Every finding on record at Yukon Kuskokwim Elder's Home

.Based on record review and interview, the facility failed to honor the rights of 17 residents (#s 1-17) out of 18 residents (total census) to be informed of, to participate in, or refuse the facility's decolonization program (a medical intervention aimed at eliminating antimicrobial-resistant microorganisms). Specifically, the facility did not notify the residents and/or their representatives of the decolonization program, the rationale and risks and benefits of the use of the following interventions: Chlorhexidine as a soap substitute used during showers, andMupirocin 2% topical ointment (used to treat bacterial skin infections) nasal swab for five days every other week. These failed practices denied all residents and their representatives, the opportunity to be informed of treatments applied to them and placed them at potential risk for adverse effects Findings:Record review on 3/2-6/26 of the quarterly Minimum Data Set (MDS - a federally required nursing assessment), revealed 15 residents had antibiotic checked as is taking and indication noted in the following MDS:Resident #1's MDS dated [DATE];Resident #2's MDS dated [DATE], 1/15/26;Resident #3's MDS dated [DATE], 2/9/26;Resident #4's MDS dated [DATE], 10/26/25, 12/18/25;Resident #5's MDS dated [DATE] and 3/2/26;Resident #6's MDS dated [DATE], 2/11/26;Resident #7's MDS dated [DATE], 1/26/26;Resident #9's MDS dated [DATE], 1/12/26;Resident #10's MDS dated [DATE];Resident #11's MDS dated [DATE], 12/22/25;Resident #14's MDS dated [DATE];Resident #15's MDS dated [DATE], 2/9/26;Resident #16's MDS dated [DATE];Resident #17's MDS dated [DATE]; andResident #21's MDS dated [DATE]. Record review from 3/2-6/26 of Residents #1, #2, #3, #4, #5, #7, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #21 medical diagnosis list included preventive measure clinical diagnosis Encounter for Prophylaxis.Record review 3/2-6/26 of the residents' medication orders, revealed 17 residents had an order of: Order name: Mupirocin topical, Status: completed, Details: 1 app [application], nasal, both nares [nostrils], form Ointment, BID [twice a day], M-F [Monday to Friday].Further review of the medical record revealed the following:Resident #1 had 10 weeks of completed ointment application from 11/16/25 to 2/26/26;Resident #2 had 12 weeks of completed ointment application from 9/27/25 to 2/26/26;Resident #3 had 17 weeks of completed ointment application from 7/13/25 to 2/26/26;Resident #4 had 5 weeks of completed ointment application from 12/14/25 to 2/26/26;Resident #5 had 7 weeks of completed ointment application from 12/15/25 to 2/26/26;Resident #6 had 17 weeks of completed ointment application from 7/1/25 to 2/26/26;Resident #7 had 8 weeks of completed ointment application from 11/16/25 to 2/22/26;Resident #8 had 4 weeks of completed ointment application from 1/11/26 to 2/26/26;Resident #9 had 15 weeks of completed ointment application from 8/11/25 to 2/26/26;Resident #10 had 13 weeks of completed ointment application from 9/8/25 to 2/26/26;Resident #11 had 8 weeks of completed ointment application from 11/24/25 to 2/26/26;Resident #12 had 10 weeks of completed ointment application from 10/19/25 to 2/26/26;Resident #13 had 18 weeks of completed ointment application from 6/29/25 to 2/26/26;Resident #14 had 9 weeks of completed ointment application from 11/10/25 to 2/26/26;Resident #15 had 13 weeks of completed ointment application from 9/8/25 to 2/26/26;Resident #16 had 2 weeks of completed ointment application from 2/8/26 to 2/26/26; andResident #17 had 10 weeks of completed ointment application from 10/27/25 to 2/26/26.During an interview on 3/4/26 at 5:38 PM, when asked why those residents mentioned above were on Mupirocin 2% topical ointment antibiotic, the Medical Director (MD) stated the Mupirocin was used for the facility's decolonization protocol. He explained the facility had been using Chlorhexidine gluconate as soap substitute during residents' shower days and every other week the residents were given Mupirocin 2% topical ointment nasal swab. When asked the rationale of the decolonization protocol, the MD stated to remove bacteria in the nose and the skin. When asked if the decolonization protocol was experimental research, the MD stated it was not, but it was considered facility's performance improvement. When asked what diagnosis supported the use of Mupirocin 2% topical ointment, the MD stated, Preventive measure Z29.9 [medical diagnosis code].During the same interview, when asked if the residents and/or their representatives were notified of the protocol, he stated No. He explained that just like any medication prescription, he would not notify the representative in every dosage changes. When asked if the protocol was discussed during the resident's care conference, the MD stated it was not, if the topic comes up just like in other medications, then he would.During an interview on 3/5/26 at 8:25 AM, Licensed Nurse (LN) #1, stated all residents were receiving Mupirocin 2% topical ointment nasal swab to bring down infection, but was not sure what infection was being prevented.During an interview on 3/5/26 at 3:15 PM, the Director of Nursing (DON) stated he did not find any documentation regarding residents and/or their representatives notification of the facility's decolonization program. The DON also stated there should have been a notification.During an interview on 3/5/26 at 6:15 PM, the Administrator stated there should be a notification based on the decolonization program.Document review on 3/6/26 at 7:30 AM of the facility's Decolonization QAPI [Quality Assurance and Performance Improvement] Program (SHIELD: Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of Multidrug-Resistant Organisms (MDROs), undated, revealed in the program approach section, Resident Communications outlined the following activities: Discussion at Resident's Council meeting, Ombudsman notification, and Resident admission Packet letter.The facility was asked to provide documentation of the above approaches; however, none was submitted. Instead, the Administrator provided the MD's text messages.Review of the email from the Administrator, dated 3/6/26 at 7:34 AM, revealed a response from the Medical Director .[name of the Administrator]: With regard to the decolonization program, the plan to (1) inform residents at a resident council, (2) notify the ombudsman, and (3) add a letter to all admits in the admission packet, this was all from a plan template from another organization. We neither adopted nor implemented that plan. Substituting chlorhexidine gluconate for the previous bath soap and administering nasal mupirocin were viewed as essentially risk-free interventions, and I did not obtain special consent before these management changes.Review of the email response from the resident representative of Residents #2, #13, #17, dated 3/6/26 at 9:44 AM, when asked regarding facility's notification of the decolonization program, revealed: I have no idea what that is, so probably not.Review of the facility's posted YOUR RIGHTS AND RESPONSIBILITIES, undated, revealed: As patient you have the right to.receive the information about .the procedure and treatments, and any known risks and side effects which may result.make informed decisions and have reasonable participation by you and your family in the decision involving your health care including .procedures, or involvement in research.Review of the facility's admission Packet, revised on 1/2/20, revealed it contained a document titled Consent for Medical Treatment & Billing, this document revealed: .each resident has the right to refuse any proposed procedures(s) and treatment(s); no resident will be involved in any research or experimental procedures without his/her knowledge and consent.

Based on observation, interview, and record review, the facility failed to ensure:1) accurate grievance officer contact information was available to residents and representatives through required postings or individual notice, and2) clear instructions were provided on how to file and submit grievances, as grievance forms and admission information did not include submission instructions.These failed practices resulted in all residents (based on a census of 18) and resident representatives not having reliable access to the grievance process due to inaccurate grievance officer identification and unclear submission instructions. This placed residents at risk for delayed reporting and resolution of concerns and created a facility-wide system failure that limited residents' ability to access and utilize the grievance process Findings:During random observations from 3/2-6/26, the grievance notice was observed posted throughout the facility in residents' rooms. The notice revealed that residents and others could submit complaints anonymously, concerning resident abuse, neglect, and/or misappropriation of resident property in the facility with Health Facilities Licensing & Certification, Medicaid Fraud Unit, Disability Law Center of Alaska, Office of Long Term Care Ombudsman, Kepro BFCC-10 Program (Beneficiary and Family Centered Care Quality Improvement Organization serving Region 10), and Adult Protective Services.The notice identified the designated Grievance Official as Grievance Officer #1 and listed the following contact information: grievanceofficer#1@ykhc.org, 1100 Chief [NAME] Hwy, P.O. Box 2687 Bethel, AK 99559, Phone: [PHONE NUMBER]. However, Grievance Officer #1 was not the facility's current designated Grievance Official.During an interview on 3/5/26 at 11:10 AM, the Administrator stated residents were provided with information about external agencies and contacts through facility bulletin boards. The Administrator stated, For each site there's a bulletin board with all of the phone numbers. previous surveys are in a basket underneath. both units have the bulletin board. the residents can see them. The Administrator also stated the information may not always be easily accessible. When shown the picture of the grievance folder in the units, the Administrator stated: That was a folder, but it was covered with a box of gloves, a box of masks. instructions and the contact information were not easily visible.During the same interview, the Administrator stated she assumed responsibility for the facility's grievance process in October (2025) after identifying a need for more formal tracking, explaining: we used to have a social worker who used to normally deal with all grievance policies. The Administrator reported she implemented a grievance log to better document and track complaints. She stated that prior to October 2025 the Social Worker, identified as Grievance Officer #1, managed grievances.The administrator further stated that grievances may be submitted by residents, family members, or friends, and staff would assist individuals when needed, explaining, If a person has a complaint and they're not able to fill it out, then we assist or the family assists or however they want it done.During the same interview, the Administrator stated residents were generally informed about the grievance process through staff rather than formal postings and that residents may submit grievances anonymously and explained, You can fill out the form. if a person is unable to fill it out and not have their name, a family member usually puts their name. She added that complaints were commonly routed through nursing staff, . they go to the nurse or get put in the box. most of the time they're handed into [in to] the nurse and come straight to me.The Administrator also stated she provided residents with her direct contact information during resident council a while ago, explaining, I put my direct cell number on all my cards. so that they knew that they could reach out to me individually. However, minutes documenting this interaction could not be found in the Resident Council meeting records.During the same interview on 3/5/26 at 11:10 AM, the Administrator stated grievance information should be included in the admission packet but acknowledged that detailed instructions on the grievance form or process were not currently being included.Review of the document admission Agreement, undated, revealed: .Elder's Home Complaint or Grievance Procedure - From time to time, residents or their families may have a question or problem regarding their stay at Elder's Home. Elder's Home has a procedure to address these concerns. Residents and their families are encouraged to discuss any concerns with the Director of Nursing or Social Services. If one of these members of management is unable to resolve the concern, the resident or family member is encouraged to discuss the concern with the Administrator of the facility. The resident or family may also fill out a grievance form, which is located in the lobby. The admission agreement did not include instructions on how to submit the completed grievance form, where it should be submitted, or who the designated grievance officer was.Review of the Yukon-Kuskokwim Health Corporation - Grievance Report, undated, revealed a standardized form used to document and resolve resident or family concerns. The form included sections for receipt of grievance information, documentation of the concern, facility follow-up actions, resolution status, notification method, and completion signatures from responsible staff, including the Administrator, Director of Nursing, and Social Worker. The form did not include instructions for residents or representatives regarding how or where the form should be submitted.During an interview on 3/4/26 at 2:10 PM, with the Resident Council, Residents (#1, #2, #4, #8, #10, #14) stated they did not know who the Grievance Officer (GO) was or how to formally submit a grievance. When asked who they would go to if they had a complaint or concern, residents were uncertain. Resident #14 identified a staff member and stated they would go to CNA #9, referring to him/her as the person they would talk to if there was a problem. Residents did not clearly identify him/her as the facility's designated grievance officer and appeared unfamiliar with the formal grievance process.During the discussion, residents indicated they were not aware of a formal grievance system or how to submit complaints in writing. Resident #14 further stated, When I first came. I didn't say anything because I didn't know what they were talking about and I didn't know what was going on. The Resident continued by saying they were not informed about how to raise concerns and explained, I didn't know there was complaints. I did not tell questions or make any comments. Residents suggested they would typically report concerns verbally to staff rather than through a formal grievance process.During the same interview, Residents #1 and #14 also stated that some individuals may be hesitant to report concerns. Resident #14 reported that another resident had missing items but was reluctant to report it, stating, He/She said they were missing things, but they were scared to ask.Review of the procedure titled on Resident's Rights and Responsibilities, last reviewed on 2/2/22, revealed: .In accordance with these standards and Yukon Kuskokwim Health Corporation (YKHC) Corporate Policies and Procedures each resident possesses certain rights while receiving treatment. Per Centers for Medicare & Medicaid Services (CMS) these include the resident's right to: a dignified existence, self-determination, and individuality; and communication with and access to persons and services inside and outside the facility. All residents will be treated with respect and dignity, recognizing their individuality and rights as US citizens.Review of the procedure titled on LTC [Long Term Care] Concerns/Grievances (LTC-057), last reviewed on 3/2/25, revealed: .YK Elder's Home supports each resident's right to voice concerns/grievances. 1. Concerns/grievances may be presented verbally or in writing and may include such items as: a. Treatment, b. Care, c. Lost personal items, d. Management of funds, e. or violation of rights.YK Elder's Home will actively seek resolution to concerns/grievances and attempt to keep the resident or griever updates on progress toward resolution.YK Elder's Home will uphold the resident's. right to voice customer concerns/grievances or file anonymous concerns/grievances without discrimination or reprisal.The Social Worker will assure that residents or legal representative(s) receive a written copy and review of their rights and responsibilities upon admission . The Activities Director/Designee will complete a grievance form when a global issue is raised at a Resident Activities Council Meeting . The Social Worker will log all concerns/grievances received onto the facility grievance log.Review of the Policy LTC Abuse Prevention Policy, reviewed 11/7/24, revealed: .E. Residents, families and staff shall be provided feedback regarding any incidents, concerns, and/or grievances upon completion of facility investigation. F. Incident/Accident Investigations shall be done according to the Facility Incident/Accident Investigation policy & procedures. G. Grievance Investigations will be done according to the Facility Grievance policy & procedures.

