Every finding on record at Wrangell Medical Center LTC

.Based on record review and interview, the facility failed to update and revise a care plan for 1 resident (#5), out of 8 sampled residents. Specifically, the facility failed to revise Resident #5's care plan to reflect a new diagnosis of post-traumatic stress disorder (PTSD). This failed practice placed the resident at risk for not receiving appropriate care and services to maintain the resident's highest practicable mental, physical, and psychosocial well-being. Findings: Record review on 3/9-12/26 revealed Resident #5 was admitted to the facility with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body) following a cerebral infarction (when a blood vessel in the brain becomes blocked, cutting off blood and oxygen to that area, which cause brain tissue death).Further review revealed Resident #5 had a diagnosis, first entered on 9/10/25, of: Chronic post-traumatic stress disorder (PTSD). A second diagnosis of: PTSD (post traumatic stress disorder) was later entered on 2/25/26.Review of the MDS (Minimum Data Set, a federally required nursing assessment) quarterly assessment, dated 12/8/25, revealed: . Active Diagnoses. Post-traumatic stress disorder, chronic. This active diagnosis remained on all subsequent assessments after. Review of Resident #5's quarterly, LTC Care Conference. notes from 9/24/25, 12/25/25, and 3/9/26, revealed no discussion of the resident's PTSD diagnosis. Review of Resident #5's Care Plan, last reviewed 3/5/26, did not show a problem, outcomes, or interventions addressing the resident's PTSD.During an interview on 3/11/26 at 11:45 AM, Resident #5 stated loud noises, such as when doors were slammed or when the snow removal machine was outside of his/her room, and the bucket was hit against the ground, the noise brought back memories of . mortar shells exploding. or . rockets going off back from the war .During an interview on 3/11/26 at 2:55 PM, the Director of Nursing (DON) stated she was unaware of Resident #5's specific PTSD triggers. The DON confirmed the diagnosis should have been incorporated into the care plan and pointed out that the resident was receiving services related to PTSD.Review of the facility provided policy, Care Planning, last reviewed on 7/22/25, revealed: Care plans will incorporate the resident's goals, preferences. and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change.

.Based on record review, interview, and observation, the facility failed to provide pharmaceutical services, that included procedures to ensure 1 resident (Resident #3) of 8 sampled residents, consistently received ordered insulin as prescribed. Specifically, the facility did not ensure Resident #3 received the prescribed mealtime sliding scale insulin on 74 occasions between 10/3/25 and 3/11/26. This deficient practice placed the resident at risk for uncontrolled blood glucose and related complications.Findings: Resident #3 Record review on 3/9-12/26 revealed Resident #3 was admitted with diagnoses that included diabetes mellitus (a chronic metabolic disorder characterized by elevated blood glucose levels due to impaired insulin production or utilization), mild dementia, and anemia. Review of Resident #3's Care Plan, last reviewed on 3/5/26, revealed: .Medication Management. I require medication management daily for various health conditions. I will be provided with medications as ordered. Encourage [Resident #3] to take medication. I have a medical dx [diagnosis] of DMII [diabetes mellitus type 2] with other complications. Diabetes medication as ordered by doctor.During an interview on 3/12/26 at 8:30 AM, Resident #3 stated, My insulin is very important. I expect to be woken up when I'm supposed to have it. An observation on 3/11/26 at 8:20 AM revealed Licensed Nurse (LN) #1 withheld Resident #3's morning dose of insulin. LN #1 stated the facility's process was to document the medication as not administered when the resident was sleeping. LN #1 further stated there was a communication order written by the physician permitting medications to be held if the resident was asleep. LN #1 attempted to locate the referenced communication order in the electronic health record (EHR) but was unable to produce documentation supporting this statement. Review of Resident #3's physician orders revealed: .Insulin Aspart Pen [novoLOG FLEXPEN] See Dose Instructions SQ [subcutaneous] AC [after meals]. Dose Instruction. Inject per sliding scale if: 151-200 = 4 units. 201-250 = 6 units. 251-300 = 8 units. 301-350 = 10 units. 351-400 = 12 units. 401-500 = 14 units. Review of Resident #3's medication administration record (MAR) from 10/3/25-3/9/26 revealed:72 missed insulin administrations with documented rationale of Patient Asleep;2 missed insulin administrations with documented rationale of Nursing Judgement. Review of the blood glucose records, from 10/3/25 to 3/9/26, in relation to the 74 missed insulin opportunities, revealed the resident experienced elevated blood glucose levels during the period the insulin doses were not administered: 10/3/25, 5:07 PM - blood glucose 164;10/6/25, 5:05 PM - blood glucose 153;10/8/25, 9:13 AM - blood glucose 201;10/15/25, 5:23 PM - blood glucose 225;10/19/25, 11:49 AM - blood glucose 191;10/19/25, 4:35 PM - blood glucose 155;10/27/25, 11:27 AM - blood glucose 198;10/28/25, 11:30 AM - blood glucose 201;10/31/25, 11:26 AM - blood glucose 240;11/14/25, 9:13 AM - blood glucose 183;11/14/25, 11:27 AM - blood glucose 179;11/15/25, 8:01 AM - blood glucose 195;11/15/25, 5:10 PM - blood glucose 231;11/16/25, 11:28 AM - blood glucose 189;11/22/25, 11:18 AM - blood glucose 168;11/23/25, 11:27 AM - blood glucose 205;11/23/25, 5:14 PM - blood glucose 212;12/3/25, 5:15 PM - blood glucose 215;12/4/25, 5:07 PM - blood glucose 237;12/5/25, 5:05 PM - blood glucose 192;12/10/25, 12:57 PM - blood glucose 231;12/13/25, 10:55 AM - blood glucose 177;12/14/25, 9:00 AM - blood glucose 177;12/16/25, 4:42 PM - blood glucose 181;12/17/25, 11:26 AM - blood glucose 176;12/19/25, 7:29 AM - blood glucose 165;12/19/25, 11:19 AM - blood glucose 196;12/19/25, 5:21 PM - blood glucose 220;12/20/25, 11:07 AM - blood glucose 169;12/20/25, 4:56 PM - blood glucose 179;12/21/25, 10:59 AM - blood glucose 162;12/21/25, 5:24 PM - blood glucose 169;12/27/25, 5:01 PM - blood glucose 166;12/28/25, 11:23 AM - blood glucose 166;12/28/25, 4:51 PM - blood glucose 160;12/29/25, 5:04 PM - blood glucose169;12/30/25, 11:02 AM - blood glucose 175;12/30/25, 4:27 PM - blood glucose 188;1/2/26, 7:12 AM - blood glucose 162;1/2/26, 11:21 AM - blood glucose 154;1/3/26, 7:09 AM - blood glucose 161;1/6/26, 11:23 AM - blood glucose 167;1/6/26, 5:04 PM - blood glucose 201;1/7/26, 5:13 PM - blood glucose 218;1/9/26, 11:14 AM - blood glucose 202;1/9/26, 4:57 PM - blood glucose 192;1/10/26, 7:16 AM - blood glucose 181;1/10/26, 11:10 AM - blood glucose 176;1/10/26, 5:41 PM - blood glucose 250;1/11/26, 8:04 AM - blood glucose 238;1/11/26, 5:12 PM - blood glucose 153;1/12/26, 1:58 PM - blood glucose 281;1/15/26, 5:17 PM - blood glucose 215;1/16/26, 5:30 PM - blood glucose 240;1/18/26, 12:59 PM - blood glucose unknown;1/19/26, 4:58 PM - blood glucose 224;1/23/26, 7:27 AM - blood glucose 173;1/31/26, 12:16 PM - blood glucose 190;2/1/26, 11:20 AM - blood glucose 200;2/1/26, 5:02 PM - blood glucose 186;2/10/26, 12:06 PM - blood glucose 209;2/13/26, 4:53 PM - blood glucose 285;2/14/26, 4:40 PM - blood glucose 227;2/15/26, 11:50 AM - blood glucose 219;2/16/26, 1:49 PM - blood glucose 236;2/17/26, 12:57 PM - blood glucose 245;2/28/26, 11:21 AM - blood glucose 253;2/28/26, 5:15 PM - blood glucose 257;3/6/26, 11:08 AM - blood glucose 295;3/7/26, 7:22 AM - blood glucose 184;3/7/26, 12:09 PM - blood glucose 223;3/8/26, 5:36 PM - blood glucose 238;3/9/26, 7:59 AM - blood glucose 293, and;3/9/26, 10:57 AM - blood glucose 165. Review of the facility policy titled, Medication Administration, last revised 6/15/25, revealed: .Time-Critical Medication: Medications in which an early or late administration of greater than 30 minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect. The individual administering the medication will verify the medication selected for administration is correct based on the medication order. The individual administering a medication will be aware of the following information concerning each medication before administration. Route and Frequency of administration. Appropriate timing of medication administration. Medications that require exact or precise timing of administration shall be administered at the scheduled time. Examples of Time-Critical medications include. insulin associated with food/mealtime doses. Review of the facility's nursing standard, Safe medication administration practices, long-term care, last revised 5/18/25, revealed: To promote a culture of safety and prevent medication errors, nurses must adhere to the five rights of medication administration. select the right medication, administer the right dose, administer the medication at the right time, and administer the medication by the right route. If any health care team member has questions about a medication, whether it's a new drug or part of the resident's existing regimen, contact the pharmacist on duty before administering it. Establish a standard schedule for maintenance medication doses that require administration every 4 hours or three times per day. Be sure to administer medications identified as time-critical within 30 minutes of the intended administration time. Documentation associated with safe medication administration practices includes. if a medication was not administered. the reason for not administering the medication. name of the practitioner (if notified). interventions performed. response to those interventions.

Based on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food safety. Specifically, the facility failed to ensure food was stored under proper sanitation and food handling practices. This failed practice had the potential of causing or spreading foodborne illness to all residents, based on a census of 16. Findings: Initial Kitchen Tour Pantry Storage: An observation on 10/21/24 at 4:34 PM, of the pantry storage of the kitchen, revealed the following expired items: - 1 opened Sysco Classic Chocolate Instant Pudding and Pie Filling Mix, 24-ounce bag, 1/4 full. This was stored in a Ziploc plastic bag labeled, Use by 10/19/24; - 2 unopened Nabisco Entertainment Crackers boxes, each containing 8 packages of assorted cracker types, Net weight 2.51 lbs. (pounds), with a manufacturer expiration date of 8/29/24; - 1 Ziploc plastic bag of loose pecans. This Ziploc plastic bag was not labeled and had no open date and no expiration date; - 1 opened Sysco Classic Almond Slices, 32-ounce bag, 1/4 full with a manufacturer expiration date 6/2/24; - 1 plastic container labeled Polenta - with a use by date of 7/24/24; - 1 jar Organic Coconut Oil, 14-fluid-ounces - with a manufacturer use by date 7/24/24; - 1 container Sysco Classic Imitation Vanilla Flavor, 32-fluid-ounces - 3/4 full - with a manufacturer use by date of 2/27/24; and - 1 bottle S&B Wasabi Sauce, 5.3-fluid-ounces, full and unopened - with a manufacturer expiration date of 9/2/24. Further observation revealed the following dented cans of food items: - 1 can Sysco Sliced Apples, 6.5 lbs., can dented on rim seal of the can; - 1 can Sysco Imperial Pizza Sauce, 6.63 lbs., can dented on rim seal of the can; and - 1 can Diced Pears, 6.56.lbs., can dented on rim seal of the can. Walk-In Freezer: An observation on 10/21/24 at 5:00 PM, of the kitchen's walk-in freezer, revealed the following: - 1 bag Sysco Imperial Winter Vegetables, 4 lbs. bag, this bag was open and not sealed causing the vegetables to be exposed to the elements. - 1 opened box of Sysco Cut [NAME] Beans, 30-pound box, 1/2 full. The bag inside the box was open to air. [NAME] beans visible and were covered with small ice crystals. During an interview on 10/21/24 at 5:17 PM, the Kitchen Manager stated the Ziploc bag of pecans should have been labeled and dated. The Kitchen Manager acknowledged the expired crackers, pudding, and dented cans when discovered. When shown the expired wasabi sauce, the Kitchen Manager mentioned just having purchased it from the store. Review of the facility's policy Food Safety: Food Handling, dated 2023, revealed: . All foods that are received into Aramark [Food Service Provider] locations must be labeled . Discard foods that are not labeled in accordance with these standards . Discard foods that are not used by the manufacturer's Use By/Best Before date . .

Based on observation, record review and interview, the facility failed to maintain the central kitchen's Hot Food Holding Cabinet (a unit that holds cooked food at a safe temperature prior to serving) in safe operating conditions. Specifically, the facility failed to ensure the accuracy of the cabinet's internal and external thermometers was maintained to be of similar temperatures. This failed practice had the potential to not hold cooked foods at appropriate temperatures and placed all residents (based on a census of 16) at risk for foodborne illness. Findings: Random observations on 10/21-25/24 revealed the facility used an [NAME]-Shaam Hot Food Holding Cabinet, model 1000-UP, to store and hold cooked food prior to serving for meals. An observation on 10/24/24 at 3:45 PM, revealed an external thermostat reading on the Hot Food Holding Cabinet of 200 degrees Fahrenheit (F), and an internal thermometer reading of 180 degrees F. An observation on 10/25/24 at 8:19 AM, revealed an external thermostat reading on the Hot Food Holding Cabinet of 200 degrees F, and an internal thermometer reading of 180 degrees F. Record review of the facility-provided instruction manual for the [NAME] Shaam 1000-UP, dated 7/2018, revealed directions to verify thermostat accuracy by enacting a series of diagnostic tests to ensure temperature accuracy. During an interview on 10/24/24 at 3:31 PM, the Kitchen Manager stated that kitchen staff were previously told to keep the Hot Food Holding Cabinet at 165 degrees F, but as of 10/24/24 they have kept the Hot Food Holding Cabinet at 200 degrees F to keep food warmer. During an interview on 10/24/24 at 3:37 PM, when asked how often the accuracy of the temperatures for the Hot Food Holding Cabinet was checked, the Facilities Manager stated, the unit was purchased four years ago. At that time calibration was done. Review of the facility's policy Food Safey: Service [and] Delivery, dated 4/16/24, revealed: . Facilities, Equipment, [and] Utensils: Visually inspect all utensils and equipment before using them and during operating hours to make sure they are in proper working condition. Maintain all utensils and equipment in good condition . Hot Holding: Make sure that proper hot holding temperatures can be maintained by equipment in use . Follow the manufacturer's instructions for hot holding equipment . .

Based on interview, observation, and record review, the facility failed to ensure facility approved menus were followed for 2 residents (#'s 2 and 18), out of 2 residents who received pureed meals. This failed practice had the potential to compromise the nutritive adequacy of foods, decrease palative and overall quality of food, and affect the resident's nutritional well-being. Findings: Pureed Meal Guidelines During an interview on 10/24/24 at 4:30 PM, the Kitchen Manager stated the facility used the International Dysphagia Diet Standardisation Initiative (IDDSI) standards for therapeutic diet consistency guidelines and used recipes from the Menu2U website, at www.webmenuplus.com/docs/login.asp, to make pureed diet meals. Review of the facility's IDDSI guidelines, undated, revealed: - Nectar thick liquids were considered mildly thick and a level 2 liquid and defined as Flows at a slower rate, able to sip but may take some effort using a straw. - Honey thick liquids were considered moderately thick and a level 3 liquid and defined as Can drink from a cup or with a spoon, need a wide diameter straw. - Pudding thick liquids were considered extremely thick and a level 4 liquid (EX4) and defined as can be eaten with a spoon, does not drip through fork, smooth texture. - A pureed meal was considered a level 4 diet (PU4), and defined pureed as eaten with a spoon and does not require chewing, smooth texture. Random observations on 10/21-25/24 revealed the facility used Simply Thick EasyMix instant food thickener, bulk-sized bottles of 55 fluid ounces (fl oz), to thicken liquids and pureed foods for residents who required pureed meals. Review of the Simply Thick EasyMix website at https://www.simplythick.com/How-to-Use-Videos, undated, revealed 1 pump stroke from the bulk bottle made a nectar thick consistency, 2 pump strokes made a honey thick consistency; and 4 pump strokes made a pudding thick consistency in liquids and foods. Resident #2 Record review on 10/21-25/24 revealed Resident #2 was admitted to the facility with diagnoses that included Alzheimer's Disease, reduced mobility, and abnormal weight loss. Further review revealed Resident #2 had a diet order, dated 7/19/22, which stated, Puree (IDDSI PU4) texture, Extremely Thick (IDDSI EX4) consistency, Resident need very small portions four to five times a day as tolerated. Resident #18 Record review on 10/21-25/24 revealed Resident #18 was admitted to the facility with diagnoses that included dementia, dysphagia following cerebral infarction (difficulty swallowing after a stroke), and weakness. Further review revealed Resident #18 had a diet order, dated 5/3/24, which stated, Puree (IDDSI PU4) texture, thin (IDDSI TN0) consistency, meds [medications] in applesauce, post stroke dysphagia, double portions. Pureed Meal Preparation Observation An observation on 10/24/24 at 3:44 PM, revealed [NAME] #4 was preparing pureed meals for dinner and prepared the following food items: Steamed Cabbage Cook #4 prepared to puree steamed cabbage. [NAME] #4 was observed to place a couple of unmeasured handfuls of cooked cabbage into a blender, then poured an unmeasured amount of hot water into the blender from a spout from a coffee pot machine. [NAME] #4 blended the cabbage/water mix until it was thoroughly blended, creating a watery mix. [NAME] #4 then added 8 pump strokes of thickener and blended the mix again. After this, [NAME] #4 checked the consistency and then added another 5 pump strokes of thickener and blended again. [NAME] #4 checked the consistency, then placed the pureed steamed cabbage in bowls and placed a lid on the bowls. [NAME] #4 placed the bowls in the hot food holding cabinet ready to serve to the residents. Review the facility's Menu2U recipes, dated 2022-2024, for pureed steamed cabbage revealed it called for 1/2 cup (2 1/2 cups for 5 servings) of steamed cabbage per resident. The pureed method of the recipe stated, 1. Place portions needed from regular prepared recipe into a food processor. Process to a fine texture. Add thickener and hot water. Process until smooth . Further review revealed the recipe called for only 3 tablespoons of thickener and there was no guidance on the amount of hot water to add to the recipe. Chicken Tenders Further observation revealed [NAME] #4 prepared to puree chicken tenders. [NAME] #4 placed 3 to 4 chicken tenders into a blender. [NAME] #4 added a small amount of unmeasured gravy and also placed an unmeasured amount of hot water from the coffee pot spout in the blender. [NAME] #4 blended the chicken/gravy/water mix until it was thoroughly blended. [NAME] #4 then added 5 pump strokes of thickener and blended again. [NAME] #4 checked the consistency, then placed the pureed chicken tenders in bowls and placed a lid on the bowls. [NAME] #4 placed the bowls in the hot food holding cabinet ready to serve to the residents. Review the facility's Menu2U recipes, dated 2022-2024, for pureed chicken tenders revealed it called for 2 chicken tenders per resident. The pureed method of the recipe stated, Place portions needed from regular prepared recipe into a food processor. Process to a fine texture. For every 5 portions needed, prepare a slurry with 2 [tablespoons] thickener and 1/2 [to] 2 tablespoons cup hot liquid; mix well with a wire whip. Add 1/2 of the slurry to the meat; process for 1 minute. If too dry, add more slurry until meat is pudding consistency . serve with a #6 scoop [2/3 cup] topped with . gravy or sauce. During an interview on 10/24/24 at 5:20 PM, the Dietary Manager stated the hot liquid identified in the chicken tenders pureed recipe was meaning hot water. During an interview on 10/25/24 at 8:23 AM, the Dietician stated that if the Menu2U recipe called for water, then water would be added to make pureed meals. When asked if water would decrease the nutritive value of the pureed meal, the Dietician stated water would decrease the nutritional value. The Dietician further stated that thickener added no nutritional value to the meals made. When asked for a policy or procedure for preparing therapeutic diets, the Kitchen Manager and Dietary Manager stated the facility relied on the Menu2U recipe directions to ensure these foods were prepared and served appropriately. .

