Does CENTENNIAL POST ACUTE have any serious inspection findings?

Yes, CENTENNIAL POST ACUTE has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 62 total deficiencies from recent inspections.

What are the staffing levels at CENTENNIAL POST ACUTE?

CENTENNIAL POST ACUTE has a four-star staffing rating from CMS with 0.96 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is CENTENNIAL POST ACUTE located?

CENTENNIAL POST ACUTE is located in ANCHORAGE, AK. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does CENTENNIAL POST ACUTE have?

CENTENNIAL POST ACUTE has 102 certified beds.

Who owns CENTENNIAL POST ACUTE?

CENTENNIAL POST ACUTE is a for profit - limited liability company facility and is part of the PACS GROUP chain.

What questions should families ask when visiting CENTENNIAL POST ACUTE?

Families visiting CENTENNIAL POST ACUTE should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does CENTENNIAL POST ACUTE compare to other nursing homes?

CENTENNIAL POST ACUTE has a 1-star overall rating, which is below average compared to other nursing homes in AK. Families should carefully review inspection findings and consider alternatives.

CENTENNIAL POST ACUTE

Name: CENTENNIAL POST ACUTE
Address: 9100 CENTENNIAL DRIVE, ANCHORAGE, AK, 99504, US
Telephone: (907) 333-8100
Rating: 1.0

9100 CENTENNIAL DRIVE, ANCHORAGE, AK 99504 · (907) 333-8100

For profit - Limited Liability company 102 Beds PACS GROUP Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

18/100

#19 of 20 in AK

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CENTENNIAL POST ACUTE nursing home in ANCHORAGE, AK - Photo 1 of 2

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CENTENNIAL POST ACUTE nursing home in ANCHORAGE, AK - Photo 2 of 2

Photo by Kristeen Wilks

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Last Inspection: December 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Centennial Post Acute in Anchorage, Alaska has received a Trust Grade of F, indicating poor overall performance with significant concerns about care quality. It ranks #19 out of 20 facilities in Alaska, placing it in the bottom half, and #3 out of 3 in Anchorage County, meaning there are only two local options that are better. Despite an improving trend in issues reported, dropping from 16 in 2024 to 10 in 2025, the facility still faces serious challenges. Staffing is rated 4 out of 5 stars with a turnover rate of 54%, which is average; however, the RN coverage is concerning, being lower than 89% of other facilities in Alaska. Additionally, the facility has incurred $76,756 in fines, which is higher than 85% of other local facilities, indicating ongoing compliance problems. Specific incidents include a critical failure to provide necessary care that resulted in a resident's death, and concerns about expired medications being available for use, which could compromise resident safety. Overall, while there are some strengths in staffing, the facility has significant weaknesses related to care quality and safety practices.

Trust Score: F
In Alaska: #19/20
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $76,756 in fines. Lower than most Alaska facilities. Relatively clean record.
Skilled Nurses: Each resident gets 57 minutes of Registered Nurse (RN) attention daily — more than average for Alaska. RNs are trained to catch health problems early.
Violations: 62 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 16 issues

2025: 10 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in staffing levels, fire safety.

The Bad

1-Star Overall Rating

Below Alaska average (3.5)

Significant quality concerns identified by CMS

Staff Turnover: 54%

Near Alaska avg (46%)

Higher turnover may affect care consistency

Federal Fines: $76,756

Well above median ($33,413)

Moderate penalties - review what triggered them

Chain: PACS GROUP

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 62 deficiencies on record

1 life-threatening

Aug 2025 5 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set, a federally required assessment) was accurately coded for venous ulcers for 1 resident (#5), out of 8 sampled residents. This failed practice placed the resident at risk for not receiving the necessary and/or appropriate care and services .Findings:Record review on 8/29/25, revealed Resident #5 was admitted to the facility with diagnoses that included dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking), 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) with left sided hemiparesis (partial paralysis of one side of the body), obesity, chronic pain, Diabetes Mellitus type II (disorder characterized by persistent high blood sugar levels and inability to use insulin properly), and neuropathy (nerve damage). Wound Review: Record review on 8/29/25 of SNF [Skilled Nursing Facility] Wound Care notes, dated 7/2/25, revealed: description of wound #2: left shin, diabetic wound. Further review of the SNF Wound Care notes dated 7/8/25 and 7/15/25 revealed wound #2 was now described as left shin, vascular wound. MDS Coding: Record review on 8/29/25 of the most recent MDS assessment, a quarterly assessment dated [DATE], revealed the Resident was not coded for venous or arterial ulcers under section M1030: Number of Venous and Arterial Ulcers. Further review of the document revealed Look back period for all items is 7 days unless another time frame is indicated. Record review of the Center for Medicare & Medicaid Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.20.1 section M1030, dated 10/2025, revealed: Skin wounds and lesions affect quality of life for residents because they may limit activity, may be painful, and may require time-consuming treatments and dressing changes. The presence of venous and arterial ulcers should be accounted for in the interdisciplinary care plan. This information identifies residents at risk for further complications or skin injury . Review the medical record, including skin care flow sheet or other skin tracking form. Further review of the Center for Medicare & Medicaid Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.20.1, dated 10/2025, revealed: The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive plan of care. During an interview on 8/29/25 at 4:29 PM Resident Care Manager (RCM) #8 stated that the facility had a contracted wound care provider who was classifying wounds. The RCM further stated that the facility discovered concerns regarding the incorrect classification of diabetic versus pressure. As a result, a different provider was utilized to classify the wounds correctly.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on record review and interview, the facility failed to ensure provision of necessary care and services were provided in accordance with standards of practice and/or resident care plan for 2 residents (#1 and #3) out of 8 sampled residents.Specifically, the facility failed to ensure escalation of care and interventions that included:1) notifying the physician of a leaking gastrostomy tube (G-Tube - medical device inserted through the abdominal wall directly into the stomach to provide nutrition, hydration, and medication) per facility's standard of practice.2) notifying the physician of acute hypotension and altered mental status per facility's standard of practice as established by policies and resident's care plan.These failed practices prevented the residents from receiving care and services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and placed the residents at risk for significant medical complications due to unaddressed changes in condition Past Noncompliance. After exit date of the last standard survey on12/24/25 and prior to current survey completed 8/29/25, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan per § 483.25 Quality of care as evidenced by: Resident #1 Record review on 8/27-29/25, revealed Resident #1 was admitted to the facility with diagnoses that included dysphagia following other cerebrovascular disease (swallowing difficulty post-stroke), hemiplegia and hemiparesis following other cerebrovascular disease (paralysis/weakness post-stroke), gastrostomy status (surgical stomach feeding) and unspecified severe protein-calorie malnutrition (severe nutrient deficiency). Review of Resident #1’s physician orders revealed: “enteral feed order… monitor for complications (e.g. [for example], N/V [nausea, vomiting], diarrhea, abdominal distention, aspiration, or pain at site) and document abnormal findings in the resident record before each feeding, flush, or med [medication] administration.” Review of Resident #1’s “Care Plan,” last revised 3/3/25, revealed: “Goal: The resident will remain free of side effects or complications related to tube feeding through review date. Interventions: Enteral feeds and water flushes per provider/RD [registered dietitian] order.” During an interview on 8/27/25 at 9:00 AM, with LN #9, photographic evidence was presented of Resident #1’s G-Tube, secured with makeshift rubber bands and masking tape, instead of medical grade clamps. The G-Tube port and makeshift dressing appeared soiled with tube feed and was brown/beige discolored. The makeshift repair created creases and gaps which contained stagnate content presenting a risk for infection. During an interview on 8/29/25 at 9:17 AM, LN #4 recalled the night shift on 5/10/25, in which he/she noticed a leak around Resident #1’s G-Tube. LN #4 disconnected the G-Tube from the tube feeding, leading to a loss of gastric contents. He/She then clamped the G-Tube with rubber bands and inserted a syringe tip past a tear in the G-Tube catheter to avoid backflow, then initiated a water flush. LN #4 did not notify the on-call provider, and planned to report it later, stating the feed was off for several hours. During the same interview, LN #4 further stated that “residents have daily “off-feed” windows, and calories can be made up later.” LN #4 further stated in hindsight that notifying the on-call provider and documenting the incident would have been better. The medical record has no evidence of documentation pertaining to this incident until the following LN’s shift notes. During an interview on 8/29/25 at 11:00 AM, Infection Preventionist (IP) stated that documentation for such cases requires an SBAR (Situation, Background, Assessment, Recommendation), a clinical alert, inclusion in shift reports, and physician notification based on urgency. During an interview on 8/29/25 at 4:45 PM, the Director of Nursing (DON) stated there were concerns about Resident #1 not receiving adequate nutrition due to leaking issues. Review of the facility’s adopted Lippincott procedures 2009, accessed at: https://www.wolterskluwer.com/en/solutions/[NAME]-solutions/[NAME]-procedures “Enteral nutritional practice recommendations: when troubleshooting a leaking gastrostomy tube, the nurse must …if leakage persists after troubleshooting (e.g., damaged tubing, defective balloon, persistent leakage around the stoma), notify the provider immediately for evaluation and replacement.” [NAME] emphasizes that the nurse should not improvise with non-sterile or non-medical materials to “patch” the tube. Review of the facility’s policy “Gastrostomy Feeding Tube,” last reviewed March 2019, revealed: “…Nurse will document abnormal findings in the resident’s record. 7. Corrective actions including holding the feeding, consulting the physician, consulting the dietitian and/or changing flow rate or formula should be promptly implemented if complications are identified.” Resident #3 Record review on 8/27-29/25, revealed Resident #3 was admitted to the facility with diagnoses that included acute on chronic heart failure (condition in which the heart cannot pump blood effectively), coronary angioplasty implant and graft (opening of a blocked blood vessel of the heart), and atrial fibrillation (irregular rhythm of the heart). Record review of Resident #3’s care plan, review date 7/5/25, revealed a focus area of “Cognitive Impairment: Resident exhibits cognitive loss related to Alzheimer's Disease or other dementias”. An intervention was listed as “Monitor for changes in cognitive status. Notify physician if observed.” Further review of Resident #3’s care plan revealed a focus area “Medication - Anti-hypertensive: Resident requires antihypertensive medication related to Hypertension Date Initiated: 06/14/2025”. Interventions included “Observe for side effects of medication (i.e., bradycardia, dizziness, fatigue, bronchospasm, hypotension, edema, nausea, diarrhea, rash, etc.) and notify physician promptly if observed.” Review of the “Blood Pressure Summary,” dated 7/4/25, revealed Resident #3 had a documented blood pressure (BP) of 83/52 mmHg (millimeters of mercury). Review of the resident’s prior BP trends, from 6/21/25-7/4/25, showed consistent readings above 100 systolic (pressure in the arteries when the heart muscle contracts), making the 83/52 mmHg a decline from baseline. Review of Resident #3’s “Progress Notes,” dated 7/4/25 at 10:11 PM, revealed an entry by Licensed Nurse (LN) #4: “Per report, patient refused all medications, food and fluids today and is combative during cares. [He/She] is on decline. [His/Her] BP tonight was 83/52 and HR (heart rate) was 89, presumably due to dehydration. Attempted to get [him/her] to drink something but [he/she] refused.” During an interview on 8/29/25 at 9:00 AM, LN #4 stated that the physician was not notified of the low blood pressure reading, refusal of medications, refusal of food and drink, and change in mentation. Review of Resident #3’s “Progress Notes,” dated 7/5/25 at 3:33 PM, revealed: “[Resident #3] transferred to Alaska Regional Medical Center ER [emergency room] at 1505 via stretcher with EMS [emergency medical services] per [family member] request and change in condition noted. Received report from night shift that resident BP was low, [he/she] had not eaten on night shift or day shift on 7/4/25. Assessment completed by this nurse with [family member] present in room. VS [vital signs] BP 75/45… Resident baseline cognition is alert, confused but pleasant and able to communicate with staff, hold [his/her] drinking cup, chew food when fed and aware of food being placed in [his/her] mouth to eat… Cognitive decline noted from baseline…” During an interview on 8/28/25 at 2:30 PM, Resident #3’s physician stated that it was the expectation of the facility that the physician be notified for a change in condition. Review of the facility’s policy, “Vital Signs,” revised 12/2024, revealed: “It is the policy of the facility to ensure the accurate and timely measurement, documentation, and monitoring of residents’ vital signs to support their health, safety, and well-being in compliance with state and federal regulations… Vital signs shall be monitored according to the following guidelines: … Change in Condition – Vital signs shall be taken immediately when a resident exhibits signs of distress, deterioration, or any significant change in condition… 4. Report any abnormal findings to the charge nurse and physician as required. 5. Response to Abnormal Vital Signs… Significant Deviations – Notify the physician immediately and document the notification…” Review of the facility’s policy, “Change in a Resident’s Condition or Status,” last revised 2/2021, revealed: “… 1. The nurse will notify the resident’s attending physician or physician on call when there has been a(an): … d. significant change in the resident’s physical/emotional/mental condition; … f. refusal of treatment… 2. A “significant change” of condition is a major decline or improvement in the resident’s status that… will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions… 4. Unless otherwise instructed by the resident, a nurse will notify the resident’s representative when: … b. there is a significant change in the resident’s physical, mental, or psychosocial status…” Corrective Actions The facility has since corrected this noncompliance as of 8/4/25, implementing the following: Facility RCM ensured residents with changes in condition receiving acute treatment have a clinical alert to be monitored by licensed nursing. Completed 6/14/2025. Facility DON/designee provided re-education to licensed nurses on notification of provider for changes in condition and follow up on interventions implemented. Completed 6/14/2025. Facility DON/designee provided re-education to licensed nurses on facility neglect policy. Completed 6/14/2025. Facility DON/designee provided re-education to licensed nurses on resident assessment including: vital signs policy, identification of change in condition, what to do when there are changes in vital signs from resident baseline including retaking of the vital signs, asking the resident how they feel or if they feel different than baseline, notification of provider if nurse assessment indicates additional interventions, completing documentation of provider notification on changes in condition, follow up on changes in condition, and provider response. Once an acute change is addressed using provider orders, re-assess the resident at the end of treatment, notify the provider of current status for additional direction, and On completing nursing charting on clinical alerts when a resident is having a change in condition and their assessment and follow up on their assessment. The facility/DON provided re-education to the CNAs on notifying the licensed nurse on any changes they have noted on a resident for further assessment by the licensed nurse.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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.Based on record review, observation, and interview, the facility failed to discontinue a medication order when wound care orders had changed for 1 resident (#5) out of 8 sampled residents. Specifically, the facility continued administering Santyl (prescription enzymatic debriding agent used topically to remove dead tissue from chronic skin ulcers promoting healthy wound healing) ointment after the wound care plan was revised to discontinue its use. This failed practice led to thirteen administrations of a medication that was no longer required and further placed the resident at risk for unnecessary treatment, potential adverse effects, and harm .Findings:Record review on 8/29/25, revealed Resident #5 was admitted to the facility with diagnoses that included dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking), 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) with left sided hemiparesis (partial paralysis of one side of the body), obesity, chronic pain, Diabetes Mellitus type II (disorder characterized by persistent high blood sugar levels and inability to use insulin properly), and neuropathy (nerve damage). Review of Resident #5 physician's medication orders revealed: Santyl external ointment 250 unit/gm (collagenase). Apply to sacrum topically every day shift for wound care cleanse with wound cleanser, pat dry, apply Santyl to wound bed, cover with calcium alginate, and cover with foam dressing .Order Date 7/23/25. Start Date 7/24/25. End Date 8/29/25 Record review of Resident #5's physician's orders for wound care revealed: Sacral wound- Cleanse with wound cleanser, pat dry, apply barrier cream to peri wound, pack with CA [calcium] alginate ribbon, cover with foam Q2 [every 2] days and PRN [as needed]. One time a day every 2 day(s) for wound care.Order Date 8/11/25.Start Date 8/13/25 Review of the eTAR (electronic Treatment and Administration Record) revealed thirteen documented administrations of Santyl from the period of 8/14-29/25. An observation on 8/29/25 at 3:39 PM, revealed LN #3 applied Santyl ointment to a cotton tipped applicator and then applied Santyl to the skin surrounding the sacral wound bed (periwound) during Resident #5's wound care. During an interview on 8/29/25 at 4:29 PM Resident Care Manager (RCM) #8 stated Resident #5's wound care orders were changed on 8/13/25 and no longer required Santyl. RCM further stated the Santyl should have been discontinued.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on record review and interview, the facility failed to ensure proper care for invasive devices such as the gastrostomy tube (G-Tube - medical device inserted through the abdominal wall directly into the stomach to provide nutrition, hydration, and medication) to prevent the development of infections, for one resident (#1) out of 8 sampled residents. Specifically, the facility failed to implement proper techniques for troubleshooting a leaking G-Tube, including using methods such as rubber bands and soiled tape to secure the tube, failing to clean the site with sanitary technique, and not following standard precautions to manage gastric leakage and prevent contamination.This failed practice placed the resident at risk for skin breakdown and infection, which could have affected their overall health and wellbeing Findings:Resident #1Record review on 8/27-29/25, revealed Resident #1 was admitted to the facility with diagnoses that included dysphagia following other cerebrovascular disease (swallowing difficulty post-stroke), hemiplegia and hemiparesis following other cerebrovascular disease (paralysis/weakness post-stroke), gastrostomy status (surgical stomach feeding) and unspecified severe protein-calorie malnutrition (severe nutrient deficiency).Record review of Resident #1's physician orders revealed: enteral feed order. monitor for complications (e.g. [for example], N/V [nausea, vomiting], diarrhea, abdominal distention, aspiration, or pain at site) and document abnormal findings in the resident record before each feeding, flush, or med [medication] administration; check enteral tube placement with mark/tape within one inch of stoma [surgically created opening] site, nurse initials, and verify placement prior to meds, feedings, and flushes every shift; administer water flushes of 15-30cc [cubic centimeters] pre/post medication administration and 15-30cc pre/post tube feeding administration every shift; cleanse tube insertion site with soap and water or NS (normal saline) QD [every day]; . infuse 1000 ml (milliliters) over 24 hours.Record review of Resident #1's order Summary Report, dated 8/28/25 revealed an active order for Jevity 1.5 Amount to be administered: 1000 ml/24 hours Feeding intervals: Continuous x 20hr[hours]/day, off at 1000 [10:00 AM], on at 1400 [2:00 PM] Via: pump Flow rate: 50 ml/hour Total water flush: 240 ml QID [four times a day]= 960 ml/24 hours two times a day for tube feed.During an interview on 8/27/25 at 9:00 AM with LN #9, photographic evidence was presented of Resident #1's G-Tube, secured with makeshift rubber bands and masking tape, instead of medical grade clamps. The G-Tube port and makeshift dressing appeared soiled with tube feed and was brown/beige discolored. The makeshift repair created creases and gaps which contained stagnate content presenting a risk for infection.During an interview on 8/29/25 at 9:17 AM, LN #4 stated the proper way to manage a G-Tube, which included checking tube placement, administering flushes, and managing the tube to prevent migration or leakage. LN #4 recalled the night shift on 5/10/25, in which he/she noticed a leak around Resident #1's G-Tube. LN #4 disconnected the G-Tube from the tube feeding, leading to a loss of gastric contents. He/She then clamped the G-Tube with rubber bands and inserted a syringe tip past a tear in the G-Tube catheter to avoid backflow, then initiated a water flush. LN #4 did not notify the on-call provider, and planned to report it later, stating the feed was off for several hours. When asked why he/she did not replace Resident #4's G-Tube on his/her shift, LN #4 stated: I didn't know we had replacement tubes in-house at night and wasn't sure about the order/authorization for that resident's stoma.Record review of the Jevity 1.5 Cal manufacturers product information document, dated 2024, revealed Care should be taken to avoid contamination during preparation and administration.Visually inspect for signs of leakage. DO NOT use if leakage is apparent. Further review of the product information revealed All formulated liquid diet products, regardless of type of administration system, require careful handling because they can support microbial growth. Follow these instructions for clean technique and proper setup to reduce the potential for microbial contamination.Review of Resident #1's Progress Note, on 5/10/25 at 8:00 AM, revealed the G-Tube was replaced later that day: .orders received by on call.to insert new G-Tube. 15Fr [French - unit of measurement] tube placed using sterile technique added 15 cc to fill balloon. Tube auscultated for proper placement. Residual return present. Site cleaned, Ointment applied and T Drain [drainage tube] to cover. Resident tolerated well. 300 cc water administrated at this time.Review of Resident #1's Care Plan, last revised 3/3/25, revealed: Goal: The resident will remain free of side effects or complications related to tube feeding through review date. Interventions: . G Tube Placement Check: After two weeks, if unable to verify tube placement by tube marking, you may measure the gastric residual.G Tube Site Check: G tube site will be checked for signs of skin irritation, discomfort, leakage, s/s [signs and symptoms] infection or skin ulceration. Monitoring of signs of complications shall occur prior to each feeding, tube flush or medication administration.Provide water flushes as ordered before and after medication administrations, tube feeds, and free water flushes. Tube site care Q [every] shift.During an interview with LN #4, on 8/29/25 at 9:17 AM, when asked if there were any infection control concerns with his/her makeshift dressing, LN #4 answered: I used the resident's clean room tape; the rubber band functioned as a clamp. The rip was internal to the tubing; meds were delivered past the tear. At the time I did not identify additional risks beyond leakage, but I recognize the ad-hoc (something improvised or temporary) nature isn't ideal and should involve provider notification and replacement as soon as possible.During an interview on 8/29/25 at 11:00 AM, Infection Preventionist (IP) stated that using tape or rubber bands to manage a leaking tube was not acceptable. A medical grade clamp should have been used to prevent leakage and electrolyte imbalance. When asked how LN #4 should have correctly fixed Resident #1's defective G-Tube, the IP stated that the correct action would have been to clamp the tube and replace it in-house, as G-Tubes can be replaced on-site if supplies were available. She further stated that using rubber bands poses infection control risks, though tape itself was less risky if clean, as G-tube care uses clean technique, reaffirming that staff were not trained to use rubber bands, as proper clamps were available.During an interview on 8/29/25 at 4:45 PM, the Director of Nursing (DON), when asked about clamping the G-Tube, he/she stated that most facilities have standard medical grade clamps available. The DON further addressed infection control practices, stating that audits were not consistently conducted and needed to be revamped. When asked about LN #4's makeshift G-Tube dressing and rubber band clamp, the DON acknowledged that no specific follow-up was done at that time and the use of rubber bands was not the standard practice promoted by the facility.Review of the facility's adopted Lippincott procedures 2009, accessed at: https://www.wolterskluwer.com/en/solutions/[NAME]-solutions/[NAME]-procedures Enteral nutritional practice recommendations: when troubleshooting a leaking gastrostomy tube, the nurse must follow aseptic technique and manufacturer-specific guidelines. Key steps include: verify placement and condition of tube; check balloon integrity, assess connections and ports, secure and protect the site, keep the site and tubing clean and dry. Use only medical-grade devices (such as clamps or securement devices; escalate for replacement then indicated. [NAME] emphasizes that the nurse should not improvise with non-sterile or non-medical materials to patch the tube.Review of the facility's policy Gastrostomy Feeding Tube, last reviewed March 2019, revealed: .6. Staff should monitor the enteral tube site for s/s leakage at tube entrance site, s/s infection, or skin irritation. 8. Whenever possible, a closed system will be used for the administration of tube feedings.10. Clean technique (including the use of gloves) will be used by staff when stopping, starting, flushing or administering medications per gastric tube.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected most or all residents

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.Based on observation, interview and record review, the facility failed to ensure medications and medical supplies were properly stored and labeled. Specifically, the facility failed to: 1) remove expired and/or opened medications and supplies from use and 2) maintain emergency medications under safe temperature control. These failed practices had the potential to place all residents (census of 92) at risk of receiving expired and/or compromised medications which may result in reduced efficacy or adverse reaction.Findings: .Expired/Opened Medications/Supplies An observation on 8/29/25 at 10:50 AM, of the treatment cart in the Spruce Court, revealed: -Three packs of Hypodermic Safety needles 23 G (gauge) x 1 expired 6/30/25;-One Diclofenac Sodium Topical Gel 1% (NSAID), a non-steroidal anti-inflammatory drug, expired on 7/27/25; and-One opened pack of IV [intravenous] Start Kit w/ Chloraprep App. During an interview on 8/29/25 at 1:49 PM, Infection Preventionist (IP) and Resident Care Manager (RCM) #1 confirmed the above listed expired and/or opened medication and medical supplies. They further stated the medication and supplies should have been discarded. An observation on 8/29/25 at 10:59 AM, of the medication cart in the [NAME] Court, revealed: -One bottle of C-Pantoprazole (medication that decreases the amount of stomach acid produced) 4mg (milligram)/mL (milliliter) white suspension, expired on 8/25/25;-One bottle of Aspirin 81mg enteric coated tablets, with a faded and ineligible expiration date;-One bottle of Nitroglycerin (medication used to treat chest pain) 0.4mg sublingual (under the tongue) tablets, expired on 8/23/25; and-Four 32ml TRUEPlus glucose gels in Fruit Punch, expired on 7/2025. An observation on 8/29/25 at 11:16 AM, of the treatment cart in the [NAME] Court, revealed: -Three Medline Maxorb II Reinforced Alginate Ribbon with Antibacterial Silver (used in wound care and treatment), expired on 8/1/25; and-Two AccessBio CareStart Covid-19 Antigen Home Test kits, expired on 11/22/24. During an interview on 8/29/25 at 11:57 AM, Licensed Nurse (LN) #3 confirmed the above listed expired medications and supplies and stated the expired medications and medical supplies should have been discarded. He/she further stated that due to the faded expiration date that he/she would be unable to know when to discard the bottle of medication and would consider it expired. Unsafe Refrigerator Temperature for Medication Record review of the facility's Daily Refrigerator Temperature Log in the central medication room, dated August 2025, revealed 20 instances on day shift and 26 instances on night shift where the temperatures were not documented. Further review revealed eight recorded temperatures that ranged between 48-53 degrees F(Fahrenheit). Further review of the temperature log revealed, the recommended range was 36-46 degrees F. An observation on 8/29/25 at 12:01 PM revealed the temperature of the refrigerator on two temperature gauges were 48 degrees and 51 degrees F respectively. Further observation revealed three emergency kits were in the refrigerator. Review on 8/29/25 at 12:01 PM of Pharmerica's (the facility's contracted pharmacy) Refrigerator Emergency Kit Content List revealed each kit contained the following: -Two Cathflo Alteplase 2 mg Vial a thrombolytic for Acute Ischemic Stroke, Acute Myocardial Infarction, Pulmonary embolism and Thrombolysis;-Four Phenergan Promethazine 25 mg Supp[suppository] an antihistamine for allergy/antiemetic;-One Xalatan Latanoprost 0.0005% 2.5 mL for reduction of elevated intraocular pressure;-Two Humalog Kwikpen Insulin Lispro 100 U/mL 3 mL Pen for diabetes mellitus;-One Humulin N Insulin NPH 100U/mL 3mL Pen for diabetes mellitus;-One Novolin R Insulin Regular 100U/mL 3mL Vial for diabetes mellitus;-One Semglee/Lantus Insulin Glargine-yfgn 100U/mL 3mL Pen for diabetes mellitus;-Two Novolog Flexpen Insulin Aspart 100U/mL 3mL Pen for diabetes mellitus; and-Two Semglee/Lantus Insulin Glargine- yfgn 100U/mL 3mL Pen for diabetes mellitus. During an interview on 8/29/25 at 12:01 PM, RCM #1 stated the refrigerator temperature was checked by the nurses once daily and the out-of-range temperatures should have been reported to the maintenance department. The RCM further stated he/she would file a work order ticket. During an interview on 8/29/25 at 1:49 PM, IP and RCM #1 stated the emergency kits found in the refrigerator were sent back to Pharmerica for replacement. Review of the facility's policy, Storage of Medication, dated 1/2023, revealed: Medications and biologicals are store properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Medications requiring refrigeration or temperatures between 2oC (Celsius) (36oF) and 8oC (46oF) are kept in a refrigerator with a thermometer to allow temperature monitoring . A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. Insulin products should be stored in the refrigerator until opened. Review of the Food and Drug Administration (FDA) drug storage recommendation, accessed at https://www.accessdata.fda.gov/drugsatfda_docs, undated, revealed the medications in the emergency kit [listed above], should be stored in a refrigerator (36 to 46 F [2 to 8 C]).

