Every finding on record at Wildflower Court

.Based on observation, record review, and interview, the facility failed to store, prepare, and maintain food and food-contact sanitation in accordance with food safety standards. Specifically, the facility failed to ensure: 1) Sanitizer solutions used for food-contact surfaces were maintained at the manufacturer-recommended concentration; and 2) Food items available for resident use were labeled with required use-by dates and/or removed when expired; and 3) Culinary staff followed hand hygiene and glove-use practices to prevent cross-contamination during food preparation. These failed practices had the potential to cause cross contamination during food preparation and to allow contaminated and/or expired food to be served to 54 residents who received food from the kitchen, out of a total of 55 residents, placing these residents at risk for foodborne illness. Findings:.Sanitizer Concentration An observation on 6/10/26 at 10:39 AM, in the main kitchen, revealed two sanitizer buckets available for use. When tested with QT-10 Hydrion test strips, the sanitizer solutions read 0 parts per million (ppm) and 100 ppm. [NAME] #7 verified the readings, and the buckets were removed from service. Review of the Ecolab (sanitizer manufacturer) poster titled Ecolab Apex Solid Quat Broad Range Sanitizer, posted in the dishwashing area, copyright 2012, revealed: . Testing [sanitizer] solution should be between 150 - 400 ppm. Review of the Ecolab poster titled Ecolab Oasis 146 Multi-Quat Sanitizer, posted in the janitor's closet, copyright 2015, revealed: .Testing [sanitizer] solution should be between 150 - 400 ppm. An observation on 6/10/26 at 12:15 PM, in the main kitchen, revealed follow-up testing of the sanitizer buckets showed both sanitizer solutions tested at 100 ppm. [NAME] #4 verified the readings, and the sanitizer buckets were removed from service. During an interview on 6/10/26 at 12:30 PM, [NAME] #4 stated that the sanitizer buckets contained a sanitizer solution that could either be dispensed from the dishwashing area or the janitor's closet. He/she stated that the sanitizer buckets should have been dispensed from the dishwashing area because the concentration of the janitor's closet solution was too strong. He/she further stated that the solution should have been tested before being placed into service. During an interview on 6/10/26 at 12:40 PM, the Food Services Supervisor (FSS) stated that staff should have filled the sanitizer buckets from the dispenser in the janitor's closet. He further stated that the dispenser in the kitchen area was calibrated for the large sink, and that the dispenser in the janitor's closet was calibrated for buckets. An observation on 6/11/26 at 12:07 PM, in the main kitchen, revealed follow-up testing of both sanitizer buckets showed sanitizer concentration at 350 ppm. An observation on 6/12/26 at 9:04 AM in the main kitchen revealed follow-up testing of the sanitizer buckets showed sanitizer concentration at 0 ppm. The FSS verified the reading, and the sanitizer buckets were immediately removed from service. During an interview on 6/12/26 at 9:59 AM, the Director of Culinary and Nutrition Services (DCNS) stated both sanitizer dispensers were calibrated and he did not expect staff to test sanitizer buckets after dispensing the solution and before placing the buckets into service. Review of the Ecolab sanitizer dispenser maintenance document, Regular Service Call, dated 3/19/26 at 3:43 PM, revealed: . Installed new LDS [Liquid Dilution System- a water and sanitizer dispenser] for orange force 146 quat sanitizer and wash and walk. Sink and Surface Sanitizer: 300 ppm. Review of the Ecolab sanitizer dispenser maintenance document, Ecolab Service Visit Report, dated 6/10/26 at 5:09 PM, revealed: . Sink and Surface Sanitizer. 250 ppm. Validating the dilutions and procedures are compliant to protect your employees and guests. Review of the facility policy Cleaning and Sanitizing Food Contact Surfaces, dated 5/25/12, revealed: . A.2. Wash, rinse and sanitize food contact surfaces using the following procedure: A.2.1. Wash surface with detergent solution. A.2.2 Rinse surface with clean water. A.2.3. Sanitize surface using a sanitizing solution mixed at a concentration specified on the manufacturer's label. Expired and Unlabeled Food An observation on 6/8/26 at 2:52 PM, in the main kitchen's walk-in refrigerator, revealed multiple food items in containers that were labeled with the name of the food item and the date prepared by writing on blue painter's tape and placing the painter's tape onto the plastic wrap covering the food container. Further observation revealed multiple food items that were not labeled with a use-by date, not identified with an open date, were not labeled to identify the contents, or were expired: Foods not labeled with a use-by date: Seven packages of pancakes and French toast in a metal container, dated 6/6/26. The metal container included one package of pancakes and one package of French toast wrapped in plastic wrap that was not the manufacturer's packaging;One metal container of pureed fish, dated 6/4/26;One metal container of pureed chicken, dated 6/7/26;One metal container of ground chicken, dated 6/7/26;One metal container of diced roast pork, dated 6/5/26;One clear plastic container with a red lid which contained chopped celery, dated 6/12/26;One clear plastic container of squash, dated 6/3/26;One clear plastic container of zucchini, dated 6/3/26;One clear plastic container with a red lid with approximately 4 quarts of shredded mozzarella cheese, dated 6/3/26;One clear plastic container with a red lid with approximately 5 quarts of shredded cheddar cheese, dated 6/4/26;One sheet of raspberry cake on a metal pan, dated 6/8/26;One sheet of three loaves of uncooked garlic bread, dated 6/8;One metal container of approximately 12 hard-boiled eggs without the shell, dated 6/8/26;One clear plastic container with a greed lid containing approximately two quarts of diced tomatoes, dated 6/7;One plastic container containing five one-ounce individual plastic containers of tartar sauce, dated 5/28/26; Individual containers not labeled or dated;Four clear plastic tubs with green lids approximately half full of Emerald pears, dated 6/4/26;One clear plastic bin with 24 one-ounce individual plastic containers of Emerald pears. Bin labeled 6/4/26. The individual containers inside the plastic bin were not labeled or dated;Four clear plastic containers of pound cake, dated 6/8/26;One clear plastic bin with 24 one-ounce individual plastic containers of pound cake puree. Bin dated 6/8/26. The individual containers inside the plastic bin were not labeled or dated; andOne metal container with one sealed portion of pork in manufacturer's packaging and one resealable bag containing pork labeled 6/7, metal container labeled 6/6. and no use by date. Foods without an open date or a use-by date: Five slices of whole wheat bread in manufacturer packaging;Nine slices of gluten free bread in manufacturer packaging; andApproximately eight ounces of butter, opened, labeled 6/8/26. Expired food: One metal container containing a bag of diced celery labeled with a prep date of 5/5 and use by date of 6/5, the metal container was labeled 6/7 and had no use by date. An observation on 6/8/26 at 3:07 PM, in the main kitchen's freezer, revealed multiple food items again labeled with blue painter's tape. Further observation revealed food items that were not labeled to identify the food, had no open date, an expiration date, or a use-by date: Foods with no label to identify the food item, had no open date, or an expiration date: One clear plastic bag of what appeared to be chicken tenders;One clear plastic bag of what appeared to be tater tots;One clear plastic bag of what appeared to be fried fish;One clear plastic bag of what appeared to be pepperoni;One package of what appeared to be pancakes wrapped in facility plastic wrap;One clear plastic bag of what appeared to be pizzas; andOne clear plastic bag of what appeared to be hoagie rolls. Foods not labeled with a use-by date: One plastic bag of Talapia, dated 6/4/26;One plastic bag of pepperoni, dated 2/22; One plastic bag of cinnamon rolls, dated 5/27/26; andTwo plastic bags of garlic bread, dated 5/26/26. An observation on 6/8/26 at 3:19 PM, in the main kitchen's dry storage area, revealed food items that were not properly labeled or were expired: One clear plastic container with a blue lid containing dry rice, dated 6/2 with no use by date on label;One clear plastic bin with unsecured purple lid containing granulated sugar. There was no open date or use by date on label;One unopened cardboard box of Bread Mix Puree, expiration date 4/15/26;One opened plastic squeeze bottle of Strawberry Dessert Sauce, with no open date, expiration date 5/25/26; andOne unopened plastic squeeze bottle of Kiwi Lime Dessert Sauce, expiration date 5/24/26.An observation on 6/8/26 at 3:27 PM, in the main kitchen's nourishment cooler, revealed multiple larger containers labeled with blue painter's tape. Further observation revealed these containers contained smaller individual serving-sized plastic cups of food items and the large container was labeled with the food item and preparation date. The individual cups were not labeled or dated, and there was no use-by date on the larger container, or the individual cups: One plastic container containing about 24 small individual cups of egg salad, dated 6/5/26;One plastic container containing about 24 small individual cups of cottage cheese, dated 6/8/26;One plastic container containing about 24 small individual cups of stewed prunes, dated 6/3/26;One plastic container containing about 24 small individual cups of chicken salad, dated 6/4/26; andOne plastic container containing about 24 small individual cups of dried prunes, dated 6/2/26. An observation on 6/8/26 at 4:10 PM, in the Salmonberry unit kitchen, revealed the following food items were not labeled properly, or were expired: Four packages of [NAME] Krispies cereal, expiration date 5/31/26; and One unlabeled bowl containing a malodorous liquid substance, which was undated. Home Attendant (HA) #2 was unable to identify the contents and disposed of it immediately. An observation on 6/8/26 at 4:24 PM, in the Cranberry unit kitchen, revealed the following food items that were expired:One small plastic cup labeled Cinnamon, use by 5/25;One loaf of whole wheat bread, dated 6/1/26, with a use by date of 6/7/26; andOne clear plastic resealable bag full of butter pats, with an open date of 4/2/26, and a use by date of 6/2/26.An observation on 6/8/26 at 4:24 PM, in the Cranberry unit kitchen, revealed one plastic container with green lid containing brown sugar with a scoop utensil inside the container within the sugar. During an interview on 6/11/26 at 8:38 AM, the DCNS stated the scoop utensil should not have been stored in the container with the brown sugar. An observation on 6/8/26 at 4:59 PM, in the [NAME] unit kitchen, revealed the following undated food items with no use-by date, or were expired: The following individually packaged food items had no use-by date: One plastic bag containing seven packages of sugar free syrup;One plastic bag containing nine packages of peanut butter;One plastic bag containing six packages of peanut butter;One plastic bag containing eight packages of syrup;One plastic bag containing seven packages of syrup;One plastic bag containing 17 packages of grape jelly;One plastic bag containing nine packages of honey mustard;One plastic bag full of mayonnaise packets;One plastic bag containing 36 assorted jellies; andOne plastic bag with numerous single serve dairy creamers. Food items that were expired: Five packages of Ensure Clear therapeutic nutrition, expiration date 4/1/26. During an interview on 6/8/26 at 2:52 PM, the FSS stated that opened food items should have been labeled with the date opened and expiration date, and that prepared items should have been labeled with their expiration date, or use-by date. During an interview on 6/8/26 at 3:20 PM, the DCNS stated that he did not rely on expiration dates and that he considered food to be sufficiently labeled when it contained the name of the product and the date it was prepared. He further stated that he used FATTOM [Food, Acidity, Temperature, Time, Oxygen and Moisture - a food safety acronym used to describe the six conditions bacteria need to grow] factors to determine suitability of food to be served to residents. Review of the facility policy Food Storage, Handling and Preparation, undated, revealed: . B. Potentially hazardous foods shall be labeled and dated. B.1. Refrigerated, potentially hazardous foods shall be clearly marked to indicate the name of the food, the date the food was prepared or opened, and the date by which the food must be consumed. Review of Code of Federal Regulations (CFR) 483.60(i)(2), Rev. 232, Issued 7/23/25, revealed: Store, prepare, distribute and serve food in accordance with professional standards for food service safety. CMS recognizes the U.S. Food and Drug Administration's (FDA) Food Code and the Centers for Disease Control and Prevention's CDC food safety guidance as national standards to procure, store, prepare, distribute, and serve food in long term care facilities in a safe and sanitary manner. Review of the FDA Food Code, dated 2022, revealed: On-premises preparation. Prepare and hold cold 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date, Marking. refrigerated, ready-to-eat, time/temperature control for safety of food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises. when held at a temperature of 41 F [Fahrenheit] or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. 3-501.18. A food. shall be discarded if it. is in a container or package that does not bear a date or day. Further review revealed FATTOM is not an FDA approved guideline. Review of the CDC Food Service Guidelines for Federal Facilities, dated 2017, revealed: . Food Safety Standards. The United States government works to protect the American public from foodborne illnesses through the collaborative efforts of HHS's [U.S. Department of Health and Human Services] Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC), and USDA's [U.S. Department of Agriculture] Food Safety and Inspection Service. FDA publishes the Food Code, which provides guidance for a uniform system of addressing food safety issues in all retail food and food service establishments, such as restaurants, cafes, and cafeterias. While not a regulation itself, the Food Code has served as the primary model for retail food regulations and ordinances at state, local, and tribal levels since the publication of the first edition in 1993. It has also served as the basis for food safety policy and recommendations of numerous federal agencies that have responsibility for the oversight of food service and retail facilities on federal property. The primary Food Safety standard in the Food Service Guidelines for Federal Facilities states that contractors operating in federal facilities are expected to adhere to the most recently published Food Code. Food Preparation Contamination An observation on 6/10/26 at 10:40 AM, in the main kitchen, revealed [NAME] #7 preparing raw chicken thighs on a stainless steel table and sheet pan using kitchen shears while wearing gloves. During the observation, [NAME] #7 stopped food preparation, walked to a speaker that was playing music, touched the speaker to turn it off while wearing the same gloves used during raw chicken preparation, then returned to the food preparation area and resumed handling raw chicken without removing the contaminated gloves or performing hand hygiene. During an interview on 6/12/26 at 10:27 AM, the DCNS stated [NAME] #7 should not have touched the speaker with contaminated gloves. The DCNS stated the expectation was for the cook to remove gloves before touching the speaker, wash hands, and put on clean gloves before returning to food preparation. During an interview on 6/11/26 at 10:10 AM, the Infection Preventionist (IP) stated the facility's infection prevention program included all departments and that new employees received infection prevention education during orientation, including hand hygiene, standard precautions, and cleaning and disinfection. The IP further stated staff were educated to use soap and water when hands were visibly soiled. Review of the facility policy Food Storage, Handling and Preparation, undated, revealed: . R.9. Wash hands:. R.9.2. Immediately before preparing food or handling equipment. R.9.3. As often as necessary during food preparation when contamination occurs. R.9.4. when you return to your work station. R.9.5. When switching between working with raw foods and working with ready-to-eat or cooked foods. R.9.8. After touching door knobs or handles. R.9.11. Any other time an unsanitary task has been performed.

