.Based on interview and record review, the facility failed to treat one resident (#16), out of 26 residents reviewed, with dignity and respect. Specifically, the facility's Administrator took the resident's personal checkbook, against the resident's wishes, and kept this item in her personal desk without communicating an appropriate rationale for the restriction. This failed practice violated the resident's right to be treated with dignity and respect and placed undue stress on the resident which had the potential to affect the resident's overall health and well-being. Findings:During an interview on 9/2/25 at 2:35 PM, Resident #16 stated the Administrator confiscated my checkbook and said if I didn't give it to [him/her] I would be kicked out of the hospital. Resident #16 stated, I was so angry. Resident #16 state the Administrator took the checkbook and wouldn't give it back, she held it over the weekend. Resident #16 could not identify the date this occurred. During an interview on 9/4/25 at 10:04 AM, the Administrator stated Resident #16 was having difficulty with insurance and needed an application for Medicaid completed. The Administrator stated the Power of Attorney (POA) had requested assistance in getting the checkbook because Resident #16 was writing checks and the POA couldn't have the resident writing checks he/she wasn't aware of. When asked to describe her encounter with Resident #16, the Administrator stated she took a nurse with her to Resident #16's room and told the resident he/she had not been on Medicaid since December. The Administrator stated she told Resident #16 she didn't want to initiate a discharge for him/her, but that the facility needed to get a payor source for his/her continued stay. For that reason, the Administrator stated she told Resident #16 she needed to take the checkbook so your POA can apply for Medicaid for you. The Administrator stated Resident #16 initially said no, that he/she did not want anyone to take his/her check book and asked, What are you going to do with it? The Administrator stated after conversing for a while, and only after the Administrator agreed to tell the resident if any checks were written while the checkbook was in her possession, did the resident surrender the checkbook to her. When asked what the Administrator did with the checkbook, the Administrator stated she put it in her personal desk in her office. When asked why she didn't put the checkbook in the facility's resident safe, the Administrator stated she didn't know the process for using the safe. When asked about the timeline of this event, the Administrator stated it was a day or two prior to going on remote status (returning to home out of state but continuing to work), which was the first weekend of August. When asked if she usually took personal belongings from residents, the Administrator stated it was not usual practice. When asked why the POA didn't come with the Administrator to discuss the situation with the resident prior to taking the checkbook, the Administrator stated she could have and probably should have done that. When asked why the Administrator did not give the checkbook to the POA after obtaining it, the Administrator stated she had to leave for a family emergency and switched to remote status before the checkbook could be transferred to the POA. When asked if she informed anyone that Resident #16's checkbook was in her personal desk, the Administrator stated she couldn't remember. During an interview on 9/4/25 at 10:04 AM, the Director of Nursing stated it was not common practice to take personal belongings of residents and put them in staff desks. During an interview on 9/4/25 at 10:04 AM, the Chief Nursing Officer (CNO) stated she knew that the Administrator took Resident #16's checkbook and placed it in her desk, but she was not aware of how long the Administrator had the checkbook. The CNO stated it was not usual practice to keep personal belongings in personal desks. The CNO stated once she had heard Resident #16 was inquiring about his/her checkbook, she went into the Administrator's office and retrieved the checkbook from the Administrator's desk and it was returned to the resident. During an interview on 9/4/25 at 12:18 PM, Staff #45 stated he/she witnessed an interaction between the Administrator and Resident #16, after the Administrator had possession of the checkbook, where Resident #16 said, I want my checkbook! The Administrator dismissed Staff #45 saying, you don't need to be here for this, I got this. Staff #45 left the room. During an interview on 9/4/25 at 12:54 PM, Staff #62 stated he/she witnessed the initial interaction between the Administrator and Resident #16 concerning the checkbook. Staff #62 stated his/her perspective of the conversation was that the Administrator was forcing Resident #16 to give up his/her checkbook and the words used by the Administrator were threatening saying, you don't really have a choice, you need to give me the checkbook. Staff #62 stated Resident #16 was mad. Staff #62 stated the Administrator dismissed him/her from the room prior to the conversation ending, and prior to the Administrator taking possession of the checkbook. Staff #62 was unaware of what transpired after being dismissed. During an interview on 9/4/25 at 12:58 PM, Resident #12's POA stated the Administrator called him/her about getting Resident #16's finances worked out for a payor source. The POA stated Resident #16's struggled with giving up control of his/her finances. The POA told the Administrator that he/she didn't force finances on residents, but if the facility wanted to help back him/her up, he/she felt it was in the resident's best interest to not have control of the finances. The POA further added, the Administrator stated she had no problem backing him/her up. Review of Resident #16's medical record revealed no notes regarding the Administrator's discussion with the POA, her interaction with Resident #16 to get the checkbook, that she stored the checkbook in her personal desk, or what the plan was going to be once she had the checkbook. Review of Resident #16's POA paperwork, dated 2/20/25, revealed the POA was named as Resident #16's agent with power under the category banking transactions. Review of the facility's policy LTC [Long Term Care]: Patient Rights and Responsibilities Policy, dated 1/10/25, revealed: It is the policy of PeaceHealth to define, recognize, protect and promote the rights and responsibilities of the patients and their legal, authorized or designated representatives . Review of the facility's Resident Rights and Responsibilities form, undated, which was available to all residents, revealed: . You have the right to dignity, respect and compassion. This includes your right to: Be treated with consideration, respect and dignity, recognizing reach resident's individuality . Exercise rights without interference, coercion,, discrimination, or reprisal; a homelike environment, and use personal belongings when possible . Keep personal belongings as space permits and have those possessions be kept safe .

.Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 resident (#12), out of 1 allegation of abuse investigation reviewed. Specifically, the facility failed to: 1) Accurately interview Resident #12 to determine the nature and timing of the allegation of abuse; 2) Have evidence of the Administrator's interview conducted during the investigation; 3) Contact the Resident's Provider regarding the allegation of abuse; and 3) Investigate reports of intimidation and verbal abuse received from 2 residents (#'s 20 and 25), out of 5 residents interviewed during the investigation. These failed practices: 1) caused a misinterpretation of what the allegation of abuse was and when it occurred; 2) resulted in the investigation being incomplete; and 3) denied Residents #20 and #25 the right to potentially submit a complaint for an allegation of abuse and placed them at risk for continued emotional upset from the experiences reported. Findings:Incident Reported A facility reported incident (FRI) was submitted to the State Agency for an allegation of verbal abuse, dated 7/23/25, by the Chief Nursing Officer (CNO). Incident Description During an interview on 9/2/25 at 1:45 PM, Resident #12 stated he/she had been asking about going to therapy to help strengthen his/her legs so he/she could walk again. Resident #12 stated the Administrator came to him/her one day while he/she was looking out a window in the activities room and said, You are never going to get out of that chair [meaning wheelchair]. You are a failure, and you are going to die here. Resident #12 stated this comment made him/her very sad and he/she was now hopeless, like I'll never get out of here. It was observed that Resident #12 was physically shaking when he/she told this story, wringing his/her hands and his/her voice was cracking with emotion. When asked when this conversation occurred, Resident #12 stated he/she couldn't remember the exact date, but it was before the 7/23/25 resident council meeting. Investigation by CNO During an interview on 9/3/25 at 1:34 PM, the CNO stated during the resident council meeting on 7/23/25, in the middle of the meeting, Resident #12 stated he/she felt the Administrator had verbally abused him/her. After the meeting, the facility team decided to file a State report regarding Resident #12's comment and initiate an investigation. The CNO stated the report was sent to the State Agency on 7/23/25. The CNO further stated that she contacted the HR Director for PeaceHealth on 7/23/25 about the investigation and placed the Administrator on administrative leave pending the conclusion of the investigation. The CNO further stated she completed an interview with Resident #12 on 7/23/25 about the comments in the meeting, however Resident #12 did not comment on what the verbal abuse was. When asked to see the documentation for the interview with Resident #12, the CNO stated no documentation for the interview was completed. The CNO further stated that Resident #12 stated he/she was just mad and didn't want to file a report, but the CNO felt it was her responsibility to file the report anyhow to make sure an abundance of caution was made. The CNO stated she also submitted this incident in the facility's electronic incident reporting system Safe2Share. When asked if the CNO was aware that when Resident #12 spoke of the verbal abuse in the resident council meeting, the resident was speaking about an incident that had occurred before the resident council meeting, and not about a comment made at the meeting, the CNO stated she was not aware of this and had assumed it was about a comment made in the resident council meeting on 7/23/25. When asked if the CNO interviewed the Administrator during the investigation, the CNO stated she and the Administrator had talked but this was not documented. When asked if the CNO contacted Resident #12's provider to inform them of the reported allegation of abuse, the CNO stated she did not contact the provider. When asked what other steps occurred during the investigation, the CNO stated she had a Minimum Data Set (MDS - a nationally mandated routine assessment) Nurse interview five other residents to ensure no other residents had any concerns. The CNO stated she drafted questions for the MDS Nurse to use. From these interviews, she determined these residents felt safe. When asked what the investigation's determination was, the CNO stated that because Resident #12 retracted his/her statement and because it was determined it was mainly about the Administrator's approach to communicating with others, she determined the abuse allegation as retracted and concluded the investigation on 7/28/25. The CNO stated the Administrator returned to work on 7/29/25. Review of the facility's documentation of the resident interviews that occurred during this investigation, undated, revealed two resident's, Resident #20 and #25, interviews revealed they had felt verbally abused by the Administrator. During an interview on 9/3/25 at 1:34 PM, when asked if these comments were investigated, the CNO stated, no. Review of the facility policy Allegation of Abuse Policy, dated 12/15/24, revealed: . It is the policy of PeaceHealth that any allegation of abuse by a patient against a caregiver will be responded to immediately. An investigation of the facts will be coordinated . Caregiver - Patient Present. An allegation is made against a caregiver by a patient or another party for a patient currently in the hospital or in an ambulatory setting. Receiving Party. Any caregiver or provider who observes or who receives a report that anyone is being abusive, either physically, sexually, or verbally or in any way behaving in a manner harmful or disrespectful to any patient who is under the care of PeaceHealth, must immediately report this behavior to their manager/designee . Responding Leader. Visit the patient to ensure they are safe and to advise the patient their concern is under review and who will be the point of contact for the review going forward . Contact the risk manager on call . Contact their human resources partner to determine next steps with caregiver under review . the caregiver under review may be placed on administrative leave until the conclusion of the investigation . Contact the patient's provider . Review of the facility policy Patient Complaint and Grievance Policy, dated 2/14/25, revealed: . This policy and procedure establishes a mechanism and the procedures to respond, review, and resolve patient grievances and complaints . Definitions . Grievance . Allegation of a patient rights violation, such as abuse, discrimination or violation of privacy rise to the level of a grievance . The process for responding to patient grievances according to federal regulations and regulatory guidelines is outlined in the Patient Complaint and Grievance Procedure . Patient Grievance Procedure . Leadership over the area where the grievance originated is responsible to initiate an immediate review, determine appropriate actions, and communicate findings in a timely manner investigation process will include . Interview all available witnesses identified by any sources as having personal knowledge of relevant to the complaint . Written report which includes the investigator's personal observation . A summary of all witness statements; and a statement of the basis for the finding . Review of the facility's policy LTC [Long Term Care]: State Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy, dated 2/18/25, revealed: Procedure . Charge Nurse or 1st Responder . Immediately review the initial information. Determine immediately if the resident is in any danger of harm or further abuse . If the person alleged to be the abuser is a caregiver . immediately relieves them of duty . Begin preliminary investigation by speaking to the reporting person, addressing who did what when and, if known, why. When appropriate, briefly ask the resident/family what their thoughts are about the incident. Document findings on Investigation Report form .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on record review, interview, and observation, the facility failed to provide an ongoing, resident-centered activity program, aligned with individual care plans, for 17 Residents (#'s 4, 5, 7, 9, 12, 13, 18, 20, 21, 23, 25, 27, 28, 31, 33, 34, and 36), out of 26 residents who enjoyed activities outside of their rooms. Specifically, the facility failed to: 1) Consistently provide activities as documented on the facility's monthly activity calendar for the months of July, August, and September 2025; 2) Provide scheduled outings with the use of the facility's transportation van; and 3) Allow residents with the diagnosis of dementia from participating in scheduled outings. These failed practices placed these residents at risk for loneliness, isolation, boredom and decreased their quality of life, which had the potential to affect their overall physical, mental, and psychosocial well-being .Findings: Resident Activities Preferences Resident #4 Record review on 9/2-6/25 revealed Resident #4 was admitted to the facility with diagnoses that included Type 2 diabetes mellitus (DM-disorder characterized by persistent high blood sugar levels and inability to use insulin properly), senile dementia with behavioral disturbance (age-related memory loss or confusion in older adults) and hypertension (high blood pressure). Review of Resident #4's care plan, start date of 3/13/25, revealed an identified problem [Resident #4's POA] has voiced [Resident #4's] activity preferences as conversing, cooking group, religious events/clergy, books on tape, visits from family/friends, watching TV . [Resident #4] likes [NAME] movies. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 3/13/25 through 10/31/25. Resident #5 Record review on 9/2-6/25 revealed that Resident #5 was admitted to the facility with diagnoses that included gastroesophageal reflux disease (GERD- a chronic condition where stomach acid flows back into the esophagus, causing symptoms like heartburn and acid reflux), late onset Alzheimer disease (characterized as when the disease develops in individuals aged 65 and older) without behavioral disturbance, and anxiety. Review of Resident #5's care plan, start date of 10/16/24, revealed an identified problem [Resident #5's] participation in activities can be sporadic due to [his/her] short attention span r/t [related to] Alzheimer's Dementia. [He/she] enjoys [his/her] baby doll 'Bridget, ‘, family visits, ambulating on unit, listening to music, sorting items, and watching movies with dancing. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 10/16/24 through 11/30/25. Resident #7 Record review on 9/2-6/25 revealed Resident #7 was admitted to the facility with diagnoses that included hypertension, dementia, and anxiety disorder. Review of Resident #7's care plan, start date of 11/14/24, revealed an identified problem [Resident #7's POA] has voices [his/her] activity preferences as having special events in room, listening to music, watching tv, 1:1 visits with family, family outings, van rides, visits from [NAME] (unit support dog), and going outside for fresh air. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 11/14/24 through 10/31/25. Resident #9 Record review on 9/2-6/25 revealed Resident #9 was admitted to the facility with diagnoses that included hypertension, Type 2 DM, and severe late onset Alzheimer's dementia without behavioral disturbance. Review of Resident #9's care plan, start date of 1/22/25, revealed an identified problem [Resident #9's daughter] has voiced [Resident #9's] activity preferences as group activities such as board games, manicures, cooking, making floral arrangements, arts and crafts, watching television, picture books, listening to religious music and folding/stacking. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 1/22/25 through 9/30/25. Resident #12 Record review on 9/2-6/25 revealed Resident #12 was admitted to the facility with diagnoses that included depression, hypertension, and cerebrovascular accident (CVA- also known as a stroke, is when blood flow to a part of the brain is stopped either by a blockage or rupture of a blood vessel). Review of Resident #12's care plan, start date of 12/27/24, revealed an identified problem [Resident #12] had voiced [his/her] activity preferences as coloring, books on tape, writing, painting, cooking, [playing] cards, resident council, pet therapy, watching tv, games, out on patio, sports, conversing, hair, current events and music. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 12/27/24 through 9/30/25. During an interview on 9/2/25 at 1:45 PM, Resident #12 stated the facility used to have a monthly outing to Walmart for residents. Resident #12 stated they would use the facility van to take the residents, but this hasn't happened in a while. Resident #12 stated, Residents just want to get out and look around. It's nice to leave the facility and just go out. Resident # 13 Record review on 9/2-6/25 revealed Resident #13 was admitted to the facility with diagnoses that included aphasia (disorder that affects communication due to select brain damage), stroke, and hypertension. Review of Resident #13's care plan, start date of 10/8/24, revealed an identified problem [Resident #13] has listed [his/her] activity preferences as not liking large group activities. [He/she] likes [to] attend special events and enjoys haircuts . The goal for this problem was [Resident #13] will be provided activity choices of interest that will enhance quality of life through next review. This goal was dated 10/8/24 through 11/30/25. Resident #18 Record review on 9/2-6/25 revealed Resident #18 was admitted to the facility with diagnoses that included CVA, dementia, and hemiplegia (one-sided paralysis). Review of Resident #18's care plan, start date of 2/27/25, revealed the identified problem [Resident #18] stated [his/her] activity preferences to be located in activity room with other residents. [He/she] enjoys watching tv, games, and socializing with others . [He/she] enjoys occasional outings. The goal for this problem was provide activity choices of interest that will enhance quality of life through next review. This goal was dated 2/17/25 through 11/30/25. During an interview on 9/3/25 at 10:37 AM, Resident #18 stated the residents haven't had activities for a couple of weeks now. Resident #18 stated he/she personally missed the balloon toss very much because it got us moving. Resident #18 further stated, this is what we need. He/she stated the residents looked forward to going out to the fourth of July parade every year and going the [NAME] Lake picnic, but the residents didn't go this year. When asked how not having as many activities as usual made him/her feel, Resident #18 stated, We get discouraged, I'm sadder now. Resident #20 Record review on 9/2-6/25 revealed Resident #20 was admitted to the facility with diagnoses that included hypertension, neurogenic bladder (condition that affects the bladder function due to nervous system issues), and DM. Review of Resident #20's care plan, start date of 10/17/24, revealed the identified problem [Resident #20] has voiced [his/her] activity preferences as participation in group activities and self-imitated activities in [his/her] room. [He/she] enjoys board games, cards, conversing, dominoes, BINGO, visiting with friends, arts, crafts, tv, and attending resident council. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 10/17/24 through 9/30/25. Resident #21 Record review on 9/2-6/25 revealed Resident #21 was admitted to the facility with diagnoses that included severe dementia without behavioral disturbance, chronic pain syndrome, and reactive depression. Review of Resident #21's care plan, start date of 3/5/25, revealed an identified problem [Resident #21] has voiced [his/her] activity preferences as Bingo, conversing, clergy visits, holding/playing with baby doll, drumming, singing, playing with sensory blanket, and van rides. The goal for this problem was provide activity choices of interest that will enhance quality of life through next review. This goal was dated 3/5/25 through 11/30/25. Resident #23 Record review on 9/2-6/25 revealed Resident #23 was admitted to the facility with diagnoses that included hemiparesis (one-sided muscle weakness) affecting the left side as late effect of CVA, major depressive disorder (MDD- mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension. Review of Resident #23's care plan, start date of 10/8/24, revealed an identified problem [Resident #23] has voiced [his/her] activity preferences as watching television, laptop, phone, and ipad in [his/her] room. [He/she] enjoys trips to Wal-Mart, local events, and small group activities such as special events . The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 10/8/24 through 11/30/25. Resident #25 Record review on 9/2-6/25 revealed Resident #25 was admitted to the facility with diagnoses that included hemiparesis of left non dominant side as late effect of cerebral infarction, generalized anxiety disorder (GAD- a mental health condition characterized by excessive worry), and MDD. Review of Resident #25's care plan, start date of 6/10/25, revealed an identified problem [Resident #25] is at increased risk for decreased activity participation related to health complications. See description for preferences . do group activities or to be offered group activities, wanted to be able to do some of [his/her] favorite activities as able, to go outside when the weather is nice, watch TV, play cards, van rides, and shopping . The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 6/10/25 through 11/30/25. Resident #27 Record review on 9/2-6/25 revealed Resident #27 was admitted to the facility with diagnoses that included Type 1 DM (a chronic autoimmune condition where the pancreas produces little or no insulin), Parkinson's disease (a neurodegenerative disease primarily of the central nervous system, affecting both motor and non-motor systems) and hypertension. Review of Resident #27's care plan, start date of 3/3/25, revealed an identified problem [Resident #27] has voiced [his/her] activity preferences as listening to music, visits, clergy visits, family outings, community events and van rides. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 3/3/25 through 10/31/25. Resident #28 Record review on 9/2-6/25 revealed Resident #28 was admitted to the facility with diagnoses that included MDD, GAD, and Type 1 DM. Review of Resident #28's care plan, start date of 8/20/25, revealed an identified problem [Resident #28] has voiced [his/her] activity [preferences] as coloring books, play cards, listen to books on tape, crafts, play games, knitting, getting hair done, listening to music, getting nails done, sit on patio, paint, pet therapy, planning, puzzles, reading, watch tv. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 8/20/25 through 11/30/25. Resident #31 Record review on 9/2-6/25 revealed Resident #31 was admitted to the facility with diagnoses that included hypertension, alcohol use disorder, and expressive aphasia. Review of Resident #31's care plan, start date of 7/22/25, revealed the identified problem [Resident #31] has voiced [his/her] preferences as Bingo, out on patio, puzzles, watching TV, hair, and reading . The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 7/22/25 through 10/31/25. Resident #33 Record review on 9/2-6/25 revealed Resident #33 was admitted to the facility with diagnoses that included Alzheimer's disease, schizophrenia (mental health condition that affects how people think, feel, and behave. It is characterized by a range of symptoms, including hallucinations, delusions, and disorganized thinking), and GAD. Review of Resident #33's care plan, start date of 1/24/25, revealed the identified problem [Resident #33] has voiced [his/her] activity preferences as coloring, crafts, cooking group, exercise group, listening to music, out on patio, painting, pet therapy, and 1:1 visits. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 1/24/25 through 10/31/25. Resident #34 Record review on 9/2-6/25 revealed Resident #34 was admitted to the facility with diagnoses that included dementia, CVA, and chronic kidney disease (CKD- progressive condition characterized by the gradual loss of kidney function over time) stage 2 due to DM. Review of Resident #34's care plan, start date of 10/29/24, revealed the identified problem [Resident #34] has voiced [his/her] activity preferences as watching television, movies, listening to music, reading, outside events (Senior picnic, plays, community events), 1:1 visits with family, friends, caregivers. [He/she] likes to attend special events on the unit. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 10/29/24 through 9/30/25. Resident #36 Record review on 9/2-6/25 revealed Resident #36 was admitted to the facility with diagnoses that included dementia and unspecified malnutrition. Review of Resident #36's care plan, start date of 11/20/24, revealed the identified problem [Resident #36] has voiced [his/her] activity preferences as Bingo, nails, watch tv, games, cards, hair, listening to music, play music, and 1:1 visits. The goal for this problem was to provide activity choices of interest that will enhance quality of life through next review. This goal was dated 11/20/24 through 11/30/25. Lack of Activities During an interview on 8/27/25 at 3:48 PM, Staff #40 stated the Administrator cancelled the Fourth of July parade outing. Staff #40 stated there had been multiple days in which activities were closed, that even the activity room doors were closed, because staff were pulled out of activities to work on the floor for direct resident care. During an interview on 9/2/25 at 4:10 PM, Resident #20 stated the facility have hardly had activities now. When asked about the activity calendar and if those activities were being offered, Resident #20 smiled and stated, the calendar is just for looks. They don't do them. I'd like more activities. When asked how that has made him/her feel, Resident #20 stated, I've given up. I just watch TV now. We are not happy, no one smiles anymore. There is no happiness here anymore. During an interview on 9/3/25 at 9:00 AM, Staff #84 stated he/she was pulled to the floor on this day to assist with resident cares. He/she further added, this does happen often due to short-staffing and providing cares would be more of a priority. He/she stated the activities department would need to be closed for the whole day or partially, if necessary. Staff #84 stated that the department used to have more staff to help implement the activities listed in the calendar and/or outings. Record review of the facility's activities calendar, September 2025, revealed for date 9/4/25: .Thursday. [9/4/25] Football Season Begin .1:1 Visits. Coffee/Newspaper 8:30 AM. Chair Yoga 11:00 AM. Table Games 2:00 PM. Snack Cart 2:30 PM. Afternoon TV/Movie 3:00 PM Random observations on 9/4/25 from 11:00 AM-12:00 PM, revealed the Chair Yoga, activity did not ensue. During an interview on 9/4/25 at 11:30 AM, Staff #86 stated the Activities CNA (Certified Nursing Assistant) had called out and that he/she was pulled to the floor to assist with resident cares and the scheduled 11:00 AM chair yoga was cancelled. During an interview on 9/4/25 at 11:53 AM, the Director of Nursing (DON), when asked if the scheduled activity of Chair Yoga was offered and/or provided to the residents, she verified that the staff member thought that he/she was not going to be able to do it and cancelled the activity. The DON further stated that she would educate the staff that activities still needed to be offered to residents when listed in the calendar. Record review of a facility-provided list of dates from 7/2025 through 9/2025 when the activities department were closed and/or partially closed, revealed:-7/4 open 7:00 AM-1:30 PM;-7 /6 closed;-7/18 1:00 PM-7:30 PM;-7/19 closed;-7/20 closed at 4:00 PM;-7/21 closed;-7/22 closed;-7/27 closed;-7/28 opened from 8:00 AM-1:00 PM;-7/29 closed;-8/2 opened for bingo, 3:00 PM-5:00 PM;-8/4 opened 7:00 AM- 11:30 AM;-8/11 closed;-8/12 7:00 AM-1:00 PM;-8/17 closed-8/24 closed During an interview on 9/3/25 at 4:16 PM, the Chief Nursing Officer (CNO) stated the facility has had staffing shortages since December 2024 and this had caused problems maintaining enough staff on the floor for direct resident care. When asked how this had affected the activities department, the CNO stated that there had been times when staff were pulled from activities to work the floor, and this had caused activities to be closed at times. The CNO stated the overall goal was to have activities offered every day, however this was not always possible. Outings During an interview on 8/27/25 at 3:48 PM, Staff #40 stated that the Administrator also would not let the staff utilize the facility van for outings.During an interview on 9/2/25 at 1:45 PM, Resident #12 stated the facility used to have a monthly outing to Walmart for residents. Resident #12 stated they would use the facility van to take the residents, but this hasn't happened in a while. Resident #12 stated, Residents just want to get out and look around. It's nice to leave the facility and just go out. During an interview on 9/3/25 at 9:00 AM, Staff #84 stated that the department used to have more staff to help implement the activities listed in the calendar and/or outings. During an interview on 9/3/25 at 11:00 AM, Staff #68 stated the Administrator said that staff could not use the facility van anymore for outings because there were no drivers and it was not financially feasible. Record review of facility-provided document Ticket to Ride, dated 6/25/25, revealed only 3 residents went to a Walmart outing. Record review of facility-provided document Events.Walmart.Date.8/12.Time.9:30 AM. revealed the activity has been postponed to 8/14/25. 5 residents went to the outing on 8/14/25. During an interview on 9/3/25 at 1:18 PM, Staff #90 stated the last outing offered to residents was on 8/14/25 and the next outing date offered was unknown. During an interview on 9/3/25 at 4:16 PM, when asked if the facility was adhering to the activity calendar, the CNO stated that the indoor activities were easier to offer, however the outdoor activities were harder. The CNO stated that the facility had lost drivers for the facility van, which had affected the facility's ability to offer scheduled outings, like trips to Wal-Mart. The CNO stated historically, the facility usually offered two trips a month to Wal-Mart but this had been hard to offer lately. The CNO stated that currently there were three staff that could drive the van. During an interview on 9/4/25 at 12:18 PM, Staff #71 stated that the Administrator also told staff that you all don't need to use the van this much! when discussing outings for residents. Cancelled Cooking Groups During an interview on 9/3/25 at 11:00 AM, Staff #68 stated that the Administrator told staff they were not able to offer cooking groups to the residents anymore because it was too much food. Staff #68 stated the Administrator said if the residents wanted to cook a meal, then they would have to eliminate a meal from the central kitchen. During an interview on 9/3/25 at 4:16 PM, when asked about why the cooking group was stopped, the CNO stated she was not sure, but never confirmed with the Administrator as to why this activity was cancelled. During an interview on 9/4/25 at 12:18 PM, Staff #71 stated that the Administrator told staff you guys cook too much! when planning for cooking groups. The Administrator told staff that if residents wanted to cook, they would have to eliminate a meal if you cook this much. Dementia Residents and Outings Record review revealed Resident #5 and #9 was admitted to the facility with the diagnosis of dementia. During an interview on 9/4/25 at 10:04 AM, the Administrator stated that she had concerns for two residents with dementia, Resident #5 and #9, attending the [NAME] Lake picnic. The Administrator stated she felt it was unsafe because the residents can wander, and they didn't have enough staff for a 1:1 (one staff to one resident). When asked if there was an order that stated these residents must be on a 1:1 if on an outing, the Administrator stated no 1:1 order was needed, that it would be in the care plan and a nurse could have the authority to make that decision. Review of Resident #5's and #9's care plans revealed that no 1:1 was needed for outings. During an interview on 9/4/25 at 12:18 PM, Staff #71 stated that when floor and activities staff were talking about the 7/18/25 [NAME] Lake picnic outing, and how they would plan to bring Resident #5 and #9, who were diagnosed with dementia, Staff #71 stated the Administrator came out of her office and joined the conversation. The Administrator stated, Absolutely not and that these residents will never leave the unit. Staff #71 attempted to explain to the Administrator that these residents had routinely gone on outings, and done so safely, and it would not be appropriate to exclude them, however the Administrator would not agree. Staff #71 stated the residents could not go to the outing. During an interview on 9/4/25 at 1:14 PM, when asked if she had heard that residents with dementia diagnoses were not allowed to go on outings, the CNO stated she had heard this was a concern from staff, however, did not know enough about the federal regulations at the time. During an interview on 9/9/25 at 2:53 PM, the Medical Director stated that Resident #5 and #9 did have a history of wandering, however they had attended many outings in the past without concern, and they would not need a 1:1 on outings. The Medical Director stated that caution was always needed, but there was no rule that these residents couldn't attend outings. Review of the facility's policy LTC [Long Term Care]: Activities Therapy Scope of Service, revised on 3/6/25, revealed: .Purpose. to provide appropriate daily activities for each resident. To comply with State and Federal regulations. Goals/Objectives. to provide meaningful and age appropriate activities that engage each resident while promoting dignity, respect and the well-being of each resident. Provide one on one and group activities, special events, in house and outings to community events. Types of Residents. Early to advanced dementia including Alzheimer', illnesses of all body systems, end of life care, and wound care. Operation. Sunday-Saturday, open as needed to meet the needs of events for residents. Review of the facility's policy LTC: Resident Dignity Policy, revised 2/18/25, revealed: .The purpose of this policy is to provide the following, though not all inclusive, examples of maintaining resident dignity. In this context it means that in their interactions with residents, staff carries out activities that assist the resident to maintain and enhance his/her self-esteem and self-worth.c. Assist resident to attend activities of their choosing.