Jun 2025 5 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Quality of Care (Tag F0684)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure provision of necessary care and services for one resident (#1) out of 20 sampled residents.Specifically, the facility failed to:1) monitor and evaluate the resident's response to the IV fluid bolus ordered on [DATE];2) educate and inform the resident of the risks and benefits after he/she declined vital sign measurements while in a life threatening condition;3) notify the attending provider of the resident's refusal of care, sustained hypotension and continued altered mental status; and4) ensure the resident was transferred to the emergency room for a higher level of care. These failed practices prevented Resident #1 from receiving care and services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and placed the resident at risk for serious harm and death due to unaddressed changes in condition. The resident passed away on [DATE]. A determination was made that the facility's noncompliance with one or more requirements of participation placed Resident #1 in immediate jeopardy beginning on [DATE]. This situation was brought to the attention of the facility's administration on [DATE] at 3:35 PM, at which time the facility was notified of the identified immediate jeopardy.The State Agency verified onsite on [DATE] at 12:35 PM that the immediacy was removed on [DATE] at 10:45 PM. The facility removed the immediacy by reviewing all current residents for any changes in conditions within the previous 48 hours. Any identified residents were assessed by the Director of Nursing or nursing manager and notified physicians of change in condition. Change of condition education was to be provided to licensed nurses and certified nurse aides. Following the removal of the immediacy, noncompliance remained at a scope and severity of D, no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings:Review on 6/11-13/25 revealed Resident #1 was admitted to the facility with diagnoses that included severe sepsis with septic shock (a life-threatening condition caused by the body's response to infection, leading to dangerously low blood pressure and organ dysfunction), essential hypertension, and atrial fibrillation (an irregular heart rhythm).Assessment of Resident #1's HypotensionReview of Resident #1's SBAR (Situation, Background, Assessment, Recommendation - a standardized communication tool used by healthcare staff to clearly and concisely report a resident's condition and facilitate physician notification), dated [DATE] at 12:00 PM, revealed: . Situation . Hypotensive [abnormally low blood pressure] & tachycardic [abnormally fast heart rate] . Background . 69 y/o [year old] [male/female], DNR [do not resuscitate] . Hx [history of] sepsis with shock . Assessment . 65/46 [mm/Hg (millimeters of mercury)] [BP], 107 [heart rate], increased confusion.During an interview on [DATE] at 12:23 PM, Resident #1's attending physician and Medical Director (MD), stated he was notified on [DATE], via SBAR, that Resident #1 had a critically low blood pressure and tachycardia. He assessed the resident and noted he/she was mildly obtunded (altered mental status characterized by decreased consciousness and responsiveness) with ongoing hypotension and elevated heart rate. He ordered a one-time 1000 mL (milliliter) IV (intravenous) bolus of normal saline for dehydration and hypotension. The MD stated he did not provide instructions or orders for follow-up monitoring, but expected nursing staff to notify him after shift change or upon completion of the fluids if the Resident had not improved.Review of Resident #1's Order Recap Report, revealed an order dated [DATE], Sodium Chloride Solution 0.9% Use 1000 ml IV one time only for dehydration, hypotension. Until [DATE] 23:59 bolus 1 L [liter] normal saline. This order did not include any parameters for reassessment or guidance for notifying the physician based on the resident's response to treatment.Further review revealed: Azithromycin Tablet 250 MG [milligram] Tablet Give 500 mg by mouth one time a day for infection for 1 day -Start Date- [DATE] 1230.Critical Hypotension Event - No Clinical ResponseReview of Resident #1's Progress Notes, dated [DATE] at 12:23 AM, revealed an entry by Licensed Nurse (LN) #5: Patient refused to allow staff to take vitals. Attempted 3 more times and [he/she] still refused. Further review revealed no documentation of physician and/or resident representative notification of the resident's refusal to allow staff to obtain vital signs.Review of Resident #1's Blood Pressure Summary, revealed a blood pressure reading of: . [DATE] 07:41 [AM] . 75/45 [mm/Hg].Record review on 6/11-13/25 revealed no documentation of physician and/or resident representative notification for Resident #1's blood pressure measurement of 75/45 mm/Hg.During an interview on [DATE] at 12:23 PM, the MD stated he was not informed when the resident's blood pressure remained critically low on [DATE]. The MD further stated Resident #1 would have been immediately transferred to the emergency room for possible sepsis had he been advised of Resident #1's condition and/or lack of improvement. The MD stated a blood pressure of 75/45 mm/Hg was not life-sustaining and required higher level of care. The MD stated he was unaware of Resident #1's clinical updates and considered his/her death as unexpected.During an interview on [DATE] at 3:15 PM, certified nurse aide (CNA) #4 stated after he/she obtained the blood pressure on [DATE] of 75/45 mm/Hg for Resident #1, that [he/she] appeared really out of it and was talking to [himself/herself]. CNA #4 further stated he/she reported the change in mental status to LN #2, who was assigned to the resident that shift. CNA #4 stated after he/she reported the low blood pressure and altered mental status, LN #2 responded without urgency, requested the blood pressure to be rechecked. CNA #4 stated that LN #2 kind of acted like it was nothing, and CNA #4 did not observe any further assessment or follow-up by LN #2.During an interview on [DATE] at 11:05 AM, when LN #5 was asked if vital signs would be obtained after the administration of IV fluids for hypotension, he/she stated yes. When asked if the physician would have been notified if the blood pressure remained low, he/she stated yes. LN #5 further stated when a resident refused vital sign measurements to be taken in critical situations, he/she would have notified the physician. LN #5 stated the facility had not provided specific training on how to respond to residents who refuse critical cares. LN #5 further stated the physician was not notified when Resident #1 refused to allow vital signs to be obtained.During an interview on [DATE] at 1:07 PM, LN #2 was asked how he/she would respond if a resident who presented with a blood pressure of 75/45 mm/Hg. LN #2 stated he/she would withhold blood pressure medications, notify the physician, and document the physician notification. LN #2 further stated altered mental status combined with hypotension would require physician notification, and if the resident refused to allow vital signs to have been taken, it would also warrant a physician notification. LN #2 stated Resident #1's blood pressure should have been reassessed following the administration of IV fluids to evaluate the resident's response.During an interview on [DATE] at 12:16 PM, the Resident Care Manager (RCM) revealed that on the morning of Resident #1's death, I really only got involved after [he/she] passed . I hadn't seen [him/her] that morning. The RCM further stated that the day prior, he had started an IV and administered a liter of fluids, stating, I was one of the few RNs [Registered Nurse] there that were able to do it . The nurse on the floor is the one watching the patient at all times.When asked what the nurse should have done when notified of a blood pressure of 75/45 mm/Hg, the RCM stated: Provider notification for assessment . no matter what, a provider notification. The RCM also revealed there was no specific follow-up order given after the prior day's IV fluids, stating, They [the physician] said to monitor closely and call on call if there were any issues.When asked about his/her responsibilities in supporting a new LN caring for Resident #1, the RCM stated: I would give support . but I was covering a couple of units. It varied how much attention I could give to a single nurse based on what was going on.The RCM also confirmed that if the nurse had failed to contact the provider after the fluid bolus, the provider would have had no way to know if the resident was improving or worsening.Finally, the RCM confirmed that while he/she assisted with the IV fluids and post-mortem care, he/she had not assessed the resident that morning and had no awareness of the LN's response to the low blood pressure reported by the CNA.Review of the facility's provided, Job Description: RN [registered nurse], dated 2/2024, revealed: .Monitor and adjust resident's status based on changing needs and conditions . Ensure that all nursing service personnel are in compliance with their respective job descriptions . Make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . Meet with your shift on a regularly scheduled basis to assist in identifying and correcting problem areas and/or to assist in the improvement of services . Notify the resident's attending physician and next-of-kin when there is a change in the resident's condition. Visit residents on a daily basis in order to observe and evaluate each resident's physical and emotional status .Review of the facility's provided, Job Description: LPN/LVN [licensed practical nurse/licensed vocational nurse], dated 2/2024, revealed: .The primary purpose of your job position is to provide direct nursing care to the residents . Nursing Care Functions . Consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary. Implement and maintain established nursing objectives and standards . Make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status . Notify the resident's attending physician and next-of-kin when there is a change in the resident's condition . Take and record . blood pressures, etc., as necessary . Monitor seriously ill residents as necessary . Ensure that resident's who are unable to call for help are checked frequently .Review of the facility's policy, Vital Signs, revised 12/2024, revealed: It is the policy of the facility to ensure the accurate and timely measurement, documentation, and monitoring of residents' vital signs to support their health, safety, and well-being in compliance with state and federal regulations . Vital signs shall be monitored according to the following guidelines: . Change in Condition - Vital signs shall be taken immediately when a resident exhibits signs of distress, deterioration, or any significant change in condition . 4. Report any abnormal findings to the charge nurse and physician as required. 5. Response to Abnormal Vital Signs . Significant Deviations - Notify the physician immediately and document the notification . Emergency Situations - Initiate emergency procedures (e.g., CPR, oxygen therapy) and call 911 if necessary.Review of the facility's policy, Fever/Septicemia - Clinical Protocol, last revised 3/2018, revealed: Assessment and Recognition .1. A nurse will assess a resident with a suspected infection and will document related findings . k. Description of any new or worsening decline in functional status, including confusion . decreased mobility . Assessment data will include: a. Vital signs . Management . The physician or provider will prescribe antibiotics judiciously, following CDC recommendations . Monitoring and Follow-Up . 1. The physician and nursing staff will evaluate the progress of individuals with fever and/or infection until the symptoms resolve. 2. Nursing staff and physician will monitor for other complications of infection, fever, or sepsis (for example . delirium). 3. The nurses will communicate with the physician or provider to identify whether the resident needs any special monitoring, precautions, or interventions.Review of the facility's policy, Change in a Resident's Condition or Status, last revised 2/2021, revealed: . 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): . d. significant change in the resident's physical/emotional/mental condition; . f. refusal of treatment . g. need to transfer the resident to a hospital/treatment center . 2. A significant change of condition is a major decline or improvement in the resident's status that . will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . b. there is a significant change in the resident's physical, mental, or psychosocial status .Review of the professional standard, Lippincott Nursing Procedures Ninth Edition book, dated 2023, revealed: . Blood Pressure Measurement . Frequent blood pressure measurement is critical . during any illness or condition that threatens cardiovascular stability . Frequent blood pressure measurement may also be necessary for unstable patients .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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. Based on interview and record review, the facility failed to update and revise the care plan for 1 resident (Resident #21) out of 1 resident reviewed for care plan. Specifically, the facility failed to update and revise the care plan to reflect new interventions and/or monitoring to address aggressive or escalating behaviors. This failed practice placed the resident at risk for not receiving appropriate and/or accurate care and services. Findings: Review on 6/11-13/25 revealed Resident #21 was admitted to the facility with diagnoses that included unspecified dementia (cognitive decline), aphasia (impaired ability to understand or express speech), and parkinsonism (a group of movement abnormalities such as tremor, stiffness, and slowed movement). During an interview on 6/12/25 at 11:00 AM, Resident #3 allegedly stated during a verbal altercation with Resident #21 on 4/25/25, he/she was struck in the face by Resident #21. Resident #3 then retreated to his/her room, called the police and reported the assault. Review of Resident #21's Nursing notes, dated 4/25/25, revealed: . Behavior note . Resident was reported to be walking in the dining area with only a shirt on. Another resident mentioned to him to be respectful to the ladies and put on some clothing. Resident [#3] in room . reports that is when the resident hit him in the face. During an interview on 5/21/25 at 3:15 PM, the Director of Nursing (DON) was asked if Resident #21's care plan should have been reviewed or revised following the altercation, then replied, Yes. The DON further stated that there are care plan review processes in place for residents with escalating behavioral issues. The DON also stated, We bring all reportable events to QAPI [Quality Assurance and Performance Improvement - a systematic, data-driven program designed to improve the quality of care and services in the facility through ongoing monitoring, review, and correction of system issues], this event was brought to the QAPI meeting. Review of Resident #21's Comprehensive care plan, initiated 4/18/25, revealed no interventions or monitoring for escalating behaviors or potential for aggression following the incident. Review of the facility's policy, Safety and Supervision of Residents, revised 7/2017, revealed: 1. Our individualized, resident-centered approach to safety addresses safety .for individual residents .2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific hazards or risk for individual residents .3. The care team shall target interventions to reduce individual risk 4. Implementing interventions to reduce risk and hazards .5. Monitoring the effectiveness of interventions . Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised 3/2022, revealed: . The interdisciplinary team should review and update the care plan: . when there has been a significant change in the resident's condition . .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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. Based on record review, observation and interview, the facility failed to ensure 1 resident (#5) out of a census of 94, had supervised access to an unauthorized location in the facility. This failed practice had the potential to place the Resident at risk of injury due to inadequate supervision and the lack of security measures posed the possibility of hazard including the potential for elopement through unsecured exits. Findings: Record review from 6/11-13/25 revealed, Resident #5 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis (paralysis on one side), following cerebral infarction (stroke), lack of coordination, abnormalities of gait and mobility, muscle weakness, cognitive communication deficit (impaired thinking/speech), epilepsy unspecified, not intractable without status (recurrent seizures), and depression (low mood). Record review of Resident #5's Minimum Data Set (MDS - a federally required assessment), dated 5/7/25, revealed: Wheel 150 feet: once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space required supervision or touching assistance. Review of Resident #5's, Care Plan Report, last revised on 8/16/22, revealed Resident #5 had impaired cognitive/impaired thought processes related to stroke. Resident will have needs met with assistance from staff as needed, staff will encourage resident to assist as much as tolerated by resident. It is also noted that resident was at risk for falls related to hemiplegia and hemiparesis. Resident #5 was on behavior monitoring due to suicidal statements and actions with focused behaviors such as wandering, exit seeking and sliding off wheelchair when needing assistance. An observation on 6/11/25 at 12:50 PM, revealed the basement on level 0 had one exit through the loading dock, accessible via double doors immediately to the right of the elevator. These doors were unlocked, unmanned, and lacked alarms or monitoring. This area was designated as an unauthorized zone for all residents, with access restricted to authorized staff, such as maintenance personnel or contractors. An observation on 6/11/25 at 1:00 PM, during the tour in the basement, Maintenance Director (MD) pushed the elevator button to go upstairs, and the doors opened and revealed, Resident #5 in a wheelchair on the elevator by himself/herself. Resident #5 appeared to have some difficulty answering basic questions during the encounter. The MD helped Resident to the first floor, then the Medical Records Director (MRD) further assisted Resident #5. During an interview on 6/11/25 at 12:50 PM, the MD discussed elopements and stated, residents don't come down to floor 0, it never happens, since the elevator requires a code to grant access to the floors. During an interview on 6/13/25 at 10:50 AM, when asked about Resident #5 being found on the elevator on 6/11/25 at 1:00 PM, the MRD stated Resident #5 was headed to a ceramic activity on the 1st floor and somehow got confused so the MRD escorted him/her to the dining room. During an interview on 6/13/25 at 9:30 AM, the Administrator was asked about Resident #5's incident on 6/11/25 at 1:00 PM on the elevator in the basement unsupervised. The Administrator stated Resident #5 was considered low risk for elopement, but the incident raised concerns about how residents with cognitive impairments, particularly those at risk of wandering, were monitored to prevent unsupervised access to areas like the basement. The Administrator further stated the facility was conducting monthly staff training and elopement drills. The Administrator stated Resident #5's unsupervised elevator incident would be reviewed. The Administrator further stated, the elevator's operation required a code to be entered by one person and would allow the elevator to continue to the basement, allowing unsupervised and/or unauthorized access of the residents. The Administrator stated that changing the elevator's functionality was not feasible due to its age, but staff education could be reinforced to ensure residents were not left alone in the elevator. She suggested measures like documenting when codes were used or ensuring staff accompany residents to prevent similar occurrences from reoccurring. When asked if the elevator's functionality had ever been addressed or identified through Quality Assurance and Performance Improvement (QAPI), the Administrator stated No, it never has. During a follow-up interview on 6/13/25 at 12:17 PM, the Administrator stated there was not a specific protocol on elevator usage for the staff, but during orientation, the maintenance department provided verbal education on how to use the elevator code and the procedure to escort a resident back to their court if they came down to the basement. During an interview on 6/13/25 at 2:00 PM, the MD covered several key topics related to the maintenance and safety of the building, particularly its elevator system and resident oversight: He stated, The building, constructed in the mid-1980s, has aging elevators that occasionally break down. He further stated resident safety and wandering behaviors were a significant concern, particularly those with cognitive impairments like Resident #5, wandering into restricted areas such as the basement. The MD noted those incidents were rare (less than monthly) and lack a formal policy, but staff ensured residents were escorted back by authorized personnel. Review of the facility's policy, Safety and Supervision of Residents, last revised 2001, revealed a comprehensive approach to ensure a safe environment for residents, prioritizing accident prevention and supervision as facility-wide goals. It employs a dual strategy: a facility-oriented approach and an individualized, resident-centered approach. The facility-oriented approach involves identifying safety and environmental hazards .The individualized, resident-centered approach focuses on tailoring safety measures to the specific needs of each resident, with the care team analyzing assessment and observation data to identify and address individual accident hazards or risks. This includes implementing adequate supervision and assistive devices. .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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. Based on record review and interview, the facility failed to ensure timely reporting of abuse allegations for two residents (#s 8 and 15) out of 20 sampled residents. Specifically, the facility failed to report the allegations of abuse within 2 hours from the occurrence of the incident to the State Survey Agency. This failed practice placed all residents based on a census of 94 at risk for continued potential abuse. Findings: Resident #8 Record review on 6/11-13/25, revealed Resident #8 was admitted to the facility with diagnoses that included encounter for other orthopedic aftercare, subluxation (misalignment) of L4/L5 lumbar and fusion (surgical procedure that joins two or more vertebra) of spine, lumbar. Record review of the Facility Reported Incident (FRI), Initial Report, dated 5/6/25 at 7:30 AM, revealed, the FRI was reported to the State Agency on 5/6/25 at 11:30 AM by Resident Care Manager (RCM) #1. During an interview and concurrent record review on 6/13/25 at 10:22 AM, the Administrator (ADM) was provided Resident #8's Initial Report of allegation of abuse, dated 5/6/25 at 7:30 AM. When the ADM was asked of the date and time of the initial report of allegation of abuse, she stated 5/6/25 at 7:30 AM. The ADM was further asked how long the facility had to report an abuse allegation, she responded 2 hours. When the ADM was asked if the amount of time they took to report the abuse allegation was appropriate, she answered No. Resident #15 Record review on 6/11-13/25, revealed Resident #15 was admitted to the facility with diagnoses that included, cerebral infarction due to thrombosis of right middle cerebral artery (stroke), type 2 diabetes mellitus, and hypertension. Record review of the FRI, Initial Report, dated 5/6/25 at 8:30 AM, revealed the FRI was reported to the State Agency on 5/6/25 at 11:20 AM by RCM #1. During an interview on 6/12/25 at 1:52 PM, RCM #1 was asked about the process of abuse reporting, he/she stated the accused staff member would be removed immediately from the care area. The Director of Nursing (DON) and the facility ADM would be notified immediately and contact the proper authorities if deemed necessary. RCM #1 further stated any allegation of abuse must be reported to the State Agency within 2 hours of the incident. During the same interview, RCM #1 stated once the facility obtained the staff statement of the alleged event, the staff member would be placed on administrative leave and would not be allowed to return until after the investigation had been completed. RCM #1 stated the final investigation was to be completed within 5 days. Review of the facility's policy Abuse- Screening, Training, Identification, Investigation, Reporting, and Protection, revised 1/2023, revealed: . b. If with the suspicion of crime, there is abuse or a serious injury the staff member must report the incident within 2 hours of forming the suspicion to . the state survey agency . Abuse: is defined as: a. Abuse is the willful infliction. resulting in physical harm, pain or mental anguish . .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

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. Based on record review and interview, the facility failed to ensure 3 Facility Reported Incidents (FRI) for residents (#8, #9 and #15) out of 4 FRIs for allegations of abuse were thoroughly investigated. Specifically, the facility failed to provide evidence of the interventions identified in their investigations. This failed practice placed these residents at risk of having injuries or harm that were not adequately addressed and treated. Findings: Resident #8 Record review on 6/11-13/25, revealed Resident #8 was admitted to the facility with diagnoses that included: encounter for other orthopedic aftercare, subluxation (misalignment) of L4/L5 lumbar vertebra and fusion (surgical procedure that joins two or more vertebra) of spine, lumbar. Record review of the FRI, Final Report, dated 5/6/25, revealed: Interventions: . Resident was placed on Alert Charting. Skin check completed with no new injuries noted. Record review 6/11-13/25 of Resident #8's electronic medical record (EMR), no documentation of skin assessment or alert charting was noted for the interventions identified in Final Report dated 5/6/25. During an interview on 6/13/25 at 10:02 AM, the Administrator was asked if she considered alert charting and skin check as part of the investigation into the allegation of abuse and she responded yes. During an interview on 6/13/25 at 10:21 AM, the Administrator was unable to find alert charting or skin assessment documentation in the Resident #8's chart related to the abuse allegation. Resident #9 Record review on 6/11-13/25 revealed Resident #9 was admitted to the facility with diagnoses including encounter for other orthopedic aftercare [rehabilitation process after orthopedic surgery or injury] and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side [paralysis and weakness on the left side of the body following a stroke]. Record review of the FRI, Initial Report, dated 4/24/25, revealed: Interventions: . The resident was placed on alert charting for psychosocial assessment. Record review of the FRI, Final Report, dated 4/28/25, revealed: Conclusion: . A thorough skin assessment of the resident was completed. Record review 6/11-13/25 of Resident #9's EMR, no documentation of alert charting was noted for the interventions identified in Initial Report, dated 4/24/25. Record review 6/11-13/25 of Resident #9's EMR, no documentation of skin assessment was noted for the FRI identified in Final Report, dated 4/28/25. During an interview on 6/13/25 at 10:02 AM the Administrator was asked if she considered alert charting and skin check a part of the investigation into the allegation of abuse and she responded yes. During an interview on 6/13/25 at 10:21 AM, the Administrator was unable to find alert charting or skin assessment documentation in the resident's chart related to the abuse allegation. Resident #15 Record review on 6/11-13/25, revealed Resident #15 was admitted to the facility with diagnoses that included, cerebral infarction due to thrombosis of right middle cerebral artery (stroke), type 2 diabetes mellitus, hypertension, foot drop left foot, foot drop right foot and retention of urine. During an interview on 6/12/25 at 1:52 PM, RCM #1 stated Resident #15 was assessed with a thorough skin check and assessment for any injuries. RCM #1 further stated Resident #15 was placed on alert charting for one week. Record review of the incident, Final Report, dated 5/6/25, revealed: Interventions: . Resident was placed on Alert Charting. Skin check completed with no new injuries notes [d]. Record review 6/11-13/25 of Resident 15#'s EMR, no documentation of alert charting or a skin assessment was noted for the interventions identified in Final Report, dated 5/6/25. Review of the facility's policy Abuse- Screening, Training, Identification, Investigation, Reporting, and Protection, revised 1/2023, revealed: Policy. 3. Prevent and prohibit all types of abuse. 5. Investigate allegations of abuse. 7. Protect out resident from abuse. a. All alleged incidents of abuse. must be thoroughly investigated. .