.Based on record review, interview, and observation, the facility failed to provide adequate supervision and effective use of assistive fall-prevention devices for 2 residents (#17 and #37), out of 4 residents reviewed for fall precautions. Specifically, the facility failed to: 1) Ensure adequate supervision and effective use of an assistive fall-prevention device for resident #37, who was found on the floor following an unwitnessed fall; and2) Ensure the Smart Caregiver sensor pad monitoring system used for Residents #17 and #37 were functioning properly and set at an audible volume to alert staff. These failures resulted in Resident #37 experiencing an unwitnessed fall and placed both residents at risk for delayed staff response, falls, and fall-related injury. Findings: 1) Adequate Supervision and Effective Use of Device Record review on 6/8-12/26, revealed Resident #37 was admitted to the facility with diagnoses that included unspecified dementia (cognitive decline and memory loss), age-related osteoporosis (brittle bones), history of transient ischemic attack (a temporary blockage of blood flow to the brain, sometimes referred to as a mini stroke), and cognitive impairment. During an interview on 6/9/26 at 9:23 AM, Resident #37's Power of Attorney (POA) stated prior to the resident's admission to the facility, the resident had suffered an upper right femur fracture in January 2026. This had made the resident weak, and because of the resident's dementia, the resident was not able to participate in physical therapy, leaving the resident weak and bedbound. Resident #37 was completely dependent on staff for most things which included eating, hygiene, mobility, and toileting. Resident #37's POA further stated earlier that morning he/she received a call from the facility reporting Resident #37 was found on the floor by his/her bed. It was reported to the POA that Resident #37 was not injured. The POA further stated the resident frequently forgot he/she required assistance and had attempted to get up without assistance in the past. The POA was unsure if the resident's bed alarm was on when this happened. The POA added that Resident #37 was not a good historian and would not be able to remember and tell staff what had happened. Review of Resident #37's care plan dated 4/1/26, revealed, .Falls.Bed alarm per orders. During an interview on 6/9/26 at 9:31 AM, Licensed Nurse (LN) #1 stated he/she was there that morning and did not hear the bed alarm go off when Resident #37 fell out of bed. LN #1 stated that the resident was found on the floor by the bed. When asked how staff were alerted when the bed alarms were triggered, LN #1 stated the resident's sensor pad would alert the wireless monitor at the nurses' station. Staff were expected to hear the alert at the nurses' station and respond. An observation on 6/9/26 at 9:34 AM, revealed Resident #37 was lying on a Smart Caregiver sensor pad positioned beneath the resident's buttocks. Observation revealed the sensor pad was wirelessly connected to a remote monitoring system intended to alert staff when the resident attempted to rise from bed. An observation on 6/9/26 at 9:40 AM, revealed the Smart Caregiver monitor assigned to Resident #37 was located at the Cranberry Unit nurses' station. The monitor's volume control was set to LOW. An observation on 6/9/26 at 10:04 AM, revealed no staff were present at the nurses' station or in the immediate hallway area. Review of the facility-provided Event Report, dated 6/9/26, revealed, . found on floor next to bed. Was Fall Witnessed? No [was checked]. INTERVENTIONS - Immediate measures taken. None of Above [was checked, however, bed pad alarm was a choice, but was not checked]. The report did not identify that a bed alarm alerted staff before the resident was found on the floor. Review of nursing progress notes, dated 6/9/26 at 8:04 PM, revealed: . Around 0710 [7:10 AM], CNA [Certified Nursing Assistant] was heard asking for help . resident had a fall, unwitnessed . The facility was unable to provide evidence that Resident #37's bed alarm intervention functioned as intended or alerted staff prior to the resident being found on the floor. (2) Smart Caregiver Monitoring Device Functionality An observation on 6/11/26 at 3:30 PM, revealed two Smart Caregiver monitor/alert boxes at the Cranberry Unit nurses' station were set to the LOW volume setting. The chime volume settings were facing the back wall of the desk so that the name labels would face outward. These monitor/alert boxes were labeled for Resident #17. One of the monitor/alert boxes was labeled for Resident #17's recliner and another for the resident's bed. Review of Resident #17's care plan dated 5/11/26, revealed, . Bed alarm in place per orders. During an interview and concurrent observation on 6/11/26 at 3:35 PM, CNA #1 attempted twice to activate Resident #17's recliner alarm system from the resident's room. On both attempts, the monitor located at the nurses' station failed to illuminate or sound an alert. A second CNA observed the testing and confirmed the monitor did not activate. CNA #1 then changed the batteries, but did not test it to see if it would work. During the same interview, both CNAs stated they could hear alarms only if they were near the nurses' station and did not recall receiving training regarding operation or testing of the monitoring devices. Both CNAs stated they rounded on everyone regularly. During the interview, Resident #17's bed monitor activated and emitted a faint chime. CNA #1 stated he/she could not hear the soft chime down the hallway or in another resident's room. The CNA further added that if they were turned up, they would be able to hear them. During an interview on 6/11/26 at 3:54 PM, the Facility Director (FD) stated the facility did not perform preventive maintenance on the Smart Caregiver monitoring devices and relied on staff to ensure the devices functioned properly. The FD was unable to provide the manufacturer's operating instructions for the remote monitors. Review of the Smart Caregiver Cordless Caregiver Alert Monitor Installation and Use Instructions, undated, accessed at: https://smartcaregiver.com/pages/instructionitem/chair-and-bed-alarm-with-wireless-monitor, revealed: .Test the System. Test all components before use. Smart CordLess utilize wireless technology which is subject to physical and environmental considerations. These products do not have an out of range function and as such should be tested periodically in the setting in which they are to be used to understand their area of effective operation . We recommend that all personnel receive periodic training in the operation of these systems and that the systems are tested before each use . The Smart Caregiver Corporation wireless device is designed to be installed by the end user. As such, it is the entire responsibility of the buyer to verify that Smart CordLess products are properly installed and tested successfully, before each use, in the setting in which they are to be used . The system is not designed to replace good caregiving practices including, but not limited to: A.) Direct patient supervision, B.) Adequate training for staff personnel in fall management and elopement, C.) Testing of the system before each use. Review of the facility-provided policy, Managing Falls and Fall Risk, undated, revealed: .The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

.Based on record review and interview, the facility failed to ensure: 1. The Centers for Medicare & Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, was completed with the required Quality Improvement Organization (QIO) name and toll-free telephone number before issuance for 3 residents (#18, #58, and #62), out of 3 residents who were reviewed for beneficiary notifications; and 2. The Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), Form CMS-10055, was provided when required for 1 resident (#18), out of 3 residents who were reviewed. Instead, the facility issued an expired Advance Beneficiary Notice of Non-Coverage (ABN), Form CMS-R-131, which was retired from use by CMS on [DATE]. These failed practices had the potential to prevent residents from receiving complete and accurate information regarding their Medicare appeal rights, including the right to request an expedited QIO review before termination of covered services, and could have limited their ability to make informed decisions regarding potential financial liability. Findings: Review of the NOMNC forms for Residents #18, #58, and #62 revealed each form retained generic template language and was not completed with required specific information. The forms stated, in part: .Your provider and/or health plan determined that Medicare probably won't pay for your {insert type} services after the above date. The forms further stated: .Call your QIO at {insert QIO name and toll-free number of QIO} to appeal, or if you have questions. The facility's QIO name and toll-free contact number were not entered on any of the three NOMNC forms reviewed. Resident #18 Record review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review for Residents who Received Medicare Part A Services, from 6/8-12/26, revealed Resident #18's Medicare Part A skilled services episode began on [DATE], and the last covered day of Part A service was [DATE]. Review of Resident #18's NOMNC, Form CMS-10123-NOMNC, revealed the form was signed by Resident #18 on [DATE]. The form indicated the resident's Medicare-covered services would end after [DATE]; however, the form retained the {insert type} placeholder for the Medicare service description and did not include the QIO name or toll-free number. Review of the ABN, Form CMS-R-131 (Exp[iration date]. [DATE]). revealed the ABN was signed by Resident #18 on [DATE]. The ABN form had expired before Resident #18 signed it. Review of the CMS website, accessed on [DATE] at: https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-abn, revealed SNFs .issue the ABN to transfer potential financial liability for items/services expected to be denied under Medicare Part B only . During an interview on [DATE] at 11:48 AM, the Administrator stated Resident #18 should have received the correct form, CMS-10055, instead of the expired Form CMS-R-131. The Administrator stated she had no knowledge that staff attempted to correct the error or provide the appropriate form to Resident #18. The Administrator also acknowledged the ABN form used for Resident #18 had expired prior to the date it was signed. Resident #58 Record review of the SNF Beneficiary Protection Notification Review for Residents who Received Medicare Part A Services, from 6/8-12/26, revealed Resident #58's Medicare Part A skilled services episode began on [DATE], and the last covered day of Part A service was [DATE]. Review of Resident #58's NOMNC, Form CMS-10123-NOMNC, revealed the form was signed by Resident #58 on [DATE]. The form indicated the resident's Medicare-covered services would end after [DATE]; however, the form retained the {insert type} placeholder for the Medicare service description and did not include the QIO name or toll-free number. Resident #62 Record review of the SNF Beneficiary Protection Notification Review for Residents who Received Medicare Part A Services, from 6/8-12/26, revealed Resident #62's Medicare Part A skilled services episode began on [DATE], and the last covered day of Part A service was [DATE]. Review of Resident #62's NOMNC, Form CMS-10123-NOMNC, revealed the form was signed by Resident #62 on [DATE]. The form indicated the resident's Medicare-covered services would end after [DATE]; however, the form retained the {insert type} placeholder for the Medicare service description and did not include the QIO name or toll-free number. During an interview on [DATE] at 11:53 AM, the Administrator acknowledged the facility used a generic Form CMS-10123 template and stated the form should have been completed with the correct information before residents received it

.Based on record review, observation, and interview, the facility failed to complete all sections of the Resident Assessment Instrument 3.0 Minimum Data Set (MDS, a federally required nursing assessment for long term care residents) required to accurately make a comprehensive assessment for 1 Resident (#33), of 14 sampled residents. Specifically, the facility failed to complete Sections D (Mood), and E (Behavior) on both an annual and a quarterly MDS assessment, despite documentation in the medical record identifying mood concerns, refusal behaviors, and resident preferences. This failed practice had the potential to result in an inaccurate assessment of the resident's mood, behavioral, psychosocial, and care needs, placing the resident at risk for inconsistent or unmet care. Findings: Record review on 6/8-12/26, revealed Resident #33 was admitted to the facility with diagnoses that included a below the knee amputation of the right leg, heart failure, and hypothyroidism (a condition where the thyroid gland is underactive). Review of Resident #33's MDS Annual Comprehensive Assessment, completed on 3/16/26, revealed: Section D: Mood. Not assessed/no information.; and Section E: Behavior. Not assessed/no information. Review of Resident #33's MDS Quarterly Assessment, completed on 6/9/26, revealed: Section D: Mood. Not assessed/no information.; Section E: Behavior. Not assessed/no information. Review of Resident #33's care plan, dated 3/9/26, revealed: . [Resident #33] has the potential for depressed mood.[Resident #33]'s psychosocial well-being is impaired to having little interest/pleasure in doing things as evidenced by [him/her] self reporting. [Resident #33] has a mood state problem related to little interest/pleasure in doing things. [Resident #33] has impaired behavior related to refusal of cares that would reduce risk for skin breakdown; refusal of medications and weights. WC [wheel chair] MOBILITY: Patient Refuses. Pt [patient] declines getting out of bed. The care plan identified impaired psychosocial well-being and documented symptoms including little interest or pleasure and depressed mood. Further review revealed the resident exhibited refusal behaviors, including refusing medications and weights. The care plan included interventions directed to address these behaviors. Review of Wildflower Court- Site 001 Continuity of Care Document, goals for Resident #33, with a goal date of 9/11/26, revealed: . Resident will exhibit a decrease in the number of behavior episodes by the next review date. An observation and concurrent interview on 6/8/26 at 4:40 PM, revealed Resident #33 was lying in bed on his/her side in a hospital gown. When asked if he/she wanted to speak with this surveyor, Resident #33 agreed, answered several questions, then stated, It's not a good time to talk and proceeded to roll over onto his/her other side. The resident displayed limited engagement, had flat facial expressions, and did not participate in conversation beyond brief responses. Random observations from 6/8-12/26 revealed Resident #33 remained in bed, slept, and had minimal interactions with staff. Review of Resident #33's nursing progress note, dated 6/7/26, revealed: .Resident refused [his/her] V/S [vital signs] to be taken. Review of Resident #33's nursing progress note, dated 6/8/26, revealed: .Resident refused [his/her] medications scheduled this morning and lunchtime; offered twice; reiterated the importance of [him/her] taking [his/her] medications but resident stated, 'Not right now.' [Provider] was contacted. and updated regarding resident frequent refusal of medications. During an interview on 6/11/26 at 9:34 AM, the MDS Coordinator, who worked remotely, stated certain sections of the MDS were completed by other staff members. She reported that the Social Worker (SW) completed sections C, D, E, and Q. When asked how she ensured the accuracy of the assessment, the MDS Coordinator stated she could not verify the correctness of others' observations and relied on staff responsible for each section to complete it accurately. She further explained that the assessments needed to be backed up by the documentation in the resident's medical record such as progress notes, electronic medication administration records, and treatment administration records. During an interview on 6/11/26 at 10:12 AM, the SW confirmed she was responsible for completing sections C, D, E, and Q. She explained that she normally attempted to contact the resident to complete the assessment. If that was not possible, she would then complete the staff assessment sections instead. She stated that Resident #33 had been difficult to reach and that she had not spoken with the resident. Upon reviewing Resident #33's MDS assessments, the SW stated that those sections had not been completed and that it was possible the assessment dates were missed. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, effective 10/1/25, revealed: . The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20(b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status;. (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. Further review of the RAI User's Manual, Chapter 2, stated that an Item Set refers to the MDS items that are active on a particular assessment type or tracking form and that the Comprehensive (NC) [annual] Item Set and Quarterly (NQ) Item Set consists of the items active on an annual and quarterly assessment. Review of the CMS MDS 3.0 Item Matrix v1.20.1v4, dated 10/2025, revealed Section D (Mood) and Section E (Behavior) items are active on the NC-Comprehensive and NQ Quarterly Assessment item set

