Utuqqanaat Inaat

Inspectors wroteBased on record review and interview, the facility failed to: 1) Develop written policies and procedures regarding the visitation rights for residents to include procedures for safety restrictions or limitations; and 2) Implement reasonable safety restrictions or limitations against a visitor for 1 Resident (#4), out of 1 resident reviewed, when abuse by way of misappropriation of resident property was suspected. The facility's failure to establish procedures for implementing reasonable safety restrictions placed all 18 residents at risk for continued unrestricted access by visitors when concerns involving abuse, exploitation, coercion, criminal activity, disruptive behavior, or illegal substances were identified. The facility failed to implement measures to protect Resident #4 when abuse was suspected. [...]

Inspectors wroteBased on record review and interview, the facility failed to: 1) Report an allegation of abuse to the State Agency as required under CFR 483.12(c)(1). Specifically, the facility did not report suspected misappropriation of resident property for 1 Resident (#4), out of 1 resident reviewed, when first identified in January 2026; and 2) Develop and implement an accurate reporting policy for allegations of abuse that aligned with regulatory requirements. Not reporting a concern for abuse in an appropriate and timely manner subjected Resident #4 to continued misappropriation of resident property and financial insecurity causing the resident to not have money when needed, a bank overdraft, and seizure of a social security check by the bank causing the resident to be without money in May 2026 and June 2026. [...]

Inspectors wroteBased on record review and interview, the facility failed to: 1) provide 1 resident (#12), out of 1 resident reviewed, with a written notice of transfer/discharge at least 30 days prior to the transfer or discharge in a language and manner they understand to include the reason for the transfer or discharge and the resident's appeal rights, including information on how to obtain an appeal form and assistance with completing and submitting an appeal hearing request; 2) provide the resident's written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman (OLTCO) and to accurately report to the OLTCO where the resident discharged to; and 3) Develop and implement an accurate transfer/discharge policy regarding notification of transfer/discharge that aligned with regulatory requirements. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 resident (#12), out of 1 resident reviewed for care planning, was afforded the opportunity to participate in the development and implementation of his/her person-centered plan of care. This failed practice deprived the resident of the opportunity to participate in care planning and provide input regarding his/her needs, goals, choices, and preferences.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 resident (#12), out of 1 resident reviewed, was informed, orally and in writing, of the resident's rights upon admission. The facility was unable to demonstrate that the resident received the required notice of resident rights and services or that receipt of the information was acknowledged in writing. This failed practice had the potential to affect Resident #12's awareness of the resident's rights and responsibilities during the stay in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 resident (#12), out of 1 Medicaid eligible resident reviewed, was informed in writing, at the time of admission or when the resident became eligible for Medicaid, of the items and services included under the State Medicaid plan for which the resident could not be charged and those items and services offered by the facility for which the resident could be charged, including the amount of those charges. This failed practice had the potential for Resident #12 to incur charges without being informed which items and services were covered under Medicaid and which items and services could result in out of pocket costs.

Inspectors wroteBased on record review and interview, the facility failed to investigate an allegation of suspected financial abuse/exploitation involving 1 resident (#4), out of 1 resident reviewed, and failed to implement effective protective measures since January 2026 when concerns were first identified, and when allegations continued to occur unresolved. These failures allowed the suspected perpetrator continued access to Resident #4 and the resident's financial resources after facility leadership identified the concern. The facility's failure to investigate the allegation and implement effective protective measures allowed Friend #18 continued access to Resident #4 and his/her financial resources. [...]

Inspectors wroteBased on record review, interview, and observation, the facility failed to implement an effective discharge planning process for 1 Resident (#12), out of 1 resident discharge reviewed, to include documentation of: 1) ongoing discharge planning goals throughout the resident's admission to include: a) identification of discharge needs and the development of a discharge plan; b) regular re-evaluation for need of possible modifications of the discharge plan; c) involvement of the interdisciplinary team in the ongoing process of developing the discharge plan; d) involvement of the resident in the development plan; and e) addressing the resident's goals of care and treatment preferences at discharge; 2) the basis and reason for discharge; and 3) sufficient preparation and orientation to ensure safe and orderly discharge. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and/or implement a comprehensive person-centered care plan for 1 Resident (#12), out of 6 sampled residents, that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, the facility failed to develop a care plan that accurately reflected the resident's functional abilities and need for assistance with ADLs (Activities of Daily Living - basic self-care tasks essential for maintaining personal health and independence). This failed practice placed Resident #12 at risk for receiving insufficient assistance with ADLs, transfers, and mobility despite assessed functional limitations and a history of falls.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure staff followed accepted standards of practice for hand hygiene for 5 residents (#'s 5, 8, 11, 14, and 15), out of 5 residents observed. Specifically, staff failed to perform hand hygiene during personal cares and medication administration. This failed practice had the potential to place all residents at risk of contamination and transmission of infections.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure that 3 Residents (#'s 2, 4, and 15), of 8 sampled residents, received adequate supervision to prevent falls. This failed practice placed these residents at risk for injury, impaired mobility, pain, and reduced well-being.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure insulin (a medication for blood sugar maintenance) orders were followed for 2 residents (#5 and #10), out of 3 residents reviewed who received insulin. Specifically, the insulin orders were written to be administered before meals, and the insulin was administered after meals. This failed practice placed these residents at risk for experiencing potential adverse effects for not receiving insulin per the physician's orders.

Inspectors wroteBased on record review and interview, the facility failed to ensure a copy of 2 residents' (#8 and #12) transfer notices were sent to the Office of the State Long Term Care (LTC) Ombudsman. This failed practice had the potential to affect all residents, based on a census of 17, by: 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State LTC Ombudsman was aware of facility practices and activities related to transfers and discharges.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was developed and implemented with specific medical care needs for 1 resident (#8), out of 9 sampled residents. Specially, the facility failed to address risk factors or include specific information concerning the resident's prescribed anti-platelet medication (that inhibits the ability of platelets to clump together as part of a blood clot and could cause the risk of bleeding) in the resident's care plan. This failed practice had the potential to place the resident at risk for inconsistent care that could result from the many risk factors of the anti-platelet medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure the MDS (Minimum Data Set-a Federally required assessment) was coded accurately for 2 residents (#s 4 and 12), out of 9 sampled residents, and 1 resident (#19), out of 2 closed record reviews. The failure to ensure the MDS was accurately coded placed the residents at risk for ineffective care planning.

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive care plans were individualized for 1 resident (#13), out of 9 sampled residents. This failed practice placed the resident at risk for not receiving the necessary care and services to address his/her individual needs.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure infection control procedures were properly implemented. Specifically, the facility failed to ensure staff removed soiled gloves and performed hand hygiene after completing dirty tasks to clean tasks. This failed practice had the potential to affect all residents, based on a census of 17, for risk of the spread of infectious disease.