Based on interview, observation, and record review, the facility failed to prepare pureed meals by methods that conserve nutritive value for 2 residents (#'s 2 and 18), out of 2 residents who received pureed meals. Specifically, the facility failed to ensure liquids of similar nutritive value were used to make pureed meals, and instead used water and thickener which had no nutritive value. This failed practice had the potential to compromise or diminish the nutritive value of foods and affect the resident's weight and overall health. Findings: Pureed Meal Guidelines During an interview on 10/24/24 at 4:30 PM, the Kitchen Manager stated the facility used the International Dysphagia Diet Standardisation Initiative (IDDSI) standards for therapeutic diet consistency guidelines and used recipes from the Menu2U website, at www.webmenuplus.com/docs/login.asp, to make pureed diet meals. Review of the facility's IDDSI guidelines, undated, revealed: - Nectar thick liquids were considered mildly thick and a level 2 liquid and defined as Flows at a slower rate, able to sip but may take some effort using a straw. - Honey thick liquids were considered moderately thick and a level 3 liquid and defined as Can drink from a cup or with a spoon, need a wide diameter straw. - Pudding thick liquids were considered extremely thick and a level 4 liquid (EX4) and defined as can be eaten with a spoon, does not drip through fork, smooth texture. - A pureed meal was considered a level 4 diet (PU4), and defined pureed as eaten with a spoon and does not require chewing, smooth texture. Random observations on 10/21-25/24 revealed the facility used Simply Thick EasyMix instant food thickener, bulk-sized bottles of 55 fluid ounces (fl oz), to thicken liquids and pureed foods for residents who required pureed meals. Review of the Simply Thick EasyMix website at https://www.simplythick.com/How-to-Use-Videos, undated, revealed 1 pump stroke from the bulk bottle made a nectar thick consistency, 2 pump strokes made a honey thick consistency; and 4 pump strokes made a pudding thick consistency in liquids and foods. Resident #2 Record review on 10/21-25/24 revealed Resident #2 was admitted to the facility with diagnoses that included Alzheimer's Disease, reduced mobility, and abnormal weight loss. Further review revealed Resident #2 had a diet order, dated 7/19/22, which stated, Puree (IDDSI PU4) texture, Extremely Thick (IDDSI EX4) consistency, Resident need very small portions four to five times a day as tolerated. Resident #18 Record review on 10/21-25/24 revealed Resident #18 was admitted to the facility with diagnoses that included dementia, dysphagia following cerebral infarction (difficulty swallowing after a stroke), and weakness. Further review revealed Resident #18 had a diet order, dated 5/3/24, which stated, Puree (IDDSI PU4) texture, thin (IDDSI TN0) consistency, meds [medications] in applesauce, post stroke dysphagia, double portions. Pureed Meal Preparation Observation An observation on 10/24/24 at 3:44 PM, revealed [NAME] #4 was preparing pureed meals for dinner and prepared the following food items: Steamed Cabbage Cook #4 prepared to puree steamed cabbage. [NAME] #4 was observed to place a couple of unmeasured handfuls of cooked cabbage into a blender, then poured an unmeasured amount of hot water into the blender from a spout from a coffee pot machine. [NAME] #4 blended the cabbage/water mix until it was thoroughly blended, creating a watery mix. [NAME] #4 then added 8 pump strokes of thickener and blended the mix again. After this, [NAME] #4 checked the consistency and then added another 5 pump strokes of thickener and blended again. [NAME] #4 checked the consistency, then placed the pureed steamed cabbage in bowls and placed a lid on the bowls. [NAME] #4 placed the bowls in the hot food holding cabinet ready to serve to the residents. Chicken Tenders Further observation revealed [NAME] #4 prepared to puree chicken tenders. [NAME] #4 placed 3 to 4 chicken tenders into a blender. [NAME] #4 added a small amount of unmeasured gravy and also placed an unmeasured amount of hot water from the coffee pot spout in the blender. [NAME] #4 blended the chicken/gravy/water mix until it was thoroughly blended. [NAME] #4 then added 5 pump strokes of thickener and blended again. [NAME] #4 checked the consistency, then placed the pureed chicken tenders in bowls and placed a lid on the bowls. [NAME] #4 placed the bowls in the hot food holding cabinet ready to serve to the residents. Recipe Review Review of the facility's Menu2U recipes, dated 2022-2024, for pureed preparation for steamed cabbage and chicken tenders revealed: Steamed Cabbage Review of the recipe for pureed steamed cabbage revealed it called for 1/2 cup (2 1/2 cups for 5 servings) of steamed cabbage per resident. The pureed method of the recipe stated, 1. Place portions needed from regular prepared recipe into a food processor. Process to a fine texture. Add thickener and hot water. Process until smooth . Further review revealed the recipe called for only 3 tablespoons of thickener and there was no guidance on the amount of hot water to add to the recipe. Chicken Tenders Review of the recipe for pureed chicken tenders revealed it called for 2 chicken tenders per resident. The pureed method of the recipe stated, Place portions needed from regular prepared recipe into a food processor. Process to a fine texture. For every 5 portions needed, prepare a slurry with 2 [tablespoons] thickener and 1/2 [to] 2 tablespoons cup hot liquid; mix well with a wire whip. Add 1/2 of the slurry to the meat; process for 1 minute. If too dry, add more slurry until meat is pudding consistency . serve with a #6 scoop [2/3 cup] topped with . gravy or sauce. During an interview on 10/24/24 at 5:20 PM, the Dietary Manager stated the hot liquid identified in the chicken tenders pureed recipe was meaning hot water. During an interview on 10/25/24 at 8:23 AM, the Dietician stated that if the Menu2U recipe called for water, then water would be added to make pureed meals. When asked if water would decrease the nutritive value of the pureed meal, the Dietician stated water would decrease the nutritional value. The Dietician further stated that thickener added no nutritional value to the meals made. When asked for a policy or procedure for preparing therapeutic diets, the Kitchen Manager and Dietary Manager stated the facility relied on the Menu2U recipe directions to ensure these foods were prepared and served appropriately. Review of the Simply Thick EasyMix nutrition facts at https://www.simplythick.com/Nutrition-Panels-English, dated 2022, revealed there was no fat or protein nutrition to the thickener. Further review revealed the following calories for each amount of thickener: - 4 g (grams), or 0.12 fl oz (fluid ounce), each = 0 calories; - 6 g, or 0.2 fl oz, each = 5 calories; - 12 g, or 0.4 fl oz, each = 10 calories; - 48 g, or 1.6 fl oz, each = 5 calories; - 96 g, or 3.2 fl oz, each = 10 calories; and - 1.6 L (liters), 1.7 quarts, each = 5 calories. .

Based on observation, interview, and record review, the facility failed to ensure: 1) food was stored under proper sanitary conditions; and 2) concentrations of sanitizing solutions were maintained within acceptable parameters. This failed practice placed all residents (based on a census of 14) at risk for foodborne illness and communicable disease. Findings: Food Storage An observation of the central kitchen on 6/7/22 at 8:00 AM, revealed: Dry Storage (Pantry) - One bag of Baker's all-purpose [MEDICATION(S)] flour bleached, 1/4 full, opened on the shelf with no open date, exposed to the elements. The flour had visibly dusted the shelf it was sitting on. - One bag of Baker's Source basic muffin mix, 1/4 full, open on shelf with open date of 3/16/22, exposed to elements. - One box of [NAME] oven-ready lasagna noodles, less than 1/4 full, was torn and opened, exposed to elements, with no open date - Two large dry storage bins, 1 containing a large bag of Jasmine rice and 1 containing a large bag of sugar, with lids not covering the top of the bins, exposing the contents to the elements. - One opened box of Super Moist white cake mix, with no open date. - Two small Rubber Maid dry storage bins, stacked on top of one another, with the bottom container labeled AP Flour, dated 5/27/22 and use by 11/30/22, with a scoop stored inside the container. The top container was unlabeled as to the contents or dates. - One open box Gold Medal variety muffin mix, with no open date, exposed to the elements. Walk-In Freezer - Two bags of Brussel sprouts, one bag open, and exposed to the elements. The Brussel sprouts in the opened bag were discolored, some had brown spots, and ice crystals were visibly seen throughout the bag. - One opened box of Fully cooked beef steak burger patties, 3/4 full, open with plastic inner packaging open. The patties were exposed to the elements and ice crystals were visibly seen on all exposed surfaces. - One opened box of Bacon single slices, 3/4 full, opened with plastic inner packaging open. The bacon was exposed to the elements. Canned Goods - 4 6lb. 6oz. cans of Las [NAME] Enchilada Sauce, dented on sides and rims in multiple places. During an interview on 6/7/22 at 8:52 AM, the Food Service Manager stated the open flour and muffin mix bags should have been sealed closed, the lasagna box should have had an open date and should have been sealed closed, the dry storage bins should have been closed, and the cake and muffin mix boxes should have had open dates. The Food Service Manager further stated that the dented cans of enchilada sauce should have been returned to the vendor or thrown away. The Food Service Manager stated she was unaware the scoops could not be stored in dry bins. During an interview on 6/9/22 at 8:02 AM, the Food Service Manager stated the Sodexo Food Safety Management System: PQA [Product Quality Assurance] Food Product Shelf Life Guidelines (the facility's food storage guide) was not descriptive to each food item used in the facility's kitchen, and that they had called Sodexo with a lot of questions to often get clarification. Review of the facility's policy Food Storage, not dated, revealed: . Foods are regularly inspected for signs of damage due to spoilage or to detect unacceptable items, i.e. dented, swollen or rusted cans, thawed or refrozen items, crushed cases, etc. and are discarded or returned to the vendor for credit . Products are labeled and dated per NMS [[NAME] Management Systems - Food service offices in Alaska] and regulatory standards . Dry Bulk Foods: Store in non-reactive metal or plastic containers with tight fitting lids. Do not store scoops in the bulk goods . Concentration of Sanitizing Solutions An observation on 6/8/22 at 7:20 AM, revealed Cook #1 wiping down the counters in the unit kitchen during breakfast, using solution from a sanitation bucket placed the sink. During an interview on 6/8/22 at 8:05 AM, when asked what chemicals were used for the sanitation buckets, Cook #1 stated the facility used Ecolab SmartPower Sink [and] Surface Cleaner Sanitizer. When asked how the kitchen staff tested the concentration of the sanitation bucket solution, Cook #1 stated the facility used quat strips [test strips designed to test quaternary, or disinfectant, sanitizers], which Cook #1 pulled down from on top of the sanitation solution dispenser in the main kitchen sink area. Cook #1 further stated the sanitation bucket solutions were only tested when the chemical block was changed in the dispenser and not tested when each bucket was made. An observation on 6/8/22 at 8:05 AM, revealed the quat strips used by the facility were HR QAC QR Test Strips, Code SP - 2951HR strips. When asked if the facility documented on a sanitation solution log, Cook #1 stated the facility did, but only documented when staff changed the sanitation solution at every meal. An observation on 6/8/22 at 8:05 AM, through surveyor testing of the sanitation bucket in the unit kitchen and the sanitation bucket in the main kitchen (at the dishwashing station), using the quat strip HR QAC QR Test Strips, Code SP - 2951HR, revealed both bucket's had concentration levels that were less than 200 ppm (parts per million). Review of the facility's Sanitizer Solution Log - U.S., dated 07/2013, revealed: The Sanitizer Solution Log must be completed once a day for sample testing. Further review revealed 2 chemicals, and the required concentration levels for those chemicals not in use at the facility: - Required concentration for Mikroklene . stationary equipment, spray bottles, solutions for storing wiping cloths - must be maintained at 25 ppm and - Required concentration for Oasis 146: must be set at 150 - 400 ppm for all dispensing equipment, use on stationary equipment, spray bottles, solutions for storing wiping cloths. Further review of the sanitation log revealed no required concentration level for the facility's chemical Ecolab SmartPower Sink [and] Surface Cleaner Sanitizer. Review of the facility's Sanitizer Solution Log - U.S., dated 6/2022, revealed a check mark under a column labeled AM. Under that column, staff checked the S column (having a choice of marking under an S column or a U column) and the staff's initials for each date documented, 6/1-8/22. Further review of the log revealed S = Satisfactory, U = Unsatisfactory. If rating is Unsatisfactory, solution must be corrected. An observation on 6/8/22 at 8:34 AM, of the chemical storage closet in the main kitchen, revealed a poster on the wall for Ecolab SmartPower Sink [and] Surface Cleaner Sanitizer. Further review revealed concentration level testing required Ecolab Sink & Surface Cleaner Sanitizer test strips. Review of Ecolab's SmartPower Sink [and] Surface Cleaner Sanitizer: Frequently Asked Questions manufacturer's sheet, dated 2020, revealed: - Can I use quat test strips? No, quat strips . should not be used and will not work. During an interview on 6/8/22 at 8:35 AM, the Food Service Manager stated the kitchen staff had not been testing the concentration levels of sanitation buckets. When asked what education the kitchen staff received in regard to cleaning/sanitizing of the kitchen, the Food Service Manager stated all kitchen staff completed new hire training, which included cleaning/sanitizing. Review of the facility's New Hire: Two Step Food Safety Training Program Training Record, dated 9/2021, revealed during the first 10 days of employment, kitchen staff completed Cleaning and Sanitizing training. Review of the facility's Sodexo Technical Training: Food Safety - Cleaning [and] Sanitizing training curriculum, copywrite 2018, revealed no training for the use of Ecolab SmartPower Sink and Surface Cleaner Sanitizer. Review of the facility's policy Kitchen Sanitation, not dated, revealed: . To promote a clean, safety and effective environment and to prevent the transmission of disease-carrying organisms . The General Manager/Food Services Director monitors sanitation schedules and procedures . Local and State sanitation requirements are reflected in schedules, procedures, and sanitizing compounds in use .

