QUYANNA CARE CENTER
Non profit - Corporation
18 Beds
Independent
Data: November 2025
Trust Grade
60/100
#14 of 20 in AK
Photo by Robin Dern
Photo by Robin Dern
Photo by Robin Dern
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Quyanna Care Center has a Trust Grade of C+, indicating it is slightly above average but still has room for improvement. It ranks #14 out of 20 nursing homes in Alaska, placing it in the bottom half of facilities in the state, but it is the only option in Nome County. The facility is showing an improving trend, with the number of issues decreasing from 13 in 2023 to 7 in 2024. Staffing is a strength, boasting a 4 out of 5 rating and a turnover rate of 0%, which is well below the state average. However, there are some concerns, such as a failure to post complete staffing information for each shift and the improper storage and labeling of medications and food, which could pose risks to residents. Overall, while there are positive aspects regarding staff stability and ongoing improvements, families should be aware of the existing issues that need attention.
- Trust Score
- C+
- In Alaska
- #14/20
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Alaska facilities.
- Skilled Nurses ✓ Good
- Each resident gets 157 minutes of Registered Nurse (RN) attention daily — more than 97% of Alaska nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Bottom 30%
No red flags
13 → 7 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 13 issues
2024: 7 issues
The Good
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4-Star Staffing Rating · Above-average nurse staffing levels
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5-Star Quality Measures · Strong clinical quality outcomes
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Full Sprinkler Coverage · Fire safety systems throughout facility
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No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Alaska average (3.5)
Meets federal standards, typical of most facilities
The Ugly 26 deficiencies on record
Oct 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, interview, and observation, the facility failed to ensure one Certified Nursing Assistant (CNA) (#7), ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, interview, and observation, the facility failed to ensure one Certified Nursing Assistant (CNA) (#7), out of 10 personnel records reviewed, had a valid Cardiopulmonary Resuscitation (CPR) certification. This failed practice placed all residents (based on a census of 18) at risk for not receiving timely CPR or emergency care when needed.
Findings:
Review of the personnel records on [DATE] at 10:18 AM, revealed CNA #7 was hired on [DATE] with a valid CPR certificate [issue date] on [DATE], and due to expire [Renew By] on 7/2024. Review of CNA #7's work schedule revealed the CNA worked at the facility from 7/2024 through [DATE] with an expired CPR license.
During an interview with the Human Resources Director (HRD) on [DATE] at 10:18 AM, the HRD stated: Human Resources [HR] reached out to the Air Ambulance [entity responsible for this particular training] and his/her [CNA #7] supervisor and the employee themselves but hadn't heard back.
During an interview with the Director of Nursing (DON) on [DATE] at 2:40 PM, regarding who was responsible for ensuring staff was current with licenses and certifications the DON stated: ADP [Always Design for People], is the system that keeps track of CPRs and other certifications, and email alerts will go out to the DON and/or to the managers. The DON added: for example, for all the CNAs it's LN#6, who's also the Clinical Nurse Supervisor, the one being alerted by email given us the warning CNAs are about to expire on their certifications.
During the same interview the Assistant Director of Nursing (ADON) stated regarding CNA #7: yeah, we've known, we've been after his/her recertification since July of this year. There is [was] an email chain covering the notifications for BLS training, which is [was] given for free here at [NAME] Sound [Hospital], they can even be paid to do it at work. During the same interview and when answering the question, what was the expectation for continued non-compliance, the DON stated regarding the CPR expired card for CNA #7, we are taking it to HR and addressing it for insubordination and for disciplinary action. The DON also mentioned CNA #7 had previous ongoing disciplinary action unrelated to the competency and stated that they will get back to HR to know how to proceed from here, giving us a statement of the expectation.
During random observations on [DATE]-[DATE], CNA #7 was observed working in the facility. On [DATE] at 3:00 PM, the DON informed the surveyors that in conjunction with HR and the Hospital Administrators, they had decided to escort CNA #7 off the property and have him/her be put on administrative leave without pay until the certification issue was resolved.
Review of facility-provided emails, revealed opportunities for CNA #7 to take a CPR course to remain in compliance:
- Email #1: Subject: reminder for education classes, dated [DATE] at 11:43 AM revealed: All staff . to remind everyone about the [then] upcoming education classes scheduled for June and July [2024] . including 1 . BLS on [DATE]th . BLS [DATE]th .
- Email #2: Subject: Education Opportunities, dated [DATE] at 3:48 PM and addressed to LN#6 and CNA #7, from the trainers of Air Ambulance, revealed: there is a BLS class on the 12th if you haven't already taken the class or done it online.
- Email #3: Subject: Reminder for education classes for education and upcoming NRP [Neonatal Resuscitation Program] and STABLES [Sugar, Temperature, Airway, Blood Pressure, Lab Work, Emotional Support, and Seizures] training, dated [DATE] at 10:14 AM between Air Ambulance trainers and DON, stated: CNA #7 was scheduled to take BLS class back in July . he/she didn't attend. He/she was on vacation from 7/15-7/25.
Review of the facility's Facility Assessment Tool, undated, on page 10, revealed: . We utilize multiple trainings, in-service, certifications, including in person and online. We assure that our ongoing training meets the requirements for training on . emergency services/responsibilities. We train staff in the personal centered care model and practice it daily through our twice daily care coordination meetings and our 24-hour reporting module .
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and interview, the facility failed to ensure accurate medical records were maintained for 1 resident (#...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and interview, the facility failed to ensure accurate medical records were maintained for 1 resident (#14), out of 12 sampled residents. Specifically, the facility failed to ensure the medical diagnoses for Resident #14 reflected his/her actual medical status. This failed practice had the potential to affect the achievement of the Resident's plan of care and goals.
Findings:
Record review from 9/30/24 -10/4/24, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses that included dementia (a decline in intellectual functioning) and pressure ulcer.
Record review on 10/1/24 at 12:59 PM, revealed Resident #14's active diagnosis list included pressure ulcer.
Review of the Minimum Data Set (MDS- a federally required nursing assessment) Quarterly Assessment, dated 8/8/24, revealed in Section M-Skin Conditions, the response was no for unhealed Pressure ulcers/injuries.
Review of the CMS (Centers for Medicare and Medicaid Services) form 2802 Matrix (used to identify resident's pertinent care categories) on 10/1/24 at 12:59 PM, revealed Resident #14 had no pressure ulcer.
Review of the Provider Progress Note, dated 8/26/24 at 10:46 AM, revealed: Previous pressure ulcer of left glute [buttocks]. Per nursing staff, area seems to be closed and healed. No complaints from resident.
During an interview on 10/1/24 at 2:07 PM, the Director of Nursing (DON) stated Resident #14 had a pressure ulcer in July 2024 that resolved within a week, about 4-5 days. The DON stated the Resident's medical diagnosis of pressure ulcer should have been resolved.
During a joint interview on 10/3/24 at 9:14 AM, Licensed Nurse (LN) #2 and LN #5 confirmed that Resident #14 had no pressure ulcer.
During an interview on 10/3/24 at 6:57 PM, the DON stated there was no medical record documentation policy for providers.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0915
(Tag F0915)
Could have caused harm · This affected 1 resident
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Based on observation and interview, the facility failed to provide 2 residents (#s 3 and 10), out of 12 sampled residents a window to the outside within their sleeping room. This failed practice pla...
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Based on observation and interview, the facility failed to provide 2 residents (#s 3 and 10), out of 12 sampled residents a window to the outside within their sleeping room. This failed practice placed the residents at risk for less than optimal living conditions and increased risk for mood changes.
Findings:
During random observations on 9/30/24-10/4/24, revealed Resident #3 and Resident #10's only window in his/her room were obstructed by the new addition being built onto the facility. Further observation revealed the view outside the window contained a visual of metal studs of opposing new construction wall.
During random interviews on 9/30/24-10/3/24, the Director of Nursing (DON) stated that the resident's window had been obstructed by the new addition being built onto the facility. The DON stated the obstructed windows occurred after the construction company built a wall that was not in the original building plans.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and interview, the facility failed to ensure a competent nursing staff provided nursing services to 1 r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and interview, the facility failed to ensure a competent nursing staff provided nursing services to 1 resident (#119) out of 12 sampled residents in accordance with the physician's order. Specifically, the nurse failed to notify the provider of Resident's high blood glucose levels. This failed practice placed the diabetic resident at risk for delay in treatment and complications.
Findings:
Record review on 9/30/24-10/4/24 revealed Resident #119 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (insulin resistance disorder), Cerebrovascular Accident with involvement of right side of the body (damage to the blood vessels in the brain) and Dysphagia (difficulty swallowing).
Review of Resident #119's physician orders, dated 9/30/24, revealed an order for insulin aspart (a fast acting insulin that works by lowering glucose, or sugar levels) with additional instructions to . Notify provider if 2 or more Blood Glucoses are above 200 mg/dl in a 24-hour period . Further review revealed an order, dated 9/30/24, for . POCT [Point of Care Testing] Glucose ACHS [before meals and at bedtime] .
Record review on 10/2/24 at 4:30 PM of Resident #119's, Plan of Care Summary, revealed: [Resident #119] will have no complications for Diabetes Mellitus [Resident #119's] blood glucose will be within normal limits .
Review of Resident #119's medical record, dated 9/30/24-10/4/24, revealed the following POCT blood glucose results:
9/30/24 at 3:33 PM was 301 mg/dl
9/30/24 at 6:18 PM was 337 mg/dl
9/30/24 at 8:12 PM was 280 mg/dl
10/1/24 at 11:11 AM was 265 mg/dl
10/1/24 at 8:17 PM was 311 mg/dl
10/2/24 at 12:01 PM was 303 mg/dl
Record review on 10/2/24 at 10:13 AM, revealed no nursing documentation informing Resident #119's provider of his/her blood glucose levels.
