Wildflower Court
Inspection history, citations, penalties and survey trends for this long-term care facility in Juneau, Alaska.
- Location
- 2000 Salmon Creek Lane, Juneau, Alaska 99801
- CMS Provider Number
- 025027
- Inspections on file
- 17
- Latest survey
- May 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Wildflower Court during CMS and state inspections, most recent first.
Nursing staff were found to lack required competencies, with several nurses missing current oxygen safety training and a CNA working without a valid CPR certificate. Personnel files and interviews confirmed these deficiencies, despite facility policies mandating annual oxygen safety education and BLS certification for all clinical staff.
Surveyors identified failures in food storage and preparation, including expired and unlabeled food items in kitchen and unit storage areas, as well as inconsistent documentation of cooked food temperatures. Staff interviews revealed confusion about labeling practices and recent changes to temperature recording procedures, resulting in incomplete or missing temperature logs.
Nursing staff did not document pain reassessments within 30 to 60 minutes after administering opioid pain medications to multiple residents with complex medical conditions, despite facility policy and clinical guidelines requiring such follow-up. This deficiency was confirmed through record review and staff interview.
A resident with multiple medical conditions was allowed to self-administer medications, including a controlled substance, without a documented assessment or physician order. Nursing staff left medications at the bedside and did not observe ingestion, contrary to facility policy and without care plan documentation supporting self-administration.
A CNA failed to follow a care plan requiring two-person assistance for a resident with anoxic brain damage and reduced mobility, instead performing transfers and toileting alone and using improper techniques. The resident was left unattended on the toilet, contrary to the care plan and facility policy, as confirmed by staff interviews and record review.
A resident with significant mobility impairments and a care plan requiring two-person assistance for transfers and toileting was assisted by a CNA alone, who used improper transfer techniques and left the resident unattended on the toilet. Additionally, the room's internal doorway was obstructed by a Hoyer lift, potentially impeding access. Staff interviews confirmed the resident's need for two-person assistance and the importance of keeping doorways clear.
A Hoyer lift was left blocking a resident's room entryway, making access difficult and potentially delaying emergency assistance. Additionally, an exit door in the activity room kitchen lacked a wander guard alarm or locking system, allowing a resident with dementia and a history of elopement to move freely and potentially exit the building. Staff confirmed these safety lapses, and facility policies did not address regular security checks for all exit doors.
A medication error rate of 36% was identified when a nurse handed a resident a cup containing nine medications and left the room without observing ingestion, despite no physician order or self-administration assessment. The DON confirmed that nurses are required to observe residents taking medications, and facility policy was not followed.
A CNA was found to be providing direct patient care without a valid CPR certificate, contrary to facility policy requiring all clinical staff to have completed BLS training. The CNA had not completed the required CPR course since hire and was assigned to various units, with the HR Manager confirming the lack of certification and incomplete follow-up by staff development.
The facility's pharmacy services failed to provide accurate dispensing of medications and necessary consultation, leading to multiple medication errors and unaddressed concerns despite repeated attempts by the DON to contact the pharmacy.
The facility failed to complete monthly DRRs by a licensed pharmacist for all residents from November 2023 to January 2024. Additionally, errors in the DRRs for two residents were identified, including an incorrect assessment of an active medication and inappropriate Morphine PRN orders with identical parameters.
The facility failed to submit mandatory PBJ staffing data for FY Quarter 4 2023, potentially denying residents and the public accurate staffing information. The Accounting Officer Controller cited a change of ownership as the reason for missing the deadline, resulting in a one-star staffing rating.
The facility failed to ensure that residents or their representatives were informed of the risks and benefits of psychoactive medications. Two residents had active orders for Diazepam and Lorazepam without documented informed consent forms, as confirmed by the pharmacist and the Director of Nursing.
The facility failed to provide timely SNFABN and NOMNC forms to two Medicare Part A residents, delivering the forms either on the day of or one day before the end of coverage. This did not allow the residents or their families sufficient time to appeal a denial of Medicare coverage.
