Long Term Care Manager position prior to becoming the DCS. During the interview, the Chief Administrative Officer (CAO) stated the DCS continued performing DON duties because the newly hired DON was still transitioning into the role and had not fully assumed DON responsibilities. The CAO also stated that the DCS was still in the process of learning her role as the DCS. During the interview, the DCS stated, I'm officially in the payroll system as DCS, but I'm still doing all of the Director of Nursing and long-term care manager work. During the interview, the CAO stated, She has not assumed the DCS functions, and acknowledged there was no documentation differentiating the hours or duties being performed under the DON role versus the DCS role. Review of the DCS's offer letter, dated 1/13/26, revealed the DCS was to assume her role as DCS effective 4/6/26. Review of the newly hired DON's offer letter, dated 2/5/26, revealed the new DON was to assume his role as the DON effective 4/5/26. Review of the DCS's most recent annual evaluation, dated 3/11/26, revealed that the evaluation pertained to her role as the LTC Manager for the evaluation period of 1/1/25 through 12/31/25. Review of a facility-provided internal memo, addressed to the LTC Manager/DCS from the CAO, dated 11/16/25, revealed: . Interim Assignment. We are pleased to offer you the Interim Director of Nursing role. This interim assignment will begin on November 16th 2025, and will continue until the position is filled permanently. There was no reference on the memo that this was sent to HR. During an interview on 5/15/26 at 10:18 AM, when asked who was on the Quality Assurance Performance Improvement (QAPI), or LTC Quality committee, the Senior Quality Program Manager stated the Administrator, the DCS, the newly hired DON, the Resource Coordinator, and Physicians were on the committee. Business office, the Infection Preventionist, and Environment of Care department were also invited and would attend if available. Payroll Review Review of the DCS's payroll records, from 11/1/25 through 5/15/26, did not reveal any time designated specifically to the LTC's DON role. According to the payroll records, the DCS worked Monday through Friday, forty hours a week. Review of the new DON's payroll records, from 3/1/26 through 5/15/26, revealed that his time was coded as Acute RN on 5/7/26, 5/14/26, and 5/15/26, indicating that he worked in the acute care unit rather than in the long-term care unit. Prior to that, his time was coded to Director of Nursing which began on 4/6/26. Job Descriptions Review of the facility-provided Director of Clinical Services Job Description, original creation date 2/1/08, revealed: . Reports To: Administrator. This position has direct full responsibility, authority, and accountability for the provision of administrative direction and control of the resident and nursing services in regards to the Alaska state-licensed and federally-certified Nursing Home and Critical Access Hospital. Review of the facility-provided Manager Long Term Care RN Job Description, original creation date 5/1/14, revealed: . Reports To: Director of Clinical Services. Under general supervision works in collaboration with the Director of Nursing and other members of the multidisciplinary team to deliver elder centered care in a compassionate and ethical manner according to the standards of practice. Review of the facility-provided Director Long Term Care RN Job Description, original creation date 6/1/08, revealed: . Reports To: Director of Administrative Services LTC. The Director LTC RN provides clinical leadership, day-to-day clinical management and direction at the Long-Term Care facility. delivered in accordance with Providence philosophy, Federal and State regulatory standards ensuring the delivery of high quality, cost effective health care consistent with the mission.