Dec 2024 16 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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. Based on record review, observation and interview, the facility failed to ensure two residents out of 22 sampled residents, and one resident out of 6 unsampled residents were provided care in a manner that promoted dignity and respect. Specifically, the facility failed to: 1) provide covering of the urinary catheter bags (a tube inserted through the urinary tract into the bladder, connected to a drainage bag) for 2 residents (#1 and #96); and 2) provide unsampled resident #40 a dignified dining experience. This failed practice placed the residents at risk of poor self-esteem and/or self-worth and a potential for poor quality of life. Findings: Resident #1 Record review on 12/8-12/24 revealed Resident #1 was admitted to the facility with diagnoses that included type 2 diabetes mellitus with chronic kidney disease, urinary tract infection, unspecified dementia and recurrent major depressive disorder (a mood disorder characterized by depressed mood and loss of interest and/or pleasure in activities). An observation on 12/11/24 at 11:35 AM, revealed that Resident #1 was being wheeled by Certified Nursing Assistant (CNA) #4 from the shower room through the court dining space into Resident #1's room with his/her uncovered urinary catheter bag attached to his/her shower chair. During an interview on 12/11/24 at 11:40 AM, Licensed Nurse (LN) #10 stated that the urinary bag should be covered when a resident is in a public space. Record review of the facility's policy, In-dwelling Urinary Catheter, last revised 2/2019 revealed: .preserving resident dignity . as a guideline when caring for a resident with a urinary catheter . Resident #96 Record review from 12/8-12/24 revealed Resident #96 was admitted to the facility with a diagnosis that included benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms, and bladder-neck obstruction. An observation on 12/8/24 at 10:00 AM, revealed Resident #96 ambulating in the community space of the unit with his/her uncovered urinary catheter bag attached to his/her walker. In the presence of Resident #96 were tw other residents, and two unidentified staff members. During an interview on 12/12/24 at 8:19 AM, when asked how the facility ensures a resident's right to dignity when ambulating with a foley catheter, LN #11 stated, .the urinary catheter should have a privacy bag. Record review of the facility's policy, In-dwelling Urinary Catheter, revised on 2/2019, revealed: .preserving resident dignity . as a guideline when caring for a resident with a urinary catheter . Review of Resident #96's Care Plan, dated 11/27/24, revealed: .Privacy cover to catheter bag as indicated to promote dignity . Resident #40 Record review on 12/11/24 revealed Resident #40 was admitted to the facility with diagnoses that included acquired absence of other specified parts of digestive tract, vascular dementia (dementia resulting from impaired blood flow to the brain), unspecified severity, with psychotic disturbance, adult failure to thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction and low cholesterol), and schizophrenia (mental disorder characterized by symptoms of hallucinations, delusions and cognitive challenges). During continuous observation on 12/11/24 from 12:31 PM - 1:10 PM, of the Cedar Court dining area, of which three other residents were present, the following occurred: -12:31 PM, CNA #4 brought Resident #40 his/her lunch. CNA #4 set the plate, dessert cup, drinking cup, and silverware on a bedside table by Resident #40. CNA #4 returned to passing meal trays to residents' rooms. -12:33 PM, Resident #40 poured the red liquid from his/her cup into the garbage can next to his/her recliner. Resident #40 scooped out brown pudding-like food from a dessert cup into the garbage with his/her spoon. Resident #40 tapped the spoon on the side of the garbage can, then used a tissue to wipe off the spoon. CNA #4 walked by Resident #40 and stated I thought you were hungry. -12:35 PM, CNA #4 was standing by the meal cart and stated you should eat something [while looking towards Resident #40]. Resident #40 banged a spoon on the side of the garbage can and placed tissues in the garbage. Maintenance Staff (MS) #2 walked onto the unit and looked towards Resident #40 and CNA #4. Resident #40 looked at his/her hands and the spoon. MS #2 walked over to CNA #4 and stated [Resident #40] needs a new spoon. CNA #4 took Resident #40 a clean spoon. In a raised voice, Resident #40 told CNA #4 he/she did not want to eat the food provided. CNA #4 stated I should have moved the garbage can. Resident #40 continued to put his/her hands in the garbage can. While looking at his/her hands, he/she then wiped his/her fingers on his/her blanket. Resident #40 picked up his/her dinner plate and dumped the remaining food into the garbage can. Resident #40 wiped the plate and spoon with tissues, then set them on the bedside table. -12:40 PM, CNA #4 removed all dishes from Resident #40's table. Resident #40 was not offered any alternative foods and did not receive additional food or drink during the observation period. Record review on 12/8-12/24 of Resident #40's Care Plan revealed, . Eating- 1-person limited assist . Monitor/document/report . Refusing to eat . Provide and serve supplements as ordered: prefers Ensure . Encourage good nutrition and hydration . offer supplements/alternate with intake <50% . Record review of the facility's policy, Activities of Daily Living (ADL), Supporting, last revised on 3/2018, revealed: . Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition (s) demonstrate that diminishing ADLs are avoidable . he or she has been offered alternative interventions to minimize further decline . Appropriate care and services will be provided for residents d. dining (meals and snacks) . .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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. Based on observation, interview and record review the facility failed to ensure self-administration of medication evaluation was completed for three residents (#s 14, 83, and 87) out of three residents reviewed. This failed practice placed the residents at risk of adverse effects of the medications. Findings: Resident #14 Record review from 12/8-12/24, revealed Resident #14 was admitted to the facility with diagnoses that included myocardial infarction and diabetes mellitus. An observation on 12/8/24 at 10:41 AM, revealed ear drops carbamide peroxide 6.5% was on top of Resident #14's bedside table. Resident #14 stated he/she had administered it on his/her own for two days now. Review on 12/10/24 at 11:50 AM, of active physician's order for Resident #14, revealed no physician's order for ear drops Carbamide peroxide 6.5%. During an interview on 12/11/24 at 12:14 PM, Licensed Nurse (LN) #1, stated there was no order in the electronic health record (EHR). Resident #83 Record review from 12/8-12/24, revealed Resident #83 was admitted to the facility with diagnoses that included hemiplegia (a condition that causes one sided paralysis) and hemiparesis (one sided muscle weakness). An observation on 12/8/24 at 10:59 AM, revealed clobetasol propionate ointment 0.05 % was on Resident #83's bedside table. Resident #83 stated he/she applied ointment on his/her neck because he/she had rashes. Review of the physician's order, dated 11/7/24, revealed clobetasol propionate external Cream 0.05 % apply to neck topically every morning and at bedtime for Altered Skin Integrity until 11/14/24 23:59 Apply thin film for 7 days. During an interview on 12/11/24 at 12:14 PM, LN #1 stated the nurses had been applying the medication to Resident #83 before (LN #1 could not recall the date) but now Resident #83 wanted to apply the ointment on his/her own. Resident #87 Record review from 12/8-12/24, revealed Resident #87 was admitted to the facility with diagnoses that included infection and an inflammatory reaction due to an internal fixation device of the spine, and asthma. An observation on 12/8/24 at 10:23 AM, revealed albuterol inhaler and artificial tears hypromellose dropper bottle were on Resident #87's bedside table. The Resident stated he/she had administered those medications on his/her own. Review of the physician's order dated 10/1/24, revealed: Albuterol Sulphate HFA Inhalation Aerosol Solution 108, 2 puffs inhale orally every 4 hours as needed for wheezing/SOB (shortness of breath), and Refresh Celluvisc Opthalmic gel 1%, Instill 2 drop[s] every 1 hours as needed for Dry eyes. Review of the electronic Medication Administration Record (eMAR) from October to December 2024, revealed both medications mentioned above were not administered by the LNs. During an interview on 12/11/24 at 12:14 PM, LN #1 confirmed that Resident #87 had the above medications in the resident's room. LN #1 stated the resident preferred to self- administer the medications. During an interview on 12/11/24 at 1:51 PM, the Administrator stated there were no self-administration of medication evaluations and no interdisciplinary team notes that Residents #14, 83, and 87 were evaluated for self- administration of medication. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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. Based on observation and interview, the facility failed to ensure a homelike environment was maintained in resident rooms for 3 unsampled residents (#s 34, 47, and 251), out of 6 unsampled residents reviewed. This failed practice denied the residents a functional, maintained, and homelike environment. Findings: Resident #34 An observation on 12/11/24 at 3:40 PM, Resident #34's room, on Birch Court, revealed six large cardboard boxes in the resident's bathroom. Further observation revealed one box was designated for the Birch Court's artificial Christmas tree's display in the common area, and the other five boxes were stored decorations for Birch Court's Halloween and Christmas holidays. During an interview on 12/11/24 at 3:40 PM, the Director of Business Development (DBD) stated the boxes should not have been stored in the resident's bathroom. Resident #47 An observation on 12/11/24 at 12:46 PM, of Resident #47's room, revealed the face plate to the cable outlet was cracked. The DBD acknowledged these findings upon discovery. Resident #251 An observation on 12/11/24 at 4:04 PM, of Resident #251's room, revealed the face plate to the cable outlet was not secured to the wall. Further observation of the face plate revealed it was loosely hanging, supported by the cable attached to the outlet. The DBD acknowledged these findings upon discovery. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, interview and observation, the facility failed to ensure the MDS (Minimum Data Set - a federally required assessment for long term care residents) accurately represented two residents (#37 and #97) out of 22 sampled residents. This failed practice placed the residents at risk for inadequate care planning and services to achieve their highest practicable and functional well-being. Findings: Resident #37 Record review from 12/8-12/24 revealed Resident #37 was admitted with diagnoses that included diabetes mellitus and multiple myeloma (bone marrow cancer). Review of Resident #37's MDS Quarterly review assessment, dated 11/16/24, revealed: Section O .K1.Hospice care .b. While a resident. was checked indicating the resident was on hospice. During an interview on 12/12/24 at 1:30 PM, Nurse Practitioner (NP) #1, Licensed Nurse (LN) #2 and LN#5, when asked if Resident #37 was currently on hospice services, stated Resident #37 was no longer on hospice services. Further record review included a hospice Discharge summary, dated [DATE], revealed, Patient will be transferred to Centennial PCP [Primary Care Physician]. Report given to [NP #1] at SNF [Skilled Nursing Facility]. During an interview on 12/12/24 at 1:35 PM, after reviewing the MDS quarterly assessment, dated 11/16/24, the MDS nurse stated the resident was not on hospice. Resident #97 Record review from 12/8-12/24, revealed Resident #97 was admitted with a diagnosis that included fracture of right femur. Review of Resident #97's admission MDS, dated [DATE], revealed: Section L - Oral .B. No Natural Teeth . During observation and interview with Resident #97 on 12/8/24 at 1:30 PM, it was revealed that the resident has all natural teeth. During an interview on 12/11/24 at 2:13 PM, the MDS nurse stated that she obtained the dental assessment for Resident #97 from a previously charted assessment in the resident's medical record. She also stated that after learning of the incorrect dental MDS assessment, she corrected the assessment during the survey. Review of the facility's policy titled Certifying Accuracy of the Resident Assessment, dated 11/2019 revealed, Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of the assessment .The information captured on the assessment reflects the status of the resident during the observation [look-back] period for that assessment. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, interview, and observation and the facility failed to implement care plans for two residents (#41 and #43) based on a sample of 22 residents. These failed practices placed residents at risk for not receiving the necessary and/or appropriate care and services for optimal outcomes. Findings: Resident #41 Record review on 12/8-12/24 revealed Resident #41 was admitted to the facility with a diagnosis that included end stage renal disease (a condition where the kidney reaches advanced state of loss of function. This causes changes in urination, fatigue, swelling of feet, high blood pressure, and loss of appetite). The resident also had a right arm AV (arteriovenous) fistula (a connection made between an artery and vein that is used for dialysis access). Record review of Resident #41's blood pressure readings between the dates of 12/13/23 - 12/17/24, revealed staff measured the blood pressure on the right arm 140 times. Review of Resident #41's care plan, revised on 4/24/23, revealed a nursing intervention, Do not draw blood or take B/P [blood pressure] in arm with graft right arm . During an interview on 12/11/24 at 11:00 AM, when asked how he/she would know where to take Resident #41's blood pressure, Certified Nurse Assistant (CNA) #5 stated .we can get information about the patient on the [NAME] [medical record system used by CNAs] . we can print it every shift and it will have the information from the care plan . During an interview with the Director of Nursing (DON) on 12/10/24 at 2:45 PM, when asked if CNAs were supposed to use Resident #41's right arm to obtain blood pressure readings, based on the care plan, he answered No. Hypertension (high blood pressure): Review of Resident #41's Care Plan dated 11/18/19, target date 11/28/24, revealed: Give anti-hypertensive medications as ordered. Review of Resident #41's medication order, with a start date of 3/17/24, revealed, Hydralazine [medication used to decrease blood pressure] . Give 1 tablet by mouth every 6 hours as needed for Elevated b/p [blood pressure] Give for SBP [systolic blood pressure]>[greater than] 150 or DBP [diastolic blood pressure] > 90 on NON-DIALYSIS DAYS ONLY. Review of Resident #41's blood pressure results, dated 3/17/24-12/10/24 revealed 116 missed opportunities for the administration of Hydralazine. Resident #43 Record review on 12/8-12/24 revealed Resident #43 was admitted to the facility with diagnosis of primary lateral sclerosis (motor neuron disorder), acute respiratory failure with hypoxia (severe oxygen shortage), moderate protein-calorie malnutrition (insufficient nutrition intake), dysphagia (swallowing difficulty), cellulitis (skin infection) of the left toe, retention of urine, neuromuscular dysfunction of the bladder (bladder control loss). During random observations on 12/8-12/24, revealed Resident #43 was bedbound and did not leave his/her bedroom area. Record review of the Interdisciplinary Functional Abilities Collaboration, dated 9/17/24, revealed resident is dependent in all aspect[s] of ADL's [Activities of Daily Living]. Record review of the care plan dated 11/4/24 revealed, .Interventions/tasks PT/OT [Physical Therapy/ Occupational therapy] evaluation and treatment as needed - date initiated 3/26/20 [no date available for last revision]; Resident needs to be up on his/her wheelchair during lunchtime, everyday - date initiated 12/30/21 - last revision on 8/21/24. During an interview on 12/11/24 at 1:30 PM, CNA #6 stated: once in a blue moon Resident #43 will be out on [his/her] chair but it's really only happening when [he/she] has an appointment and sometimes in the summertime because [he/she] likes to get vitamin D. Added that the nurse is usually who decides when [he/she] gets out of bed and that they only do so, when told [he/she] needs to go somewhere per nursing. During an interview on 12/11/24 at 1:40 PM, CNA #8 stated, I only got [him/her] up one time that I can remember, which was last week for [his/her] doctor appointment. When asked who decides to get Resident #43 out of bed, CNA #8 stated, I think it might be the Resident Care Manager (RCM), but I will find out some more because I really don't know. During an interview on 12/12/24 at 2:04 PM, Restorative Aide (RA) #2 stated [He/she] [Resident #43] doesn't get out of bed much, other than when [he/she] goes on appointments out of the facility. During an interview on 12/12/24 at 3:18 PM, RA #3 also stated he/she doesn't get out bed much . we [RAs] are the ones that work the upper body one day, lower body the next day . we also do ADLs like shaving, brushing teeth, dressing. CNAs should be the ones responsible for getting [him/her] in and out of bed and DON [Director of Nursing] is responsible for the CNAs. During an interview on 12/11/24 at 1:46 PM, LN #7 stated, [He/she] just got cleared by PT [Physical Therapy] to get in [his/her] chair recently because [he/she] has not been out of bed for months. During an interview with the Administrator on 12/11/24 at 2:30 PM, she noted that Resident #43 does not have any physical therapy documentation available and is not currently being seen or assessed by PT. During an interview on 12/11/24 at 1:40 PM, CNA #8 stated, The [NAME] does not reflect that the resident needs to be up on [his/her] wheelchair during lunchtime, every day. During an interview with the Director of Nursing (DON) on 12/10/24 at 3:30 PM revealed he was aware of the care plan described above, he stated, I have just read that but have no idea why this is not happening or why is it even on the care plan to begin with .I've been here since 2022 and I have always seen Resident #43 being bed bound . Resident #43 has no schedule for getting up, only for showers and appointments. The DON further confirmed that the [NAME] was used by the CNAs on Resident #43 does not accommodate the care plan intervention/task of Resident #43 being up on his/her wheelchair during lunchtime every day. When asked about who developed the care plan and is responsible for the [NAME] update he/she stated: we all do, us and the RCM's. Review of the facility policy and procedure titled Care Plan - Baseline Plan of Care/[NAME], last revised on 1/24/24, It is the policy of this facility that direct care givers have accurate information available to them to properly care for their residents. Further review of the same policy revealed . 2. Problem areas and interventions related to the resident's safety/fall risk, transfers, bed mobility, locomotion, toileting, dressing, skin care, grooming, hygiene, bathing preferences, nutrition, dining care, behavior management, cognition, communication, pain management, daily routine/activity preferences, special instructions, restorative nursing is provided on the [NAME] . 7. Staff are responsible to give care per the [NAME] interventions . staff are responsible to report this to the charge nurse for review or revision. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and interview the facility failed to revise care plans to reflect the current level of care and services for two residents (#1 and #18) based on a sample of 22 residents. This failed practice placed residents at risk for not receiving the necessary and/or appropriate care and services for optimal outcomes. Findings: Resident #1 Record review from 12/8-12/24 revealed Resident #1 was admitted with diagnoses that included Type 2 Diabetes Mellitus with Chronic Kidney Disease (non-insulin-dependent diabetes with kidney complications), and Urinary Tract Infection (infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra). An observation on 12/8/24 at 3:30 PM, revealed Resident #1 lying in bed with a foley catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag), with the bag secured to the left side of the bed. Record review of the care plan, last reviewed on 10/18/24, revealed no care planning for the foley catheter. During an interview with the Director of Nursing (DON) on 12/10/24 at 3:50 PM, when asked about Resident #1's catheter and cares, he was unaware that the resident had a foley catheter. The care plan was updated the following day. During an interview with Resident Case Manager (RCM) #1 on 12/11/24 at 2:45 PM, he/she stated that RCMs oversee and/or update care plans as needed when a resident's status changes. RCM #1 stated urinary catheters should have been included in the care plan and nurses are able to update care plans as well. During an Interview with Nurse Practitioner (NP) #1 on 12/12/24 at 11:22 AM, he/she stated that urinary catheters should be addressed under the care plan and discontinued as soon as possible. Review of the facility's policy, In-dwelling Urinary Catheter, last revised on 02/2019, revealed, .If an indwelling catheter is present, this will be documented . Comprehensive Care Plan . will be developed for indwelling urinary catheter .Care plan development addressing the catheter use may include: management of catheter, bag, and tubing changes, prevention of drag on the catheter tubing, maintenance of the catheter bag below the level of the resident's pelvis, routine catheter care, fluid intake, preserving resident dignity and monitoring for signs of complications . Resident #18 Record review on 12/8-12/24 revealed Resident #18 was admitted to the facility with diagnoses that included Parkinson's Disease (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination), diabetes, and congestive heart failure (a chronic condition that results when the heart muscle is unable to pump blood efficiently). Review of Resident #18's care plan, last revised on 12/2/23, revealed a focused problem of: At risk for constipation, ileus or impaction related to the use of morphine. Further review revealed this focus problem was started on 11/10/22. Review of Resident #18's current electronic Medication Administration Record (eMAR) revealed Resident #18 had no active order for Morphine. Review of Resident #18's physician orders on 12/12/24 at 2:00 PM, revealed Resident #18's last Morphine order was on 8/7/23 and was discontinued on 8/14/23 (110 days before Resident #18's care plan for morphine was last revised). During an interview on 12/12/24 at 2:25 PM, the DON stated Resident #18's care plan was inaccurate and should have been updated. Review of the facility's policy Care Plan - Baseline Plan of Care/[NAME], last revised 1/24/24, revealed: . The Resident Care Manager is responsible to review the [NAME] quarterly in conjunction with the quarterly MDS review. Revisions are made as needed . .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview, observation, and record review, the facility failed to communicate effectively with one resident (Resident #12) out of 22 sampled residents. This failed practice had the potential to negatively impact the resident's quality of life and overall activities of daily living (ADL's) due to communication barriers. Findings: Resident #12 was admitted to the facility on [DATE] for diagnoses that included intraspinal abscess (pus-filled infection in the spinal canal that can compress the spinal cord or nerves), osteoarthritis (degenerative joint disease), incomplete paraplegia (partial damage to the spinal cord causing impaired function of the lower half of the body while retaining some degree of movement or sensory perception), and dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking). During an interview on 12/9/24 at 8:30 AM, with Resident #12, using the facility's interpreting service, the resident stated he/she like to read the bible and only communicated through his/her family members when they visited. During an interview with Resident #12's representative (RR) on 12/10/24 at 1:00 PM, he/she stated Resident #12 can read Korean only and loves reading. The RR further stated Resident #12 would like to have papers and the activities calendar in Korean. The representative did not remember any instances where the interpretative services were used, and further stated it would be helpful. An observation on 12/9/24 at 8:30 AM, revealed Resident #12's room did not have communication cards or boards to help staff communicate with Resident #12. The activities calendar was also posted in the room in English. During the same observation, Resident #12 was unable to communicate with surveyors. During an interview on 12/8/24 at 9:16 AM, LN #13 stated he/she did not know how to access the interpretative service, if needed, he/she would use the translation application on his/her personal cell phone to communicate with Resident #12. LN #13 stated he/she would find out how to access the interpreting service. Shortly after the interview, the Administrator was observed handing out a document titled PROPIO to staff, which contained information on how to use the interpreting service. During a follow up interview on 12/8/24 at 11:00 AM, LN #13 stated he/she had never used the interpreter service to communicate with Resident #12. During an interview with the MDS Nurse (Minimum Data Set, a federally required nursing assessment) on 12/11/24 at 2:14 PM, she stated documentation written in the resident's language, was not provided. The MDS nurse further stated that if it was needed, she would get an interpreter or staff who spoke the language. If the MDS nurse needed to give the resident or the RR paperwork, she would reach out to the activities staff or to the social worker for assistance. During an interview on 12/10/24 at 10:30 AM, the admission Coordinator (AC) stated, We can have the paperwork be provided in a different language. We would contact Propio [interpreter service] and they would send us a translated copy to the requested language if we know what the language is ahead of time. The AC did not recall the last time these services were used. During a joint interview with Activity Coordinator (AC) and Activities Director (AD) on 12/11/24 at 11:30 AM, when asked if Resident #12 understood the activities calendar in his/her room, the AD stated, I'm not sure if Resident #12 understands it, but if [he/she] wants it in Korean we can make it work. Record review of Resident #12's care plan, last reviewed on 10/28/24, revealed Resident requests an interpreter Language: Korean. Review of the Resident's Rights, unknown date, revealed: Each resident and legal representative, as appropriate, has the right: 2. To be fully informed, orally and in writing in a language the resident understands as evidenced by the resident's written acknowledgment, prior to or at the time of admission and during stay, of these rights and of all rules and regulations governing resident conduct and responsibilities. Review of the facility policy and procedure titled Interpreter Services, last reviewed on 3/19, revealed: The facility will take reasonable steps to ensure that persons whose primary language is not English have meaningful access and an opportunity to participate in our services, activities, programs and other benefits . 2. If primary language of the resident's representative is not English, the facility will provide access to the same interpretive services to ensure comprehensive care coordination. 3. For any resident whose predominant language is not English we will consider the following protocols to enhance communication between the resident and staff: a. Identify a supportive family member(s) or representative who will be willing to translate resident care needs and issues either in person, via email, or over the phone (preferable using conference calling equipment). b. Identify staff member who are conversant in the same language (dialect) as the resident. c. Contract with a language bank organization who can facilitate translation of the resident's care needs and issues. d. Utilize Google Translate either on facility tablet or Workstation . .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, interview, and observation, the facility failed to provide an ongoing resident-centered activity program for one resident (#43) out of 22 sampled residents. This failed practice placed the resident at risk of boredom, loneliness, and decreased quality of life and enjoyment. Findings: Resident #43 Record review on 12/8-12/24 revealed Resident #43 was admitted to the facility with diagnosis of primary lateral sclerosis (motor neuron disorder), acute respiratory failure with hypoxia (severe oxygen shortage), moderate protein- calorie malnutrition (insufficient nutrition intake), dysphagia (swallowing difficulty), cellulitis (skin infection) of left toe, retention of urine, and neuromuscular dysfunction of bladder (bladder control loss). Record review of the quarterly MDS (Minimum Data Set - A Federally required nursing assessment) dated 9/13/24, revealed, in the communication section: makes self-understood: rarely/never understands .ability to understand others: rarely/never understands. During an interview on 12/08/24 at 1:03 PM, Resident #43's representative stated: Nothing is being done specific to [his/her] condition. The resident representative stated that a previous doctor indicated the resident would benefit from more social stimulation. The resident representative also stated that other family members who attended care planning meetings suggested this in recent meetings, but the family has not seen any improvement in the resident's activities. During an interview on 12/11/24 at 11:30 AM, the Activities Director (AD) stated there were no activity records available for Resident #43 during the months of October, November and December of 2024, as he/she had instructed staff not to document any interactions that were under 30 minutes. During a joint interview on 12/11/24 at 11:30 AM, the Activity Coordinator (AC) and the AD stated activities were being done by the Activities Assistant (AA) one-on-one in the residents' rooms. According to the AC, all other group activities happen outside of the resident rooms. During an observation and concurrent interview on 12/11/2024 at 3:48 PM, revealed the AA and AD walked in Resident #43's room to simulate what an activity would routinely look like. The AA stated that when he/she went into the room, he/she would ask Resident #43 how he/she was doing. The AA stated he/she can usually tell if the resident was interested in engaging or not depending on if he/she was making eye contact. The AA also stated that sometimes he/she would ask the Certified Nurse Assistants (CNAs) if the resident would be interested in a one-on-one ahead of time without going into the room. If the resident kept on staring at the television or grunted, that indicated that he/she was not interested in engaging with an activity and would conclude the one-on-one. Continuing the observation, the AA greeted Resident #43 who was bed bound, nonverbal, and was watching television. The resident did not make eye contact with anyone who entered the room. After a moment of silence, the AA said goodbye to Resident #43 and wished him/her a good day. At no point during this interaction was there an activity offered to the resident. After leaving the room, the AA stated the resident was not interested in activities based on the observation of the resident staring at the television and not making eye contact. The AA then charted, Check-In on the resident's electronic chart. During an interview with LN #7 on 12/11/24 at 1:35 PM, he/she stated: there are no activities being done one-on-one with [Resident #43], they [activity staff] just come around and drop off the daily chronicles with the nurses, but other than restorative [therapy], [he/she Resident #43] does not do any activities. LN #7 further stated the activity staff did not come by often and added he/she did not usually see the activities staff visiting Resident #43's room or the resident attending group activities. During an interview on 12/11/24 at 1:30 PM, when asked if Resident #43 received one-on-one activity sessions or visits from the activities staff, CNA #6 stated the resident was visited by restorative rehab staff but had not seen the activity staff with the resident. CNA #6 stated he/she worked yesterday and did not see the activities staff visiting Resident #43. CNA #7 did not recall any visits from the activities staff also. Both, CNA #6 and CNA #7, stated, Resident #43 only grunts or stares and was non-verbal. Both CNAs stated that it would be inappropriate for Resident #43 to attend group activities such as Bingo or being social, and eating treats, since he/she was on a tube feeding. During an interview on 12/12/24 at 2:04 PM, Restorative Aide (RA) #2 stated [He/she, Resident #43] doesn't get out of bed much, other than when [he/she] goes on appointments out of the facility. RA #2 further stated that he/she had never seen the resident participating in activities or had seen the activities staff in the resident's room providing one-on-one activities. During an interview on 12/12/24 at 3:18 PM, RA#3 stated he/she doesn't get out bed much and [he/she] does not participate in group or one-on-one activities. Review of the care plan dated 11/4/24, revealed: Focus: I enjoy being around others . I will confirm satisfaction with my activity participation by my re-evaluation date . preferred activities pet therapy, watching tv, newspaper cartoons, listening to country and rock music, family visits, being social, news and views, Minnesota sports teams and hockey . Staff will transport resident to activities [he/she] wishes to attend. Record review of the quarterly Activity assessment dated [DATE] revealed: Attendance and participation summary . resident is able to acknowledge [his/her] likes and dislikes regarding activities .favorite activities . pet therapy, watching tv, newspaper cartoons, listening to country and rock music, family visits, being social, news and views, Minnesota sports teams and hockey . goals were met. Record review of the quarterly Activity assessment dated [DATE] revealed: Resident is independent in [his/her] activity choices. [He/she] is able to acknowledge [his/her] likes and dislikes to activities staff . goals were not met but resident progress was achieved. During an interview on 12/11/24 at 11:30 AM, the AD was unsure on how this information was obtained, and since the resident was non-verbal, the AD assumed this information was extracted from the 3/3/20 admission paperwork that was provided by the family, since the resident was not independent. The AD further stated she started this position in September of this year, and these were done by a previous AD who no longer worked at the facility. Review of the facility policy and procedure titled Activity Programs revised on 6/18, revealed: . 3. the activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities . 5. our activity programs are designed to encourage maximum individual participation and are geared to the individual resident needs. 6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs . 10. activities participation for each resident is approved by the attending physician based on information in the resident's comprehensive assessment. Review of the facility policy and procedure titled Activity Programs - Staffing revised on 2/23, revealed: . 2. The activity director/coordinator's responsibilities include: a. completing or delegating the completion of the activities component of the comprehensive assessment; b. ensuring that the activity goals and approaches reflected in the resident's care plans are individualized to match the skills, abilities and interests/preferences of each resident; c. monitoring and evaluating the residents' responses to activities and revising the approaches as appropriate; and d. developing, implementing, supervising and evaluating the activity programs at least quarterly. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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. Based on record review and interview, the facility failed to: 1) complete a quarterly smoking assessment for one resident (#19) out of one resident who smoked marijuana. Specifically, the facility failed to complete quarterly or annual smoking safety evaluations for Resident #19 since 7/19/23; and 2) maintain accessibility to a crash cart, for immediate use during a life-saving emergency for one resident unit (Spruce Court), out of 6 units reviewed. These failed practices: 1) had the potential for the facility to be unaware of a change in status with regards to the resident's safety while smoking, placing the resident and others at risk of burns and/or fire; and 2) placed all residents of the Spruce Court, based on a census of 16, at risk of potential delay of life-saving measures during an emergency. Findings: Smoking Assessments Resident #19 Record Review on 12/8-12/24 revealed Resident #19 was admitted to the facility with diagnoses that included concussion (temporary brain injury) of unspecified duration and quadriplegia (complete paralysis of the body from the neck down). Further review of Resident #19's care plan, dated 10/18/24, revealed, The resident was a smoker. The resident will remain safe and follow facility smoking protocols. This was initiated 9/5/19 with a target date of 1/4/25. Further review of the record revealed a smoking safety evaluation, dated 7/19/23. This was the only smoking evaluation found in the record during review. During an interview on 12/9/24 at 9:32 AM, CNA #5 stated the resident goes outside and smoked independently. During an interview on 12/11/24 at 3:15 PM, Resident #19 stated he/she was independent smoking outside the facility safely. Resident #19 stated he/she preferred to smoke at night. During an interview on 12/12/24 at 10:10 AM, the Administrator stated the smoking evaluations were to be completed upon admission, when needed, and quarterly. The Administrator agreed that the smoking evaluation was overdue at this time. The facility's policy titled Medical and Recreational Marijuana Use, reviewed 9/2023 stated, It shall be the policy of this facility to follow federal marijuana laws, but we will recognize a person's right to smoke off premises as set forth by state law .Alaska-Legal for Medical and Recreational. The facility's policy titled Smoking Policy and Procedure Independent and Supervised, revised 9/2024 stated, It is the policy of Centennial Post Acute to provide a safe environment for residents, staff and visitors by limiting the use of smoking materials on its grounds. Residents who wish to smoke are evaluated for the ability to smoke safely . Residents who smoke are re-evaluated on a quarterly basis, or more frequently as dictated by any significant changes in the RAI process. This ongoing assessment is to verify that they remain capable of smoking and using smoking materials without presenting a danger to themselves or others. Crash Cart Accessibility An observation on 12/11/24 at 1:05 PM, of the Spruce Court common area, revealed the court's covered crash cart (which contained life-saving measure equipment) was sitting in an alcove between a wall (on the cart's left side) and a small wooden wall that was approximately 2 1/2 feet tall and 4 1/2 feet long (on the cart's right side). The court's Christmas tree was situated on the opposite side of the small wooden wall. Further observation revealed a string of Christmas lights was plugged into an outlet that was in the wall on the left side crash cart and ran across the length of the alcove to be strung on the Christmas tree. Further observation revealed an unoccupied wheelchair was parked in front of the crash cart as well. During an interview on 12/11/24 at 1:05 PM, the Director of Business Development stated the Christmas lights and wheelchair should not have been blocking access to the crash cart. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interviews, the facility failed to ensure the drug regimen for one resident (#25), out of 22 sampled residents, was free from unnecessary medication. Specifically, the facility failed to prevent duplicate drug therapy was prescribed. This failed practice placed the resident at risk for potential adverse effects from unnecessary medication administration. Findings: Record review on 12/8-12/24, revealed Resident #25 was originally admitted to the facility on [DATE] for rehabilitation services for diagnoses that include heart failure (inability of the heart to maintain adequate blood circulation), type II diabetes (non-insulin dependent diabetes), and Parkinson's disease (degenerative disorder characterized by tremor and impaired muscular coordination). Record review of Resident #25's Pharmacy Notes and Alert Notes, dated 11/17/2024 revealed the following: 1. Patient has two SGLT [Sodium-Glucose Cotransporter-2 Inhibitors] [a class of drugs that lower blood sugar levels by promoting excretion of excess glucose through the urine] medications on their profile Dapagliflozin 5 mg from 10/19 and a newer order for Empagliflozin 10 mg from 11/12, please discontinue one as this is a therapeutic duplication and not warranted after consulting provider. 2. Monthly Pharmacist Chart Review October 2024 . Patient has two SGLT medications on their profile Dapagliflozin 5 mg from 10/19 and a newer order for Empagliflozin10mg from 11/12, please discontinue one as this is a therapeutic duplication and not warranted. Review of Resident #25's physician orders on 12/8-12/24, revealed the following: 1. Dapagliflozin Propanediol Oral Tablet 5 MG . Give 5 mg by mouth one time a day for DM [Diabetes Mellitus], HF [Heart Failure]. -Start Date- 07/23/2024 . D/C [Discontinue] Date-12/11/2024 . 2. Empagliflozin Oral Tablet 10 MG . Give 10 mg by mouth in the morning for HF; DM. -Start Date-10/19/2024 . D/C Date-12/11/2024 . Further review of the medication administration record revealed that Resident #25 continued to receive both Dapagliflozin and Empagliflozin from 10/20/2024 until 12/11/2024. Further record review of Resident #25's nursing notes, dated 12/11/24 at 11:38 AM, revealed: Hospice provider revised medication regime. LN [Licensed Nurse] altered to d/c the following medications: Dapagliflozin .Empagliflozin . Record review of Resident #25's provider progress notes, dated 11/18/24 at 8:00 PM, revealed .No new pharmacy recommendations . During a phone interview on 12/12/24 at 9:00 AM, regarding the process of medication regimen reviews (MRR), with Pharmacist #1, he/she stated that MRRs were conducted monthly and a monthly chart note was entered in each resident's medical record. An email of all recommendations made is then sent to the 3 RNs [registered nurses], supervisor along with 2 individuals at [the Pharmacist #1 company]. For more urgent recommendations he/she would label the note as an Alert. When asked how long he/she expects recommendations to be followed up on, he/she stated about a week. When informed that the medications dapagliflozin and empagliflozin ordered for Resident #25 were not discontinued until 12/11/24 by hospice, he/she acknowledged that had those medications not been discontinued by hospice he/she would not have caught that until the next MMR. He/she further stated that the order not being addressed is longer than what he/she would expect. During an interview with the Director of Nursing (DON) on 12/12/24 at 10:15 AM, regarding the process of monthly MMRs, the DON stated he/she gets an email from the Pharmacist #1 of all recommendations, prints the recommendations off and then physically puts the recommendations in the provider's box located outside their office for them to review. The provider will then sign the recommendations indicating they were acknowledged. The DON was asked for paperwork of provider signoff on pharmacy recommendations for October 2024. Follow up interview with the DON, on 12/12/24 at 12:22 PM, the DON stated he was unable to find paperwork where the provider acknowledged pharmacy recommendations for October 2024. During an interview with NP #1 on 12/12/24 at 10:30 AM, regarding the process for monthly MMRs, the NP #1 confirmed that the DON prints off the monthly MMRs and puts the recommendations in the provider's box to review for he/she to sign off but stated typically I do not usually review those hard charts since they are in [the medical record] anyways. When asked about Resident #25's Dapagliflozin and Empagliflozin order, he/she stated he/she will follow up. Follow up interview with NP #1 on 12/12/24 at 11:22 AM, he/she stated that there was a break in the system and Resident 25's SGLT-2 Inhibitors did not get discontinued because it got missed. Record review of facility's policy Pharmacy Service Agreement Review, undated, revealed . On a monthly basis, during the previously scheduled visit to the Customer, a Consultant Pharmacist shall perform a medication regimen review (MRR) for each Resident on active Customer census on the visit date . Within 48 hours after conducting the MRR, the Pharmacy or Consultant Pharmacist shall provide the MRR report to Client's Administrator/Executive Director and Director of Nursing. When irregularities are noted, the MRR report documenting such irregularities will be provided to Client's Administrator/Executive Director and Director of Nursing. Electronic delivery of the report is an appropriate alternative to hard copy. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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. Based on record review, observation, and interview the facility failed to provide nutritious food substitutions to accommodate the preferences for one unsampled resident (#40) out of a census of 90 residents who received meals from the kitchen. This failed practice had the potential to decrease nutrition and cause unnecessary weight loss. Findings: Record review on 12/11/24 revealed Resident #40 was admitted to the facility with diagnoses that included acquired absence of other specified parts of digestive tract, vascular dementia (dementia resulting from impaired blood flow to the brain), with psychotic disturbance, adult failure to thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction and low cholesterol), and schizophrenia (mental disorder characterized by symptoms of hallucinations, delusions and cognitive challenges). During observations of the Cedar Court dining area on 12/11/24 from 11:35 AM to 12:30 PM, Resident #40 sat in a recliner chair in the dining area. Resident #40 stated, I am hungry. Certified Nursing Assistant (CNA) #3 told Resident #40, Food is coming. When Resident #40 yelled, I am hungry. CNA #4 replied, I know. Continuing with the observation, at 12:31 PM, CNA #4 brought Resident #40 his/her lunch. CNA #4 set the plate, dessert cup, drinking cup, and silverware on a bedside table by Resident #40. CNA #4 returned to passing meal trays to residents' rooms. During an observation on 12/11/24 at 12:35 PM, Resident #40 told CNA #4 he/she did not want the food provided. Resident #40 had thrown his/her lunch in the garbage can next to his/her recliner. During an interview on 12/11/24 at 12:54 PM, LN (Licensed Nurse) #10 stated Resident #40 would throw his/her food away. LN #10 stated Resident #40 would commonly say my sister peed in it and would not want the food given. LN #10 further stated Resident #40 would drink Ensure (nutitional supplement drink) and enjoyed culturally relevant foods. Resident #40 was not offered any alternative foods and did not receive additional food, or drink during the observation period. Record review during 12/8-12/24 of Resident #40's care plan revealed, . Refusing to eat . Provide and serve supplements as ordered: prefers Ensure . Encourage good nutrition and hydration . offer supplements/alternate with intake <50% . Record review of the facility's policy, Activities of Daily Living (ADL), Supporting, last revised 3/2018, revealed: . Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition (s) demonstrate that diminishing ADLs are avoidable . he or she has been offered alternative interventions to minimize further decline . Appropriate care and services will be provided for residents . d. dining (meals and snacks) . .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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. Based on record review and interview the facility failed to ensure medical records were accurately completed in accordance with accepted professional standards of practice for one resident (#43) out of 22 sampled residents. Specifically, the facility failed to ensure activities staff accurately documented groups, one-on-one (1:1) and self-directed/independent activities as indicated in Resident #43's chart. This failed practice had the potential to affect the achievement of the resident's plan of care. Findings: Resident #43 Record review on 12/8-12/24 revealed Resident #43 was admitted to the facility with diagnoses of primary lateral sclerosis (motor neuron disorder), acute respiratory failure with hypoxia (severe oxygen shortage), moderate protein-calorie malnutrition (insufficient nutrition intake), dysphagia (swallowing difficulty), cellulitis (skin infection) of the left toe, retention of urine, and neuromuscular dysfunction of the bladder (bladder control loss). Record review of the quarterly MDS (Minimum Data Set - A Federally required nursing assessment) dated 9/13/24, revealed under the communication section: . makes self-understood: rarely/never understands .ability to understand others: rarely/never understands. Record review of the care plan (CP) dated 11/4/24, Resident #43 . has a nutritional problem and eating is done NPO [Nothing by Mouth] - receiving exclusive tube feeding per RD/MD [Registered Dietitian/Medical Doctor] order. Record review of Nurse Practitioner (NP) progress note dated 7/22/24, Resident #43 . is non-verbal and unclear to this examiner [nurse practitioner] what is his/her ability to respond . Record review of the activities flowsheet, dated 9/2024, under group activities, revealed Resident #43 attended the following group activities: 9/3/24 So, A (Social, Active); .9/5/24 SD, A (Social Dining, Active); . 9/13/24 B, A (Bingo, Active); . 9/16/24 Ha, RR (Happy Hour, Resident Rights); .9/18/24 At, RR (Art Class, Resident Rights); . 9/28/24 So, A (Social, Active). Record review of the activities flowsheet dated 9/2024, under one-on-one visits/activities, revealed Resident #43 participated in the following one-on-one activities with the activities staff: 9/3/24 DC, A (Daily Chronicles, Active); 9/4/24 SO, A (Social, Active); 9/7/24 Ex, A (Exercise, Active); 9/11/24 So, A (Social, Active) .9/16/24 Cf, A (Coffee/treats, Active); 9/17/24 Cf, SO, A (Coffee/treats, Social, Active). Record review of the activities flowsheet dated 9/2024, under self-directed/independent activities: .9/4/24 SS, A (Socializing with staff, Active); 9/5/24 SS, A (Socializing with staff, Active) .; 9/7/24 SS, A (Socializing with staff, Active); 9/20/24 SE, A (Snacking/Eating, Active); 9/24/24 SS, A (Socializing with staff, Active); . During an interview on 12/11/24 at 11:30 AM, the Activities Director (AD) stated there were no activity records available for Resident #43 during the months of October, November and December of 2024, as she had instructed staff not to document any interactions that were under 30 minutes. During a joint interview with the AD and the Activities Assistant (AA) on 12/11/24 at 2:17 PM, the AA stated he/she typically delivered the one-on-one activities with the residents. The AA further stated, I typically go around and have a conversation with them, pass out the daily (news chronicles) and chart on the tablet I sometimes ask the CNA's [Certified Nursing Assistants] for help to know what they like. The AA continued to say he/she went around to all the units/courts in the mornings, but did not go into every room. The AA further stated, I just check to see if his/her [Resident #43] eyes are open, and I read him/her the chronicle and just do small talk .I did not see him/her today, since I was out of the facility shopping for other residents. Last time I saw him/her, I can't really remember, but it was a couple of days ago. Our interactions typically last about 10 to 15 minutes or less. When asked about the documentation process for activities in the medical chart, the AA stated, The previous activities director instructed me to chart on group activities for all residents even the ones that can't leave the room. Continuing with the joint interview, the AD and AA acknowledged that they both understood Resident #43 was non-verbal, was unable to get out of bed without assistance and would be unable to partake in activities where coffee, snacks or treats were to be eaten by mouth. When asked to highlight all the documented activities Resident #43 participated in, both the AD and AA acknowledged Resident #43 had not participated in the activities that were charted. During an interview with Licensed Nurse (LN) #7 on 12/11/24 at 1:35 PM, he/she stated: There are no activities being done one-on-one with Resident #43, they [activities staff] just come around and drop off the daily chronicles with the nurses, but other than restorative [therapy], he/she [Resident #43] does not do any activities. LN #7 further stated the activity staff did not come by often and added he/she did not usually see the activities staff visiting Resident #43's room or the resident attending group activities. During an interview on 12/11/24 at 1:30 PM, when asked if Resident #43 received one-on-one activity sessions or visits from the activities staff, CNA #6 stated the resident was visited by restorative rehab staff but had not seen the activity staff with the resident. CNA #6 stated he/she worked yesterday and did not see the activities staff visiting Resident #43. CNA #7 did not recall any visits from the activities staff also. Both, CNA #6 and CNA #7, stated, Resident #43 only grunts or stares and is non-verbal. Both CNA's stated that it would be inappropriate for Resident #43 to attend group activities such as Bingo or being social and eating treats, since he/she is on a tube feeding. Review of the facility policy and procedure titled Activity Programs revised on 6/2018, revealed: .3. the activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities .5. our activity programs are designed to encourage maximum individual participation and are geared to the individual resident needs. 6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs . 9. all activities are documented in the resident's medical record .10. activities participation for each resident is approved by the attending physician based on information in the resident's comprehensive assessment .12. Individualized and group activities are provided that: a. reflect the schedules, choices and rights of the residents; b. are offered at hours convenient to the residents, including evenings, holidays, and weekends; c. reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents; d. appeal to men and women, as well as those of various age groups residing in the facility; and e. incorporate family, visitor and resident ideas of desired appropriate activities. National Certification Council for Activity Professionals (NCCAP) (www.nccap.org - Copyright 2023) outlined . professional standards for documentation in its certification standards, focusing on person-centered care and activity engagement documentation requirements include recording activities, resident participation, outcomes, and adherence to care plans, ensuring activities contribute to quality of life and well-being. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

