CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 family visitor sitting next to him/her, was served the lunch meal. Resident #16 reached over and quickly grabbed a cup of juice off Resident #15's tray and began drinking it. The family visitor, notified the LN that Resident #16 had taken the juice. Resident #16 was allowed to continue drinking the juice. Resident #15's family visitor stated they frequently came in at meal time to assist the Resident with eating due to concern about the Resident's intake. For the next 12 minutes, Resident #16 sat at the table and watched as Resident #15 enjoyed lunch. At 12:55 pm, LN #10, provided Resident #16 his/her noon meal. The LN briefly sat next to the Resident and fed him/her 2 bites of food. The LN then got up and walked away to attend to other tasks. Resident #16 continued to sit at the table, with his/her meal in front of him/her, and watched as Resident #16 continued eating lunch. At 1:11 pm, 10 minutes later, Certified Nursing Assistant (CNA) #12, arrived and sat down next to Resident #16 to finish assisting the Resident with his/her lunch. During an interview, on 1/29/18 at 1:11 pm, when asked why Resident #16 had to wait for assistance with lunch, CNA #12 stated the CNAs had gone over to help feed the residents on the other wing, leaving only the LN on the unit to help. A record review on 1/30-2/2/18 of the most recent MDS dated [DATE] revealed Resident #16 was coded at a level 3 (extensive assistance needed) under Functional Status for eating assistance. A review of the care plan did not address functional need or assistance plan for meals. Television Programming An observation on 1/30/18 at 8:30 am revealed the television to be on to the cartoon Paw Patrol. Resident #s 1 and 6 were in the common area. Neither of the Residents were engaged in the programming. During an interview on 1/30/18 at 8:41 am, Resident #1 was asked if s/he liked to watch the cartoon on the television as s/he was the only Resident still in the room. Resident #1 replied s/he was not interested in watching cartoons, preferred movies. Observation of the common area on 2/1/18 at 8:13 am revealed the TV to be on Paw Patrol with Residents #s 6 and 15 present in the room. Neither of the Residents were watching the programming. During an interview on 2/1/18 at 8:13 am CNA #3 stated they had not asked for the residents input on television channel selection. LN#2 stated s/he thought Resident #16 (who was not present) liked to watch Paw Patrol and Resident #6 liked to watch the Discovery Channel or the news. Record review on 2/2/18 of the facility's admission packet revealed the facility's Residents Rights information included: Is treated with consideration, respect and full recognition of the resident's dignity and individuality . | 2020-09-01 |
| 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 | 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 submitted by Residents or family. An interview with Resident #16's Power of Attorney (POA) on 1/31/18 at 10:24 am revealed that he/she complained at the last Interdisciplinary Team meeting that his/her Resident did not like the food. There was no evidence of this complaint/grievance on record. Written Response Record review on 1/30/18 at 12:15 pm, of a form entitled Information on Grievance and Complaints, revealed that grievances can be submitted orally, in writing, and can be anonymous. The form additionally stated All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions will be responded to in writing, including a rationale for the response. A record review of the grievance log book on 1/30/18 at 10:30 am revealed three written grievances had been filed. Further review revealed there was no documentation that Resident's or family who filed grievances had received a written response. During an interview with the Social Worker (SW), when asked about reponses to grievances, she stated she was unaware written responses were part of the facility's procedure. Accessibility of Box Observation during the survey on 1/29-2/2/18 revealed a box labeled Complaints in the hallway outside the two resident units. The doors to both units were locked and required staff to open the door for Residents to access the hallway. During an interview on 1/30/18 at 10:13 am, when asked about the grievance process, the Social Worker (SW) stated the Complaints box was for written complaints by residents, family members or anonymously by staff. She stated the facility did not have a box located on the residents' side of the locked doors or a form for grievances. Grievance Tracking Record review on 1/30/18 at 12:15 pm, of a form entitled Information on Grievance and Complaints stated The results of all grievances file(s), investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. An interview with the Administrator on 1/30/18 at 4:30 pm revealed he had no additional documentation on grievances other than what was on file with the SW. | 2020-09-01 |
| 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 dated [DATE]; and - [DATE] Background check closed due to individual not submitting requested documents. During an interview on [DATE] the Director of Nursing confirmed that LN #7 had no background check validated before the individual began to work as a direct care staff on the units. Observations during the survey on [DATE]; [DATE]; and [DATE], LN #7 observed working in the facility with the residents. Nurse Aide Registry: Review of the facility's personnel files on [DATE] revealed neither CNA #6 or CNA #13 had evidence of being screened through the State nurse aide registry upon hire. During an interview on [DATE] the HR Generalist stated he/she could not provide evidence that either CNA #s 6 and 13 were checked with State nurse aide registry upon hire. Review of the facility's policy (Long Term Care) Abuse Policy, dated ,[DATE], revealed the purpose of the policy was To keep residents free from all types of abuse (Yukon-Kuskokwim) Elders Home will utilize background checks (screening) .to prevent abuse and mistreatment of [REDACTED]. Request information as to history of abuse, neglect or mistreating residents .Obtain criminal background information. Evaluation of the information obtained through the screening process is utilized to determine eligibility for employment in adherence to the policy of this facility. | 2020-09-01 |
| 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 conversational volume and all residents in double room will be required to use headphones .All residents between the hours of 8:00 (PM) and 8:00 (AM) will be required to use headphones. Residents will be responsible for purchasing and maintaining headphones. During an interview on 2/2/18 at 10:00 am the Social Worker stated the admission packet language needed to be reviewed and changed to remove the headphone requirement. In addition, the Social Worker stated if a resident needed an adaptive hearing device; the facility would help in obtaining the device without the use of resident's personal funds | 2020-09-01 |
| 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 was unaware in the change of the Resident's functional ability adding, the significant change MDS had not been completed nor the care plan updated for Resident #16 because she felt the significant change had not occurred. A record review on 2/2/18 of Resident #16's MDS Intelligence Report Card provided by the MDS Nurse revealed Resident #16 was flagged as clinically critical and needed further investigation. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, (MONTH) (YEAR), Revealed a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan . When a resident's status changes and it is not clear whether the resident meets the SCSA guidelines, the nursing home may take up to 14 days to determine whether the criteria are met .Decline in two or more of the following .Any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment and does not reflect normal fluctuations in that individual's functioning .Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days) .Emergence of a condition/disease in which a resident is judged to be unstable. . | 2020-09-01 |
