cms_AK
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| Link | rowid | facility_name | facility_id | address ▼ | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 546 | 546 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 550 | E | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the dignity of 4 residents, (#s 1, 2, 6 & 15), out of 17 residents residing in the facility. This failed practice had the potential to negatively affect the resident's self-esteem and quality of life. Findings: Dining Resident # 2 Record review on 1/31/18 of most recent Minimum Data Set (MDS, a federally required assessment) revealed Resident #2 had [DIAGNOSES REDACTED]. The Resident required total assistance with Activities of Daily Living and eating. During an observation on 1/29/18 at 9:25 am in the dining area, LN #10 was overheard referring to Resident #2 as a feeder, while delivering the morning meal tray. Resident #2 and residents were seated in the dining area within hearing distance. During an interview on 2/1/18 at 3:20 pm with the Director of Nursing (DON), when asked if residents should be referred to as feeders, the DON replied absolutely not. Resident #6 During an observation 1/29/18 at 12:35 pm, Resident #6 was presented with his/her lunch plate. At 12:45 pm, Resident #6 was observed to be sleeping with both hands in his/her food and his/her head drooped over the plate. There were no staff present to assist or prompt resident. At 12:51 pm, 21 minutes later, the Resident was still sleeping with his/her hands in the full plate of food with his/her neck bent over to the side. The Resident's full plate of food had begun to slide off the table. A family visitor alerted a nearby nurse the plate was going to fall off the table. LN #10 responded by putting the plate back on the table and woke up Resident #6. The LN didn't wipe the Resident's food soiled hands, the Resident started eating the food off the plate with food all over his/her hands. Resident #16 During an observation on 1/29/18 at 12:25 pm, a cart containing trays of food was delivered to the unit. Resident #'s 15 and 16 were seated at the same dining table. At 12:43 pm, Resident #15, who had a … | 2020-09-01 |
| 547 | 547 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 583 | E | 0 | 1 | B1D811 | Based on observation, interview, and record review the facility failed to ensure residents were notified and had provided written consent of the digital recording in common areas (dining/ living room). This failed practice denied all residents residing in the facility (census of 17) the right to privacy when living, eating, visiting, and/or participating in activities. Findings: Observation during the survey from 1/28-2/2/18 revealed 2 fisheye cameras located in the common area. The kitchenette, living room, and the dining area was visible on the screen. During an interview on 2/1/18 at 12:12 pm, the Administrator stated only he had access to log into the recording. The Administrator stated the recording was saved for 30 days before it was taped over, unless he saved it. During an interview on 2/1/18 at 10:15 am, facility security staff stated the camera in the common area was digitally recorded. The security staff stated only the Administrator at the facility and themselves were able to access the records. The recording is on a 60 day looped feed. Review of the facility admission packet on 2/1/18, provided to residents upon admission, revised 4/29/14, revealed no information for the residents and/or interested parties about the cameras. | 2020-09-01 |
| 548 | 548 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 585 | F | 0 | 1 | B1D811 | Based on observation, interview, and record review, the facility failed to 1) follow their policy by following through on Resident grievances when initiated verbally 2) provide responses in writing to Residents/family who filed grievances 3) assure the grievance box was accessible on the units for residents to submit grievances 4) demonstrate tracking in writing of all grievances, investigations, and responses. This failed practice had the potential to effect all residents residing in the facility (based on census of 17). The failure to follow the grievance process denied residents and/or interested parties the ability to exercise their rights by filing grievances, provide useful feedback about quality of life to the facility, and receive written resolution. Findings: Record review of the 'Admission Packet' on 1/30/18 under the section Elder's Home Complaint or Grievance Procedure revealed Residents and their families are encouraged to discuss any concerns with the Director of Nursing or Social Services. If one of these members of management is unable to resolve a concern, the resident or family member is encouraged to discuss the concern with the Administrator of the facility. The resident or family member may also fill out a grievance form, which is located in the lobby. Verbal Grievance Follow-up During an interview on 1/30/18 at 10:13 am the Social Worker (SW) stated many of the residents do not write in English and she is often contacted directly to take verbal grievances. An interview with Resident #15's family member on 1/30/18 at 2:20 pm revealed that they had made a complaint about the Resident not liking the food and had verbally complained to the staff because the Resident had been recently eating poorly. He/she indicated the staff responded that the cook was following the recipe. There was no documentation of this complaint/grievance, investigation or response on record. A record review of the grievance log book on 1/30/18 at 10:30 am revealed no documentation for any verbal grievances that had been s… | 2020-09-01 |
| 549 | 549 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 607 | F | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and observations the facility failed to ensure processes were correctly implemented in conjunction with the facility's abuse policy. Specifically, the facility failed to ensure 1) valid background checks completed for two direct care staff, and 2) two certified nursing assistants (CNA) were screened through the State nurse aide registry. These failed practices placed all residents (based on a census of 17) at risk for exposure to potential abuse, neglect or misappropriation. Findings: Dietitian's Background Check Review of the facility's personnel files on [DATE] revealed the Registered Dietitian had a background check on file that expired in (YEAR). During an interview on [DATE] the Human Resources (HR) Generalist stated the Dietitian's file contained no evidence of a current background check, as the background check in the Dietitian's file expired in (YEAR). During the survey on ,[DATE]-,[DATE], the Dietitian was observed working with the residents in the facility. Licensed Nurse (LN) #7 Background Check: Review of the facility's personnel files on [DATE] revealed LN #7 had no documentation of a current background check. During an interview on [DATE] the HR Generalist stated LN #7s file did not contain any documentation of a valid background check. Review of an email, dated [DATE], provided by the Administrator on [DATE], revealed the Background Check Unit (BCU) notified the facility that LN #7s background check required additional information in efforts to process the request. Review of an email, dated [DATE], provided by the Administrator on [DATE], revealed the BCU closed the application due to Information Requested - Not Received. Review on [DATE] of the BCU profile regarding LN #7 revealed the following timeline: - [DATE] - The facility submitted application for LN #7 - [DATE] - The facility was alerted that additional documents were requested; - [DATE] - Certified mail sent to LN #7 - return receipt … | 2020-09-01 |
| 550 | 550 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 620 | F | 0 | 1 | B1D811 | Based on record review and interview the facility failed to ensure the admission policy was: 1) free from requesting or requiring residents to waive facility liability for loss or theft of personal funds not kept in a resident trust account and 2) required residents to purchase their own headphones when listening to TV at night and/or in the event of a hearing impairment. These failed practices took away the residents' right to safeguarding of personal possessions and relieved the facility from their responsibility to exercise due care with respect to residents' personal property, and denied the facility the responsibility to accommodate for needs specific to hearing impairment. These deficient practices placed all residents (based on a census of 17) at risk for uncompensated loss from misappropriation of personal property and at risk for using personal funds to accommodate hearing needs. Findings: Protection Against theft or Loss Review of the facility's admission packet revealed a form entitled Admission Agreement, with a revision date 4/29/14. The document read Elder's Home offers a Resident Trust Account .If you choose not to deposit funds in a Resident trust account or keep a lock box in your room for personal funds, Elder's home is not responsible for any lost or stolen funds. During an interview on 2/2/18 at 10:00 am, the Administrator stated the form needed to be revised. Review of the facility's policy entitled (Long Term Care) Abuse Policy, dated 3/2017, revealed .Elders Home residents have the right to be free from .misappropriation of resident property .Definitions .Misappropriations of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money . Accommodation of Needs Review of the facility's admission packet revealed a form entitled Admission Agreement, revision date 4/29/14. Under the subtitle Waiver of Liability, the document read Residents with hearing deficits that require listening volumes in excess of a normal … | 2020-09-01 |
| 551 | 551 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 637 | D | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure the Interdisciplinary Team (IDT) had determined and documented if a MDS (Minimum Data Set-a Federally required assessment) comprehensive assessment was required after a significant change in weight and functional ability for 1 Resident (#16) out of 12 sampled residents. This failed practice denied the IDT and the resident and/or the resident's family the ability to reassess and implement clinical interventions in the Resident's care plan to improve the resident's overall physical condition, functional ability, and well-being. Findings: Record review on 1/31-2/1/18 revealed Resident #16 was admitted to the facility with medical [DIAGNOSES REDACTED]. The Resident was admitted to the facility following a surgical repair of a [MEDICAL CONDITION]. A record review on 1/30/18 of the facility's Significant Weight Report revealed between the dates of 10/1/17 and 1/24/18 Resident #16 had lost 12.5% of his/her total body weight. During an interview on 1/30/18 at 1:02 pm with Resident #16's Power of Attorney/family, the family stated they were concerned about the decline in the Resident's condition. Record review on 1/30/18 of Resident #16's care plan did not provide any documentation that indicated goals and interventions to address weight loss or the loss of functional ability since the most recent quarterly MDS, dated [DATE]. Review of the Resident's most recent MDS, dated [DATE], revealed Resident #16's functional status declined in his/her ability to walk in room, walk in corridor, locomotion off unit, and toilet use. Random observations of Resident #16 on 1/29/18 and 2/1/18 revealed Resident #16 was totally dependent on facility staff in every area of functioning (as listed above). During an interview 2/2/18 at 8:44 am, when asked about Resident #16's decline, the MDS Nurse stated documentation from the previous MDS assessments was inaccurate. The MDS Nurse stated she … | 2020-09-01 |
| 552 | 552 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 641 | E | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the MDS (Minimum Data Set-a Federally required assessment) was coded accurately for 6 (#s 9; 13; 14; 15; 16; and 17) residents out of 12 sampled residents. The failure to ensure the MDS was accurately coded placed residents at risk for ineffective care planning. Findings. Resident #9 Record review on 1/31-2/1/18 revealed Resident #9 had [DIAGNOSES REDACTED]. Review of the most recent annual MDS assessment, dated 12/1/17, revealed the Resident had received passive and active range of motion (PROM and AROM) while in the restorative nursing program. In addition the Resident had received Training and Practice In: walking 7 days in the restorative nursing program, during the assessment period. Resident #13 Record review on 1/31-2/1/18 revealed Resident #13 had [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 8/11/17, revealed the Resident's height was 57 for [NAME] Height (in inches) and the Resident's weight was 47 pounds for B. Weight (in pounds). Which identified the Resident as severely underweight. Review of the most recent quarterly MDS assessment, dated 1/15/18, revealed Resident #13 was 61 inches tall and weighed 97 pounds. The data indicated a gain in height of more that 6 inches. Further review of the most recent quarterly MDS assessment, coded the Resident had no short or long term memory problem. The Memory/Recall Ability, identified the Resident was normally able to recall staff names and faces and That he or she is in a nursing home/hospital swing bed. The, quarterly MDS, dated [DATE], identified the Resident had received PROM in the restorative nursing program. Resident #14 Record review on 1/29/18 - 2/1/18 received Resident #14 had [DIAGNOSES REDACTED]. Review of Resident #14's admission MDS, dated [DATE], Resident was not coded as missing his/her dentures and had coded the Resident as being in a restorative nursing program. During an interview on… | 2020-09-01 |
| 553 | 553 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 657 | E | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure care plans were revised in accordance with residents and/or family members input and/or as identified in the MDS (Minimum Data Set-a Federally required nursing assessment) for 2 residents (#s 14 and 16) out of 12 sampled residents. This failed practice denied the residents and/or family members the right to be involved in care planning and placed the residents at risk for not receiving necessary goods and services to improve or maintain quality of life. Findings: Resident #14 Record review on 1/30-2/1/18 revealed Resident #14 had [DIAGNOSES REDACTED]. Discharge Home Review of an admission MDS assessment, dated 4/25/17 and a quarterly assessment, dated 1/12/18, revealed section Q0500. Do you want to talk with someone about the possibility of leaving this facility and returning to live and receive services in the community? was coded 0. No. During an interview on 1/29/18 at 2:15 pm, Resident #14 stated he/she was depressed because she could not get help to get home. The Resident stated his/her had mold that needs to be cleaned out. The Resident stated he/she doesn't want to live here anymore. In addition, the Resident stated he/she would like to go home for a visit to pack some things to bring back to the facility. During an interview on 2/1/18 at 9:20 am, when asked about Resident #14's desire to move home or go for a visit. The Social Worker stated the Resident's home had black mold, and it would be difficult for the Resident to get in the plane to fly home or navigate on the dirt roads while in a wheel chair. Review of the Resident's IP[NAME] (care plan), updated 9/5/17, revealed Discharge to the community not anticipated at this time. The intervention included If anticipated discharge, SW will coordinate appropriate services. There was no information about the Resident's desire to go home and what interventions the facility could take to help the Resident work… | 2020-09-01 |
| 554 | 554 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 677 | E | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure hygiene assistance was provided to 3 residents (#s 13, 16 and 218) and failed to ensure dining assistance was provided to 1 resident #15, out of 12 sampled residents. The failure to ensure activities of daily living (ADL) was provided to residents placing the residents at risk for poor self worth, depression, injury, and weight loss (in the area of dining assistance). Findings: Resident #13 Record review on 1/30-2/1/18 revealed Resident #13 had [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS- a Federally required nursing assessment) assessment, dated 1/15/18 revealed the Resident required extensive assistance with personal hygiene. Observation of Resident #13 on 1/29/18 at 10:00 am, revealed the Resident was unshaven and had long soiled fingernails. Staff neither offered to shave the Resident and/or trim and clean his/her fingernails. Observation on 2/1/18 at 9:05 am, revealed Resident #13 was still unshaven and his/her fingernails were long and soiled. Observation of the Resident in the dining room, later that same day, revealed the Resident's appearance was unchanged. Review of the CORP-Messages Detail Report, dated 9/12/16, used by the Certified Nursing Assistants (CNAs) to provide care, revealed chart daily on personal hygiene. There was no specific information about fingernail care or shaving. Review of the Resident's IP[NAME] (Individualized Plan of Care), evaluated 1/28/18, revealed Personal Hygiene .Support ADLs, Set up Room For Access to Care Items. There was no information about the level of support needed to be provided by facility staff for personal hygiene. Resident #16 A record review of a progress note on 1/30/18 at 12:51 pm revealed skin appears very fragile and peeling on the coccyx area. Not open at this time. The Resident has a history of issues with this area. An Allevyn foam dressing was ordered to protect the area as a … | 2020-09-01 |
| 555 | 555 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 679 | F | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review the facility failed to ensure an ongoing activity program to include a variety of facility-sponsored group and individual activities based on individual assessment, care plan, and preference for each resident was implemented by facility staff. This failure placed all residents (with a census of 17) at risk for boredom, loneliness, and decreased quality of life. Findings: Observation On 1/29/18 the activity calendar posted in both wings of the facility listed the following: 11:00 am Balloon Volleyball 1:30 PM Resident exercise 4:00 PM 1:1 visit 7:30 PM Arts & Crafts An interview on 1/29/18 at 1:05 pm with Licensed Nurse #10, on the 300 wing, when asked about the 11:00 am activity revealed no residents attended. When asked if alternative activities were offered, LN replied, yes, coloring and music. During further random observations on 1/29/18 on both wings of the facility no activities observed. On 1/30/18 at 8:19 am no activity schedule was written on the board on 300 wing. Interview with the contract Activities Coordinator (AC) on 1/31/18 at 9:08 am revealed the AC is in the facility one week per month. AC contract included development of a group activity schedule, development of individual plans for cognitively impaired/limited mobility residents, activity organization, ensuring supplies are available, review of documentation of the on-site facility Activities Assistant (AA), and ensuring assessments are complete and current. The AC stated the facility had been without an on-site AA since 12/17. In the interim, activities were to be facilitated by nursing and social work staff. The AC stated administrative staff were supposed to monitor the certified nursing assistants (CNAs) and licensed nurses (LN) to ensure activities were being facilitated when she was not in the facility. When asked about the process for developing individualized activities, the AC stated the 1:1 plans were developed … | 2020-09-01 |
| 556 | 556 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 688 | E | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interview the facility failed to implement measures to increase/prevent/decrease Resident's range of motion (ROM) for 7 (#s 2, 6, 11, 13, 15, 14 & 16), out of 12 sampled residents. Specifically, the facility failed to ensure a nursing program was implemented for those residents requiring services based on Minimum Data Set (MDS, a federally required assessment) assessment results. This failed practice placed the residents at risk for decreased quality of life and potential medical complications. Findings: Resident #2 Record review on 1/31-2/1/18 revealed Resident #2 was admitted to the facility with medical [DIAGNOSES REDACTED]. Review of the Residents care plan (IP[NAME]), dated 6/13/17 revealed no specific problems, interventions, or goals aimed at maintaining or improving ROM. Review of the most recent MDS, dated [DATE], revealed the Resident was identified as being in a Restorative nursing program requiring 6 days of passive range of motion (PROM) and 1 day of active range of motion (AROM) during the 7 day assessment. The Resident also coded for total dependence on staff for all activities of daily living. Review of the Resident's profile in Certified Nursing Assistant (CNA) documentation in CareTracker, revealed daily passive range of motion to all extremities. Neither the Resident's profile nor care plan (IP[NAME]) contained specific information about the AROM/PROM should be performed and how many times it should be repeated. Observation on 2/1/18 of the Residents morning care by CNA #s 2 and 3 revealed no range of motion activities. Resident #6 Record review on 1/31-2/1/18 revealed Resident #6 was admitted to the facility with medical [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS assessment, dated 1/31/18 revealed the Resident was identified as being in a Restorative nursing program and receiving PROM for 3 days and AROM 7 days during the 7 day assessment and for use of cane/crut… | 2020-09-01 |
