. Based on record review, observation and interview, the facility failed to ensure residents' right to dignity and respect was honored for three residents (#'s4, 13, and 15), out of 21 residents (total census). Specifically, Certified Nurse Assistants (CNAs) used a cloth protector to wipe the residents' nose and mouth after dining. Additionally, a CNA transferred a resident in an ARJO lift (transfer lift device) from the resident's room to a chair in the living room. These failed practices placed the residents not being valued as a person with dignity and respect. Findings: Dining Experience: Resident #4 Record review on 11/18-22/24, revealed Resident #4 was admitted to the facility with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement) and dementia (a condition that affects memory and thinking). Review of Resident #4's Care Plan, dated 9/27/24, revealed: .assist me with food/fluid intake to promote adequate nutrition/hydration. During a dining observation on 11/18/24 at 4:57 PM at Salmonberry Unit, Resident #s 2, 4, 7, & 15 were at the long table having dinner. CNA #1 was feeding Resident #4. During an observation on 11/18/24 at 5:53 PM, CNA #1 was sitting next to Resident #4 and was observed to wipe Resident #4's nose with a cloth protector after dining. Then, the CNA wiped Resident's nose again with a paper napkin. After which, the CNA walked away carrying used plate and utensils and returned with a washcloth and wiped Resident's face and hands. Resident #15 Record review on 11/18-22/24, revealed Resident #15 was admitted to the facility with diagnoses that included palliative care and dementia. Review of Resident #15's Care Plan, dated 11/12/24, revealed: .I NEED: help with all my ADLs [Activities of Daily Living] .I EAT: with 1 helper providing more than half the effort.MY GOAL IS: participate in my ADLs as much as possible .maintain my dignity. During an observation on 11/21/24 at 8:47 AM at Salmonberry Unit, Resident #s 2, 4, 7, & 15 were at the long table and Resident #s 10, 18, and 72 were sitting at separate tables respectively. Further observation revealed, CNA #5 was observed to wipe Resident #15's mouth with a cloth protector after dining, then CNA #5 wheeled resident to the living room. During an interview on 11/21/24 at 10:00 AM, CNA #2 explained how the CNAs should prepare and help residents during dining. He/she stated the CNAs should bring the residents in the dining area, provide the residents with hand hygiene, place a cloth protector, and serve drinks and meals. When asked how they should wipe the residents' mouth if there were food crumbs around residents' mouth and after residents eat, CNA stated they should have used a washcloth to wipe residents' mouth or face after dining. Review of the facility's Standard of Care, dated 7/2024, revealed: . After Meal Care: Respectfully offer warm washcloth to clean hands and face. Assist as needed, Remove clothing protector. Transfer of a Resident: Record review on 11/18-22/24, revealed Resident #13 was admitted to the facility with diagnosis of a stroke. During an observation on 11/20/24 at 8:47 AM, Resident #13 was in an ARJO sling (resident elevated in the air) while CNA #2 was transferring resident from his/her room to the living room recliner. Only one CNA was operating the lift. No observation of another CNA was assisting with the transfer. During an interview on 11/19/24 at 2:10 PM, CNA #2 stated Resident #13 requires two-person assistance for care and one person assist for feeding at times. During an interview on 11/21/24 at 10:05 AM, CNA #4 stated Resident #13 requires assistance of a lift device for transfers from bed to chair or chair to bed. CNA #4 stated Resident #13 had been transferred in the ARJO lift from the resident's bed then to the living room chair in the community space because it provides less transferring of the resident. During an interview on 11/21/24 at 1:00 PM, Administrator was asked for the facilities policy for the ARJO transfer device and the manual for the equipment. ARJO, Maxi Move, Maintenance and Repair Manual, dated 7/2008 copy was provided. No policy for transfer devices or transferring of a resident was provided prior to the exit of survey. Review of ARJO Maxi Move Maintenance and Repair Manual, dated 9/2008, revealed: . The Maxi Move is a mobile patient lifter and is used for transferring patients from bed or chair to the toilet or bath . Review of the facility's My Rights and Responsibilities, undated, revealed: . I have the right. to be treated with respect and dignity by all my caregivers. .

. Based on observation, interview and record review the facility failed to ensure infection control procedures were properly implemented. Specifically, the facility failed to ensure staff contained linen during transportation. This failed practice had the potential to affect all residents (based on census of 21) for risk of the spread of infectious disease. Findings: During an observation on 11/19/24 at 9:50 AM, Certified Nursing Assistant (CNA) #2 with gloves on was transporting unbagged linen from Resident #172's room passing through the community area to the dirty linen cart. During an interview on 11/21/24 at 10:05 AM, CNA #4 stated all linens brought from a resident's room should be placed into a plastic bag before leaving the room and taken to the dirty linen cart in the hall of the community area. During an interview on 11/21/24 at 2:50 PM, Infection Control Preventionist (ICP) stated all linens should be bagged inside the resident's room before transporting. ICP stated no PPE (personal protective equipment) was required when placing bags into the dirty linen cart. Record review of the facility's 2023-2024 Chiniak Bay Elder House, Infection Prevention Program revealed: . Protecting caregivers, visitors and the healthcare environment. Limiting unprotected exposure to pathogens by using . barrier precautions including personal protective equipment . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure: 1) Informed consent was obtained prior to the use of bed rails for 16 residents (#'s 1, 2, 4, 5, 6, 10, 11, 12, 13, 15, 16, 18, 19, 72, 122, and 172), out of 21 residents reviewed; and 2) Assessments for the risk and benefits of the use of bedrails, prior to the use of bedrails, for 5 residents (#'s 4, 13, 16, 18 and 19), out of 21 residents reviewed. This failed practice had the potential to place residents at risk of falls, entrapment, and other preventable accidents. Findings: Random observations on 11/18-22/24 revealed Resident #'s 1, 2, 4, 5, 6, 10, 11, 12, 13, 15, 16, 18, 19, 72, 122, and 172 all had raised upper side rails on his/her beds. During an interview on 11/21/24 at 12:15 PM, Licensed Nurse (LN) #4 stated nurses completed a weekly nursing summary about bedrails. When asked if any consents or assessments were required with the use of bedrails, LN #4 stated he/she was not aware. LN #4 further stated that LN #7 took care of bedrail assessments. During an interview on 11/21/24 at 12:16 PM, LN #7 stated he/she had noticed some beds had the siderails up and was not aware siderails were up. LN #7 further stated the residents must have a siderail assessment completed in the electronic health record (EHR), but no resident or resident representative consent was needed, and no physician order was necessary. Resident #1 Record review on 11/18-22/24 revealed Resident #1 was admitted to the facility with diagnoses that included dementia (a condition that affects memory and thinking) and COPD (Chronic Obstructive Pulmonary Disease) (lung disease that blocks air flow and make it difficult to breathe). Review of Resident #1's medical record revealed the resident had side rail assessments completed on 10/30/23, 1/25/24, 7/16/24, and 10/14/24. Further review of Resident #1's medical record revealed no informed consent regarding the use of bed rails was found. Resident #2 Record review on 11/18-22/24 revealed Resident #2 was admitted to the facility with diagnoses that included dementia, stroke, and hemiplegia (partial or complete paralysis on one side of the body). Review of Resident #2's medical record revealed the resident had side rail assessments completed on 1/18/24, 4/15/24, 7/10/24, and 10/7/24. Further review of Resident #2's medical record revealed no informed consent regarding the use of bed rails was found. Resident #4 Record review on 11/18-22/24 revealed Resident #4 was admitted to the facility with diagnoses that included dementia and Parkinson's Disease (disorder that affects movement, often including tremors). Review of Resident #4's medical record revealed no side rail assessments or informed consent regarding the use of bed rails was found. Prior exiting from the facility, requested side rail assessments were not provided for Resident #4. Resident #5 Record review on 11/18-22/24 revealed Resident #5 was admitted to the facility with diagnoses that included Schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), hemiplegia, and seizure. Review of Resident #5's medical record revealed the resident had side rail assessments completed on 1/29/24, 4/23/24, 7/20/24, and 10/16/24. Further review of Resident #5's medical record revealed no informed consent regarding the use of bed rails was found. Resident #6 Record review on 11/18-22/24 revealed Resident #6 was admitted to the facility with diagnoses that included COPD and vision loss both eyes. Review of Resident #6's medical record revealed the resident had side rail assessments completed on 2/8/24, 8/5/24, and 10/30/24. Further review of Resident #6's medical record revealed no informed consent regarding the use of bed rails was found. Resident #10 Record review on 11/18-22/24 revealed Resident #10 was admitted to the facility with diagnoses that included heart failure, seizure disorder, diabetes mellitus, and generalized weakness. Review of the Resident #10's medical record revealed the resident had side rail assessments completed on 1/12/24, 4/8/24, 7/2/24, and 9/30/24. Further review of Resident #10's medical record revealed no informed consent regarding the use of bed rails was found. Resident #11 Record review on 11/18-22/24 revealed Resident #11 was admitted to the facility with diagnosis that included dementia. Review of the Resident #11's medical record revealed the resident had side rail assessments completed on 11/21/23, 2/15/24, 8/12/24, and 11/6/24. Further review of Resident #11's medical record revealed no informed consent regarding the use of bed rails was found. Resident #12 Record review on 11/18-22/24 revealed Resident #12 was admitted to the facility with diagnosis that included dementia. Review of Resident #12's medical record revealed the resident had side rail assessments completed on 1/9/24, 4/4/24, 7/1/24, and 9/26/24. Further review of Resident #12's medical record revealed no informed consent regarding the use of bed rails was found. Resident #13 Record review on 11/18-22/24 revealed Resident #13 was admitted to the facility with diagnoses that included dementia and depression. Review of Resident #13's medical record revealed no side rail assessments or informed consent regarding the use of bed rails was found. Prior exiting from the facility, requested side rail assessments were not provided for Resident #13. Resident #15 Record review on 11/18-22/24 revealed Resident #15 was admitted to the facility with diagnosis that included dementia. Review of Resident #15's medical record revealed the resident had side rail assessments completed on 2/12/24, 5/9/24, 8/6/24, and 11/4/24. Review of Resident #15's medical record revealed no side rail assessments or informed consent regarding the use of bed rails was found. Resident #16 Record review on 11/18-22/24 revealed Resident #16 was admitted to the facility with diagnoses that included seizure disorder, unspecified ataxia (medical problem that causes problems with movement) and reduced mobility. Review of Resident #16's medical record revealed no side rail assessments or informed consent regarding the use of bed rails was found. Prior exiting from the facility, requested side rail assessments were not provided for Resident #16. Resident #18 Record review on 11/18-22/24 revealed Resident #18 was admitted to the facility with diagnosis that included Schizophrenia. Review of Resident #18's medical record revealed no side rail assessments or informed consent regarding the use of bed rails was found. Prior exiting from the facility, requested side rail assessments were not provided for Resident #18. Resident #19 Record review on 11/18-22/24 revealed Resident #19 was admitted to the facility with diagnoses that included renal disease and depression. Review of Resident #19's medical record revealed no side rail assessments or informed consent regarding the use of bed rails was found. Prior exiting from the facility, requested side rail assessments were not provided for Resident #19. Resident #72 Record review on 11/18-22/24 revealed Resident #72 was admitted to the facility with diagnosis of dementia. Review of Resident #72's medical record revealed the resident had side rail assessment completed on 10/31/24. Further review of Resident #72's medical record revealed no informed consent regarding the use of bed rails was found. Resident #122 Record review on 11/18-22/24 revealed Resident #122 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, gout, and COPD. Review of Resident #122's medical record revealed the resident had side rail assessment completed on 11/7/24. Further review of Resident #122's medical record revealed no informed consent regarding the use of bed rails was found. Resident #172 Record review on 11/18-22/24 revealed Resident #172 was admitted to the facility on [DATE] with diagnoses that included CVA (cerebrovascular accident), hemiplegia, and unspecified dementia. Review of Resident #172's medical record revealed the resident had side rail assessment completed on 11/21/24. Further review of Resident #172's medical record revealed no informed consent regarding the use of bed rails was found. Surveyors requested the facility's Bedrail Policy on 11/22/24 from Administration. Bedrail policy not provided prior to the exit from the facility. .

