Every finding on record at Utuqqanaat Inaat

.Based on record review and interview, the facility failed to: 1) Develop written policies and procedures regarding the visitation rights for residents to include procedures for safety restrictions or limitations; and 2) Implement reasonable safety restrictions or limitations against a visitor for 1 Resident (#4), out of 1 resident reviewed, when abuse by way of misappropriation of resident property was suspected. The facility's failure to establish procedures for implementing reasonable safety restrictions placed all 18 residents at risk for continued unrestricted access by visitors when concerns involving abuse, exploitation, coercion, criminal activity, disruptive behavior, or illegal substances were identified. The facility failed to implement measures to protect Resident #4 when abuse was suspected. Resident #4 was subjected to potential misappropriation of resident property causing the resident to not have money when needed, a bank overdraft, and seizure of a social security check by the bank causing the resident to be without money in May 2026 and June 2026. Findings:1) Visitation Policy Review of State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Rev. 229; Issued 4/25/25, revealed the Code of Federal Regulations (CFR) 483.10(f)(4)(iii) and (v) addressed the resident rights to receive visitors of his or her choosing at the time of his or her choosing, as well as, the facility's obligation to initiate safety restrictions or limitations when needed: - 483.10(f)(4)(iii) - The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time; - 483.10(f)(4)(v) - The facility must have written policies and procedures regarding the visitation rights, including those setting forth any clinically necessary or reasonable restriction or limitation or safety restriction or limitation, when such limitations may apply consistent with the requirements of this subpart, that the facility may need to place on such rights and the reasons for the clinical or safety restriction or limitation. Further review of the regulation guidance revealed: . 'Reasonable clinical and safety restrictions' include a facility's policies, procedures, or practices that protect the health and security of all residents and staff. These may include, but are not limited to. Denying access or providing limited and supervised access to an individual if that individual is suspected of abusing, exploiting, or coercing a resident until an investigation into the allegation had been completed or has been found to be abusing, exploiting, or coercing a resident. Denying access to individuals who have been found to have been committing criminal acts such as theft; Denying access to individuals who are inebriated or disruptive; or Denying access or providing supervised visitation to individuals who have a history of bringing illegal substances into the facility which places residents' health and safety at risk. Review of the facility-provided policy LTC - Visitation Rights of Residents, last reviewed 3/11/26, revealed: The resident has the right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable.With respect to any restrictions on visitors during infectious disease outbreaks or the resident's medical condition, decisions will be made to the facility's infection control contact isolation policy. Further review of the policy revealed no facility guidance on the regulatory obligation for the facility to place needed safety restrictions or limitations when concerns are identified. 2) Resident #4 Record review on 7/23-29/26 revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia, such as hallucinations and delusions, and mood disorder symptoms, such as depression) and the diagnosis other symptoms and signs involving cognitive functions and awareness (a billable code used to document cognitive symptoms that do not fit into a more specific neurological or psychiatric diagnosis). Review of Resident #4's Pre-admission Screening and Resident Review (PASRR - A federally required assessment to ensure individuals with serious mental illness or intellectual disabilities meet requirements to be admitted to a nursing home and have appropriate mental health services if needed) level II assessment, dated 6/10/26, revealed: .the individual carries a documented history of schizoaffective disorder, grave disability, moderate cognitive impairment, unspecified depression, dementia, and cerebral ischemia [insufficient blood flow to the brain]. [He/she] has been identified as being at risk for acute safety concerns. The individual acknowledged some degree of memory difficulty and recognized that [he/she] would be unable to care for [himself/herself] outside the facility. During an interview on 7/23/26 at 3:01 PM, the Administrator stated Resident #4 had a friend (#18) who checked him/her out of the facility routinely. Friend #18 would take Resident #4 straight to the bank after leaving the facility and obtain money from Resident #4. The Administrator stated in May 2026, facility leadership identified a greater concern about this situation involving Resident #4 and Friend #18 after the resident's bank account became overdrawn and the resident had no money available for personal use. Then in June 2026, the resident's social security check was seized by the bank to cover these delinquent funds. When asked if the leadership would classify this concern as misappropriation of resident property, the Administrator described the concern as financial abuse. When asked what the facility did once this concern escalated to potential abuse, the Administrator stated they talked to Friend #18 several times to stop taking Resident #4's money, but he/she would counter, saying the resident gave it to him/her. The leadership also talked to Resident #4 about not giving Resident #18 money, however he/she would say Friend #18 asked for it and he/she has helped me out in the past. They have also encouraged Resident #4 to keep his/her bank card in the facility when he/she left with Friend #18, but the resident sometimes didn't. The Administrator stated Resident #4 came out of his/her room at night once reporting that Friend #18 had his/her bank card and hadn't returned it. When asked if anything else had been done, the Administrator stated nothing else had been done. The leadership would like to get Resident #4 a conservator because they felt Resident #4 needed assistance with finances. When asked if this had been initiated, the Administrator stated it had not happened at this time. The Administrator stated Friend #18 was told he/she needed to stop taking Resident #4's money in June 2026 and warned the friend they would report it if it didn't stop, but thus far the facility had not reported the concern. During an interview on 7/28/26 at 11:41 AM, the Social Worker stated that she believed Friend #18 was manipulating Resident #4 to take his/her money. When asked how long she has had this concern, the Social Worker stated shortly after the Resident's December 2025 admission, some time in January or February 2026. When asked what she did about this concern to protect the resident, the Social Worker stated she talked to the Administrator about it and also talked to Resident #4. Also, the Social Worker wanted to petition to get a conservator for Resident #4 but had not done this yet. During an interview on 7/28/26 at 1:22 PM, the Director of Nursing (DON) stated staff suspected Friend #18 was taking the resident's money in May 2026. When asked what she did about this concern, the DON stated they talked to Resident #4 about not giving Friend #18 his/her money. When asked what she had done to protect the resident, the DON stated they were going to try and get Resident #4 a conservator and that the Social Worker was working on it. The DON stated they did not stop the resident from going out with Friend #18 because it was his/her right to do so. During an interview on 7/28/26 at 3:19 PM, when asked if the facility protected the resident by restricting Friend #18's contact with Resident #4, the Administrator stated they had not done this because it was a resident right to allow Resident #4 to visit with whom he/she wanted. When asked if the Administrator was aware of the regulatory obligation to have written policies and procedures regarding reasonable restrictions or limitations for safety restrictions, particularly with suspected abuse like misappropriation of resident property, the Administrator stated she was not aware of this. Review of Resident #4's leave-of-absence log, dated 12/29/25 through 7/20/26, showed that Friend #18 took Resident #4 from the facility 25 times, with 11 of those absences taking place from May on after leadership identified a potential abuse concern. At the time of survey, there were no restrictions from Friend #18 taking Resident #4 from the facility. A review of Resident #4's progress notes, dated 1/29/26 to 7/24/26, revealed multiple documented events where Friend #18 had unrestricted access to Resident #4's bank account that was not addressed by the facility: - 1/29/26 at 6:02PM (Late Entry) - Elder made a phone call to [his/her] friend [#18] and told [him/her] over the telephone 'Hey, I have $51.00 dollars in my bank account, come up and get my bank card and go to AC and get the money.' - 1/29/26 at 7:39 PM - Elder contacted friend [#18] to retrieve their bank card for the purpose of withdrawing funds. Elder stated friend needed money and it was [his/her] choice. Supervisor made aware due to potential concerns for financial vulnerability. - 1/29/26 at 7:42 PM (Late Entry) - Elder friend [#18] came to facility at this time and retrieved elders bank card and pack of cigarettes then left facility with those items. Supervisor made aware. - 1/30/26 at 5:38 PM - Elders friend [#18] returned to facility to supposedly return bank card. When nurse asked elder for [his/her] bank card to lock up safely [he/she] said 'I don't have it. [He/she] did not give it back to me.' This nurse checked [his/her] room for the bank card and did not find it. Elder stated [he/she] said [he/she] would be back.' - 1/31/26 at 8:39 PM - Elder called friend [#18] to return bank card. [Friend #18] arrived with a friend. Returned bank card at this time also gave elder $100 in cash. Elder then mentioned [he/she] wanted to give [Friend #18] $20.00 [Friend #18] refused and left the facility. This writer and two staff CNA [Certified Nursing Assistant] present. Bankcard and money placed in elder purse in facility safety area. - 2/8/26 at 5:34 AM - Elder used phone to call friend [#18] Elder stated 'come here, go to the bank and get my money then go buy yourself cigarettes.' Elder hung up the phone walked over to the dining area for breakfast. - 3/9/26 at 8:07 PM - Elder received a visit from a friend identified as [Friend #18]. Elder voluntarily provided [Friend #18] with a shopping list, debit card, and associated PIN to facilitate a purchase. Per Elder, [Friend #18] is expected to return the purchased items and the bank card this evening. - 3/9/26 at 8:41 PM - [Friend #18] returned with purchased items and elder's debit card. Debit card and $26 in cash locked away in elder's wallet per protocol. - 4/8/26 at 6:41 PM - Elder left facility with friend [#18] due to return later this evening. Educated friend [#18] on being responsible of elder safety. Elder in stable condition. Elder and staff counted elders remaining balance in purse $18 elder signed paper confirming. Supervisor aware. - 4/8/26 at 8:20 PM - Elder returned from outing escorted by friend [#18]. Elder now has a balance of $0 in cash. Elder returned in stable condition. - 5/3/26 at 9:03 PM - Elder returned from outing with friend [#18]. Elder left with $120 returned with $30.30 and a receipt from bank of a withdrawal $70.00. Remaining balance in bank $4. Elder signed paper understanding. - 5/12/26 at 9:06 PM - Elder returned back from outing with [Friend #18]. Elder seems under the influence. Barely able to stand up periodically. Elder stated that [he/she] was high and that [he/she] smoked while out. Stumbling. Elder unable to walk to room/Elder had to be assisted to room with rolling chair by cna. Elder came back with $0.00 cash. Elder stated [he/she] spent all of [his/her] money while out. Will continue to monitor and provide support as needed. - 6/3/26 at 5:28 PM - Elder left out of the facility with friend [#18]. Elder left with purse containing ID, bank card, keys and $10.82 in cash. - 6/28/26 at 5:30 PM - Elder went out with [Friend #18], [he/she] wanted to get out and get some fresh air and a pizza. - 6/29/26 at 8:13 PM - Elder return from outing with friend [#18]. Elder has $10.89c [cash] 2 bank cards and ID. Elder in stable condition. - 6/30/26 at 8:46 PM - Elder returned from outing w/ [with] friend [#18]. Elder returned with $26.00 two bank cards and ID. Elder in stable condition.

.Based on record review and interview, the facility failed to: 1) Report an allegation of abuse to the State Agency as required under CFR 483.12(c)(1). Specifically, the facility did not report suspected misappropriation of resident property for 1 Resident (#4), out of 1 resident reviewed, when first identified in January 2026; and 2) Develop and implement an accurate reporting policy for allegations of abuse that aligned with regulatory requirements. Not reporting a concern for abuse in an appropriate and timely manner subjected Resident #4 to continued misappropriation of resident property and financial insecurity causing the resident to not have money when needed, a bank overdraft, and seizure of a social security check by the bank causing the resident to be without money in May 2026 and June 2026. Not having accurate reporting requirements within their policy placed all residents (based on a census of 18) at risk for exposure to abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property. Findings:1) Resident #4 Record review on 7/23-29/26 revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia, such as hallucinations and delusions, and mood disorder symptoms, such as depression) and the diagnosis other symptoms and signs involving cognitive functions and awareness (a billable code used to document cognitive symptoms that do not fit into a more specific neurological or psychiatric diagnosis). Review of Resident #4's Pre-admission Screening and Resident Review (PASRR - A federally required assessment to ensure individuals with serious mental illness or intellectual disabilities meet requirements to be admitted to a nursing home and have appropriate mental health services if needed) level II assessment, dated 6/10/26, revealed: .the individual carries a documented history of schizoaffective disorder, grave disability, moderate cognitive impairment, unspecified depression, dementia, and cerebral ischemia [insufficient blood flow to the brain]. [He/she] has been identified as being at risk for acute safety concerns. The individual acknowledged some degree of memory difficulty and recognized that [he/she] would be unable to care for [himself/herself] outside the facility. During an interview on 7/23/26 at 3:01 PM, the Administrator stated Resident #4 had a friend (#18) who checked him/her out of the facility routinely. Friend #18 would take Resident #4 straight to the bank after leaving the facility and obtain money from Resident #4. The Administrator stated in May 2026, facility leadership identified a greater concern about this situation involving Resident #4 and Friend #18 after the resident's bank account became overdrawn and the resident had no money available for personal use. Then in June 2026, the resident's social security check was seized by the bank to cover these delinquent funds. When asked if the leadership would classify this concern as misappropriation of resident property, the Administrator described the concern as financial abuse. When asked what the facility did once this concern escalated to potential abuse, the Administrator stated they talked to Friend #18 several times to stop taking Resident #4's money, but he/she would counter, saying the resident gave it to him/her. The leadership also talked to Resident #4 about not giving Friend #18 money, however he/she would say Friend #18 asked for it and he/she has helped me out in the past. They have also encouraged Resident #4 to keep his/her bank card in the facility when he/she left with Friend #18, but the resident sometimes didn't. The leadership would like to get Resident #4 a conservator because they felt Resident #4 needed assistance with finances. When asked if this had been initiated, the Administrator stated it had not happened at this time. The Administrator stated Friend #18 was told he/she needed to stop taking Resident #4's money in June 2026 and warned the friend they would report it if it didn't stop, but thus far the facility had not reported the concern. When asked if the Administrator was a mandated reporter, the Administrator stated she was. When asked why she did not report this concern, the Administrator stated she did not report because Resident #4 stated he/she felt Friend #18 wasn't taking advantage of him/her. During an interview on 7/28/26 at 11:41 AM, the Social Worker stated that she believed Friend #18 was manipulating Resident #4 to take his/her money. When asked how long she has had this concern, the Social Worker stated shortly after the Resident's December 2025 admission, sometime in January or February 2026. When asked what she did about this concern to protect the resident, the Social Worker stated she talked to the Administrator about it and also talked to Resident #4. Also, the Social Worker wanted to petition to get a conservator for Resident #4 but had not done this yet. When asked if she was a mandated reporter, the Social Worker stated she was. When asked if she reported this concern, the Social Worker stated she did not because she didn't feel there was anything to report. During an interview on 7/28/26 at 1:22 PM, the Director of Nursing (DON) stated staff suspected Friend #18 was taking resident #4's money in May 2026. When asked what she did about this concern, the DON stated they talked to Resident #4 about not giving Friend #18 his/her money. When asked what she had done to protect the resident, the DON stated they were going to try and get Resident #4 a conservator and that the Social Worker was working on it. When asked if she was a mandated reporter, the DON stated she was. When asked why she did not report this concern, the DON stated because Resident #4 was giving Friend #18 the money. Review of Resident #4's leave-of-absence log, dated 12/29/25 through 7/20/26, showed that Friend #18 took Resident #4 from the facility 25 times, with 11 of those absences taking place from May through July, after leadership identified a potential abuse concern. At the time of survey, there were no restrictions from Friend #18 taking Resident #4 from the facility. A review of Resident #4's progress notes, dated 1/29/26 to 7/24/26, revealed multiple documented events where Friend #18 had unrestricted access to Resident #4's bank account that was not addressed by the facility: - 1/29/26 at 6:02PM (Late Entry) - Elder made a phone call to [his/her] friend [#18] and told [him/her] over the telephone 'Hey, I have $51.00 dollars in my bank account, come up and get my bank card and go to AC and get the money.' - 1/29/26 at 7:39 PM - Elder contacted friend [#18] to retrieve their bank card for the purpose of withdrawing funds. Elder stated friend needed money and it was [his/her] choice. Supervisor made aware due to potential concerns for financial vulnerability. - 1/29/26 at 7:42 PM (Late Entry) - Elder friend [#18] came to facility at this time and retrieved elders bank card and pack of cigarettes then left facility with those items. Supervisor made aware. - 1/30/26 at 5:38 PM - Elders friend [#18] returned to facility to supposedly return bank card. When nurse asked elder for [his/her] bank card to lock up safely [he/she] said 'I don't have it. [He/she] did not give it back to me.' This nurse checked [his/her] room for the bank card and did not find it. Elder stated [he/she] said [he/she] would be back.' - 1/31/26 at 8:39 PM - Elder called friend [#18] to return bank card. [Friend #18] arrived with a friend. Returned bank card at this time also gave elder $100 in cash. Elder then mentioned [he/she] wanted to give [Friend #18] $20.00 [Friend #18] refused and left the facility. This writer and two staff CNA [Certified Nursing Assistant] present. Bankcard and money placed in elder purse in facility safety area. - 2/8/26 at 5:34 AM - Elder used phone to call friend [#18] Elder stated 'come here, go to the bank and get my money then go buy yourself cigarettes.' Elder hung up the phone walked over to the dining area for breakfast. - 3/9/26 at 8:07 PM - Elder received a visit from a friend identified as [Friend #18]. Elder voluntarily provided [Friend #18] with a shopping list, debit card, and associated PIN to facilitate a purchase. Per Elder, [Friend #18] is expected to return the purchased items and the bank card this evening. - 3/9/26 at 8:41 PM - [Friend #18] returned with purchased items and elder's debit card. Debit card and $26 in cash locked away in elder's wallet per protocol. - 4/8/26 at 6:41 PM - Elder left facility with friend [#18] due to return later this evening. Educated friend [#18] on being responsible of elder safety. Elder in stable condition. Elder and staff counted elders remaining balance in purse $18 elder signed paper confirming. Supervisor aware. - 4/8/26 at 8:20 PM - Elder returned from outing escorted by friend [#18]. Elder now has a balance of $0 in cash. Elder returned in stable condition. - 5/3/26 at 9:03 PM - Elder returned from outing with friend [#18]. Elder left with $120 returned with $30.30 and a receipt from bank of a withdrawal $70.00. Remaining balance in bank $4. Elder signed paper understanding. - 5/12/26 at 9:06 PM - Elder returned back from outing with [Friend #18]. Elder seems under the influence. Barely able to stand up periodically. Elder stated that [he/she] was high and that [he/she] smoked while out. Stumbling. Elder unable to walk to room/Elder had to be assisted to room with rolling chair by cna. Elder came back with $0.00 cash. Elder stated [he/she] spent all of [his/her] money while out. Will continue to monitor and provide support as needed. - 6/3/26 at 5:28 PM - Elder left out of the facility with friend [#18]. Elder left with purse containing ID, bank card, keys and $10.82 in cash. - 6/28/26 at 5:30 PM - Elder went out with [Friend #18], [he/she] wanted to get out and get some fresh air and a pizza. - 6/29/26 at 8:13 PM - Elder return from outing with friend [#18]. Elder has $10.89c [cents] 2 bank cards and ID. Elder in stable condition. - 6/30/26 at 8:46 PM - Elder returned from outing w/ [with] friend [#18]. Elder returned with $26.00 two bank cards and ID. Elder in stable condition. 2) Facility's Reporting Abuse Policy Procedures Review of State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Rev. 232; Issued 7/23/25, revealed the Code of Federal Regulations (CFR) 483.12(b) and (c) addressed the reporting requirements for LTC facilities when allegations of abuse are reported: - CFR 483.12(b): The facility must develop and implement written policies and procedures that: - CFR 483.12(c): In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: - 483.12(c)(1): Ensure that all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, - or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Review of the facility-provided policy LTC - Abuse Prevention, Identification, Investigation, Reporting and Protection, last reviewed 3/11/26, revealed: . Types of Abuse. Abuse is defined as. Misappropriation of residents property is defined as the illegal or improper use of a resident's resources for the personal profit or gain of another person; or borrowing resident funds; or spending resident funds without the resident's consent; or if the resident is not capable of consenting; or spending resident funds to acquire items for use in common areas when such purchase is not initiated by the resident. Further review of the policy revealed: .Investigation. Any staff member observing or receiving a report of misappropriation will immediately notify their supervisor and the administrator. Confirmation of misappropriation of resident property and physician or sexual abuse will be reported to law enforcement by Administrative personnel. Allegations of abuse or neglect will be reported within 24 hours to appropriate state survey agency by the administrator and/or his designee. Results of the investigation will be reported to the state survey agency within 5 days after initial reporting. Reporting. The following are required by law to report abuse or suspected abuse. Licensed practical nurse or registered nurse. Caregiver of a vulnerable adult. Social Worker. Administrator of a nursing home, residential care, or health care facility. If, in the performance of their duties, any of the above have cause to believe that a vulnerable adult suffers from abandonment, exploitation, abuse, neglect, or self-neglect a report shall be made no later than 24 hours after first having cause for the belief to the departments central information and referral services for vulnerable adults. The policy's verbiage did not align with CFR 483.12(c) and 483.12(c)(1) regulatory requirements to report allegations of abuse, neglect, exploitation or mistreatment immediately, but no later than two hours after the allegation was made. The Reporting section of the facility's policy directed staff to report concerns to the department's central information and referral services for vulnerable adults; however, the policy did not clearly identify the State Survey Agency or Adult Protective Services to which allegations of abuse were to be reported, resulting in an incomplete reporting protocol

