. Based on interview and record review, the facility failed to provide resident care with respect and dignity for two residents (#'s 27 and 50), out of 20 sampled residents. This failure placed the residents at risk of negatively affect the resident's quality of life. Findings: Resident #50 Resident #50 was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease) and cerebrovascular accident (stroke). During an interview on 1/6/25 at 2:06 PM, Resident #50 stated he/she requested an evening snack a couple weeks ago. Resident #50 further stated, a CNA [Certified Nurse Assistant - unknown] told me to get up and get my own damn self to get ice cream and cookies. Resident #50 stated the CNA refused to get the snack for him/her. Resident #50 stated his/her nurse noticed him/her trying to get his/her own evening snack and asked what he/she was doing. Resident #50 told the nurse what the CNA said. Afterwards, the nurse brought him/her the requested ice cream and cookies. Resident #50 further stated he/she felt the comments made by the CNA made him/her feel discriminated against. During an interview on 1/8/25 at 5:16 PM, when asked about Resident #50's allegations that occurred a few weeks ago, Resident Care Coordinator (RCC) #2 stated he/she was aware and familiar with the event. RCC #2 stated there was no investigation completed regarding the known alleged mistreatment. RCC #2 stated this was a missed opportunity. Review of Resident #50's Denali Center H & P [History and Physical], dated 1/11/24, revealed: . resident no longer able to care for [him/herself] . does independently get up from bed and ambulate [a] short distance to bathroom, but no more activity than that. evaluated at bedside, has O2 [oxygen] on by NC [nasal cannula] mild exertion ie [i.e.] moving from supine to sitting at bedside does become tachypneic still able to say a few words at a time. Assessment/Plan . severe protein - calorie malnutrition . related to [his/her] end stage [COPD]. prognosis poor . Review of Resident #50's Denali Center Progress Note, dated 12/19/24, revealed: . [he/she] had gotten up to the shower without oxygen supplementation and became very dizzy, started to have fairly severe dry heaving. Once [he/she] got back to bed and laid down, [he/she] had some sharp left upper chest pain . Assessment and Plan: . continue with oxygen at 3 L [liters] per nasal cannula at rest. Okay to increase for short term only . Review of Resident #50's LTC Care Plan Summary, dated 1/10/25, revealed: Evaluate Effectiveness of O2 and Respiratory Therapy, Evaluate Need to Pace Activities and Plan Rest Periods. Staff to Use Gait Belt With all Transfers and Ambulation. Promote gradual weight gain r/t [related to] severe PCM [protein calorie malnutrition], hx [history] of significant wt. [weight] loss. Encourage Snacks Between Meals and With Activities. Offer Meal Substitutes. Review of the facility's policy, Abuse and Neglect, dated 3/5/24, revealed: . III. Policy: 2. Each resident must be provided individualized care with dignity and respect. During the delivery of personal care and services . 7. The managerial staff provides feedback regarding the concerns that have been expressed . Resident #27 Resident #27 was admitted to the facility with diagnoses that included paraplegia (paralysis of the legs), neurogenic bladder (bladder control loss due to nerve issues), anemia (low blood oxygen), anxiety disorder and depression (mood disorder). During an interview and concurrent observation on 1/6/25 at 2:06 PM, Resident #27 stated he/she had pressed the call light right before this surveyor came into his/her room, with the intent of asking staff for bathroom assistance. The resident stated he/she had a bowel movement and had been sitting in it. Resident #27 continued to explain he/she had asked RCC #3 to call his/her CNA right after RCC #3 finished changing the resident's catheter. The resident further stated RCC #3 had left the room around 1:50 PM. This was verified by this surveyor, who had encountered RCC #3 in the hallway 10 minutes prior. Resident #27 commented that his/her assigned CNA often ran behind. The resident stated he/she did not believe there was enough staffing available on the unit. Resident #27 stated he/she wondered if staff looked at the call lights and decided to ignore them. Resident #27 further stated: It depends on who's working . I've complained verbally but they always say to us [residents] we are short staffed. Continuing the observation at 2:16 PM, LN #5 went into Resident #27's room to administer the resident's medication and acknowledged the resident's need for bathroom assistance. The LN told the resident that he/she was going to call the assigned CNA, after administering the medication. In the minutes that followed, no assistance arrived, and Resident #27 pressed the call light again. At 2:27 PM, CNA #3 stopped by the room and asked how he/she could help the resident. Resident #27, once again, explained he/she needed bathroom assistance. CNA #3 stated he/she would call for someone. After no response, Resident #27 pressed his/her call light again. At 2:56 PM, CNA #4 entered the room and asked how they could help. Resident #27 explained what had happen and requested bathroom assistance. CNA #4, stated: Let me just get my papers for the shift [referring to report] and I will come back to change you if no one else does it in the meantime. CNA #4 returned to the room at 3:17 PM and proceeded to change Resident #27. During the continued observation from 2:06 PM to 3:17 PM, Resident #27 had been sitting in his/her bed and had been requesting for a change [toileting assistance] because he/she had had a bowel movement (BM) earlier. Further observation revealed a fecal odor in the room. Resident #27 waited for toileting assistance for one hour and 11 minutes. Review of the Call Light Log, dated 1/8/25 pertaining to Resident #27's room revealed the following calls logged around the bathroom assistance request timeframe: - 1/6/25 1:45:50 PM - 1/6/25 1:45:55 PM - 1/6/25 1:45:56 PM - 1/6/25 1:55:01 PM - 1/6/25 2:07:23 PM - 1/6/25 2:36:26 PM - 1/6/25 2:51:23 PM - 1/6/25 2:55:08 PM - 1/6/25 3:13:55 PM - 1/6/25 3:16:49 PM Review of the Tamarak Unit's Assignment Sheet, dated 1/6/25 revealed the Tamarak Unit was staffed with 1 RCC, 2 nurses and 3 CNA's at the time of the call light request for bathroom assistance. During an interview on 1/8/25 at 10:38 AM, RCC #3 stated the CNA's were responsible for providing overall full care such as emptying foleys, turning residents, providing bed pans, ambulating residents to the bathroom, operating lifts and providing assistance with toileting. RCC #3 also stated that in Resident #27's case he/she would have changed him/her (Resident #27) [himself/herself], if he/she had known earlier while he/she was in the room. The RCC stated Resident #27 just asked me to call his/her CNA and was not specific about the need to be changed. The RCC further stated: Otherwise, I would have done it myself right away. The RCC continued: Still, there is no excuse for what happened . they [the CNA's] should have come and changed resident immediately. During an interview with LN #5 on 1/8/25 at 3:17 PM, he/she stated: Anybody can answer a call light, but I don't recall all of Mondays [1/6/25] and how all went down [referring to the call for assistance toileting of Resident #27]. LN #5 confirmed he/she remembered being in the room to administer medications. During an interview on 1/8/25 at 3:17 PM, CNA #1 stated: I was busy in the middle and did not see a call light . I was probably helping a different resident . no one told me that Resident #27 needed to be changed. During an interview with CNA #4 on 1/8/25 at 8:00 PM, stated he/she recalled answering the call light repeating what Resident #27 had said to him/her: [Resident #27] needed help to get changed, so I went to grab my papers [report] and then came back to help. CNA #4 further stated: [Resident #27] was happy that I came back and told me that previous staff had left the resident for a few hours without assistance . he/she [resident] was a little irritated and uncomfortable. Review of Resident #27's care plan, undated, revealed: .resident dependent for toileting .provide AM-HS [morning - bedtime] cares set up to assist with washing .peri-area .remind and cue resident to call for assistance . evaluate bowel regularity, BM color, bleeding .evaluate possible causes for change in BM consistency .evaluate skin and provide skin care to manage skin integrity .offer toileting to encourage regular elimination .evaluate for abdominal distension, tenderness, bowel motility. Review of the facility's Resident Rights, dated 3/5/24, revealed: .Denali Center will make every effort to assist each resident in exercising his/her rights and to ensure residents are always treated with respect, kindness, and dignity Residents have the right to expect the Denali Center staff to provide: 1. Considerate and respectful treatment. .

. Based on record review and interview the facility failed to implement written polices and procedures that prohibited and prevented mistreatment of residents, investigation, and reporting for 1 resident (#50) out of 20 sampled residents. Specifically, the facility failed to report an allegation of mistreatment to the Administrator within 24 hours if the events that cause the allegation do not involve abuse. This failed practice placed Resident#50 at risk of further exposure to mistreatment and/or mental anguish. Findings: Record review on 1/6-10/24, revealed Resident #50 was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease) and cerebrovascular accident (stroke). Resident #50 BIMS (Brief Interview for Mental Status) test score was 14 (which indicated intact cognitive status). During an interview on 1/6/25 at 2:06 PM, Resident #50 stated he/she requested an evening snack a couple weeks ago. Resident #50 further stated, a CNA [Certified Nurse Assistant] told me to get up my own damn self to get ice cream and cookies. Resident #50 stated the CNA refused to get the snack for him/her. Resident #50 stated his/her nurse [unknown] had seen him/her trying to get his/her own evening snack and asked what he/she was doing. Resident #50 told the nurse what the CNA stated to him/her and the nurse got him/her the requested ice cream and cookies. Resident #50 further stated he/she felt the comments made by the CNA made him/her feel discriminated against. Record review of the facility's policy, Denali Center Abuse and Neglect, effective date 3/5/24 revealed A. The Law: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals . Further review of the same policy, dated 3/5/24, revealed the reference to (§483.13) Reference F 223, 224, 225, 22. Review of the State Operation's Manual, Appendix PP, Revision 211, dated 2/3/23 revealed (§483.13) Reference F 223, 224, 225, 22. was no longer a valid section of the Social Security Act. During an interview on 1/8/25 at 5:16 PM, when asked about Resident #50's allegations that occurred a few weeks ago, LN #1[Resident Care Coordinator (RCC)] stated he/she was aware and familiar with the event. LN #1 stated there was no investigation completed regarding the known alleged mistreatment. LN #1 stated this was a missed opportunity. Record review of the facility's policy, Denali Center Abuse and Neglect, effective date 3/5/24, revealed .Mandatory Reporting requirements 1. Any physician, nurse, or other employee who has reasonable cause to believe that a resident has been abused, exploited, mistreated, or neglected must report it immediately to the Administrator or Director of Nurses for investigation. 2. Any physician, nurse, or other employee who has reasonable cause to believe that a resident has been abused, exploited, mistreated, or neglected must report to the local law enforcement for investigation within 24 hours of becoming aware. During an interview on 1/8/25 at 6:00 PM, the Administrator stated she was not aware of the allegations of mistreatment reported by Resident #50 and the allegation was not investigated or reported. Record review of the facility's policy, Denali Center Abuse and Neglect, effective date 3/5/24 revealed Investigation of abuse and neglect: Denali Center identifies and investigates every allegation of abuse. The Associate Administrator/Assigned Individual for Denali Center is responsible for ensuring that all instances or allegations of suspected abuse are investigated in an organized, efficient, and timely manner. The key steps in the investigatory process include the following. 1. Identifying who is responsible for the initial reporting, investigation of alleged violations, and reporting results to the proper authorities 2. Ensuring the residents are protected from harm during an investigation 3. The reporting of all instances and allegations of abuse to appropriate State agencies as required. During an interview on 1/10/25 at 11:00 AM, when asked about Resident #50's allegations of mistreatment, the Medical Director stated he was not aware of the allegations prior to the survey. Further stated he should have been aware, and this should have been investigated and reported to the State agency. Record of the facility's policy, Denali Center Abuse and Neglect, effective date 3/5/24 revealed: Abuse- The willful infliction of . intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes the deprivation of goods or services . It includes verbal abuse. Willful, as used in definition of abuse, means the individual must have acted deliberately . Neglect is the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Verbal abuse is the use of oral, written, or gestured language that willfully includes the use of disparaging and derogatory terms to residents . Mental abuse includes humiliation, harassment, threats of punishment, or deprivation . Mistreatment means inappropriate treatment or exploitation of a resident. M. Alleged violation is a situation or occurrence that is observed or reported by staff, resident . but has not yet been investigated . Each resident has the right to be free from abuse . Residents must not be subjected to abuse by anyone including, but not limited to, facility staff . Each resident must be provided individualized care with dignity and respect . Denali Center is committed to an abuse free environment, and as such: 1. Recognizes the seriousness of the problem . Denali Center provides information to staff. on the importance of reporting concerns, incidents, and grievances . 5. Utilizing resident and staff interviews, documentation and other evidence as appropriate, Denali Center will compile evidence that all allegations of abuse, neglect, or mistreatment have been thoroughly investigated and that further potential abuse has been prevented while the investigation is in progress. 6. The results of the investigation are reported to the State agency for Certification and Licensure, and appropriate corrective action is implemented to prevent a recurrence. Results must be reported within 5 working days of the incident . .

. Based on record review and interview, the facility failed to: 1) investigate an alleged report of mistreatment; 2) prevent further potential mistreatment once the allegation was made; and 3) report the allegation, by submitting the results of the investigation to the State Agency, administrator, or his or her designated representative within 5 working days, for 1 resident (#50), out of 20 sampled residents This failed practice placed Resident #50 at risk of further exposure to mistreatment and/or mental anguish. Findings: Record review on 1/6-10/25, revealed Resident #50 was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease) and cerebrovascular accident (stroke). Resident #50 BIMS (Brief Interview for Mental Status) test score was 14 (which indicated intact cognitive status). During an interview on 1/6/25 at 2:06 PM, Resident #50 stated he/she requested an evening snack a couple weeks ago. Resident #50 further stated, a CNA [Certified nurse Assistant-unknown] told me to get up my own damn self to get ice cream and cookies. Resident #50 stated the CNA refused to get the snack for him/her. Resident #50 stated his/her nurse had seen him/her trying to get his/her own evening snack and asked what he/she was doing. Resident #50 told the nurse what the CNA stated to him/her and the nurse got him/her the requested ice cream and cookies. Resident #50 further stated he/she felt the comments made by the CNA made him/her feel discriminated against. During an interview on 1/ 8/25 at 5:16 PM, when asked about Resident #50's allegations that occurred a few weeks ago, LN #1[Resident Care Coordinator (RCC)] stated he/she was aware and familiar with the event. LN #1 stated there was no investigation completed regarding the known alleged mistreatment. LN #1 stated this was a missed opportunity. During an interview on 1/8/25 at 6:00 PM, Administrator stated she was not aware of the allegations of mistreatment reported by Resident #50 and the allegation was not investigated or reported. During an interview on 1/10/25 at 11:00 AM , when asked about Resident #50's allegations of mistreatment, the Medical Director stated he was not aware of the allegations prior to the survey. Further stated he should have been aware, and this should have been investigated and reported to the State agency. Review of the facility's Denali Center Abuse and Neglect, effective date 3/5/24, revealed . Definitions: A. Abuse- The willful infliction of . intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes the deprivation of goods or services . It includes verbal abuse. Willful, as used in definition of abuse, means the individual must have acted deliberately . Verbal abuse is the use of oral, written, or gestured language that willfully includes the use of disparaging and derogatory terms to residents . M. Alleged violation is a situation or occurrence that is observed or reported by staff, resident . but has not yet been investigated . Policy: A. Law: Each resident has the right to be free from abuse . 2. Residents must not be subjected to abuse by anyone including, but not limited to, facility staff . Each resident must be provided individualized care with dignity and respect . C. Denali Center is committed to an abuse free environment, and as such: 1. Recognizes the seriousness of the problem . 6. Denali Center provides information to staff. on the importance of reporting concerns, incidents, and grievances . F. Investigation of abuse and neglect: Denali Center identifies and investigates every allegation of abuse. G. The Associate Administrator/Assigned Individual for Denali Center is responsible for ensuring that all instances or allegations of suspected abuse are investigated in an organized, efficient, and timely manner. The key steps in the investigatory process include the following. 1. Identifying who is responsible for the initial reporting, investigation of alleged violations, and reporting results to the proper authorities 2. Ensuring the residents are protected from harm during an investigation 3. The reporting of all instances and allegations of abuse to appropriate State agencies as required . H. Mandatory Reporting Requirements 1. Any physician, nurse, or other employee who has reasonable cause to believe that a resident has been abused, exploited, mistreated, or neglected must report it immediately to the Administrator or Director of Nurses for investigation. 2.Any physician, nurse, or other employee who has reasonable cause to believe that a resident has been abused . must report it to the local law enforcement for investigation within 24 hours of becoming aware of the event or within 2 hours if serious bodily injury. Contact Administration prior to calling law enforcement. 4. Once notified, the Administrator or Director of Nursing is required to immediately notify the State agency for Certification and Licensure, to report the allegation, and ensure that an investigation is conducted. Immediately means as soon as possible, and never to exceed 24 hours. 6. The results of the investigation are reported to the State agency for Certification and Licensure, and appropriate corrective action is implemented to prevent a recurrence. Results must be reported within 5 working days of the incident . .