Based on interview and record review, the facility failed to obtain proper and timely informed consent for [CONDITION(S)] medications (a psychoactive drug to include antipsychotics, antianxiety, or antidepressant medications, that affects behavior, mood, thoughts, or perception) prior to that medication's use for 4 residents (#'s 1; 3; 4; and 11), out of 10 sampled residents. Failing to obtain appropriate informed consent for [CONDITION(S)] medications violated the residents right to make an informed decision, based on medication education of the risk and benefits, to include side effects. Findings: [CONDITION(S)] Medication Consent Process During an interview on 6/9/22 at 10:00 AM, the Pharmacist stated all [CONDITION(S)] medications required a medication consent prior to the administration of that medication. The Pharmacist further stated that she completed a monthly [CONDITION(S)] medication review and indicated if a medication consent still needed to be obtained and submitted review findings to nursing leadership each month. The Pharmacist further stated failure to obtain consents had been an ongoing issue. During an interview on 6/9/22 at 2:59 PM, Physician #1 stated the process to obtain medication consent for a [CONDITION(S)] medication would have been to first talk to the resident and/or guardian about the risk and benefits of using the medication. The physician would have then ordered the medication and the nurse would have filled out a medication consent form, to be signed by the physician and the resident and/or guardian. The Physician further stated that a [CONDITION(S)] medication should not have been initiated prior to the medication consent form being completed. The Physician stated the medication should have been held (not given) until the consent was obtained. Review of the facility's medication consent form, on 6/7/22, revealed the form itself had gone through different revisions: - Review of the Wrangell Medical Center and Long Term Care Consent for Drug Use consent form, dated 10/21/20, revealed . This form will be updated yearly while a resident is prescribed this medication . Further review revealed that there was a section discussing risks and benefits and a signature line for the physician and resident or legal guardian. In addition, there was a line for a witness. - The consent form was updated in 01/2021, which revealed 2 different medication consent forms with different titles: 1) SEARCH Southeast Alaska Regional Health Consortium: Long Term Care Consent for [CONDITION(S)] Medication and 2) Wrangell Medical Center SEARHC Care Network: SEARCH Long Term Care Consent for [CONDITION(S)] Medication. Review of these forms revealed there was a section discussing risks and benefits and a signature line for the physician and resident or legal guardian. Further review revealed there was a line for a witness (if verbal consent) and a section that indicated, If unable to obtain Patient/Guardian signature - Document Reason. During an interview on 6/7/22 at 3:53 PM, Licensed Nurse (LN) #2 stated nurses could have obtained verbal consents over the phone for [CONDITION(S)] medication from guardians with the verification/signature of two nurses on the consent form. LN #2 further stated resident/guardian signatures would have been obtained later when the guardians were available to sign the consent forms. Resident #1 Record review from 6/7-9/22 revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. On admission, 6/3/20, Resident #1 started: [MEDICATION(S)] [[MEDICATION(S)] - A benzodiazepine, used to treat panic disorders or anxiety] 0.5mg [milligrams] by mouth PRN [as needed] for anxiety. 2. On 9/23/20, Resident #1 started: [MEDICATION(S)] [[MEDICATION(S)] - An antidepressant] 10mg by mouth daily for 7 days, then increased to 20mg daily. [MEDICATION(S)] Review of Resident #1's medical record, on 6/7/22, revealed the following [CONDITION(S)] medication consent history for [MEDICATION(S)]: [MEDICATION(S)] Consent: 6/3/20 Review of Resident #1's original [MEDICATION(S)] medication consent form, dated 6/3/20, revealed it was signed by the physician on 6/3/20 and not signed by the Power of Attorney (POA) until 6/5/20 (2 days later). Further review revealed a nurse witnessed the signature on 6/5/20. [MEDICATION(S)] Consent: 8/25/21 Review of Resident #1's renewed [MEDICATION(S)] medication consent form, dated 8/25/21, revealed the form was signed by the physician on 8/25/21 and not signed by the POA until 9/8/21 (14 days later). Further review revealed the witness (if verbal consent) and the If unable to obtain Patient/Guardian signature - Document Reason lines were blank. [MEDICATION(S)] Consent: 12/9/21 Review of Resident #1's renewed medication consent form, dated 12/9/21, revealed two different consents with two different [MEDICATION(S)] doses, to be administered the same day: 1) [MEDICATION(S)] 0.25mg every afternoon and 2) [MEDICATION(S)] 0.5mg twice a day (meaning each day [MEDICATION(S)] 0.5mg was given in the morning, [MEDICATION(S)] 0.25mg was given in the afternoon, and [MEDICATION(S)] 0.5mg was given at night). Further review of these medication consents revealed they were signed by the physician on 12/9/21 and not signed by the POA until 3/15/22 (96 days later). Further review revealed the witness (if verbal consent) and the If unable to obtain Patient/Guardian signature - Document Reason lines on both forms were blank. [CONDITION(S)] Medication Reviews Review of Resident #1's [CONDITION(S)] Medication Review FY [fiscal year] 2021 Q1 [quarter 1] + Sept [September], dated 9/2020; 10/2020; 11/2020; and 12/2020, revealed the Pharmacist documented under [MEDICATION(S)] Consent due to scheduled order for 10/2020, 11/2020, and 12/2020. Review of the Resident #1's [CONDITION(S)] Medication Review FY 2021 Q2, dated 01/2021, 02/2021, and 03/2021, revealed the Pharmacist documented under [MEDICATION(S)] Consent due to scheduled order for all 3 months. Review of the Resident #1's [CONDITION(S)] Medication Review FY 2021 Q3, dated 04/2021, 05/2021, and 06/2021, revealed the Pharmacist documented for [MEDICATION(S)] Consent due to scheduled order for 04/2021 and 05/2021; and Consent due for 06/2021. Review of the Resident #1's [CONDITION(S)] Medication Review FY 2021 Q4, dated 07/2021, 08/2021, and 09/2021, revealed the Pharmacist documented under [MEDICATION(S)] Consent due for all 3 months. Further review revealed Informed consents in out-going mail week of 9/6/21. Review of the Resident #1's [CONDITION(S)] Medication Review FY 2022 Q1, dated 10/2021, 11/2021, and 12/2021, revealed the Pharmacist documented Consent due under [MEDICATION(S)] 0.5mg PO BID for all 3 months and noted Told consent in out-going mail week of 9/6/21. Further review revealed the Pharmacist documented Need consent under [MEDICATION(S)] 0.25mg for 12/2021. Review of the Resident #1's [CONDITION(S)] Medication Review FY 2022 Q2, dated 01/2022, 02/2022, and 03/2022, revealed the Pharmacist documented under [MEDICATION(S)] Consent due for all 3 months. Review of the Resident #1's [CONDITION(S)] Medication Review FY 2022 Q3, dated 04/2022, 05/2022, and 06/2022, revealed the Pharmacist documented under [MEDICATION(S)] Consent 12/9/21. Signed by POA 3/15/22, MD 12/9/21. [MEDICATION(S)] Review of Resident #1's medical record, on 6/7/22, revealed the following [CONDITION(S)] medication consent history for [MEDICATION(S)]: [MEDICATION(S)] Consent for the 9/23/20 start date: Review of Resident #1's original medication consent form, dated 10/26/20, revealed it was signed by the physician on 10/26/20, (33 days after the start of the medication). Further review revealed the witness line of the consent form documented verbal consent obtained and signed by Licensed Nurse (LN) #2 and the MDS (Minimum Data Set - a federally required assessment) Coordinator on 10/26/20. [MEDICATION(S)] Consent: 8/19/21 Review of Resident #1's renewed medication consent form, dated 8/19/21, revealed it was signed by the Physician on 8/19/21 and not signed by the POA until 9/8/21 (20 days later). Further review revealed the witness (if verbal consent) and the If unable to obtain Patient/Guardian signature - Document Reason lines were blank. [MEDICATION(S)] Consent: 12/9/21 Review of Resident #1's renewed medication consent, dated 12/9/21, revealed they were signed by the Physician on 12/9/21 and not signed by the POA until 3/15/22 (96 days later). Further review revealed the witness (if verbal consent) and the If unable to obtain Patient/Guardian signature - Document Reason lines were blank. [CONDITION(S)] Medication Reviews Review of Resident #1's [CONDITION(S)] Medication Review FY 2021 Q1 + Sept, dated 9/2020; 10/2020; 11/2020; and 12/2020, revealed the Pharmacist documented under [MEDICATION(S)] Consent due for 09/2020; Consent done 10/26/20 for 10/2020; and Consent done 10/26/20 but need witness signature date for 11/2020, and 12/2020. Review of the Resident #1's [CONDITION(S)] Medication Review FY 2021 Q2, dated 01/2021, 02/2021, and 03/2021, revealed the Pharmacist documented under [MEDICATION(S)] Consent 10/26/20 (verbal) need signatures [and] dates. Review of the Resident #1's [CONDITION(S)] Medication Review FY 2021 Q3, dated 04/2021, 05/2021, and 06/2021, revealed the Pharmacist documented under [MEDICATION(S)] Consents 10/26/20 (verbal) need signatures [and] dates - see March MRR [Medication Regimen Review] [and] scanned into PCC [pointclickcare - electronic medical record]. Review of the Resident #1's [CONDITION(S)] Medication Review FY 2021 Q4, dated 07/2021, 08/2021, and 09/2021, revealed the Pharmacist documented under [MEDICATION(S)] Consents 10/26/20 (verbal) need signatures [and] dates - see March MRR [and] scanned into PCC. Review of the Resident #1's [CONDITION(S)] Medication Review FY 2022 Q1, dated 10/2021, 11/2021, and 12/2021, revealed the Pharmacist documented under [MEDICATION(S)] Consent due for all 3 months. Further review revealed Consents 10/26/20 (verbal) need signatures [and] dates. Review of the Resident #1's [CONDITION(S)] Medication Review FY 2022 Q2, dated 01/2022, 02/2022, and 03/2022, revealed the Pharmacist documented under [MEDICATION(S)] Consent due for all 3 months. Review of the Resident #1's [CONDITION(S)] Medication Review FY 2022 Q3, dated 04/2022, 05/2022, and 06/2022, revealed the Pharmacist documented under [MEDICATION(S)] Consent 12/9/21. Signed by POA 3/15/22, MD 12/9/21. During this survey, the surveyor requested all medication consents, verbal and written, for Resident #1's [MEDICATION(S)] and [MEDICATION(S)] medications. The facility only provided the written consents previously discussed. Resident #3 Record review from 6/7-9/22 revealed Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #3's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] .-Start Date- 4/27/2022 [9:00 AM]. Review of SEARHC LONG TERM CARE CONSENT FOR [CONDITION(S)] MEDICATION, dated 1/2021, revealed the consent for the [MEDICATION(S)] medication with an original start date of 4/26/22 was signed by the physician and the Resident on 6/9/22, 44 days after the medication was first administered. Review of the Resident #3's [CONDITION(S)] Medication Review FY 2022 Q3, dated 5/2022, revealed the Pharmacist documented the consent for [MEDICATION(S)] was due. Resident #4 Record review from 6/7-9/22 revealed Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] [antipsychotic medication] tablet 2.5 MG Give 1 tablet by mouth for psychotic disorder related to WANDERING IN DISEASES CLASSIFIED ELSEWHERE .for 14 days -Start Date- 5/6/2022 [8:00PM] -[Discontinue] Date- 5/13/2022 [1:29 PM]. 2. [MEDICATION(S)] HCl [Alzheimer's type dementia medication] Tablet 10 MG, Give 1 tablet by mouth two times a day related to ALZHEIMER'S DESEASE, UNSPECIFIED .-Start Date- 5/2/2022. A dosage change took place on 5/26/2022 and the medication was continued at a lower dosage. 3. [MEDICATION(S)] [antipsychotic medication] Tablet 25 MG Give 1 tablet by mouth two times a day related to ALZHEIMER'S DISEASE, UNSPECIFIED .; ANXIETY DISORDER, UNSPECIFIED .; RESTLESSNESS AND AGITATION .-Start Date- 05/17/2022 [6:00PM [Discontinuation] Date- 06/02/2022 [10:45 AM]. Review of Resident #4's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of SEARHC LONG TERM CARE CONSENT FOR [CONDITION(S)] MEDICATION, dated 1/2021, revealed the consent for [MEDICATION(S)], with an original start date of 5/6/22, was signed by the physician on 5/18/22, but was never signed by the Resident's POA. Review of SEARHC LONG TERM CARE CONSENT FOR [CONDITION(S)] MEDICATION, dated 1/2021, revealed the consent for [MEDICATION(S)], with an original start date of 5/2/22, was signed by the physician on 5/12/22, but not signed by the Resident's POA until 5/18/22, 16 days after the medication was initiated. Review of SEARHC LONG TERM CARE CONSENT FOR [CONDITION(S)] MEDICATION, dated 1/2021, revealed the consent for [MEDICATION(S)]. The form listed the original start date of 6/2/22, the date in which the medication dosage was changed. The date the medication was initiated, on 5/17/22, was not listed on the form. The form was signed by the physician on 6/7/22, but not consented by the Resident's POA until 6/9/22, 24 days after the medication was initiated. Further review revealed If unable to obtain Patient/Guardian signature- Document Reason: out of town fishing. This section had no date to indicate the initial attempt to contact the POA. Review of Resident #4's Wrangell Medical Center Progress Notes, a COMMUNICATION-with Family/[next of kin]/POA, dated 6/8/22 revealed Phone call made to [family member]/POA .regarding need to sign [CONDITION(S)] drug consent forms. Message left on identified voicemail to have [him/her] call [Long Term Care] back. Review of the Resident #4's [CONDITION(S)] Medication Review FY 2022 Q3, dated 5/2022, revealed the Pharmacist documented the consents for [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] were all due. Resident #11 Record review from 6/7-9/22 revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed from 5/12/22 to 6/8/22, Resident #11 has received 28 doses of [MEDICATION(S)]. Review of Resident #11's medical record revealed no medication consent form for [MEDICATION(S)]. During an interview on 6/7/22 at 2:39 PM, the MDS Coordinator stated verbal consent was obtained for Resident #11's [MEDICATION(S)] with the Resident's daughter in a meeting. During this interview, the surveyor requested written documentation of this verbal consent, by close of survey the facility did not provide this documentation. Review of Resident #11's [CONDITION(S)] Medication Review, dated 04/2022, 05/2022, and 06/2022, revealed the Pharmacist documented under [MEDICATION(S)] Need consent for 05/2022 and the Pharmacist documented under [MEDICATION(S)] Consent due for 06/2022. During this survey, the surveyor requested all medication consents, verbal and written, for Resident #11's [MEDICATION(S)], by close of survey the facility did not provide this documentation. Review of the facility's policy [CONDITION(S)] Medications, last reviewed 1/21/21, revealed: . The facility shall comply with state and federal regulations to the use of psychopharmacological medications in the long term care facility to include regular review for continued need, appropriate dosage, side effects, risk and/or benefits . Any resident who is prescribed a [CONDITION(S)] medication shall be given an informed consent for signature .The resident, representative, and family, as appropriate, shall be involved in the decisions-making process to place the resident on [CONDITION(S)] medications . Procedures . Informed consent for [CONDITION(S)] medications is completed and signed by the resident or representative and the attending and/or consulting provider or designee . Discussion is documented with the resident and/or responsible party regarding the risk versus benefit of the use of these medications . Informed consent must be obtained and signed by the resident, their personal representative or guardian and the provider or designee .

Based on observation, record review, and interview, the facility failed to obtain informed consent for or conduct necessary safety assessments for risks and benefits for the use of upper bed rails, used for mobility aids, for 4 residents (#'s 1; 2; 6; and 12), out of 10 sampled residents, and 1 unsampled resident (#14). Failure to obtain consent placed the residents at risk for not having necessary risk and benefit information; failure to conduct a safety assessment prior to use of bed rails had the potential to introduce hazards into the environment that could have lead to preventable accidents. Findings: Resident #1 An observation on 6/7/22 at 1:20 PM, revealed Resident #1's bed had the upper bed rails, on both sides, in the raised position. Review of Resident #1's MDS (Minimum Data Set - A Federally required assessment), a significant change assessment dated [DATE], revealed the Resident required extensive assistance, 2+ persons physical assist with bed mobility and transfers (how the resident moves between surfaces). Review of Resident #1's medical record revealed a Safety Assessment: Bed Rails, dated 5/13/21, was completed. Further review revealed no Resident Bed Rail Consent Form for Resident #1. During this survey, the facility obtained a Resident Bed Rail Consent Form, dated 6/9/22, for Resident #1. Resident #2 An observation on 6/7/22 at 2:10 PM revealed Resident #2's bed had the upper bed rails, on both sides, in the raised position. Review of Resident #2's MDS, a quarterly assessment dated [DATE], revealed the resident required extensive assistance, 2+ persons physical assist for bed mobility, and 1 person physical assist for transfers. Review of Resident #2's medical record revealed a Safety Assessment: Bed Rails, dated 12/22/21, was completed. Further review revealed no Resident Bed Rail Consent Form for Resident #2. During this survey, the facility obtained a Resident Bed Rail Consent Form, dated 6/9/22, for Resident #2. Resident #6 An observation on 6/7/22 at 3:19 PM, revealed Resident #6's bed had the upper bed rails, on both sides, in the raised position. Review of Resident #2's MDS, an annual assessment dated [DATE], revealed the resident required extensive assistance, 1 person physical assist for bed mobility and transfers. Review of Resident #6's medical record revealed a Safety Assessment: Bed Rails, dated 4/27/21, was completed. Further review revealed no Resident Bed Rail Consent Form for Resident #6. During this survey, the facility obtained a Resident Bed Rail Consent Form, dated 6/9/22, for Resident #6. Resident #12 An observation on 6/7/22 at 10:31 AM, revealed Resident #12's bed had the upper bed rails, on both sides, in the raised position. Review of Resident #12's MDS, a quarterly assessment dated [DATE], revealed the resident required supervised assistance, 1 person physical assist for bed mobility, and limited assistance, 1 person physical assist for transfers. Review of Resident #12's medical record revealed a completed Resident Bed Rail Consent Form, dated 7/30/21. Further review revealed no Safety Assessment: Bed Rails for Resident #12. During this survey, the facility obtained a Safety Assessment: Bed Rails, dated 6/8/22, for Resident #12. Resident #14 An observation on 6/7/22 at 1:10 PM, revealed Resident #14's bed had the upper bed rails, on both sides, in the raised position. Review of Resident #14's MDS, a quarterly assessment dated [DATE], revealed the resident required extensive assistance, 2+ persons physical assist for bed mobility and transfers. Review of Resident #14's medical record revealed a Resident Bed Rail Consent Form, had been completed. Further review revealed no Safety Assessment: Bed Rails for Resident #14. During this survey, the facility obtained a Safety Assessment: Bed Rails, dated 6/9/22, for Resident #14. Review of the facility's policy Bed Rails, last reviewed 1/14/21, revealed: . All residents will have a Bed safety Assessment completed and documented by an RN/LPN [Registered Nurse/Licensed Practical Nurse] within 24 hours of admission to the facility. This assessment must be re-evaluated with any change in the resident condition (e.g. fall, change in mentation), as this may require addition or removal of bed rails . Consent forms will be signed by resident/resident representative anytime beds rails are used and when a resident declines bed rails after they have been recommended .

Based on record review and interview, the facility failed to ensure that staff reported allegations of abuse to the facility's leadership, and in turn, to the State Agency (SA) in a timely manner for 1 resident (#13), out of six facility reported incident's (FRI) reviewed. This failure placed the resident at risk for continued abuse or mistreatment. The facility had implemented corrective actions prior to the survey conducted 6/7-9/22, therefore this is cited at past non-compliance. Findings: Record review from 6/7-9/22 revealed Resident #13 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility's FRI report revealed: Date of incident: 1/6/22 Date of initial report to the SA: 1/11/22 Date of final report to the SA: 1/13/22 1/6/22 at 3:00 AM: CNA #2 reported to LN #4 that CNA #1 forcefully guided Resident #13 to sit on the bed after toileting. Resident became agitated and combative, and swung at CNA #1. CNA #1 was reported to then grab the resident by the wrists, crossing residents' arms over his/her body, and laid Resident #13 on the bed with his/her head hanging off the bed and restrained him/her for approximately 20 seconds. This encounter re-opened a previous skin tear to the right hand. CNA#2 then went to the hallway to get help. Resident #13 became calm after toileting needs were met. 1/11/22: Administration became aware of incident with Resident #13 at 0945. Information was reported to the SA on 1/11/22 at 11:24 AM. 1/11/22: Facility Interventions revealed: Appropriate notification completed. Investigation initiated. Staff will not return to work until investigation complete. LN #4 reported to the facility that he/she was unsure of what to do and meant to follow up with staff the following day but forgot. During an interview on 6/9/22 at 9:31 AM, the Administrator stated CNA #1's last day of work at the facility was on 1/7/22 (working for one day after the abuse incident). CNA #1 employment terminated on 2/18/22 when the facility substantiated the abuse claim. Review of the facility's policy Abuse Prohibition, last reviewed 1/25/21, revealed: . Identification: Training occurs on identifying incidents, such as suspicious bruising, occurrences, patterns, and trends that may constitute abuse and to determine the direction of the investigation . the staff member will report the findings to his/her immediate supervisor and complete an incident report . Investigation: All alleged violations involving . abuse . must be reported to the administrator or administrator on call if after-hours . The investigation will be conducted as soon as possible after the allegation, preferably, within the same shift .Reporting: All alleged violations will be reported as soon as possible but ought not to exceed 24 hours after discovery of the incident to the appropriate entities (i.e . State Agency) . If LTC staff or mandated reporters, in the performance of their professional duties, who have reasonable cause to suspect abuse or neglect will follow the Abuse and Neglect policy . Corrective Actions by facility prior to survey: Further record review revealed the facility had implemented corrective action prior to the survey conducted on 6/7-9/22. State Agency received an initial report from the facility on 1/11/22. Facility conducted and completed an investigation. State Agency received a final report from the facility on 1/13/22. Record review revealed that CNA #1's last day of work was 1/7/22. CNA #1 employment terminated on 2/12/22. Record review revealed nursing staff had attended educational in-services teaching about the facility's policy Abuse and Neglect Reporting, dated 1/25/21. The teaching involved how to recognize abuse and neglect and the proper protocols for reporting such concerns. Each staff signed an attestation that they were educated, and they understood the steps for proper reporting of abuse and neglect. .