| 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 1/29/18 at 1:40 pm the Resident stated his/her dentures had been lost at a prior facility and he/she would like to walk more but the staff was too busy. Resident #15 Record review on 1/31-2/1/18 revealed Resident #15 had [DIAGNOSES REDACTED]. Review of the Resident's quarterly MDS assessment, dated 8/19/17, reveal the Resident was coded as receiving ROM while in the restorative nursing program 2 times. Resident #16 Record review on 1/31-2/1/18 revealed Resident #16 had [DIAGNOSES REDACTED]. Review of the most recent MDS admission assessment, dated 5/19/17, revealed the Resident was identified as being in a restorative nursing program. Review of a binder titled Resident's Individual Exercise Programs To Be Used In Therapy Room, revealed hand written exercise plans for Resident #12 that had not been implemented or updated. Resident #17 Record review on 2/2/18 revealed Resident #17 had [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment, dated 8/23/18, revealed the Resident's height was 57 inches. Review of the most recent quarterly assessment, dated 11/23/17, revealed the Resident's height was now 63 inches, an increase in 8 inches in height. During an interview on 2/1/18 the Director of Nursing stated the facility did not have a restorative nursing program. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, revised (MONTH) (YEAR), revealed under O 0500: Restorative Nursing Programs . 3. The following criteria for restorative nursing programs must be met in order to code O 0500 .Measurable objective and interventions must be documented in the care plan and in the medical record. If a restorative nursing program is in place when a care plan is being revised, it is appropriate to reassess progress, goals, and duration/frequency as part of the care planning process. Good clinical practice would indicate that the results of this reassessment should be documented in the resident's medical record. Evidence of periodic evaluation by the licensed nurse must be present in the resident's medical record. When not contraindicated by state practice act provisions, a progress note written by the restorative aide and countersigned by a licensed nurse is sufficient to document the restorative nursing program once the purpose and objectives of treatment have been established. Nursing assistants/aides must be trained in the techniques that promote resident involvement in the activity. A registered nurse or a licensed practical (vocational) nurse must supervise the activities in a restorative nursing program .Although therapists may participate, members of the nursing staff are still responsible for overall coordination and supervision of restorative nursing programs. . | 2020-09-01 |
| 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 towards his/her goal. Dentures During an interview on 1/29/18 ay 2:15 pm, Resident #14 stated he/she had lost his/her dentures at a previous facility. The Resident stated the kitchen chopped up the food. Review of the Resident's MDS admission assessment, dated 4/25/17, revealed the Resident was not marked for Dental: No natural teeth tooth fragments. During an interview on 2/1/18 at 9:20 am, when asked about the dentures, The SW stated Resident #14 was next on the list as it took several appointments for molds. Review of the Resident #14's IP[NAME], updated 11/29/18, revealed the interventions Evaluate eating limitations: Dentures and Whole food with finely chopped meats. There was no information about the missing dentures or how the facility would work to get them from the prior facility or obtain a new pair. Behaviors During an interview on 1/29/18 at 1:38 pm, Resident #14 stated a male Resident living here runs around naked and sneaks into every room. The Resident stated the staff stated the Resident likes him/her. The Resident stated he/she can't stand it anymore. Review of the Resident's IP[NAME], updated 5/2/17, revealed Long Term Behavioral Symptoms. The goals were Appropriate Behaviors when interacting with others .Residents, Families, Friends, and Staff. The IP[NAME] did not identify the Resident's risk for victimization and the potential for psychosocial harm. Resident #16 Nutritional Status Record review on 1/31-2/1/18 revealed the Resident was admitted to the facility with medical [DIAGNOSES REDACTED]. The Resident was admitted to the facility following a surgical repair of a [MEDICAL CONDITION]. On 1/29/18 at 12:25 pm, Resident #16 was observed in the dining room. When his/her tray was presented, he/she did not make any movement or action to eat the food. Interview with family on 1/29/18 at 3:54 pm revealed that family are concerned about Resident #16's intake, diet, weight loss and overall decline in physical ability. 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. Record review on 1/30/18 at 1:24 pm of a progress note dated 10/28/17 indicated weight loss and that Resident #16 consumed 18% of meals and 45% of snacks. The intervention was to order Ensure clear (a supplement) with meals. A record review on 1/30-2/1/18 of the most recent MDS dated [DATE] revealed Resident #16 was coded at a level 3 (extensive assistance needed) under Functional Status for eating assistance. A review of the care plan dated 12/21/17 did not address functional need for assistance for meals. Outcome stated that goals had been met despite significant weight loss. The care plan placed goal weight at 30-40 kg. Activities of Daily Living Random observations of Resident #16 on 1/29/18, 1/31/18, and 2/1/18 revealed Resident #16 was totally dependent on facility staff in every area of functioning. A record review of Resident #16's most recent MDS report dated 12/25/17 coded Resident #16 for needing extensive assistance for personal hygiene. A review the Resident's IP[NAME], with updates from 5/12/17-12/21/17, did not contain any goals, interventions, or outcome measures for Resident #16 despite significant functional decline as evidenced by the MDS report and Resident's family. | 2020-09-01 |
