Polaris Extended Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to develop, implement, and ensure appropriate oversight supervisor of the activity program to support residents in their choice of activities. Specifically, the facility failed to: 1) Ensure activities admission evaluations were completed per established activities program policy for 4 sampled residents (#'s 13; 22; 70; and 292), and 3 unsampled residents (#'s 192, 193, and 293), out of 11 residents reviewed who were admitted since 3/1/25; 2) Ensure the activity director developed, implemented and supervised the activity program which included scheduling of activities, both individual and groups, monitoring the response or reviewing/evaluating the response to the programs to determine if the activities meet the assessed needs of the resident; and 3) Develop and implement methods of ongoing evaluation of activities offered under the activities program. Specifically, the facility did not have a method to document specific resident activity participation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure their medication error rate was below 5% for 2 sampled residents (#4 and #36) and 2 unsampled residents (#49 and #55), out of 5 residents observed for medication administration. The facility's overall medication error rate was 23.08%. This failed practice placed the residents at risk for adverse medication outcomes. Findings: Resident #4 Record review on 5/18-22/25 revealed Resident #4 was admitted to the facility with diagnoses that included dysphagia (difficulty swallowing), rheumatoid arthritis (autoimmune disorder that affects the joints), and depression. An observation on 5/19/25 from 10:20 AM to 11:24 AM, revealed Licensed Nurse (LN) #2 prepared and administered medications for Resident #4. LN #2 administered the medications through the resident's G-tube (gastrotomy tube: a tube inserted through the belly that gives direct access to the stomach). Review of the physician orders for the medications LN #2 administered revealed two medications were to be administered by mouth: - DULoxetine [an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure all staff involved in food preparation, distribution, and service maintained current food handling licenses, called food handler cards, for 24 Night Shift (NOC) staff (#'s 2; 3; 5; 6; 7; 8; 9; 10; 13; 19; 20; 24; 25; 28; 29; 30; 31; 32; 34; 35; 36; 37; 41; and 43), out of 44 NOC staff, and 3 Cooks (#'s 32; 33; and 35), out of 11 Cooks. This failed practice put all 75 residents, who receive food from the kitchen, at risk of health and safety issues due to receiving food prepared and served by unqualified individuals. Findings: Food Handler Cards During an interview on 5/21/25 at 5:15 PM, the Kitchen Manager (KM) stated all staff including housekeepers, cooks, Licensed Nurses (LNs), and Certified Nursing Assistants (CNAs) who handled food must have current food handler cards: all staff are trained during orientation about snack availability, and all are supposed to hold current food handler cards, allowing them to prepare snacks. Review of the facility-provided document Food handler cards for After-hours staff,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and observation, the facility failed to: 1) Ensure residents received meals at times and in a manner consistent with their needs, preferences, and requests; and 2) Consistently offer access to suitable snacks or alternative meals outside of scheduled mealtimes to prevent prolonged periods without nourishment. These failed practices placed all 75 residents, who received food from the kitchen, at risk of less-than-optimal nutritional intake and decreased quality of life. Findings: During an interview on 5/21/25 at 2:01 PM, members of the Resident Council (Residents #'s 18; 20; 28; 34; 35; 47; 48; 68; and 87) shared their concerns about how close mealtimes were scheduled and the 15-hour gap between dinner (between 4:15 and 5:00 PM) and breakfast (8:00 AM). Residents stated snacks must be requested before cooks left at 6:00 PM, or they would go without food until breakfast. Some residents resorted to ordering food from outside the facility due to lack of consistent access to after-hours snacks. The cooks worked from 7:30 AM to 6:00 PM, leaving Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation, and record review, the facility failed to ensure staff were appropriately trained, or with competencies up to date, for direct resident care in 2 cottages, Susitna and Nenana. This failed practice had the potential to create diminished resident care for 23 residents (Susitna Cottage: #'s 2; 3; 24; 26; 33; 45; 46; 52; 60; 68; 71; and 193; Nenana Cottage: #'s 5; 20; 35; 38; 49; 50; 51; 55; 77; 83; and 492) which could affect their overall quality of care and quality of life. Findings: Nenana Cottage During an interview on 5/20/25 at 8:30 AM, Rehabilitation Aide (RA) #1 stated, I'm working in Nenana Cottage today because I was asked to help because surveyors are here. Normally I work in the Rehab department, I haven't worked as a CNA [Certified Nursing Assistant] in the cottages for over three years. During an interview on 5/21/25 at 1:03 PM, when asked to review RA #1's training and competencies for CNA duties, the Director of Community Liaison stated RA #1's last training for safe patient handling occurred during the 7/27/23 annual skills fair and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, and observation, the facility failed to ensure 4 residents (#s 4, 19, 40, and 48), out of 21 sampled residents, were given the opportunity to make choices about aspects of his/her life that were significant to them. Specifically, the facility failed to ensure residents had the opportunity to: 1) receive a shower and/or a bath; 2) be transferred in and out of bed when requested; and 3) go outside and participate in activities as specified in the plan of care. These failed practices had the potential to affect the resident's quality of life and increase feelings of frustration. Findings: Resident #4 Record review on 5/18-22/25 revealed Resident #4 was admitted to the facility with diagnoses that included dysphagia (difficulty swallowing), rheumatoid arthritis (autoimmune disorder that affected the joints), and depression. During an interview on 5/18/25 at 12:45 PM, Resident #4 stated the facility was so short-staffed that he/she only received 1 shower a week, instead of the two scheduled showers that was care planned for. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, interview, and observation, the facility failed to develop and/or implement a comprehensive care plan for 6 Residents (#s 4; 19; 51; 60; 89; and 492), out of 21 sampled residents. Specifically, the facility failed to: 1) implement showers scheduled as care planned; 2) provide adequate supervision and/or assistance to a resident who utilized a ceiling lift; 3) reposition residents and maintain skin integrity as care planned; and 4) develop a care plan for a resident's diagnosis of chronic obstructive pulmonary disease (COPD). These failed practices placed the residents at risk of not receiving necessary care and services to address the individual's needs. Findings: Shower Schedule Resident #4 Record review on 5/18-22/25 revealed Resident #4 was admitted to the facility with diagnoses that included dysphagia (difficulty swallowing), rheumatoid arthritis (autoimmune disorder that affected the joints), and depression. During an interview on [DATE] at 12:45 PM, Resident #4 stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 sampled Residents (#12, #28, #51, and #492), out 21 sampled residents, and 2 unsampled Residents (#74 and #77). Specifically, the facility failed to: 1) Implement and follow individualized turning and repositioning schedules for 3 resident (#'s 12, 51, and #492) with impaired mobility and pressure injury risk; 2) Accurately assess and document the presence of open wounds for 2 residents (#28 and #51); 3) Administer enteral nutrition and medications in accordance with physician orders and clinical standards for 2 resident (#51 