. Based on interview and record review the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Specifically, from 11/13-22/24 there was no full-time DON. This failed practice, of not having a full-time DON to provide oversight of nursing staff, daily management, direction and support, had the potential to place all residents (based on census of 21) at substantial risk for subquality of care. Findings: During an entrance conference on 11/18/24 at 4:20 PM, the Providence Kodiak Island Medical Center (PKIMC) Chief Executive Officer (CEO) stated Licensed Nurse (LN) #2, who was a nursing supervisor, was designated as DON since the DON was on leave. Review of the email from DON, dated 11/13/24, revealed the DON would be out and return on 12/2/24. Further review of the email revealed the points of contact for assistance were: . -First point of contact . [ name of Support Manager (SM)] -Second point of contact . [name of LN #2] - If you need additional support or escalation, please contact . [name of PKIMC Executive Director of Nursing (EDON)] or . [name of CEO]. Additionally . [name of Long-Term Care (LTC) Administrator] will be in the office next week if you need in-person support. Review of the facility's staff 2024 Schedule, dated 11/2024, revealed the DON was on Personal Time Off (PTO) from 11/13-22/24. LN #2: During an interview on 11/19/24 at 8:15 AM, LN #2 stated he/she was only available until 10:00 AM, then after 2:00 PM due to responsibilities of another position outside the facility. LN #2 stated had been in his/her position since 8/21/24. LN #2 stated, I am not much of a resource to staff since he/she was still new to the position and still learning the role as the nursing supervisor. During the same interview, LN #2 stated he/she was covering for the DON. However, he/she explained he/she was covering for some DON tasks because he/she did not know all the DON tasks. Further review of the facility's staff 2024 Schedule, dated 11/2024, revealed LN #2 was not on schedule on 11/14-15/24 and 11/18/24. On 11/22/24, he/she was scheduled only for 3 hours. Review of LN #2's Current Pay Period, dated 11/2024, revealed the following hours in the Daily column: On 11/14/24 3.28 hours On 11/15/24 1 hour On 11/18/24 it was blank, no hours recorded and on 11/22/24 it was blank, no hours recorded EDON: Review of the Executive Director of Nursing Kodiak Providence work schedule, undated, revealed: .Nursing Leader On-Call while LTC DON is on [leave] November 13-27/24. Review of the EDON's Previous Pay Period, dated 11/2024, revealed the EDON had regular 8 hours/day on 11/14-15/24 and 11/18-22/24. During an interview on 11/22/24 at 9:14 AM, the EDON confirmed her work hours was from 8:00-4:30 PM Monday to Friday at PKIMC as oversight of all clinical areas in the hospital. When asked what her role as EDON in the LTC, she stated she served as a resource for the LTC DON for anything about leadership. During an interview on 11/22/24 at 9:15 AM, EDON stated the LTC DON was out on leave and currently LN #2 had stepped in to handle the day-to-day needs. LN #2 would only consult with EDON if needed. EDON stated she had not come to the LTC facility over the last 2 weeks. LTC Administrator: During an interview on 11/21/24 at 4:47 PM, when asked if LN #2 covered for the DON, the LTC Administrator stated LN #2 was a LTC Manager. The LTC Administrator stated LN #2 would call the EDON or the CEO if something came up. During the same interview, the LTC Administrator [who was based out of town] stated she would report to the facility one week a month and when she was not in the facility, she was on-call and could fly to Kodiak if needed. The LTC Administrator clarified that the EDON and the LTC Administrator covered for the DON while the DON was out. Nursing Staff: During an interview on 11/19/24 at 9:38 AM, LN #3 stated [LN #2] goes back and forth but if I need [ed] to reach [him/her], I have [him/her] on my phone. [He/she]'s new in this higher position. During an interview on 11/21/24 at 2:47 PM, when asked if LN #2 covered for DON while the DON was out, LN #1, stated LN #2 was a nursing supervisor. LN #1 stated: [I] don't know what [LN #2] does, [LN #2] might support. LN #1 stated the EDON covered for the DON. Review of the facility's Director Long Term Care RN [Registered Nurse] Job Description, dated 6/1/08, revealed: .GENERAL SUMMARY The Director LTC RN provides clinical leadership, day to day clinical management and direction at the Chiniak Bay Elder House [Providence Kodiak Island Medical LTC]. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure foods were prepared, stored and labeled in accordance with professional standards for food safety for all residents (based on a census of 21). Specifically, the facility failed to ensure: 1) foods were labeled and dated; 2) expired foods were discarded; 3) proper sanitization of food surfaces; and 4) proper sanitizing of dishes and cookware. These failed practices had the potential of causing or spreading foodborne illness to all residents, who received food from the affected kitchens. Findings: Main Kitchen 1) Dry Storage: An observation, during the initial main kitchen tour on 11/18/24 at 4:30 PM, revealed: -Two- 20-ounce packages of Rana Family Size 5 Cheese Tortellini with a use or freeze by dated 09/09/2024; -One- 1 gallon container of Four [NAME] Wine Vinegar with a best if used by dated [DATE]; -Six- 13-ounce packages of Monarch Classic [NAME] Gravy Mix, dated 101824; -Three- 1-gallon containers of Kraft Mayo Light Mayonnaise, no expiration date; -Four- 13-ounce packages of Pioneer Low Sodium Roast Beef Flavored Gravy Mix, no expiration date; -Three- 12-ounce packages of Custom Culinary Pan Roast Gravy Low Sodium [NAME] Gravy Mix, no expiration date; -One clear tub containing 3 separate clear bags, with a taped piece of paper on the side of the clear tub, Thick & Easy Texture Modified Bread & Dessert Mix 9LB 9 LB [Alternate ID: 48862] with a weight of 19.70,no expiration date. 2) Kitchen Shelves: An observation, during a subsequent main kitchen tour on 11/19/24 at 12:13 PM, revealed: -One- 1 fluid ounce container of Spice Islands Pure Lemon Extract best by dated [DATE]; -One- 1 fluid ounce container of McCormick Pure Orange Extract best by dated Jun 23 19; -One- 8 fluid ounce containers of Baker's Imitation Vanilla Flavor with a written opened dated 4/14/23; -One- 1 fluid ounce container of McCormick Coconut Flavor best by dated [DATE]; -One- 1 fluid ounce container of McCormick [NAME] Food Color best by dated [DATE]; -One- 16-ounce package of Great Value Baking Soda opened dated 8/6/23. 3) Salmonberry Kitchenette: An observation, during the initial Salmonberry kitchenette tour on 11/18/24 at 6:02 PM, revealed: a) Refrigerator: - Two- 18 fluid ounce containers of Boost Balanced Nutritional Drink dated 22OCT2024; - 13- 8.45 fluid ounce containers of Katefarms Vanilla Glucose Support dated 10/25/24. b) Cupboard: - Three- 18 fluid ounce containers of Boost Balanced Nutritional Drink dated 22OCT2024. During an interview on 11/20/24 at 2:04 PM, Kitchen Manager (KM) #1 stated all containers should have been labeled with an expiration date. KM #1 also stated the staff should have labeled all containers with a used by date, if no manufacture date was on the label. KM #1 stated further, staff were to be using the Food Labeling Guidelines. Sanitizing Buckets: Upon observation, during the initial Fireweed kitchenette tour on 11/18/24 at 5:45 PM, CNA #6 tested the red sanitizing bucket with a QAR QC Test Strips (chemical test strips). CNA #6 stated the results was 50 PPM (parts per million). CNA #6 was not aware of what the recommended PPM level should be. CNA #6 stated the kitchen staff tested the buckets. During a simultaneous interview and observation on 11/18/24 at 5:58 PM, CNA #7 stated the Salmonberry kitchenette's red bucket was the rinse bucket and the green bucket was for washing. CNA # 7 tested the red bucket with a QAR QC Test Strips and stated the results was yellow. CNA #7 was not aware of what the recommended PPM level should be. QAR QC Test Strips dated [DATE]. During an interview on 11/19/24 at 11:10 AM, Food Service Staff (FSS) #1 stated FSS took the red and green buckets to the units four times per day and changed the kitchen bucket every 4 hours. The PPM results should have been between 200-400 PPM to be acceptable sanitation levels. When asked what the process was if the results were 50 PPM, FSS #1 stated that indicated the solution needed to be changed. During an interview on 11/20/24 at 2:04 PM, KM #1 stated that the sanitizing buckets were prepared by the kitchen staff and provided to the Fireweed and Salmonberry kitchenettes three times daily. When asked what the sanitizing PPM levels should have been, KM #1 stated it should have been 200-400 PPM. KM #1 further stated if the sanitizing results were less than 200 PPM, the buckets should have been changed with new sanitizing solution and retested prior use. Dishwasher: During an interview on 11/20/24 at 2:05 PM, KM #1 stated the Ecolab reader mounted on the wall next to the dishwasher read the temperatures incorrectly. KM #1 stated the Ecolab technician evaluated the reader last week and determined it was malfunctioning. KM #1 stated the Ecolab Technician verified the dishwasher gauge located on the lower portion of the dishwasher was reading accurately. KM #1 stated on the Communication Board located out in the kitchen area stated what gauge the dishwashing staff were to have been using. When asked what dishwashing temperature was sanitizing, KM #1 stated 180 degrees. When asked regarding the Dish Machine Sanitizing Log Month/Year: November 2024, rinse temperature results on 11/1-13/24 and 11/15-16/24 of below 180 degrees, KM #1 stated, I think the staff are confused what temperature from what gauge to write down. KM #1 further stated, staff needs education. Record review of facility's Dish Machine Sanitizing Log Month/Year: November 2024, - 11/1/24 at 8:00, Rinse Temp. 100, - 11/1/24 at 2:00, Rinse Temp. 102, - 11/2/24 at 10:00, Rinse Temp. 100, - 11/2/24 at 1:50, Rinse Temp. 98, - 11/3/24 at 11:00, Rinse Temp. 104, - 11/3/24 at 1:10, Rinse Temp. 103, - 11/4/24 at 10:30, Rinse Temp. 100, - 11/4/24 at 2:00, Rinse Temp. 101, - 11/5/24 at 9:40, Rinse Temp. 102, - 11/5/24 at 2:30, Rinse Temp. [no recorded number], - 11/6/24 at 11:30, Rinse Temp. 102, - 11/6/24 at 2:00, Rinse Temp. 102, - 11/7/24 at 7:30, Rinse Temp. 102, - 11/7/24 at 2:30, Rinse Temp. 102, - 11/8/24 at 8:00, Rinse Temp. 103, - 11/8/24 at 2:00, Rinse Temp. 102, - 11/9/24 at 10:50, Rinse Temp. 110, - 11/9/24 at 1:35, Rinse Temp. 102, - 11/10/24 at 7:50, Rinse Temp. 102, - 11/10/24 at 2:30, Rinse Temp. 104, - 11/11/24 at 10:10, Rinse Temp. 100, - 11/11/24 at 3:00, Rinse Temp. 102, - 11/12/24 at 11:10, Rinse Temp. 110, - 11/12/24 at 1:20, Rinse Temp. 101, - 11/13/24 at 9:55, Rinse Temp. 101, - 11/13/24 at 1:00, Rinse Temp. 100, - 11/15/24 at 2:00, Rinse Temp. 102, - 11/16/24 at 11:05, Rinse Temp. 103, - 11/16/24 at 2:00, Rinse Temp. 100. Record review on 11/18/24 at 6:00 PM, SALMONBERRY Dish Machine Sanitizer Log located in the Salmonberry Kitchenette revealed: Wash Temperature must reach 150-165 degrees, and rinse must reach 180 degrees. Record review on 11/18/24 at 6:00 PM, SALMONBERRY Dish Machine Sanitizer Log located in the Salmonberry Kitchenette revealed missing and incomplete entries dated: 10/1/24, 10/2/24, 10/3/24, 10/4/24, 10/5/24, 10/6/24, 10/11/24, 10/12/24, 10/13/24, 10/15/24, 10/18/24, 10/19/24, 10/20/24, 10/22/24, 10/23/24, 10/24/24, 10/25/24, 10/26/24, 10/27/24, 10/30/24, 10/31/24, 11/1/24, 11/2/24, 11/3/24, 11/5/24, 11/6/24, 11/7/24, 11/8/24, 11/9/24, 11/10/24, 11/12/24, 11/13/24, 11/14/24, 11/15/24, 11/17/24, and 11/18/24. Record Review on 11/18/24 at 6:00 PM, revealed that SALMONBERRY Dish Machine Sanitizer Log located in the Salmonberry Kitchenette contained Wash Temp log entries that were below 160 F (Fahrenheit) dated: - 10/1/24 at 5:30 PM: 156 F, - 10/2/24 at 7:00 AM: 156 F and 12:00 PM: 156 F, - 10/4/24 at 8:00 AM: 156 F and 1:00 PM: 156 F, - 10/7/24 at 8:30 AM: 155 F, 12:15 PM: 156 F, and 6:00 PM: 156 F, - 10/8/24 at 8:30 AM: 154 F, 1:00 PM: 156 F, and 6:30 PM: 157 F, - 10/9/24 at 8:30 AM: 157 F, 12:30 PM: 156 F, and 6:30 PM: 156 F, - 10/10/24 at 8:30 AM: 157 F, 12:30 PM: 156 F, and 6:00 PM: 156 F, - 10/13/24 at 6:00 PM: 156 F, - 10/14/24 at 8:30 AM: 156 F, 12:30 PM: 150 F, and 6:30 PM: 155 F, - 10/15/24 at 8:30 AM: 155 F, and 6:30 PM: 157 F, - 10/17/24 at 7:00 AM: 156 F, 12:00 PM: 156 F, and 5:30 PM: 157 F, - 10/19/24 at 5:30 PM: 157 F, - 10/20/24 at 8:00 AM: 154 F, - 10/21/24 at 7:00 AM: 154 F, 12:00 PM: 157 F, and 6:00 PM: 157 F, - 10/22/24 at 8:30 AM: 157 F, and 12:30 PM: 149 F, - 10/23/24 at 8:30 AM: 143 F, and 12:38 PM: 142 F, - 10/24/24 at 6:30 PM: 157 F, - 10/27/24 at 6:50 PM: 157 F, - 10/29/24 at 8:30 AM: 157 F, 1:30 PM: 150 F, and 6:30 PM: 157 F, - 10/30/24 at 6:30 PM: 151 F, - 10/31/24 at 7:05 PM: 156 F, - 11/1/24 at 6:00 PM: 157 F, - 11/2/24 at 6:45 PM: 156 F, - 11/3/24 at 8:00 AM: 152 F, and 12:30 PM: 157 F, - 11/4/24 at 7:00 AM: 157 F, 12:00 PM: 157 F, and 6:00 PM: 156 F, - 11/5/24 at 5:00 PM: 157 F, - 11/7/24 at 5:15 PM: 156 F, - 11/8/24 at 8:30 AM: 148 F, - 11/9/24 at 8:41 AM: 156 F, - 11/11/24 at 8:30 AM: 156 F, 12:30 PM: 157 F, and 5:30 PM: 152 F, - 11/12/24 at 5:00 PM: 151 F, - 11/14/24 at 6:00 PM: 156 F, - 11/15/24 at 6:00 PM: 157 F, - 11/16/24 at 8:00 AM: 157 F, 12:15 PM: 157 F, and 6:35 PM: 157 F, - 11/17/24 at 6:15 PM: 156 F, - 11/18/24 at 12:00 PM: 154 F, and 6:30 PM: 157 F. Record Review on 11/18/24 at 6:00 PM, revealed that SALMONBERRY Dish Machine Sanitizer Log located in the Salmonberry Kitchenette contained Rinse Temp log entries dated 10/23/24 was 172 F . Review of the facility's policy Dish Machine Operation, last revised on 9/2023, revealed: .Wash cycle temperature will be 160F, rinse temperature at least 180F or higher, and surface temperature at least 160F ., and .Temperature Recording: The FNS [Food Nutrition Staff] staff loading the dish machine will be responsible for checking and logging temperatures on the dish washing temperature log sheet throughout the use of the machine, at least 3 times a day . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to ensure emergency care equipment was maintained. Specifically, the facility failed to complete the Automated External Defibrillator (AED) regular maintenance per manufacturer's recommendation. This failed practice had the potential to place all residents (based on a census of 21) at risk of not receiving emergency care. Findings: Record review of the facility's 2024 [NAME] AED Plus Monthly Inspection Log, dated from 1/2024 to 12/2024, revealed five steps to inspect the AED as: Step 1 press and hold the On/Off button; Step 2 AED Status Indicator Test Red X or [NAME] as check mark; Step 3 Defibrillator unit is clean, no spills, clear of objects on top, & casing intact with response choices of Yes or No; Step 4 Cables and Connectors are secured, and not damaged (cracks, broken wires, etc.) with response choices of Yes or No; and Step 5 AED unit supplies have two pads. One for Adult and Pediatric. Further review of the inspection log revealed: Step 2 was not marked either X or check marked from 1/2024 to 11/2024, with a total of 11 months. Step 3 was not marked yes or no from 6/2024 to 9/2024 and 11/2024, with a total of 5 months. Step 4 was not marked yes or no from 2/2024 to 11/2024, with a total of 10 months. During an interview on 11/22/24 at 11:35 AM, the Administrator stated that the incomplete responses in the inspection log would mean that the staff forgot to encircle the responses. When asked for clarification, the Administrator clarified that it meant that the staff would encircle the responses if the staff had checked the AED if it was clean and the cables were secured and not damaged. Review of the [NAME]'s Ensure AED Readiness with Regular Maintenance, dated 2024, accessed at this link: https://www.[NAME].com/en-GB/Other%20Resources%20and%20Links/how-to-maintain-aed, on 11/22/24, revealed: .AEDs are sophisticated medical device that are designed for years of service, but they require regular inspections and basic care to remain in proper working condition. This includes visually inspecting the AED regularly to confirm its readiness status, storing it in an temperature controlled area, and replacing consumables such as batteries and electrode pads to comply with expiration dates . Routine Inspection and Maintenance Checklist. Follow our simple maintenance checklist to ensure that your AED will be ready when you need it: The unit is clean, undamaged, and free of excessive wear. The green status indicator shows that the AED has passed its most recent self-test. The housing has no cracks or loose parts. The electrodes are present, sealed in their package, and within their expiration date. All cables are free of cracks, cuts, and exposed or broken wires. The battery is within its expiration date. .