.Based on record review, interview, and observation, the facility failed to ensure staff treated 1 resident (#39), of 14 sampled residents, with dignity and respect by honoring the resident's expressed preference for how staff announced themselves before entering the resident's room. Specifically, staff knocked on Resident #39's door despite the resident's known request that staff ring the mounted doorbell instead of knocking due to knocking being a trigger related to the resident's history of trauma and post-traumatic stress disorder (PTSD - a mental health condition that's caused by an extremely stressful or terrifying event). This failed practice had the potential to cause psychosocial harm by triggering trauma related symptoms, decreasing the resident's sense of safety, diminishing dignity, and reducing quality of life. Findings: Record review on 6/8-12/26 revealed Resident #39 was admitted to the facility with diagnoses that included PTSD and frontal lobe and executive function deficit (impaired cognitive functioning related to the area of the brain responsible for judgment, planning, organization, impulse control, problem-solving, attention, emotional regulation, and the ability to initiate and complete tasks). During an interview on 6/9/26 at 1:02 PM, Resident #39 stated that he/she had a history of trauma and PTSD and that knocking on his/her door was a known trigger. When the resident desired privacy, he/she shut the door and preferred that staff comply with a posted sign that requested staff use the mounted doorbell instead of knocking. An observation on 6/9/26 at 1:15 PM, revealed Certified Nursing Assistant (CNA) #2 approached Resident #39's room while surveyors conducted an interview with the resident. CNA #2 knocked on the resident's door and rang the mounted doorbell. CNA #2 then opened the door. Resident #39 stated, Not now, I'm busy, and CNA #2 closed the door. Further observation revealed a paper sign posted on the outside of Resident #39's door that read, Pls. [please] Ring the Bell, Don't Knock! STOP A doorbell was mounted next to the sign. During an interview on 6/11/26 at 9:50 AM, the Assistant Director of Nursing (ADON) stated all staff members received training on trauma informed care and PTSD during new hire orientation. She stated that staff were aware of Resident #39's preference to use the doorbell, and her expectation was that staff honor the resident's wishes. During an interview on 6/11/26 at 11:00 AM, CNA #9 stated all staff received trauma informed care training during orientation and annually. He/she further stated staff are informed about residents with PTSD and their triggers, which included the reason behind each trigger. Knocking was a known trigger for Resident #39 which would make him/her very upset, and that staff were to comply with the posted sign and use the doorbell. Review of Resident #39's care plan, initiated 4/3/26, revealed: . Problem: Resident has a potential for OR actual psychosocial well being issue d/t [due to]: hx [history] of past trauma. Approach: Encourage resident to voice concerns/feelings; provide reassurance as needed. Approach: Determine resident's expectations and discuss in realistic terms. Review of the facility policy Trauma- Informed and Culturally Competent Care, undated, revealed: . Purpose. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. All staff are provided in-service training about trauma and trauma-informed care in the context of the healthcare setting.For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. e. Empowerment, voice and choice: (1) Ensure that the resident's choices and preferences are honored and that residents are empowered to be active participants in their care.(4) Avoid one-size-fits-all approaches, which can make individuals feel discounted.

.Based on record review and interview, the facility failed to follow the Preadmission Screening and Resident Review (PASRR) Level I determination and failed to notify the State of Alaska Division of Senior and Disability Services (SDS) when 1 resident (#61), out of 2 residents reviewed for PASRRs, compliance remained in the facility beyond the time-limited 90-day convalescent stay. This failed practice resulted in Resident #61 remaining in the facility without the required updated PASRR review and/or Level II evaluation to determine whether the resident required specialized services, which had the potential to adversely affect the resident's ability to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Findings: Record review on 6/8-12/26 revealed Resident #61 was admitted to the facility with diagnoses that included depression, borderline personality disorder (a mental health condition that affects emotional regulation), and chronic pain due to trauma. Review of Resident #61's Level 1 PASRR, dated [DATE], revealed: .Convalescent care for a period of 90 days or less, as certified by the physician. If the individual stays beyond the 90 days, an individualized PASRR Level II evaluation must be completed. The facility shall notify SDS [State of Alaska, Division of Senior and Disability Services] on day 85 that it anticipates the resident will need services more than 90 days. Day 85 is: [DATE]. Review of Resident #61's Discharge summary, dated [DATE], revealed that he/she was discharged from the facility on [DATE]. As a result, Resident #61 remained in the facility beyond the approved 90 day convalescent stay without documentation that the facility notified SDS by Day 85, as required by the Level I PASRR determination, or obtained an updated PASRR review and/or Level II evaluation. During an interview on [DATE] at 1:26 PM, the Administrator (ADM) stated the facility was unable to locate any record that indicated Resident #61 received a PASSR Level II evaluation. Review of email correspondence between the surveyor and SDS, dated [DATE] at 3:34 PM, revealed: .Per PASRR processes, the facility should have notified SDS before the time limited expired ([DATE]). The resident should have had an updated PASRR vs. level II evaluation. Unfortunately, SDS was never notified of ongoing LTC [Long Term Care] stay after [DATE] and this case would be considered non-compliant with PASRR processes . Review of the facility's policy WFC [Wildflower Court]: admission Criteria, undated, revealed: . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASSR) process. g. The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. h. If the level I screen indicates that the individual may meet the criteria for MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. i. Upon completion of the Level II evaluation, the state PASRR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement at the facility is appropriate.

.Based on record review, observation, and interview, the facility failed to develop, implement, and revise the comprehensive person-centered care plan for 1 resident (#39) out of 14 sampled residents. Specifically, the facility failed to: 1) implement the care-planned fall prevention intervention of placing floor mats at the resident's bedside; and 2) include interventions for multiple high risk medications with fall-related side effects. These failed practices placed Resident #39 at risk for falls and fall-related injury, with the potential to negatively affect the resident's ability to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Findings: Record review on 6/8-12/26 revealed Resident #39 was admitted to the facility with diagnoses that included osteoarthritis (a degenerative joint disease), spinal stenosis (narrowing of the spinal cord), neurosarcoidosis (inflammatory disease of the central nervous system), obstructive sleep apnea (repeated interruptions of breathing during sleep), macular degeneration (eye disease that affects and impairs central vision) and restless leg syndrome (irresistible urge to move legs). 1) Fall Mats Record review on 6/11/26 revealed Resident #39 experienced three falls since the previous recertification survey. The falls occurred on 5/13/26 at 4:24 AM, 5/19/26 at 11:45 PM, and 6/10/26 at 4:00 AM. The fall on 6/10/26 resulted in shoulder pain, and diagnostic imaging was obtained for evaluation. Review of Resident #39's care plan, initiated 5/15/26, revealed: .Resident is at risk for falls and/or fall related injury r/t [related to]: generalized weakness, limited endurance, impaired balance, unsteady gait, history of falls, and decreased vision. Start date 04/03/2026. Resident will minimize risk of fall related injuries with staff interventions thru next review date. Floor mats to sides of bed per orders. During an interview on 6/9/26 at 1:00 PM, Resident #39 stated that he/she did not currently have fall mats in place but would like them. During an interview on 6/11/26 at 9:50 AM, the Assistant Director of Nursing (ADON) stated fall mats were identified in Resident #39's care plan. The ADON further stated that orders for fall mats would be expected in the resident's order set; however, she was unable to locate fall mat orders in Resident #39's electronic medical record (EMR). During an interview on 6/12/26 at 8:28 AM, Certified Nursing Assistant (CNA) #7 stated that the Director of Nursing (DON) or the unit nurse communicated to staff when to put the mats out. CNA #7 further stated Wednesday, 6/10/26, was when staff first started using fall mats for Resident #39. During an interview on 6/12/26 at 10:37 AM, the Administrator stated the facility was aware of Resident #39's increased falls. The Administrator stated she had been involved in ongoing discussions with Resident #39 regarding his/her falls and that Resident #39 had consented to fall mats. The Administrator stated that approximately one month earlier, the facility identified it did not have enough fall mats and ordered more. The Administrator stated the fall mats had recently arrived and were implemented on the night of 6/11/26. An observation on 6/12/26 at 8:35 AM of Resident #39's room, revealed fall mats in place at the bedside. 2) Fall-Related Medication Risk Factors Review of the MDS (Minimum Data Set, a federally required assessment) last completed on 4/8/26, and current order set, revealed Resident #39 received medications in the high-risk categories: antianxiety, antidepressants, and opioids. - Diazepam (an anti-anxiety or sedative/hypnotic medication), 5 milligram (mg) tablet by mouth at bedtime for restless legs. Review of Davis's Drug Guide for Nurses, copyright 2026 revealed potential side effects for diazepam included: hypotension (low blood pressure) blurred vision, dizziness, drowsiness, lethargy (fatigue and drowsiness) and ataxia (loss of muscle coordination). Further review revealed the black box warning: .use with benzodiazepines or other CNS [Central Nervous System] depressants, including other opioids, nonbenzodiazepine sedative/hypnotic, anxiolytics, general anesthetics, muscle relaxants antipsychotics may cause profound sedation, respiratory depression, coma and death. - Escitalopram (an anti-depressant), 20mg tablet by mouth daily for depression. Review of Davis's Drug Guide for Nurses, copyright 2026 revealed potential side effects for escitalopram included: insomnia, dizziness, drowsiness, fatigue, and serotonin syndrome (a serious drug reaction caused by medications that build up high levels of serotonin in the body; symptoms include fast heartbeat, hallucinations, loss of coordination, twitching muscles, and/or agitation/restlessness). - Gabapentin (an analgesic) 400mg capsule by mouth three times a day for nerve pain. Review of Davis's Drug Guide for Nurses, copyright 2026 revealed potential side effects for gabapentin included: abnormal vision, ataxia (loss of muscle coordination, unsteady gait), confusion, dizziness, drowsiness, altered reflexes, sedation, vertigo (feeling of spinning or feeling off balance), and weakness. - Oxycodone (opioid narcotic pain medication) 5mg tablet - 1/2 tablet every four hours as needed for pain. Review of Davis's Drug Guide for Nurses, copyright 2026 revealed potential side effects for oxycodone included: orthostatic hypotension (a drop in blood pressure upon standing that can lead to dizziness or fainting), blurred vision, confusion, sedation, dizziness, floating feeling, and hallucinations. Further review revealed the black box warning: . use with benzodiazepines or other CNS depressants, including other opioids, nonbenzodiazepine sedative/hypnotic, anxiolytics, general anesthetics, muscle relaxants antipsychotics may cause profound sedation, respiratory depression, coma and death. Review of Resident #39's care plan revealed no interventions addressing medication related fall risk, despite documentation that Resident #39 experienced three falls within approximately one month and received multiple high-risk medications associated with dizziness, sedation, impaired coordination, and orthostatic hypotension. Review of the facility policy Managing Falls and Fall Risk - Resident-Centered Approaches to Managing Falls and Fall Risk, undated, revealed: .The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) for falls for each resident at risk for or with a history of falls. If underlying causes cannot be readily identified or corrected, staff will try various interventions based on assessment of the nature or category of falling until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . Review of the facility policy Falls-Clinical Protocol, undated, revealed: .The physician will help identify individuals with a history of falls and risk factors for falling. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. Examples for risk factors include light headedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension and medical conditions affecting the central nervous system. Treatment/Management. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessments of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation . Review of the facility policy Care Plan Goals and Objectives, undated, revealed: .When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goal and objectives have been established. Care plans will be modified accordingly .