Based on record review and interview, the facility failed to ensure allegations of abuse were investigated in a timely manner. The failure to investigate and take appropriate action placed the resident at risk for continued abuse/mistreatment. The facility had implemented corrective actions prior to the survey conducted on 6/7-9/22, therefore this is cited at past non-compliance. Findings: Record review from 6/7-9/22 revealed Resident #13 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility's FRI report revealed: Date of incident: 1/6/22 Date of initial report to the State Agency: 1/11/22 Date of final report to the State Agency: 1/13/22 Review of the facility's investigation revealed the incident occurred on 1/6/22 at 3:00 AM. Further review revealed Certified Nursing Assistant (CNA) #2 reported to Licensed Nurse (LN) #4 that CNA #1 forcefully guided Resident #13 to sit on the bed after toileting. The Resident became agitated and combative, and swung at CNA #1. CNA #1 was reported to then grab the resident by the wrists, crossing the residents' arms over his/her body, and laid Resident #13 on the bed with his/her head hanging off the bed and restrained him/her for approximately 20 seconds. This encounter re-opened a previous skin tear to the right hand. CNA #2 then went to the hallway to get help. Resident #13 became calm after toileting needs were met. Further reveiw revealed that on 1/11/22 the Administration became aware of incident with Resident #13 at 9:45 AM, when CNA #2 inquired about any follow up from the incident. The incident was reported to the SA on 1/11/22 at 11:24 AM. The facility's investigation revealed: Appropriate notification completed. Investigation initiated. Staff will not return to work until investigation complete. Further review of the investigation documented that LN #4 reported to the facility that he/she was unsure of what to do and meant to follow up with staff the following day but forgot. During an interview on 6/9/22 at 9:31 AM, the Administrator stated CNA #1's last day of work at the facility was on 1/7/22 (working for one day after the alleged abuse incident). CNA #1 employment terminated on 2/18/22 when the facility substantiated the abuse claim. Review of the facility's policy Abuse Prohibition, last reviewed 1/25/21, revealed: . Identification: Training occurs on identifying incidents, such as suspicious bruising, occurrences, patterns, and trends that may constitute abuse and to determine the direction of the investigation . the staff member will report the findings to his/her immediate supervisor and complete an incident report . Investigation: All alleged violations involving . abuse . must be reported to the administrator or administrator on call if after-hours . The investigation will be conducted as soon as possible after the allegation, preferably, within the same shift .Protection: LTC [Long Term Care] facility will protect residents from harm during the investigation of alleged abuse. The protection will occur until the investigation [is] completed and may include: The employee in question will be removed from duty, if reasonable cause is suspected, and placed on administrative leave until the investigation is complete. The employee in question will be paired with another staff member for all resident care if reasonable cause is not suspected . Reporting: All alleged violations will be reported as soon as possible but ought not to exceed 24 hours after discovery of the incident to the appropriate entities (i.e . State Agency) .If LTC staff or mandated reporters, in the performance of their professional duties, who have reasonable cause to suspect abuse or neglect will follow the Abuse and Neglect policy . Corrective Actions by facility prior to survey: Further record review revealed the facility had implemented corrective action prior to the survey conducted on 6/7-9/22. State Agency received an initial report from the facility on 1/11/22. Facility conducted and completed an investigation. State Agency received a final report from the facility on 1/13/22. Record review revealed that CNA #1's last day of work was 1/7/22. CNA #1 employment terminated on 2/12/22. Record review revealed nursing staff had attended educational in-services teaching about the facility's policy Abuse and Neglect Reporting, dated 1/25/21. The teaching involved how to recognize abuse and neglect and the proper protocols for reporting such concerns. Each staff signed an attestation that they were educated, and they understood the steps for proper reporting of abuse and neglect. .

Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set - A federally required assessment) accurately represented a resident's status for 1 resident (#3), out of 10 sampled residents. Without an accurate assessment, the resident was at risk for erroneous information that had the potential for inappropriate or no care and services. Findings: Record review from 6/7-9/22 revealed Resident #3 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/7/22 at 9:59 AM, Resident #3 stated he/she needed hearing aids, but became ill and had to cancel a scheduled appointment. The Resident further stated he/she hoped the facility rescheduled because he/she was sick of saying 'what' all the time. Review of Resident #3's most recent MDS, an admission assessment, dated 5/3/22, revealed under Hearing, the resident was coded as having adequate hearing. During an interview on 6/9/22 at 8:20 AM, Licensed Nurse (LN) #3 stated Resident #3 and his/her daughter talked about the Resident needing hearing aids. During a joint interview on 6/9/22 at 2:09 PM, with the MDS Coordinator and LN #2, when asked if she was aware of Resident #3's hard of hearing status, the MDS Coordinator stated she was, but when the Resident was interviewed, the television was off and the Resident heard her well. When asked if the Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It was further stated the facility was aware of the Resident's request for hearing aids prior to the Resident's admission to the facility, and the facility was working on how to honor this request with the Resident's poor health status. Review of CMS's RAI [Resident Assessment Instrument] Version 3.0 Manual, dated 10/2019, accessed at https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf, revealed the intent was to Document the resident's ability to hear, understand, and communicate with others and whether the resident experiences visual, hearing or speech limitation and /or difficulties. Further review revealed Problems with hearing can contribute to sensory deprivation, social isolation, and mood and behavior disorders. Unaddressed communication problems related to hearing impairment can be mistaken for confusion or cognitive impairment. Further review revealed Steps for Assessment .Interview the resident and ask about hearing function in different situations (e.g. hearing staff members, talking to visitors, using telephone, watching TV, attending activities) .Review the medical record . Further review revealed coding instructions for adequate, was No difficulty in normal conversation, social interaction, or listening to TV. The resident hears all normal conversational speech and telephone conversation and announcements in group activities.

Based on record review, observation, and interview, the facility failed to ensure the care plan was individualized to meet medical needs for 1 resident (# 2), out of 10 sampled residents. This failed practice placed the resident at risk for not having necessary safety measures implemented to address his/her individual needs. Findings: Record review on 6/7-9/22 revealed Resident #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 6/7/22 at 2:11 PM, revealed a fall mat on the floor by Resident #2's bed. Review of Resident #2's Minimum Data Set (MDS - a federally required assessment), a quarterly assessment dated [DATE], revealed the resident required 2+ persons physical assist for bed mobility, 1 person physical assist for transfer between surfaces, and 1 person physical assist for walking. Further review revealed Resident #2's balance when moving from seated to standing position and walking was not steady, and the resident was only able to stabilize with human assistance. During an interview on 6/7/22 at 4:07 PM, Licensed Nurse (LN) #2 stated Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LN #2 further stated the fall mats were at the nurse's discretion, not requiring a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/9/22 at 2:10 PM, when asked how Certified Nursing Assistants (CNAs) knew to use fall mats with a resident, LN #2 and the MDS Coordinator stated the CNAs used the Resident's Care Plan, that detailed the interventions used daily. Review of Resident #2's Care Plan, last revised on 3/22/22, revealed: Focus: The resident is High Risk for falls [related to] [CONDITION(S)] and ocular hypertension [when the pressure inside the eye is higher than normal]. Further review revealed no intervention for the use of a fall mat by his/her bed for safety. Review of the facility's policy Fall Assessment and Prevention, last reviewed 7/15/20, revealed: . Nursing staff (RNs, LPNs, CNAs) caring for residents assessed for fall risk must be familiar with the care plan and intervention(s) to prevent falls and work to support those interventions during each shift . Further review revealed no mention of fall mats, when they should have been initiated, how they would have been initiated, or who was responsible for initiating them when needed.

Based on record review and interview, the facility failed to ensure 2 residents' (#4 and #11), out of 10 sampled residents, drug regimen was free from unnecessary drugs. Specifically, the facility failed to: 1) write pain parameters for multiple PRN (as needed) pain medications; and 2) identify potential errors in administration with 2 separate PRN orders for the same medication. These failed practices had the potential to improperly medicate the residents. Findings : Resident # 4: Record review from 6/7-9/22 revealed Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's most recent physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Ibuprofen Tablet 400 MG [Milligrams] Give 1 tablet by mouth every 6 hours as needed for fever ., and 2. Ibuprofen Tablet 400 MG Give 1 tablet by mouth every 6 hours as needed for pain or inflammation . Further review revealed no documentation regarding the maximum dosage of ibuprofen the Resident should not exceed. During an interview on 6/8/22 at 4:24 PM, when asked how he/she would have ensured the ibuprofen medication was not given more frequently than every 6 hours with 2 separate orders, Licensed Nurse (LN) #1 stated the Resident had not been taking the medication, so he/she did not know. LN #1 further stated the electronic health record would not have notified the nurses if they attempted to administer both ibuprofen orders within a 6-hour window. The LN stated there was a potential for the Resident to receive the medication more frequently than every 6 hours with 2 separate orders. During an interview on 6/9/22 at 10:02 AM, the Pharmacist confirmed that it was possible for Resident #4 to receive the ibuprofen medication greater than every 6 hours with 2 separate orders. Review of Ibuprofen Dosage, dated 5/5/22, accessed at https://www.drugs.com/dosage/ibuprofen.html, revealed Usual Adult Dose for [CONDITION(S)] For minor pains of arthritis: Initial dose: 200 mg orally every 4 to 6 hours; may increase to 400 mg orally every 4 to 6 hours as needed Maximum dose: 1200mg/day (over the counter) Further review revealed Usual Adult Dose for Pain Oral 200 to 400 mg orally every 4 to 6 hours as needed Maximum dose: 3200 mg/day (prescription strength); 1200mg/day (over-the counter). Further review revealed Usual Adult Dose for Fever . Maximum dose: 1200 mg/day. Resident #11 Record review from 6/7-9/22 revealed Resident #11 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] 1) On 4/17/22, started Acetaminophen [Tylenol - a medication to treat minor aches and pains] 650mg [milligrams] by mouth every 6 hours as needed for breakthrough pain; and 2) On 4/25/22, started [MEDICATION(S)]-Acetaminophen [[MEDICATION(S)] - an opioid, narcotic medication for pain] 5-325mg by mouth every 6 hours as needed for pain control . Further review revealed no parameters to indicate which pain medication to give based on a nursing assessment for pain. Additional review revealed that, from April 2022 to June 2022, Resident #11 received Tylenol 20 times, used for pain that ranged from 2 to 10 (based on a pain scale of 0, no pain, to 10, worst pain), and was effective to treat that pain 19 out of the 20 times administered. Resident #11 also received [MEDICATION(S)] 20 times, used for pain that ranged from 3 to 9, and was effective 19 out of 20 times. Review of Resident #11's Medication Regimen Review (MRR- a monthly medication review from the pharmacist), dated 4/28/22, revealed: . PRN [MEDICATION(S)] added 4/25/22, PRN acetaminophen added 4/17/22 . If continues on both PRN pain medications, recommend adding pain scale parameters and acetaminophen limitations . Further review revealed the Director of Nursing signed the Medication Regimen Review on 5/17/22 with the comment, Reviewed and agree. Additional review revealed Physician #1 signed the MMR on 5/11/22 with the comment, . As needed [MEDICATION(S)] added by another provider. We will see what [his/her] need is for this medication over the next month . Asking for pain medication may be more of a habit then a need at this point . Further review revealed no comment from Physician #1 to add pain parameters to the PRN Tylenol and PRN [MEDICATION(S)]. Review of Resident #11's Medication Regimen Review, dated 5/28/22, revealed: . continues PRN [MEDICATION(S)][.] need parameters on both PRN acetaminophen (used x9 for pain scale 3-7 since last review with effective results documented) and PRN [MEDICATION(S)] (used x 14 for pain scale also 3-9 with effective results). Increased c/o [complaints of] on tasks . Further review revealed the MRR was signed by Licensed Nurse (LN) # 2 with the comment, Agree with recommendations. [Tylenol] trial ineffective for pain. [MEDICATION(S)] effective for pain in conjunction with [MEDICATION(S)] patch [a topical medication patch for pain]. Further review revealed Physician #1 signed on 6/8/22 with the comment, At this month's appointment, I will evaluate [his/her] use of as needed [MEDICATION(S)] over the last 4 weeks. If [he/she] requests it with any significant frequency, we will increase [his/her] [MEDICATION(S)] patch dose. If [he/she] has not been using it with any significant frequency, we will discontinue the as needed [MEDICATION(S)] and leave the [MEDICATION(S)] patch at the current dose . Additional review revealed no comment from Physician #1 to add pain parameters to the PRN Tylenol and PRN [MEDICATION(S)]. During an interview on 6/9/22 at 2:43 PM, LN #2 stated he/she would have used what the resident was saying and describing during a pain assessment to determine which pain medication to use, however he/she could not identify the pain parameters for Resident #11's Tylenol and [MEDICATION(S)] orders. During an interview on 6/9/22 at 2:59 PM, Physician #1 stated multiple PRN medications for pain ordered for a resident should have absolutely had pain parameters set for each medication. Physician # 1 further stated that the parameters for Resident #11's PRN medications were missed. Surveyors requested a facility policy or procedure for parameters of pain medication; however, the facility representative stated the facility did not have a policy.

Based on interview, observation, and record review, the facility failed to ensure 3 residents (#s 1, 9, and 14) 1.) had the information necessary to file a grievance, had information on how to file a grievance anonymously; 2.) failed to assist 1 resident (#5) with filing a grievance, and 3.) failed to address repeated verbal complaints by the residents. This failed practice denied all residents (based on a census of 14) their right to file a grievance and have their concerns and problems resolved. Findings: During an interview on 4/26/21 at 4:09 PM, when asked how to file a grievance with the facility, Resident #9 stated if they have a concern, they go to Licensed Nurse #3 if he/she not here they go to the current Director of Nursing, the backup. An observation on 4/26/21 revealed a poster on the wall at the entryway of the facility. The sign listed the State Agency, the Ombudsman, the Quality Improvement Organization, and the Grievance Officer. The Grievance Official was located in another city. A phone call was placed to the Grievance Official's number listed on the sign on 4/26/21 and it was routed to the Long-Term Care Administrator. During an interview on 4/28/21 08:32 AM the Administrator and the Director of Nursing were notified of the wrong phone number on the sign. The Administrator stated she thought the Grievance Official's phone might have been forwarded to her. During a group meeting with Resident #s 1, 9, and 14 on 4/28/21 at 11:00 am, when asked if the Grievance Official responded to the Resident Council's concerns, the group replied Staff #1 used to respond, now the grievances go to Certified Nursing Assistant #5 , or LN #3. When asked about recent concerns the group had expressed, they responded when there was a COVID 19 exposure the facility went to an alternative menu. They stated there were no alternative food choices available. In addition, all the meals were served on disposable plates and with plastic spoons, forks, and knives. Resident #9 stated he/she had a difficult time eating with plastic eating utensils. During the meeting, Resident #14 stated staff do not deliver water to his/her room in the evening. He/she was not allowed to take his/her garlic pills anymore, and he/she is no longer allowed to keep Vicks (Vaporub mentholated ointment) at the bedside. The Resident stated although the facility told him/her, the garlic pills were not available. The Resident said garlic pills were available at the local store. Resident #9 stated he/she had no longer been able to keep Biofreeze roll-on or cough drops at the bedside. Neither of the Residents had been satisfied with the facilities response to their concerns. During an interview on 4/27/21 at 9:15 am, Resident #5 expressed frustration regarding plastic eating utensils for meals. Resident #5 said he/she was naturally left-handed but since having a stroke, he/she had to learn to use right hand, and it has been a challenge. Resident #5 said, It is very, very hard to eat peas with a plastic spoon. The Resident said he/she needed metal silverware to eat. An observation on 4/27/21 at 9:20 am revealed Resident #5 eating breakfast. He/she held a spoon in his/her right hand. The Resident grasped the spoon in the palm of his/her hand with all fingers wrapped around the spoon handle and the spoon facing downward. When asked why he/she used plastic eating utensils, the Resident said it was what they gave him/her because of the virus (COVID). Resident #5 said when the facility was on the virus [referring to COVID-19] process, he/she had no choice; said the staff told him/her they had to use plastic. The Resident further expressed additional complaints about not being able to sleep through the night for the past month and the lack of meal substitutions that the facility offered. A record review revealed that in March 2021, Resident #5 expressed a choice to his/her physician to not be awakened every two hours during the night because he/she was not getting enough sleep. The Resident verbalized this choice to the physician during a visit. The physician concurred and wrote an order dated 3/23/21 that read; reduce skin checks to Q4hrs [every 4] while asleep; if there is active skin breakdown, alert provider. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #5] complains that [he/she] has been woken up every 2 hours for skincare We discussed with nursing staff that [resident] should be allowed to sleep at least 4 hours uninterrupted unless there is changes in skin breakdown. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . [He/she] is also frustrated by [his/her] food being cold and chopped up too small for [him/her]. The physician noted a 25 lb. weight loss since admission. Review of a nurse's note dated 5/3/21 revealed, Requesting 4 hours on uninterrupted sleep at night. States that this did not happen last night, and he has requested it already and is requesting it again. During an interview on 4/29/21 at 2:27 PM, the Dietitian stated when the facility went on lockdown they used plastic disposable cutlery and plates and a limited menu. This menu was intended to be used if they were short-staffed due to COVID. She stated Resident #5 would have a difficult time eating with plastic flatware. A review of the Complaint/Grievance Log provided by the facility on 4/28/21 at 11:01 AM revealed 3 grievances had been filed in 3 years. None of the ongoing concerns shared by the residents were listed in the log. During an interview with the Performance Improvement Manager ([NAME]) and the Administrator on 4/30/21 at 9:07 AM, they were asked about their involvement with the resident council. The [NAME] stated she attends the resident council meetings upon invitation. When asked about the residents not seeming to be aware of how to file a grievance, the [NAME] said she told the residents about projects and explained how they file a grievance; I assist them and showed them phone numbers. When asked about the grievance policy identifying a box to place grievances in, the Administrator stated it was in the old building before moving. The Administrator noted the facility recently gave the residents updated booklets with updated numbers, and they do daily huddles to try to fix stuff on the spot. On 4/29/21 review of the Resident Council meeting minutes for 3/23/21 revealed, Residents' rights and responsibilities will be taken over to the LTC [long term care] for each resident to have a copy. CNA and activities can help the resident read and understand their rights. On 4/29/21 review of the Resident Bill of Rights, revised 7/30/20, revealed: 25. To be informed of the facility's grievance procedure for handling complaints related to your care and the express grievances without interference, coercion, discrimination from the facility. Such a grievance can be made to the grievance officer either verbally or in writing. Individuals who file a grievance will be free from any form of retaliation or intimidation. 26. You have the right to carry concerns or grievances about the care you receive directly to the State of Alaska Extended Care Ombudsman at [PHONE NUMBER]; or the State of Alaska Department of Health Facilities Licensing and Certification; the Medicaid Fraud Unit; the Disability Law Center of Alaska; and Adult Protective Services. Addresses and phone numbers are posted within the facility.

