Every finding on record at Quyanna Care Center

.Based on observation, interview, and record review, the facility failed to ensure foods were labeled and stored in accordance with professional standards for food service safety for 17 residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) out of 17 residents who received meals from the kitchen. Specifically: 1) frozen custom foods were labeled incorrectly; 2) spoiled fruits and vegetables were stored in the cooler; and 3) failure to conduct planned manufacturer's required 6 months maintenance on the kitchen's ice machine. These failed practices placed the residents who received meals from the kitchen at risk of consuming contaminated food and at risk of contracting foodborne illness .Findings:Food LabelingDuring an initial tour in the facility's main kitchen on 1/12/26 at 11:22 AM, revealed the custom frozen food in the walk-in freezer were labeled as follows:Six small bowls of tomato garlic beans, labeled as USE FIRST FRI [Friday] 12/26/25 6:59 PM;Six small Ziploc (a resealable plastic bag) of buttermilk pancakes, labeled as Enjoy By 12/22/25 9:31 AM;Seven small Ziploc of Macaroni and Cheese, labeled USE BY 01/05/26 4:56 PM;12 small Ziploc of baked beans, labeled as USE FIRST FRI 12/19/25 1:26 PM;14 small Ziploc of cubed pancakes, labeled as Enjoy By 12/21/25.During an interview on 1/12/26 at 11:22 AM, the Kitchen Manager (KM) stated the kitchen staff used the wrong label. The label should have been on the day the custom food was packaged. He further stated the frozen food would be good for a year.During a joint interview on 1/14/26 at 2:24 PM, with the KM and the Dietary Director (DD), the DD stated that the facility had been using an old system for food labeling. When asked about the frozen custom food labels that were found during the initial tour, the DD confirmed that the labels were wrong. She added that the staff should have written packaged on the date it was made and the frozen food should have been good for a year.Review of USDA (United States Department of Agriculture), Food Safety and Inspection Service, Food Product Dating, last updated on 4/23/25, accessed on 1/20/26 at https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/food-product-dating, revealed: .dates may be voluntarily applied provided they are labeled in a manner that is truthful, not misleading and in compliance with FSIS [Food Safety and Inspection Service] regulations.Manufacturers provide dating to help consumers and retailers decide when food is of best quality.There are no uniform or universally accepted descriptions used on food labels for open dating in the United States. As a result, there are a wide variety of phrases used on labels to describe quality dates. Examples of commonly used phrases: A Best if Used By/Before date indicates when a product will be of best flavor or quality. A Sell-By date tells the store how long to display the product for sale for inventory management. A Use-By date is the last date recommended for the use of the product while at peak quality. A Freeze-By date indicates when a product should be frozen to maintain peak quality.Food StorageDuring an initial tour in the facility's main kitchen on 1/12/26 at 11:42 AM, revealed spoiled fruits and vegetables were stored in the walk-in cooler as follows:A box of multiple pieces of blistered soft and mushy red bell peppers;An uncovered tray of sliced lettuce with brown discoloration on the edges of each piece;13 pieces of whole honeydew with soft brown and black spots scattered on the skin;10 cantaloupes with black discoloration scattered on the skin;2 whole watermelons with a soft and slimy skin texture; and1 whole watermelon with an estimated size of 4 inches in diameter of white and black mold on the skin.During an interview on 1/12/26 at 11:42 AM, the KM stated the spoiled fruits and vegetables should have been discarded.During a joint interview on 1/14/26 at 2:24 PM, with the KM and the DD, the DD stated the kitchen staff were responsible for checking the food upon receipt and before use for service. She further stated the fruits and vegetables delivered to the kitchen ended up frozen and mushy. She added that the spoiled fruits and vegetables should have been discarded. The DD also stated the supervisor should have gone through the cooler. They ideally had two supervisors and an inventory technician, however the facility was short staffed, and they had no inventory technician at that time.Review of the facility's Nutrition Services Infection Control Guidelines, last revised on 3/21/24, revealed: 12. Storage a. The objective is to maintain high quality food at approved temperatures and conditions to ensure retention of quality foods.Special considerations are as follows: a. Rotate all food items in storage and use within a safe period of time, using oldest items first.Review of USDA (United States Department of Agriculture), Food and Nutrition Service, last updated on 6/3/24, accessed on 1/20/26 at https://www.fns.usda.gov/fs/produce-safety/storage, revealed: .Location of fruits and vegetables is important because fruits, in general, produce ethylene gas, which fosters natural ripening, but it also can cause most vegetables and a few non-ethylene producing fruits to deteriorate more quickly and develop undesirable characteristics.Review of FDA (Food and Drug Administration) Selecting and Serving Produce Safely, dated 3/5/24, accessed on 1/20/26 at https://www.fda.gov/food/buy-store-serve-safe-food/selecting-and-serving-produce-safely , revealed: .Fresh produce may also become contaminated after it is harvested, such as during storage or preparation. Furthermore, like any fresh produce that is consumed raw. may contain bacteria that can cause foodborne illness. Eating contaminated produce can lead to foodborne illness, often called 'food poisoning'.Ice MachineReview of the Indigo NXT[unknown acronym] Ice Machines Installation, Operation and Maintenance Manual, Rev [Revised] 11 12/23, revealed: .You are responsible for maintaining the ice machine in accordance with the instructions in this manual. de-scale and sanitize the ice machine every six months for efficient operation. check all water fittings and lines for leaks. Detailed De-scaling/ Sanitizing Procedure. This procedure must be performed a minimum of once every six months. The ice machine and bin must be disassembled de-scaled and sanitized.Cleaning the Air Filter and Condenser. A dirty condenser restricts airflow, resulting in excessively high operating temperatures. Clean the condenser at least every six months.Review of the facility's ice machine work order Maintenance Work Order #37276, Due [DATE], revealed: Tasks: The ice machine and bin must be disassembled cleaned and sanitized. All ice produced during the cleaning and sanitizing procedures must be discarded. Removes mineral deposits from areas or surfaces that are in direct contact with water. Clean area around ice machine as often as necessary to maintain cleanliness and efficiency. Replace filter cartridge and write replacement date on new cartridge. Completion information. [DATE] 2:52 PMDuring an interview and concurrent document review on 1/15/26 at 2:00 PM, the Safety Officer, Plant Operations (SOPO) stated that to do the manufacturer's required six-month maintenance on the ice machine, staff would use Worxhub software to generate the work orders on a specific timeline. He further stated that the software failed to generate the August 2025 work order. Upon review of the work order, the SOPO verified and confirmed that the filter was changed on 3/19/25 and the filter should have been changed 6 months after it was last changed. He confirmed that it should have been changed on 9/2025. The SOPO further stated that maintenance staff would clean the exterior and interior parts of the ice machine according to manufacturer's instruction.Review of the facility's policy Equipment Cleaning, last reviewed on 3/21/24, revealed: Purpose: To maintain a healthy and safe work environment, all equipment and appliances must be cleaned regularly and effectively.Procedure: Staff will adhere to cleaning guidelines located in the operational manuals for each piece of equipment located in the kitchen. Operational manuals are located in the staff office.

.Based on record review, observation, and interview, the facility failed to maintain the dignity and respect of 1 resident (#12) out of 18 residents. Specifically, a Certified Nursing Assistant (CNA) used the resident's clothing protector to wipe the resident's mouth while dining. This failed practice undermined the resident's right to a dignified existence and placing the resident at risk of diminished quality of life .Findings:Record review on 1/12-20/25 revealed Resident #12 was admitted to the facility with diagnoses that included dementia with anxiety (a decline in intellectual functioning, including problems with memory, reasoning and thinking), osteoarthritis (a degenerative joint disease), spinal stenosis of lumbar region at multiple levels (narrowing within the spinal canal), and unable to ambulate.Review of the Resident #12's care plan, last updated 12/16/25 at 6:30 PM revealed: .[Resident #12] needs maximal assistance with meals, snacks and hydration.During an observation on 1/12/26 at 1:20 PM, CNA #3 was observed to be feeding Resident #12. Further observation revealed at 1:23 PM, 1:24 PM, 1:26 PM, 1:28 PM, and 1:31 PM, CNA #3 helped wiped Resident #12's mouth with his/her clothing protector.During an interview on 1/14/26 at 4:30 PM, CNA #4 stated if a resident had food in his/her mouth, the CNA would use a napkin which would be provided in the tray. When asked if the use of cloth protector was acceptable, he/she stated No.During an interview on 1/15/26 at 4:05 PM, the Director of Nursing (DON) stated the CNAs were expected to use a napkin when wiping the resident's mouth.Review of the facility's policy Feeding Residents, last reviewed on 5/8/09, revealed: .PROCEDURE: I. The following equipment is needed to feed a resident:a. Tray and silverware (no plastic utensils)b. Napkinc. Food items per diet orderd. Seasoning as allowed by resident's prescribed diete. Clothing protector (if indicated)Review of the facility's Orientation for QCC [Quyanna Care Center] CNA , undated, revealed no instruction on how the CNA would help the dependent residents wipe their mouth.Review of the facility's Resident [NAME] of Rights and Responsibilities, undated, revealed: .As a resident at Q.C.C. you have the RIGHT to: Quality care and treatment. Considerate and respectful care at all times with recognition of your personal dignity and needs.