| 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 precaution. On 1/31/18 at 4:00 pm Resident #16 was observed in the common area of the unit watching television. His/her nails were long and had chipped blue nail polish at the base of the nail plate. During an observation on 2/1/18 at 11:57 am, Resident #16's skin on the coccyx was assessed by the physician. Licensed Nurse (LN) #2 stated that Resident #16 had reached into her brief and scratched feces into open wounds on the affected area. The LN stated the area was red with multiple open scratch marks visible. LN #2 then measured and documented the scratches. The LN stated the Resident's nails were too long and needed to be trimmed to avoid further injury. A record review of Resident #16's most recent MDS report dated 12/25/17 coded Resident #16 as needing extensive assistance for personal hygiene. A review of Resident #16's IP[NAME] care plan, last updated 1/29/18 for skin integrity issues did not contain any interventions regarding ADL care for skin integrity and did not address goals, interventions, or measures for ADL care as a care area. Resident #218 Record review on 1/30-2/1/18 revealed Resident #218 had [DIAGNOSES REDACTED]. On 1/29/18 at 3:15 pm, Resident #218 was observed ambulating on the unit. The Resident's fingernails were long, dirty underneath, and had chipped polish at the base of the nail plate. Observation on 2/1/18 at 5:11 pm, revealed Resident #218's nails were long, dirty, and had chipped polish. During the observation the Resident used his/her nails to pick at the skin on his/her face and arms. Review of the CORP-Messages Detail Report, dated 9/26/16, revealed Report and skin issues to your charge nurse immediately. The information, dated 10/27/17, revealed Encourage Personal hygiene During an interview on 2/1/18 at 5:47 pm, when asked who was responsible for Resident nail care, LN #7 stated she thought someone came in to do the residents nail care. During an interview on 2/1/18 ay 6:00 pm, LN #2 stated the LNs do the trimming and the CNAs do the filing and painting. The LN stated Physical Therapy staff came in to trim some of the residents toenails, not fingernails. | 2020-09-01 |
| 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 by a Resident's interests and documented in the electronic medical record (EMR). Activities are reviewed at monthly Interdisciplinary Team meetings to determine if goals are being met. Outings and activities are planned with Resident interest and cultural appropriateness in mind. The Resident participation was documented through Care Tracker system. Resident #1 During an interview on 1/29/18 at 9:53 am Resident #1 stated that activities were insufficient. Resident #1 stated They don't do nothing around here. A record review of the Resident's individualized plan of care (IP[NAME]), last updated 1/30/18 revealed activity interventions included personalized interests, methods of engaging Resident to participate, and measures to evaluate participation. Watching TV was not listed as this Resident's activity preference. The goal was for Resident #1 to be out of his/her room daily. There was no information this goal had been met. Review of the Activity Detail Report for the month of (MONTH) revealed Resident #1 had participated in 2 hours of individual Physical Activity, 2 hours of Mental Activity (current events), and 2 hours of group Spiritual/Emotional activity, 1 hour of individual Eating Experience, 2 hours of movies, and 2 hours of Self-directed Socialization. The remainder of the activity participation entries was documented as 37 hours of individual and group activity of Watching TV. Resident #2 Record review on 1/30-2/1/18 of the Resident's most recent annual MDS (MDS-a Federally required assessment) dated 7/11/17, coded the resident for the following activities, reading books, newspapers or magazines, keeping up with the news and participating in favorite activities Review of the Resident's IP[NAME], dated 6/16/17, revealed Long Term Care Activities listing numerous interventions with only two nonspecific goals, and documented all interventions as being met. Review of the Residents activity detail report from 1/1/18 through 1/28/18 revealed conflicting results. For example on 1/7/18 the resident is documented to be watching TV at 4:09 pm for an hour (individual activity) and attending a religious services (group activity) at 4:10 pm for an hour. Resident #5 During an interview on 1/30/18 at 2:30 pm, Resident #5 stated there are not enough activities. It is boring. I am able to go out and visit but there's no activity here or nothing. I like art and they don't have anything to do that. They need things for people who are capable of doing things. Record review on 1/31/18 of Resident #5's IP[NAME] revealed no active goals related to activities. Interventions included preferred activities and individualized information. The Resident was to be supported in maintaining independent activity. Review of Resident #5's Activity Detail Report for the month of (MONTH) indicated 3 hours of Movies and 6 hours of Watching TV. Observation of Resident #5 during the survey from 1/29/18-2/1/18 did not demonstrate that Resident participated in any facility activities. Resident #6 Record review on 1/30-2/1/18 revealed Resident #6's most recent MDS, dated [DATE], identified the Resident enjoyed the following activities; listening to music, keeping up with the news, participating in group activities, getting fresh air and participating in religious practices. Review of the Residents IP[NAME], dated 12/7/17, listed numerous activities including the Resident will, attend and participate in 1 act/daily with appropriate behavior, attend religious/spiritual activities when offered monthly, and identify interests: cooking, painting, physical ex., music, outings, socials, TV/movies. Review of Resident's #6 Activity Detail report, from 1/7/18 to 1/30/18, revealed descriptions/activities such as self-directed socialization happened 5 times (or days), and watching TV 25 times. Of those 25 documented TV activities, was the only activity documented for that given day. Resident #9 Record review on 1/30-2/1/18 revealed Resident #9 had [DIAGNOSES REDACTED]. The Resident was hard of hearing and had visual deficits. Review of the Resident's most recent MDS annual assessment, dated 12/1/18, revealed activity preferences that were very important included; listening to music, participating in religious services, keeping up with the news, getting fresh air outside when the weather is good. Review of the Resident's IP[NAME], updated 1/11/18, revealed a goal of .will be involved in 1 group or individual activity of interest daily. The interventions included; interests-hunting, fishing, subsistence lifestyle, Native culture, spiritual, music, TV/movies, special events, outings, and walking. Review of the 30 minute log sheets, dated 1/29-1/30/18, revealed facility staff only documented 1 activity besides sleeping, sitting, standing, and eating throughout the day. Observations on 1/29/18 at 10:00 am, Resident #9 was observed coloring in the dining room. Other activities that day included watching television at various times throughout the day. Review of the Activity Detail Report, revealed on 1/29/18 the LN had documented the Resident refused to participate in active games. Under the entry Self Directed Socialization the LN had documented the Resident was sleeping during those times. Other items documented were watching TV and Eating Experiences. Review of the Resident's activity idea book kept at the front desk that, listed several games and activities that could be implemented that included items such as ring toss, puzzles, table board games, and memory games. In addition, facility staff documented Resident #9 had listened to recorded music on 1/29/18 at 6:19 am and 3:26 pm. Resident had refused to participate in active games that afternoon. Resident #11 Record review on 1/30-2/1/18 of Resident #11's most recent annual MDS, dated [DATE], revealed the Resident was admitted to the facility with a medical [DIAGNOSES REDACTED]. Review of the Resident's IP[NAME], revised 11/27/17 revealed Long Term Care Activities listing numerous interventions without measurable goals or evaluations of the listed interventions. Review of Resident #11's Activity Detail report, from 1/2/18 through 2/1/18, revealed the Resident had participated in two music activities, 34 TV watching activities, and four self-directed socialization activities. Resident #12 Review of the EMR on 1/30/18 revealed Resident #12 had [DIAGNOSES REDACTED]. During an interview on 1/29/18 at 9:53 am, Resident #12, stated don't do nothing around here. My coming out bothers people so I