The facility failed to implement the care plan for a resident with a known eye condition, resulting in unaddressed needs for glasses repair and eye exams. The resident's care plan included actions for specialist referrals and glasses maintenance, but these were not followed through, potentially delaying necessary treatments.
The facility failed to ensure that a new open area on a resident's skin was communicated to the nurse. The resident, who had spinal stenosis and cellulitis, reported soreness and a high pain level. CNAs discovered a small open wound but did not report it, leading to a lack of documentation and treatment. The Director of Nursing confirmed that the CNAs should have reported the wound immediately, as per facility policy.
The facility failed to ensure that a resident who smoked followed the care plan and smoking policy by smoking outside in a wood-framed gazebo lacking safety measures, instead of the designated smoking shed equipped with fire safety measures. This non-compliance posed a potential fire hazard.
A resident experienced significant weight loss, which was not reported to the physician as required. Despite a care plan indicating the need for regular weight monitoring, the facility failed to document interventions or communications regarding the weight loss. Observations and interviews revealed concerns from the resident's family and acknowledgment from staff that proper procedures were not followed.
The facility failed to ensure a resident's medication regimen was free from unnecessary drugs by not providing specific parameters for four different Morphine as-needed orders. The resident, with severe cognitive impairment and on palliative care, had identical parameters for each Morphine order, risking excessive or subtherapeutic administration. Interviews with the DON, ADON, and a pharmacist confirmed the orders were inappropriate.
The facility failed to ensure that two residents were provided with their ordered diets, leading to potential risks for poor health outcomes. Observations revealed discrepancies in meal preparation and serving sizes, and a lack of oversight and training among staff. One resident with dietary restrictions was served inappropriate food items, while another resident with swallowing difficulties did not receive the ordered side of moisture with meals.
A facility failed to ensure staff performed hand hygiene during wound care for a resident with sepsis and a sacral wound. A licensed nurse did not wash hands or change gloves when moving from a dirty to clean task. The infection preventionist confirmed the requirement for hand hygiene in such situations, as per the facility's policy.
Failure to Ensure Staff Competency in Oxygen Safety and CPR Certification
Penalty
Summary
The facility failed to ensure that nursing staff possessed the required competencies and certifications necessary to provide safe and appropriate care to residents. Specifically, six licensed nurses did not have current training in safe oxygen handling, as evidenced by personnel file reviews and interviews with the Human Resources Manager and Assistant Director of Nursing. Some of these nurses, including a traveler nurse, had not completed the required annual oxygen safety education until after the survey began. Observations confirmed the presence of compressed gas cylinders in a unit, and the ADON acknowledged that oxygen tanks were stored for resident use. Additionally, one certified nurse aide was found to be working without a valid CPR certificate, as confirmed by a review of personnel files and interviews with the HR Manager. The aide had been hired without completing the required CPR course, and there was no documentation of certification in the personnel file. Facility policy required all clinical staff providing direct patient care to have completed Basic Life Support (BLS) training, but this requirement was not met for the aide in question.
Deficient Food Storage, Labeling, and Temperature Documentation
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During observations in the main kitchen and unit kitchens, surveyors found multiple instances of expired food items not being discarded, including expired pork loin chops, smoked sausage, and instant oatmeal. Additionally, several food containers and bags were not labeled with expiration or best-by dates, and some containers held unidentified or improperly stored food items, such as brown bread placed on top of brown sugar. The Director of Nutrition Services (DNS) confirmed that some labeling practices were based on when items were placed in containers, and that dry goods were rotated every two weeks, but this did not ensure proper tracking or removal of expired items. In the walk-in cooler, a large bag of shredded mozzarella cheese was found without an expiration date, and the DNS was unable to provide this information. Unlabeled and undated containers of prepared food were also observed. Review of facility policies and position descriptions indicated that all stored food should be labeled and dated, and that staff are responsible for following health department guidelines for safe food handling and storage. However, these procedures were not consistently followed, as evidenced by the presence of expired and unlabeled food items in storage areas. The facility also failed to consistently record the temperatures of cooked potentially hazardous foods after cooking. While staff took temperatures of foods such as chicken after cooking, they did not document these temperatures, following a recent management directive to only record temperatures before food was transported to dining units. Temperature logs were incomplete or missing for several days, and some logs were found discarded in the garbage. Staff interviews confirmed that temperature documentation practices had changed and that there was confusion about where and when to record food temperatures. Facility policies required that potentially hazardous foods be cooked to appropriate temperatures and that these temperatures be documented, but these requirements were not met.