.Based on record review, observation, and interview, the facility failed to prepare meals by methods that conserve nutritive value and ensure safe and appetizing food temperature for 1 resident (#11) out of 1 resident on a pureed diet. Specifically, 1) the cook did not measure the temperature after pureeing the food, 2) the cook added unmeasured amount of water into the food to be pureed, and 3) the cook did not follow the Simply Thick (a thickening agent) instruction for food and thickener ratio. These failed practices had the potential to compromise or diminish the nutritive value of food and palatability and affect resident's nutritional intake and/or weight loss .Findings:Record review on 1/12-20/26, revealed Resident #11 was admitted to the facility with diagnoses that included Alzheimer's dementia (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), impaired physical mobility and dysphagia (difficulty swallowing).Review of the diet order, dated 9/27/25, revealed: Regular Diet. Further review of the order, revealed on 4/7/25 the diet texture was changed to Puree, from minced and moist. There was no IDDSI (International Dysphagia Diet Standardization Initiative) level specified in the order.During an observation and concurrent interview on 1/13/26 at 3:37 PM, [NAME] #2 scooped an unmeasured amount of pasta into the blender, and blended the pasta until the desired consistency was reached. [NAME] #2 tested the pasta with a spoon to check the consistency; the pasta was not dripping so [NAME] #2 covered the bowl without measuring the temperature and placed the covered bowl in the hot box [a food warming cabinet] with a temperature of 177 degrees Fahrenheit (F).During the same observation [NAME] #2 removed a tray of cooked Italian green beans from the oven, and measured the temperature at 190 degrees F. Then, the cook scooped an unmeasured amount of cooked green beans into the blender and added water straight from the faucet. The cook did not measure the amount of water added into the cooked beans. When asked how much water he/she added, [NAME] #2 stated maybe half a cup. When asked how he/she measured the green beans he/she scooped, he/she stated just enough to fill two bowls. The cook blended the green beans with water and transferred the pureed food into the bowls. Further observation revealed the pureed green beans were watery, so the cook added a thickening liquid. The cook stated two pumps first, he/she then stirred the puree, and added another pump of thickening liquid. The cook stated he/she would stir for 30 seconds and test with a spoon until the pureed food had a pudding consistency. After adding the thickener, the cook did not measure the temperature. Placed the covered bowl into the hot box with a temperature of 177 degrees F.During an interview on 1/13/26 at 3:52 PM, when asked why he/she did not measure the amount of water added to the pureed food, he/she stated he/she had been doing it for so many years. [NAME] #2, also stated I don't need to. When asked if the amount of water added to the pureed food would affect the nutritive value of the food, he/she stated No. He/she further stated there were more vegetables in there and the water added just helped the vegetable blend.During a joint interview on 1/14/26 at 2:24 PM, with the Kitchen Manager (KM) and Dietary Director (DD), the DD stated the amount of thickener added to the pureed food depends on the person who was preparing it. She also added that the cook may add water. When asked if there was a recipe being used, she stated there was no recipe for adding water, it would depend on the texture and consistency of the food. The DD further stated the facility used the IDDSI guidelines.Review of the facility provided SIMPLY THICK Bottle and Pump instruction, undated, revealed: Extremely Thick (Pudding)- IDDSI Level 4 oz - 4 pump and 8 oz - 8 pump.Review of The IDDSI Framework, dated 2019, accessed on 1/20/26 at https://www.iddsi.org/standards/framework revealed: PUREED 4 EXTREMELY THICK.During a joint interview on 1/14/26 at 2:24 PM, with the KM and the DD, the KM stated there was no need to measure the temperature of the food after it had been pureed because the food would come out of the oven with a temperature of 165-180 degrees F and the cook would work pretty quickly that the temperature would not go down. He also stated the pureed food would be transferred to the hot box with a temperature set at 185 degrees F. The KM further stated food temperature would be measured after cooking, before the food service, and after it was delivered into the long-term care unit.Review of the facility's Nutrition Services Infection Control Guidelines, last revised on 3/21/24, revealed: .Holding and point of service temperature standards are verified by food service personnel. These temperatures are measured using a calibrated bimetallic stemmed thermometer. Further review of the policy revealed no policy for pureed food preparation.Review of the Food and Drug Administration 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, dated 2022, accessed at https://www.fda.gov/media/164194/download?attachment, revealed: .TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained:(1) At 57 C (135 F) or above. Further review of the food code revealed: .57 C (135 F) or greater during hot holding is sufficient to prevent the growth of pathogens and is therefore an effective measure in the prevention of foodborne illness.

Based on observation, interview, and record review, the facility failed to ensure expired medical products were removed from the medication storage room. This failed practice placed the residents, who required these products for services, out of a census of 17, at risk of complications from use of expired products. Findings: An observation of the medication storage room on [DATE] at 3:23 PM, revealed the following expired medical supplies: 3- green top blood collection vials, expired on [DATE]; 4 - gray top blood collection vials, expired on [DATE]; 1 - yellow top Quantiferon blood collection vial, expired on [DATE]; 79 - purple top blood collection vials, expired [DATE]; 3 - Gentle heel newborn incision devices, expired on ,d+[DATE], ,d+[DATE], and ,d+[DATE] During an interview on [DATE] at 3:34 PM, Licensed Nurse (LN) #2 stated everyone was supposed to pay attention to the expiration dates of supplies. LN #2 did not know who was responsible for the removal of expired supplies. During an interview on [DATE] at 3:40 PM, LN #7 stated he/she did not know when the medical supplies were checked for expiration dates. During an interview on [DATE] at 3:46 PM, the Staff Development Coordinator stated she did not know when the medical supplies were checked for expiration dates. A medical supply storage policy was requested on [DATE] but was not provided by the end of survey.

Based on observation, interview, and record review, the facility failed to ensure food safety with preparation and distribution. Specifically, the facility failed to ensure temperatures for hot and cold foods were measured prior to service. This failed practice had the potential to affect any resident receiving food served from the kitchen of potentially contracting food-borne illness and affecting the palatability of the food. Findings: Review of the dinner menu for 6/7/23, revealed: Herbed Pork Loin, Hawaiian Bread, Mashed Potatoes, Vegetable Blend, 2 % Milk, Chilled Fruit Salad, and Hot Tea. An observation with concurrent interview on 6/7/23 at 5:25 PM, revealed Cook #1 had already taken and documented temperatures for the dinner items being served. Cook #1 further stated that the hot cooked items were those documented on the Meal Temperature Log. During an interview on 6/8/23 at 10:40 AM, the Manager of Nutritional Services (MNS), stated that temperatures for pureed items and cold items were not being taken/documented prior to meal service. Review of facility document Meal Temperature QCC [Quyanna Care Center]/Acute Care LOG, dated 6/7/23, revealed documented temperatures for the Pork Roast, Veggie, and Mash (mashed potatoes). The pureed items and the cold food items had no documented temperatures. Review of facility policy Feeding Residents, dated 6/4/19 revealed: . Make sure that hot foods are hot and cold foods are cold .

Based on interview and record review, the facility failed to develop a policy regarding the use and storage of food brought to residents by family and other visitors. This failed practice had the potential to place residents, based on a census of 17, at risk for foodborne illness. Findings: During an interview on 6/8/23 at 5:20 PM, the Director of Nursing and Staff Developmental Coordinator stated there was no policy or procedure with regards to food brought by visitors into the facility that required refrigeration. They further stated this was not a common occurrence and most items brought in required non-refrigeration. Review of facility policy, Native Food Usage, revised on 3/10/04, revealed the processes for donated food and food managed by the activities staff.

