Centennial Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Anchorage, Alaska.
- Location
- 9100 Centennial Drive, Anchorage, Alaska 99504
- CMS Provider Number
- 025025
- Inspections on file
- 32
- Latest survey
- December 24, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Centennial Post Acute during CMS and state inspections, most recent first.
Two residents were discharged without adequate planning, resulting in unsafe and inappropriate transitions. One was sent home to an inaccessible and unsafe environment without necessary support or services, leading to distress, a fall, and reliance on unplanned third-party assistance. Another was discharged despite unresolved behavioral and cognitive issues, without required mental health referrals or involvement of their representative, causing distress and confusion. The facility lacked documented discharge planning standards and failed to coordinate essential post-discharge care.
A resident with dementia, depression, anxiety, and other complex conditions was admitted without the PASRR Level II report being available or reviewed. The facility did not initiate specialized mental health services as required, delayed updating the care plan, and discharged the resident without addressing PASRR-identified needs or following recommended discharge options. This resulted in untreated behavioral symptoms and increased psychotropic medication use.
A resident with complex medical needs developed multiple pressure ulcers and infections due to the facility's failure to provide timely and consistent wound care interventions, delayed care planning, poor documentation of noncompliance, and lack of coordination for higher-level wound care referrals. Discrepancies between wound care provider recommendations and actual treatment orders, as well as improper antibiotic administration in relation to dialysis, contributed to persistent wound infection and ultimately led to hospitalization with sepsis and death.
Systemic failures in the QAPI program led to ongoing deficiencies in staffing, grievance procedures, activities, medication management, and therapy services. Residents experienced long wait times for assistance, were not properly informed about grievance processes, and were not consistently offered activities as documented in their care plans. Incomplete narcotic count documentation and lapses in therapy services further contributed to suboptimal care.
Two residents did not receive care according to physician orders and care plans. One resident with hypertension and heart failure had daily vital signs ordered but only had them documented twice over several months. Another resident with skin breakdown risk had orders for offloading boots and wound care that were not implemented, as observed during the survey. Facility policies required adherence to these orders and care plans.
A resident with dementia and a documented POA was discharged without the facility providing the Notice of Medicare Non-Coverage (NOMNC) to the POA or obtaining the POA's signature. Instead, the NOMNC was signed by the resident, and there was no documentation that the POA was informed of appeal rights prior to discharge.
Two residents did not receive comprehensive, person-centered care plans addressing their specific needs. One resident with dementia and behavioral symptoms lacked dementia-related interventions in the care plan, despite documented diagnoses and medication use. Another resident, identified as high risk for falls after spinal surgery, did not have fall-risk interventions documented in the care plan and subsequently experienced a fall. Facility assessments and policies required these care plans, but they were not implemented.
A resident with cognitive impairment and a history of exit-seeking behaviors, who was on wander guard precautions, was able to leave the facility undetected after staff failed to respond to an activated wander guard alarm. The resident exited through the front door, took a cab to a local store, and was missing for over two hours before being returned by members of the public. Facility policies lacked clear instructions for staff response to wander guard alarms, contributing to the delayed intervention.
A resident with significant mobility impairments and recent spinal surgery did not receive ordered physical therapy for an extended period when the facility's PT went on leave. Despite ongoing physician orders for skilled PT, services were interrupted for several days, with no documented updates to care plans or formal notification to the resident or their representative. Facility staff confirmed the lapse and lack of documentation regarding communication or order changes during the interruption.
Surveyors found expired and/or opened medications and medical supplies on multiple medication and treatment carts, including items with illegible expiration dates. Staff confirmed these items should have been discarded. Additionally, emergency medications were stored in a refrigerator with temperatures above the recommended range, and temperature logs showed inconsistent monitoring and documentation.
A resident with multiple diagnoses, including diabetes and neuropathy, had a wound on the left shin that was reclassified from diabetic to vascular in wound care notes. However, the most recent MDS assessment did not reflect the presence of a venous or arterial ulcer, as required. The facility had relied on a contracted wound care provider for wound classification and later identified issues with incorrect wound categorization.
Two residents did not receive care in accordance with professional standards and their care plans when staff failed to notify the physician and document interventions after significant changes in condition, including a leaking G-Tube and acute hypotension with altered mental status. Improvised repairs and lack of timely escalation led to missed care and increased risk for complications.
A resident with multiple chronic conditions continued to receive Santyl ointment for wound care after the medication was discontinued in the updated care plan. Staff administered the ointment thirteen times following the change, and observation confirmed ongoing use despite the revised orders. The Resident Care Manager acknowledged that Santyl should have been stopped according to the new wound care instructions.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
Staff did not consistently follow physician orders or honor a resident’s preferences and goals, resulting in care that was not aligned with the resident’s individualized needs and directives.
The facility did not report abuse allegations involving two residents to the State Survey Agency within the required two-hour timeframe, as confirmed by staff interviews and record review. This delay was not in accordance with the facility's policy and placed all residents at risk for continued potential abuse.
The facility did not provide documentation that required interventions, such as alert charting and skin assessments, were completed during investigations of alleged abuse for three residents with complex medical needs. Although these interventions were listed in the incident reports, electronic medical records did not contain evidence that they were performed, as confirmed by staff interviews.
A resident with dementia, aphasia, and parkinsonism was involved in an altercation where they struck another resident after being prompted to dress appropriately in a common area. Despite this behavioral incident, the care plan was not updated to include interventions or monitoring for aggression, contrary to facility policy and staff acknowledgment that a review was warranted.
A resident with cognitive and physical impairments, including a history of wandering and exit-seeking, was found alone in a wheelchair on the elevator at the basement level, an area restricted to staff. The elevator required a code for access, but once entered, allowed unsupervised resident use. There was no formal protocol for staff regarding elevator use with residents, and the facility's policy did not address this specific risk, resulting in inadequate supervision and unauthorized access.
A resident with epilepsy and anoxic brain damage did not receive their prescribed Valproic Acid due to unavailability, leading to multiple seizures and hospitalization. The facility failed to follow procedures for medication shortages, and there was no evidence of communication with the physician or pharmacist. The hospital confirmed that the lack of medication led to the seizures, and the facility's policies on medication administration and reporting were not adhered to.
A resident with epilepsy and other medical conditions did not receive multiple doses of Valproic Acid due to the facility's failure to manage medication inventory and reorder in time. This led to the resident experiencing seizures and requiring hospitalization. The facility did not follow its policy to notify the physician when vital medication doses were missed.
A resident with epilepsy did not receive multiple doses of Valproic Acid due to unavailability, leading to seizures and hospitalization. The facility failed to reorder the medication in time and did not notify the physician about the missed doses, resulting in a significant medication error.
A resident with epilepsy was hospitalized after missing multiple doses of Valproic Acid due to the facility's failure to reorder the medication. The incident was not reported to the State Survey Agency within the required timeframe, and the facility's policies on medication administration and reporting were not followed. The resident experienced seizures and was transferred to the emergency room, where it was confirmed that the lack of medication led to the seizures.
A resident with epilepsy experienced multiple seizures and was hospitalized after missing several doses of Valproic Acid due to the medication's unavailability. The facility failed to investigate the incident thoroughly and report it to the State Survey Agency within the required timeframe. Interviews revealed inadequate inventory management and communication regarding the medication's availability, contributing to the deficiency.
The facility failed to ensure medications and medical supplies in two storage rooms and two medication carts were unexpired. Expired items, including Sodium Chloride Injection, Glucose Control Solutions, Dextrose Injection, eSwab Collection kits, Vancomycin Injection, and GeriCare Zinc, were found during observations. Interviews with the DON and nurses confirmed these items should have been removed or returned to the pharmacy, contrary to the facility's Medication Storage policy.
The facility failed to maintain food safety and sanitation standards in its kitchen operations. Observations revealed improperly stored and unlabeled food items, unsanitary conditions in the pureed station, and failure to check food temperatures during preparation. Staff acknowledged these deficiencies, which were not in compliance with the facility's food preparation policy.
The facility failed to ensure that both patient care and non-patient care related electrical equipment underwent regular preventative maintenance inspections. Numerous pieces of equipment, including oxygen concentrators, nebulizers, and space heaters, were found without maintenance stickers or with outdated stickers, indicating a lack of recent maintenance. This oversight was acknowledged by the Director of Business Development, and the facility's policy lacked documentation on preventative maintenance procedures.
A resident with ESRD and hypertensive chronic kidney disease did not receive dialysis care consistent with professional standards. Staff repeatedly took blood pressure on the resident's right arm, which has an AV fistula, against care plan instructions. Additionally, anti-hypertensive medication was not administered as ordered, and pre- and post-dialysis assessments were frequently missing.
The facility failed to maintain the dignity and respect of residents by not covering urinary catheter bags and not providing a dignified dining experience. A resident was wheeled through a public space with an uncovered catheter bag, and another was seen with an uncovered bag in a community area. Additionally, a resident with dementia and schizophrenia was observed discarding food and not offered alternatives, despite care plan requirements. These actions were contrary to facility policies on preserving dignity and supporting daily living activities.
Three residents were found self-administering medications without proper evaluations, placing them at risk. One resident with myocardial infarction and diabetes used ear drops without a physician's order. Another with hemiplegia applied ointment independently, contrary to the physician's order. A third resident with asthma self-administered an inhaler and artificial tears, with no documented evaluation. The facility failed to conduct necessary assessments for self-administration.
