Providence Kodiak Island Med LTC

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a culture where residents were treated with dignity and respect for 2 residents (#'s 6 and 19), out of 13 sampled residents. Specifically, the facility failed to: 1) Respond appropriately to the toileting needs for Resident #6, which resulted in the resident being forced to defecate the bed; 2) Maintain Resident #6's dignity and privacy by allowing the resident's catheter urine collection bag to remain uncovered and visible to individuals passing by in the hallway; and 3) Ensure Resident #19's privacy, by way of closing the bedroom door, while providing personal care. These failed practices placed the residents at risk for diminished self-esteem and/or self-worth and the potential for a poor quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure adequate screening was conducted in accordance with the abuse and neglect policy. Specifically, the facility did not reference the State Nurse Aide Abuse & Neglect Registry for potential new Certified Nursing Assistant (CNA) hires. This failed practice placed all residents (based on a census of 21) at risk for exposure to abuse, neglect, exploitation, mistreatment, and misappropriation of their property.

Inspectors wroteBased on record review, interview, and observation, the facility failed to develop and implement comprehensive, person-centered care plans for 6 Residents (#'s 1, 2, 12, 13, 16, and 17), out of 13 sampled residents. Specifically, the facility failed to: 1) Develop and maintain accurate care plans to meet the current needs of 5 Residents (#'s 1, 2, 13, 16, and 17); and 2) Carry forward previously identified needs, that were care planned for, when the facility initiated the use of a new electronic medical record (EMR) for 2 Residents (#'s 12 and 16). These failed practices placed the residents at risk of not receiving services that enable them to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review, observation, and interview, the facility failed to adhere to professional standards for food safety. Specifically, the facility failed to ensure: 1) Food items stocked for residents had not expired; 3) Canned foods with damaged rims were removed from inventory; 4) Opened food items were properly labeled and stored; 5) The dishwasher on the Salmonberry unit had achieved proper temperature during the wash cycle; and 6) Safe food temperatures were maintained prior to serving. These failed practices placed all residents (based on a census of 21) at increased risk for foodborne illness.

Inspectors wroteBased on record review and interview, the facility failed to: 1) Ensure their facility assessment (a mandatory, comprehensive evaluation to understand the specific resident population's needs and match them with necessary staffing, equipment, and resources to meet those needs) was up to date and accurate; and 2) Establish an accurate competency training program for Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) to ensure all 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 21) at risk of: 1) not having the necessary care and resources required for day-to-day operations (including nights and weekends) and emergencies; [...]

Inspectors wroteBased on record review and interview, the facility failed to implement federally required in-service training for Certified Nursing Assistants (CNAs), ensuring continuing competencies of no less than 12 hours per year that included dementia management, cognitive impairment, and resident abuse prevention training. This failed practice placed all residents (based on a census of 21) at risk of not receiving services that enable them to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to have an active restorative program (an exercise program focused on maximizing resident independence and function through individualized plans) for appropriate treatment and services to maintain or improve a resident's ability to carry out the activities of daily living (including but not limited to hygiene, mobility, elimination, dining, and/or communication) for 4 Resident (#'s 1, 7, 13, and 16), out of 13 samples residents. This failed practice placed the residents at risk of not receiving services to enable them to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure gradual dose reductions (GDRs), or contraindications for GDRs, were clearly documented for 1 Resident (#13) who used psychotropic medications (medications that affect behavior, thoughts, or perception), out of 13 sampled residents. This failed practice placed the resident at risk for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure neurological (neuro) checks (assessments to determine if any neurological changes/symptoms arose from a potential head injury) were performed after an unwitnessed fall with head injuries per resident care polices for 1 Resident (#7), out of 13 sampled residents. This failed practice placed the resident at risk for delay in treatment from any potential changes in neuro status.

Inspectors wroteBased on record review and interview, the facility failed to ensure Long-Term Care (LTC) staff were sufficiently and consistently trained for trauma-informed care. This failed practice placed 2 residents (#'s 3 and 5), out of 13 sampled residents, with documented trauma history, at risk of not receiving appropriate care for trauma-related needs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the posted nurse staffing information included the actual hours worked by nursing staff. This failed practice had the potential to provide limited transparency regarding staffing levels, affecting all residents (based on a census of 21) and visitors' ability to evaluate the adequacy of nursing care provided.