.Based on record review and interview, the facility failed to ensure residents, or resident representatives, had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he or she preferred. Specifically, the facility failed to document that the resident or resident representative was able to accept or decline the initiation or continued use of the psychotropic medication (any chemical substances that affect brain function, altering a person's mood, thought, perceptions, or behavior) after receiving information about the risks, benefits, and alternatives for 3 residents (#'s 2, 6, and 9), out of 5 residents reviewed for unnecessary medications. This failed practice, of not documenting that the resident or resident representative was able to accept or decline the initiation or continued use of the psychotropic medication use, violated the resident's right to participate in their treatment decisions. Findings:Resident #2 Record review on 5/11-15/26 revealed Resident #2 was admitted to the facility with diagnoses that included vascular dementia, moderate with mood disturbance (dementia resulting from impaired blood flow to the brain, with associated aggressive or agitated behavior), Alzheimer's disease (a progressive mental deterioration characterized by confusion, memory failure, disorientation, restlessness, speech disturbances, and the inability to carry out purposeful movement), and depression. Review of Resident #2's Medication Administration Record (MAR), dated 5/2026, revealed he/she was taking the following psychotropic medications: 1- Duloxetine (Cymbalta - an antidepressant, used to treat depression and pain) DR (delayed release) 30mg (milligrams) capsule by mouth daily - scheduled every morning for depression and back pain, with an order start date of 2/16/26; 2- Duloxetine DR 60mg capsule by mouth daily - scheduled for every morning for depression and back pain, with an order start date of 2/16/26; 3- Hydroxyzine hydrochloride (Atarax - an antihistamine to treat itching and a psychotropic medication used to treat anxiety) 25mg tablet by mouth nightly for agitation and to reduce itching, with an order start date of 2/15/26; 4- Quetiapine (Seroquel - an antipsychotic, used to treat mood and depression) 25mg tablet - 1 1/2 tablets (37.5mg total dose) by mouth every morning and 1 tablet (25mg) in the afternoon for agitation, impaired emotional outbursts, and difficulty controlling anger, with an order start date of 4/1/26; and 5- Memantine (Namenda - used to treat moderate to severe Alzheimer's disease) 10mg tablet by mouth twice a day for impairing emotional outbursts, with an order start date of 6/10/23. Review of Resident #2's Psychotropic Risk/Benefit Form Verification of Informed Consent paper document, dated 12/18/25, revealed this consent form was for the Duloxetine DR 30mg and 60mg doses, Memantine 10mg dose, and a past Quetiapine 25mg twice a day dose. This form documented an explanation of the risks and benefits were discussed with Resident #2's family member, and no additional information was requested by the family. The form also had the following statement: . The resident or their surrogate decision maker has the right to accept or refuse the proposed medication treatment and if he/she consents, has the right to revoke his/her consent for any reason, at any time. Further review of the Psychotropic Risk/Benefit Form Verification of Informed Consent paper document revealed no documentation that the family accepted or declined the initiation or continued use of these psychotropic medications. Review of Resident #2's Psychotropic Risk and Benefits Note electronic document for psychotropic medication consent, dated 4/1/26, and completed by Provider #20, revealed this consent was for the Seroquel 37.5mg and the 25mg doses. This form documented an explanation of the risks and benefits were discussed with Resident #2 and his/her POA (power of attorney), and no additional information was requested by the resident or POA. The form also had the following statement: . This note is indicative of informed consent of the provider recommending the need to order a psychotropic medication. The resident, POA, surrogate decision maker has the right to accept or refuse the proposed medication treatment and if he/she consent, has the right to revoke his/her consent for any reason, at any time. Further review of the Psychotropic Risk and Benefits Note electronic document revealed no documentation that the family accepted or declined the initiation or continued use of this psychotropic medication. Review of Resident #2's Psychotropic Risk/Benefit Form Verification of Informed Consent paper document, dated 8/25/25, revealed this consent form was for the hydroxyzine hydrochloride 25mg dose, and additional past medications and doses that had been since changed. This form documented an explanation of the risks and benefits were discussed with Resident #2's family member, and no additional information was requested by the family. The form also had the following statement: . The resident or their surrogate decision maker has the right to accept or refuse the proposed medication treatment and if he/she consents, has the right to revoke his/her consent for any reason, at any time. Further review of the Psychotropic Risk/Benefit Form Verification of Informed Consent paper document revealed no documentation that the family accepted or declined the initiation or continued use of these psychotropic medications. Resident #6 Record review on 5/11-15/26 revealed Resident #6 was admitted to the facility with diagnoses that included vascular dementia (dementia resulting from impaired blood flow to the brain) and depression. Review of Resident #6's MAR, dated 5/2026, revealed he/she was taking Sertraline (Zoloft - an antidepressant used to treat depression) 100mg tablet by mouth daily for depression, with an order start date of 4/19/26. Review of Resident #6's Psychotropic Risk/Benefit Form Verification of Informed Consent paper document, dated 8/27/25, revealed this consent form was for the Sertraline 100mg dose. This form documented an explanation of the risks and benefits were discussed with Resident #6's family member and no additional information was requested by the family. The form also had the following statement: . The resident or their surrogate decision maker has the right to accept or refuse the proposed medication treatment and if he/she consents, has the right to revoke his/her consent for any reason, at any time. Further review of the Psychotropic Risk/Benefit Form Verification of Informed Consent paper document revealed no documentation that the family accepted or declined the initiation or continued use of this psychotropic medication. Resident #9 Record review on 5/11-15/26 revealed Resident #9 was admitted to the facility with diagnoses that included Alzheimer's disease with behavioral disturbance and agitation due to dementia. Review of Resident #9's MAR, dated 5/2026, revealed he/she was taking the following psychotropic medications: 1- Hydroxyzine hydrochloride 12.5mg tablet by mouth daily at 2:30 PM for reduced itching, with an order start date of 6/13/24; 2- Hydroxyzine hydrochloride 25mg tablet by mouth nightly for reduced itching, with an order start date of 6/4/24; 3- Sertraline 75mg tablet by mouth daily for dementia with behavioral disturbance, mood disturbance, and anxiety, with an order start date of 7/29/23. 4- Trazadone (Desyrel - an antidepressant used to treat depression) 25mg tablet by mouth nightly for agitation, with an order start date of 11/26/25. Review of Resident #9's Psychotropic Risk/Benefit Form Verification of Informed Consent paper document, dated 12/15/25, revealed this consent form was for the Hydroxyzine Hydrochloride 12.5mg and 25mg doses, Sertraline 100mg dose, and the Trazadone 25mg dose. This form documented an explanation of the risks and benefits were discussed with Resident #9's family member, and no additional information was requested by the family. The form also had the following statement: . The resident or their surrogate decision maker has the right to accept or refuse the proposed medication treatment and if he/she consents, has the right to revoke his/her consent for any reason, at any time. Further review of the Psychotropic Risk/Benefit Form Verification of Informed Consent paper document revealed no documentation that the family accepted or declined the initiation or continued use of these psychotropic medications. During an interview on 5/15/26 at 11:40 AM, the Director of Clinical Services (DCS) stated psychotropic medication consent was documented using either the paper Psychotropic Risk/Benefit Form Verification of Informed Consent or the electronic Psychotropic Risk and Benefits Note. When asked how the resident's or representative's decision was documented, the DCS stated the response to education was typically placed in a note. When asked to locate notes documenting the resident's or representative's acceptance or refusal for Residents #2, #6, and #9, the DCS stated she could not locate any notes documenting consent. When asked to review the paper and electronic forms for language showing acceptance or refusal, the DCS stated the forms did not contain language showing the families or POAs accepted or refused the psychotropic medications. Review of the resident right's posted on the resident's unit, undated, revealed: . Your Rights. You have rights as a nursing home resident under Federal Law. Those rights include: The right to participate in your own care. The right to make independent choices.

.Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set, a federally required nursing assessment) quarterly review requirements for 2 residents (#'s 6 and 7), out of 5 residents were followed. Specifically, the facility failed to complete quarterly review assessments at least every 92 days from the last assessment of any type. This failed practice placed the residents at an increased risk for improper monitoring of decline and/or progress over time and inadequate care and services to maintain their highest practicable well-being. Findings:Resident #6 Record review on 5/11-15/26 revealed Resident #6 was admitted to the facility with diagnoses that included vascular dementia (dementia resulting from impaired blood flow to the brain) with behavioral disturbance, depression, dysphasia (difficulty swallowing), dehydration, and a history of falls. Review of Resident #6's most recent MDS data, dated 11/29/25, revealed this assessment was an annual review. The facility was 75 days past the 92-day timeline for the next quarterly review assessment. Resident #7 Record review on 5/11-15/26 revealed Resident #7 was admitted to the facility with diagnoses that included dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking), subarachnoid hemorrhage due to ruptured aneurysm (a type of stroke in which a ballooned blood vessel in the brain bursts, causing bleeding into the brain), cardiomyopathy (abnormal enlargement of the heart muscle), congestive heart failure (a condition in which the heart cannot pump efficiently enough to meet the body's need for blood), and chronic hip pain after a total replacement of the left hip joint. Review of Resident #7's most recent MDS data, dated 11/26/25, revealed this assessment was an annual review. The facility was 78 days past the 92-day timeline for the next quarterly review assessment. During an interview on 5/13/26 at 4:45 PM, the Director of Clinical Services (DCS) stated the most current assessments for Residents #6 and #7 were completed in 11/2025. Their quarterly assessments were due in 2/2026, however, they were not completed. Review of the facility-provided policy Resident MDS Assessment, effective date 10/2025, revealed: . In keeping with the philosophy. Providence [NAME] Medical Center (PVMC) Long Term Care Unit will complete initial, annual and quarterly comprehensive assessments of the Resident's needs. Quarterly Assessment.When Form is Completed. No later than the ARD [Assessment Reference Date] of prior assessment + 92 calendar days.