| 557 | 557 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 689 | E | 1 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, and interview the facility failed to ensure 1) a residents fall was reviewed and subsequent interventions were implemented to prevent further falls were implemented for 1 resident (#1) out of 12 sampled residents, and 2) facility staff were provided guidance and evaluated for the proper use of mechanical lift slings, used in lifting residents. 3) failed to ensure damaged slings were removed from service, and 4) lift slings were maintained in accordance with manufacturers recommendations and guidelines. This failed practice created a risk for harm and/or injury from falls for 1 resident (#1) and misuse of the mechanical lift slings created a risk of injury for 4 residents (#s 2, 13, 16 and 11) observed utilizing the mechanical lifts, out of 12 sampled residents. Findings: Fall Precaution Record Review on 1/30-2/1/2018 revealed Resident #1 [DIAGNOSES REDACTED]. During an interview with Resident #1 on 1/30/18 at 8:53 am the Resident described a recent fall (approximately 1 week prior) when he/she sustained a broken arm. The Resident was unsupervised, had been looking out the window and the wheelchair slid out from behind him causing him/her to fall upside down into the chair. An observation on 1/30/18 at approximately 3:31 PM revealed Resident #1 being taken to the hospital by emergency services after falling out of the wheelchair during a bowling activity. During an observation on the unit on 2/1/18 at 8:30 am, CNAs (certified nursing assistant staff) were overheard discussing the accident. They indicated that Resident #1 had been participating in the activity, was holding his/her broken arm, and when he/she threw the ball he/she lost balance in the wheelchair, tumbled out of the wheelchair, and bumped his/her head on the floor. A review of Resident #1's IP[NAME] (care plan) revealed the care plan had not been reviewed and/or revised for falls precautions since the previous falls. Interventions did not des… | 2020-09-01 |
| 558 | 558 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 697 | D | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure 1 resident (#13), out of 3 residents reviewed for pain management, had the need to preemptively treat pain addressed and treated. This failed practice placed the resident at risk for further discomfort during cares and potential injury from precarious behaviors during positioning and transfers. Findings: Record review on 1/31-2/1/17 revealed Resident #13 had [DIAGNOSES REDACTED]. The Resident required total assistance with transfers in and out of the bed with the use of a mechanical lift. During an observation on 1/29/18 at 10:30 am, Certified Nursing Assistants (CNA) #s 2 and 3 assisted the Resident onto a gray and black sling and attached it to the overhead mechanical lift. The sling appeared too small and during the transfer, after being lifted into the air, the Resident began to call out, wave both arms around, and shift around in the sling, sliding further down with his/her buttocks sliding towards the edge of the sling. During an interview on 1/29/18 at 10:45 am CNA #3, stated the Resident had stated (in Yupik) he/she was in pain. The CNA added the Resident is supposed to receive the pain medication first because he/she will resist care because of the pain. Review of the Resident's medication regime revealed the Resident was prescribed the medication [MEDICATION NAME] (used for gouty arthritis) 100 mg 2 times daily. The Resident had PRN (as needed) orders for Tylenol 650 mg every 4 hours PRN and [MEDICATION NAME] (narcotic pain medication) 10 mg 3 times a day PRN. The Resident had not yet taken the [MEDICATION NAME] that morning and had received 10 mg of [MEDICATION NAME] 1/29/18 at 11:00 am, after he/she had already gotten out of bed. Review of the most recent MDS (Minimum Data Set-a Federally required nursing assessment), dated 1/15/18, revealed the Resident had been coded for pain 2-4 times out of the 5 day assessment window by exhibiting [NAME] Non-Verb… | 2020-09-01 |
| 559 | 559 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 726 | F | 0 | 1 | B1D812 | Based on record review and interview the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and other related services, to ensure safety and attain or maintain the highest practical well-being of each resident. Specifically, the facility was unable to provide licensed nurses completion documentation for the following up dated training competencies; residents rights, grievances, comprehensive assessment after significant change, care plan timing and revision, activities of daily life care, activities, range of motion, accidents, pain management, behavioral health, as well as other training based on staff evaluations. This failed practice placed all residents residing in the facility (based on census of 17) at risk for receiving less than optimal care by licensed nurses. Findings: Review of the facility's Plan of Correction with a correction date of 3/9/18 revealed staff education in the following F tags: F550 - Staff have been educated to encourage resident #6 to not sleep at the table. Staff have also been educated to assist a resident to clean hands if covered in food. Staff were educated to allow the first resident who is in the TV area to select the program. Any concerns about residents not being treated with dignity will be corrected immediately and staff educated as needed. F585 - All staff were educated on the revised Long Term Care Grievance Policy. Education stressed the need to report any verbal grievances so appropriate follow up can be completed. F637 - Social Worker, Director of Nursing (DON), Dietitian, MDS (Minimum Data Set-a Federally required nursing assessment) Coordinator and all Licensed Nursing were educated on the guidelines to completing significant change MDS. Licensed Nurses education included reporting any declines in function on the daily huddle form. The Dietitian was educated on the need to continue to report significant weight loss/gain to the rest of the interdisciplinary team. All nursing staff (Licensed and CNA) were educated on r… | 2020-09-01 |
| 560 | 560 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 741 | E | 1 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and observation the facility failed to ensure facility staff had received competencies in caring for dementia residents that exhibited behaviors. This failed practice denied the staff caring for residents with specific psychosocial and/or mental needs the necessary training to apply methods for non-pharmalogical interventions for 3 residents reviewed with dementia with behaviors (#s 9, 13, and 218) out of 12 sampled residents, and created a risk for residents being overmedicated and having a diminished sense of well-being. Resident #9 Record review on 1/31-2/1/18 revealed Resident #9 had [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set-Federally required assessment) assessment, dated 12/1/17, revealed Resident #9 had behavior that included hallucinations and had exhibited Physical behavioral symptoms directed towards others. During an interview on 2/1/18 at 3:35 pm, when asked what training certified nursing assistants (CNAs) had received regarding Resident #9's behaviors, the Director of Nursing (DON) stated the information was in a book located at the nurses' desk. Review of a book located at the nurses' desk, revealed a pamphlet and cover sheet titled Training Education Documentation-100, Policy and/or Procedure . (Resident #9's) book with charting directives, 1:1 requirements and resident profile information, dated 3/6/17. The cover sheet was marked read only and had a list of 24 nursing employees names. Of the 24 employees, 11 had signed off they had reviewed the book/pamphlet. Closer review of the list, revealed 8 of the current nursing staff, out of the 31 listed on the facility roster (regular and PRN), had signed off they had read the information. Neither the facility's Social Worker or DON had signed off they had reviewed the information. Review of an Interdisciplinary Team note revealed staff is unable to redirect as in fear of (Resident #9) and that the increased supervisio… | 2020-09-01 |
| 561 | 561 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 758 | D | 1 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > . Based on record review and interview the facility failed to ensure 1 Resident's PRN (as needed) order for a [MEDICAL CONDITION] medication had not exceeded 14 days without a documented rationale in the medical record and the duration of use of the medication, for 1 Resident (#9), out of 12 sampled residents. The facility's failure to ensure there was a process for the review of PRN [MEDICAL CONDITION], placed the resident at risk for adverse effects and/or reactions from potentially unnecessary medications. Findings: Record review on 1/31/18 revealed Resident #9 had [DIAGNOSES REDACTED]. Review of the Resident's medication regime included [MEDICATION NAME] 10 mg at bedtime (antipsychotic that can cause dizziness, personality changes, abnormal body movements, and restlessness, among others), [MEDICATION NAME] 4.5 mg at bedtime (antianxiety that can cause worsening [MEDICAL CONDITION], dizziness, trouble sleeping, and unusual tiredness or weakness), and a PRN order for [MEDICATION NAME] 2.5 mg two times a day as needed for agitation. The PRN order was dated 1/9/18, more than 22 days ago. During an interview on 2/1/8 at 12:12 pm, when asked about the PRN order, Resident #9's Physician stated he had missed that order. When asked what process the facility used to ensure he was reminded if the the need to review a PRN [MEDICAL CONDITION] order, the Physician stated he had been setting reminders in his phone or sometimes the nurses would remind him. Licensed Nurse #2, who had entered the room, stated he/she was aware PRN [MEDICAL CONDITION] medications needed to be reviewed by the physician at 2 weeks. | 2020-09-01 |
| 562 | 562 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 761 | D | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure the labels on medications matched the medication order for 2 residents (#s 1 and 3), out of 4 residents observed receiving medications. This failed practice created the risk of residents receiving the wrong medication. Findings: Resident #3 Observation during a medication pass on 1/31/18 at 9:25 am revealed Licensed Nurse (LN) #7 preparing to give medication to Resident #3 medication. The LN removed the 31st pill from the bubble pack and placed it in the medication cup. Review of the medication administration record (MAR) revealed Resident #3 was to receive [MEDICATION NAME] (a medication used to treat gastric acid) 20 mg every morning. Review of the bubble lack medication card, after the nurse had removed the dose revealed the label Give the [MEDICATION NAME] for 30 days. the card was dated 12/22/17, more than 30 days ago. During an interview on 9:37 am, LN #7 stated he/she was unsure why the label read that way. Resident #1 During an observation of a medication pass on 1/31/18 ay 11:45 am, LN #5 prepared medication for Resident #1. Review of the MAR on 1/3/18, revealed Resident #1 was to receive 8.5 Grams of [MEDICATION NAME] (a laxative) /0.5 mixed in water daily. Review of the label on the bottle of [MEDICATION NAME] read 1 capful 17 grams in 8 oz. of water every other day. During the observation, LN #5 poured out a capful (17 Grams) of the medication. The LN then double checked the MAR and noticed the order was different than the label on the bottle, wasted 1/2 of the [MEDICATION NAME] and prepared the correct dose for the Resident. The LN stated he/she would call the pharmacy and obtain another label. | 2020-09-01 |
| 563 | 563 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 803 | E | 0 | 1 | B1D811 | Based on interview and record review the facility failed to meet the needs of the facility's ethnic and cultural diet preferences for facility residents as well as address input, regarding food preferences, received from residents and their families. This failed practice affected 5 residents (#s 5, 12, 14 15, 16) out of 12 sampled residents, and had the potential to cause preventable weight loss and diminished quality of life. Findings: The facility is located in rural western Alaska and considered a transportation and administrative hub for more than 56 surrounding villages. Most the residents residing in the facility were Alaskan Native and had lived a subsistence life style. Resident #5 During an interview on 1/30/18 at 2:36 PM, Resident #5 stated Sometimes I don't eat. It's not my kind of food. I prefer Native food. He/she stated that he/she has made his requests known to staff but there have been no changes. Resident #12 During an interview on 1/29/18 at 10:14 AM, Resident #12 revealed I would prefer some Native food choices. The hospital doesn't provide much. The Resident stated he/she had talked to staff about his preferences. Resident #14 During an interview on 1/29/18 at 1:41 pm, Resident #14 stated he/she was sick of the food here and craves his/her own food. Resident #15 During an interview on 1/29/18 at 11:54 am Resident #15's family member stated that he/she had come to visit for lunch because the Resident had not been eating. The family member stated Resident #15 does not like the food because it was too spicy and/or salty for those that prefer Alaska Native food. The family member stated he/she had talked to staff about the food but they had told him/her the cook follows recipes and no changes had been made to the food. The family member stated the Resident had been recently losing weight and he/she was concerned. Resident #16 During an interview on 1/29/18 at 3:54 pm with Resident #16's family member stated Most of the patients are Native people. The cook puts too much spice. I complained to the c… | 2020-09-01 |
| 564 | 564 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 804 | E | 0 | 1 | B1D811 | Based on observation, interview, and record review the facility failed to provide visually appealing food with variation of color and texture to the Residents. This failed practice affected all Residents (with a census of 17) and had the potential to cause weight loss, decrease nutrition status, and prevent recovery from injury and/or illness. findings: During a dining observation on 1/29/18 at 12:20 pm Resident #15 was served his/her meal. The plate contained chopped chicken, mashed potatoes and gravy, and chopped mixed vegetables, slightly overcooked. The plate lacked color, texture, and visual interest. There was no garnish or appetizing arrangement of the food. The plate appeared colorless and bland. During an interview on 1/30/18 at 2:20 pm, Resident #15's family member stated the food is often to salty/spicy for the Resident's taste. During a dining observation on 1/29/18 at 12:55 pm, Resident #16 received his/her tray 35 minutes after his/her table mate's tray arrived. The plate contained pureed chicken, pureed mashed potatoes and gravy and pureed vegetable. The plate appeared colorless and lacked variation in color to improve appearance. The Resident did not demonstrate any interest in eating. During an dining observation on 2/1/18 at 8:40 am, Resident #218 received his/her breakfast. The meal consisted of a brown muffin, cooked oatmeal, and corn beef hash. The Resident drank a supplement drink that was provided with the meal, and returned to his/her room without eating any of the food. Review of the Residents #16's medical record revealed the Resident had experienced a significant weight loss. On 2/1/18 at 8:56 am Resident #15 was observed seated in front of his/her plate alone in the dining room. The Resident's plate contained corned beef hash (third time during the survey week), a muffin, and oatmeal in a side bowl. The array of food was monochromatic in color and lacked garnish or arrangement to give it an appetizing appearance. Resident #15 pushed the food around in his/her plate for 30 minutes befor… | 2020-09-01 |
| 565 | 565 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 838 | F | 0 | 1 | B1D811 | Based on record review and interview the facility failed to conduct a facility-wide assessment to determine necessary resources for the facility. This failed practice placed all residents residing in the facility (based on census of 17) at risk for not receiving necessary goods and services to meet their needs, potentially negatively effecting both the day to day operations of the facility and emergency planning. Findings: Record review of facility education and interviews during the survey from 1/28-2/2/18 identified: Education for all facility staff in the care for residents with dementia and volatile behaviors was incomplete. Refer to F-741 and F-947 for the extent of this deficient practice. The facility was unable to consistently provide activities to the residents after the loss of their full time activities coordinator. Refer to F-679 for extent of deficient practice. Lift slings, used to transfer, residents were worn and not washed according to manufactures recommendations . In addition, facility staff were using the wrong sizes of slings for residents, creating a risk for injury to the Resident. Refer to F-698 for extent of deficient practice. The Residents had concerns about not receiving enough of their Native foods. Refer to F-803 for extent of deficient practice. Resident were not receiving interventions to maintain and/or prevent further functional decline. Refer to F-676, F-688, and F-825 for extent of deficient practice. During an interview on 2/1/18 at 4:35 pm with the facility Administrator when asked if a facility wide assessment had been conducted in the past year, the Administrator replied, no. At the time of the exit, the facility failed to produce its facility wide assessment. . | 2020-09-01 |
| 566 | 566 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 840 | E | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to utilize outside resources from therapies, in a timely manner, to assist with assessment of residents function and help develop individualized care plans for 4 residents (#s 1; 14; 15; and 16) out of 12 sampled residents. The failure to ensure therapies was an integral part of the interdisciplinary team (IDT) placed residents at risk for injuries and functional decline and/or lack of improvement. Findings: Resident #1 Record review on 1/30-2/1/18 revealed Resident #1 had [DIAGNOSES REDACTED]. Observation on 1/28-2/1/18 revealed Resident #1 utilized a wheelchair for mobility. The Resident's right arm was in a sling and positioned at a 90 degree angle across his/her chest. During an interview on 1/30/18 at 8:52 am, Resident #1 stated he/she had fallen out of a wheel chair when trying to look out the window. The Resident stated the fall had broken his/her arm. On 1/30/18 at 3:31 pm, while participating in a bowling activity the Resident fell out of the wheelchair and hit his/her head. 2/01/18 at 8:30 am 3 CNAs (certified nursing assistants) were discussing resident's fall two days ago. the staff stated the Resident was participating in bowling activity and was holding his broken arm still. When he threw the ball, he lost balance in his chair and tumbled forward out of his chair and bumped his head. Further review of the medical record revealed the Resident had not been evaluated by PT ,after the first fall more than 2 weeks ago, for safety in positioning and/or a review of Resident #1's strengths and weakness in an attempt to mitigate further falls. Resident #14 Record review on 1/31-2/1/18 revealed Resident #14 had [DIAGNOSES REDACTED]. During an interview on 1/29/28 at 1:49 pm, Resident #14 stated he/she doesn't get to practice walking enough, adding the staff will complain they are too busy. Review of the most recent MDS quarterly assessment, dated 1/12/18, revealed the Resident had w… | 2020-09-01 |
| 567 | 567 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 842 | F | 0 | 1 | B1D811 | Based on interview and record review the facility failed to make available its electronic medical record (EMR) system to the survey team by the end of the first full day of the survey. This failure and subsequent delay impeded the survey process and prohibited the survey team from accessing medical records needed to help ensure the facility was optimizing the health, safety, and quality of care for all the residents residing in the nursing home in a timely manner (based on census of 17). Findings: During the entrance conference with the Administrator and the Director of Nursing (DON) on 1/28/18 at 9:39 pm, a formal request was made for EMR access for the survey team. The Administrative team was notified the survey team would need access to the required documentation as well as access to the Minimum Data Set (MDS-a Federally required assessment ) data and Certified Nursing Assistant (CNA) documentation. On 1/29/18 the facility stated they had provided the survey team with log on passwords and access to the EMR. Review of the EMR (Raven) on 1/29/18, revealed the survey team was unable to see CNA documentation, vital signs, chronological documentation of weights, care plans, MDS assessments, skin documentation, behaviors, as well as other documentation. During an interview on 1/29/18 at 4:24 pm, when shown the surveyors view of the EMR and asked where some of the documentation was located, the MDS Nurse and Licensed Nurse (LN) #2 stated the surveyors screen was missing some of the data. During an interview on 1/30/18 at 8:15 am, when asked where wound documentation was located for Resident #218, LN #7 stated the surveyor view of the EMR was missing the wound documentation as the surveyor's view looked different. The LN logged on to the EMR and pulled up his/her view which was much more in depth. During an interview on 1/30/18 at 8:30-8:45 am, the Administrator and the DON were notified the surveyors did not have access to necessary documentation of residents nursing care in the EMR. In addition, Administrator stated… | 2020-09-01 |
| 568 | 568 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 880 | F | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on facility document review and interview the facility failed to develop and implement policies and procedures to inhibit microbial growth in their building water system to reduce the risk for growth and spread of legionella and other opportunistic pathogens in water. 2) The facility failed to ensure 2 facility and/or contract staff had evidence of an annual tuberculoses test (TB). This failed practice placed all residents residing in the facility (based on census of 17) at risk for a serious type of pneumonia from Legionnaires' Disease and/or exposure to TB. Findings: Review of the facility's YKHC LTC Infection Prevention and Control Plan (YEAR)-18, on 2/1/18, revealed no information about a Legionella Disease Water Maintenance Program. During an interview on 2118 at 3:50 pm, the Director of Nurse (DON) was asked for evidence of the facility's Legionella Disease Water Maintenance Program. Review of Yukon-Kuskokwim Health Corporation Committee Agenda: Infection Prevention, provided by the DON on 2/1/18, dated 12/11/17, revealed Legionella Prevention .Policy to be drafted. Review of the CMS (Centers for Medicare and Medicaid Services) Center for Clinical Standards and Quality/Survey and Certification Group letter, dated 6/2/17, revealed .42 CFR 483.80 for skilled nursing facilities and nursing facilities: 'The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections' .CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard 1 calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of [DIAGNOSES RED… | 2020-09-01 |