and #77); and 4) Provide timely incontinence care for 1 resident (#74). These failures resulted in prolonged periods of immobility, inaccurate wound assessments, compromised nutrition safety, and delays in hygiene care-placing residents at risk for pressure injuries, aspiration, infection, discomfort, and psychosocial harm. Findings:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, and observation, the facility failed to have sufficient nursing staff to provide care and services for 7 sampled residents (#'s 4; 12; 19; 40; 48; 51; and 492), out of 21 sampled residents, and 1 unsampled resident (#74). Specifically, the facility failed to ensure: 1) Scheduled showers were provided for 3 resident (#'s 4, 19 and 40); 2) Requests to get out of bed to go outside and participate in activities was honored for 1 resident (#48); 3) Timely incontinence care was provided for 1 resident (#74); 4) Scheduled turning and repositioning interventions for 3 residents (#'s 12, 51 and 492) with impaired mobility and at high risk for pressure injuries, were followed. These failed practices placed the residents at risk for not receiving care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings: Scheduled Showers Resident #4 Record review on 5/18-22/25 revealed Resident #4 was admitted to the facility with diagnoses that included dysphagia (difficulty swallowing), rheumatoid arthritis (autoimmune…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, revealed the facility failed to ensure medication and medical supplies were labeled appropriately, and removed from service if expired, in 2 medication carts, out of 8 medication carts inspected, and 1 treatment cart, out of 1 treatment cart inspected. These failed practices had the potential to place the residents at risks of: 1) having inaccurate blood sugar analysis due to expired supplies or the use of an uncalibrated blood sugar monitor; and/or 2) receiving expired medications and supplies which could cause adverse reactions and/or complications. Findings: Aniak Medication Cart An observation on 5/20/25 at 11:35 AM, of the Aniak cottage, revealed a medication cart which had an opened box labeled Medline EvenCare Glucose Control Solutions (solutions used at quality control checks for glucose monitors to ensure they were accurately measuring blood sugar) that contained: - One opened 2.5 ml (milliliters) bottle of EvenCare High Control Solution, with no open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure medical records were complete and/or accurate for 5 sampled residents (#'s 28; 31; 42; and 343), out of 21 sampled residents, and 1 unsampled resident (#89). This failed practice created incomplete medical records which placed the resident at risk for inconsistencies in treatment and care provided. Findings: Resident #28 Oxygen Order Record review on 5/18-22/25 revealed Resident #28 was admitted to the facility with diagnoses that included non-Alzheimer's dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking), Parkinson's disease (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination), heart failure (inability of the heart to maintain adequate blood circulation), and hypertension (repeatedly elevated blood pressure). An observation on 5/18/25 at 12:07 PM, revealed Resident #28 was lying in bed receiving 2 LPM (liters per minute) of humidified oxygen through a nasal cannula (a thin flexible tube…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure residents' rights were honored. Specifically, the facility failed to provide care in a manner that promoted dignity and respect for 2 sampled residents (#19 and #51), out of 21 sampled residents, and 1 unsampled resident (#74). This failed practice had the potential to cause psychosocial harm and placed the residents at risk of not attaining or maintaining the highest practicable physical, mental, and psychosocial well-being. Findings: Resident #19 Record review on 5/18-22/25 revealed Resident #19 was admitted to the facility with diagnoses that included multiple sclerosis (chronic autoimmune disease where the immune system attacks the protective covering of nerve cells), neuromuscular dysfunction of the bladder (a condition where the bladder lacks control due to nerve or muscle problems), and major depressive disorder (mood disorder characterized by persistent feeling of sadness and loss of interest in activities). Review of the Resident #19's Care Plan Report, initiated 4/29/25, revealed: .Focus:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to fully inform a Resident Representative in advance, of the care to be provided and treatment options for 1 resident (#343), out of 21 sampled residents. This failed practice violated the resident's and resident representative's right to be fully informed and to participate in the resident's treatment. Findings: Resident #343 Record review on 5/18-22/25 revealed Resident #343 was admitted to the facility with diagnosis that included spinal stenosis of lumbar region with neurogenic claudication (narrowing of the lower spine causing pain), vascular dementia, severe, with mood disturbance (brain damage from blood vessel issues, severe, with mood changes), obstructive sleep apnea (breathing issues during sleep), overactive bladder (frequent need to urinate), and major depressive disorder (severe sadness). Due to his/her dementia diagnosis Resident #343 was not able to complete an interview. During an interview on 5/19/25 at 9:05 AM, Resident #343's Representative stated that after Resident #343's admission, he/she was pressured…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, and observation, the facility failed to ensure reasonable accommodation of needs were maintained for 1 resident (#28), out of 21 sampled residents. Specifically, the facility failed to ensure the resident's call light device was within reach. This failed practice placed the resident at risk for not being able to call for help if needed. Findings: Record review on 5/18-22/25 revealed Resident #28 was admitted to the facility with diagnoses that included non-Alzheimer's dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking), and Parkinson's disease (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination). Review of Resident #28's MDS (Minimum Data Set- a federally required nursing assessment) annual assessment, dated 2/20/25, revealed the resident had limited range of motion in the upper and lower extremities and required substantial/maximal physical assistance for bed mobility, transfers, personal hygiene, and toileting. Further review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure resident funds were deposited into the resident's trust account for 1 resident (#31), out of 21 sampled residents. This failed practice resulted in the resident not having access to their personal funds which violated the resident's right to manage his/her financial affairs. Findings: Record review from 5/18-22/25 revealed Resident #31 was admitted to the facility with diagnoses that included legal blindness. During an interview on 5/18/25 at 1:10 PM, Resident #31 stated the last time money was put into his/ her account, he/she had not been able to access it. The resident further stated the funds were deposited over a month ago. When Resident #31 asked about the funds, the facility assured him/her that it was available. Review of Resident #31's Receipt, dated 3/27/25, revealed: Deposit to trust fund, for $200.00. Review of Resident #31's Trust Statement, dated 3/31/25, revealed no deposit of $200.00 was listed. Review of Resident #31's Resident Fund Management Service Statement, with a statement period of 2/20/25 to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to: 1) Provide written information related to bed holds at the time of transfer for 2 residents (#'s 48 and 90), out of 4 residents assessed for hospitalization; and 2) Document a physician's order for discharge for 1 resident (#90), out of 3 closed records reviewed. These failed practices: 1) had the potential for the residents to be displaced from their room or incur charges they would not