.Based on record review and interview, the facility failed to: 1) provide 1 resident (#12), out of 1 resident reviewed, with a written notice of transfer/discharge at least 30 days prior to the transfer or discharge in a language and manner they understand to include the reason for the transfer or discharge and the resident's appeal rights, including information on how to obtain an appeal form and assistance with completing and submitting an appeal hearing request; 2) provide the resident's written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman (OLTCO) and to accurately report to the OLTCO where the resident discharged to; and 3) Develop and implement an accurate transfer/discharge policy regarding notification of transfer/discharge that aligned with regulatory requirements. This failed practice denied the resident his/her right to receive the notice and know of his/her right to understand and exercise the right to appeal the transfer or discharge decision. Findings:1) Resident #12 Record review on 7/23-29/26 revealed resident #12 was admitted on [DATE] with diagnoses that include; major depressive disorder, history of falling, hypertension (high blood pressure), hyperlipidemia (high cholesterol), urinary incontinence, anemia, benign prostatic hyperplasia (enlarged prostate). Further review revealed Resident #12 discharged from the facility on 2/27/26. Review of Resident #12's Care Conference Summary, dated 2/16/26, which was the resident's discharge conference, revealed: . Resident Goals of Care: safe discharge planning . Risks/Needs/Preferences/Strengths: Doesn't want to leave . Discharge Plan/Return to Community Referral: Safe discharge to the community . Special Requests/Choices/Conditions: wants to stay longer, however doesn't meet criteria . Elder refused to have assistance [with] filling out applications for housing. Staff will continue to offer assistance [with] safe discharge planning . Elder asked staff to [lie] on authorization so [he/she] can stay longer . Further review of Resident #12's medical record revealed: 1) no discharge planning progress notes; and 2) one hand-written discharge summary prepared by the DON and signed by Provider #7. There was no discharge order. Review of Resident #12's medical record revealed no notification of discharge paperwork. Review of Resident #12's Discharge Summary, handwritten note, dated 2/27/26, revealed: . Brief History: [AGE] year old [male/female] admitted for endurance and strength training. [which was not an accurate representation for why he/she was admitted ] Pertinent Physical and Laboratory Findings: Improvement in ADL status. Improvement in labs. Does not meet requirements for long term care . Further review revealed no documentation as to why the resident was being discharged or where Resident #12 discharged to. During an interview on 7/29/26 at 8:21 AM, the Administrator stated Resident #12's admission intent was to stay long-term, he/she wasn't admitted strictly for rehab services, and there was no documentation to support why this resident was discharged from the facility. The medical record revealed no other provider notes documenting the reason for the resident's discharge, where he was discharging to, or disposition at discharge. During an interview on 7/23/26 at 3:01 PM, the Administrator stated resident came to the facility very weak but barely met admission standards. The resident was only approved for 85 days of stay. When asked about Resident's discharge, the Administrator stated the Resident was very evasive with any kind of discharge planning. Attempts to work with the resident on senior housing applications were attempted but the resident refused. When asked if there was documentation for these attempts and the resident's refusals, the Administrator stated there was none. When asked about the resident's original housing situation, the Administrator stated he/she couch surfed from house to house. When asked why Resident #12 was discharged , the Administrator stated he/she met PT (Physical Therapy) goals, didn't participate in the program, and the resident left daily to go out into the community. The Administrator stated he/she was only approved for 85 days, and it was very hard to get those days approved. When asked if an attempt was made to get more days authorized for the resident, the Administrator stated she was told by the past Administrator, who completed the LTC authorizations, the resident would not qualify, so no. When asked if the resident was admitted for rehab, the Administrator stated, No. When asked if it was the resident's right to not participate in the program and go out into the community, the Administrator stated it was the resident's right to do so. The Administrator could not state why the resident was discharged from the facility other than the resident was only approved for 85 days. The Administrator agreed that every resident was only authorized for a limited number of days and re-authorizations were completed on every resident routinely. The Administrator could not state why Resident #12 was not offered the same opportunity. During the survey, leadership confirmed there was no discharge planning documentation, no notification of discharge given, and no way of knowing where Resident #12 was going when he/she left the facility. Review of the facility's discharge notification faxed to the LTC Ombudsman's Office, dated 3/5/26, revealed Resident #12 D/C [discharged ] to home on 2/27/26. When leadership was asked about this, they acknowledged the resident didn't discharge to his/her home and that they couldn't identify where he/she went after leaving the facility. During an interview on 7/28/26 at 11:41 AM, the Social Worker stated she was an LPN and had no degree or license as a Social Worker. She stated she completed a 10-hour online course and started working with no training. The Social Worker stated she was still learning the role. When asked about Resident #12's discharge, and if a notification of discharge was provided to the Resident, the Social Worker stated she didn't know what that was. When asked about discharge planning, the Social Worker stated about two or three weeks prior to discharge she approached the resident to discuss where he/she was going, what the resident was going to do, and what his/her discharge would look like. She attempted to review housing applications with the resident, but he/she refused. He/she was also banned from one of them for past behavior. When asked if there was any documentation on any of these discussions or attempts to complete housing applications, the Social Worker stated there was not. When asked if Resident #12's authorization for admission was attempted to be extended, the Social Worker stated she was told by the past Administrator Resident #12 would not re-qualify, so there was no re-authorization attempted. When asked how she ensured Resident #12 was safely discharged , the Social Worker stated they completed a discharge care conference, but the resident would not give any information. When asked if she implemented the facility's Transfer and Discharge policy (of documenting discharge planning and notification), the Social Worker stated she thinks she read the policy but didn't know the content and stated there was little to no training for the Social Worker role. During an interview on 7/28/26 at 1:22 PM, when asked if she could assure staff accurately completed the discharge process for Resident #12, the DON stated, No. The DON stated the Resident's discharge should have been an AMA (against medical advice) but was not. The DON stated she did not see any documentation to show the resident was notified of discharge and was not aware of the regulatory requirement to notify the resident in writing or give residents appeal rights. During an interview on 7/28/26 at 2:30 PM, Provider #7 stated he was the Medical Director for the long-term care and oversaw the medical care for the residents. When asked about Resident #12's admission and care, Provider #7 stated he had rounded on Resident #12's care a couple of times and remembered him/her to be overall stable. Resident #12 was his/her own decision maker, and he/she required one-person assist with bathing, toileting, and dressing. Resident #12 was also incontinent. When asked how he determined what level of assistance a resident would need with ADLs, Provider #7 stated he would ask the nurses while rounding. When asked about Resident #12's discharge on [DATE], Provider #7 stated he was informed that it was a planned discharge and did talk with Resident #12 prior to him/her leaving. Provider #7 stated he didn't have a concern with Resident #12's home environment. When asked if Resident #12 had a home, Provider #7 stated he could not elaborate on that. Provider #7 stated he didn't get an understanding of where Resident #12 was going and did not ask where he was being discharged to. When asked Provider #7 documented a provider discharge summary note for Resident #12, Provider #7 stated he usually completed a discharge summary note for residents discharging but did not do one for Resident #12. Review of Resident #12's progress note, dated 2/25/26, revealed: Elder stated, 'I only have two days left here maybe I will fall down and break my hip so I can stay longer' Resident redirected and educated on importance of safety and preventing injury. Staff alerted to provide frequent checks on elder . During an interview on 7/28/26 at 3:19 PM, when asked if there was adequate documentation within the medical record to show the resident's discharge was properly handled, the Administrator stated, No. When asked if the resident was given a notification of discharge, the Administrator stated the facility did not have a notification of discharge form, and it was normally completed verbally. When asked if the resident was given rights to appeal information, the Administrator stated, No. During an interview on 7/29/26 at 11:44 AM, when asked how his/her discharge occurred, Resident #12 stated he was told on Friday, 2/27/26, you are leaving this weekend, pack all your stuff. Resident #12 stated he/she asked for more days to prepare where he/she would go, because he/she had no plan, but staff were adamant I had to leave. Resident #12 stated he/she told them he/she would have liked to have stayed at the facility but they made up their mind [that he/she had to leave]. When asked how it felt knowing he/she had to discharge, Resident #12 got emotional, his/her voice cracked and said, not wanted. When asked how leaving without a plan affected him/her, Resident #12 stated, there I was outside, I didn't have enough money, and it was wintertime. Resident #12 stated he/she had no idea where he/she was going to go. He/she started staying with friends, but it wasn't a place to stay long because they were drinking and he/she didn't feel safe in those situations. When asked if staff helped to try and find Resident #12 a place to go once discharged , Resident #12 stated the discussion about housing never happened. The staff just told him/her to gather his/her stuff, place it at the door, and leave. Staff told Resident #12 he/she could come back to get his/her belongings when he/she found a place to stay. During the course of the survey, leadership was not able to adequately show proof of an appropriate discharge or prove they provided a safe discharge. They did not notify the resident of discharge or his/her rights to appeal. 2) Facility's Transfer/Discharge Policy Notification Procedures Review of the facility-provided policy Transfer or Discharge, last reviewed 1/23/26, revealed: - . ADDITIONAL CONSIDERATION(S): A. Notice to Patient of Intent to Transfer or discharge: 1. The transfer notice is to include an explanation of the right to appeal the transfer to the State as well as the name, address, and phone number of the State Long Term Care Ombudsman: To be completed by Social Service Director in Long Term Care.Office of Long Term Care Ombudsman3745 Community Park Loop, Suite 200Anchorage, Alaska 99508Local - (907) [PHONE NUMBER]Fax - (907) [PHONE NUMBER]Toll Free - (800) [PHONE NUMBER]2. Prior to transferring or discharging a patient, Utuqqanaat lnaat will notify the patient and/or their representative of the intent to transfer or discharge, and the reason for such action.3. Discharge planning will ensure that the patient has sufficient preparation andeducation to enable them to safely leave the facility . Further review of the policy revealed it did not include the regulatory requirement to: 1) Provide the notice of transfer/discharge at least 30 days prior to the transfer or discharge; or the notice must be made as soon as practicable before transfer or discharge when: (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or(E) A resident has not resided in the facility for 30 days. 2) Include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request per CFR 483.15(c)(5)(iv); and 3) For nursing facility residents with intellectual or developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.) per CFR 483.15(c)(5)(vi); and 4) For nursing facility residents with a mental disorder or related disabilities, the mailing address and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act per CFR 483.15(c)(5)(vii)

.Based on record review and interview, the facility failed to ensure 1 resident (#12), out of 1 resident reviewed for care planning, was afforded the opportunity to participate in the development and implementation of his/her person-centered plan of care. This failed practice deprived the resident of the opportunity to participate in care planning and provide input regarding his/her needs, goals, choices, and preferences. Findings:Record review on 7/23 - 29/26 revealed Resident #12 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, history of falling, primary hypertension (high blood pressure), hyperlipidemia (high cholesterol), urinary incontinence, anemia, benign prostatic hyperplasia (enlarged prostate), and lower back pain. Further review revealed Resident #12 was discharged from the facility on 2/27/26. Review of Resident #12's medical record revealed no admission paperwork to include: 1) consent for treatment; 2) admission Agreement; 3) Explanation of Charges; 4) Acknowledgement of receiving the Resident Rights; and 5) Acknowledgement of receiving the Resident Handbook. Review of Resident #12's most recent admission MDS (Minimum Data Set - a federally required nursing assessment), dated 12/22/25, revealed the Resident was coded as having clear speech, was able to make self-understood, understood others, and had a brief interview for mental status (BIMS - a cognitive screening tool used to assess memory and thinking) of 14 (on a scale of 00 to 15, which indicated a normal cognitive level with no impairments). Review of Resident #12's medical record revealed only one care conference meeting note, dated 2/16/26, which was the resident's discharge care conference. Further review revealed no initial care conference meeting was documented, nor any other progress notes or interdisciplinary notes to indicate Resident #12 was involved in his/her planning of care while at the facility. During an interview on 7/28/26 at 3:19 PM, the Administrator stated that leadership was unable to provide Resident #12's admission paperwork that included: 1) consent for treatment; 2) admission Agreement; 3) Explanation of Charges; 4) Acknowledgement of receiving the Resident Rights; and 5) Acknowledgement of receiving the Resident Handbook. The Administrator further stated there were no other care conferences held for Resident #12 during his/her admission. The Administrator stated there was usually an initial admission care conference held around the time of a resident's admission, but Resident #12 did not have one completed. During an interview on 7/29/26 at 11:44 AM, Resident #12 stated he/she didn't recall attending or being invited to attend care conference meetings. Review of the facility-provided Residents Rights and Facility Responsibilities, undated and which was supposed to be offered upon admission, revealed: . Each resident has the right to be informed of, and participate in his or her treatment including: to be fully informed in advance about changes to the plan of care; the right to be informed in advance of the care to be furnished and the type of care giver or professional that will furnish [care]. Review of the facility-provided policy LTC -Quarterly MDS/Care Plan Review, last reviewed 4/7/26, revealed: Residents will have a CMS standardized clinical assessment no less frequently than quarterly. This will be done through the RAI process. This quarterly review is to ensure the care plan is reflective of the resident's current needs and also identify if there have been significant changes in the resident's condition which may warrant a more comprehensive assessment. The care plan will be reviewed at least every 92 days with revisions made as needed. The resident/responsible party will be invited to participate in the scheduled care conference.

.Based on record review and interview, the facility failed to ensure 1 resident (#12), out of 1 resident reviewed, was informed, orally and in writing, of the resident's rights upon admission. The facility was unable to demonstrate that the resident received the required notice of resident rights and services or that receipt of the information was acknowledged in writing. This failed practice had the potential to affect Resident #12's awareness of the resident's rights and responsibilities during the stay in the facility. Findings:A review of the facility's admission packet (a packet of documents to review and/or sign upon admission) revealed the document Resident Rights and Facility Responsibilities, undated, which revealed: . Each resident has the right to be informed, both orally and in writing (including Braille) in a language that the resident understands of his/her rights and all the rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. Further review revealed the facility's admission packet contained a Resident Rights acknowledgment form requiring the resident's signature to document that the rights were read or explained to the resident: I have read the Resident's Rights and Facility Responsibilities or had them read to me. I fully understand them and have no questions at this time. I understand that I can ask questions later as well. Resident #12's medical record revealed no completed acknowledgement of resident rights. There was no documentation that Resident #12 acknowledged receipt of these resident rights by signature, no acknowledgement the resident rights were provided orally to him/her, or a note stating resident understood/acknowledged these rights. During an interview on 7/28/26 at 3:19 PM, the Administrator stated that leadership was unable to locate Resident #12's admission paperwork that included: 1) Acknowledgement of receiving the Resident Rights; and 2) Acknowledgement of receiving the Resident Handbook

.Based on record review and interview, the facility failed to ensure 1 resident (#12), out of 1 Medicaid eligible resident reviewed, was informed in writing, at the time of admission or when the resident became eligible for Medicaid, of the items and services included under the State Medicaid plan for which the resident could not be charged and those items and services offered by the facility for which the resident could be charged, including the amount of those charges. This failed practice had the potential for Resident #12 to incur charges without being informed which items and services were covered under Medicaid and which items and services could result in out of pocket costs. Findings:A review of the facility's admission packet (a packet of documents to review and/or sign upon admission) revealed: 1) A Consent to Treat signature page which documented: This Consent to Treat is made between the following parties: Utuqqanaat Inaat and. Resident. The Facility shall admit and provide the services specified herein to the Resident until the date of the Resident's discharge. Additional Terms and Conditions are included in the admission Packet to follow. 2) An admission Agreement which documented: . Acknowledgements. Before signing, the undersigned acknowledge they have received and read this Agreement in its entirety, and have received the following information. Explanation of charges, providing a list of what items and services are not included in the private Daily room charge, Medicare benefits or any other applicable programs; and 3) An Explanation of Charges document which indicated items and services covered in the daily room rate, as well as other items and services offered by the facility which the resident may be charged out of pocket for. Review of Resident #12's medical record revealed there was no signed or dated consent for treatment; admission agreement; or explanation of charges in his/her record. During an interview on 7/28/26 at 3:19 PM, the Administrator stated that leadership was unable to locate Resident #12's admission paperwork that included: 1) Consent for Treatment; 2) admission Agreement; and 3) Explanation of Charges. During an interview on 7/28/26 at 1:22 PM, the Director of Nursing (DON), stated that he/she was responsible for ensuring all paperwork related to admissions were completed and acknowledged that adequate documentation was missing from Resident #12's chart. During an interview on 7/29/26 at 9:25 AM, the past Administrator stated he/she could not answer why resident #12 did not have any admission notices in his/her medical record chart