| 569 | 569 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 914 | E | 0 | 1 | B1D811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure there were curtains to provide privacy during personal care for 4 residents (#s, 2, 3, 6, & 13) out of 4 residents residing in the facility's 2 double rooms. Specifically, the privacy screens located in the 2 double rooms, used instead of curtains, only partially blocked the resident from their roommate's and/or visitors view when receiving personal care. This failed practice placed residents at risk for being exposed when receiving activities of daily living from facility staff and denied them of the right to privacy in their personal space. Findings: Observations on 1/29/18 through 2/1/18 revealed two double occupancy rooms without the ability to provide full privacy for the residents. The ceiling had a mechanical lift track located around the beds and facility did not utilize suspended ceiling curtains. Instead, the facility provided movable three panel screens for privacy during cares and other activities. Each privacy screen was made up of three individual accordion style panels estimated to be 18 inches wide and 6 feet tall. The screen was on wheels and could be moved to block the view either from the door or block the view from of either bed. Anyone entering the room or seated on the other side of the room, would have be able to see the resident in bed and/or seated on the opposite side of the room, as the screen was not wide enough to completely surround either bed. Resident #s 2 and 6 and Resident #s 3 and 13 shared the double rooms without suspended curtains. Interview on 1/30/18 at 3:00 pm with Certified Nursing Assistant (CNA) #2 stated the privacy panel was the only means to provide privacy in the double rooms. Resident #2 Record review on 1/29/18 revealed Resident #2 had [DIAGNOSES REDACTED]. On 2/1/18 at 9:22 am observation of morning cares for Resident #2 revealed while CNA staff were providing pericare (cleansing the groin and buttocks), one of t… | 2020-09-01 |
| 570 | 570 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-02-02 | 947 | F | 1 | 1 | B1D811 | > . Based on record review, interview and observation the facility failed to ensure maintain an in-service training program for nurse aides that is appropriate and effective, as determined by nurse aide evaluation or the facility assessment. In addition, the facility failed to ensure all nurse aides received dementia training. These failed practices placed all residents (based on a census of 17) at risk for receiving less than optimal care by the nurse aides. Findings: Record review, from 1/29/18 through 2/2/18, of all facility provided documents revealed no facility assessment or nurse aide evaluation had been completed by the facility in effort to address any weakness in nurse aides' performances. During an interview on 2/1/18 the facility's Administrator stated no facility assessment or nurse aide evaluation had been completed to find weakness in nurse aides' performance. Record review of a facility provided document entitled Dementia Training, facility reviewed on 2/2/18, revealed 13 of th CNAs had not yet received dementia training. During an interview on 2/2/18 at 8:23 am the Director of Nursing stated the 13 nurse aides listed had not received dementia training. , | 2020-09-01 |
| 571 | 571 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 550 | E | 0 | 1 | PJFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure resident dignity was maintained. Specifically, the facility to 1) ensure a resident was sufficiently covered during a wheelchair (WC) transport from the shower room to the bedroom for 1 resident (#5); and 2) ensure 6 residents (#'s 4; 6; 7; 12; 13; and 16) out of 10 sampled residents had their gait belts (device put on a person with mobility issues) removed from public view. This failed placed the residents at risk for poor quality of life from decreased self-esteem. Findings: Sufficient Covering Resident #5 Record review on 2/24-27/20 revealed Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #5 used a WC due to limited functional mobility. During an observation on 2/25/20 at 8:09 am, Resident #5 was wheeled from his/her room to the unit bathroom across the common area. Resident #10 was sitting in the dining room waiting for breakfast. During an observation on 2/25/20 at 8:37 am, Resident #5 was wheeled back across the unit from the bathroom to his/her bedroom. He/she had a white covering fabric draped over the front and back of his/her body poncho style. Resident #5's body was fully exposed from head to toe from the right side. During an interview on 2/28/20 at 11:00 am, Certified Nurse Assistant (CNA) #4 stated that he/she had helped Resident #5 with an undergarment change in the bedroom. CNAs used a large sheet/towel that was big enough to cover all the way around the Residents body. CNA #4 stated CNA's were instructed to ensure residents were completely covered before leaving their bedrooms. CNA #4 further stated residents who use WCs were bathed in the unit shower room instead of the bedroom shower. During an interview on 2/28/20 at 11:04 am, Licensed Nurse (LN) #2 stated he/she had not noticed when Resident #5 was wheeled through the unit with the sides of his/her body exposed. LN #2 stated if he/she had noticed, he/she would ha… | 2020-09-01 |
| 572 | 572 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 568 | D | 0 | 1 | PJFV11 | Based on interview and record review, the facility failed to provide quarterly statements of personal fund accounts to 1 resident (#6), out of 1 sampled resident whose money was held by the facility. This failed practice placed the resident at risk for not receiving a complete and accurate accounting of his/her personal funds entrusted to the facility. Findings: During an interview on 2/25/20 at 2:09 pm, Resident #6's family member stated that the facility held the Resident's money. A review of Resident #6's Client Fund Statement, dated 12/31/18, 3/31/19, 6/30/19, and 9/30/19 revealed the facility held a personal fund account for the Resident. During an email exchange on 2/28/20 at 12:03 pm, Resident #6's guardian wrote to the surveyor that the facility had not provided him/her with the Resident's quarterly statements. During an interview on 2/28/20 at 2:31 pm, the Administrator stated she spoke to the Human Resources Manager, who stated the quarterly statements had not been sent. | 2020-09-01 |
| 573 | 573 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 572 | F | 0 | 1 | PJFV11 | Based on interview, facility document review, observation, and policy review, the facility failed to inform residents of their rights, rules and responsibilities. Specifically, the rights form did not include all rights, rules, responsibilities, or all the methods to process complaints and grievances. This failed practice effected all residents of the facility and their families/guardians, with a census of 17, to be unaware of resident rights and ability to address concerns. Findings: During an interview at the survey entrance meeting on 2/24/20 at 12:45 pm, the Administrator (AD) stated there was no active Resident and Family Council. Review on 2/25/20 at 10:02 am, of the admission packet paperwork provided by the facility revealed there was no Resident Rights and Responsibilities page in the packet. An observation on 2/25/20 at 10:35 am revealed Resident Rights were not posted on the units. Review on 2/25/20 at 11:09 am, of the Quality Assurance Performance Improvement (QAPI) plan, revealed there was no plan to provide ongoing rights information to the Residents. During an interview on 2/25/20 at 12:42 pm, the AD revealed that Residents received the Ombudsman pamphlet, Your Rights Living in a Long Term Care Facility as the notice of the rights. The AD further stated the rights were not posted on the units. Review on 2/25/20 at 12:49 pm of the Ombudsman pamphlet, revealed an incomplete and abbreviated version of the resident rights. No responsibilities, grievance/complaint process or contact information was given. During an interview on 2/26/20 at 1:27 pm, the Activities Coordinator (AC) stated that the Resident Council meeting had not been meeting for 18 months due to lack of Residents interest. The AC further stated there had been no additional efforts by the Activities department on informing Residents of their rights. During an interview on 2/27/20 at 10:56 am, Licensed Nurse (LN) #2 stated that there were no rights posted on the units. During an interview on 2/27/20 at 10:58 am, the Social Worker (SW) state… | 2020-09-01 |
| 574 | 574 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 574 | C | 0 | 1 | PJFV11 | Based on observation, record review, interview and policy review, the facility failed to ensure 1) a list of names, addresses, and telephone numbers of State regulatory and information on external agencies was correct on unit postings and 2) correct information and contact information for filing grievances or complaints was posted or orally communicated to residents or their families. Specifically, the Quality Improvement Organization number was not current and the name of the current grievance officer had not been updated. This failed practice affected all residents and their families/guardians of the facility, with a census of 17, to be unaware of resident rights and the ability to address concerns. Findings: During on observation on 2/24/20 at 3:00 pm, posters on the units were observed as having listed the previous Social Worker (SW) as the Grievance Officer (GO). Additionally, the Quality Improvement Organization (QIO) was listed as Livanta, who was no longer the QIO for Medicare. During a record review on 2/25/20 at 10:02 am, the admission packet revealed the GO listed as the former SW. During an interview of 2/25/20 at 12:42 pm, the Administrator (AD) stated that the SW was the GO. The AD further stated he/she was unaware that the contact information for internal and external agencies posted on the unit was incorrect. During an interview on 2/27/20 at 10:58 am, the SW stated that he/she is the current GO. He/she further stated that nursing staff was responsible for updating the unit internal and external contact information postings. The SW/GO was not aware the posted information was incorrect. During an interview on 2/28/20 at 1:20 pm, the Director of Nursing stated she was unaware the postings of external contact agencies was incorrect. Review of the facility policy entitled, LTC Grievance Policy, effective date 10/1/13 revealed, I. POLICY: It is the center's policy to support each resident's right to voice concern/grievances. Concerns/grievances may be presented verbally or in writing and may include su… | 2020-09-01 |
| 575 | 575 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 584 | D | 0 | 1 | PJFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility record review, the facility failed to ensure repairs were completed to maintain wall integrity and promote an appealing homelike environment for 2 residents (#12 and #15) out of 17 residents. This failed practice had the potential to cause a diminished self-worth and a reduced sense of well-being. Findings: During an observation on 2/24/20 at 1:48 pm, the wall in Resident #12's room had one area of chipped paint down to the sheet rock approximately 12 inches in length and 4 inches wide. The area of disrepair was near the foot of the Resident's bed. Additionally, there were several areas near the head of the bed with chipped paint, one area approximately 3 inches by 3 inches and 8 smaller areas of chipped paint of varying size. During an observation on 2/24/20 at 2:22 pm, the wall in Resident #15's room near the window had multiple small areas of chipped paint, matching the height of a chest of drawers placed against the wall. Chipped paint was also observed on the wall above the Resident's bed. A subsequent observation on 2/24/20 at 2:30 pm revealed chipped paint on the wall adjacent to the dining room, near room [ROOM NUMBER]. During an interview on 2/26/20 at 2:12 pm, Licensed Nurse (LN) #2 stated if repairs needed to be done, he/she would put in a HEAT (facility work order) ticket to alert the facility of the needed repair. During a joint interview and facility document review on 2/27/20 at 11:18 am, the HEAT tickets were reviewed with the Director of Nursing (DON). There were no HEAT tickets received to notify the facility of the wall damage to Resident #12's or Resident #15's room. The DON stated that a new reporting system for repairs, called Work Hub, started in May of 2019. The Work Hub requests were reviewed and revealed no documentation of the wall damages. During an interview on 2/27/20 at 11:29 am, LN #1 stated that disrepair of walls in the Resident's rooms would have been reported thr… | 2020-09-01 |
| 576 | 576 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 585 | F | 0 | 1 | PJFV11 | Based on interview, facility document review, and policy review, the facility failed to ensure all written grievance documentation of steps taken to address grievances, pertinent findings, corrective actions taken, and the final result of grievances was provided to the patient or person filing the grievance. This failed practice effected all residents of the facility and their families/guardians, with a census of 17, to not be informed of the outcome of their grievances and the facility response. Findings: During an interview on 2/27/20 at 10:58 am, the Social Worker (SW) stated that he/she was responsible for the grievance process. The SW provided the facility grievance log book. Review of the log book on 2/27/20 revealed approximately 5 grievances logged. There were no steps to address written grievances, pertinent findings, corrective actions taken or responses to the grievant available in the log book. During an interview on 2/27/20 at 1:00 pm, the Administrator (AD) stated that he/she would look for additional documentation on follow up for the grievances. During an interview on 2/28/20 at 9:20 am, the AD stated there was no additional documentation on the steps to address written grievances, pertinent findings, corrective actions taken or responses to the grievant completed in writing. Review of the facility's policy entitled, LTC Grievance Policy, effective date 10/1/13 revealed, I. POLICY: It is the center's policy to support each resident's right to voice concern/grievances. Concerns/grievances may be presented verbally or in writing and may include such items as: treatment, care, lost personal items, management of funds, or violation of rights. The center will actively seek resolution to concerns and attempt to keep the resident or griever updates on progress toward resolution. The center will uphold the resident, legal representative, other involved family member(s), or resident advocates right to voice customer concerns without discrimination or reprisal .III. PROCEDURE: A. The Social Worker will assu… | 2020-09-01 |
| 577 | 577 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 607 | C | 0 | 1 | PJFV11 | Based on record review, interview and policy review, the facility failed to ensure staff was screened prior to employment. Specifically, the facility failed to check references for 1 Certified Nursing Assistant (CNA) # 3, out of 4 CNA personnel records reviewed. This failed practice prevented the facility from reviewing and screening the CNA's past employment history, which had the potential to affect all residents, based on a census of 17. Findings: Review on 2/27/20 at 1:06 pm, of personnel records for CNA #3, revealed the CNA was hired on 2/4/20. Further review revealed no reference checks were done when the CNA was hired. Review on 2/27/20 at 2:00 pm, of the facility's staff schedule, dated 2/24-28/20, revealed CNA #3 was scheduled to work on 2/24/20 and 2/25/20. During an interview on 2/27/20 at 4:21 pm, the Director of Nursing (DON) stated that she found out the day before that no reference checks were done for CNA #3. Review on 2/28/20 at 3:00 pm, of the facility's policy LTC (long term care) Abuse Prevention Policy, dated 10/1/13 revealed no mention of screening employees to prevent abuse, neglect and exploitation of the residents. Review on 2/28/20 at 3:00 pm, of the facility's LTC Sexual Abuse Policy, dated 10/1/13, revealed All prospective employees undergo criminal background checks according to State Law and are screened for a history of abuse, neglect, and/or exploitation by inquiries to former employers . | 2020-09-01 |
| 578 | 578 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 656 | D | 0 | 1 | PJFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to address the medical needs of 2 residents (#9 and #13) out of 10 sampled residents whose care plans were reviewed. Specially, the facility failed to address 1) a pacemaker in resident #9's care plan and 2) a neurostimulator (a device in which wires are placed into parts of the brain that are sending the abnormal nerve signals causing tremors which are associated with [MEDICAL CONDITION] and other types of tremors) in resident #13's care plan. This failed practice placed the residents at risk for inconsistent care that could result from consequences of insufficient monitoring and care. Findings: Resident #9 Record review on 2/24-28/20 revealed Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. People are treated with a permanent pacemaker being implanted to assure proper heart beating) and dementia. Review of the most recent MDS (Minimum Data Set, a federally required nursing assessment) assessment, a quarterly assessment dated [DATE], revealed Resident #9 was not coded for [MEDICAL CONDITION]. During a record review on 2/26/20 at 10:34 am, Resident #9's care plan, last updated 12/12/19, revealed no documentation in the care plan for pacemaker monitoring, checking or any specialized cares resident may have needed. During an observation on 2/26/20 at 2:42 pm, in the medication room, a white erase board that had Resident #9's name with dates of his/her pacemaker checks for the current year was written. During an interview on 2/27/20 at 12:04 pm, the Director of Nursing (DON) stated Resident #9 had his/her pacemaker checked every 3-4 months. During an interview on 2/27/20 at 3:49 pm, the DON stated the pacemaker was not in Resident #9's care plan and needed to be in care plan. Review of the facility's policy Pacemaker Policy, reviewed date 12/31/18, revealed .D. Note pacemaker use on care plan with interventions that include 1. Monitor signs and symptoms of … | 2020-09-01 |
| 579 | 579 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 689 | D | 1 | 0 | PJFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview the facility failed to ensure 1 resident (#7) with wandering behaviors (leaves the premises or safe area without authorization and/or necessary supervision) had adequate supervision when exhibiting exit seeking behaviors. (Based on a sample of 10) These failed practices placed the resident's health and safety at risk. Findings: According to the Agency for Healthcare Research and Quality, accessed 3/9/20 at www.psnet.ahrq.gov , the definition of elopement is a resident with decreased mental capacity related to dementia, or temporary [MEDICAL CONDITION], or intermittent status changes related to medication, disease, or traumatic injury who leaves the building with intent and without permission. The definition of wandering is a resident that strays beyond the view or control of staff without intent of leaving (cognitive impairment). Both elopement and wandering could place residents at risk for serious harm. Observations of the 300 wing from 2/24-26/20 revealed, a large open common area with resident rooms opening to the units common area. The unit was locked with staff needing a badge to go in and out of the unit. When the door was shut it was locked. Record review on 2/24-28/20 revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. The blood collection can be within the brain tissue or underneath the skull, pressing on the brain.) The Resident used a wheel chair (WC) for mobility. Review of the most recent Minimum Data Set (MDS-a federally required assessment tool), dated 1/22/20, quarterly assessment, revealed the Resident was coded as having behaviors affecting others: including rambling, unclear or illogical flow of ideas, unpredictability which changes with severity; wandering behavior that occurred 1 to 3 days a week with the impact of placing the resident at risk for getting to a potentially dangerous place (e.g., . outside the facility). During an observation on 2… | 2020-09-01 |
| 580 | 580 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 732 | E | 0 | 1 | PJFV11 | Based on observation and interview, the facility failed to ensure current date and nursing staff information was posted on the 200 unit on a daily basis in a readily accessible location for residents and visitors. This failed practice effected all residents and visitors, based on a census of 8 residents on the 200 unit, to be unaware of the date and staff who were on duty. Findings: During an observation on Monday, 2/24/20 at 2:00 pm, the white board on the 200 unit revealed the date as Sunday, February 23, 2020. Staff were listed but it is unknown if it was the staff working on 2/24/20 or if staff were on duty. During an observation on Tuesday, 2/25/20 at 8:02 am, the white board on the 200 unit revealed the date as Monday, February 23, 2020. The staff listed were the staff on the previous day shift. During a second observation on 2/25/20 at 1:04 pm, the white board in the common area of the 200 unit revealed Monday's date and staff list. During a third observation on 2/25/20 at 3:15 pm, the white board on the 200 unit revealed Monday's date and staff list. During an interview on 2/27/20 at 10:56 am, Licensed Nurse (LN) #2, when asked about the white board in the common area, stated that the board should have been changed daily, each shift, by the charge nurse. During an observation on 2/27/20 at 11:58 am, the white board on the 200 unit was dated February 26, 2020. During an interview on 2/27/20 at 11:58 am, Resident #5 stated, I need to call my son, today is his birthday.it's February 26? Resident #5 was informed it was February 27. He/she replied, Oh no, I've missed his birthday, I can't even remember that anymore. I should call him anyway. During an interview on 2/28/20 at 1:15 pm, the Director of Nursing (DON), when asked about the expectation for the unit white board to be updated, the DON stated that they should contain correct date and staff information by shift and the task was assigned to the charge nurse. The DON further stated there were no policies, procedures, or guidelines available for this task. | 2020-09-01 |