Based on the interview, observation, and record review, the facility failed to ensure sufficient dietary staff, adequate training, and supervision to effectively provide services to all the residents residing in the facility (based on a census of 14). This failed practice affected the ability of the dietary staff to meet residents' needs and placed residents at risk for inadequate nutrition. Findings: During an initial kitchen tour, when asked what the menu was on 04/26/21 09:49 AM, Cook #1 said dietary staff usually ask the residents what they wanted but had not been offering that option because dietary was short-staffed. Cook #1 stated the meals had been served from the central kitchen because they had been on a COVID menu (a menu for emergency operations). The meals had been served from the hospital's main kitchen. The Cook stated they had just started operating from the Long-Term Care (LTC) kitchen today. During an observation of meal service on 4/26/21 at 12:19 PM, Cook #1 prepared and served lunch for the residents. The Cook was observed marking the residents' names off a list as he/she prepared the trays. When asked about the residents' diets and menu cards, Cook #1 stated they had a computer program but were not using it. The residents received the main menu because it was the COVID menu and did not get to select. The Cook said the always available menu was not available today because they were short-staffed. During the observation on 4/26/21 at 12:19 PM, Cook #2 stated that dietary was short-staffed, so they don't have an alternative menu today and are using the COVID menu. An observation on 4/29/21 at 8:30 AM revealed Resident #3 was covered with a blanket and asleep in the dining room. During the observation, CNA #4 approached Cook #3 and asked what breakfast alternatives were available. Cook #3 responded there were no choices because the kitchen did not have enough staff, but the residents could have oatmeal or cream of wheat. During an interview on 4/29/21 at 12:30 PM, Cook #3 was serving lunch to the residents. As he/she prepared the trays, the Cook marked residents' names off a scrap of paper on the counter. There was no diet or allergy information, nor information about the type of assistive devices the residents needed to eat. When asked how he/she knew what each resident received, the Cook stated most of the residents were on mechanical soft diets. During an observation on 4/29/21 at 12:45 PM, the Dietitian was in the back running the dishwasher. When asked why she was washing dishes, the Dietitian stated the Dietary Manager (DM) was not at work that day, and the facility was short-staffed. The Dietitian was a consulting Dietitian and visited the facility every few months and as needed. During a telephone interview on 4/29/21 at 2:51 PM, the DM stated the dietary staff had been using plastic flatware and paper plates to serve the residents until it was clarified last Thursday. When asked about resident assistive devices, the DM stated the staff was great about giving the residents what they needed. When asked about the meals service being provided without the benefit of resident meal tickets or diet, the DM stated the staff knows the residents after working here for years. During an interview on 4/29/21 at 2:51 PM, the Dietitian stated the point of having an open kitchen was so the residents could eat anytime they wanted and have alternative options. The Dietitian said dietary was down three staff positions, and the DM had just put in his resignation last week; the Dietitian stated she had a temporary replacement. The survey identified the following concerns. Resident concerns about lack of alternative food items. Refer to F561 During the survey, concerns were identified regarding residents having to use plastic/ paper eating utensils and not being provided with adaptive eating equipment when the facility was on COVID precautions during the pandemic. Refer to F585 Staff not referring to residents' meal tickets when plating and serving meals and not implementing physicians' orders. Refer to F803 Residents' meals being left on a cart after the kitchen closed, being served unpalatable food. Refer to F804 Concerns regarding the dietary staff hand hygiene and facility oversight-Refer to F812 During an interview on 4/30/21 at 8:47 AM, the Performance Improvement Manager ([NAME]) was asked about the concerns in the kitchen. The [NAME] stated they had recently done a walk-through and were working on things with the Dietary Manager. She said that the DM had been late reporting any quality data and had issues with being short-staffed in dietary. The [NAME] stated it was hard to hire in the dietary and environmental services positions, as the work pool in town was not very large.

Based on observation, interviews, and record review the facility failed to ensure all resident diets (based on census of 14) were followed when serving meals and failed to ensure 2 residents (#3 and #12) had their diet orders incorporated into their meal service. This failed practice placed residents at risk for receiving the wrong diet and inadequate nutrition which had the potential to contribute to residents receiving an improper diet and/or weight loss. Findings: During an initial tour of the kitchen on 4/26/21 at 9:49-10:00 AM, Cook #3 was asked about the dining process. The Cook replied normally, when they are fully staffed a dietary aide would go around and asked the residents what they want to eat. Cook #3 said they are not doing the ala cart menu as they were on the COVID menu for 2 weeks and all the residents were served from the main kitchen. Cook #3 stated he/she had started working at the facility a few months ago. During an interview on 4/26/21 at 12:19 PM Cook #1 was asked what the menu was and how he/she knew what to serve each resident, Cook #1 replied they have a computer system to print the menus but the facility is not currently using it. The Cook stated they are just using the main everyday menu. 4/26/21 at 12:40 PM Cook #1 was observed plating food for the residents' lunch. After preparing a tray for Resident #5, the Cook grabbed a pen, scratched the Resident's name off a piece of paper. Cook #1 then repeated the process for Resident #4, marking their name off the list after preparing the tray. During an observation on 4/26/21 at 11:45 AM Cook #3 was observed preparing lunch for the residents. During the observation, the Cook#3 stated to Cook #2 I still have an hour to serve. I don't know if we have enough food. When asked about the shortage, the Cook stated it was because the hospital had seven patients which messed with their number. During an observation on 4/26/21 at 12:15-30 PM Cook #3 was plating the meals for the residents from the steam table. Each resident received a scoop of green beans, duck casserole, and a cup of pudding for desert. The Cook then used a pen to scratch the resident's names off a piece of paper. The resident's diets were not listed on the trays. Each tray was identified by the residents name written on magic marker on cellophane wrap on their desert or fruit cup. Observation on 4/29/21 at 11:40 AM, Cook #3 was plating and serving food from the LTC kitchen. The Cook used scoops to serve the lunch meal of duck casserole and green beans on a plate. During the observation, the Cook would prep the food and cross the residents' names off a scrap of paper. During an interview on 4/29/21 at 11:35 PM, when asked about his/her job, Cook #3 stated he/she had only worked there a couple of months. When asked what training was provided, the cook stated it was primarily on-the-job training. During an interview on 4/29/21 at 12:35 PN, when asked how he/she know what each resident was supposed to receive, Cook #3 stated it was just from working here. The Cook stated her training was mostly on the job and he/she had worked here about 2 months. Resident #3 Record review on 4/29/21 revealed the Resident had a diagnosis that included Alzheimer's disease and anxiety. The Resident's diet was a general diet, one pureed item per meal, thin liquids, Add 1 scoop of protein per day. Review of the Resident's weights revealed on 10/4/20 a weight of 139 pounds, and on 4/25/21 a weight of 127 pounds. A total weight loss of 12 pounds or 8.7 % of body weight. Review of a physician's order, dated 4/19/21 revealed, Consult dietician. Calorie Count for 7 days. Further review of the clinical record revealed the calorie count was not conducted for Resident #3. During an interview on 4/29/21 at 2:27 PM the Registered Dietician (RD) stated was not aware of the calorie count order for the Resident. Resident #12 Record review on 4/28/21 revealed Resident #12 had diagnoses that included dysphagia (difficulty swallowing), [CONDITION(S)] (lack of ability to speak or comprehend speech), and Alzheimer's disease. Review of the Resident weights revealed on 10/04/20 a weight of 175 pounds and on 4/25/21 a weight of 145.6. In total the Resident lost 19.4 pounds and 16.8 percent of body weight. Review of a speech therapy telehealth evaluation completed 3/23/21 by the Speech Therapist, revealed [Resident #12] was observed via a telehealth during [his /her] morning meal for a swallow screening due a significant change [MDS] .[Resident #12] has lost a significant amount of weight [about 20 pounds] recently and has low intake due to inability to propel bolus posteriorly. The recommendation was to provide nutritionally dense and high calorie foods unless tube feedings want to be considered. Review of a progress note, dated 3/15/21, written by Licensed Nurse #2 revealed, Note to Dr. to relay a 9 lb. weight loss though some of this may be weight error. A reweigh has been done X 2 and [Res #12] is visibly thinner to abdomen and face. Is having more difficulty tolerating sitting up in wheelchair, not holding head up for very long. Review of physician orders, dated 3/29/21, revealed an order for a 2200 calorie diet with pureed consistency texture, Nectar consistency fluids. Review of a care conference note, dated 4/7/2, revealed Eating increased. The physicians diet orders and results of the speech evaluation was not documented. During an observation on 4/28/21 at 1:02 PM - 1:20 PM Certified Nursing Assistant (CNA) #3 was feeding Resident #12 a lunch that consisted of pureed roast beef, carrots, and rice. When the Resident began to hiccup every 15 seconds, the CNA stopped feeding the Resident and discussed the concern with CNA #2. The CNA then returned the tray to the kitchen. The Resident had consumed 10% of the meal. During an interview on 4/28/21 at 1:15 PM CNA #2 stated Resident #12 could get another meal later. During an interview on 4/28/21 at 2:20 PM CNA #2 stated Resident # 12 had not received anything else to eat or drink because of the hiccups. The CNA went to the kitchen and retrieved an Ensure (high calorie sense food) pudding cup and assisted the Resident with eating it. The Resident ate 25% of the pudding. During an interview on 4/29/21 at 11:45 AM, when asked about the Resident's diet orders, the MDS Nurse stated that Resident had lost weight, and this was due to early onset diagnosis of Alzheimer's. During an interview on 4/29/21 02:52 PM, the Registered Dietician stated there were concerns with no one updating orders and that she was not knowledgeable about new recommendations from the Speech Therapist in March 2021 about high calorie diet. During a telephone interview on 4/29/21 at 2:51 PM, when asked how the staff knew which diet to serve each resident, since the staff were just marking them off a list of names, the Dietary Manager (DM) replied We know the residents from working here for years. The DM stated nursing was responsible for getting the dietary orders into the program. After the call ended, the Dietitian, who was present during the interview added it was a concern the computer program was not being used for reports. The Dietitian stated the Dietary Manager should run off the meal ticket for the staff every morning. Review of the diet slips requested from the facility revealed they were from 2/03/21. The diet slips were a paper ticket that included a food texture resident's texture, the amount of food they were supposed to receive , the type if fluids, how the meal was to be served, and what special eating equipment (scoop plate or spoon) the resident was supposed to receive. The meal ticket also had a section that listed allergies. .

Based on observation, interview, and record review the facility failed to ensure food safety practices were implemented and monitored in the area of food storage and hand hygiene. This failed practice placed all residents receiving food from the kitchen at risk for food borne illnesses (based on a census of 14). Findings: Observation of the facility's central kitchen on 4/26/21 at 09:45 AM revealed two hand washing sinks on opposite sides of the wall. When the spigot was opened for several minutes, the water ran cold. After running the sink on the other side of the wall for a few minutes, the temperature was tepid. Sink #2 also contained an eye-wash station. During an interview on 4/26/21 at 09:45 AM, when asked if the water to the first sink ever got warm, Cook #2 replied, rarely. The Cook said the one on the other side of the wall (sink #2) got warm if you held the tap open long enough. According to the U.S. Food & Drug Administration Food Code (2017) (A) Except as specified in ¶ (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under § 5-202.12 and Subpart 6-301. (B)FOOD EMPLOYEES shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms: (1) Rinse under clean, running warm water . Observation on 4/26/21 at 10:00 AM of the reach-in cooler, located in the long-term care (LTC) service kitchen, revealed four plastic gallon pitchers containing colored liquids. Four of the pictures were covered with lids, and one was covered with saran wrap. None of the pitchers were labeled or dated. During an interview on 4/26/21 at 10:00 AM, when asked about the pitchers, Cook #1 replied staff had made it over the weekend. The Cook stated the containers were usually labeled. According to the Food Code (2017), refrigeration prevents food from becoming a hazard by significantly slowing the growth of most microbes. The growth of some bacteria, such as Listeria monocytogenes, is significantly slowed but not stopped by refrigeration. Over a period of time, this and similar organisms may increase their risk to public health in ready-to-eat foods .A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. During a dining observation on 4/26/21 at 12:40, Cook #1 was observed serving venison and rice from the steam table located in the LTC service kitchen. While preparing plates for Residents #s2 and 5, the Cook, while wearing gloved hands, touched the mask on his face two times. Without washing hands and donning new gloves, the Cook continues to plate food for Resident #5, lowered his/her mask to talk. After placing the plate and the food on the tray, Cook #1 placed the tray on the cart. While wearing the same gloves the Cook, picked up a pen, crossed a name of a piece of paper, and plated lunch (two scoops carrots, one scoop of rice, one ladle of soup) for Resident # 4 During an observation on 4/29/21 at 11:20 AM, Cook #3 was observed preparing a salad in the LTC service kitchen. The Cook was using both gloved hands to cut up lettuce on a cutting board. The Cook scooped up the lettuce and placed it on a large plate. The Cook touched the cart with the same gloved hands, retrieved a steam table pan from Cook #2 and put it in a steam table. With the same gloved hands, Cook #3 started cutting a tomato on the cutting board. The Cook picked up a cucumber rinsed over the sink. Two sanitizing buckets were located on one side and soiled mixing pitcher and robo mixer container was soaking, carried the cucumber over to the cutting board, and began cutting it up. The Cook then plated a few slices on the plate. The Cook removed both disposable gloves and the white glove he/she was wearing on his/her left hand to reveal another pair of disposable gloves underneath. While wearing the gloves, Cook #3 put the cover on the salad plate, used their right hand to open the reach-in cooler and removed three slices of cheese, sliced them up, and arranged the cheese on the same salad plate. The Cook then removed the left glove, opened the kitchen door, went to the big kitchen, and obtained a prepared boiled egg. Cook #3 removed the right glove and donned new gloves without hand hygiene. The Cook opened the reach-in refrigerator, removed some lunch meat (he/she identified as turkey), sliced it up, and plated it on the same salad plate. Cook #3 then sliced up the boiled egg, placed it on the salad, put the cover back on, and placed it in the reach-in cooler. During an interview at 11:32 AM, Cook #3 stated the salad was for Resident #9. On 4/29/21 at 11:35 am, Cook #3 removed both gloves and used a wipe from sanitizing bucket to clean the counter. After putting the wipe back in the bucket, the Cook washed both hands, donned a new pair of disposable gloves, white gloves, and another pair of disposable gloves on top. He/she then washed a tomato over the dishes and buckets in the sink, carried it to the cutting board and sliced it up into quarters, and placed the slices into a plastic container. He/she then removed the gloves without hand hygiene, scooped some water into what he/she said was the chicken broth that was sitting on the stove. On 4/29/21 at 11:40 AM, the Cook wrapped up the remaining uncut vegetables, returned them to the central kitchen for storage, and without hand hygiene, put on a new pair of gloves, opened a bag of kale, and began breaking it into smaller pieces placing into a plastic container with his/her gloved hands. At 12:00 pm, Resident #1 was observed to wheel up to the counter and request a milkshake. Cook #3 made the Resident a strawberry shake with Ensure and ice cream in the blender; the cook then removed both gloves and obtained a straw for the resident. Without performing hand hygiene, Cook #3 donned a new pair of gloves and used the left gloved hand to place a kale and pear garnish on a plate. While wearing the same gloves, the Cook used the scoop to put serve the lunch meal of duck casserole and green beans on a plate. During the observation, the Cook would prep the food and cross names off a scrap of paper, then using his/her gloved hands, the Cook placed kale garnish on the plates and used the scoop to plate the casserole and green beans. While wearing the same gloves and without hand hygiene, the Cook donned the white glove of his/her left hand, another pair of disposable gloves, and began slicing lettuce for a garnish. During the observation, Cook #3 crossed names off a list on a scrap of paper as he/she prepared the plates. While wearing the same gloves, the cook placed the kale garnish on a tray with the scoop of duck casserole and scoop green beans. While wearing the same gloves, the DA donned a white glove on the left hand and donned disposable gloves. The Cook picked up a cutting board and slice lettuce and put it on a plate sitting on the cart. During an interview on 4/29/21 at 11:35 PM, when asked about his/her job, Cook #3 stated he/she had only worked there a couple of months. When asked what training was provided, the cook stated it was primarily on-the-job training. The cook said he/she had a food handler's card. Review of the kitchen quality improvement information, provided by the dietitian on 4/29/21, revealed no evidence of hand hygiene audits in the kitchen. -301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation, including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (49(E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands.