. Based on record review, observation, and interview, the facility failed to ensure the comprehensive care plan reflected the current status and care for one resident (#31) out of two sampled residents with assistive seat belt devices. This failed practice placed the resident at risk for not receiving adequate care and increased risk for injuries. Findings: Record review on 1/6-10/25, revealed Resident #31 was admitted to the facility with diagnoses that included dementia (a condition that affects memory and thinking) and Parkinson's disease (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination). Review of the facility's Quarterly Assessment, dated 12/2/24, revealed: . Other: tremors . Mobility Braden: Very limited . Can resident appropriately call for assistance?: Yes . Morse Mental Status . Orientated to own ability . Does the resident have a hx [history] of falls?: Yes . Is resident able to communicate needs?: Yes . Free of restraints . Minimum Data Set (MDS -a federally required nursing assessment) Review: Review of the MDS OBRA Quarterly Review Assessment, dated 12/4/24, revealed: . P0100. Physical Restraints, Physical restraints are any manual method or physical or mechanical device, mater or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . Used in Chair or Out of Bed. G. Chair prevents rising. 0 = Not used. H. Other. 0 = Not used. P0200. Alarms. An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected . F. Other alarm. 0 = Not used. Care Plan Review: Review of Care Plan Summary, dated 1/9/25, revealed . Current Interdisciplinary Plan of Care, LTC [Long Term Care] Falls. Interventions . Do Not Leave Alone in Wheelchair in Room, Ensure Resident Can Remove Velcro Seatbelt Independently. Resident Review: During an observation and simultaneous interview on 1/6/25 at 2:48 PM, revealed Resident #31 was sitting in a manual wheelchair in his/her room alone. Resident #31 had a belt around his/her waist that was attached to the wheelchair. In the center of the belt was a plastic piece that resembled a belt buckle. When resident was asked if he/she could remove the belt, he/she stated no. Resident #31 was observed to exhibit bilateral upper extremity tremors when trying to grab the belt to demonstrate the inability to remove it. Certified Nurse Assistant (CNA) #2 walked into Resident #31's room during this interview, he/she did not know if Resident #31 was able to remove independently. During an interview on 1/9/25 at 4:30 PM, Resident Care Coordinator (RCC) #2 stated there was no documented seat belt evaluation for Resident #31. RCC #2 further stated he/she was not aware who verified that the resident was able to physically remove the belt. During an interview on 1/9/25 at 5:01 PM, when the Director of Nursing (DON) was asked if Resident #31 could remove his/her wheelchair seat belt, she stated I think so, he can paint. When further asked if there was an evaluation completed to verify that the resident was assessed, she stated I sure hope so, it would be if I was on the floor. Review of facility's policy, Denali Center- Care Plan Process, last reviewed 7/26/23, revealed: . 1. To assure all residents admitted and residing at Denali Center will have current care plans reflecting care received from all disciplines. 2. INTERDISCIPLINARY CARE PLAN: . e. identify the professional services/team members that are responsible for each element of care. c. Approach to be used-CNA/LN [Licensed Nurse] task list are developed from plan of care . .

. Based on record review and interview, the facility failed to ensure an accurate medical record was maintained for one resident (#10) out of 20 sampled residents. Specifically, the facility's medical record process failed to ensure medical records were accurate. This failed practice created incomplete medical records which placed the resident at risk for inconsistencies in treatment and care provided. Findings: Record review from 1/6-10/25 revealed Resident #10 was admitted to the facility with diagnoses that include generalized anxiety disorder, heart failure, and chronic kidney disease. Review of the facility's Medical Director's progress note, dated 1/1/25 at 5:16 PM, revealed: [Resident #10] suffers from bi-polar [mental health condition characterized by extreme mood swings including periods of elevated and irritable to low mood and energy levels], hallucinations, anxiety, and depression . Review of the facility's Medical Director's annual history and physical, dated 7/27/24 at 12:08 PM, revealed: [Resident #10] has a history of bipolar disorder with auditory hallucinations. We are following [his/her] mental health issues as well as pain concerns through the BIT/PIT [Behavioral Intervention Treatment/Pain Intervention Treatment] process. Review of the Denali Center Consultation dated 3/27/23, revealed: [Resident #10] has been seen by [Psychiatrist] in 2018 who diagnosed the patient with bipolar disorder type 1 . Review of the MDS (Minimum Data Set, a federally required nursing assessment), dated 10/31/24, revealed in Section I-Active Diagnosis, the response was unmarked for I5900. Bipolar Disorder. Review of the Diagnoses and Problems, on 1/9/25 at 11:43 AM, did not list bipolar disorder in Resident #10's electronic health record (EHR). During an interview with MDS Coordinator #1 on 1/9/25 at 1:07 PM, he/she stated active diagnosis were filled out in the MDS based off the diagnosis list in the EHR. He/she further stated he/she did not update the diagnosis list in the EHR. During an interview with [NAME] #2 on 1/9/25 at 2:00 PM, he/she stated coders updated the diagnosis list for residents in the facility and that he/she was the most recent coder assigned to Resident #10. He/she further stated diagnoses were updated based off the most recent physician progress notes, which were checked on Monday, Wednesday and Fridays. When asked if Resident #10 should have had bipolar disorder listed as a diagnosis based off the most recent progress note by the Medical Director on 1/1/25 at 5:16 PM, he/she confirmed Resident #10 should have had bipolar disorder listed as a diagnosis. [NAME] #2 stated, he/she doesn't know why it never got picked up. Review of the Resident #10's care plan, undated, .Notify Provider if Hallucinations or Delusions are Distressing to Resident as Needed .Evaluate Medications for Desired and Adverse Outcomes .Take Resident to BIT/PIT Quarterly and PRN .Consult BIT/PIT for Evaluation of Causes and Treatment Options .Administer Medications as Ordered . During an interview with the Administrator on 1/9/25 at 4:00 PM, Administrator stated there was no policy and procedures on medical records coding of medical diagnoses. .

. Based on observation, interviews and record review, the facility failed to ensure three residents (#s 19, 22, 25) out of 20 sampled residents were given the opportunity to make choices about aspects of their lives that were significant to them. Specifically, the facility failed to ensure residents' rights to choose and participate in activities consistent with his/her interest. This failed practice had the potential to affect residents' quality of life. Findings: Activities participation: An observation on 1/6/25 at 1:14 PM revealed a white board by the Activity Room, stated, January 6th, 2025. Happy New Year! No group activities today, sorry for inconvenience . Resident #19 Record review on 1/6-10/25, revealed Resident #19 was admitted to the facility with diagnoses that included morbid obesity (a complex chronic disease that is characterized by a Body Mass Index [BMI] of 40 or higher), major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest), anxiety, and hemiplegia (neurological condition that involves paralysis of one side of the body). During an interview on 1/6/25 at 11:46 AM, Resident #19 stated he/she did not like how they are on lockdown and stated that, he/she enjoys bingo and socializing with others. Furthermore, he/she added that bingo hasn't happened since this lockdown. Review of the resident's care plan, undated, revealed: . Participate in Activity of Choice Daily . Encourage Active participation for Social Interaction Needs . Activities will Post Calendar in room . Remind Resident of Upcoming Activities of Interest . Resident #22 Resident #22 was diagnosed with anxiety, aphasia (impairment in a person's ability to comprehend or formulate language because of damage to specific brain regions), hemiplegia, and major depressive disorder. During an interview on 1/6/25 at 2:19 PM, the Resident stated that he/she was not able to go to activities due to being on lockdown. Furthermore, he/she added that there were no alternative activities offered for church. Review of the resident's care plan, undated, revealed: .Encourage Active Participation for Social Interaction Needs . Encourage Active Participation for Religious Spiritual Needs . Invite and Assist to Group Activities of Interest . Resident #25 Resident #25 was diagnosed with morbid obesity, chronic obstructive pulmonary disease (lung obstruction), hypertensive heart disease with heart failure (high-pressure heart), type 2 diabetes mellitus (insulin resistance), and major depressive disorder. During an interview on 1/7/25 at 11:24 AM, Resident #25 stated: Upper management are the ones making the rules. We are not allowed to go to church. We were told we couldn't go, not even with a mask. Visitors can come in and have a mask. We are not allowed to visit out there [referring to the common areas] anymore. This affects activities too, because if everyone wanted to play Bingo there is not enough room in the sunroom to have things as they should. During a meeting with the Resident Council on 1/8/25 at 2:05 PM, Resident #25 further stated they closed down our store, church and we can't walk around freely. During the same meeting, all residents in attendance confirmed that the option of Church [religious services] happening via Zoom (an online video conferencing tool) was not presented to them. During an interview with the Medical Director on 1/10/25 at 11:00 AM, he stated suspending activities just happens by default . the point is to not have people near each other. During an interview with Activities Assistant #1 on 1/9/25 at 12:00 PM, he/she stated that church was cancelled on two different days due to the lockdown. He/she further stated the facility had not considered Church activity via Zoom as an option. Review of the resident's care plan, undated, revealed: .involve in activities of choice and interest . adapt care and environment to optimize independence .engage in daily independent activities. .

. Based on record review, interview and observation, the facility failed to monitor, evaluate, and determine the use of assistive devices as physical restraints for two residents (#31and #61) out of 20 sampled residents. This failed practice placed residents at an increased risk for unnecessary physical restraints, inadequate monitoring of devices, and physical injury. Findings: Resident #31 Record review on 1/6-10/25, revealed Resident #31 was admitted to the facility with diagnoses that included dementia (a condition that affects memory and thinking) and Parkinson's disease (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination). During an observation and simultaneous interview on 1/7/25 at 11:56 AM, Resident #31 was wearing a belt around his/her waist that was attached to the wheelchair. In the center of the belt was a plastic piece that resembled a belt buckle. When resident was asked if he/she could remove the belt, he/she said no. Resident #31 further stated maintenance personnel or clinical staff were the only ones that could remove the belt. When asked what the belt was for, Resident #31 stated it keeps me from falling out. During an interview on 1/9/25 at 4:39 PM, Resident Care Coordinator (RCC) #2 stated Resident #31 started wearing the seat belt on 6/19/24 after a fall. When asked if Resident #31 was able to remove the belt, RCC #2 stated he/she was not aware. RCC #2 was unable to locate in the EHR (electronic health record) if Resident #31 was able to remove his/her seat belt. RCC #2 stated Resident #31 transfers with one person assist. RCC #2 further stated Resident #31 transfers with the use of a sit to stand device. RCC #2 explained residents must have strength to use a sit to stand device being able to hang on and bear weight with their legs. During an interview on 1/9/25 at 5:01 PM, when the Director of Nursing (DON) was asked if Resident #31 could remove his/her wheelchair seat belt, she stated I think so, he/she can paint. When further asked if there was an evaluation completed to verify that the resident was assessed, she stated I sure hope so, it would be if I was on the floor. Review of the facility's, Quarterly Assessment, dated 12/2/24, revealed: . Other: tremors . Mobility Braden: Very limited . Can resident appropriately call for assistance?: Yes . Morse Mental Status . Orientated to own ability .Does the resident have a hx [history] of falls?: Yes . Is resident able to communicate needs?: Yes . Free of restraints . Review of the MDS (Minimum Data Set, a federally required nursing assessment) OBRA Quarterly Review Assessment, dated 12/4/24, revealed: P0100. Physical Restraints, Physical restraints are any manual method or physical or mechanical device, mater or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . Used in Chair or Out of Bed. G. Chair prevents rising. 0 = Not used. H. Other. 0 = Not used. P0200. Alarms. An alarm is any physical or electronic device that monitors resident movement and alerts the staff when movement is detected . F. Other alarm. 0 = Not used. Review of the Care Plan Summary, dated 1/9/25, revealed: . Interventions . Ensure Resident Can Remove Velcro Seatbelt Independently. Resident #61 Record review on 1/6-10/25, revealed Resident #61 was admitted to the facility with diagnoses that included 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 (a severe mental disorder characterized by delusions [false beliefs], hallucinations [perception of sights, sounds, etc. that are not actually present], incoherence and physical agitation). During an observation and simultaneous interview on 1/6/25 at 2:48 PM, Resident #61 was sitting in a manual wheelchair in his/her room. Resident #61 had a belt around his/her waist that was attached to the wheelchair. In the center of the belt was a plastic piece that resembled a belt buckle, which would alarm when it was released. When the Resident was asked if he/she could remove the belt, he/she stated no and was shaking his/her head back in forth. Resident #61 was observed with upper extremity tremors when trying to grab the belt to demonstrate the inability to remove it. Certified Nursing Assistant (CNA ) #2 walked into Resident #61's room during the conversation and stated, the strap is to prevent a fall, if the Resident tries to stand up, it alarms. CNA #2 stated to Resident #61, I am going to set off the alarm and then pulled the hook and loop belt apart, which set off the alarm. When asked if Resident #61 was able to remove the seat belt, CNA #2 stated he/she did not know. During an interview on 1/9/25 at 4:30 PM, RCC #2 stated Resident #61's seat belt alarm was initiated on 10/28/24 after a fall. RCC #2 stated residents must be able to open the belt independently or it was a restraint. RCC #2 stated there were no documented seat belt evaluations for Resident #61. RCC #2 further stated he/she was not aware who verified that the resident was able to physically remove the belt. During an interview on 1/9/25 at 4:54 PM, the Administrator stated residents must be able to remove seat belts prior to the initiation of the device. She further stated if the resident was unable to remove the seat belt, a seat alarm [chair pad alarm] should be used. Review of the Post Fall Evaluation Long Term Care, dated 1/6/25, revealed: . Mechanism of Fall: . resident found by staff in [his/her] room .and [his/her] w/c [wheelchair] which was tipped over. Orientation Assessment: Disoriented x 4. Record review of the MDS OBRA Quarterly Review Assessment, dated 10/23/24, revealed: . Section P - Restraints . P0200. Alarms. An alarm is a physical or electronic device that monitors resident movement and alerts the staff when movement is detected. D. Motion sensor alarm. 1 = used less than daily. No other documentation for alarms reviewed. Review of the facility's Quarterly Assessment LTC, dated 10/23/24, revealed: . Ambulates with 1 person assist, . Free of restraints, Other: ez stand [sit to stand lift] . Review of the facility's policy, Restraints/Resident Behavior and Practices, effective date 10/15/24, revealed: Purpose/Expected Outcome: A. This facility believes that each resident has the right to be free from any physical restraints imposed. for purposes of discipline or convenience. If physical restraints . are utilized, they must treat the resident's medical symptoms. Definitions: A. Physical Restraints: any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety belts, and geri-chairs can be physical restraints. 2. A seat belt is a restraint when: a. When the resident can move self from sitting position to standing and is unable to remove the seat belt. .