44893 47929 Based on record review, observation, and interview the facility failed to ensure a sanitary environment for all residents out of a census of 17. Specifically, the facility failed to ensure: 1) glove changes/hand hygiene with wound care; 2) appropriate hand hygiene with resident cares; 3) cleanliness of reusable medical equipment; and 4) cleanliness of the dining area. These failed practices had the potential to increase the development and transmission of communicable diseases and infections. Findings: Wound Care Record review on 6/5-9/23 revealed Resident #1 was admitted to the facility with diagnoses that included dementia (a decline in cognitive abilities), hypertension, and neurogenic bladder (bladder malfunction). An observation on 6/6/23 at 11:33 AM, revealed Licensed Nurse (LN) #1 performed wound care to Resident #1's buttocks. The LN performed hand hygiene, put on new gloves then removed and discarded the old wound dressing (Mepilex). The LN removed the soiled gloves and put on new gloves without performing hand hygiene. The LN applied skin cleanser to the wound and then removed the soiled gloves and put on new gloves without performing hand hygiene. Lastly, the LN placed a new dressing to the wound. During an interview on 6/8/23 at 10:56 AM, Infection Preventionist (IP) #1 stated hand hygiene should have been performed before wearing and after removing gloves because gloves could be punctured and torn during the performance of cares or procedures. Resident care Record review on 6/5-9/23 revealed Resident #5 was admitted to the facility with diagnoses that included coronary artery disease (reduced blood flow to the heart), hypertension and benign prostatic hyperplasia (enlargement of the prostate). During an observation on 6/6/23 at 11:48 AM, Certified Nurse Assistant (CNA) #s 2 and 4 performed perineal care (a process of cleaning the private areas of a patient) to Resident #5. After the perineal care, CNA #2 put away the trash bag and removed his/her gloves. Without hand hygiene, CNA #2 took 2 new sets of gloves from a box. CNA #2 handed one set of gloves to CNA #4. CNA #2 placed the second set of gloves under his/her left armpit and then sanitized his/her hand, put on the gloves, and assisted Resident #5 with dressing and transferring to the wheelchair. During an interview on 6/8/23 at 10:56 AM, the IP#1 stated hand hygiene should have been performed before and after removing personal protective equipment (PPE), and before and after touching the resident. Review of the facility's Handwashing policy, dated 2/12/07, revealed: .handwashing will be done .before applying and after removing gloves . Review of Centers for Disease Control and Prevention, Hand Hygiene in Health Care Settings, dated 1/8/21, accessed at https://www.cdc.gov/handhygiene/providers/, revealed: .Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves . Medication administration During a medication administration observation on 6/6/23 at 8:06 AM, LN #3 began preparing crushed medications at the medication cart for Resident #12 without performing hand hygiene. LN #3 then mixed the medications in apple sauce and put on gloves without performing hand hygiene. The LN picked up the medications, walked over to the kitchen and picked up a metal spoon from a kitchen drawer, then proceeded to the common dining area where Resident #12 was seated in his/her wheelchair at a table. LN #3 fed the medication mixed with apple sauce to Resident #12. The LN then returned to the medication cart, removed a marker from a medication drawer, and proceeded to write the date on Resident #12's medication patch with the same gloved hands. LN #3 then went over to Resident #12, removed the old medication patch, removed his/her gloves, and put on another pair of gloves without performing hand hygiene. The LN then placed the new medication patch on Resident #12's back. LN #3 returned to the medication cart with the used medication patch and removed his/her gloves. The LN did not perform hand hygiene after glove removal. Further observation revealed LN #3, without performing hand hygiene, pulled Resident #4's medication packets and placed the medication into a medication cup. Next, the LN pulled out 2 inhalers, and a [NAME] Respironics Optichamber Diamond (a valved inhaled medication chamber) from the medication cart drawer. LN #3 mixed another medication with water in a paper cup. The LN put on gloves without hand hygiene, picked up the medication cups, inhalers and Optichamber and proceeded to give the oral medications and both inhalers with the Optichamber to Resident #4. With the same gloved hands, LN #3 detached the inhaler, returned to the medication cart, and placed the Optichamber into a medication cart drawer without cleaning it. During an interview on 6/6/23 at 8:23 AM, LN #3 stated he/she did not know how often the Optichamber was cleaned. Review of the [NAME] Respironics Optichamber Diamond's cleaning instructions revealed, .Clean your chamber and mask weekly ., accessed on 6/14/23 from: https://www.documents.[NAME].com/doclib/enc/11446331/OptiChamber_Diamond_TearOff.pdf#:~:text=1.%20Remove%20cap%2C%20rotate%20mouthpiece%20to%20disassemble%2C%20remove,parts%20with%20warm%20clean%20water%20and%20air%20dry. During an interview on 6/8/23 at 10:57 AM, the IP #1 stated hand hygiene should have been performed before and after each resident's medication pass and before and after glove use. Environment An observation on 6/7/23 at 6:07 PM, revealed the community dining tables were visibly dirty with crumbs and dried liquid residue. During an interview with concurrent observation on 6/7/23 at 6:08 PM, CNA #5 stated the dining tables were washed with soapy water after meals. CNA #5 further stated if residents sat at the tables in between meals for snacks or drinks the tables could be left dirty. CNA #5 proceeded to prepare a bucket of soapy water and washed down the dining tables as residents were now seated at them.

Based on record review and interview, the facility failed to provide behavioral health training consistent with the facility assessment in regards to psychosocial difficulties and history of trauma. This failed practice had the potential to exacerbate or trigger ongoing psychosocial difficulty and affect the residents' ability to attain the highest practicable mental and psychosocial well-being. Findings: Review of the facility's Matrix for Providers, revealed the resident population contains the following condition: - PTSD (Post-traumatic Stress Disorder)/Trauma: 3 residents. Review on 6/5-9/23 of the facility's CMS-672: Resident Census and Conditions of Residents form revealed: Mental Status: - Documented signs and symptoms of Depression: 11 residents; - Documented psychiatric diagnosis: 5 residents. Medications: - Antipsychotic medications: 5 residents; - Antianxiety medications: 1 resident; - Antidepressant medications: 11 residents. Review of Facility Assessment Tool revealed: - Disease/conditions, physical and cognitive disabilities .Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions. - Part 2: Services and Care We Offer Based on Resident Needs .identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. During an interview on 6/8/23 at 4:57 PM, the Director of Human Resources and Director of Nursing stated trauma-informed care training was not provided during new hire orientation, or during annual training for nursing staff. Review of the facility's policy, Comprehensive Care Plan for QCC [Quyanna Care Center] Residents, approved date 6/4/19, revealed, .The facility must develop a comprehensive care plan for each resident .to meet a resident's medical, nursing, mental and psychosocial needs .

47929 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 1 and 12) out of 17 residents. This failed practice placed the residents at risk for psychological harm from feelings of poor self-esteem and/or self-worth and a potential for a poor quality of life. Findings: Assistance with meals Resident #1 Record review on 6/5-9/23 of Resident #1's medical record revealed admission to the facility with diagnoses that included dysphagia (difficulty in swallowing food or liquid). A continuous dining observation on 6/6/23 from 8:05 AM to 8:24 AM, revealed Resident #1 was on a pureed diet. Certified Nurse Assistant (CNA) #1 was feeding the Resident cream of wheat, egg omelet, cinnamon toast, chilled mandarin, jelly, lemonade, almond milk, and prune juice. The following observation was made: From 8:07 AM to 8:24 AM, CNA #1 fed the Resident a spoonsful of pureed food eight times. Each time the CNA fed the resident, the CNA collected excess food from around the Resident's mouth and fed the collected food to the Resident. Review of a facility policy titled Feeding Residents, approved date 6/4/19, revealed: .the following equipment is needed to feed a resident .silverware (no plastic spoon) . help the resident to wipe mouth . Resident # 12 Record review from 6/5-9/23 revealed Resident #12 was admitted to the facility with diagnoses that included dementia (a decline in cognitive abilities). An observation on 6/7/23 at 6:14 PM, revealed Licensed Nurse (LN) #1 stood behind the resident while helping Resident #12 hold a spoon to his/her mouth. Further into the meal, LN #1 continued to stand behind the Resident while reaching to the table to place a cup in his/her hand. LN #1 continued to stand behind the resident while assisting Resident #12 with the rest of the meal. During an interview on 6/8/23 at 3:05 PM, the Director of Nursing (DON) stated staff should have been seated while assisting residents with their meals. Review of the facility's policy Feeding Resident, approved date 6/14/19, revealed: .All staff must be seated while assisting resident to eat unless contraindicated . Medication patch An observation on 6/6/23 at 8:14 AM, revealed Resident #12 was seated at a dining table in the common dining room, along with 3 other residents, for breakfast. LN #3, who was administering medications, approached Resident #12 at the dining table, pulled down his/her shirt exposing the Resident's back. The LN removed a patch located at the base of the Resident's shoulder blade. As the shirt was pulled down, the front neckline of Resident #12's shirt pressed into the resident's front neck region. LN #3 released the shirt and picked up a new medication patch. LN #3 then, reached down Resident #12's shirt for a second time and placed the new medication patch on the resident. During an interview on 6/8/23 at 3:05 PM, the DON stated medication patch removal was discouraged during mealtimes. Review of the facility's policy, Resident [NAME] of Rights and Responsibilities, no date, revealed: .as a resident at Q.C.C (Quyanna Care Center) you have the RIGHT to: quality care .considerate and respectful care at all times with recognition of your personal dignity and needs .

47929 Based on record review and interview, the facility failed to obtain informed consent for psychotropic medications (medications in the class of either antipsychotics, antianxiety, or antidepressants that would have affected behavior, mood, thoughts, or perception) prior to use for 3 residents (#'s 7, 12 and 16) out of 5 residents reviewed for unnecessary medications. This failed practice denied the resident the right to consent to medications and be informed of the risk and benefits for medication use. Findings: Resident #7 Record review from 6/5-9/23 revealed Resident #7 was admitted to the facility with a diagnosis of PTSD (Post-Traumatic Stress Disorder). Review of Resident #7's current [Physician] Orders, revealed: Duloxetine 20 mg, Oral, Cap-DR [delayed release], BIDAB [Twice a day Morning/Bedtime], Start date: 01/10/23 . No indication/diagnosis included in the order. During an interview on 6/8/23 at 6:21 PM, the Director of Nursing (DON) stated a psychotropic medication consent was unable to be found for the medication duloxetine. Resident # 12 Record review on 6/5-9/23 revealed Resident #12 was admitted to the facility with a diagnosis of dementia (a decline in cognitive abilities) with psychosis (severe mental condition affecting thought and emotions). Review of Resident #12's current [Physician] Orders, dated 4/16/23, revealed risperiDONE (RisperDAL) 0.5 mg, 1 tab(s) 1 tab oral QHS [at bedtime]. Diagnosis: dementia, dementia with psychosis. Resident #16 Record review from 6/5-9/23 revealed Resident #16 was admitted to the facility with diagnoses that included dementia, and a personal history of other mental and behavioral disorders. Review of Resident #16's current [Physician] Orders, revealed: Risperidone, 1 mg, Oral, Tab, HS, Start date: 5/14/23; Risperidone, 0.5 mg, Oral, Tab, qAM [every morning], Start date: 05/14/23; mirtazapine, 30 mg, Oral, Tab, HS, Start date: 01/17/23. During an interview on 6/8/23 at 6:21 PM, the DON stated a psychotropic medication consent was not obtained for residents #12 and #16 since these residents were admitted to the facility already taking these medications. The DON also stated that residents taking psychotropic medications should be informed of the side effects and consent to taking these drugs. Review of the facility's policy Resident [NAME] of Rights and Responsibilities, no date, revealed: .As a resident at Q.C.C. [Quyanna Care Center] you have the right to .be informed by a physician .in making plans about your health care, give informed consent to treatment .

