Food storage, labeling, and sanitation practices were not followed in the kitchen. Sanitizer buckets tested outside the manufacturer range, numerous prepared and packaged foods were found unlabeled, missing open or use-by dates, or expired across multiple storage areas, and a cook handled raw chicken with contaminated gloves after touching a speaker without removing the gloves or performing hand hygiene.
A facility failed to complete NOMNC forms with the required QIO name and toll-free number for three residents, leaving generic template language and missing Medicare service details on the notices. For one resident, staff used an expired ABN instead of the correct SNFABN, and the DON/Administrator acknowledged the incorrect form was used and that the generic NOMNC template should have been completed before being given to residents.
Failure to ensure effective fall alarms and supervision: two residents had Smart Caregiver monitoring devices set to LOW volume, and one resident's bed alarm did not alert staff before the resident was found on the floor after an unwitnessed fall. One resident had dementia, osteoporosis, prior TIA, and cognitive impairment and was fully dependent on staff, while staff also found that a second resident's bed and recliner alarms did not activate properly during testing.
Staff failed to honor a resident’s expressed preference to use a mounted doorbell instead of knocking before entering the room. The resident had PTSD and a history of trauma, and knocking was a known trigger. During observation, a CNA knocked, rang the doorbell, and opened the door while the resident was being interviewed, despite a posted sign requesting staff ring the bell and not knock. Interviews confirmed staff knew the resident’s preference and trigger.
Incomplete MDS Mood and Behavior Assessments: A resident with a BKA, HF, and hypothyroidism had annual and quarterly MDS assessments that left Sections D and E as not assessed/no information, despite care plan documentation of depressed mood, little interest in activities, refusal of meds, weights, and cares, and limited engagement noted during survey observations. Nursing notes also showed refusals of VS and meds, while the SW said she had not spoken with the resident and the MDS Coordinator could not verify the accuracy of the completed sections.
A resident with multiple fall risk factors and several recent falls had a care plan that listed floor mats, but staff did not have the mats in place until later and could not locate corresponding orders in the EMR. The resident also received multiple high-risk meds, including a benzo, antidepressant, gabapentin, and opioid, yet the care plan did not address medication-related fall risk despite the resident’s falls and the meds’ known side effects.
A resident with depression, borderline personality disorder, and chronic pain due to trauma remained in the facility beyond a PASRR-approved 90-day convalescent stay. The facility did not notify SDS by the required day 85 or obtain an updated PASRR review and/or Level II evaluation, and the ADM could not locate any record of a PASRR Level II evaluation.
A resident with pneumonia, COPD, and respiratory failure developed severe behavioral and psychiatric concerns, including suicidal and homicidal statements, threats toward staff, and uncontrolled pain. The DON, NP, and IDT sent the resident to the ER, but when the hospital later sought return to the LTC, the facility declined readmission, did not issue a second discharge notice, and did not document the basis for discharge, unmet needs, attempts to meet those needs, or services available at the receiving facility.
A resident with pneumonia, COPD, respiratory failure, chronic delusions, and escalating suicidal and homicidal statements was transferred to the ER after staff determined the facility could not meet the resident’s needs. When the hospital later sought to return the resident, the facility declined readmission but did not issue the required second discharge notice with appeal rights, discharge details, State appeal contact information, or LTCO information, and did not notify the LTCO of the discharge.
The facility failed to keep an employee’s State of Alaska background check clearance valid while the employee continued working with resident contact. Assistant #3 helped prep and cook resident meals and served lunch and dinner to LTC residents, including hand-delivering trays to residents in their rooms, while the renewed background check was still pending after the prior clearance expired. Payroll records showed the employee worked 164.38 hours without valid clearance, despite state notices that a new background check was needed and facility policies requiring screening and renewal.
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