Review on 10/3/24 at 10:30 AM of the facility's, 24-hour Monitor Report, dated 9/30/24, revealed no identification of Resident #119's blood glucose levels.
Review on 10/3/24 at 10:30 AM of the facility's, 24-hour Monitor Report, dated 10/1/24, revealed no identification of Resident #119's blood glucose levels.
During an interview on 10/3/24 at 10:01 AM, Licensed Nurse (LN)#5 stated he/she used the Plan of Care Summary in the electronic health record (EHR) all the time for each resident, this is how the nurse knows the residents. LN # 5 stated Resident #119 was ordered insulin and blood glucose checks before meals and at bedtime. LN #5 reviewed Resident #119's blood glucose results since 9/30/24 and stated, he/she had more than two blood glucose readings of 200 mg/dl or greater in a 24-hour period. LN #5 also stated communication between the nurse and the provider should have been documented in the resident's EHR or on the 24-hour report sheet that was discussed during the facility's stand up or stand down meetings. LN #5 further reviewed Resident #119's EHR nursing notes and laboratory results (Point of Care [POC] blood glucose) and stated no documented communication of the blood glucose levels above 200 mg/dl or greater were noted. LN #5 reviewed the tiger text [a cell phone secure messaging system] documentation and stated there were no messages found informing the provider of the blood glucose levels above 200 mg/dl or greater. LN #5 stated Resident #119's provider should have been notified when his/her blood glucose results were 200 mg/dl or greater, as ordered by the provider.
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
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Based on observation, interview and record review, the facility failed to ensure complete nurse staffing information for each shift was posted to provide accurate information to all residents (based...
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Based on observation, interview and record review, the facility failed to ensure complete nurse staffing information for each shift was posted to provide accurate information to all residents (based on a census of 18) and representatives. Specifically, the facility failed to post the total number and actual hours worked by Certified Nursing Assistants (CNAs), Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) per shift. This failed practice provided incomplete information to the residents, families, and other visitors the right to know who were responsible for resident care and the number of residents in their care.
Findings:
An observation on 10/3/24 at 11:30 AM, of the facility document titled Quyanna Care Center - Nursing Staff, dated 10/3/24, posted on the bulletin board along the entryway of the Long-Term Care (LTC) side, revealed information including, the facility's census (resident census) and the nursing staff (CNA, LPN, RN and other staff) scheduled for the day. Further review of the posting revealed the total number and actual work hours of nursing staff per shift was not documented.
During a simultaneous interview on 10/3/24 at 11:42 AM, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), when asked how you interpret or explain the daily nursing staff schedule posted to someone trying to understand the staff member caring for the resident, the DON and ADON stated that the current schedule sheets did not provide an auxiliary legend to explain the meaning of the numbers. The DON and ADON further stated the number 4 pertained to the quantity of staff and 7 AM-7 PM refers to the dayshift and 7 PM - 7 AM refers to nightshift. When asked the DON and ADON about the total number of hours worked not being represented, the ADON stated they weren't aware of this requirement.
Review of the other Nursing Staff sheets provided by the DON and ADON from 9/29-10/3/24, the actual and total hours per shift were not documented.
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
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Based on interview, observation, and record review, the facility failed to properly label and store drugs and medical supplies. Specifically, the facility failed to ensure: 1) expired medication was...
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Based on interview, observation, and record review, the facility failed to properly label and store drugs and medical supplies. Specifically, the facility failed to ensure: 1) expired medication was removed from 1 medication storage room, out of 1 total medication storage rooms; 2) opened and damaged sterile medical supplies were removed from 1 medication storage room, out of 1 total medication storage rooms; and 3) opened medications were labeled with an expiration date. These failed practices had the potential to place all residents (based on a census of 18) at risk of receiving expired and/or damaged medications and supplies and subsequent adverse effects.
Findings:
During an interview on 9/30/24 at 2:04 PM, License Nurse (LN) #1 stated nurses were responsible to check the medication expiration before medication administration to the resident. He/she stated expired medications would be disposed of in a disposal bin in the pharmacy.
Random observations on 9/30/24-10/4/24 revealed the facility had one medication storage room and one medication cart.
During a concurrent interview and observation on 9/30/24 at 2:04 PM, of the medication storage room revealed the following deficiencies:
Expired Medication:
One bottle of Ondansetron (nausea relief medication) 4 mg tablet expired on 9/25/24. This bottle of medication was stored in the upper cabinet in the medication storage room . LN #1 stated that medication was a prn (as needed) medication that was not being used anymore. She also stated this should have been removed and discarded.
Opened and damaged sterile dressing:
Two opened packs of Dressing, Telfa brand, 2x3 inches of sterile non-adherent pad and
Seven opened packs of Dressing, Telfa brand, 2x3 inches of sterile non-adherent pad with damaged packaging tied together with a rubber band.
LN #1 stated that those dressings should have been discarded and removed the dressing from the cabinet.
Labeling of opened medication:
One- 84 oz package of Kirkland organic virgin coconut oil. There was no opened date and no expiration date; and
One- 128 oz package of Isopropyl alcohol. There was no opened date and no expiration date.
An observation of the facility's medication cart on 9/30/24 at 2:32 PM, revealed the following deficiencies:
One- 4 fl oz package of Biofreeze (pain relief gel) for pain with an open date of 7/30 [24]. There was no use by date;
One jar of Bag Balm (moisturizing ointment) for pain with original date and filled date of 5/3/24. There was no expiration date; and
One tube of Calmoseptine (skin protectant ointment) for skin breakdown with start date of 5/10/24. There was no expiration date.
Review of the facility's policy Labeling Standards, revised on 8/2024, revealed: . All drug containers shall be labelled, and drug labels must be clear, consistent, legible and in compliance with state and federal requirements.
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review the facility failed to ensure potentially hazardous foods were stored and l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review the facility failed to ensure potentially hazardous foods were stored and labeled accordingly for 17 residents out of 18 residents (total census) who received food from the main kitchen. Specifically, the facility failed to ensure: 1) food was labeled and dated and 2) discard expired food. These failed practices had the potential to place residents at risk of or food borne illness.
Findings:
During an initial tour of the main kitchen, on 9/30/24 at 10:50 AM, food items were stored and labeled as follows:
One package of Knorr Hollandaise Sauce Mix, there was no opened date and no expiration date ;
One green lid container, containing a brown powder resembling brown sugar; there was no opened date and with no label as to the content;
One blue lid container, containing a white powder resembling white sugar; there was no label as to the content;
One package of Umami Wing Sauce, there was no opened date;
One package of vanilla extract, there was no opened date;
One package of [NAME] Corn Starch, there was no opened date;
One package of baking soda, there was no opened date;
One bottle of red wine vinegar, there was no opened date;
One package of Rustic Baby Reds mashed potatoes, there was no opened date;
One package of Croutons Con Queso, there was no opened date;
One package of medium piece pecans, there was no opened date;
One plastic bag with an opened date 9/30/24 at 8:50 AM, containing a brown substance resembling cereal, there was no label as to the content;
Twenty tall containers of miscellaneous spice and seasoning, there was no opened date;
One refrigerated plastic bag containing carrots, there was no opened date and no label as to the content;
One refrigerated container of Sweet Chili Cochujang Wing Sauce, there was no opened date;
One package of sliced American Cheese, there was no opened date;
During an initial tour of the auxiliary Long-Term Care (LTC) kitchen, on 9/30/24 at 11:33 AM, food items were stored and labeled as follows:
One family size package of Oakdell Farm eggs with an expiration date, and use by date on 9/1/24;
Three plastic bags containing what resembled to be sliced bread, there was no label as to the content, no opened date and no expiration date.
During an interview on 9/30/24 at 11:50 AM, the Manager of Nutrition Services (MNS) stated he/she was unsure about certain items described above, adding: it looks like sugar, but it does not have a label.
During a simultaneous interview on 10/1/24 at 2:30 PM, the Director of Nutrition Services (DNS) and MNS acknowledged the concern regarding all the food and food products with the lack of labeling or the missing of labeling items, she stated: there is a labeling system and they [referring to the kitchen staff] are supposed to be putting a label on with a date and time . we have a machine that prints labels and we realize the staff hasn't been doing it as much anymore . things get busy and things slide off . they are supposed to also write the name by hand on the label for any container with no label. The MNS stated staff were trained every two weeks and the kitchen supervisors met once a week to address issues: we give everybody the copies of the policy, so they can understand why certain things need to happen, but we will educate again [regarding training on labeling and food storage]. Sometimes we get short staffed and then corners get cut.
Review of the facility policy and procedure titled: Nutrition Services, last revised on 3/21/24, revealed: 9. Food preparation . iv. Ingredients used frequently must be stored in a clean, tightly sealed, labeled containers .c. Procedure . All items not in their original package are covered, dated, and labeled as to contents .12. Storage .8. Special considerations are as follows: a. Rotate all food items in storage and use within a safe period of time, using the oldest first. B. No more than six months of inventory supplies should be kept on hand. Cleaning supplies, paper goods, and food items are each stored separately. C. The maximum storage period for frozen food is one year.
Review of the facility document, Huddle Notes, dated 10/1/24, revealed: We need to get back to labeling all spices, opened dry items again. If you have a container of product not in its original packages, write down the name of the product on the label. Sugar for example. Any gravies or sauces in the cooler.
Review of the Food and Drug Administration (FDA) guidelines (Food labeling 2020), accessed at this link: https://www.FDA.gov, revealed concerning food storage and labeling, while the FDA does not mandate expiration dates, it encourages to use best by, use by, or sell by dates to indicate peak quality and safety as well as practices of inventory management such as First In, First Out (FIFO), inventory management practice that helps ensuring that older stock is used before newer stock, reducing waste and spoilage.