| 581 | 581 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 760 | E | 1 | 0 | PJFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure 1 resident (#13) out of 5 residents sampled for medication review were free from significant medication errors. Specifically, the resident experienced a medication error that negatively impacted his/her health and well-being, which lead to disruptive behaviors and depression. This failed practice placed the resident at risk for decreased quality of life and decreased self-esteem due to abrupt medication withdrawal. Findings: Resident #13 Record review from 2/24-28/20, revealed Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. Review on 2/28/20 at 9:55 am, of the Admission History and Physical Note dated 3/8/18, revealed an order for [REDACTED]. Review on 2/28/20 at 10:30 am, of the Nursing Progress Note, dated 1/27/19 at 4:52 pm, revealed Resident #13 had an unwitnessed fall in the dining room. Further Review of a Nursing Progress Note, dated 1/28/19 at 9:54 am, revealed Resident #13 had spent most of the day in his/her bedroom. Review of Nursing Progress Note, dated 1/28/19 at 5:59 pm, revealed Resident was restless this shift. Up at times unassisted. Staff sitting 1:1 (monitoring with continuous visual observation) at times. Review on 2/28/20 at 12:30 pm of a facility provided Initial Incident Report, dated 3/1/19 at 12:05 pm, revealed the Quetiapine 25 mg was not administered on 1/25/19, 1/26/19 or 1/27/19. Review on 2/28/20 at 12:30 pm, of the facility provided Initial Incident Report dated 3/1/19 at 12:05 pm, the Minimum Data Set Coordinator (MDSC) documented, when reviewing Resident #13's Medication Administration Record [REDACTED]. was not given for 3 days. Further review revealed The MDSC noticed and discussed with the Pharmacist. During a phone interview on 2/28/20 at 2:04 pm, when asked about the missed Quetiapine doses, the Pharmacist stated, We think the 30 day renewal was not entered, or the discharge date was put in by accident. The Pharmaci… | 2020-09-01 |
| 582 | 582 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 802 | F | 0 | 1 | PJFV11 | Based on observation, interview, and facility document review the facility failed to ensure sufficient dietary support staff were available to safely and effectively carry out the functions of the food and nutrition services. This failed practice effected all residents and visitors, based on a census of 17, to potentially be exposed to foodborne illness as a result of improper food storage. Findings: Kitchen During an observation on 2/24/20 at 12:49 pm, revealed the following food and beverage issues on initial inspection of the kitchen: 2 serving cups of diced pears and 2 tartar sauce condiment cups were unlabeled and undated in the refrigerator; Sliced lemons were unlabeled and undated in the refrigerator; 1 opened jar of raspberry preserves with a use by date of [DATE] was on the shelf, unrefrigerated; 1 opened bottle of sweet chili sauce with an expiration date of 6/27/19; and 1 flat of nectar thick orange juice with an expiration date of 2/2/20 was in the refrigerator. During an interview on 2/24/20 at 12:57 pm, the Dietary Manager (DM) stated that he/she had just returned from vacation. The DM further stated that there were serious staffing issues for the kitchen in his/her absence. 3 staff members had not come in as scheduled while he/she was on leave. He/she stated there had been ongoing issues keeping trained staff to meet the needs of the kitchen. The DM stated that he/she routinely checked the stored food items weekly to ensure they were within date. During his/her absence, the food checks were not completed. The DM further stated that when a Dietary Aide (DA) did not come to work, only the cook was on shift to complete all tasks and meals, and often tasks were overlooked. Observation from 2/24-28/20 revealed the only kitchen staff working was the DM and DA #1. During an observation on 12/24/20 at 1:27 pm of the freezer, revealed the following: 1/2 bag of breadsticks were open, with a use by date of 2/2/19; Multiple pieces of bread/rolls were in an unsealed Ziplock with a use by date of 12/1/19; 5 pies… | 2020-09-01 |
| 583 | 583 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 812 | F | 0 | 1 | PJFV11 | Based on observation, interview, and policy review, the facility failed to ensure 1) frozen food and thickened juice was stored in accordance with professional standards 2) food products on unit refrigerators were within the use date, 3) packaged snack foods provided by the facility in unit refrigerators were properly labeled with open dates and were packaged for storage after opening to prevent spoilage. This failed practice effected all residents and visitors, based on a census of 17, to potentially be exposed to foodborne illness as a result of improper food storage. Findings: Kitchen During an observation on 2/24/20 at 12:49 pm, revealed the following food and beverage issues on initial inspection of the kitchen: 2 serving cups of diced pears and 2 tartar sauce condiment cups were unlabeled and undated in the refrigerator; Sliced lemons were unlabeled and undated in the refrigerator; 1 opened jar of raspberry preserves with a use by date of [DATE] was on the shelf, unrefrigerated; 1 opened bottle of sweet chili sauce with an expiration date of 6/27/19; and 1 flat of nectar thick orange juice with an expiration date of 2/2/20 was in the refrigerator. During an interview on 2/24/20 at 12:57 pm, the Dietary Manager (DM) stated that he/she had just returned from vacation. The DM further stated that there were serious staffing issues for the kitchen in his/her absence. 3 staff members had not come in as scheduled while he/she was on leave. He/she stated there had been ongoing issues keeping trained staff to meet the needs of the kitchen. The DM stated that he/she routinely checked the stored food items weekly to ensure they were within date. During his/her absence, the food checks were not completed. The DM further stated that when a Dietary Aide (DA) did not come to work, only the cook was on shift to complete all tasks and meals, and often tasks were overlooked. Observation from 2/24-28/20 revealed the only kitchen staff working was the DM and DA #1. During an observation on 12/24/20 at 1:27 pm of the freezer, r… | 2020-09-01 |
| 584 | 584 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 838 | D | 0 | 1 | PJFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a comprehensive facility assessment for all medical devices used in the facility. Specifically, the facility failed to ensure; 1) the clinical needs of 2 residents (#9 and 13) out of 2 residents who were identified as having implanted devices, 2) staff had the specialized training, and 3) competency opportunities was provided for staff caring for these residents. This failed practice placed 1 resident (#9) of 1 resident with a pacemaker at risk for not having necessary cardiac monitoring with care and 1 resident (#13) of 1 with a neurostimulator (a device in which wires are placed into parts of the brain that aren't working properly to send electrical stimulation to a certain area of the brain that sends the abnormal nerve signals causing tremors which are associated with [MEDICAL CONDITION] and other tremors) at risk for insufficient monitoring. Findings: Review of the facility assessment, dated 8/19, revealed the facility assessment had not identified Resident #9 with an implanted cardiac device that needed special monitoring, equipment and care or Resident #13 who had the neurostimulator implanted with any monitoring or care that resident may need. In addition, the assessment did not identify any specific training, equipment or required care. During an interview on 2/28/20 at 3:31 pm, the Director of Nursing stated the facility assessment did not include Resident with the implantable cardiac device or the Resident with the neurostimulator, care the Residents or training staff needed. | 2020-09-01 |
| 585 | 585 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2020-02-28 | 943 | F | 0 | 1 | PJFV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to implement an effective training program for staff. Specifically, the facility failed to provide 1 Certified Nursing Assistant (CNA) (#2) with abuse and neglect training and 2 CNAs (#2 and #6) with dementia training, out of 4 CNA personnel records reviewed. This failed practice had the potential to decrease the reporting of activities that constitute abuse and neglect for all residents based on a census of 17. Findings: Abuse and Neglect Training: Review on 2/27/20 at 1:06 pm, of personnel records for CNA #2, revealed the CNA was hired on 10/8/19. Further review of the CNA's education file revealed no training for abuse prohibition. During an interview on 2/28/20 at 2:18 pm, the Director of Nursing (DON) stated that CNA #2 had not completed his/her abuse and neglect training. The DON further stated that CNA #2 started after the yearly trainings were scheduled and that training was not scheduled on CNA #2's healthstream (employee training database). Review on 2/28/20 at 3:00 pm, of the facility's LTC (long term care) Abuse Prevention Policy, dated 10/1/13, revealed It is the policy of this facility to utilize education, supervision, symptom identification .to prevent abuse and mistreatment of [REDACTED]. Review on 2/28/20 at 3:00 pm of the facility's LTC (long term care) Sexual Abuse Policy, dated 10/1/13, revealed Facility employees receive training at orientation .on the definitions of abuse (including sexual abuse), neglect and exploitation, recognition of abuse, neglect and exploitation, reporting of known or suspected abuse, neglect and exploitation and interventions to deal with abuse, neglect and exploitation. Dementia Training: Review on 2/27/20 at 1:06 pm, of personnel records for CNA #2, revealed the CNA was hired on 10/8/19. Further review of the CNA's education file revealed no dementia training. Review on 2/27/20 at 1:06 pm, of personnel records for CNA #6,… | 2020-09-01 |
| 586 | 586 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 550 | C | 0 | 1 | YK7L11 | Based on observation, interview and record review the facility failed to ensure an environment that maintained and/or enhanced each resident's dignity and respect during dining. Specifically the facility failed to: 1) ask resident's permission when applying clothing protectors for 15 Residents (#s 1; 4; 5; 6; 7; 8; 9; 10; 11; 12; 13; 14; 15; 16 and 17), out of a total census of 17; 2) provide feeding assistance for 1 resident (#12) in a dignified manner; and 3) inquire if 1 resident (#11) was done eating prior to ending a meal. These failed practices devalued the resident's decisions, infantilized the adult residents and placed residents at risk for depression and psychological Findings: Based on observation, interview and record review the facility failed to ensure 3 residents (#s 5, 15 and 17) out of a census of 17 the opportunity to vote in the 11/6/18 State election. This failed practice denied residents the opportunity to exercise their rights as citizens, specifically their right to vote. Findings: Applying Clothing Protectors During a dinner observation on 11/5/18 at 5:16 pm, Resident #s 6; 10; 13; 14 and 15 were seated at the tables. Certified Nursing Assistant (CNA) #5 was observed putting clothing protectors on the Residents without asking first. CNA #5 stated to Resident #6, Put this on. Observation on 11/5/18 at 5:32 pm, Resident #7 was placed at the table and a clothing protector was placed without asking the resident by Licensed Nurse (LN) #3. Observation on 11/5/18 at 5:40 pm, revealed Resident #5 was placed at the dining table. The clothing protector was put on the Resident without asking. During an observation on 11/6/18 at 8:26 am, CNA #7 was observed placing a clothing protector on Resident #10 without asking. During an observation on 11/6/18 at 8:40 am, CNA #1 was observed placing clothing protectors on Residents #s 1; 4; 9; 11; and 17 without asking. During an observation on 11/6/18 at 8:48 am, CNA #3 was observed placing a clothing protector on Resident #8 without asking. During on observati… | 2020-09-01 |
| 587 | 587 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 578 | E | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a procedure/process was in place to offer residents without an advanced directive assistance to formulate an advanced directive. This failed practice denied 4 residents (#s 6;9;10; and 11) out of a sample of 11 residents, and/or their representatives, the right to choose and make end of life medical decisions and placed those residents and all future residents at risk for receiving (or not receiving) their chosen end of life care. Findings: Resident #6 Record review on 11/5-9/18 revealed Resident # 6 was admitted with [DIAGNOSES REDACTED]. Record review on 11/6/18 at 1:10 pm revealed no advance directive was on file nor evidence the Resident or Resident's Representative had been offered assistance to formulate an advanced directive. During an interview on 11/6/18 at 3:21 pm, the Social Worker (SW) stated Resident #6 did not have an advanced directive on file. She further stated there is no documentation that the Resident was offered assistance in making an advance directive. Resident #9 Record review on 11/5-9/18 revealed Resident # 9 was admitted with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. During an interview on 11/8/18 at 3:00 pm, the SW stated Resident #9 does not have an advanced directive or a power of attorney on file. She further stated there is no documentation that the Resident was offered assistance in making an advance directive. Resident #10 Record review on 11/5-9/18 revealed Resident # 10 was admitted with [DIAGNOSES REDACTED]. Record review on 11/6/18 at 1:12 pm of the Resident's electronic medical record (EMR) revealed a flag that Resident #10 had an advance directive on file. A power of attorney document was downloaded under multimedia in the EMR but not the advance directive. Record review on 11/7/18 at 9:00 am of the Resident's paper medical record revealed there was no advance directive on file. During an intervie… | 2020-09-01 |
| 588 | 588 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 607 | F | 0 | 1 | YK7L11 | Based on record review and interview, the facility failed to ensure reference checks of previous employers were performed for 9 of 12 sampled employees currently working in the facility. This failed practice placed all residents (nased on census of 17) of the facility at risk for abuse and/or neglect. Findings: During a record review on 11/8/18 of a sample of 12 employee files, no documentation of previous employer reference checks were found. During an interview on 11/8/18 at 11:00 am, the Director of Nursing stated that he/she had no documentation in employee files of reference checks. During an interview on 11/8/18 at 11:30 am, the Interim Human Resource Director stated that the organization contracted with an external resource for reference checks, but only for employees that come from out of state. He/she confirmed there was no documentation of reference checks in 9 of the 12 sampled employee files. Record review of the facility policy entitled, LTC Abuse Employment Screening last updated 10/1/13 revealed, It is the policy of this facility to screen all potential employees for a history of abuse, neglect, or mistreating residents. The policy further revealed under the procedure section, [NAME] Secure permission from potential employees to obtain background information from but not limited to previous employers, licensing boards and registries, and law enforcement agencies. B. Contact previous employers requesting employment history to include but not limited to; dates of service, position held, performance history, history of abuse, neglect, or mistreating residents. | 2020-09-01 |
| 589 | 589 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 637 | D | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure a MDS (Minimum Data Set-a Federally required assessment) comprehensive assessment was completed after a significant change in functional ability for 1 Resident (#7) out of 12 sampled residents. This failed practice placed the resident at risk for not receiving interventions to improve or maintain overall physical condition, functional ability, and well-being. Findings: Resident #7 Record review on 11/5-9/18 revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 11/5-9/18 of the most recent MDS dated [DATE] revealed that Resident #7 required limited, one person assistance for transfers and walking. Record review on 11/5-9/18 of nursing progress note dated 9/7/18 revealed (Patient #7) has a wheelchair but seldom uses it- staff uses it to take him outside on the unit. He/she prefers to ambulate and has his/her gait belt on. He/she is a direct staff observation. No (complaint of) pain, no distress noted. Ongoing monitoring. Record review on 11/5-9/18 of the Interdisciplinary Care Plan Meeting dated 9/19/18 revealed there were no changes to the Resident #7's plan of care and that he/she walks often with staff. No concerns were discussed about decline in functioning with Resident or family. Record review on 11/5-9/18 of nursing progress note dated 9/28/18 revealed, Resident assessment completed, alert, oriented with confusions, remains on increased supervision, resident sitting in his/her wheelchair . Record review on 11/5-9/18 of nursing progress note dated 10/11/18 revealed, (Resident #7) total dependence on staff for all ADLS (activities of daily living). Observation on 11/5/18 at 1:00 pm, Resident #7 was asleep in bed. The bed was lowered to the ground and pads were placed on floor beside the bed. During an observation on 11/6/18 at 9:10 am, Resident #7 had been seated at the dining table. He/she made multiple attempts to stan… | 2020-09-01 |
| 590 | 590 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 641 | D | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure an interview was done with 1 Resident (#5) out of a sample of 11 sampled residents during the MDS (Minimum Data Set, a Federally required assessment) assessment for mental status (BIMS, Brief Interview for Mental Status). This failed practice had the potential to inaccurately reflect the resident's status and careplanning participation and a risk to decrease the resident's highest practicable mental and psychosocial well-being. Findings: Resident # 5 Record review on 11/5-9/18 revealed Resident #5 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Resident #5's medical record revealed the Resident is his/her own decision maker. Record review of the most recent MDS assessment, an admission assessment dated [DATE], revealed the Resident did not have a BIMs (13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment) assessment completed. Further review of the MDS admission assessment revealed conflicting codes in Section B versus Section C for the Resident. Section B - Hearing, Speech, and Vision Speech Clarity: Clear speech-distinct intelligible words Makes Self Understood: Usually understood- difficulty communicating some words or finishing thoughts but is able if prompted or given time Ability to Understand Others: Usually understands-misses some part/intent of message but comprehends most conversation Section C - Cognitive Patterns Should Brief Interview for Mental Status be Conducted? - Attempt to conduct interview with all residents: No (resident is rarely/never understood) Random observations from 11/5 - 9/18 revealed staff conversing with Resident #5 in Yupik and he would respond back at the dining table. Observation during cares on 11/7/18 at 9:46 am revealed Resident #5 following instructions given him by Certified Nursing Assistant #2. During an interview on 11/7/18 at 10:23 am, the MDS Nurse stated the Social Worker was… | 2020-09-01 |
| 591 | 591 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 655 | D | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement a baseline care plan within 48 hours of 1 resident's (#4) admission, out of 11 sampled residents. This failed practice placed the resident at risk for a breakdown in continuity of care, resident safety, and inhibited the placement of safeguards against adverse events that may occur right after admission. Findings: Record review on 11/5-9/18 revealed Resident #4 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's care plan revealed it was first initiated on 8/22/18, 7 days after admission, with 1 identified problem of Activities. Further review revealed additional problems of falls; cognitive loss; communication; [MEDICAL CONDITION]; pressure ulcer; and visual function were first initiated on 8/23/18, 8 days after the Resident's admission. During an interview on 11/7/18 at 1:33 pm, the MDS (Minimum Data Set) Nurse stated the care plan for Resident #4 was late getting initiated. Review of the facility care plan policies, accessed through the facility's website, revealed no policy in regards to baseline care plans. | 2020-09-01 |
| 592 | 592 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 656 | D | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop care plan goals and interventions to address care areas identified by the MDS (Minimum Data Set-a Federally required assessment) for 2 resident (#s 7 and 15), out of 11 sampled residents. This failed practice placed the residents at risk for not receiving medical, nursing, mental and psychosocial interventions to maintain the highest practicable well-being. Findings: Resident #7 Record review on 11/5-9/18 revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. During random observations from 11/5-9/18, Resident #7 was observed in his/her bedroom alone. He/she was not seen interacting with other residents or in meaningful interaction with staff. Record review on 11/5-9/18 of the annual MDS dated [DATE] revealed Resident #7 triggered the Care Area Assessment (CAA) to include cognitive loss/dementia, vision, and behaviors. The CAA further stated the triggered areas were addressed in the care plan. Record review on 11/5-9/18 of Resident #7's care plan revealed no goals or interventions for cognitive loss/dementia, vision, or non-pharmacological interventions other than long term use of [MEDICAL CONDITION] medication. Resident #15 Record review on 11/5-9/18 revealed Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. During random observations from 11/5-9/18, Resident #15 was observed to anxiously pace the unit. He/she was not observed to participate in daily activities or meaningful interactions with staff. An interview was attempted interview with Resident #15 on 11/5/18 at 3:30 pm. While attempting to interview Resident #15 at 11/5/18 at 3:30 PM, CNA #7 stated in response resident was hard of hearing and was rarely understood. He/she could understand written communication when using a whiteboard but staff had difficulty understanding him/her because his/her hands shake very badly and when he/she would try to write responses, the writing was… | 2020-09-01 |