Inspectors wroteBased on interview and record review the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Specifically, from 11/13-22/24 there was no full-time DON. This failed practice, of not having a full-time DON to provide oversight of nursing staff, daily management, direction and support, had the potential to place all residents (based on census of 21) at substantial risk for subquality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were prepared, stored and labeled in accordance with professional standards for food safety for all residents (based on a census of 21). Specifically, the facility failed to ensure: 1) foods were labeled and dated; 2) expired foods were discarded; 3) proper sanitization of food surfaces; and 4) proper sanitizing of dishes and cookware. These failed practices had the potential of causing or spreading foodborne illness to all residents, who received food from the affected kitchens.

Inspectors wroteBased on record review and interview, the facility failed to ensure emergency care equipment was maintained. Specifically, the facility failed to complete the Automated External Defibrillator (AED) regular maintenance per manufacturer's recommendation. This failed practice had the potential to place all residents (based on a census of 21) at risk of not receiving emergency care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1) Informed consent was obtained prior to the use of bed rails for 16 residents (#'s 1, 2, 4, 5, 6, 10, 11, 12, 13, 15, 16, 18, 19, 72, 122, and 172), out of 21 residents reviewed; and 2) Assessments for the risk and benefits of the use of bedrails, prior to the use of bedrails, for 5 residents (#'s 4, 13, 16, 18 and 19), out of 21 residents reviewed. This failed practice had the potential to place residents at risk of falls, entrapment, and other preventable accidents.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure residents' right to dignity and respect was honored for three residents (#'s4, 13, and 15), out of 21 residents (total census). Specifically, Certified Nurse Assistants (CNAs) used a cloth protector to wipe the residents' nose and mouth after dining. Additionally, a CNA transferred a resident in an ARJO lift (transfer lift device) from the resident's room to a chair in the living room. These failed practices placed the residents not being valued as a person with dignity and respect.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure infection control procedures were properly implemented. Specifically, the facility failed to ensure staff contained linen during transportation. This failed practice had the potential to affect all residents (based on census of 21) for risk of the spread of infectious disease.

Inspectors wroteBased on observation and interview, the facility failed to post the daily total number and the actual hours worked for all residents (based on census of 21) care per shift worked by the Certified Nurse Assistants (CNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). This failed practice provided inaccurate information to the all residents and their families.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure: 1) food was stored under proper sanitary conditions; and 2) concentrations of sanitizing solutions were tested correctly to assure the solutions were maintained within acceptable parameters. These failed practices placed all residents (based on a census of 21) at risk for foodborne illness and/or communicable disease.

Inspectors wroteBased on record review, observation, and interview, the facility failed to have an antibiotic stewardship program (ASP), a program that monitors antibiotic usage and effectiveness. This failed practice had the potential, for all residents (based on a census of 21), to receive an ineffective and inaccurate implementation of antibiotic protocols for antibiotic use.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a private space for the Resident Council meetings. This failed practice had the potential to affect all resident's choosing to attend the meetings, based on a census of 21, by preventing the group members from expressing their concerns or recommendations affecting their care.

Inspectors wroteBased on interview and record review, the facility failed to provide quarterly statements for personal fund accounts to 2 residents (#'s 8 and 13) and/or their Power of Attorneys (POAs), out of 2 sampled residents whose money was held by the facility. This failed practice placed the residents and/or their POAs at risk for not receiving a complete and accurate accounting of their personal funds entrusted to the facility.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure 1) a physician's order for restraint was obtained in a timely manner; and 2) direct care staff (Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) on-going re-evaluation of the restraint use was documented in 1 resident's medical record (#2) out of 1 resident investigated for restraints. This failed practice had the potential to deny the resident's highest practicable wellbeing.

Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of assessment was reported in the quarterly Minimum Data Set (MDS- a federally mandated assessment for all residents of long-term care facility) for 1 resident (#18) out of 13 sampled residents. This failed practice had the potential to report inaccurate resident's status.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 resident (#16) out of 13 sampled residents, were free from significant medication errors. Specifically, the resident was not provided with the ordered ear drop medication prior to the physician's procedure of ear wax removal. This failed practice had the potential to place the resident at risk for decreased quality of life due to incomplete removal of wax build-up, which potentially affected the resident's hearing.

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure resident food preferences were honored for 1 resident (#16), out of 13 sampled residents. This failed practice had the potential to place the resident at risk of inadequate nutritional intake and weight loss.