.Based on record review and interview, the facility failed to investigate an allegation of suspected financial abuse/exploitation involving 1 resident (#4), out of 1 resident reviewed, and failed to implement effective protective measures since January 2026 when concerns were first identified, and when allegations continued to occur unresolved. These failures allowed the suspected perpetrator continued access to Resident #4 and the resident's financial resources after facility leadership identified the concern. The facility's failure to investigate the allegation and implement effective protective measures allowed Friend #18 continued access to Resident #4 and his/her financial resources. Resident #4 subsequently experienced continued depletion of his/her personal funds, an overdrawn bank account, and loss of access to his/her Social Security payment when the bank applied the payment toward the delinquent balance. The financial losses interfered with Resident #4's ability to use his/her funds according to her expressed preferences, including his/her stated desire to save money for his/her grandchildren, and resulted in the resident borrowing money from a family member for his/her own personal needs. Findings:Record review on 7/23-29/26 revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia, such as hallucinations and delusions, and mood disorder symptoms, such as depression) and the diagnosis other symptoms and signs involving cognitive functions and awareness (a billable code used to document cognitive symptoms that do not fit into a more specific neurological or psychiatric diagnosis). Review of Resident #4's Pre-admission Screening and Resident Review (PASRR - A federally required assessment to ensure individuals with serious mental illness or intellectual disabilities meet requirements to be admitted to a nursing home and have appropriate mental health services if needed) level II assessment, dated 6/10/26, revealed: .the individual carries a documented history of schizoaffective disorder, grave disability, moderate cognitive impairment, unspecified depression, dementia, and cerebral ischemia [insufficient blood flow to the brain]. [He/she] has been identified as being at risk for acute safety concerns. The individual acknowledged some degree of memory difficulty and recognized that [he/she] would be unable to care for [himself/herself] outside the facility. During an interview on 7/23/26 at 3:01 PM, the Administrator stated Resident #4 had a friend (#18) who checked him/her out of the facility routinely. Friend #18 would take Resident #4 straight to the bank after leaving the facility and obtain money from Resident #4. The Administrator stated in May 2026, facility leadership identified a greater concern about this situation involving Resident #4 and Friend #18 after the resident's bank account became overdrawn. The Administrator further stated that Resident #4 .had no money to do what she wanted to do, which resulted in the Resident's inability to use personal funds according to his/her preferences. Then, in June 2026, the resident's Social Security check was seized by the bank to cover these delinquent funds. When asked if the leadership would classify this concern as misappropriation of resident property, the Administrator described the concern as financial abuse. When asked what the facility did once this concern escalated to potential abuse, the Administrator stated they talked to Friend #18 several times to stop taking Resident #4's money, but he/she would counter, saying the resident gave it to him/her. The leadership also talked to Resident #4 about not giving Friend #18 money, however he/she would say Friend #18 asked for it and he/she has helped me out in the past. They have also encouraged Resident #4 to keep his/her bank card in the facility when he/she left with Friend #18, but the resident sometimes didn't. The Administrator stated Resident #4 came out of his/her room at night once reporting that Friend #18 had his/her bank card and hadn't returned it. When asked if anything else had been done, the Administrator stated nothing else had been done. The leadership would like to get Resident #4 a conservator because they felt Resident #4 needed assistance with finances. When asked if this had been initiated, the Administrator stated it had not happened at this time. When asked if an investigation was initiated to determine if this concern was ruled out or confirmed, the Administrator stated no investigation had occurred. During an interview on 7/23/26 at 4:18 PM, Resident #4 further stated he/she wasn't giving Friend #18 any more money because he/she wanted to save money to send to his/her grandchildren. Resident #4 stated he/she stopped giving money to Friend #18 a month ago, however this was not an accurate interpretation per staff interviews and ongoing concerns from leadership. During an interview on 7/28/26 at 11:41 AM, the Social Worker stated that she believed Friend #18 was manipulating Resident #4 to take his/her money. When asked how long she has had this concern, the Social Worker stated shortly after the Resident's December 2025 admission, sometime in January or February 2026. The Social Worker stated Resident #4 would leave with Friend #18 and return to the facility with small amounts of money remaining. In addition, purchased items and cash would be left a Friend #18's residents. Furthermore, the Social worker stated that the resident had to borrow money from a family member due to insufficient personal funds. During the same interview, when asked what she did about this concern to protect the resident, the Social Worker stated Resident #4 thought Social Security was taking her money when in fact her account was overdrawn. The Social Worker provided her awareness of the concern approximately in January or February 2026 with the Administrator, as well as spoke to Resident #4 about the concern. Also, the Social Worker wanted to petition to get a conservator for Resident #4 but had not done this yet. When asked if an investigation was initiated to determine if this concern was ruled out or confirmed, the Social Worker stated no investigation had occurred. During an interview on 7/28/26 at 1:22 PM, the Director of Nursing (DON) stated staff suspected Friend #18 was taking the resident's money in May 2026. When asked what she did about this concern, the DON stated they talked to Resident #4 about not giving Friend #18 his/her money. When asked what she had done to protect the resident, the DON stated they were going to try and get Resident #4 a conservator and that the Social Worker was working on it. When asked if an investigation was initiated to determine if this concern was ruled out or confirmed, the DON stated no investigation had occurred. During an interview on 7/28/26 at 4:35 PM, Certified Nursing Assistant (CNA) #12 stated the resident would continue to leave with Friend #18 and come back with no money. CNA #12 further stated he/she raised the concern of financial misappropriation with the Social Worker and considered the situation a form of abuse. During an interview on 7/28/26 at 4:51 pm, License Nurse (LN) #27 stated due to Resident #4's cognitive deficits, he/she was concerned about the resident's finances. He/she stated he/she would help count the Resident's money after being out with Friend #18 and always came back with significantly less personal funds due to concerns that Friend #18 was manipulating his/her for money. During an interview on 7/28/26 at 4:59 pm, CNA #10 stated he/she had concerns about Resident #4 leaving with Friend #18 who would keep his/her bank card and staff having to contact Friend #18 to return it. During an interview on 7/28/26 at 5:22 PM, LN #14 stated Friend #18 came to the facility approximately once or twice each week and that concerns regarding Friend #18 and Resident #4's money were frequently discussed among staff. The LN stated he/she heard Friend #18 asking for money from Resident #4 to pay utility bills. Resident #4 responded to Friend #18, I get paid tomorrow, come get me and we'll pay your electricity bill. Review of Resident #4's leave-of-absence log, dated 12/29/25 through 7/20/26, showed that Friend #18 took Resident #4 from the facility 25 times, with 11 of those absences taking place from May through July after leadership identified a potential abuse concern. At the time of survey, there were no restrictions from Friend #18 taking Resident #4 from the facility. A review of Resident #4's progress notes, dated 1/29/26 to 7/24/26, revealed multiple documented events where Friend #18 had unrestricted access to Resident #4's bank account that was not addressed by the facility: - 1/29/26 at 6:02 PM (Late Entry) - Elder made a phone call to [his/her] friend [#18] and told [him/her] over the telephone 'Hey, I have $51.00 dollars in my bank account, come up and get my bank card and go to AC and get the money.' - 1/29/26 at 7:39 PM - Elder contacted friend [#18] to retrieve their bank card for the purpose of withdrawing funds. Elder stated friend needed money and it was [his/her] choice. Supervisor made aware due to potential concerns for financial vulnerability. - 1/29/26 at 7:42 PM (Late Entry) - Elder friend [#18] came to facility at this time and retrieved elders bank card and pack of cigarettes then left facility with those items. Supervisor made aware. - 1/30/26 at 5:38 PM - Elders friend [#18] returned to facility to supposedly return bank card. When nurse asked elder for [his/her] bank card to lock up safely [he/she] said 'I don't have it. [He/she] did not give it back to me.' This nurse checked [his/her] room for the bank card and did not find it. Elder stated [he/she] said [he/she] would be back.' - 1/31/26 at 8:39 PM - Elder called friend [#18] to return bank card. [Friend #18] arrived with a friend. Returned bank card at this time also gave elder $100 in cash. Elder then mentioned [he/she] wanted to give [Friend #18] $20.00 [Friend #18] refused and left the facility. This writer and two staff CNA [Certified Nursing Assistant] present. Bank card and money placed in elder purse in facility safety area. - 2/8/26 at 5:34 AM - Elder used phone to call friend [#18] Elder stated 'come here, go to the bank and get my money then go buy yourself cigarettes.' Elder hung up the phone walked over to the dining area for breakfast. - 3/9/26 at 8:07 PM - Elder received a visit from a friend identified as [Friend #18]. Elder voluntarily provided [Friend #18] with a shopping list, debit card, and associated PIN to facilitate a purchase. Per Elder, [Friend #18] is expected to return the purchased items and the bank card this evening. - 3/9/26 at 8:41 PM - [Friend #18] returned with purchased items and elder's debit card. Debit card and $26 in cash locked away in elder's wallet per protocol. - 4/8/26 at 6:41 PM - Elder left facility with friend [#18] due to return later this evening. Educated friend [#18] on being responsible of elder safety. Elder in stable condition. Elder and staff counted elders remaining balance in purse $18 elder signed paper confirming. Supervisor aware. - 4/8/26 at 8:20 PM - Elder returned from outing escorted by friend [#18]. Elder now has a balance of $0 in cash. Elder returned in stable condition. - 5/3/26 at 9:03 PM - Elder returned from outing with friend [#18]. Elder left with $120 returned with $30.30 and a receipt from bank of a withdrawal $70.00. Remaining balance in bank $4. Elder signed paper understanding. - 5/12/26 at 9:06 PM - Elder returned back from outing with [Friend #18]. Elder seems under the influence. Barely able to stand up periodically. Elder stated that [he/she] was high and that [he/she] smoked while out. Stumbling. Elder unable to walk to room/Elder had to be assisted to room with rolling chair by cna. Elder came back with $0.00 cash. Elder stated [he/she] spent all of [his/her] money while out. Will continue to monitor and provide support as needed. - 6/3/26 at 5:28 PM - Elder left out of the facility with friend [#18]. Elder left with purse containing ID, bank card, keys and $10.82 in cash. - 6/28/26 at 5:30 PM - Elder went out with [Friend #18], [he/she] wanted to get out and get some fresh air and a pizza. - 6/29/26 at 8:13 PM - Elder return from outing with friend [#18]. Elder has $10.89c [cash] 2 bank cards and ID. Elder in stable condition. - 6/30/26 at 8:46 PM - Elder returned from outing w/ [with] friend [#18]. Elder returned with $26.00 two bank cards and ID. Elder in stable condition. Review of the facility-provided policy LTC - Abuse Prevention, Identification, Investigation, Reporting and Protection, last reviewed 3/11/26, revealed: . Types of Abuse. Abuse is defined as. Misappropriation of residents property is defined as the illegal or improper use of a resident's resources for the personal profit or gain of another person; or borrowing resident funds; or spending resident funds without the resident's consent; or if the resident is not capable of consenting; or spending resident funds to acquire items for use in common areas when such purchase is not initiated by the resident. Further review of the policy revealed: .Investigation. Any staff member observing or receiving a report of misappropriation will immediately notify their supervisor and the administrator. Confirmation of misappropriation of resident property and physician or sexual abuse will be reported to law enforcement by Administrative personnel. Allegations of abuse or neglect will be reported within 24 hours to appropriate state survey agency by the administrator and/or his designee. Results of the investigation will be reported to the state survey agency within 5 days after initial reporting.

.Based on record review, interview, and observation, the facility failed to implement an effective discharge planning process for 1 Resident (#12), out of 1 resident discharge reviewed, to include documentation of: 1) ongoing discharge planning goals throughout the resident's admission to include: a) identification of discharge needs and the development of a discharge plan; b) regular re-evaluation for need of possible modifications of the discharge plan; c) involvement of the interdisciplinary team in the ongoing process of developing the discharge plan; d) involvement of the resident in the development plan; and e) addressing the resident's goals of care and treatment preferences at discharge; 2) the basis and reason for discharge; and 3) sufficient preparation and orientation to ensure safe and orderly discharge. These failed practices resulted in Resident #12 leaving the facility without an established safe destination or adequate preparation to meet his/her ongoing care needs. Following discharge, Resident #12 experienced unstable and unsafe living conditions, inadequate access to food, two falls, including one that required ambulance assistance after the resident was unable to get up from the street, increased fear and depression, and worsening pain after losing assistance with medications and topical pain treatment. Resident #12 also reported that his/her weight decreased from approximately 165 pounds while residing at the facility to approximately 130 pounds following discharge, which the resident attributed to not having enough food. Findings:Resident #12 Record review on 7/23-29/26 revealed Resident #12 was admitted to the facility on [DATE] with diagnoses that included low back pain, major depressive disorder, history of falling, and unspecified urinary incontinence. Review of Resident #12's provider health and physical note, dated 11/18/25, revealed: . Physical for LTC [long term care] placement . [He/she] is seeking admission to long-term care due to [his/her] declining functional status and unsafe living conditions. The patient reports progressive difficulty with mobility over the past several years, now unable to walk and experiencing frequent falls. [He/she] describes [his/her] feet as being similar to [his/her] hands, with toes that cannot move or turn up, causing significant pain and contributing to instability . [His/her] fingers and toes are becoming claw-like and [he/she] stated it is hard to open medication bottles [on] [his/her] own and [to] self hygiene . [He/she] has fallen multiple times . The patient reports ongoing urinary incontinence . Function: Bathing, Dressing, Toileting, Transferring: 1 person assist -- high risk for falls .Review of systems. musculoskeletal: Positive for pain in feet and hands. Positive for inability to move toes. Positive for joint deformity in toes and fingers. Positive for muscle weakness. Positive for back pain. Positive for joint stiffness. Appearance. Patient is ambulating with a very wide based gait. [He/she] uses cane at all the time to prevent falls. Chronic pain behavior as usual. Oriented in time, place, person. Able to have a conversation with me and seem to understand my questions and answered them pretty well. Arthritis pain. Arthritis with hand and foot deformities, pain, and functional impairment; worsening toes contractures/hammer toes; contributing to falls and difficulty ambulating. Review of Resident #12's medical record revealed a Facility Verification Form, for admission, undated, revealed: We have information indicating that the person listed above is a patient in your facility. Before we can determine this person's eligibility for Medicaid or calculate their cost-of-care obligation, we need the following information: Date of admission: [DATE]. Expected length of stay . More than six months . Name of Facility: Utuqqanaat Inaat . Review of Resident #12's Long Term Care Facility Authorization Request, dated 11/20/25, revealed the request was completed for a new admission with an intended length of stay identified as Long Term Placement (more than 90 days). The authorization documented that Resident #12 required 24-hour supervision, one-person extensive assistance with activities of daily living (ADLs), meal preparation, chore services, medication administration, provisions for safety, and transportation. The authorization further documented that alternative community placement was not feasible or appropriate due to the lack of available community support services, the resident's skilled needs exceeding available community resources, and the absence of family to provide care. The documented discharge plan stated Resident #12 could only be transferred to a facility that provided 24-hour supervision and assistance due to the resident's complex medical and physical needs. Review of Resident #12's admission minimum data set assessment (MDS - a federally required nursing assessment), dated 12/22/25, revealed Resident #12 had a brief interview for mental status (BIMS - a cognitive screening tool used to assess memory and thinking) score of 14 (on a scale of 00 to 15, which indicated a normal cognitive level with no impairments). Further review revealed Resident #12 needed supervision/touch support (which indicated a helper was needed to provide verbal cues and/or touching/steadying and/or contact guard assistance as resident completed activities and that assistance may have been needed throughout the activity or intermittently) for oral hygiene; upper body dressing; lower body dressing; putting on/taking off footwear; personal hygiene; chair/bed to chair transfer; toilet transfer; care transfer; and walking certain distances. Further review revealed Resident #12 needed partial/moderate assistance (which indicated a helper did less than half the effort. The helper lifted, held, or supported the resident's trunk or limbs, but provided less than half the effort) for toileting hygiene; shower/bathe self; and tub/shower transfer. The admission MDS assessment documented that Resident #12's weight upon admission was 147 lbs. During an interview on 7/23/26 at 3:01 PM, the Administrator stated resident came to the facility very weak but barely met admission standards. The resident was only approved for 85 days of stay. When asked about the Resident's discharge, the Administrator stated the Resident was very evasive with any kind of discharge planning. Attempts to work with the resident on senior housing applications were attempted but the resident refused. When asked if there was documentation for these attempts and the residents' refusals, the Administrator stated there was none. When asked about the resident's original housing situation, the Administrator stated he/she couch-surfed from house to house. When asked why Resident #12 was discharged , the Administrator stated he/she met PT (Physical Therapy) goals, didn't participate in the program, and the resident left daily to go out into the community. The Administrator stated he/she was only approved for 85 days, and it was very hard to get those days approved. When asked if an attempt was made to get more days authorized for the resident, the Administrator stated she was told by the past Administrator, who completed the LTC authorizations, the resident would not qualify, so no. When asked if the resident was admitted for rehab, the Administrator stated, No. When asked if it was the resident's right to not participate in the program and go out into the community, the Administrator stated it was the resident's right to do so. The Administrator could not state why the resident was discharged from the facility other than the resident was only approved for 85 days. The Administrator agreed that every resident was only authorized for a limited number of days and re-authorizations were completed on every resident routinely. The Administrator could not state why Resident #12 was not offered the same opportunity. Review of Resident #12's Primary Care Provider note, dated 2/12/26 and completed by Provider #7, revealed Resident #12 had diagnoses that included cerebellar ataxia, traumatic brain injury related to a fall in 2017, chronic pain, mild cognitive impairment, hypertension, recurrent falls, and progressive functional decline affecting multiple activities of daily living. The provider documented that Resident #12 continued to require one-person assistance with bathing, dressing, toileting, and transfers. Resident #12 was independent with feeding and remained incontinent of urine, requiring the use of briefs. The provider note also documented ongoing evaluation and treatment for joint pain, rheumatoid arthritis, and significant right foot deformity and degenerative joint disease. Conservative treatment was recommended for the resident's foot condition. Review of Resident #12's medical record revealed no initial care conference meeting was documented, nor any other progress notes or interdisciplinary notes to indicate Resident #12 was involved his/her planning of care while at the facility. Review of Resident #12's one and only Care Conference Summary, dated 2/16/26, which was the resident's discharge conference, revealed: . Resident Goals of Care: safe discharge planning . Risks/Needs/Preferences/Strengths: Doesn't want to leave . Discharge Plan/Return to Community Referral: Safe discharge to the community . Special Requests/Choices/Conditions: wants to stay longer, however doesn't meet criteria . Elder refused to have assistance [with] filling out applications for housing. Staff will continue to offer assistance [with] safe discharge planning . Elder asked staff to [lie] on authorization so [he/she] can stay longer . Further review of Resident #12's medical record revealed: 1) no discharge planning progress notes; and 2) one hand-written discharge summary prepared by the DON and signed by Provider #7. There was no discharge order. Review of Resident #12's medical record revealed no notification of discharge paperwork. Review of Resident #12's Discharge Summary, handwritten note, dated 2/27/26, revealed: . Brief History: [AGE] year old [male/female] admitted for endurance and strength training. [which was not an accurate representation for why he/she was admitted ] Pertinent Physical and Laboratory Findings: Improvement in ADL status. Improvement in labs. Does not meet requirements for long term care . Further review revealed no documentation as to why the resident was being discharged or where Resident #12 discharged to. Review of the facility's discharge notification faxed to the LTC Ombudsman's Office, dated 3/5/26, revealed Resident #12 D/C [discharged ] to home on 2/27/26. When leadership was asked about this, they acknowledged the resident didn't discharge to his/her home and that they couldn't identify where he/she went after leaving the facility. During an interview on 7/28/26 at 11:41 AM, the Social Worker stated she was an LPN and had no degree or license as a Social Worker. She stated she completed a 10-hour online course and started working with no training. The Social Worker stated she was still learning the role. When asked about Resident #12's discharge, and if a notification of discharge was provided to the Resident, the Social Worker stated she didn't know what that was. When asked about discharge planning, the Social Worker stated about two or three weeks prior to discharge she approached the resident to discuss where he/she was going, what the resident was going to do, and what his/her discharge would look like. She attempted to review housing applications with the resident, but he/she refused. He/she was also banned from one of them for past behavior. When asked if there was any documentation on any of these discussions or attempts to complete housing applications, the Social Worker stated there was none. When asked if Resident #12's authorization for admission was attempted to be extended, the Social Worker stated she was told by the past Administrator that Resident #12 would not re-qualify, so there was no re-authorization that was attempted. When asked how she ensured Resident #12 was safely discharged , the Social Worker stated they completed a discharge care conference, but the resident would not give any information. When asked if she implemented the facility's Transfer and Discharge policy (of documenting discharge planning and notification), the Social Worker stated she thinks she read the policy but didn't know the content and stated there was little to no training for the Social Worker role. During an interview on 7/28/26 at 1:22 PM, when asked if she could assure staff accurately completed the discharge process for Resident #12, the DON stated, No. The DON stated the Resident's discharge should have been an AMA (against medical advice) but was not. The DON stated she did not see any documentation to show the resident was notified of discharge and was not aware of the regulatory requirement to notify the resident in writing or give residents appeal rights. During an interview on 7/28/26 at 2:30 PM, Provider #7 stated he was the Medical Director for the long-term care and oversaw the medical care for the residents. When asked about Resident #12's admission and care, Provider #7 stated he had rounded on Resident #12's care a couple of times and remembered him/her to be overall stable. Resident #12 was his/her own decision maker, and he/she required one-person assist with bathing, toileting, and dressing. Resident #12 was also incontinent. When asked how he determined what level of assistance a resident would need with ADLs, Provider #7 stated he would ask the nurses while rounding. When asked about Resident #12's discharge on [DATE], Provider #7 stated he was informed that it was a planned discharge and did talk with Resident #12 prior to him/her leaving. Provider #7 stated he didn't have a concern with Resident #12's home environment. When asked if Resident #12 had a home, Provider #7 stated he could not elaborate on that. Provider #7 stated he didn't get an understanding of where Resident #12 was going and did not ask where he was being discharged to. When asked whether Provider #7 documented a provider discharge summary note for Resident #12, Provider #7 stated he usually did complete a discharge summary note for the residents discharging but did not do one for Resident #12. During an interview on 7/28/26 at 3:19 PM, when asked if there was adequate documentation within the medical record to show the resident's discharge was properly handled, the Administrator stated, No. When asked if the resident was given a notification of discharge, the Administrator stated the facility did not have a notification of discharge form, and it was normally completed verbally. When asked if the resident was given rights to appeal information, the Administrator stated, No. During the survey, there was an identified inconsistency between care plan (which documented Resident #12 was fully independent in all ADLs), the MDS assessments (which documented Resident #12 needed supervision/touch assistance with some ADLs and partial/moderate assistance for some ADLs), and LTC provider notes (which documented one-person assist in all ADLs except feeding). During an interview on 7/28/26 at 3:19 PM, the Administrator acknowledged Resident #12 needed assistance in most ADLs and the care plan did not reflect that. The Administrator stated Provider #7 considered the need for ADLs assistance as a one-person assist. Review of Resident #12's progress note, dated 2/25/26, revealed: Elder stated, 'I only have two days left here maybe I will fall down and break my hip so I can stay longer' Resident redirected and educated on importance of safety and preventing injury. Staff alerted to provide frequent checks on elder . Review of Resident #12's discharge MDS, dated [DATE], revealed Resident #12 had a BIMS score decreased to 13 (which still indicated a normal cognitive level with no impairments). Further review revealed Resident #12 continued to need supervision/touch support for oral hygiene; upper body dressing; lower body dressing; putting on/taking off footwear; personal hygiene; chair/bed to chair transfer; toilet transfer; care transfer; and walking certain distances. Further review revealed Resident #12 needed for assistance with toileting hygiene; shower/bathe self; and tub/shower transfer was upgraded to supervision/touch support, however still needed that level of functional care. The discharge MDS assessment documented that Resident #12's weight upon discharge was 160 lbs. During an interview on 7/29/26 at 8:21 AM, the Administrator stated Resident #12's admission intent was to stay long-term, he/she wasn't admitted strictly for rehab services, and there was no documentation to support why this resident was discharged from the facility. The Administrator further stated there were no other care conferences held for Resident #12 during his/her admission. The Administrator stated there was usually an initial admission care conference held around the time of a resident's admission, but Resident #12 did not have one completed. The medical record revealed no other provider notes documenting the reason for the resident's discharge, where he was discharging to, or disposition at discharge. During the course of the survey, the leadership confirmed there was no discharge planning documentation, no notification of discharge given, and no way of knowing where Resident #12 was going when he/she left the facility. During an interview on 7/29/26 at 9:25 AM, the past Administrator stated she was in charge of completing the initial authorizations and re-authorizations for the LTC residents. When asked about Resident #12's admission, the past Administrator stated she completed Resident #12's initial authorization for his/her admission. The past Administrator recalled Resident #12's cognitive status had only mild cognitive deficits. Resident #12's functional status needs were listed on the authorization. Resident #12 was approved for a 90-day stay, and he/she was admitted into the facility. At the time of admission, the past Administrator stated Resident #12 was more debilitated than he/she was in the past (as she knew him/her from the community). When asked about Resident #12's discharge, the past Administrator stated she recalled he/she went out into the community pretty much every day. So, because of this, she did voice her concerns to the nursing team that when it came to a reauthorization, the resident would not qualify for reauthorization due to his/her level of function. The past Administrator stated the facility would have resistance because his/her level of function was not as acute as when he/she was when admitted . When asked if a re-authorization was attempted for Resident #12, the past Administrator initially stated she submitted a re-authorization to extend the resident's stay, and they came back stating he/she didn't meet criteria. Because of this, the LTC staff informed him/her that he/she was denied a continued stay at the facility. The past Administrator stated the resident was not happy with that and Resident #12 relayed that he/she didn't want to leave the facility, but staff explained, he/she was denied to stay. When asked if going out into the community was a resident right, the past Administrator stated, she agreed with that. When asked, why then would that be a determining factor for him/her to have to leave the facility, the past Administrator stated because his/her level of functioning showed he/she didn't need the LTC level of care. When reminded he/she needed touch support, which was considered one-person assist by Provider #7, with most ADLs, the past Administrator stated that level of care was documented on the re-authorization and the state still denied more days. When surveyors asked to see the re-authorization paperwork and the state's denial, the past Administrator stated she would try and locate this information. The past Administrator then came back and stated that no re-authorization was completed and based on Resident #12's level of functioning, and his/her leaving the facility daily, she had determined he/she wouldn't meet criteria and didn't want to waste the State's time by submitting a re-authorization and just determined by herself that Resident #12 wouldn't meet criteria for more days. When asked what the past Administrator looked at to determine if a resident met criteria for a re-authorization, the past Administrator stated she would have looked at cognitive status, ADLs function level of need status for transfers, bathing, locomotion, and dressing. The past Administrator stated she found this information through a chart review, talked to staff, and used her own observations. When asked if she looked at the MDS assessments when making this determination, she said she did not because it was just a snapshot in time and didn't reflect the overall level of function. When shown Provider #7's progress note, dated 2/12/26, which determined that Resident #12 was a one-person assist with bathing, dressing, toileting, transferring and when shown that the 12/22/25 admission MDS assessment and 2/27/26 discharge MDS assessment which indicated he/she was supervision/touch support for oral hygiene; toileting hygiene; shower/bathe self; upper body dressing; lower body dressing; putting on/taking off footwear; personal hygiene; chair/bed to chair transfer; toilet transfer; tub/shower transfer; care transfer; and walking certain distances, the surveyor asked how she could determination that the resident's level of functioning need didn't meet criteria for continued stay. The past Administrator stated, right or wrong, she made the determination that the resident wouldn't be approved for re-authorization because it was a nursing assessment and she was a nurse, and it was what she observed at the time. During an interview on 7/29/26 at 10:46 AM, LN #11 stated he/she assisted with the initial authorization forms, and he/she did assist with Resident #12's initial authorization. When asked to explain Resident #12's authorization, LN #11 stated because Resident #12 had issues with ambulation, was unstable on his/her feet, and was incontinent were the factors in needing the LTC level of care. Resident #12 didn't have any family at the time, and he/she was staying at a friend's house. He/she experienced chronic pain in his/her hands and feet. These factors were used to determine that he/she needed 24-hour supervision and care. LN #11 stated he/she only assisted with initial authorizations and did not help with re-authorizations. During an interview on 7/29/26 at 11:44 AM, Resident #12 stated he/she was admitted to the facility because he/she needed help because he/she had difficulty with his/her right leg and because his/her hands were clawed and he/she couldn't help himself/herself anymore. Resident #12 stated when he/she first got there, it was to be there for an extended period of time, but because he/she was able to move (as in walking) and staff didn't have to do a lot for him/her, he/she was told that he/she could only stay for three months. Resident #12 stated he/she wanted to stay there, but staff told him/her that he/she had to go. When asked about his/her experience with staff, Resident #12 stated his/her overall stay at the facility was good. However, the leadership was not open to residents who voiced their opinions or wanted to be part of their care. Resident #12 stated there was a nurse that teased the residents, and one time the resident called attention to this in a meeting when residents were invited to speak. Resident #12 stated he/she told the staff if they treat people like that, he/she would go to the board meeting and tell them. Resident #12 stated the staff asked him/her not to do that. He/she stated staff treated him/her differently after that and avoided talking to him/her. When asked how his/her discharge occurred, Resident #12 stated he/she was told on Friday, 2/27/26, you are leaving this weekend, pack all your stuff. Resident #12 stated he/she asked for more days to prepare where he/she would go, because he/she had no plan, but staff were adamant I had to leave. Resident #12 stated he/she told them he/she would have liked to have stayed at the facility but they made up their mind [that he/she had to leave]. When asked how it felt knowing he/she had to discharge, Resident #12 got emotional, his/her voiced cracked and said, not wanted. When asked how leaving without a plan affected him/her, Resident #12 stated, there I was outside, I didn't have enough money, and it was wintertime. Resident #12 stated he/she had no idea where he/she was going to go. He/she started staying with friends, but it wasn't a place to stay long because they were drinking and he/she didn't feel safe in those situations. When asked if staff helped to try and find Resident #12 a place to go once discharged , Resident #12 stated the discussion about housing never happened. The staff just told him/her to gather his/her stuff, place it at the door, and leave. Staff told Resident #12 he/she could come back to get his/her belongings when he/she found a place to stay. Resident #12 stated when he/she was at the facility, they helped him/her set-up for showers and clothes for dressing because his/her fingers were clawed. Having staff apply cream everyday helped with pain, but he/she doesn't have that support anymore. Resident #12 stated he/she was afraid all the time now and has safety concerns now that he/she is not at the facility. Resident #12 stated he/she had fallen twice since leaving the facility, once an ambulance was called because he/she was lying in the street and couldn't get up. Resident #12 further stated he/she was currently living in a cabin on the beach; however, it is about a three and a half mile walk on sand and because he/she used a cane to walk, it was a struggle and almost impossible to walk on when it rained. When asked if he/she had enough to eat, Resident #12 stated he/she was not able to get enough to eat and that he/she was 165 lbs. when he/she was at the facility and now weighed 130 lbs. Losing 35 lbs. has caused his/her health to decline. Resident #12 has been down and depressed since leaving the facility, and his/her pain has been bad because he/she had no support with his/her medications and cream. Resident #12 stated he/she doesn't have enough money and worries all the time. An observation on 7/29/26 at 11:44 AM, revealed that when compared to Resident #12's 12/15/25 admission picture, and then seeing the resident on 7/29/26, surveyors would not have been able to identify him/her as the same person. Resident #12's face was very gaunt, much skinnier than his/her admission picture, and had no semblance of the facial features he/she had in December 2025. During the course of the survey, the leadership was not able to adequately show proof of an appropriate discharge or prove they provided a safe discharge. They did not notify the resident of discharge or his/her rights to appeal. Review of the facility-provided policy Transfer or Discharge, last reviewed 1/23/26, revealed: - CMS [Centers of Medicaid and Medicare Services] requirements for the transfer or discharge of LTC residents. Policy. Patients and/or guardians shall be directly involved with all decisions related to transfer and discharges of Elders. Transfer or discharge of Elders will be done in accordance with the following criteria. The facility must permit each patient to remain in the facility, and not transfer or discharge unless: 1. The transfer or discharge is necessary for the welfare of the patient and the patient's needs cannot be met at the facility; 2. Transfer or discharge is appropriate because the health of the patient has improved sufficiently so the patient no longer needs the services provided by the facility; 3. The safety of individuals in the facility is endangered; 4. The health of the individuals in the facility would otherwise be endangered; 5. The patient has failed, after reasonable and appropriate notice, to pay for (or have paid for under Medicare or Medicaid) a stay at Utuqqanaat Inaat. 6. The facility ceases to operate. - 1. Prior to any transfer or discharge, the multidisciplinary team, including the provider, will conduct an appropriate assessment to determine if a new plan of care would allow Utuqqanaat lnaat to continue meeting the patient's needs. - 2. Detailed, multidisciplinary planning will begin upon admission, so should begin far enough in advance that the patient's needs when they leave the facility will be appropriately met. A care conference to discuss what will be required to meet the patient's needs, as well as the teaching needs of the patient and family, will be scheduled when necessary. This multidisciplinary conference is to include patient and/or guardian in the discussion to ensure patient's goals and preferences relative to transfer or discharge are heard. Written discharge instructions detailing the routine medications, diet, activity, care needs, and any follow-up appointments for the patient will be given at the time of discharge. - 3. The provider will write an order to transfer or discharge the patient. The provider will document in the chart the reason for the transfer or discharge. In the case of a transfer, the provider order should include the specific chart information that is to be sent with the patient (i.e., history & physical, lab results, x-ray reports, EKGS [electrocardiogram or EC is a non-invasive test that records the electrical activity of the heart to diagnose various heart conditions], consultations). - 4. Upon receiving the provider order to transfer or discharge the patient, the Charge Nurse will notify the patient, their family and/or representative, and Social Services. The patient should be notified as soon as possible of the date of the transfer or discharge. The reason for the transfer or discharge will be explained to the patient and their family or guardian. The patient will be given written notice of the reason for the discharge or transfer.