| 593 | 593 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 657 | E | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to ensure 1) an interdisciplinary team developed plans of care with input from the resident or legal representative for 1 resident (#4); 2) the care plan was revised to reflect current interventions and needs for 1 resident (#5); 3) the care plan was revised to reflect the current level of nutritional care and services required for 1 resident (#11); and 4) the care plan was revised when antipsychotic medication interventions for behaviors were re-implemented for dementia care in 1 resident (#17), out of 11 sampled resident. This failed practice placed the residents at risk for less than the highest practicable mental, physical, and psychosocial well-being. Findings: Resident #4 Record review on 11/5-9/18 revealed Resident #4 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 11/6/18 at 1:05 pm, Resident #4's daughter, and medical decision maker/representative, stated she had never been invited to participate in the plan of care for the Resident since admission to the facility. Review of Resident #4's care plan revealed it was first initiated on 8/22/18, 7 days after admission. Review of Resident #4's medical record, on 11/7/18 at 1:45 pm, revealed no interdisciplinary team (IDT) communication about Resident's care was documented. During an interview on 11/7/18 at 2:05 pm, the MDS (Minimum Data Set) Nurse stated there had been no IDT meeting or care conference held for Resident #4 since his/her admission. Resident #5 Bed Wedges Record review on 11/5-9/18 revealed Resident #5 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident also has a history of visual impairments. Review of Resident #5's medical record revealed Resident #5 was documented as being his/her own decision maker. Observation on 11/7/18 at 9:46 am revealed Resident #5 had 2 bed wedges with approx. 35 degree angle and approximately 48 inches long tucked unde… | 2020-09-01 |
| 594 | 594 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 658 | D | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to identify needed care and document treatment in accordance with professional standards of practice for 1 resident (#11), out of 11 sampled residents. This failed practice placed the resident at risk for delay of care and interventions that could contribute to a decline in health. Findings: Record review on 11/5-9/18 revealed Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the medical record on 11/6/18 revealed Resident #11 was transported to the hospital on [DATE] due to having respiratory distress. After examination, the Resident was admitted to the hospital for dyspnea (difficult or labored breathing) and a urinary tract infection. Review of the Resident's nursing notes prior to the hospitalization revealed the following: - Nurse's note, dated 4/30/18 at 5:02 am, revealed the following symptoms: .wheezing and crackles at bilateral lobes upon assessment, (shortness of breath) when performing activities . Further review revealed no respiratory rate was documented on this day, nor any interventions completed for the Resident's symptoms. - No nurse's notes were documented on 5/1/18 or 5/2/18. - Nurse's note, dated 5/3/18 at 9:49 pm, revealed: Resident noted (shortness of breath) and wheezing when assisting to bed by an aide, (nebulizer) (treatment) (as needed) as ordered, (vital signs) taken . Further review revealed the Resident's respiratory rate at 9:00 pm was 22. No follow up respiratory rate after the nebulizer treatment was documented. - Nurses note, dated 5/4/18 at 4:56 pm, revealed: (shortness of breath) and expiratory wheezing .given (as needed) (nebulizer) treatment .will keep monitoring further development. Further review revealed the only documented respiration on 5/4/18 was at 4:06 pm, which was a rate of 20. - Nurses note, dated 5/4/18 at 5:23 pm, revealed: .no improvement in respiratory distress, (medical doctor) notified, whom ordered resid… | 2020-09-01 |
| 595 | 595 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 676 | D | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to provide the necessary care and services to maintain or improve independent nutritional intake for 1 resident (#11), out of 11 sampled residents. This failed practice placed the resident at risk for a decline in weight that could affect the resident's health and well-being. Findings: Record review on 11/5-9/18 revealed Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], revealed Resident #11 was coded as requiring extensive assistance with eating. Review of Resident's quarterly nutrition assessment, performed on 10/4/18, revealed: Summary of Feeding Ability: Extensive assist per ADL (evaluation) on 9/21/18. Feeding ability varies, will feed herself, needs cueing, and sometimes need fed. Further review revealed no restorative aids or a restorative dining program was recommended. During an observation of breakfast on 11/06/18 at 8:57 am, Resident #11 had considerable trouble to feed himself/herself: - Certified Nursing Assistant (CNA) #3 set up breakfast: One scoop of corn beef hash in the middle of a dinner-size plate. Cream of wheat and diced fruit situated to the right of this plate in separate bowls. - The Resident had to unwrap the silverware, which caused the napkin fall on his/her plate in front of the hash. - The Resident used the fork to blindly attempt to scoop up the hash, over the napkin, however missed and brought the empty fork to his/her mouth 6 different times. Licensed Nurse (LN) #2 came over and talked with the Resident while giving morning medication. LN #2 did not aid the Resident or remove the napkin from the hash. - At 9:00 am, CNA #1 sat down at Resident's table to assist another Resident and offered no feeding assistance to Resident #11. - Subsequent bites had very small portions on fork, food fell off the fork half way to his/her mouth about 25% … | 2020-09-01 |
| 596 | 596 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 678 | E | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure that 1 employee out of 11 sampled employees had not provided verification of current Cardio [MEDICAL CONDITION] Resuscitation (CPR) certification. This failed practice placed all residents of the facility, that did not have a Do Not Resusitate status, at risk for not receiving necessary life saving measures in the event of a respiratory or circulatory emergency. Observation on ,[DATE]-,[DATE] revealed Licensed Nurse (LN) #1 was working day shift on the 300 wing. Record review of employee sample form completed by the Director of Nursing (DON) on [DATE] at 4:00 pm revealed that LN #1's CPR certification expired on [DATE]. During an interview on [DATE] at 4:15 pm, the DON stated that she had not received updated CPR certification for LN #1 and had not realized the certification had expired until he/she completed the surveyor employee sample form. During an employee file review with the Human Resources (HR) department on [DATE] at 10:35 am, no updated CPR certification was found in LN #1's file. During an interview on [DATE] at 11:25 pm, the Interim Human Resource Manager confirmed there was no updated CPR certification on file for LN #1. During an interview on [DATE] at 4:00 pm, DON confirmed he/she did not have updated CPR certification for LN#1 and that he/she would be removed from the schedule until it was provided. | 2020-09-01 |
| 597 | 597 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 685 | D | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to assist 1 resident (#11), out of 11 sampled residents, to locate and utilize available resources to ensure proper treatment and assistive devices to maintain hearing abilities. This failed practice left the resident without hearing aids, inhibiting the ability to hear, for approximately 1 year which affected the resident's physical, mental, and psychosocial well-being. Findings: Record review on 11/5-9/18 revealed Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) assessment, a quarterly assessment dated [DATE], revealed Resident #11 was coded as having moderate difficulty with hearing and used hearing aids. Review of the Resident's care plan revealed an identified problem of Communication: (Resident) has compromised ability to understand (related to) hearing loss. An identified intervention listed read: (Resident) wears hearing aids. This problem was last updated on 6/24/18. An observation of breakfast on 11/6/18 at 8:57 am, revealed Resident #11 was not wearing his/her hearing aids. An observation of lunch on 11/7/18 at 12:15 pm, revealed Resident #11 was not wearing his/her hearing aids. During an interview on 11/7/18 at 12:33 pm, Certified Nursing Assistant (CNA) #6 stated Resident #11's hearing aids were lost a while ago. During an interview on 11/08/18 at 5:04 pm, the Social Worker stated Resident #11's hearing aids were lost within the facility in (MONTH) (YEAR) and replaced. The right hearing aid was lost again, date unknown, in the facility however the Social Worker was not notified of this until (MONTH) (YEAR). The Social Worker stated he/she got administrative approval to purchase new hearing aids for Resident #11 on 7/26/18. The Social Worker continued to state that he/she attempted to purchase the hearing aids in (MONTH) and on 9/14/18; 9/17/18; and 9/20/18 however the transactions were unsuccessful due to… | 2020-09-01 |
| 598 | 598 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 688 | E | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to provide interventions to maintain or improve range of motion (ROM) or prevent further decline recommended by the Physical Therapist (PT) for 8 residents (#s 4; 6; 9; 11; 10; 12; 15; and 17) based on a sample of 11. This failed practice placed all residents at risk for a decrease in mobility, functionality, and independence. Findings: Resident #4 Record review on 11/5-9/18 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Resident's PT evaluation, dated 8/20/18, revealed: - Chief Complaint: deconditioning (the reform or reversal of previously conditioned behavior), Left Lower Extremity Pain; - Assessment: Impairments/limitations: ambulation (walking around) deficits; balance deficits; endurance deficits; pain limiting function; strength deficits; and transfer (moving from bed to wheelchair, wheelchair to bed) deficits; - Summary of needs: (Resident) would benefit from restorative therapy (a form of physical therapy designed to restore function) at this time to assist (him/her) in maintaining (his/her) current ambulation status; and - Additional Information: Restorative therapy, strategically placing (wheelchair) further from room each day to encourage (patient) ambulation to table for meals (3-5 days/week) and 1-2 days/week train on Nu-Step (a high-back low seated bicycle with arm exercise handles to work for both legs and arms comfortably) for up to 15 minutes as tolerated on Level 1-2 to help recover strength and cardiovascular fitness with low impact to knees. Review of Resident's care plan revealed an identified problem of Activities of Daily Living (ADL) Function Rehab, last updated on 10/8/18. Further review revealed the PT evaluation recommendations were not included in the interventions for this problem. Additional review revealed: (Resident) occasionally ambulates in her room and uses (wheelchair) on the unit and up for m… | 2020-09-01 |
| 599 | 599 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 726 | D | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure that Licensed Nurses (LN) had the specific competencies and skill set to perform a sterile technique for 1 resident (#4), out of 11 sampled residents. Specifically, the facility failed to ensure licensed nurses were competent in performing a sterile straight catheterization. This failed practice placed the resident at risk for infection and pain that could affect the resident's physical, mental, and psychosocial well-being. Findings: Record review on 11/5-9/18 revealed Resident #4 was admitted with [DIAGNOSES REDACTED]. Review of Resident #4's medical record on 11/6/18 revealed an order for [REDACTED]. During an observation, on 11/8/18, of a straight catheterization by LN #3 for the Resident revealed sterilization was breached at the initiation of supply set up therefore contaminating the entire procedure placing the Resident at risk for a bladder and/or kidney infection. Observation of the straight catheterization revealed: - A non-sterile underpad, also known as a chux pad, was used as a sterile field for sterile catheter supplies; - Sterile gloves were placed on the non-sterile underpad; - Sterile lubricant was opened and poured onto the non-sterile underpad; and - Cleaning of the perineum (vaginal area) before catheterization was not completed appropriately. During an interview on 11/8/18 at 9:55am, LN #3 stated he/she just forgot about sterile field technique and standards of perineum cleaning prior to a catheterization. During an interview on 11/8/18 at 1:10 pm, the Chief Nursing Executive, who is the interim Infection Preventionist, stated all LNs had competency training for the sterile technique of straight catheterization on both male and female anatomy in (MONTH) (YEAR). During an observation on 11/9/18 of a straight catheterization by LN #2 for the Resident revealed sterilization was again breached at the initiation of supply set up. Observation of the… | 2020-09-01 |
| 600 | 600 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 744 | D | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed ensure patient centered services were provided for 2 residents (#s 7 and 15) diagnosed with [REDACTED]. This failed practice denied the residents the treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. Findings: Resident #7 Record review on 11/5-9/18 revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. During random observations from 11/5-9/18, Resident #7 was observed in his/her bedroom alone the majority of the observations. He/she was observed at 2 meals of 4 observed. He/she was not seen interacting with other residents nor in meaningful interaction with staff. Record review on 11/5-9/18 of the annual MDS (Minimum Data Set-a Federally required assessment) dated 12/1/17 revealed the Resident was coded as: 1) rarely/never understood verbally; 2) being moderately cognitively impaired with poor decisions and cues/supervision required; 3) as having hallucinations (perceptual experiences in the absence of real external sensory stimuli); and 4) as having no participation for his/herself, family or legally authorized representative in the assessment and goal setting process. Further review of the MDS revealed Care Area Assessment (CAA) in which indicated Resident #7 triggered for cognitive loss/dementia, psychosocial well-being, and behavioral symptoms. The CAA revealed these areas were addressed in the care plan. Record review on 11/5-9/18 of Resident #7's care plan revealed no goals or interventions for cognitive loss/dementia, psychosocial wellbeing, or behavioral symptoms other than long term use of [MEDICAL CONDITION] medication. Resident #15 Record review on 11/5-9/18 revealed Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. During random observations from 11/5-9/18, Resident #15 was observed to anxiously pace the unit. He/she was not observed to participate in dail… | 2020-09-01 |
| 601 | 601 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 756 | C | 0 | 1 | YK7L11 | Based on interview and facility policy review the facility failed to develop and maintain policies and procedures for the monthly drug regimen review (DRR) that included: 1) steps of reporting to the Medical Director and Director of Nursing (DON) when the pharmacist identifies an irregularity; 2) times frames for the different steps in the process; and 3) steps the pharmacist must take when he/she identifies an irregularity that requires urgent action. This failed practice placed all residents (based on a census of 17) at risk for a delay in medication management. Findings: During an interview on 11/7/18 at 10:52 am, the DON stated she does not receive DRRs from the pharmacist. During an interview on 11/7/18 at 10:52 am, the Chief Nursing Executive, who was the past DON, stated she had never reviewed DRRs while she was the DON. During an interview on 11/7/18 at 10:52 am, the Pharmacist stated DRR irregularities are not reported to the DON. She further stated the Physician for the facility is currently the Medical Director so he/she receives all DRRs. Review of the facility policy (Long Term Care) Medication Regimen Review - Pharmacy Recommendations, dated 10/1/13, revealed no procedures to collaborate with the medical director and/or the director of nursing with medication irregularities noted by the Pharmacist; no time frames for the different steps of the process; and no procedure the pharmacist must take when an irregularity requires urgent action. | 2020-09-01 |
| 602 | 602 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 812 | F | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to store food under proper sanitation and food handling practices in the central kitchen. This failed practice placed all residents (based on a census of 17) at risk for foodborne illnesses, food contamination, and communicable disease. Findings: An observation of the central kitchen on 11/5/18 at 1:10 pm, revealed: 1) Dry Storage/Counter area: - 4 large dry goods bins. Only 1 bin labeled as sugar. No fill dates, no expiration dates on any of the bins; - 1 - metal container of thicket powder, a plastic spoon was stored within the container; - 1 - 4.5lbs. Instant Puree Bread Mix container, a plastic cup was stored within the container; - 1 - 5.3lbs. Instant Mashed Potatoes container with spices mixed in, a plastic cup was stored within the container; - 1 - 5.3lbs. Instant Mashed Potatoes container, a plastic cup was stored within the container; - 1 - 24oz. bag of Country Style Gravy Mix with corner of bag cut off, bag left open to the elements; - 1 - 12oz. bag of Low Sodium Chicken Flavored Gravy Mix with corner of bag cut off, bag left open to the elements; - 1 - 16oz. bag of Low Sodium Brown Gravy Mix with corner of bag cut off, bag left open to the elements; - 1 - 16oz. bag of[NAME]Sauce with corner of bag cut off, bag left open to the elements; - 1 - 28oz. bag of Chocolate Pudding Mix with corner of bag cut off, bag left open to the elements; - 1 - 24oz. bag of Vanilla Pudding Mix with corner of bag cut off, bag left open to the elements; and - 1 - 24oz. bag of Cherry Gelatin Mix with corner of bag cut off, bag left open to the elements. 2) Walk-in Freezer: - Large black tool chest-type container on the freezer floor, personal food of the cook; - 1 - 16oz box of 8 cod fillets. Flip lid to box is loosely covering the fillets. 3 fillets situated on top inside the container were freezer burned, a very white hard crystal crust over 90% of each upper side of the fillets; - 3 whole, skinned … | 2020-09-01 |
| 603 | 603 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2018-11-09 | 880 | D | 0 | 1 | YK7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to provide safe and sanitary practices that helped to prevent the development and/or transmission of communicable diseases and infections for 1 resident (#4), out of 11 sampled residents. Specifically the Licensed Nurses (LNs) failed to: 1) maintain consistent sterile techniques during straight catheterizations and 2) comply with standards of practice to clean/disinfect a bladder scanner after each use. This failed practice placed the resident at risk for infection and pain that could affect the resident's physical, mental, and psychosocial well-being. Findings: Record review on 11/5-9/18 revealed Resident #4 was admitted with [DIAGNOSES REDACTED]. Review of Resident #4's medical record on 11/6/18 revealed an order for [REDACTED]. Straight Catheterizations During an observation on 11/8/18 of a straight catheterization by LN #3 for the Resident revealed sterilization was breached at the initiation of supply set up therefore contaminating the entire procedure placing the Resident at risk for a bladder and/or kidney infection. Observation of the straight catheterization revealed: - A non-sterile underpad, also known as a chux pad, was used as a sterile field for sterile catheter supplies; - Sterile gloves were placed on the non-sterile underpad; - Sterile lubricant was opened and poured onto the non-sterile underpad; and - Cleaning of the perineum (vaginal area) before catheterization was not completed appropriately. During an interview on 11/8/18 at 9:55am, LN #3 stated he/she just forgot about sterile field technique and standards of perineum cleaning prior to a catheterization. During an interview on 11/8/18 at 1:10 pm, the Chief Nursing Executive, who is the interim Infection Preventionist, stated all LNs have had competency training for the sterile technique of straight catheterization on both male and female anatomy. During an observation on 11/9/18 of a straight cathet… | 2020-09-01 |
| 621 | 621 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 154 | D | 0 | 1 | 9VF811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure 1 resident (#3) out of 6 sampled residents or his/her responsible party were fully informed of potential risks and benefits of an antipsychotic medication. The failure to provide the potential risk and benefits information denied the Power of Attorney (POA) the right of an informed consent for the use of antipsychotic medication for behaviors. Findings: Record review from 1/31/17 - 2/4/17 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Resident's most current physician's orders [REDACTED]. During an interview on 2/2/17 at 4:35 pm the MDS Coordinator stated there was no risk and benefit information for the antipsychotic medication provided to the Resident's responsible party. Review of the LTC Behavior and [MEDICAL CONDITION] Medications policy dated 10/1/13 revealed, The risk/benefits of the drug used and informed consent will be obtained by nursing or Social Services from the resident or family/responsible party prior to administration of any psychoactive medication. | 2020-05-01 |