stay in my room. Resident #15 Record review on 1/31/18 of Resident #15's IP[NAME] revealed no outcome goals for the Resident's activity plan. Interventions include information about Resident history but lack any substantial interests or Resident reported preferences. Review of the Resident's IP[NAME] revealed facility staff was encouraged to invite the Resident to activities and that staff were to document attendance, participation and refusal in activities. No documentation of attendance, participation or refusal was in the record. A record review of the Activity Detail report for the month of (MONTH) revealed that Resident #15 had attended 17 hours of a combination of group and individual Watching TV and 1 hour of Self-directed Socialization During the survey period from 1/29-2/1/18, Resident #15 was not observed participating in any group or individual activity. Resident #16 A record review on 1/30/18 of Resident #16's IP[NAME] revealed no activities were care planned. A record review of Activity Detail Report for (MONTH) on 12/31/18 reveals that Resident has participate in 3 hours of group religious service, 5 hours of movies, 1 hour of individual eating experience, and 9 hours of watching TV. Observation from 1/29-2/1/18 revealed very little interaction between staff and Resident. Resident was observed watching TV once independently. The Resident had limited ability to communicate. Resident #218 Record review on 1/29-2/1/18 revealed Resident #218 had [DIAGNOSES REDACTED]. Review of the Resident's admission MDS assessment, dated 12/21/17, revealed the Resident activity preferences included; snacks between meals, being around animals such as pets, participate in favorite activities, spending times outdoors, and participate in religious activities. Review of Resident #218's IP[NAME], updated 1/11/18, revealed the goal (Resident #218) will be involved in either group or individual activities. Interventions included Invite and assist (Resident #218) to activities of interest .Assist (Resident #218) as necessary to be successful during activities of interest .will attend and participate in 1-2 group or individual activities of interest outside room daily .will request items for independent activities of interest appropriately .interests-games, arts/crafts, walks, music, TV/movies, outings, social/special events .identifies with the Russian Orthodox religion. Review of an Initial Activity assessment dated [DATE] (prior to the Residents admitted ), revealed Resident's interests included; bingo, drawing, arts and crafts, cooking, baking, walking, parties, television, culture, and gospel or easy listening music. Observation on 1/29/18 during 8:00 am-3:00 pm revealed the Resident had not engaged in any activities, the Resident intermittently sat in the dining room or napped in his/her room throughout the day, the Resident was not engaged in any activities. Review of the Activity Detail Report, revealed the Resident had prompted participation in the Resident council on 1/29/18 at 2:41 pm and had participated in active games at 3:49 pm. Observation of the Resident at various times on 1/30/18 revealed the Resident was unoccupied throughout the day and intermittently napped in bed with the TV on. During an interview on 2/1/18 at 7:44 am, the LN stated Resident #9 had a special book that outlined activities, the LN stated although the Resident was 1:1 the staff are too busy to implement them. | 2020-09-01 |
| 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/crutches, walker and wheel chair as mobility devices. Review of the Resident's IP[NAME], dated 1/11/18, and profile (in CareTracker) revealed no specific problems, interventions, or goals that addressed how to maintain or improve the Resident's functional ability and/or ROM. Resident #11 Record review on 1/31-2/1/18 revealed the Resident was admitted to the facility with medical [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment dated [DATE], revealed the Resident was identified as being in Restorative nursing program and had received AROM & PROM exercises 4 days in the 7 day assessment window and as using a wheelchair as a mobility device. Review of the Resident's IP[NAME], dated 12/22/17, revealed no specific problems, interventions, or goals addressing how to maintain or improve the Resident's functional ability and/or ROM. Resident #13 Observation on 1/29/18 at 10:28 am, CNA #s 2 and 3, provided morning care to Resident #13. When the Resident was transferred into a Geri-chair (recliner type chair on wheels), the Resident's lower extremities were so contracted and he/she was unable to straighten them out when seated. As a result, Resident #13 was seated in a squatting position in the chair. No stretching or ROM was offered and/or provided to the Resident during the interaction. During an interview on 1/29/18 at 10:45 am, when both CNAs were asked if they ever do ROM for the Resident, CNA# 3 stated if (resident) lets them. Review of the Resident's most recent MDS quarterly assessment, dated 1/15/18, revealed the Resident was identified as being in Restorative nursing program and had received PROM 4 times and AROM 6 times, in the 7 day assessment window. Review of the CORP-Messages Detail Report, dated 8/10/16, revealed Resident #13 was to receive Physical Therapy recommends DAILY PROM. The instructions gave specific instructions on the joints that needed the PROM, but did not give instructions on the number of times the ROM need to be repeated. Review of the Residents most recent IP[NAME], updated on various dates, revealed the risk for further contractions was not identified and the interventions for PROM/AROM were not included in the IP[NAME]. 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 walked in his/her room with support from 1 staff and had walked in the corridor 1 time, during the 7 day assessment window. In addition, the MDS identified Resident #14 was on a restorative nursing program and had received AROM and ROM 5 days that week. Review of the CORP-Messages Detail Report, utilized by the CNAs to provide care, revealed (Resident #14) may use the exercise equipment in the MDS office .is on short list for Physical Therapy. If they have a cancellation they will call the Charge Nurse and see if (Resident #14) is available for PT. Review of the Resident's exercise program, undated, revealed Resident #14 was to walk the length of the parallel bars .free range pulleys-3 minutes. 3) Transfer to Nustep (a sit down elliptical type machine) using Hoyer lift. Review of the Resident's care plan Long Term ADL Function Rehab IP[NAME], revised 12/5/18, revealed the interventions: (Resident) uses a wheelchair for ambulation (he/she) cannot bear weight .is on the short list for PT @ the Hospital. There was no information the care plan about the Resident's exercise program or AROM/ROM. Resident #15 Record review on 1/31-2/1/18 revealed the Resident was admitted to the facility with medical [DIAGNOSES REDACTED]. After a recent [MEDICAL CONDITION], the Resident had surgical repair and therapy. Review of a MDS annual assessment, dated 1/14/18, revealed the Resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the Resident's IP[NAME] dated 12/22/17, revealed no specific problems, interventions or goals aimed at maintaining or improving ROM or mobility. Review of the Resident's MDS, dated [DATE] revealed the Resident was on a restorative nursing program had received PROM 6 out of 7 days and AROM 7 out of 7 days between 1/23/18 and 1/29/18. Review of the facilities exercise program for Resident #15, dated 6/7/17, revealed Resident #15 was to walk the length of the parallel bars (located