Based on record review and interview, the facility failed to ensure physicians consistently assessed residents in person at least once every 60 days for all residents (based on a census of 7). This failed practice placed all residents at risk for delayed identification of changes in medical condition and unmet medical care needs. Findings: Record review on 3/5/25 at 10:00 AM of the facility's Physician Visits Non-compliance Flowsheets, undated, revealed multiple instances where residents exceeded the 60-day interval between physician visits: Resident #1 had a gap of 73 days between physician visits (7/9/24 to 9/20/24) and another gap of 109 days between physician visits (9/20/24 to 1/7/25). Resident #2 had a gap of 128 days between physician visits (7/9/24 to 11/14/24). Resident #3 had a gap of 104 days between physician visits (10/23/24 to 2/4/25). Resident #4 had a gap of 368 days between physician visits (12/1/23 to 12/4/24). Resident #5 had a gap of 75 days between physician visits (8/22/24 to 11/5/24) and another gap of 71 days between physician visits (12/25/24 to 3/5/25). Resident #7 had a gap of 97 days between physician visits (7/31/24 to 11/5/24). Resident #8 had a gap of 82 days between physician visits (11/14/24 to 2/4/25). During an interview on 3/6/25 at 1:03 PM, the Long-Term Care Manager (LTCM) stated, Tracking physician visits has been a significant challenge. Nurses keep logs, but there's no reliable system for follow-up if physicians miss appointments. The LTCM further explained, We created the flowsheet because we knew it was a problem. However, even with the flowsheet, some residents are still not being seen timely because physicians rely on us for reminders, and sometimes those reminders aren't communicated effectively. During an interview on 3/6/25 at 2:00 PM, the Medical Director (MD) stated: I depend on my staff to keep track. I don't have time or a way to track that myself. The MD further explained, If someone misses a visit, the nursing staff or medical records department usually reminds us. But the system doesn't always work, especially if physicians are on vacation or busy. During the same interview, the MD acknowledged awareness of missed visits, stating, I'm probably one of the people who missed visits, especially when I'm busy or on vacation. Review of the facility's policy titled: Physician's Visits in Long Term Care, effective date 11/2023, revealed: Residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. Long Term Care staff will make appointments with the Primary Care Clinic for physicians to see residents in Long Term Care. The Team Leader on duty on day of the appointment is responsible for notifying Physician's office staff of missed appointments promptly and rescheduling if necessary. Notify LTC Manager of any barriers to make these appointments.

Based on record review and interview, the facility failed to ensure the Medical Director(MD) fulfilled responsibilities for oversight and coordination of medical care in the facility. Specifically, the MD did not provide adequate oversight to ensure physician compliance with required visits. This failed practice placed residents at risk for unmet medical needs, delayed medical treatment, and diminished quality of care. Findings: Review of the facility's document titled Description of Medical Director Duties, undated, revealed: .Duties and Responsibilities: .The medical director is responsible for implementation of resident care policies and the coordination of medical care in the facility. Medical director responsibilities must include their participation in: Administrative decisions including recommending, developing and approving facility policies related to residents' care. Resident care includes the resident's physical, mental and psychosocial well-being; Issues related to the coordination of medical care identified through the facility's quality assessment and assurance committee and other activities related to the coordination of care; Organizing and coordinating physician services and services provided by other professionals as they relate to resident care; Participate in the Quality Assessment and Assurance (QAA) committee or assign a designee to represent him/her. Review of the facility's policy titled Physician's Visits in Long Term Care [LTC], effective date 11/2023, revealed: Residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. Long Term Care staff will make appointments with the Primary Care Clinic for physicians to see residents in Long Term Care. The Team Leader on duty on day of the appointment is responsible for notifying Physician's office staff of missed appointments promptly and rescheduling if necessary. Notify LTC Manager of any barriers to make these appointments. Review on 3/5/25 at 1:00 PM of the facility's Physician Visits Non-compliance Flowsheets, undated, revealed multiple instances where residents exceeded the 60-day interval between physician visits: Resident #1 had a gap of 73 days between physician visits (7/9/24 to 9/20/24) and another gap of 109 days between physician visits (9/20/24 to 1/7/25). Resident #2 had a gap of 128 days between physician visits (7/9/24 to 11/14/24). Resident #3 had a gap of 104 days between physician visits (10/23/24 to 2/4/25). Resident #4 had a gap of 368 days between physician visits (12/1/23 to 12/4/24). Resident #5 had a gap of 75 days between physician visits (8/22/24 to 11/5/24) and another gap of 71 days between physician visits (12/25/24 to 3/5/25). Resident #7 had a gap of 97 days between physician visits (7/31/24 to 11/5/24). Resident #8 had a gap of 82 days between physician visits (11/14/24 to 2/4/25). During an interview with the MD on 3/6/25 at 2:00 PM, when asked how the MD ensured compliance with physician visits, she stated, I depend on my staff to keep track. I don't have time or a way to keep track of that. She further stated, .Obviously it's all going to hell in a hand basket, but it can't be just me. During an interview on 3/6/25 at 4:31 PM, when asked about the MD participation in the QAPI (Quality Assurance and Performance Improvement) meetings, the Regional Quality Manager (RQM) stated: The Medical Director doesn't bring up issues to QAPI; she listens and asks questions. During the same interview, when informed about physician's noncompliance with visits, including one resident who had not received a physician visit in over a year, the RQM stated: I didn't know about that, but I agree-this issue would be ideally addressed in QAPI. I'll put it on my radar to ensure more accountability and ownership by the Medical Director.