be aware of from the facility; and 2) created an incomplete medical record. Findings: Resident #48 Record review on 5/18-22/25 revealed Resident #48 was admitted to the facility with diagnoses that included type 2 diabetes mellitus (non-insulin-dependent diabetes), end stage renal disease (a condition in which kidney function is less than 10% of normal; the kidneys can no longer remove wastes, concentrate urine, and regulate electrolytes), hemiplegia (a condition in which half of the body is paralyzed) and hemiparesis (partial paralysis of one side of the body)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure activities of daily living (ADLs) were provided to maintain good personal hygiene for 3 dependent residents (#'s 4, 19, and 40), out of 21 sampled residents. Specifically, the facility failed to assist residents with oral hygiene and bathing as specified in the plan of care. This failed practice had the potential to place residents at risk of poor outcomes from lack of hygiene, infection, and a decreased sense of self-worth. Findings: Resident #4 Record review on 5/18-22/25 revealed Resident #4 was admitted to the facility with diagnoses that included dysphagia (difficulty swallowing), rheumatoid arthritis (autoimmune disorder that affected the joints), and depression. Review of Resident #4's Minimum Data Set (MDS - A federally required assessment) quarterly assessment, dated 1/7/25, revealed Resident #4 had an impairment of the upper limbs. Resident #4 was dependent on staff for his/her shower transfers. Review of Resident #4's Care Plan Report, dated 3/15/25, revealed: .Focus: ADL Self Care Performance Deficit r/t…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure residents received the necessary care and services to monitor for and prevent the development of pressure ulcers for 3 sampled residents (#28, #51, and #492), out of 21 sampled residents. Specifically, the facility failed to: 1) Accurately assess and monitor for wounds for Resident #28; and 2) Consistently turn and reposition 2 residents (#51 and #492). These failed practices had the potential to place the residents at risk for unnecessary pain, increased risk of infection, skin breakdown, and impair the residents' overall health and wellbeing. Findings: Accurately Assess and Monitor Skin Resident #28 Record review on 5/18-22/25 revealed Resident #28 was admitted to the facility with diagnoses that included non-Alzheimer's dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking), Parkinson's disease (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination), heart failure (inability of the heart to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, revealed the facility failed to ensure 1 unsampled resident (#60) was free from accident hazards. This failed practice had the potential to cause an accident that may have resulted in resident injury. Findings: Record review on 5/18-22/25 revealed Resident #60 was admitted to the facility with diagnoses that included non-traumatic subarachnoid (the space in the brain where cerebrospinal fluid circulates) hemorrhage, hemiplegia (paralysis of one side of the body), and hemiparesis (one sided muscle weakness). Review of Resident #60's Care Plan Report, initiated on 3/11/25, revealed: Requires assistance . for transferring from one position to another r/t [related to]: Cognitive deficit, Decreased strength Provide two persons for supervision/physical assist with mechanical aid or transfer belt. An observation on 5/18/25 at 11:05 AM, Resident #60 was lying in bed. Certified Nursing Aide (CNA) #7 provided Resident #60's personal cares. During the cares, CNA #7 inserted a ceiling lift sling behind the Resident and hooked the sling to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, observation, and interview, the facility failed to ensure safe and appropriate administration of enteral nutrition (the introduction of nutrients directly into the stomach by a soft plastic feeding tube surgically implanted directly through the abdomen) and medication was free of possible complications for 1 sampled resident (#51) and 1 unsampled resident (#77), out of 2 residents reviewed with feeding tubes. Specifically, the facility failed to: 1) Check Resident #51's gastric residual volume prior to initiating enteral nutrition; 2) Ensure Resident #51's head-of-bed remained elevated to an angle of 30 degrees or higher during active feeding; 3) Follow a physician order for flushing Resident #51's feeding tube before and after medication administration; and 4) Use non-contaminated enteral tubing for Resident #77's enteral nutrition. These failed practices placed the residents at risk for aspiration, tube occlusion, infection, and other gastrointestinal complications. Findings: Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, observation, and interview, the facility failed to provide necessary respiratory care and services for 2 sampled residents (#2 and #28), out of 21 sampled residents, and 1 resident (#89), out of 3 closed records reviewed. Specifically, the facility failed to: 1) Properly monitor and assess Resident #2's, and #89's supplemental oxygen use; and 2) Ensure written physician orders were in place for oxygen use for Resident #28 and #89. These failed practices placed the residents at risk for not receiving necessary oxygen therapy and not having oxygen therapy appropriately monitored for effectiveness. Findings: Resident #2 Record review on 5/18-22/25 revealed Resident #2 was admitted to the facility with diagnoses that included vascular dementia unspecified severity, without behavioral disturbance (problems with blood flow to the brain, resulting in brain tissue damage), anxiety, and dependence on supplemental oxygen. An observation on 5/19/25 at 9:08 AM, revealed Resident #2 received 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview the facility failed to ensure orders for residents' care were provided for 2 sampled residents (#28 and #31), out of 21 sampled residents, and 1 resident (#89), out of 3 closed records reviewed. This failed practice had the potential to place the residents at risk for not receiving the necessary care and services to maintain their highest practicable physical well-being. Findings: Oxygen Orders Resident #28 Record review on 5/18-22/25 revealed Resident #28 was admitted to the facility with diagnoses that included non-Alzheimer's dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking), Parkinson's disease (a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination), heart failure (inability of the heart to maintain adequate blood circulation), and hypertension (repeatedly elevated blood pressure). An observation on 05/18/25 at 12:07 PM, revealed Resident #28 was receiving 2 liters per minute (LPM) of humidified oxygen through a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, interview, and observation, the facility failed to ensure that licensed nursing staff had appropriate competencies, and skill sets necessary to care for resident's needs for 3 residents (#'s 49, 51, and 77), out of 21 sampled residents. Specifically, nursing staff failed to ensure: 1) Medication parameters were met before administration of medications for Resident #49; 2) Approved vital sign equipment was used for resident care in the Nenana cottage; 3) Resident #51's gastric residual volume was checked prior to initiating enteral nutrition; 4) Resident #51's head-of-bed remained elevated to an angle of 30 degrees or higher during active feeding; 5) A physician's order for flushing Resident #51's feeding tube before and after medication administration was followed; 6) Sterility was maintained during tracheostomy care for Resident #51; and 7) Non-contaminated enteral tubing was used for Resident #77's enteral nutrition. These failed practices represented significant deviations from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure drug regimen review irregularities documented by the pharmacist had a documented review and response from the attending physician and/or medical director for 1 resident (#31), out of 5 residents