in the PT room) 3 times and do free range pulley exercises for 1 minute. Observations on 1/29/19 and 2/1/18 of the Resident's care revealed no range of motion activities was offered or performed. Resident #16 Record review on 1/29-2/1/18 revealed Resident #16 has not been walking since he/she had fallen and broken a hip. Further record review revealed the Resident was admitted to the facility with medical [DIAGNOSES REDACTED]. During an interview on 1/31/18 at 10:28 am, Resident #16's power of attorney (POA) revealed the Resident was admitted to the facility after sustaining a [MEDICAL CONDITION] that required surgery where pins were placed to repair the fracture. Based on an increased level of care required, the assisted living home the resident had previously resided was unable to provide the level of care needed. The Resident consequently was admitted to the LTC facility with the understanding he/she would receive interventions to improve mobility and/or prevent further decline. The POA stated he/she was worried about the Resident's decline. Review of the MDS admission assessment dated [DATE], revealed Resident #16 had required extensive assistance for bed mobility, toilet use, walking in the corridor and personal hygiene. The Resident required limited assistance with eating. Review of the most recent MDS assessment, dated 12/25/17, revealed the Resident was now totally dependent on 2 staff for bed mobility, transfers and dressing. The Resident only used the toilet 1 time during the assessment period and needed extensive assistance with eating. Review of the Resident's IP[NAME], dated 5/12/18, revealed Resident #16 had the problem Alteration of Physical Mobility. No interventions or goals aimed at maintaining or improving functional ability and/or ROM. Observations on 1/31/18 and 2/1/18 of the Resident's morning care revealed no range of motion activities or walking in the PT room was offered or performed. During an interview on 1/31/18 at 3:25 pm, when asked how they knew what exercises to do for each Resident, CNA #s 2 and 3 stated they just look in CareTracker or just do it. Both CNAs stated they do at least 15 minutes then document how the Resident tolerated it. On 1/31/18 at 4:40 pm, the survey team attempted to call the Physical Therapist with the phone number provided by the facility. Although a message was left there was no return call. During an interview on 2/1/18 at 9:35 am, when asked what exercises or completed for each Resident, CNA# #12 stated it's mostly up to the CNA's and we try to incorporate it into daily stuff. When asked if they had received any instruction from Physical Therapy (PT) staff, the CNA stated We don't have PT. During an interview on 2/1/18 at, when asked about the facilities restorative nursing program, or how facility staff knew what exercises to implement for each resident, the MDS Nurse stated the facility did not have a restorative nursing program, but had an exercise program. Further review of the Resident's Individual Exercise Programs to be used in therapy room revealed Resident #s 2, 6, 11, 13, and 16 were not listed. The programs identified for Resident #s 14 and 15 were not being offered or performed and were not identified in the Resident's individualized care plans. Review of the Yukon-Kuskokwim Health Corporation policy dated 10/1/13, titled LTC Restorative Nursing revealed the following: Residents assessed with [REDACTED]. | 2020-09-01 |
| 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 describe what level of support Resident #1 required, aside from a magnet outside his/her room (that indicated fall risk), utilization of a lowered bed, using a lift for transfer, and help in position of the wheelchair. The care plan had one measurable outcome of no injury from falls for 120 days. The care plan also indicated that Resident #1 was at high risk for falls r/t (related to)[MEDICAL CONDITION] immobility. During an interview on 2/1/18 at 9:46 am the Minimum Data Set (MDS-a Federally required assessment) Nurse stated the facility was not very concerned about falls for Resident #1 because there had been no documented falls for 3.4 years prior. The MDS Nurse stated that the care plan had not been reviewed and/or updated by the Interdisciplinary team because it had occurred within the past two weeks and she had been out on leave. Transfers Resident #2 Record review on 1/31-2/1/18 revealed Resident #2 had [DIAGNOSES REDACTED]. The resident required total assistance with transfers in and out of the bed with the use of a ceiling mechanical lift (Hoyer/Arjo sky lift). Review of the Resident's IP[NAME], revised 12/8/17, revealed Hoyer lift for all transfers. The sling size used for transfers was not identified on the care plan. Observation and interview on 2/1/18 at 9:25 am, CNA #s 2 and 3 assisted the Resident into a sling and attached it to the overhead mechanical lift. When asked what size the sling was being used to transfer the Resident and if it were the appropriate size, the CNAs were unable to provide the information and stated they used this sling because it fit (the Resident). Resident #13 Record review on 1/31-2/1/18 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. Review of the Resident's IP[NAME], revised 8/22/17, revealed Long Term ADL (activities of daily living) Function Rehab. The interventions included .uses a Hoyer lift for all transfers. The Arjo (Hoyer) lift and the size colors of the sling were not identified on the care plan. During an observation on 1/29/18 at 10:30 am, CNAs #2 and 3 assisted the Resident onto a gray and black sling and attached it to the overhead mechanical lift. The sling had multiple straps including a strap with a buckle in the middle of the sling. 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. The strap with the buckle was not attached to anything. During an interview on 2/1/18 at 7:35 am, when asked about education for the facility CNAs and how they determined which lift size sling to use, Licensed Nurse (LN) #6 stated the facility staff followed the In a Nut Shell manual. Review of the In a Nut Shell manual, revealed information on how to use a Hoyer lift (movable lift on wheels) and a Maxi Sky ceiling lift. The instructions listed several types of loop sling lifts and Sling Selection .All slings are color coded for size by having a different colored edge binding or attachment strap coloring The sizing consisted of: gray or teal-extra extra small; white or brown-extra small; red-small; yellow-medium; green-large; blue-extra-large; and terracotta-extra extra-large. The gray and black sling used on Resident #13 was not listed or described. Observation of a transfer on 2/1/18 at 9:05 am revealed CNA #s 1 and 11 used the Arjo lift to transfer the Resident from the bed to a wheelchair. The CNAs used a blue sling with green and white piping. The Resident was cradled in the sling (green is large for 154-264 pounds), and although the sling looked large, the Resident was not struggling or resisting during the transfer. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/15/18, revealed the Resident's weight was 97 pounds. During the observation, when asked how it was determined what size to use, the CNAs stated the night shift staff placed the slings in the rooms. Resident #16 Record review on 1/20-2/1/18 revealed Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. The Resident was transferred using a mechanical lift that hung from the ceiling. Observation on 2/1/18 at 8:19 am revealed sling with blue trim and multi-colored loops was placed on Resident #16's chair for use during transfer according to CNA #3, Resident #16 was sleeping so the transfer was postponed. During an interview on 2/1/18 at 8:19 am, LN #2 stated the smallest size sling available in the facility is size Medium. The LN stated the sling in the room was the wrong size for Resident #16 and stated I try to work with the CNAs to make the correct size selection. I think it should be documented in the care plan. Observation on 2/1/18 at 11:57 am revealed CNAs, attending to ADLs for Resident #16. CNA #3 stated to the LN #2 that the sling she had in the room was the smallest size available, adding he/she thought it was a size large. The sling had the same blue trim as the sling observed earlier in the day. The resident knees were bent due to contractures and had little movement potential when CNAs tried to loosen them up. During the lift process, in the blue trimmed sling on both yellow and green loop, Resident #16 buttocks were visibly hanging out of the opening at the bottom of the sling. The Resident's severe contracture bent both legs in a flexed position which hooked on then on edge of the sling and prevented the Resident from falling through the large gap at the bottom of the sling. Review of the sling size revealed the blue trimmed sling was an extra large and was intend for a weight range of 308-440 pounds. Review of the most recent MDS assessment, dated, revealed Resident #16's weight was 71 pounds. Resident #16 was transferred twice with this sling, once to the wheel chair to get weighed, and once to the Geri-chair to go out to the dining area. Review of the handbook for slings provided by hospital management on 2/1/18 at 12:30 PM revealed the sling with blue trim and multicolored loops was size Extra Large. According to sling sizing, located at www.arjohuntleigh.com, accessed 2/17/18, revealed Choosing the right sling size is important in order to achieve the highest possible patient comfort and safety. Each sling size has its own color, which is found on the binding of the sling . Choosing the right sling size; There are three basic components for a proper sling fit: 1. Patient height 2. Patient waist size (when applying the sling on the patient) 3. Patient thigh size (when applying the sling on the patient) In most cases only the height needs to be measured. For some patients also the waist and thighs might need to be measured. Other factors like the patients physical disabilities, weight distribution and general physique might need to be taken into consideration . Height Using the ArjoHuntleigh Measuring Tape: The patient can either be in a seated or laying position. Measure from the coccyx to the top of the head. The color level at the top of the head indicates the required size .After determining proper size of the sling using the height, apply the sling around the patient making sure the sling is centered on the spine. If the patient's body touches or falls outside the binding, change to a larger and wider sling. This will prevent skin abrasions and tears as well as minimize the risk of a patient falling or rolling out of the side of an undersized sling. Damaged Slings During an observation of the Arjo slings, located in the clean linen room, revealed several slings with worn holes in the fabric where the straps attached to the slings. During an interview on 2/1/18 at 6:30 am, CNA #6 stated the slings located in the room were ready for use. When asked about the damaged slings, the CNA stated the damaged slings should not be used. The CNA stated the facility used the canvas slings for showers instead of mesh. Record review on 1/30-2/1/18 revealed Resident #11 had a [DIAGNOSES REDACTED]. Observation in Resident 11's room on 2/1/17 at 6:40 am revealed a yellow trimmed sling located on the seat of the Resident's wheelchair. The sling had multiple frayed holes where the straps were attached. Washing Slings During an interview on 2/1/18 at 8:20 am, when asked how the Arjo slings were laundered, Housekeeping Staff (HS) #1 stated the slings were laundered with the sheets and towels. Observation of the laundry room washers with the HS revealed a sling in the washer mixed with white linen. When asked how it was determined what setting to use, the HS stated they pressed the button for 12, the heavily soiled wash with hot water and bleach. Review of the ArjoHuntleigh Maxi Sky 600 manual, Revised (MONTH) 2013, revealed The expected operational life for fabric slings and fabric stretchers is approximately two years from date of purchase. This life expectancy only applies if the slings and stretchers have been cleaned, maintained and inspected in accordance with the ArjoHuntleigh Sling Application Guide . Under General Instructions .Note: ArjoHuntleigh lifts are specifically designed for KWIKtrack (Trademark) rail systems, ArjoHuntleigh slings and accessories. Review of the available clip and/or loop slings and the color coded sizing revealed the looped gray and black sling with the extra buckle was not pictured or listed. Under Care and Maintenance the manual revealed Inspect all sling parts (attachments, fabric, stitch, areas, and strap) for signs of wear, discoloration, deterioration, or loose threads .before every use .clean sling as indicated on tag . Under Sling Laundering revealed NOTE: with regards to laundering, slings should not be classified as linen, but as an accessory to a patient transfer lifting and classified as a medical device. Slings should be cleaned and disinfected only in strict accordance with the manufacturers instructions. Inspection of several of the Arjo slings located throughout the facility revealed the washing instruction label was either missing or worn so as to be unreadable and several of the slings were damaged with frayed holes where the straps attached. During an interview on 2/1/18 at 3:45 pm, the Director of Nursing (DON) stated the damaged slings should not used for transferring the residents. When asked how the CNA staff were to know which size to use, the DON stated facility staff should follow the CNA Nutshell Manual. The DON was asked for information about the gray and black slings that were located in the facility linen. The Administrator and DON later stated they thought those slings may had come from the hospital. Neither was able to locate information about that particular sling size and to what purpose the buckle in the middle served. | 2020-09-01 |
| 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-Verbal sounds (e.g. crying, whining gasping, moaning, or groaning) B. Vocal complaints of pain (e.g. that hurts, ouch, stop) C. Facial expressions (e.g. grimaces, winces, wrinkled forehead, furrowed brow, cleaned teeth or jaw) D. Protective body movements or postures (e.g. bracing, guarding, rubbing, or massaging a body part/area, clutching or holding a body part during movement). Review of the MDS Pain Management revealed the Resident had received PRN (as needed) pain medication and non-medication interventions for pain. Review of the Resident #13's care plan titled Long Term Pain IP[NAME] (Plan of Care); updated 8/22/17, revealed the Resident's Outcome goals were Pain Level Maintained at Less than Moderate . and Recognition of Pain using Resident Pain/Tool Clinical Judgment to Provide Appropriate Intervention . The Interventions included Evaluate Effectiveness of Pharmacological Interventions .Provide Emotional Support to Alleviate Anxiety .Evaluate Effectiveness of Comfort Measures .Consult Physician if Pain Remains a 4 Post Intervention . The potential discomfort felt by the Resident during cares and transfers and [MEDICATION NAME] treatment had not been addressed. | 2020-09-01 |