.Based on interview and record review, the facility failed to allow resident-invited visitors and/or guests to attend a resident council meeting. This failed practice denied the resident's right to invite visitors to the resident council meeting, which denied all residents (based on a census of 26) the right and opportunity to advocate for themselves and placed them at risk for decreased feelings of self-worth and had the potential to affect their mood and overall wellbeing. Findings:During an interview on 9/2/25 at 1:45 PM, Resident #12 stated that he/she invited his/her family member, who was his/her resident representative, to the resident council meeting that occurred on 7/23/25. Resident #12 further stated that his/her family member invited the Mayor and a City Council member, along with a previous member, to the meeting on his/her behalf. Resident #12 wanted his/her family member and local officials in the meeting to hear of program concerns that had been happening in the facility lately, such as limited activities and low staffing. Resident #12 stated that when the family member and local officials arrived for the meeting, the facility Administrator removed them from the meeting. Resident #12 stated he/she told the Administrator his/her family member was his/her advocate, and the other visitors were there because he/she wanted them there. Resident #12 stated the Administrator still had them vacate the meeting. This upset him/her because he/she wanted their support on resident concerns. During an interview on 9/2/25 at 4:10 PM, Resident #20 stated he/she was happy to see the Mayor and City Council member at the Resident Council meeting on 7/23/25, but the Administrator ordered them to leave. Resident #20 stated he/she was the President of the Resident Council, and he/she told the Administrator he/she couldn't have them leave, but the Administrator said, no way and had them removed anyway. That upset Resident #20 because he/she would have liked them to have stayed for the meeting to hear what the residents had to say. During an interview on 9/3/25 at 10:37 AM, Resident #18 stated he/she was at the 7/23/25 resident council meeting and was happy to see the presence of the Mayor and City Council representative. Resident #18 stated that when the Administrator said they were not allowed to stay, he/she heard other residents tell the Administrator they wanted the visitors to stay. Resident #18 stated he/she would have liked to have had them present in the meeting to hear from the residents. During an interview on 9/3/25 at 12:43 PM, the Resident Representative for Resident #12 stated the resident invited him/her to the 7/23/25 resident council meeting. After hearing the concerns, the residents had planned to address in the meeting, the Resident Representative invited a City Council member, a previous City Council member, and the Mayor to the meeting to hear what the residents had to say. The Resident Representative stated Resident #12 approved of him/her inviting the local officials to the meeting. The Resident Representative stated that when they got to the unit for the meeting, the Administrator met him/her at the activities room door and told him/her that the resident council meeting was for residents only. The Administrator stated they could not attend the meeting. The Resident Representative stated that the City Council member, previous City Council member, and him/her went into the meeting anyway, however the Administrator would not let the meeting start until the resident invited visitors left the room. During an interview on 9/4/25 at 10:04 AM, the Administrator stated that at the time of the meeting, she had a conversation with Resident #12's family member and told him/her that resident council meetings were not a public meeting, was a closed meeting, and that family and visitors couldn't be there. The Administrator stated she thought the resident council meeting was an internal meeting to talk about activities and resident rights and that if any resident wanted a visitor to a meeting, they would have to vote on that at the meeting prior to the visit. When asked if she recalled residents telling her they wanted the visitors to stay for the resident council meeting, the Administrator stated she did not remember hearing that. During an interview on 9/4/25 at 1:14 PM, the Chief Nursing Officer (CNO) stated she was in the 7/23/25 resident council meeting and confirmed the Administrator told the visitors they could not stay for the meeting. The CNO further stated that she witnessed several resident state that they wanted the visitors to stay for the meeting. During an interview on 9/8/25 at 10:45 AM, Visitor #3 stated he/she was invited to the resident council meeting because he/she had heard some of the residents had concerns they wanted to voice, namely about activities. Visitor #3 stated when he/she got there, the Administrator stated she didn't want the meeting to turn political, and Visitor #3 stated the Administrator asked him/her several times to not attend the meeting. Visitor #3 stated he/she left because he/she didn't want to disrupt the resident council meeting or cause a problem. Review of the facility's policy LTC [Long Term Care]: Patient Rights and Responsibilities Policy, dated 1/10/25, revealed: It is the policy of PeaceHealth to define, recognize, protect and promote the rights and responsibilities of the patients and their legal, authorized or designated representatives . Review of the facility's Resident Rights and Responsibilities form, undated, which was available to all residents, revealed: . You have the right to dignity, respect and compassion. This includes your right to: Be treated with consideration, respect and dignity, recognizing each resident's individuality . Exercise rights without interference, coercion, discrimination, or reprisal; You have the right to self-determination. This includes your right to . choice about designating a representative to exercise your rights; Organize and participate in resident and family group . You have the right to access to: Individuals, services, community members, and activities inside and outside the facility; Visitors of your choosing, at any time . Review of the facility policy LTC: Visitation Policy, dated 1/3/25, revealed: . The purpose of this policy is to define how the facility develops, implements, monitors, and evaluates visitation rights for applicable residents. The facility promotes visitation for all residents subject to the resident's wishes . Residents are permitted to have visitors of their choosing at the time of their choosing . Visitation will be resident-centered . Residents are permitted to visit with representatives from federal and state survey agencies, resident advocates . space and privacy are provided as needed for such visits . Review of the facility's policy LTC: Resident Council Meetings Policy, dated 1/10/25, revealed: The purpose of this policy is to promote empowerment of the residents and to provide opportunity for residents to have a voice regarding the Long Term Care Unit and the care that is being provided to them . Further review revealed no documentation that residents were permitted to invite visitors to the meetings as is their resident right.