Failure to Reassess Pain After Opioid Administration
Penalty
Summary
The facility failed to ensure that residents who received opioid pain medications were re-evaluated for pain within 30 to 60 minutes following administration, as required by facility policy. Record reviews and interviews revealed that for 11 residents with various complex medical conditions—including cerebral palsy, hemiplegia, anxiety disorder, PTSD, neurogenic bladder, heart failure, depression, renal insufficiency, anemia, peripheral vascular disease, multiple sclerosis, dementia, schizophrenia, seizure disorder, cellulitis, chronic pain, arthritis, and paraplegia—there was no documentation of pain reassessment after opioid administration. The number of missed reassessments ranged from two to 62 instances per resident during the review period. The residents involved were prescribed and administered different opioid medications such as hydrocodone-acetaminophen, Norco, oxycodone, Tylenol-Codeine #3, Percocet, Endocet, and Dilaudid, all on an as-needed basis for pain management. Despite the administration of these medications, the clinical records and electronic medication administration records (eMAR) lacked evidence that nursing staff performed or documented pain reassessments within the specified timeframe after each dose. During an interview, the DON confirmed that the facility's policy required nurses to perform pain reassessments within 30 to 60 minutes after administering pain medications. The facility's written policy and referenced clinical guidelines also supported this requirement. However, the documentation review showed consistent noncompliance with this standard for the identified residents.
Failure to Assess and Document Safe Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including cellulitis, chronic pain, and arthritis was observed to have medications, including Tylenol and a controlled substance (oxycodone), left at the bedside without direct supervision or confirmation of ingestion by nursing staff. The resident reported that nurses routinely left medications in the room, allowing the resident to take them at their discretion. Observations confirmed that a licensed nurse handed the resident a cup containing multiple medications, including a controlled substance and other critical medications, and then exited the room without verifying that the medications were taken. Record review revealed there was no documented assessment for the resident's ability to safely self-administer medications, nor was there a physician's order authorizing self-administration. The resident's care plan did not address self-administration of medications, and facility policy required physician and interdisciplinary team determination of a resident's capacity to self-administer. The Director of Nursing confirmed that nurses should not leave medications with residents and should observe ingestion, but this was not followed in the case of this resident.
Failure to Follow Two-Person Assist Care Plan for Resident Transfers and Toileting
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) failed to follow the care plan for a resident with anoxic brain damage and reduced mobility, who required the use of ankle-foot orthoses (AFOs) and a two-person assist for transfers and toileting. The care plan specifically stated that two staff members were needed to assist with all transfers and toileting, using a Sara Steady device and providing extensive assistance. However, during observation, only one CNA was present and assisted the resident out of bed and to the toilet. The CNA used improper technique by pulling the resident by the wrists and allowing the resident to lower themselves onto the toilet without assistance. Further, the CNA left the resident unattended on the toilet while leaving the room to make the bed, despite the care plan's requirement for two-person assistance. Interviews with the Director of Nursing and another CNA confirmed that the resident was always to be assisted by two staff members for transfers and toileting. The facility's policy on safe patient movement and handling also emphasized the responsibility of staff to ensure patient safety during handling activities. These actions and inactions resulted in the care plan not being implemented as required for the resident's basic care needs.