| 622 | 622 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 156 | F | 0 | 1 | 9VF811 | . Based on record review and interview the facility failed to ensure all advocacy groups, State agencies contact information and information about the residents rights to file a complaint was provided to residents and/or their representatives in writing and information about the residents' right to file a complaint with these agencies. This failed practice denied all residents (based on a census of 14) and/or interested parties access to information on how to contact these agencies/groups to file a complaint and/or grievance. Findings: Review of the facility admission packet on 2/1-3/17, provided to residents and their families/representatives upon admission, revealed no contact information for State agencies and advocacy groups or how to file a complaint with these agencies. During an interview on 2/3/17 at 4:40 pm, the Administrator stated the information was not in the admission packet. | 2020-05-01 |
| 623 | 623 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 159 | E | 0 | 1 | 9VF811 | Based on record review and interview the facility failed to: 1) ensure 2 residents (#s 1 and #11) had written authorization for the facility to manage their personal funds; 2) ensure 12 of 14 residents who had trust accounts had access to petty cash; and 3) ensure the residents and/responsible party's were informed in writing of the regulatory changes, effective 11/28/16, regarding the amount of resident personal funds that must be in interest bearing accounts if the resident requested the facility to manage their funds. These failed practices placed residents at risk for misappropriation of funds, access to personal funds upon request, and knowledge of the new requirements for interest bearing accounts managed by the facility. Findings: Review of the Authorization forms for facility management of Resident funds on 2/7/17, revealed Resident's #1 and # 11 had no authorization form for their fund management. During an interview on 2/2/17 at 3:00 pm, the Administrator was asked to provide documentation of the petty cash log. The Administrator stated the petty cash drawer usually had a balance of $100.00 but at present time there was no cash available for residents. Record review of the petty cash log on 2/2/17 at 3:15 pm revealed 2 Residents had withdrawn funds for $50.00. One withdraw was on 1/25/17 and the second was on 1/26/17. The petty cash had a zero balance for 8 days with no monies available to residents. During the same interview, the Administrator was asked what the facility would do today if a Resident requested petty cash. He stated they would have to wait until the petty cash funds had been replaced. In addition, the Administrator confirmed residents and/or responsible parties were not informed of new regulatory changes regarding the amount of resident personal funds that must be in interest bearing accounts if the resident requested the facility to manage their funds. Review of the Residents Rights provided in the admission packet, revealed .less than $50/$100 in a non-interest bearing account . | 2020-05-01 |
| 624 | 624 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 164 | E | 0 | 1 | 9VF811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure supervision of 1 resident (2) who wandered into other resident's room while the resident was receiving personal care out of 8 residents residing on the unit. This failed practice denied the resident the right to privacy and placed the resident at risk for feelings of embarrassment, poor self-worth and psychological harm. Findings: During an observation on 1/31/17 at 1:25 pm Resident #2 walked to room # 304, opening the closed door and entered the room. Where a Certified Nursing Assistant (CNA) was observed providing personal care to Resident #11. Resident #11 was in the transfer lift sling, suspended from the ceiling with his/her arms and legs exposed. The Resident was wearing an incontinence brief which was visible as the CNA moved Resident #11 to the bed. After a few minutes, CNA #1 knocked on room [ROOM NUMBER]'s door, entered the room and guided Resident #2 out of the room back into the common area. During an observation on 1/31/17 from 1:45-3:30 pm Resident #2 was observed wandering through the unit. Staffs were on the unit and observed attending to other residents in the common area and unaware of Resident #2's movement on the unit. During an interview on 2/1/17 at 1:00 pm CNA # 2 stated the other residents don't like Resident #2, s/he touches them and goes into their rooms when s/he is wandering around. During an interview on 2/3/17 at 5:00 pm with the Administrator and Licensed Nurse #1, when asked about Resident #2 behavior, both staff stated Resident #2 sometimes wandered into other residents rooms. | 2020-05-01 |
| 625 | 625 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 166 | F | 0 | 1 | 9VF811 | Based on record review and interview the facility failed to include all the necessary information regarding grievances and concerns in the grievance policy, and in the resident's rights admission packet. This placed all the residents (based on a census of 14) at risk for not having the information needed to file a grievance. Findings: Review of the facilities policy on 2/3/17, titled LTC Grievance Policy .Effective Date 10/1/13 revealed none of the following elements were addressed in the policy: 1) Grievance officials contact information; 2) The right to file a grievance anonymously; 3) Receive a written decision; 4) Contact information of independent entities where grievances may be filed; 5) Prevent further potential violations of any resident rights during the investigation; 6) Immediately report allegations as required by State law; 7) All written grievance decisions include all information required; and 8) Taking appropriate corrective action when confirmed and demonstrating evidence of the result of all grievances for a period of no less than 3 years from the grievance decision. During an interview on 2/3/17 at 4:40 pm the Administrator confirmed the Grievance policy had not been updated. | 2020-05-01 |
| 626 | 626 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 167 | F | 0 | 1 | 9VF811 | Based on observation and interview the facility failed to ensure a notice had been posted in a prominent and public area of the availability of the previous 3 years of survey results. This failed practice denied the residents, (based on a census of 14) and the public of being informed of previous survey results and the facilities plans for correction. Findings: Observation on 1/31/17 in the common hall across from physical therapy revealed only the (YEAR)'s survey results with the plan of correction. No notice was posted that the previous 3 years of surveys were available upon request. During an interview on 2/2/17 at 4:00 pm the Administrator stated he was not aware of this new regulation, as of 11/28/16, that required the posting for previous survey results. | 2020-05-01 |
| 627 | 627 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 225 | D | 0 | 1 | 9VF811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the facility failed to ensure a resident elopement was investigated and failed to report the elopement to the State Survey Agency for 1 resident (#2), out of 6 sampled residents, with known elopement risk and wandering behaviors. The facility's failure to thoroughly investigate the elopement and report the potential neglect of the resident, with known elopement risk and wandering behaviors, to the State Survey Agency placed the resident at further risk for injury or harm and denied the facility the opportunity to identify and implement systemic measures to help mitigate the risk for further incidents. Findings: Resident #2 Record review from 2/1-3/17 revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of a nursing progress note dated 8/27/16 at 8:13 pm revealed Resident jumped out of (his/her) room's window and landed on (Res. #2) knees .resident trying to stand up and started to walk, visibly frightened and shaking . Record review of an incident description dated 8/27/16 revealed documentation stating, .Brief Summary .Resident jumped out of his room window landed on his knees as per resident's information . During an interview on 2/3/17 at 4:40 pm, when asked about the incident the Administrator stated, the facility had no idea how the Resident got out the window or how long the Resident had been outside. On 2/3/17 at 5:00 pm Surveyors asked the Administrator to see the facility investigation of the elopement event, which occurred on 8/27/16. The Administrator was not able to produce an investigation of the incident. When asked if the event was reported to the State Agency, the Administrator stated No, the Resident was not injured. Resident #2 was observed on the unit with staff unaware of the Resident's whereabouts as s/he wandered aimlessly. Review on 2/4/17 of the facility's policy, LTC Elopement-Wandering, with an effective date of 10/1/13, reveal… | 2020-05-01 |
| 628 | 628 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 226 | C | 0 | 1 | 9VF811 | Based on policy review and interview the facility failed to update the policy for abuse and neglect that included the use of photographs or recordings in any manner that would demean or humiliate a resident(s). The failure to update policy placed all residents (based on a census of 14) at risk for abuse and neglect. Findings: Review on 2/1/17 of the facility's policy LTC Abuse Policy effective date of (MONTH) (YEAR) revealed the policy did not address videotaping or photographing of residents. During an interview on 2/2/16 at 5:00 pm, the Administrator confirmed the policy provided did not include videotaping and photographing of residents. | 2020-05-01 |
| 629 | 629 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 248 | F | 0 | 1 | 9VF811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observations the facility failed to ensure specific resident centered activities in the residents' care plans and ensure facility staff had the information needed to engage the residents in individualized activities for 6 residents (#s 1; 2; 3; 4; 5; and 7) out of 14 residents residing in the facility. The lack of regularly planned activities based on the residents' needs and preferences may result in social isolation and poor quality of life. Findings: Resident #1 Record review from 1/31/17 - 2/4/17 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Residents most current care plan, dated 1/31/17, for Activities revealed Offer Activity of choices sometimes (Resident) enjoys sorting, items, provide activities accordingly . encourage active participation for physical, cognitive stimulation; social interaction needs; Enjoys outings. The care plan did not specify interventions for sorting, how to provide cognitive stimulation, social interactions, and what type of outings the Resident enjoyed. Random observations during the survey from 1/31-2/3/2017 revealed a tray full of Legos in the dishwasher located on the Resident's unit. During an interview on 1/31/17 at 8:25 am Licensed Nurse (LN) #3 was asked about the Legos in the dishwasher and stated they were sometimes given to Resident #1 for behavior distraction. Observations on 1/31/17 from 8:30 am - 1:00 pm revealed no staffs attempted to engage Resident #1 in individual or group activities. Random observations on 2/2/17 from 8:10-10:15 am revealed no staff attempted to engage Resident #1 in individual or group activities. Resident #2 Record review from 2/1-3/17 revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #2's care plan dated 12/30/16, for Activities revealed Interventions .Confirm Resident's Identity; Assess (Resident's) Functional Level; Utilize Adaptive Material a… | 2020-05-01 |
| 630 | 630 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 279 | F | 0 | 1 | 9VF811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop comprehensive care plans that addressed resident specific likes and dislikes for 6 (#s 1, 2, 3, 4, 5 and 7) of 6 care plans reviewed. Without appropriate care plan interventions and coordination, residents were at risk for not receiving the necessary and/or appropriate care and services to ensure optimal outcomes. Findings: Resident #1 Record review from 1/31/17 - 2/4/17 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Residents most current care plan, dated 1/31/17, for Activities revealed Offer Activity of choices sometimes (Resident) enjoys sorting, items, provide activities accordingly . encourage active participation for physical, cognitive stimulation; social interaction needs; Enjoys outings. No Resident specific likes or dislikes had been care planned. Resident #2 Record review from 1/31/17 - 2/4/17 revealed Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident's care plan, dated 12/30/16, for Activities revealed Interventions .Confirm Resident's Identity; Assess (Resident's) Functional Level; Utilize Adaptive Material and Techniques to Meet Needs; Offer (Resident) Activity Choices; Encourage Active Participation for Physical, Cognitive Stim; Encourage Passive Participation Socialization, Religious Spiritual Needs . No Resident specific person-centered activities for the resident. Resident #3 Record review from 1/31 - 2/4/17 revealed Resident #3 was admitted with a [DIAGNOSES REDACTED]. Review of the Residents most current care plan, dated 8/12/16, printed by the MDS Coordinator on 2/2/17 at 9:11 am, revealed no activities had been care planned. Resident #4 Record review from 1/31 - 2/4/17 revealed Resident #4 was admitted with a [DIAGNOSES REDACTED]. In addition, the Resident had just returned from cataract surgery to both eyes on 1/13/17. Review of the Residents most current care plan, dated … | 2020-05-01 |
| 631 | 631 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 323 | J | 0 | 1 | 9VF811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure 1 resident (#2) with wandering behaviors and a history of elopement (leaves the premises or safe area without authorization and/or necessary supervision) and assaultive/sexualized behaviors toward female residents and/or aggressive physical behaviors towards other residents, had adequate supervision when wandering in the facility. These failed practices constituted an immediate jeopardy to the health and safety of resident #2 and the other 7 residents residing on the unit. The facility administration was notified of the immediate jeopardy on 2/7/17 at 10:20 am. The facility submitted an abatement plan on 2/7/17 at 4:34 pm. The mitigation of the risk was verified during an extended survey on 2/13-14/17. Findings: Record review from 2/1-3/17 revealed Resident #2 had [DIAGNOSES REDACTED]. Observation of the 300 wing during the survey revealed, a large open common area with resident rooms opening to the units common area. The unit consisted of 3 women and 4 men, all with different physical and mental abilities to defend themselves. Review of the most recent Minimum Data Set (MDS-a federally required assessment tool), dated 12/1/16, annual assessment, revealed the Resident was coded as having short and long term memory problems; moderately impaired in cognitive skills for daily decision making (Decisions poor; cues/supervision required); Behaviors-Potential for psychosis hallucinations (perceptual experiences in the absence of real external sensory stimuli) and Delusions (misconceptions or beliefs that are firmly held, contrary to reality). Behaviors directed toward others occurring every 1 to 3 days include verbal behavioral symptoms (e.g., threatening others, screaming at others, cursing at others); other behavioral symptoms not directed toward others (e.g., .rummaging, public sexual acts, disrobing in public .). Wandering occurred 4 to 6 days a week with the impact… | 2020-05-01 |
| 632 | 632 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 329 | D | 0 | 1 | 9VF811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure duplicate medications had been discontinued for 1 Resident (#1) of 6 sampled resident records reviewed. This had the potential for increased risk of adverse effects, overdosing, and diminished quality of life. Findings: Resident #1 Record review from 1/31 - 2/4/17 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. [MEDICATION NAME] Review of the Resident's electronic Medication Administration Record [REDACTED]. In addition, the Resident had an order, dated 7/7/16, for [MEDICATION NAME] 50mg to be given every 4 hours as needed for agitation. Based on the U.S Food and Drug Administration website http://www.accessdata.fda.gov/scripts/cder/daf/index.cfm, accessed 2/9/17, the maximum dose for [MEDICATION NAME] is 800 mg per day. Based on the U.S Food and Drug Administration website http://www.accessdata.fda.gov/scripts/cder/daf/index.cfm, black box warning: WARNING: Increased Mortality in Elderly Patients with Dementia .? Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION NAME] Review of the Resident's electronic MAR indicated [REDACTED]. In addition, the Resident had 2 additional orders for [MEDICATION NAME] to be given as needed (PRN) for agitation: [MEDICATION NAME] 1mg IM Q12 hours PRN anxiety/agitation, dated 2/29/16; and [MEDICATION NAME] 0.5mg orally q12 hours PRN anxiety/agitation. Based on the U.S Food and Drug Administration website http://www.accessdata.fda.gov/scripts/cder/daf/index.cfm .[MEDICATION NAME], produce increased CNS-depressant effects when administered with other CNS depressants such as . antipsychotics . During an interview on 2/2/17 at 9:45 am Licensed Nurse (LN) #2 stated the PRN (given only when needed) medications for [MEDICATION NAME] and [MEDICATION NAME] had not been given in months. In addition, the LN confirmed the PRN medication could … | 2020-05-01 |
| 633 | 633 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 366 | F | 0 | 1 | 9VF811 | Based on record review, interview and observation the facility failed to ensure the meal substitutes listed on the weekly menus were readily available upon request. This failed practice placed all residents (based on a census of 14) at risk for inadequate nutrition and quality of life. Findings: Record review on 1/31 - 2/4/17 of the 3 week menus revealed alternative menu's for both lunch and dinner had been planned. During the group interview on 2/1/17 at 1:45 pm 2 of the 4 residents (# 12 and 15) who attended the meeting stated the menus were not varied enough. In addition, they would like more traditional foods. Observations from 2/1-3/17 of lunches and 1 dinner meal revealed the substitute meals listed on the menu had not been prepared. During an interview on 2/3/17 at 12:30 pm the Executive Chef was asked if substitute menus were prepared in advance and available upon resident request. In response, he stated No. The Chef also stated the alternative menu was only available if the resident requested the substitute lunch or dinner meal a day ahead. When asked what foods residents would be offered if they did not want the food that was served the Chef stated the residents have soups; jello; applesauce; toast; cereal; and yogurt available to them on the courts. | 2020-05-01 |
| 634 | 634 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 428 | D | 0 | 1 | 9VF811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure during the drug regimen review completed by the Pharmacist for, 1 resident (#1) out of 5 residents reviewed, alerted the physician to discontinue the PRN (as needed) duplicate medications and to alert the physician to the last used date. This failed practice placed the resident at risk for receiving unnecessary medications. Findings: Resident #1 Record review from 1/31 - 2/4/17 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Seroquel Record review on 2/3/17 of the Medication Administration Record [REDACTED]. Record review on 2/3/17 of the Pharmacist Drug Regimen Review dated 1/24/17, for the Resident revealed: Quetiapine 50 mg q6h prn agitation, appropriate therapy .continue . Record review of the MAR from 7/1/16 - 2/3/17, revealed an additional, a PRN dose of Seroquel 50mg had been given on 7/7/16; 8/10/16; 8/20/16; and 9/26/16. Based on the U.S Food and Drug Administration website http://www.accessdata.fda.gov/scripts/cder/daf/index.cfm the maximum dose for Seroquel is 800 mg per day. In addition, a black box warning: WARNING: Increased Mortality in Elderly Patients with Dementia .? Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Lorazepam Record review on 2/3/17 of the Pharmacist Drug Regimen Review dated 1/24/17, for the Resident revealed: Lorazepam 0.5mg PO q 12H prn .continue . Lorazepam, 1mg IM q 12H prn agitation .appropriate therapy .continue . Based on the U.S Food and Drug Administration website http://www.accessdata.fda.gov/scripts/cder/daf/index.cfm accessed, 2/9/17, .lorazepam, produce increased CNS-depressant effects when administered with other CNS depressants such as .antipsychotics . During an interview on 2/3/17 at 2:30 pm, the Pharmacist stated s/he should have alerted the physician to discontinue the PRN duplicate medications. | 2020-05-01 |
| 635 | 635 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 441 | F | 0 | 1 | 9VF811 | Based on record review and interview the facility failed to: 1) developed an infection prevention and control plan specific to the long term care (LTC); 2) establish an active infection prevention and control committee; and 3) provide documentation of any infection prevention activities or meeting minutes for the previous 12 months. These failed practices increased the risk for the development and transmission of disease and infection in a vulnerable population of all residents based on a current census of 14. Findings: Record review on 2/3/17 at 10:30 am of the LTC Infection Control Program policy, dated 10/1/13 revealed, The purpose of the program is to prevent Healthcare Associated Infections in the LTC .the YKHC LTC Facility Infection Control Program will follow the YKHC Infection Control Plan . The infection control program was not specific to the LTC. During an interview on 2/3/17 at 5:45 pm with the Administrator and the Director of Nurses (DON), the DON stated the Infection Prevention and Control Committee was her responsibility. When asked if she had any training in infection prevention, she stated she had not. When asked to provide documentation of any surveillance and or meeting minutes, none was provided. During the same interview on 2/3/17 at 5:45 pm the Administrator and the DON were asked when the last urinary tract infection was or when the last antibiotic was prescribed for a resident, they both confirmed they were not sure. In addition, the DON and the Administrator were asked to provide any infection prevention data and/or meeting minutes and nothing was provided at the time of exit on 2/4/17. Review of the QA/PI minutes agenda/minutes dated: 12/15/16 - Infection Control Rounds, blank, nothing reported. 2/10/16 - Infection Control Rounds, reviewed report. No report provided. 3/31/16 - Infection Control Rounds, blank, nothing reported. | 2020-05-01 |