.Based on interview and record review, the facility failed to ensure residents were free from abuse. Specifically, the Administrator's conduct towards residents was construed, by residents and staff, as verbally abusive. This failed practice placed all residents (based on a census of 26) at risk for continued exposure to verbal abuse and mental anguish which had the potential to affect their overall health and well-being.Findings:Resident #12 During an interview on 9/2/25 at 1:45 PM, Resident #12 stated she felt verbally abused by negative comments the Administrator had said to him/her, and this made him/her very sad, and he/she was now hopeless, like I'll never get out of here. It was observed that Resident #12 was physically shaking when he/she told this story, wringing his/her hands and his/her voice was cracking with emotion. Resident #20 During an interview on 9/2/25 at 4:10 PM, Resident #20 stated the Administrator, scares me, [he/she] is really bossy and is mean to me. When asked to elaborate on anything the Administrator may have said, Resident #20 couldn't recall a specific conversation, it's how [he/she] talks, its loud and speaks meanly. During an interview on 9/3/25 at 11:45 AM, Staff #76 stated residents have reported to him/her that they didn't feel safe on the unit because the Administrator's interactions were rough with a lack of respect. During an interview on 9/4/25 at 1:14 PM, when asked if she had ever been informed that the Administrator's behavior towards residents was a concern, the Chief Nursing Officer (CNO) stated some things were said and she had started to receive feedback around the time of a staff meeting on 6/25/25. The CNO stated that during this time the information that was shared did not always appear accurate and was different than what the Administrator was sharing with her, so nothing really made her concerned, until almost a month later at the 7/23/25 resident council meeting and she witnessed the Administrator's behavior that day. The CNO stated that when the Administrator addressed the residents in the meeting, the Administrator's voice was raised, and her arm/hand movements were very animated as she talked and the CNO stated she was concerned with the Administrator's presentation. The CNO stated that the way the Administrator addressed the residents made her feel anxious and the conversation had become uncomfortable, and from her perception she felt that the group was not being heard or seen. When asked if the Administrator's oral and gestured language may have been frightening or intimidating to the residents, the CNO stated, Absolutely. The CNO stated she stood up, during this meeting, to nonverbally cue the Administrator that the conversation was veering onto an uncomfortable path, however the Administrator did not stop the behavior. During an interview on 9/4/25 at 4:55 PM, Staff #83 stated that the Administrator's tone of voice was very rude when she talked to residents and the Administrator would often willfully cut them off in conversations. Review of the facility's abuse allegation investigation documentation of the resident interviews, that occurred during the investigation surrounding the concerns identified during the 7/23/25 resident council meeting, revealed an additional resident (#25), had felt verbally abused by the Administrator. Review of the facility's policy LTC [Long Term Care]: Abuse, Neglect, Exploitation and Misappropriation of Residents Property Policy, dated 3/6/25, revealed: Definitions . Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident or their families, or within hearing distance . Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident . Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment . The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property . Review of the facility's Resident Rights and Responsibilities, undated, revealed: . You have the right to dignity, respect, and compassion. This includes your right to . Freedom from abuse, neglect, exploitation and misappropriation of property .

.Based on record review and interview, the facility failed to implement written policies and procedures to investigate an allegation of abuse for 1 Resident (#12), out of 1 allegation of abuse investigation reviewed. Specifically, the facility's HR Department and Risk Management Department failed to: 1) adequately monitor the investigation process to ensure all steps of the investigation procedure were completed appropriately; 2) ensure all investigations processes were adequately documented; and 3) ensure additional investigations from the results of the investigation process were appropriately carried out 2 residents (#'s 20 and 25), out of 5 residents interviewed during the investigation. This failed practice resulted in an inadequate grievance investigation which placed all residents (based on a census of 26) at risk for suboptimal investigations of any resident complaints and grievances. Findings:Incident Reported A facility reported incident (FRI) was submitted to the State Agency for an allegation of verbal abuse, dated 7/23/25, by the Chief Nursing Officer (CNO). Investigation by CNO During an interview on 9/3/25 at 1:34 PM, the CNO stated during the resident council meeting on 7/23/25, in the middle of the meeting, Resident #12 stated he/she felt the Administrator had verbally abused him/her. After the meeting, the facility team decided to file a State report regarding Resident #12's comment and initiate an investigation. The CNO stated the report was sent to the State Agency on 7/23/25. The CNO further stated that she contacted the HR Director for PeaceHealth on 7/23/25 about the investigation and placed the Administrator on administrative leave pending the conclusion of the investigation. The CNO further stated she completed an interview with Resident #12 on 7/23/25 about the comments in the meeting, however Resident #12 did not comment on what the verbal abuse was. When asked to see the documentation for the interview with Resident #12, the CNO stated no documentation for the interview was completed. The CNO stated she also submitted this incident in the facility's electronic incident reporting system Safe2Share. When asked if the CNO interviewed the Administrator during the investigation, the CNO stated she and the Administrator had talked but this was not documented. When asked if the CNO contacted Resident #12's provider to inform them of the reported allegation of abuse, the CNO stated she did not contact the provider. When asked what other steps occurred during the investigation, the CNO stated she had a Minimum Data Set (MDS - a nationally mandated routine assessment) Nurse interview five other residents to ensure no other residents had any concerns. The CNO stated she drafted questions for the MDS Nurse to use. From these interviews, she determined these residents felt safe. When asked what the investigation's determination was, the CNO stated that because Resident #12 retracted his/her statement and because it was determined it was mainly about the Administrator's approach to communicating with others, she determined the abuse allegation as retracted and concluded the investigation on 7/28/25. The CNO stated the Administrator returned to work on 7/29/25. Review of the facility's documentation of the five other resident interviews that occurred during this investigation, undated, revealed two resident's, Resident #20 and #25, interviews revealed they had felt verbally abused by the Administrator. During an interview on 9/3/25 at 1:34 PM, when asked if these comments were investigated, the CNO stated, no. Facility Policy about Abuse Investigations Review of the facility policy Allegation of Abuse Policy, dated 12/15/24, revealed: . It is the policy of PeaceHealth that any allegation of abuse by a patient against a caregiver will be responded to immediately. An investigation of the facts will be coordinated . Caregiver - Patient Present . Risk Management and Human Resources; - Risk Management and Human Resources, working with the department manager will outline an action plan for investigating the incident using the steps listed here as a guide; - The Risk Manager will review the patient components of the event while human resources will direct their focus on the caregiver . ; - Human Resources (HR) Meet with manager and place caregiver on administrative leave (if appropriate). Meet with and lead caregiver interview. Conduct review of evidence and report findings to HR leadership. Maintain caregiver related documentation in HR records; - Risk Manager. Risk Management [facilitates] the investigation. Obtain lists of involved parties and witnesses. Review CareConnect to learn purpose of admission/encounter, medical history and general information about care that is underway. Lead interviews with patient/legal representative and witnesses. Secure evidence and maintain documentation of the event. Assist with law enforcement reporting. Following discussion with human resources and manager, will close case and identify lessons learned and any process improvement opportunities. Maintain documentation (for the patient) of this event in Safe2Share - Feedback . Risk Management During an interview on 9/5/25 at 9:00 AM, the Clinical Risk Manager and the PeaceHealth Director of Quality, the Clinical Risk Manager stated one of his daily duties was to monitor the facility's variance (or grievance) reporting system Safe2Share; assign correct clinical leaders to complete investigations to grievances submitted, and to ensure compliance with State and Federal regulations. The Clinical Risk Manager also stated he was available for clinical consultation and was a resource for clinical leaders. When asked about the 7/23/25 Safe2Share report submitted by the facility's CNO, the Clinical Risk Manager stated he did receive notice that a report was submitted, and he did contact the CNO. The Clinical Risk Manager stated the CNO reported that the resident retracted her complaint and the CNO stated the HR Department at the facility was assisting her through the investigation. Based on this information, the Clinical Risk Manager stated he was satisfied that he didn't need to be involved in this investigation. When asked if the Risk Management team oversaw the CNO and HR Department's handling of the 7/23/25 investigation, the Clinical Risk Manager stated, no because Risk Management team and the HR Department maintain their own files and Risk Management never sees the HR Department's files. When asked what the expectation would be for an investigation for an allegation of abuse would be, the Clinical Risk Manager stated that at a minimum it should include, but is not limited to: 1) making sure the resident is safe; 2) interview the resident; 3) make sure the alleged perpetrator is interviewed; and see if there were any witnesses. When asked if the Safe2Share report was reviewed by Risk Management to ensure the minimum was completed once the report was closed, the Clinical Risk Manager stated he had a verbal conversation with the CNO on the investigation results. The Clinical Risk Manager stated the CNO reported that she interviewed the resident, talked to several other residents to see if any other residents had concerns which concluded that they didn't like how the Administrator talked to them but didn't feel abused or unsafe, and that she planned to follow up with HR and the Administrator to talk to her about the way to interact with residents. The Clinical Risk Manager stated from this conversation he felt the CNO's investigation was adequate. When asked if he reviewed the investigation documentation, the Clinical Risk Manager stated he did not. When this surveyor reviewed the investigation documentation with the Clinical Risk Manager and the PeaceHealth Director of Quality, areas of incomplete steps in the investigations were identified. The PeaceHealth Director of Quality stated it appeared that the CNO may not have asked the right questions during the investigation. When asked who was responsible for the overall quality of a grievance investigation to ensure all grievance investigations were thoroughly completed and the investigation documentation met the facility's requirements, the Clinical Risk Manager stated the leadership assigned to the investigation was responsible for the quality. The Clinical Risk Manager stated, The Risk Management team was responsible for completeness, but not quality of the Safe2Share report investigations submitted. When asked if the facility had a grievance committee as stated in the facility's policy Patient Complaint and Grievance Policy, the Clinical Risk Manager stated that currently the facility did not have a grievance committee and that all grievances were being addressed in the Quality Assurance and Performance Improvement (QAPI) committee. The Clinical Risk Manager stated that they were in the process of revamping the grievance committee, for a more robust and effective plan moving forward, and recognized there was room for improvement in this area. HR Department During an interview on 9/5/25 at 10:52 AM, the HR Director for PeaceHealth stated she was part of the 7/23/25 investigative process for the allegation of abuse by Resident #12. The HR Director for PeaceHealth stated the CNO had contacted her by phone, as she was out of state at the time, and the HR Director for PeaceHealth stated she provided verbal guidance and help to assist in placing the Administrator on administrative leave pending the investigation. When asked if to describe the guidance she provided, the HR Director for PeaceHealth stated she wasn't involved in the investigation itself but did go over the CNO's findings after. When asked to explain what was discussed, the HR Director for PeaceHealth stated the CNO said she talked to the Administrator, talked with the residents and residents. When asked if the CNO went over the additional resident interviews during the discussion, the HR Director for PeaceHealth couldn't remember. When asked what the expectation would be for an investigation for an allegation of abuse would be, the HR Director for PeaceHealth stated she would expect documentation that included: 1) talk to any witnesses; 2) get to the bottom of what actually transpired; 3) interview the resident; 4) and interview the alleged perpetrator. When the investigation documentation was reviewed with the HR Director for PeaceHealth, and what was not completed during the investigation, she acknowledged items were missing from the investigation. When asked if the CNO included her investigation documentation in the Safe2Share file, as indicated in the Safe2Share Electronic Reporting Policy, the Clinical Risk Manager stated, no. When asked who was responsible for the overall quality of a grievance investigation to ensure all grievance investigations were thoroughly completed and the investigation documentation met the facility's requirements, the HR Director for PeaceHealth stated they do not have any access to the Safe2Share system, and it was the department head who would be the leader of the investigation and not HR. The HR Director for PeaceHealth further stated they were not part of the QAPI committee. Review of the facility's policy Safe2Share Electronic Reporting Policy, dated 12/15/23, revealed: . It is the policy of PeaceHealth that caregivers and credentialed providers complete a Safe2Share report under the following circumstances: Upon any occurrence or event that involves a) an unsafe condition, b) an unanticipated outcome with respect to a patient care, c) a potential or actual unexpected or adverse outcome . Safe2Share is an important tool to support Clinical Excellence and Risk Management to help improve the provision of health care services[.] It is an integral part of that commitment is to maintain an awareness and improve situations that may present a risk of harm . Leadership Responsibility. Leaders of the primary department/unit named in the Safe2Share file are expected to review and investigate the submitted event, and document the investigation in the Safe2Share file . Network leadership is responsible to provide appropriate steps are taken to mitigate the harm or risk of harm, prevent further such events, to maintain patient safety, and respond to patient grievances . Risk Team members reviews Safe2Share files for completeness and additional routing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on record review and interview, the facility failed to report the results of an investigation of an allegation of abuse to the State Agency within 5 working days as required under CFR 483.12(c)(4). The lack reporting investigation results concerning an allegation of abuse in an appropriate and timely manner inhibited the State Agency from accurately assessing and investigating this allegation, which placed all residents (based on a census of 26) at risk for future exposure to potential abuse. Findings:A facility reported incident (FRI) was submitted to the State Agency for an allegation of verbal abuse, dated 7/23/25, by the Chief Nursing Officer (CNO). During an interview on 9/3/25 at 1:34 PM, the CNO stated she faxed the final report to the State Agency on 8/4/25. When asked to show proof of this fax, the CNO stated she could not provide this proof. A review of the State Agency's fax line and email revealed no final report received from the facility for the 7/23/25 incident. Review of an email received on 9/7/25, from the CNO, revealed: I was talking to . our HR Director Friday [9/5/25] after you guys headed to the airport. She triggered my brain to remember something regarding the final report that I could not prove that I had submitted. I did fax it to the state because on 7/28 I received a phone call from the state asking me to fill out the paperwork electronically for my final report. I am attaching the final report I saved because I wanted to ensure that I had proof of it . Review of the email attachment revealed the report was an Adult Protective Services Intake Report. This report was dated 7/28/25 and labeled initial report. Further review revealed the detailed statement was identical to the initial report and contained no results from the investigation. Review of the facility policy LTC [Long Term Care]: State Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy, dated 2/18/25, revealed: . Reporting: In accordance with Alaska state law, 42CFR483.13(b)(c), all suspected cases of abuse and/or neglect will be reported as outlined below: Health Facilities Licensing and Certification (HFL&C): The initial reporting of the incident must be faxed or phoned immediately. Fax is the preferred method of contact; please fax (907) [PHONE NUMBER] or call (907) [PHONE NUMBER] for allegations including that involving nursing aide abuse. The results of the investigation must be followed up through a written report within five days of the initial reporting of the incident . Further review of the facility policy revealed the facility was also required to submit the initial report to the Division of Senior Services, which was where the Adult Protective Services Intake Reports would be generated. The policy stated: . it is not required to follow up with the Division of Senior Services with the results of the investigation .