| 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 restorative nursing an exercise programming. The DON and MDS RN/designee was educated on the need to keep MDS documents accurate. F657 - The MDS RN/Designee and the DON were educated using a nursing care plan textbook. F677 - All licensed nurses received education on proper technique on nail care. All nursing staff (Licensed and CNA) were educated on the need to provide personal hygiene care for all residents. Education included return demonstration. F679 - The Activity Coordinator received education from the Activity Consultant. The education included: Section F of the MDS, section F instructions from the RAI MDS 3.0, F248 Federal Regulations and interruptive guidelines and CMS Instructors Guide Book for Section F slide presentation. All Nursing Staff (Licensed and CNA) were educated on activities and documentation. Education includes a written test. F688 - All nursing staff (Licensed and CNA) were educated on the need to provide AROM/PROM for all residents. Education included return demonstration. F689 - The DON, MDS/designee and all Licensed Nurses were educated on the need to include sling size in care plans and in the care tracker resident profile. All Nursing staff (Licensed and CNA) were educated on using the overhead lift and all portable lifts. Education included sizing, use of the color coded straps, inspection of slings prior to use and a return demonstration of proper usage. F697 - All Nursing Staff (Licensed and CNA) were educated on the need to modify how they care for residents if they exhibit signs and symptoms of pain. Education included a written test. F741 - Staff were educated on the changes. The Behavior Committee provided any additional staff education needed for the identified residents. F840 - All nursing staff (Licensed and CNA) were educated on the need to provide AROM/PROM for all residents. Education included return demonstration. F842 - Licensed Staff were educated on the process to grant Surveyors access to EMR. Staff education included the need to help any Surveyor to navigate the RAVEN EMR. Record review on 3/27/2018 revealed no documentation/evidence of the aforementioned competencies completed by licensed nursing staff. During an interview on 3/28/18 at 9:45 am, the MDS nurse was asked to produce documentation demonstrating completion of the listed competencies. The nurse was unable to provide the documentation. | 2020-09-01 |
| 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 supervision (will aggravate) his agitation and he will strike out at staff when they try to redirect his exit seeking behavior or redirect him from entering Residents room uninvited. Resident #13 Record review on 1/31-2/1/18 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, CNA #s 2 and 3 assisted the Resident onto a gray and black sling and attached it to the overhead mechanical lift. After being lifted into the air, the Resident began to call out, wave both arms around, attempt to strike at staff, 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 10:30 am, CNA #3 stated We have to take care of them (residents) when they fight, by ourselves. Review of the most recent MDS quarterly assessment, dated 1/15/18 revealed the Resident had potential indicators of [MEDICAL CONDITION] that exhibited as hallucinations and delusions and had coded for behavior symptoms Physical behavioral symptoms directed towards others 1-3 days during the assessment period. Review of the Resident's care plan, revised 8/22/17, revealed under Long Term Psychosocial Well-Being IP[NAME] the care pan listed a goal Appropriate Social Interactions with Others. The interventions included Identify yourself, Role, and expectations .Encourage, Provide Positive Reinforcement Coping Skills .Develop Trusting Relationship with Resident .Monitor Changes on Resident Behavior . Review of the CORP-Messages Detail Report, utilized by CNAs to provide care to Resident #13 revealed, Needs Yupik translator .Provide a calm milieu (environment), when able too .Provide care with a smile, gentle voice, and reassurance .Establish and maintain a regular daily routine .Chart on Moods, Behaviors, and [MEDICAL CONDITION] every shift in CareTracker. There was no information how the CNAs were to respond if the Resident became physically aggressive with staff or resisted care. Resident #218 Record review on 1/31/18-2/1/18 revealed Resident #218 had [DIAGNOSES REDACTED]. Review of the Resident's care plan titled Long Term Psychosocial Well-being IP[NAME], updated 12/20/17, revealed the outcome To Have Appropriate Social Interactions With Others. The interventions included Encourage, Provide Positive Reinforcement in Coping Skills .Develop Trusting Relationship with (Resident #218) .Encourage Verbalization of Thoughts . The problem Behavioral Symptoms IP[NAME], updated 12/20/17, revealed the outcome (Resident #9) to have appropriate behavior when interacting with others . Interventions included Provide a Calm Milieu .Establish and Maintain a Regular Daily Routine .Allow (Resident) to Verbalize Feelings of Anxiety or Fear . During an interview on 2/1/18 at 8:20 am Licensed Nurse (LN) #7 stated the Resident was nervous about all the extra people on the unit. Observation on 2/1/18 from 8:20-8:40 am, Resident was sitting at the dining table picking at the skin on his/her face. There were 3 maintenance men working on the doors nearby. As the Resident sat with his/her untouched breakfast in front of him/her, the Resident motioned to the surveyor to sit on his/her walker seat, blocking the view of the maintenance men. The Resident #218 told the surveyor to follow him/her to the room and wanted the surveyor to sit on the bed while the Resident napped. During the observation, none of the facility staff approached the Resident or addressed the picking behavior. Review of a facility provided document titled Dementia Training,, revealed 13 of the facility's CNAs, had not yet received dementia education and/or training. During a second interview on 2/2/18 at 8:23 am, the DON stated the 13 CNAs had not received dementia education and/or training. | 2020-09-01 |
| 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 | 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 | 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 cook who replied he/she was just doing his/her job. Resident #16's family member stated they had been coming in more at mealtimes to encourage him/her to eat because Resident #16 doesn't want to eat. The family member tasted the food and confirmed that it has been salty and/or over seasoned. During an interview on 1/31/18 at 10:30 am Resident #16's Power of Attorney stated he/she was concerned about Resident #16 receiving pureed food. The POA stated he/she did not recall being notified of the pureed diet. The POA stated he/she didn't understand why because Resident #16 had all of his/her teeth. The POA stated Resident #16 stated he/she didn't like the food. Review of the medical record on 1/30/18 at 12:50 PM revealed that Resident #16 has experienced extreme weight loss of 12.5% between 8/9/2017 to 1/24/2018. During an interview on 1/29/18 at 12:58 PM Licensed Nurse (LN) #10 stated if a Resident indicated a dislike for food, it would be communicated to the nurse, who would pass on the information to the dietician (who is on site once per month) and the Interdisciplinary team (IDT) would decide if the food specified would be removed or remain on the Resident's diet card. During an interview on 2/1/18 at 12:03 pm, the Dietitian stated she approves all the meal plans. When notified of the Resident's concerns, the Dietitian stated the facility tried to incorporate Native foods using a regional