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Jun 2023
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, and interview the facility failed to ensure baseline care plans were initiated within 48 hours of admi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, and interview the facility failed to ensure baseline care plans were initiated within 48 hours of admission for 2 residents (#'s 16 and 17), out of a census of 17. This failed practice placed the residents at risk for not receiving necessary care and services. Findings:
Resident #16
Record review on 6/5-9/23 revealed Resident #16 was admitted to the facility on [DATE] with diagnoses that included a history of falls, neurogenic bladder (a urinary dysfunction in which the bladder does not empty properly), osteopenia (a condition of below normal mineralized bone), dementia (a decline in cognitive abilities), psychiatric disorder, and a history of above the left knee amputation.
Review of Resident #16's comprehensive care plan, revealed it was initiated on 2/8/23, 22 days after admission.
During an interview on 6/7/23 at 3:33 PM, the Director of Nursing (DON) confirmed Resident #16's care plan was initiated on 2/8/23. She stated the care plan should have been created within 48 hours of admission to the facility.
Resident #17
Record review on 6/5-9/23, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses that included dementia (a decline in cognitive abilities) and coronary artery disease (reduction of blood flow to the heart muscle).
Review of Resident #17's comprehensive care plan, revealed it was initiated on 4/4/23, 26 days after admission.
During an interview on 6/7/23 3:42 PM, the Minimum Data Set (MDS) Coordinator stated the care plan was created on 4/4/23. She confirmed the baseline care plan should have been established within 48 hours of admission to the facility.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
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Based on record review, observation and interview, the facility failed to ensure nursing staff were provided the appropriate competencies and skill sets to provide nursing care and related services ...
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Based on record review, observation and interview, the facility failed to ensure nursing staff were provided the appropriate competencies and skill sets to provide nursing care and related services to 3 residents (#'s 3, 11, and 16) out of census of 17 residents. Specifically, the facility failed to ensure: 1) staff had training and competency regarding medication administration assessments; and 2) staff were able to interpret medication order abbreviations. These failed practices placed all residents at risk of receiving inaccurate medication dosages. Findings:
Medication assessments
Review of Resident #11's current [Physician] Orders, revealed: metoprolol (metoprolol succinate 100 mg oral tablet, extended release) 100 mg, Oral, Tab-ER, qAM [every morning] Start date 8/6/21 . No indication/diagnosis included in the order.
Review of Resident #11's Vital Signs dated from 5/18/23 to 6/7/23, revealed:
In a period of 21 days the Apical Heart Rate was assessed once on 6/6/23.
Peripheral Pulse Rates were assesed on 6/6/23, 5/24/23, 5/23/23, 5/21/23.
During an interview on 6/7/23 at 9:32 AM, Licensed Nurse (LN) #2 stated the Resident's pulse was not assessed but the blood pressure was assessed prior to the administration of metoprolol.
During an interview on 6/7/23 at 2:15 PM, the Director of Nursing (DON) stated Resident #11's apical pulse should have been taken prior to the administration of the medication metoprolol.
During an interview on 6/8/23 at 3:20 PM, the Pharmacist stated that assessments of pulse and blood pressure should have been conducted prior to any heart medication administration.
Review on 6/12/23 at 10:00 AM of facility's Medication Administration drug guidance, revealed: metoprolol . CONTRAINDICATIONS . Bradycardia (heart rate [pulse] less than 45 to 50 beats per minute [bpm]) . systolic blood pressure less than 90 mmHg .
Review of the facility's policy Medication Administration, revised on 6/4/19, revealed: .Apical pulse for all medications that need a pulse .
Abbreviations for medication orders
Record review from 6/5-9/23 of Resident #3's medication administration record (MAR), revealed the following abbreviations: lisinopril .BIDAP .; amlodipine .BIDAP .: calcium carbonate .TIDANP .: Soduim Chloride .TIDWM .
Record review from 6/5-9/23 of Resident #16's MAR, revealed the following abbreviations: docusate .BIDAP .
During an interview on 6/7/23 at 1:54 PM, when asked what the abbreviations (BIDAP, TIDWM, TIDANP) on the MAR meant, Licensed Nurses (LNs) #2 and #7 stated they understood the first three letters but did not know what the rest of the abbreviations meant. Both LN's further stated that the abbreviations were not common medication abbreviations. When asked if the facility had a list defining the abbreviations, they did not know and had not received training on the abbreviations.
During a subsequent observation and interview on 6/7/23 at 1:57 PM, the Staff Development Coordinator (SDC) found a definition list for the abbreviations in the nurses' horizontal paper holder on the nurse's desk. The SDC stated these abbreviations were specific to their Pillbox Program established by the pharmacy for the electronic medical record. The SDC stated the staff were trained on medication order abbreviations during unit orientation.
Review of the facility's document Standard Med[ication] Times revealed:
BIDAN (BID [two times a day] am and noon) 9am, 1200
BIDAB (BID am and hs) 9am, 2100
BIDPA (BID am and pm) 9am, 1700
BIDNP (BID noon and pm) 1200, 1700
BIDNB (BID noon and bedtime) 1200, 2100 BIDPB (BID pm and bedtime) 1700, 2100
TIDANP (TID [three times a day] am, noon, pm) 9am, 1200, 1700 TIDAPB (TID am, pm, bedtime) 9a, 1700, 2100 TIDNPB (TID noon, pm, bedtime) 1200, 1700, 2100 QID [four times a day] 9am, 1200, 1700, 2100;
A= AM (0900/9am), N=noon (1200/12pm), P=PM (1700/5pm), B=hs (2100/9pm)
Review of the facility's Nurse Initial Competency [checklist], revised on 9/2/21, revealed MAR abbreviations or Pillbox Program training was not listed.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
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Based on record review, observation and interview, the facility failed to ensure medication order dosing was clear and accurate for 1 resident (#11) out of 8 sampled residents. Specifically, the fac...
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Based on record review, observation and interview, the facility failed to ensure medication order dosing was clear and accurate for 1 resident (#11) out of 8 sampled residents. Specifically, the facility failed to accurately document the dosage of an antipsychotic medication in the physician's order. This failed practice had the potential to place the resident at risk for adverse medication outcomes related to receiving more or less than the intended/ordered dose. Findings:
Record review on 6/5-9/23 revealed Resident #11 was admitted to the facility with a diagnosis that included dementia (decline in cognitive abilities) with behavioral symptoms.
Review of Resident #11's current [Physician] Orders, revealed:
Aripiprazole (Abilify) 10 mg, Oral, Tab, qAM [every morning], Start date 6/6/23, Special Instruction: Use 5 mg half tab from pill bottle.
Aripiprazole (Aripiprazole 5 mg oral tablet) 5 mg, Oral, Tab, HS [at night], Start date 5/19/23.
During an interview with concurrent observation on 6/7/23 at 9:32 AM, when asked what the morning dose of Abilify was, Licensed Nurse (LN) #2 stated 15 mg. LN #2 showed this surveyor that a 10 mg tablet was in Resident #11's blister pack (a prepackaged medication envelope prepared by the pharmacy with scheduled medications) and a 5 mg Abilify tablet was in a separate bottle labeled for Resident #11. When asked if the dose in the order was clear, LN #2 did not comment.
During an interview with concurrent record review of the Abilify order on 6/7/23 at 2:15 PM, the Director of Nursing and the Staff Development Coordinator agreed the order was confusing.
Review of Resident #11's Medication Administration Record (MAR), dated 6/5-7/23, revealed: 6/6/23 10 mg Aripiprazole (Abilify) was given at 7:27 AM, and 10 mg of Aripiprazole (Abilify) was given at 7:35 AM [a total dose of 20 mg] . 6/7/23 15 mg Aripiprazole (Abilify) was given at 8:14 AM.
During an interview on 6/14/23 at 1:15 PM, Psychiatrist #1 stated Resident #11 should have gotten a total daily dose of 15 mg Abilify in the morning. The Psychiatrist further stated that the nurses put in the medication orders and agreed there was a concern with the documented orders.
Review of facility policy Medication Dispensing, revised 1/2017, revealed: . The Pharmacy Department shall provide all acute, as needed, and over-the-counter medication, as requested by QCC [Quyanna Care Center] Nursing Staff .
Review of facility policy Monthly Drug Regimen Review, revised 7/2019, revealed: .Ongoing medication monitoring shall involve a collaborative approach between the medical provider, pharmacist, .and all the caregivers .
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
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Based on record review, observation, and interview, the facility failed to ensure a culture where residents were treated with dignity and respect for 2 residents (#'s 1 and 12) out of 17 residents. ...
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Based on record review, observation, and interview, the facility failed to ensure a culture where residents were treated with dignity and respect for 2 residents (#'s 1 and 12) out of 17 residents. This failed practice placed the residents at risk for psychological harm from feelings of poor self-esteem and/or self-worth and a potential for a poor quality of life. Findings:
Assistance with meals
Resident #1
Record review on 6/5-9/23 of Resident #1's medical record revealed admission to the facility with diagnoses that included dysphagia (difficulty in swallowing food or liquid).
A continuous dining observation on 6/6/23 from 8:05 AM to 8:24 AM, revealed Resident #1 was on a pureed diet. Certified Nurse Assistant (CNA) #1 was feeding the Resident cream of wheat, egg omelet, cinnamon toast, chilled mandarin, jelly, lemonade, almond milk, and prune juice. The following observation was made:
From 8:07 AM to 8:24 AM, CNA #1 fed the Resident a spoonsful of pureed food eight times. Each time the CNA fed the resident, the CNA collected excess food from around the Resident's mouth and fed the collected food to the Resident.