.Based on record review and interview, the facility failed to develop and/or implement a comprehensive person-centered care plan for 1 Resident (#12), out of 6 sampled residents, that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, the facility failed to develop a care plan that accurately reflected the resident's functional abilities and need for assistance with ADLs (Activities of Daily Living - basic self-care tasks essential for maintaining personal health and independence). This failed practice placed Resident #12 at risk for receiving insufficient assistance with ADLs, transfers, and mobility despite assessed functional limitations and a history of falls. Findings:Resident #12 Record review on 7/23-29/26 revealed Resident #12 was admitted to the facility on [DATE] with diagnoses that included low back pain, major depressive disorder, history of falling, and unspecified urinary incontinence. Review of Resident #12's provider health and physical note, dated 11/18/25, revealed: . Physical for LTC placement . [He/she] is seeking admission to long-term care due to [his/her] declining functional status and unsafe living conditions. The patient reports progressive difficulty with mobility over the past several years, now unable to walk and experiencing frequent falls. [He/she] describes [his/her] feet as being similar to [his/her] hands, with toes that cannot move or turn up, causing significant pain and contributing to instability . [His/her] fingers and toes are becoming claw-like and [he/she] stated it is hard to open medication bottles [on] [his/her] own and [to] self hygiene . [He/she] has fallen multiple times . The patient reports ongoing urinary incontinence . Function: Bathing, Dressing, Toileting, Transferring: 1 person assist -- high risk for falls .Review of systems. musculoskeletal: Positive for pain in feet and hands. Positive for inability to move toes. Positive for joint deformity in toes and fingers. Positive for muscle weakness. Positive for back pain. Positive for joint stiffness. Appearance. Patient is ambulating with a very wide based gait. [He/she] uses cane at all the time to prevent falls. Chronic pain behavior as usual. Oriented in time, place, person. Able to have a conversation with me and seem to understand my questions and answered them pretty well. Arthritis pain. Arthritis with hand and foot deformities, pain, and functional impairment; worsening toes contractures/hammer toes; contributing to falls and difficulty ambulating. Review of Resident #12's admission minimum data set assessment (MDS - a federally required nursing assessment), dated 12/22/25, revealed Resident #12 had a brief interview for mental status (BIMS - a cognitive screening tool used to assess memory and thinking) score of 14 (on a scale of 00 to 15, which indicated a normal cognitive level with no impairments). Further review revealed Resident #12 needed supervision/touch support (which indicated a helper was needed to provide verbal cues and/or touching/steadying and/or contact guard assistance as resident completed activities and that assistance may have been needed throughout the activity or intermittently) for oral hygiene; upper body dressing; lower body dressing; putting on/taking off footwear; personal hygiene; chair/bed to chair transfer; toilet transfer; care transfer; and walking certain distances. Further review revealed Resident #12 needed partial/moderate assistance (which indicated a helper did less than half the effort. The helper lifted, held, or supported the resident's trunk or limbs, but provided less than half the effort) for toileting hygiene; shower/bathe self; and tub/shower transfer. Review of Resident #12's Primary Care Provider Note, dated 2/12/26 and written by Provider #7, revealed: . [AGE] year-old [male/female] past medical history cerebellar ataxia [dysfunction in the cerebellum resulting in coordination and balance issues], TBI [traumatic brain injury - a brain injury caused by external force, such as a blow, bump, jolt, or penetrating object that causes brain injury] secondary to a fall in 2017, chronic pain, mild cognitive impairment, hypertension and recurrent falls being seen today for 30-day visit. Patient admitted due to progressive functional decline with multiple ADLs. Since admission, patient has been doing well. 02/02/2026: ANMC [Alaska Native Medical Center] rheumatology follow-up. Patient evaluated for arthralgias [joint pain] and rheumatoid factor XV [refers to an autoantibody produced by the immune system that mistakenly targets healthy immunoglobulin molecules in the body, forming immune complexes that deposits in tissues, triggering chronic inflammation and contributes to damage in conditions such as rheumatoid arthritis]. Patient reported morning stiffness to [his/her] hands, right wrist ultrasound showing cellulitis and an elevated CRP [blood test that indicates inflammation in the body]. [He/she] was diagnosed with seronegative RA [a form of rheumatoid arthritis where patients exhibit typical RA symptoms such as joint pain, swelling, stiffness]. 01/22/2026: ANMC orthopedic consult. Evaluated for severe right foot hallux valgus [a bunion - a deformity where the big toe angles toward the second toe creating a bony bump at the base of the big toe] and first MTP DJD [metatarsophalangeal degenerative joint disease - a degenerative disease of the big toe joint]. Patient is not interested in surgical options. Conservative therapy recommended with supportive footwear, toe spacers, bunion orthosis [devices to relieve pain, improve foot function, and slow bunion progression]. Function: Bathing: 1 person assist; Dressing: 1 person assist; Toileting: 1 person assist; Transferring: 1 person assist; Feeding: Independent; Continence: Urine incontinent --- uses diapers. Review of Resident #12's care plan, last reviewed 12/29/25, revealed: - Focus: [Resident #12] has an ADL self-care performance deficit r/t [related to] low back pain which was initiated on 12/16/25 and cancelled on 3/30/26. Further review revealed inaccurate Interventions/Tasks associated with this Focus problem included: - BATHING/SHOWERING: [Resident #12] is able to shower independently with set up;- DRESSING: [Resident #12] is able to dress independently;- ORAL CARE: [Resident #12] has upper and lower dentures. [Resident #12] requires oral inspection weekly and Report changes to the Nurse;- PERSONAL HYGIENE/ORAL CARE: [Resident #12] is independent with oral care.- TOILET USE: [Resident #12 ] is able to toilet independently;- TRANSFER: [Resident #12] is able to transfer independently. During the survey, this inconsistency between the care plan (which documented Resident #12 was fully independent in all ADLs), the MDS assessments (which documented Resident #12 needed supervision/touch assistance with some ADLs and partial/moderate assistance for some ADLs), and Provider #7's notes (which documented one-person assist in all ADLs except feeding) was identified. During an interview on 7/28/26 at 3:19 PM, the Administrator acknowledged Resident #12 needed assistance in most ADLs and stated the care plan did not reflect what the MDS assessment captured and it should have. The Administrator stated Provider #7 considered the need for ADL assistance as a one-person assist. Review of the facility-provided policy LTC -Quarterly MDS/Care Plan Review, last reviewed 4/7/26, revealed: Residents will have a CMS standardized clinical assessment no less frequently than quarterly. This will be done through the RAI process. This quarterly review is to ensure the care plan is reflective of the resident's current needs and also identify if there have been significant changes in the resident's condition which may warrant a more comprehensive assessment. The care plan will be reviewed at least every 92 days with revisions made as needed. The resident/responsible party will be invited to participate in the scheduled care conference.

.Based on record review, observation, and interview, the facility failed to ensure staff followed accepted standards of practice for hand hygiene for 5 residents (#'s 5, 8, 11, 14, and 15), out of 5 residents observed. Specifically, staff failed to perform hand hygiene during personal cares and medication administration. This failed practice had the potential to place all residents at risk of contamination and transmission of infections.Findings: Resident #5 Record review on 9/22-26/25 revealed Resident #5 was admitted to the facility with diagnoses that included Type 2 Diabetes Mellitus (non-insulin-dependent diabetes). An observation on 9/23/25 at 12:55 PM, revealed Licensed Nurse (LN) #2 prepared Resident #5's insulin injection at the medication cart wearing gloves. LN #2 walked over to Resident #5 and offered him/her the medication. Resident #5 agreed and LN #2 pushed him/her in his/her wheelchair to his/her room wearing the same gloves. Without changing gloves or performing hand hygiene, LN #2 cleansed an area on Resident #5's abdomen with an alcohol wipe and administered the insulin injection. Resident #8 Record review on 9/22-26/25 revealed Resident #8 was admitted to the facility with diagnoses that included Type 2 Diabetes Mellitus. An observation on 9/23/25 at 12:46 PM, revealed LN #2 prepared Resident #8's insulin injection at the medication cart wearing gloves. LN #2 walked over to Resident #8 and offered him/her the medication. Resident #8 agreed and LN #2 pushed him/her in his/her wheelchair to his/her room wearing the same gloves. Without changing gloves or performing hand hygiene, LN #2 cleansed an area on Resident #8's abdomen with an alcohol wipe and administered the insulin injection. Resident # 11 Record review on 9/22-26/25 revealed Resident #11 was admitted to the facility with diagnoses that included dementia (decline in intellectual functioning, including problems with memory, reasoning and thinking), chronic kidney disease stage 2 (a mild loss of kidney function often with early signs of kidney damage), and systolic heart failure (a condition where the left ventricle cannot contract effectively, leading to impaired blood pumping out of the heart). An observation on 9/24/25 at 10:00 AM, revealed Certified Nursing Assistant (CNA) #2 and CNA #5 entered Resident #11's room without performing hand hygiene. After speaking with the resident, the CNA's exited the room, and were observed looking around for the location of the alcohol-based hand rub dispenser outside of the room. Once found, both staff performed hand hygiene, put on gloves, and assisted the resident into the bathroom. With their gloved hands, the CNAs helped the resident lower his/her pants and brief, after which the resident sat on the toilet while both CNAs waited outside of the bathroom doorway. When Resident #11 was finished, CNA #5 re-entered the bathroom and wiped the resident wearing the same gloves. Next, while still wearing the dirty gloves, CNA #5, along with CNA #2 pulled up the resident's brief and pants then removed their gloves. Next, without performing hand hygiene, CNA #2 pushed the resident into the common area without offering hand hygiene to the resident prior to leaving the bathroom. Resident #14 Record review on 9/22-26/25 revealed Resident #14 was admitted to the facility with diagnoses that included diastolic congestive heart failure (heart failure caused by the hearts inability to relax and fill properly), localized edema (fluid accumulation in the tissues limited to a specific area), and chronic obstructive pulmonary disease (a progressive lung condition that causes airflow limitation and breathing difficulty due to airway and air sac damage). An observation on 9/24/25 at 9:34 AM, revealed CNA #1 and LN #2 entered Resident #14's room to assist him/her to the bathroom. Both staff performed hand hygiene and put on gloves. CNA #1 pushed the resident in his/her wheelchair to the commode and the resident self-transferred with assistance to stand in front of the commode. Using gloved hands, CNA #1 assisted the resident by pulling down the resident's pants and brief. While on the commode, LN #2 removed the resident's dirty brief from around the resident's ankles. CNA #1 handed LN #2 a new brief. Without changing gloves or performing hand hygiene, LN #2 placed the new brief above the resident's pants, which were still around the resident's ankles while the resident was still urinating. At the same time, CNA #1 prepared a damp wipe using toilet paper and a spray. When Resident #14 finished urinating, he/she stood up and turned around to be wiped. CNA #1 wiped the resident. Without changing gloves or performing hand hygiene, CNA #1 pulled up the resident's pants with LN #2's assistance, who was still wearing the dirty gloves from the brief change. The resident then turned around and sat back down in the wheelchair. Without performing hand hygiene and wearing the same gloves used to wipe the resident, CNA #1 pushed the resident up to the sink so the resident could wash his/her hands. Resident #15 Record review on 9/22-26/25 revealed Resident #15 was admitted to the facility with diagnoses that included dementia and a closed fracture of the right femur in an unspecified part of the femoral neck (break in the upper part of the thigh bone just below the ball of the hip joint). An observation on 9/24/25 at 11:01 AM, revealed Resident #15 told staff he/she had to use the restroom. CNA #5 wheeled Resident #15 to his/her room and assisted him/her to the toilet using a walker. Without performing hand hygiene or putting on gloves, CNA #5 helped Resident #15 stand while CNA #12 pulled down Resident #15's briefs and pants before assisting him/her to the toilet. After Resident #15 stated he/she was finished using the restroom, both CNA #5 and CNA #12 performed hand hygiene and put on gloves. CNA #5 assisted Resident #15 up while CNA #12 used toilet paper to wipe the resident. CNA#12 then disposed of the soiled toilet paper, and without changing gloves or performing hand hygiene, CNA #12 helped pull up Resident #15's briefs and pants. During an interview on 9/24/25 at 7:31 AM, LN #2 was asked if he/she was supposed to perform hand hygiene when entering a Resident's room and he/she replied, yes. When asked why he/she did not perform hand hygiene after pushing Residents #5 and #8 to their rooms and before administering insulin the previous day he/she responded by saying, it slipped my mind. During an interview on 9/25/25 at 10:40 AM, the Infection Preventionist (IP) stated that staff should perform hand hygiene after handling DME (durable medical equipment - medically necessary items for individuals such as wheelchairs) and before administering medications. She further stated that staff should perform hand hygiene after performing peri care (perineal care- cleaning the private areas of a patient to prevent infections and odors) before pulling up a resident's pants. Review of the facility policy Hand Hygiene, review date 10/21/2024, revealed: . Employees engaged in Patient Care Activities will perform hand hygiene in the following instances: Before each patient encounter . After coming in contact with patient's intact skin . Between tasks or procedures on the same patient to prevent the transmission of infectious agents from a dirty body site to a clean site. Hand hygiene is necessary between glove changes . After coming in contact with any of the following, regardless if hands become visibly soiled or not: Used patient equipment, etc., (e.g. handling sputum containers, bedpans, urinals, catheters) . After toileting a patient .