reviewed for medication regimen reviews. This failed practice placed the resident at risk for adverse outcomes related to the resident's medication therapy, which had the potential to prevent the resident from achieving their highest practicable level of physical, mental and psychosocial well-being. Findings: Resident #31 Record review on 5/18-22/25 revealed Resident #31 was admitted to the facility with diagnoses that included anxiety disorder, delusional disorder (a mental health condition characterized by persistent delusions), and bipolar disorder (mental health condition characterized by alternating episodes of emotional highs and lows, significantly affecting mood, energy, and daily functioning). Review of Resident #31's medication order, start date of 3/1/25, revealed: . QUEtipine Fumarate [Seroquel - an antipsychotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation and interview, the facility failed to ensure 2 sampled residents (#36 and #47), out of 21 sampled residents, and 2 unsampled residents (#49 and #56), were free from significant medication errors. These failed practices caused an adverse reaction of low blood pressure for resident #49 and placed these residents at risk of possible serious complications and hospitalization. Findings: Resident #36 Record review on 5/18-22/25 revealed Resident #36 was admitted to the facility with diagnoses that included unspecified dementia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side (paralysis on one side of the body due to a stroke), and type 2 diabetes (insulin dependent diabetes). Review of Resident #36's insulin orders revealed: Lantus [long-acting insulin] Solostar Subcutaneous [placing the needle between the skin and muscle, injecting medication into the fatty layer between the muscle and skin] Solution Pen-injector 100 unit/mL [milliliters] - Inject 14 unit[s] subcutaneously one time a day Diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide or obtain dental services to meet the needs of 1 resident (#31), out of 21 sampled residents. This failed practice placed the resident at risk for not receiving the necessary care and services to maintain his/her highest practicable physical well-being. Findings: Record review on 5/18-22/25 revealed Resident #31 was admitted to the facility with diagnoses that included legal blindness, and disorder of teeth and supporting structures. During an interview on 5/18/25 at 1:24 PM, Resident #31 stated he/she was having dental pain intermittently. The resident put in a request to see a dentist about two months ago but had not heard anything more about it. Review of Resident #31 provider's progress note, dated 4/28/25, revealed, . [Resident#31] would like to go to the dentist, has broken tooth . Poor dentition . [Resident #31] will return to dentist when [he/she] feels [he/she] is ready to tolerate further extractions. -please schedule appointment for f/u extractions . Review of Resident #31's medical record revealed there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food in the kitchen at Susitna and Talkeetna Cottages were prepared, distributed, and served in accordance with professional standards of food safety for 3 residents (#s 29, 37, and 84), out of 19 residents who were receiving food from these kitchens. This failed practice placed the residents at risk of eating contaminated food and at risk of contracting foodborne illness. Findings: Susitna Cottage: During a continuous observation on 5/18/25, from 11:34 AM through 11:51 AM in the Susitna kitchen, revealed at 11:43 AM, [NAME] #2 scooped cooked chicken and corn mixture unto the plate, served the plate to Resident #37 and began to feed the resident. While [NAME] #2 was feeding Resident #37, the pans of cooked chicken and cooked corn mix was set on top of a stove uncovered. This surveyor asked Licesned Nurse (LN) #12 who entered the kitchen about the uncovered pans. LN #12 notified [NAME] #2, who rushed to the kitchen and covered the pans at 11:51 AM. During an interview on 5/21/25 at 9:23 AM, when this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure: 1) A urinary catheter (a medical device that helps drain urine from the bladder) bag was hung in a manner to remain clean and sanitary for 1 resident (#19), out of 10 residents with indwelling catheters (a tube inserted through the urinary tract into the bladder, connected to a drainage bag); 2) Sterile technique was maintained during tracheostomy care and suctioning for 1 resident (Resident #51), out of 1 resident reviewed for tracheostomy care; 3) Appropriate implementation of droplet precautions for 1 resident (Resident #71), out of 1 resident reviewed for infection control precautions; 4) Safe infection control practices were followed during enteral tube feeding administration for 1 residents (Resident #77), out of 2 residents reviewed for tube feedings; and 5) Food was prepared and served under sanitary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure: 1) stored drugs and biologicals were in locked compartments to protect them from unauthorized personnel; and 2) separately locked, permanently affixed compartments for storage of controlled drugs were maintained. Specifically, the medication carts in two out of eight cottages (Kenai and Aniak Cottages) were not secured when Licensed Nurses (LNs) were not in sight of the carts. This failed practice had the potential to allow for diversion and unauthorized access to medications that could have affected the health and safety of all residents in Kenai and Aniak Cottages. Findings: Kenai Cottage A continuous observation, with a concurrent interview, on 3/17/25 from 12:23 PM to 12:49 PM, revealed the Kenai Cottage's medication cart was positioned outside of room [ROOM NUMBER] and had the right top two drawers opened and unlocked. It was noted that room [ROOM NUMBER]'s door was closed, and the LN was nowhere in the vicinity. At 12:27…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to honor the rights to choose his/her attending physician for 1 Resident (#3), out of 1 resident reviewed. This failed practice denied the resident the right to choose his/her physician or provided the opportunity for the resident to work with the facility to seek alternate physician participation if his/her choice was unavailable. Findings: Record review on 11/25-26/24 revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included stage 3b chronic kidney disease (mild to moderate damage to the kidneys), hypertension (high blood pressure), and diabetes. During an interview on 11/25/24 at 9:55 AM, Resident #3 stated that he/she had, since admission to the facility, asked to be seen and work with a Medical Doctor (MD) instead of a Nurse Practitioner (NP). Resident #3 stated he/she had never worked with an NP and preferred an MD to address his/her care and treatments. Resident #3 stated that he/she had repeatedly asked the NP to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to ensure regular follow up care by a nephrologist (medical doctor who specializes in kidneys) for 1 Resident (#3), out of 1 resident reviewed. This failed practice had the potential to cause the resident to miss needed kidney treatment and care, which had the potential to affect the resident's kidney function and overall health. Findings: Record review on 11/25-26/24 revealed Resident #3 was admitted to the facility on [DATE] with a diagnoses that included 3b chronic kidney disease ( mild to moderate damage to the kidneys), hypertension (high blood pressure), and diabetes. During an interview on 11/25/24 at 9:55 AM, Resident #3 stated, .from April [2024] I had been asking about going to my kidney doctor, but nothing was ever done . Review of Resident #3's Nephrology consultation report, dated 9/26/23, revealed a recommendation by the Nephrology provider stating .follow-up with Nephrology at least every 3 months. Review of Resident #3's medical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Specifically, from 6/21/24 to 7/15/24 there was no full-time DON for the facility. This failed practice, of not having a full-time DON