. Based on record review, observation and interview, the facility failed to ensure 1) a physician's order for restraint was obtained in a timely manner; and 2) direct care staff (Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) on-going re-evaluation of the restraint use was documented in 1 resident's medical record (#2) out of 1 resident investigated for restraints. This failed practice had the potential to deny the resident's highest practicable wellbeing. Findings: Record review from 9/18-22/23 revealed Resident #2 was admitted to the facility with diagnosis of dementia. An observation of 9/18/23 at 4:07 PM revealed Resident #2 sitting in the common room in his/her wheelchair with a seat belt clipped around his/her waist. During an interview on 9/19/23 at 1:08 PM, Resident #2's family member stated the Resident was wearing the seatbelt to prevent him/her from sliding, and the Resident was unable to remove the seatbelt on his/her own. The family member further stated the facility had planned to order something more comfortable for the Resident. An observation on 9/20/23 at 9:40 AM revealed Resident #2 sitting in the common room watching TV. The Resident was sitting in his/her wheelchair with the seatbelt fastened around his/her waist. During a follow up observation on 9/20/23 at 11:30 AM, Resident #2 was observed in his/her wheelchair in the common room with the seatbelt fastened. Review of Resident #2's PHYSICIAN ORDERS RECAP, dated 9/20/23 at 10:44 AM, of the current electronic physician's orders, revealed no electronic order for Resident #2's seatbelt restraint. Review of Resident #2's current Care Plan, dated 9/5/23, revealed obtain consent for restraint use (seat belt & lap tray) while in [wheelchair] (consent provided by [family member] 9/5/23), obtain physician order for device/restraint use, check device/restraint every 30 minutes for comfort & restrictions, ensure that seat belt is released or lap tray is removed every hour & that I am repositioned .evaluate need for device/restraint use weekly with weekly nursing summary . Review of Resident #2's NURSES NOTES, dated 9/5/23 to 9/20/23 revealed no documentation of the seatbelt restraint, nor an ongoing evaluation of the restraint need. During an interview on 9/20/23 at 11:30 AM, when asked the start date of Resident #2's seatbelt restraint, CNA #1 stated the seatbelt started within the past month. When asked what he/she monitored, CNA #1 stated he/she just made sure the device was positioned correctly. When asked if the seatbelt was ever released, the CNA stated no, but he/she needed to look at the care plan. CNA #1 added that he/she knew the belt looked like a restraint, but it was used for safety. CNA #3 then joined the interview and stated the belt was released every hour for 10 minutes. When asked where the restraint usage was documented, CNA #3 stated it was documented in the repositioning tab of the electronic health record. When asked to review the repositioning tab, CNA #3 pulled up the tab which revealed no restraint documentation. During an interview on 9/21/23 at 11:29 AM, when asked the indications for Resident #2's seatbelt restraint, LN #2 stated the seatbelt was indicated for safety. The LN stated the facility obtained consent from the family and the physician. When asked to provide the consent and physician's order, the LN called the MDS (Minimum Data Set-a federally mandated assessment for all residents of a long-term care facility) Nurse to assist. During an interview on 9/21/23 at 11:32 AM, the MDS Nurse retrieved the physician's order in the Resident's paper chart, dated 9/12/23. When asked when the restraint was initiated, the MDS Nurse stated the restraint was initiated on 9/5/23. The MDS Nurse further stated she noticed the Resident had a seatbelt on and alerted the staff the facility needed to obtain a consent before initiating the device. The MDS Nurse stated she obtained family consent, and the LN was to obtain the physician's order. When asked if the physician should have been notified prior to placement of the seatbelt restraint, the MDS Nurse stated yes, the facility definitely needed the physician's order first, and the facility struggled with communication issues. Additionally, when asked how the facility would have reevaluated the need for the restraint usage, the MDS Nurse stated part of the reevaluation process was to look at how often the device was worn. When asked if the CNAs were instructed to document the restraint frequency, the MDS Nurse stated they were instructed to document with the safety checks. When asked to show this documentation, the MDS Nurse showed one note written today, 9/21/23 at 10:45 AM. The MDS Nurse further stated the CNAs were confused as to where to document the restraint usage. When asked if the CNA documentation would have been helpful to reevaluate the need for Resident #2's seatbelt restraint, LN #2 stated the CNA documentation would have been helpful, so that he/she would have known if the Resident was restrained and if the Resident was released from the restraint. When asked how he/she performed weekly evaluations, the LN stated he/she would have documented what was seen for that day. When asked if Resident #2's behavior changed from day to day, the LN stated yes, at times the resident was restless, but today he/she was calm. During a follow up interview on 9/22/23 at 9:33 AM, the MDS Nurse stated the facility employed a lot of new people who did not know what restraints were. The MDS Nurse further stated a different resident, Resident #18, had a history of restraint because the facility unplugged the Resident's lift chair, preventing the Resident from standing up on his/her own. The MDS Nurse stated Resident #18 no longer had his/her chair unplugged because the facility was unable to obtain consent for the restraint. Review of the facility's policy Restraint Use in the LTC Center, dated 5/2023, revealed: A physician's order for the use of physical restraint must include the date and time the order was written, type of restraint to be used a time limit and the order must be renewed every 24 hours .Devices considered restraints are those that restrict freedom of movement .If restrained, the resident must be observed every 30 minutes for safety .Documentation of these procedure will be ongoing by the resident assistance and charge nurse. Documentation to include the type of restraint, time applied and removed, care and assessment .continued need and the resident's response to interventions . .