The facility failed to maintain a homelike environment in resident rooms, affecting three residents. A resident's bathroom was used to store large cardboard boxes for holiday decorations. Another resident's room had a cracked cable outlet face plate, while a third resident's room had a face plate that was not secured to the wall, hanging loosely by the cable. The Director of Business Development acknowledged these issues.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential inadequate care planning. One resident was incorrectly documented as being on hospice, while another was inaccurately noted as having no natural teeth. Errors were acknowledged by the MDS nurse, highlighting a lapse in adherence to the facility's policy on certifying assessment accuracy.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. A resident with end-stage renal disease had their blood pressure taken on the arm with an AV fistula, contrary to care plan instructions, and missed doses of hypertension medication. Another resident, diagnosed with multiple conditions, was not assisted to be up in their wheelchair daily as per their care plan. Staff interviews revealed confusion about responsibilities, and the Kardex did not reflect care plan interventions.
The facility failed to update care plans for two residents, leading to potential risks. A resident with a foley catheter did not have it included in their care plan, and another resident's care plan inaccurately included a focus on morphine use despite the absence of an active order. The facility's policies for care plan updates were not followed.
A resident with Korean as their primary language faced communication barriers due to the facility's failure to provide necessary translation services and materials. Despite the resident's need for communication aids and translated documents, staff were unaware of or did not utilize the available interpreting services, impacting the resident's quality of life and ability to engage in activities of daily living.
A facility failed to provide a resident-centered activity program for a non-verbal, bed-bound resident with multiple health conditions. Despite a care plan indicating preferences for activities, no documented activities were provided, and interactions were limited to brief check-ins. The activities director and assistant did not offer activities, relying on outdated information and non-verbal cues to assess interest, contrary to facility policy.
A facility failed to conduct a quarterly smoking assessment for a resident with quadriplegia who smoked marijuana, with the last evaluation being several months overdue. Additionally, a crash cart in the Spruce Court unit was obstructed by Christmas decorations and a wheelchair, potentially delaying emergency response. The Director of Business Development confirmed the obstruction was inappropriate.
A resident with heart failure, type II diabetes, and Parkinson's disease was prescribed duplicate SGLT-2 inhibitors, Dapagliflozin and Empagliflozin, due to a breakdown in the facility's medication regimen review process. Despite pharmacy alerts, the medications were not discontinued until later, highlighting a lapse in communication and follow-up by the nursing staff and provider.
A facility failed to provide nutritious food substitutions for a resident with multiple diagnoses, including vascular dementia and schizophrenia. The resident expressed hunger and dissatisfaction with the meal provided, discarding it without being offered alternatives. Despite the care plan's directive to offer supplements or alternatives if intake was less than 50%, no additional food or drink was provided. This failure potentially compromised the resident's nutritional status.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure that residents were discharged in a manner that protected their health, safety, and psychosocial well-being. Specifically, the facility did not develop or implement an effective discharge planning process for two residents, resulting in unsafe and inappropriate discharges. The facility lacked documented standards for discharge planning, relying instead on verbal expectations within the social services department. Discharge planning was limited to care conferences at admission and two weeks prior to discharge, with no ongoing reassessment or structured involvement of resident representatives. The facility also did not conduct home visits prior to discharge, and referrals for post-discharge services and equipment were inconsistently arranged or delayed. One resident was discharged to a home environment that was known to be unsafe and inaccessible, without adequate caregiver support or required services in place. The resident, who had a history of joint replacement surgery, infection, and a recent femur fracture, required wound care, mobility assistance, and ongoing medical follow-up. Despite the resident's home being multi-level, in disrepair, and infested with rodents, the facility proceeded with discharge planning that did not ensure safe access or adequate support. The resident was left reliant on unplanned third parties, such as the fire department and community members, for essential care and experienced distress, emotional harm, and physical compromise, including a fall after discharge. Another resident with cognitive impairment, acute behavioral changes, and a documented need for nursing facility level care and specialized mental health services was discharged without required referrals or representative involvement. The facility did not review or incorporate the resident's PASRR Level II findings into the discharge plan, nor did it address a documented change in condition on the day of discharge. As a result, the resident experienced distress, confusion, and loss of security, with the POA having to assume unplanned caregiving responsibilities to prevent harm. The failures in discharge planning led to actual physical and psychosocial harm for both residents.
Failure to Incorporate PASRR Level II Findings into Care and Discharge Planning
Penalty
Summary
The facility failed to comply with PASRR (Pre-admission Screening and Resident Review) requirements by not incorporating the PASRR Level II determination into the assessment, care planning, and discharge planning for a resident with multiple mental health diagnoses. The PASRR Level II evaluation, which identified the need for continued nursing facility services and specialized mental health services, was not available at the time of admission and was not reviewed during the resident's stay or at discharge. The Level II report was only retrieved after the resident had already been discharged, and its recommendations were not integrated into the resident's care plan or discharge process. The resident in question had a complex medical history, including dementia, depression, anxiety, delirium, encephalopathy, and a recent femur fracture with surgical site infection. The PASRR Level II assessment specifically noted the need for specialized services to address mental health needs and provided recommendations for care and discharge options. Despite these findings, the facility did not order or initiate any specialized mental health services during the resident's stay. The care plan was delayed and, when eventually updated, did not include the specialized services recommended by the PASRR Level II evaluation. Throughout the resident's admission, there were documented episodes of aggression, combativeness, and non-compliance, which led to the initiation and escalation of psychotropic medications. The discharge summary and post-care instructions did not address the need for specialized mental health services or follow the recommended discharge options outlined in the PASRR Level II report. Facility staff acknowledged that the lack of access to and review of the PASRR Level II report negatively impacted the adequacy of care planning and discharge for the resident.
Failure to Provide Appropriate Pressure Ulcer Care and Timely Interventions
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with a facility-acquired pressure ulcer. The resident, who had significant comorbidities including end-stage renal disease and diabetes, developed multiple wounds during their stay, including a left iliac crest pressure injury and sacral wounds. There were significant delays and inconsistencies in wound assessment and treatment orders, with documented discrepancies between wound care provider recommendations and the actual orders transcribed and implemented by nursing staff. For example, wound care interventions recommended by the wound care team were not consistently reflected in the Treatment Administration Record (TAR), and antibiotics were not always administered as prescribed, particularly in relation to the resident's dialysis schedule, resulting in subtherapeutic dosing. Documentation revealed that wound care interventions were not promptly added to the resident's care plan, with a delay of 21 days after wounds were first identified. There was also a lack of documentation regarding the resident's reported noncompliance with repositioning and wound care, as noted by the wound care provider, with no corresponding nursing or CNA notes, risk/benefit documentation, or care plan updates to address these issues. Additionally, there was a failure to initiate and document referrals for higher-level wound care as recommended by external providers, and the facility did not coordinate or document efforts to ensure the resident attended outpatient wound care or follow-up appointments, despite family requests and external provider recommendations. Throughout the resident's stay, wound healing was minimal, and infections persisted despite multiple rounds of antibiotics, which were at times administered incorrectly or not as ordered. The lack of timely and appropriate wound care interventions, poor communication and documentation among staff, and failure to coordinate necessary higher-level care contributed to the resident's hospitalization with sepsis and subsequent death. The facility's actions and inactions directly resulted in a deficiency related to the provision of pressure ulcer care and prevention of new ulcers.
Systemic QAPI Failures Result in Multiple Deficiencies Across Facility Operations
Penalty
Summary
The facility failed to develop, implement, and maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, analyzed, and corrected systemic quality deficiencies. Despite collecting data from various sources such as electronic health records, staffing reports, maintenance logs, and resident council feedback, the QAPI committee did not effectively use this information to identify trends, prioritize high-risk issues, or implement and sustain corrective actions. This resulted in ongoing patterns of deficient practice in areas including staffing, grievance process, clinical care, activities, medication management, therapy services, discharge planning, environmental conditions, and care planning. Internal reports, resident council concerns, medical record documentation, staffing data, and direct observation all indicated these issues, but they were not recognized or acted upon through the QAPI process. Staffing deficiencies were evident, particularly on weekends, where staffing levels consistently fell below the facility's own assessment standards. Payroll Based Journal (PBJ) data and review of staffing schedules showed that the number of nurses, CNAs, and restorative aides scheduled was frequently less than the minimum required. Residents reported long wait times for assistance, with one resident waiting over two hours to be helped out of bed, and another experiencing delays in having a urinal emptied. Resident council meeting minutes repeatedly documented concerns about inadequate staffing and slow response times, with little evidence of effective facility response or improvement. The administrator and QAPI committee were not aware of the low weekend staffing, relying instead on reports that did not reflect actual staffing shortages. Additional deficiencies included failures in the grievance process, where residents were not properly informed of the current grievance officer, and posted information was outdated. Residents and council members were unaware of the new grievance officer, and there was no documentation of her introduction or updated contact information. The activities program was also deficient, with multiple residents reporting that they were not offered or able to participate in activities as documented in their care plans and assessments. Activity flowsheets showed minimal or no activity participation or offers for extended periods. Medication management was compromised by incomplete narcotic count documentation, with missing required signatures in narcotic logbooks across multiple units and months. Physical therapy services were not provided as ordered for a resident due to staff absence, with no evidence of alternative arrangements or continuity of care.
Failure to Follow Physician Orders and Care Plans for Vital Signs and Pressure Reduction
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and person-centered care plans for two residents. For one resident with a history of hypertension, heart failure, and transient ischemic attack, there was a physician's order for daily vital signs and an order for antihypertensive medication. However, record review showed that vital signs were only documented twice over a period of 177 days, despite the daily order. The acting DON confirmed that daily monitoring should have occurred, and facility policy required vital signs to be monitored as ordered for residents on antihypertensive medications. For another resident with diagnoses including weakness, mild cognitive impairment, and osteoarthritis, there were orders for wound care to leave the left heel open to air and to use offloading boots for the left lower extremity. Observation revealed the resident was lying in bed with both heels on the mattress and covered by non-skid socks, with no offloading boots in place. The care plan did not include interventions for keeping the left heel open to air or for the use of offloading boots, and a licensed nurse confirmed the order for heel boots. Facility policy required care plans to reflect services necessary to maintain the resident's highest practicable well-being and to follow recognized standards of practice.