.Based on observation, interview and record review the facility failed to ensure food was stored, labeled, and prepared in accordance with professional standards of practice for food safety. Specifically, the facility failed to ensure: 1) foods were properly labeled and dated; 2) expired foods were removed and discarded; and 3) food items were stored in a manner that maintained the required clearance from sprinkler heads to promote temperature distribution.These failed practices had the potential of causing or spreading foodborne illness to all residents (based on a census of 18), who received food from the kitchen .Findings:.Main KitchenAn observation, during the initial main kitchen tour, on 3/2/26 at 3:01 PM, revealed:1) Meal Prep Area Refrigerator:One half-gallon carton of open Glenview Farms - Grade A Ultra-Pasteurized 40% Milkfat milk was unlabeled, with a use-by date of 3/9/26.2) Walk-in Freezer:One clear plastic bag containing hot dogs, unlabeled, with a date of 3/1/26.One clear plastic bag containing Salisbury steak, unlabeled, with no best-used-by or expiration date3) Dry Storage:Twenty-six packages of Gran Grape Ocean Spray Grape Cranberry Juice Drink (4 Fl oz [fluid ounces] / 118 mL [milliliters]), with a best-by date of 2/15/26.4) Wing B Kitchen:One plastic bag containing an unidentified food item resembling white bread, unlabeled, with no best-used-by or expiration date.Random observations conducted during the main kitchen tour on 3/2/26 at 3:01 PM revealed the walk-in freezer and refrigerator contained multiple rows of tightly stacked cardboard boxes stored on metal wire shelving from the floor up to the ceiling (approximate 1-3 inches between the top box and the ceiling. The storage areas appeared congested and cluttered, with limited spacing between items. Several boxes were observed in very close proximity to two large industrial cooling fans.During an interview on 3/5/26 at 9:00 AM, the Kitchen Manager (KM) explained that staff were expected to write the name, store it, and routinely check refrigerators, freezers, and dry storage areas for proper labeling and dating, further stating there was a pretty high turnover and that new staff were simply shown the process upon hire. When asked about expired or mislabeled items described above, he/she confirmed such items would be discarded. During the interview, the KM reported that staff training was primarily conducted through verbal instruction and demonstration. The KM further stated I just show them what to do. indicating the absence of a formalized or structured training process.The KM further stated that the facility followed a storage policy requiring items to be kept 18 inches from the ceiling to maintain proper clearance and safety. He/she explained that staff were instructed not to store items on top shelves, noting, I tell them about it, which indicated that training on storage and fire safety practices had been provided verbally rather than through formal or documented processes.During a concurrent interview on 3/5/26 at 9:00 AM, the Dietitian reported that the facility served 18 residents and followed therapeutic diet guidelines dictated by our diet manual, while incorporating preferences gathered during admission and care planning. He/she emphasized ongoing communication through care conferences and interdisciplinary meetings. Regarding food safety, he/she noted he/she was available as a resource but currently works remotely and does not have a direct hands-on capability to ensure compliance. He/she further identified inconsistencies in labeling practices, training, and monitoring, alongside resource and staffing limitations impacting food safety compliance.He/she added that while he was ServSafe (food safety certification) certified and available as a resource for additional trainings, he/she did not have direct oversight of daily kitchen operations. It was also noted that only one staff member held a ServSafe certification, while other dietary staff-maintained Alaska State food handler cards.Review of the document titled YKHC [Yukon-Kuskokwim Health Corporation] Fire Protection, Sprinkler Heads, and Storage of Supplies, reviewed 2/2/24, revealed: . A. The minimum vertical clearance between sprinklers and material(s) below shall be 18-inches (45.7 cm [centimeters]). The 18-inch applies only to areas that have sprinklers installed. 1. Example: Picture a horizontal plane parallel to the ceiling that is 18 inches below the sprinkler heads. Nothing should be in that area between the bottom of the sprinkler heads and the imaginary horizontal plane parallel to the ceiling that is 18 inches below. This is done to allow an even and unobstructed spray pattern from the sprinklers when triggered to extinguish the fire.Review of the document titled LTC - Safe Food Procurement, Handling and Storage, reviewed on 1/20/26, revealed: I. POLICY: It is the policy of The Long Term Care Center (LTC) at Yukon-Kuskokwim Health Corporation (YKHC) that all Food & Nutrition Services staff (FNS) and cooks will procure, store, handle, prepare, distribute, and serve food in accordance with the safe food handling and storage practices established by the State of Alaska Food Safety & Sanitation Program, the United States Department of Agriculture (USDA), the U.S. Food and Drug Administration (FDA), and the Centers for Disease Control and Prevention (CDC). II. PURPOSE: Unsafe food handling practices represent a potential source of pathogen exposure. Per Centers for Medicare & Medicaid Services (CMS), sanitary conditions must be present in health care food service settings to promote safe food handling. CMS recognizes the U.S. Food and Drug Administration's (FDA) Food Code and the Centers for Disease Control and Prevention's (CDC) food safety guidance as national standards to procure, store, prepare, distribute and serve food in long term care facilities in a safe and sanitary manner.Review of the document titled LTC Food and Nutrition Services Safe Food Handling, reviewed on 4/20/24, revealed: .M. Storage: only receptacles (plastics) approved for food storage may be used in the FNS Kitchen. N. When Opened: Dry foods will be marked with an out-date that adheres to dry items and manufacturers' expiration. O. Opened items, whether refrigerated or dry storage, will be tightly capped and serving spoons/scoops will not be left in the item.Review of the Food and Drug Administration (FDA) guidelines (Food labeling 2020), accessed on 3/16/26 at this link: https://www.FDA.gov, revealed: .concerning food storage and labeling, while the FDA does not mandate expiration dates, it encourages to use best by, use by, or sell by dates to indicate peak quality and safety as well as practices of inventory management such as First In, First Out (FIFO), inventory management practice that helps ensuring that older stock is used before newer stock, reducing waste and spoilage .

.Based on interview and record review, the facility failed to monitor the effectiveness of its performance improvement activities to ensure that improvements were sustained. Specifically, the facility had no evidence of tracking, trending or monitoring the decolonization (a medical intervention aimed at eliminating antimicrobial-resistant microorganisms) program. This failed practice placed all residents (based on a census of 18) at risk of receiving an ineffective decolonization intervention and at potential risk for adverse effects .Findings:.Residents' Medical Record ReviewRecord review on 3/2-6/26 of the quarterly Minimum Data Set (MDS - a federally required nursing assessment), revealed 15 residents had antibiotics checked as is taking with indication noted in the following MDS:Resident #1's MDS dated [DATE];Resident #2's MDS dated [DATE], 1/15/26;Resident #3's MDS dated [DATE], 2/9/26;Resident #4's MDS dated [DATE], 10/26/25, 12/18/25;Resident #5's MDS dated [DATE] and 3/2/26;Resident #6's MDS dated [DATE], 2/11/26;Resident #7's MDS dated [DATE], 1/26/26;Resident #9's MDS dated [DATE], 1/12/26;Resident #10's MDS dated [DATE];Resident #11's MDS dated [DATE], 12/22/25;Resident #14's MDS dated [DATE];Resident #15's MDS dated [DATE], 2/9/26;Resident #16's MDS dated [DATE];Resident #17's MDS dated [DATE]; andResident #21's MDS dated [DATE]Record review from 3/2-6/26 of Residents #1, #2, #3, #4, #5, #7, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #21 medical diagnosis list included preventive measure clinical diagnosis Encounter for Prophylaxis.Record review 3/2-6/26 of the residents' medication orders, revealed 17 residents had the following order: Order name: Mupirocin topical, Status: completed, Details: 1 app [application], nasal, both nares [nostrils], form Ointment, BID [twice a day], M-F [Monday to Friday].Further review of the medical record revealed the following:Resident #1 had 10 weeks of completed ointment application from 11/16/25 to 2/26/26;Resident #2 had 12 weeks of completed ointment application from 9/27/25 to 2/26/26;Resident #3 had 17 weeks of completed ointment application from 7/13/25 to 2/26/26;Resident #4 had 5 weeks of completed ointment application from 12/14/25 to 2/26/26;Resident #5 had 7 weeks of completed ointment application from 12/15/25 to 2/26/26;Resident #6 had 17 weeks of completed ointment application from 7/1/25 to 2/26/26;Resident #7 had 8 weeks of completed ointment application from 11/16/25 to 2/22/26;Resident #8 had 4 weeks of completed ointment application from 1/11/26 to 2/26/26;Resident #9 had 15 weeks of completed ointment application from 8/11/25 to 2/26/26;Resident #10 had 13 weeks of completed ointment application from 9/8/25 to 2/26/26;Resident #11 had 8 weeks of completed ointment application from 11/24/25 to 2/26/26;Resident #12 had 10 weeks of completed ointment application from 10/19/25 to 2/26/26;Resident #13 had 18 weeks of completed ointment application from 6/29/25 to 2/26/26;Resident #14 had 9 weeks of completed ointment application from 11/10/25 to 2/26/26;Resident #15 had 13 weeks of completed ointment application from 9/8/25 to 2/26/26;Resident #16 had 2 weeks of completed ointment application from 2/8/26 to 2/26/26; andResident #17 had 10 weeks of completed ointment application from 10/27/25 to 2/26/26.During an interview on 3/4/26 at 5:38 PM, when asked why those residents mentioned above were prescribed Mupirocin 2% topical ointment antibiotic, the Medical Director (MD) stated the Mupirocin was used for the facility's decolonization protocol. He explained the facility had been using Chlorhexidine gluconate as soap substitute during residents' shower days and every other week the residents received Mupirocin 2% topical ointment nasal swab. When asked the rationale for the decolonization protocol, the MD stated to remove bacteria in the nose and the skin. When asked if the decolonization protocol was experimental research, the MD stated it was not, but it was considered the facility's performance improvement initiative. Quality Assurance and Performance Improvement (QAPI) Committee InterviewDuring an interview on 3/6/26 at 9:59 AM, the Administrator stated the facility's Quality Assurance and Performance Improvement (QAPI) committee was working on projects such as pressure injuries. She stated that QAPI was tracking and trending the project and if the plan was not working, they would discuss and plan again.When asked if the QAPI committee was aware of the facility's decolonization program, the QAPI committee stated the decolonization program was implemented through the infection control and that it was not discussed in QAPI meetings. The Chief Nursing Executive (CNE) provided a historical background to the project. She stated the MD implemented the decolonization program. When asked if the decolonization program was one of QAPI's performance projects, the CNE did not directly answer the question but stated that the MD reported it to QAPI. When asked what the timeframe of the program was, the committee had not provided the information and that the MD was collaborating with the Infection Preventionist. The CNE further stated the MD had been tracking and trending the program but had not submitted to QAPI. Infection Preventionist interviewDuring an interview on 3/5/26 at 11:08 AM, when asked about the decolonization program of the facility, the Infection Preventionist stated she was aware that Chlorhexidine was used as soap for the residents and the facility was initiating nasal swab. She further stated she was not up to date on the program; she was only recently made aware of it. When asked if she was monitoring the program, she stated she had not and she was not actively involved in the decolonization program, other than knowing about it.During the same interview, when asked if the decolonization program was discussed in the Infection Prevention and Control (IPC) meeting, she stated it could have been discussed but she could not say for sure.Review of the IPC meeting minutes dated 4/23/25, revealed in the LTC (long term care) report, .CHG [unknown acronym] Bathing Program.There was no other information about the program in the meeting minutes (3/1/25 and 1/29/26) provided by the facility. Medical Director InterviewDuring an interview on 3/6/26 at 10:47 AM, the MD stated the decolonization program was implemented on 7/1/25. He stated that the program would be permanent because it seems to be helping the residents in preventing infection and hospitalization.When asked if he had data from the facility that led him to the implementation of the program, the MD stated he was tracking hospitalization due to congestive heart failure and in September (unknown year) there was a respiratory illness that was never identified. He stated that possibly there was an infection that had no test for.During the same interview, the MD stated he listened to a webinar on decolonization. The MD could not remember the title but stated he would provide the email he had sent to YKEH personnel about the decolonization program. He further stated that the webinar made him excited and anticipated that if the facility implemented the program, it would reduce the hospitalization per year.Review of the MD's email, dated 7/25/24, revealed the email was sent to several personnel in YKEH (Yukon Kuskokwim Elders Home). Further review revealed: Esteemed colleagues, I have just listened to webinar #13 on decolonization in the AHRQ [Agency for Healthcare Research and Quality] Safety Program for MRSA [Methicillin-Resistant Staphylococcus Aureus] Prevention. Subsequently, I read the attached November 2023 New England Journal of Medicine article entitled: Decolonization in Nursing Homes to Prevent Infection and Hospitalization, which describes a study which found that continuous, routine decolonization of nursing home residents significantly reduced the rate of hospitalization. The interventions were.1. substituting 4% rinse-off chlorhexidine gluconate (CHG) for soap during routine bathing [CHG binds to the proteins of the skin and has an effect duration of about 24 hours] AND 2. Nasal decolonization twice daily, 5 days per week [Mupirocin 2% ointment would be my choice].The number needed to treat to prevent one hospitalization (apparently over the 18 month study period) was 8.9, which is relatively low. The article concluded that the 'cost-benefit ratio is likely to be very favorable' . I am currently tracking Elders Home hospitalization, so we can easily assess for impact.this sounds like relatively easy intervention for us to implement.During an interview on 3/6/26 at 10:47 AM, the MD stated he was tracking and trending the decolonization program. When asked if he reported or updated the QAPI committee in the monthly meetings, he stated No. He stated that the full year data would be available on 6/30/26, which he would then present it to QAPI. QAPI Minutes of the MeetingReview of the facility's QAPI minutes of the meeting dated 12/18/25, 1/15/26, and 2/19/26, revealed decolonization program was not discussed. QAPI PlanReview of the facility's QAPI Plan, dated 8/2025, revealed: .Monitoring and Evaluation Activities.Administrator, DON, and QAPI Committee participants monitor a number of ancillary activities which, when combined with the mandatory measures, provides YKHC [Yukon Kuskokwim Health Corporation] with data for an overall evaluation of quality of care and safety.The QAPI Committee reviews data on a monthly basis, and trends data quarterly.Further review of the plan revealed: .The Elder's Home team members will conduct Performance Improvement Projects (PIPs) designed to take a systematic approach to revise and improve care or services in areas that are identified as needing attention. Leadership will conduct PIPs that lead to change and guide corrective actions within our systems, which cross multiple departments, and have impact on the quality of life and quality of care for residents residing at the Elder's Home. As PIPs are identified, we will focus on conducting those that will improve care and service delivery, increase efficiencies, lead to improved staff and resident outcomes and lead to greater staff, resident, and family satisfaction. An important aspect of our PIPs is in monitoring the effectiveness of the performance improvement activities to determine whether the improvement has been sustained. Ongoing monitoring of the PIP, will be documented. The team will report their progress to the QAPI committee on a regular basis. The QAPI committee, in turn, will ensure that the following individuals and groups are informed of the PIPs and other QAPI activities: Board members, Elder's Home Staff, Residents and their families, [and] Others.