Based on observation, record review, and interview, the facility failed to ensure correct medication labeling for two residents (#s 5 and 7) out of seven sampled residents. Specifically, the facility failed to ensure: 1) medications were labeled according to physician's order and 2) contained an expiration date. These failed practices placed all residents at risk of adverse effects and complications from receiving incorrect dosage and an expired medication. Findings: Medication Labelling: a. Glipizide tablet (a diabetes medicine that helps control blood sugar levels) An observation on [DATE] at 12:26 PM revealed during the medication preparation for Resident #7, one pack of Glipizide tablet 10 mg was labelled three times daily with meals. Record review of the medication administration record (MAR) on [DATE] revealed Glipizide tablet 10 mg was to be administered two times daily before meals. Review of the physician's order, dated [DATE], revealed GlipiZIDE (GLUCOTROL) Tablet 10 mg, Frequency: 2 TIMES DAILY BEFORE MEALS. During an interview on [DATE] at 2:49 PM, Licensed Nurse (LN) #1 stated the label for Glipizide 10 mg should have been changed by the pharmacist to one tablet twice a day before meals. b. Famotidine tablet (a medicine that reduces stomach acid) An observation and concurrent interview on [DATE] at 9:32 AM, at the nurses' station, during the medication preparation for Resident #5, LN #2 prepared Famotidine 20 mg morning dose because the evening dose was on hold. Record review of the MAR on [DATE], revealed Famotidine 20 mg one tablet every evening was on hold. During the same observation, a pack of Famotidine 20 mg label read: take 1 tablet by mouth every evening, dated [DATE]. Further observation of the label revealed a time: 0900, handwritten in black marker. LN #2 stated the label should have been changed. LN #2 further stated he/she would contact the pharmacist to provide the correct label. Review of the physician's order, dated [DATE], revealed: famotidine (PEPCID) tablet 20 mg DAILY. evening dose on hold. No order for the morning dose. During a follow-up interview and observation on [DATE] at 12:34 PM, LN #2 stated the label had been changed [by showing the new label] and the physician's order was changed to daily. During an interview on [DATE] at 3:37 PM, the Clinical Director (CD) stated that the facility had been struggling with the pharmacy provider, the way the pharmacy had packaged the medication was not ideal. Expired medication: An observation on [DATE] at 12:26 PM, during the medication preparation for Resident #7, revealed one bottle of Cholicalciferol (Vitamin D) capsule 5,000 units had no expiration date. During an interview on [DATE] at 2:43 PM, LN #1 stated the expiration date on the Cholicalciferol capsule [Vitamin D] 5,000 units was erased because the nurses had been using Avagard (alcohol-based hand sanitizer) during medication preparation. When asked how he/she would determine that the medication was not expired, LN #1 stated he/she knew the expiration date was printed in the label before and the nurses checked the expiration date of the medications monthly. Review of the facility's policy titled: Labeling Standards for Medications and Chemicals, dated ,d+[DATE], revealed: . ensure all medication containers are labeled to i[e]nsure safe and effective patient care. Medication label must be clear, consistent, legible and in compliance with state and federal requirements .Dispensing label requirements.the label also includes .g. directions for use and any applicable accessory label.

Based on record review and interview, the facility failed to ensure the medical record included documentation of the education provided to the resident or resident representative (RR) regarding the Influenza and Pneumococcal immunizations benefits and potential side effects before signing or declining the vaccine administration for five residents (#s 3; 4; 5; 7; and 8) out of five residents reviewed. This failed practice had the potential to affect all residents (based on census of seven) who were residing in the facility. Findings: Record review on 3/6/25 at 4:00 PM of the facility's list of residents' immunization information, untitled and undated, revealed the following Residents received immunizations: Resident #3 received Influenza immunization on 10/28/24 and Pneumococcal 20 immunization on 11/21/24. Resident #5 received Influenza immunization on 10/28/24. Resident #7 received Influenza immunization on 10/28/24. Resident #8 received Influenza immunization on 10/28/24. Further review of the list revealed Resident #4 declined Influenza immunization (no date). Review of the nurse's progress notes, dated 10/15/24, revealed Resident #4's representative declined influenza immunization for him/her on 10/11/24. Review on 3/3-6/25 of all the Residents' electronic health record (EHR), revealed no documentation that Residents #3, #4, #5, #7 and #8 or their RRs were provided education of the benefits and potential side effects of the vaccines before offering the Influenza and Pneumococcal immunizations. During an interview on 3/6/25 at 4:10 PM, the Long-Term Care Manager (LTCM) stated the residents' vaccination was scheduled with the State of Alaska Public Health (SOAPH). When asked if education was provided to the residents, she stated the facility asked the residents and/or RRs for immunization consent and the SOAPH provided the education before administration of vaccination. When asked if the education provided to the residents and/or RRs was documented, the LTCM showed the SOAPH vaccination documents of Residents #3; #5; #7; and #8 and stated according to SOAPH, the vaccination record would show that the immunization was given and that indicate that education was provided. The LTCM also stated that Resident #4's RR declined immunization for him/her. The LTCM further stated there was no education documentation provided to Resident #4's RR. During an interview on 3/6/25 at 5:14 PM, the Clinical Director (CD) stated that staff were educating the residents and their POA (Power of Attorney) before offering the vaccination, but that was not documented. Review of the facility's PVEC[unknown acronym] Pneumococcal, COVID-19, RSV [Respiratory Syncytial Virus] & Influenza Vaccination, dated 12/2024, revealed: PURPOSE/SCOPE All Long Term Care .residents, regardless of age and/or medical condition, will be offered vaccination when clinically indicated/recommended by the US Centers for Disease Control & Prevention (CDC), unless it is contraindicated or otherwise declined by the physician, or resident' legal representative. Education will be provided to all residents & resident's legal representative regarding individual vaccination risks and benefits.

Based on record review and interview, the facility failed to ensure the medical record included documentation of education provided to the resident or resident representative (RR) regarding the COVID-19 immunization benefits and potential side effects before signing or declining the vaccine administration for four residents (#s 3; 4; 5; and 7) out of five residents reviewed. This failed practice had the potential to affect all residents (based on census of seven) who were residing in the facility. Findings: Record review on 3/6/25 at 4:00 PM of facility's list of residents' immunization information, undated, revealed the following residents received immunization: Resident #3 received COVID-19 immunizations on 6/3/24 and 10/28/24. Resident #5 received COVID-19 immunizations on 6/3/24 and 10/28/24; and Resident #7 received COVID-19 immunizations on 6/3/24 and 10/28/24. Further review of the list revealed Resident #4 declined COVID-19 immunization (no date). Review of the nurse's progress notes, dated 10/15/24, revealed Resident #4's RR declined COVID-19 immunization for him/her on 10/11/24. Review on 3/3-6/25 of the residents' electronic health record (EHR), revealed no documentation that Residents #3, #4, #5, and #7 or their RRs were provided education of the benefits and potential side effects of the vaccines before offering COVID-19 immunization. During an interview on 3/6/25 at 4:10 PM, the Long-Term Care Manager (LTCM) stated the residents' vaccination was scheduled with the State of Alaska Public Health (SOAPH). When asked if education was provided to the residents, she stated the facility asked the resident or RR for immunization consent and the SOAPH provided the education before administration of vaccination. When asked if the education provided to the resident and RR was documented, the LTCM showed the SOAPH vaccination documents of Residents #3; #5; and #7 and stated according to SOAPH, the vaccination record would show that the immunization was given and that would indicate education was provided. The LTCM also stated that Resident #4's RR declined COVID-19 immunization for him/her. LTCM further stated there was no education documentation provided to Resident #4's RR. During an interview on 3/6/25 at 5:14 PM, the Clinical Director (CD) stated that staff were educating the residents and their POA (Power of Attorney) before offering the vaccination, but that it was not documented. Review of the facility's PVEC[unknown acronym] Pneumococcal, COVID-19, RSV [Respiratory Syncytial Virus] & Influenza Vaccination, dated 12/2024, revealed: PURPOSE/SCOPE All Long Term Care .residents, regardless of age and/or medical condition, will be offered vaccination when clinically indicated/recommended by the US Centers for Disease Control & Prevention (CDC), unless it is contraindicated or otherwise declined by the physician, or resident' legal representative. Education will be provided to all residents & resident's legal representative regarding individual vaccination risks and benefits.