. Based on record review, interviews, and observations, the facility failed to ensure activities of daily living (ADLs) were provided to two residents (#s 19 and 67), out of 20 sampled residents. Specifically, showers or baths were not provided to the residents as specified in their individualized plans of care. This failed practice resulted in residents not receiving ADLs to maintain personal care and hygiene . Findings: Resident #19 Record review on 1/6-10/25, revealed Resident #19 was admitted to the facility with diagnoses that included morbid obesity (a complex chronic disease characterized by a Body Mass Index [BMI] of 40 or higher), and hemiplegia (neurological condition that involves paralysis of one side of the body). Review of the facility's .Bath/Shower Schedule, dated 12/12/24, revealed Resident #19 was noted to have scheduled shower days on Tuesdays and Saturdays. During an interview on 1/6/25 at 11:15 AM, Licensed Nurse (LN) #2 stated the Bath/Shower schedule was the most recent version. During an interview on 1/6/25 at 11:20 AM, when asked if he/she was provided with a shower or bath, Resident #19 stated, I can't remember when the last time was . During an interview on 1/9/25 at 8:31 AM, LN #4 stated that when ADL cares were completed it would be documented in the Electronic Health Record (EHR). Review of the MDS (Minimum Data Set, a federally required nursing assessment) Quarterly Assessment, dated 11/14/24, revealed Resident #19 was assessed as dependent in Section GG. GG0130. Self-Care E. Shower/bathe self. Review of the Resident #19's Care Plan, undated, revealed: .Goals Functions at Optimal Level with ADLs, Interventions .Provide Total Assistance x2 with Maxi Lift Transfers .Provide Bath/Shower- 2 times a Week .Resident needs extensive assist .may use shower gurney . Review on 1/9/25, of the facility's Resident Bathing Chart, dated 11/11/24 to 1/9/25, revealed no shower or bath was provided for Resident #19 since 12/31/24 (9 days prior). Further review of the Resident #19's Bathing Chart, revealed no documentation for a tub bath, bed bath, whirlpool bath, and other form of bathing provided. During an interview on 1/9/25 at 8:42 AM, the Administrator acknowledged that the resident had no documented shower from 1/1-9/25. Resident #67 Record review on 1/6-10/25, revealed Resident #67 was admitted to the facility with diagnoses that included atherosclerotic heart disease (hardening of the arteries from plaque), cerebral edema (swelling of the brain) and compression of brain. During an interview on 1/7/25 at 10:33 AM, when asked if he/she was provided with shower or bath, Resident #67 stated no, Review of the MDS admission Assessment, dated 12/2/24, revealed Resident #67 was assessed as dependent in Section GG. GG0130. Self-Care E. Shower/bathe self. Review of the Resident #67's Care Plan, undated, revealed: .Goals Functions at Optimal Level with ADLs, Interventions .Provide Bath/Shower- 2 times a Week . Review of the facility's Resident Bathing Chart from 11/29/24 -1/8/25, revealed no shower or bath provided on the following periods: 12/2-7/24- 6 days had passed since last shower on 12/1/24 12/11-14/24- 4 days had passed since last shower on 12/10/24 12/16-23/24- 8 days had passed since last shower on 12/15/24 12/25/24-1/6/25 - 13 days had passed since last shower on 12/24/24 Further review of the Resident #67's Bathing Chart, revealed no documentation for a tub, bed bath, whirlpool, and other form of bathing provided. During an interview on 1/8/25 at 1:46 PM, the Administrator stated the staff provided a bed bath to Resident #67 when the resident was unable to shower but was not documented. During a joint interview on 1/8/25 at 3:22 PM, Certified Nurse Assistant (CNA) #1, stated the residents were provided with a shower . When asked what the process was if the resident was unable to take a shower, LN #5 stated, the CNAs would provide a bed bath. When asked if the CNAs documented once the bed bath was provided to the residents, CNA #1 stated he/she would document it. Review of the facility's policy, CNA Expectations and Standards of Care, last updated 5/6/24 revealed: .2. Bathing/Personal Hygiene . a. bath/shower 2x a week, or as care planned . .

. Based on record review, observation and interview the facility failed to obtain residents' consent for bedrails use and conduct accurate risks and benefits assessments for four residents (#'s 4, 8, 31 and 61) out of 20 sampled residents and one unsampled resident (#11) reviewed for bedrails use. This failed practice had the potential to place residents at risk of falls, entrapment, and other preventable accidents and potentially place residents at risk of feelings of isolation and helplessness . Findings: Resident #4 Record review on 1/6-10/25, revealed Resident #4 was admitted to the facility with diagnosis that included cerebral palsy (congenital disorder of movement, muscle tone, or posture). During an observation and simultaneous interview on 1/7/25 at 11:12 AM, Resident #4 had right upper extremity (RUE) contractions. Resident #4's bed had both upper side rails, and the right lower side rail raised. The raised and uncovered upper bed rails began at the top of the bed and ended by Resident #4's lower chest and the raised right lower side rail began at his/her right hip and ended by his/her right knee. Resident #4's bedside table was placed along the opened left lower side of bed. When asked if he/she could lower the bed rails, Resident #4 stated he/she did not think so. When asked why the bed rails were raised, Resident #4 stated staff put the rails up and not sure why they are up. Review of the most recent Quarterly Assessment LTC [Long Term Care], dated 5/21/24, revealed: . Has resident requested to have side rails up for use of bed controls?: No, Has the resident requested to have side rails up for comfort or security?: No . Bed Safety PT/OT Recommend Side Rails: No . Does resident have a hx [history] of falls from the bed?: yes . Bed Safety Side Rail Use: Left Upper side rail, Left Lower side rail, Right Upper side rail, Right Lower side rail . Bed Safety Review W [with] Resident/Legal Rep: No . Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment), OBRA Quarterly Review Assessment, dated 11/20/24, revealed: . Section P - Restraints, P0100 . Used in Bed. A. Bed rail. 0 = Not used. Review of the Care Plan Summary, dated 1/9/25, revealed: . LTC Falls . Intervene for Unsafe Behaviors Effecting Fall Risk . Keep bed controls out of reach and locked when in bed . upper side rails up with seizure pads . Further review of Resident #4's medical record revealed no physician order and/or informed consent regarding the use of bed rails was found. During an interview on 1/9/25 at 4:06 PM, Resident Care Coordinator (RCC) #2 stated Resident #4 should only have both upper side rails raised. RCC #2 was asked if Resident #4 had a bed rail assessment. RCC #2 was unable to locate a bed rail assessment in the medical record. Resident #8 Record review on 1/6-10/25, revealed Resident #8 was admitted to the facility with diagnoses that included a fracture of the lower end of the left tibia (shin bone) and diabetes mellitus. During an observation and simultaneous interview on 1/10/25 at 9:00 AM, revealed Resident #8 had four side rails raised on his/her bed. Resident #8 stated he/she was not sure why all side rails were raised. Record review of the most recent MDS OBRA Quarterly Review Assessment, dated 11/27/24, revealed: . Section P- Restraints, P0100 . Used in Bed. A. Bed Rail. 0 = Not used . Further review of Resident #8's medical record revealed no physician order and/or informed consent regarding the use of bed rails was found. Resident #11 Record review on 1/6-10/25 revealed Resident #11 was admitted to the facility with diagnoses that included pressure ulcer (bed sore) of the sacral (end of spine) region and diabetes mellitus. An observation on 1/10/25 at 9:15 AM, revealed Resident #11 had three side rails raised on his/her bed. Resident #11 stated he/she was not sure why the side rails were raised. Record review of the most recent MDS OBRA Quarterly Review Assessment dated 12/10/24, revealed: .Section P- Restraints, P0100 . Used in Bed. A. Bed Rail. 0 = Not used . Further review of Resident #11's medical record revealed no physician order and/or informed consent regarding the use of bed rails was found. Resident #31 Record review on 1/6-10/25, revealed Resident #31 was admitted to the facility with diagnoses that included dementia (a condition that affects memory and thinking) and Parkinson's disease (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination). During an observation and simultaneous interview on 1/7/25 at 11:56 AM, Resident #31 had both upper side rails raised. The raised upper side rails began at the top of the bed and ended by Resident #31's lower chest. When asked if he/she could lower the side rails, Resident #31 stated: No but staff can. Review of Resident #31's Quarterly Assessment LTC, dated 12/2/24, revealed: . Bed Safety Assessment . Has resident requested to have side rails up for use of bed controls?: No Has resident requested to have side rails for comfort or security?: No . Bed Safety PT/OT Recommend Side Rails: No . Bed Safety Side Rail Use: Left Upper side rail, Left Lower side rail, Right Upper side rail, Right Lower side rail . Bed Safety Review w/ Resident/Legal Rep: No . Record review of the most recent MDS OBRA Quarterly Review Assessment, dated 12/4/24, revealed: . Section P- Restraints, P0100 . Used in Bed. A. Bed Rail. 0 = Not used. Review of Resident #31's Care Plan Summary, dated 1/9/25, revealed: . LTC ADL [Activities of Daily Living] Function Rehab [rehabilitation] . Assist Resident With Transfers . Staff Will Not Leave Resident Alone Sitting on Bed . LTC Falls . Use High Low Bed. Keep in Low Position . During an interview on 1/9/25 at 4:06 PM, when asked RCC #2 if Resident #31 had a bed rail assessment. RCC #2 was unable to locate a bed rail assessment in the medical record. Further review of Resident #31's medical record revealed no physician order and/or informed consent regarding the use of bed rails was found. Resident #61 Record review on 1/6-10/25, revealed Resident #61 was admitted to the facility with diagnoses that included 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 (a severe mental disorder characterized by delusions [false beliefs], hallucinations [perception of sights, sounds, etc. that are not actually present], incoherence and physical agitation). During an observation and simultaneous interview on 1/6/25 at 2:48 PM, Resident #61 had both upper side rails raised, and a right lower side rail raised. The raised upper bed rails began by the top of the bed and extended down the side of the bed and ended by Resident #61's lower chest, and the raised right lower side rail started by the resident's right hip and extended down the side of the bed ending by his/her right knee. When asked if he/she could lower the side rails, Resident #61stated: No. Review of Resident #61's PT [physical therapy] Evaluation LTC II dated 10/22/24 revealed: . answers questions limited to yes/no or short phrases . been found out of bed sitting in a chair in [his/her] room with all 4 bed rails up, self-transferring unwitnessed . Bed Mobility: . did not use rails . Review of the most recent MDS, OBRA admission Assessment, dated 10/23/24, revealed: . Section P- Restraints, P0100 . Used in Bed. A. Bed Rail. 0 = Not used . Review of Resident #61's Quarterly Assessment LTC, dated 1/9/25, revealed: . Orientation Assessment: Disorientated x 4 . Is resident able to state preferences about side rail use?: No Has resident requested to have side rails up for use of bed controls?: No Has resident requested to have side rails for comfort or security?: No . Is resident able to change position in bed without using side rails?: Yes . Bed Safety PT/OT Recommend Side Rails: No . Bed Safety Side Rail Use: Left Upper side rail, Right Upper side rail. Bed Safety Review W Resident/Legal Rep: No . Review of Resident #61's Care Plan Summary, dated 1/9/25, revealed: . LTC Delirium . Interventions . Adapt Care and Environment to Optimize Comfort and Safety . LTC ADL Function Rehab. Assist Resident With Transfers . Staff Will Not Leave Resident Alone Sitting on Bed . LTC Falls . Use High Low Bed. Keep in Low Position . Further review of Resident #61's medical record revealed no physician order and/or informed consent regarding the use of bed rails was found. During an interview on 1/9/25 at 12:25 PM, surveyors requested individual resident assessments to include bed safety from the Director of Nursing (DON). The DON stated there were no bed rail assessments completed. During an interview on 1/9/25 at 4:06 PM, when asked RCC #2 if Resident #61 had a bed rail assessment. RCC #2 was unable to locate a bed rail assessment in the medical record. Review of the facility's policy Bed Safety Assessment Process, effective date 10/11/24, revealed: . 1. Side rails present an inherent safety risk, particularly when the patient is elderly or disoriented . patients may become trapped between the mattress or bed frame and the side rail. Disoriented patients may view a raised side rail as a barrier to climb over, may slide between raised, segmented side rails, or may scoot to the end of the bed to get around a raised side rail. When attempting to exit the bed by any of these routes, the patient is at risk for entrapment, entanglement, or falling from a greater height posed by the raised side rail, with a possibility for sustaining greater injury or death . Policy, A. Registered Nurse, with resident/family, and interdisciplinary (social work, rehab) participation, will complete an individual resident assessment to include bed safety . B. No resident will be placed with all four side rails unless it is clearly demonstrated and documented in the assessment . C. risks and benefits will be presented to the resident and/or responsible party . D. The Resident Care Coordinator/LPN[Licensed Practical Nurse]Manager will review all bed safety assessments. E. The Interdisciplinary Care Plan will be completed by day 21 of admission and the Registered Nurse will develop the plan for bed safety . Review of the facility's A Guide to Bed Safety [a pamphlet provided in residents' admission packet], undated, revealed: The Benefits and Risks of Bed Rails . more serious injuries from falls when patients climb over rails. inducing agitated behavior when bed rails are used as a restraint. Feeling isolated or unnecessarily restricted . Meeting Patients' Needs for Safety, Most patients can be in bed safely without bed rails. Consider the following: Use beds that can be raised and lowered close to the floor to accommodate both patient and health care worker needs. Keep the bed in the lowest position with wheels locked . When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitoring high-risk patients. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview, observation and record review, the facility failed to ensure residents were provided with clear instructions on how to file a grievance while units were quarantined and segregated due to an Influenza outbreak, along with easy access to the grievance box during this time. This failed practice denied all residents and/or their representatives based on a census of 71, the right to submit grievances without fear of discrimination or reprisal. Findings: During a meeting with the Resident Council on 1/8/25 at 2:05 PM, when asked if they knew how to file a grievance, Resident #48 stated: there is one by the Administrator's office, the problem is that we are on full lockdown that started 10 days ago, and we are stuck in our wings [Units] so we cannot go get it, we cannot file a grievance. Resident #27, Resident #25 and Resident #51 also expressed confusion regarding the process of who handled the grievances and how to access the grievance forms and the grievance box. When asked if residents can file a grievance without fear of retaliation, Resident #25, and Resident #27, both stated they fear retaliation if they complained about their care. During observations from 1/6-10/25, all units were quarantined and segregated due to an Influenza outbreak, with doors to all the units closed. The units did not have any indications on how to file a grievance. Further observation revealed the grievance drop box was located next to the entry door of the Administrator's office. The Administrator's office was located by the front entrance of the facility, away from where the units were located. Review of the document Denali Center Grievance Procedure, date unknown, revealed the Denali Center Grievance Official was the Administrator. During an interview with Resident Care Coordinator #1 (RCC) on 1/10/25 at 8:17 AM, when asked how residents were able to file grievances, the RCC stated: Most of the time they [the residents] come find me or tell a nurse and I do an investigation and then take it to the Director of Nursing [DON], depending on what it is and its severity. The RCC further stated they did not have a grievance box on the units and that the grievance box was located away from all the resident rooms, outside the administrator's office. During an interview on 1/10/25 at 8:20 AM, regarding how to file a grievance, RCC #3 stated: there is a board near the cafeteria with a form they can fill out and there is a box by the administrator's office, but normally what happens is that they [the residents] come to me and either myself or the social worker fills out a formal grievance. They can also call Ombudsman and fill out an anonymous grievance that way. During random observations from 1/6-10/25, both the Denali Center Grievance Procedure and Denali Concern Form were located on the bulletin board near the common Dining Room (room [ROOM NUMBER]) in the Mall area of the facility, outside the care units. No other instructions were available on the bulletin board to indicate where the physical location of the grievance box or where to deposit the Denali Concern Form. During an interview on 1/8/25 at 4:35 PM, the Administrator confirmed that the box used for grievances was a wooden box located outside of her office, which was by the Long-Term Care entrance of the building, away from the care units. The Administrator further stated she did not want to take the risk of spreading Influenza A to the vulnerable residents, which was the reason why the facility was on lockdown. She stated the measures implemented were like COVID-19 measures, where resident interactions were kept minimal. She further stated the residents were able to access the grievance box despite this lockdown measure. When informed of the Resident Council concerns, she stated: What am I supposed to do, move a box to the units for 5- or 6-days' worth of a lockdown? She further added that residents can go through their social worker to submit the form or that residents can still come out to submit their grievances. When asked about the confidentiality aspect of the grievance process due to the location of the box, the Administrator said that confidentiality was maintained despite of the box being in front of her office. She further added that there would not be a difference whether the box was on the units or in front of her office. She further stated they can still be seen dropping a form. She further stated, she was concerned the forms would be missed