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure: 1) expired food was discarded; and 2) the temperature of cooked potentially hazardous food was recorded after cooking. These failed practices had the potential of causing or spreading foodborne illness to all residents, based on a census of 53, who received food from the affected kitchens. Findings: Main Kitchen Observation on 5/5/25 at 10:55 AM, during the initial main kitchen tour with the Director of Nutrition Services (DNS), revealed: 1) Dry Storage: - One- 12-quart clear plastic container with a blue lid and a handwritten label that said, Brown Sugar 5-1-25 which contained two pieces of brown bread on top of the contents in the container. -Four- gallon size plastic bags which contained single servings of Smucker's Apple Butter not labeled with manufactures expiration or best used by date. -One- large clear plastic container with a blue lid labeled, Perfect [NAME] 4/30, no expiration date or best used by date. -One- small clear plastic container with a blue lid labeled, Perfect [NAME] 4/30, no expiration date or best used by date. During an interview on 5/5/25 at 11:10 AM, the DNS stated the bread was placed on top of the brown sugar in the container to keep the sugar from getting hard. The date on the label was when the contents were placed in the container. When the DNS was asked how long the bread was kept, the DNS stated dry goods were on a 2-week rotation. 2) Walk-in Cooler: -One- Arrezzion, Shredded Low Moisture Part Skim Mozzarella Cheese - 5-pound plastic bag- no expiration date, manufacture labeled #2329413, packed 11/11/24 13:13 400. The DNS was not able to provide an expiration date of the cheese. -One- unidentified large clear plastic container was not labeled and not dated. The DNS stated that the container was prepared celery to be used that day. 3) [NAME] Unit Kitchen: -One- expired PORK LOIN CHOPS, CENTER CUT, BONELESS, FROZEN - 16-ounce package- with manufacture best if use by 02/25/2025; -One- expired Johnsonville JALAPENO CHEDDAR Smoked Sausage - 14-ounce package- with manufacture best by date of 4/14/25. 4) Blueberry Unit Kitchen: - One box expired Instant Quaker Original Oatmeal- 10 packets- with manufacture best if used before Apr. [April] 12 25. An observation of the main kitchen dry storage area, on 5/8/25 at 4:10 PM, revealed a 12-quart clear plastic container with a blue lid and a handwritten label that said, Brown Sugar 5-1-25, which contained multiple pieces of brown bread on top of the contents in the container. Review of Sysco Food Safety & Quality Assurance, Customer Specification, for Mozzarella Cheese, revised 4/29/25, revealed: . 2329413 . ARREZZION . Shred Low Moisture Part Skim Mozzarella Cheese .5 pound . Shelf Life . Dry and Refrigerated 90 Days . Review of the facility's policy HOW TO: Properly Store Food, dated 2019, revealed: Label & Date All Stored Food . Review of the facility's policy Food Storage, Handling and Preparation, undated, revealed: Purpose: All foods will be stored, prepared, cooked and served using appropriate practices and procedures to ensure safety . Policy: A. Foods are stored, handled and prepared by safe methods that conserve nutritive value. Review of the facility's POSITION DESCRIPTION, dated 3/29/23, revealed: . [NAME] II . Ensures proper food storage procedures are being followed in all coolers, freezers and food storage areas . Follows all health department guidelines for safe handling of food . Review of the facility's POSITION DESCRIPTION, dated 11/21/24, revealed: . Director of Nutrition Services . This position independently manages the full food service and nutritional operations and assists with . patient and staff dietary needs for the. Wildflower Court . The Director of Nutrition Services is responsible for planning, coordination, staffing. of the Dietary Department. coordinate employee training, maintain effective communication, and participate in teaching and directing staff .Establishes and maintains standards of food . storage, sanitation, safety. Develops and mentors' staff . Makes department rounds to identify issues; observes and coaches staff . Education: Facilitates the education necessary for staff to perform competently . Must comply with all workplace health and safety requirements . Potentially Hazardous Cooked Foods During an observation on 5/5/25 at 11:05 AM, of the main kitchen, revealed a poster from the State of Alaska Division of Environmental Health posted on walk-in cooler listed cooking for meat and eggs. Cook to this temperature or hotter: . Poultry 165 [degrees] F [Fahrenheit] . During an interview on 5/5/25 at 11:45 AM, with the Home Attendant (HA) #5 in the Cranberry Unit kitchen, when asked if the HAs took the temperature of the food before serving the resident, HA #5 stated they stopped taking the food temperatures on the unit and that the main kitchen took the temperatures. HA #5 further stated the food steamer was prepared 30 minutes prior to the food arriving from the kitchen. HA #5 stated in order to prepare the steamer, water was put in and the steamer was turned on. HA#5 stated the temperature did not need to be adjusted on the steamer, he/she stated the steamer water needed to be 165 degrees or higher. During an interview on 5/5/25 at 12:10 PM, with HA #6 in the [NAME] Unit kitchen, HA #6 stated the food arrived warm and was served family style. HA #6 further stated the food was not kept in the steamer longer than 2 hours. During an interview on 5/6/25 at 4:05 PM, with HA #4 in the Blueberry Unit kitchen, HA #4 stated the temperature was not adjusted on the steam table. HA #4 further stated he/she took the temperature of the water in the steam table and the temperature was to be 165 degrees or higher. HA #4 stated once food was delivered by the kitchen and placed on the steamer it was served to the residents immediately. HA #4 further stated food was discarded after 1 1/2 to 2 hours. During an observation and concurrent interview on 5/7/25 at 11:20 AM, in the main kitchen, Food Service (FS) staff #1 removed chicken from the oven, FS staff #1 took the temperature with a digital thermometer and stated it was 167 degrees F. FS staff #1 did not document the temperature. FS staff #1 placed the cooked noon meal into metal pans and transferred to the steamer unit. The steamer unit temperature displayed 200 degrees F. During an observation and concurrent interview on 5/7/25 at 11:56 AM, in the main kitchen, FS staff #1 removed the noon meal from the steamer and obtained the temperatures of the food. FS staff #1 read off the temperatures after the recording: Chicken 162 degrees F, ground chicken 156 degrees F and pureed chicken 150 degrees F. FS staff #1 and FS staff #2 stated they were to only record temperatures of the food before it was taken to the dining units. FS staff #1 stated this was a recent change that was directed by management. FS staff #1 further stated the temperatures used to be documented after cooking. FS staff #1 and FS staff #2 stated they continued to take temperatures after cooking to ensure the food reached the recommended temperatures to prevent foodborne illnesses but no longer have a place to document them. When asked what temperature chicken needs to be, FS staff #1 and FS staff #2 stated 165 degrees F or higher. During an interview and concurrent observation on 5/8/25 at 4:15 PM, the DNS stated the cooks have a poster to use for guidance of minimum food temperatures before serving. The DNS further stated the temperature log was to make sure the food was cooked to the minimum temperature before going upstairs. The temperature log was titled Cart Temp Log. During an interview and concurrent observation on 5/9/25 at 11:17 AM, FS staff #2 was asked for the food temperature logs for 5/6-8/25. FS staff #2 stated he/she knew where the documents were located. FS staff #2 retrieved the clipboard that had sheets titled, Cart Temp Log. FS staff #2 stated those requested dates were not on the clipboard. FS staff #2 then started going through a stack of paper on the desk in the main kitchen. FS staff #3 then asked FS staff #2 what he/she was looking for. FS staff #2 stated he/she was looking for temperature logs for 5/6-8/25. FS staff #3 advised FS staff #2 to look in the garbage can by the dishwashing area. FS staff #2 stated the garbage can, FS staff #3 stated the DNS had thrown a bunch of papers in the garbage can previously. FS staff #2 retrieved 5/6-8/25 Cart Temp Log sheets that appeared to be the original documents. This surveyor obtained pictures of the documents as they had been taken out of the garbage can. FS staff #2 kept the original log sheets. Review of the facility's Cart Temp Log revealed: Dated 5/9/25- Chicken 162; Ground 156; Puree 150; Dated 5/8/25 - Chicken no recorded temperature- Ground no recorded temperature- Puree no recorded temperature; Dated 5/4/25- Chicken 164- Ground 162- Puree 162; Dated 5/3/25- Chicken . Ground 161; Puree 162; Dated 5/1/25- Chicken no recorded temperature; Ground 162- Puree 162; Dated 4/29/25- Chicken . Puree 162; Dated 4/23/25- Turkey. Ground 161- Puree 161; Dated 4/20/25- Chicken. Ground 161- Puree 162 . Pizza no recorded temperature- Veg [Vegetable] no recorded temperature- Mash [potatoes] no recorded temperature- Gravy no recorded temperature- Ground no recorded temperature- Puree no recorded temperature. Review of the facility's FOOD TEMP LOG revealed: Dated 4/15/25- Turkey. Puree 161; Dated 4/13/25- Chicken 164- Ground 161- Puree 161; Dated 4/12/25- Turkey. Ground 162- Puree 161; Dated 4/7/25- Turkey. Puree 163; Dated 4/6/25- Chicken 164- Ground 161- Puree 160; Dated 4/5/25- Chicken. Ground 162- Puree 162; Dated 3/31/25- Chicken. Ground 161- Puree 162; Dated 3/28/25- Turkey. Ground 162- Puree 162; Dated 3/26/25- Turkey. Ground 162- Puree 162; Dated 3/25/25- Chicken. Puree 161; Dated 3/23/25- Chicken. Ground 162- Puree 162; Dated 3/19/25- Chicken. Ground 162- Puree 162; Dated 2/23/25- Chicken. Ground 161- Puree 162; Dated 2/19/25- Chicken. Ground 162- Puree 162; Dated 2/17/25- Chicken. Puree 156; Dated 2/15/25 Turkey. Ground 164- Puree 162; Dated 2/12/25- Chicken. Ground 162- Puree 162; Dated 2/11/25- [NAME] no recorded temperature- Chicken no recorded temperature- Veggies no recorded temperature- Mash no recorded temperature- Gravy no recorded temperature- Ground no recorded temperature- Puree no recorded temperature; Dated 2/9/25- Chicken 164- Ground 162- Puree 162; Dated 2/8/25- Chicken. Ground 162- Puree 162; Dated 1/15/25- Chicken 162- Ground 162- Puree 162; Dated 1/12/25- Chicken. Ground 162- Puree 162; Dated 1/11/25- Chicken. Ground 162- Puree 162; Dated 1/9/25- Chicken. Ground 159. Review of the facility's POSITION DESCRIPTION, dated 3/29/23, revealed: . [NAME] II . Follows all health department guidelines for safe handling of food . Completes required documentation for temperatures of food . Must comply with all workplace health and safety requirements . Review of the facility's POSITION DESCRIPTION, dated 11/21/24, revealed: . Director of Nutrition Services . This position independently manages the full food service and nutritional operations and assists with . patient and staff dietary needs for the. Wildflower Court . The Director of Nutrition Services is responsible for the planning, coordination, staffing. of the Dietary Department. coordinate employee training, maintain effective communication, and participate in teaching and directing staff . ensure food is prepared. and served at proper temperatures. Establishes and maintains standards of food . storage, sanitation, safety. Develops and mentors' staff . Makes department rounds to identify issues; observes and coaches staff . Education: Facilitates the education necessary for staff to perform competently . Must comply with all workplace health and safety requirements . Review of the facility's policy Food Storage, Handling and Preparation, undated, revealed: Purpose: All foods will be stored, prepared, cooked and served using appropriate practices and procedures to ensure safety . Policy: A. Foods are stored, handled and prepared by safe methods that conserve nutritive value. H. Potentially hazardous foods requiring cooking are heated to the appropriate temperature and held at that temperature . H.1.1. All poultry, all food made from poultry, all stuffed meats, and the stuffing in them must reach 165 [degrees] F [Fahrenheit] or hotter to destroy Salmonella and other bacteria . H.2.6. Temperatures of foods placed in steam tables or other hot holding units must be taken when the product is placed . Review of Food and Drug Administration (FDA), 2022 Food Code U.S. Food and Drug Administration, dated 12/28/22. Accessed at this link: https://www.fda.gov/media/184685/download?attachment, revealed: 3-401 Cooking, 3-401.11 Raw Animal Foods. (A) . POULTRY, and FOODS containing these raw animal FOODS, shall be cooked to heat all parts of the FOOD to a temperature . (3) 74 C (165 F) or above . .

Based on record review and interview, the facility failed to ensure nursing staff have the specific competencies and skills set necessary to care for residents' needs. Specifically, the facility failed to ensure: 1) 6 Licensed Nurses (LN #'s 1, 2, 3, 4, 5, and 6), out of 15 LN personnel files reviewed, had current training for safe oxygen handling; and 2) 1 Certified Nurse Aide (CNA #1), out of 3 CNA personnel files reviewed, had a valid Cardiopulmonary resuscitation (CPR) certificate. This failed practice had the potential to place all residents (based on a census of 53) at risk of not receiving the necessary treatment and care and immediate assistance during an emergency. Findings: Oxygen Safety Education During an interview on [DATE] at 3:35 PM, during a review of personnel files, the Human Resources (HR) Manager stated LN #4 had no training for oxygen handling safety. During an interview on [DATE] at 4:33 PM, the Assistant Director of Nursing (ADON) stated oxygen safety education was required annually for all licensed nurses. She stated LN #4 was a traveler nurse and had been to the facility before 2024. Since then, there was no record of oxygen safety training. The ADON stated LN #4 had no designated unit because he/she was a traveler. Review of oxygen safety education documents on [DATE] at 10:13 AM, revealed LN #s 1, 2, 3, and 5 had just completed their training on [DATE]; and LN #4 and #6 had just completed their training on [DATE] (during the survey). During an interview on [DATE] at 10:13 AM, when asked if the training was conducted after the personnel files review on [DATE] at 3:35 PM, the ADON stated, yes. An observation on [DATE] at 11:00 AM, revealed 13 compressed gas cylinders were stored at the Salmonberry unit. During an interview on [DATE] at 1:37 PM, ADON confirmed that there were oxygen tanks in the Salmonberry unit storage reserved for residents who might need oxygen. CPR certification Review of the personnel files on [DATE] at 3:35 PM, the HR Manager stated CNA #1 was hired on [DATE]. Further review revealed CNA #1's personnel file did not contain a CPR certificate. During an interview on [DATE] at 4:20 PM, the HR Manager confirmed that CNA #1 had no CPR certificate since hire. The HR Manager explained that the CNA was enrolled in a CPR class, but the CNA had not completed the course. The HR Manager also added that the Staff Development Office should have followed up with the completion of the course. During an interview on [DATE] at 4:27 PM, when asked if CNA #1 was allowed to work on the floor without a CPR certificate, HR Manager did not answer the question. Review of the facility's Emergency Procedure- Cardiopulmonary Resuscitation, dated [DATE], revealed: Policy statement [:] Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR). Review of the facility's policy Mandatory Education for All hospital Staff (that the HR Manager confirmed was applicable to Wildflower Court staff as well), dated [DATE], revealed: .F. Mandatory classes and competencies for clinical staff are.BLS (Basic Life Support) is required for all clinical employees providing direct patient care. .