. Based on record review and interview, the facility failed to ensure accuracy of assessment was reported in the quarterly Minimum Data Set (MDS- a federally mandated assessment for all residents of long-term care facility) for 1 resident (#18) out of 13 sampled residents. This failed practice had the potential to report inaccurate resident's status. Findings: Record review on 9/18-22/23 of the facility's electronic health record (EHR) revealed Resident #18 was admitted to the facility with diagnoses that included right hip osteoarthritis (degenerative joint disease), and hypertension. Record review on 9/18-22/23 of Resident #18's quarterly MDS assessment, dated 7/17/23, revealed MDS Section N. N0410 Medications received during the last 7 days were antipsychotic (the resident received the medication once) and antibiotic (the Resident received the medication for 6 days). Review of Resident #18's current and discontinued physician's orders from 10/20/22 to 9/22/23, revealed no orders for antipsychotics and/ or antibiotic medications. Review of the electronic medication administration record (eMAR) from July to September 2023, revealed no antipsychotic and/ or antibiotic medications administered to Resident #18. Review of the Medication Regimen Review (MRR) for the month of July 2023, revealed: .the resident has no active psychotropic medication orders .no antibiotic administered in July . During an interview with Licensed Nurse (LN) #1 on 9/22/23 at 8:50 AM, when asked if Resident #18 received any antipsychotic and / or antibiotic medications, LN #1 was not certain Resident #18 had received those medications. LN #1 provided a copy of eMAR for the month of July 2023 and stated the Resident had Nystatin (antifungal) powder and Lozarepam (benzodiazepine) ordered. During an interview on 9/22/23 at 9:31 AM, the MDS Coordinator (MDSC) stated Resident #18 was coded for antibiotic because the Resident received Nystatin in July 2023. She stated the pharmacist told her that Nystatin was classified as antibiotic in the facility's EPIC (Electronic Patient Information Center) so she was coding Nystatin as antibiotic in the MDS. The MDSC confirmed that Resident #18 was not on antipsychotic. She thought she entered zero in the MDS. The MDSC stated she would make corrections in the MDS entry. This surveyor requested a copy of facility's medication classification in the electronic patient information center (EPIC). A copy was not provided by the end of the survey. Review of National Library of Medicine Medline Plus, accessed at this link https://medlineplus.gov/druginfo/meds/a682758.html, last revised 12/15/18, revealed: .Nystatin is in a class of antifungal medications called polyenes. It works by stopping the growth of fungi that cause infection . .

. Based on record review and interview, the facility failed to ensure 1 resident (#16) out of 13 sampled residents, were free from significant medication errors. Specifically, the resident was not provided with the ordered ear drop medication prior to the physician's procedure of ear wax removal. This failed practice had the potential to place the resident at risk for decreased quality of life due to incomplete removal of wax build-up, which potentially affected the resident's hearing. Findings: Record review from 9/18-22/23 revealed Resident #16 was admitted to the facility with diagnoses that included cancer and chronic kidney disease. The resident had a BIMS (brief interview for mental status) score of 15, which indicated the resident was cognitively intact. During an interview on 9/18/23 at 12:01 PM, when asked about his/her hearing, Resident #16 stated he/she had wax in his/her ears, which was irrigated by Physician #1. The Resident stated the physician removed the earwax about a month or so ago. The Resident further stated he/she was still having trouble hearing and stated that could have been from old age. The Resident further stated the physician had ordered ear drops, but he/she had not received the ear drops. Review of Resident #16's Physician orders revealed an order for Carbamide Peroxide (Debrox) 6.5% solution, 2 drops to both ears at bedtime as need for aural cerumen (ear wax) removal, Administer for 3 days followed by ear irrigation with an order date of 2/6/22. Review of the Physician's Progress Notes, dated 7/24/23, revealed Finally, [Resident #16] would like me to check [his/her] ears today. [He/She] feels like they are both pretty plugged with wax. Further review revealed The patient does have cerumen in bilateral ears. I used a curette [surgical instrument designed for scraping] and was able to remove almost all the wax from the right ear. The left ear is unable to get all of it out and there is a pretty significant impaction on the side. During a concurrent interview and record review on 9/20/23 at 2:27 PM, the Director of Nursing (DON) stated Resident #16 had not received the ear drops prior to the ear irrigation on 7/24/23. The DON further stated she remembered the physician arriving that day with his/her equipment to irrigate the Resident's ears. The DON stated the medication was missed due to a communication issue. During a follow up interview on 9/21/23 at 2:31 PM, Resident #16 stated in the past, he/she would have used the ear drops for 3 days and then go to the physician's office for the ear irrigation. The Resident stated now the physician comes to him/her for the treatment. The Resident added that last time the physician was able to remove the wax from the right ear, but the left ear remained blocked, and he/she had trouble hearing when his/her ears were blocked with wax. During a phone interview on 9/22/23 at 10:02 AM, when asked the intent of the ear drop order, Physician #1 stated Resident #16 has complained of difficulty hearing. On examination, the Resident had a rock-hard ear wax in the ear canal that wouldn't move, it was a solid mass. The order was to soften up the ear wax prior to the irrigation. The Physician stated the missed ear drops was a communication issue. Physician #1 added the facility's medical records were not streamlined, which was a chronic source of ineffectiveness and potential error. Review of the Carbamide Peroxide 6.5% (Debrox) solution instructions, accessed at https://www.debrox.com/how-does-debrox-work, dated 2023, revealed Excessive earwax buildup is a common problem that can lead to ear discomfort, itchy ears or partial loss of hearing .When drops are placed in the ear .it gently softens and loosens earwax. Once broken down, earwax is able to naturally drain from the ear .Any earwax remaining after treatment may be removed by gently flushing the area with warm water . .

. Based on record review, interview and observation, the facility failed to ensure resident food preferences were honored for 1 resident (#16), out of 13 sampled residents. This failed practice had the potential to place the resident at risk of inadequate nutritional intake and weight loss. Findings: Record review from 9/18-22/23 revealed Resident #16 was admitted to the facility with diagnoses that included failure to thrive syndrome (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol) and hand weakness. The resident had a BIMS (brief interview for mental status) score of 15, which indicated the resident was cognitively intact. During an interview on 9/18/23 at 12:01 PM, when asked about the facility's food service, Resident #16 stated he/she had alerted staff on multiple occasions of his/her dislike for peppers. The resident further stated he/she still received peppers and alerted staff again, who assured him/her the kitchen was aware of his/her dislikes. The resident stated he/she was still receiving the peppers and had to pick them out of his/her food, but since the peppers gave him/her indigestion, he/she ultimately stopped ordering foods which contained the peppers. Review of Resident #16's NUTRITION NOTES, dated 4/28/23, revealed [Registered Dietician] also reminded kitchen that [Resident #16] cannot eat bell peppers. A sign was made for the kitchen, in order to reinforce this. Review of Resident #16's NUTRITION NOTES, dated 7/26/23, revealed [Resident #16] noted [he/she] is somewhat tired of the menu at the Elder House and finds it is easier for [him/her] to order different foods when [he/she] knows something on the menu may have bell peppers, because in the past [he/she] has . found bell peppers in [his/her] meals .I communicated [his/her] feedback to kitchen staff. Review of the August Resident Council Meeting [minutes], dated 8/8/23, revealed [Resident #16] reported that there are too many peppers in the food .Information was notated by dietary. During an observation and concurrent interview on 9/20/23 at 4:02 PM, a posting in the main kitchen entitled, 11:30 LUNCH/4:30 DINNER Fireweed [Resident's unit], revealed under Resident #16's name Do Not Serve/Allergy Bell Peppers . When asked about resident preferences and allergy information, [NAME] #2 stated he/she was aware of Resident #16's dislike of peppers. During an interview on 9/20/23 at 2:30 PM, Resident #16 stated he/she ordered a salad today and the salad contained peppers. The resident further stated he/she did not eat the salad and saved it for a different resident who enjoyed peppers. During an interview on 9/20/23 at 3:00 PM, when alerted Resident #16 had received peppers and did not eat the salad because of the peppers, the Food Service Manager stated the cooks should have known the Resident's preference, but the dietary aide might have prepared the salad today. During an interview on 9/22/23 at 1:30 PM, the Resident's physician (MD #1) stated the conversation regarding the resident receiving peppers in his/her meal occurred every 2 months. Review of the facility's admission Package revealed a form entitled Food Likes and Dislikes Questionnaire, not dated, which stated The purpose of this questionnaire is to learn which food you like and dislike. Please cross out any foods you would prefer not to eat or would not buy at the grocery store. Further review of the facility's admission Package revealed the My Rights and Responsibilities form, dated 3/8/22, which stated I have the right .to reside and receive services in the facility with reasonable accommodation of my needs and preferences . .