Based on observation, interview, and record review, the facility failed to ensure an ongoing activity program to include a variety of facility - sponsored group and individual activities based on individual assessment, care plan, and preference was implemented by facility staff for 3 residents (#s 6, 9, and 3) out of 3 residents reviewed for activities. This failure placed residents residing in the facility at risk for boredom, loneliness, and decreased quality of life. Findings: Resident #6 During an interview on 4/26/21 at 11:45, AM Resident # 6 was asked what activities he/she participated in at the facility. Resident #6 stated sometimes he/she eats in the day room. The Resident said he/she used to go to church and enjoyed listening to church music. Random observations on 4/26/21 from 11:00 AM to 12:30 PM revealed Resident #6 lying awake in bed. The Resident was not participating in activities. Random observations on 4/26/21 from 2:00 PM to 03:30 PM revealed Resident #6 lying awake in bed. The Resident was not participating in any activities. Random observations on 4/27/21 from 9:00 AM until 10:23 AM revealed Resident #6 lying awake in bed; the Resident was not participating in any activities. Random observations on 4/29/21 from 9:00 AM until 11:00 AM revealed Resident #6 was awake in bed. After the Resident received morning care and consumed breakfast, he/she remained in the room. The Resident did not get out of bed or listen to any gospel music. Record review on 4/28-5/4/21 revealed Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Resident's care plan, revised 3/10/21, revealed no care plan for activities. Resident #6 focus was impaired interaction to embrace positive thinking statements; the care plan did not identify specific activity interventions for the Resident. Review of the plan of care revealed: Focus Impaired Social Interaction r/t diagnosis of [CONDITION(S)] Goal Resident Will Embrace Positive Thinking Statements Interventions/Tasks Position Freq/Resolved Resident Will Participate in Social Situations . Consult facility activities coordinator . Determine underlying cause of low self-esteem . Encourage Resident to be involved in self-care . Encourage Resident to participate in recreational activities . Encourage Resident to participate in social situations . Evaluate effect . Evaluate Resident's ability to perform ADLs / IADLs [Activities of Daily Living/ Independent ADLs] . Monitor for presence of negative thoughts, feelings . Monitor interactions with others . Monitor Resident's level of social interaction . Provide positive enforcement when Resident participates in activities . Review of the Activities Initial Review, dated 11/16/20, revealed Resident #6 had cognitive, visual, and mobility deficits that affected ability to participate in activities. .please describe the accommodation that should be made to encourage/promote activity participation (i.e., porter to activities, provide large print where appropriate, sit near leader so the resident can hear better). Resident says that [he/she] remembers some things such as people, but it is hard to tell because [his/her] vision isn't good anymore. I will try to find a Christian channel for [him/her] so residents can hear Church services. Resident stated [he/she] would come to the day room if [he/she] could. A review of the activity participation notes on 4/30/21-5/4/21 revealed Resident #6 had participated in 4 documented activities on 4/2021, 8 documented activities on 3/2021, and 4 documented activities on 2/2021. View 4/26/2021 12:46 Activity Participation Note Note Text: [Resident #6] rang [his/her] bell this morning to be pulled up in bed. He/she said that it was still nice outside. View 4/23/2021 15:41 Activity Participation Note Note Text: I talked in the dining room with [Resident #6] about how nice the weather is today, [he/she] said [he/she] used to love to go for walks to town in the sunshine. View 4/12/2021 15:41 Activity Participation Note Note Text: [Resident #6] had a visitor today. View 4/2/2021 15:40 Activity Participation Note Note Text: [Resident #6] was in the LTC living room and ate a piece of chocolate. View 3/31/2021 15:49 Activity Participation Note Note Text: [Resident #6] was in the LTC [long term care] living room today after lunch. View 3/29/2021 15:04 Activity Participation Note Note Text: [Resident #6] got an Easter Card from one of [his/her] old coffee friends. We are going to mail a card out tomorrow. View 3/22/2021 15:49 Activity Participation Note Note Text: I went into [Resident #6's] room and looked at [his/her clothing] with [him/her] and [he/she] would like the [clothing he/she] gets to go to [his/her] ankles. View 3/19/2021 15:35 Activity Participation Note .[Resident #6] and I visited in the living room today and talked about [his/her] friend [name], and how [he/she] used to go to the Stik cafe and have coffee . View 3/18/2021 15:25 Activity Participation Note .I went into [Resident #6's] room and read a chapter in [his/her] bible, [he/she] fell asleep. View 3/15/2021 15:25 Activity Participation Note .I went in to go and visit [Resident#6], but [he/she] was asleep at the time. View 3/9/2021 15:07 Activity Participation Note .[Resident] came into the living room today and was listening to some Johnny Cash on the tv. View 3/1/2021 15:03 Activity Participation Note .[Resident #6] came into the dining room today for a meal. View 2/25/2021 14:57 Activity Participation Note .I went in and said hi to [he/she] said hello back to me. View 2/10/2021 15:32 Activity Participation Note .Read a letter to resident and turned-on gospel music for her. View 2/8/2021 16:35 Activity Participation Note .Read Bible verses to resident and prayed with her. View 2/5/2021 16:10 Activity Participation Note .Spent time reading the Bible and singing Gospel Hymns with resident. Resident #9 During an interview on 04/27/21 at 10:56 AM, when asked what activities he/she enjoyed, Resident #9 stated that the activities person works in acute care now. The Resident said the Activity Aide is only suitable for Bingo on [his/her] terms. The Resident stated he/she used to have friends on the outside. Resident #9 stated he/she was not aware when the facility would start to allow visitation again. In addition, the Resident stated the facility was going to start taking them for drives again, but he/she had received no information about it. Observations during the survey from 4/26-28/30 revealed Resident #9 got out of bed to attend the group meeting, throughout the week the Resident remained in bed watching TV and talking on the phone. Record review on 4/29-5/4/21 revealed Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Quarterly/ Annual Participation Review dated 3/3/21 [Resident # 9] doesn't participate in bingo like [he/she] used to. [Resident # 9] does attend the monthly Resident Council meetings .3. Progress Toward Residents Activity goals the box b. Goals were met was checked. A review of the Resident's care plan, revised 3/24/21, revealed: Focus The resident has little or no activity involvement r/t Immobility. Goals The resident will participate in activities of choice at least 2 times per week by review date. Interventions/Tasks [Resident] enjoys a Wordsearch every now and then, nothing too simple as [he/she] Ive's [loves] a challenge. [Resident #9] is the [involved in resident council]. We have meeting's once every month on the second Tuesday. Remind the resident that the resident may leave activities at any time and is not required to stay for entire activity. The resident needs assistance/escort to activity functions. Review of the activity participation notes for 3/1/21-4/30/21 revealed Resident #9 was offered the opportunity and refused to go to bingo 11 times. There was no information about other activities that were provided instead of bingo. Effective Date: 4/28/2021 11:02 Type: Activity Participation Note [Resident #9] attended a resident council meeting with the surveyors. 'Effective Date: 4/27/2021 15:52 Type: Activity Participation Note [Resident #9] refused to come play bingo today when offered. Effective Date: 4/23/2021 15:47 Type: Activity Participation Note [Resident #9] helped paint for our Memorial Day decorations. Effective Date: 4/22/2021 15:35 Type: Activity Participation Note [Resident #9] painted something for a craft project we are doing for LTC. Effective Date: 4/19/2021 15:32 Type: Activity Participation Note I went into [Resident #9's] room today and adjusted [his/ her] pillows under [his/her] arm and his/her] neck and [he/she] said [he/she] was so much more comfy. Effective Date: 4/16/2021 15:13 Type: Activity Participation Note Today I went into [Resident #9's] room and [he/she] asked me to remove [his/her] clear fingernail polish from [his/her] nails. I did so and asked [him/her] if [he/she] wanted to take a break from nail polish as it's healthy to take a break from it, [he/she] agreed. Effective Date: 4/15/2021 15:41 Type: Activity Participation Note [Resident #9] and I had a nice visit while I was trimming [his/her] nails today. [He/she] got some Gunk [sic] mail) it had some cards in it that I put together for [him/her]. Effective Date: 4/8/2021 15:20 Type: Activity Participation Note [Resident #9] almost came to play bingo [sic] and at the last minute changed [his/her] as a family member had called [him/her]. Effective Date: 4/5/2021 15:03 Type: Activity Participation Note [Resident #9] refused to come to play bingo. Effective Date: 4/1/2021 15:11 Type: Activity Participation Note [Resident #9] got a haircut today. Effective Date: 3/31/2021 15:58 Type: Activity Participation Note [Resident #9] requested my presence to clean [his/her] nails this morning. Effective Date: 3/30/2021 15:21 Type: Activity Participation Note [Resident #9] refused to play bingo today but had a few minutes on Facebook. Effective Date: 3/29/2021 15:10 Type: Activity Participation Note [Resident #9] refused to play bingo today. Effective Date: 3/26/2021 14:54 Type: Activity Participation Note [Resident #9] refused to come play bingo today. Effective Date: 3/25/2021 15:46 Type: Activity Participation Note [Resident #9] received some mail today and had shower. Effective Date: 3/24/2021 15:48 Type: Activity Participation Note [Resident #9] had a care conference today, and hair appointment has been rescheduled for next Thursday. Effective Date: 3/22/2021 15:54 Type: Activity Participation Note I stopped and visited [Resident #9] for a few minutes today, and [he/she] had me write [his/her] room phone number on his/her] white erase board. Effective Date: 3/19/2021 15:58 Type: Activity Participation Note [Resident #9] had nails trimmed, and filed and I also polished nails. [Resident #9] didn't want to play bingo today. Effective Date: 3/18/2021 13:06 Type: Activity Participation Note Today [Resident #9] is working on another Brainspark word search game in room. Effective Date: 3/17/2021 15:54 Type: Activity Participation Note I gave [Resident #9] a word search today, and [he/she] finished all but 3. I helped [him/her] with those. [He/she] was on a facetime call with [family member] at the time. When [Resident] was done with [family member] [he/she] mentioned that I was the cat's meow. Effective Date: 3/17/2021 15:50 Type: Activity Participation Note Note Text: St. Patrick's Day Activity: Leprechaun Rocks. Asked resident to wash the rock. [He/she] dropped the rock in vinegar and watched as it started to fizz and bubble. Resident was laughing and enjoyed seeing the rock turn into a golden coin [Resident #9] loved the activity and was able to share it with [family member] while they were facetiming. Effective Date: 3/15/2021 15:32 Type: Activity Participation Note [Resident #9] didn't want to play bingo today. Effective Date: 3/12/2021 15:28 Type: Activity Participation Note [Resident #9] refused to play bingo today. Effective Date: 3/11/2021 15:54Type: Activity Participation Note [Resident #9] got mail today and a newspaper to read. [His/her family member] stopped by to visit by [his/her] bedroom window, Effective Date: 3/10/2021 15:47 Type: Activity Participation Note [Resident #9] received some mail today. Effective Date: 3/9/2021 15:16 Type: Activity Participation Note Today when I went into [Resident #9] room, [he/she] was on Facebook watching videos. I filed [his/her] nails for [him/her]. [Resident #9] also asked about the pen [NAME] for LTC. I mentioned that I would look into it, and I have. Effective Date: 3/8/2021 15:38 Type: Activity Participation Note Today [Resident #9] didn't want to leave [his/her] room to play bingo as it was shower day. Effective Date: 3/3/2021 14:29 Type: Activity Participation Note [Resident #9] got some mail today. [He/she] was asleep, so I stuck it on bedside table today. Effective Date: 3/2/2021 15:18 Type: Activity Participation Note Today I put [Resident #9] white erase board in room on the counter. Effective Date: 3/1/2021 15:09 Type: Activity Participation Note [Resident #9] refused to play bingo today. Resident #3 During an observation on 4/27/21 at 10 AM, Resident #3 was in bed, the room was darkened and resident was resting with eyes open. There was no music playing on the TV or a radio. During observation and interview on 4/28/21 at 12:15 PM, Certified Nursing Assistant (CNA) #2 assisted Resident #3 up for lunch. When asked who provides activities for Resident #3, CNA #2 stated, Christian music is available on the TV, and the CNA's provide activities for the residents and do resident care. On 4/29/21 at 11:15 AM, Resident #3 is lying in bed with the lights out, the Resident is alone, and no music was playing in the room. During a phone call on 4/26/21 at 3:20 PM with Resident #3's Representative (RR #3). The RR stated that sometimes Resident #3 is in [his/her] room with no activities. RR #3 stated the Resident has to be read to and has Christian music to listen to. The RR said they are not happy if the Resident sits in the room with no activity. During an interview on 4/29/21 at 10:48 AM, the CNA # 5 stated, I am the activities assistant. I haven't completed [Resident #3's] activities care plan. [Resident #3] likes to come to Bingo and calls out numbers occasionally and prefers 1 on 1 activity and loves listening to the gospel with the firestick on [his / her] TV. There has been no music this week. The activities director is out on an emergency, and the AA had called off. 4/29/21 11:35 AM, the MDS Nurse stated, We try to keep [Resident #3] engaged as much as possible. The MDS Nurse said, This week, Resident #3 received no music. On 5/04/21 at 9:25 AM, during a telephone interview, the Activities Coordinator (AC) stated she now worked at the hospital and is not currently allowed to go to the long-term care center (LTC) due to COVID-19. She said she is a Physical Therapy Assistant and had worked in the activity department at the LTC for almost two years. She stated the Activity Aide (AA) was new to activities. When asked who the activities coordinator was, as she and the AAs did not meet the minimum qualifications, the AC stated that Occupational Therapist is actually over the activities program. When asked what oversight he has over the program, the AC stated she ran things by him. During the interview when asked who's responsible for the activity's assessments and the care planning for activities, the AC stated AA can do the activities assessment and works with the MDS Nurse to do the care plan. When asked who participated in the interdisciplinary team meetings, the AC stated she could. When questioned about the interventions provided to Resident # 6, compared to her likes and dislikes and the observations. The AC said Resident # 6 usually has music tuned onto her favorite station. However, she sleeps a lot and can refuse. She stated that evening and weekend nursing staff are good about providing activities as she used to work a split shift since they have no way of documenting its activities, so she does not think it's captured. During the telephone interview, the AC was asked about the van rides. The AC stated they had not started up yet because the residents had to social distance in the van, even if they had been vaccinated.

Based on record review, observation, and interview the facility failed to offer sufficient fluids for 1 resident (#6) of 1 resident reviewed for hydration and failed to implement nutritional interventions for 2 residents (#s 3 and 12) of 4 residents reviewed for nutrition. These failed practices placed residents at risk for dehydration and weight loss. Findings: Record review on 4/28-5/04/21 revealed Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) quarterly assessment, dated 2/09/21, revealed: The Resident's vision was adequate, and was usually able to make him/herself understood and usually understood others. The Resident Scored 8 out of 15 on the Brief Interview for Mental Status (a score of 8-12 is considered moderate impairment). Under Activities of Daily Living, the MDS assessment coded the Resident as needing extensive assistance with eating, bed mobility, and personal hygiene. The Resident required total assistance of staff for transfers, dressing, bathing and toilet use. Review of a physician's progress note, dated 4/26/21, revealed Late Entry: Note Text: Chief Complaint LTC Monthly Exam #6 High Risk for Malnutrition #7 High Risk for Dehydration #8 Underweight, BMI 19.63 kg/m2 --Continue malnutrition and dehydration cares --Nursing staff to actively work with patient to promote eating and hydration --Frazier Free Water Protocol Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No directions were specified for the order. Observation on 4/26/21 from 2:24-3:30 PM revealed Resident #6 had no fluids at bedside. When asked how he/she can get help, the Resident stated he/she can use the call light if he/he needs help. The Resident had an indwelling urinary catheter that drained fluid into collection bag at the end of the bed. During an observation on 4/28/21 at 12:14 PM, Resident #6 was observed lying in bed. A small paper cup containing a small amount of liquid was near the Resident on a bed side table. The Resident's urine in the tubing and collection bag was observed to be a dark straw color. On 4/28/21 at 12:55 PM Resident #6 was observed eating lunch. The Resident was in bed with the head of bed at 40 degrees, The night table was positioned over the Residents lap with the tray almost to his/her chin. Next to the Resident's meal was a full glass of water. The water in the drinking glass appeared cloudy and light gray. During an interview on 4/28/21 at 1:03 PM, when asked about the water, the Resident stated he/she didn't like the water thickened by the staff put it in there. The resident stated he/she coughs sometimes. The Resident stated it was difficult to eat because he/she has to catch it [food with a spoon]. The Resident stated it was hard anyway because he/she can't see. The Resident did not drink any of the water during or after the meal. During an observation on 4/29/21 at 9:05 AM, Resident #6 was observed lying in bed, there were no fluids in the room or at bed side. During an observation on 4/29/21 at 10:11 AM, Certified Nursing Assistant (CNA) #5 served the Resident breakfast. The water was in a glass and was clear. The CNA picked up a plastic container containing red juice, shook it several times and poured it into a smaller glass. CNA #5 stated it was thickened cranberry juice. The CNA assisted the Resident with eating breakfast. On 5/03/21 at 03:33 PM, during an interview, when asked who passed out fluids to the residents the Director of Nursing (DON) stated the staff did it. When asked what Frazier Free Water was the DON stated it was allowing the resident to have un-thickened water, the DON further stated the Resident had to request it. Review of Resident #6's care plan, revised 3/10/21 revealed Focus Risk for Altered Fluid Balance r/t increased fatigue Goal; Resident Will Achieve Fluid Balance . Interventions/Tasks included: -Position Freq/Resolved \Encourage / administer IV fluids per order . -Evaluate blood pressure; -Evaluate heart rate; -Evaluate skin turgor -Monitor and record output (emesis, drains, NG tube); -Monitor urine color and amount; and -Provide oral care Review of CNA task B&B [Bowel and Bladder]-Catheter Output in mLs [milliliters] Look Back 14 Days, dated 5/2/21, revealed from 4/20-5/3/21 all Resident #6's urinary output was documented as a check mark. Review of Nutrition Report, dated 4/12-4/27/21, revealed the Resident's fluid intake varied from 0 to 1680 ml during the 2 week review. Resident #3 Record review on 4/29/21 revealed the Resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident's diet was a general diet, one pureed item per meal, thin liquids, Add 1 scoop of protein per day. Review of the Resident's weights revealed on 10/4/20 a weight of 139 pounds, and on 4/25/21 a weight of 127 pounds. A total weight loss of 12 pounds or 8.7 % of body weight. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Calorie Count for 7 days. Further review of the clinical record revealed the calorie count was not conducted for Resident #3. During an interview on 4/29/21 at 2:27 PM the Registered Dietician (RD) stated he/she was not aware of the calorie count order for the Resident. Resident #12 Record review on 4/28/21 revealed Resident #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident weights revealed on 10/04/20 a weight of 175 pounds and on 4/25/21 a weight of 145.6. In total the Resident lost 19.4 pounds and 16.8 percent of body weight. Review of a speech therapy telehealth evaluation completed 3/23/21 by the Speech Therapist, revealed [Resident #12] was observed via a telehealth during [his/her] morning meal for a swallow screening due to a significant change [MDS] .[Resident #12] has lost a significant amount of weight [about 20 pounds] recently and has low intake due to inability to propel bolus posteriorly. The recommendation was to provide nutritionally dense and high calorie foods unless tube feedings want to be considered. Review of a progess note, dated 3/15/21, written by Licensed Nurse #2 revealed, Note to Dr. to relay a 9 lb. weight loss though some of this may be weight error. A reweigh has been done X2 and [Res #12] is visibly thinner to abdomen and face. Is having more difficulty tolerating sitting up in wheelchair, not holding head up for very long. Review of physician orders, dated 3/29/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care conference note, dated 4/7/21, revealed Eating increased. The physicians diet orders and results of the speech evaluation was not documented. During an observation on 4/28/21 at 1:02 PM - 1:20 PM revealed Certified Nursing Assistant (CNA) #3 was feeding Resident #12 a lunch that consisted of pureed roast beef, carrots, and rice. When the Resident began to hiccup every 15 seconds, the CNA stopped feeding the Resident and discussed the concern with CNA #2. The CNA then returned the tray to the kitchen. The Resident had consumed 10% of the meal. During an interview on 4/28/21 at 1:15 PM CNA #2 stated Resident #12 could get another meal later. During an interview on 4/28/21 at 2:20 PM CNA #2 stated Resident #12 had not received anything else to eat or drink because of the hiccups. The CNA went to the kitchen and retrieved an Ensure (high calorie food) pudding cup and assisted the Resident with eating it. The Resident ate 25% of the pudding. During an interview on 4/29/21 at 11:45 AM, when asked about the Resident's diet orders, the MDS Nurse stated that Resident had lost weight, and this was due to early onset diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 4/29/21 02:52 PM, the Registered Dietician stated there were concerns with no one updating orders and that she was not knowledgeable about new recommendations from the Speech Therapist in March 2021 about a high calorie diet.