Review of a facility policy titled Feeding Residents, approved date 6/4/19, revealed: .the following equipment is needed to feed a resident .silverware (no plastic spoon) . help the resident to wipe mouth .
Resident # 12
Record review from 6/5-9/23 revealed Resident #12 was admitted to the facility with diagnoses that included dementia (a decline in cognitive abilities).
An observation on 6/7/23 at 6:14 PM, revealed Licensed Nurse (LN) #1 stood behind the resident while helping Resident #12 hold a spoon to his/her mouth. Further into the meal, LN #1 continued to stand behind the Resident while reaching to the table to place a cup in his/her hand. LN #1 continued to stand behind the resident while assisting Resident #12 with the rest of the meal.
During an interview on 6/8/23 at 3:05 PM, the Director of Nursing (DON) stated staff should have been seated while assisting residents with their meals.
Review of the facility's policy Feeding Resident, approved date 6/14/19, revealed: .All staff must be seated while assisting resident to eat unless contraindicated .
Medication patch
An observation on 6/6/23 at 8:14 AM, revealed Resident #12 was seated at a dining table in the common dining room, along with 3 other residents, for breakfast. LN #3, who was administering medications, approached Resident #12 at the dining table, pulled down his/her shirt exposing the Resident's back. The LN removed a patch located at the base of the Resident's shoulder blade. As the shirt was pulled down, the front neckline of Resident #12's shirt pressed into the resident's front neck region. LN #3 released the shirt and picked up a new medication patch. LN #3 then, reached down Resident #12's shirt for a second time and placed the new medication patch on the resident.
During an interview on 6/8/23 at 3:05 PM, the DON stated medication patch removal was discouraged during mealtimes.
Review of the facility's policy, Resident [NAME] of Rights and Responsibilities, no date, revealed: .as a resident at Q.C.C (Quyanna Care Center) you have the RIGHT to: quality care .considerate and respectful care at all times with recognition of your personal dignity and needs .
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected multiple residents
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Based on record review and interview, the facility failed to obtain informed consent for psychotropic medications (medications in the class of either antipsychotics, antianxiety, or antidepressants ...
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Based on record review and interview, the facility failed to obtain informed consent for psychotropic medications (medications in the class of either antipsychotics, antianxiety, or antidepressants that would have affected behavior, mood, thoughts, or perception) prior to use for 3 residents (#'s 7, 12 and 16) out of 5 residents reviewed for unnecessary medications. This failed practice denied the resident the right to consent to medications and be informed of the risk and benefits for medication use. Findings:
Resident #7
Record review from 6/5-9/23 revealed Resident #7 was admitted to the facility with a diagnosis of PTSD (Post-Traumatic Stress Disorder).
Review of Resident #7's current [Physician] Orders, revealed: Duloxetine 20 mg, Oral, Cap-DR [delayed release], BIDAB [Twice a day Morning/Bedtime], Start date: 01/10/23 . No indication/diagnosis included in the order.
During an interview on 6/8/23 at 6:21 PM, the Director of Nursing (DON) stated a psychotropic medication consent was unable to be found for the medication duloxetine.
Resident # 12
Record review on 6/5-9/23 revealed Resident #12 was admitted to the facility with a diagnosis of dementia (a decline in cognitive abilities) with psychosis (severe mental condition affecting thought and emotions).
Review of Resident #12's current [Physician] Orders, dated 4/16/23, revealed risperiDONE (RisperDAL) 0.5 mg, 1 tab(s) 1 tab oral QHS [at bedtime]. Diagnosis: dementia, dementia with psychosis.
Resident #16
Record review from 6/5-9/23 revealed Resident #16 was admitted to the facility with diagnoses that included dementia, and a personal history of other mental and behavioral disorders.
Review of Resident #16's current [Physician] Orders, revealed: Risperidone, 1 mg, Oral, Tab, HS, Start date: 5/14/23; Risperidone, 0.5 mg, Oral, Tab, qAM [every morning], Start date: 05/14/23; mirtazapine, 30 mg, Oral, Tab, HS, Start date: 01/17/23.
During an interview on 6/8/23 at 6:21 PM, the DON stated a psychotropic medication consent was not obtained for residents #12 and #16 since these residents were admitted to the facility already taking these medications. The DON also stated that residents taking psychotropic medications should be informed of the side effects and consent to taking these drugs.
Review of the facility's policy Resident [NAME] of Rights and Responsibilities, no date, revealed: .As a resident at Q.C.C. [Quyanna Care Center] you have the right to .be informed by a physician .in making plans about your health care, give informed consent to treatment .
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
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Based on record review and interview, the facility failed to ensure care plans were individualized to meet the psychosocial needs for 2 residents (#'s 7 and 16), out of 8 sampled residents. Specific...
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Based on record review and interview, the facility failed to ensure care plans were individualized to meet the psychosocial needs for 2 residents (#'s 7 and 16), out of 8 sampled residents. Specifically, trauma informed care interventions were not included in the care plans. This failed practice placed the residents at risk for not receiving necessary services to address their individual needs to attain or maintain their highest practicable well-being. Findings:
Record review from 6/5-9/23 of the facility's Matrix for Providers revealed the resident population contained the following condition: PTSD (post-traumatic stress disorder)/Trauma: 3 residents.
Resident #7
Record review from 6/5-9/23 revealed Resident #7 was admitted to the facility with diagnoses that included PTSD.
Record review of Resident #7's, Behavioral Health Psych [psychiatric] Provider Note, dated 1/16/20, revealed: .Psychiatric Review of Systems: .Active Problems . Chronic post-traumatic stress disorder (PTSD) after military combat .
During an interview on 6/8/23 at 10:03 AM, the Director of Nursing (DON) stated as per Resident #7's first behavioral health note there has been no knowledge of any triggers for the resident based on past history. The facility staff have only documented residents behaviors observed in the facility.
Review of CNA [certified nurse assistant] Initial Competency, updated 9/8/21, revealed: .CareTracker/Kiosk/Charting .Behaviors -Refused Care -Inappropriate .
Review of Resident #7's, Behavioral Health Psych Provider Note, dated 3/14/23, indicated that behaviors and depression showed signs of improvement. This note addressed complaints of random noises that were no longer a concern.
Review of Resident #7's current Care Plan, revealed under behavioral symptoms interventions of appropriate behavior when interacting with others and allowing for staff to assist resident with cares.
During an interview with concurrent observation on 6/9/23 at 8:00 AM, Licensed Nurse (LN) #3 stated he/she was unaware of any triggers or past trauma with Resident #7. LN #3 reviewed the nursing care plan that revealed .Brief history of behaviors with management techniques: Occasionally agitation and refuses cares. Sometimes refuses to participate in activities. Likes to be alone but can be encouraged to come out in the common room .Has occasional paranoia of people coming into [his/her] room to steal checks and money . LN #3 further stated that the facility provided trainings online for cultural sensitivity but no trauma-based care training.
Resident #16
Record review from 6/5-9/23 revealed Resident #16 was admitted to the facility with diagnoses that included dementia, and a personal history of other mental and behavioral disorders.
Review of Resident #16's Behavioral Health Psych Provider Note, dated 5/10/23, included a history of psychiatric hospitalization, history of self-inflicted injuries, history of auditory and visual hallucinations, suspected abuse at a previous assisted living facility, and a traumatic above the left knee amputation.
Review of Resident #16's LTC [Long Term Care] Provider Progress Note, dated 4/24/23, revealed a history of grabbing [others] anatomy, and a history of aggression when someone tells [resident] what to do.
Review of Resident #16's care plan, dated 5/7/23, does not reveal identified triggers or interventions related to Resident #16's personal trauma.
During an interview on 6/8/23 at 4:57 PM, the Director of Human Resources and Director of Nursing stated they have not identified triggers for residents with histories of trauma, and there was no trauma-informed care training provided during new hire orientation, nor during annual training for nursing staff.
Review of the facility's policy, Comprehensive Care Plan for QCC Residents, dated 2/3/03, revealed, .The facility must develop a comprehensive care plan for each resident . to meet a resident's medical, nursing, mental and psychosocial needs .
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
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Based on record review and interview, the facility failed to ensure residents that wore a wander guard received adequate supervision and monitoring. This failed practice placed 4 residents (#s 12, 4...
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Based on record review and interview, the facility failed to ensure residents that wore a wander guard received adequate supervision and monitoring. This failed practice placed 4 residents (#s 12, 4, 8, and 11) out of 4 residents reviewed for wander guard, at risk for potential elopement. Findings:
Resident #12
Record review on 6/5-9/23 revealed Resident #12 was admitted to the facility with a diagnosis that included dementia (a decline of cognitive abilities) with psychosis (a severe mental condition affecting thought and emotions).
Review of Resident #12's Minimum Data Set (MDS- a federally required nursing assessment) Quarterly Assessment, dated 4/16/23, revealed: . Section E- Behavior. E0900 Wandering .Behavior of this type occurred 4 to 6 days, but less than daily was marked .P0200. Alarms. Wander/ elopement alarm was marked . used daily .
Review of Resident #12's Care Plan, dated 5/18/23, revealed behavioral symptom interventions .Monitor [Resident #12] for possible wandering into rooms .
During an interview on 6/7/23 at 11:36 AM, Certified Nurse Assistant (CNA) #2 confirmed that Resident #12 wore a wander guard on Resident #12's ankle. The CNA further stated the nurses monitored and checked the wander guard battery.
During an interview on 6/7/23 at 11:53 AM, Licensed Nurse (LN) #1 stated he/she did not know that Resident #12 wore a wander guard.
During an interview on 6/7/23 at 1:08 PM, the Director of Nursing (DON) stated the wander guard battery was checked during every resident's head to toe assessment on a weekly basis.