.Based on record review, interview, and observation, the facility failed to ensure that 3 Residents (#'s 2, 4, and 15), of 8 sampled residents, received adequate supervision to prevent falls. This failed practice placed these residents at risk for injury, impaired mobility, pain, and reduced well-being. Findings: Resident #2 Record review on 9/22-26/25 revealed Resident #2 was admitted with diagnoses that included cerebrovascular accident (CVA - also known as stroke, when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel). Further review revealed that Resident #2 had multiple falls: 6/25/25, 7/29/25, and 9/20/25. The fall that occurred on 9/20/25 resulted in a major injury. Review of Resident #2's care plans, dated 6/24/25 and 9/23/25, revealed: . [Resident #2] has limited physical mobility. AMBULATION: The resident uses rolling walker for walking . LOCOMOTION: [Resident] uses rollator for locomotion . Review of Resident #2's care plan, last review completed on 6/24/25, revealed: . Focus: [Resident #2] is High risk for falls. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . [Resident #2] needs a safe environment with: even floors free from spills and/or clutter. a working and reachable call light. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure that [Resident #2] is wearing appropriate footwear (correct client footwear or nonskid socks when ambulating or mobilizing in w/c [wheelchair]. Follow facility fall protocol. Fall #1 Review of the facility's investigation #684 Un-witnessed fall, dated 6/25/25 at 5:27 AM, revealed Resident was ambulating to the bathroom when he/she suddenly felt dizzy which led to an unwitnessed fall. He/she was found to be lying on his/her back on the floor by staff. He/she denied losing consciousness and had no signs or symptoms of injury. During an interview on 9/24/25 at 11:57 AM, the Director of Nursing (DON) and the Administrator (ADM) stated that following Resident #2's fall on 6/25/25, the resident's in-room care plan was revised to require the assistance of one staff member and the use of a walker whenever the resident was out of bed. Fall #2 Review of the facility's investigation #694 Un-witnessed fall, dated 7/29/25 at 8:30 AM, revealed Resident #2 was found on the floor by staff after they had heard him/her calling out. He/she was lying on the floor on his/her right side beside his/her closet. Resident #2 stated he/she was looking for something in his/her closet and lost his/her balance. It was also noted that he/she did not call for assistance before getting up. The resident was assessed, and no injury was found. Review of Resident #2's in-room care plan, dated 8/17/25, revealed: Walk in room: limited Assist/ walker. Walk in unit: limited assist 1 person/ walker. Left sided weakness encourage use. Locomotion on unit: Limited 1 assist /walker. Locomotion off unit: Limited 1 assist /walker. Left sided weakness encourage use. Safety/fall precautions: Fall risk Q [every] 15 minute checks at night . During an interview on 9/24/25 at 11:57 AM, the DON and the ADM stated that after Resident #2's second fall on 7/29/25, the care plan was updated to include 15-minute checks during the day. Review of the electronic health record (EHR) revealed no physician orders for Q15 minute checks and no documentation of the every15 minute checks being completed. Fall #3 Review of the facility's investigation #698 Un-witnessed fall, dated 9/20/25 at 2:00 PM, revealed the staff responded to Resident #2 shouting for help. Resident #2 was found laying on the floor next to his/her refrigerator. The Resident told staff that he/she was walking to his/her window to get something and his/her shoe dragged and kicked off. This caused him/her to slip and land on his/her hip and hit his/her head. The incident was unwitnessed. Resident #2 was assessed; no injury was found at the time, and he/she was administered as needed pain medication. Resident was later evaluated at the Maniilaq Emergency Department where imaging was done to the head, pelvis, spine, chest, left femur, left hip, and left tibia-fibula. Review of the Maniilaq Emergency Department notes, dated 9/20/25 at 7:32 PM, revealed: Ct scan shows cortical fracture of the left femoral greater tuberosity. During an interview on 9/24/25 at 11:57 AM, the DON and the ADM stated following Resident #2's third fall on 9/20/25, the resident was placed on 15-minute checks around the clock. The DON and ADM stated that the fall on 9/20/25 occurred between the scheduled daily every 15-minute checks. Further review of Resident # 2 care plan, review completed on 9/23/25, revealed the addition of Q-15 minute checks while in bed for safety. Record review of Resident #2's in-room care plan dated 8/17/25, revealed an update, dated 9/20/25, Q-15 minute checks at all times. Record review of Resident #2's Morse Fall Scale (a standardized tool to assess a resident's risk of falling), dated 9/9/25, revealed a score of 65, scores of 45 and higher being considered high risk for falls. During an interview on 9/24/25 at 11:57 AM, the ADM stated that Resident #2 was currently being evaluated for a change of status. When asked about documentation for the every 15 minute checks, the ADM explained that there was no documentation, and the expectation was that they were being done. When asked about the possibility of bed and/or chair alarms as an intervention, the ADM stated they were not being used at the facility because they considered them a restraint. Review of the facility provided Certified Nursing Assistant (CNA) report sheet, undated, revealed a total of nine residents (#'s 4, 5, 6, 8, 9, 10, 11, 12, 14), were on . Q 15 min[ute] Checks. Resident #2 was not documented as being on Q 15 min[ute] checks. During an interview on 9/24/25 at 9:26 AM, CNA #1 stated staff used the CNA report sheet as a quick reference to guide resident cares. Resident #4Record review on 9/22-26/25 revealed Resident #4 was admitted to the facility with a diagnosis of dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking). Further review revealed Resident #4 has had multiple falls: 6/12/24, 6/13/24, 6/25/24, 7/12/24, 9/24/24, and 5/29/25. Review of Resident #4's care plan, last review completed on 7/31/25, revealed: . [Resident #4] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Activity Intolerance, Confusion, Dementia Disease Process Chronic Kidney Disease, Epilepsy . TOILET USE: [Resident #4] requires limited assistance by 1 staff for toileting. TRANSFER: [Resident #4] requires total assistance by 2 staff to move between surfaces as necessary with the hoyer lift. Further review of the care plan revealed: [Resident #4] has had an actual fall with serious injury Poor Balance, Poor communication/comprehension, Unsteady gait. [Interventions/Tasks] . Contact Guard Assist while ambulating. Q [Every] 15-minute checks while in bed checks [initiated 8/13/2023] . Review of Resident #4's In-Room Care Plan, updated 5/29/25, revealed: TRANSFER: Extensive w/[with] staff w/ gait belt WC [Wheelchair] LINE OF SIGHT WHILE OUT OF ROOM.SAFETY/FALL PRECAUTIONS: HIGH RISK FOR FALLS Q-15-minute checks, CGA [Contact Guard Assist] while ambulating in room. gripper socks on at all times. Monitor for toileting times and needs at night.5/29/2025: Elder is to be line of sight when out of room.Fall #1 Review of the facility's investigation #621 Un-witnessed Fall, dated 7/12/24, revealed: . [Resident #4] slid out of lounge chair onto carpet. Dycem [anti-slip] mat not under [him/her] .[Resident #4] needs [anti-slip mat] underneath [him/her] . Review of Resident #4's Post-Fall Huddle Tool, dated 7/12/24, revealed Resident #4 was found sitting on the floor in front of his/her recliner. In response to the question, What changes will we make in this [resident's] plan of care to decrease this [resident's] risk for recurrent fall based on the immediate cause of the fall? What injury reduction intervention will we make to protect the [resident] from recurrent injury? the facility wrote, Make sure Dycem [mat's] under [Resident #4] at all times when out of bed & sitting up in chair or wheelchair. Review of Resident #4's current care plan and in-room care plan revealed a Dycem mat was not included as an intervention. Fall #2 Review of the facility's investigation #636 Un-witnessed Fall, dated 9/24/24, revealed: . CNA was sitting very near room [ROOM NUMBER] when [he/she] heard a thud and found [Resident #4] laying on the floor near [his/her] bed. Nurse was called to the room and a full assessment was done. [Resident #4] has a small abrasion to the left side of knee 1 cm x 1 cm. [Resident #4] stated, I was going to use the restroom. [Resident #4] has dementia and was bare footed . Review of Resident #4's Post-Fall Huddle Tool, dated 9/24/24, revealed Resident #4 was found near bed, on carpet, on [his/her] back. In response to the question, What changes will we make in this [resident's] plan of care to decrease this [resident's] risk for recurrent fall based on the immediate cause of the fall? What injury reduction intervention will we make to protect the [resident] from recurrent injury? the facility wrote, Watch [Resident #4] closely while [he/she] is in bed. Wear grippy socks at all times. Review of Resident #4's In-Room Care Plan, updated 5/29/25, revealed: gripper socks on at all times. Review of Resident #4's care plan, reviewed on 7/31/25, revealed: . [Resident #4] is High risk for falls . Ensure that [Resident #4] is wearing appropriate footwear non-skid socks or tennis shoes while ambulating or mobilizing in w/c . Further review revealed no intervention documented to ensure gripper socks were worn at all times. Fall #3 Review of the facility's investigation #678 Un-witnessed Fall, dated 5/29/25, revealed: . [Resident #4] got up unassisted and was walking to [his/her] room and fell in the hallway, unwitnessed fall .[Resident #4] was going to use the bathroom .[Resident #4 complains of] right knee pain and has a small abrasion to left side of right knee which measured 1.5 cm x 1.0 cm and another abrasion to left knee 0.5 cm x 0.25 cm . Review of Resident #4's Post-Fall Huddle Tool, dated 5/29/25 revealed: . [Resident #4] was in dining room going toward [his/her] room . CNA was helping CNA with a [resident], 2 CNA's helping another [resident] nearby . In response to the question, What changes will we make in this [resident's] plan of care to decrease this [resident's] risk for recurrent fall based on the immediate cause of the fall? What injury reduction intervention will we make to protect the [resident] from recurrent injury? the facility wrote, Line of sight when out of room. Review of Resident #4's ED [Emergency Department] NOTE-Provider dated 5/30/25 at 5:31 PM, revealed: . Fall 2 days ago in the room to [his/her] knees. [He/she] did not hit [his/her] head. [He/she] is noted to have soft tissue abrasion over [his/her] right knee afterwards by staff . Additionally there is concern for right lower extremity swelling . Review of an XR [X-Ray] Ankle Complete Right, dated 5/31/25 at 4:59 PM, revealed: . HISTORY: Pain following fall, bruising over [right] lateral malleolus [ankle]. Findings suspicious for nondisplaced lateral malleolar fracture . Review of Resident #4's In-Room Care Plan, updated 5/29/25, revealed: 5/29/2025: Elder is to be line of sight when out of room. Review of Resident #4's care plan, last review completed on 7/31/25, revealed: . [Resident #4] has had an actual fall with serious injury Poor Balance, Poor communication/comprehension, Unsteady gait. [Interventions/Tasks] Q 15-minute checks while in bed checks. Further review of the care plan revealed Resident #4 Interventions/Tasks of Q-15 minute checks while in bed was initiated on 8/14/23. Further review of the care plan revealed no documentation that the resident was to be line of sight when out of room. During an interview, on 9/24/25 at 3:01 PM, Licensed Nurse (LN) #2 stated it was after Resident #4's fall on 5/29/25, that Resident #4 was made a Q-15-minute check. LN #2 further stated the staff do not document the Q-15 minute checks. Review of the EHR revealed no physician orders for Q15 minute checks and no documentation of the 15 minute checks being completed. Resident #15 Record review on 9/22-26/25 revealed Resident #15 was admitted to the facility with diagnoses of dementia. Further review revealed Resident #15 has had multiple falls: 10/5/24, 3/1/25, 6/15/25, and 7/27/25[EW1] . Review of Resident #15's care plan, last review completed on 9/2/25, revealed: . [Resident #15] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Activity Intolerance, Fatigue, Arthritis Pain . [Interventions/Tasks] Ambulation: Due to weakness for illness [Resident #15] is walking with walker to help prevent falls .TRANSFER: [Resident #15] requires supervision assistance by 1 staff to move between surfaces as necessary. [Resident #15] is High risk for falls r/t Deconditioning, Gait/balance problems. Review of Resident #15's In-Room Care Plan, updated 7/27/25, revealed: TRANSFER/ REPOSITIONING: SUPERVISION.8/16/2023, Line of sight while out of room.HIGH FALL RISK .7/27/2025 Q-15 minute checks for safety, offer to assist with toileting if found awake. Fall #1 Review of the facility's investigation #639 Witnessed Fall, dated 10/5/24, revealed: . [Resident #15] was on the bathroom floor sitting on [his/her] buttocks legs in front of [him/her] and shoulders up against the wall. [Resident #15] had [his/her] walker and 1 shoe was on, the other off of [his/her] foot.[Resident #15] states [he/she] was going to the bathroom and lost [his/her] balance when the door swung open too fast . Review of Resident #15's Post-Fall Huddle Tool, dated 10/5/24, revealed: . I [Resident #15] tried to grab the door but it opened to[o] fast when I [Resident #15] lost my balance . In response to the question, What changes will we make in this [resident's] plan of care to decrease this [resident's] risk for recurrent fall based on the immediate cause of the fall? What injury reduction intervention will we make to protect the [resident] from recurrent injury? the facility wrote, Remind [Resident #15] to slow down has a tendency to walk fast. Fall #2 Review of the facility's investigation #659 Witnessed Fall, dated 3/1/25, revealed: . [Resident #15] was in common area sitting in chair when [he/she] stood up, turned to the left and lost [his/her] balance tipping backwards. [He/she] grabbed toward the medicine cart that was nearby to catch [himself/herself] but unable to reach it. [He/she] landed on [his/her] buttocks and rolled back.[He/she] was quick to stand up saying I'm ok. Lost [his/her] forward balance using walker . Review of Resident #15's Post-Fall Huddle Tool, dated 3/1/25, revealed: . [Resident #15] on floor in front of high back chair in sitting room. In response to the question, What changes will we make in this [resident's] plan of care to decrease this [resident's] risk for recurrent fall based on the immediate cause of the fall? What injury reduction intervention will we make to protect the [resident] from recurrent injury? the facility wrote, Be aware that [he/she] is less stable on [his/her] feet. In response to the question, What are you implementing now? the facility wrote, Frequent checks [with] neuros [and] staff aware to help be on standby to help [with] sitting and standing. Fall #3 Review of the facility's investigation #683 Witnessed Fall, dated 6/15/25, revealed: . [Resident #15] attempted to stand with walker and lost balance. Staff was close enough grab [Resident #15] and assist [him/her] to floor. [Resident #15] laughed and stated [he/she] was okay . [Resident #15] stated his/her foot slipped as he/she was attempting to get up . Review of Resident #15's Post-Fall Huddle Tool, dated 6/15/25, revealed: . foot slipped. sitting on the floor near the chair . In response to the question, What changes will we make in this [resident's] plan of care to decrease this [resident's] risk for recurrent fall based on the immediate cause of the fall? What injury reduction intervention will we make to protect the [resident] from recurrent injury? the facility wrote, Encourage [Resident #15] to ask for assistance. In response to the question, Is this a system-wide learning event? the facility wrote, Inservice educating staff about fall risk and preventing falls. In response to the question, What are you implementing now? the facility wrote, Assist [Resident #15] when standing up to use walker. Fall #4 Review of the facility's investigation #692 Un-witnessed Fall, dated 7/27/25, revealed: . Resident found lying on RIGHT side in floor in front of WC. [Resident #15] stated [he/she] was trying to get into [his/her] chair and missed and fell. [Resident #15] stated [he/she] was getting into [his/her] WC and missed and landed on [his/her] RIGHT side, c/o [complains of] pain in RIGHT hip 10/10. Send to ER for evaluation. Review of Resident #15's Post-Fall Huddle Tool, dated 7/26/25, revealed Resident #15 was found lying on [right] side [at] foot of bed in front of WC. In response to the question, What changes will we make in this [resident's] plan of care to decrease this [resident's] risk for recurrent fall based on the immediate cause of the fall? What injury reduction intervention will we make to protect the [resident] from recurrent injury? the facility wrote, Placed [Resident #15] on Q-15 minute checks. Offer to assist [with] toileting if awake. Review of the Health Status Note, dated 7/27/25 at 12:50 AM, revealed: . This writer and CNA heard loud noise coming from room. Found [Resident #15] lying in floor on [his/her] RIGHT side at the foot of [his/her] bed in front of [his/her] WC. [Resident #15] c/o of 10/10 pain to the RIGHT hip. advised to send to [Emergency Room] for evaluation . Review of Resident #15's CT Hip without Contrast, dated 7/27/25 at 10:53 AM, revealed: . HISTORY: GLF [ground level fall], right hip pain, unable to raise leg; eval for fracture. IMPRESSION: 1. Impacted but otherwise nondisplaced subcapital femoral neck fracture [break just below the head of the femur (the long leg bone which inserts into the hip socket) where the bone cracks but remains properly aligned without shifting out of place] . Review of Resident #15's Primary Care Provider Note, dated 8/22/25 at 1:23 PM, revealed: . Status post hospitalization 7/27/2025 through 8/13/2025 for right hip fracture and surgery. [Resident #15] had an unwitnessed fall on 7/26/2025, when transitioning from [his/her] wheelchair into [his/her] bed. underwent a close reduction percutaneous pinning (CRPP) right hip fracture [fractured hip bone is realigned without a large incision and then secured with pins inserted through the skin to stabilize the bone during healing] 7/29/25. [His/her] hospital stay was complicated by community-acquired pneumonia associated with hypoxia and was treated successfully while hospitalized . In addition, patient developed urinary retention and was maintained on Foley catheter upon [his/her] hospital discharge . Review of Resident #15's In-Room Care Plan, updated 7/27/25, revealed: . HIGH FALL RISK .7/27/2025 Q-15 minute checks for safety, offer to assist with toileting if found awake . Review of the current care plan and revisions revealed no documentation on the resident's every 15 minute safety checks. Review of the daily CNA report sheet revealed Resident #15 required: Q 15 MIN CHECKS. Review of the EHR revealed no physician orders for Q15 minute checks and no documentation of the every 15 minute checks being completed. Review of the facility provided CMS-802.Resident Matrix, date printed 9/22/25, revealed a total of seven residents, had fallen within the reporting period of 120 days. Review of the facility policy LTC - Fall Management, last reviewed 2/23/25, revealed: . The resident will be provided a safe environment to prevent falls. During an interview conducted on 9/24/25 at 4:17 PM, the DON and the ADM explained the facility's fall prevention strategy was to apply the least restrictive means necessary such as removing hazards, and increasing safety checks. The most restrictive intervention was to implement one on one monitoring for a resident. The facility considered bed alarms and wheelchair seat belts restraints. The fall prevention strategy would be applied on a case-by-case basis. The ADM and DON stated the first steps in the facility's strategy were to update the in-room care plan to require one-person assistance and the use of a walker whenever the resident was out of bed. If the resident experienced another fall, the care plan was revised to include 15-minute safety checks during the day. Following an additional fall after implementing the daytime 15-minute safety checks, the resident would be placed on 24 hour 15-minute safety checks. The DON further added that the 15-minute safety checks were enough to prevent falls. During an interview on 9/25/25 at 4:37 PM, the ADM stated that the facility's Quality Assurance and Performance Improvement (QAPI) committee met quarterly. The Administrator explained that the committee identified and selected performance improvement projects, referred to as QAs (Quality Assurances), based on factors such as severity, frequency, and identified trends. When asked whether the QAPI committee was working on any active QAs, the Administrator stated that there were no active QAs as of 9/22/25.