Based on record review and interview, the facility failed to ensure care plans were individualized to meet the psychosocial needs for 2 residents (#'s 7 and 16), out of 8 sampled residents. Specifically, trauma informed care interventions were not included in the care plans. This failed practice placed the residents at risk for not receiving necessary services to address their individual needs to attain or maintain their highest practicable well-being. Findings: Record review from 6/5-9/23 of the facility's Matrix for Providers revealed the resident population contained the following condition: PTSD (post-traumatic stress disorder)/Trauma: 3 residents. Resident #7 Record review from 6/5-9/23 revealed Resident #7 was admitted to the facility with diagnoses that included PTSD. Record review of Resident #7's, Behavioral Health Psych [psychiatric] Provider Note, dated 1/16/20, revealed: .Psychiatric Review of Systems: .Active Problems . Chronic post-traumatic stress disorder (PTSD) after military combat . During an interview on 6/8/23 at 10:03 AM, the Director of Nursing (DON) stated as per Resident #7's first behavioral health note there has been no knowledge of any triggers for the resident based on past history. The facility staff have only documented residents behaviors observed in the facility. Review of CNA [certified nurse assistant] Initial Competency, updated 9/8/21, revealed: .CareTracker/Kiosk/Charting .Behaviors -Refused Care -Inappropriate . Review of Resident #7's, Behavioral Health Psych Provider Note, dated 3/14/23, indicated that behaviors and depression showed signs of improvement. This note addressed complaints of random noises that were no longer a concern. Review of Resident #7's current Care Plan, revealed under behavioral symptoms interventions of appropriate behavior when interacting with others and allowing for staff to assist resident with cares. During an interview with concurrent observation on 6/9/23 at 8:00 AM, Licensed Nurse (LN) #3 stated he/she was unaware of any triggers or past trauma with Resident #7. LN #3 reviewed the nursing care plan that revealed .Brief history of behaviors with management techniques: Occasionally agitation and refuses cares. Sometimes refuses to participate in activities. Likes to be alone but can be encouraged to come out in the common room .Has occasional paranoia of people coming into [his/her] room to steal checks and money . LN #3 further stated that the facility provided trainings online for cultural sensitivity but no trauma-based care training. Resident #16 Record review from 6/5-9/23 revealed Resident #16 was admitted to the facility with diagnoses that included dementia, and a personal history of other mental and behavioral disorders. Review of Resident #16's Behavioral Health Psych Provider Note, dated 5/10/23, included a history of psychiatric hospitalization , history of self-inflicted injuries, history of auditory and visual hallucinations, suspected abuse at a previous assisted living facility, and a traumatic above the left knee amputation. Review of Resident #16's LTC [Long Term Care] Provider Progress Note, dated 4/24/23, revealed a history of grabbing [others] anatomy, and a history of aggression when someone tells [resident] what to do. Review of Resident #16's care plan, dated 5/7/23, does not reveal identified triggers or interventions related to Resident #16's personal trauma. During an interview on 6/8/23 at 4:57 PM, the Director of Human Resources and Director of Nursing stated they have not identified triggers for residents with histories of trauma, and there was no trauma-informed care training provided during new hire orientation, nor during annual training for nursing staff. Review of the facility's policy, Comprehensive Care Plan for QCC Residents, dated 2/3/03, revealed, .The facility must develop a comprehensive care plan for each resident . to meet a resident's medical, nursing, mental and psychosocial needs .

Based on record review and interview, the facility failed to ensure residents that wore a wander guard received adequate supervision and monitoring. This failed practice placed 4 residents (#s 12, 4, 8, and 11) out of 4 residents reviewed for wander guard, at risk for potential elopement. Findings: Resident #12 Record review on 6/5-9/23 revealed Resident #12 was admitted to the facility with a diagnosis that included dementia (a decline of cognitive abilities) with psychosis (a severe mental condition affecting thought and emotions). Review of Resident #12's Minimum Data Set (MDS- a federally required nursing assessment) Quarterly Assessment, dated 4/16/23, revealed: . Section E- Behavior. E0900 Wandering .Behavior of this type occurred 4 to 6 days, but less than daily was marked .P0200. Alarms. Wander/ elopement alarm was marked . used daily . Review of Resident #12's Care Plan, dated 5/18/23, revealed behavioral symptom interventions .Monitor [Resident #12] for possible wandering into rooms . During an interview on 6/7/23 at 11:36 AM, Certified Nurse Assistant (CNA) #2 confirmed that Resident #12 wore a wander guard on Resident #12's ankle. The CNA further stated the nurses monitored and checked the wander guard battery. During an interview on 6/7/23 at 11:53 AM, Licensed Nurse (LN) #1 stated he/she did not know that Resident #12 wore a wander guard. During an interview on 6/7/23 at 1:08 PM, the Director of Nursing (DON) stated the wander guard battery was checked during every resident's head to toe assessment on a weekly basis. During an interview on 6/8/23 at 9:50 AM, after the DON reviewed Resident #12's assessment for Activity of Daily Living (ADL) abilities, this section of the EHR revealed the wander guard battery was last checked on 4/4/23. The DON confirmed no other documentation after that date occurred. When asked the expectiation for monitoring the wander guard, the DON stated nurses should have checked the wander guard weekly. Resident #4 Record review on 6/5-9/23 revealed Resident #4 was admitted to the facility with a diagnosis of vascular dementia (a decline in cognitive abilities) with behavioral disturbance. Review of Resident #4's MDS Quarterly Assessment, dated 2/5/23, revealed: . Section P0200. Alarms .Wander/ elopement alarm was marked . used daily . Review of Resident #4's Care Plan, dated 2/4/21, revealed: . [Resident #4] has a wander guard on [his/her] wheelchair . Review of Resident #4's assessment for ADL abilities, revealed Wander alert device alarm was not checked on 11/17/22; 12/12/22; 4/17/23; 5/22/23; 5/29/23; and 6/5/23. Resident #8 Record review on 6/5-9/23 revealed Resident #8 was admitted to the facility with diagnoses that included emphysema/chronic obstructive pulmonary disease (COPD), and dementia (a decline in cognitive abilities). Review of Resident #8's MDS Quarterly Assessment, dated 3/19/23, revealed: . Section P0200. Alarms .Wander/ elopement alarm was marked . used daily . Review of Resident #8's Care Plan, dated 5/18/22, revealed: . [Resident #8] has a wander guard on [his/her] wheelchair . Review of Resident #8's assessment for ADL abilities, revealed Wander alert device alarm was not checked on 5/31/23 and 6/6/23. Resident #11 Record review on 6/5-9/23 revealed Resident #11 was admitted to the facility with a diagnosis of dementia (a decline in cognitive abilities) with behavioral problems. Review of Resident #11's MDS Quarterly Assessment, dated 3/19/23, revealed: . Section P0200. Alarms .Wander/ elopement alarm was marked . used daily . Review of Resident #11's Care Plan, dated 11/26/21, revealed: . utilize wandering device . Review of Resident #11's assessment for ADL abilities, revealed Wander alert device alarm was not checked on 3/14/23; 5/16/23; 5/23/23; and 5/31/23. Review of the facility's policy Floor alarms, Bed alarms and WanderGuard System, revised on 9/15/20 revealed .wander guard devices are checked weekly . Review of WanderGuard Blue v1.4 Quick Reference Guide, no date, revealed: .check the Tag battery at least once a week .

Based on record review and interview, the facility failed to ensure drug regimens/medication orders included an indication and/or diagnosis for 4 residents (#'s 3, 7, 11 and 12) out of 8 sampled residents. This failed practice had the potential to place residents at risk for medication errors and adverse effects. Findings: Resident #3 Record review from 6/5-9/23 revealed Resident #3 was admitted to the facility with diagnoses that included urinary incontinence and recurrent urinary tract infections (UTI). Review of Resident #3's [Physician] Order, with a start date 5/6/23 for a duration of 5 days, for sulfamethoxazole-trimethoprim (Bactrim DS) (an antibiotic), revealed no diagnosis or indication. Resident #7 Record review from 6/5-9/23 revealed Resident #7 was admitted to the facility with diagnoses that included atrial fibrillation or other dysrhythmias and heart failure. Review of Resident #7's current [Physician] Orders, revealed: apixaban [a blood thinner] 2.5 mg, Oral Tab, BIDAB [twice a day Morning/Bedtime], Start date 5/23/23. No diagnosis documented. During an interview on 6/6/23 at 12:10 PM, when asked the indication/diagnosis for Resident #7's apixaban, Licensed Nurse (LN) #1 was unable to provide an answer nor find the answer in the physician's order. During an interview on 6/6/23 at 12:27 PM, the Director of Nursing (DON) and Staff Development coordinator stated that pharmacy advised as needed medications (PRNs) and antibiotics required the order to contain a diagnosis or indication. When asked about what medications were utilized for off label use, the DON stated that these were discussed during staff huddles. During an interview on 6/8/23 at 1:55 PM, the Pharmacist #1 stated that medication indications and/or diagnoses were not required by the Alaska Pharmacy Regulations nor the code of regulations. The Pharmacist further stated that indications and/or diagnoses could be found in physician notes or the monthly drug regimen review. During an interview on 6/8/23 at 2:31 PM, Psychiatrist #2 stated that some medications have an off label use and that a diagnosis code should be included in the order. During an interview on 6/14/23 at 1:15 PM, Psychiatrist #1 stated a diagnosis and/or indication should be listed in the order for every medication. This information could also be found in the psychiatric notes of the medical record. Resident #11 Record review on 6/5-9/23 revealed Resident #11 was admitted to the facility with diagnoses that included dementia with behavioral symptoms. Review of Resident #11's current [Physician] Orders, revealed: Aripiprazole (Abilify) 10 mg, Oral, Tab, qAM [every morning], Start date 6/6/23, Special Instruction: Use 5 mg half tab from pill bottle. Aripiprazole (Aripiprazole 5 mg oral tablet) 5 mg, Oral, Tab, HS [at night], Start date 5/19/23. No diagnosis or indication documented in the order. Resident #12 Record review on 6/5-9/23 revealed Resident #12 was admitted to the facility with diagnoses that included dementia (a decline in cognitive abilities) with psychosis (severe mental condition affecting thought and emotions). Review of the [Physician] Order, originally ordered on 5/3/22, revealed rivastigmine (rivastigmine 9.5 mg/24 hours transdermal patch) no indication for use or diagnosis in the order. Review of the progress note, dated 5/10/23, revealed current medications .rivastigmine (rivastigmine 9.5 mg/24 hours transdermal patch) . qAM [every morning] . During an interview on 6/8/23 at 6:44 PM, after the DON reviewed the medication order in the electronic health record (EHR), she confirmed that there was no indication or diagnosis in the order. Review of facility policy Monthly Drug Regimen Review, revised 7/2019, revealed: .To promote the safe and effective use of medications for all residents of the Quyanna Care Center, while minimizing the risks for adverse events associated with treatment . Ongoing medication monitoring shall involve a collaborative approach between the medical provider, pharmacist, the patient, the patient's family, and all the caregivers with QCC .