Based on record review and interview, the facility failed to ensure that residents who received opioid pain medications (a class of strong pain-relieving medications that act on the nervous system, with potential for dependence, overdose, and serious side effects) were re-evaluated for pain for 11 residents (#1, #2, #6, #12, #20, #24, #26, #37, #49, #51, and #259), out of 53 residents reviewed for pain management. Specifically, the facility failed to re-evaluate the residents' pain level within 30 to 60 minutes following opioid administration. This failed practice had the potential to result in unrelieved pain, delayed identification of medication ineffectiveness, or overmedication. Findings: Resident #1 Record review on 5/5-9/25 revealed Resident #1 was admitted to the facility with diagnoses that included cerebral palsy (a group of neurological disorders that affect movement and muscle tone), hemiplegia (paralysis on one side of the body), and anxiety disorder. Review of Resident #1's Electronic Medication Administration Record (eMAR) and clinical progress notes revealed the Resident received an opioid pain medication: .Hydrocodone 5 mg-acetaminophen 325 mg tablet.as needed for severe back & hip pain, from 4/19/25 through 5/8/25. Further review revealed 25 instances in which opioid medications were administered, but no documentation of a pain reassessment was found within 30 to 60 minutes following administration. Resident #2 Record review on 5/5-9/25 revealed Resident #2 was admitted to the facility with diagnoses that included post-traumatic stress disorder (PTSD), neurogenic bladder (a condition where nerve damage affects bladder control), and heart failure (a chronic condition where the heart cannot pump blood effectively). Review of Resident #2's eMAR and clinical progress notes revealed the Resident received an opioid pain medication: .Norco 5 mg-325 mg tablet.as needed.for pain, from 4/16/25 through 5/5/25. Further review revealed two instances in which opioid medications were administered, but no documentation of pain reassessment was found within 30 to 60 minutes following administration. Resident #6 Record review on 5/5-9/25 revealed Resident #6 was admitted to the facility with diagnoses that included depression, renal insufficiency (impaired kidney function that affects waste elimination and fluid balance), and anemia (a condition marked by low red blood cell count or hemoglobin, leading to fatigue and weakness). Review of Resident #6's eMAR and clinical progress notes revealed the Resident received opioid pain medications: .Oxycodone 5mg tablet.Oxycodone 15 mg tablet.as needed for pain, from 4/20/25 through 5/9/25. Further review revealed 37 instances in which opioid medications were administered, but no documentation of pain reassessment was found within 30 to 60 minutes following administration. Resident #12 Record review on 5/5-9/25 revealed Resident #12 was admitted to the facility with diagnoses that included peripheral vascular disease (narrowing of blood vessels outside of the heart and brain, causing poor circulation), heart failure, and anemia. Review of Resident #12's eMAR and clinical progress notes revealed the Resident received an opioid pain medication: .Tylenol-Codeine #3 300mg-30 mg tablet.PRN (as needed) for DJD [degenerative joint disease] knee pain, from 4/17/25 through 5/8/25. Further review revealed 25 instances in which opioid medications were administered, but no documentation of pain reassessment was found within 30 to 60 minutes following administration. Resident #20 Record review on 5/5-9/25 revealed Resident #20 was admitted to the facility with diagnoses that included multiple sclerosis (a progressive disease of the central nervous system affecting movement, sensation, and coordination), dementia (a decline in memory and cognitive ability that interferes with daily function), and neurogenic bladder. Review of Resident #20's eMAR and clinical progress notes revealed the Resident received an opioid pain medication: .Percocet 5 mg-325 mg tablet.as needed for pain, from 4/2/25 through 5/8/25. Further review revealed 17 instances in which opioid medications were administered, but no documentation of pain reassessment was found within 30 to 60 minutes following administration. Resident #24 Record review on 5/5-9/25 revealed Resident #24 was admitted to the facility with diagnoses that included schizophrenia (a serious mental disorder affecting perception, thought, and behavior) and PTSD. Review of Resident #24's eMAR and clinical progress notes revealed the Resident received an opioid pain medication: . Oxycodone 5 mg tablet.as needed for pain, from 4/23/25 through 5/3/25. Further review revealed 36 instances in which opioid medications were administered, but no documentation of pain reassessment was found within 30 to 60 minutes following administration. Resident #26 Record review on 5/5-9/25 revealed Resident #26 was admitted to the facility with diagnoses that included hemiplegia, seizure disorder, and depression. Review of Resident #26's eMAR and clinical progress notes revealed the Resident received an opioid pain medication: .Oxycodone 5 mg tablet.as needed for pain, from 4/19/25 through 5/8/25. Further review revealed 10 instances in which opioid medications were administered, but no documentation of pain reassessment was found within 30 to 60 minutes following administration. Resident #37 Record review on 5/5-9/25 revealed Resident #37 was admitted to the facility with a diagnosis of anxiety disorder. Review of Resident #37's eMAR and clinical progress notes revealed the Resident received an opioid pain medication: .Oxycodone 5 mg tablet.as needed for pain, from 4/11/25 through 5/9/25. Further review revealed seven instances in which opioid medications were administered, but no documentation of pain reassessment was found within 30 to 60 minutes following administration. Resident #49 Record review on 5/5-9/25 revealed Resident #49 was admitted to the facility with diagnoses that included cellulitis (a bacterial skin infection causing redness, swelling, and pain) of the right lower limb, chronic pain, and arthritis (inflammation of one or more joints causing pain, stiffness, and reduced mobility) of the right knee. Review of Resident #49's eMAR and clinical progress notes revealed the Resident received an opioid pain medication: .Oxycodone 5 mg tablet.as needed for septic arthritis, from 4/22/25 through 5/9/25. Further review revealed 44 instances in which opioid medications were administered, but no documentation of pain reassessment was found within 30 to 60 minutes following administration. Resident #51 Record review on 5/5-9/25 revealed Resident #51 was admitted to the facility with diagnoses that included paraplegia, anxiety disorder, and neurogenic bladder. Review of Resident #51's eMAR and clinical progress notes revealed the Resident received an opioid pain medication: .Endocet 5 mg-325 mg tablet.PRN for pain, from 4/20/25 through 5/9/25. Further review revealed 62 instances in which opioid medications were administered, but no documentation of pain reassessment was found within 30 to 60 minutes following administration. Resident #259 Record review on 5/5-9/25 revealed Resident #259 was admitted to the facility with diagnoses that included neurogenic bladder and multiple sclerosis. Review of Resident #259's eMAR and clinical progress notes revealed the Resident received opioid pain medications: . Norco 5mg-325 mg tablet. as needed for pain. Dilaudid 2mg tablet. as needed for severe pain, from 4/12/25 through 5/9/25. Further review revealed 14 instances in which opioid medications were administered, but no documentation of pain reassessment was found within 30 to 60 minutes following administration. During an interview on 5/9/25 at 4:35 PM, the Director of Nursing (DON) stated that nurses were to perform pain reassessments within 30 to 60 minutes after administering pain medications. Review of the facility policy, Administering Pain Medications, dated 12/17/23, revealed: . Re-evaluate the resident's level of pain 30-60 minutes after administering. Review of an article from the U.S. Government's National Library of Medicine: Improving the Quality of Care Through Pain Assessment and Management, accessed at: https://www.ncbi.nlm.nih.gov/books/NBK2658/#:~:text=Assessment%20of%20effect%20should%20be,45%E2%80%9360%20minutes%20after%20administration. revealed: .Assessment of effect should be based upon the onset of action of the drug administered.oral opioids and nonopioids are reassessed 45-60 minutes after administration. .

Based on record review, observation, and interview, the facility failed to ensure the care plan was implemented for 1 resident (#40), out of 14 sampled residents. Specifically, a Certified Nurse Aide (CNA #2) failed to follow Resident #40's care plan for basic care needs while assisting the resident out of bed to the toilet. This failed practice had the potential to injure the resident and negatively impact the resident's physical well-being. Findings: Record review during 5/5-9/25 revealed Resident #40 was admitted to the facility with diagnoses that included anoxic brain damage (a brain injury that occurs when the brain is deprived of oxygen), and other reduced mobility. The resident also used ankle-foot orthoses (AFOs, devices designed to support the foot and ankle) to help him/her stand and perform transfers. Review of Resident #40's Care Plan, with a start date of 4/15/25, revealed: Approach . TRANSFERS: I need 2 PEOPLE to assist with my transfers. Sara Steady and 2-person extensive assist . TOILETING: I need 2 PEOPLE to assist with my toileting for using the flush toilet . An observation and concurrent interview on 5/5/25, at 2:58 PM, revealed upon entering Resident #40's room, a Hoyer lift (a lift device designed to assist caregivers in safely transferring residents with limited mobility) was obstructing the room's internal entryway. Also, Resident #40 was laying down in bed, with the head of the bed elevated to approximately 45 degrees and the upper quarter side rails were raised. A Sara Steady device was positioned by the side of the bed. CNA #2 was standing with his/her feet firmly planted, leaning forward while holding the resident by the wrists. The CNA then leaned backward and used a tugging motion to assist the resident up into a seated position as the resident simultaneously twisted toward the bed's edge, with his/her face briefly resting on the side rail. After achieving a seated position, CNA #2 released the resident's wrists. The resident then adjusted his/her position by slightly swinging both feet back and forth, which were fitted with AFOs, and scooted his/her bottom toward the Sara Steady. With the resident's feet positioned on the Sara Steady, CNA #2 assisted the resident with grasping the support bar, and the resident proceeded to stand. Further observation revealed CNA #2 transported the resident to the bathroom. Resident #40 was positioned in front of the toilet. The CNA took down the resident's brief, and the resident lowered himself/herself shakily down to the toilet with no assistance. Next, CNA #2 hung several wet wipes from the bar of the Sara Steady that was parked in front of the resident. Afterwards, CNA #2 closed the bathroom door partially and went to make the resident's bed. While making the bed, CNA #3 stuck his/her head in the room and told CNA #2 that the tub will be available for Resident #40 at 4:00 PM. Afterwards, CNA # 2 and #3 both left the room while the resident was still on the toilet. Outside in the hallway, CNA #2 stated Resident #40 was good about pulling the call light when he/she finished and went on to further explain how different locations in a resident's room will make a different alert noise based on different initiation of call lights. CNA #2 then went back into the room stating he/she needed to make the bed. During an interview on 5/8/25 at 9:31 AM, the Director of Nursing (DON) stated that CNA's were trained on transferring residents and lift devices during orientation. She further stated Resident #40 was a 2-person assist, and staff should never pull on residents while assisting them. During an interview on 5/9/25 at 10:25 AM, CNA #4 stated that Resident #40 was always a 2 person assist out of bed and to the toilet. Review of the facility's policy Safe Patient Movement and Handling, undated, revealed: . It is the duty of each employee to take reasonable care of their own health and safety as well as that of their co-workers and of patients during patient handling activities . .

Based on record review, observation, and interview, the facility failed to ensure 1 resident (#49), out of 5 residents observed for medication administration, was appropriately assessed for safe self-administration of medications. This failed practice placed the resident at risk of medication errors and adverse outcomes. Findings: Record review on 5/7/25 revealed Resident #49 was admitted to the facility with diagnoses that included cellulitis of the right lower limb (a bacterial skin infection causing redness, swelling, and pain), other chronic pain, and arthritis of the right knee due to other bacteria (inflammation of the joints that causes pain, stiffness, and swelling). An observation on 5/6/25 at 12:14 PM, revealed a medication cup containing two tablets of Tylenol sitting on Resident #49's bedside table. Review of Resident #49's Electronic Medication Administration Record (EMAR), dated 5/6/25, revealed an entry which documented that two tablets of Tylenol were administered at 12:00 PM. During an interview on 5/6/25 at 12:29 PM, Resident #49 stated the nurses usually left his/her medications in his/her room. He/she would take the two Tylenol with lunch or sometimes he/she would take it later. An observation on 5/7/25 at 9:00 AM, revealed Licensed Nurse (LN) #4 prepared and administered medications for Resident #49. LN #4 handed the resident a medication cup containing 9 medications, asked the resident to rate his/her pain level, and then exited the room. LN #4 did not observe the resident to ensure he/she ingested the medications. The medications included a controlled substance, oxycodone (an opioid pain medication used to treat moderate to severe pain, with potential for abuse and dependence). Further observation revealed the medications that were left with the resident, without being observed as being taken, were: - Entresto (a medication used to treat heart failure) 49mg/51mg tablet; - Eliquis (a blood thinner used to reduce risk of stroke and blood clots) 5mg tablet; - Allopurinol (a medication used for gout and kidney stone prevention) 100mg tablet; - Florastor (a probiotic used to promote gut health) 250mg capsule; - Metoprolol succinate (a medication used to treat high blood pressure, heart failure, and to reduce heart rate) ER (extended release) 50mg tablet; - Jardiance (a medication that lowers blood sugar) 10mg tablet; - Eplerenone (a medication used to treat high blood pressure and/or heart failure) 25mg tablet; - Torsemide (a medication used to reduce fluid buildup in the body) 20mg tablet; and - Oxycodone (a federally controlled substance, opioid pain medication) 5mg tablet. During an interview on 5/7/25 at 11:00 AM, LN #4 stated, [Resident # 49] takes the medications [himself/herself]. [He/She] is very independent, so we don't stand over [him/her]. There is an order to leave the medication with [him/her]. During an interview on 5/7/25 at 2:55 PM, when asked if it was appropriate for the LN's to leave medication with the residents, the Director of Nursing (DON) stated there was, No medication the nurse should walk away from . The nurse should watch the resident swallow the medication. When asked to provide a medication self-administration assessment or a physician's order authorizing medications to be left with Resident #49, the facility was unable to provide either document. Record review of Resident #49's current care plan, undated, revealed no documentation of Resident #49 being able to self-administer his/her own medications. Record review of Resident #49's PHYSICIAN ORDERS FOR 05/07/2025, revealed no orders for self-administered medications. Review of the facility's policy Administering Medications, dated 11/6/23, revealed: Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. .

Based on observation and interview, the facility failed to ensure the medication error rate was below 5%. The medication error rate was 36%. 9 medication administration errors were identified, out of 25 opportunities, during medication administration observations. This failed practice placed the resident at risk for adverse medication effects. Findings: Record review on 5/7/25 revealed Resident #49 was admitted to the facility with diagnoses that included cellulitis of the right lower limb (a bacterial skin infection causing redness, swelling, and pain), other chronic pain, and arthritis of the right knee due to other bacteria (inflammation of the joints that causes pain, stiffness, and swelling). An observation on 5/7/25 at 9:00 AM, revealed Licensed Nurse(LN) #4 prepared and administered medications for Resident #49. LN #4 handed the resident a medication cup containing the following 9 medications: - Entresto (a medication used to treat heart failure) 49mg-51mg tablet; - Eliquis (a blood thinner used to reduce risk of stroke and blood clots) 5mg tablet; - Allopurinol (a medication used for gout and kidney stone prevention) 100mg tablet; - Florastor (a probiotic used to promote gut health) 250mg capsule; - Metoprolol succinate (a medication used to treat high blood pressure, heart failure, and to reduce heart rate) ER (extended release) 50mg tablet; - Jardiance (a medication that lowers blood sugar) 10mg tablet; - Eplerenone (a medication used to treat high blood pressure and/or heart failure) 25mg tablet; - Torsemide (a medication used to reduce fluid buildup in the body) 20mg tablet; and - Oxycodone (a federally controlled substance, opioid pain medication) 5mg tablet, as needed. LN #4 asked the resident to rate his/her pain level and then exited the room. LN #4 did not observe the resident to ensure he/she ingested the medications. During an interview on 5/7/25 at 11:00 AM, LN #4 stated, [Resident #49] takes the medications [himself/herself]. [He/She] is very independent, so we don't stand over [him/her] . There is an order to leave the medication with [him/her]. During an interview on 5/7/25 at 2:55 PM, when asked if it was appropriate for the LN's to leave medication with the residents, the Director of Nursing (DON) stated there was, No medication the nurse should walk away from and The nurse should watch the resident swallow the medication. When asked to provide a medication self-administration assessment or a physician's order authorizing medications to be left with Resident #49, the facility was unable to provide either document. Review of Resident #49's MEDICATION RECORD FOR 05/2025 revealed 4 medications (Entresto, Eliquis, Allopurinol, and Florastor) were recorded on 5/7/25 as administered at 8:00 AM, and the remaining 5 medications (Metoprolol, Jardiance, Eplerenone, Torsemide and Oxycodone 5mg) were recorded as administered at 9:00AM. Record review of the facility's policy Administering Medications, dated 11/6/23, revealed: .As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered. Review of the facility's policy Resident Self-Administration of Medications, dated 11/9/23, revealed: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so . .