. Based on record review and interview, the facility failed to ensure float nursing staff (NS) and travel NS, had the job specific competencies and skill sets necessary to care for long-term care (LTC) residents' needs. Specifically, the facility failed to ensure: 1) float/travel NS had current LTC training for ADL (activities of daily living) Coding and Definitions;2) float/travel NS had current LTC training for Behavioral Health (BH);3) float/travel NS had current LTC training for QAPI (quality assurance performance improvement);4) float/travel NS had current LTC training for Dementia for LTC; and5) float/travel NS had current LTC training for Trauma Informed Care. This failed practice had the potential to place all residents (based on a census of 26) at risk of not receiving the necessary specific treatment and care needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being .Findings: Record review on 9/2-5/25 of the float NS training records revealed: 1) 17 NS (NS #'s 1, 2, 3, 4, 5, 6, 8, 9,10, 11, 12, 13, 14, 16, 17, 19, 20), out of 20 NS personnel files reviewed, did not have current training for ADL Coding and Definitions; 2) 17 NS (NS #'s 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 16, 17, 19, 20), out of 20 NS personnel files reviewed, did not have current training for BH; 3) 17 NS (NS #'s 1, 2, 3, 4, 5, 6, 8, 9, 10, 11,12,13, 14, 16, 17, 19, 20), out of 20 NS personnel files reviewed, did not have current training for QAPI; 4) 11 NS (NS #'s 3, 4, 5, 6, 8, 9, 12, 14, 17, 19, 20), out of 20 NS personnel files reviewed, did not have current training for Dementia for LTC; and 5) 17 NS (NS #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 16, 17, 19, 20), out of 20 NS personnel files reviewed, did not have current training for Trauma Informed Care. During an interview with the Clinical Nurse Educator on 9/4/25 at 11:00 AM, she stated that she was only aware of abuse and neglect training being required for staff who floated to the LTC. She also stated that she did not know about dementia specific modules being required and therefore the float staff did not complete the same training as the core staff. When asked if she thought a staff member floating to the LTC without this specific job training could impact resident care, she stated: I think they are still giving good care, but it's possible the lack of LTC specific training could have an impact. Review of the document Facility Assessment - staff training and competencies, dated 5/2024, revealed: .The Nurse Educator keeps records of all training and skill fair documents. The Nurse Educator and Facility Administration education department ensure all areas are included. These training programs are also reviewed by PeaceHealth System education department. Evaluation of the facility's training program and effectiveness in ensuring training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. During an interview on 9/4/25 at 1:00 PM, NS #20 stated that he/she had not received any LTC specific education prior to working in the LTC unit. He/she stated: .I only had general orientation. He/she further stated that no education was provided for dementia care, trauma-informed care, and cultural competency. During an interview on 9/4/25 at 12:23 PM, House Supervisor #1 stated that to float nursing staff to the LTC unit, staff must have completed an online module that provided education on abuse and neglect. When asked if the module educated on dementia care or trauma-informed care, House Supervisor #1 stated that abuse and neglect was the only education being tracked. Review of the facility provided policy Trauma Informed Care Policy, dated 9/3/2025, revealed: .Health Care organizations often train their clinical staff in trauma-specific treatment approaches. Facility Environment: train all staff to be sensitive to individuals (residents or staff) who are responding to a situation due to past trauma and understand how to support them. Review of the facility training module LTC ADL Coding and Definitions, updated in 2023 revealed that the module focuses on educating caregivers about accurately coding ADL's such as bathing, dressing, eating, and toileting, which are critical for assessing a resident's functional status and support needs in LTC. It outlines objectives to define self-performance and support required for ADLs, code them correctly on the MDS (Minimum Data Set - federally mandated assessment tool used in long-term care). Review of the facility training module Care of the Resident with Mental Disorders, updated in 5/2023 revealed that the module aims to enhance caregivers' ability to support residents with behavioral health issues, focusing on identifying signs, symptoms, and triggers of these conditions, as well as specific strategies for improved communication with residents who have experienced trauma. It emphasizes the importance of trauma-informed care to mitigate triggers and ensure culturally competent care, aligning with regulatory standards that mandate facilities should eliminate or reduce abuse and provide care in accordance with residents' preferences and professional standards. Review of the facility training module QAPI Training for Caregivers, updated in 2023, revealed that the module aims to equip caregivers with the knowledge to contribute to QAPI by discussing how caregivers can participate, describing QAPI elements and tools, identifying regulatory mandates, and informing about available resources and supports. It emphasizes the importance of caregivers in all post-acute care settings in enhancing care quality through systematic improvement processes. Review of the facility training module Dementia-related Conditions - Resident Care - PeaceHealth's Long Term Care Education, updated 5/2023, revealed that caregivers are encouraged to adopt a person-centered approach, recognizing stress triggers (physical, psychosocial, environmental) and using a four-step behavioral model (Prevent, Gather, A.C.T. [Ask, Collect, Treat], Redirect) to manage behaviors effectively. The module further trains caregivers with job specific behavioral models that include specific strategies such as preventing escalation with calm interactions, gathering information on resident preferences, and triggers. Review of the document Facility Assessment - Ketchikan Med [Center] New Horizons Transitional Care, dated 5/2024 indicated that total number of beds for the facility at the time of the assessment was 29. From this assessment, the residents that required assistance with ADLs, with specific needs included: bathing (20 residents), dressing (21), transferring (20 residents), toilet use (20 residents), and eating (20 residents). Behavioral health conditions or diagnoses were also identified in the facility assessment. The summary showed the most common conditions, and combinations of conditions that the facility may accept, such as dementia/impaired cognition (12 residents), depression (8 residents), anxiety disorders (4 residents), and others like schizophrenia (1 residents) and Post-traumatic stress disorder (1 residents)

.Based on record review and interview, the facility failed to ensure their facility assessment was reviewed and updated annually. This failed practice had the potential to place all residents (based on a census of 26) at risk of not having the necessary care and resources from an accurate assessment. Findings:Review of the facility's Proactive LTC Consulting Facility Assessment revealed this assessment was last updated on 5/21/24. The Chief Nursing Officer (CNO) acknowledged this finding and stated the facility assessment needed to be updated

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on record review and interview, the facility failed to ensure four float Certified Nurse Assistants (CNAs) out of four float CNAs chosen for review, received the required 12 hours of annual in-service training, specifically including education on dementia care and abuse/neglect prevention. This failed practice placed all residents (based on a census of 26) at risk for substandard care due to staff not being provided with the education necessary to ensure continuing competence in the care of long-term care (LTC) residents .Findings: Record review on 9/2-5/25 of CNA training records revealed:CNA #52 - 12 Hour Annual CNA Training with Dementia/Abuse/Neglect, expired on [DATE];CNA #53 - 12 Hour Annual CNA Training with Dementia/Abuse/Neglect, not completed;CNA #54 - 12 Hour Annual CNA Training with Dementia/Abuse/Neglect, not completed;CNA #55 - 12 Hour Annual CNA Training with Dementia/Abuse/Neglect, expired on [DATE]. Review of the facility provided schedule document Charge Back - Non Home Employee Detail, dated [DATE]-[DATE], revealed the following CNAs worked without the required 12 hours of annual in-service training on the following dates:CNA #52 worked in the LTC on [DATE] and [DATE];CNA #53 worked in the LTC on [DATE];CNA #54 worked in the LTC on [DATE];CNA #55 worked in the LTC on [DATE]. During an interview with the Director of Nursing (DON) on [DATE] at 9:30 AM, she stated that she was unaware that float staff needed LTC specific training to care for LTC residents, other than the abuse and neglect module. During an interview on [DATE] at 11:00 AM, CNA #55 stated that he/she had worked as a float in the LTC and had not received any education on dementia care or abuse/neglect within the past year. During an interview on [DATE] at 12:23 PM with the House Supervisor #1, he/she stated that to float a CNA to the LTC unit, they must have completed an online module that provided education on abuse and neglect. When asked if the module educated on dementia care, the House Supervisor stated that abuse and neglect was the only education being tracked. During an interview on [DATE] at 11:30 AM with the Clinical Nurse Educator, she stated that float CNAs working in LTC do not attend the annual educational retreats provided to the LTC CNAs to meet the 12-hour requirement. She further stated, There's a program for float CNAs, an article that they do for their Continuing Education Units (CEUs) to renew their license, but it does not provide education for dementia care or abuse and neglect in the LTC residents. Review of the document Facility Assessment - staff training and competencies, dated 5/2024, revealed: .The Nurse Educator keeps records of all training and skill fair documents. The Nurse Educator and Facility Administration education department ensures all areas are included. These training programs are also reviewed by PeaceHealth System education department. Evaluation of the facility's training program and effectiveness in ensuring training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Review of the facility adopted training module Dementia-related Conditions - Resident Care - PeaceHealth's Long Term Care Education, updated 5/2023, revealed that caregivers like CNAs are encouraged to adopt a person-centered approach, recognizing stress triggers (physical, psychosocial, environmental) and using a four-step behavioral model (Prevent, Gather, A.C.T. [Ask, Collect, Treat], Redirect) to manage behaviors effectively. The module further trains caregivers with job specific behavioral models that include specific strategies such as preventing escalation with calm interactions, gathering information on resident preferences, and triggers. Review of the facility adopted training module Abuse, Neglect, and Exploitation in the Elder Care Setting, updated in 6/2022, revealed the module aimed to educate caregivers on recognizing and reporting abuse, neglect, and exploitation in elder care settings, covering types such as physical, verbal, mental, and financial abuse, as well as neglect and exploitation

