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.
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.
A facility failed to timely report an allegation of verbal intimidation/harassment involving inappropriate sexual comments made by a CNA to a resident, and its abuse policy did not align with CFR reporting requirements. The resident had Alzheimer’s disease with behavioral disturbance, anxiety, and decreased functional mobility, required extensive assistance with personal care, and could not participate in an interview. Staff documented that the CNA made sexually explicit remarks during care, but leadership did not report the allegation to the State Survey Agency within the required timeframe and initially treated it as a disturbing conversation rather than abuse.
The facility failed to clearly designate one RN as the full-time DON for the LTC unit. Records, interviews, and observation showed conflicting roles for the DCS, LTC Manager, and a newly hired DON, with the DCS still performing DON and LTC Manager duties while payroll and HR records identified her as DCS and the new DON was at times coded as Acute RN instead of LTC DON. Facility documents, committee lists, badges, and job descriptions all reflected inconsistent leadership assignments.
Failure to document resident/rep acceptance or refusal of psychotropic meds. Three residents with dementia, depression, or behavioral symptoms were receiving psychotropic meds such as duloxetine, hydroxyzine, quetiapine, sertraline, trazodone, and memantine. The records showed risks and benefits were discussed with family members or POAs, but there was no documentation that the resident or surrogate accepted or declined the meds, and the DCS could not locate any notes showing consent.
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