if there were multiple boxes in different areas of the facility and she may not have time to check multiple places daily. Review of the document Denali Center Grievance Procedure, date unknown, revealed: . to assist you [Residents] when a problem does arise, we have prepared the following guide. In following the steps indicated, we will be able to provide a timely response to your concerns. It is our preference to resolve issues with our internal process, but we have included steps to contact outside agencies should you feel it appropriate . Step 1. We encourage you to speak up about the things that concern you. Step 2. If you have a concern or complaints, ask to see the charge nurse or social worker. Step 3. You may voice your concerns to any staff member you wish. They will help you by first remedying the problem if they can and notifying the charge nurse or social worker for follow up. Step 4. You have the right to file grievances anonymously. Step 5. You should expect a visit from the Charge Nurse/RCC [Resident Care Coordinator] or social worker within 1 hour of voicing your concerns. Step 6. We will discuss your concerns and begin a process to investigate and correct or make changes to resolve any problems identified. Your concern will be reported to our administrator and any departments involved. Step 7. Within seven (7) working days you can expect to receive a follow up about the concerns you have raised. Step 8. Within fourteen (14) working days you will receive a written or a verbal response from our administrator/nurse/manager/case manager with the findings of our investigation about your complaint. Further review of this document, there were no clear instructions on how to file a grievance and where to deposit the grievance form. Review of the document Denali Concern Form, revised on 5/2019, revealed the following: Reporter's name (may be anonymous); Date; Contact Information (address/telephone); Location [options to select the location] (Aspen, Birch, Tamarack, Willow, Spruce, Court Mall, Lobby or Other; Department (Nursing, Environmental .); Summary of Statement; List of Any Witnesses; Date Received by Grievance Officer; Name of the person completing the form if different; Steps to investigate; Summary of Findings; Formal grievance confirmed [checkboxes for Yes/ No]. Review of the Denali Center Concern Form and the Denali Center Grievances Procedure documents did not provide details on how to turn in a grievance form, or where the location of the grievance box was. Review of the policy and procedure titled Denali Center: Grievance Process dated 3/5/24, revealed: A. All residents have the right to voice grievances without decriminalization or reprisal or fear of discrimination or reprisal .E. Residents are notified through postings of the right to file grievances orally or in writing: the right to file grievances anonymously; the contact of information of the grievance official with who a grievance can be filed and a reasonable time frame for completing the review of the grievance: the right to obtain a written decision regarding his or her grievance, and the contact information of independence [independent] entities with whom grievances may be filed. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to properly store drugs and medical supplies. These failed practices had the potential to place all residents (based on a census of 71) at risk of receiving expired and non-sterile medications and supplies and subsequent adverse effects. Findings: Tamarack and [NAME] Medication Shared Room: An observation on 1/8/25 at 6:15 PM, revealed the following medical supplies were expired: - One box of 1.5 mL BD [[NAME], [NAME] and Company] ChloraPrep FREPP Clear applicators, expired on 10/24; - One quart bottle of Distilled [NAME] Vinegar in the ear irrigation tray, expired on 10/24. During an interview on 1/8/25 at 6:15 PM, Resident Care Coordinator (RCC) #3 confirmed expired supplies should have been discarded. Tamarack Medication Room: An observation on 1/8/25 at 6:28 PM, revealed the following medical supplies and medications were expired: - Two boxes of Nicotrol Inhaler 10 mg cartridges (smoking cessation aid), expired on 5/24; - One bottle of Children's Chewable Multivitamin, expired on 3/24; - One Stat Strip Xpress Glu Control Level 3, expired on 12/26/24; - Two Protexis PI Surgical Gloves, expired on 8/31/24 and 9/30/24; - Five 4 in. by 12 in. Mepilex Border AG dressings, expired 8/25/24; - One 4 in. by 4 in. Replicare Ultra dressing, expired on 10/22. During an interview on 1/8/25 at 6:28 PM, RCC #3 confirmed expired medications should have been returned to the pharmacy and the expired medical supplies should have been discarded. During an interview, on 1/9/25 at 10:05 AM, Pharmacist #1 stated the Nicotrol Inhalers were home medications of a current resident. He/she further stated home medications stored in medication carts were not monitored by the pharmacy department. Pharmacist #1 confirmed expired home medications were typically returned to and discarded by the pharmacy department. The pharmacist added Nicotrol had not yet been discarded as Nicotrol cartridges were expensive and difficult to obtain as they were no longer produced. Pharmacist #1 stated the facility follows the retail pharmacy's provided label for expiration dates. Denali Center BLS (Basic Life Support) Cart: An observation on 1/9/25 at 7:49 AM, revealed the following expired medical supply: One 4-1/2 x 4-1/8 yd Kerlix bandage roll expired on 8/22. Record review on 1/9/25 at 7:49 AM, of the facility's Emergency Equipment Cart log revealed the following: Check Weekly .Restock when expired & After Use . 1-Drawer of dressing supplies . [last checked] 12/22/24. During an interview on 1/9/25 at 7:49 AM, RCC #1 stated night shift charge nurses were responsible for inspections of the crash (BLS) cart weekly. Review on 1/9/25 at 3:00 PM, of the facility's Night Charge Nurse Duties, undated, revealed: Check the Crash cart every Wednesday. Document in the notebook marked weekly checks located in [RCC's] office on the Emergency cart. Review on 1/9/25 at 3:00 PM, of the facility's 12 HOUR NIGHT CHARGE procedures, undated, revealed: CHECK CRASH CART ON WEDNESDAY. Birch Medication Room: An observation on 1/9/25 at 8:01 AM, revealed the following opened and expired medical supplies: - One 1000 ml 0.9% Sodium Chloride Injection USP bag not in original packaging; - One I.V. (Intravenous) dressing kit not in the original packaging; - One 1.5 mL BD Chloraprep FREPP Clear applicator, expired on 10/24; - One Adult Pulse Oximeter Adhesive Sensor, expired 11/1/21. During an interview on 1/9/25 at 8:01 AM, RCC #2 stated expired and opened supplies should have been discarded. He/she further stated nurses should have been responsible for ensuring no expired medications and/or expired medical supplies were stored in the medication rooms. During a follow up interview on 1/9/25 at 1:15 PM, RCC #2 stated, based on the LPN( Licensed Practical Nurse) manager job description, the RCCs were responsible for ensuring medications storage rooms do not have expired supplies. Review of the facility's job description of LPN Mgr [Manager], undated, revealed Essential Functions .provides daily operational resource management including . supplies Aspen and Birch Medical Supply Room: An observation on 1/9/25 at 8:20 AM revealed the following expired products: - Seven .81 oz of Juven Therapeutic Nutrition Powder packets, expired on 8/1/24; - One .81 oz of Juven Therapeutic Nutrition Powder packets, expired on 3/1/24; - 32 .81 oz of Juven Therapeutic Nutrition Powder packets, expired on 11/1/24; - 43 0.14 oz Nutrisource fiber supplement packets, expired on 07/11/24. During an interview on 1/9/25 at 8:20 AM, RCC #2 stated expired nutritional supplements should have been discarded however it was the responsibility of Nutrition Services (NS) to ensure supplements stored in the storage rooms were not expired. During an interview on 1/9/25 at 2:59 PM, NS #3 confirmed NS were responsible for ensuring dietary products such as tube feeding formulas and nutritional supplements stored in the medical supplies room were not expired. He/she further stated, NS typically rounded every day to check the stock in the facility, but expired products were either missed or packaging was not checked for expiration dates. When asked about written policies and procedures regarding storage of dietary products, NS #3 stated there were none. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review the facility failed to ensure potentially hazardous foods were stored, labeled and prepared foods in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) foods were labeled and dated; 2) expired foods were discarded; 3) Nutrition Services staff performed hand hygiene with glove changes and during the cooking and the preparation of foods. These failed practices had the potential of causing or spreading foodborne illnesses to residents, based on a census of 70, who received food from the kitchen. Findings: An observation, during the initial main kitchen tour, on 1/6/25 at 10:50 AM, revealed: 1) Dry Storage in Fireweed Café: - 30 expired Alpine Spiced Apple Cider Original- single serving packets- with manufacture best by date of 11/11/24; - 44 expired Kraft Sweet & Sour Sauce- 1- ounce single serve containers-with a manufacture used by date of 12/28/24; - One expired Kikkoman Less Sodium Soy Sauce-5-ounce bottle-with manufacture best by date of 7/13/24; -One expired Monarch Mandarina Segmentos Enteros-6-pound 10 ounce can- received on 7/15/24 and expired on 12/15/24; -One-expired Monarch California Sliced Yellow Cling Peaches-6-pound 9 ounce can- received on 2/3/24 and expired on 9/3/24; -One-expired Mae Ploy Sweet Chili Sauce- 25-ounce bottle-with manufacture expiration date 4/11/24; -16-expired Nutri Grain Apple Cinnamon Soft Baked Breakfast Bars-1.3-ounce packages, with manufacture expiration date 10/22/24; -One-box Heinz Tartar Sauce- open box [full box quantity 200 count] 1/2 full box- 0.12-gram single serve packages, with manufacture expiration date 12/18/23; -One-clear plastic bag [containing multiple] Kikkoman Soy Sauce 1/2 full- single served packets [size of packet unknown], with manufacture best by date 4/13/24; -One- box Kraft Fat Free Classic Ranch Dressing open box [full box quantity 200] 1/2 full- 12.4-gram single served packet, with no best used by date or expiration date; -Two-boxes Kraft Golden Italian Dressing open box [full box quantity 200] 3/4 full box-12.4- gram single served packet, no best used by date or expiration date; -One plastic container Chef's Pride Canola Oil-1 gallon bottle- no best used by date or expiration date; -One plastic container Kraft Mayo Light-1 gallon container, no best used by date or expiration date; -One box Herb Ox Sodium Free Granulated Chicken Bouillon - single serving packets- half full box, no used by date or expiration date; -One box Monarch Non-Dairy Creamer open box [full box quantity 2000] 3/4 full-2.5-gram packet, no best used by date or expiration date; During an interview on 1/6/25 at 10:57 AM, the Culinary Director (CD) stated after the food arrived the products were taken through the hospital kitchen for processing. He stated that the food products were dated with a sticker gun and to be used within 6 months from the received date. When asked about food products that were not dated, and products that did not have a best used by date or expiration date, the CD did not provide an answer. 2) Fireweed Café Dining Refrigerator: -One- expired Chobani Blueberry Greek Yogurt individual container-4 ounces, with manufacture expiration date 12/31/24; -One plastic container labeled G. Macaroni, no best used by date or expiration date; -One-plastic container labeled P. Macaroni, no best used by date or expiration date; -Two-disposable containers, labeled apple containing light yellow liquid with the sliced apples, no best used by date or expiration date; During an interview on 1/6/25 at 11:33 AM, Nutrition Service (NS ) #3 stated the macaroni containers contained ground and pureed macaroni salad. NS #3 stated they were not dated since they were prepared to be used that day. NS #3 further stated the liquid in apples was apple juice and were going to be used later that day. An observation during the hospital kitchen [a kitchen that stored food and prepared meals for residents in the long-term care] tour, on 1/8/25 at 9:30 AM, revealed: 3) Walk-in Freezer: -One- open box Plant-Based Smashed Patty in open plastic bag- 3/4 full- 2.6-ounce patty, no best used by date or expiration date; -One- clear plastic bag, food not identified [appeared to be large shell pasta noodles], not labeled, no best used by date or expiration date; -One- clear plastic bag, food not identified [appeared to be hotdog buns], 11 buns, not labeled, no best used by date or expiration date; -One- clear plastic bag, food not identified [appeared to be biscuits], quantity unknown, not labeled, no best used by date or expiration date; -Two- clear plastic bags, food not identified [appeared to be angel food cake], both containing 1/2 cake, not labeled, no best used by date or expiration date; -One- open box Hilltop Hearth Blueberry Muffins, 5 muffins, no best used by date or expiration date; -One- open box Columbia Blueberry, in open plastic bag- 3/4 full, no best used by date or expiration date; -One- metal cart with three shelves- containing metal trays appeared to be chicken strips, French fries, and chicken wings not covered, not labeled, no best used by date or expiration date; -One-open box Grimmway Farms Carrots individual packets- 1.6 ounce- best if used by [DATE]; -One-open box US Foods Cheese loaf of white cheese wrapped in plastic, no best used by date or expiration date; -One-open box Cubed Cheese -5-pound packages- 2 opened bags, wrapped in plastic, both 1/2 full, no open date, no best used by date or expiration date. 4) Main Kitchen Food Preparation: -One- open box Quacker Quick Creamy Wheat-28-ounce box, contents not sealed opened to air; -One- open box Albers Enriched Hominy Quick Grits-20-ounce box, contents not sealed opened to air; -One- 1/2 loaf Franz Wheat Sandwich Bread- 24-ounce bag, with manufacture best by date [DATE]; -One- clear plastic bag Franz English Muffin -6 muffins, no best used by date or expiration date; -One- clear plastic bag Franz Bagel -6 bagels, no best used by date or expiration date; -One-clear plastic bag White bread -full bag, appears unopened, no label, no best used by date or expiration date. During a simultaneous interview on 1/8/25 at 9:40 AM, reviewed items found in the walk-in freezer and food preparation area of the kitchen, CD stated food products were not dated in the freezer since it is frozen and safe, only the quality goes down. NS #4 stated the carrots are good as long as they are kept frozen, we take out what we need and use, they can last for years. NS #4 further stated as products come in we just rotate the food, use older stuff first, we go through it quick. 5) Food Preparation and Plating Observation: An observation on 1/9/25 at 6:30 AM, food was prepared in the hospital kitchen and placed in metal containers with plastic wrap over the containers. Containers were placed in a warming cart for transport to the LTC. An observation on 1/9/25 at 7:00 AM, NS #2 placed metal containers in the steam table with gloved hands. Using the same gloved hands, NS #2 then made pancakes and French toast, placed the food in a metal container and moved it into the steam table. Continuing the observation on 1/9/25 at 7:25 AM, NS #2, still using the same gloved hands, measured the food temperatures for all food on the steam table. An observation on 1/9/25 at 7:43 AM, NS #1 was wearing gloves, while preparing supplemental shakes, pureed bananas, and was going in and out of the refrigerators. NS #1 changed his/her gloves without performing hand hygiene. During an interview on 1/9/25 at 7:43 AM, the CD stated staff was to perform hand hygiene between glove changes. An observation on 1/9/25 at 7:51 AM, NS #1 removed his/her gloves in the main kitchen, walked into Fireweed dining room to retrieve supplies, returned and, without performing hand hygiene, and put on a new pair of gloves. During a continuous observation on 1/9/25 at 7:53 AM through 9:08 AM, NS #2 cooked and prepared food with gloved hands. NS #2 wiped his/her gloved hands on a towel placed next to steam table. Next, NS #2 cracked raw eggs into a container, then whisked, and then poured the whisked eggs into a pan to cook. Next, NS #2 placed shredded cheddar cheese on top with the same gloved hands and then placed the cooked cheesy eggs onto a resident plate. Next, NS #2 returned to the steam table, which contained sausage gravy, turkey sausage, bacon, scrambled eggs, cream of wheat cereal, oatmeal, hashbrowns, pancakes, blueberry muffins and French toast, and prepped several resident's plates with cooked food from the steam table. While NS #2 prepared another resident plate, he/she touched the cooked eggs and bacon with same gloved hands used to handle raw eggs from earlier in the observation. NS #2 continued creating additional resident plates with food from the steam table while using the same gloved hands. NS #2 did not perform hand hygiene after he/she prepared raw food and served cooked food. During a follow-up observation of the dry storage in Fireweed Café on 1/9/25 at 9:50 AM, revealed: -One expired Kikkoman Less Sodium Soy Sauce-5-ounce bottle-with manufacture best by date of 7/13/24; - 30 expired Alpine Spiced Apple Cider Original- single serving packets- with manufacture best by date of 11/11/24. Review of the facility's policy Food Safety and Sanitization, last reviewed 5/28/24, revealed: 2) Employees . will hand all foods safely. 4. All staff will wash their hands just before they start to work in the kitchen and when they have used their hands in an unsanitary way.4) Food Storage . 4. Foods are protected from contamination . 8. All leftovers are labeled, covered, and dated when stored . 9. Foods with expiration dates and best by dates are used prior to the date on the package . 10. Canned and dry foods without expiration dates are used within six months of delivery or according to the manufacture's guidelines . Review of the facility's policy Food Preparation, effective date 10/28/22, revealed: . k. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods . Review of the facility's Food Service Worker- Job Code: 3304, undated, revealed: . Requires the ability to follow . and maintaining sanitation standard. This position requires the ability to learn and follow established policy and procedures . Must be able to learn food handling regulations . Review of the facility's Cook- Job Code: 3298, undated, revealed: . Must be able to learn and follow established policies and procedures . Must be able to learn food handling regulations . Review of the Food and Drug Administration (FDA) guidelines (Food labeling 2020), accessed at this link: https://www.FDA.gov, revealed: . concerning food storage and labeling, while the FDA does not mandate expiration dates, it encourages to use best by, use by, or sell by dates to indicate peak quality and safety as well as practices of inventory management such as First In, First Out (FIFO), inventory management practice that helps ensuring that older stock is used before newer stock, reducing waste and spoilage. .