. Based on interview and record review, the facility failed to update and revise the care plan for two residents (#s 1 and 19), out of 13 sampled residents. Specifically, the facility failed to update and revise the care plans to reflect: 1) anticoagulant medication use for Resident #1; and 2) chronic right shoulder pain for Resident #19. Failure to assess and revise care plan problems, goals, and interventions placed the residents at risk for not receiving appropriate and/or necessary care and services. Findings: Resident #1 Record review on 2/24-28/25 revealed Resident #1 was admitted to the facility with diagnoses that included atrial fibrillation (an abnormal heart rhythm originating in the atria that reduces the atrium's efficiency and can lead to blood clots forming in the atrium), heart failure (inability of the heart to maintain adequate blood circulation), and diabetes. Review of Resident #1's medications, on 2/26/25, revealed he/she was taking Apixaban (Eliquis, an anticoagulant medication to reduce clot formation) 5 milligrams (mg) twice a day. Further review revealed this medication started on 12/17/24. Review of Resident #1's care plan, on 2/27/25, revealed Apixaban was not on his/her care plan to alert staff to be aware the Resident was on this high-risk medication, so they were aware of potential risks and side effects associated with being on an anticoagulant. Review of Resident #1's care plan event log (a log that showed all changes made to the care plan since admission), revealed: - 12/17/24: the anticoagulant medication was added to the care plan, [Resident #1] is at risk for side effects and/or adverse reactions related to use of diuretics [,] anticoagulant medications. - 1/28/25: the anticoagulant medication was removed from the care plan, [Resident #1] will be free from side effects and/or adverse reactions related to diuretic medication through next review. Anticoagulant medication was never put back on the care plan. Review of Resident #1's medication history revealed he/she was still taking Apixaban on 1/28/25 and was not held any time prior to this date since admission. Further review revealed the only time Resident #1's anticoagulant medication was held was on 2/13/25 (for both doses that day) and 2/14/25 (for only one dose in the morning and resumed that evening) for bleeding associated with a tooth extraction that occurred on 2/12/25. During an interview on 2/27/25 at 10:36 AM, the MDS Coordinator stated that Resident #1's anticoagulant medication was not on his/her care plan and needed to be added. Resident #19 Record review on 2/24-28/25 revealed Resident #19 was admitted to the facility with diagnoses that included a subdural hematoma (a collection of blood between the dura mater, outer covering of the brain's membrane, and the arachnoid layer, inner layer of the brain's membrane, usually caused by head trauma) and a fracture of the right tibial plateau (break in the upper part of the shin bone near the knee joint) requiring a right total knee replacement (surgical procedure in which the damaged or worn-down knee joint is replaced with an artificial implant). During an interview on 2/24/25 at 4:04 PM, Resident #19 stated he/she had been having right shoulder pain. Resident #19 further stated he/she had hardly been able to move his/her right shoulder, and tasks such as putting on a jacket was very painful. He/she further stated the right shoulder pain had been an issue since admission. Review of the Physical Therapy Progress Note, dated 1/23/25 at 2:49 PM, revealed: Pt [Patient] c/o [complained of] pain right hip. Bilateral feet ankle and right shoulder, at varying times during evaluation . Review of the Physical Therapy Progress Note, dated 1/30/25 at 3:42 PM, revealed: Pain/Discomfort Assessment . Pain Type Chronic pain (ankle/foot, knee RLE [right lower extremity], right shoulder) Intervention(s) to Relieve Pain/Discomfort Medicated for pain (prior per RN [Registered Nurse]. RN notified of shoulder pain) . Review of the Nursing Note, dated 2/1/25 at 12:46 AM, revealed: [He/she] was given Oxycodone [prescription opioid pain medication used to treat moderate to severe pain] for [his/her] pain in right shoulder and right knee to shin. [He/she] reported that [he/she] wants the Vicks Vaporub [a topical ointment used as a cough suppressant but also used to relieve aches and pains in muscles and joints. It contains menthol and camphor which works by stimulating sensory receptors to provide cooling pain relief] for [his/her] right shoulder pain . Review of the Nursing Note, dated 2/2/25 at 12:30 AM, revealed: [Resident #19] requested only Vick's for [his/her] right shoulder discomfort . Review of the Nursing Note, dated 2/7/25 at 1:29 AM, revealed: [Resident #19] only complaint was pain: a HA [headache] and pain in the right leg to foot and then later also in the right shoulder . Review of the Nursing Note, dated 2/8/25 at 11:21 PM, revealed: [His/her] only complaint was pain in right thigh to foot, right shoulder and HA. [He/she] was given oxycodone vicks vaporub on right shoulder and ice on leg . Review of the Physical Therapy Progress Note, dated 2/10/25 at 4:40 PM, revealed: Patient attempted to transfer from bed to wheelchair required mod assist [moderate assistance] due to reports of pain in RLE and R [right] shoulder . Review of the Nursing Note, dated 2/11/25 at 1:59 AM, revealed: [Resident #19] only complaint was pain: a HA and pain both legs (right leg to foot was the majority of the pain) and also in the right shoulder. [He/she] was given Oxycodone with night meds[medications] for 9/10 pain, and Vicks applied to right shoulder pain. Review of the Nursing Note, dated 2/20/25 at 12:32 PM, revealed: [Resident #19] reported continued pain in [his/her] right shoulder area. [He/she] states this has been ongoing since admission. Currently receiving Vick's vapor rub with ease. [He/she] asks if [he/she] could have imaging. Message sent to [provider] regarding this and the resident notified of the above . Review of the Nursing Note, dated 2/20/25 at 1:35 PM, revealed: Complaints of right shoulder pain during morning rounds, vicks vapo rub applied as per resident request. [He/she] verbalized a little bit of relief upon assessment. [He/she] asked this writer if [he/she] could have imaging on [his/her] right shoulder since [the right shoulder pain] has been ongoing pain since admission. Charge [Nurse] notified and Provider notified . At [4:00 PM] resident was sitting on the edge of the bed appears to not be in pain but when I approach [him/her] [he/she] [complained] of pain and was about to cry . Review of the Physical Therapy Progress Note, dated 2/20/25 at 1:40 PM, revealed: [Resident #19] reported [he/she] was not feeling well today and when asked in what way [he/she] reported that [his/her] right shoulder is in significant pain . Review of the Speech and Language Pathologist Progress Note, dated 2/24/25 at 3:44 PM, revealed: [Resident #19] complained of leg and shoulder pain and was expecting some medication which was administered by the RN during the session. [Resident #19] reported [he/she] feels [he/she] can't concentrate very well when [he/she] has things on [his/her] mind or when [he/she] is hurting but [he/she] endorsed it is getting better. Review of the Baseline Care Plan, effective from 1/22/25 to 1/30/25, revealed: [Resident #19] is at risk for Pain related Total knee replacement Goal: Pain will be controlled through next review Interventions: Assess for pain q[every] shift, administer pain medications as ordered, notify Provider of any non-relieved pain . Further review revealed no documentation in Resident #19's care plan about his/her right shoulder pain. During an interview on 2/26/25 at 8:53 AM, MDS Coordinator stated he/she and the Director of Nursing (DON) are the only ones that updated the care plans. The MDS Coordinator further stated he/she reads all the notes daily in the residents' chart and nurse communications to ensure updates are completed. During an interview on 2/26/25 at 10:50 AM, when asked when he/she became aware of Resident #19's right shoulder pain, the MDS Coordinator stated he/she became aware on Monday 2/24/25. During a follow up interview on 2/26/25 at 2:10 PM, when asked if Resident #19's right shoulder pain should have been included in the care plan, the MDS Coordinator stated yes, it should have been included. Later in the day, Resident #19's care plan was updated to reflect his/her right shoulder pain. Review of the facility's policy LTC [Long Term Care]: Care Planning Policy, effective date 3/2/24 revealed: Purpose .To provide a multi-disciplinary approach to patient care demonstrated by a care plan that is generated, updated and followed by each discipline caring for any individual resident and to maximize communication between discipline members so that all team members are aware of, and supportive of, each discipline's resident goals and interventions .The Care Plan is to be considered a dynamic document. It is to [be] updated on a continual basis and is based on the assessed needs of the individual resident. The MDS RN-Coordinator is in charge of and responsible for completing, reevaluating and revision of the Resident Care Plan. The MDS RN-Coordinator reports directly to the Director of Nurses for all aspects of the care planning process and works very closely with the charge nurse when developing, evaluating and revising care plans .As indicated above the care plan is to be a dynamic document that is to be updated often. To that end, the MDS Coordinator or the Charge will update the Care Plan as necessary. The expectation is, that this care plan will become more refined overtime and, as a result, become more resident specific and more inclusive, as time goes on . When reviewing and updating the Plan of Care there are several areas to consider and assess the residents need relative to these areas they include but are not limited to the following: . the specific indication for which any PRN type medication is to be given. .

. Based on record review and interview, the facility failed to provide a program of meaningful activities for 1 resident (#44), out of 13 sampled residents based on an individualized assessment and care plan. This failed practice denied the resident opportunities that contributed to quality of life and placed the resident at risk for depression, loneliness, and boredom. Findings: Record review on 3/11-15/24 revealed Resident #44 was admitted to the facility with diagnoses that included pressure injury of the left heel, post-surgical left hip fracture repair, anxiety disorder, schizoaffective disorder bipolar type (a chronic mental health disorder that sometimes included episodes of mania and major depression), and moderate Alzheimer's dementia. During an interview on 3/11/24 at 5:03 PM, Resident #44 stated the activities in the facility did not appeal to him/her. The resident stated he/she preferred to listen to music, go to the store of his/her preference, and avoid large loud crowds. He/she further stated that his/her major interest was shooting. The resident also stated no one at the facility had discussed what he/she liked to do. During an interview on 3/14/24 at 9:34 AM, the Activity Coordinator (AC) stated a resident centered activities program for each newly admitted resident was developed from an initial activity assessment form. This assessment was normally completed within 1-2 weeks after admission. When asked if an activities program was developed for Resident #44, the AC stated it was not. When asked if activities that were offered to residents were documented, the AC stated they were not. The AC stated she kept all resident assessments on paper in her assessment folder. Review of the AC's activity assessment folder revealed a resident list titled: Daily Resident Attendance List .assessments we have [handwritten at the top of the page], not dated. Resident #44 was not included on this list. During an interview on 3/15/24 at 10:48 AM, the Long-Term Care (LTC) Administrator stated the AC determined residents' activity preferences in order to develop an activities program, then those preferences were included in the care plan. The LTC Administrator located one activity related to service dog visits on Resident #44's care plan. The LTC Administrator further stated that Resident #44 was to have an activities program created by the end of the day. The AC presented Resident #44's Activity Initial Assessment form, dated 3/15/24 at 2:14 PM, the last day of the survey. Review of the policy LTC: Activities Therapy Scope of Service, dated 3/2/24, revealed: Assessment .Complete Activity Initial Assessment upon admission .Assist with development of initial care plan. Reassess at any time when change in level of care .Assess each resident upon admission to ensure appropriate level of activities. Implement activities for each resident. Provide individual, group, and/or one on one in room activities. .

. Based on record review and interview, the facility failed to ensure 1 resident (#9), out of 13 sampled residents, received ordered restorative exercises. This failed practice placed the resident at risk of not maintaining or decreasing his/her highest level of range of motion and mobility. Findings: Record review on 3/11-15/24 revealed Resident #9 was admitted to the facility with diagnoses that included primary osteoarthritis (a degenerative joint and bone disease) of both knees, leg swelling bilateral, and weakness of both lower extremities. During an interview on 3/12/24 at 10:34 AM, Resident #9 stated he/she did not remember when the last time he/she had physical therapy. Review of Active Order, dated 2/9/24, revealed: Nursing Communication RA (Restorative Aide) Goal: To promote lower extremity circulation and maintain flexibility. Exercise: Ankle pumps 20, hip reduction 5R[right] 5L[left] . Priority: Routine. Review of Resident #9's Care plan' with start date on 3/22/21, revealed: .Problem: Impaired strength and mobility as evidenced by need for extensive assist with ADL cares. Goal: To maximize resident's own strength and mobility by end of the restorative program . Intervention . Document . [Resident #9's] participation in RA program . During an interview on 3/14/24 at 11:47 AM, when asked how he/she provided restorative exercises to the resident based on the order, the RA stated ankle pumps were the only exercise that popped-up in his/her documentation so he/she provided ankle pumps only. Review of the Restorative Aide Plan of Care, with a written note: verified [on] 1/9/23, revealed: .Exercises: 1. Ankle pumps x 20 . During an interview on 3/14/24 at 12:20 PM, when asked if there was a new restorative order for Resident #9 other than the order on 2/9/24, the RA stated the order on 2/9/24 was the current order but did not make it through smartphrase (a facility's electronic messaging). Interview and concurrent review on 3/14/24 at 3:36 PM, of RA's documentations in the electronic health record, revealed the RA provided ankle pumps only to Resident #9 since 2/9/24. When asked if another restorative aide had provided exercises to the resident, the RA stated no. This surveyor requested the RA to provide a copy of RA's documentation since 2/9/24 to 3/14/24. Review of the RA's documentation from 2/9/24-3/7/24, revealed: Goal: Maintain strength and mobility .Plan: supervise/assist .with the following three to six times per week .ROM [range of motion] active or active assist exercises performed by resident, with cueing, supervision, or physical assist by staff .Ankle pumps 20 . Further review of the document revealed the RA provided ankle pumps only on the following dates: 2/9/24, 2/12/24, 2/14/24, 2/15/24, 2/16/24, 2/19/24, 2/20/24, 2/22/24, 2/23/24, 2/26/24, 2/27/24, 2/29/24, 3/01/24, 3/4/24, 3/5/24, 3/6/24, 3/7/24. Hip reduction 5R[right] 5L[left] was not provided and no restorative exercises provided from 3/7-14/24. During an interview on 3/15/24 at 9:13 AM, the Administrator stated the facility had no policy regarding restorative exercises. .