47929 Based on record review, and interview the facility failed to ensure baseline care plans were initiated within 48 hours of admission for 2 residents (#'s 16 and 17), out of a census of 17. This failed practice placed the residents at risk for not receiving necessary care and services. Findings: Resident #16 Record review on 6/5-9/23 revealed Resident #16 was admitted to the facility on [DATE] with diagnoses that included a history of falls, neurogenic bladder (a urinary dysfunction in which the bladder does not empty properly), osteopenia (a condition of below normal mineralized bone), dementia (a decline in cognitive abilities), psychiatric disorder, and a history of above the left knee amputation. Review of Resident #16's comprehensive care plan, revealed it was initiated on 2/8/23, 22 days after admission. During an interview on 6/7/23 at 3:33 PM, the Director of Nursing (DON) confirmed Resident #16's care plan was initiated on 2/8/23. She stated the care plan should have been created within 48 hours of admission to the facility. Resident #17 Record review on 6/5-9/23, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses that included dementia (a decline in cognitive abilities) and coronary artery disease (reduction of blood flow to the heart muscle). Review of Resident #17's comprehensive care plan, revealed it was initiated on 4/4/23, 26 days after admission. During an interview on 6/7/23 3:42 PM, the Minimum Data Set (MDS) Coordinator stated the care plan was created on 4/4/23. She confirmed the baseline care plan should have been established within 48 hours of admission to the facility.

Based on record review, observation and interview, the facility failed to ensure nursing staff were provided the appropriate competencies and skill sets to provide nursing care and related services to 3 residents (#'s 3, 11, and 16) out of census of 17 residents. Specifically, the facility failed to ensure: 1) staff had training and competency regarding medication administration assessments; and 2) staff were able to interpret medication order abbreviations. These failed practices placed all residents at risk of receiving inaccurate medication dosages. Findings: Medication assessments Review of Resident #11's current [Physician] Orders, revealed: metoprolol (metoprolol succinate 100 mg oral tablet, extended release) 100 mg, Oral, Tab-ER, qAM [every morning] Start date 8/6/21 . No indication/diagnosis included in the order. Review of Resident #11's Vital Signs dated from 5/18/23 to 6/7/23, revealed: In a period of 21 days the Apical Heart Rate was assessed once on 6/6/23. Peripheral Pulse Rates were assesed on 6/6/23, 5/24/23, 5/23/23, 5/21/23. During an interview on 6/7/23 at 9:32 AM, Licensed Nurse (LN) #2 stated the Resident's pulse was not assessed but the blood pressure was assessed prior to the administration of metoprolol. During an interview on 6/7/23 at 2:15 PM, the Director of Nursing (DON) stated Resident #11's apical pulse should have been taken prior to the administration of the medication metoprolol. During an interview on 6/8/23 at 3:20 PM, the Pharmacist stated that assessments of pulse and blood pressure should have been conducted prior to any heart medication administration. Review on 6/12/23 at 10:00 AM of facility's Medication Administration drug guidance, revealed: metoprolol . CONTRAINDICATIONS . Bradycardia (heart rate [pulse] less than 45 to 50 beats per minute [bpm]) . systolic blood pressure less than 90 mmHg . Review of the facility's policy Medication Administration, revised on 6/4/19, revealed: .Apical pulse for all medications that need a pulse . Abbreviations for medication orders Record review from 6/5-9/23 of Resident #3's medication administration record (MAR), revealed the following abbreviations: lisinopril .BIDAP .; amlodipine .BIDAP .: calcium carbonate .TIDANP .: Soduim Chloride .TIDWM . Record review from 6/5-9/23 of Resident #16's MAR, revealed the following abbreviations: docusate .BIDAP . During an interview on 6/7/23 at 1:54 PM, when asked what the abbreviations (BIDAP, TIDWM, TIDANP) on the MAR meant, Licensed Nurses (LNs) #2 and #7 stated they understood the first three letters but did not know what the rest of the abbreviations meant. Both LN's further stated that the abbreviations were not common medication abbreviations. When asked if the facility had a list defining the abbreviations, they did not know and had not received training on the abbreviations. During a subsequent observation and interview on 6/7/23 at 1:57 PM, the Staff Development Coordinator (SDC) found a definition list for the abbreviations in the nurses' horizontal paper holder on the nurse's desk. The SDC stated these abbreviations were specific to their Pillbox Program established by the pharmacy for the electronic medical record. The SDC stated the staff were trained on medication order abbreviations during unit orientation. Review of the facility's document Standard Med[ication] Times revealed: BIDAN (BID [two times a day] am and noon) 9am, 1200 BIDAB (BID am and hs) 9am, 2100 BIDPA (BID am and pm) 9am, 1700 BIDNP (BID noon and pm) 1200, 1700 BIDNB (BID noon and bedtime) 1200, 2100 BIDPB (BID pm and bedtime) 1700, 2100 TIDANP (TID [three times a day] am, noon, pm) 9am, 1200, 1700 TIDAPB (TID am, pm, bedtime) 9a, 1700, 2100 TIDNPB (TID noon, pm, bedtime) 1200, 1700, 2100 QID [four times a day] 9am, 1200, 1700, 2100; A= AM (0900/9am), N=noon (1200/12pm), P=PM (1700/5pm), B=hs (2100/9pm) Review of the facility's Nurse Initial Competency [checklist], revised on 9/2/21, revealed MAR abbreviations or Pillbox Program training was not listed.

Based on record review, observation and interview, the facility failed to ensure medication order dosing was clear and accurate for 1 resident (#11) out of 8 sampled residents. Specifically, the facility failed to accurately document the dosage of an antipsychotic medication in the physician's order. This failed practice had the potential to place the resident at risk for adverse medication outcomes related to receiving more or less than the intended/ordered dose. Findings: Record review on 6/5-9/23 revealed Resident #11 was admitted to the facility with a diagnosis that included dementia (decline in cognitive abilities) with behavioral symptoms. Review of Resident #11's current [Physician] Orders, revealed: Aripiprazole (Abilify) 10 mg, Oral, Tab, qAM [every morning], Start date 6/6/23, Special Instruction: Use 5 mg half tab from pill bottle. Aripiprazole (Aripiprazole 5 mg oral tablet) 5 mg, Oral, Tab, HS [at night], Start date 5/19/23. During an interview with concurrent observation on 6/7/23 at 9:32 AM, when asked what the morning dose of Abilify was, Licensed Nurse (LN) #2 stated 15 mg. LN #2 showed this surveyor that a 10 mg tablet was in Resident #11's blister pack (a prepackaged medication envelope prepared by the pharmacy with scheduled medications) and a 5 mg Abilify tablet was in a separate bottle labeled for Resident #11. When asked if the dose in the order was clear, LN #2 did not comment. During an interview with concurrent record review of the Abilify order on 6/7/23 at 2:15 PM, the Director of Nursing and the Staff Development Coordinator agreed the order was confusing. Review of Resident #11's Medication Administration Record (MAR), dated 6/5-7/23, revealed: 6/6/23 10 mg Aripiprazole (Abilify) was given at 7:27 AM, and 10 mg of Aripiprazole (Abilify) was given at 7:35 AM [a total dose of 20 mg] . 6/7/23 15 mg Aripiprazole (Abilify) was given at 8:14 AM. During an interview on 6/14/23 at 1:15 PM, Psychiatrist #1 stated Resident #11 should have gotten a total daily dose of 15 mg Abilify in the morning. The Psychiatrist further stated that the nurses put in the medication orders and agreed there was a concern with the documented orders. Review of facility policy Medication Dispensing, revised 1/2017, revealed: . The Pharmacy Department shall provide all acute, as needed, and over-the-counter medication, as requested by QCC [Quyanna Care Center] Nursing Staff . Review of facility policy Monthly Drug Regimen Review, revised 7/2019, revealed: .Ongoing medication monitoring shall involve a collaborative approach between the medical provider, pharmacist, .and all the caregivers .