. Based on observation, interview and record review the facility failed to ensure staff followed hand hygiene practices. Specifically, nutrition service staff did not performed hand hygiene and/or glove changes during the cooking and the preparation of the food. This failed practice placed all residents who receive food from the kitchen, based on a census of 70, at risk for cross contamination and spread of infectious disease; Findings: Dietary Hygiene: An observation on 1/9/25 at 7:43 AM, NS #1 was wearing gloves, while preparing supplemental shakes, pureed bananas, and was going in and out of the refrigerators. NS #1 changed his/her gloves without performing hand hygiene. An observation on 1/9/25 at 7:51 AM, NS #1 removed his/her gloves in the main kitchen, walked into the Fireweed dining room to retrieve supplies, returned and, without performing hand hygiene, and put on a new pair of gloves. During a continuous observation on 1/9/25 at 7:53 AM through 9:08 AM, NS #2 cooked and prepared food with gloved hands. NS #2 wiped his/her gloved hands on a towel placed next to steam table. Next, NS #2 cracked raw eggs into a container, then whisked, and then poured the whisked eggs into a pan to cook. Next, NS #2 placed shredded cheddar cheese on top with the same gloved hands and then placed the cooked cheesy eggs onto a resident plate. Next, NS #2 returned to the steam table, which contained sausage gravy, turkey sausage, bacon, scrambled eggs, cream of wheat cereal, oatmeal, hashbrowns, pancakes, blueberry muffins and French toast, and prepped several resident's plates with cooked food from the steam table. While NS #2 prepared another resident plate, he/she touched the cooked eggs and bacon with same gloved hands used to handle raw eggs from earlier in the observation. NS #2 continued creating additional resident plates with food from the steam table while using the same gloved hands. NS #2 did not perform hand hygiene after he/she prepared raw food and served cooked food. During an interview on 1/9/25 at 7:43 AM, the Culinary Director stated staff were to perform hand hygiene between glove changes. Review of the facility's policy, Food Safety and Sanitization, last reviewed 5/28/24, revealed: . 2) Employees . will handle all foods safely. 4. All staff will wash their hands just before they start to work in the kitchen and when they have used their hands in an unsanitary way. Review of the facility's policy, Food Preparation, effective date 10/28/22, revealed: . k. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods . Review of the facility's Food Service Worker- Job Code: 3304, undated, revealed: . Requires the ability to follow . and maintaining sanitation standard. This position requires the ability to learn and follow established policy and procedures . Must be able to learn food handling regulations . Review of the facility's Cook- Job Code: 3298, undated, revealed: . Must be able to learn and follow established policies and procedures . Must be able to learn food handling regulations . Review of the U.S. Food and Drug Administration (2022) FDA Food Code 2022 (FDA Publication No. 2022) U.S. Department of Health and Human Services, accessed on 1/22/25 at https://www.fda.gov/media/153455/download, revealed 2-301.14 . FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and . (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 . (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD . (H) Before donning gloves to initiate a task that involves working with FOOD . (I) After engaging in other activities that contaminate the hands. Further review of Review of the U.S. Food and Drug Administration (2022) FDA Food Code 2022 (FDA Publication No. 2022) U.S. Department of Health and Human Services, accessed on 1/22/25 at https://www.fda.gov/media/153455/download, revealed 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. .

. Based on record review, observation and interview, the facility failed to ensure acceptable professional standards of infection control. Specifically, the facility failed to wear gloves when working with PICC (peripherally inserted central catheter) lines (during flushes and medication administration) for 2 Residents (#'s 65 and 68) out of 2 residents with PICC lines. This failed practice had the potential of spreading infectious disease. Findings: Record review on 6/26-30/23 revealed Resident #65 was admitted to the facility with diagnoses that included hypertension. An observation on 6/26/23 at 3:00 PM, revealed Licensed Nurse (LN) #4 disconnected and flushed Resident #65's PICC line and did not wear gloves during the intervention. Record review on 6/26-30/23 revealed Resident #68 was admitted to the facility with diagnoses that included cachexia (loss of body weight and muscle mass leading to weakness) and diabetes. Review of Resident #68's physician order, dated 6/15/23, revealed ceftriaxone (an antibiotic) 2 milligrams in 50 milliliters IVPB (intravenous piggyback) for osteomyelititis [bone infection] was ordered. An observation on 6/28/23 at 12:50 PM, revealed LN #1 flushed and hung Resident #68's scheduled antibiotic medication. LN #1 did not perform hand hygiene prior to entering the room and gloves were not worn throughout the intervention. During an interview on 6/29/23 at 1:02 PM, the Administrator stated she would need to follow up on the use of gloves while working with PICC lines. The below policy was provided as the follow-up. Review of facility policy Peripherally inserted central catheter (PICC) bolus injection, home care, revised 8/18/22, revealed: . Put on gloves . comply with standard precautions [hand hygiene, use of personal protective equipment] . Review of Lippincott procedures, Peripherally inserted central catheter (PICC) flushing and locking, dated 9/18/22 revealed, .Gather and prepare the necessary equipment and supplies .Perform hand hygiene .Put on gloves to comply with standard precautions . .

. Based on record review and interview, the facility failed to ensure influenza immunization documentation (administered or declined) was completed for 1 resident (#59) of 5 residents sampled for influenza immunization. This failed practice denied the residents the opportunity to accept or decline the immunization and to receive education on the benefits and potential side effects. Findings: Record review on 6/26-30/23 revealed Resident #59 was admitted to the facility with diagnoses that included hypertension and COPD (chronic obstructive pulmonary disease- a progressive lung disease that causes airflow limitation). During an interview on 6/29/23 at 4:33 PM, the Administrator (AD) and Dispensing Pharmacist (DP) #1 were unable to locate documentation of the immunization being administered or refused for Resident #59. The AD and DP further stated that as evidenced by VacTrAK (a database of state recorded vaccinations) Resident #59 had not received an influenza immunization prior to admission to the facility. Review of the CDC (Centers for Disease Control and Prevention) website at https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm, dated 11/21/22, revealed: . If possible, all residents should receive inactivated vaccine (IIV) annually before influenza season . Although vaccination by the end of October is recommended, influenza vaccine, administered in December or later . is likely to be beneficial . because the duration of the season is variable . .

. Based on observation, interview, and record review, the facility failed to ensure: 1) Food was stored under proper sanitation and food handling practices in the main hospital kitchen; and 2) Hair nets were worn properly by food service workers assembling food in the kitchen in the Long Term Care (LTC) Center. These failed practices had the potential of causing or spreading food borne illness to all residents who utilized the kitchen services, based on a census of 72 residents. Findings: 1) Food Storage in Main Kitchen An observation of the walk-in refrigerator on 6/26/23 at 12:15 PM, revealed unlabeled, opened brats (sausages) not completely covered with plastic wrap. There were approximately 15 brats in each container. During an interview on 6/26/23 at 12:15 PM, the Dietary Manager stated that the brats were expired, weren't labeled correctly, and should have been thrown away. 2) Hair nets worn improperly An observation on 6/28/23 at 11:40 AM revealed the Food Service Supervisor and Food Service Worker #1 assembling food onto the resident dining trays on the food tray assembly line. The Food Service Supervisor had his/her hair confined in a disposable hair covering with about 1 inch of hair hanging down about 1 1/2 inches below the hair covering. Food Service Worker #1's hair net covered the center part of the head; however, approximately 1 ½ inches of hair in the front portion of the head was uncovered completely from the ears upward to the top of the head. During an interview on 6/28/23 at 3:18 PM, the Dietary Manager stated the hair nets of the Food Service Workers should have covered the hair completely. Review of the facility's policy Food Safety and Sanitation, dated 10/7/22, revealed, Purpose / Expected Outcome: A. All local, state, and federal standards are followed in order to assure a safe and sanitary food service department . Procedures / Interventions . All staff are required to have their hair styled so that it does not touch the collar, wear hair covers . Hair restraints are required and should cover all hair on the head . Food storage 1. Food that is protected from contamination and growth of any pathogenic organisms . all leftovers are labeled, covered, dated when stored. They are used following the guidelines of the Discard date attachment or discarded . opened containers and prepped foods are used and discarded within the time frame of the 'Discard dates' form, developed by Management. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to ensure activities of daily living (ADLs) were received to maintain good personal hygiene for one resident (# 52), out of 18 sampled residents. Specifically, the facility failed assist the resident with bed baths when he/she was unable to receive showers or baths due to wound care instructions. This failed practice placed the resident at risk for skin breakdown, a loss of dignity, and a decline in cleanliness, health, and well-being. Findings: Resident #52 Record review from 7/18-22/22 revealed Resident #52 was admitted [DATE] with diagnoses that included a stage 3 pressure ulcer to the sacrum (tailbone area), a surgical wound to the right lower buttock, and a traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). Further review revealed Resident #52 had surgical repair of the pressure wound to coccyx and the buttock wound on 6/13/22 and 6/20/22. During an interview on 7/19/22 at 9:01 AM, Resident #52 stated I've been here two months and have only received one shower and one bed bath. Review of the Tamarack Bath/Shower Schedule, no date, revealed Resident #52 was scheduled for showers on Mondays and Thursdays. Review of Resident #52's care plan revealed an identified problem LTC [Long Term Care] ADL Function Rehab [rehabilitation] IPOC [interdisciplinary plan of care], last updated 6/8/22. Further review revealed the following interventions for this problem: Keep bath time calm, keep water warm and resident warm, last evaluated 7/6/22, and Provide Bath/Shower - 2 times a week ., last evaluated 7/6/22. Review of Resident #52's Resident Bathing Type by Day Chart, dated 6/21/22 to 7/20/22, revealed a chart that included spaces to document: Shower, Tub, Bed Baths, Whirlpool, Other, Patient Refused, Patient with Family, Patient outside Family, Not Scheduled, and Total. Further review revealed Resident #52 had a shower on 7/2/22 and he/she refused personal hygiene twice, 7/11/22 and 7/18/22. Further review revealed no further documentation of personal hygiene for Resident #52. Additional review of the Care Plan's stipulation of personal hygiene two times a week, and the documented personal hygiene on the Resident Bathing Type by Day Chart, the facility only provided 3 out of 8 opportunities for personal hygiene from 6/21/22 to 7/20/22. During an interview on 7/21/22 at 4:37 PM, Resident Care Coordinator (RCC) #2 stated that the surgical doctor, who completed the surgical repair of Resident #52's wounds, ordered no baths or showers upon admission due to the severity and condition of the wounds. RCC #2 further stated that in reviewing Resident #52's chart, there was no order to state Resident #52 could not have showers or baths. During the same interview, Nurse Manager #1 stated nursing staff (licensed nurses and certified nursing assistants) were to set the resident up for independent bed baths in his/her room, but this was not being documented. Nurse Manager #1 further stated Resident #52's care plan did not indicate he/she required bed baths and not showers or baths. A review of Resident #52's MDS (Minimum Data Set - a Federally required assessment) assessment, an admission assessment dated [DATE], revealed: Bathing: Self-Performance: Physical help in part of bathing activity. Support provided: One-person physical assist. Further review revealed: Functional limitation in Range of Motion: Upper extremity: no limitation. Lower extremity: Impairments on both sides. During an interview on 7/21/22 at 8:50 AM, the Administrator confirmed Resident #52 has had only one shower, on 7/2/22, since 6/21/22: Because of [his/her] wound [he/she] couldn't get in the tub, but the staff should have been giving [him/her] bed baths. Review of facility's policy CNA [certified nursing assistant] Expectations and Standards of Care, dared 4/7/22, revealed: Cares . Bathing/Personal Hygiene: Bath/shower [two times] week, or as care planned (shampoo, body lotion, nail care and linen change on bath days) . Review of facility's policy Multidisciplinary Resident Care Review and Care Plan Process, dated 7/11/22, revealed: Multidisciplinary Resident Care Review . At resident care review, the discipline representative attending for each department will participate and update the resident's plan of care as needed . The neighborhood nurse is then responsible for communication of changes and updates to the CAN/LN [licensed nurse] flow sheets. Resident Care Coordinator is responsible for updates to the computer version of the resident care plan . At conference, the following must be discussed: Resident concerns [and] needs will be discussed and documented . Care plan review needs to include . psychosocial, functional, clinical and leisure areas, resident strengths and weaknesses . Care Planning: A Plan of Care will include: Focus of problems, long-term and short-term goals which are measurable, including therapy goals, approaches from care plan will be used to create the CNA/LN flow sheets . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to reassess and implement interventions to improve positioning for 1 resident (#6), out of 18 sampled residents. The failure, to reassess the resident's wheelchair seating and leg rest/foot pedal use, placed the Resident at risk for harm from injury and or nerve/muscle damage to his/her feet resulting in pain and deformity. Findings: Record review on 7/20-21/22 revealed Resident #6 had diagnoses that included dementia with agitation and arthritis. During an observation on 7/19/22 at 8:37 AM, Resident #6 was observed seated in a wheelchair in the communal area. The wheelchair had no pedals or leg rests attached to it. The Resident was wearing bootie socks. Certified Nursing Assistant (CNA) #4 assisted Resident #6 to the table, both of the Resident's feet were dragging across the floor as he/she was positioned at a table for breakfast. During an observation on 7/19/22 at 1:05 PM, CNA #4 transported the Resident to his/her room backwards through the door. The wheel of the left front wheelchair bumped the Resident's left foot as he/she was brought through the door frame. The Resident's leg rests, and foot pedals were observed on the floor in Resident #6's room. During an observation on 7/20/22 at 9:40 AM, Resident #6 was observed seated in a wheelchair in the dining room. There were no pedals or footrests attached to his/her wheelchair and both Resident's legs and feet were dangling. During an observation on 7/21/22 at 9:30 AM, CNA #6 was observed pushing Resident #6 to the communal area for breakfast. The Resident did not have foot pedals or leg rests on, and as Resident #6 was pushed across the room, the bottoms of his/her stockinged feet dragged across the ground. During an interview on 7/21/22 at 11:00 AM, when asked if Resident #6 ever used the foot pedals in his/her room, CNA #6 stated he/she had worked at the facility for one and a half years and had never seen the Resident use the foot pedals. Review of a Resident #6's Physical Therapy evaluation, conducted on 11/2/2020, revealed: Wheelchair Details: Uses B [both] feet for propulsion forwards very short distances. Tends to slouch in WC; able to assist with scooting back in WC when [his/her] mood allows. Review of Resident #6's MDS (Minimum Data Set-a Federal required nursing assessment) assessment, an annual assessment dated [DATE], revealed: Section G Functional Assessment: E. Locomotion on unit - how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair- Extensive assistance - resident involved in activity, staff provide weight-bearing support Review of Resident #6's most recent MDS quarterly assessment, dated 4/28/22, revealed: E. Locomotion on unit - how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair-4 Total dependence - full staff performance every time during entire 7-day period. Review of Resident #6's comprehensive care plan, evaluated 6/16/22, revealed Ensure proper footwear while awake. During an interview on 7/21/22 at 11:30 AM, Licensed Nurse (LN) #2 stated the Resident used to grab the handrails and use his/her feet to shuffle short distances. The LN stated he/she had not attempted to propel him/herself in over a year.