Failure to Follow Two-Person Assist and Safe Transfer Protocols
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to follow the care plan for a resident with anoxic brain damage and reduced mobility, who required two-person assistance for transfers and toileting. During an observed transfer, the CNA assisted the resident alone, using improper technique by pulling the resident by the wrists and allowing the resident to twist toward the bed's edge, with the resident's face briefly resting on the side rail. The resident, who wore ankle-foot orthoses (AFOs), was then assisted to stand using a Sara Steady device and transported to the bathroom, where the CNA again provided assistance without a second staff member present, contrary to the care plan instructions. Additionally, the internal doorway to the resident's room was obstructed by a Hoyer lift, which could have impeded access to the room. The CNA left the resident unattended on the toilet and exited the room, relying on the resident to use the call light when finished. Interviews with the Director of Nursing and other staff confirmed that the resident was always to be assisted by two people for transfers and toileting, and that doorways should remain clear for safety. Facility policy required staff to ensure safe patient handling and clear access during care activities.
Obstructed Room Entry and Unsecured Exit Door Create Safety Hazards
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards in two key areas: obstruction of a resident's room entryway and inadequate security of an exit door for residents at risk of elopement. In one instance, a Hoyer lift was left positioned directly behind the door of a resident's room, preventing the door from opening fully. This required individuals entering the room to step over the lift's legs and squeeze through a narrow space, despite there being other available areas in the room to store the lift. Staff interviews confirmed that doorways should remain clear to ensure timely assistance in emergencies, and facility policy emphasized the importance of safety during patient handling activities. Additionally, the facility did not ensure that all exit doors were secured to prevent elopement among residents identified as at risk for wandering. One resident with dementia and a history of elopement was observed moving freely throughout the facility, including approaching an exit door in the activity room kitchen that lacked both a wander guard alarm and a locking system. Staff confirmed that this door could be opened from the inside, providing direct access to the outside, and acknowledged that a resident with a wander guard could exit through it. The facility's policy on wandering and elopements did not include procedures for checking the security of all exit doors. These deficiencies were identified through record review, observation, and staff interviews, and involved residents with significant mobility and cognitive impairments. The lack of clear entryways and unsecured exits placed residents at risk for delayed emergency response and potential elopement, as evidenced by a prior incident where a resident exited the facility through a door with a locking failure.
Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 36% based on 9 errors out of 25 observed medication administration opportunities. During medication administration, a licensed nurse prepared and handed a resident a cup containing nine different medications, including Entresto, Eliquis, Allopurinol, Florastor, Metoprolol, Jardiance, Eplerenone, Torsemide, and Oxycodone. The nurse asked the resident to rate their pain level and then left the room without observing the resident ingest the medications. There was no documentation of a physician's order or a self-administration assessment authorizing the resident to self-administer or be left with medications. Interviews with facility staff revealed that the nurse believed the resident was independent and routinely took medications without supervision, but the Director of Nursing confirmed that nurses should not leave medications with residents and must observe ingestion. Review of the resident's medication record showed discrepancies in administration times, and facility policies required documentation of medication administration and an interdisciplinary team determination for self-administration. The facility was unable to provide evidence of compliance with these requirements for the resident involved.
CNA Provided Direct Care Without Required CPR Certification
Penalty
Summary
A Certified Nurse Aide (CNA) was found to be providing direct patient care without having a valid Cardiopulmonary Resuscitation (CPR) certificate, as required by facility policy. Review of the CNA's personnel file confirmed the absence of a CPR certificate since the date of hire. The Human Resources (HR) Manager acknowledged that the CNA had been enrolled in a CPR class but did not complete it, and that the Staff Development Office should have followed up on the completion. The HR Manager did not answer when asked if the CNA was allowed to work on the floor without the required certification. Facility policy mandates that all clinical staff providing direct patient care must have completed Basic Life Support (BLS) training, which includes CPR. The CNA in question was assigned to various units, including during the orientation period, and could be assigned to any unit as needed. Documentation of the CNA's specific unit assignments and corresponding unit census was requested but not provided by the end of the survey. This lapse in ensuring required certification was identified through personnel file review and staff interviews.