to provide oversight of nursing staff, including scheduling, responsibilities, and support, placed all residents (based on a census of 93) at substantial risk for subquality of care. Findings: During an interview on 7/10/24 at 3:26 PM, the Administrator stated the DON's last full-time day was 6/21/24 and went to a schedule of coming to the facility Monday through Friday, 4:00 AM to 6:00 AM and then coming back in the afternoon if needed. Also, the DON would work Saturday and Sunday 6:00 AM to 12:00 PM or 2:00 PM depending on need. The Administrator stated a new DON was hired and his/her start date was 7/29/24. When asked for a timesheet accounting of the exact hours the DON worked weekly, from 6/21/24 to present, through the kronos system (time keeping system that tracked working hours of an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation, and record review, the facility failed to: 1) ensure a dignified dining experience for all who received cooked meals in the Aniak Cottage (based on a census of 12); and 2) respond in a timely manner for assistance for two residents (#34 and #92), out of 20 sampled residents. These failed practices placed the residents at risk for psychological harm from loneliness, feelings of poor self-esteem and a potential for a poor quality of life. Findings: Aniak Cottage Dining During an interview on 7/8/24 at 9:27 AM, Certified Nurse Assistant (CNA) #10 stated that the cottage did not have a home keeper (cook) that day for the cottage. When the cooks are short staffed, the meals for the cottage were prepared in another cottage and placed in separate disposable Styrofoam clamshell food containers labeled with the resident's room number and brought over. The CNA and licensed nurse (LN) would serve the meals. During an observation on 7/8/24 at 11:59 AM, an open cart, containing disposable Styrofoam clamshell food containers, was brought into the cottage by [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, and observation, the facility failed to ensure 2 residents (#34 and #39), out of 20 sampled residents, were able to make choices that were important to them. This failed practice had the potential to affect all residents by denying them the right to make choices that effect their care and quality of life. Findings: Resident #34 Record review on 7/8-12/24 and 7/15-19/24 revealed Resident #34 was admitted to the facility with diagnoses that included Parkinson's disease (a chronic and progressive movement disorder that affects the nervous system and causes movement problems, such as tremors, stiffness and slowed movements), congestive heart failure (a chronic condition where the heart doesn't pump blood as effectively as it should) and weakness. During an interview on 7/8/24 at 1:50 PM, Resident #34 stated that he/she was at the mercy of the staff. He/she stated that he/she would like to shower every night before bed but he/she was told the facility policy was to shower twice a week. The resident stated that his/her shower days were Wednesdays and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation, and record review, the facility failed to provide a homelike dining experience for all residents who received cooked meals in the Aniak cottage (based on a census of 12). This failed practice had the potential to cause a sense of being institutionalized, resulting in diminished self-worth and a reduced sense of well-being. Findings: During an interview on 7/8/24 at 9:27 AM, Certified Nurse Assistant (CNA) #10 stated that the cottage did not have a home keeper (cook) that day for the cottage. When the cooks were short staffed, the meals for the cottage were prepared in another cottage, placed in separate disposable Styrofoam clamshell food containers labeled with the resident's room number, and brought over. The CNA and licensed nurse (LN) would serve the meals. During an observation on 7/8/24 at 11:59 AM, an open cart, containing disposable Styrofoam clamshell food containers, was brought into the cottage by [NAME] #1. [NAME] #1 placed all containers on the kitchen counter. At 12:02 PM [NAME] #1 left the cottage. The CNA and LN began serving the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide written notice which specified the duration of the bed-hold policy and the reserve bed payment policy for 3 residents (#'s 13, 76, and 93), out of 20 sampled residents, who were transferred to the emergency department (ED) for medical treatment. This failed practice had the potential for residents to be uninformed of the facility's bed-hold and reserve bed payment policy, placing them at risk for losing their beds at the facility due to an extended stay at the hospital. Findings: Transfer Process Record review on 7/8-12/24 and 7/15-19/24 revealed the facility utilized a form called Resident Transfer Form Emergency Department whenever a resident was transported to the ED for evaluation and/or treatment. The form had two parts: 1) the original form, which was white, to which nurses documented on and sent to the ED with the resident; and 2) a carbon copy page, which was yellow, that was torn off and kept at the facility, which was placed in the resident's hard chart (or paper only) medical record. Resident #13 Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to ensure the comprehensive care plan: 1) included the listing of potential serious side effects of medications used, to ensure monitoring was established for resident safety, for 1 resident (#13), out of 20 sampled residents; and 2) included smoking interventions, for resident and cottage safety, for 1 resident (#92), out of 20 sampled residents. These failed practices had the potential to: 1) place the resident #13 at risk for a delay in identifying serious side effects that could affect the resident's health and wellbeing; and 2) place the Aniak Cottage (based on a census of 11) at risk for potential smoke and fire exposure. Findings: Resident #13 Record review on 7/8-12/24 and 7/15-19/24 revealed Resident #13 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis (weakness or paralysis of one side of the body) following a cerebral infarction affecting left non-dominant side and acute kidney failure. Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, interview, and observation, the facility failed to ensure all treatments and care were provided for 4 Residents (#'s 35, 39, 48 and 82), out of 20 sampled residents. This failed practice placed the residents at risk of decreased overall health and wellbeing. Findings: Resident #35 Record review on 7/8-12/24 and 7/15-19/24 revealed Resident #35 was admitted to the facility with diagnoses that included other paralytic syndrome following subarachnoid hemorrhage, bilateral (a paralysis after a brain hemorrhage) and essential hypertension (high blood pressure). Further review revealed the resident was verbal, confused about time, had a short attention span, and needed assist with transferring. A double-sided padded mitten had been placed on the right hand to prevent the resident from injuring him/herself. Review of Resident #35's physician orders, dated 2/8/24, revealed the double-sided padded mitten was to be removed and the resident was to be checked every 2 hours for adverse effects.