| 636 | 636 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2017-02-14 | 520 | F | 0 | 1 | 9VF811 | Based on interview and record review the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program designed to monitor concerns specific to the long-term care. Specifically, the facility failed to: 1) ensure 1 resident (#2) with wandering behaviors and a history of elopement (leaves the premises or safe area without authorization and/or necessary supervision) and assaultive/sexualized behaviors toward female residents and/or aggressive physical behaviors towards other residents, had adequate supervision when wandering in the facility. This failed practice constituted an immediate jeopardy to the health and safety of resident #2 and the other 8 residents residing on the unit; 2) identify and document tracking and trending data for quality process improvement projects; and 3) have a functioning infection prevention committee with documentation of meeting minutes and surveillance. These failed practices placed all residents in the facility (based on a census of 14) at risk for not receiving necessary care and services. Findings: During an interview on 2/4/17 at 4:30 pm the Administrator and Director of Nursing were asked what projects the QAPI committee was working on. The Administer stated falls, antipsychotic medications and adverse events. Review of the only QAPI minutes provided, dated 2/10/16 and 3/31/16 (almost 1 year old), revealed no trending data, action plans, or minutes that identified concerns, even though the Administrator stated the committee had concerns with falls, antipsychotic medications and adverse events. In addition the QAPI committee had not identified behaviors as an issue even though there was documentation of Resident #2's wandering which led to the Resident's ability to have inappropriate sexual behavior with female residents. (See F323) No Infection Prevention Committee minutes were provided after multiple requests. | 2020-05-01 |
| 825 | 825 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 155 | E | 0 | 1 | PN1E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review and interview the facility failed to ensure 5 out of 9 staff files reviewed contained a valid updated cardiopulmonary resuscitation (CPR) certification. This failed practice placed all residents electing to have resuscitation interventions (based on a census of 15) at risk of poor performance or insufficient knowledge base from staff during a resuscitation event. Findings: During an interview on [DATE] Human Resources Staff #1 stated CPR certification would be under section 5 of each staff's personnel file. Review of section 5 in staff's personnel files on [DATE] revealed certified nursing assistant (CNA) #s 1, 3, 4, 5 and 6 did not have valid updated CPR certification cards. | 2018-12-01 |
| 826 | 826 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 156 | C | 0 | 1 | PN1E11 | Based on record review and interview the facility failed to ensure residents or designated guardians were notified in writing of their visitation rights. This failed practice placed all residents or designated guardians at risk of not being informed of the right to visit any time. Findings: Review of the facility's admission packet, revised 4/29/14, revealed no written explanation of residents or guardians visitation rights. During an interview on 1/13/16 at 12:59 pm the Administrator stated he thought the information was placed in the admission packets, but confirmed there was no written explanation of visitation rights in the admission packet. . | 2018-12-01 |
| 827 | 827 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 159 | F | 0 | 1 | PN1E11 | Based on record review and interview the facility failed to ensure: 1) quarterly financial account statements were sent to residents and/or their legal representatives for 11 out of 11 residents that had trust accounts, and 2) residents were notified when their account reached $200 less than the Supplemental Security Income (SSI) resource limit for 3 residents (#s 5, 10 and 11) out of 11 residents with trust accounts. These failed practices denied consistent access to personal fund account balances and had the potential for the residents to lose eligibility for Medicaid. Findings: Trust Accounts Record review on 1/14/16 at 12:10 pm revealed Resident Trust Account statements with the date 12/31/15. There was no address on the statements to which the statements would be sent. The statements showed account balances but no activity (deposits and/or withdrawals). When asked if the statements should show account activity the Finance Administrator (FA) stated Yes. When asked what the time period for the statement was, the FA stated it was for the period ending 11/30/15. The date of 11/30/15 was not on the statements. The facility was unable to provide any other statements. During an interview on 1/14/16 at 12:15 pm, the FA stated s/he created Resident Trust Account statements last night for the first time. The FA stated s/he worked in this position for 2 years and had never sent out statements. When asked if s/he was supposed to send out trust account statements quarterly, the FA stated, Yes, I know that we are supposed to send them. During an interview on 1/14/16 at 7:45 am, the Long Term Care (LTC) Administrator stated the finance department has struggled with sending them (statements). The LTC Administrator further stated the facility needed a simpler process. During an interview on 1/14/16 at 12:25 pm, when asked for a policy and procedure related to Resident Trust Accounts, the FA stated I have not seen any. Medicaid Account Balances Notices Record review on 1/14/16 at 12:10 pm of the Resident Trust Account stateme… | 2018-12-01 |
| 828 | 828 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 226 | C | 0 | 1 | PN1E11 | Based on policy review the facility failed to incorporate into written policy and procedure all the components related to abuse and neglect. Specifically, the policy and procedure did not include that residents have the right to be free from misappropriation of resident property. This omission placed residents at risk for potential abuse and neglect situations and affected all residents residing in the long term care units (based on a census of 15). Findings: Review of the policy LTC Abuse Prevention revealed The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Misappropriation of resident property was not included in the potential abuse and neglect of a resident. | 2018-12-01 |
| 829 | 829 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 244 | E | 0 | 1 | PN1E11 | Based on record review, interview and policy review the facility failed to resolve grievances brought forth by residents who attended the Residents Council (based on the 3-4 documented number of residents who attended the meetings). As a result, residents were denied the right to have their concerns validated. Findings: Review of the Residents Council meeting minutes, on 1/13-14/16, for January-December (YEAR) revealed residents met 7 times with facility staff who attended the council meetings. The following grievances were documented in the meeting minutes: Multiple missing clothing items; Missing purse, coat, and 1 box after a resident returned from visiting family; Clothes were not being returned to the right residents; Missing key; Missing hearing aid; Missing camera; Increased noise at night outside the facility; 1 resident said he was missing 1 pair of shorts and 1 pair of pants. No description was given so no follow up at this time.; No one was available in the evening to translate; and Multiple food concerns. Continued review of the council meeting minutes revealed no documented resolutions of any of the residents grievances listed above. During an interview on 1/12/16 at 10:00 am, the Activity Coordinator (AC) stated she gets residents' concerns/grievances from the resident's council meetings. During an interview on 1/12/16 at 1:00 pm, the AC said she was responsible for the resident's council since there wasn't a social worker. She confirmed residents have complained about missing clothing, a purse, coat, camera, in addition to other concerns. She did not do any investigations on the grievances, did not forward concerns/grievances to appropriate department heads, and did not keep a log of the residents' concerns/grievances. She did confirm there was no documented resolution of grievances/concerns in the council meeting minutes. The Surveyors requested a policy and procedure on grievances. They were given 2 policies with the same title, number and effective date but the policies and procedures were diffe… | 2018-12-01 |
| 830 | 830 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 248 | E | 0 | 1 | PN1E11 | Based on record review the facility failed to provide an activity program designed to meet the wishes of the residents who attended the Resident Council meetings. (based on the 3-4 documented number of residents who attended the meetings). Findings: Review of the Resident Council meeting minutes for (YEAR) revealed Suggestions for any special activities? The following were documented suggestions made by residents: Knitting; Yarn work; Embroidery; Skin sewing; Wood working crafts; More rides (vehicle); Going outside more; Fiddle dancing; Playing cards; Chinese checkers; Going to the VFW to play bingo; More shopping; Bible study; and More native dancing in the gathering room. Review of the Activity Calendar, dated (MONTH) (YEAR), revealed no knitting, yarn work, embroidery, skin sewing, wood working crafts, fiddle dancing, Chinese checkers, bingo at the VFW, and native dancing were on the activity calendar. 9 out of the 14 resident suggestions for special activities was not on the calendar. There was no documented reason in the Resident Council meeting minutes as to why these requested activities were not going to be resident activities. Review of the policy LTC (Long Term Care) Activity Calendar, dated 10/1/13, revealed The Activity Coordinator will ensure that calendars are designed with input from the residents. | 2018-12-01 |
| 831 | 831 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 279 | E | 0 | 1 | PN1E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and revise comprehensive care plans that addressed specific needs and instructions for 4 residents (#s 2, 3, 4 and 8) out of 7 sampled residents whose care plans were reviewed. Specifically, the care plans were not care planned in the following areas: 1) dehydration - fluid maintenance; 2) pressure ulcers; 3) [MEDICAL CONDITION] drug use; and 4) activities. Without appropriate care plan interventions and coordination, residents were at risk for not receiving the necessary and/or appropriate care and services to ensure optimal outcomes. Findings: Resident #2 Record review from 1/12-14/16 revealed Resident #2 had [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) assessment, an annual assessment dated [DATE], revealed the Resident was triggered on the care area assessment (CAA) for dehydration - fluid maintenance, pressure ulcers and [MEDICAL CONDITION] drug use. The CAA also was checked by the facility for requiring care planning. Review of the most recent comprehensive care plan last updated 12/14/15 revealed, no care plan for dehydration - fluid maintenance; pressure ulcers; or [MEDICAL CONDITION] drug use. During an interview on 1/13/16 at 2:25 pm, the Director of Nursing (DON) confirmed there was no care planning done for these triggered areas and there was no documentation as to the reasons why they were not care planned. Resident #3 Record review from 1/11-14/16 revealed Resident #3 had [DIAGNOSES REDACTED]. Review of the most recent significant change MDS assessment dated [DATE], revealed Resident #3 triggered for a CAA related to activities. Review of Resident #3's care plan, last updated 12/20/15 revealed no care plan for activities. During an interview on 1/13/15 at 9:35 am the DON confirmed Resident #3 did not have a care plan for activities and should have had one in place. Resident #4 Record review from 1/12-14/16 revealed Resident #4 had [DIA… | 2018-12-01 |
| 832 | 832 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 282 | D | 0 | 1 | PN1E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and document review the facility failed to ensure a qualified staff member was feeding 1 resident (#10) out of 15 residents in accordance with the care plan. This failed practice placed the resident at risk of improper feeding techniques and complications related to feeding. Findings: Record review from 1/11-14/16 revealed Resident #10 had a [DIAGNOSES REDACTED]. Review of the Residents care plan, last updated 10/16/15, revealed alteration in nutrition with the interventions listed as having a pureed, nectar thick diet; assist with feeding by using a spoon; ensure the Resident swallowed all food; and ensure mouth is clear after feeding. Observations from 1/11-12/16 revealed the Activities Coordinator feeding Resident #10 a pureed diet with nectar thick liquids. During an interview on 1/13/16 at 12:59 pm the Administrator stated the Activities Coordinator was not currently a certified nursing assistant. During an interview on 1/13/16 at 1:45 pm the Registered Dietician (RD) stated only a certified nursing assistant or Licensed Nurse could feed Resident #10. In addition, the RD confirmed the Resident was on a pureed food diet with nectar thick liquids. Review of the Activities Coordinator's job description, dated 2/11/14, revealed no job duties that included feeding residents. | 2018-12-01 |
| 833 | 833 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 332 | D | 0 | 1 | PN1E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure 1 resident (#2), out of 6 residents observed during medication administration, received medications per physician's orders [REDACTED]. These failed practices placed the facility's medication error rate above 5% and placed the resident at risk for not receiving a therapeutic dose and increased the risk for adverse side effects from the medications. Findings: Record review from 1/12-13/16 revealed Resident #2 had a [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED] Dulcera - [MEDICATION NAME]-mometasone (Dulcera 100 mcg-2 puff(s), Inhalation, form: Aerosol, BID (2 times a day) .wash mouth out after use. [MEDICATION NAME] - [MEDICATION NAME] (an inhaled medication that relaxes the airways) 18 mcg , = 1 inh, Inhalation, form: Powder-Inh, Daily . Observation during a medication administration pass on 1/12/16 at 8:15 am revealed, LN #3 administered the ordered inhalation therapy to Resident #2. First, LN #3 administered 1 puff of Dulcera and after waiting 2 seconds, administered a second puff of Dulcera. Then, 2 seconds later, LN #3 administered 1 inhalation of [MEDICATION NAME] using the HandiHaler device (a medication device used for inhaling medication). The nurse did not offer Resident #2 the opportunity to rinse his/her mouth with water as instructed on the MAR. During an interview on 1/12/16 at 8:20 am, LN #3 stated, (the Resident) should have rinsed. I should have offered water after the inhaler. During an interview on 1/12/16 at 1:45 pm, the Pharmacist stated 2 seconds is not long enough between inhalations of Dulcera. The Pharmacist further stated, There should be at least 5 seconds between the inhalations in order to get the medication into the lungs. Review of the manufacturer's package insert, dated 2010, for DULCERA, provided by the Pharmacist on 1/13/16 at 10:00 am, revealed the following inhalation instructions, When you have… | 2018-12-01 |
| 834 | 834 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 356 | C | 0 | 1 | PN1E11 | Based on observation, interview and record review, the facility failed to ensure: 1) the daily nurse staffing and resident census information was posted; and 2) the facility maintained 18 months worth of the posted daily nurse staffing data. Failure to post and to keep 18 months of the nurse staffing and resident census information denied residents, family, and other visitors the right to know the numbers of licensed and unlicensed staff available who were responsible for resident care and the number of residents in their care for a census of 15 residents. Findings: Nursing Staffing/Resident Census Postings: Observation during the initial tour on 1/11/16 at 8:55 am revealed a plastic wall hanging holder on the wall between the 200 and 300 wings of the facility, with Daily Staffing Report forms that were blank. No information related to the daily nurse staffing and resident census information was posted. During an interview on 1/11/16 at 9:00 am, the Administrative Assistant (AA) stated, Licensed Nurse (LN) #3 was responsible for completing and posting the daily information. During an interview on 1/11/16 at 9:15 am LN #3 stated s/he had been on leave for 6 months and just returned 1 week ago. LN #3 further stated s/he was unaware it was her/his responsibility to complete the daily nurse staffing/resident census information until today. During an interview on 1/12/16 at 8:35 am, the Director of Nursing (DON) confirmed the facility had not posted the nursing staffing/resident census report sheet and said they were not there yesterday. During an interview on 1/12/16 at 8:45 am, the AA stated the information was not posted from 1/7-11/16. The AA further said, I pick them up on Monday and they (the forms in the plastic wall holder)was empty. Retention of 18 months of Posted Daily Nurse Staffing Data: Record review on 1/12/16 revealed the facility was not able to provide 18 months of nurse staffing/resident census information. The facility was able to provide documentation of the posted nurse staffing data for 11/20-27… | 2018-12-01 |
| 835 | 835 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 371 | F | 0 | 1 | PN1E11 | Based on observation, interview and record review the facility failed to ensure: 1) temperature monitoring of the food refrigerators; 2) monitoring food temperature prior to serving; 3) daily cleaning of kitchen appliances; and 4) hair nets are worn during food preparation. These failed practices created a potential for food contamination and increased the risk for food-borne illnesses. Findings: No Thermometer in the 200 Unit Refrigerator: Random observations from 1/11-12/16 revealed there was no thermometer in the 200 unit refrigerator. During an interview on 1/11/16 at 10:10 am, the Dietary Manager (DM) confirmed there was no thermometer in the 200 unit refrigerator. Record review from 1/11-14/16 of refrigerator and freezer temperature monitoring logs from the 200 and 300 units, revealed no monitoring documentation. Observations on 1/14/16 at 2:00 pm revealed refrigerator and freezer temperature's in the 200 and 300 unit kitchens were not being monitored and logs not maintained. Main Kitchen An observation of the main kitchen on 1/14/16 at 1:30 pm revealed temperature logs on the freezer and the 2 refrigerators. Review of the temperature logs revealed no temperature had been recorded from 1/12-14/16. During an interview on 1/14/16 the Administrator confirmed the temperature of the freezer and the refrigerators in the main kitchen had not been recorded from 1/12-14/16. Food Temperature: Observation on 1/11/16 at 9:45 am, in the main kitchen, revealed cream of wheat and scrambled eggs were served for breakfast. Review of the food temperature log revealed only the scrambled eggs had been tested for temperature. During an interview with DM who was in the kitchen at the time of observation confirmed the temperature for cream of wheat had not been documented. Dirty Kitchen Appliances: Observation on 1/11/16 at 9:40 am in the main kitchen revealed, the Tea/Coffee Bunn was dirty with multiple dried spills on the top and sides of the appliance. During an interview with DM who was in the kitchen at the time of observati… | 2018-12-01 |
| 836 | 836 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 431 | E | 0 | 1 | PN1E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure vaccines kept in the medication room refrigerator were monitored per Centers for Disease Control and State of Alaska Immunization guidelines. Specifically, the facility failed to have a system in place for recording 24 hour temperatures of the refrigerator that stored vaccines. This failed practice had the potential to affect all residents (census of 15) who required vaccines. Findings: Observation on 1/12/16 at 8:05 pm of the medication refrigerator on the 300 wing, revealed the following vaccines in the refrigerator: Pneumococcal 13 (PCV13) - 10 single dose vials; Pneumococcal 23 (PPSV23) - 4 single dose vials; and Tetanus, [DIAGNOSES REDACTED], pertussis (Tdap) - 5 single dose vials. During an interview on 1/13/16 at 10:30 am, the Vaccine Distribution Technician stated s/he did not have any responsibility for vaccines once they brought them over from the hospital to the long term care (LTC). During an interview on 1/13/16 at 11:00 am, the Administrator stated he was unaware that vaccines were stored in the refrigerator. During an interview on 1/13/16 at 4:05 pm, the Vaccine Distribution Technician stated the facility did not have a process for 24 hour monitoring of the vaccine refrigerator temperatures. During an interview on 1/14/16 at 4:40 pm, the Administrator confirmed, there was not a process in place that monitored the temperatures of the vaccine refrigerator for 24 hours. The Centers for Disease Control and Prevention Vaccine Storage and Handling Toolkit 2014, obtained at http://www.ded.gov.vaccines website, revealed, CDC recommends use of a continuous monitoring device/digital data logger to record and store temperature information at frequent programmable intervals for 24-hour temperature monitoring. The State of Alaska Immunization Alaska Vaccine Distribution Handbook revised (MONTH) (YEAR), obtained at http://dhss.alaska.gov website, revealed, Tempe… | 2018-12-01 |