. Based on interview, observation and record review, the facility failed to ensure a private space for the Resident Council meetings. This failed practice had the potential to affect all resident's choosing to attend the meetings, based on a census of 21, by preventing the group members from expressing their concerns or recommendations affecting their care. Findings: On 9/20/23 at 9:02 AM, the Resident Council meeting commenced in the main dining area on the Fireweed unit with 4 residents in attendance. The table where the residents were seated was in the center of the large room, which was near the open kitchen area, and surrounded by the resident's rooms and the open seating area where the TV was located. During the Resident Council meeting on 9/20/23 at 9:12 AM, when asked if the Council could have met without staff present, Resident #16 stated it bothered him/her that people walked back and forth and could have heard what was said. During the meeting at 9:30 AM, Licensed Nurse #1 approached the table where the meeting was being held and administered several oral medications to Resident #16. During the meeting from 9:02 AM to 9:45 AM, multiple staff members, including Certified Nursing Assistants (CNAs) were observed to walk past the meeting table. One unidentified CNA had entered the kitchen area and Resident #15 asked for a beverage. The unidentified CNA brought the beverage to the resident during the meeting. Another unidentified staff member wheeled a cart full of supplies into the kitchen area and began putting the items into the refrigerator. When asked if staff passing by during the meeting was a source of distraction to them, Resident #5 stated this was irritating to him/her. Resident #15 stated staff had restocked the kitchen and housekeeping had gone back and forth during the meetings. Resident #16 stated he/she felt like he/she could not have expressed his/her concerns with people walking back and forth. Resident #16 further stated staff had come later and talked about what was said during the meeting. During an interview on 9/20/23 at 2:47 PM, when asked what her role was with Resident Council, the Activity Coordinator (AC) stated the facility currently did not have a social worker, so running the resident council meetings became her role. When asked if the residents could have had the meeting without staff present, the AC stated she would have asked the residents if staff could have attended, such as the kitchen supervisor, since the residents had a lot of questions regarding food choices. The AC further stated the meetings were typically held in the main area, where the surveyor's resident council meeting was held that morning. When asked how she ensured privacy during the meetings, the AC stated she had asked staff to come back later and mentioned a time when a CNA had sat down during the meeting, and she explained to that CNA the meeting was private. The AC stated the Social Worker who held the meetings in the past was not aware that staff were not allowed in the meetings. When asked if she had noted disruptions during the meetings, the AC stated yes, sometimes there was loud talking, or the TV was on and needed to be turned down. When asked if she witnessed staff stocking the kitchen area during the meetings, the AC stated yes, they probably did. The AC further stated in the past, the facility used to ask the CNAs to go into the sunroom and close the door and chart during the meetings, however that was difficult because the CNAs needed to answer the resident's call lights. Review on 9/20/23 of the facility's policy Resident Council for Long Term Care, dated 5/2023, revealed: The Resident Council will meet monthly in the common area with the Activities Coordinator and Social Worker. Further review revealed Common area-Areas in the facility where residents may gather together with other residents, visitors, and staff or engage in individual pursuits, apart from their residential rooms. This includes but is not limited to living rooms, dining rooms, activity rooms, outdoor areas, and meeting rooms where residents are located on a regular basis. .

. Based on interview and record review, the facility failed to provide quarterly statements for personal fund accounts to 2 residents (#'s 8 and 13) and/or their Power of Attorneys (POAs), out of 2 sampled residents whose money was held by the facility. This failed practice placed the residents and/or their POAs at risk for not receiving a complete and accurate accounting of their personal funds entrusted to the facility. Findings: During an interview on 9/18/23 at 1:57 PM, Resident #13 stated the facility held his/her money and he/she had not received quarterly statements from the facility. During an interview on 9/19/23 at 1:41 PM, Resident #8's POA stated the facility held the resident's funds. When asked if he/she had received quarterly statements of Resident #8's funds from the facility, the Resident's POA stated he/she was unsure if the statements were sent quarterly. During an interview on 9/22/23 at 9:41 AM, when asked to show quarterly statements that were sent to residents and/or their POAs, the Manager of Support Services (MSS) stated the Patient Navigator (PN) was responsible for sending those out. When asked to provide documentation, the MSS stated she believed that might have been missed since the PN was new to his/her role. During a follow up interview on 9/22/23 at 9:55 AM, the MSS stated she verified the quarterly statements had been stopped 1 year ago, due to a miscommunication between the Business Office in Anchorage and the PN. Review on 9/22/23 of the facility's policy Resident Trust Account, dated 5/2023, revealed Issue balance/activity statements to the Social Worker and the resident or their guardian [POA] by U.S. mail, as directed by the Social Worker, within 30 days after the end of each quarter and upon request. A copy of the memo/email sent to Social Services, and a copy of the dated memo mailed to the guardian shall be kept on file for documentation purposes . Review of the facility's admission Package revealed the My Rights and Responsibilities form, dated 3/8/22, which stated Residents' Personal Funds .A financial record will be available to me through quarterly statements and upon my request. .

. Based on observation and interview, the facility failed to post the daily total number and the actual hours worked for all residents (based on census of 21) care per shift worked by the Certified Nurse Assistants (CNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). This failed practice provided inaccurate information to the all residents and their families. Findings: Random observation from 9/18-22/23 in the Fireweed and Salmonberry units' common area, revealed staff postings displaying the name of the facility, names of staff (RN and CNA) on duty per shift per day, and resident census were written on the whiteboard. Further review of the posting revealed the total number of staff and actual hours worked of nursing staff per shift was not documented. During an interview on 9/22/23 at 10:45 AM, the Director of Nursing (DON) stated the whiteboard had daily nurse staffing information for the residents and family. When asked if the total number and actual hours of nursing staff who provided direct resident care should have been included in the posting, she stated the time range for each shift was provided day shift 7:00 AM-3:30 PM, evening shift 3:00-11:30 PM, and night shift 11:00 PM-7:00 AM. No further comment was made regarding posting the total number or actual hours worked. .

. Based on observation, interview and document review, the facility failed to ensure: 1) food was stored under proper sanitary conditions; and 2) concentrations of sanitizing solutions were tested correctly to assure the solutions were maintained within acceptable parameters. These failed practices placed all residents (based on a census of 21) at risk for foodborne illness and/or communicable disease. Findings: Walk-in freezer During the initial tour of the kitchen on 9/18/23 at 9:00 AM, the walk-in freezer was observed. In the middle of the freezer were 4 boxes of frozen food placed on top of a milk crate. Behind these boxes were 2 Sterilite brand plastic containers stacked on top of one another, the bottom container was placed directly on the floor. Inside the container located on the floor were 10 bags of frozen fresh cut green beans. During an interview on 9/21/23 at 12:19 PM, the Food Service Manager (FSM) stated the plastic containers containing food should not have been stored on the floor. The FSM further stated the containers should have been placed 6 inches off the floor. At the conclusion of the interview, the FSM was asked to provide the facility policy for storage of food in the main kitchen. By close of survey, the policy had not been provided. Sanitation buckets During the initial tour of the kitchen on 9/18/23 at 9:35 AM, a sanitation bucket was observed in the 3rd sink. A poster was located above the sink with instructions for the Apex Solid Quat Broad Range Sanitizer [brand used by the facility] using the Hydrion QT-40 test strips. Further observation of the poster revealed Testing solution should be at room temperature- 65 degree F-75 degree F .Dip paper for 10 seconds. Don't shake. Cook #1 was asked to demonstrate the method to check the concentration of the sanitation solution. [NAME] #1 retrieved the QT-40 HYDRION test strips, placed the strip in the sanitation bucket, and immediately compared the color of the test strip (from the bucket) to the color on the QT-40 HYDRION test strip control. An observation of the QT-40 HYDRION test strips revealed an expiration date of May 15, 2020. Cook #1 stated he/she was not aware the test strips had expired and explained he/she could not see the expiration date because the writing was too small. Then, Dietary Aide (DA) #1 arrived with a second vial of test strips labeled as QAC QR /TEST STRIPS and stated these were the new test strips the facility would have been using. When asked for instructions for these test strips, the DA #1 stated he/she thought the procedure was the same. An observation and review of the package insert of the QAC QR /TEST STRIPS, with expiration date 10/2024, revealed Hold strip level for 5 seconds. Shake off excess water from pad .Sample must be at room temperature (above 75 degree F). During an interview on 9/21/23 at 12:19 PM, the FSM stated the facility changed the sanitation buckets 3 times per day and had a log to document the tests. When asked for the policy, the FSM stated there was no policy, but the instructions for testing were located on the log sheets. Review on 9/21/23 at 4:00 PM of the facility's Hospital Sanitizer Bucket Log sheets, dated August 2023 and September 2023, both revealed Testing solution should be between 65-75 degrees. Dip paper in solution .for 10 seconds. Don't shake . Further review revealed no documentation of the type of test strip used. Review on 9/21/23 at 5:00 PM of the Providence Chiniak Bay Elder House Procedure Sanitizer Buckets, dated 1/20/20, revealed The dietary aides will fill and refill sanitizer buckets for the kitchenettes, however if the liquid is visible dirty, anyone may change it out immediately. LTC [long term care] cooks must help change buckets for kitchenettes at these times: Sat/Sun: 10[am], every day at 5:15 pm. Further review revealed no instructions for testing the sanitation bucket solution. .

. Based on record review, observation, and interview, the facility failed to have an antibiotic stewardship program (ASP), a program that monitors antibiotic usage and effectiveness. This failed practice had the potential, for all residents (based on a census of 21), to receive an ineffective and inaccurate implementation of antibiotic protocols for antibiotic use. Findings: Record review on 9/18-22/23 of the electronic health record (EHR) revealed Resident #13 was admitted to the facility with diagnoses that included bronchiectasis (a condition in which the airways of the lungs remain permanently damaged and widened due to persistent infection) and chronic obstructive pulmonary disease. Review on 9/19/23 at 1:40 PM of Resident #13's electronic medication administration record (eMAR), revealed an order for Azithromycin (antibiotic) 250 MG Tablet (1 tablet/250 mg) to be administered in the morning three times a week on Monday, Wednesday, and Friday for bronchiectasis with an entry date on 10/20/20. An observation on 9/20/23 at 10:15 AM of the medication administration, revealed LN #1 administered Azithromycin to Resident #13. During an interview on 9/21/23 at 1:15 PM, when asked if the facility had an ASP, the Pharmacist stated the facility piggybacked the ASP with Providence in Anchorage, Alaska. He stated the Long-term Care facility had no ASP and no ASP committee who would have reviewed the residents' antibiotic use. He stated the facility was working on developing and implementing an ASP. During an interview with the Infection Preventionist (IP) on 9/21/23 at 3:36 PM, the IP stated the Pharmacist led the ASP. She stated her role as an IP was to track the type of infections, type of antibiotic, dosage, and frequency. She stated that any discrepancies found would have been reported to the Pharmacist. When asked if the facility had ASP, she stated ASP was a work in progress. During an interview on 9/22/23 at 8:50 AM, when asked the facility's process for antibiotic use, LN #1 stated if the resident exhibited signs and symptoms, the CNAs (Certified Nurse Assistants) would have taken the vital signs and reported to the nurse on duty. The nurse on duty would have assessed the resident, then informed the physician . During the same interview, when asked about the tool used to communicate the signs and symptoms to the physician, LN #1 stated they do not have a tool. The Infection Preventionist (IP) stated they have had McGreer criteria (an infection surveillance criteria) in the electronic health record (EHR). LN #1 stated he/she was not aware of the criteria and was unable to locate the McGreer criteria in the EHR. The IP directed the LN where to find the tool. The LN stated he/she had not used the McGreer criteria. The LN explained he/she would have only verbalized the resident's signs and symptoms to the physician, the physician would then prescribed the antibiotic based on laboratory and culture results. When asked if they would have reassessed the resident after few days on antibiotic use (also called a time-out), the LN stated he/she did not know about it. The IP stated the facility did not have a time-out. LN #1 stated the Pharmacist reviewed antibiotic use during the monthly medication regimen review (MRR). He/she stated Resident #13 was the only resident who received antibiotic for bronchiectasis. During an interview on 9/20/23 at 10:18 AM, Physician #1 stated Resident #13 was prescribed the antibiotic (Azithromycin) for prophylaxis ( action taken to prevent disease, especially by specified means or against a specified disease) that would have been recommended by a pulmonologist. Review of the facility's Infection Control Program for 2022-2023, revealed ASP was not included. .