Pharmacy Services Deficiency
Penalty
Summary
The facility's pharmacy services failed to meet the obligations of its contract agreement, specifically in providing accurate pharmaceutical services and consultation. The contract stipulated that a pharmacist would be available for consultation and that medications would be supplied in unit dose sizes. However, an observation revealed a dispensing error in a bubble pack card of Warfarin for a resident, where one dose contained half a tablet instead of a whole tablet. This error was part of a pattern of issues identified by the Director of Nursing (DON), who reported multiple instances of incorrect medications being sent and difficulties in contacting the pharmacy for resolution. The DON provided an account of several attempts to contact the pharmacy about these issues, including wrong doses, discontinued medications being sent, and a lack of response from the pharmacy owner. Despite multiple messages and texts, the pharmacy owner failed to address the concerns or provide the necessary consultation. The facility's policy on accepting delivery of medications requires notifying the dispensing pharmacy and returning incorrect medications, but the ongoing issues indicate that these steps were not effectively resolving the problems.
Failure to Complete and Accurately Document Monthly Drug Regimen Reviews
Penalty
Summary
The facility's pharmacy services failed to complete monthly drug regimen reviews (DRRs) by a licensed pharmacist for all residents from November 2023 to January 2024. This failure was due to the resignation of the pharmacist responsible for these reviews, and the pharmacy did not provide a replacement despite repeated requests from the facility. As a result, no DRRs were completed for any residents during this period, placing all residents at risk for unnecessary medications, medication errors, and adverse reactions. During the survey, a pharmacist from the hospital that acquired the facility completed the overdue DRRs for November and December 2023. For Resident #2, the DRRs contained an error indicating that Diazepam had been discontinued, although the medication order remained active. This error persisted in the DRRs from June to October 2023 and was not corrected in the December 2023 review by the new pharmacist. The pharmacist acknowledged that the medication should have been assessed as an active order. For Resident #35, who was on palliative care with severe cognitive impairment, the DRRs failed to identify inappropriate Morphine PRN orders. The orders had identical parameters for different doses, which lacked clear instructions on when each dose should be administered. Both the DON and ADON confirmed the inappropriateness of these orders, and the pharmacist admitted that this concern should have been documented in the DRR.
Failure to Submit PBJ Data for FY Quarter 4 2023
Penalty
Summary
The facility failed to ensure the mandatory submission of staffing information based on Payroll-Based Journal (PBJ) data for Fiscal Year (FY) Quarter 4 2023 (July 1 - September 30, 2023). This failure potentially denied residents and/or their representatives, as well as the public, accurate staffing data when accessing the Nursing Home Compare website. The review of the facility's PBJ Staffing Data Report revealed that the facility did not submit the required data for the specified quarter, resulting in a one-star staffing rating. During an interview, the Accounting Officer Controller stated that the facility missed the deadline due to a change of ownership. The facility's policy on reporting direct care staffing information specifies that data must be submitted no less frequently than quarterly, with a submission deadline for Fiscal Quarter 4 being November 14.