Based on record review, observation, and interview, the facility failed to ensure residents' environment remains free of accident hazards. Specifically, the facility failed to ensure: 1) resident's room internal entryway was not obstructed for 1 resident (#40), out of 14 sampled residents; and 2) 1 exit door, out of 11 possible exit doors, was secured to prevent elopement of 6 residents (#'s 9, 1, 14, 20, 34, and 41), out of 53 residents (total census) who were at risk of wandering. This failed practice: 1) placed the resident at risk of delay in timely assistance in his/her room in emergency situations; and 2) placed residents who wandered at risk for unsafe situations if they eloped from the facility. Findings: Blocked Doorway Record review during 5/5-9/25 revealed Resident #40 was admitted to the facility with diagnoses that included anoxic brain damage (a brain injury that occurs when the brain is deprived of oxygen), and other reduced mobility. An observation on 5/5/25 at 2:58 PM, when this surveyor opened the door to Resident #40's room, revealed a Hoyer lift (a lift device designed to assist caregivers in safely transferring residents with limited mobility) was positioned on the opposite side of the door, which obstructed the room's door from opening fully. To access the room, this surveyor had to step over the Hoyer lift's legs and slide into the room sideways through the small space available. It was noted there were other open areas away from the entryway in the room where the lift could have been positioned. During an interview on 5/5/25 at 3:10PM, Certified Nurse Aide (CNA) #2 stated Resident #40 used a Hoyer lift to get into his/her wheelchair for a shower. During an interview on 5/9/25 at 10:25 AM, CNA #4 stated that when a Hoyer lift was needed inside of a resident's room, he/she would park it by the end of the resident's bed or in the bathroom, but never in front of the door as it could delay help in cases of emergency. During an interview on 5/8/25 at 9:31 AM, the Director of Nursing (DON) stated the resident doorways should have remained clear of obstruction because the resident's safety was a priority. Review of the facility's policy Safe Patient Movement and Handling, undated, revealed: . It is the duty of each employee to take reasonable care of their own health and safety as well as that of their co-workers and of patients during patient handling activities . Risk of elopement Review of the facility-provided list Wildflower Court Resident's at Risk for Elopement, date revised 4/24/25, revealed six residents (#'s 9, 1, 14, 20, 34, and 41) were listed with pictures. This list was available for the front desk staff to identify residents that may wander out of the main door. Random observations on 5/5-9/25 revealed Resident #41 was actively wandering around the facility. Record review on 5/5-9/25, Resident #41 was admitted to the facility with diagnosis of dementia (a decline in cognitive functioning including memory, thinking and reasoning). Review of Resident #41's physician's order, dated 11/22/24, revealed: Check Roam Alert Tag [a system that triggers an alarm when a resident approaches a monitored exit door] . Review of Resident #41's care plan, dated 4/9/25, revealed: . [Resident #41] is at risk for elopement . from anxiety, as evidenced by panic, exit seeking, pacing and trembling. [Resident #41] will remain safe within the facility. Review of the facility's reported incident (FRI) to the State of Alaska Health Facilities Licensing and Certification (HFLC) office, revealed Resident #41 eloped from the facility on 12/9/24 through a door going out of Cranberry Unit. Further review of the report revealed: .during the investigation it was found that the door the resident used to go out had a locking failure. An observation on 5/7/25 at 3:10 PM, revealed Resident #41, who was accompanied by Home Attendant (HA) #1, was going back to the [NAME] Unit, which was Resident #41's home unit. The staff stated he/she found Resident #41 in the main hallway by the Cranberry Unit. The Cranberry Unit is located on the opposite side of the of the facility away from the [NAME] Unit. An observation on 5/7/25 at 3:12 PM, revealed while CNA #1 demonstrated the operation of the wander guard alarm system on the [NAME] Unit's main door, Resident #41 wheeled himself/herself down the [NAME] hallway through the door that went into the Salmonberry Unit. No alarm/lock system was triggered. CNA #1 reported there was no alarm or locking system on the [NAME] door leading to Salmonberry, allowing residents to move freely throughout the two units. Further observation revealed Resident #41 wheeled himself/herself up to the front desk, which was by the building's main entrance. An observation and concurrent interview on 5/7/25 at 4:00 PM, revealed Licensed Nurse (LN) #7 accompanied the surveyor to inspect all exits when asked about the functionality of the wander guard alarm and locking system throughout the facility. During the inspection, it was noted that the door in the activity room kitchen lacked a wander guard locking or alarm system. LN #7 confirmed that the door had neither a locking system nor an alarm. Additionally, a no exit sign was observed above the door, which led to the outside. The door had a doorknob that could be opened from the kitchen, providing access to the outside. When asked if a resident with wander guard could exit through this door, LN #7 acknowledged this possibility and stated that it could be reported to the facility's maintenance team. During this observation, in the activity room, a piano session was in progress, with several residents listening to the music. Review of the attendance sheet of the piano session on 5/7/25, revealed Resident # 41 was on the list. Review of the facility's policy Wandering and elopements, dated 12/6/23, revealed checking the security of all exit doors was not included. .

Based on record review, observation, and interview, the facility failed to ensure 1 resident (#40), out of 14 sampled residents received quality care. Specifically,1) a Certified Nurse Aide (CNA #2) failed to follow 2 person assist during a transfer and toileting as specified in the comprehensive care plan; 2) CNA #2 did not safely handle the resident during transfer; and 3) the internal doorway to Resident #40's room was obstructed. This failed practice had the potential to place the resident at risk of injury and negatively impact the resident's physical health and well-being. Findings: Record review during 5/5-9/25 revealed Resident #40 was admitted to the facility with diagnoses that included anoxic brain damage (a brain injury that occurs when the brain is deprived of oxygen), and other reduced mobility. The resident also used ankle-foot orthoses (AFOs, devices designed to support the foot and ankle) to help him/her stand and perform transfers. Review of Resident #40's Care Plan, with a start date of 4/15/25, revealed: Approach . TRANSFERS: I need 2 PEOPLE to assist with my transfers. Sara Steady and 2-person extensive assist . TOILETING: I need 2 PEOPLE to assist with my toileting for using the flush toilet . An observation and concurrent interview on 5/5/25, at 2:58 PM, revealed upon entering Resident #40's room, a Hoyer lift (a lift device designed to assist caregivers in safely transferring residents with limited mobility) was obstructing the room's internal entryway. Also, Resident #40 was laying down in bed, with the head of the bed elevated to approximately 45 degrees and the upper quarter side rails were raised. A Sara Steady device was positioned by the side of the bed. CNA #2 was standing with his/her feet firmly planted, leaning forward while holding the resident by the wrists. The CNA then leaned backward and used a tugging motion to assist the resident up into a seated position as the resident simultaneously twisted toward the bed's edge, with his/her face briefly resting on the side rail. After achieving a seated position, CNA #2 released the resident's wrists. The resident then adjusted his/her position by slightly swinging both feet back and forth, which were fitted with AFOs, and scooted his/her bottom toward the Sara Steady. With the resident's feet positioned on the Sara Steady, CNA #2 assisted the resident with grasping the support bar, and the resident proceeded to stand. Further observation revealed CNA #2 transported the resident to the bathroom. Resident #40 was positioned in front of the toilet. The CNA took down the resident's brief, and the resident lowered himself/herself shakily down to the toilet with no assistance. Next, CNA #2 hung several wet wipes from the bar of the Sara Steady that was parked in front of the resident. Afterwards, CNA #2 closed the bathroom door partially and went to make the resident's bed. While making the bed, CNA #3 stuck his/her head in the room and told CNA #2 that the tub will be available for Resident #40 at 4:00 PM. Afterwards, CNA # 2 and #3 both left the room while the resident was still on the toilet. Outside in the hallway, CNA #2 stated Resident #40 was good about pulling the call light when he/she finished and went on to further explain how different locations in a resident's room will make a different alert noise based on different initiation of call lights. CNA #2 then went back into the room stating he/she needed to make the bed. During an interview on 5/8/25 at 9:31 AM, the Director of Nursing (DON) stated that CNA's were trained on transferring residents and lift devices during orientation. She further stated Resident #40 was a 2-person assist, and staff should never pull on residents while assisting them. In addition, resident doorways should remain clear because resident safety was a priority. During an interview on 5/9/25 at 10:25 AM, CNA #4 stated when a Hoyer lift was needed inside of a resident's room, he/she would park it by the end of the resident's bed or in the bathroom, but never in front of the door where it could block someone from coming in to help. CNA #4 further stated that Resident #40 was always a 2 person assist out of bed and to the toilet. Review of the facility's policy Safe Patient Movement and Handling, undated, revealed: . It is the duty of each employee to take reasonable care of their own health and safety as well as that of their co-workers and of patients during patient handling activities . .

Based on record review and interview, the facility failed to ensure 1 Certified Nurse Aide (CNA #1), out of 3 CNAs personnel file reviewed, had Cardiopulmonary Resuscitation (CPR) certificate before providing direct patient care. This failed practice had the potential to place all residents (based on a census of 53) at risk of not receiving CPR immediately during an emergency. Findings: Review of facility personnel files on [DATE] at 3:35 PM, revealed the Human Resources (HR) Manager stated CNA #1 was hired on [DATE]. Further review revealed CNA #1's personnel file did not contain a CPR certificate. During an interview on [DATE] at 4:20 PM, the HR Manager confirmed that CNA #1 had no CPR certificate since hire. The HR Manager explained that the CNA was enrolled in the CPR class, but the CNA did not complete the course. The HR Manager also added that the Staff Development Office should have followed up with the completion of the course. During an interview on [DATE] at 4:27 PM, when asked if the CNA was allowed to work on the floor without a CPR certificate, the HR Manager did not answer the question. Review of the facility's policy Emergency Procedure- Cardiopulmonary Resuscitation, dated [DATE], revealed: Policy statement [:] Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR). Review of the facility's policy Mandatory Education for All hospital Staff (that the HR Manager confirmed was applicable to Wildflower Court staff as well), dated [DATE], revealed: .F. Mandatory classes and competencies for clinical staff are.BLS (Basic Life Support) is required for all clinical employees providing direct patient care. Unit Assignments During an interview on [DATE] at 4:06 PM, the Assistant Director of Nursing (ADON) stated CNA #1 was assigned mostly to the [NAME] unit, but the CNA could be assigned to other units. The ADON further stated CNA #1 was assigned to different units during the orientation period from 9/2024 to [DATE]. A request was made to ADON for CNA #1's unit assignments since his/her hire date ([DATE]), along with the unit census for each assigned unit. This document was not provided at the end of the survey. .

Based on record review and interview, the facility failed to ensure the mandatory submission of staffing information based on payroll based journal (PBJ) data was submitted for the Fiscal Year (FY) Quarter 4 2023 (July 1 - September 30, 2023). This failed practice potentially denied residents and/or representatives (based on a census of 48), and the public, accurate staffing data when accessing the Nursing Home Compare website. Findings: Review on 2/12-16/23 of the facility's PBJ Staffing Data Reported, FY Quarter 2023 (July 1 - September 30), revealed the facility failed to submit data for the Quarter and had a one star staffing rating due to the failure to submit the data. During an interview on 2/15/24 at 3:50 PM, the Accounting Officer Controller stated the facility had missed the deadline to send the PBJ data for July 1 - September 30, 2023 due to the [NAME]/Wildflower transition (the facility had a change of ownership). Review of the facility's policy Wildflower Court Reporting Direct Care Staffing Information (Payroll-Based Journal), dated 11/12/23, revealed: .Direct care staffing information is submitted on the schedule specified by CMS [Centers for Medicare and Medicaid], but no less frequently than quarterly . Fiscal Quarter 4, date range: July 1-September 30, Submission Deadline: November 14 .

Based on record review and interview, the facility's pharmacy services failed to: 1) complete monthly drug regimen reviews (DRRs), from November 2023 to January 2024, by a licensed pharmacist for all residents (based on a census of 48); and 2) complete accurate DRRs for 2 residents (#'s 2 and 35), out of 14 sampled residents. This failed practice placed all residents (based on a census of 48) at risk for unnecessary medications, medication errors, and/or adverse reactions. Findings: Consistent Monthly DRRs Record review of the facility's contract agreement between the facility and Pharmacy #1, dated 1/1/23, revealed the pharmacy would: . provide the clinical services of a Registered Pharmacist and supply prescriptions in conformance with Federal and State regulations and the need of Wildflower Court patients, particularly as follows .: 1) Clinical Pharmacy Services . A pharmacist will review each patient's chart every month. The drug therapy will be evaluated for proper application and dosage for each patient. The review will be documented in the patient's record in accordance with State and Federal laws. Any potential or current improper drug utilization will be identified, and the proper health professionals will be consulted. Recommendations will be based on currently accepted drug therapy. These reviews will be conducted on the premises of Wildflower Court. A pharmacist will work directly with the nursing staff to [ensure] proper and continued usage of drugs . This agreement as signed by Pharmacist #3 on 12/28/23, through Power of Attorney authority from Pharmacy #1. Further review revealed an amendment the contract, dated 12/19/23, when Hospital #1 acquired the facility, to add standard terms and insurance requirements, however the agreed upon pharmacy services remained the same: This Agreement shall expire December 31, 2024 . Except as expressly modified herein, all other terms and provisions of the Agreement shall be and remain valid and enforceable by and between [Hospital #1] and [Pharmacy #1] . This amendment was signed by the owner of Pharmacy #1 on 11/16/23. Record review on 2/12-16/24 of 5 sampled resident records (#'s 2,13, 26, 35, and 39) revealed no DRRs after the October 2023 review that was completed in November 2023. During an interview on 2/15/24 at 2:50 PM, the Director of Nursing (DON) stated Pharmacist #3 had been consistently completing the facility's DRRs for the residents up until November 2023, however had resigned from Pharmacy #1 after the assessments for November were completed. The pharmacy had not sent over another Pharmacist to take over this contractual obligation, despite repeated attempts from the facility to request this, as part of the pharmacy services for the facility. As a result, no DRRs for any residents in the facility had been completed for the review periods of November 2023 through January 2024 (three months). During the course of the survey, Pharmacist #8, who worked for Hospital #1, came to the facility and completed DRRs for the months of November and December 2023 for all residents. Accurate DRRs Resident #2 Record review on 2/12-16/24 revealed Resident #2 was admitted to the facility with diagnoses that included depressive disorder and restless leg syndrome (a condition characterized by a nearly irresistible urge to move the legs). A review of Resident #2's active medication orders revealed an order for Diazepam [Valium - an anti-anxiety medication, which can be used to treat muscle spasms] 5 mg [milligrams] PO [by mouth] every HS [nighttime]. Further review revealed this medication was originally ordered on 6/11/18. A review of Resident #2's Physician's Orders, dated 1/6/23 through 2/16/24, revealed this Diazepam order had remained active all thirteen months. A review of Resident #2's DRRs, completed by Pharmacist #3, revealed there was an error on the assessment, dated 6/10/23 (for the May 2023 review), that indicated the Diazepam had been discontinued: . Diazepam 5mg at bedtime for restless legs - discontinued 6/1/23 . Further review revealed this assessment error remained on the DRRs for the review periods of June, July, August, September, and October 2023. A review of Resident #2's DRR, completed by Pharmacist #8 and dated 2/15/24 (for the December 2023 review), revealed the same assessment error. During an interview on 2/16/24 at 10:13 AM, Pharmacist #8 stated Resident #2's Diazepam medication should have been assessed as an active order on his December 2023 DDR. Resident #35 Record review on 2/12-16/24 revealed Resident #35 was admitted to the facility with diagnoses that included dementia and anxiety. Further review revealed Resident #35 was on palliative care (specialized medical care for people with a serious illness, the focus is on providing relief from the symptoms of the illness to improve quality of life). Review of Resident #35's MDS (Minimum Data Set - a federally required assessment) admission assessment, dated 11/15/24, revealed Resident #35 had a BIMS (Brief Interview for Mental Status) score was 3, which indicated severe cognitive impairment. Further review revealed Resident #35 had unclear speech, could make himself/herself understood sometimes, and could have understood others sometimes. Review of Resident #35's medication orders, dated 1/2/24, revealed the following four Morphine PRN orders: 1. Morphine concentrate 100mg [milligrams]/5mL [milliliter] [meaning 5 mL of liquid Morphine equaled 100mg] (20mg/mL) [meaning 1 mL of liquid Morphine equaled a 20mg dose] oral solution - 0.25 ml by mouth every 1 hour as needed for pain, pain scale 6-10/10 [pain scale 0 to 10, for any pain rated at a 6 or up to 10]. Titrate up for comfort . 2. Morphine concentrate 100mg/5mL (20mg/mL) oral solution - 0.5 ml by mouth every 1 hour as needed for pain, pain scale 6-10/10 [pain scale 0 to 10, for any pain rated at a 6 or up to 10]. Titrate up for comfort . 3. Morphine concentrate 100mg/5mL (20mg/mL) oral solution - 0.75 ml by mouth every 1 hour as needed for pain, pain scale 6-10/10 [pain scale 0 to 10, for any pain rated at a 6 or up to 10]. Titrate up for comfort . and 4. Morphine concentrate 100mg/5mL (20mg/mL) oral solution - 1 ml by mouth every 1 hour as needed for pain, pain scale 6-10/10 [pain scale 0 to 10, for any pain rated at a 6 or up to 10]. Titrate up for comfort . Further review revealed each Morphine PRN order had identical parameters, with the same pain scale rating. Review of Resident #35's DRR, dated 2/15/24 (for the December 2023 review), revealed Pharmacist #8 identified four different Morphine orders on the medication list: .Morphine concentrate 100mg/5 mL (20 mg/mL) oral solution [generic]; [Physician #4] Morphine concentrate 100mg/5 mL (20 mg/mL) oral solution [generic]; [Physician #4] Morphine concentrate 100mg/5 mL (20 mg/mL) oral solution [generic]; [Physician #4] Morphine concentrate 100mg/5 mL (20 mg/mL) oral solution [generic]; [Physician #4] . Further review revealed No new concerns at this time was documented at the bottom of the DRR. During an interview on 2/15/24 at 3:04 PM, the DON and Assistant Director of Nursing (ADON) both stated Resident #35's Morphine orders were not appropriate as written. The DON stated if there were multiple orders of the same medication, there needed to be very clear parameters to indicate which medication dose was to be given and when. During an interview on 2/16/24 at 10:04 AM, Pharmacist #8 stated Resident #35's Morphine as needed orders should have had a parameter specific to each dose order and should not have had all the same parameters. Pharmacist #8 further stated this concern should have been documented on the December 2023 DRR. Review of the facility's policy Medication Regimen Reviews, dated 5/2019, revealed: . The consultant pharmacist performs a medication regimen review (MRR) [DRR] for every resident in the facility receiving medications. Medication reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated . The consultant pharmacist provides the director of nursing services and medical director with a written, signed and dated copy of all medication regimen reports . 43792