.Based on record review, observation, and interview, the facility failed to provide an ongoing program of individualized, meaningful activities designed to meet the interests and needs of residents for 2 of 18 sampled residents (Residents #7 and #10). Specifically, the facility failed to: 1. implement activities consistent with residents' assessed preferences and care plan goals,2. ensure activities were actually provided as scheduled, and3. maintain effective oversight and evaluation of the activity program.These deficient practices placed residents at risk for social isolation, decreased psychosocial well-being, and diminished quality of life Findings:.Resident #7Record review from 3/2-6/26 revealed Resident #7 was admitted to the facility with diagnoses that included heart failure (mildly reduced heart pumping ability) with associated hemiparesis (weakness on one side of the body), hyperlipidemia (high blood fats/cholesterol), hypertension (high blood pressure), insomnia (difficulty sleeping), and colorectal cancer (cancer of the colon or rectum).During an interview with Resident #7's Representative on 3/3/26 at 1:12 PM, he/she stated that there was a lack of meaningful and consistent activities provided to residents. The representative reported that although an activities calendar was posted with scheduled events, such as baking and other programs, many of those activities did not actually occur, with bingo identified as the only activity consistently offered. He/she stated that when concerns were raised, activity offerings temporarily improved but were not sustained. Additionally, he/she stated that outings were infrequent, though a recent trip to a local high school was well received due to its rarity. The representative also reported that while an Eskimo dance group practices within the facility, residents were not informed or invited to participate or observe. Overall, he/she described the residents' daily routine as repetitive, consisting primarily of medications, meals, and bedtime, with little variation, including on weekends and holidays.Review of Resident #7's Activities Evaluation, dated 11/11/25, revealed: Activity Interests: Cards and Games Interest: Card games. Crafts and Art Interest: Hand crafts, Sewing, Other: tying fishing nets and other related items to subsistence lifestyle. Physical Activity Interest: Ball catching, Walking. Music Interest: Listen to music: Ball, Live music, Other: old school like Elvis. Spirituality and Religious Interest: Attend worship, Read Bible . Outing Interest: Movies, Seasonal events, Sightseeing.Review of the plan of care for Long Term Activities, last updated on 11/21/24, revealed: Resident #7 will participate in group activities x5/wk [week].will be involved with individual activities daily. (GOAL).Interests: Country and gospel music, Yup'ik radio call in shows, TV/movies, outings.Storytelling, working on fishing nets, Alaska Native culture, socials and sports.Review of Resident #7 Minimum Data Set (MDS - a federally required nursing assessment), Section F: Preferences for Customary Routine and Activities, dated 11/10/24 revealed Resident #7 responses to the importance of various activities while in this facility, coded on a scale where 1 is Very important, 2 is Somewhat important, and 3 is Not very important: A. How important is it to you to have books, newspapers, and magazines to read? [coded] 2 (Somewhat important); B. How important is it to you to listen to music you like? [coded] 2 (Somewhat important); C. How important is it to you to be around animals such as pets? [coded] 3 (Not very important); D. How important is it to you to keep up with the news? [coded] 1 (Very important); E. How important is it to you to do things with groups of people? [coded] 1 (Very important); F. How important is it to you to do your favorite activities? [coded] 2 (Somewhat important); G. How important is it to you to go outside to get fresh air when the weather is good? [coded] 2 (Somewhat important); H. How important is it to you to participate in religious services or practices? [coded] 2 (Somewhat important).Review of the Activity Detail Report - [Caretracker] for January, February, and March 2026 for Resident #7 revealed multiple entries for activities such as television viewing, music, exercise, socialization, and group programming. However, the documentation did not align with the posted activity calendar, as recorded activities did not correspond with scheduled events or times. Additionally, entries reflected generalized or repetitive activity types without clear evidence of individualized, meaningful engagement based on the resident's assessed interests and care plan goals. Due to these inconsistencies, the documentation did not provide sufficient evidence that activities were implemented as planned. Random observations conducted throughout the survey from 3/2-6/26 revealed Resident #7 was consistently observed in his/her room and was not observed participating in or being offered scheduled group or individual activities. Despite a posted activity calendar indicating ongoing programming, there was no observed evidence of Resident #7's engagement in activities during the survey period. These observations were not consistent with the Resident's assessed interests and care plan goals for regular participation in both group and individualized activities.Resident #10Record review from 3/2-6/26 revealed Resident #10 was admitted to the facility with diagnoses that included low back pain (chronic lower back discomfort), microalbuminuria (small amounts of albumin in urine), osteoarthritis (joint degeneration and pain), pressure ulcer of coccyx (bed sore over tailbone area), and dementia (progressive cognitive decline).During an interview with Resident #10 on 3/2/26 at 4:48 PM, when asked about the activities that had been offered, he/she stated: Only Bingo but we haven't had that for a while.it's pretty boring, we don't do much.Review of Resident #10's Activities Evaluation, dated 1/30/26, revealed: Activity Interests: Cards and Games Interest: Bingo. Crafts and Art Interest: Hand crafts. Physical Activity Interest: Cooking: Low impact exercise, Hand crafts. Music Interest: Listen to music. Reading and Writing Interest: Mail. Spirituality and Religious Interest: Attend worship. Outing Interest: Movies, Seasonal events, Sightseeing . Interest in Social Conversation: Family/Friends, Other residents, Staff, Volunteer. Review of the plan of care for Long Term Activities, last updated on 7/23/24, revealed Resident #10 will participate in group activities x5/wk [week].will be involved with independent activities of choice daily. (GOAL).interests: Bingo, cooking, crafts, exercise, music/radio, church, tv/movies, van rides., community events, Native Alaskan Culture, socializing, mail. Review of Resident #10 MDS, Section F: Preferences for Customary Routine and Activities, dated 4/9/25, revealed Resident #10 responses to the importance of various activities while in this facility, coded on a scale where 1 is Very important, 2 is Somewhat important, and 3 is Not very important: A. How important is it to you to have books, newspapers, and magazines to read? [coded] 2 (Somewhat important); B. How important is it to you to listen to music you like? [coded] 3 (Not very important); C. How important is it to you to be around animals such as pets? [coded] 3 (Not very important); D. How important is it to you to keep up with the news? [coded] 3 (Not very important); E. How important is it to you to do things with groups of people? [coded] 3 (Not very important); F. How important is it to you to do your favorite activities? [coded] 2 (Somewhat important); G. How important is it to you to go outside to get fresh air when the weather is good? [coded] 1 (Very important); H. How important is it to you to participate in religious services or practices? [coded] 3 (Not very important).Review of the Activity Detail Report - [Caretracker] for January, February, and March 2026 for Resident #10 included documented entries for activities such as television viewing, music, exercise, socialization, and occasional group programming, including bingo. However, the documentation did not align with posted activity calendar, as recorded activities lacked correlation with scheduled events, specific times, or structured programming. Entries were generalized and did not clearly demonstrate individualized or goal-directed activity implementation based on the resident's assessed preferences. As a result, the documentation did not provide sufficient evidence that an ongoing, meaningful activity program was consistently provided.Random observations conducted throughout the survey from 3/2-6/26 revealed Resident #10 was primarily observed in his/her room and was not observed participating in scheduled activities, with the exception of one instance of participation in a Bingo activity. Despite a posted activity calendar indicating ongoing programming, there was limited observed evidence of consistent engagement in activities. These observations were not consistent with the Resident's assessed interests and care plan goals participation in both group and individualized activities.During an interview on 3/4/26 at 2:10 PM, with the Resident Council, Residents (#1, #2, #4, #8, #10, #14) stated they had very limited activity options, reported no activities and when asked what they do during the day, responded, nothing. Residents stated that just bingo was the only activity they were aware of, with no other consistent programming. When asked about activities occurring that day, residents reported no activities were offered. Residents expressed interest in having more variety, including outings in the summertime, as well as activities such as knitting, dancing, and cultural programs, indicating current activity offerings were minimal, lacked variety, and did not meet their interests.During an interview on 3/5/26 at 2:45 PM, Certified Nurse Assistant (CNA) #9 stated staff did not have an effective way to accurately track or log activities and reported that 'CareTracker' often did not reflect actual resident participation. CNA #9 stated the system did not allow staff to free-type notes and did not accurately reflect the activities that were actually provided, resulting in documentation that did not match what occurred. CNA #9 further described attempts to engage residents in activities such as crocheting, sewing, games, movies, and group exercises; however, residents frequently declined participation due to discomfort, lack of interest, or returning to their rooms after meals, and at times during Resident Council, residents expressed that activities were boring, making consistent engagement challenging. CNA #9 further added staff were not able to document refusals, since one cannot add those to 'Caretracker'.During an interview with the Activities Director (AD) on 3/5/26 at 2:00 PM, she stated she had been overseeing the activity program remotely from Minnesota and reported limited direct interaction with residents, stating, I haven't been out there since COVID, and that she was not able to complete face-to-face visits, relying instead on chart review and staff input. She stated, I rely on the staff quite a bit, and further explained, I'm remote, and it's not ideal. When asked about oversight of activity implementation, she stated she was dependent on knowing who's in the building doing the job and reported she was not responsible for creating the activity calendar, stating, I'm not the one making it because I'm not there. Regarding weekend programming, she stated, We don't have weekend coverage that I'm aware of. it's mostly what nurses can do, and described scheduled weekend activities as probably lacking. When asked about discrepancies between the activity calendar and documentation, she stated, That's why I need a copy of the calendar so I can check it against 'CareTracker', and added, I'm not there, so I can only do what I'm sent. She also stated she completed audits and QAPI (Quality Assurance Performance Improvement) reviews but had fallen off doing those lately, and reported, I would say they probably want more. it's obvious there are things we're missing. When asked the AD could not provide evidence the facility evaluated or revised the activity program in response to resident dissatisfaction.Review of the document titled Yukon Kuskokwim Health Corporation - Activity Director Job Description, revealed: . Position Summary: responsible for coordinating, directing, planning, and conducting the life enrichment activity programs, and this position will also work closely with community volunteers; . Position Responsibilities: .2. Designs a creative and exciting life enrichment program to meet group and individual needs and interests of the residents; 3. Plans and implements a life enrichment calendar each month that includes life skills, education, wellness, recreational, and spiritual programming, while providing individualized calendars for each resident, his or her families, and friends, and posting calendars throughout the facility; 4. Provides one-to-one programming for residents who cannot participate in a group setting; 5. Provides transportation for resident medical appointments and recreational outings; 6. Coordinates the holiday decorations with the help of residents and coordinating volunteers to help with events, as well as coordinating the help of other staff as necessary to bring residents to and from activities and events located on campus; 7. Maintains life enrichment budget, equipment, and supplies.Record review of the facility policy LTC [Long Term Care] Activity Evaluation & Care Plan, reviewed 5/2/23, revealed: .It is YKHC [Yukon-Kuskokwim Health Corporation] Elder's Home policy to assess each resident's physical, mental, spiritual, cultural, and leisure choices as well as each resident's preferences for participation in activities. This assessment will occur on admission, quarterly, and with condition changes per the Minimum Data Set (MDS) schedule. PURPOSE: To assure that the facility delivers an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. This may be achieved through group participation, independent activity, individual visits, and/or independent activity.

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed. Specifically, the facility failed to: 1) provide hand hygiene to 7 residents (#s 1, 5, 6, 9, 11, 12, and 13), out of 8 residents observed for hand hygiene before meals; and 2) ensure clean laundry of all (census of 18) residents was transported with appropriate measures to prevent contamination. This failed practice had the potential for the transmission of infectious disease and place residents at risk of acquiring communicable diseases. Findings: Hand hygiene before meals: A dining observation on 1/27/25 at 4:55 PM, on the Wing A unit, revealed Certified Nurse Assistants (CNAs) were serving dinner meals to the residents. Further observation revealed the CNAs did not offer hand hygiene to the residents before meals as follows: - 5:00 PM: CNA #1 served the plate of food to Resident #1 without offering hand hygiene; - 5:01 PM: CNA #4 served the plate of food to Resident #13 without offering hand hygiene; - 5:02 PM: CNA #4 served the plate of food to Resident #6 without offering hand hygiene; and - 5:04 PM: CNA #4 served the plate of food to Resident #12 without offering hand hygiene. An observation on 1/29/25 at 11:30 AM, during the dining observation on the Wing A unit, revealed Resident #6 was sitting in the wheelchair in the dining area while waiting for lunch. Licensed Nurse (LN) #1 placed Resident #6's meal on the table and then informed Resident #6 that lunch was ready at the table. Further observation revealed Resident #6 was not offered hand hygiene before meals. An observation on 1/30/25 at 11:30 AM, during the dining observation on the Wing A unit, revealed Resident #1 was sitting in the dining area while waiting for lunch. CNA #1 set up lunch for the resident and did not offer hand hygiene. Further observation revealed Residents #5 and #6 were sitting in their wheelchairs in the dining area while waiting for lunch. LN #1 placed Resident #6's meal on the table and CNA #2 placed Resident #5's meal on the table. Further observation revealed Residents #5 and #6 were not offered hand hygiene before meals. Hand hygiene after bathroom use: Resident #12 Record review on 1/27-31/25 revealed Resident #12 was admitted to the facility with diagnoses of dementia (neurological disease characterized by a general decline in memory, thinking, and social abilities), anxiety, and insomnia (a sleep disorder). A continuous observation on 1/29/25 between 11:04 AM to 11:10 AM, revealed CNA #3 wheeled Resident #12 to the bathroom to check if he/she had a BM (bowel movement). Once in the bathroom, CNA #3 had Resident #12 stand and hold on the straight grab bar on the wall next to the toilet. As CNA #3 checked his/her brief, feces fell from the brief onto the floor. The feces was picked up by Student #1 (a student CNA assisting CNA #3). The floor surface was not cleaned after. The Resident was given perineal care and was changed to a new clean brief. CNA #3 had Resident #12 sit back down on the wheelchair after and then CNA #3 removed his/her gloves and instructed Student #1 to take the Resident to the dining area for the lunch service. No hand hygiene was offered to the Resident prior to leaving the bathroom. Resident #12 was served his/her lunch shortly after and no hand hygiene was offered prior to the Resident eating. A continuous observation on 1/30/25 between 11:10 AM to 11:15 AM, revealed CNA #1 wheeled Resident #12 to the bathroom to check if the Resident needed a change of brief. CNA #1 had the Resident stand up and hold to the straight grab bar and CNA #2 checked Resident #12's brief, which was noted to be dry. CNA #1 had the Resident sit back down in his/her wheelchair and asked CNA #2 to take the Resident to the dining room for lunch service. No hand hygiene was offered to the resident prior to leaving the bathroom. CNA #2 served Resident #12's lunch shortly after and no hand hygiene was offered prior to the Resident eating. During a joint interview on 1/30/25 at 11:38 AM, the Chief Nursing Executive (CNE) stated residents were offered hand hygiene before and after meals. The Director of Nursing (DON) added that the facility used Sani wipes (a disposable disinfecting cloth) for resident's hand hygiene. During an interview on 1/31/25 at 8:30 AM, the DON confirmed that hand hygiene was to be offered to the residents before and after meals and when the resident used the bathroom. Review of the facility's policy Hand Hygiene, dated 10/13/22, revealed: .the following CDC [Centers for Disease Control and Prevention] recommendations are the [facility's] policy for hand hygiene.before and after eating and after using a restroom, wash hands with non-antimicrobial soap and water or with antimicrobial soap and water. Laundry Services: During the laundry area tour, on 1/30/25 at 12:30 PM with the Environmental Services Manager (ESM) and Environmental Services (EVSW) #1, the ESM stated that there were two laundry rooms in the facility, one in each unit (Wing A and B). EVSW #1 stated that the clean laundry was placed in a clean blue bin and transported from the dryer to the folding room uncovered. EVSW #1 stated he/she would push the blue bin with clean clothes out of the dryer area to the folding area. The folding area was in another room passing through the hallway of the common area of the unit. When asked how the residents clean clothing was transported into residents' rooms, EVSW #1 stated, he/she would place the clean clothing in the blue bin and push the bin to each of the residents' room and put the clothes in the resident closet. When asked if the blue bin was covered during the transport, EVSW #1 stated no. Review of the facility's policy Procedure: on YKDRH [Yukon Kuskokwim Delta Regional Hospital] and LTC [Long Term Care] Linen Management, dated 8/8/24, revealed: .Laundry should be delivered to the units in a clean covered container.