During an interview on 6/8/23 at 9:50 AM, after the DON reviewed Resident #12's assessment for Activity of Daily Living (ADL) abilities, this section of the EHR revealed the wander guard battery was last checked on 4/4/23. The DON confirmed no other documentation after that date occurred. When asked the expectiation for monitoring the wander guard, the DON stated nurses should have checked the wander guard weekly.
Resident #4
Record review on 6/5-9/23 revealed Resident #4 was admitted to the facility with a diagnosis of vascular dementia (a decline in cognitive abilities) with behavioral disturbance.
Review of Resident #4's MDS Quarterly Assessment, dated 2/5/23, revealed: . Section P0200. Alarms .Wander/ elopement alarm was marked . used daily .
Review of Resident #4's Care Plan, dated 2/4/21, revealed: . [Resident #4] has a wander guard on [his/her] wheelchair .
Review of Resident #4's assessment for ADL abilities, revealed Wander alert device alarm was not checked on 11/17/22; 12/12/22; 4/17/23; 5/22/23; 5/29/23; and 6/5/23.
Resident #8
Record review on 6/5-9/23 revealed Resident #8 was admitted to the facility with diagnoses that included emphysema/chronic obstructive pulmonary disease (COPD), and dementia (a decline in cognitive abilities).
Review of Resident #8's MDS Quarterly Assessment, dated 3/19/23, revealed: . Section P0200. Alarms .Wander/ elopement alarm was marked . used daily .
Review of Resident #8's Care Plan, dated 5/18/22, revealed: . [Resident #8] has a wander guard on [his/her] wheelchair .
Review of Resident #8's assessment for ADL abilities, revealed Wander alert device alarm was not checked on 5/31/23 and 6/6/23.
Resident #11
Record review on 6/5-9/23 revealed Resident #11 was admitted to the facility with a diagnosis of dementia (a decline in cognitive abilities) with behavioral problems.
Review of Resident #11's MDS Quarterly Assessment, dated 3/19/23, revealed: . Section P0200. Alarms .Wander/ elopement alarm was marked . used daily .
Review of Resident #11's Care Plan, dated 11/26/21, revealed: . utilize wandering device .
Review of Resident #11's assessment for ADL abilities, revealed Wander alert device alarm was not checked on 3/14/23; 5/16/23; 5/23/23; and 5/31/23.
Review of the facility's policy Floor alarms, Bed alarms and WanderGuard System, revised on 9/15/20 revealed .wander guard devices are checked weekly .
Review of WanderGuard Blue v1.4 Quick Reference Guide, no date, revealed: .check the Tag battery at least once a week .
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
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Based on record review and interview, the facility failed to ensure drug regimens/medication orders included an indication and/or diagnosis for 4 residents (#'s 3, 7, 11 and 12) out of 8 sampled res...
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Based on record review and interview, the facility failed to ensure drug regimens/medication orders included an indication and/or diagnosis for 4 residents (#'s 3, 7, 11 and 12) out of 8 sampled residents. This failed practice had the potential to place residents at risk for medication errors and adverse effects. Findings:
Resident #3
Record review from 6/5-9/23 revealed Resident #3 was admitted to the facility with diagnoses that included urinary incontinence and recurrent urinary tract infections (UTI).
Review of Resident #3's [Physician] Order, with a start date 5/6/23 for a duration of 5 days, for sulfamethoxazole-trimethoprim (Bactrim DS) (an antibiotic), revealed no diagnosis or indication.
Resident #7
Record review from 6/5-9/23 revealed Resident #7 was admitted to the facility with diagnoses that included atrial fibrillation or other dysrhythmias and heart failure.
Review of Resident #7's current [Physician] Orders, revealed: apixaban [a blood thinner] 2.5 mg, Oral Tab, BIDAB [twice a day Morning/Bedtime], Start date 5/23/23. No diagnosis documented.
During an interview on 6/6/23 at 12:10 PM, when asked the indication/diagnosis for Resident #7's apixaban, Licensed Nurse (LN) #1 was unable to provide an answer nor find the answer in the physician's order.
During an interview on 6/6/23 at 12:27 PM, the Director of Nursing (DON) and Staff Development coordinator stated that pharmacy advised as needed medications (PRNs) and antibiotics required the order to contain a diagnosis or indication. When asked about what medications were utilized for off label use, the DON stated that these were discussed during staff huddles.
During an interview on 6/8/23 at 1:55 PM, the Pharmacist #1 stated that medication indications and/or diagnoses were not required by the Alaska Pharmacy Regulations nor the code of regulations. The Pharmacist further stated that indications and/or diagnoses could be found in physician notes or the monthly drug regimen review.
During an interview on 6/8/23 at 2:31 PM, Psychiatrist #2 stated that some medications have an off label use and that a diagnosis code should be included in the order.
During an interview on 6/14/23 at 1:15 PM, Psychiatrist #1 stated a diagnosis and/or indication should be listed in the order for every medication. This information could also be found in the psychiatric notes of the medical record.
Resident #11
Record review on 6/5-9/23 revealed Resident #11 was admitted to the facility with diagnoses that included dementia with behavioral symptoms.
Review of Resident #11's current [Physician] Orders, revealed:
Aripiprazole (Abilify) 10 mg, Oral, Tab, qAM [every morning], Start date 6/6/23, Special Instruction: Use 5 mg half tab from pill bottle.
Aripiprazole (Aripiprazole 5 mg oral tablet) 5 mg, Oral, Tab, HS [at night], Start date 5/19/23. No diagnosis or indication documented in the order.
Resident #12
Record review on 6/5-9/23 revealed Resident #12 was admitted to the facility with diagnoses that included dementia (a decline in cognitive abilities) with psychosis (severe mental condition affecting thought and emotions).
Review of the [Physician] Order, originally ordered on 5/3/22, revealed rivastigmine (rivastigmine 9.5 mg/24 hours transdermal patch) no indication for use or diagnosis in the order.
Review of the progress note, dated 5/10/23, revealed current medications .rivastigmine (rivastigmine 9.5 mg/24 hours transdermal patch) . qAM [every morning] .
During an interview on 6/8/23 at 6:44 PM, after the DON reviewed the medication order in the electronic health record (EHR), she confirmed that there was no indication or diagnosis in the order.
Review of facility policy Monthly Drug Regimen Review, revised 7/2019, revealed: .To promote the safe and effective use of medications for all residents of the Quyanna Care Center, while minimizing the risks for adverse events associated with treatment . Ongoing medication monitoring shall involve a collaborative approach between the medical provider, pharmacist, the patient, the patient's family, and all the caregivers with QCC .
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure expired medical products were removed from t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure expired medical products were removed from the medication storage room. This failed practice placed the residents, who required these products for services, out of a census of 17, at risk of complications from use of expired products. Findings:
An observation of the medication storage room on [DATE] at 3:23 PM, revealed the following expired medical supplies:
3- green top blood collection vials, expired on [DATE];
4 - gray top blood collection vials, expired on [DATE];
1 - yellow top Quantiferon blood collection vial, expired on [DATE];
79 - purple top blood collection vials, expired [DATE];
3 - Gentle heel newborn incision devices, expired on 11/2021, 9/2021, and 8/2022
During an interview on [DATE] at 3:34 PM, Licensed Nurse (LN) #2 stated everyone was supposed to pay attention to the expiration dates of supplies. LN #2 did not know who was responsible for the removal of expired supplies.
During an interview on [DATE] at 3:40 PM, LN #7 stated he/she did not know when the medical supplies were checked for expiration dates.
During an interview on [DATE] at 3:46 PM, the Staff Development Coordinator stated she did not know when the medical supplies were checked for expiration dates.
A medical supply storage policy was requested on [DATE] but was not provided by the end of survey.
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
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Based on observation, interview, and record review, the facility failed to ensure food safety with preparation and distribution. Specifically, the facility failed to ensure temperatures for hot and...
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Based on observation, interview, and record review, the facility failed to ensure food safety with preparation and distribution. Specifically, the facility failed to ensure temperatures for hot and cold foods were measured prior to service. This failed practice had the potential to affect any resident receiving food served from the kitchen of potentially contracting food-borne illness and affecting the palatability of the food. Findings:
Review of the dinner menu for 6/7/23, revealed: Herbed Pork Loin, Hawaiian Bread, Mashed Potatoes, Vegetable Blend, 2 % Milk, Chilled Fruit Salad, and Hot Tea.
An observation with concurrent interview on 6/7/23 at 5:25 PM, revealed [NAME] #1 had already taken and documented temperatures for the dinner items being served. [NAME] #1 further stated that the hot cooked items were those documented on the Meal Temperature Log.
During an interview on 6/8/23 at 10:40 AM, the Manager of Nutritional Services (MNS), stated that temperatures for pureed items and cold items were not being taken/documented prior to meal service.
Review of facility document Meal Temperature QCC [Quyanna Care Center]/Acute Care LOG, dated 6/7/23, revealed documented temperatures for the Pork Roast, Veggie, and Mash (mashed potatoes). The pureed items and the cold food items had no documented temperatures.
Review of facility policy Feeding Residents, dated 6/4/19 revealed: . Make sure that hot foods are hot and cold foods are cold .
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected most or all residents
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Based on interview and record review, the facility failed to develop a policy regarding the use and storage of food brought to residents by family and other visitors. This failed practice had the po...
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Based on interview and record review, the facility failed to develop a policy regarding the use and storage of food brought to residents by family and other visitors. This failed practice had the potential to place residents, based on a census of 17, at risk for foodborne illness. Findings:
During an interview on 6/8/23 at 5:20 PM, the Director of Nursing and Staff Developmental Coordinator stated there was no policy or procedure with regards to food brought by visitors into the facility that required refrigeration. They further stated this was not a common occurrence and most items brought in required non-refrigeration.