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, interview, and observation, the facility failed to facilitate the necessary treatment and services to promote healing, prevent infections, and prevent new pressure ulcers for 3 residents (#'s 39, 48, and 82), out of 9 sampled residents with pressure ulcer wounds. This failed practice caused pressure injuries for Residents #39 and #82 and impaired Resident #39, #48, and #82's overall health and wellbeing, which had the potential to create the need for hospitalization. Findings: Resident #39 Record review on 7/8-12/24 and 7/15-19/24 revealed Resident #39 was admitted to the facility with diagnoses that included Quadriplegia, C5-C7 Complete (paralysis of the body from the neck down) and Neurogenic Bowel (loss of normal bowel function due to a nerve or spinal cord problem). Further review revealed the resident was verbal, had a suprapubic catheter (medical device that helps drain urine from your bladder through a surgical opening in abdomen), had a colostomy (a surgical opening through the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to maintain accurate contents of dialysis communication binders consistent with professional standards of practice, which was shared between the facility and off-site dialysis centers, for 3 unsampled residents (#'s 40, 54, and 61) and 3 sampled residents (#'s 65, 83, and 87), out of 6 residents who receive off-site dialysis services. This failed practice had the potential to place the residents at risk for inconsistent care, potential for medication errors/interactions, and miscommunication between facilities which could affect overall resident wellbeing and outcome. Findings: Record review on 7/8-12/24 and 7/15-19/24 revealed there were a total of six residents in the facility that required off-site dialysis services. Each resident had scheduled dialysis treatments at a dialysis center off campus and had a dialysis communication binder that accompanied them to each treatment and was used as a communication tool between the facility and the dialysis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, interview, and observation, the facility failed to: 1) ensure personal protective equipment (PPE) was worn during wound care for 1 resident (#48), out of 9 wound care records reviewed; and 2) ensure proper hand hygiene was performed and completed during wound care treatments for 1 resident (#82), out of 4 wound care treatments observed. This failed practice created potential risk for infection in the wounds, decreased wound healing, and resident well-being. Findings: Resident #48 Review on 7/8-12/24 and 7/15-19/24 revealed Resident # 48 was admitted to the facility with diagnoses that included diabetes mellitus, multiple CVA's (cerebrovascular accident - strokes), resulting in severe expressive aphasia (defect or loss of the power of expression by speech, writing, or signs, or of comprehending spoken or written language, due to injury or disease of the brain centers), severe dysphagia (difficulty swallowing), right sided hemiparesis (partial paralysis of one side of the body), and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the attending provider monitored changing medical status for 1 resident (#48), out of 20 sampled residents. Specifically, Medical Provider #4 failed to monitor weekly laboratory tests that he/she ordered and failed to respond to critically abnormal laboratory results from those tests. This failed practice placed the resident at risk for decompensation and a delay in intervening treatment, which had the potential to create the need for hospitalization. Findings: Record review from 7/8-12/24 and 7/15-19/24 revealed Resident #48 was admitted to the facility with diagnoses that included diabetes mellitus, multiple cerebrovascular accidents (CVA's), severe expressive aphasia (defect or loss of the power of expression by speech, writing, or signs, or of comprehending spoken or written language, due to injury or disease of the brain centers), severe dysphagia (difficulty swallowing), right sided hemiparesis (partial paralysis of one side of the body), and failure to thrive (weight loss of more than 5%, decreased appetite,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and interview, the facility failed to accurately maintain, dispense, and have accountability of controlled drugs for 1 unsampled resident (#54) who received dialysis, out of 6 dialysis residents reviewed. Specifically, the facility sent the controlled drug oxycodone (an opioid pain medication) with the resident when he/she went to dialysis, which inhibited the facility's control and accountability for this medication. This failed practice placed the resident at risk for not receiving this medication and increased the risk of possible loss or diversion of the medication. Findings: Review of Resident #54's most recent MDS assessment, a quarterly assessment dated [DATE], revealed active diagnoses that included end stage renal disease, hypotension of hemodialysis (low blood pressure during dialysis), chronic pain syndrome, and dementia. Resident #54 had a physician's order for dialysis, dated 5/29/24. Resident #54 was to be transported to the dialysis center every Tuesday, Thursday, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to: 1) discard expired medical supplies in the Nenana cottage; and 2) remove and replace expired medication for 1 resident (#93), out of 12 residents reviewed for medication. These failed practices: 1) placed the residents of the Nenana cottage (based on a census of 11) at risk of receiving expired medical supplies and experiencing potential adverse reactions; and 2) placed resident #93 at risk for not having therapeutic emergent medication during a medical emergency. Findings: Nenana Cottage An observation, during the Nenana cottage tour, on 7/12/24 at 8:20 AM, revealed: 1) Medication supply storage room: - 1- BD Secondary Set (vented/nonvented), MS3500-15, intravenous (IV) tubing secondary set; manufacture expiration date was 4/21/24. - 3- BD MaxGuard Extension Set (microbore), ME2020, IV tubing; manufacture expiration date was 12/21/23. - 2- BD MaxGuard Extension Set (microbore), ME2020, IV tubing; manufacture expiration date was 12/20/23. - 1- BD MaxGuard Extension Set (microbore), ME2020, IV tubing; manufacture expiration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure sufficient dietary support staff were available to safely and effectively carry out the functions of the food and nutrition services in 1 cottage (Aniak), out of 8 cottages sampled. This failed practice placed all residents in the Aniak cottage (based on a census of 12), who received meals from the kitchen, at risk to be served meals that did not meet their needs and cause a less than optimal dining experience. Findings: Random observations on 7/8/24 in the Aniak cottage, revealed there was no Home Keeper (cook) working in the kitchen. During an interview on 7/8/24 at 9:27 AM, Certified Nurse Assistant (CNA) #10 stated there was no cook assigned to the Aniak Cottage that day. During an observation and interview on 7/8/24 at 12:04 PM, Resident #34 was sitting in his/her room, at his/her bedside table with a disposable Styrofoam clamshell food container containing the resident's lunch. Resident #34 stated that the food was cold, but it was no use to call someone to warm it up as it might be forgotten in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation, and record review, the facility failed to ensure food and drinks were prepared at a safe and appetizing temperature for 1 resident (#34) in the Aniak cottage (out of 12 residents in the cottage), and all residents who received meals prepared in the Deska cottage (based on a census of 11), out of 8 sampled cottages. Failure of the food to be at a palatable temperature had the potential to lower consumption and place the residents at risk for decreased nutritional intake and/or weight loss. Findings: Aniak Cottage: During an interview on 7/8/24 at 9:27 AM, Certified Nurse Assistant (CNA) #10 stated that the cottage did not have a home keeper (cook) that day for the cottage. When the cooks are short staffed, the meals for the cottage were prepared in another cottage, placed in separate disposable Styrofoam clamshell food containers labeled with the resident's room number, and brought over. The CNA and licensed nurse (LN) would serve the meals. During an observation on 7/8/24 at 11:59 AM, an open cart, containing disposable Styrofoam clamshell food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure: 1) food was stored under proper sanitary conditions and stored at safe temperatures for the Aniak and Yukon cottages, out of 4 cottages observed, and 2) staff wore hairnets consistently when in the kitchen for the Matanuska and Kenai cottages, out of 4 cottages observed. This failed practice placed all residents who received food from the affected kitchens, based on a census of 46, at risk