Failure to Provide NOMNC to Resident's POA
Penalty
Summary
The facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) was provided to and signed by the legally authorized Power of Attorney (POA) for a resident who had documented dementia and a legal POA with authority over insurance and government benefit decisions. Instead, the NOMNC was signed by the resident, whose signature did not match their legal name, and there was no documentation that the POA was informed of the notice or the associated appeal rights prior to discharge. The facility's process, as described by the Director of Social Services (DSS) and Social Services Coordinator (SSC), was to review the NOMNC with the POA and obtain their signature if the resident had a POA, but this was not followed in this case. Record review confirmed that the POA was listed as the resident's agent in the medical record and that the POA was not provided the NOMNC paperwork or informed of appeal rights before discharge. The POA stated in an interview that they were unaware of the appeal rights and would have considered appealing the discharge decision. The DSS acknowledged that the NOMNC was signed by the resident and not the POA, and there was no documentation of the notice being reviewed with the POA.
Failure to Develop and Implement Comprehensive Care Plans for Dementia and Fall Risk
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with identified needs. For one resident with a diagnosis of unspecified dementia and behavioral disturbances, the care plan did not address dementia-related interventions. Despite multiple medical records and provider notes indicating a history of dementia and the use of antipsychotic medication for behavioral symptoms, the resident's MDS did not code for dementia, and the care area of cognitive loss/dementia was not triggered or addressed in the care plan. The facility's own dementia clinical protocol requires the interdisciplinary team to identify and document resident-centered care plans for individuals with confirmed dementia, but this was not followed in this case. For another resident with a history of spinal surgery, radiculopathy, and spinal stenosis, assessments upon admission identified the individual as a moderate to high risk for falls. The Morse Fall Assessment and nursing observations documented impaired gait, non-ambulatory status, and dependence on a wheelchair or geri-chair for mobility. The resident's MDS triggered the care area of falls, but the care plan did not include any interventions or documentation addressing fall risk. Subsequently, the resident experienced a fall while attempting to use the bathroom independently, resulting in pain and further medical evaluation. Interviews with facility staff confirmed that care plans should have included interventions for both dementia and fall risk based on assessments and diagnoses. Facility policies require comprehensive, person-centered care plans with measurable objectives and interventions derived from thorough assessments. However, these requirements were not met for the two residents, as evidenced by the lack of appropriate care planning and documentation for their specific needs.
Failure to Respond to Wander Guard Alarm Leads to Resident Elopement
Penalty
Summary
A deficiency occurred when a resident identified as high risk for elopement, with diagnoses including a displaced hip fracture, chronic kidney disease, schizophrenia, and anxiety, was not adequately supervised despite being on wander guard precautions. The resident had a documented history of exit-seeking behaviors and was assessed as cognitively impaired and unable to make independent decisions. The care plan included interventions such as the use of a wander guard, routine checks of the device, and monitoring for elopement risk, but did not specify staff response protocols for wander guard alarms. On the day of the incident, the resident left the facility by calling a cab and was able to exit through the front door. Although the wander guard alarm was triggered, staff did not respond to the alarm, and there was no one present at the front desk to intervene. The absence of immediate action allowed the resident to leave the premises undetected for approximately two and a half hours. Staff only became aware of the resident's absence when attempting to deliver medications and meals, at which point a search was initiated. The resident was eventually found stranded at a local store by members of the public and returned to the facility. Review of facility policies revealed that while the use of wander guards and care plan updates were required, there was a lack of clear guidance on staff roles and required actions when a wander guard alarm was activated. This contributed to the delayed response and failure to prevent the resident's elopement.
Failure to Provide Ordered Physical Therapy Services During Therapist Leave
Penalty
Summary
The facility failed to ensure continuity of ordered physical therapy (PT) services for a resident with significant mobility and functional limitations, including radiculopathy, spinal stenosis, and a recent lumbosacral spinal fusion. The resident was admitted with orders for skilled PT five times per week for four weeks, with specific goals and interventions outlined in the physician's plan of care. Documentation showed that after the facility's physical therapist went on leave, PT services were not provided for 12 calendar days (8 business days), despite no modifications, discontinuation, or suspension of the physician's orders during this period. Interviews with facility staff, including the Director of Rehabilitation and the Regional Director of Clinical Nursing Services, confirmed that PT services were interrupted due to the therapist's leave and that efforts to secure a replacement were ongoing during the lapse. There was no documentation that residents or their representatives were formally notified of the interruption, nor were care plans or physician orders updated to reflect the change in services. The facility's assessment indicated that they provide rehabilitative services to meet resident needs, but during this period, the ordered PT services were not delivered as required.
Expired Medications and Improper Storage Temperatures Identified
Penalty
Summary
Surveyors observed that the facility failed to properly store and label medications and medical supplies. Specifically, expired and/or opened medications and supplies were found on multiple medication and treatment carts, including hypodermic safety needles, Diclofenac Sodium Topical Gel, IV start kits, C-Pantoprazole suspension, Aspirin tablets with an illegible expiration date, Nitroglycerin tablets, glucose gels, wound care products, and COVID-19 antigen test kits. Staff interviews confirmed that these items were expired or opened and should have been discarded, and that faded expiration dates made it impossible to determine if some medications were still safe for use. Additionally, the facility failed to maintain emergency medications under safe temperature control. Review of the medication refrigerator temperature logs revealed numerous instances where temperatures were not documented, as well as several recorded temperatures above the recommended range of 36-46°F. On the day of observation, the refrigerator was found to be operating at 48°F and 51°F, and emergency medication kits containing various critical drugs were stored inside. Staff confirmed that temperature checks were not consistently performed and that out-of-range temperatures were not reported as required. Facility policy and FDA recommendations both require proper storage and temperature monitoring for these medications.
Failure to Accurately Code MDS for Vascular Wound
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded for a resident with a vascular wound. Record review showed that the resident was admitted with multiple diagnoses, including dementia, CVA with left-sided hemiparesis, obesity, chronic pain, diabetes mellitus type II, and neuropathy. Wound care notes initially described a wound on the left shin as a diabetic wound, but subsequent documentation reclassified it as a vascular wound. Despite this, the most recent MDS assessment did not code for venous or arterial ulcers under section M1030, even though the look-back period included the time when the wound was documented as vascular. Further review of the Resident Assessment Instrument (RAI) User's Manual confirmed that the presence of venous and arterial ulcers should be documented and used to inform the resident's care plan. During an interview, the Resident Care Manager stated that the facility had previously relied on a contracted wound care provider for wound classification and had discovered issues with incorrect classification of wounds. This led to the use of a different provider for more accurate wound identification. The failure to accurately code the MDS assessment for the resident's vascular wound constituted a deficiency in ensuring accurate assessment and documentation.
Failure to Notify Physician and Provide Standard Care for Changes in Condition
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice and resident care plans for two residents. For one resident with a gastrostomy tube (G-Tube), the nurse observed a leak around the tube and improvised a repair using rubber bands and masking tape instead of medical-grade equipment. The nurse did not notify the on-call provider or document the incident at the time, resulting in the resident being off tube feeds for several hours. The makeshift repair led to soiling and discoloration at the G-Tube site, with stagnate content present, increasing the risk for infection. Facility policy and adopted clinical procedures required immediate provider notification and proper documentation for such complications, which was not followed. Another resident with a history of heart failure, coronary angioplasty, and atrial fibrillation experienced a significant decline in condition, including acute hypotension, refusal of medications, food, and fluids, and altered mental status. The nurse documented the low blood pressure and change in mentation but did not notify the physician or document any provider notification. The resident's care plan specifically required monitoring for changes in cognitive status and prompt physician notification for observed changes or side effects of medication, including hypotension. Facility policy also mandated immediate physician notification and documentation for significant changes in condition or refusal of treatment, which was not done in this case. These failures to escalate care, notify the physician, and document interventions as required by facility policy and professional standards resulted in the residents not receiving timely and appropriate treatment and care. The deficiencies were identified through record review and staff interviews, with evidence showing that the required actions were not taken at the time of the incidents.
Failure to Discontinue Medication After Change in Wound Care Orders
Penalty
Summary
A deficiency occurred when the facility failed to discontinue a medication order after a change in wound care orders for one resident. The resident, who had multiple diagnoses including dementia, CVA with left-sided hemiparesis, obesity, chronic pain, diabetes mellitus type II, and neuropathy, was initially prescribed Santyl ointment for sacral wound care. The physician's order for Santyl was replaced with a new wound care regimen that no longer included Santyl. Despite this change, the facility continued to administer Santyl ointment for thirteen documented instances after the new order was in effect. Observation confirmed that a licensed nurse applied Santyl to the resident's sacral wound area even after the medication was discontinued in the updated care plan. Interview with the Resident Care Manager confirmed that the Santyl should have been discontinued following the revised wound care order. This failure resulted in the resident receiving unnecessary medication administrations that were not aligned with the current physician's orders.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that staff did not consistently follow prescribed care plans or honor the expressed wishes and goals of the resident. The lack of adherence to orders and resident preferences resulted in care that was not aligned with the individualized needs and directives for the resident at the time of the survey.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations for two residents out of a sample of twenty. In both cases, the facility did not report the allegations of abuse to the State Survey Agency within the required two-hour timeframe from the occurrence of the incidents. For one resident, the initial report of abuse was documented at 7:30 AM, but the report was not submitted to the State Agency until 11:30 AM. For the second resident, the initial report was made at 8:30 AM, but the State Agency was not notified until 11:20 AM. Both delays exceeded the facility's policy and regulatory requirement for reporting within two hours. Interviews with facility staff, including the Administrator and Resident Care Manager, confirmed awareness of the two-hour reporting requirement and acknowledged that the reporting in these cases was not timely. The facility's policy, revised in January 2023, clearly states that any suspicion of abuse or serious injury must be reported to the State Survey Agency within two hours. The failure to adhere to this policy and regulatory standard placed all residents at risk for continued potential abuse.