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. Based on observation, interview and record review, the facility failed to ensure one resident (#41), out of one resident reviewed for dialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood), received the services consistent with professional standards of practice. Specifically, the facility failed to ensure: 1) blood pressure measurements were taken on the appropriate extremity; 2) medications used to treat blood pressure were administered according to the medical provider's orders; and 3) documented assessments were completed before and after dialysis treatments. This failed practice placed the resident at risk for: 1) damage to the right AV (arteriovenous) fistula (connection made between an artery and vein that is used for dialysis access), 2) increased risk of blood clot formation, 3) worsening hypertensive chronic kidney disease (condition that occurs when chronic high blood pressure damages the kidney), 4) worsening ESRD (end stage renal disease) symptoms. Findings: Record review on 12/8-12/24, revealed Resident #41 was admitted to the facility with a diagnosis that included ESRD, and hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease. Right arm AV fistula : Review of Resident #41's care plan, revised on 4/24/23, revealed a nursing intervention, . Do not draw blood or take B/P [blood pressure] in arm with graft right arm . During an interview with the Director of Nursing (DON) on 12/10/24 at 2:45 PM, when asked if nursing aides were to be using Resident #41's right arm to obtain blood pressure readings, based on the care plan, he answered No. Record review on 12/12/24 of the facility's policy titled, Hemodialysis Care, last revised 11/2023, revealed, . No blood pressure readings in access arm . Review of Resident #41's blood pressure measurements revealed staff measuring the blood pressure on the right arm 140 times between the dates of 12/13/23 - 12/17/24. Review of Lippincott procedures, Hemodialysis, arteriovenous access, dated 8/14/24, accessed at: https://procedures.lww.com/lnp/view.do?pId=5967808&disciplineId=12427, revealed .not to allow anyone to use the access arm to measure blood pressure . During an interview with the DON on 12/10/24 at 2:45 PM, when asked if Certified Nurse Assistants (CNAs) were supposed to use Resident #41's right arm to obtain blood pressure readings, based on the care plan, he answered No. Hypertension (high blood pressure): Review of Resident #41's Care Plan last reviewed 11/1/24, revealed: Give anti-hypertensive medications as ordered. Review of Resident #41's medication order, with a start date of 3/17/24, revealed, Hydralazine [medication used to decrease blood pressure] . Give 1 tablet by mouth every 6 hours as needed for Elevated b/p Give for SBP [systolic blood pressure]>[greater than] 150 or DBP [diastolic blood pressure] > 90 on NON-DIALYSIS DAYS ONLY. Review of Resident #41's blood pressure results on non-dialysis days, dated 3/17/24-12/10/24 revealed 116 missed opportunities for the administration of Hydralazine. During an interview with the DON on 12/10/24 at 2:40 PM, when asked about the indications for giving hydralazine, he said . I would say if the blood pressure is greater than 150 or diastolic is greater than 90, we should give the medication . Review of Lippincott procedures, Safe medication administration practices, long term-care, dated 9/19/24, accessed at: https://procedures.lww.com/lnp/view.do?pId=5967599&hits=medications,medication,administration&a=false&ad=false&q=MEDICATION%20ADMINISTRATION, revealed . to promote a culture of safety and prevent medication errors . select the right medication, administer the right dose, administer the medication at the right time . Pre/Post Dialysis Assessments: Record review of the dialysis pre/post evaluation forms for Resident #41 revealed missing pre-dialysis evaluation forms for the following dates: 8/24/24 8/13/24 8/6/24 7/23/24 Missing post-dialysis evaluation forms were found for the following dates: 11/30/24 11/16/24 11/9/24 9/21/24 8/31/24 During an interview on 12/11/24 at 11:10 AM, Licensed Nurse (LN)#12 stated, . A pre and post dialysis assessment should be charted in the electronic chart, when they [residents] go [to dialysis] and when they come back . Record review of the facility's Hemodialysis Care policy, revised on 11/2023, revealed, Residents who require hemodialysis are provided ongoing assessment and monitoring of the resident's condition before and after dialysis treatments including monitoring for complications and interventions as part of nursing standard of practice. Review of Lippincott procedures, Hemodialysis, arteriovenous access, dated 8/18/24, access at: https://procedures.lww.com/lnp/view.do?pId=5967808&hits=evaluating,assessment,dialysis,evaluation&a=false&ad=false&q=dialysis%20assessments , revealed . Documentation associated with hemodialysis includes . predialysis assessment . ongoing assessment . response to treatment . .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure medication and/or medical supplies in two medication storage rooms (the main medication storage room and in [NAME] Court), out of five medication storage rooms, and two medication carts (located on the Birch Court and [NAME] Court), out of three medication carts, were unexpired. Specifically, the facility failed to discard expired medications and/or medical supplies. These failed practices placed all residents (based on census of 99) at risk for adverse effects or complications from receiving expired medications and/or medical supplies. Findings: Main Medication Storage Room An observation on 12/10/24 at 8:28 AM, of the facility's main medication storage room revealed the following medications and/or medical supplies on the open shelves were expired: - 4 - 100ml (milliliter) 0.9% Sodium Chloride Injection USP (US Pharmacopeia is a nonprofit organization that sets quality standards for medications to ensure quality and safety), expired on 8/2024; - 2 boxes- EvenCare G2 Glucose Control Solutions Net Contents: 5 mL, expiration dated 2024- 08-17; - 1- 1000ml 5% Dextrose Injection USP, expired on 8/2024; - 1- 1000ml 5% Dextrose Injection USP, expired on 10/2024. During an interview on 12/10/24 at 8:32 AM, the Director of Nursing (DON) stated that the medications and/or medical supplies were expired and should have been removed from the supply shelves. Willow Court Medication Room An observation on 12/10/24 at 9:13 AM, of the facility's [NAME] Court medication room, revealed the following medications and/or medical supplies were expired: -7- eSwab Collection & preservation of Aerobic, Anaerobic & Fastidious Bacteria (type of collection swabs for testing resident wounds for bacterial growth), expired on 5/22/24. During an interview on 12/10/24 at 9:14 AM, the DON stated that the medications and/or supplies were expired and should have been discarded. Birch Court Medication Cart An observation on 12/10/24 at 10:24 AM, concerning the facility's Birch Court medication cart, revealed the following medications and/or medical supplies were expired: -3 Single Dose Flexible Bags- Vancomycin (an antibiotic intravenous medication) Injection 1.25g[rams] per 250 mL(mililiter), expired on 11/24/24, pharmacy labeled for a resident; During an interview on 12/10/24 at 10:33 AM, LN #1 stated the expired medications should have been returned to the pharmacy. [NAME] Court Medication Cart An observation on 12/10/24 at 11:21 AM, of the facility's [NAME] Court medication cart, revealed the following medications and/or medical supplies were expired: -1 container- GeriCare Zinc 50mg (miligrams), expired on 11/24. During an interview on 12/10/24 at 11:22 AM, LN #6 stated the expired medication should have been returned to the pharmacy. Additional Interviews: During an interview on 12/10/24 at 8:35 AM, the DON stated the nurses were expected to monitor the medication carts to ensure that expired medications were discarded or returned to the pharmacy. During an interview on 12/12/24 at 9:12 AM, Pharmacist #1 confirmed that the facility should have returned the expired medications to the facility's pharmacy provider. Review of the facility's Medication Storage policy, dated 1/2023, revealed: . Outdated . medications . are immediately removed from stock, disposed of according to procedures for medication disposal . .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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. Based on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) food was stored under proper sanitation and food handling practices in the main kitchen; 2) the kitchen was kept in a clean, sanitary condition. These failed practices had the potential of causing or spreading foodborne illness to all residents, based on a census of 99. Findings: Main Kitchen An observation, during the initial main kitchen tour, on 12/8/24 at 8:20 AM, revealed: 1) Main Kitchen Freezer Unit: - 1 clear plastic bag of chicken nuggets - 3/4 full - not sealed, no label, no date. - 1 clear plastic bag of sausage patties in cardboard box - 3/4 full - not sealed, open to the elements. - Food tray with six small bowls of individual cake-like desserts, covered with clear plastic wrap - No labels, no dates. 2) Main Kitchen Refrigerator Unit: - Metal tray containing sliced fruit - loosely wrapped in clear plastic wrap, leaving some portions of fruit exposed to the elements no label, no date. - Metal square tray containing sliced tomato - loosely wrapped in clear plastic wrap, leaving some portions of tomato exposed to the elements - no label, no date. - Block of orange cheese slices, loosely wrapped in clear plastic wrap, leaving some portions of cheese exposed to the elements. - Unsealed plastic bag containing red grapes - half full - open to elements. - Metal square tray containing sliced black olives - covered with clear plastic wrap - no label, no date. - Metal square tray containing sliced onions - covered with clear plastic wrap - no label, no date. - Metal square tray containing sliced fruit - covered by clear plastic wrap - not sealed, no label, no date. - Metal square tray containing lettuce - covered with clear plastic wrap - no label, no date. - Metal square tray containing sliced pickles - covered with clear plastic wrap - no label, no date. - Food tray with 5 premade salads on plates covered with clear plastic wrap - No labels, no dates. - On the food tray with the premade salads were seven different individual-size cups with lids of salad dressings - No labels, no dates. - Metal square kitchen container containing eight whole tomatoes. There were black dented spots over 50% on four tomatoes. There were black dented spots over 20% on four different tomatoes. - Metal cylinder tray labeled vanilla pudding, covered by clear plastic wrap, unsealed. - Metal square tray containing two unsealed clear plastic bags of sliced meat. One bag contained what appeared to be sliced turkey. The other bag contained what appeared to be sliced ham resting in clear gelatinous substance. The ham had a use by date of 11/19/24. During an interview on 12/8/24 at 8:40 AM, when asked about a tray holding premade ham sandwiches, [NAME] #4 stated the sandwiches were made using the ham that was in the fridge. 3) Main Kitchen Large Bin Containers: - 22-quart container labeled rice dated 11/24 - Lid loose sitting askew on the tub, contents open to air. - 22-quart tub labeled sugar dated 7/24 - Plastic round scoop in the container with the sugar. 4) Dry Storage/Pantry area: - Box of fresh whole bananas stored in the pantry with dry goods - Box of fresh whole potatoes stored in the pantry with dry goods 5) Downstairs Walk-In Refrigerator: - 1 Large square plastic tub storing fresh green and purple whole cabbages and 1 large square plastic tub storing fresh green lettuce. Both tubs not covered and open to air, sitting on the bottom shelf of the refrigerator closest to the evaporator coil/fan system. This evaporator coil/fan system was visibly loaded with a large amount dust/dirt-like debris throughout the grill covering the fan blades. The air was blowing directly onto the cabbages and lettuce. 6) Downstairs Walk-In Freezer: - Ice build up was visibly built up on the piping of the evaporator coil/fan system inside the freezer. This build up was also coating the food packages sitting directly below the evaporator coil/fan system. - Food was stacked to the ceiling on the two shelves on either side nearest the freezer's door. During an interview on 12/8/24 at 8:38 AM, [NAME] #4 stated all food items in the unit refrigerator and freezer should be labeled and dated and the rice bin should have been closed. [NAME] #4 further stated all foods found open to the elements should have been closed or covered. [NAME] #4 stated the tomatoes should have been thrown away. 7) Pureed Station: An observation of the kitchen's pureed station, on 12/8/24 at 8:42 AM, revealed this station was in a corner of the kitchen with a 90-degree metal counter with two deep sinks that fit flush into the corner and against the walls, making an L shaped station. Standing in front of the 90-degree corner of the station, the counter with the two sinks was against the right wall of the corner station and the counter space was against the left wall of the corner station. An observation of the left wall counter space section of the pureed station, revealed: - The blender machine base, without the blender pitcher attached, was sitting on the counter visibly soiled with a white, dried, food substance coating the left side of the base. - The blender machine base was sitting on a white kitchen towel. This towel was visibly soiled with food particles and stained. - The counter was visibly soiled with dried food particles and white powder particles scattered on the counter. - On the wall directly in front of the counter were two magnetic strips with hooks secured to the wall approximately 2 feet long each. Seven clean knives were stuck to the magnetic strips by the blades of the knives. The wall was visibly soiled throughout the length of the counter with food particles of varying colors and sizes. The knives were exposed to these particles. - To the right of the blender was a handheld pitcher on a small cooking tray, about 1/8 full of white powder. The pitcher's contents were not covered exposing it to air. Further observation of the pureed station revealed a one shelf directly 2 feet above, and running the length of, the left counter. An observation of the shelf above the left counter, on 12/8/24 at 8:51 AM, revealed a medium size metal square container of several loaves of uncut bread. This container was covered with plastic wrap. There was no label or date on the container. An observation of the right wall counter, with the two large deep sinks, section of the pureed station, revealed: - On the left side of the sink was a large 22-quart square container of a white powdery substance. The container was not labeled or dated. This container was not covered and open to the elements. Further observation revealed this container was sitting approximately 19 1/2 inches from the sink. The counter area between the container and sink had visible pooling of standing water on the counter. Further observations of the pureed station revealed two shelves above, and running the length of, the right counter with the sinks. The first shelf on the right was approximately 1 foot above the counter, the second shelf was approximately 2 feet above the counter. An observation of the shelf above the right counter revealed: - 3 cans of Sysco Mandarin Oranges, 6.61 lbs. cans. 1 can was dented on the rim of the can. - 1 square metal container holding 5 whole onions. A small fly-like insect was observed to be sitting on one onion. When the container was moved the fly flew off into the air. During an interview on 12/8/24 at 9:02 AM, [NAME] #4 stated the pureed station was dirty. [NAME] #4 acknowledged the wall was soiled with food, the blender and the towel under the blender were dirty, the counter was wet, and the bread should have had a label and date. When asked what the white powder in the 22-quart container to the left of the sink was, [NAME] #4 stated the container held powder thickener used during the pureeing process, and it should have been covered with a lid. [NAME] #4 stated the container should have been stored in a dry area. When asked how the cooks determined the amount of thickener to use during the pureed process, as there was no guide chart or book visible in the area, [NAME] #4 stated they just know. Cook #4 further stated the 3 cans of mandarin oranges were to be served to residents during meals. When asked if the can with the dented rim would be served as well, [NAME] #4 stated it would be served to residents. 8) Main Kitchen Plating Area: - The food warmer by the ice machine was visibly soiled throughout the front outer surface area, especially the door of the warmer. The door handle was visibly soiled and sticky to the touch. - The overall condition of the kitchen floor was dirty. Debris build up was observed in every corner throughout the flooring, food particles were observed in all areas of the flooring. Pooled standing water was observed in the entrance to the cook station area. An observation on 12/10/24 at 11:18 AM, of the pureed station in the main kitchen, revealed: - The 22-quart container of powder thickener remained positioned to the left of the sink, still uncovered. The lid to the container sat on vertically stacked cutting boards to the left of the container. To the right of, and approximately 1 inch from the powder thickener container, was a red sanitation bucked of cleaning solution with a white washcloth in the solution. - The wall with the knives stuck to the magnetic strips was still soiled with food particles - The blender used to puree foods was sitting on the left counter. The blender machine base was visibly soiled with white, dry food particles over the left and face of the machine base. - A pitcher was seated on the blender machine base. This pitcher was dry and had a clean cover sitting within the pitcher. The pitcher appeared to have been washed, however there were dried food particles stuck to the inner surface of the pitcher. These food particles were at the inner top portion of the pitcher, to the left of the upper portion of the handle base of the pitcher. Food Tray Preparation An observation of hot food tray preparation was conducted on 12/11/24 at 4:00 PM. Previously prepared hot food trays were obtained from the hot holding cabinet and were used to replace depleted hot food trays in the steam table. It was noted that during this exchange, food temping (the process of measuring the internal temperature of food to ensure food safety and quality) had not occurred and this untemped food was plated for residents. During an interview on 12/11/24 at 4:26 PM, when asked how often food temperatures should be temperature checked, the Kitchen Manager stated, .after food comes out of the oven, and after food comes out of the warmer, before going to the steam table . Pureed Food Preparation: An observation of pureed food preparation, on 12/12/24 at 10:00 AM, revealed [NAME] #4 was observed pouring previously prepared fish broth into a blender. He/she then added other ingredients along with an unmeasured amount of food thickener. It was noted that during the process of preparing and placing the puree food mixture into bowls to be served to residents, no temperature checks occurred. During an interview with [NAME] #4 on 12/12/24 at 10:15 AM, when asked if the food should have been temperature checked, he/she stated, Yes. Review of the facility's policy Food Preparation and Service, revised 11/2022, revealed: .temperatures of foods held in steam tables are monitored throughout the meal service by food nutrition services staff . .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure electrical equipment was maintained in safe operating conditions. Specifically, the facility failed to ensure: 1) All patient care related electrical equipment (PCREE) had regular, routine preventative maintenance (PM) inspections to ensure they were in safe operating condition; 2) All non-patient care related electrical equipment (N-PCREE) was inspected to ensure it was safe for operation in resident care areas and used in a safe manner; and 3) Space heaters used in non-resident care areas were inspected by maintenance and used in a safe manner. These failed practices placed all residents, based on a census of 99, at risk for: 1) receiving inadequate treatment and/or care, from equipment not subjected to routine preventive maintenance monitoring, that could affect the resident's overall physical, mental, and psychosocial well-being; 2) electrical shock and/or exposure to electrical fire. Findings: PCREE An observation on 12/11/24 at 1:25 PM, in resident room [ROOM NUMBER], revealed the following PCREE: 1) one Drive DeVilbiss model 1025DS 10-liter oxygen concentrator (a machine that purifies natural air, into a higher concentration of oxygen, that a resident breaths through a mask or nasal cannula); 2) one Drive Power Nebultra nebulizer (a machine that turns medicine into a mist that a resident can breathe, which helps to opens airways for easier breathing); 3) one Direct Supply DS-ASP Attendant aspirator (or suction) machine; and 4) one Covidien Kangaroo E-pump Enteral Feeding and Flush pump (a machine used for feeding a resident, through a tube inserted into the stomach, when a resident cannot eat food). None of these PCREE had PM stickers. An observation on 12/11/24 at 1:52 PM, in resident room [ROOM NUMBER], revealed one Invacare [NAME] 2 V oxygen concentrator (different brand of machine that purifies natural air). Further observation revealed a PM sticker that indicated the next service was due on [September] 2020. An observation on 12/11/24 at 1:25 PM, in resident room [ROOM NUMBER], revealed the following PCREE: 1) one Covidien Kangaroo E-pump Enteral Feeding and Flush pump currently being used to feed the resident with no PM sticker; 2) one Drive Power Nebultra nebulizer with no PM sticker; and 3) one Direct Supply suction machine with a PM sticker that indicated the next service was due 6/[2020]. An observation on 12/11/24 at 2:36 PM, in resident room [ROOM NUMBER], revealed one Invacare [NAME] 2 V oxygen concentrator. Further observation revealed the concentrator had no PM sticker. An observation on 12/11/24 at 2:38 PM, in resident room [ROOM NUMBER], revealed one Invacare [NAME] 2 V oxygen concentrator. Further observation revealed the concentrator had no PM sticker. An observation on 12/11/24 at 3:34 PM, in resident room [ROOM NUMBER], revealed one Invacare [NAME] 2 V oxygen concentrator. Further observation revealed the concentrator had no PM sticker. An observation on 12/11/24 at 3:40 PM, in resident room [ROOM NUMBER], revealed one Covidien Kangaroo E-pump Enteral Feeding and Flush pump. Further observation revealed the pump had no PM sticker. An observation on 12/11/24 at 3:56 PM, revealed a portable GE Carescape V100 vital sign machine for Birch court had no PM sticker. An observation on 12/11/24 at 3:59 PM, in resident room [ROOM NUMBER], revealed one Invacare [NAME] 2 V oxygen concentrator. Further observation revealed the concentrator had no PM sticker. An observation on 12/11/24 at 4:01 PM, in resident room [ROOM NUMBER], revealed one Invacare [NAME] 2 V oxygen concentrator. Further observation revealed a PM sticker that indicated the next service was due on 6/2020. An observation on 12/11/24 at 4:04 PM, in resident room [ROOM NUMBER], revealed one Drive Power Nebultra nebulizer. Further observation revealed the nebulizer had no PM sticker. An observation on 12/11/24 at 4:11 PM, in resident room [ROOM NUMBER], revealed one Invacare [NAME] 2 V oxygen concentrator. Further observation revealed a PM sticker that indicated the next service was due on [March] 2019. An observation on 12/11/24 at 4:14 PM, in the alcove between resident rooms [ROOM NUMBERS], revealed one Invacare [NAME] 2 V oxygen concentrator. Further observation revealed the concentrator had no PM sticker. An observation on 12/11/24 at 4:30 PM, revealed a portable GE Carescape V100 vital sign machine for [NAME] court had a PM sticker that indicated the next service was due [September] 2020. An observation on 12/11/24 at 4:34 PM, in resident room [ROOM NUMBER], revealed one Drive Power Nebultra nebulizer. Further observation revealed the nebulizer had no PM sticker. An observation on 12/11/24 at 4:51 PM, in resident room [ROOM NUMBER], revealed one Invacare [NAME] 2 V oxygen concentrator. Further observation revealed the concentrator had no PM sticker. An observation on 12/11/24 at 4:52 PM, in resident room [ROOM NUMBER], revealed one Covidien Kangaroo E-pump Enteral Feeding and Flush pump. Further observation revealed the pump had no PM sticker. An observation on 12/11/24 at 4:59 PM, in resident room [ROOM NUMBER], revealed one Covidien Kangaroo E-pump Enteral Feeding and Flush pump. Further observation revealed the pump had no PM sticker. The Director of Business Development acknowledged the PCREE observed either had no PM stickers, or the PM stickers attached were outdated upon discoveries. Oxygen Concentrator Preventative Maintenance Guidelines Review of the facility-provided Category: Oxygen Concentrators In-House Maintenance guide, dated 2024, revealed: . At a minimum, preventative maintenance MUST be performed according to the maintenance record guidelines . Review of the Drive DeVilbiss service manual, dated 2020, revealed the 1025 series models should have preventative maintenance every 3 years. Review of the Invacare [NAME] 2 V service manual, dated 2014, revealed this model had an Invacare SensO2 oxygen sensor. Because of this feature, the maintenance record guidelines recommended that this oxygen concentrator have preventative maintenance every 26,280 hours or 3 years, whichever comes first. Nebulizer Preventative Maintenance Guidelines Review of the Drive Power Nebultra Instruction Guide, dated, revealed: . Nebulizer Cleaning . Filter Change. Filter should be changed every 6 months or sooner if filter discolors . Maintenance. All maintenance must be performed by a qualified Drive provider or authorized service center . Electric shock hazard. Do not remove compressor cabinet. All disassembly and maintenance must be done by a qualified Drive provider . Aspirator Maintenance Guidelines Review of the Direct Supply DS-ASP Attendant aspirator owner's manual, dated 2011, revealed: . Maintenance . Do not attempt to open or remove the suction cabinet. If a service is required then return your suction to an authorized service center . Bacteria Filter Change . Bacteria filter should be replaced as needed. If overflow occurs, change the filter immediately During an interview on 12/26/24 at 9:03 AM, a Direct Supply representative stated the DS-ASP Attendant aspirator's filter should be changed every 2 months. Tube Feeding Maintenance Guidelines Review of the Covidien Kangaroo E-pump Enteral Feeding and Flush pump operation Manual, dated 2012, revealed: . Performance Evaluation. System Performance Tests. A series of tests can be performed to verify pump performance. It is recommended that tests be run at least once every two years, or any time the pump is suspected of having improper performance . Preventative Maintenance. This pump must be periodically tested to assure proper functioning and safety. The recommended service interval is every 2 years . Vital Sign Machine Maintenance Guidelines Review of the GE Carescape V100 vital sign machine service manual, dated 2011, revealed: . Maintenance schedule. To ensure the monitor and its components remain in proper operational and functional order, the following maintenance schedule is recommended . Calibration procedures and tests: every 12 months, or whenever the accuracy of the reading is in doubt . Electrical safety tests: Upon receipt of the equipment, every 12 months thereafter, and each time the unit is serviced . During the course of this survey, the surveyor requested a facility list of all PCREE and the last Preventative Maintenance report of all PCREE. This was not provided from the facility. N-PCREE 1) Fans Random observations on 12/11-12/24 revealed there were a variety of non-industrial fans, of several different brands, throughout resident rooms and common areas of all six courts that were actively being used, plugged in and ready for use, or stored in resident rooms for future use. Some of the brands included: 1) Feature comforts; 2) Bionaire; 3) Air King; 4) Honeywell; 5) Polaraire; 6) [NAME]; and 7) Utilitech. Further observation revealed some fans used had no brand label. Further observation revealed there were a variety of sizes of fans from: 1) small desk-size fans; 2) box-style fans; 3) fans on short square bases; 4) fans on tall pole stands; and 5) larger diameter fans attached directly to the court walls in common areas. None of these fans had maintenance inspection stickers to indicate these fans were inspected for electrical and functional safety. During an interview on 12/11/24 at 1:38 PM, Resident #38's spouse stated the Maintenance Assistant had brought in a box fan into the resident's room just today. This box fan was actively turned on in the room during the interview. There was no maintenance sticker on the fan. The Director of Business Development acknowledged none of the fans had maintenance inspection stickers upon discoveries. 2) Food Processor An observation on 12/11/24 at 2:00 PM, revealed resident room [ROOM NUMBER], Bed A, had a small Hamilton Beach food processor on top of the resident's refrigerator. Further observation revealed no maintenance inspection sticker on the food processor. During an interview on 12/11/24 at 2:00 PM, Resident #85, who resided in room [ROOM NUMBER], Bed A, stated he/she used the food processor to grind personal foods for easier consumption. The Director of Business Development acknowledged the food processor had no maintenance inspection sticker upon discovery. 3) Air Purifier An observation on 12/11/24 at 1:45 PM, revealed resident room [ROOM NUMBER] had a Levoit air purifier in the room. Further observation revealed this air purifier had no maintenance inspection sticker. The Director of Business Development acknowledged the air purifier had no maintenance inspection sticker upon discovery. 4) Oil-filled Space Heaters An observation on 12/11/24 at 1:54 PM, revealed a [NAME] oil-filled space heater in resident room [ROOM NUMBER], Bed A. Further observation revealed no maintenance inspection sticker on the heater. An observation on 12/11/24 at 3:50 PM, revealed a [NAME] oil-filled space heater in resident room [ROOM NUMBER]. Further observation revealed no maintenance inspection sticker on the heater. An observation on 12/11/24 at 4:22 PM, revealed a Delonghi oil-filled space heater in resident room [ROOM NUMBER]. This space heater was situated closely between resident's personal belongings. A small cardboard box was touching the coils of the space heater. Further observation revealed no maintenance inspection sticker on the heater. The Director of Business Development acknowledged the space heaters had no maintenance inspection stickers upon discovery and resident room [ROOM NUMBER]'s space heater was situated too close to the resident's personal belongings. Review of a Delonghi space heater identical to the one observed on room [ROOM NUMBER] on the Diikon website at https://diikon.com/products/delonghi-radia-s-eco-digital-full-room-radiant-heater-15w-x-6d-x-25h-light-gray?sku=18067619570543220572323120&msclkid=6814f84064cf138ac5d99f2b4d18fc35 revealed this space heater did not have a tip over-shut off safety feature. Space Heaters in Non-Resident Care Areas Employee office on Cedar Court An observation on 12/11/24 at 2:00 PM, revealed a [NAME] space heater under the desk of the office near resident room [ROOM NUMBER]. No model number was located on the space heater. Further observation revealed no maintenance inspection sticker on the heater. The Director of Business Development acknowledged the heater had no maintenance inspection sticker. Review of a [NAME] space heater identical to the one observed on the on the [NAME] website at https://[NAME].com/collections/[NAME]-heaters/products/[NAME]-1500w-electric-oscillating-ceramic-tabletop-space-heater-with-adjustable-thermostat-5409-gray revealed this space heater did not have a tip over-shut off safety feature. Receptionist Desk on First Floor An observation on 12/11/24 at 2:49 PM, revealed a [NAME] oil-filled space heater under the receptionist desk on the first floor by the main entrance doors. This space heater was placed very close to electrical cords under the desk. Further observation revealed this space heater had no maintenance inspection sticker. The Director of Business Development acknowledged the heater had no maintenance inspection sticker and was too close to the electrical cords under the desk. Employee Office on [NAME] Court An observation on 12/11/24 at 4:27 PM, revealed a [NAME] space heater situated in front of and touching a cubby style shelving unit. The space heater's left side coils were physically touching a cloth covered cubby bin. The coils were hot to the touch. The Director of Business Development acknowledged the heater had no maintenance inspection sticker and was too close to the cubby style shelving and cubby bin. Review of the [NAME] oil-filled space heater user manual, dated 2016, at https://www.[NAME].com/ec/pdf/53TY90_1.pdf revealed: . This heater is hot when in use . Keep combustible materials, such as furniture, pillows, bedding, papers, clothes, and curtains at least 3 feet from the front of the heater and keep them away from the sides and rear . do not allow foreign objects to enter any ventilation or exhaust opening as this may cause an electric shock or fire . To prevent a possible fire, do not block air intakes or exhaust in any manner . Review of the facility's policy Electrical Safety for Residents, dated 2001, revealed: The resident will be protected from injury associated with the use of electrical devices, including electrocution, burns, and fire . Inspect . electrical devices as part of routine fire safety and maintenance inspections . Equipment such as space heaters used with administrative approval only . A policy on preventative maintenance of PCREE was requested during the course of this survey, the Director of Business Development directed this surveyor to the Electrical Safety of Residents policy. This policy had no documentation on preventative maintenance of PCREE, an expected interval of preventative maintenance, or how this would be accomplished. .