Based on record review, observation, and interview, the facility failed to develop a revised, comprehensive care plan following a quarterly review assessment for 1 (Resident #14) of 13 sampled residents. Specifically, the care plan lacked updated restorative aide interventions. This failed practice placed the resident at risk of his/her care not being individualized regarding amending goals, preferences and needs of the resident. Findings: Record review on 6/6-9/22 revealed Resident #14 was admitted to the facility with diagnoses that included: hemiplegia (paralysis of one side of the body) and hemiparesis (weakness) following cerebral infarction (stroke) affecting unspecified side, and schizoaffective disorder. An observation on 6/7/22 at 10:43 AM, revealed Resident #14 in bed with both upper side rails elevated. Review of Resident #14's MDS (Minimum Data Set- a federally required nursing assessment) Quarterly Assessment, dated 03/03/2022, revealed G0400 Functional Limitation in Range of Motion A. Upper extremity (shoulder, elbow, wrist, hand)- Impairment on one side B. Lower extremity (hip, knee, ankle, foot)- Impairment on one side. Review of Resident #14's Care Plan, dated 6/7/22, revealed I NEED: to participate in ROM [range of motion] exercise program .I need my aides to- assist/encourage me with AAROM [active assisted range of motion] (left upper & lower extremities) & AROM [active range of motion] (right upper & lower extremities). Review of, Occupational Therapy [OT] Annual Evaluation, dated and signed by OT therapist 1/14/22, revealed Discontinue restorative aide program. Review of Physical Therapy [PT] Annual Evaluation, dated 2/3/22 and signed 2/4/22 by PT therapist, revealed No physical therapy services required at this time. During an interview on 6/8/22 at 11:17 AM the Long Term Care Director (LTCD) confirmed restorative therapy was discontinued on 2/22/22. During an interview on 6/8/22 at 4:23 PM, Licensed Nurse (LN) #2 stated restorative aides mainly complete ROM exercises and that the care plan would now be updated after conferring with the MDS Coordinator. During an interview on 6/9/22 at 10:04 AM the Rehabilitation Aide (RA) stated the RAs had not completed therapies on Resident #14 for a while. Review of the facility policy Resident Care Plans for Long Term Care, last revised 11/2018, revealed The Social Worker determines specific Care Plan goals that are person-centered care after completing the initial assessment and asking the resident and the resident representative for their input.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to assess urinary voiding patterns for 1 resident (#4), out of 13 sampled residents, to ensure interventions were implemented for the prevention of urinary incontinence and/or urinary tract infections. The failure to monitor voiding patterns and assess the significance of anticholinergic medications (block the binding of a receptor to nerve cells responsible for involuntary movement of smooth muscles present in the gastrointestinal tract, urinary tract, and lungs) placed the resident at risk for continued urinary incontinence and/or urinary tract infections and dehydration from self-imposed fluid restrictions. Findings: During an interview on 6/06/22 at 3:52 PM, the Resident stated he/she has problems with an urgency to void. During an interview on 6/08/22 at 11:30 AM certified nursing assistant (CNA) #6 stated the Resident will sometimes call to use the urinal. Record review on 6/07-09/22 revealed Resident #4 had diagnoses that included Parkinson's disease (disorder of the central nervous system that affects movement also including tremors) and BPH (benign prostatic hyperplasia-age associated prostate gland enlargement that can cause difficulty with urination). Review of an annual MDS (minimum data set) assessment, dated 8/03/21, coded the Resident H0200. A. Has a trail of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training been attempted on admission. Reentry or since urinary incontinence was noted in this facility? 0. No. H0300. Urinary Continence. Urinary Continence -Select the one category that describes the resident. 0. Occasionally incontinent (less than 7 episodes of incontinence). Within the 7 -day assessment window. Review of the most recent quarterly MDS assessment, dated coded the Resident H0200. A. Has a trail of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training been attempted on admission. Reentry or since urinary incontinence was noted in this facility? 0. No. H0300. Urinary Continence. Urinary Continence -Select the one category that describes the resident. 0. Occasionally incontinent (less than 7 episodes of incontinence). Review of Resident #4's most recent comprehensive care plan, dated 5/02/22, revealed Need/Preference .Occasional to frequent bladder incontinence due to neurogenic bladder (disease of the nervous system in control of urination) & not getting to the toilet or the urinal placed in time. Approach .I need my nurses to administer my medications per my physician's orders for urinary frequency & overactive bladder, help me choose the best absorbent product for my needs, adjust my environment, provide me with a urinal, provide-offer me fluids-encourage me not to limit fluids . Review of the Resident's fluid intake from 4/27/22-6/08/22 revealed the Resident averaged less than 1000 milliliters (mls) of fluid per day. (1000 mls is approximately 34 ounces) Review of Resident's medication regime included: Oxybutynin-an anticholinergic medication that relaxes bladder muscles (adverse reactions can cause urinary hesitantly, hallucinations and psychosis). Flomax 0.4 mg -relaxes the prostate muscle to improve urine flow (adverse reactions can cause dizziness and fatigue). Proscar 5mg daily for BPH (benign prostatic hypotrophy) Hydrochlorothiazide 12.5 daily used for high blood pressure (diuretic increases urination) Aricept 5mg-a cognition enhancing medication-at bedtime (adverse reactions can cause abnormal dreams, depression, urinary obstruction). Seroquel XR 200mg-antipsychotic (adverse reactions can include extrapyramidal side effects, tardive dyskinesia, insomnia, and irritability) at bedtime for psychosis; and Celexa-antidepressant (side effects include extrapyramidal symptoms) Per 2022 [NAME] Drug Guide for Nurses Review of a nurse's notes: 4/07/22 Urinalysis due to altered mental status. UA came bac positive for UTI [urinary tract infection]. Review of a nurses note, dated 5/12/22, Resident confused this shift. Resident stated to this writer that [he/she] can't urinate. Resident had just urinated and had previously urinated on this shift for a total of 2 voids. Review of Behavior and Mood note 8/06/21 Refused to drink lots of fluids at nighttime, [he/she] stated [he/she] doesn't want to wake up in the middle of the night to pee. During an interview on 6/07/22 Licensed Nurse (LN) #2 stated the facility had a bladder scanner, used to non-invasively measure for urinary retention post voiding, in storage. During an interview on 6/09/22 at 5:00 PM, LN #4 stated the Resident uses the urinal to urinate in. The LN stated the staff hold it for the Resident. LN #4 stated the Resident is sometimes damp with urine as the staff cannot get to him/her fast enough. Further review of the EMR revealed no evaluation of urinary retention post void and/or patterns of urination. .

. Based on record review, observation, and interview the facility failed to ensure 2 dependent residents (#s 4 and 20) out of 5 dependent residents observed during dining, were offered sufficient fluids. This failed practice placed the residents at risk for dehydration and other adverse effects due to lack of fluid intake. Findings: Resident #4 Record review on 6/07-09/22 revealed Resident #4 had diagnosis that included Parkinson's disease (disorder of the central nervous system that can cause tremors and affects movement) and dementia. Review of Resident #4's most recent Minimum Data Set (MDS) quarterly assessment, dated 4/23/22, revealed the Resident was coded 4=Total dependence-full staff performance every time during 7-day period from 2=One-person physical assist for the activity of daily living (ADL) task H. Eating-how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parental nutrition, IV fluids administered for nutrition or hydration). During an observation on 6/06/22 at 3:45 PM Resident #4 was observed seated in a Geri chair (large, padded chair with a padded base). A water cup, containing liquid, was located on a bedside table, out of the Resident's reach. During observations on 6/08/22 8:50 AM: Resident #4 was seated in his/her bedroom. There were no fluids within the resident's reach. 9:20 AM: No staff had entered the room, and there was no change in the Resident. 10:00 AM: No staff had entered the room; the Resident was in the recliner with eyes closed. 10:25 AM Certified Nursing Assistant (CNA) #6 entered Resident #4's room. The CNA used a thermometer to obtain the Resident's temperature and a pulse oximeter to check oxygen levels. The CNA did not offer the Resident any fluids during the interaction. The Social Worker, who had been in the room visiting, ended their visit. 10:31 AM, the Long-Term Care Manager visited with the Resident. 11:17 AM Resident #4 was alone in room, his/her position was unchanged. A water glass ½ full of water was observed on the bathroom sink, out of the Resident's reach. During an interview on 6/08/22 at 11:17 AM, when asked if he/she was offered fluids, Resident #4 replied he/she drank a little water earlier. During a second observation on 6/08/22, Resident #4 was brought out to the dining room for lunch. After CNA #2 prepared the Resident's meal, the CNA sat down to assist the Resident with eating. A small can of soda was provided with the meal. Closer examination revealed it was an 8 ounce can (240 mLs). No other fluids were offered during the meal. Observation on 6/09/22 at 8:00 AM, CNA #2 prepared the Resident's breakfast and assisted him/her with dining. The Resident had one cup of coffee with his meal, no other fluids were offered or provided during breakfast. Review of the Resident Daily Fluid Intake Goals, posted on the unit revealed Resident #4's fluid goal was 2700 ml /day. Review of a comprehensive Care Plan, dated 4/25/22, revealed Preferences . I need to be offered extra fluids and to be reminded to drink more because I: restrict fluids due to being incontinent. I show this by not drinking enough fluids. Approach: I need my nurses too give me fluids consistently throughout the day, observe me for changes in my mental status or behavior. I need my aides too-encourage fluid intake, remind me to take two sips of fluid after two bites of food per SLP [speech language pathologist] recommendations. Encourage me to drink up to 2300 ML of fluid per day. I need everyone to-encourage me to drink fluids. Record my fluid intake, offer me a variety of fluids keep my fluids within reach. Review of nurse notes dated 4/07/22 at 11:43 AM . Encourage [him/her] to drink more fluids explaining dehydration and associated problems resident remains fearful of having an accident. Review of Resident #4's documented intake revealed: 6/06/22 480 mLs in 24 hours 6/07/22 680 mLs in 24 hours 6/08/22 420 mLs in 24 hours Resident #20 Record review on 6/07-09/22 revealed Resident #20 had a diagnosis of Alzheimer's dementia and anxiety disorder. Review of Resident #20's recent MDS quarterly assessment, dated 5/17/22, revealed the Resident was coded 4=Total dependence-full staff performance every time during 7-day period from 2=One-person physical assist for the ADL task H. Eating-how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parental nutrition, IV fluids administered for nutrition or hydration). During an observation on 6/08/22: 9:00 AM Resident #20 was seated in a Geri-chair in the dining room and had just finished breakfast. The Resident remained by the dining room table looking out the window speaking to him/herself. The Resident had an IPad in from of him/her. From 9:00 AM-11:45 AM the Resident remained in the dining room. The Resident was not offered or assisted with any hydration during the 2 hours and 45-minute continuous observation. At 11:45 observation CNA #2 provided the Resident with his/her noon meal. The Resident was provided one 8 ounce can of root beer. At 12:15pm the Resident had eaten all his/her food and drank the entire 8 oz can of (thickened) soda that was fed to him by the CNA. The Resident was not offered any other fluids during the noon meal. During an observation of care on 6/08/22 at 1:00 PM, CNA #6 stated Resident #20 was dependent on staff for all ADL care. Review of Resident #20's care plan, dated 5/19/22, revealed the Goal I need: to be reminded to drink more and be provided with IDDSI [international dysphagia diet standardization initiative] level 2 mildly thick liquids. Because I: don't get enough to drink. I Show This By: not drinking enough, being dependent on staff to provide fluids. Approach .I need my nurses to-give my fluids consistently throughout the day, observe for changes in my mental status or behavior. I need my aides to-offer me a variety of fluids, provide me with oral care each shift, assist me with eating and drinking fluids. I need everyone to- encourage me to drink fluids, provided thickened liquids. My Goal Is To: feel better and have more energy, be adequately hydrated my daily fluid intake goal is 2100 mls/ day