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and interview, the facility failed to follow accurate oxygen administration protocol for 1 resident (#46), out of 7 residents receiving respiratory care. Specifically, the facility did not obtain appropriate orders for the safe administration of oxygen. The failure to clinically identify and care plan for the amount of oxygen to use and the targeted oxygen saturation to reach, had the potential to affect the resident's overall health and well-being. Findings: Record review on 7/18-22/22 revealed Resident #46 was admitted to the facility with diagnoses that included end stage renal disease (a condition in which kidney function is less than 10% of normal; the kidneys can no longer remove wastes, concentrate urine, and regulate electrolytes), type 2 diabetes, and nicotine dependence. Review of Resident #46's most recent MDS (Minimum Data Set - A Federally mandated assessment), a quarterly assessment dated [DATE], revealed Resident #46 had a BIMS (Brief Interview for Mental Status - to determine a person's cognitive level) score of 15, which indicated his/her cognition was intact. An observation on 7/19/22 at 12:30 PM, revealed Resident #46 was using oxygen via a nasal cannula while in bed. Review of Resident #46's Nursing Notes revealed Resident #46 had returned from the E.R. on 7/18/22 at 8:52 PM after being evaluated for hypotension [low blood pressure] during dialysis. Further review revealed: - 7/18/22 at 9:10 PM - Resident started having difficulty breathing, O2SAT [oxygen saturation of blood which indicates how well a person's lungs are delivering oxygen to the body] was low 70s [normal range 95% to 100%]. O2 [oxygen] via nasal cannula started. - 7/19/22 at 1:36 AM - This CRN [Charge Nurse] notified resident was having difficulty taking breaths, upon entering resident's room resident was found in distress, unable to take deep breaths and having trouble talking . SaO2 [oxygen saturation] noted to be between mid 60s and low 70s . O2 applied 4Lpm [liters per minute] and SaO2 increased to 97% within a few minutes . O2 decreased to 2Lpm at [11:00 PM] O2 off at [12:30 AM] SaO2 = 93%, at [1:00 AM] resident c/o of difficulty breathing again, Stats in low 80s, O2 reapplied at 2 Lpm . An observation on 7/20/22 at 9:55 AM, revealed Resident #46 was getting ready to leave for dialysis. Resident #46 was wearing a nasal cannula and Licensed Nurse (LN) #6 was observed to adjust his/her the oxygen gauge on the oxygen cylinder attached to the back of his/her wheelchair. Review of Resident #46's medical record revealed no order for the use of oxygen. An observation on 7/21/22 at 8:17 AM, revealed a sign on Resident #46's bedroom door: oxygen in use. Further observation revealed Resident #46 was sitting in bed watching TV with a nasal cannula in place and an oxygen concentrator running. During an interview on 7/21/22 at 8:22 AM, Resident Care Coordinator (RCC) #2 stated nurses could initiate oxygen for residents based on assessments and interventions, however oxygen required an order and the order usually had parameters for the amount of oxygen to use and the desired oxygen saturation to reach. During this interview, RCC reviewed Resident #46's medical record and stated that Resident #46 should have an order for the use of oxygen but did not. When asked if a physician had assessed Resident #46 after the initiation of oxygen, RCC #2 stated the Nurse Practitioner assessed Resident #46 on 7/19/22, however upon reading the 7/19/22 note, RCC #2 stated that interaction was for a different matter, and there was no documentation an assessment for the use of oxygen was completed. Review of Resident #46's medical record on 7/21/22 at 5:45 PM, revealed: Order - RT [Respiratory Therapy] Oxygen: Routine, 2 liters, Keep at 90% or higher, which was started on 7/21/22 at 8:49 AM. During an interview on 7/22/22 at 8:27 AM, the Medical Director, who was Resident #46's physician, stated he was informed on 7/19/22 that Resident #46 started oxygen the night prior. The Medical Director stated he discussed this with the Nurse Practitioner for her to assess. Review of Lippincott's article Oxygen administration, long-term care, dated 11/19/21, revealed: A resident needs oxygen when hypoxemia [abnormally low concentration of oxygen in the blood] results . The equipment that you'll need depends on the type of delivery system that the practitioner ordered . Implementation: Verify the practitioner's order for oxygen therapy, gather and prepare the necessary equipment and supplies, perform hand hygiene, confirm the resident's identity . perform a baseline physical assessment . explain the procedure to the resident . check the resident's room to make sure it's safe for oxygen administration, if the resident care area isn't already labeled clearly place an 'oxygen precautions' sign on the door to the resident's room . Help place the prescribed oxygen delivery device on the resident. Make sure that it fits properly . Adjust the oxygen flow rate as ordered. Monitor the resident's response to oxygen therapy. Monitor the oxygen saturation level . if ordered . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and interview, the facility failed ensure: 1) assistance with dining was provided for 3 sampled residents (#s 6, 22, and 41), out of 18 sampled residents, and 1 non-sampled resident (#66), who required assistance with dining; 2) meal selections were honored for 2 residents on a therapeutic diet (#s 18 and 39); and 3) menu choices were offered to 3 residents (#s 31, 33, and 69), out of 9 residents on a therapeutic diets. These failed practices placed residents at risk for not receiving assistance that enhanced their self-esteem that promoted self-worth, and denied residents on therapeutic diets the opportunity to make choices about their meal and participate in shared social events with their peers. Findings: Dignity While Dining Resident #6 Record review on 7/20-21/22 revealed Resident #6 had diagnoses that included dementia with behavioral disturbances, Post Traumatic Stress Disorder, and kidney disease. During a continuous observation on 7/19/22 from 8:25 - 9:30 AM, Resident #6 was observed sitting in a wheelchair in the communal area. The Resident had two clear cups filled with apple and cranberry juice, covered with plastic lids with a straw inserted, a banana, and a cut up waffle, egg and ham on a plate in front of him/her. At 8:37 AM, Resident Care Coordinator (RCC) #2 gave the Resident his/her morning medication and offered him/her a drink of the juice. Resident #6 drank all the apple juice with the RCC's help. The Resident began to feed him/herself the banana. At 9:23 AM, the Resident picked up the cup of cranberry juice, fumbled, and dropped it in his/her lap. The Resident had not been provided further assistance to finish his/her juice. At 10:23 AM, Resident #6 continued to sit in the dining room, with the juice in his/her lap, an empty plate in front of him/her. The Resident had not consumed any more fluids. During an observation on 7/19/22 from 12:16 - 1:45 PM, Resident #6 was sitting in the same position at the table with a plate of chicken strips, a roll and PB&J Uncrustables sandwich on the plate in front of him/her. The Resident was not attempting to pick up any of the food or attempting to eat. Facility staff did not offer the Resident assistance with the meal. During an observation on 7/19/22 at 2:05 PM, Certified Nursing Assistant (CNA) #s 2 and 4 transferred Resident #6 on to his/her bed with the use of a lift. The front and the back of the Resident's pants were wet. When asked if the Resident had spilled something on his/her lap, CNA #4 stated it could be urine or juice. During an observation on 7/20/22 from 9:40-10:40 AM, Resident #6 was seated at a table in the communal area eating breakfast. During the observation, the Resident fed him/herself an English muffin. The Resident had two transparent plastic cups covered with lids and straws inserted. One cup contained cranberry juice and one contained apple juice. At 9:45 AM, the Resident attempted to pick up the apple juice with his right hand, fumbled with it and dropped the cup. The cup landed on its side on the table apple juice began to leak out and spread across the table. There were no staff in the area to assist the Resident with his/her fluids. The Resident continued to sit at the table, not drinking his fluids, the the spilt apple juice running across the table in front of him/her. At 10:02 AM, CNA #4 came over to table and wiped up the spilt juice. The Resident was not offered assistance with his/her fluids, and he/she did not drink any fluids during the observation. Review of Resident #6's comprehensive care plan, last evaluated 6/16/22, revealed the problem Nutritional Status IPOC [interdisciplinary plan of care] Outcomes Nutritional Intake Meets Needs (Goals) Average Meal Consumption Per Day (IND [Indicator]). The interventions included Set Up Meals, Then Can Eat Independently (INT [intervention]) and (At times may need cueing to eat and drink (INT). Review of the problem LTC ADL [activities of daily living] Function Rehab IPOC (Initiated), last evaluated 6/16/22, revealed the interventions Resident Requires Supervision While Eating (INT [intervention]) Activated and Resident Requires Cueing/Encouragement to Eat (INT) (Activated). Resident #22 Record review on 7/20-21/20 revealed Resident #22 had diagnoses that included dementia and a history of CVA (cardiovascular accident-stroke). During an observation on 7/20/22 from 9:30 - 10:30 AM, Resident #22 was sitting in a lounge chair in the communal area feeding him/herself a breakfast of waffles and bacon. The Resident had a Styrofoam cup with a lid and a straw and a plastic cup with a lid and a straw. The Resident did not attempt to drink any of the fluids provided to him/her. The Resident fell asleep, the fluids next to him/her untouched, Staff were in and out of the area intermittently as they assisted residents in rooms located down the hall. Review of Resident #22's Plan of Care, last evaluated 7/18/22 revealed LTC Nutritional Status IPOC (initiated) included the interventions offer fluids more frequently (INT) and Promote Socialization and Comfort at Mealtime. Review of the LTC ADL Function Rehab IPOC (initiated), last evaluated 7/18/22, revealed the intervention Resident Requires Cueing/Encouragement to Eat (INT) and Requires cueing, encouragement, and at times assist with feeds (INT). Resident #41 Review of the clinical medical record on 7/20-21/11 revealed Resident #41 had diagnoses that included Alzheimer's disease, chronic pain, and dysphagia (difficulty swallowing). During an observation on 7/19/22 at 9:17 AM, CNA #4 was assisting Resident #41 with breakfast, The CNA held a plate of pureed food under Resident # 41's chin gave him/her five heaping spoonfuls of food in rapid succession, giving each bite while the Resident was still chewing the last bite. CNA #4 then offered the Resident a sip of apple juice, and tipped the cup to the Resident's lips, at which the Resident began to cough. The CNA then told Resident #42 he/she would return and left to go help CNA #2 in another room. At 9:24 AM, the CNA returned, gave Resident #41 a sip of juice and fed him/her 3 large spoonsful of yogurt out of a container. At 9:26 AM, the CNA stood up and walked away, telling the Resident I'll be right back, I'm sorry. The CNA returned at 9:28 AM, and held a cup to Resident #41's lips stating Here's some juice. CNA #4 then pick up a cup of Jell-O and fed the Resident 3 bites, gave the Resident a sip of juice, and gave him/her the remainder of the Jell-O in 3 bites. At 9:30 AM, CNA #4 stood up and told the Resident he/she would be right back. The CNA returned after one minute and gave Resident #41, two more large spoonfuls of yogurt. Review of the Resident's most recent Minimum Data Set (MDS) quarterly assessment, dated 6/02/22 coded the Resident as 4 Total dependence-full staff performance every time during the entire 7-day period for H. Eating-how the resident eats and drinks regardless of skill . Review of Resident #41's Plan of Care, last reviewed 6/15/22 revealed LTC Nutritional Status IPOC (initiated) included the interventions Total assist with eating and Promote Socialization and Comfort at Mealtime. Resident #66 (non-sampled) During an observation on 7/20/22 at 10:00 AM, Resident #66 was in the communal area feeding him/herself with his/her her left hand from a plate located on table on his/her left side. The Resident was sitting in a Geri chair (a geriatric chair-a large, padded chair on wheels). During the observation, Resident #66 was unable to locate his/her drinking cup, which had slipped down the right side of his/her abdomen. In addition, the Resident's pink footie socks had slipped of his/her feet and lay on the ground in front of the Resident's Geri-chair. The Resident then dropped his/her fork on the floor. CNA #4 came over to the Resident and handed him/her a peeled banana to eat. At 10:11AM, CNA #4 handed Resident #66 a cup of grapes and told the Resident Don't eat them too fast' and walked away. The Resident began to rapidly eat the grapes from the bowl. Housekeeper #1, who was standing behind the Resident stepped forward and stated to the Resident Slow Down [Resident's Name]. The Resident appeared not to have heard as he/she continued to eat the grapes rapidly. During an interview on 7/21/22 at 11:45 PM, when asked about the residents observed eating without assistance, Licensed Nurse (LN) #2 stated they used to have 3 CNAs on the unit. The LN stated the 2 CNAs were still taking care of the residents in the room. The LN stated not having anyone in the communal area is a concern during meals, because sometimes the residents fight when they are alone in the communal room together. LN #2 stated the facility had been unable to staff with the 3rd person due to staffing concerns. During an interview on 7/21/22 at 2:29 PM, when asked about the assigned CNAs providing care on the unit and Resident #41's dysphasia, the Director of Nursing (DON) stated the Resident should be given small bites. When asked about the Resident's not receiving assistance with meals, the DON stated it due to the loss of the 3rd staff member on the unit. During the interview on 7/22/22 at 2:29 PM, the Administrator stated other staff should step in to assist with meals. Meal Choices Review of the facility revealed it was attached to the main hospital building. There were two separate kitchens used to make the resident's meals: a smaller kitchen on the Long-Term Care (LTC) side and the main hospital's larger kitchen. A lunch observation on 7/21/22 at 11:44 AM, revealed the facility had planned a social barbecue (BBQ) lunch, which was different from the regular standard menu. The residents of the facility were given white paper slips with the BBQ menu choices to select what they wanted for lunch. Review of the lunch menu selection slip, Lunch BBQ 12:00 - 1:30 PM, revealed there were three meat choices: Pork [NAME], Hamburger, or Hotdog with bun. Baked beans were also offered. There were two vegetable choices: corn on the cob or carrots, as well as, a choice of potato salad, watermelon, chocolate chip cookie, and chips. During an interview on 7/21/22 at 11:56 AM, Food Service Worker #2 stated that all therapeutic meals of ground diets (a diet where food is soft, moist, and easily mashed with a fork) and pureed diets (food that does not need to be chewed, like mashed potato consistency) were prepared at the main hospital kitchen using the main hospital menu, so these residents would not receive the BBQ lunch. Food Service Worker #2 further stated the smaller LTC kitchen prepared therapeutic meals for breakfasts, but not for lunches or dinners. Not Honoring Menu Selections Resident #18 Record review from 7/18-22/22 revealed Resident #18 was admitted to the facility with diagnoses that included memory deficit following ischemic stroke (when disrupted blood flow to the brain occurs due to problems with blood vessels that supply it) and coronary artery disease (disease of the heart artery blood vessels). Review of Resident #18's MDS (Minimum Data Set - A Federally required assessment) assessment, a quarterly assessment dated [DATE], revealed Resident #18 had unclear speech, which was slurred or mumbled, but was assessed as being able to make self understood: Sometimes understands - responds adequately to simple direct communication only. Further review revealed Resident #18 sometimes had the ability to understand others: Sometimes understands - responds adequately to simple, direct communications only. An observation of lunch preparation on 7/21/22 at 1:00 PM, revealed Resident #18 required a ground diet. Resident #18 was given the opportunity to select food choices from the Lunch BBQ menu slip. He/she selected pork [NAME], carrots, potato salad, chocolate chip cookie, and watermelon. Further observation revealed Resident #39 did not receive these choices, and instead received ground fish, ground quiche, and carrots which was the main hospital menu for the day. An observation on 7/21/22 at 1:24 PM, revealed Certified Nursing Assistant (CNA) #1 ([NAME]) attempted to assist Resident #18 with eating lunch. Resident #18 refused the meal, not eating anything of what was offered. Resident #39 Record review from 7/18-22/22 revealed Resident #39 was admitted to the facility with diagnoses that included stroke and aphasia (loss of ability to understand or express speech). Review of Resident #39's MDS assessment, an annual assessment dated [DATE], revealed Resident #39 had clear speech and was able to make self understood: Understood. Further review revealed Resident #39 was able to understand others: Understands - clear comprehension. An observation of lunch preparation on 7/21/22 at 12:28 PM, revealed Resident #39 required a ground diet. Resident #39 was given the opportunity to select food choices from the Lunch BBQ menu slip. He/she selected pork [NAME], potato salad, and watermelon. Furter observation revealed Resident #39 did not receive these choices, and instead received ground fish, ground quiche, carrots and watermelon. An observation on 7/21/22 at 12:25 PM, Resident #39 was sitting at a table in the cafeteria for lunch. He/she was situated around other peers who were eating the BBQ meal at the same table. When