Based on interview and record review, the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Specifically, from the end of March 2024 through the end of May 2024, there was no full-time DON for the facility. This failed practice of not providing a full-time DON to oversee daily management and the monitoring of care practices, had the potential to place all residents (based on a census of 18) at substantial risk for subquality of care. Findings: During an interview on 1/30/25 at 12:45 PM, the Yukon Kuskokwim Delta Regional Hospital's (YKDRH) Chief Nursing Officer (CNO) stated she had resigned as the DON at the Yukon Kuskokwim Elder's Home (YKEH) on 3/2024. When asked who the designated YKEH DON was, the CNO stated the new DON started in 5/2024. When further asked who the designated DON was from 3/2024 to 5/2024, the CNO provided no response. During an interview on 1/30/25 at 2:00 PM, the DON stated she worked at YKEH as a charge nurse from 10/2023 to 5/2024. The DON further stated she accepted the DON position at YKEH the end of May 2024. When asked who the designated DON was for YKEH from 3/2024 to 5/2024, the DON stated [the YKDRH CNO] was a resource if the facility needed. Review of the facility-provided email, Announcement of my New Role within YKHC, dated 2/23/24 and written by the YKDRH CNO, revealed: . I will be transitioning from my current position as the Director of Nursing at YK Elders Home to take on a new role as the Chief Nurse Executive for YKHC. This change will take effect on 3/17/24 . Review of the facility's job description Director of Nursing Services, dated 8/2012, revealed: . D. Position Responsibilities. 1. Responsible for the delivery of the nursing services .of each resident . 2. Oversee that the residents' dignity and right to privacy are upheld .3. Responsible for making sure that there is adequate staff . 4. Keeps the facility in compliance . 5. Develops and evaluates with the health care team and administration resident goals and policies . 6. Maintains safety rules and procedures . 7. Responsible for keeping the department on budget . 8. Observes, mentors, and trains new and current staff . 9. Keeps the administrator up to date on resident changes, staffing changes and service plan changes . 11. Supports a dignified and caring atmosphere . 13. Maintains a safe and secure working environment . 16. Assist with special projects . Record review of the facility's job description LTC [Long-term Care] Registered Nurse Charge Nurse, undated, revealed: . D. Position Responsibilities . 13. Report changes in resident condition to the DNS [Director of Nursing Services/DON] . in a timely manner .

Based on observation, interview and record review the facility failed to ensure that food was stored, labeled, and prepared foods in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) foods were labeled and dated; and 2) expired foods were discarded. These failed practices had the potential of causing or spreading foodborne illness to residents, based on a census of 18, who received food from the kitchen. Findings: Main Kitchen An observation, during the initial main kitchen tour, on [DATE] at 1:15 PM, revealed: 1) Walk-in Cooler: - 3- expired Darigold Heavy Whipping Cream- 64-ounce carton- with manufacture best by date of [DATE]; - 2- expired Yoplait Light Strawberries & Banana Yogurt - 6-ounce single serving container- with manufacture best if used by date of [DATE]; and - 2- expired Monarch Chopped Garlic in Oil- 32-ounce plastic container-with manufacture best if used by date of [DATE]. 2) Walk-in Freezer: -1- clear plastic bag, food not identified, not labeled, no best used by date or expiration date. Food & Nutrition Service staff (FNS) #2 stated contents were oxtail; -1- clear plastic bag, Duck, no best used by date or expiration date; -1- white paper package, HB no best used by date or expiration date; and -6- expired Monarch Chopped Garlic in Oil- 32-ounce plastic container-with manufacture best if used by date of [DATE]. 3) Dry Storage: - 1- plastic container Sweet Baby Rays Barbecue Sauce-1 gallon container, open ,d+[DATE] full, no open date. - 14- expired C&H Confectioner Sugar -16-ounce box- with manufacture best if used by date of [DATE]; - 6- expired Monarch Honey Grade A - 12-ounce plastic bottle- with manufacture best by date of [DATE]; - 6- expired Monarch Honey Grade A - 12-ounce plastic bottle- with manufacture best by date of [DATE]; - 2- expired Jif Natural Low Sodium Creamy Peanut Butter Spread - 28-ounce plastic container - with manufacture best by date of [DATE]; - 4- expired Gold Medal [NAME] Cake Mix - 5 lb. box- with manufacture best by date of [DATE]; - 5- expired Gold Medal Yellow Cake Mix - 5 lb. box- with manufacture best by date of [DATE]; - 1- expired box General Mills [NAME] Chex Gluten Free - 1.4-ounce plastic single serve container- with manufacture best by date of [DATE]; - 1- box Sysco Creamy Fudge Icing Mix open box- ,d+[DATE] full- [DATE] [written in black marker], no best used by date or expiration date; - 1- box Sysco Creamy Fudge Icing Mix open box- ,d+[DATE] full- [DATE] [written in black marker], no best used by date or expiration date; - 1- large white bin container with clear lid, not labeled, contained 1- 25 lb. [pound] bag, Panko and 1 - 25 lb. bag, All Purpose Flour noted substance that appeared to be white rice on the bottom of the container. 4) Meal Prep Area: - 1- expired Simply Thick Easy Mix Instant Food Thickener - 55-ounce plastic container- with manufacture best by date of [DATE]. During interview on [DATE] at 1:15 PM, FNS #2 stated food was rotated to prevent expired products, old in front and new in the back when asked about expiration dates. FNS #2 was unable to provide expiration dates or how long products are kept without expiration dates. 5) Wing B Kitchen: - 3- clear plastic bags appeared to be white bread, no best by used date or expiration date. Review of the Food and Drug Administration (FDA) guidelines (Food labeling 2020), accessed at this link: https://www.FDA.gov, revealed: . concerning food storage and labeling, while the FDA does not mandate expiration dates, it encourages to use best by, use by, or sell by dates to indicate peak quality and safety as well as practices of inventory management such as First In, First Out (FIFO), inventory management practice that helps ensuring that older stock is used before newer stock, reducing waste and spoilage . Review of the facility's policy LTC - Safe Food Procurement, Handling, and Storage, dated [DATE], revealed: . Yukon-Kuskokwim Health Corporation (YKHC) that all Food & Nutrition Service staff and cooks will procure, store, handle, prepare, distribute, and serve food in accordance with the safe food handling and storage practices established by the State of Alaska Food Safety & Sanitation Program, the United States Department of Agriculture (USDA), the U.S. Food and Drug Administration (FDA), and the Centers for Disease Control and Prevention (CDC). II. Purpose: Unsafe food handling practices represent a potential source of pathogen exposure . CMS [Centers for Medicare & Medicaid Services] recognizes the [FDA] Food Code and the [CDC] food safety guidance as national standards to procure, store, prepare, distribute and serve food in long term care facilities in a safe and sanitary manner. Review of the facility's policy LTC- Native Foods Donation, dated [DATE], revealed: . I. Policy: It is the policy of the [YKHC] Elder Home to provide guidance on traditional native foods. Both federal law and CMS set guidelines on foods which are allowed to be brought into the facility by families and/or donated to the Elder Home. the food once in the Kitchen is labeled, dated, and stored separately from other food .

Based on record review, observation, and interview, the facility failed to obtain the residents' consent for bedrails use and conduct accurate risks and benefits assessments for 7 residents (#'s 1, 2, 5, 6, 8, 12, and 167), out of 8 sampled residents and 2 unsampled residents (#s 11 and 13), reviewed for bedrails use. This failed practice had the potential to place the residents at risk of falls, entrapment, and other preventable accidents and potentially place residents at risk of feelings of isolation and helplessness. Findings: Resident #1 Record review on 1/27-31/25 revealed, Resident #1 was admitted to the facility with diagnoses of Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), chronic kidney disease (CKD), type 2 diabetes mellitus (DM, non-insulin-dependent diabetes), and cognitive deficits following a cerebrovascular accident (CVA, also known as stroke, is when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel). An observation on 1/29/25 at 10:30 AM, revealed Resident #1's bed had the two upper side rails raised. Review of Resident #1's most recent MDS (Minimum Data Set, a federally required nursing assessment), OBRA Annual Assessment, dated 12/15/24, revealed: . Section P - Restraints, P0100 . Used in Bed. A. Bed rail. 0 = Not used. Review of Resident #1's Long Term ADL [Activities of Daily Living] Function Rehab IPOC [Interdisciplinary Plan of Care], last updated on 11/4/24, revealed: .impaired ADL function . x1-2 assist with ADLs . Further review of Resident #1's medical record revealed no physician order, no risk and benefits and/or no informed consent regarding the use of bed rails was found. Resident #2 Record review on 1/27-31/25 revealed, Resident #2 was admitted to the facility with diagnoses of major depressive disorder (MDD- mood disorder characterized by depressed mood and loss of interest and/or pleasure in activities), hallucinations (the perception of the presence of something that is not actually there, it may be auditory or visual or involve smells, tastes or touch), and expressive aphasia (characterized by partial loss of the ability to produce language). An observation on 1/29/25 at 10:30 AM, revealed Resident #2's bed had the two upper side rails raised. Review of Resident #2's most recent MDS, OBRA Quarterly Review Assessment, dated 11/9/24, revealed: . Section P - Restraints, P0100 . Used in Bed. A. Bed rail. 0 = Not used. Review of Resident #2's Long Term ADL Function Rehab IPOC, last updated on 12/16/24, revealed: .dependent with all ADLs . x1-2 assist with ADLs . Further review of Resident #2's medical record revealed no physician order, no risk and benefits and/or no informed consent regarding the use of bed rails was found. Resident #5 Record review on 1/27-31/25 revealed, Resident #5 was admitted to the facility with diagnoses of aortic valve regurgitation (a heart valve disease that causes blood to leak backward to the heart), CKD, gait disorder, and MDD. An observation on 1/29/25 at 10:30 AM, revealed Resident #5's bed had the two upper side rails raised. During an interview with Resident #5 on 1/31/25 at 09:34 AM, he/she stated it's always been up. I don't remember it being down. Review of Resident #5's most recent MDS, OBRA Quarterly Review Assessment, dated 12/11/24, revealed: . Section P - Restraints, P0100 . Used in Bed. A. Bed rail. 0 = Not used. Review of Resident #5's Long Term ADL Function Rehab IPOC, last updated on 12/16/24, revealed: .has impaired ADL function . x1-2 assist with ADLs . Further review of Resident #5's medical record revealed no physician order, no risk and benefits and/or no informed consent regarding the use of bed rails was found. Resident #6 Record review on 1/27-31/25 revealed Resident #6 was admitted to the facility with diagnoses of dementia (loss of cognitive functioning), CVA, seizure disorder, and asthma. An observation on 1/29/25 at 10:30 AM, revealed Resident #5's bed had the left upper side rail raised. Review of Resident #6's most recent MDS, OBRA Admission Assessment, dated 11/13/24, revealed: . Section P - Restraints, P0100 . Used in Bed. A. Bed rail. 0 = Not used. Review of Resident #6's Long Term ADL Function Rehab IPOC, last updated on 12/10/24, revealed: .has impaired ADL function . x1 assist with ADLs . Further review of Resident #6's medical record revealed no physician order, no risk and benefits and/or no informed consent regarding the use of bed rails was found. Resident #8 Record review on 1/27-31/25 revealed, Resident #8 was admitted to the facility with diagnoses of impaired mobility, rheumatoid arthritis (a chronic inflammatory disorder that affects the joints and other body systems), and Lewy body dementia (a progressive brain disorder that is characterized by the buildup of proteins into masses which affects thinking, memory, movement, and sleep). An observation on 1/29/25 at 10:30 AM, revealed Resident #8's bed had the two upper side rails raised. Review of Resident #8's most recent MDS, OBRA Quarterly Review Assessment, dated 12/11/24, revealed: . Section P - Restraints, P0100 . Used in Bed. A. Bed rail. 0 = Not used. Review of Resident #8's Long Term ADL Function Rehab IPOC, last updated on 12/9/24, revealed: .impaired ADL function . x1-2 assist with ADLs . Further review of Resident #8's medical record revealed no physician order, no risk and benefits and/or no informed consent regarding the use of bed rails was found. Resident #11 Record review on 1/27-31/25 revealed, Resident #11 was admitted to the facility with diagnoses of dementia, type 2 DM, and aortic valve stenosis (narrowing of the heart's aortic valve). During an observation on 1/29/25 at 10:30 AM, revealed Resident #11's bed had the left upper side rail raised. Review of Resident #11's most recent MDS, OBRA Quarterly Review Assessment, dated 1/7/25, revealed: . Section P - Restraints, P0100 . Used in Bed. A. Bed rail. 0 = Not used. Review of Resident #11's medical record revealed no care plan for Long Term ADL Function Rehab IPOC. Further review of Resident #11's medical record revealed no physician order, no risk and benefits and/or no informed consent regarding the use of bed rails was found. Resident #12 Record review on 1/27-31/25 revealed, Resident #12 was admitted to the facility with diagnoses of dementia, anxiety and insomnia (a sleep disorder). During an observation on 1/29/25 at 10:30 AM, revealed Resident #12's bed had the left upper side rail, and the right lower side rail raised. Review of Resident #12's most recent MDS, OBRA Annual Assessment, dated 10/23/24, revealed: . Section P - Restraints, P0100 . Used in Bed. A. Bed rail. 0 = Not used. Review of Resident #12's Long Term ADL Function Rehab IPOC, last updated on 2/5/24, revealed: .has impaired ADL function . x1 assist with ADLs . Further review of Resident #12's medical record revealed no physician order, no risk and benefits and/or no informed consent regarding the use of bed rails was found. Resident #13 Record review on 1/27-31/25 revealed, Resident #13 was admitted to the facility with diagnoses of dementia, depression, and benign prostatic hyperplasia (BPH- a condition in which the flow of urine is blocked due to the enlargement of prostate gland). During an observation on 1/29/25 at 10:30 AM, revealed Resident #13's bed had both upper side rails raised. Review of Resident #13's most recent MDS, OBRA Quarterly Review Assessment, dated 10/18/24, revealed: . Section P - Restraints, P0100 . Used in Bed. A. Bed rail. 0 = Not used. Review of Resident #13's Long Term ADL Function Rehab IPOC, last updated on 12/9/24, revealed: .mostly independent with ADLs but is forgetful at times . may require x1 assist . Further review of Resident #13's medical record revealed no physician order, no risk and benefits and/or no informed consent regarding the use of bed rails was found. Resident #167 Record review on 1/27-31/25 revealed, Resident #167 was recently admitted to the facility with diagnoses of dementia, CKD, and BPH. During an observation on 1/29/25 at 10:30 AM, revealed Resident #167's bed had the left upper side rail raised. No MDS assessment was available during record review on 1/27-31/25. Review of Resident #167's Long Term ADL Function Rehab IPOC, last updated on 1/17/25, revealed: .1-2 assist with ADLs . Further review of Resident #167's medical record revealed no physician order, no risk and benefits and/or no informed consent regarding the use of bed rails was found. During an interview on 1/30/25 at 2:20 PM, the Director of Nursing (DON) stated that the facility did not obtain consent or complete assessments for risks and benefits of side rail usage. A bedrail assessment policy was requested from the DON. She stated the facility had no policy on bedrails. During an interview with Certified Nursing Assistant (CNA) #1 on 1/31/25 at 9:45 AM, he/she stated that the residents that utilized the bed side rails were to help promote mobility while in bed.

Based on record review and interview, the facility failed to ensure 5 residents (#s 3, 5, 8, 9, and 14), out of 8 sampled residents, were examined in person by a medical provider within the required interval of at least 60 days, or no later than 10 days after the date the visit was required. This failed practice placed the residents at risk for substandard medical care. This further placed the residents at risk for exacerbation of health conditions. Findings: Resident #3 Record review on 1/27-31/25, revealed Resident #3 was admitted to the facility with diagnoses that included osteoarthritis (degenerative joint disease), congestive heart failure (CHF- a chronic condition that results when the heart muscle is unable to pump blood efficiently), dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking), and depression. Review of Resident #3's medical record on 1/29/25 at 2:00 PM, revealed during the last 12 months of physician progress notes, he/she was seen in person on 3/28/24, 5/23/24, 7/10/24, 8/19/24 and 1/29/25. Further review revealed there was 163 calendar days between the Physician's in person visits on 8/19/24 and 1/29/25. Resident #5 Record review on 1/27-31/25, revealed Resident #5 was admitted to the facility with diagnoses that included CHF, aortic valve regurgitation (a heart valve disease that causes blood to leak backward to the heart), chronic kidney disease, gait disorder, and major depressive disorder (mood disorder characterized by persistent feelings of sadness, loss of interest, and changes in sleep and/or appetite). Review of Resident #5's medical record on 1/29/25 at 2:00 PM, revealed during the last 12 months of physician progress notes, he/she was seen in person on 3/28/24, 5/16/24, 6/11/24 and 8/2/24. Further review revealed there was 180 calendar days between the Physician's in person visit on 8/2/24 and the record review conducted on 1/29/25. Resident #8 Record review on 1/27-31/25, revealed Resident #8 was admitted to the facility with diagnoses that included impaired mobility, rheumatoid arthritis (a chronic inflammatory disorder that affects the joints and other body systems), CHF, peripheral vascular disease (a disorder of the blood vessels outside the heart), and Lewy body dementia (a progressive brain disorder that is characterized by the buildup of proteins into masses which affects thinking, memory, movement, and sleep). Review of Resident #8's medical records on 1/29/25 at 2:00 PM, revealed during the last 12 months of physician progress notes, he/she was seen in person on 3/28/24 and 7/10/24. Further review revealed there was 104 calendar days between these visits. Resident #9 Record review on 1/27-31/25, revealed Resident #9 was admitted to the facility with diagnoses that included dementia and chronic kidney disease. Review of Resident #9's medical record on 1/29/25 at 2:00 PM, revealed during the last 12 months, a medical provider in person visits occurred on 2/27/24, 7/26/24 and 1/13/25. Further review revealed there was 170 calendar days between the Physician's in person visits on 2/7/24 and 7/26/24 and 171 calendar days between 7/26/24 and 1/13/25. Resident #14 Record review on 1/27-31/25, revealed Resident #14 was admitted to the facility with diagnoses that included dementia, diabetes mellitus, paroxysmal atrial tachycardia (abnormal heart rhythm) and adenocarcinoma of colon (cancer in large intestine). Review of Resident #14's medical record on 1/29/25 at 2:00 PM, revealed during the last 12 months, a medical provider in person visits occurred on 4/24/24, 8/19/24, and 12/16/24. Further review revealed there was 117 calendar days between the Physician's in person visits on 4/24/24 and 8/19/24 and 119 calendar days between 8/19/24 and 12/16/24. During an interview on 1/30/25 at 2:00 PM, when asked how often the residents were seen in person by a medical provider, the Director of Nursing (DON) stated: minimum quarterly and within the first week of admission. When asked to clarify how often the residents were seen, the DON stated, on admission and 4 times per year, quarterly. When the facility policy for provider visits was requested from the DON on 1/31/25 at 10:20 AM, she stated the facility did not have a policy specific to provider visits. Review of the email from the facility's DON on 1/31/25 at 2:30 PM, revealed: .the Medical Director uses the federal guidelines for the timing of his visits. It is not in a written policy .

Based on record review and interview, the facility failed to ensure that the staff received education and training of the Q-Straint QRT-1 Series Wheelchair Restraint. This securement system was used to secure wheelchair bound residents during transport in the facility vehicle. Specifically, 1 resident (#67) out of 2 closed records obtained a superficial injury after his/her wheelchair tipped over in the facility's vehicle. This failed practice had the potential to affect all 8 out of 8 sampled residents and 2 unsampled residents who utilized wheelchairs for mobility at risk for injury during transportion in the facility's vehicle. Findings: Resident #67 Record review on 1/27-31/25 revealed Resident #67 was admitted to the facility with diagnoses of Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), anemia (a decrease in the number of red blood cells or hemoglobin, resulting in a lower ability for the blood to carry oxygen to body tissues and organs), and atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and death). Record review of Resident #67's Nurse's Note, dated 8/5/24 at 5:09 PM, revealed: Resident #67's wheelchair was placed in the facility's transport vehicle, and it tipped over while the vehicle was going around a curve. The resident sustained a superficial laceration to the right temple. Further review revealed the wheelchair was confirmed to had been secured by two Licensed Nurses (LNs). During random interviews from 1/27-31/25, the facility leadership was not able to identify the two LNs annotated in the nurses note above. Record review of the facility-provided self-reported incident document report, dated 8/9/24, revealed a corrective action plan was initiated by the facility which stated, .Instructions for use of wheelchair securement continues to be posted on the back of the transport van where wheelchairs are secure . All nurses and the activity coordinator have been assigned a skills check off using the instructions for use within HealthStream [an online education platform] with a due date of 8/16/24 . Record review on 1/29/25 of the HealthStream assignment completion report of the 2024 LTC [Long Term Care] Transport Restraint Training, revealed that this training was assigned to eight staff members (LN #s 2, 3, 4, 5, 6, and 7, CNA #6). Further review revealed six staff members (LN #s 3, 4, 5, 6, 7) were past due and had not completed the training. Record review on 1/27-31/25 of the facility staffing schedule revealed: staff members (LN #s 2, 3, 4, 5, 6, and 7, CNA #6) were active employees working with residents. During an interview on 1/30/25 at 2:15 PM, when asked about the overdue completion of the HealthStream assignment, the Director of Nursing (DON) stated only three staff members have been trained to secure wheelchair bound residents in the facility vehicle, herself and Certified Nursing Assistants (CNAs) # 1 and #5. When proof of this training was requested, the DON stated the training was completed by a previous employee and was not able to produce the proof. When further inquired about the incident with Resident #67 and the investigation process of the facility, the DON stated she was out on leave when the incident occurred and did not have access to the interim DON's investigation as he/she was no longer an employee. During an interview on 1/31/25 at 9:34 AM, CNA #1 stated that he/she secured residents in the facility's transport vehicle when needed. When asked if he/she had any HealthStream skills check-off for the Q-Straint QRT-1 Series Wheelchair Restraint, he/she stated that there was none. Record review of Resident #67's medical record from 1/27-31/25, revealed the Resident was not longer at the facility and unable to be interviewed.

Based on record review and interview, the facility failed to ensure the Monthly Regimen Review (MRR) were completed for 3 Residents (#s 3, 8, and 12), out of 8 sampled residents. This failed practice placed residents at risk for adverse consequences related to medication therapy. Findings: Resident #3 Resident #3 was admitted to the facility with diagnoses of osteoarthritis (degenerative joint disease), congestive heart failure (CHF) (a chronic condition that results when the heart muscle is unable to pump blood efficiently), dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking), and depression. Record review of Resident #3's Pharmacy Consult notes, dated January 2024 through January 2025, revealed no MRRs were completed for September 2024 and December 2024. Resident #8 Resident #8 was admitted to the facility with diagnoses of impaired mobility, rheumatoid arthritis (a chronic inflammatory disorder that affects the joints and other body systems), CHF, peripheral vascular disease (a disorder of the blood vessels outside the heart), and Lewy body dementia (a progressive brain disorder that is characterized by the buildup of proteins into masses which affects thinking, memory, movement, and sleep). Record review of Resident #8's Pharmacy Consult notes, dated January 2024 through January 2025, revealed no MRRs were completed for September 2024 and December 2024. Resident #12 Resident #12 was admitted to the facility with diagnoses of dementia, anxiety and insomnia (a sleep disorder). Record review of Resident #12's Pharmacy Consult notes, dated January 2024 through January 2025, revealed no MRRs were completed for September 2024 and December 2024. During an interview on 1/30/25 at 1:46 PM, Pharmacist #2 stated that every month the resident's medications were reviewed and documented in the chart by Pharmacists. He/she added that the standard of MRRs were to be completed monthly. The Pharmacist further stated the pharmacy was previously short staffed, however the department is currently fully staffed. During an interview 1/30/25 at 4:37 PM, Pharmacist #1 stated that the MRRs would be documented under Pharmacy Consult notes. Pharmacist #1 further stated the MRRs were not completed for September and December 2024 due to the pharmacy being short staffed. Record review of the facility's policy, LTC Pharmacy Services & Medication Management, last review dated 6/2/21, revealed: .Complete a monthly drug regimen review of each resident's medical chart . Complete a Medication Regimen Review as often as is needed .

Based on observation, interview and record review, the facility failed to ensure expired medical supplies in 1 medical supply storage room (room [ROOM NUMBER]), out of 2 medical supply storage rooms were removed. This failed practice placed all residents (based on census of 18) at risk for adverse effects and/or complications from receiving expired medical supplies. Findings: An observation on [DATE] at 12:35 PM, of the facility's room [ROOM NUMBER], a medical supplies storage room, revealed the following expired medical supplies: - 8- BARD (brand name) 70cc (cubic centimeter) Syringes with Catheter Tip and Luer Tip Adaptors with a use by date of ,d+[DATE]; - 1- BARD 70cc Syringe with Catheter Tip and Luer Tip Adaptors with a use by date of ,d+[DATE]; - 2- CardinalHeatlh Self-Adherent Bandages 3-inch x 5 yard with an expiration date of [DATE]; - 15- PolyMem 4 x 4 Non- Adhesive Pads with an expiration date of ,d+[DATE]; - 34- Tefla 8 x 3 Non-adherent Pad Prepacks with an expiration date of [DATE]; - 1- ConMed 6' Long Suction Connection Tubing with an expiration date of [DATE]; - 1- [NAME] Distilled Water, 3 Liters, with a best by date of [DATE]; and - 1- Arrowhead Distilled Water, 1 Liter, with a best by date of [DATE]. During an interview on [DATE] at 1:10 PM, Licensed Nurse (LN) #1 stated that the medical supplies mentioned above were expired. During an interview on [DATE] at 2:05 PM, the Director of Nursing (DON) stated that LNs were expected to have audited the medical supplies and discard supplies that were expired. When asked about the frequency of this auditing, she stated that it should have been done each shift but predominantly expected to be completed by the night shift LNs. Record review of the facility's policy on LTC Audit of Expired Items, last reviewed [DATE], revealed: . Designated staff shall inspect storage areas . Products that have expired or are within 30 days of expiration or have been damaged shall be removed from inventory and stored in a secure area until the product is disposed of by the facility .

Based on record review, interview, and observation, the facility failed to revise the care plan for 2 residents (#'s 6 and 117), out of 8 sampled residents. Specifically, the facility failed to: 1) include interventions to address edema (swelling of the legs) for Resident #6; and 2) include interventions to address a urinary tract infection (bladder infection) for Resident #117. This failed practice placed the Resident #6 at risk of exacerbation of edema and discomfort; and Resident #117 at risk for not receiving the necessary and/or appropriate care and services. Findings: Resident #6 Record review on 1/27-31/25 revealed Resident #6 was admitted to the facility with diagnoses that included vascular dementia (loss of cognitive functioning) and cardiovascular accident (CVA-stroke), seizure disorder, congestive heart failure (CHF - inability of the heart to supply blood to organs and tissues) and asthma. During an interview with Resident #6's representative (RR) #1, he/she stated Resident #6 had edema in his/her legs. Review of Resident #6's Alert Note, dated 11/23/24, revealed: Resident [#6] has bilateral lower extremity 2+ pitting edema. Review of Resident #6's progress notes, Comprehensive Assessments, revealed edema was noted on the following days: 11/25/24 11:01 PM; 12/3/24 12:25 PM; 12/17/24 5:59 PM; 12/23/24 8:26 PM; 12/30/24 9:59 AM; 1/20/25 8:25 PM. During an interview on 1/29/25 at 10:45 AM, Licensed Nurse (LN) #1 stated Resident #6 was taking Furosemide 20 mg (miligram) for swelling of the legs. He/she stated the nurses would notify the physician if Resident #6's weight increased over 5 lbs. When asked if the Resident's care plan included interventions for edema of the legs, LN #1 stated yes and he/she further stated they are located in the CHF Care Plan. When LN #1 was asked when Resident #6's edema had started, he/she stated it's been a couple of months. Review of Resident #6's Care Plan, dated 12/3/24, the CHF identified problem, revealed no interventions for edema. During an observation on 1/29/25 at 11:20 AM, revealed Resident #6 was in his/her wheelchair. Further observed Resident #6 was wearing sneakers without socks and his/her legs appeared to be swollen. During an interview on 1/31/25 at 8:30 AM, the Director of Nursing (DON) stated the Minimum Data Set (MDS) Coordinator created the care plan. The DON further stated the MDS Coordinator would review the care plan once a week and quarterly for MDS quarterly assessment. When asked about Resident #6's edema not included in the care plan, the DON stated that the [NAME] hose was just ordered. The DON, who was currently covering for the MDS Coordinator, stated she will update the care plan next week. Resident #117 Record review on 1/27-31/25, revealed Resident #117 was admitted to the facility with diagnoses that included history of malnutrition and CVA. During an interview on 1/27/25 at 4:30 PM, Resident #117 stated he/she had difficulty urinating, unable to void at times, and was incontinent. He/she stated that the symptoms started a couple days ago, and he/she was upset for not being able to hold his/her urine. Resident #117 further stated that staff were not listening to his/her concerns. During an interview on 1/28/25 at 1:30 PM, LN #2 stated Resident #117 was diagnosed with a urinary tract infection (UTI). LN #2 further stated the Resident had not started on the ordered antibiotic because it had not arrived at the facility but was expected to arrive later in the day. During an interview on 1/30/25 at 2:00 PM, the DON stated, Care plans are to be updated quarterly but anytime a change of condition occurs. Nurses cannot update care plans, but they reach out to myself to be updated . A UTI should be care planned and when a resident is on an antibiotic . Review of Resident #117's Nursing Progress Note, dated 1/27/25 at 7:02 PM, revealed: c/o not urinating . Md [medical doctor] made aware order[ed] some labs . Review of Resident #117's Nursing Progress Note, dated 1/27/25 at 7:27 PM, revealed: Resident noted with round and hard abdomen. M.D. made aware. Review of Resident #117's Alert Note, dated 1/27/25 at 8:38 PM, revealed: [UTI] SBAR [Situation, Background, Assessment, Recommendation] criteria are met with dysuria, urinary urgency, and suprapubic pain. Lab testing is ordered: urinalysis with urine culture if positive. Review of Resident #117's Nursing Progress Note, dated 1/27/25 at 10:28 PM, revealed: UTI SBAR complete . criteria is met. Urinalysis with reflex is ordered. Urine is collected via clean catch method. Urine is yellow and cloudy . Resident complains of urgency/frequency and suprapubic pain. Urine is sent to YKDRH [Yukon Kuskokwim Delta Regional Hospital]-Lab for analysis. Review of Resident #117's Nursing Progress Note, dated 1/28/25 at 4:25 PM, revealed: . New order given for Nitrofurantoin 100mg bid [two times daily] for UTI with no adverse reaction. Review of Resident #117's Alert Note, dated 1/28/25, revealed: . urinary tract infection . Give Nitrofurantoin 100 mg by mouth twice daily for 5 days . Review of the facility provided Care Plan for Resident #117, dated 1/28/25, revealed no care plan for the UTI. An updated care plan was requested on 1/29/25 but was not provided prior the survey exit date. Review of the facility's policy Person Centered Care Planning, dated 1/6/22, revealed: . It is the policy of [Facility's name] to provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths.and goals. The purpose of this policy is to ensure that each resident will have a person-centered comprehensive care plan developed and implemented to . address the residents' medical, physical, mental, and psychosocial needs.

Based on observation, interview, and record review, the facility failed to ensure: 1) food was stored and/or labeled properly; and 2) food was stored away from chemicals. These failed practices had the potential of causing or spreading food-borne illnesses to all residents, based on a census of 17, who utilized the kitchen services. Findings: Food Storage An observation of the walk-in freezer in the kitchen on 12/11/23 at 2:05 PM, revealed a whole King Salmon fish stored in a black garbage bag which was not sealed or labeled with the date it had been placed into the freezer or brought to the facility. During an interview on 12/11/23 at 2:06 PM, the Food Nutrition Supervisor stated the fish was not properly stored and would be discarded. During an interview on 12/14/23 at 3:30 PM, the Food Nutrition Supervisor stated the fish would have been processed if it came in the correct way and then served. However, since the fish did not come in correctly, it would never be served and had been thrown away. Food and Chemical Storage An observation on 12/11/23 at 2:15 PM, revealed Dawn Dishwater detergent and Dawn Pot and Pans detergent were stored next to a bottle of Worcestershire sauce, a container of garlic powder, and a container of Simply Thick thickening powder in the cooking area of the kitchen. During an interview on 12/11/23 at 2:16 PM, the Food Nutrition Supervisor stated the bottles of dishwashing detergent should not have been stored with food items. Review of the facility's policy LTC [long term care] - Native Foods Donation, dated 11/2/18, revealed: Storing Traditional Native Foods, a. Food brought into the facility will be stored in a traditional kitchen / Freezer or in the resident's room. 1. Frozen food will be kept frozen at or below 0 degrees F and be kept in the freezer for up to 3 months . Donated foods to Elder Home . if food and game are dropped off at the Elder Home without the proper receipt, the food must be discarded. The food once in the kitchen is labeled, dated, and stored separately from other food. Review of the facility's policy Safe Food Procurement, Handling and Storage, dated 11/7/18, revealed: Unsafe food handling practices represent a potential source of pathogen exposure. Sanitary conditions must be present in health care food service settings to promote safe food handling . All foods stored in the refrigerator or freezer will be covered, labeled and dated ['use by date'] . Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.

Based on interview and record review, the facility failed to ensure Resident Council meetings were held regularly for those who wished to attend. Specifically, Resident Council meetings were not held for 12 consecutive months, citing declination without rationale for each month. This failed practice had the potential to limit the voicing of the residents' collective concerns, based on a census of 17. Findings: During the Resident Council meeting held on 12/13/23 at 11:01 AM, Resident #3, the Resident Council President, stated the Resident Council did not meet on a regular basis. Resident #3 further stated the Council only met if there was a need, and he/she had wanted to attend all the meetings that were scheduled. During an interview on 12/13/23 at 11:35 AM, when asked how often the Resident Council met, the Administrative Assistant (AA), who was the former Activity Coordinator (AC), and the new AC both stated usually monthly. The new AC stated the last 2 meetings (October and November) were held with individual residents and herself because the facility had a Covid outbreak. The AC stated there was no meeting in August because she was not at the facility. When asked about coverage, the AA stated she did not coordinate a meeting for that month. When asked if the meetings were scheduled on the Residents' activity calendar, the AC stated the meetings were scheduled on the calendar. Review on 12/15/23 at 8:55 AM of the facility's procedure on LTC Resident Council, dated 9/30/23, revealed: The Administrator/Designee or Activity Coordinator will inform residents of meetings; notices should be posted at least 7 days in advance . The Administrator/Designee will ensure that designed staff are present to help facilitate the meetings as desired by the group. Review on 12/15/23 at 9:30 AM of the Activity Calendar, for the month of August 2023, revealed no scheduled Resident Council meeting. Further review of the bottom of the calendar in an undated slot revealed Residents and family interested in holding Resident or Family Council should contact the facility at (907) 543- . Review on 12/15/23 at 9:33 AM of the facility's binder containing Resident Council meeting minutes revealed meeting minutes for the months of November, October, and September 2023. Further review of each month prior revealed a blank Resident Council template. Handwritten in the upper right-hand corner of each blank template revealed: - August 7th 2023 Declined - July 3rd 2023 Declined - June 5th 2023 Declined - May 8th, 2023 Declined - April 3rd, 2023 DECLINED - MARCH 3rd, 2023 DECLINED - FEBRUARY 1st, 2023 DECLINED - JANUARY 9th, 2023 DECLINED - DECEMBER 5th, 2022 DECLINED - November 7th, 2022 DECLINED - October 10th 2022 10:00 AM DECLINED - September 10, 2022 10:00 AM Declined No further information was documented on the templates to include the facility's efforts to hold the meetings for those who wished to attend, the announcement of those meetings, the rationale for declination, or any response by the Resident Council President. Review on 12/15/23 at 8:55 AM of the facility's policy LTC [Long Term Care] Resident Council, dated 9/21/21, revealed: It is this center's policy that a resident has the right to organize and participate in resident groups in the center.

Based on observation, interview, and record review, the facility failed to ensure that all medical supplies stored in the facility were not expired. This failed practice had the potential to affect all residents, based on a census of 17, with the potential to receive expired medical supplies. Findings: An observation and concurrent interview on [DATE] at 4:20 PM, revealed the medication storage closet contained a Cotton Swab BBL Culture swab (Lab culture supply) with an expiration date of [DATE]. The Director of Nursing (DON) stated this item was expired and was stored in the wrong spot. It was further observed that a Dover Silicone Foley Catheter 14 French with a 5 milliliter/2-way retention (a medical device that helps drain urine from the bladder) had an expiration date of [DATE]. The DON stated this item was expired and would be discarded. Review of the facility's policy Audit for Expired Items, dated [DATE], revealed: In order to ensure that expired items are never present in the inventory of any department in the corporation, all items in each department with an expiration date will be audited on a monthly basis for expiration dates.

Based on observation, interview, and record review, the facility failed to ensure infection control protocols were followed for 3 residents (#'s 2, 3, and 15), out of 17 residents observed. These failed practices had the potential to place all residents, based on a census of 17, at increased risk for the development and transmission of communicable diseases and infections. Findings: Medication Administration Observations Resident #2: During an observation of medication administration on 12/13/23 at 9:20 AM, Licensed Nurse (LN) #2 placed Resident #2's nasal spray into his/her left side pants pocket, and carried Resident #2's eye drop medication in his/her hand. LN #2 approached Resident #2, who was seated in the resident dining area, where Resident #2 accepted the eye drops but refused the nasal spray. LN #2 administered the eye drops to the Resident. After this, LN #2 returned the nasal spray to the top drawer of the medication cart without cleansing this nasal spray bottle. During an interview on 12/14/23 at 11:27 AM, the Director of Nursing (DON) stated medication bottles such as nasal spray should not be kept in pockets due to cross-contamination concerns. Resident #3: During an observation on 12/14/23 at 9:22 AM, LN #1 greeted Resident #3 in the common area. The LN administered the resident his/her inhaler. After the resident received the medication, LN #1 placed the inhaler into his/her pocket, then transported Resident #3 into his/her room to administer an insulin injection. Once in the room, the LN removed gloves kept in his/her front pockets, put the gloves on, and administered the injection in Resident #3 abdomen. During an interview on 12/14/23 at 11:05 AM, when asked about cross contamination, the DON stated the facility provided glove stations throughout the units and in the resident's rooms. The staff should have been utilizing gloves from these stations for use, unless there was an emergency, such as a fall. The DON further stated using gloves stored in pockets created a risk of cross contamination, and carrying the resident's inhaler in a pocket also created a risk of cross contamination. Wheelchair Damage During an observation on 12/12/23 at 10:52 AM, Resident #15 was seated in his/her wheelchair. The wheelchair armrests, on both sides, had damage to the plastic overlay, revealing the foam padding under the cracked plastic. The resident's arm was resting directly on the foam. During an interview on 12/14/23 at 10:05 AM, when asked about damaged equipment and informed about the foam showing through the resident's armrest, the Physical Therapist stated the armrests posed a sanitation issue, and he/she would have ordered and replaced the wheelchair immediately. During an interview on 12/14/23 at 11:05 AM, when asked about the armrest damage, the DON stated the armrests posed an infection control risk because the armrests could not have been disinfected properly. During a follow-up interview on 12/14/23 at 12:42 PM, the DON stated she examined Resident #1's wheelchair and agreed the damaged armrests posed an infection control issue. The DON further stated she requested a new wheelchair be ordered for the resident. Review of the facility's procedure Applying Aseptic Technique, copyright 2023, revealed: Applying appropriate aseptic technique promotes patient safety by reducing risk of health-care associated infections. Recognizing infection-prevention techniques and using them properly is a critical component of breaking the chain of infection . It is critical for nurses to always follow infection prevention and aseptic technique and infection control practices . the goal of asepsis to break the chain of infection by decreasing the numbers of microbes through using infection prevention strategies at each of the 6 points: agent, reservoir, point of exit, mode of transmission, point of entry and host.

Based on record review and interview, the facility failed to ensure 1 resident (#13), out of a 8 sampled residents, was assessed per the physician's orders after a fall with a potential head injury. This failed practice had the potential to delay treatment if the resident had a change in status. Findings: Record review on 12/11-15/23 revealed Resident #13 was admitted to the facility with diagnoses that included stroke and osteoarthritis (degenerative joint disease). During a phone interview on 12/12/23 at 12:55 PM, Resident #13's power of attorney (POA) stated the resident had fallen twice in the last couple of months. Review of Resident #13's Progress Note-Nursing, dated 11/22/23 at 6:47 PM, revealed: Around 1300 [1:00PM] pt [patient] yelled help and was discovered on the floor .Pt said [he/she] bumped [his/her] head no bleeding or bruising visible at initial assessment. Per Provider: Post-fall Please do 'neuro checks' [look for responsiveness, equal pupils, and weakness on one side]. Monitoring after a fall will include neuro checks, blood pressure, pulse, and respirations every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every 2 hours for a minimum of 8 hours or longer until stable as determined by RN [Registered Nurse] or provider. Review of Resident #13's vital sign flowsheets, dated 11/22-23/23, revealed an initial set of vital signs (blood pressure, pulse and respirations) were taken when the resident was first discovered after the fall at 1:00 PM, and another blood pressure was documented at 1:50 PM. Further review revealed no other vital signs were documented until 8:00 PM that evening, 6 hours after the last documented check. Review of Resident #13's Progress Note-Nursing, dated 11/22/23 at 6:26 PM, revealed: [Resident] complained that [his/her] head hurts and nothing else. [He/She] has been and still is active and alert .no changes to [his/her] level of consciousness . Further review revealed no documented assessments of pupillary response or weakness of the resident's extremities. Review of Resident #13's Progress Note-Nursing, dated 11/23/23 at 6:07 AM, almost 12 hours after the last note with documented assessment of status post fall, revealed: Resident is alert and responsive .Continues on Neuro check. No change in LOC [level of consciousness] . Further review revealed no documented assessments of pupillary response or weakness of the resident's extremities. Further review revealed no other Progress Notes with neurological checks for responsiveness, equal pupils, or weakness were documented. During an interview on 12/13/23 at 4:35 PM, the Director of Nursing (DON) stated she reviewed the nursing notes and stated there were some holes in the documentation of Resident #13's neurological checks. The DON stated the facility moved from the vital sign flowsheet form with neurological checks to the narrative form to document these checks, and that could have been the reason why the checks were incomplete. Review of the facility's procedure on Fall with the Possibility of Head Injury, dated 11/20/22, revealed: This post-fall monitoring will include: 1. Blood Pressure, Heart Rate, and Respirations every a. Fifteen (15) minutes for one (1) hour, b. Then every thirty (30) minutes for 1 hour, c. Then every two (2) hours for a minimum of eight (8) hours. 2. The Certified Nursing Assistant's (CNA's) will be responsible for obtaining the vital signs and entering them into Caretracker [electronic health record]. 3. Neurological checks will follow the same schedule as the vital signs and include: a. Level of Consciousness utilizing the Glasgow Coma Scale (GCS) Score [tool used to score impairment of consciousness], b. Pupillary Response, c. Movement and Motor Strength in all four extremities, and d. Evaluation of speech. During a follow up interview on 12/14/23 at 3:00 PM, the DON stated when the fall occurred, the physician ordered the facility to follow their fall protocol.

Based on record review and interview, the facility failed to ensure a copy of 1 Resident's (#11) transfer to the hospital on 8/25/23 was sent to the Office of the State Long Term Care (LTC) Ombudsman, out of 1 resident reviewed for hospitalization . This failed practice had the potential to deny the resident access to an advocate who could have informed him/her of their rights and options after transfer or discharge with hospitalization . Findings: Record review on 12/11-15/23 revealed Resident #11 was admitted to the facility with diagnoses that included dementia. Review of Resident #11's MDS (Minimum Data Set, a federally required nursing assessment), discharge assessment dated [DATE], revealed: Status - discharged : Return anticipated. Further review of Resident #11's record revealed no documentation that the State LTC Ombudsman was notified of Resident's transfer to the hospital on 8/25/23. During an interview on 12/14/23 at 5:38 PM, the Administrator stated the facility had not sent written notice to the ombudsman of Resident #11's transfer to the hospital on 8/25/23. During an interview on 12/15/23 at 9:40 AM, the Administrator stated the facility did not have a policy concerning ombudsman notifications.

Based on record review, interview, and observation; the facility failed to ensure: 1) oral suctioning equipment was available in a ready state for immediate use for choking emergencies. The facility failed to ensure staff were trained and competent to assemble and use emergency suction equipment. These failures resulted in delayed emergency care, the facility did not provide emergency suctioning for 27 minutes when R8 was unable to clear his throat while eating (choking). The facility provided care to residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures placed all residents in immediate jeopardy and at risk for serious injury or death in the event of a choking incident. 2) the MOST [medical Order for Scope of Treatment] form was signed and dated for 1 resident (#8), out of 15 residents reviewed, 3) Comfort Care and/or Palliative Care orders were written for 1 resident (#8), out of 1 resident reviewed, consistent with the resident's advanced directive and family wishes during end-of-life care, and 4) scheduled neurological assessments were conducted for 1 resident (#12), out of 1 resident reviewed, with a potential head injury. These failed practices placed each resident at risk for not receiving the necessary and/or appropriate care and services consistent with physician orders, which had the potential for causing a delay or inconsistent end of life care for resident #8 and a risk for unrecognized brain injury and/or trauma for resident #12. Findings: The facility was notified of the immediate jeopardy to the resident's health and safety on [DATE] at 3:00 PM. The facility implemented a mitigation plan to remove the immediacy to other residents residing in the facility on [DATE]. Suction Machine Use: Observation on [DATE] at 12:15 PM revealed Resident #8 was seated in a reclining Geri chair (padded chair with a wheeled base). Staff Licensed Nurse (LN) #4 was feeding the Resident a lunch of pureed food and thickened liquids. At 12:20 PM, when the Resident began to sputter and make coughing noises, the LN held the clothing protector up to the Resident's mouth. LN #4 then pushed Resident #8 to his/her bedroom. At 12:25 PM, LN #s 1 and 4 were observed carrying a suction machine across the common area to the Resident's room. Upon entering the room, they set the machine on the overbed table. Resident #8's face was gray, and there was an audible rattling noise when breathing. LN #4 made the comment, [He/she] is a DNR [do not resuscitate]. The Resident was not responding but was still breathing. LN #1 said out loud I gave 2 drops of [MEDICATION(S)] (a medication used to reduce secretions) an hour ago. Review of the Resident's Advance Directive, dated [DATE], revealed Life support treatments include any medical test, blood product, surgery, procedures, or machine and/pr medicine needed to prolong life. The Resident requested I want to try life support treatments to see if I will get better . At 12:30 PM, LN #2 (acting Director of Nursing) entered the Resident's room and asked LN #4 to get the vital sign machine (used to take blood pressures, temperature, and oxygen levels). During this time, the Resident continued to make raspy breathing noises. Neither nurse attempted to hook up the suction machine and tubing, call for emergency support or assess the Resident's lungs for aspiration (food or liquid in airway by accident). When the Resident took a deep agonal (gasping) breath, LN #2 said the Resident had passed and hit the call bell. After a few moments, the Resident then began to breathe occasional shallow breaths. The LN did not attempt to hook up the suction machine. At 12:41 PM, LN# 4 returned with the vital sign machine and attempted to check the Resident's vital signs. The LN stated he/she was unable to obtain them. While the Resident was still breathing shallowly, both LN transferred the resident to the bed with a sling using the overhead lift and placed the Resident in bed, raising the head to approximately a 30-degree angle. At 12:43 PM, 23 minutes after initial onset of choking/coughing, LN# 4 began to set up the suction machine along with the tubing and an oral yankour attachment (used for oral suctioning). LN #4 called out to LN #1 to bring a cup of water to use with the machine. At 12:50 PM, LN #2 left the room and returned with a different suctioning machine and set it on the table. LN #s 1 and 4 set up the suctioning machine and LN #4 then suctioned Resident's mouth 27 minutes after Resident #8 began to struggle, LN#4 donned gloves and performed suctioning of the resident's mouth. Resident #8 was pale in color, his breathing was very shallow and a soft rattling noise could be heard as the resident breathed. LN #4 positioned the bed so it was flat and used a stethoscope to listen to the Resident's chest. The LN stated the Resident had passed. During an interview on [DATE] at 3:45 PM, Physician #1 stated Resident #8 was a known chronic aspirator and said as a physician, I would not initiate anything lifesaving in the emergency room . She provided a copy of the Resident's MOST form. Review on [DATE] of Resident #8's MOST form, provided by Physician #1, revealed it was undated and unsigned by a physician. Further review of the MOST form revealed Section B. Treatment options when the person has a pulse and/or is breathing. The box Comfort measures only. Use medication, positioning, and other measures to relieve pain and suffering. Use oxygen, suction, and manual treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . was marked. A record review on [DATE] revealed Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note, dated [DATE] at 1:34 PM, revealed Resident expired peacefully Today at 1251 [12:51 PM]. Review of a progress note, dated [DATE] at 3:03 PM, revealed The Resident was sitting in the dining room and staff attempted to feed [him/her] but Resident was gurgling per staff. This writer was called to check on Resident and noted Resident was trying to cough out [MEDICATION(S)] but was unable. Attempt made and Resident was taken to [his/her] room, VS [vital signs] done but was unable to obtain Sat [oxygen level] and pulse. Resident was transfer from Geri chair to the bed with another staff and suction done. Resident VS was retake and [he/she] was pulseless at 1251 [12:51 PM]. Resident death was imminent. [res] stopped eating and drinking for the past 2 weeks. During an interview on [DATE] 10:15 AM when asked why the suction machine was not set up for emergency usage in the dining room. LN #1 stated the facility had never had it set up. The LN stated not all the staff knew how to suction. LN #1 stated he/she knew how because of prior training. Resident #8 Record review on [DATE] revealed Resident #8 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8s care plan revealed outcomes of Family request palliative care measures and provide medical, emotional, spiritual, psychosocial, and palliative comfort care to meet needs, last updated [DATE]. During an interview on [DATE] at 3:45 PM, Physician #1 stated Resident #8 was a known chronic aspirator and said, as a physician, I would not initiate anything lifesaving in the emergency room . She provided a copy of the Resident's MOST (Medical Orders for Scope of Treatment) form. Review on [DATE] of Resident #8's MOST form, provided by Physician #1, revealed it was undated and unsigned by a physician. Further review of the MOST form revealed both treatment options were marked: A. Treatment options when the person is not breathing and has no pulse., the box Do Not Resuscitation (DNR/DNR) Allow Natural Death. Was marked. B. Treatment options when the person has a pulse and/or is breathing. The box Comfort measures only. Use medication, positioning, and other measures to relieve pain and suffering. Use oxygen, suction, and manual treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Was marked. A review of Resident #8's electronic medical record revealed a blue bar across the top of the screen that indicated the Resident was a DNR/DNI (Do not resuscitate/ do not intubate). Further review revealed no orders for comfort care or palliative care were written. During an interview on [DATE] at 9:00 AM, Physician #1 stated that if signed, the MOST form can be used as an official order. Further stating the overall intent of the MOST form was known and followed. During an interview on [DATE] at 9:00 AM, Physician #2 confirmed the MOST form was not signed or dated because it was a scanned form within Resident #8's medical record and electronic signature is not possible on scanned forms. Further stating that Resident #8's MOST form should have been printed off, signed, and then rescanned into the medical record. During an interview on [DATE] at 9:00 AM, Physician #2 stated he/she believed he/she may not have written orders for Comfort Care and/or Palliative Care measures for Resident #8. Resident #12 Record review from ,d+[DATE]-,d+[DATE] revealed Resident #12 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the Resident was non-ambulatory and used a wheelchair for mobility. Record review from ,d+[DATE]-,d+[DATE] revealed Resident #13 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's Progress Note-Nursing, dated [DATE] at 10:35 PM, revealed at approximately 9:00 PM, Resident #13 .grabbed a garbage can again and started hitting [Resident #12 who] was sitting at [the] dining room table with it in the head and arm on right side. Review of Resident #12's Progress Note-Nursing, dated [DATE] at 11:43 PM, revealed .this nurse checked on resident, noted red area on right temple [due to] hitting by other resident . Review of the facility's policy LTC [Long Term Care] Neurological Assessments, reviewed [DATE], revealed It is the policy of this facility to monitor neurological signs following head injury or suspected head injury. The purpose of this observation is to detect clinical manifestations of increased intracranial [within the skull] pressure. Neurological check will be completed every 15 minutes X4 [assessments], then every 30 minutes X4, then every hour X4, followed by every 4 hours X4, then every shift for 72 hours. Review of Resident #12's flowsheets, dated ,d+[DATE]-,d+[DATE], revealed Neurological Assessment and Neurological LTC assessments were completed on [DATE] at 10:00 PM and were not completed again until [DATE] at 1:00 PM. There were no 15-minute, 30 minutes, or 1 hour neurological assessments documented in the Resident's chart. Further review revealed the next assessment was not completed again until [DATE] at 8:00 PM, missing two of every 4 hour assessments. During an interview on [DATE] at 12:42 PM, LN # 3 stated that if a Resident suffered from a potential head injury, he/she would have followed the facility's Neuro Protocol. The LN further stated he/she would have done a neurological assessment every 15 minutes, then every 30 minutes, then every hour. When asked if this protocol would have been followed if a Resident were hit in the head by another Resident, the LN stated he/she would have followed the protocol anytime a Resident was hit in the head. During an interview on [DATE] at 8:58 am, when asked what to do if a Resident had hit their head, the Director of Nursing (DON) stated the Resident's vital signs and neurological checks would have been done following the fall with head injury policy. When asked if vital signs and neurological checks would have been completed per policy after Resident #12's injury, the DON stated yes. Review of the facility's policy Fall with Head Injury Monitoring, revised [DATE], revealed When the nurse is unable to rule out the head being struck during the fall staff will start neurological checks along with vital signs. Medical monitoring after a fall will include Blood pressure, pulse, and respirations [vital signs] every fifteen (15) minutes for one (1) hour, then every thirty (30) minutes for 1 hour, then every two (2) hours or until condition stabilizes. Neuro checks will follow the same schedule every 15 minutes for 1 hour, then every 30 minutes for one hour, then every 2 hours or until condition stabilizes for a minimum of eight (8) hours. Review of Resident #12's flowsheets, dated ,d+[DATE]-,d+[DATE], revealed vital signs were completed on [DATE] at 9:58 PM and 10:55 PM, and not documented again until [DATE] at 12:11 PM. Further review revealed 2 sets of 15-minute vital signs were missing, both 30-minute vital sign checks were missing, and the 3 sets of every 2-hour vital sign documentation was missing.

Based on record review, observation, and interview the facility failed to ensure 1 resident (#2) with wandering behaviors and a history of elopement (leaves the premises or safe area without authorization and/or necessary supervision) and assaultive/sexualized behaviors toward female residents and/or aggressive physical behaviors towards other residents, had adequate supervision when wandering in the facility. These failed practices constituted an immediate jeopardy to the health and safety of resident #2 and the other 7 residents residing on the unit. The facility administration was notified of the immediate jeopardy on 2/7/17 at 10:20 am. The facility submitted an abatement plan on 2/7/17 at 4:34 pm. The mitigation of the risk was verified during an extended survey on 2/13-14/17. Findings: Record review from 2/1-3/17 revealed Resident #2 had [DIAGNOSES REDACTED]. Observation of the 300 wing during the survey revealed, a large open common area with resident rooms opening to the units common area. The unit consisted of 3 women and 4 men, all with different physical and mental abilities to defend themselves. Review of the most recent Minimum Data Set (MDS-a federally required assessment tool), dated 12/1/16, annual assessment, revealed the Resident was coded as having short and long term memory problems; moderately impaired in cognitive skills for daily decision making (Decisions poor; cues/supervision required); Behaviors-Potential for psychosis hallucinations (perceptual experiences in the absence of real external sensory stimuli) and Delusions (misconceptions or beliefs that are firmly held, contrary to reality). Behaviors directed toward others occurring every 1 to 3 days include verbal behavioral symptoms (e.g., threatening others, screaming at others, cursing at others); other behavioral symptoms not directed toward others (e.g., .rummaging, public sexual acts, disrobing in public .). Wandering occurred 4 to 6 days a week with the impact placing the resident at significant risk of getting to a potentially dangerous place (e.g., .outside of the facility) and intrudes on the privacy or activities of others coded as yes. Change in behavior or other symptoms compared to prior assessments as Worse. Elopement Risk Review on 2/3/17 of nursing progress note, dated 8/27/16 at 8:13 pm, revealed Resident jumped out of his room's window and landed on his knees .resident trying to stand up and started to walk visibly frightened and shaking . Continuous observation on 1/31/17 from 12:50-1:07 pm revealed, Resident #2 walking throughout the unit, opening the door to another resident's room # 302, walking into the room and closing the door behind him/her. Nursing staff on the unit were in various resident rooms during this time. At 1:05 pm Housekeeper (HK) appeared to notice Resident #2 was no longer in the common area. The HK walked into room #301 through the open door then exited room 301. Next, the HK walked to room #302, knocked on the closed door and entered the room. The HK guided Resident #2 out of the room and back into the common area where the Resident was observed to continue to wander, back and forth through the TV area in and out of other Resident's rooms or occasionally sitting on the couch unsupervised. During an observation on 1/31/17 at 1:23 pm Resident #2 walked to room #304 opened the closed door where a Certified Nursing Assistant (CNA) was working with Resident #11. CNA #1 knocked on room # 304's door entered the room and guided Resident #2 out of the room back into the common area where s/he aimlessly wandered on the unit unsupervised. During an observation on 2/2/17 from 9:25-9:35 am Resident #2 walked unsupervised by staff on the unit, wandering through the dining and TV area picking up papers. The Resident walked to the closed door of Resident #10's room, opened the door, entered the room then closed the door behind him/her. HK walked to room #302 knocked on the door, entered the room and guided Resident #2 out of the room and back to the common area. Review of Resident #2's care plan, updated on 12/30/16, revealed problems including elopement risk. The identified interventions included .Preform frequent location checks if Exit-Seeking Behavior, Utilize Wander Alert Device, .If Resident Elopes, Find Resident and Return to Facility, Notify Authorities According to Policy. Under the listed Outcomes .Behavioral Symptoms, the identified Interventions included .Call family to talk to (Resident) when (s/he) is having behaviors .Redirect (Resident) with mega blocks when needed, Motion sensor (with chime) in (Resident's) doorway to alert staff of Resident's movement. There was no information that listed what staff should do when the Resident had exited the room. During an interview on 2/3/17 at 4:40 pm, when asked about Resident #2's elopement, the Administrator stated the staff heard Resident #2 talking, went into his/her room where the voice was coming from, but couldn't see him/her in the room. The staff approached the open window in Resident #2's room, looked out the window and saw the Resident outside of the building. By the time the staff got to the front entrance of the building Resident #2 was walking toward the front entrance. The Administrator further stated the facility had no idea how the Resident got out the window or how long the Resident was outside. During the interview the Administrator confirmed the windows in the other Resident's rooms were still able to open wide enough for the Resident to slip through. During an interview on 2/3/17 at 5:00 pm the Licensed Nurse (LN) #1 revealed the Residents door would chime sound when the Resident went in or out of his/her room. LN #1 further stated, when staff hear the chime, they are supposed to watch Resident #2 on the unit. Sexual/Aggressive Behaviors Review of Resident #2's care plan, updated 12/30/16, revealed problems including Behavioral Symptoms. The identified Interventions included .Call family to talk to (Resident) when (s/he) is having behaviors .Redirect (Resident) with mega blocks when needed, Motion sensor (with chime) in (Resident's) doorway to alert staff of Resident's movement. Identified outcomes included, .Interventions Used to Alter Behavior .The problem is sexual inappropriateness .Goal: (Resident) to have no sexually inappropriate behavior. There were no instructions on what staff was to do once the Resident had exited the room. Review of a Progress Note-Nursing, dated 2/14/16 at 7:51 pm, revealed (Resident #2) was found standing next to a woman in a Geri-chair (a reclining chair on wheels that can be pushed like a wheel chair and may have a removable tray), walked away when staff approached. Another resident stated that (Resident #2) had touched the woman in a Geri chair, she is nonverbal and appeared to still be asleep. Review of a Progress Note-Nursing, dated 8/8/16 5:54 pm, revealed At 9:30 while Resident was eating breakfast with a female Resident (s/he) tried to touch her breast. Review of a Social Work (SW) Note, dated 8/11/16 at 2:36 pm revealed, On 8/8/16 SW was notified by the staff that resident appeared to be attempting to touch a female resident inappropriately without her consent. A CNA and Activities coordinator witnessed the event. She then directed the (female/male) resident to another table. This incident occurred during breakfast. The CNA states that he saw the (female/male) resident reaching for the female resident that startled and confused her . Review of a Progress Note-Nursing, dated 9/12/16 at 11:27 pm, revealed .female resident was speaking on the phone to her daughter. She was sitting in the dining room while talking .In a few moments (s/he) repositioned (himself/herself) to be within reach of her then (s/he) placed (his/her) hands in her view, shaping the fingers in (his/her) left hand in a circle and placing (his/her) right forefinger in the circle of the left hand began pushing a retracting (his/her) finger quickly to simulate sexual copulation. At first she ignored (him/her) then (s/he) reached and touched her shoulder, when she looked up at (him/her), (s/he) pointed between her legs and made some undetermined statement. At this she looked at me and said 'Get this (Resident #2) away from me' . Review of a Progress Note-Nursing, dated 9/17/16 at 12:03 am, revealed .observed (Resident #2) place (his/her) hand on a female resident at her shoulder, slide (his/her) hand down her back near her sacrum (buttocks) and do a one arm embrace against her. The female resisted (his/her) advance by pushing (his/her) hand away and walking off. Review of a Progress Note-Nursing, dated 9/17/16, revealed At 0600 (6:00 am) .Yupik speaking female staff was called to interpret. Upon seeing her (Resident #2) suddenly became hypersexual and was asking her in Yupik to kiss (him/her), and (s/he) advanced her multiple times to embrace her. She walked at a distance to prevent this and (s/he) continued on attempting to enter other rooms. Yupik staff reported (s/he) was saying in Yupik that (s/he) was looking to leave . Review of a BH (Behavioral Health) Progress Note, dated 11/4/16, revealed (Resident #2) is occasionally refusing (his/her) night time medications. This happened twice in the last week. When (s/he) does this (s/he) tends to be up much of the night and tries to get into others' rooms. Review of a BH Progress Note, dated 1/20/17, revealed (Resident #2) .is frequently wandering around the unit until 3 - 4 am, trying to get into others' rooms. (Resident #2) has also been assaultive several times . Further review of the medical record revealed multiple observations of the Resident's insomnia and wandering around the unit and in and out of Resident's rooms at night. During an interview on 2/1/17 at 1:00 pm CNA #2 stated the other residents don't like Resident #2 because s/he touches them and goes into their rooms when s/he is wandering around. During a resident group interview on 2/1/17 at 2:30 pm Resident #12 stated, I don't like it when people come in (his/her room), especially (Resident #2), I don't like (him/her) touching me or my things. During an interview on 2/13/17 at 9:30 am, Resident #12 stated, s/he was scared to stay in his/her room because s/he has seen a man in his/her room at nighttime. Review on 2/4/17 of the facility's Abuse Policy effective date [DATE] .Definitions .Neglect means failure to provide goods and services to avoid physical harm, mental anguish or mental illness . Symptom identification .Behaviors that may lead to higher risks of abuse include; residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident's room .

F323 #1 Immediate Jeopardy Hot Pads Based on record review, observation and interview, the facility failed to ensure a safe environment free from accidents and hazards. Specifically, the facility failed to ensure: 1) staff used hot pads according to the manufacturer's directions; 2) policies and procedures were in place for the use of hot pads; and 3) staff were educated and trained for the proper use of hot pads. This failed practice placed 2 residents (#s 4 and 8) of 8 sampled residents residents at risk for harm and severe burns. This failed practice constituted an Immediate Jeopardy situation. The Immediate Jeopardy was abated on 11/19/14 at 6:45 pm. #2 Environmental Safety Based on observation and interview, the facility failed to ensure the residents' environment was free of accident hazards. Specifically, the facility failed to ensure: 1) the activity kitchen doors were secured and the oven and toaster were not able to be turned on when not in use; 2) chemicals with hazard warnings were secured; 3) the dryers and surrounding area in the dryer rooms were free from lint; and 4) common area for residents was free from trip hazards. The cumulative effect of these failed practices created an increased risk for all residents (based on a census of 18) for harm due to falls, burns, ingestion of hazardous substances by cognitively impaired residents, or other injuries. Findings: #1 Immediate Jeopardy Hot Pads Resident #4 Record review on 11/17-20/14 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of Resident #4s Nursing Progress Notes, dated 8/15/14 to 11/13/14 revealed four occurrences of the hot pads being utilized on 8/15/14, 9/10/14, 11/12/14 and 11/13/14. Additional review revealed no skin assessment was conducted before or after the use of the hot pad on 9/10/14, 11/12/14 or 11/13/14. The hot pad was left in place for 30 minutes on 9/10/14 according to the progress note. Resident #8 Record review on 11/17-20/14 revealed Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of Resident #8s Nursing Progress Notes, dated 11/13/14 to 11/17/14 revealed the hot pads were utilized for the Resident on 11/13/14, 11/16/14 and 11/17/14. Hydrocollator Observation of the PT room on 11/19/14 at 2:00 pm revealed a hot pad system that heated pads to 165 degrees in water. One thick, blue cover made for the hot pad was present next to the machine. During an interview on 11/19/14 at 2:40 pm NA #1 stated the hot pads were used for residents comfort and could be wrapped in regular towels before being placed on the residents. During an interview on 11/19/14 at 2:55 pm the DON stated the process for the use of the hot pad system was: Use tongs to lift the hot pads from the machine; Place the pad on the blue cover made specifically to be used with the heated pads; Secure the 3 strips of Velcro around the edges (to ensure the hot pad does not fall out and touch the resident's skin); and Place on the resident as needed for comfort. The DON stated the hot pad should be wrapped in the thick blue cover prior to being placed on a resident and not just wrapped in a towel. During an interview on 11/19/14 at 2:56 pm LN #5 stated physical therapy, occupational therapy or restorative will order the hot pads to be used on the Residents. In addition, the LN confirmed that Resident #4 did not have an order for [REDACTED]. During an interview on 11/19/14 at 4:30 pm the DON stated the facility did not have documentation of education for staff regarding the use of the hot pad system or a written procedure for the safe use of the hot pad system. During an interview 11/19/14 at 4:32 pm LN #5 stated the pads should be applied for 30 minutes and a skin assessment should be conducted after the removal of the hot pad. During a demonstration on 11/19/14 at 4:50 pm the DON demonstrated the preparation of the hot pad for use on Residents. When placed on the arm of this Surveyor, the skin on the Surveyor's arm under the hot pad turned red in less than a minute. The RD used a thermometer to measure the temperature of the hot pad wrapped in the thick blue cover and the side placed against the Surveyor's arm registered 136 degrees. During examination of the hot pad wrapped in the blue cover, the Surveyors identified the hot pad easily slipped out between the velcro closures, leaving no coverage of the hot pad. The pad then had the potential to be placed directly on a resident's skin. During an interview on 11/19/14 at 5:30 pm, CNA #1 stated if the blue cover made for the hot pad system was not available, she would wrap the hot pad in a regular bath towel. The CNA stated she was unsure how long to leave the hot pad in place on a resident's skin. During an interview on 11/19/14 at 5:32 pm, NA #1 stated the hot pads could be wrapped in a regular bath towel and placed on the resident's skin. The NA stated she was unsure how long to leave the hot pad in place and did not document the appearance of the resident's skin the "one time I did use (the hot pad) on a resident." Review of the Hydrocollator User Manual, not dated, revealed to "Constantly monitor HotPac application to ensure that the skin is not becoming too hot. Damage to skin can occur from exposure to extreme heat...DO NOT apply over insensitive skin or in the presence of poor circulation..." Review of the FDA website at http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDeviceSafety/ucm 8.htm, accessed on 12/01/14 <http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDeviceSafety/ucm 8.htm%20accessed%20on%2012/01/14>, revealed "Heating Devices: How to Avoid Burns By Joan Ferlo Todd, RN, BSN Nurse-ConsultantFood and Drug Administration Center for Devices and Radiological Health, Rockville, Md. Orginially Published: 1/10/1997 "A patient with arthritis suffered a second-degree burn to the hip after receiving treatment with a heating pad for pain. Set at low, the heating pad was left on for less than 20 minutes with the patient lying on top of the pad. Later testing showed that the pad was working properly and met the manufacturer's specifications. What went wrong? Therapeutic heating devices, such as heating pads, microwavable hot pads, and hot-water bottles, although generally safe, can cause bums. Most burns result from improper use or use with inappropriate patients, such as infants and elderly patients. The severity of the burn is influenced by factors such as heat intensity, length of application, and the patient's age, medical history, and ability to sense pain. What precautions can you take? Follow these do's and don'ts to keep your patient safe when using heating devices: DO inspect the device before each use to ensure it's in proper condition. DO read directions and contraindications for use. DO use a protective cover. DO place the pad or pad on top of, not underneath, the patient. DO assess skin integrity frequently and adjust the therapy interval according to the patient's skin tolerance-no longer than 15 to 20 minutes. DON'T use the device on someone who's sleeping or unconscious, an infant, or a patient with altered mental status or decreased skin sensation (such as people with diabetes or compromised skin circulation). DON'T use pins to fasten the device in place. DON'T use with ointments or salve preparations containing heat-producing ingredients. DON'T use electrical heating devices in an oxygen-enriched environment or near oxygen-emitting equipment." In Summary 1) Review of the manufacturer's instructions revealed the facility failed to follow the instructions for using hot pads on an older population of residents with compromised skin integrity; 2) facility staff were not trained specifically on how to use the hot pads; and 3) facility staff were inconsistent in their individual use of the hot pads. These failed practices resulted in an Immediate Jeopardy to the health and safety of the facility's resident population. #2 Environmental Safety Activity Kitchen Observations during the initial tour on 11/17/14 between 8:45 am - 10:00 am in the activity kitchens on both the 200 and 300 side revealed, a toaster that was plugged in and when checked for heat, it was working. In addition, the oven on both sides began doing a pre-heat and felt warm to the hand when turned on. An interview during the initial tour on 11/17/14 with LN #3 stated Resident #s 2, 3, 4, 13, 15 wandered within the units. Observations on 11/17/14 at 9:50 am, of the 200 side, revealed an unlocked drawer below the fish tank that contained an open, 2 fluid ounce container of "Clear Water." The product bottle listed the active ingredient potassium permanganate. Review on 12/5/14 of the FDA website revealed, "Potassium permanganate is a strong oxidizing agent, a highly caustic, tissue-destroying chemical, and a poison. Random observations on 11/17-18/14 in the activity kitchens on the 200 and 300 unit, revealed half full containers of Kirkland, lemon fresh dishwasher soap pods, in the unsecured cupboards below the sink. The label on the container stated "Caution harmful if swallowed." During an interview on 11/19/14 at 8:15 am the DON confirmed the findings of the unsecured Clear Water bottle used for the fish tank and the Kirkland dishwashing pods should be locked and not accessible to the Residents. In addition, she stated the ovens were supposed to be turned off with a key and the toaster was a risk to the residents for burns because the two activity kitchens did not have locked doors. Lint Random observations on 11/17-18/14 in the dryer room on both the 200 and 300 side, revealed the large commercial dryers had large layers of multicolored lint in the lint trap. There was lint build-up on the floor and behind the dryers in both the 200 and 300 side dryer rooms. During an interview on 11/18/14 at 9:55 am EVS #1 stated the lint screens on the large commercial dryer was supposed to be cleaned at the end of each day and the lint screen in the small dryer was supposed to be cleaned after each dryer load. During an interview on 11/19/14 at 2:15 pm the Administrator stated the lint traps on the large dryers should be free of lint at the end of each day because of the fire hazard. Trip Hazards Observations during the initial tour on 11/17/14 between 8:45 am - 10:00 am on the 300 side revealed the carpet transition strip had multiple splits and tears in addition to being high enough to create a trip hazard. Observations on 11/18/14 at 10:30 am on the 200 side revealed multiple attempts by Resident #3 to get the wheelchair over the carpet transition strip before being assisted by NA #1. In addition, the carpet transition strip on the 200 side was high enough to create a trip hazard. During an interview on 11/19/14 at 9:45 am NA #1 stated the carpet transition strips were too high and some residents did need help getting over them if they were in a wheelchair. During an interview on 11/19/14 at 2:15 pm the Administrator stated the carpet transition strips had been identified as being worn on the 300 side and created a trip hazard on both the 200 and 300 sides. .

Based on observation, interview, and record review, the facility failed to ensure 1 resident (#3) out of 4 sampled residents, who had been previously identified as having difficulty swallowing, received the therapeutic diet designed to meet the resident's needs. Specifically, the facility failed to provide the supervision necessary to ensure the physician's orders [REDACTED]. This failed practice placed the resident at risk for injury or harm from choking and aspiration pneumonia, which can lead to death. Findings: On 7/17/14 at 6:40 am CNA #1 was observed serving Resident #3 a food item that was not consistent with the physician ordered diet and placed the Resident at risk for choking. Further review revealed the care plan used by the CNA staff to provide services to the Resident between meal times was not accurate. As a result an Immediate Jepordy was called. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy on 7/17/14 at 2:05 pm. The Immediate Jeopardy was abated by the facility on 7/17/14 at 4:45 pm when the facility put a system of corrective action into place. On 7/17/14 at 6:20 am, CNA #1 was observed preparing tea and toast for Resident #3 to consume at the dining table in the common area. During the observation at 6:45 am Resident #3, while seated at the dining table, began to cough. LN #1 stated the Resident had been "eating bread". The Resident was taken back to his/her room. When asked what had happened, the LN replied that the Resident was "Gagging" and stated, "I am going to check on (Resident #3)." The LN then stated the Resident was nauseated and offered the Resident some Zofran (medication used to treat nausea). Review of the "Progress Note-Nursing", dated 7/17/14 at 7:23 am, revealed "Resident nauseated this morning. Sitting at dining room table drinking coffee and eating bread assisted by staff. Resident started to gag and heave at the table without vomiting. Told CNA in Yu'pik that she feels like she needs to throw up. Zofran administered as ordered. Resident lying in bed accompanied by staff. Will continue to monitor." Record review on 7/17-18/14 revealed the Resident had [DIAGNOSES REDACTED]. Review of the physician's diet order revealed "Nutrition Cardiac Ordered 5/30/14 (2:59 pm), Constant Indicator, pureed diet, please provide extra portions. Patient may eat crackers while observed. Pureed". Review of the "Nutrition Care History" note, dated 5/30/14, completed by a dietitian, revealed "Considering (Resident #3) good po intake recommend cardiac pureed diet. Recommend speech evaluation for coughing with food/fluid and the difficulty managing drools." Review of the most recent MDS, an admission assessment, dated 6/2/14, revealed the Resident had signs and symptoms of a swallowing disorder that was indicated by "Loss of liquids/solids from mouth when eating or drinking. . .Holding food in mouth cheeks or residual food in mouth after meals. . .Coughing or choking during meals or when swallowing medications." Review of the "SLP Consult Note", completed by the SLP 6/13/14, revealed "Continue cardiac pureed diet. Provide chin support when needed to prevent loss of food. Feed only when alert. Do not give hard foods such as crackers due to the risk of choking." During an interview on 7/17/14 at 11:40 am, when asked where staff obtained information about Resident #3 's care, CNA #2 demonstrated how staff accessed the care plan in the computer program called "Care Tracker". Review of the diet information provided in the "Care Tracker" revealed the Resident's diet was "Cardiac". There was no information about the pureed diet in the care plan information provided to direct care staff. Review of the diet slip placed on the Resident #3's tray revealed Resident #3's diet was "General Pureed". During an interview on 7/17/14 at 2:35 pm, when asked about Resident #3's choking, LN #1 replied "I don't think it (choking) was on the toast. I am going to talk to (Resident #3's physician) about using a thickener (used to thicken liquids). She can have bread and crackers if the staff is with her." After clarifying in the EMR, LN #1 stated the order actually stated Resident #3 could eat crackers while observed. During an interview on 7/17/14 at 4:35 pm the Administrator, the DON, and the Chief Nurse Executive confirmed the dietary policies and policies for the care tracker care plan were not correct or current. In addition, all 3 staff confirmed the Dietary Manager/Executive Chef did not have access to the computer programs listed in the facility's dietary policies. .