Review of facility policy, Native Food Usage, revised on 3/10/04, revealed the processes for donated food and food managed by the activities staff.
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, observation, and interview the facility failed to ensure a sanitary environment for all residents out ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, observation, and interview the facility failed to ensure a sanitary environment for all residents out of a census of 17. Specifically, the facility failed to ensure: 1) glove changes/hand hygiene with wound care; 2) appropriate hand hygiene with resident cares; 3) cleanliness of reusable medical equipment; and 4) cleanliness of the dining area. These failed practices had the potential to increase the development and transmission of communicable diseases and infections. Findings:
Wound Care
Record review on 6/5-9/23 revealed Resident #1 was admitted to the facility with diagnoses that included dementia (a decline in cognitive abilities), hypertension, and neurogenic bladder (bladder malfunction).
An observation on 6/6/23 at 11:33 AM, revealed Licensed Nurse (LN) #1 performed wound care to Resident #1's buttocks. The LN performed hand hygiene, put on new gloves then removed and discarded the old wound dressing (Mepilex). The LN removed the soiled gloves and put on new gloves without performing hand hygiene. The LN applied skin cleanser to the wound and then removed the soiled gloves and put on new gloves without performing hand hygiene. Lastly, the LN placed a new dressing to the wound.
During an interview on 6/8/23 at 10:56 AM, Infection Preventionist (IP) #1 stated hand hygiene should have been performed before wearing and after removing gloves because gloves could be punctured and torn during the performance of cares or procedures.
Resident care
Record review on 6/5-9/23 revealed Resident #5 was admitted to the facility with diagnoses that included coronary artery disease (reduced blood flow to the heart), hypertension and benign prostatic hyperplasia (enlargement of the prostate).
During an observation on 6/6/23 at 11:48 AM, Certified Nurse Assistant (CNA) #s 2 and 4 performed perineal care (a process of cleaning the private areas of a patient) to Resident #5. After the perineal care, CNA #2 put away the trash bag and removed his/her gloves. Without hand hygiene, CNA #2 took 2 new sets of gloves from a box. CNA #2 handed one set of gloves to CNA #4. CNA #2 placed the second set of gloves under his/her left armpit and then sanitized his/her hand, put on the gloves, and assisted Resident #5 with dressing and transferring to the wheelchair.
During an interview on 6/8/23 at 10:56 AM, the IP#1 stated hand hygiene should have been performed before and after removing personal protective equipment (PPE), and before and after touching the resident.
Review of the facility's Handwashing policy, dated 2/12/07, revealed: .handwashing will be done .before applying and after removing gloves .
Review of Centers for Disease Control and Prevention, Hand Hygiene in Health Care Settings, dated 1/8/21, accessed at https://www.cdc.gov/handhygiene/providers/, revealed: .Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves .
Medication administration
During a medication administration observation on 6/6/23 at 8:06 AM, LN #3 began preparing crushed medications at the medication cart for Resident #12 without performing hand hygiene. LN #3 then mixed the medications in apple sauce and put on gloves without performing hand hygiene. The LN picked up the medications, walked over to the kitchen and picked up a metal spoon from a kitchen drawer, then proceeded to the common dining area where Resident #12 was seated in his/her wheelchair at a table. LN #3 fed the medication mixed with apple sauce to Resident #12. The LN then returned to the medication cart, removed a marker from a medication drawer, and proceeded to write the date on Resident #12's medication patch with the same gloved hands. LN #3 then went over to Resident #12, removed the old medication patch, removed his/her gloves, and put on another pair of gloves without performing hand hygiene. The LN then placed the new medication patch on Resident #12's back. LN #3 returned to the medication cart with the used medication patch and removed his/her gloves. The LN did not perform hand hygiene after glove removal.
Further observation revealed LN #3, without performing hand hygiene, pulled Resident #4's medication packets and placed the medication into a medication cup. Next, the LN pulled out 2 inhalers, and a [NAME] Respironics Optichamber Diamond (a valved inhaled medication chamber) from the medication cart drawer. LN #3 mixed another medication with water in a paper cup. The LN put on gloves without hand hygiene, picked up the medication cups, inhalers and Optichamber and proceeded to give the oral medications and both inhalers with the Optichamber to Resident #4. With the same gloved hands, LN #3 detached the inhaler, returned to the medication cart, and placed the Optichamber into a medication cart drawer without cleaning it.
During an interview on 6/6/23 at 8:23 AM, LN #3 stated he/she did not know how often the Optichamber was cleaned.
Review of the [NAME] Respironics Optichamber Diamond's cleaning instructions revealed, .Clean your chamber and mask weekly ., accessed on 6/14/23 from: https://www.documents.[NAME].com/doclib/enc/11446331/OptiChamber_Diamond_TearOff.pdf#:~:text=1.%20Remove%20cap%2C%20rotate%20mouthpiece%20to%20disassemble%2C%20remove,parts%20with%20warm%20clean%20water%20and%20air%20dry.
During an interview on 6/8/23 at 10:57 AM, the IP #1 stated hand hygiene should have been performed before and after each resident's medication pass and before and after glove use.
Environment
An observation on 6/7/23 at 6:07 PM, revealed the community dining tables were visibly dirty with crumbs and dried liquid residue.
During an interview with concurrent observation on 6/7/23 at 6:08 PM, CNA #5 stated the dining tables were washed with soapy water after meals. CNA #5 further stated if residents sat at the tables in between meals for snacks or drinks the tables could be left dirty. CNA #5 proceeded to prepare a bucket of soapy water and washed down the dining tables as residents were now seated at them.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0949
(Tag F0949)
Could have caused harm · This affected most or all residents
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Based on record review and interview, the facility failed to provide behavioral health training consistent with the facility assessment in regards to psychosocial difficulties and history of trauma....
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Based on record review and interview, the facility failed to provide behavioral health training consistent with the facility assessment in regards to psychosocial difficulties and history of trauma. This failed practice had the potential to exacerbate or trigger ongoing psychosocial difficulty and affect the residents' ability to attain the highest practicable mental and psychosocial well-being. Findings:
Review of the facility's Matrix for Providers, revealed the resident population contains the following condition:
- PTSD (Post-traumatic Stress Disorder)/Trauma: 3 residents.
Review on 6/5-9/23 of the facility's CMS-672: Resident Census and Conditions of Residents form revealed:
Mental Status:
- Documented signs and symptoms of Depression: 11 residents;
- Documented psychiatric diagnosis: 5 residents.
Medications:
- Antipsychotic medications: 5 residents;
- Antianxiety medications: 1 resident;
- Antidepressant medications: 11 residents.
Review of Facility Assessment Tool revealed:
- Disease/conditions, physical and cognitive disabilities .Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions.
- Part 2: Services and Care We Offer Based on Resident Needs .identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities.
During an interview on 6/8/23 at 4:57 PM, the Director of Human Resources and Director of Nursing stated trauma-informed care training was not provided during new hire orientation, or during annual training for nursing staff.
Review of the facility's policy, Comprehensive Care Plan for QCC [Quyanna Care Center] Residents, approved date 6/4/19, revealed, .The facility must develop a comprehensive care plan for each resident .to meet a resident's medical, nursing, mental and psychosocial needs .
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Aug 2022
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview, observations, and record reviews the facility failed to ensure one resident's right to self-determination ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview, observations, and record reviews the facility failed to ensure one resident's right to self-determination was promoted or facilitated. Specifically, the facility placed 1 resident (#67), out 11 sampled residents, on unnecessary isolation. This failed practice denied the resident the choice to get out of bed and/or leave his/her room and a choice in participating in dining and/or activities with peers and placed the resident at risk for loneliness and/or isolation. Findings:
During an interview on 8/08/22 at 4:56 PM, Resident #67 was lying in bed with the TV on. The Resident stated he/she had not eaten in two days and was hungry, the Resident was unable to reach the call light that was laying on the floor. The Resident stated, I hope someone brings me some hotcakes. The Resident stated he/she would need help getting out of bed. During the interview, the Resident thought it was the month of May.
During the dinner observation, on 8/08/22 at 6:00 PM, Resident #67 did not come out of his/her room for the evening meal.
Random observations during the survey from 8/08-8/12/22 revealed Resident #67 remained in bed in his/her room during the survey. The Resident was not observed engaging in meals in the common area and/or engaging in activities with other residents. The door to the Resident's room was often open, and the Resident could be seen lying in bed with the TV on.
During an interview on 8/10/22 at 10:09 am, the Director of Nursing (DON) stated Resident #67 just had his/her 2nd COVID-19 booster upon admission and was on isolation for 2 weeks. When asked about the Resident being isolated to his/her room, DON stated Resident #67 and all other residents would have to wear a mask if he/she were to go into the common area. The DON stated Resident #67 had a negative COVID test prior to admission and had had no symptoms of COVID-19.
A review of Resident #67's clinical record conducted on 8/11-12/22 revealed:
Resident #67 had diagnoses that included dementia and a history of a stroke with right sided weakness.
Review of Resident #67's immunizations revealed he/she had had received Pfizer Covid-19 vaccine 1/14/21, 2/5/21, and a booster on 11/11/21. The Resident had received his/her 2nd booster after his/her admission on [DATE].
During an observation on 8/10/22 at 9:00 AM Resident #67 was in his/her room in bed. Certified Nursing Assistant (CNA) # 7 raised the head of the Resident's bed and prepared to give the Resident breakfast. The CNA stated the Resident was not currently getting up as he/she had just gotten his/ her covid vaccine. The CNA was not wearing any PPE (personal protective equipment) equipment.
During an interview on 8/11/22 at 11:59 AM, this surveyor asked CNA #s 2 and 6 why Resident #67 had to stay in his/her room. CNA #6 was unsure; however, CNA #2 stated the Resident had just received his/her COVID vaccination. When asked how staff know how to provide care to the Resident, CNA #2 stated the information was in the kiosk where CNAs charted care. When asked if Resident #67 ever got out of bed, CNA #2 stated the Resident had gotten up for showers a couple times in the evening.
During an interview with the Department of Health Nurse ([NAME]) on 8/15/22 at 1:00 PM, when asked about being up to date with COVID vaccinations and the need for quarantine and/or isolation after a booster, the [NAME] stated the recipient was considered fully vaccinated immediately after receiving a booster.
According to the CDC guidelines, updated on 2/02/22, reviewed on 08/11/22 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.htmlt .In general, quarantine is not needed for asymptomatic patients who are up to date with all recommended COVID-19 vaccine doses or who have recovered from SARS-CoV-2 infection in the prior 90 days; potential exceptions are described in the guidance. However, some of these patients should still be tested as described in the testing section of the guidance.
A test-based strategy and (if available) consultation with infectious disease experts is now recommended for determining the duration of Transmission-Based Precautions for patients with SARS-CoV-2 infection who are moderately to severely immunocompromised .
Review of the CDC guidance When Are You Up to Date?, accessed 8/15/22, at https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html revealed
You are up to date with your COVID-19 vaccines when you have received all does on the primary series and all boosters recommended for you, when eligible. Up to Date Immediately after getting all boosters recommended for you.
Review on 8/11/22 of the facility policy, Resident Safety during COVID19, dated 3/16/21 revealed U. New QCC [Quyanna Care Center] admissions-QCC will screen, test, and Quarantine per current CMS and CDC guidelines all new admissions must complete a quarantine that follows all current CMS and CDC guidelines for admission before moving to the facility. NSHC [[NAME] Sound Health Center] will coordinate for all new admissions and the ACUTE CARE center may be used.
Review on of the Quyanna Care Center Patient [NAME] of Rights, undated, revealed As a resident at Q.C.C. you have the RIGHT to: Participate in social, religious, and community activities of your choosing so long as they don't interfere with the rights of others and Be free of unnecessary or excessive medications or treatment; and refuse treatment to the extent permitted by law.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review the facility failed to ensure a high-risk medication was coded accurately in the Minimum ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review the facility failed to ensure a high-risk medication was coded accurately in the Minimum Data Set (MDS-a federally required assessment) for 1 (#8) out of 6 residents reviewed for high-risk medications. This failed practice placed the Resident at risk for ineffective care planning. Findings:
During an interview on 8/08/22 at 9:23 AM Resident #8 stated I have problems with my heart.
Record review on 8/11/22 revealed Resident #8 had diagnoses that included coronary artery disease (damage and/or disease in the hearts major blood vessels), heart failure, atrial fibrillation (a rapid heart rate than can cause poor blood flow), and high blood pressure.
Review of the most recent MDS (Minimum Data Set) quarterly assessment, dated 6/26/22, revealed N0410. Medications Received .E. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin), the Resident was coded 0 for not receiving the medication in the 7-day assessment period.
Review of Resident #8's medication administration record, for the time period of the MDS 7-day assessment period, revealed the Resident was taking the medication APIXABAN (Eliquis) 2.5 mg. 1 tablet by mouth twice daily.
Review on 8/11/22, of the 2022 [NAME] Drug Guide for Nurses, revealed Apixaban (Eliquis) class Anticoagulant, direct thrombin inhibitor. Further review of the drug guide revealed, adverse effects included bleeding, excessive bruising, and rebound thrombotic (clots) events when stopped suddenly.
During an interview on 8/15/22 at 10:25 AM, Pharmacist #1 stated Eliquis was considered an anticoagulant.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
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Based on observation, interviews, and record reviews the facility failed to ensure the baseline care plan, initiated for 1 newly admitted resident (#67), out of 1 new admission, included care areas ...
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Based on observation, interviews, and record reviews the facility failed to ensure the baseline care plan, initiated for 1 newly admitted resident (#67), out of 1 new admission, included care areas specific to the resident's current care. This failed practice placed the resident at risk for not receiving necessary care and services and denied staff information needed for continuity of care. Findings:
During an observation on 8/08/22 at 4:46 PM Resident #67 was observed in bed, the Resident's right hand was held in a claw like shape. During an interview with the Resident at the same time, the Resident stated he/she could not get out of bed without assistance, and he/she was unable to use his/her hand.
During an interview on 8/11/22 at 11:30 PM, when asked about Resident #67 being on isolation or quarantine, the Hospital Director of Nursing Services (DNS)/ Infection Preventionist (IP) and the Director of Nursing (DON) stated new residents were placed on isolation.
During an interview on 8/11/22 at 11:59 AM with Certified Nursing Assistance (CNA) #2 and #6 when asked how staff knew how to take care of Resident #67, CNA #6 said the interim care plan was in the CNA charting program. CNA #6 stated he/she was unable to pull it up at that time because the system was down. The CNA stated the Resident has only gotten out of bed for showers and had to stay in his/her room on isolation. CNA #6 explained the Resident #6 had recently received a COVID vaccination.
Record review on 8/11/22 of the medical record, revealed Resident #67 had diagnoses that included dementia with behaviors and a history of a stroke with right sided immobility/weakness.
Review of the Baseline Care Plan LTC, initiated on 8/03/33, revealed resident concerns included:
Contracture [hand deformity] of right hand .
Review of the CNA baseline care plan, located in the care tracker revealed,
Recreation Therapy
Encourage resident to participate in bingo and other social activities.
Restorative Therapy
Passive range into hip flexion/ extension hip abduction/ adduction knee flexion/ extension and ankle planter flexion, dorsiflexion. Each to be completed x [times] 25, 3-5 x a week.
There was no information in the care plan about the Resident's two-week isolation/quarantine or the plan for the contracture to the right hand.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record reviews, observations, and interviews, the facility failed to ensure orders did not contain excessive dosing o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record reviews, observations, and interviews, the facility failed to ensure orders did not contain excessive dosing or duplicate drug therapy for 1 sampled resident (# 16) out of 11 sampled residents. Specifically, there were scheduled and PRN (as needed) Tylenol orders over the recommended daily dose for the same resident. This failed practice had the potential for the resident to receive a toxic dose of the medication. Findings:
Record review from 8/8-12/22 and 8/15/22, revealed Resident #16 was admitted to the facility with diagnoses that included: a history of falls, dementia with behavioral problem characterized by confusion and memory loss, chronic kidney disease stage 3 (staging goes from 1-5, with 5 being the most severe), fracture of greater trochanter of left femur (bone of the upper portion of the leg that connects with the hip), osteoarthritis (joint disease), and spinal stenosis (narrowing of the spine putting pressure on the spinal cord and nerves within).
Review of a Physician order, dated 8/5/21, revealed Acetaminophen [Tylenol] 325 mg oral [PO] tablet- 2 tab(s) (650 mg), q4 hr [every 4 hours], PRN for Pain, Mild (Pain Score 1-3). This would total 3,900 mg/day.
Review of a Physician order, dated 8/6/22, revealed Acetaminophen (Tylenol) 650 mg, 2 tab(s), 2 EA[ch], Dose 650 mg oral tab TIDANP [3 times daily]. This would total 1,950 mg/day.
Review of the Medication Administration Record (MAR) revealed no PRN doses of Tylenol given from 8/5/22-8/12/22.
During an observation with concurrent interview on 8/8/22 at 4:23 PM, Resident #16 stated my leg hurts want to walk back that way, as Resident #16 pointed toward the hall in the direction of his/her bedroom. When asked about the leg pain, Resident #16 stated it's getting better.
During an observation with concurrent interview on 8/10/22 at 8:04 AM, Resident #16 was coming out of his/her bedroom and mumbled something in a quiet voice about his/her left leg. When asked if there was pain or itching, Resident #16 stated no. Resident #16 then pulled up his/her pants and showed this surveyor the skin of the left leg. Licensed Nurse (LN) #2 was just coming around the corner at this time and assessed Resident #16 for pain or discomfort. Resident #16 stated he/she had no pain.
During an interview on 8/10/22 at 3:44 PM with LN #3, when asked about the process for the two Tylenol orders (a scheduled and PRN), LN #3 stated the scheduled doses of Tylenol were given at those designated times, and a PRN would be given 2 hours later if the pain was still present. LN #3 stated that he/she would not give more than four doses in a 24-hour time frame. LN #3 further stated that perhaps a PRN for this medication would no longer be necessary with the new scheduled order and would need to call and get clarification from the doctor.
During an interview on 8/11/22 at 2:43 PM, the Director of Nursing (DON) stated Resident #16 had both orders available as Resident #16 did not communicate pain well.
During an interview on 8/11/22 at 4:39 PM, the Physician confirmed the order for PRN Tylenol was too high [with regards to daily amount that could be given] as the order was written. The Physician further stated the dosage needed to be adjusted.
During an interview on 8/15/22 at 10:25 AM, the Pharmacist #2 confirmed the order should have been caught and adjusted before administering the medication to the resident. The Pharmacist #2 stated a limit of 4,000 mg should have been included in the order. Pharmacist #2 further explained had Resident #16 been given all doses of these two Tylenol orders in a 24-hour period that would have been 5,850 mg (1,850 mg over the exceeded dose for a day).
Review of facility policy, Medication Administration, dated 5/11/18, revealed Purpose: The purpose of this policy is to provide a mechanism to ensure residents will be administered medications in an orderly and safe fashion in accordance with state and federal standards of nursing practices. Procedure: Per [NAME]. 1. The nurse must use the eight rights of drug administration The right drug, The right dose .