Based on record review, observation, and interview, the facility failed to ensure one resident (#5) out of seven sampled residents was provided care in a manner that promoted dignity and respect. This failed practice placed the resident at risk of poor self-esteem and/or self-worth and a potential for poor quality of life. Findings: Record review on 3/3-6/25, revealed Resident #5 was admitted to the facility with diagnoses that included dementia (a decline in cognitive abilities), muscle weakness of right upper extremity, impaired ability to follow simple direction, and decreased functional mobility. Review of the Minimum Data Set (MDS- a federally required nursing assessment) Annual Assessment, dated 2/7/25, revealed in Section C- Cognitive Patterns C0100. Should Brief Interview of Mental Status be conducted? . the marked response was 0. No (resident is rarely/never understood). An observation on 3/5/25 at 9:54 AM, revealed Licensed Nurse (LN) #2 after the medication preparation at the nurses' station, the LN went to Resident #5's room. While LN #2 was outside the door with the door slightly opened, LN #2 asked the Certified Nurse Assistant (CNA) #2, who was inside the room, if Resident #5 was ready for medication administration. CNA #2 replied that Resident #5 was not yet ready. Since the Resident was not yet ready, LN #2 stated to the surveyor that he/she could keep the prepared medication in a locked cabinet inside the Resident's room. An observation on 3/5/25 at 9:55 AM revealed LN #2 opened the door and entered Resident #5's room followed by the surveyor. While in the room, it was observed that Resident #5 was out of the bathroom, seated in a shower chair naked with a towel on his/her back and a wet Hoyer (a lift device) sling underneath the Resident. Further observation revealed there were two CNAs inside the room. One male CNA (#1) and one female CNA (#2). An observation on 3/5/25 at 9:56 AM revealed LN #2 approached Resident #5 who was still seated in a shower chair, naked. The LN stated that he/she would administer the medication and gave the medication to the Resident. Then, LN #2 left the room. During the same observation, while Resident #5 was still naked, exposing his/her anterior (front side) body, the CNAs transferred him/her to bed through the use of a mechanical lift. The Resident was laid in bed, anterior body still exposed. The CNAs inserted chucks (an absorbent pad) underneath Resident #5 by turning him/her from side to side. CNA #2 wiped the Resident's buttocks and applied cream to the skin. Then, both CNAs helped the Resident put on his/her brief, shirt, socks and pants. During a joint interview on 3/5/25 at 2:59 PM, when asked about the process on providing a shower to a resident, CNA #2 stated that one CNA would provide the shower and one CNA would prepare the bed, apply cream to the resident's skin, and would help the resident put on his/her clothes. When asked how the CNAs ensure that privacy was provided to the resident after shower, CNA #1 stated the door was kept closed, window blinds were kept closed, and when somebody knocked at the door, the CNAs would make sure the resident was covered with blankets so the person at the door would not see the resident naked. During the same joint interview, CNA #1 stated the expectation was to provide warm blanket after shower, especially when transporting the resident from the tub room (a shared tub room located outside the residents' room) to the resident's room. CNA #1 stated Resident #5 showered in his/her own bathroom inside his/her room. CNA #1 further stated the CNAs should have covered Resident #5 with a towel. During an interview on 3/6/25 at 3:23 PM, the Clinical Director (CD) stated, each individual was provided care according to resident's preference. When asked the expectation for CNAs in providing resident's privacy after shower, the CD stated if the resident was from the tub room, the resident would be covered up and kept warm while being escorted to the resident's room. The CD further stated if the resident had showered in their own room, the resident should have been covered and toweled down because the room was heated. Then, the resident should have been transferred to their bed quickly and made the resident comfortable. When asked if the resident should have been covered, the CD stated it was not mandatory, as long as the CNAs could transfer the resident as quickly as possible. When asked if the CD was agreeable that the resident should have been covered during the medication administration, with the presence of a male and female CNAs in the room, the CD agreed that the resident should have been covered. The CD further stated: It is not the best practice; we could have done better. Review of the facility's policy titled: Activities of Daily Living, dated 11/2023, revealed: PURPOSE/SCOPE To provide for the basic needs and promote dignity and well being of all Long Term Care Residents. Review of the facility's admission packet, that contained a document titled: THE RESIDENT'S BILL OF RIGHTS, dated 1/2021, revealed: As a Resident, you have the Right to receive notices orally or in writing.any of the following information.To personal privacy of not only your own personal body, but also of your personal space, including accommodations and personal care.

Based on observation, interview, and record review, the facility failed to ensure one resident (#3) out of seven sampled residents, with a known food allergy, received a diet free of identified allergens. Specifically, the facility failed to verify ingredients in a newly introduced menu item, resulting in Resident #3 being served and consuming pineapple, an identified allergen. This failed practice placed Resident #3 at risk for allergic reactions and adverse health outcomes. Findings: An observation on 3/5/25 at 1:10 PM revealed [NAME] #3 approached Licensed Nurse (LN) #2, stating Resident #3 had eaten a sweet and sour sauce containing pineapple and that Resident #3 had an allergy to pineapple. During an interview on 3/5/25 at 2:30 PM, when asked if he/she had consumed pineapple at lunch, Resident #3 confirmed, I could taste pineapple in the food I ate at lunch. During an interview on 3/5/25 at 2:10 PM, the Kitchen Manager (KM) stated, We have a KARDEX (paper card containing concise, easily accessible patient care information) card for all the residents, which contains food allergy information. The KM further explained, Before plating a resident's meal, we check the KARDEX to ensure residents are not given food which contains allergens. The KM further stated, Because we are using a new menu, the sweet and sour sauce we used is new to me, and I was unaware it contained pineapple. Review of the sweet and sour sauce ingredient list revealed: .Ingredients.Pineapple. Review of Resident #3's dietary KARDEX, undated, revealed, .Allergies: Pineapple. Review of the facility policy titled: Cycle Menu, effective date 6/2023, revealed: Food and Nutrition Services will accommodate resident allergies, intolerances, and preferences.