Failure to Document Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed of the risks and benefits of psychoactive medications. Specifically, for Resident #2, who was admitted with depressive disorder and restless leg syndrome, there was an active order for Diazepam that had been in place for over thirteen months without an informed consent form documented in the medical record. Both the pharmacist and the Director of Nursing confirmed the absence of the informed consent form for Diazepam during interviews. Similarly, Resident #35, who had diagnoses of dementia and anxiety and a resident representative through Power of Attorney, had active orders for Lorazepam without an informed consent form documented. The medication orders for Lorazepam were not officially discontinued, and the absence of the informed consent form was confirmed by both the pharmacist and the Director of Nursing. The facility's policy on Resident Rights, which guarantees the right to be informed of and participate in care planning and treatment, was not adhered to in these cases.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to ensure the timely delivery of the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and the Notice of Medicare Non-Coverage (NOMNC) to two Medicare Part A residents or their representatives. Specifically, the forms were delivered either on the day of or one day before the end of Medicare Part A coverage. This practice did not provide the residents or their families with a timely opportunity to appeal a denial of Medicare coverage. For Resident #44, the Medicare Part A Skilled Services Episode started on 10/9/23 and ended on 10/17/23, with the forms being signed on the last day of coverage. For Resident #66, the Medicare Part A Skilled Services Episode started on 8/17/23 and ended on 9/28/23, with the forms being signed one day before the end of coverage. During an interview, the Social Services Manager stated that the facility aimed to present the SNFABN and NOMNC forms at least two days before the end of Medicare Part A coverage, but this did not always occur. The facility's policy, dated 11/16/23, also indicated that the notice should be provided at least two days before the end of a Medicare-covered Part A stay. The failure to adhere to this policy denied the residents or their families a timely opportunity to make decisions regarding their care and financial responsibilities.
Failure to Implement Comprehensive Care Plan for Resident's Eye Condition
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for a resident with a known eye condition. The resident, who was admitted in 2005 with diagnoses including traumatic brain injury, seizures, and 3rd nerve palsy of the left eye, was observed wearing glasses with tape over the right hinge. There was no documentation indicating that the resident's glasses needed repair or that an eye appointment had been scheduled during the year. The care plan identified the resident's visual function problem and included actions such as arranging for specialist referrals and checking the glasses for cleanliness and repair needs, but these actions were not followed through. Interviews with the Director of Nursing and the Resident Care Coordinator revealed that the facility was unaware of the need for glasses repair and could not determine the last time the resident had an eye exam. The facility's policies on care plan goals and comprehensive person-centered care plans emphasize the importance of measurable objectives and timetables to meet the resident's needs, but these were not implemented in this case. This failure had the potential to delay treatments to improve the resident's eyesight and affect their ability to maintain their highest practicable physical, mental, and psychological well-being.
Failure to Communicate New Skin Wound
Penalty
Summary
The facility failed to ensure that information about a new open area on the skin of Resident #34 was communicated to the nurse. Resident #34, who was admitted with diagnoses including spinal stenosis, weakness, and cellulitis, reported soreness in the sacral area and had a pain level of '8' out of 10. During an observation, CNAs discovered a red area with a small open wound on the resident's sacral area but did not report this to the nurse, leading to a lack of documentation and treatment initiation for the wound. Interviews with the licensed nurses revealed that they were unaware of the open area as it had not been mentioned in the morning report. Upon being informed, the nurse assessed the wound, cleaned it, and applied Calmoseptine. The wound was described as a fissure with bleeding, approximately 1/4 to 1/2 inch long. The resident's care plan indicated a potential for skin breakdown, but the CNAs did not report the new open area because they did not consider it a pressure ulcer. The Director of Nursing confirmed that the CNAs should have communicated the discovery of the open area to the nursing staff immediately. The facility's policies on the prevention of pressure injuries and skin assessment require CNAs to report any new or changed skin conditions to the charge nurse as quickly as possible. This failure to communicate placed the resident at risk for further skin breakdown and infection.
Failure to Enforce Smoking Policy and Designated Smoking Area
Penalty
Summary
The facility failed to ensure that the sole resident who smoked followed the care plan and smoking policy. Specifically, the resident was observed smoking outside in a wood-framed gazebo near the main entrance, which had a wood floor and lacked safety measures to prevent or address fire accidents. This was contrary to the care plan and facility policy, which stipulated that the resident should only smoke in the designated smoking shed equipped with safety measures such as a fire extinguisher, smoking apron, smoking blanket, and a metal trash can with a fire-resistant liner. Interviews with staff confirmed that the resident had scheduled smoking times and that smoking materials were stored in the nurse's medication room, but the resident was not adhering to the designated smoking area as required by the care plan and policy. Record reviews revealed that the resident had been evaluated as safe to smoke independently and was grandfathered in to continue smoking as they were admitted before the facility's smoking policy change in 2012. Despite these evaluations, the resident's non-compliance with the designated smoking area posed a potential fire hazard. The facility's policy clearly stated that residents admitted before the policy change were allowed to smoke only in designated areas, and staff were responsible for ensuring safe smoking practices. The failure to enforce this policy and ensure the resident smoked in the designated area introduced avoidable fire risks, potentially affecting all residents in the facility.