Based on observation, interview and document review the facility failed to appropriately care plan, reevaluate and monitor 1 resident (#4) out of 2 residents who smoked. Specifically, the facility failed to ensure: 1) the accurate and current development and implementation of the resident's care plan related to findings from the smoking assessment. The resident was allowed to continue smoking without direct supervision until the State Agency brought the safety issues to the attention of the CEO and DON; 2) the disposal of used cigarette materials in an safe manner; 3) the Resident was capable of safely managing an actively lit cigarette; 4) the resident wore a smoking apron correctly, which created a risk of burning skin and clothing; and 5) the resident safely ignited a cigarette. These failed practices place the resident in immediate jeopardy, and created the potential for more than minimal harm to the resident, and created the potential for harm to all the residents by having an unsafe smoking area which increased the risk for a fire and/or smoke environment. This situation was brought to the attention of the facility's administration on 6/9/15 at 4:47 pm, at which time the facility was notified of the immediate jeopardy concerns. The facility began the abatement of the immediate jeopardy on the evening of 6/9/15, after they were notified. The facility provided a written abatement plan on 6/10/15 at 7:50 am. Based on observation, interview and document review the facility failed to conduct testing on the WanderGuard system per the manufacturer's directions. This failed practice placed 1 resident (#5), that utilized the system, out of 5 sampled residents at risk for unauthorized departure, injury or death. Findings: Smoking: Resident #4 Record review from 6/8-11/15 revealed Resident #4 had [DIAGNOSES REDACTED]. Review of the most recent two quarterly MDS assessments, dated 12/28/14 and 3/28/15, revealed the Resident was noted as having trouble falling or staying asleep or sleeping too much; and feeling tired or having little energy. Additional review of the most recent MDS assessment, dated 3/28/15, revealed the Resident had functional limitations to one upper extremity. Review of Resident #4's Long Term care Resident Smoking Assessment, undated, revealed the Resident was able to properly light cigarette; properly dispose of ashes; and smoke in approved areas. Additional review revealed the Resident was not able to properly dispose of cigarette butts or safely use lighter. Review of the smoking assessment conclusions revealed the following were to be part of the care plan: the Resident had to smoke under direct supervision; safe to keep cigarettes in room; and was required to use a smoking apron. Review of Resident #4's CCP revealed a problem of altered safety related to smoking, updated 5/7/15. Additional review revealed a goal of (Resident #4) will be in a safe environment for smoking. Approaches to safe smoking included: (1) Staff must visualize (Resident) while (s/he) is smoking .(2) (Resident) needs to wear fire (retardant) smoking apron when smoking .(5) place smoking (materials) in nurses cart (for) resident safety and dispense as requested .when there is someone available to visualize (him/her) while smoking. There was conflicting information between the smoking assessment and the care plan interventions. Review of Resident #4's Activities Care Plan, dated 9/28/14, revealed the Resident was a frequent smoker and included an approach of Try to accommodate (Resident's) smoking request when unable try to give a time frame when she will be assisted. Review of the facility's policy LT 101 SMOKING POLICY, revised date 4/15, revealed Resident will be assessed for continued safety (issues related) to smoking at the quarterly care conference. Review of the Resident's previous Care Conference Review, dated 6/25/14, 10/8/14, 12/17/14 and 3/11/15, revealed the smoking assessment was reviewed by members of the interdisciplinary team. Observations from 6/8-11/15 revealed an exterior wooden deck that was accessible from the LTC unit. The deck contained a metal-like structure identified as the designated smoking area (smoking hut). The floor of the smoking hut was comprised of wood decking. Observation of the smoking area on 6/9/15 from 10:07 - 10:20 am revealed Resident #4 was transported to the smoking area by Staff #1 and positioned where the ashtray was located on the Resident's impaired left side. The Resident proceeded to ignite a cigarette after the staff member left. During observation the Resident made an unsuccessful attempt to reach across and dispose of ashes in the ashtray and began to dispose of ashes directly onto the wooden deck below. In addition, Resident #4 and Resident #2 were both observed smoking. Resident #4 was observed reaching down with right hand, while holding a cigarette, to point at something on Resident #2. During this observation Resident #4 dropped ashes on Resident #2's bare left foot. Next, Resident #4 lowered head and began to hold the cigarette near the top of his/her head for periods of 24 to 37 seconds at a time resulting in ash formation on the lit end of the cigarette approximately an inch long. A second observation of the smoking area on 6/9/15 from 10:25 - 10:32 am revealed Resident #4 igniting a cigarette in the absence of staff. Resident #4 was observed holding the cigarette for extended periods of time causing a large amount of ash (approximately an inch) accumulation on the cigarette. As a result, ash was observed falling off independently onto the wooden deck. An attempt was made by the Resident to dispose of ashes in the ashtray, but was unable to. A third observation of the smoking area on 6/9/15 from 10:50 - 10:59 am revealed Resident #4 igniting another cigarette in the absence of staff. The Resident made attempts to dispose of ashes in the ashtray, but was unable to place all ashes appropriately. As a result, the majority of the ash fell on to the wooden deck. A fourth observation of the smoking area on 6/9/15 from 11:02-11:15 am revealed Resident #4 igniting a cigarette in the absence of staff. The neck of the smoking apron was approximately 8 to 10 inches from the base of the Resident's neck, exposing the upper chest and clothing. In addition, the apron was observed gathered between both legs exposing the Resident's lower extremities. Further observation revealed the Resident holding the burning cigarette over the left thigh for extended periods of times while ash accumulated on the lit end of the cigarette. The Resident was wearing fleece-like pants. A fifth observation of the smoking area on 6/9/15 from 2:59 - 3:10 pm revealed the neck of the smoking apron was approximately 6 to 8 inches from the base of the Resident's neck, exposing the chest and clothing. Resident #4 raised the smoking apron up and ignited a cigarette underneath the smoking apron through the neck hole, in the absence of staff. When the Resident raised his/her head to pass the lit cigarette from under to over the apron, the lit tip of the cigarette brushed the inside border of the apron. Further observation revealed accumulated ash on the lit cigarette independently fell off into the Resident's left shoe. The Resident proceeded to make attempts to dispose of ashes into the ashtray. Each attempt resulted in ash missing the ashtray and falling on the wooden deck. Continuous observations, in dining area, on 6/9/15 from 3:16 - 3:27 pm revealed Resident #4 sitting outside in the smoking area smoking a cigarette. LN #2 was seated at the computer out of sight of the Resident. During the observation CNA #s 1, 2, 3 and the AC moved in and out of the nearby dining room. While the AC sat at a table located on the far side of the room to play cards with a resident. CNA #2 began doing a manicure for another resident. The crown of Resident #4's head was visible through the window located on the other side of the room. One CNA was charting in the alcove located on the far side of the room. A sixth observation of the smoking area on 6/9/15 from 3:16 - 3:27 pm revealed Resident #4 igniting a cigarette in the absence of staff. The Resident was then removed from the smoking area and placed by the deck entrance by staff in efforts to transport another Resident from the back of the smoking area to inside. During this transition Resident #4 disposed of ashes into the flower pot on the wooden deck. Once the Resident was transferred back to the smoking area the smoking apron was observed to only cover the left side of the Resident's body causing the right side to be exposed. Further observation revealed ashes independently falling onto the left side of the apron. The Resident immediately turned the apron on its side to rid of the ashes but caused the ashes to fall onto the exposed right leg covered with fleece-like material. The Resident made an attempt to dispose of ashes into the ashtray which resulted in ash missing the ashtray and falling on the wooden deck. At 3:27 pm Resident #4 attempted to reinitiate a partially lit cigarette by rapidly inhaling on the filtered-end several times. Once the cigarette was fully lit from multiple rapid inhalations s/he swiftly removed the cigarette from mouth and stated abruptly Ouch. When asked by the Surveyor what had happened, the Resident inspected the pointer and middle finger of the right hand and stated smoked it too close to the butt. During an interview on 6/9/15 at 3:30 pm, when asked how staff ensured the Resident smoked safely, CNA #1 replied the Residents were to wear a smoking apron and the staff had to be able to see them. The CNA stated they don't have to stand out there (in the smoking area) with them, visually check them now and then. During an interview on 6/9/15 at 3:35 pm, when asked what supervision needed to be provided to ensure Resident #4 was smoking safely, LN #2 stated the Resident was to wear a fire retardant apron and be within eye sight. When asked how the staff could ensure the Resident was in eye sight, the LN replied someone needs to be in the day room when the Resident is smoking. When the surveyor pointed out only the top of the Resident's head was visible, LN #2 stated you can see (Resident #4) move. The LN stated one size fits all when asked about the fit of the apron. During an interview on 6/9/15 at 4:47 pm the survey team informed the CEO and DON of concerns that the Resident was in immediate jeopardy. During an interview on 6/10/15 at 7:50 am the CEO provided a written abatement plan. An observation of the smoking area and the deck on 6/10/15 at 2:10 - 2:14 pm revealed: a burn mark on the wood deck floor of the smoking hut; a burn mark on the wood deck outside the smoking hut near the building wall; ashes on the floor of the smoking hut; 2 cigarette butts found lodged between the wood slats of the smoking hut's deck floor; and 6 cigarette butts on the ground beneath the smoking hut. During an interview on 6/10/15 at 2:15 pm the AC was asked to show the proper application of the smoking apron. AC placed the apron over his/her head, secured the apron and made sure it completely covered from the base of the neck to both lower extremities. Review of the smoking apron's manufacture information Posey Smoker's Aprons, dated 2009, revealed to properly apply the apron should include adjusting the neck strap at that the top of the apron so the device rides above the resident's chest and covers the individual's clothing. In addition, the manufacture provided the warning of This apron is not a substitute for proper supervision and all patients or residents should ALWAYS be closely supervised while smoking. During an observation on 6/10/15 at 2:45 pm in Resident #4's room, with CNA #2 present, revealed a pair of blue and white pants with a burn hole approximately 1.5 inches by 1 inch. During an in interview on 6/10/15 at 2:46 pm Resident #4 stated the blue and white pants were purchased after admission to the facility. During an interview with a family member of Resident #4 on 6/10/15 at 2:55 pm in Resident #4's room, the family member stated the resident had a history of [REDACTED]. Wander Guard System: During the initial tour on 6/8/15 at 8:30 pm Resident #5 pointed to a device located on his/her left ankle and stated s/he couldn't remember what it was for. Closer examination revealed the device was a WanderGaurd device attached to a strap around the ankle. Multiple observations from 6/9-11/15 revealed Resident #5 exhibited wandering behaviors on a daily basis. Additionally, multiple observations revealed an alarm would sound when Resident #5 approached an exit door. Review of the Resident's care plan, dated 5/28/15, revealed the resident had a history of [REDACTED]. In addition, the care plan stated the Resident was to have a WanderGuard in place for safety. Observations from 6/8-11/15 revealed the facility used 6 WanderGuard D series departure alert system monitors. During an interview on 6/11/15 at 9:55 am the MT stated the facility tested the WanderGuard system every 6 months. Review of the WanderGuard testing log provided by the facility on 6/11/15 revealed the facility had been testing the system every March and September. Review of the Wander Guard installation instructions provided by the facility on 6/11/15 revealed WARNING.Test the monitors at least weekly on each shift with all surrounding power devices turned on .Failure to regularly test your WanderGuard departure alert system could result in an unauthorized departure and cause injury to or the death of a person in your care. Review of the facility's policy LTC 115 WANDERGUARD ALARM SYSTEM, revision date 2/2006, revealed .All exit doors will have an alarm system box (LTC Staircase, LTC deck, Front Lobby, ER Door, Door to Kitchen/Staff Dining Room Area). Alarms will be checked weekly.

Based on record review, interview, and observation the facility failed to ensure 1 resident (#5), out of 7 sampled active residents reviewed, who had been identified as having difficulty swallowing was given a therapeutic diet that was correctly prepared to meet the resident's need and ensure the physician's orders [REDACTED]. As a result of this system failure, the resident had choked on a piece of meat and subsequently developed aspiration pneumonia. The failure to implement the physician's orders [REDACTED]. Based on record review, observation, and interview the facility failed to ensure consistent care plan interventions were developed for 1 resident (#2) out of 1 resident who smoked tobacco in the facility. This failed practice placed the resident risk for injury from burns. Findings: Resident #5 Food Consistency Record review on 8/11-13/14 revealed the Resident had [DIAGNOSES REDACTED]. Review of the nurses' note, dated 7/29/14 at 3:14 pm, revealed "pt. had a choking episode around (2:45 pm) after a snack with salami was passed out, mouth was swept for food and successfully retrieved by CNA, all dentures removed, pt. suctioned for small amount of saliva, sats. (Oxygen saturation levels) were 88% afterwards, BP 158/70, HR 64, RR 20, pt. recovered well with 2L NC and was up to 96%, left on O2 for a while to help improve saturation." Review of the physician's discharge summary from the hospital, dated 8/7/14, revealed ". . . During morning checks in long term care, the staff noted that (Resident #5) was hypoxic (inadequate oxygen supply) with a pulse ox (oxygen saturation levels) in the 70's. (Resident #5) had an episode of aspiration a few days prior to that and initial work-up was consistent with aspiration pneumonia. For that reason (Resident #5) was put into acute care for treatment." Review of the Resident's most recent MDS quarterly assessment, dated 6/18/14, identified the Resident had signs and symptoms of a swallowing disorder evidenced by "Loss of liquids/ solids when eating or drinking". As part of the review, a nutritional assessment, completed by the Dietitian, dated 7/3/14, revealed "Pt prefers chopped lettuce and ham due to ill-fitting dentures. Otherwise regular consistency. He self-feeds after set up in the dining room." Review of the "Dietitian's Recommendations", dated 7/1-5/14, revealed "(Resident #5) No changes Correct diet order is "Liberal Diabetic chop lettuce and grind ham". Review of the "Physician's Nursing Orders Report", dated 8/12/14, revealed the Resident's diet was listed as "Liberal Diabetic." The order did not contain the Dietitian's recommendations to chop the lettuce and grind the ham. Review of the "Dietary Recommendations", dated 8/1/14, revealed Resident #5's diet was listed as "Liberal Diabetic". The recommendations did not include the information about the chopped lettuce and ground ham. Review of the comprehensive care plan, dated 12/18/13, revealed the Resident had the problem "Inability to chew properly related to improperly fitting lower denture." The care plan included the following identified goals, and approaches: "(Resident #5) will maintain (His/Her) ability to consume (His/Her) meals without discomfort . . ." and "(Resident #5) will be able to comfortably wear (His/Her) lower dentures." The approaches listed included "Assist (Resident #5) with cleaning (the Resident's) dentures every morning and between meals as indicated" and "Apply SeaBond (denture adhesive) to upper dentures before placing in the morning." The multidisciplinary care plan did not include the information about the modified textures recommended by the Dietitian. During an interview on 8/12/14 at 12:30 pm, Resident #5's family member stated the Resident had only been wearing the upper dentures recently and there had been a decline in the Resident's speech the past 2-3 years. During an interview on 8/12/14 at 4:07 pm, CNA #2 stated when the choking episode occurred the Resident had been eating alone and had choked on a piece of summer sausage. Observations of meal service on 8/11-13/14 revealed the residents' meals were delivered on plates with lids. Stickers with the residents' names were on the lids, but the stickers did not contain any diet information. During an interview on 8/13/14 at 4:00 pm the DM stated the kitchen just put the residents' name on the plate lids. The facility did not use cards that listed the diets because there was no room on the sticker. When asked why dietary recommendations had not been implemented for Resident #5, the DM stated the kitchen sends pureed snacks to the LTC unit, but snacks for the modified diets were not cut up in the kitchen and the nursing staff were "Expected to know" they needed to cut the food up when it was served to residents that were on special diets. During an interview on 8/14/14 at 10:30 am Physician #2 confirmed the Resident had choked on a large piece of meat. During the interview, the Physician stated "(He/She)was supposed to have (His/Her) meat cut up for (Him/Her)." As a result of this system failure the dietary staff did not implement and prepare the Resident's snack according to the Dietitian's recommendation for ground ham (summer sausage). In addition, the information from the Dietitian about the needed modified textured diet was not communicated with the nursing staff in the care plan and physician's orders [REDACTED]. Review of the facility's policy,"LTC Diet Definitions", updated August 2006, revealed a "Mechanical Soft: regular diet with foods altered in texture for ease of chewing. Soft foods ground meats and minced raw vegetables are given." Thickened Liquids During an interview on 8/11/14 at 10:30 am LN #1 stated Resident #5 was on thickened liquids because "We don't want him to aspirate again." During an interview on 8/12/14 at 10:01 am, LN #2 stated Resident #5 had choked on a piece of sausage and now was supposed to have fluids thickened to the consistency of nectar. During an observation on 8/12/14 at 10:10 am, LN #2 mixed a small amount of Thick-It (food thickening product) into a medication cup containing water for Resident #5. During an interview on 8/12/14 at 10:37 am, when asked where the information about the Resident's diet was located, CNA #2 replied the staff used the EMR and could get the information verbally in report. The CNA then stated the staff did not review the residents' diets with every verbal report. Review of Resident #5's diet in the EMR with CNA #2 revealed the top of the screen listed an order for [REDACTED]. Review of Resident #5's care plan, dated 12/18/13, revealed no additional information about the thickened liquids. Closer examination of the EMR revealed the computer screen needed to be scrolled down to see the order for thickened liquids. As a result there were 2 different orders in the EMR. During an interview on 8/12/14 at 10:59 am, the DON stated the red lettering at the top of the EMR meant it was a dietary order. When asked about the 2 different orders in the EMR, the DON stated staff had forgotten to update the diet order when they had received an order for [REDACTED]. The MDS Nurse was unavailable for interview during the survey. Review of the "Chartlink Physician Entered Orders", dated 8/10/14, revealed the order, "Thickened Liquids (Nectar Cons. (Consistency))". On 8/12/14 at 5:05 pm, observations in Resident #5's room revealed an opened bottle of chocolate Ensure with a straw and a partially consumed cup of coffee sitting near the Resident on the bedside table. Closer examination of the contents revealed the fluids had not been thickened. During an interview on 8/12/14 at 5:05 pm with the Administrator and CNA #3, the CNA stated the order for thickened liquids had been canceled because Resident would not consume the thickened liquids. Review of the EMR and the physician's orders [REDACTED]. During an interview on 8/12/14 at 7:25 pm, LN #3 stated the doctor had been contacted this evening and the order was now thin liquids. During an interview on 8/13/14 at 10:30 am, Physician #2 confirmed thickened liquids had been ordered for the Resident because a nurse had reported the Resident was holding fluid in his/her mouth and was slow to swallow. Smoking Resident #2 Record review on 8/11-13/14 revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Further review revealed the Resident required a wheelchair for mobility and required stand by assistance for transfers and ambulation due to poor balance. During an observation on 8/12/14 at 3:30 pm, Resident #2 went to the smoking deck accompanied by a family member. The Resident was not wearing any type of smoking apron to help protect from burns. During an interview on 8/12/14 at 3:45 pm LN #2 stated the Resident was supposed to wear a smoking apron and was to be accompanied when smoking. During the interview the LN stated "Oh, I forgot to put a smoking bib on (Resident #2)." During an observation 8/12/14 at 6:30 pm, Resident #2 was propelled to the outside smoking area by nursing staff. The staff left the Resident on the deck to smoke independently. During an interview on 8/12/14 at 6:30 pm with LN #3 when asked what interventions were required to ensure Resident #2 could smoke safely, the LN stated staff try to stay close by when the Resident was smoking on the deck but they do not stay outside. On 8/12/14 at 6:40 pm the Resident entered the facility through the smoking deck door. The Resident's smoking apron was ineffectively hanging between both legs and not covering the lap. Review of the Resident's LTC Resident Smoking Assessment that had been scanned into the Resident's LTC chart on 6/23/2014 revealed the Resident was classified as needing "Minimal assist". Further review revealed, "The Following Conclusion for Resident's Ability to Safely Smoke: (will be a part of care plan) ...May use lighter and smoke unsupervised ...Smoking apron required." Review of the Resident's "Multi-Disciplinary Care Plan" did not include information for staff regarding the Resident's smoking plan. Review of the Resident's ADL Report which contained information and instructions regarding the Resident's daily care, revealed the Resident's smoking plan was not included. An interview was conducted on 8/13/14 at 7:00 pm with the DON. When asked whether the Resident's care plan should include information regarding the Resident's smoking assessment and information for staff, the DON confirmed it should have been care planned. .