for foodborne illness and communicable disease. Findings: 1) Food Storage Aniak Kitchen and Storage area: An observation on 7/8/24 at 9:17 AM, revealed the following food and beverages issues on the initial inspection of the kitchen and food storage areas: Main Kitchen and Refrigerator: - 1 pack - 14 oz Kirkland Black Forest Ham, open package, no open date; - 1 partial container - Glenview Farms Whipped Butter Blend Margarine, no open date. - 1 - uncovered oatmeal in a disposable Styrofoam bowl; - 1 bottle - Kirkland Organic Raw & Unfiltered Honey, no open date; - 3 partial bags - Denali [NAME] Bread, no open date;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and interview, the facility failed to ensure expired medical supplies were removed from cottage #2 nurse chart room. This failed practice placed the residents of cottage #2 at risk of receiving expired supplies. Findings: An observation on [DATE] at 9:45 AM of the cottage #2 nurse chart room revealed: - One 250 ml bag, 0.9 % sodium chloride injection usp, expired 3/2023; - Five prevantics patient preoperative skin preparation (chlorhexidine gluconate 3.15% and isopropyl alcohol 70% swab), expired 1/2023 During an interview on [DATE] at 9:46 AM, the Licensed Nurse (LN) Supervisor #1 stated that there was no designated staff member responsible for checking expiration dates of supplies. All staff should have checked expiration dates of supplies and discarded as needed before use on residents.

Based on record review, observation, and interview, the facility failed to ensure 1 resident (#8), out of 20 sampled residents, was treated in a dignified manner that respected individuality. Specifically, the facility failed to provide a dignified dining experience. This failed practice placed the resident at risk for psychosocial harm such as feelings of poor self-esteem and/or self-worth. Findings: Record review on 4/10-14/23 revealed Resident #8 was admitted to the facility with diagnoses that included multiple sclerosis (a disease that affects the central nervous system), dysphagia (trouble swallowing), and gastroparesis (a condition affecting normal stomach movements). During an observation on 4/11/23 at 9:40 AM, Resident #8 was observed having breakfast in his/her bed area. Certified Nursing Assistant (CNA) #4 was assisting the resident to eat. The CNA was standing over the resident while feeding the resident his/her meal. Further observations during the meal revealed CNA #4 had scraped food from the side of Resident #8's mouth with the spoon, then fed the scraped food back…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 1 resident (#56) out of 5 sampled residents 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: Record review from 4/10-14/23 revealed Resident #56 was admitted to the facility with diagnoses that included depression and Schizophrenia. Review of Resident #56's current Physician Orders, revealed: Order date 7/21/22, Mirtazapine 30 MG Tablet (1 tablet/30 mg) by mouth QHS [every evening] for Depression. Order date 4/3/23, Perphenazine 4 MG Tablet (2 tablet/8 mg) by mouth QAM [every morning] for Schizophrenia. During an interview on 4/14/23 at 1:07 PM, the Director of Nursing (DON) was unable to locate the risks and benefits assessments for the ordered Mirtazapine and Perphenazine in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to provide reasonable accommodation of needs for 2 Residents (#83 and #86), out of 20 sampled residents. Specifically, the facility failed to ensure the resident's call light device was within reach. This failed practice placed the resident at risk for not being able to call for help or assistance if needed. Findings: Resident #83 Record Review from 4/10-14/23 revealed Resident #83 was admitted to the facility with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis following cerebral infarction (oxygen deprivation to the brain) affecting the left non-dominant side, seizures, and dementia. An observation with concurrent interview on 4/11/23 at 10:04 AM, revealed Resident #83 lying in bed with the call light device hanging close to the floor on the Resident's right side out of reach. A follow-up observation with concurrent interview on 4/12/23 at 3:11 PM, revealed Resident #83 lying in bed with the call light device hanging close to the floor on the Resident's right side out of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure 1 resident (#'s 29) out of 20 sampled residents lived with comfortable sound levels in their bedroom. Specifically, excessive noise from medical equipment interfered with the resident's hearing and the sound levels were out of the resident's control. This failed practice denied the resident a homelike environment and placed the resident at risk for psychological harm. Findings: Record review from 4/10-14/23 revealed Resident #29 was admitted to the facility with diagnoses that included diabetes, renal (kidney) insufficiency and high blood pressure. Further review of the resident's most recent MDS (Minimum data set- a federally required assessment) dated 2/16/23, revealed the resident had not transferred between surfaces (bed to chair) for the 7 day look back period, meaning the resident had not left his/her room during that time. During an observation and interview on 4/11/23 at 1:12 PM, Resident #29 was observed lying on his/her Hillrom synergy bed, an air pump was located at the foot of the bed which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a follow-up communication to the resident or resident representative (RR) to resolve a grievance was conducted. Specifically, the facility failed to provide a resolution letter after missing property was reported for 1 resident (#51) out of 20 sampled residents. The failure to follow the grievance process denied residents and/or their representatives the ability to exercise their rights by filing grievances and receiving written resolutions of investigations. Findings: During an interview on 4/11/23 at 11:02 AM, Resident #51's representative (RR) stated the Resident had 2 iPADs (a small portable computer). The RR stated one of the iPADs had been missing since 12/2022. The RR stated he/she had reported to Licensed Nurse (LN) #6, but there was no response from the facility. Review of the facility's policy Resident Concerns and Grievances, dated 4/2023, revealed: .all residents have the right to file concerns and receive prompt resolution .if the resident verbalizes the concern, yet declines to complete a form, it is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation and interview, the facility failed to ensure 1 resident (#70), out of 2 residents sampled for restraints, 1) had a mitten restraint removed per the frequency of the physician's orders and 2) interventions were developed and implemented to potentially reduce the use of the mitten restraint. These failed practices had the potential to increase the resident's agitation and anxiety and deny the resident from attaining their highest practicable well-being. Findings: Record review from 4/10-14/23 revealed Resident #70 was admitted to the facility with diagnoses that included persistent vegetative state, respiratory failure requiring a tracheostomy (a surgical opening made into the trachea, a curved plastic tube is placed through the opening allowing air to flow in and out) and malnutrition requiring a Percutaneous endoscopic gastrostomy tube (PEG tube -a feeding tube inserted into the stomach). Removal of the mitten restraint: During a continuous observation on 4/11/23 from 9:30 AM to 10:42 AM, Resident #70 was lying in bed with a mitt covering his/her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to failed to notify the State Long-Term Care Ombudsman (LTCO) of transfers and discharges in a timely manner for 2 Residents (#51 and #86), out of 20 sampled residents. This failed practice did not afford these residents their right for continued advocacy and support provided by the LTCO. Findings: Resident #51 During an interview on 4/11/23 at 10:42 AM, Resident #51's representative stated the Resident had previous