. Based on record review, observation, and interview, the facility failed to provide reasonable accommodation of needs for 1 Resident (#3), out of 11 sampled residents. Specifically, the facility failed to ensure the resident's call light device was within reach. This failed practice placed the resident at risk for not being able to call for help if needed. Findings: Record review from 11/28/22-12/2/22 revealed Resident #3 was admitted to the facility with diagnoses that included dementia and hypertension. Review of Resident #3's MDS (Minimum Data Set- a federally required nursing assessment) Annual Assessment, dated 9/27/22, revealed the resident required extensive assistance, two-person physical assist, for bed mobility, personal hygiene, and toileting. Further review revealed Resident #3 was not steady during transitions and walking and was only able to stabilize with human assistance. Review of Resident #3's Care Plan, updated 7/11/22, revealed: Problem: Bowel incontinence related to decreased sensation as evidenced by resident stating [he/she] is unable to tell when [he/she] needs to have a bowel movement . Goal Intervention: Keep call bell in reach at all times and make [Resident #3] aware of its placement . An observation on 12/1/22 at 1:05 PM, revealed Certified Nursing Assistant (CNA) #1 exited Resident #3's room. Further observation revealed that Resident #3's call light was placed on the dresser behind the resident's bed. The dresser was approximately 4-5 feet behind Resident #3's bed. While the surveyor was with Resident #3, the resident noticed that the call light was not within reach and asked this surveyor to retrieve it. During an interview on 12/2/22 at 8:01 AM, CNA #2 stated the call light should be within the resident's reach. During an interview on 12/2/22 at 8:59 AM, the MDS Coordinator stated Resident #3 relied heavily on the call light and that all residents should always have the call light within reach. During an interview on 12/2/22 at 10:08 AM, the Director of Nursing (DON) stated call lights should be within resident reach at all times. Review of a slide in the orientation training for all staff, from Care Connect (EPIC [electronic medical record program] training for new caregivers), undated, revealed: Universal Fall Precautions .Belongings and call light within reach . During the course of the survey, a policy on call lights was requested, per the DON the facility had no policy for call lights. .

. Based on interview and record review, the facility failed to: 1) provide written information related to the facility's bed-hold policy that included the reserve bed payment policy and appropriate paperwork that afforded the resident the opportunity to either accept or decline the option to hold their bed, based on that reserve bed payment policy; and 2) provide written information related to bed-hold policies at the time of transfer, or in the case of an emergency transfer, within 24 hours, to 1 resident (#12), out of 11 sampled residents. These failed practices had the potential for the resident to be displaced from their room or incur charges, they would not be aware of, from the facility. Findings: Facility Bed-Hold Notification Practice During an interview on 12/1/22 at 3:35 PM, the Director of Nursing (DON) stated the facility's current practice for transfers and/or discharges of residents to the Emergency Department (ED) or hospital was to provide the residents with a copy of the facility's policy LTC [Long Term Care] Bed Hold Policy, dated 7/7/22. The DON further stated an Acknowledgement of Receipt Bed Hold Policy upon Discharge or Transfer form would then be signed by the resident and this form would have been placed in the resident's medical record. Review of the facility's LTC Bed Hold Policy, dated 7/7/22, revealed: 1) . a resident who is a Medicaid recipient, is allowed a planned Leave of Absence (LOA) of up to twelve (12) days in a 12 month period. LTC will honor the State's rule and a resident bed will only be held for up to twelve (12) days, which is the time allowed by Alaska Medicaid for continued stay eligibility. LOAs are for purposes as visiting family or friends, or for attending a therapeutic or rehabilitative program . Any resident who extends beyond the 12 days will be expected to pay the current daily billing rate if their bed is to be held beyond this number of days .; 2) Residents other than Medicaid recipients, may take a planned Leave of Absence (LOA) and their bed will be held by the facility for up to six (6) days, in a twelve (12) month period. This type of LOA would be short-term for purposes of visiting family or friends, or for special events which require a resident to be gone from the facility for one or more overnights. Non-Medicaid Residents will be expected to pay the current daily billing rate if their bed is to be held for any number of days.; and 3) . any resident emergently discharged and transferred, or discharged for medical treatment to a hospital or another facility, will be held by PeaceHealth New Horizons, until the resident is medically cleared to return. Residents discharged for medical care who are gone longer than fourteen (14) days may need to be reassessed prior to readmission to determine whether return is anticipated/indicated. Attempts will be made to keep the resident's original room when out on an extended bed hold. In keeping with CMS regulations, residents who are transferred to a higher level of care will sign an acknowledgement of the facility's requirement to hold their bed for return to the LTC . Further review of the policy revealed no documentation of the daily monetary rate to hold the resident's bed. Review of the facility's Acknowledgement of Receipt Bed Hold Policy upon Discharge or Transfer form, undated, revealed the following statement: This is to Acknowledge that discharging Resident [space here to resident's name] has received a copy of the New Horizons Bed Hold Policy, upon discharge or transfer, as mandated by CMS Regulation. There were spaces for the discharging resident, or decision maker if not resident, and a PeaceHealth Representative to sign. Further review revealed no ability for the resident or representative to document their choice to accept, or decline, to hold their bed based on the daily monetary rate to hold that bed. Resident #12 Record review on 11/28/22 - 12/2/22 and 12/5/22 revealed Resident #12 was admitted to the facility with diagnoses that included Parkinson's disease and chronic pain. Review of Resident #12's medical record revealed a Transport Data Form, dated 10/16/22, which indicated the need for emergency transport to Anchorage for medical intervention for gall stones (hardened deposits within the fluid of the gall bladder, a small organ under the liver). Further review revealed this form indicated I consent to transfer and was signed by the resident's representative. Review of Resident #12's Nursing Note, dated 10/16/22, revealed the resident expressed acute abdominal pain. Review of Resident #12's Physician Discharge Summary, dated 10/16/22, revealed: discharge date and time: 10/16/22 1:03 PM . Discharge Diagnoses: Common bile duct gallstones . patient developed acute onset severe RUQ [right upper quadrant abdominal] pain on 10/16 after lunch at which time [he/she] discharged to emergency department. Of note, ED has arranged for ERCP [endoscopic retrograde cholangiopancreatography - the use of x-rays to view and treat bile and pancreatic ducts] at [Anchorage] and patient will be discharging from the ED to [Anchorage] today 10/16 for ERCP. Further review of Resident #12's medical record revealed no Acknowledgement of Receipt Bed Hold Policy upon Discharge or Transfer form. Further review revealed no other documentation that the bed hold notification was completed. During an interview on 12/1/22 at 3:35 PM, the DON stated Resident #12's bed hold notification was not completed for the 10/16/22 transfer and subsequent discharge to Anchorage for medical care. .

. Based on record review and interview, the facility failed to update and/or revise the care plan for 1 Resident (#16), out of 11 sampled residents. Specifically, the facility failed to include antibiotic use and wound care for a MRSA infection. This failed practice had the potential to affect the staff's ability to implement consistent care, which could affect the resident's ability to attain healing and overall wellbeing. Findings: Record review on 11/28/22 - 12/2/22 and 12/5/22 revealed Resident #16 was admitted to the facility with diagnoses that included diabetes, and severe Alzheimer's dementia. Further record review revealed that 20 days after admission, Resident #16 developed redness and pain to his/her left upper thigh, which was near a healing graft site from a previous medical procedure: - Wound Instructions, dated 10/31/22: . L [left] upper thigh: Daily - clean graft donor site with NS [normal saline], pat dry. Graft site is to be kept moist with xeroform and secured with kerlix. - Nursing Note, dated 11/16/22: Accompanied resident to clinic were [he/she] saw MD [Medical Doctor] for L upper thigh, redness and pain. MD evaluated resident and ordered antibiotics and swabbed area. - Physician's Note, dated 11/16/22: [Resident #16] is a resident in long term care. [He/She] was seen today to address a rash on [his/her] left thigh . Cellulitis and abscess of left leg. The area of redness and swelling on the left upper anterior thigh is revealed to be a localized abscess and cellulitis that has already begun to drain . The wound was swabbed for culture and [he/she] will be treated with TMP/Sulfa DS [Bactrim Double Strength - an antibiotic] twice daily [for] 10 days, with appropriate wound care as well . - Wound Instructions, dated 11/16/22: . L upper thigh (above graft site): Daily and PRN. Clean thoroughly with NS, pat dry. Protect peri-wound with Cavilon skin prep. Apply small amount of medihoney to wound. Cover with mepilex. - Nursing Note, dated 11/18/22: Informed [MD] of the resident's positive MRSA culture and appearance of new reddened area of concern on R [right] groin. Pharmacy confirmed that the current antibiotic would cover MRSA. MD ordered chlorhexidine bath's daily. Chlorhexidine mouth wash twice daily and nasal mupirocin twice daily all administered for five days twice per month for six months. MD would like warm compress applied to L thigh wound as often and for as long as the resident will allow to encourage draining. - Pharmacy Note, dated 11/29/22: . Antibiotic Use: Bactrim twice daily. Course extended until 12/5/22 . - Nursing Note, dated 11/29/22: . Bactrim restarted due to induration on left groin for 7 days. No changes to wounds . - Physician's Note, dated 11/30/22: . [He/She] has completed an extended course of Bactrim twice daily with good results . I do not think that [he/she] need any more antibiotics as long as we continue with wound care . Review of Resident #16's medication orders revealed the following medication orders: - sulfamethoxazole-trimethoprim DS [Bactrim DS] 800-160mg [milligrams] PO [by mouth] BID [twice a day] Started on 11/16/22, ended on 11/17/22. - sulfamethoxazole-trimethoprim [Bactrim] 400-80mg PO every 12 hours scheduled. Started on 11/17/22, ended 11/26/22. - sulfamethoxazole-trimethoprim [Bactrim] 400-80mg PO every 12 hours scheduled. Started on 11/28/22, ended 11/30/22. Review of Resident #16's care plan revealed: Problem: Alteration in Skin Integrity related to surgical wound, skin graft, and rashes. Start date: 10/28/22. Goal: [Resident #16] will be free of any skin breakdown or pressure ulcers and any surgical incisions will heal until next review of care plan. Start date: 10/28/22. - Care plan goal interventions, all with a start date of 10/28/22: - Ensure adequate nutrition for healing - Keep area clean and dry at all times - Photograph and measure areas of skin breakdown or wounds and post in record . - Full body skin and nail assessment by RN on scheduled bath days. Document rashes . Further review of Resident #16's care plan revealed no documentation of the MRSA infection, antibiotic use, or wound care instructions. During an interview on 12/1/22 at 3:12 PM, the MDS Coordinator confirmed Resident #16's care plan was not updated to include the MRSA infection, antibiotic use, and wound care instructions. The MDS Coordinator stated Resident #16's care plan should have been revised to include them. Review of the facility's policy LTC [Long Term Care] Care Planning Policy, dated 11/29/22, revealed: The Care Plan is to be considered a dynamic document. It is to be kept up-to-date on a continual basis, and based on the assessed needs of the individual resident . To that end, the MDS Coordinator or the Charge will update the Care Plan as necessary. The expectation is, that this care plan will become more refined over time and, as a result, become more resident specific and more inclusive, as time goes on . .

. Based on record review and interview, the facility failed to ensure dental appointments had been scheduled for 1 Resident (#1), out of 11 sampled residents. This failed practice had the potential to place the resident at risk for altered nutrition, which could affect overall health and wellbeing. Findings: Record review from 11/28/22-12/2/22 revealed Resident #1 was admitted to the facility with a diagnosis of Vascular Dementia without Behavioral Disturbance. Review of Resident #1's nursing note, completed by the MDS Coordinator and dated 4/26/22, revealed: [Resident #1] has upper dentures that fit well. [He/she] does not have lower dentures. Review of Resident #1's nursing note, completed by the MDS Coordinator and dated 10/25/22, revealed: [Resident #1] reports only having upper dentures and states [his/her] lower dentures are left at home . states [he/she] is interested in getting lower dentures. Review of Resident #1's nursing note, completed by the MDS Coordinator and dated 10/27/22, revealed: Quality Care Conference . Activities Coordinator stated, [Resident #1] is requesting lower dentures [he/she] only has upper. Further record review revealed as of 12/2/22, a dental appointment had not been scheduled for Resident #1. During an interview on 11/29/22 at 2:22 PM, Resident #1 stated, I have trouble with my dentures. It is hard to chew. During an interview on 11/29/22 at 2:43 PM, the Activity Director was not aware if Resident #1 had a dental appointment scheduled yet. Review of the policy titled LTC [Long Term Care] Dental/Oral Care Procedure, effective 11/29/22, revealed: The LTC staff will . Notify the personal dentist or the consulting dentist when evaluation or care is necessary . assist residents in arranging appointments and transportation when needed. .

