Denali Center

Inspectors wroteBased on record review and interview, the facility failed to:1) Ensure an alleged violation involving possible neglect and serious bodily injury was reported immediately, but no later than 2 hours, to the State Survey Agency (SSA) for 1 resident (#1), out of 1 resident reviewed for reporting of alleged violations, before any investigation was initiated. Specifically, the facility did not report the unexpected death of Resident #1, who required intermittent supervision and strict aspiration precautions (measures used to reduce the risk of food, liquid, or other material entering the airway or lungs) during meals. Resident #1 was found cyanotic (bluish discoloration caused by insufficient oxygen), unresponsive, and pulseless during the evening meal, and after attempted emergency intervention, was pronounced deceased . [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive, person-centered care plan for 1 resident (#1), out of 1 resident reviewed, that included measurable objectives and timeframes to meet the resident's needs during meals. Specifically, the facility did not incorporate the Speech-Language Pathologist's (SLP) recommendations during meals to address Resident #1's dysphagia (difficulty swallowing), aspiration risk (when food, liquid, saliva, or other material was inhaled into the lungs), and positioning and supervision needs to include:1. upright, supported wheelchair seating during meals; 2. positioning supports and repositioning during oral intake in the resident's room; 3. safe-swallowing techniques; and 4. clear instructions defining the frequency and responsibility for intermittent supervision. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure the resident environment was free from accident hazards by failing to monitor and control the temperature of hot beverages provided to 1 resident (#29), out of 18 sampled residents. Specifically, staff served hot coffee from a staff designated coffee pot to a cognitively impaired resident without verifying safe temperature parameters, resulting in burns that required nursing assessment and treatment. This failed practice caused the resident to endure second degree burns and constituted actual harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure potentially hazardous foods were stored and labeled in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) expired foods were discarded; 2) foods were labeled and dated; and 3) foods were stored at safe temperatures in the Fireweed Cafe (Long-Term [LTC] Care Dining Room) refrigerators. These failed practices had the potential of causing or spreading foodborne illnesses to residents (based on a census of 73 out of 77) who received food from the kitchen

Inspectors wroteBased on record review and interview, the facility failed to establish an accurate competency training program for travel Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) to ensure all travel nursing staff had the specific competencies and skill sets necessary to care for resident's needs as identified in the facility's facility assessment. This failed practice had the potential to place all residents (based on a census of 77) at risk of: 1) not having the necessary care and resources required for day-to-day operations (including nights and weekends) and emergencies; and 2) not receiving services that enable them to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program to provide a safe and sanitary environment. Specifically, the facility failed to: 1. Ensure enteral feeding equipment was properly labeled in accordance with infection prevention practices; and 2. Ensure clean linens were protected from environmental contamination during transport. These failed practices placed residents (based on a census of 77) at risk for the development of communicable diseases and/or infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure Long-Term Care (LTC) travel nursing staff (licensed nurses and certified nursing assistants [CNAs]) completed assigned trauma-informed care training. This failed practice placed 2 sampled residents (#'s 3 and 39), out of 18 sampled residents, and one unsampled resident (#66), with a documented trauma history, at risk of not receiving appropriate care for trauma-related needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure timely notification to the State's Senior Disability Services that a resident's stay would exceed 90 days and to request a Level II Preadmission Screening and Resident Review (PASRR - a federally required process to determine whether individuals with mental illness or intellectual disabilities need specialized services) evaluation for 1 resident (#3), out of 18 sampled residents. This failed practice delayed the required assessment and placed the resident at risk of not receiving necessary services and care to meet their individualized disability-specific needs.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure 1 resident (#29), out of 18 sampled residents, received treatment and care, in accordance with the professional standards of practice based on manufacture's recommendations. Specifically, the facility failed to use an appropriately sized lift sling while using a mechanical lift (a device designed to assist in the safe lifting and transferring a resident with limited mobility) during transfer. This failed practice placed the resident at risk for discomfort/pain during a transfer which had the potential to negatively impact the resident's physical health and/or psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility's provider failed to: 1) write, sign, and date progress notes at each visit; and 2) review the residents total program of care, including treatment for a burn, at each visit for 1 resident (#29), out of 18 sampled residents. This failed practice resulted in inconsistent medical record documentation which placed the resident at risk of diminished continuity of care.

Inspectors wroteBased on record review and interview, the facility's pharmacy services failed to ensure medication administration orders were accurate to meet resident needs for 2 residents (#'s 29 and 53), out of 18 sampled residents. This failed practice, of potentially having medications administered incorrectly, placed the residents at risk of choking and/or aspiration which could affect their overall health and wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication and medical supplies were labeled appropriately, and removed from service if expired, in 1 medication cart, out of 7 medication carts inspected, and 1 unit medical supply storage area, out of 3 unit medical supply storage areas inspected. These failed practices had the potential to place the residents of the Tamarack unit (based on a census of 24) at risk of receiving expired medications and supplies which could cause adverse reactions and/or complications.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure residents were provided with clear instructions on how to file a grievance while units were quarantined and segregated due to an Influenza outbreak, along with easy access to the grievance box during this time. This failed practice denied all residents and/or their representatives based on a census of 71, the right to submit grievances without fear of discrimination or reprisal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store drugs and medical supplies. These failed practices had the potential to place all residents (based on a census of 71) at risk of receiving expired and non-sterile medications and supplies and subsequent adverse effects.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure potentially hazardous foods were stored, labeled and prepared foods in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) foods were labeled and dated; 2) expired foods were discarded; 3) Nutrition Services staff performed hand hygiene with glove changes and during the cooking and the preparation of foods. These failed practices had the potential of causing or spreading foodborne illnesses to residents, based on a census of 70, who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff followed hand hygiene practices. Specifically, nutrition service staff did not performed hand hygiene and/or glove changes during the cooking and the preparation of the food. This failed practice placed all residents who receive food from the kitchen, based on a census of 70, at risk for cross contamination and spread of infectious disease

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure three residents (#s 19, 22, 25) out of 20 sampled residents were given the opportunity to make choices about aspects of their lives that were significant to them. Specifically, the facility failed to ensure residents' rights to choose and participate in activities consistent with his/her interest. This failed practice had the potential to affect residents' quality of life.