Based on record review, observation, and interview, the facility failed to ensure insulin (a medication for blood sugar maintenance) orders were followed for 2 residents (#5 and #10), out of 3 residents reviewed who received insulin. Specifically, the insulin orders were written to be administered before meals, and the insulin was administered after meals. This failed practice placed these residents at risk for experiencing potential adverse effects for not receiving insulin per the physician's orders. Findings: Resident #5: Resident #5 was admitted with diagnoses that included Type 2 Diabetes Mellitus with unspecified complications and essential hypertension (high blood pressure). Record review on 4/22/24 of Resident #5's insulin order, dated 2/14/24, revealed: Novolog Flex Pen [insulin] Subcutaneous [injection under the skin] Solution Pen-Injector 100 unit/ml [milliliter] (insulin aspart). Inject 8 unit subcutaneously before meals related to Type 2 Diabetes Mellitus with unspecified complications . (This medication is a rapid-acting anti-diabetic medication to help regulate blood sugar needs in the body. Type 2 Diabetes is a condition because of a problem the way the body regulates and uses sugar as a fuel). An observation on 4/22/24 at 11:30 AM, revealed Licensed Nurse (LN) #1 checked Resident #5's blood sugar. The blood sugar result was 290 (normal blood sugar results are about 70-100). An observation on 4/22/24 at 12:42 PM, revealed LN #1 administered the insulin injection into the Resident's abdomen after the resident had finished eating lunch. During an interview and concurrent observation on 4/24/24 at 1:03 PM, LN #1 stated Resident #5's blood sugar was 225. LN #1 was observed to administer insulin to Resident #5 after the resident had finished eating lunch. Resident #10: Resident #10 was admitted with diagnoses that included Type 2 Diabetes Mellitus without complications and essential hypertension. Record review on 4/22/24 revealed Resident #10's insulin order, dated 4/19/24, revealed: Novolog Flex Pen Subcutaneous Solution Pen-Injector 100 unit/ml (insulin aspart). Inject 8 unit subcutaneously before meals related to Type 2 Diabetes Mellitus without complications . During an interview on 4/22/24 at 11:50 AM, LN #1 stated Resident #10's blood sugar was 153. LN #1 further stated insulin would be administered after the resident was finished eating. An observation on 4/22/24 at 1:01 PM, revealed LN #1 administered the insulin injection into Resident #10's abdomen after the resident had finished eating lunch. During an interview on 4/22/24 at 1:05 PM, LN #1 stated the insulin order had been written to administer the insulin before meals. During an interview on 4/24/24 at 4:00 PM, when asked about Resident #5 and #10's insulins being given after lunch and not before lunch, the Director of Nursing (DON) stated Residents #5 and #10 blood sugars would bottom out and so the insulin was given after the meals instead of before. During an interview on 4/25/24 at 9:45 AM, when asked if giving Resident #5 and Resident #10 the insulin after lunch instead of before was a medication error, the Administrator stated these were medication errors. She further stated the reason for the late administration of the insulin had been discussed with the physician, and this was due to the bottoming out of the blood sugars if the insulin was given before meals. During an interview on 4/25/24 at 12:20 PM, the Physician stated the late administration of these insulins was a timing issue. He also stated, I have told nursing they can give the insulins before, during, or after meals. The nurses can use their own judgement with how the patient is eating. We could have written after meals. If that is difficult to interpret, then this should be written differently. The expectation is for the nurse to follow their nursing judgement with the order. We want to prevent hypoglycemic (low blood sugar) episodes. I talk to [the DON] three times a month about blood sugar levels. Review of the facility's policy Medication Administration, dated 10/27/23, revealed: Medications are administered by Registered Nurses and Licensed Practical Nurses in accordance with the State and Federal regulations and the Alaska Board of Nursing .the nurse will follow up and check the 'eight rights' before administering medications, right medication, time, resident, dose, route, documentation, reason, and response.

47929 Based on record review and interview, the facility failed to ensure a copy of 2 residents' (#8 and #12) transfer notices were sent to the Office of the State Long Term Care (LTC) Ombudsman. This failed practice had the potential to affect all residents, based on a census of 17, by: 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State LTC Ombudsman was aware of facility practices and activities related to transfers and discharges. Findings: Resident #8: Record review from 4/22-25/24 revealed Resident #8 was admitted to the facility with diagnoses that included dementia, epilepsy, stroke, and a history of falls. Further review revealed Resident #8 was hospitalized and discharged from the facility on 12/12/23 with a return anticipated and readmitted on [DATE]; discharged and hospitalized on [DATE] with a return anticipated and readmitted on [DATE]; and discharged and hospitalized on [DATE] with a return anticipated and readmitted on [DATE]. During an interview on 4/23/24 at 4:00 PM, when asked about the process of notifying the Ombudsman for discharges or transfers to the hospital, the Director of Nursing (DON) stated the facility just became aware of the need to notify the Ombudsman this year. During an interview on 4/23/24 at 5:02 PM, when asked for the notification documentation for December 2023 and March 2024, the DON stated the facility just started the Ombudsman notification for hospital discharges in January (2024), so there were no notifications for the December hospitalization s. Review of Notification of Discharge: Month: March, 2024, revealed No Discharges for the Month of March. The DON further stated the facility had not alerted the Ombudsman of Resident #8's hospitalization transfer in March because the resident was not admitted to the hospital, but remained in the Emergency Department in observation status. During an email correspondence with the Ombudsman on 4/25/24 at 11:30 AM, the Ombudsman wrote: A notice of transfer must be provided to the resident and resident representative as soon as practicable .Copies of notices for emergency transfers must also be sent to the Ombudsman when practicable such as on a monthly basis. Resident #12 Record review on 4/22-25/24 revealed Resident #12 was admitted to the facility with diagnoses that included dementia, mild cognitive impairment, chronic obstructive pulmonary disease (chronic lung disorders resulting in blocked air flow in the lungs), hypertension (high blood pressure), and a history of myocardial infarction (heart attack). Further review revealed Resident #12 was admitted to the hospital on 1/17-20/24 for sepsis (a life-threatening complication of an infection), pneumonia, and acute kidney injury. Review of the facility's Notification of Discharge, dated 1/2024, that was sent to the Ombudsman, revealed Resident #12's discharge to the hospital was not included. During an interview on 4/25/24 at 1:21 PM, the Administrator stated, in January 2024, the facility had implemented a new monthly process of notifying the Ombudsman, which included a form with every resident that was admitted to the hospital for the entire month. She further stated Resident #12 should have been on the Ombudsman's notification form, but it was missed somehow. Review of the facility's policy, Transfer or Discharge, dated 1/23/24, revealed: Upon receiving the provider [physician] order to transfer or discharge the patient, the Charge Nurse will notify the patient, their family and/or representative, and Social Services .The patient will be given written notice of the reason for the discharge or transfer .The transfer notice is to include an explanation of the right to appeal the transfer to the State as well as the name, address, and phone number of the State Long Term Care Ombudsman . .

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed and implemented with specific medical care needs for 1 resident (#8), out of 9 sampled residents. Specially, the facility failed to address risk factors or include specific information concerning the resident's prescribed anti-platelet medication (that inhibits the ability of platelets to clump together as part of a blood clot and could cause the risk of bleeding) in the resident's care plan. This failed practice had the potential to place the resident at risk for inconsistent care that could result from the many risk factors of the anti-platelet medication. Findings: Record review from 4/22-25/24 revealed Resident #8 was admitted to the facility with diagnoses that included dementia, epilepsy, stroke, and anemia. Further review revealed the resident had a history of falls. Review of Resident #8's Skin/Wound Note, dated 12/10/23, revealed: When Elder came to lunch, noticed left eye to be black and swollen. Palpated [felt] eye and around eye, Elder denies any pain or discomfort. When asked Elder denies any fall or injury. Noted both of Elders eyes watering and Elder aggressively wiping them with tissue . During an interview on 4/23/24 at 2:35 PM, Licensed Nurse (LN) #1 recalled the incident and stated the facility alerted the physician who assessed Resident #8's eye and thought the blood thinners and aggressive rubbing of the eyes caused the bruising. LN #1 further stated the physician concluded since the Resident was taking blood thinners, he/she had busted a capillary under the skin around his/her eye, which was black, and looked like a hematoma (an abnormal pooling of blood under the skin that results from a broken or ruptured blood vessel). Review of Resident #8's current Physician's orders, active as of 4/23/24, revealed the Resident was prescribed Clopidogrel Bisulfate (Plavix- an anti-platelet medication) once a day, with a start date of 3/11/23. Review of Resident #8's current Care Plan revealed no documentation of the Resident taking the Clopidogrel medication, nor interventions regarding the medication and the potential side effects or risks, such as bleeding. During an interview on 4/23/24 at 5:19 PM, when asked about the Resident's injury, the Director of Nursing (DON) stated the facility reviewed the resident's medical record which included the note about the resident aggressively wiping his/her eyes, and the physician was notified. When asked if the blood-thinning medication should have been included on the Resident's care plan, the DON stated it was not included because that medication was discontinued. When shown Resident #8's physician's orders which included the medication, the DON further stated, yes, the Resident's care plan should have included the blood thinning medication. Review of the facility's policy CARE PLANNING, dated 11/2023, revealed: It is the policy of Manillaq Health Center to provide an individualized nursing care plan for all patients to provide continuous, consistent care .The written plan of care is based on the patient's goals and the time frames, settings, and services required to meet those goals .

Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set-a Federally required assessment) was coded accurately for 2 residents (#s 4 and 12), out of 9 sampled residents, and 1 resident (#19), out of 2 closed record reviews. The failure to ensure the MDS was accurately coded placed the residents at risk for ineffective care planning. Findings: Diagnosis miscoding: Record review on 1/30/23-2/2/23 revealed both Resident #'s 4 and 12 were admitted to the facility with diagnoses that included dementia. Review of Resident #4's MDS assessment, a quarterly assessment dated [DATE], revealed the resident's dementia diagnosis was not coded. Further review of the resident's previous MDS assessments, dated 9/6/22 and 6/6/22, revealed the dementia diagnosis was coded. Review of Resident #12's MDS assessment, a quarterly assessment dated [DATE], revealed the resident's dementia diagnosis was not coded. Further review of the resident's previous MDS assessments, dated 9/19/22 and 6/19/22, revealed the dementia diagnosis was coded. During an interview on 2/2/23 at 12:33 PM, the MDS Coordinator stated if the resident was actively receiving treatment for dementia, it would have been a coding error if the diagnosis was not included in the quarterly MDS assessments. Wound infection miscoding: Further review of Resident #4's MDS assessment, a quarterly assessment dated [DATE], revealed the resident was coded as having a wound infection-other than foot. During an interview on 1/31/23 at 11:03 AM, Licensed Nurse (LN) #1 stated Resident #4 had an ingrown toenail months ago, which was now healed. The LN further stated the resident was receiving foot soaks and antibiotics months ago. Record review of Resident #4's Health Status Note, dated 4/4/22 at 11:31 PM, revealed: .infected [right] great toe, soaking per instructions, no [complaints] antibiotic end 4-8-2022. During an interview on 2/2/23 at 12:33 PM, the MDS Coordinator stated she did not remember Resident #4 being treated for a wound infection in December. The MDS Coordinator further stated she remembered the Resident had an ingrown toenail in April of 2022, but she thought she had removed the wound from the MDS assessment for December. The MDS Coordinator verified the data and stated the wound infection was coded in error. Discharge miscoding: Record review on 2/1/23 revealed Resident #19 was admitted in the facility with diagnoses that included failure to thrive and atherosclerotic heart disease (a condition where the arteries become narrowed and hardened due to buildup of plaque [fats] in the artery wall.) Review on 2/1/23 at 4:25 PM of Resident #19's Discharge Summary, dated 11/2/22, revealed the resident was discharged to home. Review of Resident #19's MDS assessment, a discharge assessment dated [DATE], revealed the resident was discharged to an acute hospital. During an interview on 2/2/23 at 10:51 AM, when asked about Resident #19's discharged status, the MDS Coordinator checked the MDS and confirmed it was coded as discharged to acute hospital. The MDS Coordinator stated the coding should have been discharged to community. The MDS Coordinator further stated the coding needed to be modified. Review of the facility's policy, Quarterly MDS/Care Plan Review, dated 6/6/22, revealed: .This quarterly review is to ensure the care plan is reflective of the resident's current needs and also identify if there have been significant changes in the resident's condition which may warrant a more comprehensive assessment .Care plans will be updated at least quarterly with the quarterly MDS .

Based on record review and interview, the facility failed to ensure comprehensive care plans were individualized for 1 resident (#13), out of 9 sampled residents. This failed practice placed the resident at risk for not receiving the necessary care and services to address his/her individual needs. Findings: Record review on 1/30/23-2/2/23 revealed Resident #13 was admitted to the facility with diagnoses that included adult failure to thrive and chronic kidney disease. During an interview on 1/31/23 at 11:30 AM, Resident #13 stated he/she asked the staff for water when he/she was thirsty because the staff watched how much fluid he/she drank. Review of Resident #13's current comprehensive care plan, revised on 12/3/22, revealed: Encourage fluids during the day to promote prompted voiding responses. Review of the Resident's current physician orders revealed an order for a 2 Liter Fluid restriction [related to] hyponatremia [low blood sodium levels] with a start date of 4/29/22. During an interview on 2/1/23 at 4:07 PM, Licensed Nurse (LN) #1 stated Resident #13 was on a fluid restriction. When asked if the fluid restriction would have been documented in the care plan, LN #1 stated it should have been. During an interview on 2/2/23 at 11:53 AM, the Director of Nursing (DON) stated the fluid restriction should have been added to the comprehensive care plan. Review of the facility provided document, Care plan preparation, long-term care, dated 5/20/22, revealed: Care planning is driven by a resident' conditions and issues as well as a resident's unique characteristics. Each resident's care plan should be based on assessment of the resident, effective clinical decision making, and must be compatible with current standards of clinical practice. These three pillars can provide a strong base for quality of care and quality of life for residents .

Based on observation, interview, and policy review, the facility failed to ensure infection control procedures were properly implemented. Specifically, the facility failed to ensure staff removed soiled gloves and performed hand hygiene after completing dirty tasks to clean tasks. This failed practice had the potential to affect all residents, based on a census of 17, for risk of the spread of infectious disease. Findings: An observation on 2/1/23 at 9:38 AM revealed Certified Nurse Assistant (CNA) #s 2 and 3 assisted Resident #10 to use the bathroom. Both CNAs wore gloves. CNA #2 was assisting the resident on one side to hold onto the handrail, while CNA #3 prepared the wet wipes. CNA #2 assisted the resident to a standing position after Resident #10 had a bowel movement. CNA #3 wiped the resident's anal area with wet wipes three times and discarded the soiled wipes in the trash can. CNA #3, while still wearing the soiled gloves, pulled Resident #10's brief and pants up, fixed the resident's jacket, and touched one of the handles of the wheelchair. Further observation revealed CNA #3, while still wearing the soiled gloves, removed the trash bag from the trash can and placed the bag on the floor. CNA #3 then put a new bag in the trash can. CNA #3 was observed removing his/her gloves one at a time while tying the trash bag. The CNA, with one ungloved hand, held the soiled gloves while continuing to hold the trash bag. CNA #3 then carried the trash bag outside the bathroom and placed it on the floor. Then, CNA #3 turned on the water at a sink [located outside the bathroom] and had the water flowing for the resident's use. CNA #3 was not observed to perform hand hygiene during this observation. During the same observation, CNA #2 pushed Resident #10's wheelchair out of the bathroom and assisted the resident to wash his/her hands. After the resident washed his/her hands, CNA #3 wiped the resident's hands with a paper towel. Then, CNA #3 pushed the wheelchair away from the sink. CNA #2 took over and pushed the wheelchair out of the room. Both CNAs sanitized their hands with alcohol-based hand sanitizer from a dispenser attached on the wall outside the room. During a joint interview on 2/1/23 at 9:49 AM, CNA #'s 2 and 3 stated they were trained to wash their hands before going into the residents' rooms and bathrooms. The CNA's further stated they were also trained to wear gloves before performing resident cares. After performing resident cares, they would have removed their gloves and performed hand hygiene with soap and water for 20 seconds and then dried their hands with paper towels. Record review on 2/2/23 at 8:40 AM of the Hand hygiene policy, dated 6/19/22, revealed: .performing hand hygiene as promptly and thoroughly as possible between direct or indirect contact .body fluids, and any other potentially infectious materials .hand hygiene is necessary between glove changes after coming in contact with any of the following, regardless if hands become visibly soiled or not .after toileting a patient .Gloves should always be changed when moving from dirty tasks to clean tasks even when hands or gloves are not visibly soiled. During an interview on 2/2/23 at 1:45 PM, the Administrator stated staff should have removed gloves after completing a dirty task and then should have performed hand hygiene.

Based on record review and interview, the facility failed to complete a comprehensive reassessment within two weeks after the Resident experienced a significant change in physical or condition for 1 of 9 sampled residents (#14). As a result, the Resident's altered physical needs were at risk for not being addressed in a timely manner and therefore putting the Resident at risk for potential decline in health and functioning. Findings: Resident #14 Review of the Electronic Health Record (EHR) Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The review showed that Resident #14 was transferred out of the facility due to a fall, had left hip surgery on 9/6/21, and returned to the facility for readmission on 9/11/21. Review of the Significant Change in Status Assessment (SCSA) Minimum Data Assessment (MDS) for Resident #14 occurred on 10/6/21. An SCSA MDS was not completed for the change in status for Resident #14 since his / her return to the facility on [DATE]. SCSA MDS is a federally mandated process comprehensive assessment that is required when the Interdisciplinary Team has determined that a resident meets the significant change guidelines for either major improvement or decline. Regarding the change in ambulation status decline: Further review revealed the Resident had a loss of mobility due to a left hip surgery. An In - room care plan dated 9/15/21 evidenced the Resident was non-weight bearing and needed assist with 2 - 3 person assist with transfer. The Resident's Care Plan dated 8/24/21 revealed the Resident had been assessed to safely ambulate in a Merry Walker and was able to scoot around on the floor when out of bed at times. Regarding change in pain management status: Also, the Resident's pain status showed a change since the fall, hip surgery, and return to the facility. The MDS assessment on 8/18/21 revealed no pain indicators or need for scheduled or as needed pain medications. The Care plan dated 8/24/21 revealed no care planning goals or tasks for pain management. After the Resident's return to the facility, the need for pain medication was documented in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This document revealed, Pain management, Been on a scheduled pain medication regimen . Tylenol 975 mg [milligrams] TID [three times a day] and oxycodone 5 mg TID prn [as needed.] . Elder had some relief from current medication regimen, will continue assessment to note if pain regimen will remain effective . Received non - medication intervention for pain . reposition, distraction, comforting . Elder had a girdle stone surgical procedure performed and the pain associated with this procedure is worse than expected with a traditional hip replacement. During an interview on 10/6/21 at 4:04 PM, the MDS nurse stated there was confusion with the surgery and this delayed the assessments including the significant change assessment. When questioned about what date this significant change assessment should have occurred by, the MDS nurse stated, I am not sure. The MDS nurse also explained that personal leave had delayed the assessment's completion.