Based on observations, interviews, and record review, the facility failed to ensure that food was stored and prepared in accordance with professional standards for food safety. Specifically, the facility failed to ensure : 1) food was stored under proper sanitation and food handling practices in the Long Term Care (LTC) kitchen/pantry;, 2) food was stored under proper sanitation and food handling practices in the main kitchen's walk in refrigerators;, 3) concentrations of sanitizing solution buckets were monitored for the main kitchen;, 4) food was stored off the floor in the main kitchen;, and 5) dry storage can goods were free from dents. These failed practices had the potential of causing or spreading foodborne illness to all residents (census of 16 residents of the facility that received food from the kitchen). Findings: LTC Kitchen/Pantry An observation with concurrent interview on 8/8/22 at 2:14 PM, revealed the following unlabeled and undated items: 1. a plate of spam covered with saranwrap, unlabeled and undated 2. Northwest Dairy Fat Free Milk 64 fl oz opened 8/4/22 at 11:35 AM, expiration date of 8/7/22 3. Three cups of gravy in coffee cups with lids, unlabeled and undated CNA #1 confirmed these items should have been labeled and dated. CNA #1 then gathered these items from the refrigerator and threw them out. An observation with concurrent interview on 8/8/22 at 2:30 PM, of the activity freezer in the pantry room revealed: 1. One-quart sized zip lock bag that had an unknown meat product, unlabeled and undated CNA #7 confirmed this unknown meat as unlabeled and undated. An observation on 8/10/22 at 4:50 PM, revealed the quart sized zip lock bag of unknown meat dated with a date in and date out. Main Kitchen walk-in Refrigerator/ walk-in Vegetable & Milk Refrigerator An observation on 8/8/22 at 2:55 PM, revealed a shelving unit with the following: 1. Large silver tray of reindeer sausages, the bag torn open to air and the elements and missing 1-2 sausages, undated and no thaw date 2. Two 10 lb foster turkeys, undated and no thaw dates 3. Tray of stuffed cooked cabbage, undated During an interview on 8/8/22 at 3:00 PM, Cook #1 stated the turkeys were thawed the day before but did not know about the reindeer sausages or cooked cabbage. An observation on 8/8/22 at 3:10 PM, of the walk-in vegetable and milk refrigerator revealed 30 moldy green peppers at the top and some throughout. During an interview on 8/8/22 at 3:13 PM, the Dietary Manager (DM) stated a walk-through inventory would be performed today. The DM further stated the cooks would not prepare or serve items past their prime. An observation on 8/10/22 at 11:15 AM, revealed the green peppers were no longer in the walk-in vegetable & milk refrigerator and were replaced with red peppers. Sanitation Buckets/3 sink wash method An observation with concurrent interview on 8/8/22 at 3:20 PM, revealed no log for concentration of the sanitation solution monitored. When asked the process for monitoring sanitation buckets, the DM stated the buckets were changed before every meal and the concentration was monitored with the paper strip ever so often. The DM further stated there was no log to track the buckets being monitored. When asked if ECO LABS (a food safety partner) came and performed any monitoring or maintenance on the system, the DM stated ECO LABS had not come to do any on-site maintenance. An observation on 8/8/22 at 3:25 PM, revealed 3 different types of monitoring strips being used to test the chemical concentration of the sanitation buckets and the sanitizing sink of the 3-sink method. 1. Hydrion qt 40 strips, no expiration date 2. QAC paper (yellow), no expiration date 3. QAC QR strips, expiration date of June 2022 During an interview on 8/8/22 at 3:26 PM, the DM stated that the QAC QR strips were used mostly to test the concentrations. An observation on 8/10/22 at 11:20 AM, revealed Cook #2 prepared a new sanitation bucket and used the Hydrion qt 40 strips. No date was indicated on package. During an interview/phone call on 8/19/22 at 9:25 AM, the ECO LAB Representative stated that he/she was new to the accounts and did not know the last time an on-site visit was completed. He/she continued to say that the QT 40's should only be used and would get back to this surveyor regarding expiration dates. The ECO LAB Representative further stated that education and training would be performed at next on-site visit. Main Kitchen Walk-In Freezer An observation with concurrent interview on 8/8/22 at 3:40 PM, revealed 6 boxes of frozen goods stacked on the floor. The DM stated he/she educated staff about not stacking things on the floor and then they turned around later and did it anyway. Dry good storage An observation with concurrent interview on 8/8/22 at 3:45 PM, of the dry good storage room revealed the following dented can goods: 1. One can- 50 oz tomato with tomato pieces 2. Two cans- 50 oz cream of chicken, dented at the seams 3. Three cans- 5 lb oyster clam sauce, dented at the seams The DM stated there was no policy for dented cans, but that they would not be used if the can bulged at the top. Record review of facility procedure Nutrition Services Infection Control Guidelines, date reviewed &/or revised 1/20/22, revealed . 2. Orientation and in-service education . iii. Sources of foodborne illness . vi. Techniques to minimize sanitation hazards during handling, storing, preparation, and serving of food . 9. Food preparation . i. All kitchenware and food contact surfaces used in the preparation and/or serving of food and drink are cleaned and sanitized before use and cleaned after each meal preparation . Procedure 11. All items not in their original package are covered, dated, and labeled as to contents . Equipment 3. No containers of food are stored on the floor of the refrigerator or freezer . No policy for dented cans was provided by the end of survey. Review of FoodSafety.gov on 8/18/22 at 2:19 PM, from https://www.foodsafety.gov/people-at-risk, revealed . Do not buy or use damaged, swollen, rusted, or dented cans.

Based on interview, observations, and record reviews the facility failed to ensure one resident's right to self-determination was promoted or facilitated. Specifically, the facility placed 1 resident (#67), out 11 sampled residents, on unnecessary isolation. This failed practice denied the resident the choice to get out of bed and/or leave his/her room and a choice in participating in dining and/or activities with peers and placed the resident at risk for loneliness and/or isolation. Findings: During an interview on 8/08/22 at 4:56 PM, Resident #67 was lying in bed with the TV on. The Resident stated he/she had not eaten in two days and was hungry, the Resident was unable to reach the call light that was laying on the floor. The Resident stated, I hope someone brings me some hotcakes. The Resident stated he/she would need help getting out of bed. During the interview, the Resident thought it was the month of May. During the dinner observation, on 8/08/22 at 6:00 PM, Resident #67 did not come out of his/her room for the evening meal. Random observations during the survey from 8/08-8/12/22 revealed Resident #67 remained in bed in his/her room during the survey. The Resident was not observed engaging in meals in the common area and/or engaging in activities with other residents. The door to the Resident's room was often open, and the Resident could be seen lying in bed with the TV on. During an interview on 8/10/22 at 10:09 am, the Director of Nursing (DON) stated Resident #67 just had his/her 2nd COVID-19 booster upon admission and was on isolation for 2 weeks. When asked about the Resident being isolated to his/her room, DON stated Resident #67 and all other residents would have to wear a mask if he/she were to go into the common area. The DON stated Resident #67 had a negative COVID test prior to admission and had had no symptoms of COVID-19. A review of Resident #67's clinical record conducted on 8/11-12/22 revealed: Resident #67 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #67's immunizations revealed he/she had had received Pfizer Covid-19 vaccine 1/14/21, 2/5/21, and a booster on 11/11/21. The Resident had received his/her 2nd booster after his/her admission on 8/02/22. During an observation on 8/10/22 at 9:00 AM Resident #67 was in his/her room in bed. Certified Nursing Assistant (CNA) # 7 raised the head of the Resident's bed and prepared to give the Resident breakfast. The CNA stated the Resident was not currently getting up as he/she had just gotten his/ her covid vaccine. The CNA was not wearing any PPE (personal protective equipment) equipment. During an interview on 8/11/22 at 11:59 AM, this surveyor asked CNA #s 2 and 6 why Resident #67 had to stay in his/her room. CNA #6 was unsure; however, CNA #2 stated the Resident had just received his/her COVID vaccination. When asked how staff know how to provide care to the Resident, CNA #2 stated the information was in the kiosk where CNAs charted care. When asked if Resident #67 ever got out of bed, CNA #2 stated the Resident had gotten up for showers a couple times in the evening. During an interview with the Department of Health Nurse ([NAME]) on 8/15/22 at 1:00 PM, when asked about being up to date with COVID vaccinations and the need for quarantine and/or isolation after a booster, the [NAME] stated the recipient was considered fully vaccinated immediately after receiving a booster. According to the CDC guidelines, updated on 2/02/22, reviewed on 08/11/22 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.htmlt .In general, quarantine is not needed for asymptomatic patients who are up to date with all recommended COVID-19 vaccine doses or who have recovered from [CONDITION(S)]-CoV-2 infection in the prior 90 days; potential exceptions are described in the guidance. However, some of these patients should still be tested as described in the testing section of the guidance. A test-based strategy and (if available) consultation with infectious disease experts is now recommended for determining the duration of Transmission-Based Precautions for patients with [CONDITION(S)]-CoV-2 infection who are moderately to severely immunocompromised . Review of the CDC guidance When Are You Up to Date?, accessed 8/15/22, at https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html revealed You are up to date with your COVID-19 vaccines when you have received all does on the primary series and all boosters recommended for you, when eligible. Up to Date Immediately after getting all boosters recommended for you. Review on 8/11/22 of the facility policy, Resident Safety during COVID19, dated 3/16/21 revealed U. New QCC [Quyanna Care Center] admissions-QCC will screen, test, and Quarantine per current CMS and CDC guidelines all new admissions must complete a quarantine that follows all current CMS and CDC guidelines for admission before moving to the facility. NSHC [Norton Sound Health Center] will coordinate for all new admissions and the ACUTE CARE center may be used. Review on of the Quyanna Care Center Patient Bill of Rights, undated, revealed As a resident at Q.C.C. you have the RIGHT to: Participate in social, religious, and community activities of your choosing so long as they don't interfere with the rights of others and Be free of unnecessary or excessive medications or treatment; and refuse treatment to the extent permitted by law.