| 837 | 837 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 441 | F | 0 | 1 | PN1E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to:1) ensure good hand hygiene practices for one resident (#5) out of 4 observed; 2) ensure surveillance of staff and personnel processing laundry in a manner to prevent cross contamination; 3) ensure staff use good aseptic technique during medication handling/pass; and 4) have a formal infection control program. These failed practices increased the risk for the development and transmission of disease and infection in a vulnerable population. Findings: Hand Hygiene: Record review on 1/11-14/16 revealed Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The Resident's care plan stated the Resident's mobility was to scoot around the floor and to feel for objects. Observation during the initial tour on 1/11/16 from 8:30 am - 9:30 am revealed dirty carpet on both the 200 and 300 units of the facility. During an observation on 1/11/16 at 11:45 am revealed Resident #5 scooting around the floor on her/his bottom, with both hands on the dirty carpet in the TV area. Observation on 1/11/16 at 12:00 pm revealed Resident # 5 was assisted to the wheelchair by Certified Nursing Assistant (CNA) #2 from the floor and transported to the dining table to have noon meal. Continuous observation until 12:55 pm revealed hand hygiene was not provided to the Resident prior to serving the food, even though the Resident's hands had been on the dirty carpet. Observation on 1/12/16 at 7:10 pm revealed Resident #5 sitting on the dirty carpeted floor scooting around on her/his bottom with both hands. The Resident was assisted to the wheelchair by CNA #4 and transported to the dining table for an evening snack. Continuous observation until 7:35 pm revealed hand hygiene was not provided to the Resident prior to the snack. Observation on 1/13/16 during lunch at 12:15 pm, revealed Resident #5 was scratching an area above the left buttock under her/his clothing while dining. Licensed Nurse (… | 2018-12-01 |
| 838 | 838 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2016-01-14 | 518 | E | 0 | 1 | PN1E11 | Based on personnel file review and interview the facility failed to ensure 7 out of 9 staff personnel files reviewed contained fire emergency training. This failed practice placed all residents at risk for delayed evacuation and response from staff due to potential lack of fire emergency training. Findings: During an interview on 1/13/16 Human Resources (HR) Staff #1 stated fire and life safety training would be under section 3 of each staff's personnel file. Review of the personnel files on 1/13/16 revealed no recent fire emergency training for Certified Nursing Assistant (CNA) #s 1, 3, 4, 5 and 6. Additional review revealed no recent fire emergency training for Licensed Nurse #3 or Cook #3. Review of training documents provided by the Director of Nursing on 1/14/16 did not contain any recent fire emergency training for CNA #s 1, 3, 4, 5 and 6. Additional review revealed no recent fire emergency training for Licensed Nurse #3 or Cook #3. | 2018-12-01 |
| 963 | 963 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 151 | E | 0 | 1 | 00JH11 | Based on interview and record review the facility failed to ensure 2 sampled residents (#s 5 and 8) and 1 non-sampled resident (#10) out of 6 residents in a group interview were afforded the opportunity to vote in the 11/4/14 election. This failed practice denied the residents the opportunity to exercise their rights as citizens, specifically their right to vote. Findings: During a resident group interview on 11/19/14 at 10:30 am, Resident #s 5, 8, and 10 stated the facility staff had not informed them of the recent election or assisted them to vote. The Residents also stated they would have exercised their right to vote in the recent election if they had been informed and assisted to do so. During an interview on 11/20/14 at 8:45 am, the Administrator stated he was unsure why the Residents had not been informed of or assisted to vote in the recent election. Record review from 11/17-20/14 of Admission Packet, dated 4/29/14, revealed Resident Rights and Responsibilities .Is encouraged and assisted, throughout the period of stay, to exercise his/her rights as a resident and as a citizen of the United States of America . | 2018-05-01 |
| 964 | 964 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 156 | F | 0 | 1 | 00JH11 | Based on observation and interview the facility failed to include information in the admission packet and to inform the current residents and representatives that the facility was changed to locked units where the residents resided. The facility did not ensure: 1) residents/representatives were informed that the facility was locked; 2) residents may not leave the facility at will; and 3) that family members may not enter or leave the units without first seeking assistance of staff (staff must unlock the door). These failures denied residents and representatives the opportunity to be informed (based on a census of 18). Findings: Observation during the initial tour of the facility on 11/17/14 at 9:20 am revealed the resident units were locked and entry or exit required staff assistance. During a resident group interview on 11/19/14 at 10:30 am, Resident #s 5, 8, and 10 stated they had never been told about the locked doors to the resident units. Resident #8 stated having locked doors may inhibit family from visiting. During an interview on 11/18/14 at 1:35 pm, the Administrator stated the locked doors had been installed on the resident units a week earlier. The Administrator confirmed residents and their representatives had not been informed of that the facility units were now locked. The Administrator also stated the admission packet given to new admits to the facility did not contain information that would identify the facility as contained locked units. | 2018-05-01 |
| 965 | 965 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 159 | F | 0 | 1 | 00JH11 | Based on record review and interview the facility failed to ensure: 1) residents funds over $50 dollars were kept in an interest bearing account; 2) quarterly statements were provided; and 3) access to monies under $50 were provided in a timely manner for 4 (#s 2, 3, 4 & 8) sampled residents and 5 (#s 11, 16, 17, 18 & 19) non-sampled residents for whom petty cash accounts were reviewed. These failed practices created a risk for misuse of resident funds and denied residents interest on their money. Findings: Record review on 11/20/14 of the RTA Balance Report, dated 11/20/14, revealed 9 resident trust accounts, over $50, were not accumulating interest. During an interview on 11/20/14 at 12:30 pm the Administrator stated the facility did not keep cash on hand and resident monies were not available the same day. In addition, the Administrator confirmed the accounts currently do not accrue interest and account statements are not provided to all residents or their representatives quarterly. Review of the facility's trust account policy, effective date 10/1/14, revealed Interest shall be accrued for accounts .The resident shall have ready and reasonable access to his/her personal funds deposited in the Resident Trust Account .a quarterly accounting of financial transactions shall be given to the resident .Request for less than $50.00 .shall be honored within the same day. | 2018-05-01 |
| 966 | 966 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 202 | E | 0 | 1 | 00JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the transfer or discharge summary was documented by a physician in the medical record for 2 residents (#s 6 and 8) out of 3 records reviewed for discharge or transfer. Specifically, there was no physician documentation of a transfer summary for resident #6s transfer to the hospital and the documentation of a discharge summary for resident #8s discharge from the facility. This failed practice denied the residents the right to a complete medical record. Findings: Record review on 11/20/14 revealed Resident #6s medical record did not contain a physician transfer summary for the Resident's transfer to the hospital on [DATE]. Record review on 11/20/14 revealed Resident #8s medical record did not contain a physician discharge summary for the Resident's discharge from the facility on 9/3/14. During an interview on 11/20/14 at 2:00 pm, the DON stated Resident #6 and 8s medical records did not contain the required discharge and/or transfer summaries. | 2018-05-01 |
| 967 | 967 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 241 | E | 0 | 1 | 00JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to provide care and services in a manner to maintain and promote dignity for 6 sampled residents (#s 1, 2, 3, 4, 5, and 8) and 7 non-sampled residents (#s 9, 10, 11, 12, 13, 15, and 19). As a result: 1) care was provided in an institutional manner that did not promote resident dignity; and 2) the manner and atmosphere in which residents were assisted with eating can potentially affect their quality of life in general. Findings: Resident #3 Record review from 11/17-20/14 revealed Resident #3 was admitted to the facility with a [DIAGNOSES REDACTED]. Observations during morning cares on 11/18/14 between 9:00 - 9:30 am revealed NA #1 had removed a soiled brief from Resident #3 and tossed it on the floor in the Resident's room. The soiled brief remained on the floor until after the Resident was assisted into the wheelchair at 9:30 am. The Resident questioned why the brief was on the floor during the care. Resident #4 Record review on 11/17-20/14 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, a quarterly assessment, dated 10/28/14, revealed the Residents assessment was coded as moderately impaired decision making and required extensive assistance with eating. Continuous observation on 11/17/14 from 12:11 - 12:28 pm revealed Resident #4 with food on the left side of the face. An observation on 11/17/14 at 12:29 pm revealed LN #3 used a clothing protector to clean Resident #4s face. Observation on 11/17/14 at 12:50 pm revealed the DON assisting the Resident with the meal without providing the Resident an opportunity to feed themselves. An observation on 11/17/14 at 12:58 pm revealed NA #1 used Resident #4s clothing protector to clean food from the Resident's face. Continuous observations on 11/17/14 from 1:15 - 1:27 pm revealed Resident #4s head lying in pooled saliva on the table. Random observations on 11/18/… | 2018-05-01 |
| 968 | 968 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 246 | E | 0 | 1 | 00JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to accommodate the dining needs for 2 (#s 8 and 11) of 6 residents observed during meals. As a result, the environment did not meet the needs of two residents. Findings: Resident #8: Record review on 11/17-20/14 revealed Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, an annual assessment, dated 10/19/14, revealed the Residents assessment was coded as having limitations in ROM on both sides and needed assistance with eating. Observation on 11/17/14 at 12:55 pm revealed Resident #8 eating at the dining table. The Resident's eyes were observed to be at the same level as the dining table. Further observation revealed the Resident had to reach over her head and tray to obtain bites of food from the plate. During an interview on 11/19/14 at 1:00 pm, LN #5 confirmed the tables height could have been adjusted. Resident #11 Record review on 11/17-20/14 revealed Resident #11 was admitted with [DIAGNOSES REDACTED]. During an observation on 11/17/14 from 12:05 - 12:35 pm, Resident #11 was brought to the dining table in a recliner chair for the lunch meal. The Resident was observed making multiple attempts to obtain food from the plate with a spoon. The chair prevented the Resident from being close enough to the table to be able to reach his plate with a spoon. Nursing Assistant Students were observed using a spoon to assist the Resident with dining because the Resident was unable to reach the plate. During an observation on 11/18/14 from 12:45 - 12:55 pm, Resident #11 was observed sitting at the dining table in a wheelchair that allowed the Resident to reach the table. The Resident was observed placing the food on his own spoon and feeding himself. Record review on 11/17-20/14 of Admission Packet, dated 4/29/14, revealed Resident Rights and Responsibilities .Is treated with consideration, respect and full recognition of th… | 2018-05-01 |
| 969 | 969 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 276 | D | 0 | 1 | 00JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to complete a required MDS comprehensive quarterly assessment in a timely manner for 1 resident (#4) of 5 sampled residents whose MDS assessments were reviewed. The failure to complete a timely assessment put the resident at risk for an incomplete or inaccurate care plan. Findings: Record review on 11/17-20/14 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, an admission assessment revealed it was completed on 6/2/14. Addition review revealed a quarterly MDS assessment, dated 10/28/14, was completed 4 months and 26 days after the admission assessment. During an interview on 11/19/14 at 12:01 pm, the DON further confirmed the quarterly MDS assessment was completed late and should have been completed at the three month interval. Review of the RAI User's Manual Version 3.0, dated October 2013, revealed the primary purpose of the MDS is as an assessment tool used to identify resident care problems that are then addressed in an individualized care plan and assessments must be completed within 92 days from the previous assessment reference date. | 2018-05-01 |
| 970 | 970 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 279 | D | 0 | 1 | 00JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to develop a complete comprehensive care plan that was based on the clinical history and condition for 1 resident (#4) out of 5 sampled residents. Specifically, the resident's care plan did not include any problems, goals, outcomes or interventions relevant to the resident's risk for skin integrity issues and did not reflect implementations of new interventions identified as necessary for resident safety related to falls. This placed the resident at increased risk for falls and skin integrity issues. Findings: Record review on 11/17-20/14 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, a quarterly assessment, dated 10/28/14, revealed the Residents assessment was coded as having a history of falling. Skin Integrity Record review on 11/17-20/14 of the Resident's physician LTC Progress Note, dated 6/16/14, revealed the Resident scooted on her buttocks as a form of mobility resulting in abrasions to the buttocks. Record review of the Care Plan Meeting notes, dated 6/27/14, revealed no discussion of current or potential skin issues. Record review of the LTC Interdisciplinary Care Plan Meeting, dated 8/6/14, revealed the Resident had a small abrasion on the buttocks. In addition the note stated there were no changes made to the plan of care. Record review of the LTC Interdisciplinary Care Plan Meeting, for 9/10/14 and 10/29/14, revealed no discussion or implementation of problems, goals, or interventions for the Resident's risk for skin integrity issues. Record review of the Care Plan Meeting notes, dated 11/07/14, revealed no discussion on the Resident's risk for impaired skin integrity. In addition the notes stated the team agreed with current care plan and interventions. Record review of the Resident's LTC Progress Note, dated 11/18/14, revealed the Resident had a new abrasion on her left buttock as a resu… | 2018-05-01 |
| 971 | 971 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 309 | E | 0 | 1 | 00JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide the necessary care and services per the comprehensive care plan for 2 residents (#s 2 and 4) out of 5 sampled residents and 1 non-sampled resident (#9). Specifically, the facility failed to ensure: 1) 1 resident (#2) wore hipsters while awake and ambulating; 2) 1 resident (#4) wore hipsters while awake and room was free of clutter; and 3) 1 resident (#9) was wearing a hearing aid. These failed practices placed Residents at risk of not receiving care and services to attain or maintain their highest practicable physical and mental well-being. Findings: Resident #2 Record review on 11/17-20/14 revealed Resident #2 was admitted to the facility with a [DIAGNOSES REDACTED]. Record review on 11/17-20/14 of the Resident's most recent MDS assessment, a significant change assessment dated [DATE], revealed the Residents assessment was coded as having falls since admission. Record review on 11/17-20/14 of the Resident's comprehensive care plan, last updated 10/14/14, revealed a goal of .will not have a major injury from falls for 90 days .Interventions .Hipsters (underclothing with pads inserted at the hip area) will be worn by (Resident #2) while awake and ambulating . An observation of Resident personal care on 11/18/14 at 1:15 pm, revealed LN #4 assisted Resident #2 with toileting and dressing. The LN assisted the Resident with putting on briefs, pants and slippers. The LN did not offer hipsters to the Resident. The Resident then ambulated out of his room and around the common area unassisted. During an interview on 11/20/14 at 12:45 pm, the DON stated Resident #2 should have hipsters on for safety whenever the Resident was up ambulating as required on the Resident's comprehensive care plan. The DON also stated there was no documentation in the Resident's medical record regarding failures to implement care plan items because the CNAs did not document in the Resident's ch… | 2018-05-01 |
| 972 | 972 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 323 | K | 0 | 1 | 00JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F323 #1 Immediate Jeopardy Hot Pads Based on record review, observation and interview, the facility failed to ensure a safe environment free from accidents and hazards. Specifically, the facility failed to ensure: 1) staff used hot pads according to the manufacturer's directions; 2) policies and procedures were in place for the use of hot pads; and 3) staff were educated and trained for the proper use of hot pads. This failed practice placed 2 residents (#s 4 and 8) of 8 sampled residents residents at risk for harm and severe burns. This failed practice constituted an Immediate Jeopardy situation. The Immediate Jeopardy was abated on 11/19/14 at 6:45 pm. #2 Environmental Safety Based on observation and interview, the facility failed to ensure the residents' environment was free of accident hazards. Specifically, the facility failed to ensure: 1) the activity kitchen doors were secured and the oven and toaster were not able to be turned on when not in use; 2) chemicals with hazard warnings were secured; 3) the dryers and surrounding area in the dryer rooms were free from lint; and 4) common area for residents was free from trip hazards. The cumulative effect of these failed practices created an increased risk for all residents (based on a census of 18) for harm due to falls, burns, ingestion of hazardous substances by cognitively impaired residents, or other injuries. Findings: #1 Immediate Jeopardy Hot Pads Resident #4 Record review on 11/17-20/14 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of Resident #4s Nursing Progress Notes, dated 8/15/14 to 11/13/14 revealed four occurrences of the hot pads being utilized on 8/15/14, 9/10/14, 11/12/14 and 11/13/14. Additional review revealed no skin assessment was conducted before or after the use of the hot pad on 9/10/14, 11/12/14 or 11/13/14. The hot pad was left in place for 30 minutes on 9/10/14 according to the progress note. Resident #8 Record review… | 2018-05-01 |
| 973 | 973 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 364 | F | 0 | 1 | 00JH11 | Based on observation, interview and record review the facility failed to provide palatable meals at the appropriate temperature for a total census of 18 residents. As a result, the residents were placed at risk for poor nutrition and weight loss. Findings: Lunch Observations on 200 Wing Dining Area on 11/17/14 at 1:20 pm revealed a food cart containing two trays. One tray was served to Resident #13. The next tray was to be served to Resident #14. During an interview on 11/17/14 from 1:20 pm to 1:25 pm, the EC was asked how long the trays had been stored in the food cart. The EC stated since 11:55 am, total time elapsed 1 hour and 25 minutes. The EC was asked by the Surveyor to measure the temperature of Resident #14's tray. The EC stated the mixed vegetables were at 98 degrees Fahrenheit and the macaroni and cheese was at 103 degrees Fahrenheit. When asked about the expected serving temperature for food at the facility, the EC stated it was 125 degrees Fahrenheit. The EC confirmed the food was not at the expected serving temperature for the residents. Breakfast During an interview on 11/18/14 at 8:04 am, the EC was asked to temp the remaining food on the serving line after preparing and placing resident breakfast trays in the food cart. The EC measured the temperature and stated the French toast was 96 degrees Fahrenheit and the bacon was 96 degrees Fahrenheit. The EC confirmed these temperatures were too low for palatable serving. Continuous observations on the 200 Wing during breakfast on 11/18/14 from 8:40 am to 9:20 am revealed the food cart's door open for a total of 40 minutes. Inside the cart were residents trays, already prepared with the breakfast meal. During an interview on 11/19/14 at 10:33 am the RD stated the serving temperature for food should be served at 130 degrees Fahrenheit and food carts should remain closed when not in use. Lunch During an observation on 11/18/14 at 12:50 pm, LN #1 heated a bowl of soup in the activity kitchen for Resident #2. The LN was observed removing the bowl from the m… | 2018-05-01 |
| 974 | 974 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 366 | F | 0 | 1 | 00JH11 | Based on interview and policy review the facility failed to ensure substitutes were offered according to resident individual taste for 1 resident (#5) out of 5 sampled residents and 1 non-sampled resident (#9). This failed practice placed residents at risk for not having their nutritional needs met. Findings. Review of the ALTERNATIVE MENU on 11/17/14 at 1:28 pm revealed four choices of alternatives Salmon; Halibut; White Fish; and Fish Soup. Additional review revealed a secondary choice of Bread Stix or Fry Bread. During an interview on 11/17/14 at 1:28 pm the EC confirmed the only alternatives offered for lunch and dinner came from the Alternative Menu. During an interview on 11/18/14 at 8:30 am the RD confirmed there was no alternative for side dishes and the only alternatives for main courses were the 4 fish choices on the alternative menu slip. During an interview on 11/18/14 at 9:25 am Resident #9 stated she has toast every day and wished she could have pancakes. During a Resident Group Interview, on 11/19/14 at 10:30 am, Resident #5 stated the facility served too many fish dishes. Review of the policy manual used by the RD, Idaho Diet Manual, dated 2010, revealed Honor individual food preference whenever possible .Provide foods with a variety of taste, textures, colors . | 2018-05-01 |
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CREATE TABLE [cms_AK] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );