Every finding on record at Searhc Sitka Long Term Care

Based on observation, interview, and record review, the facility failed to ensure hot foods were monitored to confirm safe hot-holding temperatures were maintained prior to plating and meal service for 14 residents who received food from the kitchen. Specifically, staff plated and served hot food items without conducting temperature checks before service. This deficient practice had the potential to result in residents receiving food held below safe temperatures, increasing the risk of foodborne illness and potentially negatively affecting nutritional intake, and potential weight loss. During an observation on 4/29/26 at 11:40 AM, kitchen staff plated hot foods such as soup, chicken, mashed potatoes, broccoli, broccoli puree, poultry gravy, rice, and hamburger. Further observation revealed kitchen staff did not check food temperatures at the point of plating and tray line service. During an interview on 4/29/26 at 12:05 PM, the Lead [NAME] (LC) stated that food temperatures were usually checked directly before plating. The LC further confirmed that kitchen staff did not check food temperatures before plating that day. Review of the facility document Traditional Service Trayline Temperature Log, dated 4/29/26, revealed the following foods were temperature checked at 11:00 AM: Soup of the Day - 196 degrees Fahrenheit; Hot Entree #2 - 180 degrees Fahrenheit; Mashed Potatoes - 183 degrees Fahrenheit; [NAME] - 184 degrees Fahrenheit; Poultry Gravy - 189 degrees Fahrenheit; Vegetable #1 - 167 degrees Fahrenheit; Chopped Vegetable - 167 degrees Fahrenheit; and Pureed Vegetable - 167 degrees Fahrenheit. Further review of the Trayline Temperature Log, dated 4/29/26, revealed no additional documentation of temperatures from 11:01 AM to the time of plating at 11:40 AM. During an interview on 4/29/26 at 1:00 PM, the Kitchen Manager (KM) stated: We prepare the food at eleven o'clock, we put it in the holder, we check the temperature, we put it on the steam table. When asked whether additional temperature checks should occur prior to plating, KM stated: Normally, because we're not holding it for more than two hours, that initial final cooking temperature check that they do. that's sufficient. Review of the facility policy SAFE Standards and Procedures - Service and Delivery Food Safety, last revised 1/31/24, revealed: .At least every 2 hours, check TCS [Time/Temperature Control for Safety] food temperatures to make sure they are held at the correct temperatures before loading/transporting them from the production area to the event, before serving them, and during display or service periods. Check hot foods regularly to make sure they're held at or above 140 degrees F [Fahrenheit]. 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: At 57 C [Celsius] (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 record review, observation and interview, the facility failed to revise the comprehensive care plans to include medication self-administration for two residents (#s 3 and 11), out of 5 residents reviewed for medication self-administration. This failed practice placed the residents at risk for not receiving appropriate care and services. Findings: Resident #3 Record review on 4/7-10/25 revealed Resident #3 was admitted to the facility with diagnoses that included Chronic Kidney Disease (a long-term condition where the kidneys do not work effectively), Anemia (a condition marked by a deficiency of red blood cells), and Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain). Record review on 4/8/25 of Resident #3's medication orders found: Clotrimazole External Cream 1% . Apply to affected area topically two times a day. An observation on 4/8/25 at 9:40 AM, LN #4 asked Resident #3 if he/she had applied medical cream to his/her groin. Resident #3 stated that he/she had done it earlier in the morning. LN #4 then administered Resident #3's PO (by mouth) medications and exited his/her room. During an interview on 4/8/25 at 9:40 AM, when asked if Resident #3 was assessed for medication self-administration capability, Licensed Nurse (LN) #4 stated: We let [him/her] apply the medication on [his/her] own, because it is in a private area, and [he/she] would rather do it [himself/herself]. Review of Resident #3's care plan on 4/7/25 revealed no plan for medication self-administration. Resident #11 Record review on 4/7-10/25 revealed Resident #11 was admitted to the facility with diagnoses that included Vascular Dementia (a condition caused by reduced blood flow to the brain, resulting in cognitive impairment) and Asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing). Record review on 4/7/25 of Resident #11's medication orders revealed: Budesonide/Formoterol Fumarate (Symbicort 160-4.5 Mcg Inhaler) 2 puff IH BIDNP [inhaled twice daily at noon and nightly] . Problem . Pulmonary emphysema. An observation on 4/8/25 at 9:25 AM, revealed LN #2 gave Resident #11 a Budesonide/Formoterol Fumarate (medication used to treat Asthma) inhaler. Resident #11 self-administered the medication, taking three puffs in quick succession, without holding his/her breath in between puffs. LN #2 then took the inhaler away and stated: You were only supposed to take two puffs. LN #2 then exited the resident's room without having Resident #11 rinse his/her mouth with water. During an interview on 4/8/25 at 9:35 AM, when asked if Resident #11 was assessed for medication self-administration capability, LN #2 stated: Yes, [he/she] self-administers the inhaler. Review of Resident #11's care plan on 4/7/25 revealed no plan for medication self-administration. During an interview on 4/9/25 at 1:20 PM, when asked if a resident's care plan should include a plan for self-administering medications if they have been approved to self-administer, the Minimum Data Set (MDS) Nurse stated, Yes.

Based on record review, observation and interview, the facility failed ensure self-administration of medication was clinically appropriate for one resident (#11), out of five residents reviewed for medication self-administration. Specifically, the facility failed to accurately assess the resident's capability for appropriateness of administering an inhaler. This failed practice had the potential to place the resident at risk of receiving incorrect medication dosages and subtherapeutic treatment of inhalants for medical conditions. Findings: Record review on 4/7-10/25 revealed Resident #11 was admitted to the facility with diagnoses that included Vascular Dementia (a condition caused by reduced blood flow to the brain, resulting in cognitive impairment) and Asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing). Record review on 4/7/25 of Resident #11's Minimum Data Set (MDS - a standardized assessment of a resident's health, function, and preferences), dated 1/28/25, revealed a Brief Interview for Mental Status (BIMS - a numerical score used to assess a person's cognitive functioning) score of 12 (8-12: Indicates moderate cognitive impairment). Review of Resident #11's medication orders revealed: Budesonide/Formoterol Fumarate (Symbicort 160-4.5 Mcg Inhaler - medication used to treat Asthma) 2 puff IH BIDNP [inhaled twice daily at noon and nightly] . Problem . Pulmonary emphysema [a chronic lung disease that permanently damages the lung's air sacs] (the resident had no active diagnosis for pulmonary emphysema). Medication Administration: An observation on 4/8/25 at 9:25 AM, revealed Licensed Nurse (LN) #2 gave Resident #11 a Budesonide/Formoterol Fumarate inhaler. Resident #11 self-administered the medication, taking three puffs in quick succession, without holding his/her breath in between puffs. LN #2 then took the inhaler away and stated: You were only supposed to take two puffs. LN #2 then exited the resident's room without having Resident #11 rinse his/her mouth with water. During an interview on 4/8/25 at 9:35 AM, when asked if Resident #11 was assessed for medication self-administration capability, LN #2 stated: Yes, [he/she] self-administers the inhaler, however I'm not sure if there was an assessment completed. Assessments for Self-Administration of Medications: Review of Resident #11's Medication Self-Administration Safety Screen, dated 11/3/22, revealed: . The resident can correctly read label and/or identify each medication: unable . The resident can correctly state what each medication is for: unable . The resident can correctly state the time/frequency of medication are to be taken: unable . The resident can correctly state the correct dosage/quantity for each administration: unable . The resident can correctly administer inhalant medications according to proper procedure: unable . Review of Resident #11's Observation Tool for Self-Administration, dated 3/16/25, revealed a scoring matrix to assess whether a resident was appropriate to learn to self- administer their own medications. Further review revealed Resident #11 scored a 1 on Cognitive Skills, which indicated: Follows simple directions with 1 step prompting and encouragement. Further review revealed the rest of the assessment scored Resident #11 at mostly the highest score for: - Fine Motor Coordination: 3 - Able to pick up and/or manipulate small objects - Feeding: 3 - Fully independent - Behaviors: 3 - Reacts typically to daily life events - Vision: 3 - Normal vision with/without glasses - Communication: 3 - Communicates clearly - Colors: 3 - Constantly identifies and states color - Shapes: 3 - Constantly identifies shapes - Numbers: 3 - Understands number concepts and identifies and writes numbers - Time: 3 - Ability to tell time by clock or watch - Letters/Name: 3 - Writes name - Medication: 3 - Always takes medication well - Medication Recognition Side Effects: 1 - Able to say names of current medications, but not able to identify specific pill bottles or medication card - Side Effects: 0 - Unable to identify/understand possible side effects of current medications. From this 3/16/25 assessment the facility gave Resident #11 an . Average Score 2.3 . If Average Score is . Greater than 1.7 - Individual is appropriate to learn to self-administer to the full extent of his/her ability. Further assessment of this Observation Tool for Self-Administration had no documentation of witnessing Resident #11 manipulating his/her inhaler for appropriate use and administration of correct dosages of medication. The assessment also did not list out any medications Resident #11 was clinically cleared to self-administer. Review of the Symbicort Inhaler Quick Guide accessed at https://www.symbicorttouchpoints.com/content/dam/physician-services/us/526-rwd-symbicort-hcp/pdf/03_using_the_symbicort_inhaler.pdf, accessed on 4/10/25, revealed: . 3. Breathe out fully, then place the mouthpiece into your mouth and close your lips around it. Make sure that the inhaler is upright and that the opening of the mouthpiece is pointing towards the back of your throat. Inhale deeply and slowly while pressing down firmly on the top of the counter on the inhaler. 4. Continue to breathe in and hold your breath for about 10 seconds, or for as long as comfortable. Before you breathe out, release your finger from the top of the counter. Keep the inhaler upright and remove from your mouth. For your second puff, shake the SYMBICORT inhaler again for 5 seconds and repeat steps 3 and 4. After you finish taking SYMBICORT (two puffs), rinse your mouth with water.

Based on record review, observation, and interview, the facility failed to provide adequate supervision to ensure the environment remains as free of accident hazards as is possible for one resident (#16) out of six residents who attended an activity. Specifically, the facility failed to ensure Resident #16 had limited opportunity to access an unsafe equipment for cutting his/her hospital wrist band off during a baking activity. This failed practice placed the resident at risk of self-harm and a potential of harming other residents. Findings: Record review on 4/7-10/25, revealed Resident #16 was admitted to the facility on [DATE] with diagnoses that included Parkinson's (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination) disease with dyskinesia (involuntary movement disorder) and low back pain. Further review revealed Resident #16 was diagnosed with Post-Traumatic Stress Disorder (PTSD) on 3/5/25. Review of Resident #16's Pre-Admission Screening and Resident Review (PASRR) Level 1, dated 11/22/24, revealed: . Functional and Adaptive Needs . Harmful to Self or Others . suicidal ideation/attempt past history . Review of Resident #16's, Brief Interview for Mental Status (BIMS), dated 1/14/25 revealed; . Score: 11, Category: Moderately Impaired [difficulty with cognitive task and may require assistance with activities of daily living] . Mood and Behavior: Review of the Physician Progress Note, dated 2/11/25, revealed: . Depression and PTSD related to military service . I will still place a referral to behavioral health. Review of the Behavior Note, dated 2/20/25, revealed resident stated, they are going to kill me. Review of the Behavior Note, dated 2/21/25, revealed: Resident reporting to staff and other residents during a resident council meeting, 'Somone with a gun was shooting at our building last night and security came to my room and asked if I was alright.' . Attempts to reorientation [Resident #16] was successful with the announcement of BINGO was starting. Review of the Behavior Note, dated 3/4/25, revealed: [Resident #16] requested to lay down in bed. Once resident entered [his/her] room [he/she] began yelling at the female staff members, calling them crude names . Resident transferred to bed and attempted [to] hit a female staff member. The resident's agitation continued to increase even with staff's attempts to calm . Son notified and advised staff to take [him/her] to the ED [emergency room ] if agitations continues . Review of the Behavior Note, dated 3/5/25, revealed Resident #16 grabbed staff wrist and would not let go when asked. Resident #16 was yelling at staff and agitated. Review of the Physician Progress Note, dated 3/6/25, revealed: Chief Complaint: Parkinson's dementia and PTSD with increasing agitation and paranoia . Apparently has a history of 'going into blind rages' related to PTSD. According to [his/her] son . I was asked to see [him/her] today because of multiple daily outbursts of agitation or otherwise inappropriate behavior such as climbing out of [his/her] bed . [he/she] complains of the sitter outside of [his/her] room . [Resident #16] states as far as the food and [his/her] medications 'I feel like it is doing something to me' that staff here is trying to poison [him/her] . Record review on 4/7-10/25, Nurse Note, dated 3/23/25, revealed: . [he/she] became very agitated . grabbing at staff with nails digging into their skin . verbally abusive [with staff] . An observation in the resident dining room on 4/7/25 at 12:40 PM, revealed Resident #16 stated Don't let them take me, they will lock me up. Resident #16 looked over at the Director of Nursing (DON) during his/her statement. Certified Nurse Assistant (CNA) #1 approached Resident #16 and Resident #16 followed CNA #1 and left the area. Review of the Resident #16's care plan, LTC [Long Term Care] (PTSD) Post Traumatic Stress Disorder, dated 3/17/25 at 2:22 PM, revealed: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Give the resident as many choices as possible about care and activities. Monitor every shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report PRN any s/sx [signs and symptoms] of resident posing danger to self and others. [Resident #16] triggers for physical aggression are telling [Resident #16] 'no' without allowing [Resident #16] time to process the reasoning, medications changes. [Resident #16's] behaviors is [are] deescalated by provided phone time with [his/her] family, outings with family, anti-anxiety medication. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Medication: Review on 4/10/25 of the eMAR [electronic medication administration record] Administration Report, revealed on: 4/6/25, .Lorazepam 2mg/Ml Inj 0.25 ML . PRN [as needed] Reason: Agitation Label Comments: DOSE = 0.5MG = 0.25ML. GIVE IF UNABLE TO GIVE PO [by mouth].Lorazepam 0.5 mg tab . dose 0.5mg PO . PRN Reason: Agitation Label Comments: ATTEMPT PO FIRST BEFORE GIVING IM [intramuscular] . no doses were provided. 4/7/25, .Lorazepam 2mg/Ml Inj 0.25 ML . PRN Reason: Agitation Label Comments: DOSE = 0.5MG = 0.25ML. GIVE IF UNABLE TO GIVE PO.Lorazepam 0.5 mg tab . dose 0.5mg PO . PRN Reason: Agitation Label Comments: ATTEMPT PO FIRST BEFORE GIVING IM . no doses were provided. Incident: Review of the facility's documentation of the Group Baking Social, dated 4/7/25, revealed Resident #'s 4, 6, 9, 11, 14 and16 attended the baking activity. During a joint interview on 4/7/25 at 4:35 PM, Activities Aide (AA), DON, Social Worker (SW) and Administrator stated from 1:30-3:00 PM a baking activity was conducted with the residents. The AA stated during the activity Resident #16 requested to have his/her hospital wrist band removed that had been placed on 4/3/25 at his/her emergency room (ER) visit. The AA further stated the DON approached Resident #16 to cut off the wrist band and Resident #16 grabbed the scissors from the DON. The AA stated Resident #16 threatened to harm himself with the scissors. The AA further stated a code grey was activated quietly since Resident #16 does not do well with a lot of people. The AA stated the hospital security department, police department, and emergency medical services (EMS) were notified of the incident as well. The AA stated the staff tried to deescalate the resident but were unsuccessful. When asked what the de-escalation techniques were used, AA stated we asked the resident to return the scissors. The AA further stated the residents in attendance of the activity were removed from the unit kitchen. The SW and Administrator stayed with Resident #16 while the AA assisted in taking other residents out of the room. During the same interview, the DON was asked about the surveyors' observations upon entrance of Resident #16 agitation and paranoia of being locked up and behaviors increased as the DON approached the resident. The DON stated Resident #16 had PTSD with delirium and when [he/she] gets in these states we try to remove [him/her] from others. The DON was asked if the resident was appropriate for the activity related to his/her observed behaviors that day. The DON stated, sometimes activities calm [him or her] down, [he/she] does like outings. When the DON was asked if she had any concern with Resident #16 being around other residents with the observed agitation and paranoia, the DON stated, it was just [AA] and residents but when I came into the room I noticed [Resident #16] backing up. When the DON was asked if Resident #16 was triggered when she approached, the DON stated, yes [he/she] gets aggressive with me. When the DON was asked if Resident #16 had had any prior episodes of being a danger to self or others, the DON stated, [Resident #16] became delusional, aggressive and threatened staff stated 'I am going to kill you. The DON stated the event happened in February 2025. The DON stated after the incident the provider was notified, and a behavioral health referral was requested. The DON further stated the facility was still learning the triggers of Resident #16's PTSD. When the DON was asked why the scissors were provided to Resident #16, the DON stated she had noticed Resident #16 was still wearing the hospital identification band from 4/3/25 ER visit and was pulling on it. The DON then asked Resident #16 if he/she wanted the ID band removed and Resident #16 stated I want it off. The DON further stated she went to her office and retrieved her desk scissors. The DON stated she approached Resident #16 to remove the ID band and had her fingers in the loops of the handle. The DON stated, Resident #16 grabbed the scissors from the pointed end and opened the blades of the scissors. The DON stated she released the scissors because she did not want Resident #16 to get hurt. The DON further stated Resident #16 pressed the open blades against his/her chest. The Administrator stated [Resident #16] will have scratches from them (scissors). The Administrator further stated the more she talked with Resident #16, the more he/she pushed the Administrator away with use of his/her elbows. The Administrator stated during this time Resident #16 continued making threats he/she wanted to kill his/herself. When the Administrator was asked how long the event took place, she stated from 2:30 to 3:45 PM. The Administrator stated the police were finally able to remove the scissors after they took Resident #16 down to the ground and EMS took Resident #16 to the ER for an evaluation. During a joint interview on 4/9/25 at 3:03 PM, with the DON and Minimum Data Set (MDS) Nurse, when asked about 4/7/25 incident with Resident #16, the MDS stated she asked Resident #16 for the scissors, but he/she wouldn't release them and continued to be agitated. The MDS Nurse stated the AA had a good relationship with Resident #16 but too, was unable to get Resident #16 to return the scissors. During the same interview, the DON was asked why the decision was made to remove the ID band during the baking activity. The DON stated Resident #16 wanted it removed and stated, I probably didn't make the best choice. When the DON was further asked why safety scissors were not used instead of desk scissors with a pointed end, the DON stated none were available. emergency room Visit: Record review on 4/10/25, Emergency Department Note, dated 4/7/25, revealed: . Delirium due to medical condition with behavioral disturbance . Presented with concerns for attempted self-harm with scissors . 1:1 sitter, suicide precautions .admitted as Inpatient . Chief Complaint: Psychiatric Symptoms . Review of the facility's policy Difficult behavior management, long-term care, dated 2/23/25, revealed: . Confirm your willingness to work with the resident . Ask the resident what you can do to make the situation better. Be alert for signs of escalating behavior . agitation .

47929 Based on record review, observation, and interview, the facility failed to ensure resident dignity was maintained. Specifically: 1) 1 resident (#4) was assisted with dining in a non-dignified manner; and 2) 7 residents (#'s 1; 3; 5; 6; 8; 11; and 14) beds had the sheets and blankets pulled down, and incontinent pads were placed on the residents' beds and visible from the hallway. These failed practices placed the residents, based on a census of 14, at risk for a poor quality of life from decreased self-esteem. Findings: Dignity while dining: Record review on 1/22-25/24 revealed Resident #4 was admitted to the facility with diagnoses that included other paralytic syndrome following bilateral cerebrovascular disease (a medical condition that affects the blood vessels and circulation of the brain), muscle weakness, dysphagia (difficulty swallowing), and left sided paralysis. Further review revealed Resident #4 had communication challenges related to expressive aphasia (knowing what he/she wants to say but is unable to produce the words). The resident also required extensive assistance with meals and preferred to be fed by staff. An observation on 1/22/24 at 5:34 PM, revealed Certified Nurse Aide (CNA) #1 stood by the side of the bed while assisting Resident #4 with his/her meal. The CNA fed Resident #4 soup with a spoon and would occasionally scrape the spoon up the resident's chin to remove the excess food. The CNA then used the same spoon to scoop up other various foods which were fed to the resident. When finished, the CNA picked up a napkin, wiped the resident's mouth, then removed the clothing protector, folded it up and finished wiping the resident's face with the clothing protector. During an interview on 1/25/24 at 5:31 PM, the Director of Nursing (DON) stated the facility had allowed standing while staff assisted Resident #4 with his/her meals because the resident did not want to have his/her bed lowered. However, this preference was not noted in Resident #4's care plan. When asked if it was the normal standard of care for staff to use a spoon to wipe food away from a resident's mouth or use a clothing protector to wipe a resident's mouth, the DON replied staff should not have been doing that. Review of the facility's policy Nursing Procedures, reviewed 6/20/23, revealed [NAME] Nursing Procedures .is an online guide providing best practice and evidence-based guidance on nursing procedures .It is the SEARHC [Southeast Alaska Regional Health Consortium] policy that all nursing staff follow [NAME] for all nursing procedures . Review of Lippincott procedures titled Feeding, long-term care, revised 12/10/23, revealed Position a chair next to the resident's bed so you can sit comfortably if you need to provide cues or maximal assistance with feeding . Review of the Statement of Resident Rights and Responsibilities, not dated, revealed Residents have the right to .Considerate, dignified, and respectful care . Resident bedrooms: During a facility walk through on 1/23/24 at 9:13 AM, Resident #5's room was observed from the hallway to have clean bedding, with the bed covers pulled down and incontinent pads visible on the bed. Under the incontinent pad, a bath blanket was visible. At 9:17 AM, Resident #14's room was observed from the hallway to have clean bedding, with the bed covers pulled down and incontinent pads visible on the bed. A maxi lift (mechanical device used by staff to lift a resident) was left over the resident's bed area. At 9:22 AM, Resident #1 was observed seated in his/her reclining chair. The resident's bed had clean bedding, with the bed covers pulled down and 2 incontinent pads visible on the bed. During an observation on 1/24/24 at 3:21 PM, Resident #6's room was observed from the hallway to have clean bedding, with the bed covers pulled down and incontinent pads visible on the bed. Under the incontinent pad, a bath blanket was visible. A recliner facing the doorway also had a clean incontinence pad laid over the seat. The resident was not in his/her room. During an observation on 1/24/24 at 3:22 PM, Resident #8's room was observed from the hallway to have clean bedding, with the bed covers pulled down and incontinent pads visible on the bed. Under the incontinent pad, a bath blanket was visible. The resident was not in his/her room. During an observation on 1/24/24 at 3:23 PM, Resident #11's room was observed from the hallway to have clean bedding, with the bed covers pulled down and incontinent pads visible on the bed. Under the incontinent pad, a bath blanket was visible. The resident was not in his/her room. During an observation on 1/25/24 at 8:19 AM, Resident #3's bed was observed to have clean bedding, with the bed covers pulled down. Two incontinent pads and one bath blanket were placed on the bed. Further observation of Resident #3's room on 1/25/24 at 4:30 PM revealed a clean incontinent brief laying open on the Resident's bed, on top of the incontinent pads and bath blanket. Heel protectors were placed near the foot of the bed. During an interview on 1/25/24 at 5:30 PM, when asked about the bed sheets being pulled down on the resident's beds, CNA #1 stated these were open beds so that it was easier for the residents to go back to bed. When asked about residents who needed assistance back to bed, like Resident #1, the CNA stated Resident #1 had a foot device at the bottom of his/her bed and used the maxi lift, and it was easier to assist the resident back to bed. CNA #1 further stated he/she changed the Resident's bed sheets daily. During an interview on 1/25/24 at 5:45 PM, the DON stated that she would talk to the staff about leaving the beds turned down and laying a clean incontinent brief open on the bed. The DON stated she understood this to be a dignity issue. Review of the Statement of Resident Rights and Responsibilities, not dated, revealed Residents have the right to .Full consideration of privacy concerning his/her medical care program .

Based on observation, interview, and record review, the facility failed to ensure a homelike environment for all residents, based on a census of 14. Specifically, institutional signage was placed on doors throughout the facility. This failed practice increased the institutional character of the home and had the potential to cause diminished self-worth and a reduced sense of well-being for all residents. Findings: Random observations from 1/22-25/24 revealed signage placed on multiple doors, facing common areas, throughout the facility to include: - A door to the bath reading DO NOT OPEN DOOR TOO WIDE IT WILL BREAK, and another sign reading Attention Do not force the door open wider than it is designed to go (it damages the mechanism at the top); - Double door at the end of the hall near resident room [ROOM NUMBER] which read KEEP OUT and Door must remain Locked at all times. If you enter, RE-LOCK door; - Dirty utility room (door with code to enter) with bright orange sign reading KNOCK BEFORE ENTERING.; - A metal meal tray cart, facing the common room with a sign stating, Do NOT place anything on top of the cart.; - The conference room in the main hall leading to the dining area with a sign reading Please keep door closed, below that sign was another which read STAFF ONLY with a figure of a hand and a red cross/circle below the words; - A room next to the dining room with a sign reading Please keep door closed and next to that sign STORAGE ROOM EMPLOYEES ONLY. During an interview on 1/23/24 at 3:42 PM, the Administrator stated that some of the signs hung around the facility did not contribute to a homelike environment, especially the ones with stop signs. She mentioned that a resident requested to have one of the signs removed from outside of his/her room, which was accommodated. Review of the facility's Statement of Resident Rights and Responsibilities, not dated, revealed Residents have the right to .A safe, clean, comfortable and homelike environment that would maximize the resident's independence and does not pose a safety risk.

Based on observation, record review, and interview, the facility failed to ensure one resident (#14), out of 9 sampled residents, had the care plan revised to include goals and preferences for pain management. The failure to provide a care plan to manage acute and chronic pain, based on the Resident Assessment Instrument (RAI-the tool used for conducting the Minimum Date Set-MDS), placed the resident at risk for ineffective pain management. Findings: Record review on 12/01-02/22 revealed Resident #14 had diagnoses that included cerebral infarction (stroke-damage to the brain from interruption of blood supply), bilateral (both sides) osteoarthritis of the hip, and hemiplegia (partial paralysis to one side of the body) affecting nondominated side. During an interview on 11/28/22 at 2:59 PM Resident #14 was asked about his/her pain. The Resident became visibly distressed and stated, because he/she was an early riser, he/she had been up since 6:00 AM. The Resident stated he/she had a stroke on the left side and now has pain to his/her left shoulder and lower back. When asked what he/she took for pain, the Director of Nursing (DON) who was nearby came over and reminded the Resident he/she had scheduled and PRN (as needed) Tylenol this afternoon. The DON began massaging the Resident's back and stretched out the Resident's left shoulder, adding the Resident's muscles were tight and they needed a massage. Review of Resident #14's medication for pain management revealed medications included Cyclobenzaprine (a muscle relaxer) 0.5 mg (milligrams) tablets for hip pain/spasms, Tylenol 325mg 2 tablets by mouth three times a day, Tylenol 325mg give 2 tabs every 24 hours as needed for pain do not take more than 9 tablets a day, Baclofen tablet (a muscle relaxer) 10mg 1 tablet as needed by mouth every 8 hours, and Menthol-Camphor Ointment apply to affected areas every 6 hours as needed for pain. During an observation on 11/29/22 at 2:20 PM, Physical Therapist #1 told Resident #14 that if his/her hip was not hurting as much tomorrow, he/she could try to do therapy again. Review of an admission Minimum Data Set (MDS - a Federally required assessment), dated 8/03/22, revealed under the section J0100 Pain Management A. Received scheduled pain medication regime? 0 had been answered No. B. received PRN pain medications or was offered and declined? had been answered Yes. c. Received non-medication intervention for pain? had been answered yes. J0200. Should Pain Assessment Interview be Conducted? Was marked Yes. Review of the assessment interview revealed. J0400. Pain Frequency Ask resident: How much of the time have you experienced pain? 3. Occasionally. J0500 A. Pain Effect on Function A. Ask resident: over the last 5 days, has pain made it hard for you to sleep at night? No B. Over the last 5 days, have you limited your day-to-day activities because of pain No. B. Verbal Descriptor Scale Ask resident: 'please rate the intensity of your worst pain over the last 5 day. (show resident verbal scale) 1. Mild Review of the Care Area Assessments revealed the pathway for pain had not been triggered as needing a care plan. Review of a Quarterly MDS assessment, ADR 11/02/22, revealed section J0100 Pain Management A. Received scheduled pain medication regime? 0 had been answered yes B. received PRN pain medications or was offered and declined? had been answered Yes. c. Received non-medication intervention for pain? had been answered yes. J0200. Should Pain Assessment Interview be Conducted? Was marked Yes. Review of the assessment interview revealed. J0400. Pain Frequency Ask resident: How much of the time have you experienced pain? 3. Occasionally. J0500 A. Pain Effect on Function A. Ask resident: over the last 5 days, has pain made it hard for you to sleep at night? No B. Over the last 5 days, have you limited your day-to-day activities because of pain No. B. Verbal Descriptor Scale Ask resident: 'please rate the intensity of your worst pain over the last 5 day. (show resident verbal scale) 1. '3' [rating on a scale of 0-10 with 10 being the worst pain]. Review of Resident #14's Progress Notes revealed: 10/28/22 at 8:48 AM Left arm and left shoulder chronic pain. 10/30/22 at 8:14 AM .Feeling pretty bad today as per resident pointing to left shoulder and arm offered warm compress and muscle rub but refused and opted for medications only. 11/01/22 at 6:38 AM .Stating this morning 'I want to die' that [Resident #14]'s in a lot of pain irritated with [his/her] body not functioning well. 11/04/22 at 8:55 AM .'It really hurts' as stated by the r\Resident pointing to left arm, left shoulder, left leg foot, and lower back. Offered warm compress, Resident refused and opted to go back to bed. 'No thank you I'll go back to bed' as per [Resident #14] reassurance given and ensure safety. 11/04/22 at 2:33 PM .Left shoulder arm and leg. Chronic pain. 11/24/22 at 2:19 AM Pt [Patient] woke up from sleeping with leg pain. 11/24/2022 at 10:13 AM .Menthol Camphor Ointment .Applied to lower back due to c/o [complaints of] pain in that area. Unable to rate [his/her] pain. PRN applied. 11/25/22 at 5:21 AM .Pt co leg pain mostly upper thigh and lower back. Repositioned Pt. in bed w/o [without] relief. Given per Pt. request for pain. 11/26/22 at 7:57 AM .reports pain to [his/her] L hip this morning rates 10/10; [he/she] states pain in [his/her] femur is much better. Further review revealed Resident #14 often refused to wear his/her TED hose (a compression stocking used to reduce swelling) on his/her left lower leg due to pain. Review of a Physician's Progress note, updated 10/10/22, revealed . [Resident #14] concerns are [he/she] is having some pain in [his/her] knees mostly the left side . Assessment/ Plan: Knee pain Medical Reasoning and Treatment: currently on Tylenol [he/she] is not on NSAID [nonsteroidal anti-inflammatory drug] probably due to bleeding risk we will continue with conservative measures including physical therapy. Review Resident #14's Nurse's Notes revealed: 11/29/22 at 1:43 AM .At HS [bedtime] Resident [#14]requested assistance getting into bed, positioning, and getting covered up with blankets due to low back pain complaint. Pain managed adequately with scheduled pain medications. 11/28/22 at 6:51 AM .Resident [#14] has been compliant in using call button when needing to transfer this shift. [Resident] has not had any outbursts since 19:30. [He/she] was heard talking and laughing with staff in her room this morning. No c/o pain since 19:30 arm, shoulder and back pain which was effectively managed with scheduled medication. 11/27/22 at 6:53 PM .Resident [#14] up in wheelchair self-propelling around facility. Did have one episode of complaints of pain to left arm. Applied muscle rub and was effective. No behaviors this shift. No complaints or distress. Call bell and frequently used items in reach. 11/25/22 . [Resident #14] c/o pain to L leg, hip and lower back this morning. Per [name] RN night shift nurse [Resident] had same complaints during night shift. [Physician] ordered X-rays, appointment made for Resident at 2 pm, shuttle took her to and from appointment. Results not back at this time. 11/25/22 at 6:55 AM .0500 CNA [Certified Nursing Assistant] went to attend to call bell from pt. Resident requested bedpan and states, My leg hurts Resident is tearful during cares. This RN went in an assessed pain. L thigh and lower back were the complaint. no edema or bruising noted. skin intact. Tylenol given, deemed effective. needs attended too. message sent to [Physician] in Cerner [electronic medical record] requesting x-ray for Resident due to number of recent falls. 10/31/22 at 12:18 AM . pt. woke up around 0145 in pain, requesting medication. PRN Tylenol given which was effective. pt. woke up in pain again at 0545. refuses muscle rub and hot packs. just leave me alone. CNA is able to assist pt. to bedside commode, but after pt. is withdrawn and inconsolable. pt. refused cares and VS [vital signs] this morning. Review of the electronic medical record (EMR) on 12/01/22 revealed no information in the care plan that identified goals for Resident #14's pain management that included pharmacological and non-pharmacological interventions. During an interview on 12/01/22 at 3:20 PM, the DON was asked if the care plan contained any information about the pain management program for Resident #14, the DON stated she could not find it woven into any other care areas but she would double check. The DON identified the MDS had not triggered a care plan be performed for pain management. On 12/01/22 the DON provided the following care plan. Focus- [Resident #14] has limited physical mobility r/t [related to] stroke Goal- [Resident 14] will remain free of complications related to immobility, including contractures, thrombus [clot] formation, skin breakdown, fall related injury through the next review date. Revision on 10/29/22. Interventions-Monitor and treat for chronic pain. date initiated 10/03/22, revision date on 12/01/22. During an interview on 12/02/22 at 8:40 AM, when asked about Resident #14's pain, CNA #1 stated the Resident usually had pain in the mornings, sometimes in the afternoon. When asked what interventions he/she had to implement, the CNA stated he/she usually would inform the nurse about the pain. During an observation on 12/02/22 at 8:51 AM, Resident #14 spoke to the DON and stated his/her left arm and shoulder hurt. Licensed Nurse #1 gave Resident #14 some medications and stated there was some Tylenol in there and it should help him/her feel better.

Based on observation, record review, and interview the facility failed to ensure measures were implemented to promote healing and assess progress of a wound, for 1 resident (#10), out of 1 resident reviewed with a pressure injury. Failure to implement care that prevented shearing and repositioning created a risk for further skin damage and/or pressure injury. The failure to implement a process to assess wound improvement, denied the interdisciplinary team consistent information to make decisions about wound management, potentially creating a risk for delayed healing. Findings: Random observation on 11/28/22-12/01/22 revealed Resident #10 lying in bed. The Resident was nonresponsive when spoken to but made eye contact when approached from the left side. The Resident was unable to move his/her legs and right arm, although the Resident was observed lifting his/her left arm with no purposeful movement. The Resident was receiving nutrition through a gastric tube [G-tube] implanted in his/her stomach and had an indwelling urinary catheter that drained urine into a bag. The Resident was unable to turn his/herself or express any needs. The Resident was positioned on an air mattress. Record review on 11/20/22-12/01/22 revealed Resident #10 had a history of rupture of a blood vessel in the brain complicated by dysphagia (difficulty swallowing) and immobility of his/her extremities. Review of Admission Nursing Assessment, completed on Resident #10 on 5/22/22, revealed the Resident had 3. Communication .3e. Aphasia [language disorder that effects ability to communicate]. 4. Motor Control .4e. Paralysis/Hemiplegia [impaired/inability to move on one side] /Quadriplegia [impaired/inability to move all extremities]. L. Skin. Site 23. Coccyx Type Scar Site 36. Left Thigh (rear) Type. Blister. Review of a Kardex [a brief overview of resident care] care plan, dated 12/01/22, revealed Bed mobility interventions included bed mobility [Resident #10] requires full assistance by two staff to turn and reposition in bed every two hours and as necessary. Bedfast [Resident #10] is bedfast all or most of the time. Resident Care included the interventions Do not wipe areas of new skin development and evaluate skin integrity during weekly skin checks and as needed. During a continuous observation on 12/01/22, from 7:10 AM-8:34 AM, Resident #10 was lying in bed, in the same position, slightly to right side towards the window, At 8:35-8:42 AM-Licensed Nurse (LN) #3 entered the room, administered the Resident's medication via G-tube. The LN removed the nutrition bags and raised the head of Residents' bed and placed the bed in a low position. The Resident's body position was unchanged. At 9:00 AM-no changes in position At 9:15 AM the Director of Nursing (DON) entered Resident's room. There was no change in the Resident's position. At 9:25 AM Activity Staff (AS) #1 entered the Resident's room and left after 2 minutes. The AS stated he/she had tried to wake the Resident up for range of motion. There was no change in the Resident's position. At 9:30 AM the Housekeeper entered room and started cleaning the floor. At 9:45 AM the Resident remained in bed in the same position. From 9:54-10:00 AM, 2 hours and 50 minutes after the observation began, Certified Nursing Assistant (CNA) #2 and #3 entered the Resident's room to reposition him/her. The CNA #3 used both hands to grasp a quilted incontinence pad that, was under the Resident, and using that, pulled the Resident across the bed. The Resident's buttocks and back dragged across the bed. When the CNA's repositioned the Resident so he/she was laying on the right side, a wadded-up cloth was observed between the Resident's legs. When asked about the sheet, CNA #2 stated they were supposed to use that instead of the disposable undergarments. When the staff raised the head of Resident #10's bed, the Resident began to cry. During an interview on 12/01/22 at 3:21 PM, the DON stated Resident #10 should be turned every 2 hours. An observation on 12/02/22 at 9:00 AM, revealed Resident #10 was lying in bed on his/her back. CNA #5 entered Resident #10's room and stated he/she was going to reposition the Resident. The Resident was observed to have the cloth incontinence pad and had a cloth between his/her legs. LN #2 entered the room and assisted with repositioning the Resident. CNA #5 stated the staff were no longer supposed to use the disposable undergarments. Review of a wound care Teleconsult, dated 8/03/22, revealed A Wound Clinic image review was requested .Reason for Consultation: 'moisture lesions' Date of Injury: Chronic Recommended Plan of Care: I[t] appears these ulcers moisture associated skin damage complicated by shearing. The linear appearance suggests [he/she] is sliding in the bed. No E./ infection or acute complications. 1. Elevate head of bed less than 30 [degrees]. However [he/she] is G tube dependent so [NAME] knees when head of bed elevated to prevent shear injury. 2. Do not use closed incontinence briefs .While in bed, a flat incontinence pad is recommended when not up in a chair 3. Continue offload with frequent repositioning. Use positioners to ensure proper turning degrees Keep excess layers of material off the bed. Having several layers of sheets, pads, briefs, chucks, etc. decrease the effectiveness of the mattress Weekly Skin Check and shower every morning on Wednesday and Saturday Directions every day shift every Wednesday, initiated 11/16/22. Low Airloss Mattress, initiated 5/06/22 Apply barrier cream to the bottom after each incontinent care Review of the most recent MDS quarterly assessment, assessment refence date (ADR) 11/22/22, revealed MDS 3.0 Section M-Skin Conditions M0100. Determination of Pressure Ulcer/ Injury Risk A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable device. Yes B. Formal assessment instrument/ tool (e. g., Braden, Norton, or other). Yes C. Clinical assessment. Yes M0150. Risk of Pressure Ulcers/ Injuries Is this resident at risk of developing pressure ulcers/injuries? 1. Yes. M0210. Unhealed Pressure Ulcers/ Injuries Does this resident have one or more unhealed pressure ulcers/ injuries? 1. Yes M0300. Current Number of Unhealed Pressure Ulcers/ Injuries at Each Stage B1. Number of Stage 2 pressure ulcers, 1 B2. Number of these stage two pressure ulcers that were present upon admission/ entry or re-entry. 1 M1040 Other Ulcers, Wounds and Skin Problems D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion. H Moisture Associated Skin Damage (NASD) (incontinence associated dermatitis [IAD], perspiration, drainage) M1200. Skin and Ulcer/ Injury Treatments A. Pressure reducing device for chair. Yes B. Pressure reducing device for bed. Yes C. Turning repositioning program. No D. Nutrition or hydration intervention to manage skin problems. Yes E. Pressure ulcer/ injury care. Yes F. Surgical wound care. No G. Application of nonsurgical dressings (with or without topical medications) other than to feet. Yes. H. Applications of ointments/ medications other than to feet. Yes Review of Residnet #10's plan of care on 12/01-02/22, revealed: Revised 7/07/22: Focus: [Resident #10] has impaired Skin and is at risk for further impairment as evidenced by immobility and Braden Scale for Prediction Pressure Ulcer Risk High Risk for Pressure Ulcer (Episodic) . Goal: [Resident's #10 MASD [moisture associated skin damage] will show improvement through next review Interventions: o Do not wipe areas of new skin development .Shows on Kardex. o Evaluate skin integrity during weekly skin checks and as needed .Shows on Kardex. o Keep residents' perineum clean and dry. Turn and repositioning [Resident #10] every 2 hours . o Monitor nutritional status with RD quarterly and as needed with changes in condition. o Perform objective pressure ulcer risk tool such as Braden / Norton scale quarterly and as needed .Shows on Kardex. o Provide skin care per facility guidelines and PRN as needed. Revised 9/01/22 Focus: The Resident has an indwelling catheter: Pressure Ulcer bilateral gluteal area. Review on 12/01-02/22 of the nursing Skin/Wound Notes, from 5/10/22 until 11/30/22, revealed documented descriptions of the wounds and the dressing changes did not contain measurements of size and/or depth. During an interview on 12/01/22 at 3:21 PM, when asked how nurses documented the size of the wound, the DON stated the nurse took photos for upload into the hospital's electronic medical record. Review of the photographs on 12/02/22, revealed a series of photographs of Resident #10's buttocks. The photographs were taken from different angles and distances and did not use a consistent tool that identified the width and length of the wound (s). During an interview on 12/02/22 at 10:00 AM, when asked how the wounds for Resident #10 were measured, LN #2 stated he/she used a paper dressing package containing measurements on one side and photographed the wound with that side of the package. Review on 12/02/22 of the facility policy Wound Management, reviewed 8/25/22, revealed Wound Assessment will include wound measurements more details outlined below . It is SEARHC [southeast Alaska regional health consortium] policy for all nursing staff to follow Lippincott for all nursing procedures include but are not limited to: A. Wound cleaning B. Wound Measuring C. Dressing D. Negative Pressure Wound Therapy. Review on 12/02/22 of the Lippincott Procedures-Wound Management protocol, revised 2/17/22 revealed, Introduction: A thorough wound assessment should consist of objective criteria and measurements that promote accurate consistent comparisons to determine the extent of the word and effectiveness of wound healing. Comprehensive wound assessment is necessary during every dressing change comparison of assessment results to previous findings helps to monitor communicate treat and document wound healing progression and or complication or complications Drainage Descriptions Acute versus Chronic Wound Wound Color Measure the wound with a disposable wound measuring device for example a square, transparent card with concentric [circular] circles arranged in a bullseye fashion bordered with a straight edge ruler. Use a uniform, consistent method for measuring the wound to allow for meaningful comparisons for evaluating wound healing classify the wound using a staging system.

Based on observation, interview, and policy review the facility failed to 1) ensure food storage protected the integrity of in-use food products, and 2) remove expired food products from potential use. The failure to date food products when opened, ensure products were sealed, and rotate expired food product out of production, placed 14 of 15 residents receiving food from the kitchen, at risk for suboptimal nutrition, poor food quality, and/or potential foodborne illness. Findings: Observation of the kitchen on [DATE] at 1:33 PM revealed the following: Walk-in Freezer -Bags of corn, green beans, mixed veggies, opened and reclosed, no date when opened -One opened bag of frozen chopped broccoli, no date when opened -One bag of French fries opened, and resealed, no date when opened -One 29.5 lb. box of corn on the cob open to elements, no date when opened -1 30#box Sysco bag of carrots opened and closed, no date when opened Dry Storage -One 5 lb. box of Krusteaz Pancake Mix opened. Resealed, no date when opened. -One box of 16 oz corn starch opened and not dated -One 28 oz box of Creamy Wheat Farina opened with no written date when opened. -One case of unopened [MEDICATION(S)] calorie and protein food enhancer, expired [DATE], and still on shelf -One bag of Knorr instant chicken flavor gravy opened, resealed, no date when opened. -1.3 oz. of turkey gravy mix opened, resealed, no date when opened. -One opened bag instant potatoes, reclosed, no date when opened. -1 large bag of pasta LA [NAME], opened and loosely closed, no date when opened -1 large, opened bag of La [NAME] Orzo pasta, rewrapped no opened date. -1 large, opened bag pasta la [NAME] noodles, loosely closed, no opened date -1 large, opened bag [NAME] shell pasta, reclosed with no open date -1 loosely wrapped partially open bag of La [NAME] Pasta rainbow pasta, no opened date -1 open and closed bag of La [NAME] elbow macaroni pasta, no opened date Walk-in Cooler -One 32 oz. carton liquid whole egg opened, use by [DATE], no open date -One box of fully cooked bacon opened, rewrapped, no open date -One tub of apple pie filling, use by [DATE], still on shelf -One 2-pound container of horse radish classic, use by [DATE] -Chicken soup, use by [DATE], still on shelf -1 quart Land O'Lakes half and half opened, partially consumed, no date when opened. -One tub sliced apples, use by [DATE], still on shelf. -One 64 oz. Dairigold whole milk, best by 10 20 21, partially consumed with no opened date -One container of cooked white rice, use by [DATE], still on shelf During an interview on [DATE] at 2:12 PM, the DM, stated the facility uses FIFO (first in first out) for stock rotation. When asked how long products were good for once opened, she pointed out the laminated sheets hanging on the wall. The DM stated food products should be dated when opened. Review on ,d+[DATE]-,d+[DATE] of the Sodexo Food Products Self Guidelines, issued [DATE], revealed: Refrigerator: -Liquid pasteurized eggs, 3 days after opening -Juices in carton, fruit juices, punch refrigerator, ,d+[DATE] days after opening -Half and Half ,d+[DATE] days -Canned fruits-,d+[DATE] days opened -Milk: Whole, Reduced & Low Fat, & Fat Free 7 days Dry Storage: -Baking powder-6 months opened -Cereals ready to eat ,d+[DATE] months opened and unopened -Potatoes, instant ,d+[DATE] months -Pasta (dry spaghetti, macaroni, etc.) 2 years once opened store in airtight container Unit Kitchen Fridge: Observation on [DATE] at 9:51 AM revealed: -100% HC plus apple juice 32 oz. opened and partially consumed, no date when opened. -100% HC plus cranberry juice 32 oz. opened and partially consumed, no date when opened. Observation in the kitchen during meal prep on [DATE] at 12:07 PM revealed what appeared to be dust balls on the wall and around the window of the Dietary Manager's office which is in the serving area and immediately above the outgoing food cart.

Based on observation, interview, and record review the facility failed to ensure the deep freeze was maintained in a good operating condition. This failed practice had the potential to cause partial thawing and refreezing and reduce the quality of the food. Findings: During an observation on 9/13/21 at 1:19 PM, the door to the walk-in freezer was observed to be propped open. Pieces of ice were observed to be falling from the ceiling of the freezer. During an interview on 9/13/21 at 1:32 PM the Dietary Manager (DM) said facility staff had fixed the freezer door seal 3 weeks ago. The DM stated she was still having issues and they were having to defrost the freezer weekly. Observation in the freezer revealed: The current freezer temperature was 12 degrees Fahrenheit. Contents in the freezer were: -2 large bags of broccoli, frozen solid in a block with ice crystallization in the bag. -1 large bag of carrots, open and reclosed, frozen solid in a hard block in the bag. -29.5-pound box of corn on the cob, open to air, frost crystals on food. -1large bag of French green beans, frozen solid with ice crystallization in bag. -1 large bag of chopped onions frozen solid with ice crystallization in bag. During an interview on 9/15/21 at 1:20 PM, Maintenance Staff #1 stated that on 6/25/21 a leak around the freezer door seal had been corrected, the latch was repaired, and ice was chipped out. Repairs were done to the walk-in cooler on 8/9/21. Review of the requested repair log for the walk-in freezer on 9/20/21, emailed by the facility on 9/17/21 at 4:41 pm, revealed: a repair ticket was submitted on 6/24/21 at 9:10 am and the repairs were conducted on 6/25/21. There were no further repair tickets provided for review.

Based on record review and interview the facility failed to ensure 1 resident (#15) had reasonable access to their funds. This failed practice had the potential to affect all 12 residents with trust accounts by allowing them reasonable access to their funds: Findings: Review on 9/15-16/21 of Resident #15's medical record revealed a Social Services Note, dated 8/31/21, [He/she can get cash from the Resident Trust Account $200/ mo .[He/she] seems to accept this for now. [He/she] says [he/she] spent the $25 [he/she] had in [his/her] wallet last week on cookies, [he/she] would like to get more cash, but [Fiscal Manager], who administers the Resident Trust Account is OOO [out of office]. During an interview on 9/16/21 at 9:30 AM, the Finance Manager (FM) stated 12 residents had accounts maintained at the facility. When asked how the residents could access their funds, he said there was a petty cash account. He stated he was the one that could access it. When asked how the residents could access funds if he were off work or on vacation, he stated he would come in on his day off. When asked about the incident with Resident #15, the FM replied he came in the next day to resolve it. Review of a policy provided by the FM on 9/16/21 at 10:20 AM, revealed Resident Trust Funds, revised 8/01/19, 3. Withdrawals: a. For resident convenience, the money available for resident personal use will be 'borrowed' through the Petty Cash Fund in Fiscal Services. Review on 9/16/21 of the Sitka Long Term Care [LTC] Trust Fund Log for [Resident #15] revealed no withdrawals from the account until 9/09/21. Review on 9/16/21 of the Resident Fund Enrollment, signed by residents that wish to participate in the Resident Trust Account, undated, revealed: Southeast Alaska Regional Health consortium (SEARHC) will hold, safeguard, manage an account for you if you choose to deposit funds with the facility. There are two ways in which we can hold your funds, Petty Cash Fund and/ or LTC Resident Trust Fund. Petty Cash Fund: The Petty Cash Fund is an amount of cash less than $50 kept on hand and maintained by LTC Activities. There will be one Petty Cash Fund for each resident in the safe in the LTC Director's office. Each Petty Cash Fund will be stored in a clear bag, identified for each resident, and stored in the LTC safe. Withdrawals or Deposits: You are able to deposit and withdraw money at any time. All that must be done is to inform the nursing staff or LTC activities. You will be asked to sign the Petty Cash Fund Ledger and provide receipts of purchases for tracking purposes. You may deposit money into the Petty Cash Fund at any time. However, if there is more than $50 in your Petty Cash Fund nursing or LTC Activities will inform you that you must keep it in your personal possessions until it can be deposited into your personal account. Withdrawals or Deposits: You are able to withdraw/deposit money during Fiscal Service business hours. Requests will be processed the next day, or when requested funds are available. During an interview on 9/16/21 at 12:50 PM the Director of Nursing (DON) stated she did not actually keep a Petty Cash Fund, she stated the money is kept by the FM. The DON stated she did keep the funds for Resident's #1 and #15. When asked about Resident #15 not being able to access his/her money the DON said Resident #15 was often confused and forgot how much money he/she had. During an interview on 9/17/21 at 10:30 AM, when asked about the Petty Cash Fund, the LTC Activities Coordinator said the Petty Cash Fund was kept in a safe in the DON's office.

Based on interview and record review, the facility failed to ensure 11 residents of 12 residents (#s 1; 3; 4; 5; 7; 10; 11; 12; 13; 14; and 15), with trust accounts, received quarterly statements. This failed practice denied residents current information about the status of their financial accounts. Findings: During an interview 9/16/21 at 9:30 AM the Finance Manager (FM) stated he managed the resident's accounts. When asked if the residents received statements, the FM replied he did not send statements unless the residents and/or representatives requested. The FM stated Resident #9's family member usually requested a statement. Review of the facility policy provided by the FM on 9/16/21 at 10:20 am revealed Resident Trust Funds, revised 8/01/21, 5) Resident Statements: a. The accountant will give an accounting report to each resident and/or their conservator quarterly or anytime the resident/ conservator makes a request.

Based on observation, interview, and record review, the facility failed to ensure infection control procedures were properly implemented. Specifically, the facility failed to ensure: 1) 5 out of 5 residents observed (#s 3; 15; 11; 2; and 6) were offered hand hygiene prior to dining. This failed practice had the potential to place all residents in the home at risk for transmission of communicable infections. Findings: Observation on 9/14/21 at 8:21 AM, revealed Licensed Nurse (LN) #1 was carrying a meal tray, entered Resident #3's room, placed meal tray on the chair and performed hand hygiene. The LN left the room and came back with a placemat, performed hand hygiene and put the placemat on top of Resident #3's table. LN #1 asked the resident if he/she was done using the commode, the resident replied yes. Then LN #1 placed the plate and a glass of milk on the table. The LN was not observed offering hand hygiene to the resident before meal. An observation on 9/14/21 at 7:37 AM, revealed Certified Nurse Aide (CNA) #2 delivered a meal tray to Resident #15. The CNA did not set-up food on the table and did not offer hand hygiene to the Resident prior to the meal. An observation on 9/14/21 at 8:20 AM, revealed CNA #2 delivered a meal tray to Resident #11, The CNA did not ask the Resident if he/she wanted to perform hand hygiene prior to the meal. On 9/14/21 at 8/14/21 at 8:23 AM, revealed CNA #2 delivered a room tray to Resident #2, the CNA did not ask the Resident if they wanted to wash their hands prior to eating. An observation on 9/14/21 at 8:26 AM, revealed CNA #1 delivered a tray to Resident #6. The CNA prepared the Resident's dentures and handed them to the Resident. After the Resident inserted his/her dentures, the CNA cleaned and handed the Resident his/her glasses. CNA #1 opened the Resident's milk, prepared the Resident's oatmeal. The CNA did not ask the Resident if he/she wanted to perform hand hygiene prior to the meal. During an interview on 9/16/21 at 1:05 PM, when asked about the hand hygiene procedure/policy, the Infection Preventionist (IP) stated the facility followed the Centers for Disease Control and Prevention guidelines. IP stated handwashing was performed before mealtimes. Hand sanitizing wipes were provided, and residents were offered hand hygiene before meals. IP also stated the residents have the right to refuse hand hygiene. Review on 9/17/21 at 3:30 PM of the Hand Hygiene policy, revealed Indication for Handwashing .Before eating .After using a restroom . According to CDC Handwashing: Clean Hands Save Lives. When and How to Wash Your Hands accessed on 9/17/21 at this link, https://www.cdc.gov/handwashing/when-how-handwashing.html, revealed Key Times to Wash Hands .Before and after eating food . After using the toilet .

Based on record review, interview, and observation the facility failed to develop an individualized care plan that identified necessary safety communication methods for 1 resident (#5) out of 1 resident that independently smoked tobacco. This failed practice places the resident at risk of not receiving a timely response and care if an emergency in the smoking area occurs. Findings: Review on 9/13/21 at 2:00 PM of the Resident who Smoke, revealed Resident #5 has been grand-fathered in to use our smoking shed near the entrance to the facility. During an interview on 9/14/21 at 11:05 AM, Resident #5 stated he/she smoked 3 sticks a day. The Resident stated he/she kept the cigarettes and matches in a jacket in the room. The Resident also stated the facility provided a smoking area by the garage. Resident #5 stated he/she wore a protective apron when he/she smoked. Review of Electronic Health Record (EHR) on 9/13-17/21, revealed Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident used a wheelchair for mobility. Review on 9/15-17/21 of the quarterly Minimum Data Set (MDS a Federally required nursing assessment), dated 7/6/21, revealed the Resident was coded for J1300 Current Tobacco Use. Review of the annual MDS, dated [DATE], revealed the response to J1300 was not marked. During an interview on 9/15/21 at 9:52 AM, the Activities Coordinator (AC), when asked about the smoking schedule of Resident #5, AC stated there was no schedule, the Resident smoked whenever he/she wanted. The AC further stated the staff did not go with Resident when he/she wanted to smoke. The staff would help the resident to transfer to the wheelchair. AC also stated Resident #5 was independent and knew where to go and knew the boundaries . During an interview on 9/15/21 at 10:00 AM, the Administrator showed the smoking area to the surveyor. The Administrator stated that Resident #5 had a key to the smoking room. The administrator stated Resident #5 was grandfathered to smoke and was the only smoker in the facility. Random observations from 9/15-17/21, revealed the smoking area was a closed locked room, with a key lock, outside the Long-Term Care (LTC) next to the main entrance door of the facility. The entrance door was locked all the time. For a person to get inside the facility, he/she would call the number posted at the door or staff would swipe their badges. Further observation on 9/15/21 at 10:00 AM, there was no call system inside the smoking room. Review of the EHR, on 9/15/21 at 10:30 AM, revealed Resident #5 had a smoking agreement on 5/31/18 and 6/30/21, both agreements were signed by the resident and the Director of Nursing (DON). Information about Resident #5's ability to call the facility in case of emergency was not mentioned. Review on 9/17/21 at 1:50 PM, of the Smoking -Safety Screen, dated 8/21/20, 12/31/20, 4/5/21, and 6/30/21 revealed a plan of care was used to ensure resident was safe while smoking. Yes option was marked. There was no mention about how resident will contact the facility in case of emergency. Review on 9/15-17/21 of the Resident's care plan, dated 8/12/21, revealed Focus: At risk for injury related to smoking; Goals will remain free from injury related to smoking; Interventions: Provide res with smoking cessation materials; res able to store his own smoking materials in a safe area located in his bedroom; res is strongly encouraged to wear smoking apron while smoking; res prefers to independently go off campus to smoke, but is grand-fathered to use LTC smoking room. Resident is required to wear smoking apron while utilizing smoking room; smoking assessment to be conducted every 92 days. Further review of the care plan revealed there was no mention about the use of call pendant and Resident's refusal of it's use or use of cell phone as an alternative means of communication to the facility in case of emergency while smoking in the designated room. During an interview on 9/17/21 at 8:30 AM, Resident #5, stated there was no call button in the smoking room. Resident added he/she did not know about the need for call button until this interview. When asked how he/she would call for help in times when he/she needed one, Resident #5 replied his friends pass by so he could get help. Resident #5 also stated has cell phone to use when needed help. The resident paused a moment and he/she recalled there was a time when Resident #5 needed help, he/she called the front desk, but the line was busy. The resident could not recall how long he/she waited and when it happened, adding he/she smokes about 10 minutes every time. During an interview on 9/17/21 at 9:15 AM, when asked about the process of smoking assessment of Resident #5. DON stated she physically assessed the resident quarterly and report it to the Interdisciplinary Team (IDT). The DON stated that morning when coming to work she saw the resident smoking, she observed the resident while talking to him/her. When asked how she monitors Resident #5 smoking, the DON stated she monitors him if there was a change in condition; and residents' ability to do things cognitively. The DON also added, may not be outside when resident smoke. When asked if there was regular monitoring on resident while smoking, the DON stated no, because Resident #5 was unsupervised and prefers to be by himself, stating monitoring might irritate him. During an interview on 9/17/21 at 9:15 AM, when asked how the resident could call for help in case of emergency or if he needed help, the DON stated resident had cell phone to contact facility, DON added the resident should be carrying a [call] button with him. The DON also stated that the resident told the DON that he had cell phone and would use it when needed help. DON added the call button was like a pendant in a lanyard that was provided to the resident but Resident #5 was not wearing the pendant. The DON stated she would look for the pendant in the resident's room. During a follow-up interview with the DON on 9/17/21 at 2:55 PM, the DON stated there was no pendant in the room and would continue to look for it, adding that it's been a long time since he had it. When asked if the use of pendant should have been included in the care plan, DON replied that the use of pendant should be care planned if the resident was using it. The DON further stated, if Resident #5 did not want to use the pendant, maybe put a call button in the wall of the smoking room.

Based on record review, observation, and interview the facility failed to ensure anti-embolism stockings, used to decrease risk of blood clots, were applied correctly for 1 resident (#6), out of 2 residents observed wearing stockings. The incorrect application of the stockings placed the resident at an increased risk for harm. Findings: Review on 9/14/21 of the medical record, revealed Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 9/14/21 at 11:00-11:35 AM Resident #6 was observed seated in a lounge chair with both legs dependent (in downward position). The Resident was wearing TED hose,(long tight-fitting stockings that place mild static pressure on the legs to prevent blood from clotting),on both lower legs. The stocking on the right leg had a noticeable wrinkle around the circumference of the right ankle and the left stocking was upside down with the heel portion on top of the foot. During an interview on 9/14/21 at 1:34 PM, when asked about Resident #6's TED hose, the Director of Nursing (DON) stated Resident #6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she would let the nurse know about the wrinkling. Review of Resident #6's care plan, on 9/15/21, revealed Focus: The resident has altered cardiovascular [heart] status [related to] arrhythmia. The interventions included Apply ted hose before resident gets out of bed in the am and remove at bedtime. Hand wash and air dry nightly. According to Cardinal Health, the makers of T.E.D. Anti-Embolism stockings, accessed on 9/27/21 at, https://www.cardinalhealth.com/en.html , Carefully position stocking over foot and heel. Be sure heel is centered in heel pocket. 4) Pull stocking up and lift around ankle and calf, working up to final position (top of stocking is positioned approximately one to two inches below the bottom of kneecap). Make sure heel and toe are positioned correctly. Smooth out any excess material between top of stocking and ankle. Pull toe section forward to smooth ankle and instep area and allow for toe comfort.

Based on record review and interview the facility failed to ensure: 1) as needed orders for [MEDICAL CONDITION] drugs (any drug that affects brain activities associated with mental processes and behavior) in excess 14 days were observed as irregularities and reported to the physician for two residents (#s 1 and 6); and 2) a policy was maintained for monthly drug regimen reviews that included time frames for different steps in the process and steps taken by pharmacist when an urgent action was identified during the monthly medication regiment reviews. This failed practice placed 2 residents at risk for receiving unnecessary medication and placed all residents (based on a census of 15) at risk for delay or impediment of reviews of their monthly medication regime. Findings: Pharmacist Recommendations: Resident #1: Record review of Resident #1's medical record from 1/6-10/20 revealed the Resident had [DIAGNOSES REDACTED]. Further review revealed the Resident's medication regime included scheduled antidepressant medication. Record review from 1/6-10/20 revealed an order for [REDACTED]. Review of the physician's progress notes, dated 10/23/19 to 12/18/19, revealed Physician #1 did not provide any rational for the extended use of an as needed order for [MEDICATION NAME]. Further review revealed no indicated duration for the use of [MEDICATION NAME] past 14 days. Review of the Medication Regimen Review, dated 9/2019 to 12/2019, revealed a decrease in the as needed (PRN) use of [MEDICATION NAME] from (MONTH) through November. No documentation regarding the use of PRN [MEDICAL CONDITION] was noted in the medication regimen review by Pharmacist #1. Resident #6: Record review of Resident #6's medical record from 1/6-10/20 revealed the Resident had [DIAGNOSES REDACTED]. Further review revealed the Resident's medication regime included scheduled antidepressant medication, as well as, a scheduled antianxiety medication. Record review from 1/6-10/20 revealed an order for [REDACTED]. Review of the physician's progress notes, dated 9/17/19 to 12/19/19, revealed Physician #2 did not provide any rational for the extended use of an as needed order for [MEDICATION NAME]. Further review revealed no indicated duration for the use of [MEDICATION NAME] past 14 days. Review of the Medication Regimen Review, dated (MONTH) 2019 to (MONTH) 2019, revealed: - 8/2019 - 5 PRN doses of [MEDICATION NAME] used; - 9/2019 - no PRN doses of [MEDICATION NAME] used; - 10/2019 - 1 PRN dose of [MEDICATION NAME] used; - 11/2019 - 1 PRN dose of [MEDICATION NAME] used; and - 12/2019 - no PRN doses of [MEDICATION NAME] used. Further review of the medication regimen reviews revealed no documentation regarding the use of PRN [MEDICAL CONDITION] past 14 days was noted in the medication regimen review by Pharmacist #1. During an interview on 1/9/20 at 3:01 pm the Pharmacist stated the orders for Resident #s 1 and 6 were written without an end date and had exceeded 14 days. The Pharmacist further stated he/she was unable to provide any documentation by the physician indicating a rational for use of the antianxiety medication exceeding 14 days. In addition, the Pharmacist stated he/she was not aware that PRN [MEDICAL CONDITION] medication orders could not continue past 14 days without a physician documented rational and duration. As a result, the Pharmacist did not notify the physicians through the monthly medication regiment reviews as recommendation. Monthly Medication Regimen Policy: Review of the facility's policy Drug Regimen Review, revised date 6/1/19, revealed no time frames were established for the various steps of the monthly medication regiment review. Further review revealed the policy did not include steps to have been taken by the pharmacist in the event that he/she identified an irregularity that required urgent action to protect the resident. During an interview on 1/9/20 at 3:01 pm, Pharmacist #1 stated the policy did not include timelines for the various steps of the monthly medication regiment review. The Pharmacist further stated the policy did not include steps to have been taken by a pharmacist in the event that he/she identified an irregularity that required urgent action to protect the resident.

Based on record review and interview the facility failed to identify and correct systematic failures related to quality of patient care and medication management through the Quality Assurance and Performance Improvement (QAPI) program. This failed practice placed all residents (based on a census of 15) at risk for receiving less than optimal care and/or unnecessary medications. Findings: Review of the facility's Quality Assurance/Performance Improvement Plan, dated (Fiscal Year) 2019, revealed The scope of the Quality Assurance and Performance Improvement (PI) program is organization wide. All personnel and departments are expected to be actively involved in improving performance. The PI program evaluates the quality and appropriateness of the [DIAGNOSES REDACTED].Mediation therapy .Quality and appropriateness of [DIAGNOSES REDACTED]. During an interview on 1/10/20 at 9:20 am the Performance Improvement (PI) Manager stated the QAPI Committee met monthly and discussed ongoing projects and educated the staff. The PI Manager further stated the facility interviewed staff and reviewed medical records for potential issues. Unnecessary medications: [REDACTED] Review on 1/6-10/20 of medical records for Resident #s 1 & 6 revealed both residents were on an as needed (PRN) [MEDICAL CONDITION] medication (any drug that affects brain activities associated with mental processes and behavior) for the past several months. Review of the physicians' progress notes, for both residents, revealed no rational or duration documented for the use of PRN [MEDICAL CONDITION] medications greater than 14 days. In addition, the Pharmacist did not identify the irregularity and report it the physicians' for review of the recommendation. Refer to F756 and F758. During an interview on 1/9/20 at 3:01 pm the Pharmacist stated he/she was not aware that PRN [MEDICAL CONDITION] medication order could not continue past 14 days without physician rational and documented duration and had not notified the physicians through the monthly medication regiment reviews. Electronic Medical Record (EMR): Record review on 1/6-10/20 of EMR dashboard screen revealed multiple residents (#s 1; 6; 11; 12; and 14) had overdue entries required by the physician to evaluate orders. During an interview on 1/8/20 at 9:00 am the Medical Director stated the physicians' should renew residents' orders every 60 days. The Medical Director further stated he had been aware of several orders that were overdue for evaluation. The Medical Director stated the EMR will flag an order evaluation as late when 60 days had passed since the last review. Further review of the facility's EMR revealed an additional area of smoking assessment was illustrated as being overdue. The EMR was not recognizing the completion of smoking assessments in other parts of the EMR. During an interview on 1/10/20 at 9:20 am the Performance Improvement (PI) Manager stated the facility was aware of the EMR flagging deficiencies in areas of activities and interim care plans but was not aware of the alert warnings related to physician medication orders and smoking assessment. The PI Manager further stated he/she was unaware how to review these in report form in efforts to create a plan and resolution. When asked about the systematic issues of the extended use of PRN [MEDICAL CONDITION] medications past 14 days and failure to identify the extended use of these medication by the Pharmacist, the PI Manager stated the facility was unaware of these failures. The PI Manager further stated the QAPI Committee discussed gradual dose reduction of medications but not the extended use of PRN [MEDICAL CONDITION] medication.

Based on observation and interview the facility failed to ensure food items were maintained in a safe and/or sanitary manner. This failed practice placed 12 out of 15 residents at risk for food borne illness. Findings: Observation of the central kitchen on 1/6/20 from 1:50 pm to 2:15 pm revealed: - One can of slide apples (6 lbs., 8 oz.) - two dents on seal; - One can of applesauce (6 lbs., 12 oz.) - dent on seal; - One can of sliced pears (7 lbs.) - large (4-5) dent to body of can; - Food debris on the top of several food items; - Six red bell peppers with white fuzzy areas located in the walk in cooler; and - Eight cardboard boxes with bread were stacked from floor to ceiling preventing adequate air circulation in the walk in freezer. During an interview on 1/9/20 at 2:30 pm, the Dietary Manager stated the dented cans needed to be removed from use and the area should have been free of food debris. The Dietary Manager further stated the scoop should not have been stored in the flour. During the interview the Dietary Manager was made aware of the stacked boxes and potential for poor air circulation. Review of the U.S. Food & Drug Administration Food Code, dated (YEAR), accessed on 1/27/20 at https://www.fda.gov/media/ 2/download, revealed .dented cans may also present a serious potential hazard and .do not use moldy or decomposed food and .food shall be protected from contamination by storing the food .in a clean, dry location .Where it is not exposed to .dust, or other contamination.

Based on record review, interview and observation the facility failed to update and revise the care plan to reflect the current care and services for 2 residents (#s 10 and 15) out of 8 sampled residents whose care plans were reviewed. This failed practice placed the residents at risk for not receiving appropriate and/or necessary care and services. Findings: Resident # 10 Record review on 1/6-10/20 revealed Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on 1/7/20 at 12:44 pm, Resident #10 stated he/she had been to the hospital since admission but could not remember how many times or the reason for going to the hospital. Record review on 1/9/20 at 2:08 pm, of the electronic medical record (EMR), revealed Resident #10 was transferred from Long Term Care (LTC) for [MEDICAL CONDITION] to Mt. Edgecum Hospital Emergency Department (MEHED) then transported by medi vac (flown in an air ambulance) to Alaska Native Medical Center for care on 9/15/19. Further review of the EMR revealed Resident #10 returned from ANMC to the LTC when stabilized on Levetiracetam (an anti-[MEDICAL CONDITION] medication) 500 mg by mouth two times a day for [MEDICAL CONDITION]. Review of the Residents care plan does not contain information on [MEDICAL CONDITION]. During an interview on 1/9/20 at 4:42 pm, Licensed Nurse (LN) #1when asked about the care plan having [MEDICAL CONDITION] activity, the LN replied it was not in the care plan and the care plan but should have had the [MEDICAL CONDITION] listed on the care plan. The LN further stated, was a new [DIAGNOSES REDACTED]. Resident #15 Record review on 1/6-10/20 revealed, Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. An observation on 1/7/20 at 11:28 am, revealed Resident #15 was in the rehabilitation room for physical therapy session. Resident #15 was on the Nustep (exercise machine) and complained that his/her left leg was hurting and took it off the pedal and continue on the exercise with right foot only. During an interview with the Restorative Nursing Assistant (RNA) on 1/7/20 at 11:28 am, he/she stated that Resident #15 therapy schedule was Monday, Wednesday and Friday for Physical Therapy (PT) then Tuesday and Thursday for restorative therapy focusing on range of motion. When asked about the process when there was a change of condition or plan for resident care, he/she stated that it was reported to the Director of Nursing (DON) then the DON enters or updates the care plan in the computer. During an interview with Resident #15 on 1/7/20 at 1:00 pm, the Resident stated he/she took Tylenol. The medication was given by LN #3 after the Resident's physical therapy session. Resident #15 also stated that he/she takes [MEDICATION NAME] (a medication for nerve pain) and another medication he/she cannot recall. The Resident stated he/she does not take pain medication before therapy sessions. Resident #15 added that LN #4 gives him/her something that calms down his/her legs. Record review on 1/9/20 at 11:12 am, of Resident #15's Clinical Physician order [REDACTED]. Record review on 1/9/20 at 11:58 am, of Resident #15 Care Plan Review Start Date: 12/9/19, revealed no care plan for pain management. During an interview with LN #2 on 1/9/20 at 3:12 pm, when asked about Resident #15's pain management, the LN stated the Resident was on scheduled medication. The LN added Resident #15 doesn't complain of pain unless asked if he/she has pain. LN #2 further stated that Resident #15 would get PRN (as needed) [MEDICATION NAME] for muscle spasm. When asked about the care plan for pain, LN #2 stated it was included in the care plan, when asked to look at the facility's EMR where to find the care plan, there was no plan that focused on pain management. The LN stated pain should have been included as one of the focus areas under physical therapy. LN #2 further explained that there is an increase in the physical therapy session from 2 times a week to 5 times a week and that's why there is an increase in his/her pain or spasm. The LN stated that is something to look at and talk to the Doctor about. Record review on 1/9/20 at 4:35 pm, of PT Daily notes; Plan from 11/6/19 to 1/28/20, revealed, Instructions: . Start a conditioning program including arm bike, arms on Nustep, wc (wheelchair) mobility, and transfer training. Record review on 1/9/20 at 4:41 pm, of the PT Daily notes dated 12/11/19, revealed Instructions: . Incorporate seeing the Restorative Nursing Assistant (RNA) 2 days/week to include arm bike, Nustep for general strengthening. During an interview with LN #2, on 1/9/20 at 3:12 pm, when asked who updates the care plan, LN #2 stated the nurse's review and change it as applicable to the resident.

Based on record review and interview the facility failed to ensure as needed orders for [MEDICAL CONDITION] drugs (any drug that affects brain activities associated with mental processes and behavior) were limited to 14 days without clinical rationale or duration for extended use. This failed practice placed 2 residents (#s 1 and 6) out of 8 sampled residents at risk for receiving unnecessary medication. Findings: Resident #1: Record review of Resident #1's medical record from 1/6-10/20 revealed the Resident had [DIAGNOSES REDACTED]. Further review revealed the Resident's medication regime included scheduled antidepressant medication. Record review from 1/6-10/20 revealed an order for [REDACTED]. Review of the Primary Care Provider Note, dated 10/23/19, revealed Physician #1 documented that the Resident had a decrease in usage of [MEDICATION NAME] with a stable dose of [MEDICATION NAME] (a medication used to treat depression, panic attacks, [MEDICAL CONDITION], post-traumatic stress disorder, social anxiety disorder). Review of the Progress Note, dated 10/31/19, revealed Physician #1 documented There has been a noticeable reduction in usage of PRN (as needed) medications by this resident .(Resident #1) remains on [MEDICATION NAME] 100 mg daily .I recommend continued use of this dosage of [MEDICATION NAME] for chronic depression with anxiety. (Resident) remains stable in this regard. Review of the Sitka Long Term Care Progress Notes, dated 11/22/19, revealed Physician #1 documented .Anxiety (Resident) use of [MEDICATION NAME] is gradually reducing and minimal. Review of the Sitka Long Term Care Progress Notes, dated 12/18/19, revealed Physician #1 documented .Chronic Depression Stable on [MEDICATION NAME] .Anxiety As above. PRN (as needed) [MEDICATION NAME] is used sparingly. Review of the Medication Regimen Review, dated 9/2019 to 12/2019, revealed a decrease in the as needed use of [MEDICATION NAME] from (MONTH) through November. No documentation regarding the use of PRN [MEDICAL CONDITION] was noted in the medication regimen review by Pharmacist #1. Resident #6: Record review of Resident #6's medical record from 1/6-10/20 revealed the Resident had [DIAGNOSES REDACTED]. Further review revealed the Resident's medication regime included scheduled antidepressant medication, as well as, a scheduled antianxiety medication. Record review from 1/6-10/20 revealed an order for [REDACTED]. Review of the Sitka Long Term Care Progress Notes, dated 11/15/19, revealed Physician #2 stated No concerns of anxiety . Review of progress notes from 9/17/19 to 12/19/19 revealed no documentation pertaining to the rational for extended use of PRN [MEDICATION NAME] past 14 days or a documented duration in excess of 14 days. Review of the Medication Regimen Review, dated (MONTH) 2019 to (MONTH) 2019, revealed: - 8/2019 - 5 PRN doses of [MEDICATION NAME] used; - 9/2019 - no PRN doses of [MEDICATION NAME] used; - 10/2019 - 1 PRN dose of [MEDICATION NAME] used; - 11/2019 - 1 PRN dose of [MEDICATION NAME] used; and - 12/2019 - no PRN doses of [MEDICATION NAME] used. Further review of the medication regimen reviews revealed no documentation regarding the use of PRN [MEDICAL CONDITION] past 14 days was noted in the medication regimen review by Pharmacist #1. During an interview on 1/9/20 at 3:01 pm the Pharmacist stated the orders for Resident #s 1 and 6 were written without an end date and had exceeded 14 days. The Pharmacist further stated he/she was unable to provide any documentation by the physician indicating a rational for use of the antianxiety medication exceeding 14 days. In addition, the Pharmacist stated he/she was not aware that PRN [MEDICAL CONDITION] medication orders could not continue past 14 days without a physician documented rational and duration. As a result, the Pharmacist did not notify the physicians through the monthly medication regiment reviews as recommendation.

Based on record review, interview and observation the facility failed to ensure timely skin assessments were completed to prevent a pressure injury for 1 resident (# 9) out of 8 sampled residents. This failure had the potential to cause the resident unnecessary pain, an increased risk for infection, delayed healing, and poor medical outcome. Findings: Pressure Injury: According to the National Pressure Ulcer Advisory Panel, accessed 9/19/18 at www.nouap.org <http://www.nouap.org> A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Record review on 9/10-14/18 revealed Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS-a federally mandated assessment) a quarterly assessment dated [DATE] revealed the Resident had no pressure injuries or skin conditions. Further review of the MDS revealed Resident #9 was non-ambulatory, totally dependent on staff for bed movement, locomotion in wheelchair, bathing and needing extensive assistance (requiring two personal physical assistance) for dressing, toileting, transfers, and personal hygiene. Review of Resident #9's care plan revealed: Focus - Revision on: 5/10/18 .self-care performance deficit .AM ROUTINE: .is extensive assistance with grooming, oral care, and dressing .BATHING: .requires extensive assistance by 2 staff .Skin inspection: The resident requires SKIN inspection weekly and as needed. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse . Focus - Revision on: 5/9/18 .limited physical mobility .Goal .The resident will remain free of complications related to immobility .skin-breakdown . Monitor/document/report .skin-breakdown . Focus - Revision on: 5/9/18 .potential for pressure ulcer development .The resident will have intact skin, free of redness, blisters or discoloration .Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Record review of nurses' note dated 9/2/18 at 4:23 am, revealed Area of dark necrotic (death of cells and tissue) tissue noted to left lower extremity . Review of a skin/wound note dated 9/2/18 at 3:01 pm, revealed faxed a note to PMD (Primary Medical Doctor) re: 27x27 mm sore/necrotic to outer aspect of left foot . Further review revealed a note dated 9/3/18 at 7:04 pm, which stated Resident has area of dark red/black tissue to distal/lateral (on the side) aspect of plantar (bottom of the foot) surface of left foot .one small blister seen . Record review of Physician's progress notes dated 9/4/18 at 9:37 am, revealed .On patient's left lateral foot proximal fifth metatarsal (5th long bone in the foot) is 3 cm x 2 cm blister appearing non-open ulcer .Uncertain of grade at this time . Record review of physician progress notes [REDACTED].The lesion is on the left lateral foot in the region of the 5th metatarsal phalangeal joint (a hinge joint between the bones in the toes). It is partially covered with eschar (dry crust that results from trauma) and somewhat boggy (soft, wet, spongy feeling) to the touch as there appears to be subcutaneous (just beneath the skin) ecchymosis (bruising). It is also surrounded by callus (hard boney tissue). In my mind it is unstageable at this point and does require debridement .Assessment/Plan: Stage 3 left lateral foot ulcer . According to Mountain-Pacific Quality Health, a quality improvement organization, Stage 3 is full thickness skin loss in which fat is visible; a deep tissue injury is intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation; and an Unstageable pressure injury is a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed due to slough or eschar (dead tissue). Record review of the Weekly skin observation tool dated 7/13/18 at 6:27 am, revealed skin is intact and free of any red or open area marked A. yes . no other skin assessments were documented to present day. During an interview 9/14/18 at 10:39 am, the Director of Nursing (DON) confirmed no other weekly skin observation tools were documented after 7/13/18. Braden scale (an assessment tool used for predicating pressure sore risk) dated 7/19/2018 at 6:53 am, revealed score of 15, indicating at risk for developing pressure injuries. During an observation on 9/13/18 at 12:00 pm, Licensed Nurse (LN) #3 changed the dressing on left side of the sole of left foot. The ulcer, measured by the LN, measured 1 centimeters (cm) by 2 cm with 1 droplet of blood and black colored tissue on 2 cm of the outer aspect of the wound. While the LN irrigated the pressure injury the Resident yelled out and exhibited facial grimacing. When asked what may have caused the pressure injury the LN stated possibly from the Resident's foot rests on the wheelchair, (the Residents foot is abnormally rotated inward causing the sole of the foot (area of the 5th metatarsal) to rest on the foot of the single unit foot rest.) During an interview on 9/14/18 at 9:57 am, Certified Nursing Assistant (CNA) #2 was asked about how the skin assessments are completed he/she stated after the Residents bath/shower the CNA calls the LN to inspect the Residents skin or if when caring for the Resident and see a skin problem the CNA will call nurse to look at the area. The CNA further stated the assessment is also charted in Point of Care (P[NAME]) section in Electronic Medical Record or any skin issues. During an interview on 9/14/18 at 10:14 am, LN #2 stated weekly resident skin assessments are done with Residents bath/shower. CNA's notify the LN when the resident is ready for observation of their skin and the LN goes into shower room to assess the skin. During an interview on 09/14/18 at 11:03 am, the Director of Nursing (DON) stated they (the facility) has not found the cause of the pressure injury and confirmed the pressure injury was acquired in the facility. Review of the facility's Policy tilted Pressure Injury/Skin Breakdown, dated 7/2018, revealed .Procedure .4) Nursing staff will reassess the skin and document and any changes. A. Residents skin assessments will be completed weekly and as needed .i. Nursing staff will document weekly skin assessments in the resident medical record .

Based on record review, observation and interview the facility failed to ensure 1 resident's (#3), of 3 sampled residents, acute pain was managed to prevent pain and promote comfort, failed to: 1) ensure the care plan reflected treatment for [REDACTED]. These failed practices caused the resident actual harm from acute pain and discomfort following a tooth extraction. Findings: Record review on 11/17-19/15 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. In addition, the Resident had an acute dental abscess (infection) that required treatment with antibiotics. The Resident's medication regime included [MEDICATION NAME] IR (immediate release) 5 mg 4 times a day; [MEDICATION NAME] XR (extended release) 37.5 mg 2 times a day; [MEDICATION NAME] IR 5 mg PRN (as needed) every 4 hours; [MEDICATION NAME] 5 mg as needed every 8 hours; and Tylenol 650 mg as needed every 4 hours. Review of the Resident #3's separate care plans revealed the problem musculoskeletal pain related to chronic pain. The goal was Have controlled pain at an acceptable level with nursing interventions that included, Administer pain medications per orders-note relief; position for comfort. Review of the computerized care plan, dated 10/2/15, revealed the outcome Activity Intolerance .knowledge .medication .pain control .reduced pain. Further review of the computerized care plan revealed interventions included assess for behavioral and psychological indicators of pain .discharge planning .guided imagery .heat/cold application .maintain quiet environment .positioning .range of motion .relaxation exercises .simple relaxation therapy .teaching: individual .teaching: prescribed medication. During an observation on 11/18/15 at 6:40 am, Licensed Nurse (LN) #5 reminded the Resident of a dental appointment that morning. Review of the medical record revealed the Resident had a scheduled tooth extraction at the dental clinic on the morning of 11/18/15. During an observation on 11/18/15 the Resident returned from the dental appointment at 9:45 am. During an observation on 11/18/15 at 10:15 am, LN #1 entered the room to give the Resident regularly scheduled medications. During the interaction, the LN told the Resident let me know when your mouth starts hurting so I can give you some pain medications. The Resident stated at that time his/her mouth was still numb. Observation on 11/18/15 at 4:00 pm, LN #1 entered the resident dining room and told CNA #s 1, 6 and 7 that Resident #3 was in pain but could not have his/her pain medications yet because it was too early and s/he was trying to get the Resident back on schedule. Observation on 11/18/15 at 4:45 pm, crying was heard outside Resident #3's bedroom door. Upon entering, Resident #3 was observed in bed. CNA #1 and #6 were preparing to assist the Resident out of bed. The Resident was crying out, visibly tearing, red-faced, and holding the side of his/her right jaw in hand. The Resident confirmed s/he was having dental pain. During the observation, CNA #6 stated S/he's hurting; the hot packs don't work. During an interview on 11/18/15 at 4:55 pm, when asked about Resident #3's post-dental procedure pain management, LN #1 stated the Resident had just had his/her routine dose of [MEDICATION NAME] at 4:30 pm. The LN stated s/he had been trying to space it out because Resident #3 was off schedule. When questioned about the PRN (as needed) medication available, the LN stated I can't give 10mg of [MEDICATION NAME]; I could give her PRN (as needed) Tylenol. When asked about what the post procedure instructions were regarding dental surgery, LN #1 stated they had received a verbal report from the transport aide Activity Staff #2 and the dental clinic had not sent over any post discharge instructions. When asked how staff knew what interventions to follow when treating a Resident following a tooth extraction, the LN stated they were expected to go back to the regular schedule (for pain management). Further review of the medical record revealed no information about the type of or level of pain the Resident had been experiencing until 8:15 pm that night, more than 4 hours later. At 8:15 pm, Resident #3 identified the pain was a 6/10 (moderate to severe pain on a verbal pain scale with 10 being excruciating). Review of the Medication Administration Record [REDACTED]. Review of the nurse's note for 11/18/15 at 6:00 pm revealed, Repetitive Health Complaints, Repetitive anxious complaints/concerns. Under comments Resident had tooth extraction and fillings this AM. Had several episodes of tearfulness and wanting to call her daughter (daughter (name), visited at lunch aware of dental procedure). Frequent requests for pain medication and to 'Call SEARHC (dental clinic).' Frequent reminders about where she was this AM. Will continue to reassure, educate, and active listening. During an interview on 11/19/15 at 8:20 am when asked about documenting pain before and after a PRN (as needed) medication intervention, LN #7 stated the pain would have to be documented in the general notes because there was no place to document reassessment after PRN medication in the Medication Administration Record [REDACTED]. There was no medical information in the record that provided information to what dental procedure had been performed and which tooth/teeth had been extracted. During an interview on 11/19/15 at 12:00 pm, Activity Staff #2 confirmed s/he had accompanied Resident #3 to the dental appointment on 11/18/15. The Activity Staff stated the dental clinic had not sent post procedure information and instructions post tooth extraction on 11/18/15. The Activity Staff stated they had called the dental clinic and they were supposed to email something over to him/her. During an interview on 11/19/15 at 12:30 pm, when asked what procedure the Resident had done the Long Term Care (LTC) manager stated the Resident had multiple fillings at the gum line of the lower jaw and a tooth extraction on the lower right side. When questioned about the communication between the facility and the dental clinic the LTC Manager stated information should have been communicated to the nurse yesterday. During an observation on 11/19/15 at 3:30 pm, Activity Staff #1 entered Resident #3's room and stated s/he had gotten some more ice for the Resident's tooth pain. At that point LN #7 entered the room and stated that was wrong, the ice was only supposed to be for the first 24 hours, then it was supposed to be warm packs to the affected area. Review of Resident #3's prior dental appointment note from the dentist following a tooth extraction on 10/16/15, revealed Ice pack to (R) and (L) (right and left) side of face for first 12 hours. 20 minutes/ 1 hour. Recommend to increase [MEDICATION NAME] if needed for post-op pain. No straws for 5 days. Review of the Core Principles of Pain Management, accessed at www.geritaricpain.org <http://www.geritaricpain.org> on 11/23/15 revealed Every older adult deserves adequate pain management. Certain populations, including racial minorities, people with limited ability to communicate, older adults, and people with past or current substance abuse, are at higher risk for inadequate pain management .Evaluate the effectiveness of all therapies to ensure that they are meeting the resident's goals. Achievement of an effective treatment plan requires therapy to be individualized for each older adult, often requiring adjustments in drug, dosage, or route. Consistent reassessment is critical to good outcomes.