hospitalizations. Review of the Minimum Data Set (MDS-a federally required nursing assessment) revealed there were 3 discharge assessments dated 12/2/22, 2/2/23, and 2/27/23. Review of Resident #51's medical record revealed the Resident was admitted to the hospital on the following dates: 12/2-12/23, 2/2-6/23, and 2/27-3/8/23. Resident #86 During an interview on 4/11/23 at 9:01 AM, Resident #86's representative stated that Resident #86 went to the hospital for a month. Review of the MDS revealed there was 1 discharge assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, and observation, the facility failed to ensure the baseline care plan/ resident daily care plan (RDCP) and comprehensive care plan were consistent with residents care needs for 1 resident (#83), out of 20 sampled residents . This failed practice placed the resident at risk for not receiving necessary services to address his/her individual needs. Findings: Record Review from 4/10-14/23 revealed Resident #83 was admitted to the facility with diagnoses that included hemiplegia (paralysis of one side of the body) following cerebral infarction (lack of oxygenation to the brain) affecting the left non-dominant side. An observation on 4/12/23 at 3:11 PM, revealed Resident #83 lying in bed watching television with both upper bed side rails up and the lower side rails were down. The upper side rails were one continuous rail beginning from the head of the bed extending the length of the arm. The lower side rails began below the waist and extended to the foot of the bed. Review of Resident #83's Baseline Care Plan/RDCP, dated 4/12/23, revealed: .Put LEFT…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the comprehensive care plan was updated to meet the needs of 1 resident (#7) out of 20 sampled residents. This failed practice had the potential to cause an inconsistent provision of treatment and services. Findings: Record review on 4/10-14/23 revealed Resident #7 was admitted with diagnoses that included chronic respiratory failure, unspecified whether with hypoxia (low levels of oxygen in body tissue) or hypercapnia (abnormally high levels of carbon dioxide); and anoxic brain damage (damage to brain due to lack of oxygen). Review of the Minimum Data Set (MDS, a federal mandated nursing assessment) significant change of condition, dated 3/14/23, revealed the resident was on hospice. Review of the care plan for the facility, dated 3/7/23, revealed hospice care was not addressed. Review of the medical record revealed a Skilled Nurse admission for Evaluation for Hospice dated 3/7/23 with a hospice benefit period of 3/7/23 - 6/4/23 with a verbal order received by the physician on 2/28/23. Further review of the record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to provide activities of daily living, specifically, nail care for 1 resident (#83), out of 20 sampled residents. This failed practice placed the resident at risk for poor outcomes from lack of hygiene and potential risk for infection. Findings: Record Review from 4/10-14/23 revealed Resident #83 was admitted to the facility with diagnoses that included hemiplegia (paralysis of one side of the body) following cerebral infarction (lack of oxygenation to the brain) affecting the left non-dominant side. Review of Resident #83's MDS (Minimum Data Set, a federally required nursing assessment) Annual Assessment, dated 3/1/23, Section G revealed extensive assistance for personal hygiene and a one-person physical assist. During a phone interview on 4/11/23 at 9:38 AM, Resident # 83's Representative stated Resident #83's hands had smelled of poop and the fingernails were long and dirty at visits. An observation on 4/11/23 at 10:05 AM, revealed Resident #83's fingernails were long and dirty on both hands, with the left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure: 1) the physician's PRN (as needed) orders for an antipsychotic medication had not exceeded 14 days; and 2) the prescribing practitioner evaluated the resident prior to ordering the medication for 1 resident (#87), out of 5 residents sampled for unnecessary medications. These failed practices placed the resident at risk for adverse effects and/or reaction from potentially unnecessary medications. Findings: Record review from 4/10-14/23 revealed Resident #87 was admitted to the facility with diagnoses that included unspecified dementia with behavioral disturbance and post-traumatic stress disorder. Review of Resident #87's most current physician orders revealed the Resident was prescribed the medication Quetiapine (an antipsychotic medication), with a start date of 4/12/23, on a PRN basis to be discontinued after 14 days (end date 4/25/23). Further review revealed on 11/21/22, Resident #87 had an order for the Quetiapine PRN with a start date of 11/21/22 and an end date of 1/30/23, a period consisting of 71 days.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review the facility failed to ensure the quality of laboratory services. Specifically, 1) control solutions for the glucometer used in cottage #2 were not labeled with open dates when in use; and 2) lab supplies in cottage #1 and #2 were expired. These failed practices had the potential to affect resident testing results. Findings: An observation on [DATE] at 9:45 AM of cottage #2 nurse chart room revealed: - 3 yellow top blood tubes, expired on [DATE]; - 4 light blue top blood tubes, 3 expired on [DATE] and 1 expired on [DATE]; - 1 gray top with powder blood tube, expired on 5/22; - 1 gray top with gel blood tube, expired on [DATE] An observation on [DATE] at 9:45 AM of supplies in cottage #2 nursing chart room revealed, two sets of controls opened for the Accu Check Inform II Meter (glucometer- a blood glucose testing device). One set of controls was on the counter near the glucometer charging station. The expiration date on the box was [DATE]. No open dates for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review, the facility failed to ensure food was protected from cross contamination during distribution. Specifically, meals were delivered uncovered to 6 residents (#'s 11; 68; 89; 33; 80; & 56) out of 12 residents in Cottage #1. This failed practice had the potential for contamination of the food items and placed residents at risk for foodborne illness. Findings: A continuous observation on 4/13/23 from 11:36-11:44 AM revealed Certified Nurse Assistant (CNA) #1 delivered lunch to Residents #11, #68 and #89 in their rooms. The food items were uncovered. An observation on 4/13/23 at 11:50 AM revealed CNA #2 delivered lunch to Resident #33 in his/her room. The food items were uncovered. An observation on 4/13/23 at 11:57 AM revealed CNA #2 delivered lunch to Resident #80 in his/her room. The food items were uncovered. An observation on 4/13/23 at 12:07 PM, revealed CNA #1 delivered lunch to Resident #56 in his/her room. The food items were uncovered. During an interview on 4/13/23 at 3:02 PM, the Infection Preventionist stated food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a sanitary environment for 10 Residents (#'s 11; 29; 33; 51; 56; 61; 68; 70; 86; and 89) out of a census of 96 residents. This failed practice had the potential to increase the development and transmission of communicable disease and infections. Findings: Resident #29 During an observation on 4/12/23 at 1:23 PM, Licensed Nurse (LN) #2 assisted Certified Nursing Assistant (CNA) #3 with repositioning Resident #29 onto his/her left side. LN #2 left the bedside and donned (put on) new gloves without performing hand hygiene, walked over to a chair by the Resident's dresser and began opening and preparing wound dressing supplies. Next, LN #2 returned to Resident #29's bedside and removed a soiled bed pad and brief. While wearing the same gloves, LN #2 removed a Mepilex dressing (a dressing to protect broken or fragile skin) from the resident's sacral (lower back) area, walked over to the trash can and threw away the used Mepilex. Then LN #2, while wearing the same soiled gloves, picked up a stack of clean 4x4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.