Review of Davis's Drug Guide for Nurses 17th edition, copyright 2021, revealed acetaminophen . Metabolism and Excretion: 85-95% metabolized by the liver . Metabolites may be toxic in overdose situation. Metabolites excreted by the kidneys . Use Cautiously in: Hepatic disease/renal [kidney] disease (lower chronic doses recommended) . Route/Dosage . PO (Adults and Children > 12 yr): 325-650 mg every 6 hr or 1g 3-4 times daily or 1300 mg every 8 hr (not to exceed 3 g or 2 g/24 hr in patients with hepatic/renal impairment) .
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
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Based on observations, interview and record reviews, the facility failed to follow infection control policies and procedures for 1 out of 1 wound care dressing change observed (Resident #6) and 1 ou...
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Based on observations, interview and record reviews, the facility failed to follow infection control policies and procedures for 1 out of 1 wound care dressing change observed (Resident #6) and 1 out of 1 eye scrub topical administration observed (Resident #8). This failed practice placed residents receiving wound care and eye scrub topical administration at increased risk of infection. Findings:
Wound Care with Lack of a Clean or Sterile field under the Dressing Supplies
During an observation with Resident #6 on 8/10/22 at 11:30 AM, Licensed Nurse (LN) #2 was observed to lay out wound care supplies on the resident's bed by opening the sterile packages including a Mepiplex dressing and an abdominal pad dressing. These opened packages were observed to be resting on the bed sheets. There was no sterile or clean field placed under these dressing supplies. LN #2 was observed to complete wound care to the resident's small wound in the abdominal area and a 3 cm long X 1 cm centimeter wide with noted depth sacral area wound (lower spine area) with these dressing supplies.
During an interview on 8/11/22 at 2:05 PM, the Director of Nursing (DON), when asked if the LN should have placed a clean field under dressing supplies, stated that a clean field should have been placed under the dressing supplies by the LN.
Review on 8/12/22 of a policy titled Decubitus Ulcer Assessment and Care with an approval date of 6/4/2019 stated, Get needed supplies ready. When a clean dressing is to be applied, open dressing packages onto a sterile field . Put on clean gloves and remove old dressing and discard into appropriate bag. 7. Wash hands. 8. Put on clean or sterile gloves as indicated. 9. Cleanse skin around ulcer with appropriate wound cleanser and a dressing . 11. Apply appropriate dressing .
Eye Scrub Administration
During a medication administration on 8/9/22 at 9:07 AM, LN #3 was observed to administer nasal spray into Resident #8 nostrils with gloved hands. LN #3 then changed his / her gloves but did not sanitize or wash hands prior to putting on the new gloves and completed an Ocusoft Lid scrub (eyelids cleanser) treatment to both eye lids. LN #3 then discarded the gloves and sanitized his / her hands.
A review on 8/12/22 of the policy titled Hand washing reviewed 2/12/2007 stated, Hand washing will be done . after removing gloves.
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record review, the facility failed to ensure that food was stored and prepared in accordance with professional standards for food safety. Specifically, the facil...
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Based on observations, interviews, and record review, the facility failed to ensure that food was stored and prepared in accordance with professional standards for food safety. Specifically, the facility failed to ensure : 1) food was stored under proper sanitation and food handling practices in the Long Term Care (LTC) kitchen/pantry;, 2) food was stored under proper sanitation and food handling practices in the main kitchen's walk in refrigerators;, 3) concentrations of sanitizing solution buckets were monitored for the main kitchen;, 4) food was stored off the floor in the main kitchen;, and 5) dry storage can goods were free from dents. These failed practices had the potential of causing or spreading foodborne illness to all residents (census of 16 residents of the facility that received food from the kitchen). Findings:
LTC Kitchen/Pantry
An observation with concurrent interview on 8/8/22 at 2:14 PM, revealed the following unlabeled and undated items:
1.
a plate of spam covered with saranwrap, unlabeled and undated
2.
Northwest Dairy Fat Free Milk 64 fl oz opened 8/4/22 at 11:35 AM, expiration date of 8/7/22
3.
Three cups of gravy in coffee cups with lids, unlabeled and undated
CNA #1 confirmed these items should have been labeled and dated. CNA #1 then gathered these items from the refrigerator and threw them out.
An observation with concurrent interview on 8/8/22 at 2:30 PM, of the activity freezer in the pantry room revealed:
1.
One-quart sized zip lock bag that had an unknown meat product, unlabeled and undated
CNA #7 confirmed this unknown meat as unlabeled and undated.
An observation on 8/10/22 at 4:50 PM, revealed the quart sized zip lock bag of unknown meat dated with a date in and date out.
Main Kitchen walk-in Refrigerator/ walk-in Vegetable & Milk Refrigerator
An observation on 8/8/22 at 2:55 PM, revealed a shelving unit with the following:
1.
Large silver tray of reindeer sausages, the bag torn open to air and the elements and missing 1-2 sausages, undated and no thaw date
2.
Two 10 lb foster turkeys, undated and no thaw dates
3.
Tray of stuffed cooked cabbage, undated
During an interview on 8/8/22 at 3:00 PM, [NAME] #1 stated the turkeys were thawed the day before but did not know about the reindeer sausages or cooked cabbage.
An observation on 8/8/22 at 3:10 PM, of the walk-in vegetable and milk refrigerator revealed 30 moldy green peppers at the top and some throughout.
During an interview on 8/8/22 at 3:13 PM, the Dietary Manager (DM) stated a walk-through inventory would be performed today. The DM further stated the cooks would not prepare or serve items past their prime.
An observation on 8/10/22 at 11:15 AM, revealed the green peppers were no longer in the walk-in vegetable & milk refrigerator and were replaced with red peppers.
Sanitation Buckets/3 sink wash method
An observation with concurrent interview on 8/8/22 at 3:20 PM, revealed no log for concentration of the sanitation solution monitored. When asked the process for monitoring sanitation buckets, the DM stated the buckets were changed before every meal and the concentration was monitored with the paper strip ever so often. The DM further stated there was no log to track the buckets being monitored. When asked if ECO LABS (a food safety partner) came and performed any monitoring or maintenance on the system, the DM stated ECO LABS had not come to do any on-site maintenance.
An observation on 8/8/22 at 3:25 PM, revealed 3 different types of monitoring strips being used to test the chemical concentration of the sanitation buckets and the sanitizing sink of the 3-sink method.
1.
Hydrion qt 40 strips, no expiration date
2.
QAC paper (yellow), no expiration date
3.
QAC QR strips, expiration date of June 2022
During an interview on 8/8/22 at 3:26 PM, the DM stated that the QAC QR strips were used mostly to test the concentrations.
An observation on 8/10/22 at 11:20 AM, revealed [NAME] #2 prepared a new sanitation bucket and used the Hydrion qt 40 strips. No date was indicated on package.
During an interview/phone call on 8/19/22 at 9:25 AM, the ECO LAB Representative stated that he/she was new to the accounts and did not know the last time an on-site visit was completed. He/she continued to say that the QT 40's should only be used and would get back to this surveyor regarding expiration dates. The ECO LAB Representative further stated that education and training would be performed at next on-site visit.
Main Kitchen Walk-In Freezer
An observation with concurrent interview on 8/8/22 at 3:40 PM, revealed 6 boxes of frozen goods stacked on the floor. The DM stated he/she educated staff about not stacking things on the floor and then they turned around later and did it anyway.
Dry good storage
An observation with concurrent interview on 8/8/22 at 3:45 PM, of the dry good storage room revealed the following dented can goods:
1.
One can- 50 oz tomato with tomato pieces
2.
Two cans- 50 oz cream of chicken, dented at the seams
3.
Three cans- 5 lb oyster clam sauce, dented at the seams
The DM stated there was no policy for dented cans, but that they would not be used if the can bulged at the top.
Record review of facility procedure Nutrition Services Infection Control Guidelines, date reviewed &/or revised 1/20/22, revealed . 2. Orientation and in-service education . iii. Sources of foodborne illness . vi. Techniques to minimize sanitation hazards during handling, storing, preparation, and serving of food . 9. Food preparation . i. All kitchenware and food contact surfaces used in the preparation and/or serving of food and drink are cleaned and sanitized before use and cleaned after each meal preparation . Procedure 11. All items not in their original package are covered, dated, and labeled as to contents . Equipment 3. No containers of food are stored on the floor of the refrigerator or freezer .
No policy for dented cans was provided by the end of survey.
Review of FoodSafety.gov on 8/18/22 at 2:19 PM, from https://www.foodsafety.gov/people-at-risk, revealed . Do not buy or use damaged, swollen, rusted, or dented cans.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Alaska facilities.
Concerns
- • 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Quyanna's CMS Rating?
CMS assigns QUYANNA CARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Alaska, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Quyanna Staffed?
CMS rates QUYANNA CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes.
What Have Inspectors Found at Quyanna?
State health inspectors documented 26 deficiencies at QUYANNA CARE CENTER during 2022 to 2024. These included: 26 with potential for harm.
Who Owns and Operates Quyanna?
QUYANNA CARE CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 18 certified beds and approximately 17 residents (about 94% occupancy), it is a smaller facility located in NOME, Alaska.
How Does Quyanna Compare to Other Alaska Nursing Homes?
Compared to the 100 nursing homes in Alaska, QUYANNA CARE CENTER's overall rating (3 stars) is below the state average of 3.5 and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Quyanna?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Quyanna Safe?
Based on CMS inspection data, QUYANNA CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Alaska. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Quyanna Stick Around?
QUYANNA CARE CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Quyanna Ever Fined?
QUYANNA CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Quyanna on Any Federal Watch List?
QUYANNA CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.