Based on record review, interview, and observation, the facility failed to develop an individualized care plan that addressed residents' care needs. Specifically, the facility failed to 1) develop a fall risk care plan for Resident #66 and 2) develop a pain management care plan for Resident #14. This failed practice places 2 residents out of 9 sampled residents at risk of not receiving timely response and care. Findings: Resident # 66 Review of the Electronic Health Record (EHR) Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Resident #66's Minimum Data Set Admission Assessment (MDS), dated [DATE], revealed J1700 Fall History on Admission, Did the resident have fall any time in the last month prior to admission? Yes; Did the resident have fall any time in the last 2- 6 months prior to admission? Yes; Did the resident have any fracture related to fall in the 6 months prior to admission? Yes During an interview on 10/05/21 at 1:04 PM, Resident #66 stated he/she fell and broke his/her leg last month. Resident #66 explained it happened when he/she was in their room alone and slipped. All [staff] came into Resident's room and took him/her to the physician. The Resident further stated that he/she was brought to the hospital in Anchorage and had his/her leg fixed. During the same interview, Resident #66 stated when he/she came back from the hospital, the Long-Term Care staff helped the Resident to the bathroom and assisted him/her to do everything. Review on 10/06/21 at 10:59 AM of the Care Plan on admission, revealed fall risk was not included. Review on 10/06/21 at 11:39 AM of the Morse Fall assessment dated [DATE] 8:35 AM, revealed Post Fall Score: 80.0. Has the Resident ever fallen before? Yes, what ambulatory aids if any, does the resident use? 2. Uses crutches, cane, or walker; Does the resident . know the limits of their abilities to ambulate safely? 2.Overestimates or forgets limits. During an interview on 10/06/21 at 3:30 PM, when asked if fall risk should be included in the care plan, the MDS Nurse replied there was an Interdisciplinary Team (IDT) care plan meeting after the fall. The MDS Nurse explained that during the IDT meeting, the IDT discussed what happened and the care to be done. IDT care plan was different from the regular care plan. It was kept in the binder in the office. The surveyor requested a copy of the IDT care plan in which the MDS Nurse provided after the interview. During the same interview, when asked why fall risk was not included on Resident #66's care plan, the MDS nurse stated any interventions applied to the Resident were written in the in-room care plan then transferred to a regular care plan which was done quarterly or annually. Review on 10/06/21 at 4:45 PM of the IDT Care plan Conference Summary dated 9/14/21, revealed Other discussed with the Resident's Representative was marked with a comment Transferred to ER. In the Summary of care plan conference section, a handwritten note Elder did not call for assistance when exiting [the] bathroom [res] is very forgetful, elder fell while ambulating from bathroom to bed. All facility staff who attended the conference signed the document. There was no documentation on what care was to be done after the fall. Review on 10/06/21 at 4:54 PM of the In-room care plan, revealed on 9/14 fall-transferred out to the hospital; 9/14 Q15 checks when elder is awake in room [lined out] Dc' d [discontinued] 9/21/21. 9/21 Q15 minutes checks at night. There was no documentation on other interventions to prevent fall prior to 9/14/21. Resident #14 Review of the Electronic Health Record (EHR) Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The review showed that Resident #14 was transferred out of the facility due to a fall, had left hip surgery on 9/6/21, and returned to the facility for readmission on 9/11/21. The care plan review failed to reveal the care plan had been updated to include pain management. This care plan included three parts: an in - room care plan, a care plan from the EMR, and a care plan conference summary which was completed with the family and the IDT. Review of Resident #14's MDS assessment, dated 8/18/21 revealed . J0100 Pain Management at anytime in the last 5 days, has the resident A. Been on a scheduled pain medication regimen? No. B. Received prn pain medication? No C. Received non - medication interventions for pain? No. D. Should pain interview be conducted? No. E. Indicators of pain or possible pain in last 5 days? No During an interview on 10/5/21 at 10:18 AM, the Resident Representative for Resident #14 stated that pain has been an issue for Resident #14 since he / she returned home for hospital after having hip surgery in early September 2021. The nursing staff had discussed the need to manage the Resident's pain with him / her, and the Resident's pain status and condition were constantly monitored. The representative stated it was very important to not have the Resident in any pain or discomfort. During an observation on 10/5/21 at 12:10 PM, loud crying was heard from Resident #14's room. The door was closed. After the surveyor knocked on the door, an unknown staff, who was behind the closed door, stated the staff were transferring Resident #14 from the bed to a Geri chair. After the door was opened, staff brought out Resident #14 in a Geri chair to the dining room and wheeled him to the dining room. The Resident was quiet and when asked about pain, did not respond. During an observation on 10/6/21 at 11:04 AM, Resident #14 was observed lying in bed. Two Certified Nursing Assistants (CNAs) were observed to wash their hands and don clean gloves. CNA # 1 and #5 pulled the privacy curtain and turned Resident #14 side - to - side by rolling the Resident back and forth in bed to complete incontinence care and apply a clean incontinence brief. As Resident #14 was rolled to his / her right side, Resident #14 grabbed and shook the bedrail and tried to grab both CNAs. The Resident #14 was observed to grimace and cry. The Resident #14's face was red and tightened and the neck veins were noted to be distended and taut. When asked if the Resident was always in pain with transfers and incontinence care, the CNA #1 nodded affirmatively. The CNA #5 stated it had been hit and miss with incontinence care and how much pain the Resident had prior to the Resident's fall and surgery but now the pain was continuous. The CNA #5 stated the nurses are aware of the Resident's severe pain and help at times with the transfers and care. Review on 10/6/21 at 1 PM of the Care Plan in the Electronic Medical Record dated 8/24/21 revealed no pain management on this document. Review on 10/6/21 at 3 PM of the In - Room Care Plan updated 9/15/21 failed to reveal any pain management interventions or tasks. An update note dated 9/6/21 revealed Elder in [hospital] for surgery at this time. Will evaluate ambulation, merry walker use, etc. upon [his / her] return . 9/15/21 Elder is non - weight bearing, transfer to Geri chair via 2 - 3 person assist. During an interview on 10/6/21 at 3:46 PM, the MDS Nurse stated the In-room Care Plan was to be used and stated a care plan meeting had occurred with Resident #14's Representative and family. The MDS Nurse stated the care plan will be updated quarterly when it is due for the quarterly update. During an interview on 10/6/21 at 4:04 PM, the MDS Nurse stated there was confusion with the surgery and this delayed the completion of the assessments and update to the care plans. The MDS nurse stated that the family wished the Resident would not be in any pain and this was discussed at a recent IDT conference with the family. The recommendation was to give pain management. Review on 10/6/21 at 4:20 PM of a Care Plan Conference Summary document signed by the Resident Representative on 9/27/21 revealed Met with elder and family r / t [related to] elder's current pain management regimen to about surgical procedure performed, also [his / her] rehab and prognosis following girdle stone procedure. This was also signed by the DON, Administrator, Social Worker, and MDS Nurse on this date. There were no care plan elements completed on this document. No pain management tasks, or interventions were documented. Review on 10/7/21 at 2:30 PM of Pain interview 3.0 dated 9/11/21 2:35 PM revealed, Pain management, Been on a scheduled pain medication regimen . Tylenol 975 mg (milligrams) TID (three times a day) and oxycodone 5 mg TID prn [as needed.] . Elder had some relief from current medication regimen, will continue assessment to note if pain regimen will remain effective . Received non - medication intervention for pain . reposition, distraction, comforting . Elder had a girdle stone surgical procedure performed and the pain associated with this procedure is worse than expected with a traditional hip replacement. This was signed by the Director of Nursing (DON) on 9/29/21. Review on 10/7/21 at 2:30 PM of a progress note titled Health Status Note dated 9/12/21 12:30 PM revealed, Oxycodone HCL Tablet 5 mg (milligrams) Give 1 tablet by mouth as needed for pain TID [ three times a day] severe pain [Score 8-10]. Pain noted on movement . A review on 10/7/21 at 2:30 PM of the PAINAD Assessment (with pain level of 0 being for no pain and 10 being severe pain) showed pain assessments completed from 9/11/21 - 10/7/21. On 9/17/21 at 8:07 PM, the pain level was recorded as a ten. On 10/6/21 at 10:42 PM pain was recorded at a level 6. On 9/28/21 at 2:20 PM, pain was recorded at a level 8. At 9/27/21 at 4:20 PM pain was recorded at level 9. Pain levels recorded ranged from 0 - 10 with the many pain assessments recorded onto this document. Review on 10/8/21 at 9:30 AM of an Orthopedic Provider clinic note dated 9/27/21 at 2:37 PM revealed, Chief complaint: Left hip girdle stone [a surgical procedure on the left hip] . spoke with head of nursing for the patient's [pt.] LTC due to the pt.'s severe dementia . [Director of Nursing (DON)] has significant concerns that the pt is in a large amount to pain when [he / she] is ambulating . now when the pt is out of bed, [he / she] screams and cries due to the large amount of pain [he / she] is in . the staff at the facility is concerned that the pt did not undergo the right procedure and this is the cause of [his / her] significant pain. Review on 10/8/21 at 8:45 AM of the facility policy titled Care Plan Preparation, long term care revised 5/21/21 revealed, Evaluate the resident's progress, and revise the care plan as appropriate.

Based on record review, interview, and observation the facility failed to develop a comprehensive care plan that addressed residents' care needs. Specifically, the facility failed to 1) develop a fall risk care plan for Resident # 66. This failed practice placed 1 resident out of 9 sampled residents at risk of not receiving appropriate care. Findings: Review of the Electronic Health Record (EHR) Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Resident #66's Minimum Data Set Admission Assessment (MDS), dated [DATE], revealed J1700 Fall History on Admission, Did the resident have fall any time in the last month prior to admission? Yes; Did the resident have fall any time in the last 2- 6 months prior to admission? Yes; Did the resident have any fracture related to fall in the 6 months prior to admission? Yes During an interview on 10/05/21 at 1:04 PM, Resident #66 stated he/she fell and broke his/her leg last month. Resident #66 explained it happened when he/she was in their room all by alone and slipped. All [staff] came into Resident's room and took him/her to the physician. The Resident further stated that he/she was brought to the hospital in Anchorage and had his/her leg fixed. During the same interview, Resident #66 stated when he/she came back from the hospital, the Long-Term Care staff helped the Resident to the bathroom and assisted him/her to do everything. Review on 10/06/21 at 10:59 AM of the Care Plan on admission, revealed fall risk was not included. Review on 10/06/21 at 11:39 AM of the Morse Fall assessment dated [DATE] 8:35 AM, revealed Post Fall Score: 80.0. Has the Resident ever fallen before? Yes, what ambulatory aids if any, does the resident use? 2. Uses crutches, cane, or walker; Does the resident's . know the limits of their abilities to ambulate safely? 2.Overestimates or forgets limits. During an interview on 10/06/21 at 3:30 PM, when asked if fall risk should be included in the care plan, the MDS Nurse replied there was an Interdisciplinary Team (IDT) care plan meeting after the fall. The MDS Nurse explained that during the IDT meeting, the IDT discussed what happened and the care to be done. IDT care plan was different from the regular care plan. It was kept in the binder in the office. The surveyor requested for a copy of the IDT care plan in which the MDS Nurse provided after the interview. During the same interview, when asked why fall risk was not included on Resident #66's care plan, the MDS nurse stated any interventions applied to the Resident were written in the in-room care plan then transferred to a regular care plan which was done quarterly or annually. Review on 10/06/21 at 4:45 PM of the IDT Care plan Conference Summary dated 9/14/21, revealed Other discussed with resident representative was marked with a comment transferred to ER. In the Summary of care plan conference section, a handwritten note Elder did not call for assistance when exiting [the] bathroom [res] is very forgetful, elder fell while ambulating from bathroom to bed. All facility staff who attended the conference signed the document. There was no documentation on what care was to be done after the fall. Review on 10/06/21 at 4:54 PM of the In-room care plan, revealed on 9/14 fall-transferred out to the hospital; 9/14 Q15 checks when elder is awake in room [lined out] Dc'd [discontinued] 9/21/21. 9/21 Q15 minutes checks at night. There was no documentation on other interventions to prevent fall prior to 9/14/21. .

Based on observation, record review, and interview, the facility failed to prevent for 1 resident at risk to develop pressure ulcers. The resident who was admitted to the facility without pressure ulcers developed two avoidable pressure ulcers. Specifically, the facility failed to 1) identify the blister as a pressure ulcer; 2) provide timely notification to the physician regarding the pressure ulcer; 3) provide timely implementation of care and services to prevent the increase in size of the pressure ulcer; and 4) care plan for the treatment of [REDACTED].#1) of 1 resident reviewed with a pressure ulcer, suffered harm from the development of pressure ulcers and delay in healing. Findings: Record review on 11/7-10/16, revealed Resident #1 was admitted to the facility 5/1/14 with [DIAGNOSES REDACTED]. Review of the 2 most recent MDS (Minimum Data Set, a comprehensive nursing assessment) dated 5/2/16 and 8/2/16 revealed, the Resident was identified as high risk for pressure ulcers and was coded as not having any unhealed pressure ulcers in both assessments. Heel Ulcer Observation on 11/9/16 at 8:40 am revealed a pressure ulcer on Resident #1 left heel; it had a black center with granulation surrounding the outer edges of the wound. Review of the comprehensive nursing care plan, last updated 2/15/16, revealed no care planning or interventions for the increased risk for pressure ulcers. In addition, the care plan was not updated to reflect a pressure ulcer on the left heel or the pressure ulcer on the right shin. Chorological Record Review - Skin Condition Record: 9/24/16 L heel blister, 3cm x 2 cm. - Nurses' note on 9/25/16 revealed Staff found blister to left heel during care. Blister is approximately 3cm x 2cm and intact. Elevated feet on pillow to let pressure off heel. Will continue to monitor and note if any changes. No updates were identified on the care plan. Professional reference review: National Pressure Ulcer Advisory Panel at <http://www.npuap.org>, revealed this would be staged as a stage 2 pressure ulcer. - Nurses' note on 10/8/16 at 11:25 am revealed Resident has large ruptured blister on left heel measuring 3.0 x 2.4x 0 cm. with serous odorless drainage. No s/s (signs/symptoms) of infection. - MD order dated 10/8/16 at 11:45 am revealed wet to dry drsg (dressing) twice daily L (left) heel gauze/kerlix. Relieve pressure L heel. p/o (phone order) Dr. MD was not notified of the blister until 15 days after the blister had been identified. - Nurses' note on 10/11/16 at 3:13 pm revealed, Assessed elder left heel wound, wound appears to have been a blister that has ruptured, wound bed (is) red and granulating, some of the skin of blister still attached to wound edges. (MD) updated on wound condition and stated he will remove skin on Friday (10/14/16) when he visits. Wound measures 6.0 x 6.2 x 0.1, wet to dry dressing applied . Decubitus has increased in size from 3 days ago. - Physician order [REDACTED]. - Nurses' Note on 10/19/16 at 2:10 pm, revealed .wound to left heel has necrotic tissue in center of heel and loose skin to surrounding wound edges, wound has mod amt (amount) of serosanguinous drainage with no odor (6.0 x 8.2 x .02) . The wound continues to increase in size. - physician progress notes [REDACTED]. Center ½ of wound has dark color surface that is moist. Mild exudate. Granulation tissue mild surrounding this center area .Lateral heel has stage 2 under peeled off blister . - Nurses' note on 10/25/16 revealed .Dressing on left heel changed, wound has foul smell with drainage seeping from around the duoderm extra thin dressing, dressing removed and wound cleansed with NS, heel had black center and measures 8.0 x 8.0 from edge to edge on would including where skin is disturbed. Pink to red edged around black center of heel. Wound continues to increase in size. Professional reference review: National Pressure Ulcer Advisory Panel at <http://www.npuap.org>, revealed this would be staged as unstageable because the depth of the pressure ulcer is not known due to the eschar. - Nurses' note on 10/28/16 revealed .(MD) here, debrided wound left heel. Ordered [MEDICATION NAME] (to start today) and [MEDICATION NAME]. Wound culture done. CBC and CMP completed today . (Debridement is a surgical removal of tissue). - Nurses' note on 10/31/16 revealed .today wound does not have odor, yellow/green slough had formed black eschar cap to 75% of wound bed, the other 25% of wound bed is pink granulating tissue. - Nurses' note on 11/4/16 revealed (MD) here .debridement to left heel .measurement of 5.0 cm x 4.5cm, depth 5mm, area surrounding wound is pink. - MD progress notes on 11/4/16 revealed Left heel ulcer, improved after debridement last week and starting antibiotics. Wound debrided today . ulcer dimensions 5 cm x 4.5 cm and 4mm deep. During an interview on 11/8/16 at 12:30 pm, when asked what lead to the pressure ulcer on the left heel, LN#1 stated the Resident rubbed . legs together all the time, that's why . has the ulcer. Left shin Pressure ulcer Observation on 11/9/16 at 8:40 am revealed a pressure ulcer on the bony prominence (ridge of the shin). The ulcer was full thickness (through all layers of skin) and had beefy red granulation tissue with a small area of yellow slough (dead tissue). Record review of the physician progress notes [REDACTED]. Pt (patient) has had a right shin decubiti for quite some time that is healing per nurses. It is getting wet to dry dressing changes. Record review of the Skin Condition Record from 8/12 - 8/24/16 revealed date first observed 4/15/16. Further review of the skin assessments dated 8/12 and 8/18/16 revealed 2.4 x 1.6 cx 0.1 cm, serous drainage, 50% slough, 50 % granulation, surrounding skin color discolored. Skin assessment of the right shin on 10/9/16 revealed 2.1 x 2.6 x 0.1 cm, 75% granulation, pink surrounding skin color. Record review of the monthly physician progress notes [REDACTED]. A physician progress notes [REDACTED]. other leg to rub on this area on a daily basis. Because of . dementia it has been very difficult to redirect .from not putting pressure on this area of ulceration. We are in the process of getting a shin guard and hopefully we can keep all pressure off that area throughout the day. A physician's orders [REDACTED]. Record review found no PT assessment regarding evaluation of lower leg positioning. A progress note indicated a PT assessment was completed on 8/2/16 however the assessment did not address lower leg positioning. During an interview on 11/10/16 at 1:55 pm Physical Therapy (PT) Director stated he had not specifically instructed staff on Resident #1's leg positioning. The facility provided documentation of the shin and heel ulcers. A facility form titled Skin Condition record for non-pressure ulcer skin conditions included serial entries that indicated a venous stasis ulcer on the right lower leg. This entry made by facility staff was not consistent with the description or [DIAGNOSES REDACTED]. The facility provided similar documentation for left heel blister. The facility did not identify the heel wound or the shin wound as pressure ulcers. The forms the facility used to document the wounds had blanks to fill in and did not include the required information to monitor healing of pressure ulcers such as staging which is important to determine appropriate treatment. A review of the resident's current 17-page care plan found no mention of the resident's risk for development of pressure ulcers and no plan for pressure ulcer prevention. Although the facility was aware the resident rubbed his legs together, the care plan did not indicate this and did not include measures to prevent self-injury from this behavior. The care plan did not include information about the decubitus ulcers on the shin or the heel. The care plan did not identify measures to prevent the development of new pressure ulcers. The care plan did not provide direction regarding the application of the shin guard. A single page In-Room Care Plan read stasis ulcer RLE (right lower extremity), pad, discourage rubbing legs together, and pressure-ulcer L (left) heel-keep legs floated. The in-room plan did not include the shin guard and did not direct staff how to position the legs or what measures to employ to decrease rubbing legs together. Review of the Prevention and treatment of [REDACTED]. 2) Stage . 3) Dimensions . 4) Undermining/tunneling . 5) Wound base description . 6) Drainage . 7) Wound edges . 8) Odor . 9) Pain . 10) Progress . Stage II: Partial thickness loss of dermis presenting .An an intact or open/ruptured serum-filled blister . Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough .and or eschar in the wound bed.