Based on observation, interview, and record review, the facility failed to ensure dishes were properly sanitized. All residents who received dishware or food from LTC kitchen were determined to be at risk for serious harm, impairment or death from food borne illness due to this failure. As a result this failed practice constituted an immediate jeopardy to residents' health and safety. This situation was brought to the attention of the facility's administration on 12/8/14 at 4:45 pm. On 12/8/14 at 1:50 pm, it was determined that the immediacy of the jeopardy had been abated through the facility's staff removing the un-sanitized dishes from the shelves after the surveyor brought the concern to their attention. Based on observation, interview, and record review, the facility failed to: 1) communicate to maintenance the malfunctioning of the kitchen's 3 dishwashing sinks; and 2) discard outdated milk. As a result, these failed practices created a potential for food borne illnesses for all residents receiving food from the kitchen, (based on a census of 10). Findings: IJ - Non-Sanitizing LTC Dishwasher During an observation of the LTC dishwashing process on 12/8/14 at 1:15 pm, the Surveyor asked Kitchen Staff (KS) #1 to test the sanitizing concentration in the dishwasher. KS #1 used the Chlorine Sanitizer Test Strips and stated the color corresponded with at least 10 ppm but less than 50 ppm. KS #1 stated the strip should indicate the sanitizing solution was at 100 ppm. KS #1 then ran another load of dishes through the dishwasher after identifying the sanitizer level was too low to properly sanitize the dishes and set the dishes up to dry. KS #1 did not notify the Kitchen Manager (KM) of the low level of the sanitizer solution. During an interview on 12/8/14 at 1:25 pm, at the Surveyor's request, the KM tested the dishwashing sanitizer. The KM read the strip as 10 ppm and stated that was too low to properly sanitize the dishes. KM further stated KS #1 would stop using the dishwasher and would wash dishes using the 3 sink process. An observation on 12/8/14 at 1:45 pm revealed KS #1 placed the dishes, that had been run through the dishwasher after the sanitizing solution was identified as too low, on the shelves making them available for use in preparing and serving food to the Residents of the LTC facility. After the Surveyor brought it to the attention of KS #1 that the un-sanitized dishes had been placed on the shelves, KS #1 then removed the un-sanitized dishes from the shelves. During an interview on 12/8/14 at 1:50 pm, the Kitchen Manager stated, the dishes should have been put back through the dishwasher to be sanitized and not placed on the shelves to be available for use. Review on 12/8/14 of the manufacturer guidelines for the dishwasher, Revision 1.01A, revealed "Chemicals...Follow the directions precisely that are on the litmus paper...Concentration should be 50 p.p.m. minimum to 100 p.p.m. maximum. If concentration is incorrect contact your chemical supplier." Policy review on 12/8/14 of "Cleaning Procedures", dated 9/08, revealed "Warewashing...The chlorine concentration levels will also be monitored daily. If the chlorine level falls below 50 ppm, the maintenance department will be notified and no warewashing will occur until the problem has been corrected." Because the non-sanitized dishes were on the shelf available for use in preparing and serving meals to the Residents of the LTC, Immediate Jeopardy was called. Review of <http://www.fda.gov>, accessed on 12/23/14, revealed, " Epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness: ? Improper holding temperatures, ? Inadequate cooking, such as undercooking raw shell eggs, ? Contaminated equipment, ? Food from unsafe sources, and ? Poor personal hygiene. " Further review of the website revealed, "As we age, it is normal for our bodies not to work as well as they did when we were younger. Changes in our organs and body systems are expected as we grow older. These changes often make us more susceptible to contracting a foodborne illness or food poisoning. For example, our stomach and intestinal tract may hold on to foods for a longer period of time; our liver and kidneys may not readily rid our bodies of toxins; and our sense of taste or smell may be altered. 1) By the age of 65, many of us have been diagnosed with [REDACTED]. The side effects of some medications or the chronic disease process may weaken the immune system, causing older adults to be more susceptible to contracting a foodborne illness. 2) After the age of [AGE] years and older, many adults often have a weakened immune system and are at an increased risk for contracting a foodborne illness. 3) Essentially, as we age, our immune system and other organs in our bodies have become a bit sluggish in recognizing and ridding the body of harmful bacteria and other pathogens that cause infections, such as foodborne illness. Should older adults contract a foodborne illness, you are more likely to have a lengthier illness, undergo hospitalization , or even die. 4) To avoid contracting a foodborne illness, older adults must be especially vigilant when handling, preparing, and consuming foods. " Malfunctioning Sinks During an interview on 12/9/14 at 7:30 am, the Kitchen Manager (KM) stated the 3 sinks used for washing dishes did not hold water and therefore could not be used as a back-up when the dishwasher was not operational. KM further stated the problem of the sinks not holding water was identified in November 2014 and maintenance had been notified verbally of the needed repair. During an interview on 12/9/14 at 7:45 am, Maintenance Staff (MS) #2 stated maintenance was not aware of the problem with the 3 sinks in the kitchen not holding water and therefore were not working on the repairs. Policy review on 12/8-11/14 of "Preventive and Corrective Maintenance", dated 03/06, revealed "...Special maintenance requests will be submitted in writing by the Food Services Manager by e-mail to the Service Request address. This will be dated, the nature of the work needed stated clearly and the urgency of the need indicated." Outdated Milk Observation in the kitchen refrigerator on 12/8/14 at 12:45 revealed: 5 containers of Darigold low-fat chocolate milk with an expiration date of 12/4/14; and 2 gallon jugs of Columbia 1% lowfat milk with an expiration date of 12/5/14. .

Based on record review, observation, and interview the facility failed to provide timely intervention for the prevention of pain for 1 resident (#1), and failed to assess and reassess pain after interventions for 3 residents (#s 1,2 and 4) out of 5 sampled residents. This failed practice caused resident #1 unnecessary pain during a transfer and created further risk for under treated pain for the residents, Findings: Resident #1 Record review on 2/3-6/14 revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) quarterly assessment (a federally required assessment tool), dated 1/6/14, revealed the assessment coded the Resident as having pain frequently that made it hard to sleep at night and limited day-to-day activities. The Resident had rated the pain as 7 out of 10, with 7 being severe pain. The Resident's medication regime included the pain medications Tylenol 1000 mg three times a day, [MEDICATION NAME] (used for nerve pain) 300 mg two times a day, [MEDICATION NAME] (narcotic [MEDICATION NAME]) 50 mcg [MEDICATION NAME], and [MEDICATION NAME] (narcotic [MEDICATION NAME]) 5 mg as needed (PRN) every 4 hours and [MEDICATION NAME] 10 mg PRN every 4 hours. Review of the "Resident Care Plan", dated 1/7/14, revealed the concern and problem, "Impaired Tissue Integrity", the approach Plan included, "Assess level of discomfort using pain scale " and "Medicate as prescribed, nsg (nursing) assess for effectiveness". Under the concern and problem, "Impaired physical mobility", the approach plan included "Assess and implement the need of [MEDICATION NAME] prior to activity." Under the concern and problem, "Alteration in Comfort . . ." the approach plan included "assess pain every 2 hours prior to repositioning for comfort" and "document pain level and comfort". On 2/5/14 at 3:49 pm, Certified Nursing Assistants (CNA) #2 and #7 were observed preparing to transfer the Resident out of bed for a bath. Immediately prior to the transfer, Licensed Nurse (LN) #7 entered the room and gave the Resident [MEDICATION NAME] 10 mg for pain. The LN then stated, "He should report it if it's not working. It's (the transfer) tough on his back." After the LN left the room both CNAs lowered the head of the bed, positioned the resident on the sling, and transferred the Resident out of bed using a mechanical lift. During the process the Resident cried out "Oh, Oh, Oh my back", "Damn", "(family members name)".The Resident continued to cry out, moan, and exclaimed "Be careful" and" I wish (family member's name) was here too!" At 4:09 pm, the 2 CNAs used the lift to propel the Resident to the tub room and lowered him into the tub. Resident #1's right arm trembled and the Resident continued to cry out. After the bath, the Resident was transferred back into the bed and continued to cry out "(family member's name), help me!" During an interview on 2/5/14 at 4:46 pm, when asked why the pain medication was not given earlier prior to the Resident's transfer, LN #6 replied they usually give the Resident a pain pill 30 minute before a bath but because the Resident had one at noon, it messed up the schedule. As a result, the Resident did not receive effective pharmaceutical pain management in a manner to prevent pain prior to the bath and transfers. Further review of the medical record revealed the physician had ordered a short acting pain medication PRN for breakthrough pain ([MEDICATION NAME] 5 or 10 mg). The medicine administration record (MAR) revealed the nurse failed to assess the effectiveness of the pain medication 7 of 18 times from 1/1-31/14 and failed to assess the pain prior to administration of the pain medication 4 of 18 times. For the month of February, the nurse failed to assess the pain prior to administration 4 out of 7 times and failed to assess for effectiveness of the pain medication 7 of 7 times, from 2/1-5/14. In addition no pain scale was used in assessing the severity of the pain. Resident #2 Record review on 2/3-6/14 revealed the Resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the medical record revealed the physician had ordered [MEDICATION NAME] 5 mg every morning, Tylenol 650 mg every 6 hours PRN, and [MEDICATION NAME] 5 mg/ml four times a day PRN for pain. Review of the Resident's care plan, evaluated 11/15/13, revealed "Alteration in comfort (related to decreased) mobility, contractures" Approaches included "Assess pain daily (and as needed)-facial grimaces, crying, extremity movement medicate per orders and not relief by body language." Review of the MAR for the month of January revealed the Resident had received 12 doses of PRN [MEDICATION NAME] and 8 doses of PRN Tylenol. further review revealed the pain was not assessed prior to administration 10 times and not reassessed for effectiveness 16 times. The PRN done of [MEDICATION NAME] given to the Resident 2/1/14 was not reassessed for effectiveness. Resident #4 Resident #4 was admitted to the facility on [DATE]. Prior to admission the resident suffered a stroke and as a result her [DIAGNOSES REDACTED]. The Resident had complained of pain in the right shoulder and arm. Record review on 2/4-6/14 revealed Resident had a doctor's order written on 1/23/14 for [MEDICATION NAME] (a pain medication) 5/325 every 6 hours PRN for pain and an order written [REDACTED]. Review of the residents care plan revealed there was no plan for pain. Review of the January MAR, dated 1/24-31/14, revealed Resident #4 received PRN pain medication 19 times. Further review revealed there was no pain scale used to document level of pain, and 13 of the 19 pain medications administrations were not reassessed for effectiveness. Review of the February MAR indicated [REDACTED]. During an interview on 2/5/14 at 5:00 pm, when asked how nurses were to assess pain for effectiveness, LN #2 replied the nurses should have documented in the MAR. When asked about how the nurses were to assess for pain severity, LN #2 replied the facility did not use the pain scale in the long-term care. During an interview on 2/5/14 at 5:30 pm, the Director of Nursing (DON) and the Long-Term Care Manager (LTCM) confirmed pain should be assessed and reassessed when administering an [MEDICATION NAME]. During the interview, the DON confirmed a numeric pain scale should be used for long-term care. The LTCM stated Resident #1 "lets someone know when he is in pain." The LTCM confirmed she was responsible for auditing the MAR .