Based on record review and interview the facility failed to ensure a gradual dose reduction and/or contraindications were implemented for the use of psychotropic medications for 1 (#4) resident out of 5 residents reviewed. The failure to ensure the resident's adequate indications for continued use for an excessive duration, placed the resident at risk for adverse consequences from side effects. Findings: Record review on 6/07-09/22 revealed Resident #4 had diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement often includes tremors), heart disease, anxiety, depression, and dementia. Review of the most recent quarterly Minimum Data Set assessment, dated 4/21/22, revealed under Section N-Medications. The Resident had taken A. Antipsychotics B. Antianxiety C. Antidepressant daily during the 7-day assessment period. The date of the last attempted GDR was 2/03/20, and D. physician documented GDR [gradual dose reduction-a gradual step decreased trial of a medication] as clinically contraindicated and No-GDR has not been documented by a physician as clinically contraindicated. Review of Resident's medication regime included: Oxybutynin-anticholinergic medication that relaxes bladder muscles (adverse reactions can case hallucinations and psychosis). Aricept (donepezil) 5 mg daily-a cognition enhancing medication-at bedtime (adverse reactions can cause abnormal dreams, depression, urinary obstruction). Clonazepam 0.5 mg-an antianxiety (adverse reactions can include confusion and depression) at bedtime. Seroquel XR 200 mg daily-antipsychotic (adverse reactions can include extrapyramidal side effects, tardive dyskinesia, insomnia, and irritability) at bedtime for psychosis; and Celexa-40mg daily antidepressant (side effects include extrapyramidal symptoms). Pharmacist Medication Regime Reviews February 2022 Review of a medication regime review (MRR) conducted for Resident #4 by the Pharmacist on March 2022 for February 2022 revealed: Psychiatric Medication Use: The Resident is on Citalopram, Clonazepam, and Quetiapine. AIMS [Assessment of Involuntary Movement Screening] test done on 1/24/22, with a final score of 16, slightly decreased from August 2021. Parkinson's diseases likely contributing to the involuntary movements observed. Resident is at risk for tardive dyskinesia [condition cause by long term use of psychiatric drugs that can cause repetitive involuntary movements]. Side effects reported: None Behavior/mood trend: No mood depression indicators documented in February. Last change in dose: Quetiapine [Seroquel] dose successfully decreased to 200 mg ER [extended release] PO [by mouth] nightly on 2/3/20. Assessment for possible dose decrease recommended for January 2021. Per MD, current 'current quetiapine dose is medical medically necessary. No need to decrease (see MMR findings from January 2021). GDR again proposed December 2021, pending provider response. Clonazepam and citalopram dose reduction considered to be clinically contraindicated on April 2021 (see March 2020 MRR recommendation). Although the Resident would have been due for a dose reduction assessment in April 2021, given reports from Outpatient Mental Health Clinician (4/2021 and 5/10/21) documenting residents increased anxiety and insomnia due to worsened Parkinson's symptoms, a dose reduction recommendation was postponed a couple months. GDR [gradual dose reduction] again proposed November 2021, pending response from provider. Review of the Director of Nursing Comments, dated 3/21/22, revealed No further needs Cannot complete until MD order received, dated 3/21/22. Review of the Physician comment I will address GDR in next visit, was dated on 3/29/22 The MRR Finding was dated by the Medical Director on 4/7/22. March 2022 Review of a medication regime review conducted for Resident #4 by the Pharmacist on April 2022 for March 2022 revealed: Psychiatric Medication Use: The Resident is on Citalopram, Clonazepam, and Quetiapine. AIMS [Assessment of Involuntary Movement Screening] test done on 1/24/22, with a final score of 16, slightly decreased from August 2021. Parkinson's diseases likely contributing to the involuntary movements observed. Resident is at risk for tardive dyskinesia [condition cause by long term use of psychiatric drugs that can cause repetitive involuntary movements]. Side effects reported: None Behavior/mood trend: No mood depression indicators documented in February. Last change in dose: Quetiapine dose successfully decreased to 200 mg ER [extended release] PO [by mouth] nightly on 2/3/20. Assessment for possible dose decrease recommended for January 2021. Per MD, current 'current quetiapine dose is medical medically necessary. No need to decrease (see MMR findings from January 2021). GDR [gradual dose reduction] again proposed December 2021, pending provider response. Clonazepam and citalopram dose reduction considered to be clinically contraindicated on April 2021 (see March 2020 MMR recommendation). Although the Resident would have been due for a dose reduction assessment in April 2021, given reports from Outpatient Mental Health Clinician (4/2021 and 5/10/21) documenting residents increased anxiety and insomnia due to worsened Parkinson's symptoms, a dose reduction recommendation was postponed a couple months. GDR again proposed November 2021, pending response from provider. Recommendations: No new recommendations for month of March. Follow up on GDR for quetiapine, clonazepam, and citalopram. Review of the Director of Nursing Comments, dated 3/21/22, revealed the information that Recommendations were reviewed with the Interdisciplinary team and Risk/Benefit of accepted changes discussed with resident and/or representative was checked off and signed by the Director of Nursing on 5/02/22. The physician had entered Comments: Will document GDR [with] next visit, dated 4/28/22. April 2022 Review of a medication regime review conducted for Resident #4 by the Pharmacist on May 2022 for April 2022 revealed: Psychiatric Medication Use: The Resident is on Citalopram, Clonazepam, and Quetiapine. AIMS [Assessment of Involuntary Movement Screening] test done on 1/24/22, with a final score of 16, slightly decreased from August 2021. Parkinson's diseases likely contributing to the involuntary movements observed. Resident is at risk for tardive dyskinesia [condition cause by long term use of psychiatric drugs that can cause repetitive involuntary movements]. Side effects reported: None in April Behavior/mood trend: No mood/depression indicators documented in April. [He/she] has stated meeting with [Social Worker] twice monthly, she reports in March note depression and anxiety are under control. One episode of confusion noted, prompted a UA [urinalysis] and subsequent treatment for UTI [urinary tract infection]. Last change in dose: Quetiapine dose successfully decreased to 200 mg ER [extended release] PO [by mouth] nightly on 2/3/20. Assessment for possible dose decrease recommended for January 2021. Per MD, current quetiapine dose is medical medically necessary. No need to decrease (see MMR findings from January 2021). GDR [gradual dose reduction] again proposed December 2021, pending provider response. Clonazepam and citalopram dose reduction considered to be clinically contraindicated on April 2021 (see March 2020 MMR recommendation). Although the Resident would have been due for a dose reduction assessment in April 2021, given reports from Outpatient Mental Health Clinician (4/2021 and 5/10/21) documenting residents increased anxiety and insomnia due to worsened Parkinson's symptoms, a dose reduction recommendation was postponed a couple months. GDR again proposed November 2021, pending response from provider. Recommendations: No new recommendations for month of April. Physician Progress Note Review of a Progress Note, dated 3/10/22, revealed the GDR and/or contraindication for the dose reduction were not addressed. Review of a Progress Note dated 5/06/22, revealed Depression/Increased emotional lability. The patient is very tearful today as we talk about [his/her] birthday which occurred last month. He is distraught over [his/her] current physical condition. Nightmares: Occasional nightmares. Disturbing. Nursing doesn't report any difficulty with nightmares. Patient hasn't been reporting them Emotionally labile. Cries frequently throughout evaluation. Stereotypical Parkinson's tremor, etc. Depression: Worsening as his physical condition worsens -Increase citalopram to 40mg daily -Counseling [Social Worker] to do weekly visits -Spiritual care provided today, Consider having chaplain dome up and visit. Swallowing issues: -Decrease Pill Burden: Stop B12, ASA, Lipitor, and Donepezil, Change Tylenol for scheduled to PRN . Nightmares: The patient continues to have nightmares. He hasn't reported these to nursing staff. Encouraged [him/her] to do so. Further review revealed the antipsychotic, and the anti-anxiety medication usage was not addressed by the physician. Review of the physician's orders revealed the Donepezil (Aricept) had not been discontinued. Interviews During an interview on 6/06/22 at 3:11 PM, Resident #4 stated [his/her] spouse had passed away last year. The Resident stated [his/her] children used to visit more frequently but had not been coming as much lately. During an interview with the Social Worker in 6/08/22 at 3:15 PM, when asked if psychosis were a symptom and how Resident #4's symptoms would monitor the symptoms. The SW provided a reference by NAMI (National Alliance on Mental Illness). Review on 6/08/22 of the NAMI, transcript from a podcast, copyright 2021, titled Psychosis revealed Psychosis is a symptom, not an illness and is more common that you may think .Psychosis includes a range of symptoms .hallucinations are seeing, hearing or feeling things that aren't there .Delusions are strong beliefs that are not consistent with the persons culture and unlikely to be true and may seem irrational to others. During an interview on 6/09/22 at 9:00 AM, when asked about the repeated request for a GDR and the lack of action, The Pharmacist stated the physician did but didn't respond. The Physician did address he would review the medication during the next visit with the Resident, then it was not. The Pharmacist stated the documentation of the effectiveness and the need for the psychotropics were not consistent, as Resident #4 would not report having nightmares to the nursing staff, as it was happening. The Resident waited and only told the Physician or the Social Worker when he/she saw them. Care Plan Review of Resident #4's plan of care, revised 5/02/22 revealed I have the potential to feel/experience side effects from my medications because I take psychotropic medications Celexa, Clonazepam, and Seroquel. I need my nurses to ask me how I'm feeling, remind & encourage me to report nightmares, delusional thoughts hallucinations as soon as they occur .review monthly drug regimen review completed by pharmacist. Policy Review Review of the Elder House Pharmaceutical Services policy, revised 12/2018, revealed A medication regime review (MRR) conducted monthly by a licensed pharmacist. The pharmacist must report any irregularities to the attending physician and director of nursing and these reports must be acted on. This review will ensure that each residence drug regimen review is free from unnecessary drugs and that psychotropic drugs are used appropriately . 3. Whether the medication dose frequency, route of administration and duration are consistent with the resident's condition, manufacturer's recommendations, and applicable standards of practice . 6. Whether the prescriber, upon rejecting a pharmacist recommendation, provide some basis for disagreeing with the recommendation. According to the Food and Drug Administration, www.accessdata.fda.gov, accessed 6/17/22, Seroquel side effects include uncontrolled muscle movements in your face (chewing, lip smacking, frowning, tongue movement, blinking or eye movement); mask-like appearance of the face, trouble swallowing, problems with speech; a light-headed feeling, like you might pass out. Common side effects include speech problems; dizziness, drowsiness, tiredness; lack of energy; fast heartbeats; stuffy nose; increased appetite, weight gain upset stomach, vomiting, constipation, dry mouth, or problems moving. Citalopram side effects include dizziness, drowsiness. dry mouth, thirst, increased sweating or urination;/loss of appetite, nausea, diarrhea, constipation; feeling anxious, agitated, or shaky; feeling weak or tired. sleep problems (insomnia); yawning; increased muscle movement; nosebleeds, heavy menstrual bleeding; or cold symptoms such as stuffy nose, sneezing, and sore throat. Clonazepam side effects include Common clonazepam side effects may include drowsiness, dizziness; feeling tired or depressed; memory problems; or problems with walking or coordination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure: 1.) use of professional standards for manual washing and sanitizing using the 3-step process; 2.) dating refrigerated and frozen foods to monitor for growth of microorganisms; and 3.) safe food preparation with reheating foods. These failed practices placed all residents, based on a census of 22, at risk of foodborne illness. Findings: Manual Washing and Sanitizing During an observation on 6/06/22 at 11:36 AM Dietary Staff (DS) #1 was wearing regular latex gloves to wash dishes in the sink. There were 3 sinks, the first on the left was filled with soapy water, the one in the middle filled with rinse water, and the last sink contained water with a sanitizing solution. Sink 1 and sink 3 were also filled below the designated water line clearly marked on the outside of the sinks. There was a noticeable smell of mildew in the area. The DS #1 stated the automatic dish washer was broken so staff were washing dishes and pans by hand until it could be repaired. The DS #1 stated the sanitizing solution was added to the third sink by turning a knob. During an interview on 6/06/22 at 12:00 PM, when asked how the sanitizing solution was evaluated, the DS #1 demonstrated by pulling a piece of paper from a plastic roll labeled Q-10 Hydrion. The DS #1 ripped off a piece of the paper and dipped it in the third sink, he/she then displayed the paper with the plastic roll, explained, the paper must discolor and would show 100 parts (of the [NAME] sanitizing solution) per million. During the interview on 6/06/22 at 12:00 PM, DS #1, did not know if the dishwater needed to be a specific temperature. DS #1 tested the solution temperatures of the 3 sinks, using a food grade thermometer. The sink of soapy water revealed 79.9 degrees Fahrenheit (F), the sink of rinse water revealed 101 degrees F, and the sink with sanitizing solution revealed 101 degrees F. Review of the book where staff documented dishwasher temperatures and sanitation bucket levels revealed no monitoring of the wash water temperatures and the sanitation levels for the 3-sink manual method of washing dishes. During an interview on 6/06/22 at 12:36 PM the Dietary Manager (DM) stated the facility should have a policy for monitoring the sanitation of the 3-sink method During an observation on 6/09/22 at 11:22 AM DS #2 was observed washing dishes using the three-sink method wearing regular latex gloves. DS #2 washed the dishes in a small green plastic bucket filled with soapy water placed inside the sink. The water temperature revealed 98.8 degrees F. There was a noticeable smell of mildew in the area. During an interview on 6/09/22 at 11:22 AM when asked about the temperature of the dishwater, DS #2 stated it was supposed to be 165 degrees F. The DS #2 then confirmed she was talking about the automatic dishwasher. On 6/09/22 at 11:45 PM, review of the Three-Compartment Sink policy, last reviewed 12/2021, revealed Wash items in first sink in a detergent solution at 110F . Immerse items in the third sink in a chemical-sanitizing solution. -Use APEX Broad Range Sanitizer -Ensure that pHydrion papers QT-40 when immerse for 10 seconds read 200-400 parts per million before use. Dating of Refrigerated and Frozen Foods During an observation on 6/06/22 at 12:48 PM revealed 2 bags of corn in the walk-in freezer that were opened and tied shut with no open or expiration dates marked. These bags of corn were confirmed with staff and thrown away. Next in the walk-in refrigerator there was no open date on sweet pickle relish 1 gallon container, [NAME] Mayo Light Mayonnaise 1 gallon container, buttermilk ranch dressing [NAME] 1 gallon container, etc. During an interview on 6/06/22 at 1:01 PM the DM after conferring with the Dietician stated there was no policy for writing opened dates on goods and that the only dates listed were expiration dates. Reheating Foods An observation on 6/09/22 at 10:30 AM, DS #3 was preparing food for the residents' noon meal, a large metal tray of barbequed (BBQ) chicken sitting on the counter, a pan of sliced zucchini (Italian vegetables), and a pan of scalloped potatoes, partially covered with foil. Review of the temperature log revealed when the food was removed from the oven at 10:00 the: BBQ chicken was 178 degrees F, zucchini was 172 degrees F, the chicken gravy was 183 degrees F, and the potatoes were 184 degrees F. During continuous observation on 6/09/22 from 10:30 AM until 11:52 AM, DS #3 prepared each resident's individual plate. DS #3, as the plates were prepared, had to stop to chop or puree the food to the necessary texture for each resident. DS #3 would then put each plate in the microwave for times ranging from 30 seconds to 1 minute (the times were not consistent) and without checking the temperature of the food, covered each plate with foil that had the resident's name. DS #3 then placed the foil covered plate or dish into the warmer. There was no observation of a clean sanitation bucket in this area and dry clothes were used to clean the other side of the serving countertop space. During the meal service preparation, the BBQ chicken sat open on the kitchen counter for a total 1 hour and 22 minutes. According to the 2017 FDA Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roast cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5ºC (41ºF) or less. 3-403.11 Reheating for Hot Holding (A) Except as specified under (B) and (C) and in (E) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74oC (165oF) for 15 seconds. P (B) Except as specified under (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding shall be reheated so that all parts of and minimum time and temperature conditions specified under 3-401.11(B) the FOOD reaches a temperature of at least 74oC (165oF) and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. (C) READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that has been commercially processed and PACKAGED in a FOOD PROCESSING PLANT that is inspected by the REGULATORY AUTHORITY that has jurisdiction over the plant, shall be heated to a temperature of at least 57oC (135oF) when being reheated for hot holding. P (D) Reheating for hot holding as specified under (A) - (C) of this section shall be done rapidly and the time the FOOD is between 5ºC (41ºF) and the temperatures specified under (A) - (C) of this section may not exceed 2 hours. (E) Remaining unsliced portions of MEAT roasts that are cooked as specified under 3-401.11(B) may be reheated for hot holding using the oven parameters. Surveyor Guild, [NAME] N.