his/her meal was presented, Resident #39's facial expression and body language indicated he/she noticed the meal was not what was expected. The unidentified CNA seated next to him/her pointed out the watermelon, which the Resident ate. Resident #39 only ate 35% of the meal. No Opportunity to Choose from Menu Resident #31 Record review from 7/18-22/22 revealed Resident #31 was admitted to the hospital with diagnoses that included Alzheimer disease and coronary artery disease. Review of Resident #31's MDS assessment, a quarterly assessment dated [DATE], revealed Resident #31 had clear speech and was able to make self understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. Further review revealed Resident #31 had the ability to understand others: Understands - clear comprehension. An observation of lunch preparation on 7/21/22 at 1:00 PM, revealed Resident #31 required a pureed diet. Further observation revealed Resident #31 was not provided an opportunity to choose from the Lunch BBQ menu slip, instead only having a main hospital menu diet slip. Resident #31 received pureed fish, pureed quiche, mashed potatoes with gravy, and a pureed green vegetable. Resident #33 Record review from 7/18-22/22 revealed Resident #33 was admitted to the hospital with diagnoses that included traumatic brain dysfunction (brain injury caused by an outside force to the head) and traumatic hemorrhage of the cerebrum with loss of consciousness of unspecified duration (a collection of blood within the skull from an injury). Review of Resident #33's MDS assessment, a quarterly assessment dated [DATE], revealed Resident #33 had no speech, but was able to make self-understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. Further review revealed Resident #33 had the ability to understand others: Understands - clear comprehension. An observation of lunch preparation on 7/21/22 at 1:00 PM, revealed Resident #33 required a pureed diet. Further observation revealed Resident #33 was not provided an opportunity to choose from the Lunch BBQ menu slip, instead only having a main hospital menu diet slip. Resident #33 received pureed fish, pureed quiche, mashed potatoes with gravy, and a pureed green vegetable. Resident #69 Record review from 7/18-22/22 revealed Resident #69 was admitted to the hospital with diagnoses that included stroke and hemiplegia and hemiparesis affecting right dominant side (weakness or paralysis to the right side of the body). Review of Resident #69's MDS (Minimum Data Set - A Federally mandated assessment) assessment, a quarterly assessment dated [DATE], revealed Resident #69 had clear speech and usually made self understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. Further review revealed Resident #69 had the ability to understand others: Understands - clear comprehension. An observation of lunch preparation on 7/21/22 at 1:00 PM, revealed Resident #69 required a pureed diet. Further observation revealed Resident #69 was not provided an opportunity to choose from the Lunch BBQ menu slip, instead only having a main hospital menu diet slip. Resident #69 received pureed fish, pureed quiche, mashed potatoes with gravy, and a pureed green vegetable. During an interview on 7/22/22 at 8:23 AM #2 stated the facility had special social meals, which were different from the regular standard menu, about twice a month. Nurse Manager #1 was not aware that residents with therapeutic diets did not receive the BBQ lunch. Review of the facility's policy Resident Rights and Responsibilities, dated 4/7/22, revealed: It is the policy of this facility to promote and protect the rights of each resident residing at Denali Center; to provide equal access to [quality] care regardless of diagnosis, severity of condition, or payment source . Residents have our commitment to uphold the following rights . Residents have the right to expect the Denali Center staff to provide: considerate and respectful treatment. Care that supports continued personal freedom, dignity, and individual autonomy . The resident has the right to participate in facility and community social and religious activities . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan, to include measurable objectives to meet resident's medical, nursing, mental, psychosocial, and/or safety needs. Specifically, the facility failed to ensure: 1) individualized bathing needs were care planned and implemented for 1 Resident (#52), out of 18 sampled residents; 2) smoking safety was care planned and interventions implemented for 3 Residents (#'s 46, 50, and 61), out of 3 residents who smoked; and 3) individualized non-pharmacological behavior interventions were care planned and implemented for 1 Resident (#44), out of 1 sampled resident reviewed for psychiatric services. These failed practices had the potential to affect the resident's ability to: 1) attain or maintain their highest practicable physical, mental, and psychosocial well-being; and/or 2) maintain safety expectations while smoking. Findings: Bathing Resident #52 Record review from 7/18-22/22 revealed Resident #52 was admitted [DATE] with diagnoses that included a stage 3 pressure ulcer to the sacrum (tailbone area), a surgical wound to the right lower buttock, and a traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). Further review revealed Resident #52 had surgical repair of the sacrum pressure wound and the buttock wound on 6/13/22 and 6/20/22. During an interview on 7/19/22 at 9:01 AM, Resident #52 stated I've been here two months and have only received one shower and one bed bath. Review of the Tamarack Bath/Shower Schedule, no date, revealed Resident #52 was scheduled for showers on Mondays and Thursdays. Review of Resident #52's care plan revealed an identified problem LTC [Long Term Care] ADL Function Rehab [rehabilitation] IPOC [interdisciplinary plan of care], last updated 6/8/22. Further review revealed the following interventions for this problem: Keep bath time calm, keep water warm and resident warm, last evaluated 7/6/22, and Provide Bath/Shower - 2 times a week ., last evaluated 7/6/22. Review of Resident #52's Resident Bathing Type by Day Chart, dated 6/21/22 to 7/20/22, revealed a chart that included spaces to document: Shower, Tub, Bed Baths, Whirlpool, Other, Patient Refused, Patient with Family, Patient outside Family, Not Scheduled, and Total. Further review revealed Resident #52 had a shower on 7/2/22 and he/she refused personal hygiene twice, 7/11/22 and 7/18/22. Further review revealed no further documentation of personal hygiene for Resident #52. Additional review of the Care Plan's stipulation of personal hygiene two times a week, and the documented personal hygiene on the Resident Bathing Type by Day Chart, the facility only provided 3 out of 8 opportunities for personal hygiene from 6/21/22 to 7/20/22. During an interview on 7/21/22 at 4:37 PM, Resident Care Coordinator (RCC) #2 stated that the surgical doctor, who completed the surgical repair of Resident #52's wounds, ordered no baths or showers upon admission due to the severity and condition of the wounds. RCC #2 further stated that in reviewing Resident #52's medical record, there was no order to state Resident #52 could not have showers or baths. During the same interview, RCC #2 stated Resident #52's care plan did not indicate he/she required bed baths and not showers or baths. Review of the facility's policy CNA Expectations and Standards of Care, dated 4/7/22, revealed: Cares . Bathing/Personal Hygiene. Bath/shower [two times] week, or as care planned . Smoking Resident #46 Record review on 7/18-22/22 revealed Resident #46 was admitted to the facility with diagnoses that included end stage renal disease (a condition in which kidney function is less than 10% of normal; the kidneys can no longer remove wastes, concentrate urine, and regulate electrolytes) and nicotine dependence. During this survey, RCC #2 identified Resident #46 as a resident who smoked. Review of an Annual MDS (Minimum Data Set - A Federally required assessment) Assessment, dated 3/17/22, and a Quarterly MDS Assessment, dated 6/09/22, revealed Section J-Health Conditions coded Resident #46 J1300 Current Tobacco Use Tobacco Use 0. No. Review of Resident #46's Care Plan revealed no identified problem, or interventions, for smoking. During an interview on 7/21/22 at 4:30 PM, RCC #2 stated, that after discussions with this surveyor, smoking evaluations and care plans had been reviewed for all smokers, 3 residents total, to ensure safety measure were in place. Review of Resident #46's medical record revealed a Safe Smoking Evaluation was completed on 7/19/22. Further review revealed no other Safe Smoking Evaluations were completed, from resident's admission date, on 4/2021, up to 7/19/22. During an interview on 7/22/22 at 8:16 AM, RCC #2 stated Resident #46 had been smoking since admission and smoked primarily on trips to dialysis. Review of Resident #46's order list revealed an order, dated 7/21/22, to add smoking to resident's Care Plan: add smoking to problem list. Resident #50 Record review on 7/18-22/22 revealed Resident #50 was admitted to the facility with diagnoses that included multiple sclerosis, chronic pain, and nicotine dependence. Review of a Significant Change Comprehensive MDS, dated [DATE], and an Annual MDS Assessment, dated 6/15/22, revealed Section J-Health Conditions coded Resident #50 J1300 Current Tobacco Use Tobacco Use 0. No. During this survey, RCC #2 identified Resident #50 as a resident who smoked. Review of Resident #50's Care Plan revealed no identified problem, or interventions, for smoking. Review of Resident #50's medical record revealed Safe Smoking Evaluations, dated 3/9/21, 4/19/21, 7/3/21, 3/23/22, and 5/3/22. During an interview on 7/22/22 at 8:35 AM, RCC #2 stated Resident #50 smoked intermittently, and smoking should have been added to resident's care plan. Review of Resident #50's order list revealed an order, dated 7/21/22, to add smoking to resident's Care Plan: add smoking to problem list. Resident #61 Record review on 7/18-22/22 revealed Resident #61 was admitted to the facility with diagnoses that included paraplegia (paralysis of the legs and lower body), monoplegia of upper limb affecting dominant side (a type of paralysis that impacts one limb), and nicotine dependence. During an interview on 7/18/22 at 3:22 PM, Resident #61 stated he/she smoked cigarettes across the street because the facility was a smoke free facility, and he/she could not smoke on the facility grounds. Resident #61 further stated he/she kept all cigarettes and lighters in his/her room and traveled independently across the street when he/she wanted to go. Review of an Annual MDS Assessment, dated 6/23/22, and a Quarterly MDS Assessment, dated 3/30/22, revealed Section J-Health Conditions coded Resident #61 J1300 Current Tobacco Use Tobacco Use 0. No. Review of Resident #61's Care Plan revealed no identified problem, or interventions, for smoking. Review of Resident #61's medical record revealed a Safe Smoking evaluation, dated 3/9/21. During an interview on 7/21/22 at 4:30 PM, RCC #2 stated that smoking should have been added to Resident #61's Care Plan. Review of Resident #61's order list revealed an order, dated 7/21/22, to add smoking to resident's Care Plan: add smoking to problem list. Review of the facility's policy Denali Center Residents Smoking, Dated 6/15/22, revealed: . If resident communicates, they are smoking off of campus, a smoking assessment will be completed for safety and the safety interventions will be care planned. The smoking assessment and care plan will be reviewed and updated as needed with changes in resident condition . Non-pharmacological Interventions for Behavior Resident #44 Record review on 7/18-22/22 revealed Resident was admitted to the facility on [DATE] with diagnosis of bipolar disorder (a major mental disorder characterized by episodes of mania, depression, or mixed mood). Review of a Quarterly MDS Assessment, dated 6/02/22 revealed Section I-Active Diagnoses Psychiatric/Mood Disorder Resident #44 was coded for I5900 Manic Depression (bipolar disorder). Review of Resident #44's Medication Administration Record Report, dated 7/2022, revealed Resident #44 was on several medications for bipolar disorder: - Oxcarbazepine [Trileptal - an anticonvulsant sometimes used to treat bipolar] 300 mg [milligrams] by mouth at 9:00 AM and 600mg by mouth at 9:00 PM. Indication: bipolar disorder. Start date 3/7/22. - Quetiapine [Seroquel - an antipsychotic used to treat bipolar] 200mg by mouth at 9:00 AM, 300mg by mouth at 9:00 PM. Indication: bipolar disorder. Start date 3/7/22. - Hydroxyzine [an antihistamine used to treat anxiety] 75mg by mouth twice a day [9:00 AM and 9:00 PM]. Indication: bipolar disorder. Start date 4/21/22. Review of Resident #44's physician notes revealed documentation of bipolar treatment plans and behavior issues identified: - Denali Center H&P [Health and Physical], dated 3/10/22: .Assessment and Plan . Bipolar disorder. We will continue home medication of quetiapine and oxcarbazepine . - Denali Center Progress Note, dated 4/11/22: Talked with [Resident #44] today regarding my expectations not becoming physical with staff. [He/she] stated that [his/her] leg hurt, so [he/she] will defend herself if staff hurts it when moving . - Denali Center Progress Note, dated 4/21/22: Patient asked to see me today. [He/she] was angry and hard to understand, and I had a hard time calming [him/her] down. [He/she] continues to say [he/she] was on many more psych meds at home that [he/she] was getting here, but can't name any that [he/she] is missing. [He/she] told me in the past the [he/she] was on 11 psych medication, but started yelling at me when I told [him/her] I got [his/her] medications list and couldn't find that many psych meds . I let [him/her] know we obtained a medication list, and the only psych medication from [his/her] pharmacy [he/she] is not taking is hydroxyzine. I am going to start it [again]. - Denali Center Progress Note, dated 5/5/22: . [He/she] also reports that [he/she] moved to Tamarack yesterday, when really [he/she] got here today . - Denali Center Progress Note, dated 6/16/22: .[He/she] has been difficult with staff and providers, and refused some care and refused to work with PT [physical therapy] . [He/she] made allegations that I have lied to her . During an interview on 7/19/22 at 1:16 PM. Licensed Nurse (LN) #6 stated [Resident #44] is awful, [he/she] is always cursing and arguing. During an interview on 7/21/22 at 8:33 AM, RCC #2 stated I feel like everyone is failing [him/her] because [he/she] is so difficult with staff. During an interview on 7/21/22 at 10:10 AM, the Administrator stated that a code violet [an alert throughout the building for any staff to assist with a violent resident] had been called in the past for Resident #44 when he/she became upset and started throwing any item within reach at staff, to include full bottles of soda. Review of Resident #44's Care Plan revealed the identified problem, LTC [Long Term Care] Behavioral Symptoms IPOC, last updated 3/25/22. Outcomes for this problem, last evaluated on 7/19/22, were: Appropriate behavior when interacting with others; behaviors exhibited; interventions used to alter behavior; behavior intervention result. Interventions for this problem, last evaluated on 7/12/22, were: [1] Provide care with smile, gentle touch, voice, reassurance; evaluate for signs of pain during care and intervene; [2] evaluate usual time, duration, and frequency of behavior; [3] evaluate medications for desired and adverse outcomes; [4] take resident to BIT/PIT [behavior intervention team/pain intervention team] quarterly and PRN; [5] add behavior finding to problem list . Further review of Resident #44's Care Plan revealed no non-pharmacological interventions for floor staff to use, other than provide care with smile, gentle touch, voice, reassurance, to assist with behavior problems. During an interview on 7/22/22 at 8:11 AM, when asked why Resident #44's Care Plan had no non-pharmacological interventions to assist with the resident's behaviors, RCC #2 stated Resident #44's Care Plan had no particular interventions listed yet because the Resident had only come to the Tamarack unit two months prior, on 5/5/22, and the staff were still learning about the Resident, it has been an adjustment. When asked to list any non-pharmacological interventions that the staff were currently using with Resident #44 to assist with behavior problems, RCC #2 stated at the moment, it was just to select specific staff to provide care. Review of the facility's policy LTC Psychotropic Medication Use, dated 11/1/21, revealed: Purpose/Expected Outcome: To provide a multidisciplinary team approach to ensure that . Residents with psychiatric and disruptive behavioral disorders are treated appropriately with environmental, behavioral, and psychotropic interventions tailored to the needs of the individual . Non-pharmacological interventions: should first be attempted before psychotropic medication intervention, unless the psychotropics are necessary to prevent immediate harm to himself/herself, or others. Non-pharmacological interventions may include: Environmental (including facility routines and staff approaches) . Review of the facility's policy Multidisciplinary Resident Care Review and Care Plan Process, dated 7/11/22, revealed: At resident care review, the discipline representative attending for each department will participate and update the resident's plan of care as needed . At conference, the following must be discussed: Resident concerns [and] needs will be discussed and documented on the interdisciplinary care conference form . Resident short and long term goals . use of psychotropic drugs if applicable, to include risks and benefits of drug use. Care plan review needs to include: psychosocial, functional, clinical and leisure areas, residents strengths and weaknesses. Care Planning: A Plan of Care will include: a. Focus of problems; b. Long-term and short-term foals which are measurable, including therapy goals; c. Approaches from care plan will be used to create the CNA/LN flow sheets . .