Oct 2023 21 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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. Based on record review, observation, and interview, the facility failed to ensure 2 residents (#36 and #81), out of 24 residents observed for dining, were treated in a dignified manner that respected individuality and their care needs. This failed practice placed the residents at risk of feelings of poor self-esteem and/or self-worth and a potential for poor quality of life. Findings: Resident #36 Record review on 10/8-12/23 and 10/16/23 of the Electronic Health Record (EHR), revealed Resident #36 was admitted to the facility with diagnoses that included hypertension (high blood pressure) and cerebrovascular accident (stroke). Review of the Quarterly Minimum Data Set (MDS- a federally required nursing assessment for long-term care residents) assessment, dated 9/14/23, revealed Resident #36 had a Brief Interview of Mental Status (BIMS-used to determine resident's cognitive status) of 00, which means severe cognitive impairment was present. An observation on 10/8/23 at 12:05 PM, revealed Resident #36 in his/her room, in bed, wearing a brief with fecal material that had leaked out of the brief's lining, and dried food around his/her mouth with crumbs all over the resident's shirt. Licensed Nurse (LN) #6 brought Resident #36's lunch tray to his/her room. The LN stated he/she would cover the Resident with a blanket because the Resident had a visitor and was going to eat. Without asking the resident if he/she would prefer to have the brief changed prior to the meal or have his/ her face cleaned, the LN proceeded to cover the Resident with a blanket and continued to set up the meal. The LN placed the plate with pureed food on the table in front of the resident, then poured tea into a nosey cup. The LN stated he/she would get something and would be right back. The LN went to the bathroom and returned with a wet washcloth. The LN wiped the resident's face and eyes while the Resident was drinking tea. The LN finished wiping the resident's face, then left the room so that the resident could finish eating. During an interview on 10/8/23 at 1:55 PM, Certified Nurse Assistant (CNA) #5 came out of Resident #36's room carrying a plastic bag containing a brief soiled with feces. The CNA stated he/she just finished changing Resident #36's shirt and brief because the resident had a lot of bowel movements. The CNA stated he/she was new to the job and that day he/she was working with another CNA to attend to 16 residents needs. The CNA stated they could not attend to residents needs right away. During an interview on 10/12/23 at 2:37 PM, when asked who would clean the resident if found unclean before meals. The Assistant Administrator (AA) stated the CNAs were responsible to provide personal care to the residents. She stated the staff worked as a team, so the nurse should have cleaned the resident. During an interview on 10/16/23 at 3:15 PM, the Director of Nursing (DON) stated the meal assistance was not part of the LNs competency. Review of the CNAs skills competency for meal assistance, dated 3/15/22, revealed: . provides hygiene for the resident prior to meal . Resident #81 Review on 10/8-12/23 and 10/16/23 of the EHR, revealed Resident #81 was admitted with diagnoses that included hemiplegia (a condition in which half of the body is paralyzed) and hemiparesis (partial paralysis of one side of the body), and cerebrovascular disease affecting the right dominant side. Review of a Care Conference Note, dated 9/29/23, revealed: [Resident #81] still struggles with communication due to . [his/her] stroke. This is very frustrating for [Resident #81] whom used to be a communication professor. An observation on 10/10/23 at 8:13 AM, revealed Resident #81 was seated at a table in the common room of the Birch Unit. CNA #8 served Resident #81's meal and placed silverware wrapped in a napkin on the right side of the plate. After the CNA walked away, the resident reached across his/her meal and attempted to unwrap the silverware with his/her left hand. The resident, who looked frustrated, gave up, picked up the bundle and placed it on the left side of his/her plate and successfully unwrapped the silverware. During an interview on 10/16/23 at 10:18 AM, CNA #9 stated they were trained to place silverware on the strongest functioning side of a resident during mealtimes. During an interview on 10/16/23 at 3:00 PM, the AA stated the facility had no policy for meal assistance. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, interview, and observation, the facility failed to ensure a comfortable and clean homelike environment. Specifically, the facility failed to: 1) keep personal clothing items safe from loss for 1 resident (#71); and 2) keep the bathroom environment clean and sanitary for 2 residents (#'s 71 and 90), for 1 out of 6 survey days. These failed practices had the potential to cause a diminished self -worth and a reduced sense of well-being. Findings: Missing clothing: Record review from 10/8-12/23 and 10/16/23 revealed Resident #71 was admitted to the facility with a diagnosis that included dementia. During an interview on 10/9/23 at 9:17 AM, when asked if he/she had any property go missing, Resident #71 stated some of his/her clothes went missing, and his/her family member was going to speak to the Director of Nursing (DON). During an interview on 10/9/23 at 12:39 PM, Resident #71's Family Member (FM) reported several clothing outfits went missing adding up to about $400. The FM stated he/she bought loungers for Resident #71 and 3-4 outfits went missing, or only half of the matching outfit was returned from the laundry. The FM stated he/she wanted Resident #71 to look good as the resident cared about his/her appearance prior to admission. The FM further stated he/she reported the missing items to the DON. During an observation on 10/12/23 at 2:04 PM, Resident #71 had multiple clothing items on hangers in his/her closet. A random spot check of several items revealed 3 shirts and 2 pairs of pants without a label. During an interview on 10/12/23 at 2:24 PM, Certified Nursing Assistant (CNA) #10 stated to prevent clothing from going missing, dirty clothes were placed in a bag labeled with the Resident's room number. The CNA further stated the clothing would have been labeled with the resident's last name and first initial upon admission. When asked if the facility had a protocol in place to label items that were received after the resident was admitted , CNA #10 stated there was no process for clothes brought in, only if the resident alerted him/her that the clothing items were new. During an interview on 10/16/23 at 2:58 PM, when asked the process to prevent clothing loss, the DON and Resident Care Manager (RCM) #1 stated the facility had an issue last year and began tagging the laundry bags with the resident's room number on top of the bag. RCM # 1 further stated on admission the resident's clothing would have been sent to laundry to be labeled, but sometimes family members brought in items and these items didn't get sent to laundry for labeling. Review of LAUNDRY SERVICES PROVIDED AT PRESTIGE, not dated, revealed: All laundry must be labeled, and Prestige care can assist with ensuring permanent labeling where it is not readily visible while the resident is wearing to promote their dignity. This is primarily done for tops inside the collar area, and for slacks and pants they are marked inside the waistband. Our goal is to avoid any mix-ups of your loved one's clothing during their stay. Resident bathroom: During an interview on 10/8/23 at 12:35 PM, Resident #90 stated his/her bathroom had been dirty for 2 days, since yesterday. The Resident stated his/her roommate (Resident #71) had diarrhea and the feces was left on the seat and in the bowl. Resident #90 further stated he/she alerted the CNA during meal rounds of the soiled bathroom, because he/she was unwilling to use it. During an observation immediately following Resident #90's interview, fecal matter was observed on the toilet bowl and seat. During a follow-up observation and interview on 10/9/23 at 9:21 AM, Resident #90's bathroom was clean, and remained clean during spot checks from 10/9-12/23. Resident #90 stated the facility cleaned the bathroom the evening of 10/8/23. During an interview on 10/12/23 at 9:12 AM, when asked if the facility received housekeeping complaints of dirty bathrooms from the residents, the Assistant Administrator (AA) stated she had not received any complaints. [NAME] asked about weekend housekeeping, the AA stated the Environmental Service (EVS) Leader reviewed the cleaning logs. The AA further stated direct care staff had access to cleaning supplies for resident rooms that needed cleaning at night when housekeeping was not available. The AA stated it was the facility's expectation that the CNAs would have addressed any issues in housekeeping's absence. During an interview on 10/12/23 at 2:43 PM, Housekeeper #1 stated Resident bathrooms were cleaned daily. When asked about housekeeping on Sundays, Housekeeper #1 stated the facility only had 1 housekeeper working on Sunday. Review on 10/12/23 at 2:51 PM, of the EVS schedule, revealed only 1 housekeeper was on the schedule on 10/8/23. Review on 10/16/23 at 8:00 AM, of an email correspondence with the AA, revealed the cleaning check lists for 10/7-8/23 had not been saved. The AA further wrote she spoke to the EVS Lead who will be reviewing and retaining the logs for 30 days moving forward. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to document, investigate, and resolve a grievance for 1 resident (#84), out of 21 sampled residents. This failed practice violated this resident's right to have a grievance investigated and addressed. Findings: Review on 10/8-12/23 and 10/16/23 revealed Resident #84 was admitted to the facility with diagnoses that included infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, and Peripheral Vascular Disease. During an interview on 10/10/23 at 4:00 PM, Resident #84 stated he/she had two grievances that had not been resolved with the Social Services representative: 1) there was a grievance that the billing department had contacted the Resident's Emergency Contact #2 and discussed his/her private financial matters during a recent hospitalization; and 2) there was a grievance that his/her prosthetics and a wheelchair needed to be ordered. Review of the facility's Grievance Manual, included compiled residents' complaints for 2023. Further review revealed no grievances were filed for Resident #84 from 5/1/23 - 10/10/23. Review of Resident #84's medical record revealed Resident #84 had a recent hospital stay on 9/6/23 - 9/21/23 and was readmitted to the facility on [DATE]. Further review of the medical record revealed two contact persons were listed: 1) Power of Attorney for health care, listed as Emergency Contact #1; and 2) Guarantor, Resident Representative, listed as Emergency Contact #2. During an interview on 10/11/23 at 9:25 AM, Social Worker (SW) #1 revealed that Resident #84 had a frustration (this was SW #1's definition of the Resident's concerns) that was discussed with him/her. However, the SW stated that concern was not documented as a grievance. SW #1 stated that this discussion with the resident occurred after the resident's recent hospitalization on 9/6/23 - 9/21/23. The SW stated the Resident wanted to be the guarantor and not have Emergency Contact #2 listed in that role. SW stated the billing department had reached out to Emergency Contact #2 as listed in the contacts in the EHR. During the same interview, SW #1 stated Resident #84 had also been frustrated with wheelchair issues and provider issues for future readiness for prostheses and a new wheelchair. SW #1 stated, I did talk to [Resident #84] about the emergency contact not being the guarantor. SW #1 stated he/she would discuss that event with Resident #84 again and ask Resident #84 if he/she wanted to submit a grievance. During an interview on 10/11/23 at 4:13 PM, when asked if he/she had been able to further discuss this grievance with SW #1, Resident #84 stated that there had been no meeting with social services at this time. During an interview on 10/12/23 at 9:00 AM, when asked if Resident #84's concern was a grievance or a frustration, the Administrator stated understanding that this was a grievance and needed to be investigated and resolved. A review of the facility policy Grievance, revised 3/2019, revealed: It is the facility's policy to support each resident's right to voice concerns/grievances. Concerns may be presented verbally or in writing and may include such items as treatment, care, lost personal items, management of funds, or violation of rights. The facility should actively seek resolution to concerns and attempt to keep the individual who filed the grievance updated on progress toward resolution . the Social Services Director/Designee or any staff member should assist concerned residents, resident representative, other family members, or advocate that have issues or concerns to complete a grievance/concern form. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and interview, the facility failed to ensure the MDS (Minimum Data Set- a federally required assessment for long term care residents) assessment accurately represented residents' status for 3 residents (#'s 38, 83 and 96), out of 21 sampled residents and 4 closed records. This failed practice created a risk for inadequate care planning and inaccurate goals to improve the resident's functional abilities. Findings: Resident #38 Record review on 10/8-12/23 and 10/16/23 revealed Resident #38 was admitted with a diagnosis that included incomplete paraplegia (partial paralysis of the lower half of the body including both legs, usually caused by damage to the spinal cord). Review of Resident #38's admission MDS, dated [DATE], revealed: Section P0100A .Restraints .A. Bed Rail .1 .Used Less than daily . During random observations from 10/8-12/23 and 10/16/23 of Resident #38, revealed no bedrails were utilized, and Resident #38 was in his/her wheelchair with full use of his/her upper extremities. During an interview on 10/16/23 at 3:38 PM, the Director of Nursing (DON) stated that Resident #38 was possibly coded for restraints because of a wheelchair seat belt, but the resident could release the belt himself/herself. The DON further stated that restraints for this resident was miscoded in the MDS. Resident #83 Record review on 10/8-12/23 and 10/16/23 revealed Resident #83 was admitted with diagnoses that included surgical amputation of the right and left fingers and toes. During an interview on 10/9/23 at 1:39 PM, Resident #83 stated he/she had Post Traumatic Stress Disorder (PTSD) related to a traumatic childhood event as well as from the Vietnam War. Resident #83 further stated that hearing conversations in foreign languages was a trigger and he/she had experienced this several times with staff conversing in the area outside of his/her room which made him/her uncomfortable. Record review on 10/8-12/23 and 10/16/23 revealed a Pre-admission and Resident Review (PASRR) Level I form, dated 5/18/23, with a diagnosis of PTSD listed as a primary diagnosis. PTSD was not a listed diagnosis on Resident #83's medical record. During an interview on 10/16/23 at 11:03 AM, Physician #1 stated any diagnosis listed on the admitting PASSR should have been listed as a diagnosis on the resident's medical record. During an interview on 10/16/23 at 12:16 PM, the Assistant Administrator stated diagnoses were put into the MDS and did not know why Resident #83's PTSD diagnosis did not show up on the resident's diagnosis list and will forward the information on to the DON. Resident #96 Record review on 10/8-12/23 and 10/16/23 revealed Resident #96 was admitted with a diagnosis that included a nondisplaced fracture of the right femur with routine healing. Record review from 10/8-12/23 and 10/16/23 revealed a document titled SNF [Skilled Nursing Facility] Discharge Summary/Plan of Care v2-18-V2, dated 7/14/23, which documented, Resident driven discharge to home on 7/14/23. Review of the discharge MDS, dated [DATE], revealed: Section A2100 Discharge Status .03.Acute hospital. During an interview on 10/10/23 at 12:23 PM, the DON stated Resident #96 was discharged to his/her home and that the MDS was miscoded.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed to address all risk factors to meet 1 resident's (#83) psychosocial needs, out of 21 sampled residents. This failed practice placed the resident at risk for not receiving the necessary and/or appropriate care and services. Findings: Record review from 10/8-12/23 and 10/16/23 revealed Resident #83 was admitted with diagnoses that included, surgical amputation of the right and left fingers and toes, diabetes, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), insomnia, and hyperlipidemia (high cholesterol). During an interview on 10/9/23 at 1:39 PM, Resident #83 stated he/she had Post Traumatic Stress Disorder (PTSD) related to a traumatic childhood event involving his/her parents as well as from the Vietnam War. Resident #83 further stated that hearing conversations in foreign languages was a trigger and had experienced this several times with staff conversing loudly outside of his/her room, which made him/her nervous and uncomfortable, and brought back terrible memories. Record review from 10/8-12/23 and 10/16/23 revealed PTSD was not listed as a diagnosis on Resident #83's medical record. Further review revealed a Pre-admission Screening and Resident Review (PASRR) Level I form, dated 5/18/23, that had PTSD listed as a primary diagnosis. Review of the Initial Care Management Meeting Follow-up note, dated 5/26/23, revealed no discussion or goals were identified regarding Resident # 83's PTSD. The care conference attendees were the Social Services Director (SSD), the Director of Therapy (DOT), the Resident Case Manager (RCM), Resident #83, the resident's nephew, and sister. Review of Resident #83's Minimum Data Set (MDS- a federally required nursing assessment for long term care residents) admission assessment, dated 5/29/23, and a quarterly assessment, dated 8/29/23, revealed no entries for Section I - Active Diagnoses . I5700 . Psychiatric/Mood Disorder . I61 . Post Traumatic Stress Disorder (PTSD). Review of Resident #83's Social Services Progress Note, dated 6/1/23 at 2:09 PM, revealed: SSD went to [Resident #83]'s room to socialize with [him/her] and to potentially do a suicide assessment with [him/her] as [he/she] has made comments to different staff of feeling depressed. When SSD said, I heard a rumor that you are feeling down in the dumps. [Resident #83] denied feeling this way currently but stated that [he/she] does have short term memory loss and has poor long- term memory . [he/she] is in a shared room and when they (staff) are changing or moving [his/her] roommate they (staff) are loud both with the transfers and with talking. They talk loudly like they are the only ones in the room. I don't feel respected when they are talking that loudly at night in my room. Review of Resident #83's Care Plan, initiated on 8/23/23, revealed: . Focused Behaviors . inability to sleep . yells at others/withdrawn . has suicidal thoughts ever since the Vietnam War . Interventions: 1. Ask the resident if they may know why they may not be able to sleep. 2. [He/she] bought a $30K motorcycle bike, ask [him/her] to show you a picture of [his/her] bike. 3. Encourage resident to attend activities of choice. 4. Allow resident time to express feeling as needed . Further review of the care plan revealed no identified trauma triggers. During an interview on 10/16/23 at 11:03 AM, Physician #1 stated that any diagnosis listed on the admitting PASSR should be listed as a diagnosis on resident medical records. As part of the admitting process, the nurses would have notified Physician #1 right away of the diagnosis. During an interview on 10/16/23 at 12:12 PM, the facility's Admissions Director (AD) stated copies of PASRR's would be placed in the resident's chart upon receipt of the form during admission to the long-term care facility. The AD stated she would not notify anyone about diagnoses listed on the paperwork. During an interview on 10/16/23 at 12:16 PM, the Assistant Administrator (AA) stated diagnoses were encoded into the MDS. The AA was not certain why Resident #83's PTSD diagnosis wasn't on the resident's diagnosis list. The AA stated she would forward the information on to the Director of Nursing (DON). During an interview on 10/16/23 at 4:17 PM, the SSD stated trauma informed care would have been assessed during the initial interview and then care planned. The SSD stated that he knows what trauma informed care was and had trained himself on it. He couldn't recall receiving trauma informed care training as part of his orientation or competency training for the facility. Review of the facility's policy Care Plan - [NAME]/Baseline Care Plan dated 2/2019, revealed: The admission nurse will complete the Initial Nursing Database. The nurse will collect information about the resident and their needs . Review of the facility's policy Care Conference-IDT [Interdisciplinary Team] Meeting, dated 3/2019, revealed: It is the policy of this facility to hold IDT meetings to validate completion of all components of the MDS process and review care plans prior to care conference. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to ensure the care plan was updated for 1 resident (#71), out of 21 sampled residents. Specifically, interventions to increase the resident's desire to attend activities he/she enjoyed were not included in the resident's care plan. This failed practice had the potential to place the resident at risk for not receiving necessary services to improve or maintain his/her quality of life. Findings: Record review from 10/8-12/23 and 10/16/23 revealed Resident #71 was admitted to the facility with diagnoses that included dementia and depression. During an interview on 10/9/23 at 12:35 PM, Resident #71's power of attorney (POA) stated the resident enjoyed musical activities. The POA further stated for the longest time, the facility did not assist the resident to the music activities. The POA stated with Resident #71's dementia, there were certain approaches that were helpful to increase the resident's desire to attend. The POA stated finally the Activity Coordinator was able to use the approaches to assist the resident to attend the music activities that he/she enjoyed. The POA further stated the resident had not attended nondenominational church services yet. During an interview on 10/12/23 at 2:59 PM, the Activities Director (AD) stated residents with dementia typically were not as active and it was helpful to have a tool to be used to assist the residents with dementia. When asked about Resident #71's activity tools, the AD stated she spoke with the resident's POA a lot, and Resident #71 thrived on music. The AD further stated the resident would have stated no when offered the musical activity, but then when she returned 5-10 minutes later, she would see Resident #71 singing in the court, and then she would have reapproached the resident to attend the activity. Review of Resident #71's current Care Plan, revised on 4/6/23, revealed: I know I have the right to direct my own recreation. The interventions listed included Activities I enjoy: sports, crafts, reading, listening to music (country, 70s, 80s), going outdoors, watching movies, and participating in group activities [revision date 5/31/23] .The staff will continue to evaluate the resident's desired activities as [he/she] is settling into facility . Further review revealed no mention of the tools used by the resident's POA or the AD to increase the resident's desire to attend the musical activities. Review of the facility's policy Care Plan- [NAME]/Baseline Care Plan, dated 2/2019, revealed: It is the policy of this facility that direct care givers will have accurate information available to them to properly care for their residents .The information will be updated as changes occur with the resident and reviewed no less then than quarterly. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and interview, the facility failed to ensure the necessary services to maintain good personal hygiene were provided to 2 residents (#'s 16 and 149), out of 21 sampled residents. Specifically, the residents had not been offered or given showers. This failed practice denied the residents from maintaining their highest practicable physical, mental, and psychosocial well-being. Findings: Resident #16: Record review from 10/8-12/23 and 10/16/23 revealed Resident #16 was admitted to the facility with diagnoses that included CVA (cerebrovascular accident-stroke) with hemiparesis (partial weakness or paralysis on one side of the body). Further review revealed the resident had a BIMS score of 13, which indicated the resident was cognitively intact. During an observation and interview on 10/9/23 at 11:48 AM, Resident #16 was observed with unkempt hair. Resident #16 stated few staff members knew how to help him/her with his/her hair, and the staff who usually assisted him/her was on vacation. The resident further stated he/she had not received a shower in 2 weeks. During a follow-up observation and interview on 10/11/23 at 3:45 PM, Resident #16 had unkempt hair. The resident stated he/she was scheduled for a shower that evening. Review of Documentation Survey Report v2, dated 10/11/23, revealed Resident #16's last documented shower was on 10/1/23. During an interview on 10/11/23 at 12:31 PM, the Director of Nursing (DON) confirmed Resident #16 had received 1 shower in October and no refusals had been documented. During a follow-up observation and interview on 10/12/23 at 2:19 PM, Resident #16 had unkempt hair. The resident stated he/she was not offered a shower or hair care yesterday, and he/she had wanted a shower. During a follow-up observation and interview on 10/16/23 at 12:00 PM, Resident #16 had unkempt hair and stated he/she had still not received his/her shower. During an interview on 10/16/23 at 12:13 PM, Certified Nursing Assistant (CNA) #7 stated Resident #16 had a tendency to refuse his/her showers, depending on which CNA would have worked with him/her on shower day. The CNA further stated the resident historically would have showered once a week and would have opted for a bed bath on the other shower day. CNA #7 stated a shower or bed bath would have been documented, however the facility's new system did not distinguish whether the resident received a shower or a bed bath now. CNA #7 further stated there was no documentation revealing if a resident had a hair wash. Resident #149: Record review from 10/8-12/23 and 10/16/23 revealed Resident #149 was admitted to the facility on [DATE] with a diagnosis that included aftercare following a joint replacement survey. Further review revealed the resident had a BIMS (brief interview for mental status) score of 15, which indicated the resident was cognitively intact. During an observation and interview on 10/9/23 at 9:44 AM, Resident #149 stated he/she had not received a shower since he/she was admitted to the facility (6 days ago). The resident stated he/she talked about a shower with one of the nurses or CNAs, and they said he/she would get a shower, but he/she hadn't received one yet. The resident was observed to have greasy hair. When asked the last time his/her hair was washed, the resident stated he/she was in the hospital and had not had a hair wash in several weeks. The resident was observed to have facial hair and stated he/she wanted to be shaved. During an interview on 10/11/23 at 9:24 AM, CNA #6 stated the resident's shower schedule was documented in the [NAME]. Prior to starting his/her shift, CNA #6 stated he/she would have looked at the [NAME] for resident updates and the shower schedule. CNA #6 further stated he/she would have documented if the residents refused their showers. Review of Resident #149's Visual/Bedside [NAME] Report, dated 10/11/23, revealed Resident #149's bathing preference was a shower on Saturday and Tuesday evenings. During a follow up interview on 10/11/23 (Wednesday) at 10:18 AM, Resident #149 stated he/she would like his/her hair washed and was looking forward to a shower and facial hair removal. During a concurrent record review and interview on 10/11/23 at 12:38 AM, the DON reviewed Resident #149's electronic health record and confirmed Resident #149 had not yet received a shower. During a follow-up interview on 10/16/23 at 12:46 PM, Resident #149 was observed sitting in his/her wheelchair in the common area. Resident #149 stated he/she was still waiting for a shower and hair wash. During an interview on 10/16/23 at 2:58 PM, when asked how the nurses tracked if a resident missed a shower, the DON and Resident Care Manager (RCM) #1 stated the showers were converted into a new document called Section GG, and the facility noted documentation issues within the new system. When asked if Section GG differentiated between a shower or a bed bath, the DON stated the documentation did not differentiate between the two. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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. Based on record review and interview, the facility failed to ensure needed care and services were provided to 1 resident (#53), out of 21 sampled residents. Specifically, the resident's dressing changes were not provided according to the physician's orders. The failure to provide ordered dressing changes placed the resident at risk for infection and decreased wound healing. Findings: Record review from 10/8-12/23 and 10/16/23 revealed Resident #53 was admitted to the facility with diagnoses that included Lymphedema (abnormal buildup of protein-rich fluid in any part of the body resulting from a malfunction in the lymphatic system) and chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease which causes obstructed airflow from the lungs). During an interview on 10/8/23 at 2:09 PM, Resident #53 stated he/she required dressing changes on his/her legs that were being done once a day, then every other day. The Resident stated every other day was okay, except the License Nurse (LN) had gotten too busy and pushed the dressing change off for 5 days. The Resident stated he/she was livid, and by the 5th day, the charge nurse came in and understood the facility made a mistake, and he/she was sent to Providence Hospital. The Resident further stated Providence was not happy and his/her dressing changes were increased to two times per day for 4 days. Review of Providence Alaska Medical Center admission HISTORY AND PHYSICAL, dated 7/26/23 at 1:24 AM, revealed At last visit on 7/14 is noted that [his/her] wounds are getting worse due to lack of regular dressing changes. [Resident] confirms that they have only been doing dressing changes every 4 days. Wounds have definitely been getting worse lately .ASSESSMENT AND PLAN .Acute on chronic lower extremity wounds .Not septic [bloodstream infection caused by bacteria], but worsening wounds. Has been getting less dressing changes then recommended by [Infectious Disease Physician] . Review of Resident #53's Order Review Report, dated 10/10/23, revealed an order written on 7/19/23 for the Resident's dressing changes to his/her legs to be changed every other day. The previous physician order was written on 7/17/23 for the dressing to be changed every other day. Prior to that, the dressing change orders written on 6/11/23 called for the dressing changes to be done every other day. Review of Resident #53's Progress Notes, dated 6/22/23 through 7/25/23, the date of the Resident's hospital admission, revealed the last dressing change documented with a completion note on 7/19/23 at 2:51 PM revealed: Was completed on 7/19/2023 to measure, will restart order with date to start tomorrow. An Orders- Administration Note, dated 7/24/23 and 7/22/23 revealed: Wound Tx[treatment] order . but did not include a note regarding status of wound or indicating the order was carried out. Further review on 7/17/23 at 6:49 PM of a note revealed: due dressing change tomorrow per resident. No leg wound dressing change notes were documented on 7/18/23. Further review revealed no documented leg wound dressing change notes from 7/15-16/23. On 7/14/23 at 5:48 PM, the dressing change note revealed: Resident was seen by wound care today and dressing was changed there. A Health Status Note, on 7/13/23 at 11:34 AM revealed: Note Text: Attempted X2 this am so far to do wound care. Resident is outside smoking at each attempt. Further review revealed no follow up wound care note on 7/13/23, nor any leg wound care notes from 7/10-12/23. Further review of the Health Status Note, dated 7/9/23 at 10:20 AM, which revealed: .Leg dressing remain intact at this time . with a Health Status Note, dated 7/8/23 at 4:26 PM, which revealed: [Bilateral lower extremity] dressings completed. A dressing change was also documented on 7/6/23 at 3:10 PM, which revealed: . next appointment with the wound clinic is scheduled for 7/14/2023 due to [him/her] still being on COVID precautions. No leg wound dressing changes were documented from 7/1-5/23. On 6/30/23 at 5:41 PM, Resident refused the leg wound dressing change. No documented leg wound dressing change on 6/29/23. On 6/28/23 at 11:33 AM, an Orders- Administration Note revealed: .dressing change done yesterday 6/27. Further review revealed no leg wound dressing change notes were documented on 6/27/23. Further review revealed no leg wound dressing change notes from 6/23-29/23. An Orders-Administration Note, dated 6/22/23, revealed the leg wounds were done by outpatient wound care clinic today. During an interview on 10/11/23 at 9:41 AM, LN #4 stated Resident #53's leg wound dressing changes were not easy and would have taken 45 minutes to 1 hour to complete. When asked if the dressing changes were able to be done per the Physician's order, the LN stated, we try our best. The LN further stated he/she received help from the wound care nurses on Mondays, and sometimes other days. LN #4 stated Resident #53's court was a busy one, and sometimes things happened that were very time consuming, so he/she would have tried his/her best to get the dressing changes done. During a document request on 10/11/23, the Assistant Administrator stated the facility did not have a wound care policy. During an interview on 10/11/23 at 12:55 PM, when asked if the facility investigated the root cause (RCA) of lack of dressing changes, the Director of Nursing (DON) stated an RCA was not performed because the facility was not aware. The DON further stated the reason for the resident's hospitalization was for a PICC (peripherally inserted central catheter) line for IV (intravenous) antibiotics. The DON confirmed the nurses' notes for wound care were omitted. Review of Resident #53's current care plan, initiated 7/8/21, revealed: The resident has actual impairment and at risk for further skin impairment [related to] lymphedema/trench foot to [bilateral lower extremity], and [history of] cellulitis [skin infection]/infection. An intervention included: follow MAR/TAR [medication administration record/treatment administration record] for current medical interventions. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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. Based on record review, interview, and observation, the facility failed to ensure necessary services were provided to prevent a pressure ulcer for 1 resident (#73), out of 21 sampled residents. Specifically, skin checks were not documented for the month prior to the resident developing a heel ulceration. This failed practice had the potential to delay necessary treatments to prevent further damage to the resident's skin. Findings: Record review from 10/8-12/23 and 10/16/23 revealed Resident #73 was admitted to the facility with diagnoses that included diabetes and diabetic neuropathy (nerve damage that occurs from diabetes, with symptoms that include numbness or pain in the legs, feet, or hands). Further review revealed the resident had a BIMS (brief interview for mental status) score of 13, which indicated the resident was cognitively intact. During an interview on 10/9/23 at 11:05 AM, when asked about his/her foot and heel ulcers, Resident #73 stated he/she was tall and his/her feet were touching the baseboard of the bed, which created the wounds. When asked what measures were put in place to prevent the heel ulcerations, Resident #73 stated the facility removed the footboard and the podiatrist at the VA (Veterans Administration) ordered foot boots. During an observation on 10/10/23 at 4:10 PM, Licensed Nurse (LN) #8 was performing wound care on Resident #73's feet. The resident was wearing foot boots, had a small (not measured), purplish closed ulceration on the right heel, and discoloration of the 4th and 5th toes. The left foot had open blisters of the 1st and 2nd toe and a reddened 4th toe. The heel of the left foot had a healed blister. The Director of Nursing (DON) who was assisting with the dressing changes stated the resident developed the heel blisters from the foot board. The facility extended the foot board, but the resident continued to press against it, so the facility ultimately removed the board. Review of Resident #73's Care Plan, revised on 5/8/23, revealed a focus on The resident has actual impairment to skin integrity of the abdomen [related to] surgery. At risk for additional skin impairment [due to] limited mobility and incontinence. Interventions for prevention were Encourage good nutrition and hydration .See EMR/TAR [Electronic Medical Record/Treatment Administration Record] for current medical interventions .Skin Care: Encourage resident to change position frequently .Lotion to skin as needed .Notify LN of any new skin issues . No interventions to protect the resident's heels were documented. Review of the Order Summary Report, dated 10/16/23, which included discontinued orders from the resident's admission date of 4/28/23, revealed no EMR/TAR interventions for the resident's heels. Review of Alert Note, dated 5/31/23 at 4:29 PM, revealed: Therapy called this LN at approx[imately] [1:30 PM] stating that she saw blood on res[ident's] sheets and she thinks it's from his R[ight] heel. R[ight] heel evaluated and noted DTI [deep tissue injury] and a pinpoint opening above DTI where scant amount of SS [serosanguineous] draining was coming from. Assessment done. DTI was approx[imately] 3.0 cm X 3.5 cm. Small wound approx[imately] 0.1 cm X 0.1 CM. Non adherent dressing applied and prevalon boot in place. Resident stated that [he/she] has neuropathy therefore [he/she] did not feel that [he/she] has an injury on [his/her] heel . Review of the Resident's revised Care Plan revealed an intervention to Float heels in bed, initiated on 6/5/23. Another revision, initiated 7/13/23, revealed .Uses Podus [brand of heel] Boots. During an interview on 10/12/23 at 3:30 PM, Certified Nursing Assistant (CNA) #14 stated to prevent skin breakdown, he/she would have applied lotion and massage, given a bed bath or looked at the resident's skin during brief changes. During an interview on 10/12/23 at 3:45 PM, when asked interventions to prevent skin breakdown, LN #8 stated staff repositioned the resident in bed. When asked about head-to-toe skin checks, LN #8 stated he/she would have assessed the skin during medication pass, and he/she assessed the resident's leg during pain ointment application to his/her knees. When asked about documentation, the LN stated he/she would have documented when a skin check was completed. Review of Weekly Skin Checks, dated 5/1-31/23, revealed skin checks were scheduled for Resident #73 every Friday. Further review revealed no skin check documentation was completed on the resident's electronic health record. During an interview on 10/12/23 at 4:20 PM, Resident Care Manager (RCM) #2 confirmed the skin checks were not documented for Resident #73 in May and stated the LNs would have written a narrative note to document the completion of the skin checks. Review of Resident #73's Nurse's Notes, dated 5/1-31/23, the day the right heel ulcer was discovered, revealed no documentation of weekly skin checks. Review of the facility's policy Skin at Risk/Skin Breakdown, dated 9/2020, revealed: A full body skin evaluation is completed weekly by the licensed nurse. Completion of the skin audit is documented. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected 1 resident

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. Based on record review and interview, the facility failed to include a Post Traumatic Stress Disorder (PTSD) diagnosis for 1 resident's (#83) medical record and develop a trauma-informed care plan, out of 21 sampled residents. This failed practice had the potential to exacerbate or trigger ongoing psychosocial difficulty and affect the resident's ability to attain the highest practicable mental and psychosocial well-being. Findings: Record review from 10/8-12/23 and 10/16/23 revealed Resident #83 was admitted with diagnoses that included, surgical amputation of the right and left fingers and toes, diabetes, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), insomnia, and hyperlipidemia (high cholesterol). During an interview on 10/09/23 at 1:39 PM, Resident #83 stated he/she had PTSD related to a traumatic childhood event involving his/her parents as well as from the Vietnam War. Resident #83 further stated that hearing conversations in foreign languages was a trigger and had experienced this several times with staff conversing loudly outside of his/her room, which made him/her nervous and uncomfortable, and brought back terrible memories. Record review from 10/8-12/23 and 10/16/23 revealed PTSD was not listed as a diagnosis on Resident #83's facility medical record. Further review revealed a Pre-admission Screening and Resident Review (PASRR) Level I form, dated 5/18/23, that had PTSD listed as a primary diagnosis. Record review of Resident #83's Minimum Data Set (MDS- a federally required nursing assessment for long term care residents) admission assessment, dated 5/29/23, and a quarterly assessment, dated 8/29/23, revealed no entries for Section I - Active Diagnoses . I5700 . Psychiatric/Mood Disorder . I61 . Post Traumatic Stress Disorder (PTSD). Record review of Resident #83's Social Services Progress Note, dated 6/1/23 at 2:09 PM, revealed: SSD [Social Services Director] went to [Resident #83]'s room to socialize with [him/her] and to potentially do a suicide assessment with [him/her] as [he/she] has made comments to different staff of feeling depressed. When SSD said, I heard a rumor that you are feeling down in the dumps. [Resident #83] denied feeling this way currently but stated that [he/she] does have short term memory loss and has poor long term memory . [he/she] is in a shared room and when they (staff) are changing or moving his roommate they (staff) are loud both with the transfers and with talking. They talk loudly like they are the only ones in the room. I don't feel respected when they are talking that loudly at night in my room. Review of Resident #83's Care Plan, initiated on 8/23/23, revealed: . Focused Behaviors . inability to sleep . yells at others/withdrawn . has suicidal thoughts ever since the Vietnam War . Interventions: 1. Ask the resident if they may know why they may not be able to sleep. 2. [He/she] bought a $30K motorcycle bike, ask [him/her] to show you a picture of [his/her] bike. 3. Encourage resident to attend activities of choice. 4. Allow resident time to express feeling as needed . Further review of the care plan revealed no identified trauma triggers. During an interview on 10/16/23 at 11:03 AM, Physician #1 stated that diagnoses listed on the admitting PASSR should be listed as a diagnosis on resident medical records. As part of the admitting process, the nurses would have notified Physician #1 right away of this diagnosis. During an interview on 10/16/23 at 12:12 PM, the facility's Admissions Director (AD) stated copies of PASRR's would be placed in the resident's chart upon receipt during admission to the long-term care facility. The AD stated she would not notify anyone about diagnoses listed on the paperwork. During an interview on 10/16/23 at 12:16 PM, the Assistant Administrator (AA) stated diagnoses were encoded into the MDS. The AA was not certain why Resident #83's PTSD diagnosis wasn't on the resident's diagnosis list. The AA stated she would forward the information on to the Director of Nursing (DON). During an interview on 10/16/23 at 4:17 PM, the Social Services Director (SSD) stated trauma informed care would have been assessed during the initial interview and then care planned. The SSD stated that he knows what trauma informed care was and had trained himself on it. He couldn't recall receiving trauma informed care training as part of his orientation or competency training for the facility. According to the Substance Abuse and Mental Health Services Administration (SAMHSA)'s Concept of Trauma and Guidance for a Trauma-Informed Approach, dated 7/2014, located at https://store.samhsa.gov/system/files/sma14-4884.pdf stated, A trauma-informed approach seeks to resist re-traumatization of clients as well as staff. Organizations often inadvertently create stressful or toxic environments that interfere with the recovery of clients .Staff who work within a trauma-informed environment are taught to recognize how organizational practices may trigger painful memories and re-traumatized clients with trauma histories. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

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. Based on record review and interview, the facility failed to ensure an annual performance review was completed for 1 Certified Nurse Assistant (CNA) (#1), out of 2 CNA files reviewed. This failed practice failed to monitor the CNA's performance or provide potentially needed feedback/education for any possible sub-optimal care rendered to residents (based on a census of 99). Findings: Personnel record review on 10/12/23 at 10:40 AM, revealed CNA #1 was hired on 4/23/20. Review of CNA #1's file revealed the last annual evaluation completed was 10/20/21. During an interview on 10/12/23 at 10:40 AM, Assistant Administrator (AA) stated that a new Staff Development (SD) employee was recently hired to update the staffing process and these types of concerns would be addressed. The AA further stated, We are running behind and recognized that was needed so [SD] was hired. It took us a while to hire the right person. Review of the Anchorage Team Member Handbook, undated, revealed: . The performance evaluation process is designed to provide a dialogue between the supervisor and the team member on job performance, competencies, and goals. Performance evaluations are conducted annually and can be performed as necessary any time during the team member's employment. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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. Based on record review, interview, and observation, the facility failed to ensure 2 residents (#3 and 81), out of 9 complaints/facility reported incidents investigated, were free from significant medication errors. Specifically, the residents received incorrect medications. This failed practice resulted in hospitalization for one resident and placed another resident at risk for adverse reactions. Findings: Resident #3 Record review on 10/8-12/23 and 10/16/23, revealed Resident #3 was admitted with a diagnosis that included type 2 diabetes mellitus. Review of the facility reported incident (FRI) Initial Report, dated 9/25/23, revealed Resident #3 was administered 35 units of Lispro (short acting insulin), instead of 35 units of Lantus (long-acting insulin) by Licensed Nurse (LN) #1. LN #1 recognized the medication error immediately and gave the resident 150 ml of orange juice and breakfast. Physician #1 was called immediately to the bedside, the following orders were given; hold all medications for the rest of the day, perform blood sugar checks every 15 minutes, and give PRN (as needed) glucose gel and D50 (a 50% dextrose [simple sugar] injection used to help restore blood glucose levels for those who have low blood sugar). The Director of Nursing (DON), and the resident's family were notified. Further review of the FRI report revealed Resident #3's blood sugar prior to the administration of insulin was 140. After the administration of the short acting insulin, the resident's blood sugar was 168. The resident's blood sugars remained in the 200's throughout the monitoring period (about 5 hours). The final blood sugar check was 251 at 1:00 PM. The resident remained stable throughout the day. Review of a post incident interview, dated 9/29/23, revealed LN #1 was in a hurry and accidentally grabbed the wrong medication, which was immediately reported to his/her supervisor. Review of the FRIs Final Report, dated 9/29/23, revealed the facility's corrective actions were for LN #1 to complete medication competency through Healthcare Academy, review the 5 rights of medication administration, and an English class was provided to improve communication and interpretation. Review of LN #1's personnel records on 10/8-12/23 and 10/16/23 revealed an offer for the LN to participate in the Nine Star Education and Employment Services of Anchorage English as a Second Language (ESL) educational program, it was noted that the LN accepted the offer. On 10/5/23, LN #1 participated in a medication administration skills laboratory covering resident rights, time management, and nonverbal cues. Review of the Medication Pass Observation form, dated 10/9/23, revealed an audit was performed with LN #1. The LN was noted to have met all medication administration competencies listed on the audit. During an interview with a family member on 10/9/23 at 1:12 PM, the family member confirmed that he/she was notified of the incident and stated, We all make mistakes. The family member was happy with the care the resident received during the incident. An observation of LN #1 on 10/16/23 at 4:27 PM, revealed LN #1 under the supervision of a nurse educator, administering medication. No errors were noted. A nurse educator was noted to be present throughout the survey period when LN #1 was working. Resident #81 Review on 10/8-12/23 and 10/16/23, revealed Resident #81 was admitted with diagnoses that included hemiplegia (a condition in which half of the body is paralyzed) and hemiparesis (partial paralysis of one side of the body), and cerebrovascular disease affecting the right dominant side, hypertension (high blood pressure), hyperlipidemia (high cholesterol), unspecified atrial fibrillation (a condition where the heart has an irregular rhythm). Review of the facility reported incident Initial Report, dated 9/25/23, revealed Resident #81 was administered the following wrong medications, by LN #10 which were intended for another resident: - 40 mg Protonix (used to treat acid reflux) - 300 mg Allopurinol (used to treat gout and certain types of kidney stones) - 10 mg Amlodipine (used to treat high blood pressure) - 81 mg Aspirin - 25 mg Coreg (used to treat high blood pressure and heart failure) - 20 mg Furosemide (used to reduce extra fluid in the body) - 0.4 mg Flomax (used to improve urine flow) - 320mg Valsartan (used to treat high blood pressure and heart failure) Resident #81 was supposed to receive: - 20 mg Megestrol (used to treat cancer) - 10mg Lisinopril (used to treat high blood pressure) - Vitamin B12 - 6.25mg Coreg (used to treat high blood pressure and heart failure) - 81mg Aspirin Further review of the initial report revealed the medication error occurred during the morning medication pass. LN #10 was working with a student nurse at that time. The LN #10 had placed the resident's medication in a medicine cup, went to the resident's room where the LN realized the resident was off the unit. The LN placed the resident's medicine cup in the top drawer of the medication cart and continued the morning medication pass. The student nurse was pulling medications with another LN while LN #10 was passing medications. The student nurse placed a cup of medications in the cart for another resident when the LN #10 returned. LN #10, realizing the resident had returned to the unit, picked up the wrong medication cup and proceeded to administer the medications to the resident. When the LN #10 returned to the medication cart, the student nurse asked where the cup for another resident was. The LN realized that he/she had administered the wrong medication to the resident. LN #10 took the appropriate steps to notify the physician, and staff provided the level of care as directed. During the vital sign monitoring, it was noted that the residents blood pressure dropped significantly, and staff had the resident transported to Providence Medical Center's Emergency Department (ED). The resident returned to the facility later that day stable and in good spirits. The facility's leadership notified the family of the incident. During an interview with a family member on 10/12/23 at 3:54 PM, the family member confirmed that he/she was notified of the incident and was satisfied that the resident was well cared for during this incident. Review of the FRI's Final Report, dated 6/16/23, LN #10 was no longer employed at the facility. The Director of Nursing Services or a designee was to complete audits of medications carts to ensure licensed nurses (LN's) were not pre-pouring medications. The LN's were to be re-educated on the 5 rights of medication pass, and medication pass observations/competencies were to be completed on all LN's including travel and pool nurses. Review of the PharMerica Quality Assurance Review form, dated 7/28/23, revealed a medication cart check indicating that medications were stored properly. No other medication cart audits were provided by the facility. Random observations of medication administrations on 10/8-12/23 and 10/16/23 revealed no significant medication errors or storing pre-poured medication in medication carts. Review of the All Staff Meeting Agenda, dated 9/2023, revealed: .Medication administration-no pre-pour, don't leave at bedside. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