Based on record review, observation, and interview, the facility's pharmacy services failed to meet the obligations of its contract agreement. Specifically, pharmacy services failed to: 1) provide accurate pharmaceutical services to assure the accurate dispensing of drugs; and 2) provide consultation on aspects of the provision of pharmacy services in the facility. These failed practices placed all residents (based on a census of 48) at risk for receiving improper pharmaceutical services and the potential for medication errors and/or adverse reactions. Findings: Record review of the facility's contract agreement between the facility and Pharmacy #1, the pharmacy services for the facility, dated 1/1/23, revealed the pharmacy would: . provide the clinical services of a Registered Pharmacist and supply prescriptions in conformance with Federal and State regulations and the need of Wildflower Court patients, particularly as follows .: 1) Clinical Pharmacy Services . A pharmacist will be available for consultation on any drug therapy for the Medical Director and nursing staff at a regularly scheduled day and time for each week. If the need of a pharmacist arises at a time other than the scheduled time, a pharmacist can be reached by phone . during store hours . and 2) Supply of Prescriptions . [Pharmacy #1] will stock and provide the medications in Unit Dose [individual daily dose] sizes for the care center patients . This agreement as signed by Pharmacist #3 on 12/28/23, through Power of Attorney authority from Pharmacy #1. Further review revealed an amendment of the contract, dated 12/19/23, when Hospital #1 acquired the facility, to add standard terms and insurance requirements, however the agreed upon pharmacy services remained the same: This Agreement shall expire December 31, 2024 . Except as expressly modified herein, all other terms and provisions of the Agreement shall be and remain valid and enforceable by and between [Hospital #1] and [Pharmacy #1] . This amendment was signed by the owner of Pharmacy #1 on 11/16/23. An observation on 2/15/24 at 10:21 AM, revealed a pre-packed, individual dose bubble pack card of the medication Warfarin (an anticoagulant medication that thins the blood) for Resident #42. The medication order read: Warfarin Sodium 2 mg [milligram] tabs [tablets]. Take 1 tablet by mouth once daily for Afib [atrial fibrillations, an irregular, often rapid hear rate that commonly causes poor blood flow]. The bubble pack had multiple clear bubbles with one tablet in each, which was the individual dose ordered. Further review revealed that bubble #12 of the card had a half tablet, instead of a whole tablet. This would have been half the ordered dose, which was a dispensing error made by the pharmacy. During an interview on 2/15/24 at 2:50 PM, the Director of Nursing (DON) stated that the facility had been having issues with the pharmacy's services since 1/2024. When informed of the medication error found in Resident #42's Warfarin medication, the DON stated medication dispensing errors had been an identified concern lately and they have had to send back about 15 bubble pack cards of medication due to either medication errors or the pharmacy was filling medication that had already been discontinued. The DON stated the facility had made several attempts to contact the owner of Pharmacy #1 to discuss these concerns, but the pharmacy had not responded back despite multiple email attempts and phone texts. When asked for an accounting of the facility's attempts to contact Pharmacy #1 about the dispensing errors and the need for pharmacy services consultation, the DON provided the following: - 1/11/24: The wrong dose on the medication label of a bubble pack card was written, this was sent back and relabeled. - 1/16/24: Left a message for the owner about coming to the facility to conduct monthly medication regimen reviews. - 1/23/24: Wrong medication sent, sent back card because the medication had been discontinued. - 1/31/24: Left a text message for the owner for a call back. Got a message back that the owner would call back that day or the next. This never happened. - 2/7/24: Multiple bubble pack cards were sent to the facility, these medications were discontinued and had to be returned. Sent another text message stating the facility was having major issues with the pharmacy services and needed a call back as soon as possible. The DON received a text message back that the owner would call after 5:00 PM. The owner never called. Review of the facility's policy Accepting Delivery of Medications, dated 11/6/23, revealed: . If an error is identified when receiving medication from the pharmacy, the nurse verifying the order . informs the deliver agent of any discrepancies and notes them . returns the incorrect medications . to the dispensing pharmacy . The dispensing pharmacy, consultant pharmacist, and director of nursing services are notified of medication order errors .

Based on record review and interview, the facility failed to ensure the resident's, or the resident representative's, right to be informed of the risks and benefits of proposed care of psychoactive medication (a medication that can alter perception, mood, or behavior) administration was documented for 2 residents (#'s 2 and 35), out of 14 sampled residents. This failed practice had the potential to violate the resident's, or resident representative's, right to be informed of treatment and treatment alternatives or treatment options and to choose the alternative or option he/she preferred. Findings: Resident #2 Record review on 2/12-16/24 revealed Resident #2 was admitted to the facility with diagnoses that included depressive disorder and restless leg syndrome (a condition characterized by a nearly irresistible urge to move the legs). A review of Resident #2's active medication orders revealed an order for Diazepam [Valium - an anti-anxiety medication, which can be used to treat muscle spasms] 5 mg [milligrams] PO [by mouth] every HS [nighttime]. Further review revealed this medication was originally ordered on 6/11/18. A review of Resident #2's Physician's Orders, dated 1/6/23 through 2/16/24, revealed this Diazepam order had remained active all thirteen months. Review of Resident #2's medical record revealed no Informed Consent for the use of Psychoactive Medication for Diazepam, which would have informed the resident of the risks and benefits of using the medication. During an interview on 2/16/24 at 10:13 AM, Pharmacist #8 stated Resident #2 should have had an informed consent form completed for Diazepam. During an interview on 2/16/24 at 10:50 AM, the Director of Nursing stated there was no informed consent form for Diazepam in Resident #2's medical record. Resident #35 Record review on 2/12-16/24 revealed Resident #35 was admitted to the facility with diagnoses that included dementia and anxiety. Further review revealed Resident #35 had a resident representative through Power of Attorney paperwork. A review of Resident #35's active medication orders revealed two past orders for Lorazepam (Ativan - a sedative medication, which can be used to treat anxiety): 1. Lorazepam 2mg/mL oral concentrate - 0.5mg by mouth every 4 hours as needed for anxiety/agitation and 2. Lorazepam 2mg/mL oral concentrate - 1 mg by mouth every 4 hours as needed for anxiety/agitation Further review revealed this medication was originally ordered on 11/10/23 and was documented on the Physicians Orders on 12/4/23, however was not documented after this. There was no official discontinuation order for Lorazepam. Review of Resident #35's medical record revealed no Informed Consent for the use of Psychoactive Medication for Lorazepam, which would have informed the resident representative of the risks and benefits of using the medication. During an interview on 2/16/24 at 10:04 AM, Pharmacist #8 stated Resident #35 should have had an informed consent form completed for Lorazepam. During an interview on 2/16/24 at 10:50 AM, the Director of Nursing stated there was no informed consent form for Lorazepam in Resident #35's medical record. Review of the facility's policy Resident Rights, dated 11/10/23, revealed: . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . be informed of, and participate in, his or her care planning and treatment .