Based on observations, record review, interview and policy review, the facility failed to ensure residents were provided therapeutic diets as ordered by their physicians for 4 residents (#s 2; 3; 4; and 5) of 8 sampled residents and 3 residents (#s 10; 14; and 15) of 8 non-sampled residents. As a result, these residents were served food that placed 6 of the 7 residents at extreme risk of choking, aspiration and/or death and caused 1 resident harm due to choking on food that was the wrong consistency. These practices constituted immediate jeopardy to the residents' health and safety. The situation was brought to the attention of the facility administration on 1/10/13. The immediate jeopardy was abated onsite on 1/10/13. Record review on 1/10/13 of the dietary orders for resident #s 2; 3; 4; 5; 10; 14; and 15 revealed the following: Resident #2 was on a "General/Pureed/Nectar Thick" diet; Resident #3 was on a "NAS/Mech Soft" diet, (low sodium, mechanical soft); Resident #4 was on a "Renal/CCHO/Mech Soft" diet: (consistent controlled carbohydrate) diet; Resident #5 was on a "General/Mech Soft diet; Resident #10 was on a "General/Dysphagia Mech Soft/Nectar Thick" diet (A dysphagia diet means foods that are cohesive, moist-meats are recommended to be ground or finely chopped with gravy added.); Resident #14 was on a "General/Mech Soft" diet; Resident #15 was on a "NAS/Mech Soft" diet; General observations during meals in the dining room from 1/7 - 10/13 revealed: 1/7/13 During the lunch meal on 1/7/13 from 12 pm - 2 pm residents' #s 4 & 5 were served split pea soup with ham and a sandwich made with sliced ham and cheese, applesauce, and juice. The split pea soup contained large chunks of ham. Resident #4 attempted to eat the ham chunks out of the split pea soup, but was unable to chew the large pieces and ended up just spiting them up on the side of her plate. The ham and cheese sandwich was also too difficult for the Resident to eat and she ended up just eating a little of the bread after she dipped it into her soup. Resident #5 seemed hungry, and ate most of her soup except for the ham chunks. She chewed on the ham chunks but without any teeth she found it very difficult and ended up just sucking on some of the pieces before laying them beside her bowl. The Resident ate the bread and cheese out of her sandwich, but the ham was stiff and she laid it aside and didn't eat it. When the surveyor asked her how she liked her meal the Resident said it was "not good". 1/8/13 During an observation at breakfast on 1/8/13 from 8:00 am - 9:00 am Resident #4 received thick cut bacon that was hard and overcooked. The Resident attempted to eat the bacon, but was unable to because the pieces were too large and the bacon was too hard. During an interview on 1/8/13 at 8:10 am Resident #4 stated the bacon was "too tough to eat." During an interview on 1/8/13 at 8:15 am Dietary Staff #1 confirmed thick sliced bacon was not to be served to a resident on a mechanical soft diet, unless chopped very fine. The bacon served to the residents on the morning of 1/8/13 was approximately 1/4 inch thick and over cooked. During an interview on 1/8/13 at 8:25 am the Resident Care Manager (RCM) stated a mechanical soft diet is one that is finely chopped so the Resident can chew it and not choke. During an observation at lunch on 1/8/13 from 12 pm -1:30 pm Resident #5 was given as a substitution to the regular menu, (a hamburger). The dietary staff served the hamburger cut into 4 pieces. The meat was overcook and the Resident ended up eating the bread but not the meat. 1/10/13 During the 1/10/13 observations of lunch from 12:00 - 1:30 pm the following incidences took place: Resident #2, who was on a pureed diet, was served regular rice that had not been pureed. Resident #4, who was on a mechanical soft diet, was served Cornish game hen that had been torn into strips that were 3-4 centimeters long in size. After a considerable amount of time the Resident was only able to chew off some small pieces of the Cornish game hen. The rest of the Cornish game hen remained on the plate. Resident #5, who was on a mechanical soft diet, was served a regular diet consisting of Cornish game hen (torn, with bones still attached to the meat), Brussels sprouts, rice pilaf, and a slice of bread. Resident #10, who was on a dysphagia mechanical soft diet, was served dry chopped Cornish game hen meat, cut Brussels sprouts, and dry rice. The Resident was being assisted to eat by a certified nursing assistant (CNA). Resident #14, who was on a mechanical soft diet, was served Cornish game hen pieces that had bones in them. While the surveyor was observing Resident #5 attempt to eat her lunch the Resident had taken a bite of the Cornish game hen and started to choke. The Resident continued to choke until she vomited in a waste basket that a nurse brought over to her. The Resident's breathing was affected after the choking spell for approximately 5 minutes. When she was able to talk the surveyor asked her what happen. The Resident was still having difficulty speaking but she pointed to the Cornish game hen and said "they don't know, they don't know." Lying beside the Resident's plate was a Cornish game hen bone. The Resident's plate was then taken away and the surveyor examined the Cornish game hen from the Resident's plate with the nurse and saw that part of the meat was just pulled off the bones in large pieces and the rest was still attached to the bones. I asked the nurse if that looked like a mechanical soft diet to her and she said "no." Right before the choking incident happen in the dining an interview with the Long Term Care Dietician was being completed. The surveyors were verifying the Dietician's responsibilities related to the resident's diets and if she was responsible for ensuring the therapeutic diets that were ordered by the physicians were carried out by the dietary staff. The Dietician said that when physician ordered a therapeutic diet for a resident she ensured the order got written on the Resident's dietary card. The Dietician disclosed that she did not complete any audits to ensure the dietary staffs were serving the appropriate therapeutic diets. She also said she did not have a quick reference (cheat-sheet) for the kitchen staff to follow for therapeutic diets. When the surveyors asked if she had ever provided training to the kitchen staff on what therapeutic diets were she said "no". When asked if the cooks had any reference material in the kitchen that defined what a mechanical soft diet was. She stated "probably not." The Surveyor asked the Dietician what a dysphagia mechanical soft diet would consist of. The Dietician said it would be ground meats that had gravy or moisture added, almost pureed; soft well-cooked vegetables; mashed potatoes consistency starches. After the choking incident the surveyors had the Dietician walk around and look at Residents' #s 2; 4; 10; & 14 to examine their meals and see if their food matched their therapeutic diet orders. None of the meals matched the dietary card orders. The surveyors specifically asked if Resident #10's therapeutic diet was being followed (dry chopped meat, dry chopped Brussels sprouts, and dry rice). She said no. The surveyors asked if his meal could put him at risk for choking. The Dietician said "yes" his meal could be a risk for choking. When the surveyors suggested the meal be substituted with something else, the Dietician was very determined and unwilling to do that because she felt she would be infringing on the Resident's rights. When it was explained to her that it was the Resident's right to receive the appropriate therapeutic diet so that the risk of choking and aspiration or even death was no longer a concern, the inappropriate meal was taken away. The Dietician was again asked if she had completed any dietary inservicing with the dietary staff on therapeutic diets and the Dietician confirmed she had not. She said she thought the Dietary Manager was providing the inservice training for the dietary staff. The Dietician was asked if she had instructed the CNAs on what the different kinds of therapeutic diets were. She said she had not. During an interview on 1/9/13 at 12:45 pm Staff #6 disclosed he was concerned about giving Resident #2 pancakes because she was suppose to have pureed food, but he did not really know who he was suppose to go to for questions about the Residents' diets. Review on 1/10/13 of the training records for the 5 dietary staff working in the LTC revealed they had no training on therapeutic diets. In fact, the training record did not even have a check-off line item for "therapeutic diets". During an interview on 1/10/13 at 10:40 am Dietary Staff #1 disclosed he had never had any training on therapeutic diets. During an interview on 1/10/13 at 3:15 pm the Dietary General Manager (DGM) disclosed she was not responsible for training the LTC Dietary Staff on how to cook the Therapeutic diets. When the surveyors asked to see the menu cookbook that the LTC cooks followed in the kitchen the DGM did not know where or if there was a cookbook that the dietary staff followed. During an interview on 1/10/13 at 3:45 pm with Medical Director the surveyors asked if she was notified about the choking incident that happened at lunch time with Resident #5. The Medical Director had not heard anything about a choking incident. The surveyors asked if she would expect to be called if a resident had choked on food. The medical Director said "yes" she would expect to be called. The surveyors asked if she was aware the issue of the choking and the inappropriate diets had lead to an Immediate Jeopardy situation. The Medical Director said "no" she had not been notified of any of those issues. The Medical Director was asked if she was involved in the Quality Assurance program for the LTC. The Medical Director said "no, not yet." .

Based on observation, interview, and record review the facility failed to: 1) Ensure the resident environment was free from hazardous for 2 residents (#s 4 and 6) of 8 sampled residents and 3 non-sampled residents (#s 9; 11; and 15). This failed practice constituted an immediate jeopardy to resident health and safety. This situation was brought to the attention of the facility's administration on 1/8/13 at 7:30 am. The immediate jeopardy was abated onsite. In addition, the facility failed to: 2) Ensure the safety of 3 residents (#s 1; 5; and 11) with a history of falls with injury out of 7 sampled residents with a history of falls. This situation was brought to the attention of the facility's administration on 1/9/13 at 9:30 am. The immediate jeopardy was abated on site. Findings: 1) Hazardous Environment Observations of the dining room on 1/8/13 between 7:00 am - 7:30 am revealed a dark brown stain on the carpet in front of the 2 brewed coffee carafes sitting on a waist high counter located next to the residents' dining area. At 7:00 am nursing staff served coffee from one of the coffee carafes for Resident #4. She attempted to drink the coffee, but due to her unsteady hands set the coffee back down on the table. At 7:10 am kitchen staff served Resident #6, who is legally blind, a cup of the coffee from one of the coffee carafes and did not tell her where the coffee was located and the Resident had to grope around to locate the cup of coffee. At 7:28 am Resident #11 poured himself a cup of coffee from one of the coffee carafes. While pouring the coffee and while walking back to a table his hands shook sloshing the coffee back and forth in the coffee cup. At 7:10 am Resident #9 wheeled up to the counter in his wheelchair. Even though the counter was chest high on him, he poured himself a cup of coffee from one of the self-serve coffee carafes. While pouring the coffee, the Resident spilled coffee on the counter and down the side of the counter onto the floor where the carpet was stained from previous coffee spills. At 7:15 am the surveyor asked the Dietary General Manager (DGM) to take the temperature of the coffee in the carafe. The temperature was found to be at 118 + degrees Fahrenheit. When she saw that it was 118 + degrees Fahrenheit she stated, "It's almost 120 degrees". She was then informed by the surveyor when Resident #9 got his coffee that he had spilled the coffee down the front of the counter to the floor. The DGM acknowledged that sometimes the residents did spill their coffee when they got it themselves. She then cleaned up the counter and left the pot of coffee on the counter and went back to the kitchen. Sampled Resident #4 had primary [DIAGNOSES REDACTED]. Sampled Resident #6 had primary [DIAGNOSES REDACTED]. Non-sampled resident #9 had primary [DIAGNOSES REDACTED]. Non-sampled resident #11 had primary [DIAGNOSES REDACTED]. The facility had one resident #15 that wandered about the facility picking up items off tables and counters. The self-serve hot coffee posed a risk of burn to her. At 7:28 am the surveyor spoke with the Administrator In Training (AIT) concerning the unsupervised ready access to the coffee pots and how many of the residents self-served themselves their own coffee. The (AIT) confirmed the facility's self-serve coffee was unsupervised and that all residents and visitors had free access to the self-service coffee. The AIT said there were 7 residents that used the self-serve coffee services. The surveyor then asked if these residents had been assessed for safety related their ability to self-serve their own coffee. The AIT stated they had not. When the surveyor asked if there was a policy that addressed safety issues associated with the use of the self-service coffee, the AIT said no. When the surveyor told the AIT that the coffee was 118 degrees Fahrenheit the AIT did not seem to understand the seriousness of the situation. She did not recognize that if an unsupervised resident with compromised skin integrity, who was cognitively and or physically impaired spilled coffee on themselves at 118 degrees Fahrenheit could sustain 1st, 2nd, or 3rd, degree burns. According to the Center for Medicare and Medicaid (Guidance to LTC Surveyors) 3rd degree burns to the skin can occur from hot liquids of 120 degree Fahrenheit after 5 minutes. According to Accurate Building Inspectors, (Hot Water Burn Prevention & Consumer Safety), 2011 - "...Even if the temperature is 120 degrees, a five minute exposure could result in third-degree burns." According to the Veterans Health Administration (Domestic Hot Water Temperature Limits For ...Prevention and Scald Control) 2009, "At 117 degrees Fahrenheit, scalding risk increases significantly." According to the Burn Foundation (www.burnfoundation.org) hot liquids causes more burn injuries in adults than burns by flames. Elderly residents have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize a liquid is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly. The elderly may also have conditions that make them more prone to fall while carrying hot liquids. Failure to Ensure Alarm Systems Were Functioning Review of the Resident's fall history from 1/7-11/13 revealed Resident #5 had multiple falls. Review of multi-disciplinary progress notes over the last 4 months revealed: On 10/22/12, "Resident fell and hit head trying to go to the bathroom. Resident states that she moved the alarm mat to keep it from going off and tried to step over the mat to get to w/c (wheel chair) and tripped on the alarm mat and hit head on floor. The nurse observed approx 3 inch knot on L (left) top of head. Knot felt to be soft and mushy." After fall the facility placed the Resident's bed against the left side of the wall so that the resident would have to get out on the right side of the bed. The Resident had left-sided weakness and the facility wanted to encourage the Resident to use her right side. On 10/30/12, "Staff responded to thud sound and resident trying to get up from floor. Resident fell on buttocks." On 12/30/12, after a fall with no injury the facility monitored for safety and set-up a motion sensor detector in the Resident's room. On 1/3/13, "RN called by CNA to Resident's room, Resident stated that she had fallen on the mat, but was currently on the edge of the bed. Resident helped to the restroom x1 person. Resident stated that left arm is numb and hurting. Left arm dangling, sheet placed around arm to stabilize arm." Health Facilities Licensing and Certification received a fall report on the 1/3/13. The Resident fractured her clavicle bone (a long bone of short length between the shoulder and the chest) on the left side during the fall. The facility's plan of action was to protect the resident to "Re-educated staff on use of motion detectors, and to test the motion detector and turn on when she was in bed." During an on-site survey on 1/7/13 at 1:50 pm the surveyor walked into Resident #5's room. The resident was in bed sleeping. The motion sensor detector alarm was set-up next to the Resident's bed. When the Surveyor moved her hand directly in front of the alarm the alarm did not ring. The surveyor went to the door just as a Nurse was coming into the Resident's room. After mentioning to the nurse that the alarm did not seem to be working the nurse also moved her hand back and forth in front of the alarm. Then she picked up the alarm and turned the switch from "on" and "off" twice and then it worked. The nurse then said the alarm may not have been reconnected. The surveyor asked the nurse about the fall the Resident had on 1/3/13 and the report the State office had received that said the staff were to be re-educated on the use of the motion detectors. The surveyor asked if the the staff had been retrained. She said yes they had been. The surveyor asked why was the retraining need in the first place and the nurse said there had been some confusion on how the alarm worked. On 1/8/13 at 8:00 am the surveyor walked into the Resident's room. The resident was asleep. The alarm was tested by the surveyor and it did not work. The nurse came and tested the alarm and it did not work. Bio-med staff was called and they came and tested the alarm. After testing it, the alarm was working. During an interview on 1/8/13 at 2:30 pm with RN #1 disclosed the primary use of the motion sensor detector alarm was to keep the Resident safe by alerting the staff that she was getting out of her bed. That the facility had tried a floor mat alarm, but that she didn't like the sound and she would climb out the end of the bed to get away from the sound of it. RN #1 said they had tried just about everything they could think of and the motion sensor detector alarm was the best way to let them know immediately if she was getting up. RN #1 said if the alarm was hooked up right and working staff usually could get into the room before the Resident got out of the bed. On 1/9/13 at 8:30 am the surveyor walked into the Resident's room. The Resident was sleeping. The alarm was tested by the surveyor and it did not work. RN #1 also tested the alarm and confirmed it was not working. While in the room CNA #3 said it had not been working all week. In a later interview at 8:35 am with CNA #3 she said she had never been trained on how to use any of the alarms including the motion sensor detector alarm. Once it was established the facility was not ensuring the motion sensor detector alarm was working for Resident #5, the survey team checked the motion sensor alarms that 2 other resident's were using. CNA #6 tested the alarms with the surveyors observing and found the motion sensor detector alarms did not work. Resident #1 had 2 motion sensor alarms. One alarm had a dead battery and the other one did not work until it was turned "on" and "off" several times. Resident #11 also had 2 motion sensors alarms. One of the alarms was broken and the other alarm would not work until it had been turned "on" and "of" several times. During an interview on 1/9/13 at 9:30 am CNA #6 disclosed his training on alarms was to tell the nursing staff if the alarm didn't work. CNA #6 said he was never instructed on how to use any of the alarms. During an interview on 1/9/13 at 9:40 am with CNA #1 disclosed his training on alarms was to check the alarms at the beginning of the shift and to report to the nurse if they were not working. Staff #1 said staff did not document anything about the alarms and that he had not had any instruction on the use of the alarms. Fall history of Residents #s 1 & 11 Resident #1 was found in the bathroom on 10/29/12, he had sustained a laceration to his left ear which required suturing. The facility had put the motion sensor detector alarm in place so that they could monitor and assist him when he needed to use the bathroom at night. During an interview on 1/9/13 at 9 am, RN #1 disclosed the facility had just started using a motion sensor detector alarm on Resident #11 bed because he had recently taken a fall out of his bed. Review of the Facility's policy and procedure for "Personal Alarms", dated 10/11, "To help ensure the security of both residents and staff, as well as provide immediate response to needs in the facility it is the policy of this facility that a resident who is identified as a "Fall Risk" may be assessed for use of a personal alarm". "Alarms in use will be monitored for continued function by noting use on the TAR (Treatment Assessment Record) and checking function Q (every) week." Record review on 1/9/13 of the TAR and the MAR (Medication Assessment Record for the last month for Resident #s 1 and 5 revealed there was no documentation of nurse charting that the alarms were functioning correctly. During an interview on 1/9/13 at 8:30 am RN #1 verified there had been no charting in the TAR or the MAR concerning the functioning of the alarms. Nursing staff and CNA staff were aware the alarms were not working, and yet the alarms were the facility's primary plan of action to keep these residents safe from falls. The staff chose not to act on the non-funtioning alarms. Leaving the Residents at high risk for falls that could result in injury, impairment or death. The facility had not trained key staff that were working with these Residents on how to use and troubleshoot the alarms. There was no documentation that staff had been instructed on how to use the alarms. The documentation in staff meetings disussed the need for CNAs to check to see if the alarms were working and to report to the nurses if they weren't. The facility's actions placed the Residents at immediate jeopardy for their health safety. The Administration was notified on 1/9/13 at 10:03 am of the immediate jeopardy situation. An abatement plan was accepted by the State and put into place by the facility on 1/9/13. .

Based on observation, interview, and record review, the facility failed to ensure its resources were effectively and efficiently used to attain or maintain the highest practicable, physical, mental and social well being of all residents. These failures led to the facility ' s inability to maintain substantial compliance with regulatory requirements, and resulted in: 1) Immediate Jeopardy at 483.35(e) Therapeutic Diets, harm for 1 Resident (#5) and the potential harm for 6 Residents (#s 2; 3; 4; 10; 14; & 15) who received therapeutic diets; 2) Immediate Jeopardy at 483.25(h)(l) Accidents and Supervision, potential harm for Residents who utilized the self serve coffee which was 118 degrees and readily accessible by Residents; and 3) Immediate Jeopardy at 483.25(h)(l) Accidents and Supervision, lack of adequate supervision for residents at risk to fall; failed to have a system in place to monitor resident ' s alarms that the staff relied on to alert them when residents required immediate assistance; failed to have a system in place to ensure non-functional alarms were fixed; and failed to educate/train facility staff on the use of alarm systems. As a result, 7 residents (#s 1; 4; 5; 6; 9; 11; & 15) were determined to be a risk for serious injury, harm, impairment or death. Findings: Failure to administer the facility in a manner in which its resources were effectively and efficiently used resulted in failure noted in the following regulatory areas: 483.10(b)(3) Informed of Health Status, Care, & Treatments 483.10(g)(1) Right to Survey Results - Readily Accessible 483.13(c)(1)(ii)-(iii), (c) - (4) Investigate/Report Allegations/Individuals 483.15(a) Dignity and Respect of Individuality 483.15(f)(1) Activities Meet Interests/Needs of Each Resident 483.15(f)(2) Qualifications of Activity Professional 483.20(g) - (j) Assessment Accuracy/Coordination/Certified 483.20(d), 483.20(k)(1) Develop Comprehensive Care Plans 483.20(k)(3)(i) Services Provided Meet Professional Standards 483.20(k)(3)(ii) Services by Qualified Persons/Personal Care Plan 483.25(e)(2) Increase/Prevent Decrease in Range of Motion 483.25(h) Free of Accident/Hazards/Supervision/Devices 483.35(e) Therapeutic Diet Prescribed by Physician 483.35(i)(2) Food Procurement/Store/Prepare/Serve - Sanitary Conditions 483.60(a),(b) Pharmaceutical Services/Accurate Procedures, RPH 483.60(b),(d),(e) Drug Records/Label/Store Drugs & Biologicals 483.65 Infection Control 483.75 Effective Administration/Resident Well-Being 483.75(m)(2) Disaster and Emergency Preparedness 483.75(o)(2)(ii) Quality Assessment and Assurance .

Based on interview and record review the facility failed to maintain a quality assessment and assurance committee that developed and implemented appropriate plans of action to correct quality deficiencies they had identified or should have identified. Without sufficiently identifying or adequately addressing and communicating about areas of deficient practice, systematic correction can not be achieved and maintained throughout the facility. Findings: When asked about specific QAA projects, the DON described the fall program and stated that she currently tracked falls. She had initiated greater use of fall mats, personal alarms, for those residents known to fall. Record review of the QAA meeting minutes for the last 11 months revealed they had tracked falls, but the plan of action and resolution areas of the QAA form were left blank. Interview with RN#1 on 1/9/13 at 4:15 pm and an interview with CNA#4 on 1/9/13 at 8:00 pm stated they had had no involvement in the QAA committee and had no knowledge of any QAA project. Issues identified during the survey concerning falls and the interventions put into place to prevent falls rose to the level of Immediate Jeopardy. (Refer to F323 and F225) The Administrator stated during the QAA meeting on 1/11/13 that the Registered Dietitian has been included in QAA meetings. However, record review of the QAA meeting minutes revealed over last 11 months the dietician had only attended 1 time and the dietary staff had only attended 2 times. During the survey dietary issues were identified as a management issue which rose to the level of Immediate Jeopardy. (Refer to F367 as well as citations at F490 and F371). When reviewing the QAA meeting minutes it was noted there were no reports or audits from the dietary department brought to the QAA for review and follow-up. The Administrator stated during the QAA meeting on 1/11/13 at 11:15 am the Pharmacy Department did not attend or have any input on the QAA committee. Review of the QAA committee meeting minutes for the last 11 months confirmed the Administrator's statement. During the survey concerns were identified in the facility's process for the reconciliation of controlled drugs; the follow-up on drug errors; and the lacking of direct oversight and the development of pharmacy practices and policies. (Refer to pharmacy citation F425 and F431) The Administrator stated during the QAA meeting on 1/11/13 that the QAA committee had not yet incorporated the Infection Control committees' findings/outcomes into the QAA program. Review of the QAA meeting minutes for the last 11 months confirmed his statement. Review of the "Infection Control Committee Meeting "minutes from 2/12-11/12 revealed no line item topics or reports from Long Term Care (LTC). In addition, the minutes did not reveal surveillance, antibiotic review, trending of surveillance, education, disinfectant approval, or policy and procedure updates or review. During the survey there were areas that were indentified as deficient practices in infection control. (Refer to F441) Review of the QAA meeting minutes for the last 11 months revealed the Medical Director had only attended 2 of the QAA meeting. These attendances were in the month on 10/12 and 11/12. Therefore, the Medical Director only was present for 1 quarter on the required 4 quarters for QAA meetings.