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. Based on record review and interview, the facility failed to ensure meals were served according to the resident's therapeutic dietary order for 1 Resident (#298), out of 21 sampled residents. This failed practice had the potential to place the resident at risk for adverse medical complications. Findings: Record review on 10/8-12/23 and 10/16/23 revealed Resident #298 was admitted with diagnoses that included pleural effusion (fluid build up around the lungs), fractures of the left and right femurs, and fracture of the left tibia. During an interview on 10/9/23 at 3:02 PM, Resident #298 stated, There was no way my breakfast was low sodium. I should be on a low sodium diet. The resident further stated that he/she needed to watch his/her sodium intake to keep the swelling in his/her legs down and fluid around his/her lungs from accumulating. Review of Resident #298's Diet Order and Communication form, dated 10/6/23, revealed an active diet order: regular texture, heart healthy type, small portion, thin liquids per Diet Order and communication Form. Review of Resident #298's meal tray card, dated 10/9/23, revealed: Regular, GENERAL, Small Portion. During an interview on 10/12/23 at 10:01 AM, when asked how diet orders were communicated from the floor to nutrition services, the Dietitian stated because the electronic health record did not interact with her nutrition services program, the nurses would fill out the diet order for new and/or readmissions and give it to her. Next, she would enter the order into her system to print out the diet order card. The diet order card was then joined with the completed weekly menus and sent to the kitchen. On a monthly basis the Dietitian, the Director of Dietary Services (DDS) and medical records would meet to review diet orders. The Dietitian stated she did not see the heart healthy diet order for Resident #298 and would have the order updated. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected multiple residents

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. Based on interview, observation, and record review, the facility failed to involve residents with menu planning, including alternative menu choices, for 3 residents (#'s 52, 83, and 84), out of 21 sampled residents. These failed practices denied these residents, who received food from the facility's kitchen, the opportunity to make choices that would improve their appetite and food satisfaction. Findings: Resident #52 During an interview on 10/16/23 at 10:27 AM, Resident #52 stated he/she used to attend the Food Committee meetings regularly. The last meeting, he/she remembered attending was about a year ago. Resident #52 stated it had been a long time since the Food Committee meeting was on the activity calendar and did not think they held it anymore. Recently it was brought up in residents council that early trays (trays scheduled to be delivered at 4:30 PM) were sporadically delivered late for the past 3 weeks. Resident #52 stated occasionally supper was not served until around 6:00 PM, which made mealtimes run over to the night shift. This had caused issues since night shift was unfamiliar with what needed to be completed for mealtimes. Resident #83 An observation with concurrent interview on 10/9/23 at 1:46 PM, revealed Resident #83's lunch was brought into the room and placed on the bedside table. The meal consisted of green beans, chicken pot pie and french fries. Resident #83 stated he/she was not going to eat the meal because it was cold. When asked if other alternatives were ever requested, the resident stated, You mean chicken nuggets or grilled cheese? It's been the same for the last 3 months. Why would they give that [chicken nuggets and grilled cheese] for so long? If you don't like what they have on their menu you have to get your own food, plus the food is always cold, so what's the point of eating what they make. When asked if Resident #83 knew about Food Committee meetings, the resident stated he/she did not know what that was. Resident #84 During an interview on 10/10/23 at 3:45 PM, when asked about food preferences and food satisfaction, Resident #84 stated that cheeseburgers had been suggested as a meal option and meal alternative. Resident #84 stated, I would like a good cheeseburger. The cheeseburger suggestion is not happening anymore. The resident further stated that the portions sizes were inconsistent for the foods he/she enjoyed; frequently, the pie was served frozen; and ice cream choices were vanilla and chocolate, however, strawberry ice cream was never available. Review of the daily menu items for 10/8-14/23 revealed: CHICKEN NUGGESTS OR GRILLED CHEESE WITH FRIES OR TATER TOTS OR CHICKEN CAESAR SALAD as the alternative menu for lunch and dinner every day. During an interview on 10/16/23 at 1:34 PM, the Director of Dietary Services (DDS) stated that Food Committee meetings were held on the second Wednesday of each month. During these meetings residents could choose the main menu items as well as set the alternative menu items. The DDS stated the meetings were last held 2 months ago and historically they were poorly attended. The DDS further stated meeting notes were not kept or filed. When asked how the meeting was advertised, he stated it used to be included on the activity calendar and then announced on the loudspeaker before the meeting started. He also stated the meeting had not been included on the activity calendar because there was someone new creating the calendars. The DDS was unsure of how long it had been since the Food Committee meeting was advertised on the activity calendar. The DDS further stated that mealtimes were sometimes delayed due to staffing issues. He also stated the alternative menu changed every quarter (3 months). A new alternative menu was planned to start next week that included hotdogs and hamburgers. When asked if the alternative meals were changed often enough, the DDS stated he could see how residents would want more variety. Review of the activity calendars from July through October 2023 did not show a Food Committee meeting scheduled. During an interview on 10/16/23 at 3:00 PM, the Assistant Administrator (AA) stated the facility had no policy for food service or meal assistance. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

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. Based on record review and interview, the facility failed to ensure: 1) residents and/or their representatives received a written notice of transfer that contained the reason, place, and address of transfer for 1 resident (#19), out of 6 residents reviewed for hospitalization; and 2) ensure a copy of the residents' discharge notices were sent to the Office of the State Long Term Care (LTC) Ombudsman. This failed practice had the potential to affect all residents, based on a census of 99, by: 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State LTC Ombudsman was aware of facility practices and activities related to transfers and discharges. Findings: Resident #19 Record review from 10/8-12/23 and 10/16/23 revealed Resident #19 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease which causes obstructed airflow from the lungs). Further review revealed Resident #19 was transferred to the Emergency Department in July 2023. No documented transfer or discharge notice was in the resident's electronic health record. During an interview on 10/12/23 at 10:52 AM, the Director of Nursing (DON) stated there was no discharge notice for the resident's hospitalization on record. Ombudsman Notification During an interview on 10/10/23 at 4:45 PM, the Ombudsman for LTC stated he/she did not receive a copy of the discharge notices provided to the residents or resident representatives. During an interview on 10/11/23 at 12:56 PM, when asked if he was sending discharge notifications to the ombudsman, the Social Worker (SW) stated he only notified the ombudsman for a discharge that was AMA (against medical advice) or complicated resident discharges. The SW further stated he did not notify the ombudsman for a typical or uncomplicated facility-initiated discharge. Review of the facility's policy Notice of Transfer or Discharge, dated 4/2020, revealed: When the transfer or discharge is initiated, the resident and resident's representative(s) receive written notice using the Resident Notice of Transfer or Discharge .The center sends a copy of the notice to the State Long term Care Ombudsman . .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure medication and medical supplies in one medication storage room, out of 4 medication storage rooms, and one medication cart, out of 3 medication carts, were properly labeled and stored. Specifically, the facility failed to: 1) discard expired medication and medical supplies; and 2) ensure the medication refrigerator temperature was within proper temperature controls. These failed practices placed all residents (based on census of 99) at risk of: 1) receiving expired medication and/or supplies; and 2) experiencing potential adverse reactions from medications not stored at proper temperatures. Findings: Medication Storage Room Expired Medication and/or Supplies: An observation on 10/11/23 at 9:35 AM, of the facility's main Medication Storage room, revealed an emergency kit that contained 1 box of Naloxone Hydrochloride [an emergency medication to reverse the effects of an opioid overdose] INJ. USP 1 mg/ml with an expiration date of 8/2023. Further review revealed the following medical supplies on the open shelves were expired: - 10 packs - Insure One One-day fecal immunochemical test, expired on 5/18/23; - 5 - BD Insyte Autoguard 1.1x25mm 65 ml/1min, expired on 1/31/23 - 4 - COAC sense Prothrombin time (PT)/INR Test strip kit low control strip, expired on 7/2023 - 4 - COAC sense Prothrombin time (PT)/INR Test strip kit high control strip, expired on 7/2023 - 13 - Declogger enteral feeding tube declogger, expired on 7/6/22 During an interview on 10/11/23 at 9:35 AM, Licensed Nurse (LN) #7 stated the expired medicine and supplies should have been returned to the pharmacy. During an interview on 10/16/23 at 9:02 AM, the Pharmacist confirmed that the facility should have returned the expired medications to PharMerica (facility's pharmacy provider). Refrigerator temperature monitoring: An observation 10/11/23 at 9:35 AM of the medical storage room refrigerator, revealed the temperature reading was 52 degrees Fahrenheit (F). Review of the Daily Refrigerator Temperature Log, from January- October 2023, revealed: Temperature should range between 36-46 degrees F. Further review of the temperature logs revealed the following had incomplete temperature entries: - January 2023 no entries on 1/1/23, 1/6-8/23, 1/14-26/23, 1/20-22/23, 1/26-29/23; - February 2023 no log for this month; - March 2023 no entries on 3/4-6/23, 3/10-12/23, 3/15-19/23, 3/21-26/23, 3/29-31/23; - April 2023 no entries on 4/1-2/23, 4/9-11/23, 4/15-16/23, 4/18/23, 4/21-23/23, 4/25/23, 4/27/23, 4/29-30/23; - May 2023 no entries on 5/1-2/23, 5/4-9/23, 5/11-14/23, 5/18-21/23, 5/24-28/23, 5/31/23; - June 2023 no log for this month; - July 2023 no entries on 7/1-2/23, 7/6-9/23, 7/13-16/23, 7/20-23/23, 7/25-30/23; - August 2023 no entries on 8/1-13/23, 8/17-20/23, 8/24-27/23, 8/29-31/23; - September 2023 no entries on 9/1-3/23, 9/7-10/23, 9/14-17/23, 9/20-30/23; and - October 2023 no entries on 10/1-8/23, 10/11/23. Further observation revealed the Refrigerator Emergency Kit in the refrigerator contained the following medications: - 2 - Lorazepam (Ativan -a sedative) Injectable 2 mg/ml 1 ml Vial; - 2 - Lorazepam Solution Intensol 2 mg/ml 30 ml Vial; - 2 - Alteplase Cathflo (a medication used for blood clots in strokes, heart attacks, or pulmonary embolisms) 2mg Vial; - 1 - Insulin Lispro Humalog Kwikpen 100U/ml 3 ml Pen; - 1 - Insulin NPH Humulin N 100U/ml 3ml Vial; - 1 - Insulin regular Humulin R 100U/ml 3 ml Vial; - 1 - Insulin Detemir Levemir FlexPen 100U 3ml Pen; - 1 - Insulin Aspart Novolog FlexPen 100U/ml 3ml Pen; - 4 - Promethazine (Phenergan - a medication to help with nausea) 25mg Suppository; - 2 - Insulin Glargine-yfgn Semglee/Lantus 100U/ml 3ml Pen; and - 1 - Latanoprost (Xalatan- a glaucoma medication) 0.005% 2.5ml. During an interview on 10/11/23 at 9:35 AM, when asked about monitoring the refrigerator temperature, LN #7 stated the refrigerator temperature should have been checked daily. During an interview on 10/16/23 at 9:02 AM, the Pharmacist stated the refrigerator temperature should have been no more than 44-46 degrees F. He stated he was not familiar with the facility's temperature tracking system. During an interview on 10/16/23 at 3:18 PM, the Director of Nursing (DON) stated the nurses were expected to monitor and record the refrigerator temperature every shift. The DON also stated if the temperature was out of range, the nurses should have adjusted the temperature or reported to the maintenance department or DON. Review of the facility's Medication Storage policy, dated 1/2023, revealed: .Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration .Medications requiring 'refrigeration' or temperature between 2 c [degrees Celsius] (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring .A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits .Outdated .medications are immediately removed from stock . Review of the Food and Drug (FDA) CFR - Code of Federal Regulations Title 21, FOOD AND DRUGS, dated 6/7/23, located at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch, revealed: . Storage. All prescription drugs shall be stored at appropriate temperatures and under appropriate conditions . Medication Cart During an observation and interview on 10/11/23 at 2:42 PM, in the [NAME] unit, the medication cart contained two bottles of Nitroglycerine Lingual (a medication used to treat cardiac chest pain) spray 12 grams with an expiration date on 6/2023. LN #5 stated that those two bottles should have been thrown away. Review of the facility's Medication Storage policy, dated 1/2023, revealed: .Outdated .medications .are immediately removed from stock, disposed of according to procedures for medication disposal . .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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. Based on interview, observation, and record review the facility failed to ensure food served from the kitchen was palatable and at acceptable temperatures for service 7 residents (#'s 16, 52, 53, 62, 75, 83, and 86), out of 21 sampled residents. This failed practice placed all resident at risk of poor appetite and decreased nutritional intake and/or weight loss. Findings: Resident #16 During an interview on 10/9/23 at 12:11 PM, Resident #16 stated he/she did not like the food and ordered out a lot. The resident further stated when he/she received his/her meal, it was served cold. Resident #52 During an interview on 10/9/23 at 8:35 AM, Resident #52 stated when he/she ordered grilled cheese, the sandwich was only cooked on one side. The resident stated the other side was just bread. Resident #52 further stated he/she mentioned this to the Director of Dining Services, but the sandwiches were still being served that way. Resident #53 During an interview on 10/8/23 at 2:30 PM, Resident #53 stated his/her food arrived cold. The resident described how the soup had arrived cold with cracks on top of it. Resident #62 During an interview on 10/9/23 at 9:26 AM, Resident #62 stated all his/her food was served cold this morning, and often, he/she was served cold food. Resident #75 During an interview on 10/8/23 at 11:58 PM, when asked about his/her satisfaction with meals and snacks, Resident #75 revealed that the food was not fresh and natural, and the meat was often overcooked and tough. Resident #83 An observation with concurrent interview on 10/9/23 at 1:46 PM, revealed Resident #83's lunch was brought into the room and placed on the bedside table. The meal consisted of green beans, chicken pot pie and french fries. Resident #83 stated he/she was not going to eat the meal because it was cold. Resident #86 During an interview on 10/8/23 at 3:43 PM, when asked about his/her satisfaction with meals and snacks, Resident #86 stated the food was not always hot enough. Test tray Review of the menu for 10/11/23 at lunch revealed the residents were to receive, fettuccine Alfredo, with mashed mushrooms, asparagus spears, roll with butter, and a tiramisu pudding cup. During an observation on 10/11/23 at 12:32 PM, the test tray food was plated and placed on the [NAME] Unit meal cart by dietary staff. At 10/11/23 at 12:34 PM, the meal cart arrived on the [NAME] Unit, and at 12:55 PM, the Certified Nursing Assistants (CNAs) confirmed that the last residents were served their meal trays. Using a calibrated thermometer provided by the Director of Dietary Services (DDS), the following food was tested for temperature (T) and palatability and compared to the facility's temperature chart: - Pudding: 68.7 degrees Fahrenheit (F), facility temperature chart revealed dessert should be less than 41 degrees F - Juice: 46 degrees F, facility temperature chart revealed dessert should be less than 41 degrees F - Milk: 38.4 degrees F, facility temperature chart revealed milk should be less than 41 degrees F - Coffee: 130.6 degrees F, facility temperature chart revealed hot beverages should be less than 155 degrees F - Linguine with white sauce: 134.5 degrees F, facility temperature chart revealed hot entrees should be between 160-170 degrees F - Asparagus: 133 degrees F, facility temperature chart revealed vegetables should be between 160-170 degrees F - Garlic bread: 132 degrees F facility temperature chart revealed starch should be between 160-170 degrees F The surveyor tasted the food on the tray. The pasta was overcooked and not palatable, the white sauce did not have a flavor, the garlic bread tasted like plain bread, and the asparagus was tough and not palatable and had the appearance of green beans. Review of the 2022 Food Code U.S. Public Service FDA (Food and Drug Administration) accessed at https://www.fda.gov/media/164194/download?attachment, revealed .the FOOD shall have an initial temperature of 5ºC (41ºF) or less when removed from cold holding temperature control, or 57°C (135°F) or greater when removed from hot holding temperature control . During an interview on 10/11/23 at 9:51 AM, the Dietitian stated she received complaints about cold food occasionally. When this happened, the information was verbally forwarded to the Director of Dietary Services (DDS). She would also remind the resident that food could be reheated on the unit. There were no records provided of these complaints. During an interview on 10/16/23 at 1:34 PM, the DDS stated he received complaints about cold food occasionally from the floor, and that the kitchen would do their best to replace it. The kitchen used the Trayline Temperature chart, which was established by the facility's corporate headquarters, and used as a guide for meal service temperatures. The DDS stated he was unaware of Resident #83's food being consistently cold. The CNA's were supposed to check the meals against the meal tray ticket to ensure accuracy and serve food as soon as possible. He further stated meals should be served within 10 minutes after plating. When the DDS was advised it took 23 minutes for the test meal tray to be served from when it was plated, he stated that he did not have enough staff to watch when meals were served on the units and has had issues with meal service delays on the units in the past. When asked how the facility ensures that food was palatable, the DDS stated the cooks would have tasted the food right after it was cooked. When asked if he tasted the food made from the kitchen, he stated he would have tasted it when he was the cook. During an interview on 10/16/23 at 3:00 PM, the Assistant Administrator (AA) stated the facility had no policy for food service or meal assistance. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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. Based on observation and interview, the facility failed to store food and prepare meals under proper sanitary conditions for residents, (based on census of 96), who received food from the kitchen. This failed practice placed residents at risk for foodborne illnesses and communicable disease. Findings: Food Storage: An observation and concurrent interview on 10/8/23 at 10:46 AM, of the far-left main kitchen refrigerator revealed: 1 - 16 oz container of Sysco Imperial Lobster Base, opened, no date. 1 - 32 oz container of Grove Lemon Juice, opened, no date. The Director of Dietary Services (DDS) stated that these items should have been dated when opened. The DDS immediately threw away the container of lobster base. An observation on 10/8/23 at 10:57 AM, of the downstairs walk-in refrigerator, revealed a large bag of chicken thighs thawing in a steam tray pan above another large bag of chicken thighs thawing on a baking sheet. The bag of chicken thighs in the steam tray pan were noted to fill the steam tray pan entirely, with a small portion of the bag containing the chicken hanging slightly over the edge. On the lowest shelf directly below, the bag of chicken thighs on the baking sheet were noted to have pink fluid openly pooling onto a significant portion of the baking sheet. This baking sheet was sitting about 2 inches to the left of a full, open container of cabbage heads. The unwrapped cabbages filled the container above the top of the rim. During an interview on 10/16/23 at 1:34 PM, the DDS stated frozen meat was to be labeled, dated, and placed on the lower shelf of the refrigerator for 3 days to thaw prior to use. He further stated that thawing meat should not be stored next to an open container of produce. A food storage policy was not provided by the end of the survey. According to the FDA 2022 Food Code, available at https://www.fda.gov/media/164194/download?attachment, revealed, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded . Food Preparation: During an observation on 10/11/23 at 12:05 PM, of the lunch service, [NAME] #1 was plating pasta from the steam table with serving tongs, then used the tongs to point at a meal card, briefly touching the paper, then placed the tongs back into the pasta. Further observation revealed, [NAME] #2, with gloved hands, took the temperature, cut up, and then plated some chicken nuggets. Afterward, he/she picked up a marker and wrote on a clipboard. Next, the cook began preparing more chicken nuggets using the same gloves. [NAME] #1 told [NAME] #2 to wash his/her hands after touching the marker. [NAME] #2 walked over to the hand washing station and washed his/her gloves, dried them with paper towels, then came back to the line to continue to fry up chicken nuggets. [NAME] #1 then told [NAME] #2 to replace his/her gloves. [NAME] #2 then took off his/her gloves, washed his/her hands and put on new gloves. At the end of the lunch service, [NAME] #1 walked over to the wall and turned on the overhead fans using his/her gloved hands. Using the same gloves, [NAME] #1 handled plates from the plate warmer, handled food packages, then pushed his/her glasses up on his/her face with his/her finger. Using the same gloves, he/she picked up some tongs and began plating fettuccine alfredo onto the test tray. The rest of the test tray was assembled by [NAME] #1 using the same gloves. During an interview on 10/16/23 at 1:34 PM, the DDS stated kitchen staff/cooks were trained on hand hygiene and glove changes, proper food storage and handling upon hire and during in-service trainings. The DDS further stated the frequency of training for those topics was not determined, but he would have brought up the training as needed. During an interview on 10/16/23 at 3:00 PM, the Assistant Administrator (AA) stated the facility had no policy for food service. According to the FDA 2022 Food Code, available at https://www.fda.gov/media/164194/download?attachment, revealed: 1. Code of Federal Regulations, 2-301.14 When to Wash. (e) After handling soiled equipment or utensils; . (f) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks . .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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. Based on observation, record review, and interview, the facility failed to ensure infection prevention and control protocols were performed for 13 residents (#'s 12, 19, 30, 31, 45, 48, 59, 68, 75, 81, 85, 90, and 298), out of 99 (census) residents. This failed practice had the potential to increase the development and transmission of communicable disease and infections. Findings: Hand hygiene before dining During an observation of the meal service on 10/8/23 at 12:19 PM, Certified Nursing Assistant (CNA) #11 delivered a meal tray to Resident #'s 12, 48 and 90. Upon delivery to each room, the CNA did not offer hand hygiene, nor ask the residents if hand hygiene was performed prior to his/her entrance. At 12:30 PM, CNA #11 delivered a meal tray to Resident #19. Resident #19 was not offered hand hygiene, nor asked if hand hygiene had already been performed. The CNA placed the meal tray on the bedside table, put on gloves and emptied Resident #19's urinal. CNA #11 then removed his/her gloves and served the resident his/her meal tray without first performing hand hygiene. CNA #12 then delivered lunch to Resident #30. The CNA did not offer Resident #30 hand hygiene, nor asked if hand hygiene had already been performed. During an observation on 10/9/23 at 12:06 PM, lunch was served in the common room of the Birch Unit. CNAs #8 and #13 served meals to 5 residents (#s 45, 68, 75, 81, and 85). No residents were offered hand hygiene prior to their meal, nor were they asked if hand hygiene had already been performed. Hand hygiene during wound care Resident #31 Record review on 10/8-12/23 and 10/16/23 of the electronic health record (EHR), revealed Resident #31 was admitted to the facility with diagnoses that included spinal stenosis (abnormal narrowing of the spinal canal) and pressure ulcer of the sacral region. An observation on 10/12/23 at 11:05 AM, revealed LN #8 prepared for Resident #31's wound care. The LN sprayed the wounds on the buttocks with saline wound spray. Then LN wiped each wound with a gauze. While wearing the soiled gloves, the LN grabbed the supplies then applied cream and Therahoney gel to the wound with the use of cotton swab. While wearing the same soiled gloves, the LN packed both wounds with Calcium Alginate Rope (an absorbent dressing). Then, the LN removed his/her soiled gloves and put on new gloves. The LN did not perform hand hygiene between gloves changes. The LN sprinkled collagen powder to the wound, then placed bandages to both wounds. While wearing the same gloves, the LN gathered wound care supplies and put away in the cabinet. Then, the LN removed his/her gloves and performed hand hygiene. Resident #59 Record review on 10/8-12/23 and 10/16/23 of the electronic health record (EHR), revealed Resident #59 was admitted to the facility with diagnoses that included Guillain-barre syndrome (a rare disorder where immune system attacks the nervous system) and Type 2 diabetes mellitus. An observation on 10/8/23 at 11:15 AM, Resident #59 stated he/she had a skin tear under his/her right breast. The Resident asked LN #6 to show to the surveyor his/her skin tear. LN #6 put on gloves pushed the Resident's right breast up then cleansed the skin tear with wound cleanser two times. While wearing the soiled gloves, the LN unlocked the bed, pressed the button to adjust the head of the bed and then pushed the bed back against the wall. With the same soiled gloves, the LN placed a glass of iced tea on the Resident's table. Then, the LN removed the soiled gloves, and sanitized his/her hands. During an interview on 10/11/23 at 3:02 PM, the Infection Preventionist (IP) stated the staff were expected to perform hand hygiene before and after resident contact, after changing gloves, and when moving from a dirty to clean area. The IP further stated the LN should have removed gloves and performed hand hygiene after wound dressing change. Review of the facility's Hand Hygiene policy, dated 12/15/21, revealed: Effective hand hygiene reduces the incidence of healthcare-associated infections. All members of the healthcare team will comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines .situations that require hand hygiene . before and after changing dressing .after removing gloves . Review of the CDC Hand Hygiene in Health Care Settings guidelines, dated 1/30/20, accessed at this link: https://www.cdc.gov/handhygiene/providers/guideline.html, revealed: .Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications .before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal . Transmission Based Precautions An observation on 10/9/23 at 9:29 AM, revealed LN #9 prepared medication for Resident #298, who was on quarantine Transmission Based Precautions (TBP). A Quarantine Precautions sign was hung by Resident #298's doorway, requiring those who entered to clean hands when entering and leaving the room, and to also wear a respirator, eye protection, gloves, and a gown when providing direct patient care. LN #9 entered the resident's room without performing hand hygiene or putting on gloves, gown, or a respirator. The LN gave the resident his/her medications, moved several items around on his/her bedside table, handed the resident a drink, then exited the room where the LN performed hand hygiene. Review of the facility's Transmission Based Precautions policy and procedure, dated 3/2023, revealed: Contact, or touch is the most common and most significant mode of transmission of infectious agents .Indirect transmission of infectious agents can occur through contact with resident care equipment . .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected most or all residents

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. Based on interview and observation, the facility failed to ensure satisfying, palatable meal choices were offered and individual resident's food preferences were honored for 9 residents (#'s 16, 44, 52, 53, 62, 75, 83, 84, and 86), out of 21 sampled residents. These failed practices denied the residents, who received meals from the facility's nutrition services, of their preferences and choices and placed the residents at risk for minimal food intake which could result in weight loss and/or poor health outcomes. Findings: Resident #16 During an interview on 10/9/23 at 12:11 PM, Resident #16 stated he/she did not like the food and ordered out a lot. The resident further stated when he/she received his/her meal, it was served cold. Resident #44 During an interview on 10/8/23 at 11:40 AM, Resident #44 stated he/she liked hamburgers, and they were not available when he/she requested them. Resident #52 During an interview on 10/9/23 at 8:35 AM, Resident #52 stated when he/she ordered grilled cheese, the sandwich was only cooked on one side. The resident stated the other side was just bread, meaning the other side of the bread was not toasted. The resident stated that he/she made efforts to write specifically on the menu request to toast the bread on both sides. Resident #52 further stated he/she mentioned this to the Director of Dining Services (DDS), but the sandwiches were still being served that way. The resident stated that he/ she gave up requesting this. During an interview on 10/16/23 at 10:27 AM, Resident #52 stated he/she used to attend the Food Committee meetings regularly. The last meeting, he/she remembered attending was about a year ago. Resident #52 stated it had been a long time since the Food Committee meeting was on the activity calendar and did not think they held it anymore. Recently, it was brought up in residents council that early trays (trays scheduled to be delivered at 4:30 PM) were sporadically delivered late for the past 3 weeks. Resident #52 stated occasionally dinner was not served until around 6:00 PM, which made mealtimes run over to the night shift. This had caused issues since night shift was unfamiliar with what needs to be completed for mealtimes. Resident #53 During an interview on 10/8/23 at 2:30 PM, Resident #53 stated his/her food arrived cold. The resident described the soup had arrived cold with cracks on top of it. Resident #62 During an interview and observation on 10/9/23 at 9:26 AM, Resident #62 stated he/she ordered eggs over easy, but he/she received scrambled eggs for breakfast. The resident further pointed out he/she received oatmeal but didn't like oatmeal and had ordered cream of wheat instead. An observation of the meal slip on Resident #62's meal tray revealed Note- likes over easy eggs or sunny side up egg for breakfast. Further review revealed cream of wheat documented on the resident's meal slip. Observation of the meal tray revealed scrambled eggs and oatmeal were served. Resident #75 During an interview on 10/8/23 at 11:58 PM, when asked about his/her satisfaction with meals and snacks, Resident #75 revealed that the food was not fresh and natural, and the meat was often overcooked and tough. Resident #83 An observation with concurrent interview on 10/9/23 at 1:46 PM, revealed Resident #83's lunch was brought into the room and placed on the bedside table. The meal consisted of green beans, chicken pot pie and french fries. Resident #83 stated he/she was not going to eat the meal because it was cold. When asked if other alternatives were ever requested, the resident stated, You mean chicken nuggets or grilled cheese? It's been the same for the last 3 months. Why would they give that [chicken nuggets and grilled cheese] for so long? If you don't like what they have on their menu you have to get your own food, plus the food is always cold, so what's the point of eating what they make. When asked if he/she knew about Food Committee meetings, the resident stated he/she did not know what that was. Resident #84 During an interview on 10/10/23 at 3:45 PM, when asked about food preferences and food satisfaction, Resident #84 stated cheeseburgers were suggested as a meal alternative. Resident #84 stated, I would like a good cheeseburger. The cheeseburger suggestion was not happening anymore. The resident further stated that the portions sizes were inconsistent for the foods he/she enjoyed; frequently, the pie was served frozen; and ice cream choices were vanilla and chocolate, however, strawberry ice cream was never available. Resident #86 During an interview on 10/8/23 at 3:43 PM, when asked about his/her satisfaction with meals and snacks, Resident #86 stated the food was not always hot enough. Test Tray An observation on 10/11/23 at 12:32 PM, revealed the test meal tray was the last to be plated in the kitchen for delivery to the [NAME] Unit. It was placed on the meal cart at 12:33 PM. The meal cart arrived on the [NAME] Unit at 12:34 PM. All the resident meals were served prior to the test tray, which was served at 12:55 PM. The total time from preparation to serving the meal was 23 minutes. The test tray consisted of linguine with white sauce, asparagus, toasted garlic bread, pudding, milk, juice, and coffee. The surveyor tasted the food on the tray. The pasta was overcooked and not palatable, the white sauce did not have a flavor, the garlic bread tasted like plain bread, and the asparagus was tough and not palatable and had the appearance of green beans. The temperatures of the items, compared to the facility's Trayline Temperature chart, dated 1/2017, were: - Pudding: 68.7 degrees Fahrenheit (F), facility temperature chart stated dessert should be less than 41 degrees F - Milk: 38.4 degrees F, facility temperature chart stated milk should be less than 41 degrees F - Coffee: 130.6 degrees F, facility temperature chart stated hot beverages should be less than 155 degrees F - Linguine with white sauce: 137.5 degrees F, facility temperature chart stated hot entrees should be between 160-170 degrees F - Asparagus: 133 degrees F, facility temperature chart stated vegetables should be between 160-170 degrees F - Garlic bread: 132 degrees F facility temperature chart stated starch should be between 160-170 degrees F Review of the daily menu items for 10/8-14/23 revealed: CHICKEN NUGGESTS OR GRILLED CHEESE WITH FRIES OR TATER TOTS OR CHICKEN CAESAR SALAD as the alternative menu for lunch and dinner every day. During an interview on 10/11/23 at 9:51 AM, the Dietitian stated she received complaints about cold food occasionally. When this happened, the information was verbally forwarded to the Director of Dietary Services (DDS). She would also remind the resident that food could be reheated on the unit. There were no records provided of these complaints. The Dietitian stated the same questions were asked during the Food Committee meeting and individual quarterly assessments, so the Dietitian did not attend the Food Committee meetings. During an interview on 10/16/23 at 1:34 PM, the DDS stated he received complaints about cold food occasionally from the floor, and that the kitchen would do their best to replace it. The kitchen used the Trayline Temperature chart, which was established by the facility's corporate headquarters, and were used as a guide for meal service temperatures. The DDS stated he was unaware of Resident #83's food being consistently cold. The Certified Nurse Assistants (CNA's) were supposed to check the meals against the meal tray ticket to ensure accuracy and serve food as soon as possible. Meals should be served within 10 minutes after plating. When the DDS was advised it took 23 minutes for the test meal tray to served from when it was plated, he stated that he did not have enough staff to watch when meals were served on the units and has had issues with meal service delays on the units in the past. The DDS further stated the Food Committee meetings were held on the second Wednesday of each month. During these meetings residents could choose the main menu items as well as set the alternative menu items. The DDS stated the meetings were last held 2 months ago and, historically, they were poorly attended. The DDS further stated meeting notes were not kept or filed. When asked how the meeting was advertised, he stated it used to be included on the activity calendar and then announced on the loudspeaker before the meeting started. He also stated the meeting had not been included on the activity calendar because there was someone new creating the calendars. The DDS was unsure of how long it had been since the Food Committee meeting was advertised on the activity calendar. The DDS further stated that the alternative menu changed every quarter (3 months). A new alternative menu was planned to start next week that included hotdogs and hamburgers. When asked if the alternative meals were changed often enough, the DDS stated he could see how residents would want more variety. Review of the activity calendars from July through October 2023, revealed no scheduled Food Committee meetings. During an interview on 10/16/23 at 3:00 PM, the Assistant Administrator (AA) stated the facility had no policy for food service or meal assistance. .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected most or all residents

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. Based on interview and observation, the facility failed to make reasonable efforts to develop a menu based on resident requests and resident groups. The failure to obtain input had the potential to place 9 residents (#'s 16, 44, 52, 53, 62, 75, 83, 84, and 86), out of a sample of 21, at risk for loss of appetite, lower meal consumption, and a potential for decreased nutritional intake and/or weight loss. Findings: Resident #16 During an interview on 10/9/23 at 12:11 PM, Resident #16 stated he/she did not like the food and ordered out a lot. The resident further stated when he/she received his/her meal, it was served cold. Resident #44 During an interview on 10/8/23 at 11:40 AM, Resident #44 stated he/she liked hamburgers, and they were not available when he/she requested them. Resident #52 During an interview on 10/9/23 at 8:35 AM, Resident #52 stated when he/she ordered grilled cheese, the sandwich was only cooked on one side. The resident stated the other side was just bread, meaning the other side of the bread was not toasted. The resident stated that he/she made efforts to write specifically on the menu request to toast the bread on both sides. Resident #52 further stated he/she mentioned this to the Director of Dining Services (DDS), but the sandwiches were still being served that way. The resident stated he/she gave up requesting this. During an interview on 10/16/23 at 10:27 AM, Resident #52 stated he/she used to attend the Food Committee meetings regularly. The last meeting, he/she remembered attending was about a year ago. Resident #52 stated it had been a long time since the Food Committee meeting was on the activity calendar and did not think they held it anymore. Recently, it was brought up in residents council that early trays (trays scheduled to be delivered at 4:30 PM) were sporadically delivered late for the past 3 weeks. Resident #52 stated occasionally dinner was not served until around 6:00 PM, which made mealtimes run over to the night shift. This had caused issues since night shift was unfamiliar with what needed to be completed for mealtimes. Resident #52 further stated that food issues have been brought up in Residents Council but was unsure how those issues were dealt with. The resident stated that Residents Council had asked for cheeseburgers and hot dogs to be on the menu about 2 months ago and the facility responded that it would be available in Fall with no specific timeframe. Resident #62 During an interview and observation on 10/9/23 at 9:26 AM, Resident #62 stated he/she ordered eggs over easy, but he/she received scrambled eggs for breakfast. The resident further pointed out he/she received oatmeal but didn't like oatmeal and had ordered cream of wheat instead. An observation of the meal slip on Resident #62's meal tray revealed Note- likes over easy eggs or sunny side up egg for breakfast. Further review revealed cream of wheat documented on the resident's meal slip. Observation of the meal tray revealed scrambled eggs and oatmeal were served. Resident #75 During an interview on 10/8/23 at 11:58 PM, when asked about his/her satisfaction with meals and snacks, Resident #75 revealed that the food was not fresh and natural, and the meat was often overcooked and tough. Resident #83 An observation with concurrent interview on 10/9/23 at 1:46 PM, revealed Resident #83's lunch was brought into the room and placed on the bedside table. The meal consisted of green beans, chicken pot pie and french fries. Resident #83 stated he/she was not going to eat the meal because it was cold. When asked if other alternatives were ever requested, the resident stated, You mean chicken nuggets or grilled cheese? It's been the same for the last 3 months. Why would they give that [chicken nuggets and grilled cheese] for so long? If you don't like what they have on their menu you have to get your own food, plus the food is always cold, so what's the point of eating what they make. When asked if he/she knew about Food Committee meetings, the resident stated he/she did not know what that was. Resident #84 During an interview on 10/10/23 at 3:45 PM, when asked about food preferences and food satisfaction, Resident #84 stated that cheeseburgers had been suggested as a meal option and meal alternative. Resident #84 stated, I would like a good cheeseburger. The cheeseburger suggestion is not happening anymore. The resident further stated that the portions sizes were inconsistent for the foods he/she enjoyed; frequently, the pie was served frozen; and ice cream choices were vanilla and chocolate, however, strawberry ice cream was never available. Resident #86 During an interview on 10/8/23 at 3:43 PM, when asked about his/her satisfaction with meals and snacks, Resident #86 stated the food was not always hot enough. Review of the daily menu items for 10/8-14/23 revealed: CHICKEN NUGGESTS OR GRILLED CHEESE WITH FRIES OR TATER TOTS OR CHICKEN CAESAR SALAD as the alternative menu for lunch and dinner every day. During an interview on 10/11/23 at 9:51 AM, the Dietitian stated she received complaints about cold food occasionally. When this happened, the information was verbally forwarded to the Director of Dietary Services (DDS). She would also remind the resident that food could be reheated on the unit. There were no records provided of these complaints. The Dietitian stated the same questions were asked during the Food Committee meeting and individual dietary quarterly assessments, so the Dietitian did not attend the Food Committee meetings. During an interview on 10/16/23 at 1:34 PM, the DDS stated he received complaints about cold food occasionally from the floor, and that the kitchen would do their best to replace it. The kitchen used the Trayline Temperature chart, which was established by the facility's corporate headquarters, and were used as a guide for meal service temperatures. The DDS stated he was unaware of Resident #83's food being consistently cold. The Certified Nurse Assistants (CNAs) were supposed to check the meals against the meal tray ticket to ensure accuracy and serve food as soon as possible. Meals should be served within 10 minutes after plating. When the DDS was advised it took 23 minutes for the test meal tray to be served from when it was plated, he stated that he did not have enough staff to watch when meals were served on the units and has had issues with meal service delays on the units in the past. The DDS further stated the Food Committee meetings were held on the second Wednesday of each month. During these meetings residents could choose the main menu items as well as set the alternative menu items. The DDS stated the meetings were last held 2 months ago and, historically, they were poorly attended. The DDS further stated Food Committee meeting notes were not kept or filed. When asked how the meeting was advertised, he stated it used to be included on the activity calendar and then announced on the loudspeaker before the meeting started. He also stated the meeting had not been included on the activity calendar because there was someone new creating the calendars. The DDS was unsure of how long it had been since the Food Committee meeting was advertised on the activity calendar. The DDS further stated that the alternative menu changed every quarter (3 months). A new alternative menu was planned to start next week that included hotdogs and hamburgers. When asked if the alternative meals were changed often enough, the DDS stated he could see how residents would want more variety. Review of the activity calendars from July through October 2023, revealed no scheduled Food Committee meetings. During an interview on 10/16/23 at 3:00 PM, the Assistant Administrator (AA) stated the facility had no policy for food service or meal assistance. .

Mar 2023 1 deficiency

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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. Based on observation, interview, and record review, the facility failed to ensure infection control procedures were properly implemented. Specifically, the facility failed to: 1) ensure staff removed soiled gloves and performed hand hygiene after completing dirty tasks to clean tasks for 2 residents (#s 3 and 9), out of 6 residents observed for residents' care; and 2) ensure staff cleaned or changed a soiled nasal cannula before resident's use for 1 resident (#3), out of 1 resident observed for cleaning medical devices. These failed practices had the potential to affect all residents (based on a census of 96) for risk of the spread of infectious disease. Findings: Hand Hygiene Resident #3 An observation on 2/27/23 at 10:00 AM, revealed Certified Nurse Assistants (CNAs) #1 and #2 performed resident care to Resident #3. Both CNAs were wearing gloves. CNA #1 wiped the wheelchair and covered the wheelchair seat with a white linen. While wearing the same gloves, CNA #1 applied Diclofenac Sodium (an anti-inflammatory topical medication) to Resident #3's legs. Simultaneously, CNA #2 was preparing the resident for a brief change. CNA #2 took a used washcloth from the resident and handed it to CNA #1. CNA #1 put the used washcloth in the clear plastic bag. Then, CNA #1 continued to apply Diclofenac Sodium gel to the resident's legs and feet. CNA #1 put compression socks onto the resident's legs and feet. After completing the task, CNA #1 removed his/her gloves. CNA #1 was not observed performing hand hygiene after glove removal. Further observation revealed CNA #1 removed Resident # 3's brief. CNA #1 wiped the perineal area with wet wipes 2 times. While wearing the soiled gloves, CNA #1 touched the resident's left hip. The CNA then removed the call light cord away from the resident, rolled the cord up, and placed the rolled-up cord on the bedside. CNA #1 rolled-up the soiled brief and turned the resident on his/her right side. CNA #1 wiped resident's anal area with wet wipes 2 times. He/she removed the soiled brief and threw it away in a trash bag. While still wearing the soiled gloves, CNA #1 placed a new brief onto the resident and fastened both sides. After completing the task, CNA #1 removed the soiled gloves and put on a new pair of gloves. CNA #1 was not observed performing hand hygiene between the glove change. The CNAs continued to dress the resident and transferred him/her to a wheelchair. Resident #9 An observation on 2/27/23 at 10:45 AM, revealed CNA #3 performed resident care to Resident #9. CNA #3 put on gloves, gathered supplies, then removed Resident #9's blanket and brief. The CNA took a new brief, opened it, and placed the brief on the bed. The CNA wiped the resident's perineal area with wet wipes 2 times then turned the resident to his/her right side. While wearing the same soiled gloves, the CNA adjusted the bed elevation by pressing the bed control button. Then, CNA #3 straightened the bed linen and touched the resident. The CNA continued to clean the resident's anal area with wet wipes 2 times. He/she applied cream [name unknown] to the resident's buttock area. Next, inserted a new brief, turned the resident on his/her left side, and secured the brief placement. While still wearing the same soiled gloves, the CNA put away the wet wipes package and the tube of cream. He/she replaced the resident's blanket, pulled the bedside table closer to the bed, opened the blinds, touched the bedside table, and gathered used disposable cups from the table. He/she discarded the disposable cups into the trash can. Then, CNA #3 removed the soiled gloves and threw these soiled gloves away into the trash can. The CNA was not observed performing hand hygiene after glove removal. During an interview on 2/27/23 at 3:25 PM, when asked about his/her hand hygiene and glove use training, CNA #1 stated, he/she would perform hand hygiene before going in and after going out of the resident's room. During the resident's care, he/she would put on gloves before the resident's brief change and then remove gloves after cleaning the resident. He/she would then put on new gloves before applying a new brief to the resident. When asked if he/she would perform hand hygiene between gloves changes, the CNA answered he/she would not perform hand hygiene because he/she would need to go out and get alcohol-based hand sanitizer from the dispenser on the wall outside the resident's room. When asked if there was a hand sanitizer inside the resident's room, the CNA answered there was no hand sanitizer inside the room. Review of the facility's policy Hand Hygiene, revised on 12/15/2021, revealed : . Hand hygiene with soap and water is indicated when hands are visibly soiled . hand hygiene with alcohol-based hand rub is indicated when hands are not visibly soiled. Recommended technique includes applying product to the palm of hand and rubbing hands together, covering all surfaces of hands and fingers until hands are dry . the following list . require hand hygiene: before and after resident contact . before and after assisting resident with personal care . after contact with resident's mucous membranes and body fluids or excretions . after handling soiled equipment . after removing gloves . According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene Guidance, dated 1/30/20, accessed at https://www.cdc.gov/handhygiene/providers/guideline.html, revealed: . Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, Before moving from work on a soiled body site to a clean body site on the same patient, After touching a patient or the patient's immediate environment, After contact with blood, body fluids, or contaminated surfaces, Immediately after glove removal. Cleaning/Changing of soiled Medical Device An observation on 2/27/23 at 10:15 AM, revealed CNA #1 was pulling Resident #3's oxygen tubing free, that was on the floor and stuck under the bedside table. While the CNA was pulling on the tubing, the nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) at the end of the tubing was observed to drag on the floor. The CNA straightened the oxygen tubing and then placed the soiled nasal cannula attached to this tubing into the resident's nostrils. The CNA was not observed to clean or change the soiled nasal cannula before placing it back into Resident #3's nostrils. The CNA was not observed to perform hand hygiene after completing this task. Review of facility's policy Respiratory Treatment, revised on 6/22/22, revealed: . Oxygen cannula .and tubing . is to be changed as needed if soiled . .

Jul 2022 14 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure the dignity of 2 residents (#s 30 and 36) out of 23 sampled residents. Specifically, the facility 1) failed to respond to a resident's request for assistance in a timely manner when asked to return to room/bathroom, 2) lifted the resident by clothing for positioning, and 3) did not anticipate and meet resident needs regarding communication as outlined in the care plan. These failed practices did not help to promote maintenance or enhancement for quality of life. Findings: Resident #30 Record review on 6/27/22-7/1/22 and 7/5/22 revealed Resident #30 was admitted to the facility with diagnoses that included: serve intellectual disabilities, epilepsy (seizure disorder) unspecified, dysphagia (difficulty swallowing), and unspecified dementia (impairment of memory and judgement) with behavioral disturbance. Review of Resident #30's MDS (Minimum Data Set- a federally required nursing assessment) admission Assessment, dated 4/27/22, revealed G0110. I. Toilet use- Extensive assistance, 2 persons physical assist. H0300. Urinary Continence- Frequently incontinent. H0400. Bowel Continence- Frequently incontinent. An observation on 6/27/22 at 9:26 AM revealed 2 CNAs (#1 and #3) positioning Resident #30 in a recliner located in the Spruce common area. CNA #3 used a gait belt (positioning aide) at the front of the Resident while CNA #1 pulled on the Resident's pants. A continuous observation on 6/28/22 from 10:10 AM to 11:08 AM, revealed Resident #30 sitting in a wheelchair at a small table located in the common area. Resident #30 called out that he/she needed to go to bed and the bathroom. Rehabilitation staff members were the first to be informed of Resident #30's needs and said to wait for other staff as they were working with another resident. These staff members did not communicate Resident #30's needs to any other staff. The licensed nurse (LN #4) was observed on the unit passing medications during this time. CNA #1 walked past Resident #30 two times telling Resident #30 that he/she was the only CNA and that Resident #30 would have to wait for help. At 10:32 AM CNA #1 left the unit to take a 15 minute break and did not report to the LN or any other staff the break or the needs of Resident #30. At 10:38 AM Resident #30 told another Rehabilitaiton staff member he/she had to go to the room/bathroom, this staff member walked off not addressing the request. Another resident close by informed administrative staff, that was now in the common area visiting with residents that, Resident #30 wanted to go back to his/her room. At 11:04 AM CNA #1 and CNA #3 transferred Resident #30 from the wheelchair to the recliner where again CNA #1 lifted the resident by the clothing and CNA #3 used a gait belt. Requests by Resident #30 continued to be unfulfilled. Throughout this observation Resident #30 was restless and calling out, waving his/her arms in the air. During an interview on 6/28/22 at 10:22 AM Occupational Therapy Staff #1 said the facility was short staffed on Spruce Unit and he/she thought there were 2 CNAs working. During an interview on 6/28/22 at 11:08 AM CNA #1 stated that Resident #30 had a brief change that morning and that it would be done again at lunch. During an interview on 6/30/22 at 1:01 PM the Clinical RCM (resident care manager) stated Resident #30 could say when he/she needed to toilet. During an interview on 7/1/22 at 3:07 PM when asked if there was a time schedule for resident toileting, CNA #2 said there was not a schedule but that every 2 hours residents were checked and if a resident used the bathroom [ROOM NUMBER] times in an hour that was how many times he/she would be changed. Review of Task: ADL-Toileting, dated 6/28/22, revealed the only documentation at 10:03 (AM) Extensive Assistance- Resident involved in activity, staff provided weight-bearing support. Review of Care plan, revised on 5/12/22, revealed The Resident had an ADL [activities of daily living] self care performance deficit .Toileting- 1 person extensive assistance. Resident #36 Record review on 6/27/22-7/1/22 and 7/5/22 revealed Resident #36 was admitted to the facility with diagnoses that included: quadriplegia unspecified (paralysis of all four limbs), locked-in state (paralysis of voluntary muscles except those that control the eyes), and tracheostomy status. Review of Resident #36's Care Plan, revised 4/22/21, revealed Focus-The resident has a communication problem d/t [due to] locked in syndrome . Interventions/Tasks- Anticipate and meet needs. Communication: Resident does not speak. Revised 5/17/21 Communication: Resident requires eye gaze or communication board to communicate. Ensure availability and functioning of adaptive communication equipment. Further review of Resident #36's Care Plan, initiated 5/10/21, revealed Focus- The resident has a tracheostomy r/t [relating to] injury . Interventions/Tasks . Suction as necessary. Review of Physician order, dated 5/10/21, revealed Suction tracheostomy tube Q6 hrs [every 6 hours] and PRN [as needed]. During an interview on 6/27/22 at 10:28 AM CNA #1 stated Resident #36 communicated using yes and no questions by raising his/her eyes to say yes and lowering his/her eyes to say no. An observation on 6/28/22 at 10:49 AM revealed LN #4 not asking if Resident #36 needed suctioning and instead proceeded to inform Resident #36 that he/she would then be suctioned. During this procedure, this surveyor asked LN #4 how often suctioning was needed and LN #4 stated every hour or so. An observation on 6/30/22 at 8:08 AM revealed LN #5 performing tracheostomy care and asked (following care plan interventions) Resident #36 if this task could be completed, and Resident #36 indicated yes with the eyes. During an interview on 7/1/22 at 3:19 PM Resident #36's Representative stated there was a high amount of staff turnover, with less staff including regular staff on the weekends, and that new staff needed to be trained constantly regarding Resident #36's care plan and needs. Policy review of Prestige Care, Inc. Prestige Senior Living, L.L.C. Federal Resident Rights,' undated revealed, (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Policy review of Resident Rights and Facility Responsibilities, undated, revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section . Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being . What are some things the resident has the right to refuse? Medication/Treatments/Food . How can we promote the resident's dignity? .Give toileting assistance when needed .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