. Based on record review, observation, and interview, the facility failed to ensure dietary orders were correct for 1 Resident (#9), out of 11 sampled residents. This failure had the potential to contribute to unplanned weight loss and loss of food enjoyment for this resident. Findings: Record review from 11/28/22-12/2/22 and 12/5/22 revealed Resident #9 was admitted to the facility with diagnoses that included left hemiparesis and heart failure. An observation and interview on 11/30/22 at 11:50 AM, revealed Licensed Nurse (LN) #1 delivered a lunch tray to Resident #9 who was sitting up in bed with the bedside table in front of him/her. The tray included a bowl of pureed green beans. Resident #9 asked pointing at the pureed green beans, What's this? This writer stated pureed green beans. Resident #9 stated, I can eat green beans - I just don't want them pureed. A lady came up from the kitchen this morning and said my food would be pureed. Further observation revealed a diet slip on Resident #9's lunch tray. This diet slip documented a therapeutic diet for pureed green beans; #10 scoop Bean [NAME] Pureed. During an interview on 11/30/22 at 12:15 PM, when asked about the taste of the pureed green beans, Resident #9 stated, The green beans were different but okay tasting. I am not happy with having vegetables pureed. Review of Resident #9's dietary orders revealed an active diet order, dated 11/18/22: Diet General: No caffeine, low saturated fat, low 2 - 3 gram Sodium, small portions. Review of Resident # 9's medical record revealed a diet tray instruction to Food Service from nursing, dated 11/18/22 at 1:23 PM: RD [Registered Dietician] contacted by charge RN to downgrade resident's vegetables to pureed due to difficulty chewing. Review of Resident #9's medical record, after the surveyor inquired about the pureed green beans, revealed a dietician note, dated 11/30/22: RD contacted by charge RN that this resident does not need pureed vegetables. Miscommunication received 11/18/22. Diet order for pureed vegetables discontinued today. Dietary notified. During an interview on 12/2/22 at 11:32 AM, LN #2 stated, The pureed green beans were a miscommunication. I talked to the Registered Dietician about this. During an interview on 12/2/22 at 11:45 AM, Registered Dietician stated that the pureed green beans occurred because a written order had been written for the wrong patient. Review of the policy titled Therapeutic Diets Policy, dated 12/1/22, revealed: The Registered Dietician is responsible for the interpretation of diet order prescriptions . All diet orders are in accordance with the NCM [Academy of Nutrition and Dietetics' Nutrition Care Manual]. .

. Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment that prevented the transmission of communicable diseases/infections. Specifically, the facility failed to ensure professional use of glove change with peri cares (cleaning of the genital region of a resident). This failed practice placed residents who received peri cares, 15 out of 17 residents, at risk for communicable diseases. Findings : Glove Use During Peri Cares An observation on 12/1/22 at 12:36 PM, revealed Certified Nursing Assistant (CNAs) #2 and #4 performed peri cares with Resident #18. CNA #2 donned (put on) the first set of gloves, cleansed the front genital region of Resident #18, and then with those same gloves on, moved the bedside table out of the way. CNA #2 next discarded those dirty gloves and donned a new set of gloves without performing hand hygiene. During the observation, CNA #2 said aloud that it's difficult to reapply gloves after hand hygiene. During an interview on 12/1/22 at 1:05 PM, CNA #2 confirmed hand hygiene was not performed after the first glove change and said that he/she did not realize the bedside table had been touched with a contaminated hand. During an interview on 12/1/22 at 5:20 PM, the Director of Nursing stated health care trainings came from Mosby (a healthcare resource). Review Mosby healthcare trainings with glove changes, accessed on 12/6/22 from http://mosby.lambtoncollege.ca/basic/skill/A002.html, revealed: . Wear PPE [personal protective equipment] when the anticipated patient interaction indicates that contact with blood or bodily fluids may occur. Wear gloves when it is likely that you will touch blood, bodily fluids, secretions, excretions, nonintact skin, mucous membranes, or contaminated items or surfaces. Remove your gloves and perform hand hygiene between patient care encounters and when moving from a contaminated body site to a clean one . Review of the CDC (Centers for Disease Control and Prevention) website, accessed on 12/6/22 from https://www.cdc.gov/handhygiene/providers/index.html, revealed: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient - Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices - Before moving from work on a soiled body site to a clean body site on the same patient - After touching a patient or the patient's immediate environment - After contact with blood, body fluids, or contaminated surfaces - Immediately after glove removal . .

. Based on observation, record review, and interview the facility failed to inform each Medicaid-eligible resident, in writing, at the time of admission or when they became eligible for Medicaid, of charges for other items and services, not covered by Medicaid, that the facility offered. This failed practice had the potential to affect all Medicaid-eligible residents, 15 residents out of a total census of 17, and their ability to be aware of potential charges that could incur during their admission. Findings: An observation on 12/1/22 at 2:30 PM, revealed multiple Patient Rights and Responsibilities signs posted throughout the unit. Further observation revealed: The facility will inform: - Each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the state plan and for which the resident may not be charged. - Each resident of the other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and inform each Medicaid-eligible resident when changes are made to the items and services receiving. - Each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. A review of the facility's admission packet (a packet of documents to review and/or sign with residents upon admission) revealed no written notice to Medicaid-eligible residents of the items and services to be charged to Medicaid, or a list of items and services the resident may be charged, that are not covered by Medicaid, and the amount of charges for those services. During an interview and subsequent observation on 12/1/22 at 3:48 PM, the MDS Coordinator stated the admission process did include the admission packet, but it also included going through a binder, called the Resident Information Manual, which was in each resident's room. The binder included the policy Items Not Covered by Medicare and Medicaid, dated 9/28/22. Review of the facility's policy Items Not Covered by Medicare and Medicaid, dated 9/28/22, revealed: 1) a list of Services that are included in Medicare and Medicaid payment .; and 2) a list of Items and services that may be charged to resident's funds if they are requested by a resident but not required to achieve the goals stated in the resident's care plan. The facility will inform the resident that there will be a charge and payment will not be made by Medicare or Medicaid . Review of the complete list of items and services that may have been charged to the resident's fund revealed a multitude of personal choice items, including cellphones and other personal comfort items. Further review revealed services not covered included: - Non-covered special care services such as privately hired nurses or aides .; - Private room, except when therapeutically required (for example, isolation for infection control) .; and - Specially prepared or alternative food requested instead of the food and meals generally prepared by the facility . Further review of the policy revealed there were no monetary charges listed for these services. During an interview on 12/2/22 at 9:35 AM, the Director of Nursing stated there used to be a form the facility used that outlined items and services covered and not covered by Medicaid, and charges for these items and services, but that form had inadvertently been dropped from the admission process. .

. Based on record review and interview, the facility failed to provide behavioral health training consistent with residents who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty, or who had a history of trauma, and received appropriate treatment and services based on those resident's needs. This failed practice had the potential to exacerbate or trigger ongoing psychosocial difficulty and affect the resident's ability to attain the highest practicable mental and psychosocial well-being. Findings: Review of the facility's CMS-762: Resident Census and Conditions of Residents form, dated 11/28/22, revealed: Mental Status - Documented signs and symptoms of Depression: 5 residents - Documented psychiatric diagnosis: 7 residents - Documented behavioral healthcare needs: 4 residents Medications - Antipsychotic medications: 5 residents - Antianxiety medications: 4 residents - Antidepressant medications: 9 residents Review of the Facility Assessment FY [fiscal year] 22 revealed: - Disease/conditions, physical and cognitive disabilities .We have sufficient and competent staff to care for these types of residents . Dementia related Mood Disorders: Dementia and Alzheimer type psychosis (hallucinations, delusions, etc), impaired cognition, mental disorder, depression, managed bipolar disorder (i.e. mania/depression), anxiety disorder, behavior that can be managed safely. - Decisions regarding caring for residents with conditions not listed . One early aspect we typically consider is whether or not the potential admission has a skilled need for care, and if so, can we adequately and safety meet there needs . We make every attempt to ensure that we can meet all of a resident's needs at the time of admission and any potential needs throughout the stay . - General principles of all Resident Care . Resident care planning, and resident-centric preferences are given full consideration and respect in planning activities of daily living care, therapies, activities, and resident life . - Part 2: Services and Care Based on Resident Needs . Mental health and behavior . We can identify and implement interventions to help support individuals with issues such as dealing with anxiety . we can provide care for individuals with such illnesses as depression. We can make arrangements for referral to a mental health provider . and treatment recommendations, as necessary or as ordered . During an interview on 12/2/22 at 8:06 AM, the Senior Training Specialist, RN Educator, and Director of Nursing stated there was no trauma-informed care training provided during new hire orientation, nor during annual training for nursing staff. During an interview on 12/2/22 at 12:30 PM, when asked for a Behavioral Health policy, the DON stated the facility did not have a policy related to behavioral health. .

. Based on record review and interview, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility failed to ensure the facility's abuse and neglect policy included: 1) screening of potential employees; 2) training on prohibiting and preventing, as well as, recognizing signs/symptoms of all types of abuse, neglect, exploitation, and misappropriation; 3) prevention/prohibition of all types of abuse, neglect, exploitation, and misappropriation; and 4) identification of different types of abuse. These failed practices had the potential to place all residents (based on a census of 17) at risk for abuse, neglect, exploitation, and misappropriation of resident property. Findings: During an interview on 12/2/22 at 12:24 PM, the Director of Nursing stated that the only policy the facility had for abuse and neglect was the LTC [Long Term Care] Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy. Policy Review: 1) Screening Review of the facility's policy LTC Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy, dated 11/4/21, revealed: . Unit Responsibilities . Refrain from employing any individual who had been prohibited from working in a long term care facility because of failure to report a suspicion of a crime against a resident of a long term care facility . Further review of the facility's policy revealed no written procedure for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property, to include attempting to obtain information from previous and/or current employers and/or checking with the appropriate licensing boards and registries. Further review reveals no written procedure to screen prospective consultants, contractors, volunteers, and students. 2) Training Review of the facility's policy LTC Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy, dated 11/4/21, revealed: New employees will receive a thorough orientation through Human Resources, PHKMC [PeaceHealth Ketchikan Medical Center] Long Term Care, and clinically, by being assigned to work with experienced primary staff for a period of time determined using level of education, role, and previous experience. The PeachHealth Mission Statement, State Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act policy, and other policies and procedures on how to recognize signs of burnout, frustration, and stress that may lead to abuse will be presented and explained . Further review of the policy revealed no written policies or procedures that include training new and existing staff and in-service training for nurse aides to include: - Prohibiting and preventing all forms of abuse, neglect, exploitation, and misappropriation of resident property; - Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; - Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical and psychosocial factors; and - Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. 3) Prevention Review of the facility's policy LTC Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy, dated 11/4/21, revealed no written policies or procedures to prevent and prohibit all types of abuse, neglect, exploitation, and misappropriation of resident property. 4) Identification Review of the facility's policy LTC Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act Policy, dated 11/4/21, revealed no written procedures to assist staff in identifying abuse, neglect, exploitation of residents, and misappropriation of resident property. Further review revealed no identification of the different types of abuse: 1) mental/verbal abuse; 2) sexual abuse; 3) physical abuse; and 4) deprivation by an individual of goods and services. .

. Based on observation, interview, and record review, the facility failed to ensure food was stored under proper sanitary conditions. This failed practice placed all residents (based on a census of 17) at risk for foodborne illness. Findings: An observation and interview in the kitchen on 11/28/22 at 2:42 PM, revealed 2 loaves of raisin bread and a package of ciabatta bread rolls found in the walk-in freezer were not dated. The Food Service Supervisor agreed the bread and rolls were not dated. Further observation revealed a box of frozen cod was opened and was not rewrapped. The box was undated. The Food Service Manager stated, I am not sure how long the cod has been here. Further interview and observation at 2:47 PM, revealed that a plastic tub, used to hold smaller items, had ice buildup. In the tub, resting on the ice buildup, were corn tortillas and potato wedges in plastic packaging. The Food Service Manager agreed that there was an ice buildup in the tub, and the tortillas and potato wedges should be removed. An observation and interview on 11/28/22 at 2:48 PM, in the dry storage area, revealed there were 3, 4-pound bags of spaghetti sauce in vacuum bags, undated, and 1 package of spinach tortilla wraps, undated, in a plastic wrapper. The Food Service Manager stated that the spaghetti sauce and tortilla wraps should have been dated with an expiration date. Review of the facility's policy Storage and Food and Supplies Procedure, effective 12/10/21, revealed: All goods are checked on a continuing bases for expiration dates. .