Failure to Document Abuse Investigation Interventions
Penalty
Summary
The facility failed to ensure that three Facility Reported Incidents (FRIs) involving allegations of abuse were thoroughly investigated for three residents. For each of these residents, the facility's final reports indicated that interventions such as alert charting and skin assessments were to be completed as part of the investigation process. However, upon review of the electronic medical records, there was no documentation found to support that these interventions were actually performed. Interviews with the Administrator confirmed that these interventions were considered part of the investigation, but the required documentation was not present in the residents' records. The residents involved had significant medical histories, including orthopedic aftercare, spinal fusion, hemiplegia following stroke, diabetes, hypertension, and foot drop. Despite the facility's policy requiring thorough investigation and documentation of all alleged abuse incidents, there was a lack of evidence that the specified interventions were carried out. This deficiency was identified through both record review and staff interviews, which consistently failed to produce documentation of the alert charting or skin assessments that were reported as completed in the FRIs.
Failure to Update Care Plan After Resident Aggression
Penalty
Summary
The facility failed to update and revise the care plan for a resident following an incident involving aggressive behavior. The resident, who had diagnoses including unspecified dementia, aphasia, and parkinsonism, was involved in a verbal altercation with another resident, during which the resident struck the other individual in the face. Nursing notes documented that the resident was walking in the dining area with only a shirt on, and after being asked to dress appropriately, the altercation occurred. Despite this significant behavioral event, the resident's comprehensive care plan, which had been initiated prior to the incident, was not updated to include new interventions or monitoring for escalating behaviors or potential aggression. Interviews with facility staff, including the DON, confirmed that the care plan should have been reviewed and revised after the incident, and that processes exist for reviewing care plans in cases of escalating behavioral issues. The facility's own policies require the interdisciplinary care team to analyze assessment information, identify risks, and implement targeted interventions, as well as to review and update care plans when there is a significant change in a resident's condition. However, the care plan for this resident did not reflect any changes or new interventions following the aggressive incident.
Resident with Cognitive Impairment Found Unsupervised in Restricted Area via Elevator
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments, including hemiplegia, hemiparesis, impaired thought processes, and a history of wandering and exit-seeking behaviors, was found unsupervised in a restricted area of the facility. The resident, who required supervision or assistance to wheel 150 feet in a corridor, was discovered alone in a wheelchair on the elevator at the basement level, an area designated as unauthorized for residents and accessible only to staff. The basement exit doors were observed to be unlocked, unmanned, and lacking alarms or monitoring, further increasing the risk of unauthorized access. Staff interviews revealed that the elevator required a code to access restricted floors, but once the code was entered, the elevator could be used by residents without supervision, allowing them to reach unauthorized areas. There was no specific protocol in place for staff regarding elevator usage with residents, and staff education on this topic was limited to verbal instructions during orientation. The facility's policy on safety and supervision emphasized both facility-wide and individualized approaches to accident prevention, but did not address the specific risks associated with elevator access for residents with cognitive impairments. The incident was not previously identified or addressed through the facility's Quality Assurance and Performance Improvement (QAPI) process. Staff acknowledged that while such incidents were rare, there was no formal policy to prevent residents from accessing restricted areas via the elevator, and supervision relied on staff escorting residents back when found. The lack of adequate supervision and security measures in this instance resulted in a resident with known risks being able to access an unauthorized and potentially hazardous area without staff awareness.
Failure to Administer Anticonvulsant Medication Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure the availability and administration of an anticonvulsant medication, Valproic Acid, for a resident with a history of anoxic brain damage and epilepsy. The medication was not administered on three occasions due to its unavailability, as noted in the Medication Administration Record and nursing notes. The facility's Director of Nursing stated that the procedure for unavailable medication involved contacting the provider, which was not done in this case. The resident subsequently experienced multiple seizure episodes, decorticate posturing, and nonresponsiveness, leading to hospitalization. The resident's medical records revealed that the Valproic Acid was not administered on specific dates, and there was no evidence that the nurses contacted the physician or pharmacist about the medication's unavailability. Interviews with facility staff, including the Director of Nursing and the Administrator, indicated a lack of communication and follow-up regarding the medication shortage. The facility's contracted pharmacy, PharMerica, did not receive a refill order for the medication during the time it was unavailable. The resident was hospitalized after experiencing seizures, and medical records from the hospital indicated that the lack of Valproic Acid led to the seizures. The hospital discharge summary emphasized the importance of not running out of the antiseizure medication again. The facility's policies on medication administration and unusual occurrence reporting were not followed, as the incident was not reported to the state, and the investigation into the missed doses was incomplete at the time of the survey.
Failure to Administer Anticonvulsant Medication Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide multiple doses of routine anticonvulsant medication to a resident as per the physician's order, leading to significant health complications. The resident, who had a history of hemiplegia, hemiparesis, anoxic brain damage, and epilepsy, was not administered Valproic Acid Oral Solution on three occasions due to the medication being unavailable. The nursing notes indicated that the medication was awaited from the pharmacy, but there was no evidence that the nurses contacted the physician or pharmacist about the unavailability. As a result of the missed doses, the resident experienced multiple seizure episodes, decorticate posturing, and nonresponsiveness, which required hospitalization. The hospital records indicated that the resident's valproic acid levels were undetectable, suggesting that the medication had been missed for longer than reported. The resident was treated with intravenous Ativan to manage the seizures and was subsequently discharged with a note emphasizing the importance of not running out of antiseizure medications again. The facility's medication management process was flawed, as evidenced by the lack of inventory for the resident's medication and the failure to reorder in a timely manner. Interviews with staff revealed that the facility relied on visual checks to determine when to reorder medications, and there was no leadership oversight during the holiday period when the medication ran out. The contracted pharmacy, PharMerica, did not receive a refill order, and the facility's policy required notifying the physician if two consecutive doses of a vital medication were withheld, which was not done in this case.
Failure to Administer Anticonvulsant Medication Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of an anticonvulsant medication, Valproic Acid. The resident, who had a history of hemiplegia, anoxic brain damage, and epilepsy, was supposed to receive Valproic Acid via a PEG-Tube twice daily. However, the medication was not administered on three occasions due to unavailability, as noted in the Medication Administration Record and nursing notes. The Director of Nursing indicated that the procedure for unavailable medication involved notifying the provider, but there was no evidence that the nurses contacted the physician or pharmacist about the missing medication. As a result of the missed doses, the resident experienced multiple seizure episodes, decorticate posturing, and nonresponsiveness, leading to hospitalization. The hospital records confirmed that the resident's valproic acid levels were undetectable, indicating that the medication had not been administered for longer than the reported 48 hours. The resident's condition improved with the administration of IV Ativan at the hospital, but the incident highlighted a significant lapse in medication management at the facility. Interviews with facility staff revealed that the medication was not reordered in a timely manner, and there was a lack of communication and documentation regarding the medication's unavailability. The facility's policy required that if two consecutive doses of a vital medication were withheld, the physician should be notified, which did not occur in this case. The facility's contracted pharmacy, PharMerica, confirmed that no refill order was received during the period when the medication was unavailable, contributing to the resident's adverse health outcome.
Failure to Report Missed Medication Doses Leads to Resident Hospitalization
Penalty
Summary
The facility failed to report an incident involving multiple missed doses of anticonvulsant medication for a resident, which resulted in multiple seizure episodes and subsequent hospitalization. The resident, who had a history of hemiplegia, anoxic brain damage, and epilepsy, was not administered Valproic Acid as prescribed on three occasions. The medication was unavailable due to a failure to reorder it in a timely manner, and there was no evidence that the nurses contacted the physician or pharmacist about the unavailability. The Director of Nursing (DON) and the Administrator were not immediately informed of the missed doses, and the incident was not reported to the State Survey Agency within the required timeframe. The facility's policy required that such incidents be reported within 24 hours, but this did not occur. The DON stated that the investigation into the missed doses was ongoing and had not been completed, and the Administrator confirmed that the missed medication was not discussed during the stand-up meeting on the day of the incident. The resident was transferred to the emergency room after experiencing seizure-like activity, and the hospital confirmed that the lack of medication led to the seizures. The facility's failure to maintain an adequate inventory of the medication and to follow proper reporting procedures contributed to the resident's hospitalization. The facility's policies on medication administration and unusual occurrence reporting were not adhered to, resulting in a delay in necessary actions and potential harm to the resident.
Failure to Investigate and Report Missed Medication Incident
Penalty
Summary
The facility failed to ensure that an incident involving multiple missed doses of anticonvulsant medication for a resident was thoroughly investigated and reported to the State Survey Agency within the required timeframe. The resident, who had a history of hemiplegia, anoxic brain damage, and epilepsy, was admitted to the facility with a physician's order for Valproic Acid to be administered twice daily via PEG-Tube. However, the medication was not administered on three occasions due to unavailability, leading to multiple seizure episodes and subsequent hospitalization. The facility's records indicated that the medication was not available due to a delay in delivery from the pharmacy, and there was no evidence that the nurses contacted the physician or pharmacist about the unavailability. The Director of Nursing stated that the investigation into the missed doses and hospitalization was ongoing, but it had not been completed 27 days after the incident. The facility's policy required that such incidents be reported within 24 hours, but the Administrator confirmed that the missed medication was not reported to the State Survey Agency in a timely manner. Interviews with facility staff revealed a lack of proper inventory management and communication regarding the medication's availability. The pharmacist confirmed that the amount of medication delivered would only last 11 days, yet no refill order was placed when the medication ran out. The facility's failure to investigate and report the incident promptly placed the resident at risk for further harm, as the missed doses of Valproic Acid were directly linked to the resident's seizures and hospitalization.
Expired Medications and Supplies Found in Facility
Penalty
Summary
The facility failed to ensure that medications and medical supplies in two medication storage rooms and two medication carts were unexpired. During observations, expired medications and supplies were found in the main medication storage room and [NAME] Court medication room, including Sodium Chloride Injection, Glucose Control Solutions, Dextrose Injection, and eSwab Collection kits. Interviews with the Director of Nursing (DON) confirmed that these items were expired and should have been removed from the shelves. Further observations revealed expired medications on the Birch Court and [NAME] Court medication carts, including Vancomycin Injection and GeriCare Zinc. Interviews with licensed nurses indicated that these expired medications should have been returned to the pharmacy. The facility's Medication Storage policy, dated January 2023, states that outdated medications should be immediately removed from stock and disposed of according to procedures, which was not adhered to in this instance.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food safety, as observed during a survey. In the main kitchen, several food items were improperly stored, including chicken nuggets and sausage patties in unsealed bags, and various trays of food without labels or dates. The refrigerator contained sliced fruits, vegetables, and cheese that were not properly covered, labeled, or dated, and some tomatoes were visibly spoiled. Additionally, the kitchen's large bin containers for rice and sugar were not properly sealed, and fresh produce was stored inappropriately in the dry storage area. The downstairs walk-in refrigerator and freezer also exhibited significant issues. Fresh produce was stored uncovered near a dusty evaporator coil, and the freezer had ice buildup affecting food packages. The pureed station was found to be unsanitary, with soiled equipment and surfaces, and food items were not labeled or stored correctly. The kitchen plating area was similarly unclean, with a visibly soiled food warmer and debris on the floor. During food preparation, staff failed to check food temperatures as required by the facility's policy, potentially compromising food safety. Interviews with staff revealed a lack of adherence to food safety protocols, such as labeling, dating, and proper storage of food items. Staff acknowledged the deficiencies, including the use of dented cans and the absence of temperature checks during food preparation. The facility's policy on food preparation and service, which mandates temperature monitoring, was not followed, indicating systemic issues in maintaining food safety standards.
Failure to Maintain Electrical Equipment in Safe Conditions
Penalty
Summary
The facility failed to maintain electrical equipment in safe operating conditions, as observed during a survey. Specifically, the facility did not ensure that all patient care related electrical equipment (PCREE) underwent regular, routine preventative maintenance (PM) inspections. Numerous pieces of equipment, including oxygen concentrators, nebulizers, aspirators, and enteral feeding pumps, were found without PM stickers or with outdated PM stickers, indicating a lack of recent maintenance. This oversight was acknowledged by the Director of Business Development. Additionally, non-patient care related electrical equipment (N-PCREE) such as fans, food processors, air purifiers, and space heaters were also found without maintenance inspection stickers. These items were observed in various resident rooms and common areas, and their lack of inspection posed potential safety risks. The Director of Business Development confirmed that these items had not been inspected for electrical and functional safety. The facility's policy on electrical safety for residents, dated 2001, was reviewed and found to lack documentation on preventative maintenance of PCREE, including expected intervals and procedures for maintenance. The absence of a comprehensive preventative maintenance policy contributed to the facility's failure to ensure the safety and functionality of both PCREE and N-PCREE, placing residents at risk of inadequate care and potential electrical hazards.
Deficient Dialysis Care and Monitoring
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident with end-stage renal disease (ESRD) and hypertensive chronic kidney disease. The resident's care plan specified that blood pressure should not be taken on the right arm, which has an arteriovenous (AV) fistula for dialysis access. Despite this, staff measured blood pressure on the right arm 140 times over a year. Additionally, the facility's policy and professional guidelines prohibit using the access arm for blood pressure readings, which was not adhered to by the staff. Furthermore, the facility did not administer anti-hypertensive medication, Hydralazine, as ordered on non-dialysis days, missing 116 opportunities to do so. The resident's care plan required the medication to be given when systolic blood pressure exceeded 150 or diastolic exceeded 90. Additionally, the facility failed to complete pre- and post-dialysis assessments on multiple occasions, as required by their policy and professional standards. These assessments are crucial for monitoring the resident's condition and response to dialysis treatment.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure the dignity and respect of two sampled residents and one unsampled resident by not covering urinary catheter bags and not providing a dignified dining experience. Resident #1, who was admitted with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and unspecified dementia, was observed being wheeled through a public space with an uncovered urinary catheter bag attached to their shower chair. Licensed Nurse #10 confirmed that the urinary bag should be covered in public spaces, as per the facility's policy on preserving resident dignity. Resident #96, diagnosed with benign prostatic hyperplasia and bladder-neck obstruction, was seen ambulating in a community space with an uncovered urinary catheter bag attached to their walker. This occurred in the presence of other residents and staff members. Licensed Nurse #11 acknowledged that the urinary catheter should have a privacy bag, aligning with the facility's policy and the resident's care plan, which indicated the need for a privacy cover to promote dignity. Resident #40, with diagnoses including vascular dementia and schizophrenia, experienced an undignified dining situation. During a meal, the resident was observed discarding food and drink into a garbage can and was not offered alternative food options. Despite the care plan indicating the need for monitoring and offering supplements if intake was less than 50%, the resident was not provided with additional food or drink during the observation period. The facility's policy on supporting activities of daily living emphasizes providing appropriate care and services, including dining, to prevent a decline in residents' conditions.
Failure to Evaluate Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that evaluations for self-administration of medication were completed for three residents, placing them at risk of adverse effects. Resident #14, admitted with myocardial infarction and diabetes mellitus, was observed self-administering ear drops without a physician's order. Licensed Nurse #1 confirmed the absence of an order in the electronic health record. Resident #83, with hemiplegia and hemiparesis, was found applying clobetasol propionate ointment independently, despite a physician's order indicating it should be applied by nurses. Resident #83 expressed a preference to self-administer, but no evaluation was documented. Resident #87, diagnosed with an infection, inflammatory reaction due to an internal fixation device, and asthma, was observed with an albuterol inhaler and artificial tears, which they self-administered. The physician's order allowed for these medications, but the electronic Medication Administration Record showed they were not administered by nurses. Licensed Nurse #1 confirmed the resident's preference for self-administration, yet no evaluation or interdisciplinary team notes were found to support this practice. The facility administrator acknowledged the lack of evaluations for self-administration for all three residents.
Failure to Maintain Homelike Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a homelike environment in resident rooms, affecting three unsampled residents. In Resident #34's room, six large cardboard boxes were stored in the bathroom, including one for the Birch Court's artificial Christmas tree and five for holiday decorations. The Director of Business Development (DBD) acknowledged that these boxes should not have been stored there. In Resident #47's room, the face plate to the cable outlet was found to be cracked. Similarly, in Resident #251's room, the face plate to the cable outlet was not secured to the wall and was loosely hanging, supported only by the attached cable. The DBD acknowledged these findings upon discovery.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, which could lead to inadequate care planning and services. Resident #37 was admitted with diagnoses including diabetes mellitus and multiple myeloma. The MDS Quarterly review assessment inaccurately indicated that the resident was on hospice care, despite a hospice discharge summary showing the resident was no longer receiving hospice services as of September. Interviews with the Nurse Practitioner and Licensed Nurses confirmed that the resident was not on hospice, and the MDS nurse acknowledged the error after reviewing the assessment. Resident #97 was admitted with a fracture of the right femur. The admission MDS inaccurately documented that the resident had no natural teeth, while an observation and interview revealed that the resident had all natural teeth. The MDS nurse admitted to using a previous charted assessment for the dental information and corrected the error during the survey. The facility's policy requires that any person completing any portion of the MDS assessment certifies the accuracy of the information, which was not adhered to in these cases.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for two residents, leading to deficiencies in their care. Resident #41, who was admitted with end-stage renal disease and had a right arm AV fistula, had their blood pressure taken on the right arm 140 times despite a care plan intervention stating not to do so. Additionally, there were 116 missed opportunities to administer Hydralazine, a medication prescribed for hypertension, on non-dialysis days when the resident's blood pressure exceeded specified limits. Resident #43, diagnosed with primary lateral sclerosis and other conditions, was observed to be bedbound and not leaving their bedroom area. The care plan indicated that the resident should be up in their wheelchair during lunchtime every day, but this was not happening. Interviews with staff revealed confusion about who was responsible for getting the resident out of bed, and the Kardex used by CNAs did not reflect the care plan intervention for daily wheelchair use. The facility's policy on care plans and Kardex usage was not followed, as direct caregivers did not have accurate information to properly care for the residents. The Director of Nursing and other staff members were aware of the care plans but did not ensure their implementation, leading to the deficiencies observed during the survey.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans to reflect the current level of care and services for two residents, which placed them at risk for not receiving necessary and appropriate care. Resident #1 was admitted with diagnoses including Type 2 Diabetes Mellitus with Chronic Kidney Disease and a Urinary Tract Infection. An observation revealed that Resident #1 had a foley catheter, but the care plan, last reviewed on 10/18/24, did not include any planning for the catheter. The Director of Nursing was unaware of the catheter, and the Resident Case Manager acknowledged that urinary catheters should have been included in the care plan. The facility's policy required comprehensive care planning for indwelling urinary catheters, which was not followed. Resident #18 was admitted with diagnoses including Parkinson's Disease, diabetes, and congestive heart failure. The care plan, last revised on 12/2/23, included a focus on the risk for constipation related to morphine use, despite the fact that Resident #18 had no active order for morphine since 8/14/23. The Director of Nursing confirmed that the care plan was inaccurate and should have been updated. The facility's policy required the Resident Care Manager to review and revise the care plan quarterly, which was not adhered to in this case.
Communication Barriers for Non-English Speaking Resident
Penalty
Summary
The facility failed to effectively communicate with a resident who primarily speaks Korean, which potentially impacted the resident's quality of life and ability to perform activities of daily living. The resident, who was admitted with conditions including an intraspinal abscess, osteoarthritis, incomplete paraplegia, and dementia, expressed a preference for reading the Bible and communicating through family members. However, the facility did not provide communication aids such as cards or boards in the resident's room, and the activities calendar was only available in English. Interviews with staff revealed a lack of awareness and use of the facility's interpreting services. A licensed nurse admitted to using a personal translation app instead of the official service, and the MDS nurse and Admission Coordinator were not utilizing available resources to provide documentation in the resident's language. The facility's policy on interpreter services was not effectively implemented, as evidenced by the absence of translated materials and the lack of communication support for the resident.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing resident-centered activity program for a resident diagnosed with multiple conditions, including primary lateral sclerosis, acute respiratory failure, and dysphagia. The resident was non-verbal and bed-bound, with a care plan indicating a preference for activities such as pet therapy, watching TV, and listening to music. Despite these preferences, there were no documented activities for the resident in the months leading up to the survey, and the activities director instructed staff not to document interactions under 30 minutes. Interviews with the resident's representative and facility staff revealed that the resident was not receiving adequate social stimulation or participation in activities. The activities assistant and director admitted that activities were not being offered to the resident, and interactions were often limited to brief check-ins. The resident's care plan and activity assessments were based on outdated information, and the current activities director was unsure how the resident's preferences were determined, as the resident was non-verbal. Observations confirmed that the resident was not engaged in any activities during visits from the activities staff. The activities assistant relied on the resident's lack of eye contact and grunting as indicators of disinterest, leading to the conclusion that the resident was not interested in activities. However, this approach did not align with the facility's policy, which emphasized individualized activity programs designed to encourage maximum participation based on the resident's needs and preferences.
Deficiencies in Smoking Assessment and Crash Cart Accessibility
Penalty
Summary
The facility failed to complete a quarterly smoking assessment for a resident who smoked marijuana. The resident, who had a history of concussion and quadriplegia, was admitted with a care plan indicating the need for smoking safety evaluations. However, the last recorded evaluation was dated several months prior, and no subsequent assessments were conducted. Interviews with staff and the resident confirmed that the resident smoked independently outside the facility, and the facility's administrator acknowledged the overdue evaluation. Additionally, the facility did not maintain accessibility to a crash cart in the Spruce Court unit, which could delay life-saving measures during emergencies. The crash cart was obstructed by Christmas decorations and an unoccupied wheelchair, as observed during a survey. The Director of Business Development confirmed that these items should not have been blocking the crash cart, indicating a lapse in ensuring emergency preparedness in the unit.
Failure to Prevent Duplicate Drug Therapy in Resident's Medication Regimen
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically by allowing duplicate drug therapy. Resident #25, who was admitted for rehabilitation services with diagnoses including heart failure, type II diabetes, and Parkinson's disease, was prescribed two SGLT-2 inhibitors, Dapagliflozin and Empagliflozin, which is a therapeutic duplication. Despite pharmacy notes and alerts recommending the discontinuation of one of these medications, both drugs continued to be administered to the resident from October 20, 2024, until December 11, 2024. The deficiency was further compounded by a breakdown in the facility's process for medication regimen reviews (MRR). The pharmacist conducted monthly reviews and communicated recommendations via email to the nursing staff and the Director of Nursing (DON). However, the DON failed to ensure that the recommendations were acknowledged and acted upon by the provider, as there was no documentation of provider sign-off for October 2024. The Nurse Practitioner (NP) involved admitted to not typically reviewing the hard copies of recommendations, which led to the oversight. This lapse in communication and follow-up resulted in the resident receiving unnecessary duplicate medications for an extended period.
Failure to Provide Nutritious Food Substitutions for Resident
Penalty
Summary
The facility failed to provide nutritious food substitutions to accommodate the preferences of a resident, identified as Resident #40, who was part of a census of 90 residents receiving meals from the kitchen. Resident #40 was admitted with multiple diagnoses, including acquired absence of other specified parts of the digestive tract, vascular dementia with psychotic disturbance, adult failure to thrive, and schizophrenia. During an observation in the dining area, Resident #40 expressed hunger and dissatisfaction with the food provided, ultimately discarding the meal. Despite the resident's refusal to eat and preference for culturally relevant foods and nutritional supplements like Ensure, no alternative food or drink was offered during the observation period. The resident's care plan indicated a need for supplements and encouragement of good nutrition and hydration, with specific instructions to offer supplements or alternatives if intake was less than 50%. However, the facility did not adhere to these care plan directives during the observed meal service. The facility's policy on supporting activities of daily living, including dining, emphasized providing appropriate care and services to prevent a decline in residents' ADLs unless unavoidable due to clinical conditions. The failure to offer alternative food options or supplements as per the care plan and policy potentially compromised the resident's nutritional status.
Latest citations in Alaska
A resident with ESRD and dependence on hemodialysis did not receive post-dialysis care according to physician orders, the care plan, and facility policy. The post-dialysis pressure dressing on the AV fistula was not documented as removed within the ordered timeframe, despite dialysis center instructions specifying timely removal. Although an LN later reported that the access site was bleeding and a dressing change was performed, the TAR documented the site as clear and nursing notes did not reflect any dressing change. Required shift assessments of the fistula site for bleeding, redness, and tenderness were not accurately documented, and there was no evidence that the physician was notified of the bleeding access site, contrary to facility policy and referenced CDC dialysis safety standards.
The facility failed to obtain and document informed consent for psychotropic medications before administration for multiple residents with dementia, Parkinson’s disease, and related behavioral and psychotic disturbances. In several cases, residents had OPA guardians or other representatives as medical decision-makers, yet there was no evidence that risks, benefits, alternatives, or treatment options for medications such as divalproex, valproic acid, olanzapine, quetiapine, pimavanserin, and antidepressants were discussed or that representatives were given an opportunity to choose among options. For one resident, consent for quetiapine was signed after the first dose had already been given. Staff interviews showed confusion about who was responsible for obtaining informed consent, when it should occur, and which medications required it, and leadership acknowledged that consents obtained via email were not consistently placed in the medical record and that consent audits were irregular, despite facility policies and resident rights documents requiring that residents or representatives be advised of psychotropic risks and benefits and that this be documented.
The facility failed to maintain sufficient RN, LPN, and CNA staffing levels as defined in its own facility assessment, particularly on weekends, and frequently relied on float staff to cover cottages without regularly assigned nurses. Staff and a resident reported that only one nurse and one CNA sometimes covered an entire cottage, that CNAs from other cottages had to pick up assignments when someone called in, and that staff shortages caused rushing and concerns about care. One resident with quadriplegia, fully dependent for bathing and preferring showers, missed multiple scheduled showers over several weeks and instead received bed baths or no documented hygiene care, and reported long call-light response times and staff declining small assistance due to being too busy. Another resident with multiple sclerosis and functional quadriplegia, dependent on staff and an overhead lift for transfers, was not consistently gotten out of bed on the days specified in their care plan and grievance resolution, and reported that requests to get up were often denied or deferred because staff said they were shorthanded.
A resident with multiple medical and psychiatric diagnoses, under a full court-appointed guardianship granting the guardian authority over medical and mental health treatment, was sent to a behavioral health consultation without documented notification to the guardian. The consultation report noted the resident was unescorted, that there was documentation of a guardian/POA, and that the resident could not state why they were there, with a recommendation to obtain guardian contact. The Administrator and DON confirmed there was no documented guardian notification, and although the AA reported that transportation was provided and that the resident’s recent BIMS showed intact cognition, there was no chart documentation that the guardian had been informed of or consented to the mental health appointment.
Two residents did not receive ADL services as assessed and care planned. A resident with quadriplegia, fully dependent on staff and preferring showers, was care planned for twice-weekly showers using a Carendo chair, but logs and interview showed prolonged gaps without showers and missed scheduled shower days, with staff citing CNA shortages and long call-light response times. Another resident with multiple sclerosis and functional quadriplegia, dependent on staff for bed-to-chair transfers, had a care plan and CNA tasks specifying transfers to a chair multiple times per week, and had previously expressed concerns and filed a grievance about limited opportunities to get out of bed; however, task logs showed the resident was either not gotten up or only once per week over several weeks, and the resident reported staff often declined requests to get up due to staffing and workload.
Two residents were discharged without adequate planning, resulting in unsafe and inappropriate transitions. One was sent home to an inaccessible and unsafe environment without necessary support or services, leading to distress, a fall, and reliance on unplanned third-party assistance. Another was discharged despite unresolved behavioral and cognitive issues, without required mental health referrals or involvement of their representative, causing distress and confusion. The facility lacked documented discharge planning standards and failed to coordinate essential post-discharge care.
A resident with dementia, depression, anxiety, and other complex conditions was admitted without the PASRR Level II report being available or reviewed. The facility did not initiate specialized mental health services as required, delayed updating the care plan, and discharged the resident without addressing PASRR-identified needs or following recommended discharge options. This resulted in untreated behavioral symptoms and increased psychotropic medication use.
A resident with complex medical needs developed multiple pressure ulcers and infections due to the facility's failure to provide timely and consistent wound care interventions, delayed care planning, poor documentation of noncompliance, and lack of coordination for higher-level wound care referrals. Discrepancies between wound care provider recommendations and actual treatment orders, as well as improper antibiotic administration in relation to dialysis, contributed to persistent wound infection and ultimately led to hospitalization with sepsis and death.
Systemic failures in the QAPI program led to ongoing deficiencies in staffing, grievance procedures, activities, medication management, and therapy services. Residents experienced long wait times for assistance, were not properly informed about grievance processes, and were not consistently offered activities as documented in their care plans. Incomplete narcotic count documentation and lapses in therapy services further contributed to suboptimal care.
Two residents did not receive care according to physician orders and care plans. One resident with hypertension and heart failure had daily vital signs ordered but only had them documented twice over several months. Another resident with skin breakdown risk had orders for offloading boots and wound care that were not implemented, as observed during the survey. Facility policies required adherence to these orders and care plans.
Failure to Follow Post-Dialysis Orders and Document AV Fistula Complications
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis-related treatment and care in accordance with physician orders, the resident’s care plan, and facility policy for one resident dependent on hemodialysis with ESRD and PVD. Physician orders and the MAR directed that the post-dialysis pressure dressing on the resident’s AV fistula be removed after a specified number of hours, and dialysis communication from the dialysis center reiterated that the fistula dressing must be removed within a defined timeframe to prevent clotting or narrowing of the AV graft. Record review showed no documentation that the post-dialysis dressing was removed within the ordered timeframe, and there was no indication on the MAR or in nursing progress notes that a dressing change was performed during the relevant dates. The facility also failed to assess, document, and communicate the condition of the dialysis access site as ordered and per policy. The care plan required daily checks and dressing changes at the access site with documentation and monitoring for signs and symptoms of complications, and the TAR included an order to assess the fistula site every shift for clarity, tenderness, redness, and bleeding. A nurse reported that upon the resident’s return from dialysis, the access site was bleeding and a dressing change was performed, but the TAR documentation for that shift indicated the site was “clear,” and nursing progress notes contained no record of a dressing change. Additionally, despite facility policy requiring monitoring for complications and immediate physician notification for bleeding, the medical record contained no evidence that the physician was notified about the post-dialysis bleeding AV fistula. CDC dialysis safety guidelines cited in the report state that standards of care require reassessment of the access site after dressing removal for bleeding, redness, or swelling, with accurate documentation and timely communication of findings, which was not demonstrated in this case.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to administration, thereby failing to ensure residents or their representatives were informed in advance of the risks, benefits, alternatives, and options for treatment. For Resident #1, who had severe dementia with psychotic disturbance, anxiety disorder, and depressive disorder, the record showed extensive use of multiple psychotropic medications, including divalproex, lorazepam, olanzapine, quetiapine, sertraline, and trazodone over a defined period. The resident had an Office of Public Advocacy (OPA) guardian as medical decision-maker, yet there was no documented informed consent for any of these medications. Emails to the guardian referenced that Depakote and other psychotropics had been ordered or adjusted, but did not include information on risks, benefits, alternatives, or options, nor did they document that the guardian was given an opportunity to choose a preferred option. The guardian later stated the facility had never reviewed risks, benefits, alternatives, or options for any medications and that such information would have guided decision-making. For Resident #3, who had vascular dementia and cerebrovascular disease and also had an OPA guardian, the medical record showed long-term administration of valproic acid and a period of mirtazapine use, totaling hundreds of psychotropic medication administrations. The record contained no documented informed consent for these medications. A progress note indicated that a licensed nurse was unable to reach the resident’s representative and mailed a copy of notes, including the addition of mirtazapine, but there was no further documentation of efforts to contact the representative to discuss medications or obtain informed consent. The facility was unable to provide any proof of informed consent for Resident #3’s psychotropic medications, and the guardian similarly stated that information on risks and benefits would have guided decision-making. For Resident #4, who had Parkinson’s disease with dyskinesia, dementia due to Parkinson’s disease with behavioral disturbance, hallucinations, and Lewy body dementia with psychotic disturbance, the record showed an order and ongoing administration of pimavanserin, an antipsychotic, over approximately 90 days. The resident had a representative who made medical decisions, but there was no documented informed consent for this psychotropic medication, and the facility could not provide any proof when requested. For Resident #5, diagnosed with dementia with behavioral disturbance and Parkinson’s disease, quetiapine was ordered and first administered before the facility obtained a signed Psychotropic Risk/Benefits Verification of Informed Consent form; the consent was dated one day after the first dose was given. This demonstrated that consent was not obtained prior to initial administration. Interviews with nursing staff and leadership revealed confusion and inconsistency regarding responsibility for obtaining informed consent, when it should be obtained, and where it was documented. One licensed nurse believed physicians were ultimately responsible for obtaining consent and was unsure where signed consents were stored. Another nurse did not know who was responsible, when to obtain consent, or how to verify its presence before administering a new medication, and believed only antipsychotics required consent. A third nurse assumed that if a physician wrote an order, informed consent had already been obtained, and identified psychotropics and antipsychotics as requiring consent that included discussion of risks and benefits. The DON and LTC nurse manager stated that bedside nurses were trained to obtain informed consent before the first dose of medications needing consent and that the facility did not obtain new informed consent for psychotropics if a resident was already taking the same medication on admission, assuming the resident already knew the risks and benefits. The LTC nurse manager also stated that consents were sometimes obtained via email to representatives or guardians, but copies of those emails were not placed in the medical record, and audits of consents had not been done regularly. These practices conflicted with the facility’s resident rights document and its psychopharmacological drug use policy, both of which required that residents or their representatives be advised of potential risks and benefits of psychotropic medications and that this be documented.
Insufficient Nursing Staff Leading to Missed ADLs and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff, including CNAs and licensed nurses, to meet residents’ needs as established in its own facility assessment. The assessment specified minimum staffing levels of 6–8 licensed nurses on day shift, 5–7 licensed nurses on night shift, 8–10 CNAs on day shift, and 7–8 CNAs on night shift. Review of staffing schedules for December 2025 and January 2026 showed that on multiple weekend days, the number of licensed nurses and CNAs scheduled fell below these minimums. On specific dates, day and night shifts were staffed with fewer licensed nurses than required, and several day and night shifts were staffed with fewer CNAs than the assessment’s minimums. Payroll Based Journal data further showed the facility triggered for low weekend staffing for all four quarters of federal fiscal year 2025, establishing a history of low weekend staffing. In addition to low numbers, staffing patterns showed that licensed nurses and CNAs frequently picked up resident assignments in cottages that did not have regularly assigned staff. Staff interviews confirmed that some cottages, such as Aniak, did not have a regular nurse assigned and instead relied on float nurses from other cottages. A CNA reported feeling unable to provide good quality care because of rushing and expressed concern about resident falls due to having only one nurse and one CNA in the cottage. Another nurse stated there was only one CNA caring for residents and that if that CNA called in sick, CNAs from other cottages would pick up assignments. An anonymous resident reported that staff shortages were a big problem, with shared nurses and CNAs, and described long waits and receiving bed baths instead of showers when CNAs did not have time. The insufficient staffing directly affected the provision of ADLs for specific residents. One resident with quadriplegia, dependent on staff for showers and whose care plan required showers every Sunday and Thursday night using a Carendo chair, did not receive showers as scheduled. Shower logs showed a 14-day gap between showers in December 2025, with bed baths documented instead on some scheduled shower days and no documentation of shower or bed bath on another scheduled day in January 2026. This resident stated they had not been showered for three weeks in December and again on a recent scheduled day because staff told them there were not enough CNAs, and also reported long waits for call light responses and staff declining to assist with small tasks due to being too busy. Another resident with multiple sclerosis, muscle weakness, and functional quadriplegia, who was dependent on staff for transfers and required one-person assistance with an overhead lift, experienced reduced opportunities to get out of bed. Social service documentation noted the resident’s interest in being transferred to a chair more than once a week and identified staffing concerns as a primary factor because the transfer was a two-person assist, leading to decreased participation in usual activities when left in bed. The resident later filed a grievance stating they were concerned about only being able to get out of bed once per week and had been told this limitation was due to staffing, requesting to get up three times per week. CNA task logs showed that over several weeks in December 2025 and early January 2026, the resident was not consistently gotten up on the scheduled days, including an entire week with no documented transfers out of bed. The resident reported that when they asked to get up, staff often responded that they would see, which usually meant no, citing being shorthanded or too many people getting up at once.
Failure to Notify Guardian of Behavioral Health Consultation
Penalty
Summary
The facility failed to ensure a court-appointed guardian was informed of and able to participate in care decisions for a resident with multiple complex medical and mental health diagnoses, including multiple sclerosis, renal tubule-interstitial disease, bipolar disorder, delusional disorder, and anxiety disorder. The resident had a LETTER OF GUARDIANSHIP dated 4/17/14 that appointed the Office of Public Advocacy as full guardian, with explicit authority over medical care, mental health treatment, physical and mental examinations, and approval of all medications, medical procedures, and psychotropic medications. Despite this, the resident was sent to a behavioral health consultation on 10/22/25, during which the consultation report documented that the patient was unescorted, that documentation at the time of the visit indicated a guardian/POA, and that the patient was unable to explain the reason for the visit. The consultant recommended obtaining more information about the reason for the visit and guardian contact. Interviews and document reviews showed there was no documented guardian notification regarding the scheduled psychiatric consultation. The Administrator and DON confirmed there was no documented guardian notification. The staffing schedule for the date of the appointment noted the resident needed an escort, but the DON could not verify who the escort was. An email from the Assistant Administrator stated that the facility’s driver provided transportation and ensured check-in, and referenced a recent BIMS indicating intact cognition, which the facility typically used to determine that an escort was not required. The same email and a follow-up email acknowledged that it was standard practice to notify residents and representatives of appointments, but there was no documentation in the chart confirming guardian notification for this mental health appointment. The guardian later stated it was possible they had been made aware but could not recall due to a large caseload, and there was no facility documentation verifying that notification or consent had occurred.
Failure to Provide ADL Care per Care Plans and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide activities of daily living (ADL) services in accordance with assessed needs, care plans, and resident preferences for two residents. One resident with quadriplegia was care planned to receive showers every Sunday and Thursday night using a Carendo chair and was documented on the MDS as being fully dependent on staff for bathing. The resident’s MDS also reflected a preference for showers. Progress notes reiterated the order for showers every Sunday and Thursday night with licensed nurse skin evaluations. Despite this, the December shower log showed the resident did not receive a shower between 12/18 and 12/28 and instead received bed baths on two of those days, and the January log showed missed scheduled showers on 1/1 and 1/5, with only a bed bath documented on 1/1 and no shower or bed bath documented on 1/5. During interview, this resident stated they were dependent on staff for ADLs such as showering and reported not receiving a shower for three weeks in December and again on the prior day because staff told them there were not enough CNAs available. The resident also reported long waits for call light responses, sometimes 30–40 minutes, and stated that staff told them they were too busy when the resident requested assistance with smaller tasks such as getting water or adjusting the TV volume, even when staff were already in the room. The Director of Nursing reported that showers were audited twice a week and discussed during rounds and that CNAs were supposed to notify a nurse or supervisor if a resident did not receive a shower. The second resident had multiple sclerosis, muscle weakness, and functional quadriplegia and was documented on the MDS as having upper and lower limb impairments and being dependent on staff for bed-to-chair transfers. The care plan required supervision and physical assistance with transfers using a one-person overhead lift. A social service note documented that the resident wanted to be transferred to a chair more than once a week, identified staffing as a barrier due to being a two-person transfer, and reported decreased participation in usual activities when left in bed. A grievance later documented the resident’s concern about only being able to get out of bed once per week and their request to get up on Monday, Wednesday, and Friday. CNA task documentation directed staff to ensure the resident was up every Monday, Wednesday, and Friday, but the task log showed that over several weeks in December and early January the resident was either not gotten up at all or only once per week on specified dates. In interview, the resident stated they did not get out of bed twice during December and that when they asked to get up, staff often responded that they would see, which usually meant no due to being short-handed or too many people getting up at once, despite the plan of care specifying three times per week.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure that residents were discharged in a manner that protected their health, safety, and psychosocial well-being. Specifically, the facility did not develop or implement an effective discharge planning process for two residents, resulting in unsafe and inappropriate discharges. The facility lacked documented standards for discharge planning, relying instead on verbal expectations within the social services department. Discharge planning was limited to care conferences at admission and two weeks prior to discharge, with no ongoing reassessment or structured involvement of resident representatives. The facility also did not conduct home visits prior to discharge, and referrals for post-discharge services and equipment were inconsistently arranged or delayed. One resident was discharged to a home environment that was known to be unsafe and inaccessible, without adequate caregiver support or required services in place. The resident, who had a history of joint replacement surgery, infection, and a recent femur fracture, required wound care, mobility assistance, and ongoing medical follow-up. Despite the resident's home being multi-level, in disrepair, and infested with rodents, the facility proceeded with discharge planning that did not ensure safe access or adequate support. The resident was left reliant on unplanned third parties, such as the fire department and community members, for essential care and experienced distress, emotional harm, and physical compromise, including a fall after discharge. Another resident with cognitive impairment, acute behavioral changes, and a documented need for nursing facility level care and specialized mental health services was discharged without required referrals or representative involvement. The facility did not review or incorporate the resident's PASRR Level II findings into the discharge plan, nor did it address a documented change in condition on the day of discharge. As a result, the resident experienced distress, confusion, and loss of security, with the POA having to assume unplanned caregiving responsibilities to prevent harm. The failures in discharge planning led to actual physical and psychosocial harm for both residents.
Failure to Incorporate PASRR Level II Findings into Care and Discharge Planning
Penalty
Summary
The facility failed to comply with PASRR (Pre-admission Screening and Resident Review) requirements by not incorporating the PASRR Level II determination into the assessment, care planning, and discharge planning for a resident with multiple mental health diagnoses. The PASRR Level II evaluation, which identified the need for continued nursing facility services and specialized mental health services, was not available at the time of admission and was not reviewed during the resident's stay or at discharge. The Level II report was only retrieved after the resident had already been discharged, and its recommendations were not integrated into the resident's care plan or discharge process. The resident in question had a complex medical history, including dementia, depression, anxiety, delirium, encephalopathy, and a recent femur fracture with surgical site infection. The PASRR Level II assessment specifically noted the need for specialized services to address mental health needs and provided recommendations for care and discharge options. Despite these findings, the facility did not order or initiate any specialized mental health services during the resident's stay. The care plan was delayed and, when eventually updated, did not include the specialized services recommended by the PASRR Level II evaluation. Throughout the resident's admission, there were documented episodes of aggression, combativeness, and non-compliance, which led to the initiation and escalation of psychotropic medications. The discharge summary and post-care instructions did not address the need for specialized mental health services or follow the recommended discharge options outlined in the PASRR Level II report. Facility staff acknowledged that the lack of access to and review of the PASRR Level II report negatively impacted the adequacy of care planning and discharge for the resident.
Failure to Provide Appropriate Pressure Ulcer Care and Timely Interventions
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with a facility-acquired pressure ulcer. The resident, who had significant comorbidities including end-stage renal disease and diabetes, developed multiple wounds during their stay, including a left iliac crest pressure injury and sacral wounds. There were significant delays and inconsistencies in wound assessment and treatment orders, with documented discrepancies between wound care provider recommendations and the actual orders transcribed and implemented by nursing staff. For example, wound care interventions recommended by the wound care team were not consistently reflected in the Treatment Administration Record (TAR), and antibiotics were not always administered as prescribed, particularly in relation to the resident's dialysis schedule, resulting in subtherapeutic dosing. Documentation revealed that wound care interventions were not promptly added to the resident's care plan, with a delay of 21 days after wounds were first identified. There was also a lack of documentation regarding the resident's reported noncompliance with repositioning and wound care, as noted by the wound care provider, with no corresponding nursing or CNA notes, risk/benefit documentation, or care plan updates to address these issues. Additionally, there was a failure to initiate and document referrals for higher-level wound care as recommended by external providers, and the facility did not coordinate or document efforts to ensure the resident attended outpatient wound care or follow-up appointments, despite family requests and external provider recommendations. Throughout the resident's stay, wound healing was minimal, and infections persisted despite multiple rounds of antibiotics, which were at times administered incorrectly or not as ordered. The lack of timely and appropriate wound care interventions, poor communication and documentation among staff, and failure to coordinate necessary higher-level care contributed to the resident's hospitalization with sepsis and subsequent death. The facility's actions and inactions directly resulted in a deficiency related to the provision of pressure ulcer care and prevention of new ulcers.
Systemic QAPI Failures Result in Multiple Deficiencies Across Facility Operations
Penalty
Summary
The facility failed to develop, implement, and maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, analyzed, and corrected systemic quality deficiencies. Despite collecting data from various sources such as electronic health records, staffing reports, maintenance logs, and resident council feedback, the QAPI committee did not effectively use this information to identify trends, prioritize high-risk issues, or implement and sustain corrective actions. This resulted in ongoing patterns of deficient practice in areas including staffing, grievance process, clinical care, activities, medication management, therapy services, discharge planning, environmental conditions, and care planning. Internal reports, resident council concerns, medical record documentation, staffing data, and direct observation all indicated these issues, but they were not recognized or acted upon through the QAPI process. Staffing deficiencies were evident, particularly on weekends, where staffing levels consistently fell below the facility's own assessment standards. Payroll Based Journal (PBJ) data and review of staffing schedules showed that the number of nurses, CNAs, and restorative aides scheduled was frequently less than the minimum required. Residents reported long wait times for assistance, with one resident waiting over two hours to be helped out of bed, and another experiencing delays in having a urinal emptied. Resident council meeting minutes repeatedly documented concerns about inadequate staffing and slow response times, with little evidence of effective facility response or improvement. The administrator and QAPI committee were not aware of the low weekend staffing, relying instead on reports that did not reflect actual staffing shortages. Additional deficiencies included failures in the grievance process, where residents were not properly informed of the current grievance officer, and posted information was outdated. Residents and council members were unaware of the new grievance officer, and there was no documentation of her introduction or updated contact information. The activities program was also deficient, with multiple residents reporting that they were not offered or able to participate in activities as documented in their care plans and assessments. Activity flowsheets showed minimal or no activity participation or offers for extended periods. Medication management was compromised by incomplete narcotic count documentation, with missing required signatures in narcotic logbooks across multiple units and months. Physical therapy services were not provided as ordered for a resident due to staff absence, with no evidence of alternative arrangements or continuity of care.
Failure to Follow Physician Orders and Care Plans for Vital Signs and Pressure Reduction
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and person-centered care plans for two residents. For one resident with a history of hypertension, heart failure, and transient ischemic attack, there was a physician's order for daily vital signs and an order for antihypertensive medication. However, record review showed that vital signs were only documented twice over a period of 177 days, despite the daily order. The acting DON confirmed that daily monitoring should have occurred, and facility policy required vital signs to be monitored as ordered for residents on antihypertensive medications. For another resident with diagnoses including weakness, mild cognitive impairment, and osteoarthritis, there were orders for wound care to leave the left heel open to air and to use offloading boots for the left lower extremity. Observation revealed the resident was lying in bed with both heels on the mattress and covered by non-skid socks, with no offloading boots in place. The care plan did not include interventions for keeping the left heel open to air or for the use of offloading boots, and a licensed nurse confirmed the order for heel boots. Facility policy required care plans to reflect services necessary to maintain the resident's highest practicable well-being and to follow recognized standards of practice.
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