Cordova Community Med LTC

Inspectors wroteBased on record review and interview, the facility failed to implement an abuse, neglect, and exploitation screening policy accordingly. Specifically, the facility failed to ensure individuals who had direct contact with residents, their medical or financial records, or control over or impact on the financial well-being of residents had a valid criminal history check conducted under 7 Alaska Administrative Code (AAC) 10.900-10.990. This resulted in 6 employees working at the facility without valid clearance from the Alaska Background Check program. This failed practice placed all residents (based on a census of 8) at risk for abuse and neglect.

Inspectors wroteBased on record review and interview, the facility failed to ensure nursing staff had the appropriate competencies, skill sets, and techniques to care for resident's needs. Specifically, nursing staff did not receive Trauma-Informed Care specific training. This failed practice had the potential to 1) exacerbate past trauma for 1 resident (#3), out of 8 residents, and affect the resident's ability to attain the highest practicable mental and psychosocial well-being; and 2) affect all residents (based on a census of 8) with any newly identified trauma during the course of their residency in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) food was stored under proper sanitation practices in the main kitchen; and 2) expired food items were discarded timely. These failed practices had the potential of causing or spreading foodborne illness to 6 out of 8 residents who receive food from the kitchen.

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure the MDS (Minimum Data Set- a federally required nursing assessment) assessment accurately represented the residents' status for 2 residents (#'s 1 and 3), out of 8 sampled residents. This failed practice placed the residents at risk for inadequate care planning and goals which could affect their overall health and wellbeing.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive person-centered care plan for 1 resident (#3), out of 8 sampled residents. Specifically, the resident's identified trauma history was not care planned for to ensure trauma-informed care interventions were implemented. This failed practice had the potential to exacerbate past trauma and affect the resident's ability to attain the highest practicable mental and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to inform residents, in writing, before or at the time of admission, of the services available in the facility and the charges for those services, including services not covered under Medicaid or by the facility's per diem rate, for 7 of 8 Medicaid-eligible residents reviewed. This failed practice resulted in residents not receiving required information necessary to understand the cost of care and services, placing them at risk for unexpected financial liability.

Inspectors wroteBased on record review and interview, the facility failed to address or include the staff competencies and skill sets that are necessary to provide the level and types of care needed for their resident population in their facility assessment. Specifically, trauma-informed care (TIC) training was not included in their annual facility-wide assessment. This failed practice: 1) placed 1 resident (#3), out of 8 resident's reviewed, at risk of having their past trauma exacerbated which had the potential to affect the resident's ability to attain the highest practicable mental and psychosocial well-being; and 2) placed all residents (based on a census of 8) at risk of not having newly identified trauma care planned for to mitigate retraumatization.

Inspectors wroteBased on record review and interview, the facility failed to provide proof that the Alaska Nurse Aide Abuse Registry was checked before hiring Certified Nurse Aides (CNAs). This failed practice placed all residents, based on a census of eight, at potential risk of abuse by individuals who may have had a documented history of misconduct.

Inspectors wroteBased on record review and interview, the facility failed to provide written notice of the bed hold policy and provide the facility's bed hold form (policy of reserving a resident's bed for a specified period when the resident is temporarily transferred to a hospital or another healthcare setting) for two residents (#'s eight and nine), out of nine residents reviewed, who were transferred to the emergency department (ED) and/or hospital, for medical treatment. This failed practice had the potential for the residents and/or their resident representatives to not be informed of the facility's bed hold policy, placing these residents at risk for losing their beds at the facility due to an extended stay at another healthcare facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1) ensure expired medical products were removed from the medical supply storage room; and 2) ensure the medication cart drawers were locked when unsupervised. These failed practices placed all residents (based on a census of 9) at risk for: 1) adverse effects or complications from use of expired products; and/or 2) potential loss, diversion, or accidental exposure to medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) store food under proper sanitary conditions; and 2) regularly maintain the ice machine based on manufacturer's instructions. This failed practice placed 6 residents (#s 1, 2, 5, 6, 7, and 8) out 6 residents who received meals from the kitchen, at risk for foodborne illnesses and communicable disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control protocols were performed during food preparation, medication administration, and enteral feeding (receiving nutrition through a gastrostomy tube [a tube inserted through the stomach]). These failed practices had the potential to affect all residents (based on census of 9) for the development and/or transmission of communicable diseases and infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure pneumococcal and influenza immunizations documentation (administered or declined) were completed for 1 resident (#5), of 5 residents sampled for pneumococcal and influenza immunizations. This failed practice denied the resident or resident representative the opportunity to receive education on the benefits and potential side effects, and to accept or decline the immunizations.

Inspectors wroteBased on record review and interview, the facility failed to ensure COVID-19 vaccination documentation (administered or declined) was completed for 1 resident (#5), of 5 residents sampled for COVID-19 vaccinations. This failed practice denied the resident or resident representative the opportunity to receive education on the benefits and potential side effects, and to accept or decline the immunizations.

Inspectors wroteBased on interview and record review the facility failed to ensure accurate staffing data for the 3rd quarter of 2023 (April - June 2023) was reported to Centers for Medicare and Medicaid (CMS) Payroll Based Journal (PBJ). This failed practice potentially denied residents and/or representatives (based on census of 9), and the public, accurate staffing data when accessing the Nursing Home Compare website.