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Based on record review, interview and policy review, the facility failed to include 1 resident's (#5) Power of Attorney (POA) out of 23 sampled residents, in the care planning process. Specifically, the facility failed to follow up with the resident's POA. This failed practice placed the resident at risk of not supporting his/her goals, choices, and preference related to his/her daily routine. Findings: Record review from 6/27/22-7/1/22 and 7/5/22 revealed Resident #5 was admitted to the facility with diagnoses that included Alzheimer's disease and dementia. During an interview on 6/28/22 at 10:57 AM, Resident #5's Power of Attorney (POA) stated the facility had made an appointment with him/her to review the Resident's plan of care. The POA further stated he/she was never called by the facility and hadn't had a care conference with the facility since last year. The POA stated the appointment was scheduled for 9:30 AM, and he/she called the facility at 10:30 AM to follow up, was put on hold and then disconnected. The POA further stated he/she called the facility back at 2:00 PM and left a message with the Licensed Nurse. The POA stated he/she was still waiting for the facility to call him/her back regarding the Resident's care conference, scheduled approximately 2 weeks ago. During an interview on 6/29/22 at 9:17 AM, the Director of Social Services (DSS) stated care conferences involved the resident's family or POA and would have occurred quarterly. The DSS further stated the facility would have made an appointment with the POA, and if the POA was unable to attend, the POA would have called the facility back. During a joint interview on 6/29/22 at 9:38 AM with the DSS and Social Services Coordinator (SSC), the SSC stated he/she had called Resident #5's POA and left him/her a voicemail. When asked about the care conference, the SSC stated he/she met with the Nurse Manager and had the conference, and he/she was still waiting for a call back from the Resident's POA. Record review of Resident #5's electronic medical record revealed no documentation of the phone message left for the Resident's POA. Further review revealed the last care conference documented took place on 12/23/21 at 11:36 AM. During a joint interview on 6/29/22 at 10:22 AM with the DSS and the SSC, when asked about the missing care conference documentation, the DDS confirmed the last care conference took place on 12/23/21. When asked about the care conference that occurred 2 weeks ago, it was stated the facility was waiting for the POA's input before documenting the care conference note. Review of the facility's Care Conference, policy, revised 2/2019, revealed It is the policy of this center to hold care conferences to review care plans developed and discuss current care plan goals and interventions with the resident and/or resident representative. Further review revealed .Care Conferences will be held .quarterly .Review of the care plan with the resident and/or resident representative shall be documented in EHR [electronic health record]. Review of the Resident's current Care Plan, intervention dated 12/24/20, revealed Review resident wishes quarterly with Care Conference, and as needed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to protect the privacy and confidentiality for 1 resident (#41) out of 23 sampled residents. Specifically, the day's appointment reminder sheet was left on the nursing counter in the direct visual field of all visitors, staff and residents in the area. This failed practice had the potential to cause stress and anxieties for the resident in allowing others to know of his/her health history. Findings: Record review on 6/27/22-7/1/22 and 7/5/22 revealed Resident #41 was admitted to the facility with diagnoses that included: traumatic subdural hemorrhage with loss of consciousness of unspecified duration (brain bleed), epilepsy unspecified, delusional disorders, and anxiety disorder unspecified. During an interview on 6/30/22 at 10:13 AM Resident #41 stated he/she had concerns with an upcoming appointment reminder sheet that contained protected health information (PHI) left on the Spruce Unit nursing station for all to see. An observation on 6/30/22 at 10:56 AM revealed appointment reminders face down on the Cedar Unit. During an interview on 6/30/22 at 1:06 PM the Clinical RCM (resident care manager) stated appointment sheets should not be left on the nursing counter but should be tucked into the nursing station. Further observation on 6/30/22 at 2:33 PM of the Cedar Unit revealed appointment sheets still on nursing counter face down. An observation on 7/1/22 at 12:43 PM of the [NAME] Unit revealed appointment sheets on the nursing counter flipped up for all to see. Information on the sheets contained the resident's full name and appointment type (for example dialysis). Policy review of Resident Rights and Facility Responsibilities, undated, revealed Personal Privacy and Confidentiality- Includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups . Chart, treatment record, medication record, turning schedule, care instructions- This includes any document that reveals personal information about the resident- Don't leave them where others can see them .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on record review, observation and interview, the facility failed to ensure repairs were completed to maintain wall integrity and promote an appealing homelike environment for 1 resident (#88) out of 23 sampled residents. This failed practice had the potential to cause a diminished self-worth and a reduced sense of well-being. Findings: Record review from 6/27/22- 7/5/22 revealed Resident #88 was admitted to the facility with diagnoses that included cerebral infarction (stroke) and cognitive communication deficit. An observation of Resident #88's room on 6/27/22 at 1:18 PM revealed several areas of wall damage. A paint scrape of approximately 6-inches in length was observed near the electrical outlet adjacent to the Resident's bed. A large area of paint was scraped off the same wall in the shape of a circle, measuring the approximate size of a kickball. Inside the outer circle of damage were multiple paint scrapes of varied thickness and shapes. The Resident was observed in bed, with the large paint scrape in the Resident's line of sight on his/her right-hand side. A second observation on 6/28/22 at 10:21 AM revealed an additional paint scrape on the same wall's upper portion, behind the Resident's line of sight, measuring approximately 6 inches vertically and 1 inch horizontally. During an interview on 7/1/11 at 1:41 PM, the Assistant Administrator (AA) stated the facility had performed environmental rounds and would have looked for safety concerns or damage that needed to be addressed. When asked the process for staff to report damage, the AA stated staff would have submitted a work order request to maintenance for repairs. When asked about the damage to Resident #88's wall, the AA stated the facility would have wanted to have that damage repaired for the Resident. During a follow up interview on 7/1/22 at 2:19 PM, the AA stated no current work order was documented for the damage in Resident #88's room. The AA further stated she spoke with maintenance staff who stated they might have remembered hearing about the damage, but the facility was unable to provide documentation to report the need for repairs.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, interviews, and observations the facility failed to develop and implement the comprehensive care plan effectively to meet resident care needs for 3 residents (#s 30, 90, and 5), out of 23 sampled residents. Specifically, the facility failed to update residents care plan interventions for 1) Resident's 30's MRSA (Methicillin-Resistant Staphylococcus Aureus], 2) Resident #90's fluid intake monitoring and dialysis visits, and 3) Resident #5's preferred activities. This failed practice placed residents at risk for not receiving the necessary interventions to attain residents highest practicable physical, mental, and psychosocial well-being. Findings: Resident #30 Record review on 6/27/22- 7/1/22 and 7/5/22 revealed Resident #30 was admitted to the facility with diagnoses that included severe intellectual disabilities, epilepsy (a central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness) unspecified, dysphagia (difficulty swallowing), and unspecified dementia (impairment of memory and judgement) with behavioral disturbance. Review of Resident #30's Care Plan, revised 5/19/21, revealed The resident has MRSA [Methicillin-resistant Staphylococcus aureus] in surgical incision R [right] hip . Bag and transport used linen according to facility protocol, preventing skin exposure or contamination . Contact Isolation: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry . Review of Physician order, dated 6/27/22, revealed Discontinued- Contact Precautions-MRSA. Observations at numerous times from 6/27/22- 7/1/22 and 7/5/22 revealed no signage outside Resident #30's door that indicated contact precautions. During an interview on 6/29/22 at 2:34 PM LN #5 stated that Resident #30 no longer has MRSA as the wound has healed. Observation and interview on 7/1/22 at 1:42 PM revealed Housekeeper #1 cleaned Resident #30's room and had on gloves, mask, and eye protection. When asked about precautions of rooms, Housekeeper #1 talked about the different signage on the outside of room near residents' doors. Housekeeper #1 indicated there was no precaution sign outside of Resident #30's room. Resident #90 Record review from 6/27/22-7/1/22 and 7/5/22 revealed Resident #90 was admitted to the facility with diagnoses that included diabetes, end stage renal disease (ESRD) requiring hemodialysis (a clinical purification of the blood, as a substitute for the normal function of the kidney) and chronic obstructive pulmonary disease (COPD- refers to a group of diseases that cause airflow blockage and breathing-related problems). Fluid Intake Review of Resident #90's DIALYSIS CENTER COMMUNICATION FORM, dated 6/11/22 revealed [Patient] GAINED 10.3 Kg IN 2 DAYS! NEEDS TO REDUCE FLUID INTAKE TO MAX 1.5 LITERS/DAY. [Patient] COUNC[s]ELED ON FLUID INTAKE. Review of Resident #90's DIALYSIS CENTER COMMUNICATION FORM, dated 6/18/22 revealed Please have [patient] limit fluid/salt intake. Review of Resident #90's DIALYSIS CENTER COMMUNICATION FORM, dated 6/21/22 revealed closely monitor fluid intake- [patient] was 11 kg over [his/her estimated dry weight- optimal weight] requiring [additional] fluid removal [treatment on] 6/22 @ 0730. Review of Resident #90's DIALYSIS CENTER COMMUNICATION FORM, dated 6/22/22 revealed Please limit fluid intake to 1500 ml [milliliters] per day. Review of Resident #90's current care plan, date initiated 6/8/22, revealed Weight Loss/Fluid Imbalance .Fluids at bedside, assist and encourage intake. Dialysis schedule During a phone interview on 7/1/22 at 7:01 AM with the Liberty dialysis staff nurse, when asked the dialysis schedule for Resident #90, the Liberty dialysis staff nurse stated Resident #90 was scheduled for dialysis on Tuesdays, Thursdays, and Saturdays, but the Resident missed his/her appointment last Saturday. Review of Resident #90's current care plan, date initiated 6/8/22, revealed The resident needs dialysis [related to] ESRD, with interventions Dialysis: Mon[day]-Wed[nesday]-Fri[day] @ liberty dialysis chair time is [5:20] .Services will be integrated. Initiate Coordination of Care or Communication form. Resident #5 Record review from 6/27/22-7/1/22 and 7/5/22 revealed Resident #5 was admitted to the facility with diagnoses that included Alzheimer's disease and dementia. During an interview on 6/28/22 at 10:51 AM, Resident #5's power of attorney (POA) stated he/she was working with the activity's person now because the resident stopped playing bingo and was staying in his/her room more. The POA further stated he/she was working on getting Resident #5 DVDs to watch, but if the staff did not change the Resident's DVDs, the Resident would start yelling. During an interview on 6/30/22 at 12:43 PM, the Activity's Director (AD) stated he and Resident #5's POA were working on trying to get the Resident out of his/her room to play bingo twice a week and to get the Resident's DVDs going. Review of Resident #5's most current care plan, revised on 12/30/20, revealed Focus [-] 'I like to be left alone' . Goal [-] 'I will engage in activities of my choosing daily' . Interventions/Tasks [-] Encourage participation .My activity preferences: rock and roll music and game shows . During an interview on 7/1/22 at 2:55 PM, when asked how staff knew what care and services needed to be provided to the resident, the Administrative Assistant (AA) stated the staff looked at the Resident's [NAME] and care plan. When asked about the [NAME], the AA stated the [NAME] would have included the Resident's care plan.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, interviews, and observations, the facility failed to review and revise the comprehensive care plan effectively to meet resident care needs for 2 resident (#23, and 31), out of 23 sampled residents reviewed. Specifically, the facility failed to update the residents 'care plan interventions for 1) Resident #23's NPO (nothing by mouth) and enteral tubing status, and 2) Resident #31's eyewear. This failed practice placed the resident at risk of not receiving the necessary interventions and quality care. Findings: Resident #23 Review of the electronic medical record on 6/27/22- 7/1/22 and 7/5/22, revealed, Resident #23 was admitted in the facility with diagnoses that included dysphagia (a condition with difficulty in swallowing food or liquid) following cerebral infarction (stroke). Review 6/28/22 at 2:00 PM on Minimum Data Set (MDS- a federally required nursing assessment) Significant change dated 1/23/22 and Quarterly assessment dated [DATE], revealed, Section K. Nutrition/Swallowing status .nutritional approach . feeding tube . while a resident was marked check. During an interview on 6/28/22 at 2:25 PM with Resident #23's representative stated Resident #23 received nothing by mouth) because the resident received nutrition by enteral tubing. During an interview on 6/29/22 at 11:24 AM, Licensed Nurse (LN) #7 stated Resident #23 was receiving Jevity 65 ml per hour continuous except for 5 hours a day. When asked if the resident was able to eat by mouth, the LN stated the resident was 100% NPO. Review on 6/29/22 at 1:30 PM of the Physician's order dated 3/11/22 revealed enteral feed . two times a day . and on 3/30/22 NPO diet, NPO texture, NPO consistency. Review on 6/29/22 at 1:36 PM of the Care Plan, revealed interventions included: Eating -NPO initiated on 1/11/22. .Eating aide modified, curved spoon and plate guard. Resident often refuses plate guard. Initiated on 5/21/19 .Family brings Resident home cooked meals daily. Initiated on 1/28/20 .Invite the resident to activities that promote additional intake. Initiated on 7/30/19 .Provide, serve diet as ordered. Monitor intake and record q[every] meal. Initiated on 7/30/19 During an interview 6/29/22 at 11:48 AM, Minimum Data Set (MDS) Nurse/Resident Care Manager (RCM) stated the admission nurse made the initial care plan upon admission, then the MDS nurse/RCM would update the care plan. MDS nurse/RCM also stated different staff could update, edit, and customize the care plan. Then, the Clinical RCM (CRCM) who attended the care conference would audit and update the care plan quarterly and if necessary if there were changes in the resident's condition. During an interview on 6/30/22 at 1:21 PM, CRCM stated the residents care plan was initiated by MDS nurse upon admission then the CRCM would audit quarterly and annually if there were updates, CRCM stated would check and close-out the care plan after updating. The CRCM also explained anybody could update to the care plan (CP). On the same interview with the CRCM, when asked about CP for resident with tube feeding and on NPO, the CRCM stated the care plan would include the name/ type of tube feeding (TF), the amount, flow either continuous or non- continuous, and the flushes because that was included in the physician's order. When asked about Resident #23's care plan [as stated above], the CRCM stated he/she have not updated the care plan for the resident. Review on 7/1/22 at 3:10 PM of the facility Care Plan- [NAME]/Baseline Care Plan policy, revealed .policy of this facility that care givers will have accurate information available to them to properly care for their residents .initial information will be collected on admission .updated as changes occur with resident and reviewed no less often than quarterly. Resident #31 Record review on 6/27/22-7/1/22 and 7/5/22 revealed Resident #31 was admitted to the facility with diagnoses that included hemiplegia (condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, myocardial infarction (heart attack), and vascular dementia with behavioral disturbance. Review of Resident #31's MDS (Minimum Data Set- a federally required nursing assessment) Annual Assessment, dated 4/22/22, revealed B1000. Vision Ability to see in adequate light (with glasses or other visual appliances) 0. Adequate- sees fine detail, including regular print in newspapers/books. B1200. Corrective Lenses 0. No. Review of Resident #31's Care Plan, revised 5/10/21 initiated 4/14/21, revealed Focus- The resident has impaired visual function . Interventions- Vision: Wears glasses. Review of Resident #31's Inventory of Personal Effects, dated 4/14/21, revealed Eyewear [left blank]. During an interview on 7/5/22 at 8:35 AM Certified Nursing Assistant (CNA)#1 stated I did not know Resident #31 had glasses. During an interview on 7/5/22 at 8:37 AM CNA #4 stated Resident #31 did not wear glasses. When asked how the CNAs know residents care plans, CNA #4 stated they look at the [NAME] (computer system that shows care plans) daily as things can be changed quickly, report from other CNAs and nurses, and talking with residents about their concerns and preferences. During an interview on 7/5/22 at 9:05 AM LN #1 stated I can't tell you too much about Resident #31's glasses, I [LN #1] just started last week. Observations at numerous times from 6/27/22-7/1/22 and 7/5/22 revealed Resident #31 not wearing glasses.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on record review, observation, and interviews, the facility failed to accommodate the needs of 1 resident (#31) out of 23 sampled residents. Specifically, the facility failed to complete a wheelchair assessment to ensure the wheelchair was customized to properly fit and protect the resident from possible pressure injuries. This failed practice had the potential to cause a pressure injury and impair the resident's overall health and wellbeing. Findings: Resident #31 Record review on 6/27/22-7/1/22 and 7/5/22 revealed Resident #31 was admitted to the facility with diagnoses that included: hemiplegia and hemiparesis (muscle weakness/numbness of limbs) following nontraumatic subarachnoid hemorrhage (brain bleed) affecting left non-dominant side, myocardial infarction (heart attack), and vascular dementia with behavioral disturbance. Review of Resident #31's MDS (Minimum Data Set- a federally required nursing assessment) Quarterly and Annual Assessments, dated 1/22/2022 & 4/22/2022, revealed G0600. Mobility Devices C. Wheelchair (manual or electric). Review of Resident #31's Care Plan, dated 4/14/21, revealed Focus- The resident has an ADL [activities of daily living] Self Care Performance Deficit . Interventions . Assistive Devices- Wheelchair. During an observation on 6/28/22 at 10:17 AM Resident #31 was excessively leaning to the right side on a metal bar past the arm rest/cushion of the wheelchair. The weight of the upper torso was centered on the arm pressed against the metal bar. Review of SNF [skilled nursing facility] Braden Scale [scoring system for risk of developing a pressure ulcer] for Prediction of Pressure Score Risk, dated 4/20/22, revealed At Risk- Score of 15 [scale goes from 0-18, the lower the score the more risk]. Review of Physical Therapy Note [PT], dated 4/8/21, revealed Mobility- Wheel Chair not performed. During an interview on 6/30/22 at 10:38 AM the Occupational Therapy (OT) Director stated when Resident #31 was seen on the caseload, an assessment was completed but the cushioning of the arm was not addressed. The Occupational Therapy Director further stated Resident #31 was seated in a standard wheelchair and had the capacity to sit up straight; however, due to medical diagnoses of scoliosis (sideways curvature of the spine) it may be more comfortable to lean over. In addition, the OT Director stated this issue of increased cushioning would be further evaluated. During a follow-up interview on 6/30/22 at 2:29 PM, OT #2 confirmed a wheelchair assessment had not been completed for Resident #31.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on record review, observation, interview and policy review, the facility failed to ensure 3 residents (#'s 5, 36, and 38) out of 23 sampled residents, received appropriate interventions, treatment and/or services to prevent further decrease in range of motion. This failed practice placed the resident at risk for further decline in range of motion. Findings: Resident #5: Record review from 6/27/22-7/1/22 and 7/5/22 revealed Resident #5 was admitted to the facility with diagnoses that included Alzheimer's disease, tremors, and dementia. During an observation 6/28/22 at 11:11 AM, Resident #5's bilateral hands were observed to be in a closed position and stiff. During an interview on 6/29/22 at 2:47 PM, Licensed Nurse (LN) #10 stated Resident #5 had developed contractures of his/her hands and the Resident now required staff to assist him/her with feeding. During an interview on 6/30/22 at 9:12 AM, when asked about his/her responsibilities concerning range of motion (ROM) exercises for the residents, Certified Nursing Assistant (CNA) #10 stated he/she was not responsible for ROM exercises. The CNA further clarified the Restorative Aides (RA) were responsible for ROM duties. During an interview on 6/30/22 at 12:04 PM, when asked the expectation for ROM exercises for the residents, CNA #13 stated there was no expectation for him/her to perform ROM exercises for the residents. The CNA further stated he/she would have done ROM for some residents, but he/she did not perform ROM for Resident #5. CNA #13 further stated he/she only put the hand splints on for Resident #5. During an interview on 6/30/22 at 12:47 PM, RA #2 stated Resident #5 was expected to receive restorative care services which included ROM to his/her upper and lower extremities scheduled 3-5 times per week. The RA further stated it was only the RA program providing these ROM exercises to Resident #5. Review of Resident #5's current care plan, date initiated 5/11/21, revealed The resident will utilize a restorative program .3-5 [times per] week. Record review of the facility provided Restorative treatment report, dated 5/1-31/22 and 6/1-28/22 revealed the following treatments for Resident #5: 1. 1 documented restorative exercise for the week of 5/9-15/22; 2. 2 documented restorative exercises for the week of 5/23-29/22; 3. 2 documented restorative exercises for the week of 5/30-6/5/22; 4. 2 documented restorative exercise for the week of 6/13-19/22; 5. 2 documented restorative exercises for the week of 6/20-28/22 Resident #36 Record review on 6/27/22-7/1/22 and 7/5/22 revealed Resident #36 was admitted to the facility with diagnoses that included: quadriplegia unspecified (paralysis of all four limbs), locked-in state (paralysis of voluntary muscles except those that control the eyes), and tracheostomy (tube in the front of neck) status. Review of Resident #36's Care Plan, revised 4/22/21, revealed General Information- Therapy Services: Restorative Program. Further review of Resident #36's Care Plan, revised 12/8/21, revealed The resident will utilize a restorative program. Nursing Rehab/Restorative: Passive ROM [range of motion] 3-5x/day and monitor skin. Notify nurse of any skin concerns 3-5x/week. Review of Resident #36's Tasks CNA-Task: Hand PROM [passive range of motion] 4x/day and monitor skin. RA [restorative aide] will do one time a day and CNA [certified nursing aide] on court [unit] will do the other 3. Review of Resident #36' PROM received, from 6/5/22 to 7/5/22, revealed: 1. 1 documented exercise for 6/6/22, 6/7/22, and 6/8/22; 2. No documented exercised for 6/9-12/22; 3. 2 documented exercises for 6/13/22; 4. 1 documented exercise for 6/14/22 and 6/15/22; 5. No documented exercises for 6/16/22 through 6/19/22; 6. 2 documented exercises on 6/20/22; 7. 1 documented exercise for 6/21/22 and 6/22/22; 8. No documented exercises for 6/23/22 through 6/27/22; 9. 1 documented exercise for 6/28/22 and 6/29/22; 10. No documented exercises for 6/30/22 through 7/3/22; 11. 2 documented exercises or 7/4/22;s 12. 1 documented exercise for 7/5/22 . Review of Resident #36's Tasks-Task: Restorative, from 6/5/22 to 7/5/22, revealed Task completed 7/4/22 at 05:42 [AM]. During an interview on 7/5/22 at 12:03 PM LN #1 stated I don't do any ROM [range of motion] exercises. During an interview on 7/5/22 at 12:05 PM CNA #4 stated ROM exercises with Resident #36 were completed in the mornings by the certified nursing aides (CNAs) and restorative aides for 5-10 minutes and charted in the point of care (POC) system under CNA tasks. During an interview on 7/5/22 at 12:17 PM Restorative Aide (RA)/CNA #1 stated the RA's do 1 session of ROM with Resident #36 and the CNAs do the other 3 sessions. Resident #38: Record review from 6/27/22-7/1/22 and 7/5/22 revealed Resident #38 was admitted to the facility with diagnoses that included cerebral infarction (stroke), muscle weakness and end stage renal disease. During an interview on 6/27/22 at 10:54 AM, when asked about ROM exercises for his/her left-hand weakness, Resident #38 stated he/she did the exercises him/herself. The Resident further stated staff used to come 2 times per week to assist him/her, but staff haven't come around anymore. When asked the last time he/she received ROM exercises, Resident #38 stated about a month ago. During an interview on 6/29/22 at 2:47 PM, LN #10 stated Resident #38 had a stroke and suffered from weakness on one side of his/her body. The LN further stated the resident was on a restorative program with the RA, and the RA's provided restorative care for residents on their program. During an interview on 6/30/22 at 12:47 PM, RA #2 stated Resident #38 was on the restorative program to receive ROM on one of his/her arms and legs. The RA further stated the resident was ambulating in his/her room with the RA. Review of Resident #38's current care plan, revised on 12/17/21, revealed The resident will utilize a restorative program .using 2-3 lbs weight .3-5 [times per] week or as tolerated .gentle therapeutic exercised to all planes .3-5 [times] a week. Record review of the facility provided Restorative treatment report, dated 5/1-31/22 and 6/1-28/22 revealed the following restorative treatments for Resident #38: 1. no documentation of restorative exercises for the week of 5/9-15/22; 2. 1 documented attempt for the week of 5/23-29/22 (the resident was hospitalized 5/26-27/22 and out of the facility); 3. 2 documented restorative exercises for the week of 5/30-6/5/22; 4. 1 documented restorative exercise for the week of 6/6-12/22;1 documented restorative exercise for the week of 6/13-19/22 (the resident was hospitalized 6/14-17/22 and out of the facility); 5. no documentation of restorative exercises for the week of 6/20-28/22 During an interview on 6/30/22 at 1:16 PM, the Director of Nursing (DON) stated Resident #38 should have been receiving restorative treatment 3-5 times per week, and if the resident refused, the refusal would have been documented in the Resident's medical record. When asked about the lack of treatment from 6/2-11/22 (10 days), the DON stated the facility had critical staffing and the RAs were utilized as CNAs and were unable to provide restorative care services during that time. The DON further stated the facility identified the restorative program required restructuring, and the facility was currently in the process of reviewing the program. During an interview on 6/30/22 at 4:59 PM, when asked if the restorative exercises were documented elsewhere in the Resident's medical record, the DON stated she did not find further documentation that the exercises were provided to the resident. Review of the facility's policy Restorative Nursing, revised 2/2018, revealed .Residents assessed with deficits in .mobility, range of motion .will receive necessary care and services to attain and maintain their highest practicable physical, mental and psychosocial well-being. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure 1 resident (#90) out of 1 resident sampled for dialysis, received the services consistent with professional standards of practice. Specifically, the facility failed to: 1) ensure documented communication between the facility and the dialysis clinic occurred for consistent dialogue and monitoring; 2) ensure communication between the facility and the pharmacist occurred for consistent communication for antibiotics received; 3) ensure weights were completed on non-dialysis days for consistent and accurate monitoring; 4) ensure the physician' orders accurately reflected the Resident's dialysis routine schedule; and 5) ensure the resident's care plan accurately reflected the resident's dialysis routine schedule. Not adhering to professional standards of practice placed the resident at risk for fluid overload; a potential for medication errors/interactions; and missed dialysis appointments which could have led to receiving less than optimal care and poor outcome. Findings: Record review from 6/27/22-7/1/22 and 7/5/22 revealed Resident #90 was admitted to the facility with diagnoses that included diabetes, end stage renal disease (ESRD) requiring hemodialysis (a clinical purification of the blood, as a substitute for the normal function of the kidney) and chronic obstructive pulmonary disease (COPD- refers to a group of diseases that cause airflow blockage and breathing-related problems). Further review revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 (a score of 13-15 meant the resident was cognitively intact). During an observation and interview on 6/28/22 at 9:36 AM, Resident #90 was lying in bed, lethargic, and spoke with garbled, unintelligible speech. Resident #90 closed his/her eyes, then sat up suddenly and asked if his/her oxygen, which he/she wore via nasal cannula (tubing used to administer oxygen via the nasal passages), was on. The Resident was visibly short of breath and using his/her accessory muscles to assist with breathing. Lack of communication between the facility and dialysis clinic During an interview on 6/29/22 at 12:37 PM, Certified Nursing Assistant (CNA) #9 stated he/she did not perform any special interventions when Resident #90 returned to the facility after dialysis. The CNA further stated that the Resident returned from dialysis with after care notes that would have been reviewed by the LN (Licensed Nurse). Review of Resident #90's DIALYSIS CENTER COMMUNICATION FORM, dated 6/11-22/22, revealed handwritten notes by the dialysis center communicating the Resident's status to the LTC (long term care facility). Further review under POST DIALYSIS NURSING ASSESSMENT (COMPLETED BY FACILITY ON RESIDENT RETURN), revealed a documented note dated 6/11/22. Further review revealed no documented communication from the LTC to the dialysis center on 6/14/22; 6/16/22; 6/18/22; 6/21/22; and 6/22/22. During an interview on 6/30/22 at 3:31 PM, LN #2 stated the facility had not utilized the dialysis book, which contained the DIALYSIS CENTER COMMUNICATION FORM[S]. The LN further stated he/she would have communicated with the dialysis center via phone, and this communication would have been documented in the resident's medical record. Review of all of Resident #90's chart notes, dated 6/8-29/22, revealed only one note, a Vital Note, dated 6/11/22 at 10:25 PM, which revealed the Resident gained 10.3 kg (kilograms) (22.6 pounds) in 2 days and to limit fluid intake to 1.5 liters daily. Further review of the chart notes revealed no documented phone communication with the dialysis clinic. Lack of communication between facility and pharmacy Further review of Resident #90's dialysis book, which contained the communication forms, revealed a PROGRESS NOTE, dated 6/9/22 at 7:56 PM, which revealed the resident received the antibiotic vancomycin while at the dialysis clinic. Further review of DIALYSIS CENTER COMMUNICATION FORM, dated 6/11-22/22, revealed the Resident received the vancomycin on 6/11/22; 6/14/22; 6/16/22; 6/18/22; and 6/21/22. During an interview on 7/1/22 at 11:02 AM, the Pharmacist stated he was not informed that Resident #90 had been receiving the vancomycin. The Pharmacist stated that he reviewed residents with infections and whether the antibiotics were prescribed appropriately, but he was not told about this Resident who received the antibiotic outside of the facility. The Pharmacist stated this antibiotic should have been incorporated into the Resident's monthly medication review. During an interview on 7/1/22 at 11:19 AM, when asked about the process of communicating orders or treatments from outside facilities, the Clinical Resident Care Manager (CRCM) #1 stated the LN would have filled out paperwork and put that information into a MEC book, which was reviewed by the RCMs or Director of Nursing (DON). The CRCM further stated he/she was not aware Resident #90 had been receiving antibiotics at his/her dialysis appointments. No Facility Weights Review of Resident #90's DIALYSIS CENTER COMMUNICATION FORM, dated 6/11/22, revealed [Patient] GAINED 10.3 Kg IN 2 DAYS! NEEDS TO REDUCE FLUID INTAKE TO MAX 1.5 LITERS/DAY. [Patient] COUNCELED ON FLUID INTAKE. Review of Resident #90's DIALYSIS CENTER COMMUNICATION FORM, dated 6/18/22 revealed Please have [patient] limit fluid/salt intake. Weight before dialysis was 121.2 kg and weight after was 114.8 kg. Review of Resident #90's DIALYSIS CENTER COMMUNICATION FORM, dated 6/21/22 revealed closely monitor fluid intake- [patient] was 11 kg over [his estimated dry weight- optimal weight] requiring [additional] fluid removal [treatment on] 6/22 @ 0730. Weight before dialysis was 123.2 kg and weight after was 116.4 kg. Review of Resident #90's DIALYSIS CENTER COMMUNICATION FORM, dated 6/22/22 revealed Please limit fluid intake to 1500 ml [milliliters] per day. Weight before dialysis was 117 kg and weight after was 114.1 kg. During an interview on 6/30/22 at 9:12 AM, CNA #10 stated he/she had never weighed Resident #90. The CNA further stated the Restorative Aides (RA) were responsible for obtaining the Resident's weight. During an interview on 6/30/22 at 12:47 AM, when asked about obtaining weights for the residents who received dialysis treatments, RA # 2 stated he/she documented the weights obtained at the dialysis clinic in the medical record. RA #2 further stated that since those residents were weighed at the dialysis clinic, they did not need to be weighed at the facility. Review of Resident #90's current Physician's Orders revealed Weekly weights X 4 weeks for new admissions. The order start date was 6/15/22 and the end date was 7/13/22. Review of the facility's policy Hemodialysis Care, revised 2/2019, revealed .Routine weight per physician order. Review of https://www.kidney.org/atoz/content/dry-weight, How do I maintain dry weight (normal weight without any extra fluid in your body) after dialysis? accessed on 7/1/22, revealed Keep track of your daily weight. Keeping track of your weight is important between dialysis sessions. If you see sudden weight gain between sessions, you should tell your healthcare provider immediately. Review of http://currentnursing.com/nursing_management/nursing_standards.html, ANA Standards of practice, accessed on 7/1/22, revealed Standard I. Assessment The nurse collects comprehensive data pertinent to the patients' health or situation [;] Measurement criteria 1. Collects data in a systematic and ongoing process .4. Collects pertinent data using appropriate assessment techniques 5. Document relevant data in a retrievable form. Physician orders discrepancy Review of Resident #90's current Physician's Orders revealed Dialysis: Mon[day]-Wed[nesday]-Fri[day] @liberty [dialysis clinic] dialysis chair time is [5:20 PM] During a phone interview on 7/1/22 at 7:01 AM with the dialysis staff nurse, when asked the dialysis schedule for Resident #90, the dialysis staff nurse stated Resident #90 was scheduled for dialysis on Tuesdays, Thursdays, and Saturdays, but the Resident missed his/her appointment last Saturday. Care plan discrepancies Review of Resident #90's current care plan, date initiated 6/8/22, revealed The resident needs dialysis [related to] ESRD, with interventions Dialysis: Mon[day]-Wed[nesday]-Fri[day] @ liberty dialysis chair time is [5:20] .Services will be integrated. Initiate Coordination of Care or Communication form. Further review revealed Weight Loss/Fluid Imbalance .Fluids at bedside, assist and encourage intake. During an interview on 7/1/22 at 2:55 PM, when asked how staff knew what care and services needed to be provided to the resident, the Assistant Administrator (AA) stated the staff looked at the Resident's [NAME] and care plan. When asked about the [NAME], the AA stated the [NAME] would have included the Resident's care plan. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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Based on record review, observations, and interviews, the facility failed to ensure physician's order, resident consent and assessment of risk and benefits of the use of enabler bars, were obtained prior to use for 3 residents ( #s 30, 36, and 41) out of 23 sampled residents and 1 non-sampled resident ( #348) . This failed practice had the potential to place residents at risks of falls, entrapment, physical restraint and other preventable harm/accidents. Findings: Resident #30 Record review on 6/27/22-7/1/22 and 7/5/22 revealed Resident #30 was admitted to the facility with diagnoses that included: serve intellectual disabilities, epilepsy (seizure disorder) unspecified, dysphagia (difficulty swallowing), and unspecified dementia (impairment of memory and judgement) with behavioral disturbance. An observation on 6/28/22 at 9:11 AM revealed one enabler bar up as the other side of the bed was pushed up against the wall. Record review of the Electronic Health Record (EHR) under forms revealed no assessment of risks and benefits for the use of enabler bars. Resident #36 Record review on 6/27/22-7/1/22 and 7/5/22 revealed Resident #36 was admitted to the facility with diagnoses that included: quadriplegia unspecified (paralysis of all four limbs), locked-in state (paralysis of voluntary muscles except those that control the eyes), and tracheostomy status. An observation on 6/28/22 at 10:26 AM revealed both enabler bars up, even with the other side of the bed being pushed up against the wall. Record review of the Electronic Health Record (EHR) under forms revealed no assessment of risks and benefits for the use of enabler bars, no consent, and no physician's order were obtained. Resident #41 Record review on 6/27/22-7/1/22 and 7/5/22 revealed Resident #41 was admitted to the facility with diagnoses that included: traumatic subdural hemorrhage with loss of consciousness of unspecified duration (brain bleed), epilepsy (seizure disorder) unspecified, delusional disorders, and anxiety disorder unspecified. An observation on 6/27/22 at 11:51 AM revealed both enabler bars up. Record review of the Electronic Health Record (EHR) under physician orders revealed no order for use of enabler bars. Resident #348 Record review on 6/27/22-7/1/22 and 7/5/22 revealed Resident #348 was admitted to the facility with diagnoses that included: acute and subacute infective endocarditis (inflammation of the heart), dementia with behavioral disturbance, and paroxysmal atrial fibrillation (an irregular heart rate the commonly causes poor blood flow). An observation on 6/27/22 at 2:52 PM revealed one enabler bar up as the other side of the bed was pushed up against the wall. Record review of the Electronic Health Record (EHR) under forms revealed no assessment of risks and benefits for the use of enabler bars, no consent, and no physician's order. During an interview on 6/30/22 at 1:04 PM the Clinical RCM (resident care manager) stated an audit for enabler bars, trapeze, etc. was in process. During an interview on 7/5/22 at 8:57 AM the Director of Nursing (DON) stated therapy performed an assessment for enabler bars upon admission or throughout the residents' stay as indicated. An order was then obtained from the physician and consent from either the resident or resident representative was documented prior to enable bars being used. The DON further stated these interventions were then included in the care plan. Review of policy Physical Restraints and Enablers, revised 3/2020, revealed 3.) If it determined that a resident has symptom necessitating the use of a physical or mechanical device, the Enabler/Physical Restraint Evaluation is completed prior to the device being initiated, annually and on change of condition . 5.) The resident and/or resident representative is provided risks/benefits of restraint use or enabler use, and consent obtained prior to implementation of the device .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure acceptable professional standards of infection control. Specifically, the facility failed to 1) clean/disinfect durable medical equipment, 2) encourage/perform resident hand hygiene before meals, and 3) have staff perform acceptable professional standards for hand hygiene while working with residents. These failed practices had the potential to affect 4 residents (#5,31,36, and 41) out of 23 sampled residents and 5 residents (#15, 47, 49, 64, and 89) unsampled residents at risk to spread contamination and infections throughout the facility. Findings: Pulse oximeter During an observation on 6/28/22 at 10:11 AM Occupational Therapy (OT) Staff #3 was observed taking oxygen saturation readings with a pulse oximeter (reads oxygen levels and heart rate) on Resident #41. OT Staff #3 had taken the pulse oximeter out of his/her pocket, used it on Resident #41, and then returned it right back to his/her pocket. During an interview on 6/28/22 at 10:36 AM Physical Therapy (PT) Staff #1 stated the pulse oximeter should be cleaned after each resident use. Resident hand hygiene An observation on 6/29/22 at 12:15 AM revealed CNA #5 serving lunch on the Spruce Unit to Residents #89, #31, #64 and #41. CNA #5 placed the package of hand sanitizer on Resident #89's bedside table with no mention of/encouragement of hand hygiene. Residents #31, #64 and #41, sat to eat in the common area, were not offered hand hygiene and there were no packages of hand sanitizer placed in front of them. Review of Resident #31's CNA Task: Encourage Resident to Complete Hand Hygiene, for a look back period of 30 days from 7/3/22, revealed 6/29/22 documentation of 07:32 [AM] Task Completed: Yes. During an interview on 6/29/22 at 12:45 PM, CNA #5 stated hand hygiene was offered when residents were up and anytime hands were seen to be visibly dirty. During an interview on 6/30/22 at 8:38 AM, CNA #7 stated hand hygiene was offered before every meal, after the use of the bathroom, and just all the time. Staff hand hygiene during wound care During an observation on 6/30/22 at 9:41 AM, LN #4 was observed changing a sacral wound dressing for Resident #5. LN #4 prepared for the dressing change by placing a basin full of dressing supplies on the Resident's bed. With gloved hands, the LN cleansed the Residents wound, then placed packing into the wound. With the same gloves on, LN #4 removed scissors from his/her pocket and cut a small piece of dressing, then placed that dressing over the packed wound. The LN then placed the scissors back into his/her pocket. LN #4 then took a larger dressing and placed the larger dressing over the smaller one. During an interview on 7/1/22 at 10:00 AM, when asked about the dressing change technique, the Infection Preventionist (IP) stated staff should have not taken items from their pockets while performing wound care. The IP further stated that items should had been prepared and laid out prior to the dressing change being performed. Staff hand hygiene during Tracheostomy care During an observation on 6/28/22 at 10:49 AM, revealed LN #4 did not perform hand hygiene when entering Resident #36's room. On the same observation, LN #4 performed tracheostomy care. LN #4 did not perform hand hygiene after removing soiled gloves from cleaning around the stoma (an opening in the neck for the tracheostomy) and before putting sterile gloves on prior to suctioning. During an interview on 7/1/22 at 10:17 AM the Infection Preventionist/Staff Development Coordinator (IP) stated the personal protective equipment (PPE) for tracheostomy care were gloves, eye protection and sterile gloves. The IP further stated that hand hygiene should be completed between dirty and clean procedures. Staff PPE/hand hygiene on COVID-19/Quarantine units During an observation on 6/30/22 at 2:00 PM, revealed CNA #8 coming out of the [NAME] Unit (a COVID-19 unit) and was observed wearing a regular face mask and eye protection. During an interview on 7/1/22 at 10:17 AM the Infection Preventionist/Staff Development Coordinator (IP) stated all staff that worked the COVID/Quarantine units wore N95, eye protection/face shield. During an interview on 7/1/22 at 12:43 PM LN #6 stated all staff on [NAME] Unit needed to wear eye protection and an N95 mask. An observation on 7/1/22 at 12:40 PM, revealed CNA #6 was observed in the common area serving lunch with his/her eye protection on his/her head and not in the correct placement over the eyes. An observation on 7/1/22 at 12:45 PM, revealed CNA #6 attempted to go into a resident's room that had signage outside the door of contact precautions but was stopped by LN #6 and reminded of wearing correct PPE of a gown. Continued observation on 7/1/22 from 12:49 PM to 12:54 PM revealed CNA #6 picked up lunch trays from Rooms 511 (#47), 513 (# 49 and #15 twice) and two other residents in which hand hygiene was not performed at entrance or exit of these rooms and between cleaning lunch trays. During an interview on 7/1/22 at 10:17 AM the Infection Preventionist (IP) stated weekly rounds on hand hygiene were performed and that earlier in the year there was a hand hygiene and PPE check off completed. Review of policy Cleaning and Disinfection of Resident Care Items and Equipment, dated 12/15/2021, revealed Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Review of policy Infection Control Policies and Practices, date 12/15/2021, revealed 2.) . c. Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions; . 26. Maintain on premises current CDC, OSHA, and State/Federal regulations, guidelines, and recommendations relative to infection control issues in healthcare facilities; . Review of policy Hang Hygiene, revised 12/15/2021, revealed Hand hygiene is the primary means of preventing the transmission of infection and should be performed as soon as possible after hands become contaminated and frequently during the working day. The following is a list of some situations that require hand hygiene: .c.) Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); d.) Before and after performing any invasive procedure (e.g., fingerstick blood sampling); e.) Before and after entering transmission-based precaution areas; g.) Before and after assisting a resident with meals (hand hygiene with soap and water); . Review of the CDC (Centers for Disease Control and Prevention) website https://www.cdc.gov/handhygiene/providers/index.html, revealed .Use an Alcohol-Based Hand Sanitizer- Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices .- Before moving from work on a soiled body site to a clean body site on the same patient .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure pneumococcal immunization for 1 resident (#84) out of 5 sampled residents. This failed practice posed risk of this resident acquiring or transmitting the infection to the facility with a census of 93 residents. Findings: Record review on 6/27/22-7/1/22 and 7/5/22 revealed Resident #84 was admitted to the facility with diagnoses that included: atherosclerotic heart disease (buildup of fats and cholesterol in the heart), chronic obstructive pulmonary disease lung disease), and dependence on supplemental oxygenation. Review of Pneumococcal Vaccine Informed Consent, signed 5/4/21, revealed I consent to the Pneumococcal Polysaccharide Vaccine (PPSV23), being given to me . I have received the current CDC [Centers for Disease Control and Prevention] Vaccine Information Statement. During an interview on 7/1/22 at 1:50 PM the Infection Preventionist (IP) stated Resident #84 had a consent form and order from the physician documented in the Electronic Health Record (EHR) for pneumococcal vaccination. The IP further stated he/she was unclear as to why the vaccination was not given by the nurse. By the end of the survey no documentation was provided that Resident #84 had gotten the pneumoccoal vaccination. Review of the CDC website at https://www.cdc.gov/pneumococcal/vaccinaiton.html, dated January 27,2022, revealed Recommended pneumococcal vaccines for adults- adults who have never received a pneumococcal conjugate vaccine should receive PCV15 or PCV20 if they ?Are 65 years or older ?Are 19 through [AGE] years old and have certain medical conditions or other risk factors If PCV15 is used, it should be followed by a dose of PPSV23.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to ensure unit medication refrigerator temperatures were consistently monitored and documented. This failed practice had the potential to place three out of six resident units (Spruce Court, [NAME] Court, and [NAME] Court) at risk of receiving altered, ineffective, and unsafe refrigerated medications. Findings: Review of medication refrigerator temperature logs on 6/29/22 at 11:48 AM revealed incomplete medication refrigerator temperature logs in Spruce Court for the month of June 2022. Missing AM temperature recordings on 6/4, 6/6, 6/7, 6/13, 6/19, 6/20, 6/22, 6/24 and 6/28. Missing PM recordings on 6/2, 6/3, 6/4,6/11, 6/12, 6/14, 6/20, 6/21, and 6/25. Review of medication refrigerator temperature logs on 6/29/22 at 2:35 PM revealed incomplete medication refrigerator temperature logs in [NAME] Court for the month of June 2022. Missing AM temperature recording on 6/24. Missing PM temperature recordings on 6/21,6/22, 6/24, 6/26, 6/27, and 6/28. Review of medication refrigerator temperature logs on 6/30/22 at 8:10 AM revealed incomplete medication refrigerator temperature logs in [NAME] Court for the month of June 2022. Missing AM temperature recordings on 6/4, 6/7, 6/8, 6/14, 6/15, 6/19, 6/21, 6/22, 6/26, 6/27, 6/28, and 6/29. Missing PM temperature recordings on 6/1-4/22, 6/8-25/22, and 6/29. Interview on 6/30/22 at 8:15 AM with Licensed Nurse (LN) #3, when asked how often medication refrigerators temperature were monitored and documented, LN #3 stated, they were to be documented twice a day. Review of the facility Policy and Procedures on 6/30/22 revealed under Section 4.1 STORAGE OF MEDICATION . the reading will be taken twice daily and documented on the RxNow temperature log. .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0888 (Tag F0888)

Could have caused harm · This affected most or all residents

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Based on interviews, observations, and record review, the facility failed to ensure the COVID-19 Vaccination of facility staff was monitored according to the mandated COVID-19 staff vaccination in the long-term care facility. Specifically, the facility failed to obtain the vaccination status of all volunteers who provided other services such as visiting and playing games with the residents. This failed practice placed the entire facility, with a census of 93 residents, at risk of contraction and spread of the COVID-19 virus. Findings: During an interview on 6/28/22 at 8:14 AM the Assistant Administrator (AA) stated that volunteers and nursing students were tested for COVID-19 before they provided care and services to the residents. The AA also stated the facility used rapid test (an on-site antigen test for COVID-19 that gives results in 15 minutes). During an interview on 7/1/22 at 10:17 AM the Assistant Administrator and Infection Preventionist (IP) stated the volunteer vaccination status was not checked due to privacy but that rapid tests were completed. The facility was unable to provide documentation of volunteer vaccination status by the end of this survey. During multiple observations from 6/27/22-7/1/22 and 7/5/22, revealed volunteers visited with residents in their room, played games with residents at common area tables, played the piano, etc. Record review of policy Employee Vaccination COVID-19, revised 6/21/22, revealed All employees are required to fill out the COVID-19 Vaccine Consent form and provide proof of Vaccination or receive an approved Religious or Medical exemption . Tracking 2.) Center staff include employees, consultants, contractors who conduct routine or extended visits (and the nature of visit may include contact with residents/staff), caregivers, volunteers, students (example, nurse-aide training program, or student nurses.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), $76,756 in fines, Payment denial on record. Review inspection reports carefully.
• 62 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $76,756 in fines. Extremely high, among the most fined facilities in Alaska. Major compliance failures.
• Grade F (18/100). Below average facility with significant concerns.

Bottom line: Trust Score of 18/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Centennial Post Acute's CMS Rating?

CMS assigns CENTENNIAL POST ACUTE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Alaska, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Centennial Post Acute Staffed?

CMS rates CENTENNIAL POST ACUTE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 54%, compared to the Alaska average of 46%. RN turnover specifically is 69%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Centennial Post Acute?

State health inspectors documented 62 deficiencies at CENTENNIAL POST ACUTE during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 61 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Centennial Post Acute?

CENTENNIAL POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PACS GROUP, a chain that manages multiple nursing homes. With 102 certified beds and approximately 96 residents (about 94% occupancy), it is a mid-sized facility located in ANCHORAGE, Alaska.

How Does Centennial Post Acute Compare to Other Alaska Nursing Homes?

Compared to the 100 nursing homes in Alaska, CENTENNIAL POST ACUTE's overall rating (1 stars) is below the state average of 3.5, staff turnover (54%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Centennial Post Acute?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is Centennial Post Acute Safe?

Based on CMS inspection data, CENTENNIAL POST ACUTE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Alaska. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Centennial Post Acute Stick Around?

CENTENNIAL POST ACUTE has a staff turnover rate of 54%, which is 8 percentage points above the Alaska average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Centennial Post Acute Ever Fined?

CENTENNIAL POST ACUTE has been fined $76,756 across 2 penalty actions. This is above the Alaska average of $33,846. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Centennial Post Acute on Any Federal Watch List?

CENTENNIAL POST ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 102
Avg. Residents: 96
Occupancy: 95.0%
Ownership: For profit - Limited Liability company
Chain: PACS GROUP
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Immediate Jeopardy citation: -12
62 Deficiencies: -10
Fines ($76,756): -10
Final Score: 18/100

Nearby Alternatives

POLARIS TRANSITIONAL CARE 4-star Polaris Extended Care 2-star

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 025025