Based on observation and interview, the facility failed to ensure daily nurse staffing information posted in the facility was maintained for 18 months. This failed practice had the potential to provide limited transparency regarding staffing levels, affecting all residents (based on a census of 7 residents) and visitors' ability to evaluate the adequacy of nursing care provided. Findings: An observation on 3/6/25 at 12:45 PM revealed the facility had a staffing board posted that displayed the facility name, current date, total number and actual hours worked by staff, and resident census. During an interview on 3/6/25 at 12:45 PM, when asked where the previous 18 months of staffing information was located, the Long-Term Care Manager (LTCM) responded: We don't take pictures of the staffing board every day. When asked if the facility retained records of previously posted staffing information, the LTCM said: We do not . we didn't know it was required.

Based on observation and interview, the facility failed to post, in a clear and readable format, the facility name, daily total number of staff and the actual hours worked by Certified Nurse Aides (CNAs), and Registered Nurses (RNs). This failed practice denied the residents and/or resident representatives accurate information about staffing and the facility's ability to provide care to all residents (based on a census of 10). Findings: During random observations of the facility's nurse staffing information from 11/28/23 to 12/1/23, revealed a dry erase board, located by the nurse's office, which displayed the names of the staff on duty for the day and night shifts, the number of hours each staff member were scheduled to work, the date, and the census. The shift times, 07-7pm and 7pm-7am were written in smaller print on the day and night labels. The staff disciplines were labeled for 4 out of the 8 long term care staff displayed on the board. Staff #1, 2, 3, 4s' disciplines were not identified. In addition, there were also 5 hospital acute care staff displayed on the long-term care dry erase board. The facility name, total number of staff by discipline, and the total actual hours worked by Registered Nurses and Certified Nurse Aides were not displayed. During an interview on 12/1/23 at 10:15 AM, the Director of Clinical Services/ Long Term Care Administrator (DCS/LTCA) stated the dry erase board served as the facility's nurse staffing posting, and further stated the long term care unit does not have licensed practical nurses. The DCS/LTCA was unaware of the missing components required to be displayed.

Based on observation, and interview, the facility failed to ensure expired medical products were removed from the medication storage cabinet. This failed practice placed the residents, who required these products for services (based on a census of 10), at risk of adverse effects or complications from use of expired products. Findings: An observation on [DATE] at 12:58 PM of the medication storage cabinet revealed the following expired medical supplies: 2- Ansep antimicrobial skin and wound cleanser 12 oz spray, expired on [DATE]: 1- prescription toothpaste for Resident #4: Sodium Fluoride 5000 ppm toothpaste expired on ,d+[DATE]: 1 - BD Safety Glide 27-gauge 1 ml needle, expired on [DATE]: 4 - Medline Lemon Glycerin swab stick 3/pack, expired on ,d+[DATE]: 8 - Covidiem Telfa non-adherent pads, expired on [DATE]: 3 - Covidiem Telfa Adhesive Island Dressing, expired on ,d+[DATE]: 7 - 3M Tegaderm film 6in x 8in, expired on [DATE]: 1- BD Vacutainer Urine complete cup kit, expired on ,d+[DATE]: and 2- BD Vacutainer Urine complete cup kit, expired on ,d+[DATE]. During an interview on [DATE] at 2:49 PM, the Licensed Nurse (LN) #1 stated the medical supply cabinet was checked by the night shift for expiration dates but unsure of the frequency it was checked. LN #1 was not aware of the items that had expired. During an interview on [DATE] at 3:29 PM, the Long Term Care Manager stated when items from the medical supply cabinet were expired, the supplies should have been replaced.

Based on record review and interview, the facility failed to comprehensively assess 1 resident (#9) out of 8 sampled residents using the Resident Assessment Instrument 3.0 Minimum Data Set (MDS, a federally required nursing assessment for long term care residents). Specifically, a medically necessary trunk restraint was not coded in the most recent quarterly assessment. This failed practice placed the resident at risk for inconsistent care. Findings: Record review on 11/28/23 to 12/1/23, revealed Resident #9 was admitted to the facility with diagnoses that included multiple sclerosis (a disease that affects the central nervous system), paraplegia (paralysis of the lower body), and weakness. During an interview on 11/28/23 at 11:07 AM, Resident #9 stated he/she used a torso harness to hold his/her body upright every time he/she was in his/her wheelchair. Review of the physician's order, dated 3/21/23 at 4:45 PM, revealed: May use Torso Support (staff to apply) while up in wheelchair . Review of the care plan, dated 6/10/23, revealed: Problem: Restraint/Seclusion Use for Patient Safety .[Resident #9] requests and requires a chest[torso] harness to be used for all times that [he/she] is upright in any chair, including wheelchairs . Review of Resident #9's recorded activity on 9/17/23 during the MDS look back period for quarterly assessment revealed the resident was up in chair. Review of the MDS quarterly review assessment, dated 9/21/23, revealed: Section P . E) Trunk restraint in chair or out of bed .0 . = Not used. During an interview on 12/1/23 at 8:09 AM, the Long-term care (LTC) Manager (LTCM) stated the activity on 9/17/23 would have required the use of Resident #9's chest harness. The chest harness was considered a medically necessary restraint because Resident #9 was not able to release it on his/her own. During the same interview, the LTCM stated Resident #9 was up in his/her wheelchair for short periods of time and required the use of the chest (torso) harness each time. The LTCM stated it should have been included in the MDS quarterly assessment.

Based on record review, interview, and observation, the facility failed to develop an individualized care plan that addressed resident's care needs. Specifically, the facility failed to develop a care plan to address the resident's edema (swelling caused by excess fluid trapped in tissues) for 1 resident (#10) out of 8 sampled residents. This failed practice placed the resident at risk for not receiving necessary care and services to address the individual's needs. Findings: Record review on 11/28/23 to 12/1/23, revealed Resident #10 was admitted to the facility with diagnoses that included Lewy body dementia (a type of dementia where protein deposits in the brain affecting thinking, memory and movement), hypertension, and impaired mobility. During an interview on 11/28/23 at 1:52 PM, Resident #10's representative stated the Resident had swelling in his/her legs that he/she thought was treated. Review of the Notes, dated 7/7/23, revealed: RN [Registered Nurse] Visit diagnoses 2+ pitting edema [skin rebounds after a few seconds of pressure being applied], bilateral edema of lower extremity . The note further revealed the licensed nurse (LN) communicated Resident #10's condition to the physician. Further review of the medical record revealed no physician's order concerning the edema. Review of Resident #10's care plan on 11/29/23 at 10:50 AM, did not include the edema. During an interview on 11/29/23 at 12:51 PM, LN #1 stated he/she was not aware of Resident #10's edema. The LN checked Resident #10's lower extremities for edema and found the resident's lower extremities were swollen and the resident's socks had left a noticeable dent on the area where the top of the socks end on both legs. The LN checked for edema by pressing on the resident's legs. Further observation revealed the pressure applied to the resident's skin left an indentation and the skin did not bounce back. The LN then reviewed Resident #10's medical record and stated the physician had performed an assessment on 10/21/23. The physician assessment revealed: .when asked today . [why his/her] left foot hurts .it[']s better when sock is removed, which is making a dent in [his/her] edema .pitting edema to shins . The LN further stated there were no physician orders created from that assessment. During the same interview when asked if there was a care plan for the edema, the LN stated there was not. The LN further stated the care plan should have been updated to include interventions for the edema. During an interview on 12/1/23 at 8:59 AM, the LTC (Long Term Care) Manager stated she was not aware of Resident #10's edema. She further stated she would add edema interventions to the care plan.

Based on record review and interview, the facility failed to ensure 1 resident (#3) out of 2 residents investigated for wander guards (as system used to detect residents who wander close to certain doors), received monitoring of its functionality. Specifically, the facility failed to check the wander guard battery according to the manufacturer's instruction manual. This failed practice placed the resident at risk for potential elopement. Findings: Record review on 11/28/23 to 12/1/23 revealed Resident #3 was admitted to the facility with a diagnosis of dementia (a decline of cognitive abilities). Review of the physician's order, dated 6/7/23, revealed: Wanderguard alert system bracelet worn 24 hours every day. Review of Resident #3's Care Plan for cognitive impairment, dated 6/10/23, revealed: .Intervention . [Resident #3] wears a wander guard bracelet to prevent [him/her] from wandering and getting lost . Review of [NAME] Healthcare Wanderguard Blue .User and Deployment Guide, published on 7/16/17, revealed: Checking the WanderGuard Blue Tag Battery Level .it is recommended to have the tag battery checked at least once a week. Review of the facility's policy, Resident Alarms, dated 11/2023, revealed: .Alarm function will be documented daily in the resident's record. During an interview on 11/29/23 at 12:40 PM, Licensed Nurse (LN) #1 stated the night shift nurse was responsible for checking the functionality of the wander guard. During an interview on 11/30/23 at 10:36 AM, the Long term care Manager stated the night shift nurse checked the wander guard daily. These daily checks were documented on a flowsheet. The LTC Manager stated the policy refers to all alarms used by residents including wander guard. Review of the flowsheet for wander guard monitoring from June 2023 to November 2023, revealed the night shift nurse had not checked Resident #3's wander guard daily. Further review of the flowsheet revealed the wander guard was not checked on the following weeks: 6/18-24/23, 7/23-29/23, 8/6-12/23, and 8/20-26/23.

Based on record review, observation, and interview, the facility failed to ensure 1 resident (#2) out of 5 residents observed for medication administration was free from unnecessary medications. Specifically, the facility failed to write administration parameters on a laxative (Miralax - a medication to treat constipation). This failed practice had the potential to place the resident at risk of being improperly medicated. Findings: Record review on 11/28/23 to 12/1/23 revealed Resident #2 was admitted to the facility with diagnoses that included Alzheimer's disease (a brain condition that affects memory, thinking and behavior), dementia (a decline in mental abilities that affects daily life). Review of Resident #2's most recent physician orders, dated 6/9/23, revealed: polyethylene glycol (Miralax) powder 8.5-25.5 g [grams] . PO [by mouth] . DAILY .Admin Instructions: Mix with 4-8 oz. Beverage . An observation and interview during Resident #2's medication administration on 11/30/23 at 8:34 AM, Licensed Nurse (LN) #1 prepared 17g of Miralax in water. When asked how he/she decided how much Miralax to administer to Resident #2, based on the physician's order, LN #1 stated he/she used nursing judgement. During an interview on 11/30/23 at 2:00 PM, the Clinical Pharmacist (CP) stated adverse effects of taking too little or too much Miralax could have resulted in constipation or loose stools. The CP reviewed the Miralax order and stated having administration parameters would have been a good idea to include on the order to minimize administration error. Review of the facility's policy Medication Administration and Documentation for Long Term Care, revised on 11/2023, revealed: Each nurse and physician administering medication .will be familiar with .The Five Rights: . Right Dose. Review of the Resident's [NAME] of Rights, updated on 1/2021 revealed: 12. To be free from unnecessary or excessive medications.