Based on interview and record review the facility failed to ensure a high-risk medication was coded accurately in the Minimum Data Set (MDS-a federally required assessment) for 1 (#8) out of 6 residents reviewed for high-risk medications. This failed practice placed the Resident at risk for ineffective care planning. Findings: During an interview on 8/08/22 at 9:23 AM Resident #8 stated I have problems with my heart. Record review on 8/11/22 revealed Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS (Minimum Data Set) quarterly assessment, dated 6/26/22, revealed N0410. Medications Received .E. Anticoagulant (e.g., [MEDICATION(S)], [MEDICATION(S)], or low-molecular weight [MEDICATION(S)]), the Resident was coded 0 for not receiving the medication in the 7-day assessment period. Review of Resident #8's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . 1 tablet by mouth twice daily. Review on 8/11/22, of the 2022 Lippincott Drug Guide for Nurses, revealed [MEDICATION(S)] ([MEDICATION(S)]) class Anticoagulant, direct [MEDICATION(S)] inhibitor. Further review of the drug guide revealed, adverse effects included bleeding, excessive bruising, and rebound thrombotic (clots) events when stopped suddenly. During an interview on 8/15/22 at 10:25 AM, Pharmacist #1 stated [MEDICATION(S)] was considered an anticoagulant.

Based on observation, interviews, and record reviews the facility failed to ensure the baseline care plan, initiated for 1 newly admitted resident (#67), out of 1 new admission, included care areas specific to the resident's current care. This failed practice placed the resident at risk for not receiving necessary care and services and denied staff information needed for continuity of care. Findings: During an observation on 8/08/22 at 4:46 PM Resident #67 was observed in bed, the Resident's right hand was held in a claw like shape. During an interview with the Resident at the same time, the Resident stated he/she could not get out of bed without assistance, and he/she was unable to use his/her hand. During an interview on 8/11/22 at 11:30 PM, when asked about Resident #67 being on isolation or quarantine, the Hospital Director of Nursing Services (DNS)/ Infection Preventionist (IP) and the Director of Nursing (DON) stated new residents were placed on isolation. During an interview on 8/11/22 at 11:59 AM with Certified Nursing Assistance (CNA) #2 and #6 when asked how staff knew how to take care of Resident #67, CNA #6 said the interim care plan was in the CNA charting program. CNA #6 stated he/she was unable to pull it up at that time because the system was down. The CNA stated the Resident has only gotten out of bed for showers and had to stay in his/her room on isolation. CNA #6 explained the Resident #6 had recently received a COVID vaccination. Record review on 8/11/22 of the medical record, revealed Resident #67 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Baseline Care Plan LTC, initiated on 8/03/33, revealed resident concerns included: Contracture [hand deformity] of right hand . Review of the CNA baseline care plan, located in the care tracker revealed, Recreation Therapy Encourage resident to participate in bingo and other social activities. Restorative Therapy Passive range into hip flexion/ extension hip abduction/ adduction knee flexion/ extension and ankle planter flexion, dorsiflexion. Each to be completed x [times] 25, 3-5 x a week. There was no information in the care plan about the Resident's two-week isolation/quarantine or the plan for the contracture to the right hand.

Based on interview, record review, and policy review, the facility failed to implement written policies that prohibit abuse and neglect to ensure the safety of 1 resident, (#9) out of 11 sampled residents. Specifically, 1) the facility failed to report, take measures to investigate an allegation of abuse and protect the resident during the investigation. These failed practices placed the resident at risk for immediate jeopardy of potential psychosocial harm from humiliation, neglect, and self described fear in response to the event. This immediate jeopardy to the resident's well-being was brought to the attention of the facility's administration on (MONTH) 2, 2019 at 2:24 pm, at which time the facility was notified of the deficient practice and high risk to the patient. The immediacy was removed by the facility on (MONTH) 3, 2019 at 9:00 am. Additionally, 2) the facility failed to ensure reference checks were completed for 3 direct care staff working in the facility. This failed practice placed all residents of the facility in immediate jeopardy for potential abuse. 1) Investigation of Allegations of Abuse Record review from 4/19-5/3/19 of the electronic medical record revealed Resident # 9 had [DIAGNOSES REDACTED]. During an interview on 5/1/19 at 8/49 am, Resident #9 told Surveyor #1, a nurse that worked here was mean to him/her, grabbed the buzzer (call light) and scratched him/her while pulling it from his/her hand. The Resident stated the nurse was working today and wearing a blue suit (uniform). The Resident stated he/she had notified the Social Service Associate (SSA) about the incident. Resident #9 told the Surveyor he/she was scared of the nurse, and although he/she tried to be nice now, the Resident was afraid the nurse would relapse. During an interview with Surveyor #2 on 5/2/19 at 10:50 am, Resident #9 reported that about a month before he/she had used the call light several times at night for help to use the bathroom. A certified nurse assistant (CNA) came in running fast, grabbed the buzzer from my hand, put it out of my reach, and said 'you shouldn't be doing that (Resident #9). I told (the CNA) I needed it (the call light) because I have a bad heart. (The CNA) told me to 'shut up'. I told him/her that (he/she) should not treat Resident's like that, and (the CNA) said 'shut up' again. When asked the CNA's name, Resident #9 stated that he/she could not recall, but described the CNA's physical appearance in detail. The Resident stated the CNA always wears pink or blue, and was working today, I don't want to work with (him/her) anymore. During an interview on 5/2/19 at 11:13 am, while interviewing SSA. Resident #9 came to find the Surveyor and pointed out the staff member. Resident #9 pointed to CNA #1 and stated, It was (him/her). During the interview on 5/2/19 at 11:13 am, the SSA stated that Resident #9 had complained about CNA #1 when the incident occurred. The SSA further stated that he/she would provide follow up information. On 5/2/19 at 11:25 am, review of a form titled, QCC Grievance Form, dated 4/15/19, provided by the SSA and the Minimum Set (MDS) Coordinator revealed (A) . always wears pink or blue, after (he/she) had hit (his/her) buzzer 3 times to use the toilet, came in real fast and take away my buzzer real hard and take it away from me. Further review of the documentation on the form had no evidence of an investigation and or evidence of resident protection during the investigation. Record review on 5/2/19 at 12:00 pm of a nursing note dated 4/15/19 by Licensed Nurse (LN) #1 revealed, Resident (#9) had stated earlier that someone was ripping call light away from her during the night .also (he/she) heard voices .(behavioral health services) was called . During an interview on 5/2/19 at 11:44 am with the MDS Coordinator and Director of Nursing (DON, by telephone), the DON stated that the allegation was not followed up on because Resident #9 had a history of [REDACTED].#9 had a mental health diagnosis. The MDS Coordinator and the DON stated that Resident #9 used the call bell excessively and stated that CNA in question didn't work that shift. When asked if having a mental health condition could make the Resident more vulnerable, the MDS Coordinator and the DON agreed that it could. The MDS Coordinator and DON stated the incident was discussed at the morning team meeting, they talked to the Resident, sent him/her for a psychiatric consult, and considered the process closed since the Resident never brought it up again. They admitted that there was no documentation of an investigation, the discussion, reporting, or the follow up. During an interview on 5/2/19 at 12:29 pm, the MDS Coordinator that Resident #9 had also reported the incident to him/her on the morning of 4/15/19 when he/she was looking for the SSA. Review on 5/2/19 of the staff schedule for the month of (MONTH) revealed that CNA #1 was on the scheduled for the evening shift on 4/14/19. During an interview on 5/2/19 at 1:00 pm, the MDS Coordinator stated that CNAs had been working 8 hour shifts in (MONTH) and evening shift was from 3:00 pm to 11:30 pm. During an interview on 5/2/19 at 2:55 pm, LN #1 stated that Resident #9 had approached him/her the start of his/her shift with a report that a black person had grabbed his/her call light away. LN #1 stated he/she reported this to the oncoming night nurse. Record review on 5/2/19 of CNA documentation of Behaviors in the electronic documentation program Care Tracker revealed no behaviors documented from 4/12/19-5/2/19. Record review on 5/2/19 of Resident #9's MDS quarterly assessment, dated 12/11/18, and an annual assessment, dated 3/10/19, revealed that Resident #9 had not coded as having hallucinations or delusions on either assessment, and had not triggered to be care planned for behavior issues. Record review on 5/2/19 of Resident #9's care plan last reviewed 3/17/19 revealed no problem statements regarding behaviors. Record review on 5/3/19 at 9:30 am of additional documentation that was dated from 06/2018 through 04/2019, provided by the facility of Resident #9's previous allegations revealed that the facility had followed through on investigating and reporting the alleged incidents according to policy. Record review on 5/3/19 at 10:01 am of the Behavioral Health Clinician's note revealed that Resident #9 had a history of [REDACTED]. Review on 5/2/19 of the facility policy, revised 3/8/17, titled, Abuse Prevention Program and Responses to Suspected Abuse, Neglect, Exploitation, and/or Misappropriation of Resident Property revealed .any use or oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident . and mental abuse as including but not limited to, humiliation, harassment, and threats of punishment or deprivation., and neglect failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .examples include .Failure or refusal to provide a service for the purpose of punishing or disciplining a resident (Unless withholding the service is being used as part of an integrated behavioral management program that is documented in the resident's Behavior Care Plan . Reporting is required by any employee who has knowledge of the abuse or neglect of a resident . the process was as follows, Conducts an immediate investigation (within one hour, or sooner . and Documents the review and investigation on the Report of Suspected Abuse/Neglect form . 1) Staff Reference Checks at Hire During a review of staff records on 5/2/19, there was no evidence reference checks were been completed for CNA #s 2; 3; and 4. During an interview on 5/2/19 at 9:14 am, the Human Resource (HR) staff stated that the former long-term care manager did not do the reference checks prior to the employment of these staff members. The HR staff stated, the facility had corrected the process, but had not gone back and completed the reference checks on the three CNAs. Further Review of the facility policy, titled Abuse Prevention Program and Response to Suspected Abuse, Neglect, Exploitation and/or Misappropriation of Resident Property, revised 3/8/17, III. Prevention Process .All staff will .have employment references verified before hire. .