. Based on observation, record review, and interview, the facility failed to ensure the resident environment remained as free of accident hazards as was possible. Specifically, the facility failed to ensure: 1) knives were kept out of reach of residents on the Tamarack unit; and 2) safety measures were established and in place for 2 residents (#'s 46 and 61) who smoked, out of 3 sampled residents who smoked. These failed practices had the potential to introduce avoidable accidents for all residents of the Tamarack unit, based on a census of 24. Findings: Knives on the Unit: Random observations from 7/18-22/22 of the facility's units revealed each unit had a small kitchenette located on each unit. These kitchenettes were accessible by residents and not situated near common areas where continuous monitoring was present. An observation on 7/18/22 at 10:46 AM, of Tamarack unit's kitchenette at the end of the hall, away from the common area and in the unit's sunroom, revealed a small counter with a sink out of the line of sight from of the unit's hallway and nurse's station. There were cupboards above the counter, and cupboards and drawers below. Upon inspecting the upper cupboards, a large kitchen knife, with a sharp blade estimated to be about 6 to 8 inches long, was found in the far upper right cupboard, openly sitting in the middle of the middle shelf. Further inspection revealed a sharp paring knife (a small sharp knife used for peeling fruits and vegetables) in the far upper left cupboard, situated on the right side of the middle shelf. During an interview on 7/18/22 at 12:52 PM, Resident Care Coordinator (RCC) #2 stated the unit kitchenettes should not have any sharp knives stored in them and should have immediately been returned to the kitchen for storage after use. Smoking Resident #46 Record review on 7/18-22/22 revealed Resident #46 was admitted to the facility with diagnoses that included end stage renal disease (a condition in which kidney function is less than 10% of normal; the kidneys can no longer remove wastes, concentrate urine, and regulate electrolytes) and nicotine dependence. During this survey, RCC #2 identified Resident #46 as a resident who smoked. Review of Resident #46's Care Plan revealed no identified problem, or interventions, for smoking. Additional review revealed oxygen was initiated for Resident #46, via nasal cannula, on 7/18/22 due to Resident #46 having difficulty maintaining adequate oxygen saturation while breathing on just room air. Review of Resident #46's Nursing Notes revealed Resident #46 had returned from the E.R. on 7/18/22 at 8:52 PM after being evaluated for hypotension during dialysis. Further review revealed: - 7/18/22 at 9:10 PM - Resident started having difficulty breathing, O2SAT [oxygen saturation of blood which indicates how well a person's lungs are delivering oxygen to the body] was low 70s [normal range 95% to 100%]. O2 via nasal cannula started. - 7/19/22 at 1:36 AM - This CRN [Charge Nurse] notified resident was having difficulty taking breaths, upon entering resident's room resident was found in distress, unable to take deep breaths and having trouble talking . SaO2 [oxygen saturation] noted to be between mid 60s and low 70s . O2 applied 4Lpm [liters per minute] and SaO2 increased to 97% within a few minutes . O2 decreased to 2Lpm at [11:00 PM] O2 off at [12:30 AM] SaO2 = 93%, at [1:00 AM] resident c/o of difficulty breathing again, Stats in low 80s, O2 reapplied at 2Lpm . During an interview on 7/21/22 at 4:30 PM, RCC #2 stated, that after discussions with this surveyor, smoking evaluations and care plans had been reviewed for all smokers to ensure safety measure were in place. Review of Resident #46's Safe Smoking Evaluation, dated 7/19/22, revealed: .Smoking Safety Demo: Able to use lighter, able to hold cigarette, able to extinguish cigarette. Smoking Safety Risk History: Cigarettes found in room, brought in by family/other . Further review revealed no documentation that resident was on oxygen or education about not smoking while on oxygen was present. Additional record review revealed no other Safe Smoking Evaluations were completed from resident's admission date, on 4/2021, up to 7/19/22. During an interview on 7/22/22 at 8:16 AM, RCC #2 stated Resident #46 had been smoking since admission, and smoked primarily on trips to dialysis. When asked about the process for completing Resident #46's safe smoking evaluation, RCC #2 stated he/she made sure the resident could verbalize dexterity to handle a lighter, lite a cigarette, and extinguish a cigarette. RCC #2 further stated that no visual demonstration was completed. When asked about Resident #46's use of oxygen, RCC #2 stated there was verbal education to not smoke while on oxygen that occurred on 7/19/22 during the safe smoking evaluation, but this was not documented. RCC #2 further stated the Safe Smoking Evaluation should have been in place upon admission, 4/2021, and smoking should have been added to Resident #46's Care Plan. Review of Resident #46's order list revealed the order add smoking to problem list, dated 7/21/22. Resident #61 Record review on 7/18-22/22 revealed Resident #61 was admitted to the facility with diagnoses that included paraplegia (paralysis of the legs and lower body), monoplegia of upper limb affecting dominant side (a type of paralysis that impacts one limb), and nicotine dependence. During an interview on 7/18/22 at 3:22 PM, Resident #61 stated he/she smoked cigarettes across the street because the facility was a smoke free facility, and he/she could not smoke on the facility grounds. Resident #61 further stated he/she kept all cigarettes and lighters in his/her room and traveled independently across the street when he/she wanted to go. An observation on 7/18/22 at 3:22 PM, revealed a pack of cigarettes and two lighters were on resident's bedside table during the interview. Review of Resident #61's Safe Smoking Evaluation, dated 5/3/22, revealed: .Smoking Safety Demo: Able to use lighter, able to hold cigarette, able to extinguish cigarette . Review of Resident #61's Care Plan revealed no identified problem, or interventions, for smoking. An observation on 7/20/22 at 3:33 PM, revealed Resident #61 was out of his/her room, down the hall from his/her unit, near the front entrance. Further observation revealed that Resident #61's pack of cigarettes and two lighters were left unattended in Resident #61's room on his/her bedside table. The door to Resident #61's room was open at the time. During an interview on 7/21/22 at 8:29 AM, RCC #2 stated there was no smoking agreement signed by the resident to stipulate the facility's smoking safety expectations, however there was a verbal discussion with the resident. RCC #2 stated it was verbalized to Resident #61 that he/she was to not smoke on the facility grounds or in his/her room, the Resident could not share cigarettes with other residents, and all lighters and cigarettes needed to be put up, in a drawer, away from other residents when not in use. When informed Resident #61's lighters and cigarettes were left unattended in Resident's room on the bedside table, Nurse Manager #1 stated they should not have been left out in the open as any resident could inadvertently have access to them which could be a safety risk. During an interview on 7/21/22 at 4:30 PM, Nurse Manager #1 stated that smoking should have been added to Resident #61's Care Plan. Review of Resident #61's order list revealed the order add smoking to problem list, dated 7/21/22. Review of the facility's policy Denali Center Residents Smoking, dated 6/15/22, revealed: .If residents [choose] to smoke it will occur off of FHP [Foundation Health Partners] Tobacco Free Campus. If resident communicates they are smoking off of campus, a smoking assessment will be completed for safety and the safety interventions will be care planned. The smoking assessment and care plan will be reviewed and updated as needed with changes in resident condition . Review of the facility's policy Denali Center: Safety Guidelines in Nursing Care, dated 11/1/21, revealed: . Purpose: To serve as a reference to nursing personnel for safety measures . Oxygen: Precautions to observe when oxygen is in use. Enforce No Smoking regulations . Fires: Safety measures to practice at all times . know facility-smoking policy . Review of the facility's policy Resident Rights and Responsibilities, dated 4/7/22, revealed: .Residents have the right to expect the Denali Center staff to provide . a safe, clean, and comfortable environment . .

. Based on observations, interviews, and record review, the facility failed to ensure that food was stored and prepared 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 hospital kitchen;, 2) food was stored under proper sanitation and food handling practices in the Fireweed Kitchen in the Denali Center LTC (Long Term Care Center);, 3) concentrations of sanitizing solution buckets were monitored for the Fireweed Kitchen in the Denali Center LTC;, and 4) food was stored under proper sanitation and food handling practices in the units kitchenettes. These failed practices had the potential of causing or spreading foodborne illness to all residents, based on a census of 65 (excluding those residentts that receive tube feeding). Findings: Food Storage in Main Hospital Kitchen (Large Kitchen) An observation on 7/18/22 at 10:21 AM, of the walk-in refrigerator, revealed: Unlabeled, opened items: Turkey Base (quantity 2) 16 oz containers Low Sodium Chicken Base 16 oz container Vegetable Base 16 oz container Chopped ginger (quantity 2) 9 oz containers During an interview on 7/18/22 at 10:25 AM, the Culinary Supervisor (CS) #1 stated that the above listed unlabeled, opened items should have been dated and that all staff are trained on labeling opened items. The CS #1 further stated that the cooks read the labels before being used and served to the residents. The above items were removed and trashed. When asked for an inventory of goods with only codes, the CS #1 stated no such inventory or tracking system existed and that these items were being phased out. These codes were being researched from the vendor and no further updates were provided by the end of survey. The CS #1 further stated items with only codes were pulled from stocks until the dates could be obtained. During an observation on 7/18/22 at 10:52 AM, of the walk-in freezer; revealed the floor was dirty with crumbs and ice crystals as well as throughout. Further observation revealed: An unlabeled, opened box of blue berry muffins that was missing 2-3 muffins. This box was torn open and muffins were exposed to the elements. A manufacturer package of peanut butter and grape jelly sandwich that had ice crystals inside the package. A manufacturer package muffin that had ice crystals inside the package. During an observation on 7/18/22 at 11:05 AM, of the dry/canned storage revealed: Unlabeled, opened items: Opened bag of dry rice 5 lbs, wrapped in cellophane wrap with no open date. Opened bag of small shell pasta 10 lbs, wrapped in cellophane wrap with no open date. The CS #1 confirmed these item were not properly labeled and threw them out. Food Storage in Fireweed LTC Kitchen (Small Kitchen} An observation on 7/21/22 at 8:41 AM of the Fireweed Kitchen in the Denali Center LTC, revealed: Freezer: 1 bag of waffles opened to air, not dated 2 small plastic cup containers of blueberries with use by date of 7/13/22 2 bags of chicken opened but tied shut approximately 5-10 lbs., not dated 1 bag of french fries opened but tied shut approximately 5-10 lbs., not dated During an interview on 7/21/22 at 9:17 AM Food Service Worker (FSW) #3 stated items stored in the freezer should be dated and labeled for 1 month out for discard. FSW #3 confirmed that the above listed items were not dated. Sanitation Buckets An observation on 7/21/22 at 8:47 AM, of the sink with sanitation chemicals and the sanitation bucket, revealed no log for sanitation buckets concentration monitoring. During an interview on 7/21/22 at 8:50 AM, Food Service Worker (FSW) #2, stated there was not a log that documented the sanitation concentrations as the dispenser was preprogrammed and dispensed the correct concentration every time. FSW #2 confirmed with the Culinary Supervisor #2 that there was not a log. FSW #2 further stated that the sanitation bucket was changed before every meal. During an interview on 7/21/22 at 8:59 AM, Culinary Supervisor (CS) #2 stated the procedure that used testing strips to test the concentration of the sanitization buckets stopped 1-3 years ago. The CS #2 further stated the solution was preset to be the correct dilution and there was no log of maintenance of the system. During an interview on 7/21/11 at 11:35 AM, the ECOLAB Consultant (EC) stated the sanitation buckets should be checked every time a batch of sanitation solution was made as the chemical had a shelf-life of 4 hours. The EC further stated he/she was unaware of the small Fireweed kitchen at the Denali Center LTC and had not been monitoring this kitchen. Food Storage in Unit Kitchenettes An observation on 7/18/22 at 10:46 AM, of Tamarack unit's kitchenette revealed: Refrigerator: - One grocery bag with green grapes labeled with resident's name, no date. - One grocery bag with green grapes labeled with resident's name, dated 7/13/22 - One grocery bag with green grapes, which appeared old and brown, no resident's name, no date. - Two containers of feta cheese labeled with resident's initials, no date. - Top of the refrigerator door, when opened, had a dried brown substance coating the length of the door, from hinge to outer top edge, on the inner seal molding and inner top edge of the door frame. Cupboards and Drawers of Counter: - Lower cupboards dirty, food crumbs present throughout, cracker and candy wrappers within. - Three Tri-fold suction cath-n-glove medical supply kits found in lower right cupboard. - One Mr. Coffee coffee maker sitting on counter. Glass coffee pitcher dirty inside, dried brown grime throughout interior and bottom of pitcher. During an interview on 7/18/22 at 12:38 AM, Resident Care Coordinator (RCC) #2 stated that all resident food in the refrigerator needed to be labeled with the resident's name and date it was placed in the refrigerator, and that resident food could only be kept for 3 days then must be discarded. RCC #2 further stated that all the bags of grapes and the feta cheese needed to be discarded. In the same interview, RCC #2 stated it was a joint effort between the kitchen staff and floor staff to keep the kitchenette clean and keep food labeled and dated, as well as housekeeping to clean all surfaces of refrigerators and counters/cupboards. RCC #2 further stated that the refrigerator and cupboards needed cleaning. Additionally, RCC #2 stated medical supplies should not be stored in the kitchenette. An observation on 7/19/22 at 9:00 AM revealed the kitchenette freezer on the Aspen unit had spilled ice cream residue that covered the bottom of the freezer. During an interview on 7/19/22 at 1:25 PM the Administrator said the ward clerk was responsible for keeping unit kitchenette refrigerators/freezers cleaned. An observation on 7/22/22 at 8:15 AM, revealed the kitchenette freezer on the Aspen unit had not been cleaned. Review of facility's policy Denali Center: Refrigerated Storage of Food and Drugs- Monitoring or Refrigerator Temperatures in Resident Care Areas, effective date of 11/1/21, revealed .A. Refrigerators will be maintained in a sanitary condition . F. All spills should be wiped up as they occur and or observed, to maintain cleanliness, on an ongoing basis . Review of facility's policy Food Safety and Sanitation, effective 11/26/21, revealed .C. Food Purchasing . 8. All stock is rotated to assure first in, first out . D. Food Storage . 6. All leftovers are labeled, covered, and dated when stored. They are used following the guidelines of the Discard Dates attachment or discarded. 7. Foods with expiration dates and best by dates are used prior to the date on the package. 8. Canned and dry foods without expiration dates are used within six months of delivery or according to the manufacturer's guidelines. 9. Opened containers and prepped good are used or discarded within the time frame of the Discard Dates form, developed by management . Review of facility's policy Purchasing Food and Supplies, effective 7/7/22, revealed .F. Inventory: . 3. Inventory is rotated using the FIFO [first in, first out] method . .