Failure to Report Significant Weight Loss to Physician
Penalty
Summary
The facility failed to ensure significant weight loss was reported to the physician for one resident. The resident, who was admitted with diagnoses including stroke and seizures, experienced a 16.59% weight loss from admission to early February. Despite the recorded weight loss, there were no interventions or communications documented for the significant weight loss observed on February 1st. The resident's weight history showed a consistent decline, and the care plan indicated the need for regular weight monitoring and nutritional assessments, which were not adequately followed. During observations and interviews, it was noted that the resident's family member was concerned about the weight loss and mentioned that the resident did not like the facility's food. The Registered Dietician acknowledged that the resident should have been reweighed, and the Director of Nursing confirmed that the physician should have been contacted regarding the weight loss. The facility's policies on nutrition and change in condition were not adhered to, leading to the deficiency in care for the resident's nutritional needs.
Failure to Ensure Medication Regimen Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure the medication regimen for one resident was free from unnecessary medication. Specifically, the facility did not provide specific parameters for four different Morphine as-needed medication orders for a resident with severe cognitive impairment and on palliative care. Each Morphine order had identical parameters, which could lead to excessive or subtherapeutic medication administration and potential adverse reactions. Record review revealed that the resident had a BIMS score indicating severe cognitive impairment and was on palliative care for dementia and anxiety. Interviews with the DON, ADON, and a pharmacist confirmed that the Morphine orders were inappropriate as written, lacking clear parameters to indicate which dose to administer and when. The facility's policy required medication orders to include the clinical condition or symptoms for which the medication is prescribed, which was not followed in this case.
Failure to Provide Ordered Diets and Adequate Oversight
Penalty
Summary
The facility failed to ensure that two residents were provided with their ordered diets, leading to potential risks for poor health outcomes. During a resident council meeting, multiple residents expressed concerns about the food served, specifically mentioning excessive sugar and carbohydrates and the lack of diabetic diets. One resident noted that meal cards were sometimes inaccurate. Observations revealed that a Home Attendant (HA) was not following the correct menu extension sheet and served inappropriate food items to a resident on an 1800 calorie consistent carbohydrate (CCHO) diet. The Registered Dietitian (RD) and nursing staff did not provide adequate training or oversight to ensure the correct diets were served, leading to discrepancies in meal preparation and serving sizes. Additionally, the facility's policy on food and nutrition services was not followed, as the food trays were not inspected to ensure the correct meals were provided to each resident. Another resident with multiple sclerosis and a history of stroke, who had significant weight loss and trouble swallowing, was not provided with the ordered side of moisture with meals. Despite the physician's order for a side of moisture, the resident had to request it from the staff, indicating a lack of adherence to dietary orders. Interviews with the staff, including the RD, Licensed Nurses (LNs), and the Director of Nursing (DON), revealed a lack of clarity and responsibility regarding oversight and training for meal preparation and serving, contributing to the deficiencies observed in the residents' dietary care.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure staff performed hand hygiene according to accepted professional practices during wound care for one resident. Specifically, a licensed nurse did not perform hand hygiene or change gloves when moving from a dirty to clean task while treating a resident's sacral wound. The resident was admitted with sepsis due to a urinary tract infection and had a sacral wound/tear. The infection preventionist consultant confirmed that hand hygiene was required during wound care when moving from a contaminated to a clean task. The facility's hand hygiene policy also mandated hand washing or disinfection when moving from a contaminated body site to a clean body site during patient care.
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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