Based on record review and interview the facility failed to ensure [CONDITION(S)] medications (drugs that affect brain activities associated with mental processes and behaviors) used on a as needed basis (PRN) 1) were reassessed after 14-days, for the appropriateness of continued use and duration of the medication, for 4 residents (#5, 6. 9, and 10, out of 5 residents reviewed for unnecessary medications, and 2) [CONDITION(S)] medications were given for anxiety had a rational for dosage selection for 1 resident (#9) out of 4 residents reviewed on [CONDITION(S)] medications. These failed practices placed residents at risk for adverse consequences and/or impairment from medication side effects. Findings: Resident (R) #5 Record review on 11/7-8/22 revealed R#5 was admitted with diagnoses that included cerebellar atrophy (brain wasting away), diabetes, anxiety, and depression. Review of the November 2022 physician orders revealed a PRN (as needed) medication order for an anti-anxiety medication ordered on 9/30/22, [MEDICATION(S)] [benzodiazepine used for anxiety that can also treat muscle spasms and seizures] 5 mg PO [by mouth] Q [every] 6-hour PRN anxiety, 2 tablet maximum daily. Further review revealed the PRN [MEDICATION(S)] was originally ordered on 5/1/20. Review of the physician orders revealed no documentation rationale why the [MEDICATION(S)] was utilized for longer than 14 days or how long it was going to be used. Review of the MAR (medication administration record) sheets for June 1, 2022 to November 9, 2022, revealed R #5 was given one dose of the PRN [MEDICATION(S)] on 8/31/22. No other administration was documented. R #6 Record review on 11/7-8/22 revealed R #6 was admitted to the facility with diagnoses that included dementia, [CONDITION(S)], depression (disorder of the central nervous system that can affect movement including tremors), and [CONDITION(S)]. Review of R #6's MAR for November 2022 revealed a PRN medication for [MEDICATION(S)] [Tricyclic antidepressant (TCA) medication] 50 mg 1/2 tab PO HS [hour of sleep] PRN for [CONDITION(S)]. Ordered 1/14/2021. Current Risk & Benefit completed 10/25/22. Review of the MAR sheets for July 1, 2022 through November 9, 2022, revealed the PRN medication list included the Trazadone. Further review revealed the medication was administered a total of five times over the 4-month span. Review of the physician orders revealed no documentation of the order being renewed for longer than 14 days or a rationale for a longer PRN duration. R #9 Record review on 11/7-8/22 revealed R #9 had diagnoses that included dementia, anxiety, pain, and depression. Review of R #9's November medication orders, revealed the medications [MEDICATION(S)] (anti-Alzheimer's medication) 5mg Q every AM and 10 mg at HS, [MEDICATION(S)] (selective serotonin reuptake inhibitor-SSRI-antidepressant) 50 mg daily, [MEDICATION(S)] 25 mg at 1:00 PM and [MEDICATION(S)] 50 mg at bedtime. R #9's PRN orders included [MEDICATION(S)] (benzodiazepam-an antianxiety medication that can cause confusion and drowsiness) 0.25 mg to 1 mg PO Q 8 H PRN anxiety and [MEDICATION(S)] PO up to one-time daily PRN agitation. Further review of the physician orders revealed the [MEDICATION(S)] was started 2/14/22 and the PRN Trazadone was started 10/20/22. During an interview on 11/08/22 at 6:00 PM, when asked how nursing would know what dosing of [MEDICATION(S)] to administer, LN #3 replied It's a range it's in the MAR and based on how agitated [he/she] is. The LN added, To me [he/she] seems to ger more agitated. LN #3 stated they were using the lowest dose and the staff also have the PRN [MEDICATION(S)]. Review of the MAR for October 2020 revealed R #9 received 1 mg of [MEDICATION(S)] for restless and 4 extra PRN doses of [MEDICATION(S)] for restless. Review of the MAR for November revealed R #9 received 2 doses of PRN [MEDICATION(S)] for agitation. Review of a nurses note dated 7/14/22 revealed Behaviorally [he/she] has settled in. [MEDICATION(S)] [[MEDICATION(S)]] needed-1mg works. During an interview on 11/10/22 at 2:42 PM, when asked about R #9's medication regime, the Pharmacist stated the introduction of the PRN [MEDICATION(S)] was working as a cross titration to attempt to get R #9 off duplicative therapy, using the [MEDICATION(S)]. When asked about the range of dosing for the [MEDICATION(S)], the Pharmacist stated, the use was alright for the short term, but it puts nurses in the doctors' seat. When asked about the range of dosing for the [MEDICATION(S)], the Pharmacist stated, the use was alright for the short term, but it puts nurses in the doctors' seat. R #10 Record review on 11/9-10/22 revealed R #10 had diagnoses that included a history of stroke with weakness on one side of the body, disorder of the brain, [CONDITION(S)], dementia, and [CONDITION(S)]. Review on 11/09-10/22 of R #10's November medication orders included the medications [MEDICATION(S)] (antidepressant) 50 mg PO Daily, [MEDICATION(S)] 10 mg (used to treat Alzheimer's disease), [MEDICATION(S)] 25 mg PO up to 2 more times per day at least 1 hour between PRN agitation, [MEDICATION(S)] 50 mg PO HS may repeat 1 x one hour later PRN agitation/restlessness, and [MEDICATION(S)] (benzodiazepine-used to treat [CONDITION(S)] disorders and anxiety) 0.5 mg PO every 6 hours PRN anxiety. Review of the physician's orders revealed R #10 was prescribed the PRN Klonapin on 6/22/22 and the extra PRN dose of Trazadone on 10/06/22. Neither order had been reviewed for continued use after 14 days or had projected end date. During an interview with the Pharmacist on 11/10/22 at 2:35 PM, when asked about the [CONDITION(S)] PRN medications and the medications needing to be reevaluated and renewed after 14 days, the Pharmacist stated, I've not been paying attention to that, I will start looking at them. The Pharmacist stated he was aware of the policy and Federal requirement. During an interview on 11/10/22 with Physician #1, when asked about [CONDITION(S)] PRN medications, Physician #1 stated awareness of the requirements. Further stating most times the diagnosis warrants the potential need for the medication. We don't necessarily want to have to medicate, we try other things first, but if that fails the medication would be needed, the residents often need the meds for greater than a 14-day time period. Review of the facility policy titled [CONDITION(S)] Medication Use, effective date 11/2021, revealed preventative measures under procedures .B. PRN [CONDITION(S)] medications will be given only as needed for a specific diagnosed conditions or distressed behavior .1. PRN orders are limited to 14 days unless the physician documents a longer duration and the rationale in the record. 2. PRN orders cannot be renewed unless the physician evaluates the resident for appropriateness of continuing the medication and documents that in the chart. According to the 2019 Beers Criteria(R) for Potentially Inappropriate Medication ([NAME]) Use in Older Adults published by the American Geriatrics Society in 2019. Older adults have increased sensitivity to benzodiazepines and decrease metabolism of long-acting agents; in general, all benzodiazepines increase risk of cognitive impairment, [CONDITION(S)], falls, fractures, and motor vehicle crashes in older adults. May be appropriate for [CONDITION(S)] disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal [MEDICATION(S)] withdrawal severe generalized anxiety disorder and peri-procedural anesthesia. The drugs SNRI, SSRI, TCA may exacerbate or cause SIADH (syndrome of inappropriate antidiuretic hormone secretion), hyponatremia; monitor sodium level closely when starting or changing dosages in older adults. The recommendation was use with caution the strength of the recommendation was Strong.