Based on record review, interview and observation, the facility failed to ensure; 1) the interventions put in place to protect 1 resident (#35) from harm during unsafe wandering were evaluated for effectiveness to prevent future harm; 2) residents who smoked were evaluated for safety; specifically, 1 resident (#29) was observed to smoke without a smoking apron, and 2 residents (#6 and #38) who smoked were not assessed for safety; and 3) residents who were at risk for elopement (#8 and #38) were monitored for safety. These failed practices placed 7 residents identified to wander, and 3 residents who smoked, and may have needed increased supervision, at risk for avoidable accidents and potential harm. Findings: Unsafe wandering: Record review on 8/15-26/21 revealed Resident #35 was admitted to the facility with diagnoses that included dementia and [CONDITION(S)]. Record review on 8/15-26/21 revealed Resident #52 was admitted to the facility with diagnoses that included dementia and hypertension (high blood pressure). During an interview on 8/17/21 at 10:46 am, when asked about any incidents that may have occurred with other residents, Resident #35's Power of Attorney (POA) stated that he/she was contacted after Resident #35 had wandered into Resident #52's room. Resident #52 had his/her hand on Resident #35's chest. The POA stated this happened twice, but not since an alarm was placed on both Resident's doors. The POA further stated Resident #52 was blind and he/she walked along the walls of the facility. If a door was open, Resident #52 had been known to wander into those rooms. An observation on 8/15/21 at 5:00 pm revealed Resident #52 had a door (tab) alarm device attached to the outside of his/her doorframe, the clip that connected the alarm was not attached to the Resident's opened door, therefore the door alarm was not engaged to alarm if Resident #52 wandered out or if Resident #35 wandered in. An observation on 8/19/21 at 9:58 am revealed Resident #35 napping in his/her bedroom. The Resident's door was slightly opened, and the alarm was not engaged to sound if Resident #52 wandered in. Record review on 8/18/21 at 1:21 pm of the facility's investigation of the unsafe wandering incident, dated 5/20/21, revealed Incident Summary: Residents were found in the room of [Resident #52]. [Resident #35] was standing next to the bed where [Resident #52] was sitting. [He/She] was fondling [his/her] genital area through [his/her] clothing. Further review revealed Interventions Implemented: Care plans have been reviewed and reflect interventions. Review of Resident #35's Care Plan, dated 7/2/21, revealed [Resident #35] and others will not experience harm from wandering behavior .Residents who appear triggered to react to [Resident #35's] wandering include [Resident #23 and Resident #36]. Ensure there is distance between residents and intervene calmly when necessary to ensure safety, separate and redirect. Report occurrences per protocol. There was no guidance or direction documented to keep Resident #35 separated from Resident #52. Further review revealed Tabs alarm on the outside of resident's door. Leave resident's door open when sleeping for rounds. During an interview on 8/19/21 at 9:47 am, when asked about the unsafe wandering incident between the Residents, Certified Nursing Assistant (CNA) #13 stated that the incident happened yesterday (8/18/21) and he/she removed Resident #35 from Resident #52's room. CNA #13 stated Resident #52's door was opened, and the tab alarm was not engaged. The CNA further stated Resident #35 was standing near the bed area trying to fix the bed, while Resident #52 was seated near the head of the bed. When asked about the incident that occurred in May, CNA #13 stated he/she was not aware of that incident. When asked how staff kept Resident #35 out of Resident #52's room, CNA #13 stated staff kept the door closed or kept the tab alarm on the door. The CNA further stated that if Resident #52's door is left open, Resident #35 would wander in. When asked about reporting Resident #35 being found near the bed area in Resident #52's room, CNA #13 stated staff did not have to report this, that the Residents would just be monitored. Record review of Resident #35's nurse's notes, dated 8/18/21, revealed no documentation of Resident #35 wandering into Resident #52's room. During a follow up interview on 8/19/21 at 11:34 am, when asked if a notation was made in the Resident's chart to alert staff to the Resident's unsafe wandering, CNA #13 stated he/she did not document the incident. During an interview on 8/19/21 at 11:51 am, Licensed Nurse (LN) #5 stated both Residents had tab alarms on their door for protection and would have alerted staff that Resident #52 was on the move. LN #5 further stated that Resident #35 had wandered into Resident #52's room, but staff was alerted by the tab alarm. The LN further stated he/she was not aware of any unsafe incidents since the tab alarm was put in place. When asked how he/she evaluated whether the interventions to keep the Residents safe were working, LN #5 stated the interventions would have been evaluated if there were a near miss event (an event that had the potential to cause harm). When asked if the CNAs were to report unsafe wandering incidents, the LN stated the expectation was the nursing staff would have been alerted right away. On 8/19/21 at 2:45 pm, the Facility Administrator (FA) was notified of Immediate Jeopardy (IJ). The facility submitted a removal plan and the State agency determined the immediacy was removed on 8/19/21 at 4:30 pm prior to the survey exit. Following the removal of the immediacy, noncompliance remained at no actual harm with potential for more than minimal harm. During an interview on 8/25/21 at 10:13 am, when asked how the facility monitored the effectiveness of the Resident's care plan interventions, the Director of Nursing (DON) stated the facility relied on the staff to let her know if the interventions were not effective. Review on 8/25/21 at 8:47 am of Nurse Aide Qualifications and Training Requirements, revised 5/2019, revealed staff receive training regarding resident's right to be free from abuse/neglect and mistreatment and to report instances to appropriate facility staff. Review on 8/25/21 at 8:43 am of Departmental Supervision, revised 4/2006, revealed The director of nursing services and/or the nurse supervisor/charge nurse, as a minimum, is responsible for .reviewing individual resident care plans for appropriate goals, problems, approaches, and revisions based on nursing needs; assuring that the resident's plan of care is being followed . Smoking: Resident # 29 Review on 8/15-26/21 of Resident #29's medical record revealed the Resident was admitted with diagnoses that included head injury, adult failure to thrive, [CONDITION(S)] (weakness on one side of the body), [CONDITION(S)] (altered speech), dementia without behavior disturbance, [MEDICATION(S)] dependence, cannabis abuse, and mouth cancer. Resident #29's BIMS was recorded at 15 on 6/20/2021. A score of 15 indicated the Resident had intact cognition. Review on 8/15/21 at 4:00 pm of the facility's Information for Residents & Families of Wildflower Court, updated 7/3/21, revealed Smoking: Wildflower Court is a non-smoking facility. Smokers prior to April 1, 2012 are grandfathered in & may use the designated area outside of Cranberry home dining area until further notice . Review of facility's list of residents who smoke on 8/15/21 at 4:00 pm, revealed the facility identified one smoker (Resident #29). Review on 8/19/21 at 9:40 am of Resident #29's Care Plan revealed he/she was grandfathered in and allowed to continue to smoke. A smoking assessment dated [DATE] revealed Resident #29 wore a smoking apron and was able to smoke independently. During an interview on 8/18/21 at 10:16 am, Resident #29 stated he/she kept his/her smoking material including his/her lighter in his/her pocket and went outside to smoke by himself/herself. During an interview on 8/18/21 at 9:50 am, CNA #10 stated that there was one smoker in the home and the Resident was grandfathered in when facility became nonsmoking facility. CNA #10 further stated Resident #29 kept his/her smoking material with him/her. CNA #10 stated he/she was not aware of any rules surrounding smoking. During an interview on 8/18/21 at 10:12 am, CNA #7 stated there were two smokers in the facility that used the door providing access to smoking area. CNA #7 identified Resident #29 and Resident #6. CNA #7 stated the Residents always smoked together, and they were independent. CNA #7 added that he/she did not need to provide the residents who smoked any supervision. During an interview on 8/18/21 at 10:18 am, CNA #6 stated there were two smokers in the home, Resident #29 and Resident #6. The Residents smoked together in the designated smoking area. CNA #6 further stated Resident #29 kept his/her own cigarettes, but Resident #6 did not have any cigarettes in his/her possession. The CNA stated Resident #29 provided cigarettes to Resident #6. During an interview on 8/18/21 at 1:15 pm, when asked how many smokers were in the facility LN #1 replied two, and stated they were independent, and did not require supervision. An observation on 8/18/21 at 1:34 pm, revealed Resident #29 was smoking in the facility's smoking area and the Resident was observed not to be wearing a smoking apron. Resident #6 Record Review on 8/15-26/21 revealed Resident #6 was admitted to the facility with diagnoses that included long standing cognitive dysfunction, [CONDITION(S)] (a violent blow or jolt to the head causing temporary or permanent [CONDITION(S)]), and [CONDITION(S)]. Resident #6's Brief Interview for Mental Status (BIMS) was 10. A score of 10 indicated the Resident had moderately impaired cognition. Further review of the medical record on 8/15/21 at 4:40 pm, revealed no smoking safety assessment evaluation found in Resident #6's chart. Review of the facility's Interim COVID-19 Smoking Policy-Residents, revised 6/10/20, revealed 14. Residents are not permitted to give smoking articles to other residents. During an interview on 8/18/21 at 5:00 pm, the Facility Administrator (FA) and the DON stated they were not aware that Resident #6 smoked. Resident #38 Review on 8/15-26/21 revealed Resident #38 was admitted to the facility with diagnoses that included Wernicke's [CONDITION(S)] (disorder that primarily affects the memory system in the brain), mild cognitive impairment, adult Failure to thrive, ataxia (loss of muscle coordination, unsteady gait), and alcohol dependence. The Resident's Brief Interview for Mental Status (BIMS) was 11. A score of 11 indicated the Resident had moderately impaired cognition. An observation on 8/15/21 at 2:59 pm revealed a half-rolled cigarette that appeared to be marijuana laid on Resident #38's overbed table next to the bed. During an interview on 8/16/21 at 2:47 pm, when asked if he/she smoked, Resident #38 confirmed that he/she smoked marijuana. Resident # 38 also stated he/she would go out to the facility's smoking area to smoke. Resident #38 added that someone took his/her lighter and that he/she would need to buy a new one. An observation on 8/18/21 at 1:29 pm, revealed a cigarette and a half-cigarette, that appeared to be marijuana with a burnt tip, laid on Resident #38's overbed table next to the bed. Record review revealed no safety smoking assessment completed for Resident #38. Review of the facility's Interim COVID-19 Smoking Policy-Residents, revised date 6/10/20, revealed 15. Residents without smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision . On 8/18/21 at 5:00 pm, the Facility Administrator (FA) was notified of Immediate Jeopardy (IJ). The facility submitted a removal plan and the State agency determined the immediacy was removed on 8/19/21 at 4:30 pm. Following the removal of the immediacy, noncompliance remained at no actual harm with potential for more than minimal harm. Elopement Resident #38 Review on 8/15-26/21 revealed Resident #38 was admitted to the facility with diagnoses that included Wernicke's [CONDITION(S)], mild cognitive impairment, adult failure to thrive, ataxia, and alcohol dependence. Resident's Brief Interview for Mental Status (BIMS) was 11. An observation on 8/16/21 at 3:01 pm, revealed Resident #38 was wearing a wander guard bracelet (a device that is designed to alert a facility when a resident made an unauthorized attempt to leave a facility's premises) on his/her left ankle. During an interview on 8/16/21 at 3:02 pm, Resident #38 stated that he/she was wearing an ankle bracelet so I can't escape. During an interview on 8/18/21 at 1:23 pm, LN #4 stated Resident #23 was at risk for elopement. LN#4 further stated Residents (#35, 38, 40 and 47) wander around the facility. When asked how to identify residents who wander, LN #4 stated there was a list with residents' names and pictures. When questioned about how the wander guard bracelet worked, LN #4 stated when residents would try to open the door, it would lock, and the alarm would be triggered. LN #4 stated the locking system should have been on every door of the facility. LN #4 added that the devices (Wander Guard bracelet) were tested every week and the test results were documented in the eTAR (electronic treatment records) of each resident. Review on 8/18/21 at 1:35 pm of Resident #38's ID [Interdisciplinary] Notes dated 7/10/21 at 4:12 pm revealed the installation of the Securaband (Trademark) Tag [wander guard] .Power of Attorney (POA) has given this nurse verbal permission to attach a watch that controls access in/out of the building to put on resident to make sure [he/she] stays safe and does not elope without assistance. POA .will sign the paper at [his/her] earliest ability, likely after current visit . Further review of an entry on 7/19/21 at 4:20 pm revealed Resident eloped facility between 10:30-11:00 this morning. Notified POA, family, JPD ([NAME] Police Department). DON (Director of Nursing) and Administrator found resident at Triangle Club [bar]. Returned to facility at approx. 1400 [2:00pm] . Review of Resident #38's medical record on 8/18/21 at 1:50 pm, revealed no record that wander guard bracelet had been tested and no documentation of the wander guard bracelet on Resident #38's care plan. During an interview with the Director of Facility (DOF) on 8/18/21 at 2:21 pm, he/she stated there was a wander guard device detector on all doors of the facility. The DOF further stated due to an issue with employee card access, the main entrance detector was deactivated to not alarm if a Resident with a wander guard tried to exit. When asked when the system was deactivated, the DOF stated around the beginning of COVID-19. During an interview on 8/18/21 at 2:21 pm, Maintenance Manager (MM) confirmed that the Wander Alert device at the front door was deactivated following issue with employee cards. He/she also stated facility maintenance team tested the doors every month and the Nursing Staff were responsible for testing the battery once the Securaband (Wanderguard) Tag was placed on the residents. During a follow-up interview on 8/18/21 at 3:06 pm, LN #4, was asked when the last test was conducted for the Securaband Tag for Resident #38. LN #4 confirmed that today (8/18/21) was the first day it was tested since the installation on 7/10/21. LN #4 further stated that the device was working correctly but could not confirm where to find and/or chart the device's expiration date. During an interview on 8/18/21 at 3:24 pm, the DON stated there was no written policies concerning the Securaband Tag. When asked how the staff would know the expectation related to the Securaband Tag care, he/she stated it is expected that staff knew to add the information on care plan and would test it weekly. When the investigation documentation from the July's elopement was requested, the DON stated no investigation was conducted by the facility because the police were involved, and the facility took care of it. The facility did not report the incident to State Agency. Resident #8 Review on 8/15-26/21 revealed Resident #8 was admitted to the facility with diagnosis that included unspecified intellectual disabilities. Resident's Brief Interview for Mental Status (BIMS) was 15. Review on 8/18/21 at 10:58 am of the facility's posting of residents at elopement risk, revealed Residents #35, #40, #47, #32, #38 and #32 were listed. Resident #8 was not included on the list. During an interview on 8/18/21 at 1:15 pm, LN #1 stated that Resident #8 left the facility during the night last week and was found outside near the hospital area. During an interview on 8/18/21 at 2:01 pm, when asked about the incident report concerning elopement of Resident #8, the DON stated he/she was not informed about Resident #8's elopement. Consequently, it had not been investigated and not reported to the Survey Agency. The DON provided a copy of the ID (Interdisciplinary) Notes dated 8/12/21 at 3:35 am. The DON further stated that the LN did not finish his/her charting and that the note was still in progress. Review on 8/18/21 at 2:05 pm of Resident #8's ID (Interdisciplinary) Notes, dated 8/12/21 at 3:35 am, revealed . @ around 2200 [10:00pm], resident came out of [his/her] room again and without knowing [resident] came out of the side door. One of the [CNAs] saw [resident] out and immediately ran after her/him but resident was so fast. CNA finally got [resident] when resident almost [at] hospital area. CNA reported that resident refused to come back . resident back to unit unharmed. Encouraged staff to make sure doors are locked since the resident is now at risk of elopement. During an interview on 8/18/21 at 1:13 pm, Administrative Assistant (AA) stated that he/she was aware of 6 residents at risk of elopement. The AA showed the document with the pictures of the 6 residents at risk of elopement. Further review revealed Resident #8 was not included on the document. When questioned on Wander Guard system, the AA stated that he/she was not aware of any residents who were wearing the wander guard. Review on 8/19/21 at 10:45 am of the facility's Incident log-Fall/Skin/General-Medication error-Abuse/Neglect-Elopement for the timeframe 1/1/2020-8/18/2021, revealed no entry concerning Resident #8's elopement. Review of Abuse /Neglect log, for the timeframe of 2019 to current, revealed no entry about Resident #8. Review on 8/19/21 at 10:45 am of Resident #8's Care Plan revealed no documentation of elopement risk on the Resident's Care Plan and no elopement risk assessment was completed. On 8/18/21 at 5:00 pm, the FA was notified of Immediate Jeopardy (IJ). The facility submitted a removal plan that was accepted by the State Agency but was not fully implemented. The State Agency conducted an onsite verification of removal plan and determined the immediacy was removed on 8/25/21 at 10:00 am. Following the removal of the immediacy, noncompliance remained at no actual harm with potential for more than minimal harm.

Based on observation, interview, and record review the facility failed to ensure staff had the knowledge of the chlorine sanitation process for the low temperature dishwasher and failed to implement a policy that stated the appropriate color or the expected parts per million (ppm) of the chlorine test strips they used daily. These failed practices had the potential to affect all residents with food borne illness. Findings: Observation on 8/6/13 at 9:40 am during a revisit for the plan of correction for the recertification survey conducted 6/15-18/13, revealed Kitchen Staff (KS) #1 testing the concentration of sanitation of the dishwasher. The Ecolab chlorine color strip revealed a 25 ppm (parts per million) concentration of bleach. When asked what the chlorine concentration should be KS #1 pointed to the color chart for the test strip and stated "it was good." Observation on 8/6/13 at 10:25 am Maintenance Staff (MS) #1, tested the sanitation of the dishwasher using the Ecolab test strip and it revealed there was 0 ppm of chlorine in the water. When the surveyor asked what level of chlorine should be in the water? He stated, he was not sure. During an interview on 8/6/13 at 10:30 am the Administrator stated the staff education for sanitation testing had been done by MS #1 because the DM has just returned from leave. During interviews on 8/6/13 at 9:50 am the DM was asked what the chlorine concentration should be for dish sanitation and he stated "100 ppm." In addition, the manager stated they had run out of the chlorine test strips and were currently using the wrong test strips to test for sanitation. Review of the facility policy "Procedures for washing dishes" dated 1/29/13 provided by the Dietary Manager on 8/6/13, revealed "Midway thru the rinse cycle open door, dip test strip into the rinse waster and match test strip against the color chart." The policy did not specify the correct color to match the chlorine strip to or the ppm of chlorine needed for dish sanitation. During an interview on 8/6/13 at 11:30 am the Ecolab lab technician stated the staff was testing the chlorine at the wrong time during the dishwashing cycle. Based on the "U.S. Public Health Service Food Code 2009" revealed, "After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: ...A contact time of at least 7 seconds for a chlorine solution of 50 mg/L (ppm)..." During the onsite revisit the kitchen staff, dietary manager, and the maintenance staff who did the training for dishwashing sanitation revealed they were not knowledgeable in the concentration of chlorine needed to meet sanitation for the low temperature dishwasher. In addition, the facility's policy and procedure for chlorine testing for the low temp dishwasher did not include the testing method the facility staff were using. .