Based on record review, interview, and policy review, the facility failed to: 1) Maintain evidence , allegation of misstreatment and denial of services was investigated and 2) protect the resident during the investigation for, 1 resident (#9) out of 11 sampled residents. These failed practices placed the resident at risk for immediate jeopardy of potential psychosocial harm from humiliation, neglect, and self described fear in response to the event. Findings: This immediate jeopardy to the resident's well-being was brought to the attention of the facility's administration on (MONTH) 2, 2019 at 2:24 pm, at which time the facility was notified of the deficient practice and the risk to the patient. The immediacy was removed by the facility on (MONTH) 3, 2019 at 9:00 am. Record review from 4/29-5/3/19 of the electronic medical record revealed Resident # 9 had [DIAGNOSES REDACTED]. During an interview on 5/1/19 at 8:49 am, Resident #9 told Surveyor #1, a nurse that worked here was mean to him/her, grabbed the buzzer (call light) and scratched him/her while pulling it from his/her hand. The Resident stated the nurse was working today and wearing a blue suit (uniform). The Resident stated he/she had notified the Social Service Associate (SSA) about the incident. Resident #9 stated he/she was scared of the nurse, and although he/she tries to be nice now, the Resident is afraid the nurse will relapse. During an interview with Surveyor #2 on 5/2/19 at 10:50 am, Resident #9 reported that about a month before he/she had used the call light several times at night for help to use the bathroom. A certified nurse assistant (CNA) came in running fast, grabbed the buzzer from my hand, put it out of my reach, and said 'you shouldn't be doing that (Resident #9). I told (the CNA) I needed it (the call light) because I have a bad heart. (The CNA) told me to 'shut up'. I told him/her that she should not treat Resident's like that, and she said 'shut up' again. When asked the CNA's name, Resident #9 stated that he/she could not recall, but described the CNA's physical appearance in detail. The Resident stated the CNA always wears pink or blue, and is working today, I don't want to work with (him/her) anymore. During an interview on 5/2/19 at 11:13 am, while interviewing SSA. Resident #9 came to find the Surveyor and point out the staff member. Resident #9 pointed to CNA #1 and stated, It was (him/her). During the interview on 5/2/19 at 11:13 am, the SSA stated that Resident #9 had complained about CNA #1 when the incident occurred. The SSA further stated that he/she would provide follow up information. On 5/2/19 at 11:25 am, review of a form titled, QCC Grievance Form, dated 4/15/19, provided by the SSA and the Minimum Set (MDS) Coordinator revealed (A) . always wears pink or blue, after (he/she) had hit (his/her) buzzer 3 times to use the toilet, came in real fast and take away my buzzer real hard and take it away from me. Further review of the documentation on the form had no evidence of an investigation and or evidence of resident protection during the investigation. Record review on 5/2/19 at 12:00 pm of a nursing note dated 4/15/19 by Licensed Nurse (LN) #1 revealed, Resident (#9) had stated earlier that someone was ripping call light away from her during the night .also (he/she) heard voices .(behavioral health services) was called . During an interview on 5/2/19 at 11:44 am with the MDS Coordinator and Director of Nursing (DON, by telephone), the DON stated that the allegation was not followed up on because Resident #9 had a history of [REDACTED].#9 had a mental health diagnosis. The MDS Coordinator and the DON stated that Resident #9 used the call light excessively and stated that the CNA in question didn't work the night shift. When asked if having a mental health condition could make the Resident more vulnerable, the MDS Coordinator and the DON agreed that it could. The MDS Coordinator stated that Resident #9 had previously been on medication and it had helped. The MDS Coordinator and DON stated the incident was discussed at the morning team meeting, they talked to the Resident, sent him/her for a psychiatric consult, and considered the process closed since the Resident never brought it up again. They stated there was no documentation of an investigation, the discussion, reporting, or the follow up. During an interview on 5/2/19 at 12:29 pm, the MDS Coordinator stated that Resident #9 had also reported the incident to him/her on the morning of 4/15/19 when the Resident was looking for the SSA. Review on 5/2/19 of the staff schedule for the month of (MONTH) revealed that CNA #1 was on the scheduled for the evening shift on 4/14/19. During an interview on 5/2/19 at 1:00 pm the MDS Coordinator stated that CNAs had been working 8 hour shifts in (MONTH) and evening shift was from 3:00 pm to 11:30 pm. During an interview on 5/2/19 at 2:55 pm, LN #1 stated that Resident #9 had approached him/her the start of his/her shift with a report that a black person had grabbed his/her call light away. LN #1 stated he/she reported this to the oncoming night nurse. Record review on 5/2/19 of CNA documentation of Behaviors in the electronic documentation program Care Tracker revealed no behaviors documented from 4/12/19-5/2/19. Record review on 5/2/19 of Resident #9's MDS quarterly assessment, dated 12/11/18, and an annual assessment, dated 3/10/19, revealed that Resident #9 had not coded as having hallucinations or delusions on either assessment, and had not triggered to be care planned for behavior issues. Record review on 5/2/19 of Resident #9's care plan last reviewed 3/17/19 revealed no problem statements regarding behaviors. Record review on 5/3/19 at 9:30 am of additional documentation that was dated from 06/2018 through 04/2019, provided by the facility of Resident #9's previous allegations revealed that the facility had followed through on investigating and reporting the alleged incidents according to policy. Record review on 5/3/19 at 10:01 am of the Behavioral Health Clinician's note revealed that Resident #9 had a history of [REDACTED]. Review on 5/2/19 of the facility policy, revised 3/8/17, titled, Abuse Prevention Program and Responses to Suspected Abuse, Neglect, Exploitation, and/or Misappropriation of Resident Property revealed .any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident . and mental abuse was defined as including but not limited to, humiliation, harassment, and threats of punishment or deprivation., and neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . examples include . Failure or refusal to provide a service for the purpose of punishing or disciplining a resident (Unless withholding the service is being used as part of an integrated behavioral management program that is documented in the resident's Behavior Care Plan . Reporting is required by any employee who has knowledge of the abuse or neglect of a resident . the process was as follows, Conducts an immediate investigation (within one hour, or sooner . and Documents the review and investigation on the Report of Suspected Abuse/Neglect form .

Based on record review and interview the facility failed to provide services in a timely manner for 1 sampled Resident (#5), out of 7 sampled residents. This failed practice placed the resident at risk for physical harm from not receiving necessary services. Findings: Resident #5 Record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally required assessment tool) revealed Resident #5 required extensive assistance with transfer, dressing, eating, toileting, personal hygiene and bathing. Record review on 10/29-30/18 revealed Quyanna Care Center admission orders [REDACTED]. Further review revealed there were no lab results to include sodium level until 10/12/18, 8 days after admission (10/4/18). Review of nurses' notes, dated 10/12/18 at 7:45 pm revealed CBC, BMP (and) UA completed on this day. MD notified of abnormal lab results - Sodium 120, Chloride 90 . Awaiting new order. MD stated he would review labs and would F/U (follow up) (with) this nurse in am. Negative results this time on UA. Review of lab results, dated 10/12/18, revealed Sodium 120 mmol/L (millimoles per liter) (mmol and mEq (milliequivalent) are the same measurement when measuring electrolytes.) Normal Sodium levels have a range between 135 and 145 mEq or mmol/L. Further review of nurses' notes, dated 10/12/18 at 10:00 pm revealed Dr.(NAME)returned call et (and) new order received to send Resident to E/R (emergency room ) R/T (related to) abnormal lab results. POA (power of attorney) .aware et (and) in agreement. Review of physician orders, dated 10/12/18 at 10:00 pm, revealed Send to ER R/T abnormal labs. During an interview on 10/30/18 at 4:00 pm, when asked about the procedure for processing physician orders, the Director of Nursing (DON) stated that there was a system in place. This included the primary licensed nurse as the first check; the second check is the night charge nurse (this check is done with a 24 hour chart check - where the licensed nurse ensured the physician orders [REDACTED]. During the interview, the DON stated the omission of the physician's lab orders on admission could be seen as a form of neglect. Review of the facility's Abuse Prevention Program And Response to Suspected Abuse and/or Neglect, undated, revealed, Neglect is defined as failure to provide goods or services necessary to avoid physical harm Neglect occurs on an individual basis when a resident does not receive care in one or more areas .examples include: 1. Failure to provide adequate nutrition and fluids 2. Failure to take precautionary measures, as ordered, to protect the health and safety of the resident .