Based on interview and record review the facility failed to have a written plan for the Quality Assurance and Performance Improvement (QAPI) program. This failed practice disallowed the identification and correction of deficiencies as well as opportunities for improvement facility wide that could influence the well-being and safety of all residents, based on a census of 22. Findings: During an interview on 6/9/2022 at 5:40 PM with the Interim Director of Nursing and Long-Term Care (LTC) Director they confirmed there is currently no documented written plan for the QAPI program, and that the policy was umbrellaed with the Hospital. No QAPI policy was provided by the end of the survey.

Based on record review and interview the facility failed to have an antibiotic stewardship program, a program that monitors antibiotic use and effectiveness. This failed practice placed all residents, based on a census of 22, at risk of not receiving optimal antibiotic treatment and/or at risk for adverse reactions associated with antibiotic use. Findings: Resident #4 Record review on 6/06-09/22 revealed Resident #4 had diagnoses that included urinary incontinence, Parkinson's disease (disorder of the central nervous system the affects movement that often causes tremors), and Benign Prostatic Hyperplasia (prostate gland enlargement that can cause urinary difficulty). Nursing Note for 4/07/22 at 2:07 PM revealed Contact with [MD] regarding Resident's current confusion. New order for UA [urinalysis], VS [vital signs] taken no abnormalities. Physician's orders for 4/07/22 revealed the following medications for Resident #4: 10:25 AM T.O. [telephone order] [MD Name] UA DX: Confusion/mental status change. 1:35 PM T.O. [MD Name] Bactrim DS 1 tab BID [twice a day] PO [by mouth] X 7 days. 1:50 PM T.O. [MD Name/Pharmacist Name] D/C [discontinue] Bactrim, Cephalexin 500mg orally BID x 7 days Dx: UTI Review of the urinalysis test, conducted on 4/07/22 at 12:00 revealed the Resident's urine was positive for blood, nitrites (indicative of bacteria), leukocytes esterase (white blood cells) and was cloudy. There was no information a urine culture had be conducted to identify the pathogen. During an interview on 6/09/2022 at 2:49 PM when asked about) the Infection Preventionist (IP role in the antibiotic stewardship program, the IP stated this program is still getting ramped up and that historically the pharmacist had more charge and/or input in this program. During an interview with the Pharmacist on 6/09/22 at 9:00 AM when asked about the antibiotic use and the surveillance program, the Pharmacist stated the facility had been struggling with antibiotic stewardship. The Pharmacist stated a turnover in staff and resources had contributed to that. When asked about the switch of antibiotics for Resident #4, the Pharmacist stated he had requested the physician switch to a more broad-spectrum antibiotic. Resident #6 Record review on 6/09/22 revealed Resident #6 had diagnoses that included a major neurocognitive disorder and impaired mobility. Review of a nurses note, dated 6/08/22 at 9:48 AM revealed .complains of burning when [he/she] urinates. Message left for [MD Name] and or case manager. Call returned and KAKA staff states they will try to have [MD name] order the UA .vital signs: b/p 141/79 T 98.2 R 20 P 75 O2 96% on RA .lab request form faxed over .12:13 PM Urine Sample: collected clean catch, sample sent to lab. 6/08/22 at 6:05 PM: New Orders: 1. Start cephalexin 500mg PO BID x 7 days, DX: UTI acute. No laboratory results were available for review. Review of line list of infections, provided by the Infection Preventionist, revealed the Resident #6 was put on the antibiotic Ciprofloxacin, the information indicated if the criteria for McGeer's met or not met was not filled out. During an interview on 6/09/22 at 3:43 PM Licensed Nurse #1 stated the nurses followed McGeer' s criteria for infections and provided a copy of the protocol for UTI. Review of the provided protocol revealed the handout which was the McGeer's algorithm to follow if a resident has a catheter and symptoms of a UTI. According to the McGeer's criteria for urinary tract infections, as per Stone ND, et al. 2012, Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria accessed on 6/24/22 at https://pubmed.ncbi.nlm.nih.gov/22961014/ Table 2. Urinary Tract Infection (UTI) Surveillance Definitions UTI without indwelling catheter Must fulfill both 1 AND 2. 1. At least one of the following sign or symptoms Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate Fever or leukocytosis, and ? 1 of the following: Acute costovertebral angle pain or tenderness Suprapubic pain Gross hematuria New or marked increase in incontinence New or marked increase in urgency New or marked increase in frequency If no fever or leukocytosis, then ? 2 of the following: Suprapubic pain Gross hematuria New or marked increase in incontinence New or marked increase in urgency New or marked increase in frequency 2. At least one of the following microbiologic criteria [greater than/or eqaul sign] 105 cfu/mL of no more than 2 species of organisms in a voided urine sample [greater than/or eqaul sign] 102 cfu/mL of any organism(s) in a specimen collected by an in-and-out catheter The following 2 comments apply to both UTI with or without catheter: UTI can be diagnosed without localizing symptoms if a blood isolate is the same as the organism isolated from urine and there is no alternate site of infection. In the absence of a clear alternate source of infection, fever or rigors with a positive urine culture result in the non-catheterized resident or acute confusion in the catheterized resident will often be treated as UTI. However, evidence suggests that most of these episodes are likely not due to infection of a urinary source. Urine specimens for culture should be processed as soon as possible, preferably within 1-2 h [hour] If urine specimens cannot be processed within 30 min of collection, they should be refrigerated and used for culture within 24 h Review of the provided PKIMC LTC Line Listing of Resident Infections, for the months of January 2022, one undated, March 2022, April 2022, and May 2022, revealed the lists do not have documentation for Resident #4 or #6, who both had infections. Further review revealed the columns for infection criteria and cultures had no documentation and the April 2022 list was completely blank, lacking Resident #4 information. Review of facility policy Antimicrobial Stewardship LTC [Long Term Care] program plan, updated 3/31/22, revealed Whether by antimicrobial stewardship team or by ordering physician, all antimicrobial orders CBEH should be assessed for appropriateness after 48-72 hours of administration.