Based on record review and interview the facility failed to ensure food that was served to 1 resident (#5) out of 7 active residents reviewed was prepared in a manner to reduce the risk of choking. The failure to ensure the recommended dietary interventions were implemented for the resident contributed to the resident choking and developing aspiration pneumonia. Findings: Record review on 8/11-13/14 revealed the Resident had [DIAGNOSES REDACTED]. Review of the nurse's note, dated 7/29/14 at 3:14 pm, revealed "pt. had a choking episode around (2:45 pm) after a snack with salami was passed out, mouth was swept for food and successfully retrieved by CNA, all dentures removed, pt. suctioned for small amount of saliva, sats. (Oxygen saturation levels) were 88% afterwards, BP 158/70, HR 64, RR 20, pt. recovered well with 2L NC and was up to 96%, left on O2 for a while to help improve saturation." Review of the physician's discharge summary from the hospital, dated 8/7/14, revealed ". . . During morning checks in long term care, the staff noted that (Resident #5) was hypoxic (inadequate oxygen supply) with a pulse ox (oxygen saturation levels) in the 70s. (Resident #5) had an episode of aspiration a few days prior to that and initial work-up was consistent with aspiration pneumonia. For that reason (Resident #5) was put into acute care for treatment." Review of the nutritional assessment, completed by the Dietitian, dated 7/3/14, revealed "Pt prefers chopped lettuce and ham due to ill-fitting dentures. Otherwise regular consistency. He self-feeds after set up in the dining room." Review of the "Dietitian's Recommendations", dated 7/1-5/14 revealed "(Resident #5) No changes Correct diet order is "Liberal Diabetic chop lettuce and grind ham". Review of the "Dietary Recommendations", dated 8/1/14, revealed Resident #5's diet was listed as "Liberal Diabetic". The recommendations did not include the information about the chopped lettuce and ground ham. During an interview on 8/13/14 at 4:00 pm the DM stated the kitchen just put residents' names on the plate lids. The facility did not use diet cards becuse they did not use trays and there was no room for the diets on the sticker. When asked why the dietary recommendations had not been implemented for Resident #5, the DM stated the kitchen sends pureed snacks to the LTC unit, but snacks for the modified diets were not cut up in the kitchen. Nursing staff were "Expected to know" they needed to cut the food up when it was served to residents that were on special diets. During an interview on 8/14/14 at 10:30 am Physician #2 confirmed the Resident had choked on a large piece of meat. During the interview, the Physician stated "(He/She) was supposed to have (His/Her) meat cut up for Him/Her)." As a result of this system failure the dietary staff did not prepare the Resident's snack according to the Dietitian's recommendation for ground ham (summer sausage). .

1) Based on observation, interview, and record review the facility failed to ensure the whirlpool tub, used for bathing, was properly disinfected between residents. The failed practice placed all 5 residents (#s 1, 3, 4, 5, and 10) who used the tub at immediate risk for infection and created a risk for serious harm, impairment, or death. This constituted an immediate jeopardy to the residents' health and safety. The situation was brought to the attention of the facility's administration on 8/20/13 at 4:40pm. On 8/20/13 at 6:25 pm, it was determined the immediacy of the jeopardy had been abated through the facility's implementation of an action plan addressing the proper disinfecting of the whirlpool tub. 2) Based on observation, interview and record review the facility failed to ensure: 1) equipment was cleaned and disinfected between resident uses; 2) resident laundry was sanitized; 3) fans were maintained free of dust; 4) that personnel followed accepted standards for hand washing; 5) an infection control program across all departments and disciplines. These failed practices increased the risk for the development and transmission of disease and infection in a vulnerable population. Findings: Whirlpool Tub/Immediate Jeopardy During an observation on 8/20/13 at 10:43 am, after Resident #4 was bathed, Certified Nursing Assistant (CNA) #1 began cleaning the whirlpool tub by filling the tub with water to the level of the seat and turning on the disinfectant knob. At 11:07 am CNA #1 turned off the disinfectant knob and scrubbed the sides and floor of the tub with a hand mop. The CNA#1 then drained the water from the tub and a CNA student rinsed the tub with fresh water. Observations in the tub room on 8/20/13 at 2:50 pm, the whirlpool tub was dry and had a brownish/yellow discoloring on all surfaces with a brown ring of scum; when the whirlpool tub was touched by the surveyor it had a gritty film on the sides and inside base of the tub. During this same observation CNA #1 was asked if the tub had been cleaned after the last resident bath of the morning. CNA #1 stated the tub is cleaned after each bath. CNA #1 confirmed Resident #s 4 & 10 had bathed in the tub that morning. CNA #1 was asked to demonstrate cleaning the whirlpool tub. CNA #1 turned the water on, turned the disinfectant knob to the on position, and attempted to open the jets; 2 of the jets would not open. When asked about the flow meter knob for the disinfectant, CNA #1 replied she had been trained by another CNA to turn only the disinfectant knob to the on position. When CNA #1 was asked if she had been trained on the facility policy for cleaning the whirlpool tub the CNA replied she had not. The observations of the tub cleaning process did not reflect the staff using the 19 step instructional policy posted in 2 locations near the tub. Final observation of the whirlpool tub revealed the disinfectant flow meter was turned to "0" and no disinfectant was entering the tub or the jets. On 8/20/13 at 3:35 pm the Infection Preventionist (IP) #1 was asked to clean the whirlpool tub by following the 19-step instructional policy posted on the wall. The IP filled the tub with water to the seat level and adjusted the disinfectant flow knob to 35cc/mm. The brown scum ring on the sides of the tub slid off into the water, rendered the water a brown color with significant film on the surface, and many brown floating particles were noted in the water. IP #1 acknowledged the instructions were difficult to follow and the water in the whirlpool tub was dirty. Review of the policy "Whirlpool Cleaning, Closed Loop System" no date, posted on 2 walls near the tub revealed, step "...8. Turn the disinfectant on/off valve to the on position... step 9. Turn the adjustment knob on the flow meter until the floating ball rises to a level of 35cc/min. (at 35cc/min disinfectant is being mixed with water at the proper level." A hand-written addition to the policy, entered by the previous IP (IP#2), dated 2/5/13, instructed the user to "do not fill the tub with water - you must follow this procedure." Record review on 8/19-23/13 of "LTC (Long Term Care) Bath/CLC Schedule," revealed Resident #s 1, 3, 4, 5, and 10 were bathed twice a week using the whirlpool tub. Positive Cultures Record review on 8/19-23/13 revealed Resident #3 had 5 positive urine cultures reported from 9/10/12 - 7/30/13 with 4 caused by Escherichea coli bacteria (E. Coli). Record review on 8/19-23/13 revealed Resident #4 had 1 positive urine culture reported on 2/14/13 caused by E. Coli. Record review on 8/19-23/13 revealed Resident #1 experienced cellulitis of the breast with a positive skin culture for E. coli. During an interview on 8/22/13 at 1:00 pm, the IP confirmed the facility had 12 UTI's in 2012 and 9 so far in 2013. The infections were predominately caused by E. Coli bacteria. During an interview on 8/20/13 at 5:20 pm, Physician #1 confirmed that his Residents that were having recurrent infections could have been caused by the poor cleaning of the whirlpool tub and the tub's use by multiple Residents. Review on the Center for Disease and Control website, 9/2/13 revealed, "Escherichia coli (E. coli) bacteria normally live in the intestines of people and animals... can be transmitted through contaminated water...Swimming and wading pools and hot tubs can harbor live E. coli if the water is under-chlorinated." Blood Glucose Meter Cleaning Observation on 8/21/13 at 5:00 pm, during medication pass revealed Licensed Nurse (LN) #2 using a hand-held glucometer (instrument used to measure the blood sugar level) to perform blood glucose testing for two residents. After obtaining the first Resident's blood specimen and determining the sugar level, the nurse went to the second Resident and obtained another blood specimen for blood sugar. No cleaning of the glucometer was performed in-between the first and second specimens. Immediately following the second blood sugar done by LN #2, LN #3 took the same glucometer and cleaned it with an alcohol pad before collecting a blood specimen for a third Resident. During an interview on 8/21/13 at 5:30 pm, LN #2 stated she cleaned the glucometer once a day at the end of her shift. During an interview on 8/21/13 at 5:35 pm, LN #3 stated she cleaned the glucometer with alcohol after each use. During an interview on 8/22/13 at 1:40 pm IP #1 stated the staff was to clean the blood glucose meter after each use with 10% bleach solution. Record review of the policy "Glucometer Cleaning" no date, instructed cleaning of the meter "between all patients ... with 10% bleach solution followed by water." Tub room therapy table Observation of care on 8/20/13 at 10:15 am, revealed CNA #s 1 & 3 using the therapy table in the tub room to change the soiled clothing of Resident #4. When the care was completed, Resident #4 was returned to the wheelchair and taken from the room by CNA #s 1 & 3. Multiple used pink incontinence pads remained on the therapy table and a crumpled towel covered the pillow. None of the linens were changed and the therapy table was not cleaned. Observation of care on 8/20/13 at 10:50 am, revealed CNA #s 1 & 3 were using the therapy table in the tub room to change Resident #1's soiled brief. The Resident was placed on the soiled linens left from the previous Resident's care. After Resident #1's care was completed, the Resident was returned to the wheelchair and taken from the room by the CNAs. The used pink incontinence pads remained on the therapy table. None of the linens were changed and the therapy table was not cleaned. Observation of care on 8/20/13 at 11:45 am revealed, CNA #s 1 & 3 using the therapy table in the tub room to change the soiled clothing for Resident #10. At the start of care, the therapy table had multiple pink incontinence pads lying on top of a large light weight blanket and a pillow with a crumpled looking towel on it. Resident #10 was placed on the soiled linens. When the CNA staff was preparing to transfer the Resident back into the wheelchair, CNA #1 touched the pink pad under the Resident's feet and rubbed her fingers together as if the pad was wet; she picked up the Resident's feet off the pad and held them until the Resident was transferred to the wheelchair. The surveyor touched the pads on the therapy table and found them to be damp. None of the linens were changed and the therapy table was not cleaned. During an interview on 8/22/2013 at 11:15, CNA #1 confirmed she was aware the pink incontinence pad on the therapy room table under Resident #10's feet was wet on 8/20/13 while providing care, but it was not visibly soiled so it was not changed. When asked how often the therapy table was cleaned Staff #1 reported the therapy table was cleaned once a week. Bedside Commode Observation on 8/19/13 at 5:30 pm of the Physical Therapy tub room revealed a strong urine odor from the bedside commode (BSC) that was used for multiple Residents. Observation of care on 8/20/13 at 11:30 am in the Physical Therapy tub room revealed CNA #3 and a CNA student assisted Resident #2 to use the BSC. The Resident was then assisted to sit on the BSC with the lid down, without a brief on. After care was completed, CNA #3 rinsed the BSC pail with water and placed it back into the BSC and the unit moved to the corner of the room. The toilet seat and lid were not cleaned. Continued observation of care on 8/20/13 at 11:54 am in the Physical Therapy tub room revealed CNA #1 and a CNA student retrieved the BSC from the corner of the room and assisted Resident #9 to use the BSC that was soiled from the previous Resident's use. During an interview on 8/22/13 at 11:26 am, Staff #1 confirmed not all staff clean the whole BSC after every use; some just clean the pail. Laundry During an observation on 8/20/13 at 11:45, CNA #1 picked up an afghan from a Resident's wheelchair and stated she was not going to use the afghan because the same afghan had been used on a different resident the previous day and had been soiled. CNA #3 replied laundry personnel did not like staff to send the Resident afghans to be washed all the time. During an interview on 8/22/13 at 11:26, Staff #1 stated staff had been instructed to only send Resident afghans to the laundry every 3 weeks. This process concerned the Staff because the afghans were used interchangably with different Residents even when soiled. The Staff also stated changing the pink incontinence pads on the therapy room table was only done when visibly soiled; this process also concerned the staff because the table was used for all Residents. The Staff went on to state the Laundry staff got angry when large amounts of linens were sent to be washed and the Director of Nursing had asked Staff to limit the amount of linens sent to be washed. During an interview on 8/20/13 at 3:35 pm, IP #1 confirmed she had shared with the Support Services Supervisor the CNAs concerns regarding not sending soiled linens to the laundry and being berated by laundry staff over using too many pink pads, towels, etc. Observation in the laundry room on 8/20/13 between 1:40 pm-2:00 pm revealed the single non-commercial washing machine had a temperature of 136 degrees on the water supply gauge. Observation of the commercial washing machine, with a hot water booster tank, had a temperature of 140 degrees. Both washing machines were on a wash cycle. During an interview on 8/20/13 between 1:40 pm - 2:00 pm Laundry Aide (LA) #1 stated residents' personal laundry was co-mingled and washed in the non-commercial washing machine. Bleach was not used due to colored clothing. In addition, LA #1 stated the afghans were washed in the non-commercial washer with Oxyclean detergent. Additionally, LA #1 stated the commercial washing machine temperature was frequently below 160 degrees but that "laundry had to get done", and if it was non-colored, more bleach would be added to the wash. Record review on 8/20/13 at 2:00 pm of the "Pre-programmed formula amount" posted on the wall revealed, spreads, pink incontinence pads, delicates and colored linen did not have bleach added to the wash cycle. Record review on 8/20/13 at 2:00 pm of the "Booster Tank Temperature Log" dated for July/August 2013, revealed the following days had a temperature below 160 degrees: July: 2, 3, 4, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 29, and 31; August: 1, 3, 15, 16, 20, 21. During an interview on 8/20/13 at 1:40 pm the LA #1 stated she reported the low water temperatures to the Director of Nurses and the Quality Committee when it was her month to report, but not to the Infection Preventionist. When asked if the low water temperatures were a concern for infection transmission she stated "yes, they could be." During an interview on 8/21/13 at 1:15 pm the Maintenance Supervisor stated the hot water temperature is difficult to maintain at 160 degrees due to the volume of water used on a daily basis. In addition he stated the non-commercial washer did not have a hot water booster. Review of the CDC (Centers for Disease Control and Prevention) "Guidelines for Environmental Infection Control in Health-Care Facilities" revealed the following: "Contaminated textiles and fabrics often contain high numbers of microorganisms from body substances, including blood, skin, stool, urine, vomitus, and other body tissues and fluids; Disease transmission attributed to health-care laundry has involved contaminated fabrics that were handled inappropriately; Hot water provides an effective means of destroying microorganisms. A temperature of at least 160?F (71?C) for a minimum of 25 minutes is commonly recommended for hot-water washing; and Low-temperature laundry cycles rely heavily on the presence of chlorine- or oxygen-activated bleach to reduce the levels of microbial contamination." The CDC Guidelines summarized proper laundry procedures as involving: "...b) proper use of temperature, detergent, and laundry additives." As a result, the required 160 degrees F water temperature nor a disinfecting laundry detergent was utilized; and there was no written policy or procedure/instructions for handling residents' personal laundry to ensure commingled laundry was disinfected and infection transmission did not occur. Fan in Dining Room During an observation on 8/19/13 at 6:25 pm, the fan in the dining room, by the recliner chair, was blowing and had thick dust on the blades and cage surrounding the blades. During an interview on 8/22/13 at 1:25 pm, the IP #1 confirmed the fans should not be used when dirty, and was not sure who was responsible for cleaning the fans. Hand Hygiene During an observation of care 8/20/13 at 10:50 am CNA #1 cleaned Resident #1 of stool, retrieved a tube of protective gel from the storage area, and applied the protective gel to the Resident's anal area. CNA #1 did not change gloves and perform hand hygiene between soiled and clean tasks. During an observation of care on 8/20/13 at 11:30 am a CNA student assisted CNA #3 to toilet Resident #2. The student went from handing the Resident's soiled briefs to the storage area for a clean brief and cleaning supplies. CNA Student did not change gloves and perform hand hygiene between soiled and clean tasks. During an observation of care on 8/20/13 at 11:45 am, CNA #1 changed Resident #10's soiled brief, retrieved a tube of protective gel from the storage area, applied the protective gel to the Resident's anal area. CNA #1 did not change gloves and perform hand hygiene between soiled and clean tasks. During an observation of care on 8/21/13 at 9:30, CNA #3 and a CNA student gave Resident #3 a bed bath. CNA #3 removed the Resident's soiled brief, gathered dirty linens, set the dirty linens on the counter, left the room and returned with a laundry bag, placed the dirty laundry in the bag and wiped off the counter. All actions were performed without wearing gloves. Additionally, CNA student cleaned the Resident of stool, dried the Resident's back, applied protective gel the Resident's anal area, applied a new brief, and then changed gloves but failed to perform hand hygiene. On 8/19-23/13 review of the facility policy "Care of the Incontinent Resident" revised 7/2010, instructs staff to put on gloves before removing Resident's soiled clothing and to wash and dry hands only after the Resident's soiled brief has been removed, protective cream applied, dirty linens removed, clean linens are in place, resident's clothes are changed, and soiled linens are placed in a hamper. The facility policy does not reflect best practice as evidenced by review of the Center for Disease Control and Prevention website accessed 9/5/13 revealed, "...H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care... J. Decontaminate hands after removing gloves (In the management of HAI.)...Change gloves during patient care if moving from a contaminated body site to a clean body site (II)." Infection Control Committee During an interview on 8/22/13 at 1:15 pm the IP #1 stated there was no formal Infection Control committee; it was incorporated into the QA Committee and that committee met monthly. She stated it was her understanding that she was to report infection surveillance data to the Quality Committee and provide education as needed or as directed by the Director of Nursing. IP #1 also confirmed she did not have a job description for the Infection Preventionist. In addition, the Infection Preventionist stated no staff training or surveillance for whirlpool tub disinfection had been performed since the implementation of the 19 step instructions were posted on 2/5/13. She also stated she did not perform surveillance of the kitchen, laundry, or physical therapy, or housekeeping practices; infection prevention practices in those areas were monitored by the supervisors of those departments. Record review on 8/21/13 of the Infection Control Minutes for 2013 revealed: 1) no action plans for 9 urinary tract infections in 2013; 2) no action plans for 12 urinary tract infections for 2012; and 3) no surveillance activities from other departments 4) no ongoing surveillance activities had been completed by Infection Preventionist to identify compliance with high risk opportunities for infection prevention and control practices. Review of the "Infection Control and Prevention Program" no date, revealed "The goal is to establish a comprehensive infection prevention and control program to ensure that the facility has a process in place to reduce the risks of HAI (hospital acquired infections) in patients and health care workers... Attend the monthly Infection Control meeting... Complete monthly IC/Safety inspections... Identify and track performance measure that may lead to continuous improvement in the management of HAI." .