Inspectors wroteBased on record review, interview and observation, the facility failed to monitor, evaluate, and determine the use of assistive devices as physical restraints for two residents (#31and #61) out of 20 sampled residents. This failed practice placed residents at an increased risk for unnecessary physical restraints, inadequate monitoring of devices, and physical injury.

Inspectors wroteBased on record review, interviews, and observations, the facility failed to ensure activities of daily living (ADLs) were provided to two residents (#s 19 and 67), out of 20 sampled residents. Specifically, showers or baths were not provided to the residents as specified in their individualized plans of care. This failed practice resulted in residents not receiving ADLs to maintain personal care and hygiene .

Inspectors wroteBased on record review, observation and interview the facility failed to obtain residents' consent for bedrails use and conduct accurate risks and benefits assessments for four residents (#'s 4, 8, 31 and 61) out of 20 sampled residents and one unsampled resident (#11) reviewed for bedrails use. This failed practice had the potential to place residents at risk of falls, entrapment, and other preventable accidents and potentially place residents at risk of feelings of isolation and helplessness .

Inspectors wroteBased on interview and record review, the facility failed to provide resident care with respect and dignity for two residents (#'s 27 and 50), out of 20 sampled residents. This failure placed the residents at risk of negatively affect the resident's quality of life.

Inspectors wroteBased on record review and interview the facility failed to implement written polices and procedures that prohibited and prevented mistreatment of residents, investigation, and reporting for 1 resident (#50) out of 20 sampled residents. Specifically, the facility failed to report an allegation of mistreatment to the Administrator within 24 hours if the events that cause the allegation do not involve abuse. This failed practice placed Resident#50 at risk of further exposure to mistreatment and/or mental anguish.

Inspectors wroteBased on record review and interview, the facility failed to: 1) investigate an alleged report of mistreatment; 2) prevent further potential mistreatment once the allegation was made; and 3) report the allegation, by submitting the results of the investigation to the State Agency, administrator, or his or her designated representative within 5 working days, for 1 resident (#50), out of 20 sampled residents This failed practice placed Resident #50 at risk of further exposure to mistreatment and/or mental anguish.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure the comprehensive care plan reflected the current status and care for one resident (#31) out of two sampled residents with assistive seat belt devices. This failed practice placed the resident at risk for not receiving adequate care and increased risk for injuries.

Inspectors wroteBased on record review and interview, the facility failed to ensure an accurate medical record was maintained for one resident (#10) out of 20 sampled residents. Specifically, the facility's medical record process failed to ensure medical records were accurate. This failed practice created incomplete medical records which placed the resident at risk for inconsistencies in treatment and care provided.

Inspectors wroteBased on record review and interview, the facility failed to adhere to facility's standards of care expectations, in the form of regular resident location and safety checks (called walking rounds), for 1 resident (#14), out of 4 residents reviewed. This failed practice resulted in the staff not being aware of the resident's elopement from the facility for an extended period, causing a delay in action to locate, which placed the resident at an increased risk for injury and accidents.

Inspectors wroteBased on record review and interview, the facility failed to notify the Resident Representative (a Public Guardian) and the Office of the State Long-Term Care (LTC) Ombudsman, in writing, of a facility-initiated transfer or discharge for one resident (#1), out of one resident discharge reviewed. Specifically, the facility failed to: 1) Provide the Public Guardian in writing the intent to transfer/discharge the resident that included: The reason for transfer or discharge; the effective date of transfer or discharge; and information regarding: a) a statement of the resident's appeal rights, including the name, address, and telephone number of the entity which receives such requests, and how to obtain an appeal form and assistance in completing the form; b) the name, address, and telephone number of the Office of the LTC Ombudsman; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1) Food was stored under proper sanitation and food handling practices in the main hospital kitchen; and 2) Hair nets were worn properly by food service workers assembling food in the kitchen in the Long Term Care (LTC) Center. These failed practices had the potential of causing or spreading food borne illness to all residents who utilized the kitchen services, based on a census of 72 residents.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure acceptable professional standards of infection control. Specifically, the facility failed to wear gloves when working with PICC (peripherally inserted central catheter) lines (during flushes and medication administration) for 2 Residents (#'s 65 and 68) out of 2 residents with PICC lines. This failed practice had the potential of spreading infectious disease.

Inspectors wroteBased on record review and interview, the facility failed to ensure influenza immunization documentation (administered or declined) was completed for 1 resident (#59) of 5 residents sampled for influenza immunization. This failed practice denied the residents the opportunity to accept or decline the immunization and to receive education on the benefits and potential side effects.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure complete and current survey results and plans of correction were readily available to the residents, family members and resident representatives. This failed practice denied the residents and their family members or representatives (based on a census of 72) the right to be informed of previous survey results and the facility's plans for correction.

Inspectors wroteBased on observation and interview, the facility failed to post the daily total number and the actual hours worked by Certified Nurse Aides (CNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). The failure to ensure accurate data was posted denied the residents and/or resident advocates information about staffing and the facility's ability to provide care to all residents residing in the facility (based on a census of 72).