cook book. The Dietitian stated she was unaware of any residents who are complaining about the food, adding you can't please everyone. When asked about the long process for adding personal likes/ and dislikes to residents' diet profiles. The Dietitian stated the nurses could just change it in the EMR themselves and/or notify her of the change. The Dietitian stated she was aware of the movement towards serving traditional native foods in western Alaska. Review of the facility menu for week three (the current week), revealed the facility served 1 Native Alaskan food item on 4 days for lunch and 1 Native Alaskan food item on 4 days during dinner, during the 7 day menu. The alternate food choices offered 3 native food items that were not on varying days. Review of Resident #15's EMR on 1/31/18, revealed that in an IDT meeting, that included the Dietician, Resident #15's daughter voiced concerns about the spiciness of the rood. Dietitian responded that Resident #15's weight was stable at that time. Review of Resident #12's EMR on 1/31/18, revealed the Resident had requested frozen fish with seal oil and more goose soup at his/her last IDT meeting. The Dietician had been present. Review of a skilled nursing note, dated 1/28/18, revealed Resident #12 .became upset .has asked for more Native Alaskan foods to be on the menu . | 2020-09-01 |
| 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 before taking a bite. Observation of a test tray on 1/30/18 at 12:30 pm revealed the plate contained roast turkey with gravy, mashed potatoes and brown gravy, and cooked broccoli that was an olive color. The alternate meat was Salisbury steak with gravy. The plate had minimal variation in the color scheme, which was mainly light brown. | 2020-09-01 |
| 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 | 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 walked in his/her room with support from 1 staff and had walked in the corridor 1 time, during the 7 day assessment window. Review of the CORP-Messages Detail Report, utilized by the CNAs to provide care, revealed (Resident #14) may use the exercise equipment in the MDS office .is on short list for Physical Therapy. If they have a cancellation they will call the Charge Nurse and see if (Resident #14) is available for PT. Review of the Resident's exercise program, undated, revealed Resident #14 was to walk the length of the parallel bars .free range pulleys-3 minutes. 3) Transfer to Nustep (a sit down elliptical type machine) using Hoyer lift. Review of the Resident's care plan Long Term ADL Function Rehab IP[NAME], revised 12/5/18, revealed the interventions: (Resident) uses a wheelchair for ambulation (he/she) cannot bear weight .is on the short list for PT @ the Hospital. Resident #15 During an interview on 1/30/18 at 3:11 pm, Resident #15's family member stated the Resident needed PT for a broken hip. Record review on 1/31-2/1/18 revealed the Resident was admitted to the facility with medical [DIAGNOSES REDACTED]. (neurological disease that can cause immobility and/or repetitive movement). After a recent [MEDICAL CONDITION], the Resident had surgical repair and therapy. Review of the Resident's IP[NAME] dated 12/22/17, revealed no specific problems, interventions or goals aimed at maintaining or improving ROM or mobility. Review of the Resident's Individualized Exercise Programs to be Used in Therapy Room, for Resident #15, dated 6/7/17, revealed the Resident was to walk the length of the parallel bars (located in the PT room) 3 times and do free range pulley exercises for 1 minute. The handwritten plan, developed by PT had not been implemented, or reevaluated for effectivnes. Resident #16 Further record review revealed the Resident was admitted to the facility with medical [DIAGNOSES REDACTED]. During an interview on 1/29/18 at 4:22 pm, the family member stated Resident #16 was admitted to the facility after surgical repair of a [MEDICAL CONDITION]. The Resident's family member stated the Resident used to walk prior to the fracture. The family member stated the Resident needed PT to get better. The family member stated he/she had been told by the IDT that he/she would need to call the hospital and arrange an appointment and transportation for the Resident to receive PT as PT is not available in the facility. During an interview with the MDS Nurse on 1/30/18 at 12:37 pm he/she stated that there were not enough PT services in the community to meet the Residents' needs. She stated new appointments were months out and that the facility had arranged to fill no show appointments for Residents who really need it. If a PT patient, no showed for an appointment, they would call the facility to see if a Resident could come over and be seen. During an interview on 1/31/18 at 10:28 am, Resident #16's power of attorney (POA) revealed the Resident was admitted to the facility after sustaining a [MEDICAL CONDITION] that required surgery where pins were placed to repair the fracture. Based on an increased level of care required, the assisted living home the resident had previously resided was unable to provide the level of care needed. The Resident consequently was admitted to the LTC facility with the understanding he/she would receive interventions to improve mobility and/or prevent further decline. The POA stated he/she was worried about the Resident's decline. Review of the Resident's IP[NAME], dated 5/12/18, revealed Resident #16 had the problem Alteration of Physical Mobility. No interventions or goals aimed at maintaining or improving functional ability and/or ROM. Review of the Resident's Individualized Exercise Programs to be Used in Therapy Room, developed by PT, revealed Resident's individualized program and not been implemented by the facility and/or reassessed by PT. During an interview on 1/31/18 at 3:25 pm, when asked how they knew what exercises to do for each Resident, CNA #s 2 and 3 stated they just look in CareTracker or just do it. Both CNAs stated they do at least 15 minutes then document how the Resident tolerated it During an interview on 2/1/18 at 9:35 am, when asked what exercises or completed for each Resident, CNA #12 stated it's mostly up to the CNAs and we try to incorporate it into daily stuff. When asked if they had received any instruction from Physical Therapy (PT) staff, the CAN stated We don't have PT. During an interview on 2/1/18 ay 6:00 pm, LN #2 stated Physical Therapy staff only came in to trim some of the residents toenails. On 1/31/18 at 4:40 pm, the survey team attempted to call the Physical Therapist with the phone number provided by the facility. Although a message was left there was no return call prior to exit on 2/2/18. . | 2020-09-01 |
| 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 the CNA care tracker and the MDS program were web based and the surveyors did not have access to that program yet. The Administrator stated the Yukon Kuskokwim Health Corporation (YKHC) was in the process of making a decision about whether to grant the survey team access or not. On 1/30/18 at 2:20 pm the survey team continued to have difficulty accessing the EMR records. On 1/30/18 at 3:25 pm, 2 complete days after initiating the survey, the Administrator stated the survey team had access to the EMR in its entirety. Review of the YKHC policy, Notice of Privacy Practices revealed Health and Safety Oversight-Information may be used or disclosed to a health oversight agency when required by law. These oversight activities included audits, investigations, medical licensure, etc . . | 2020-09-01 |
| 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 REDACTED] was published in (YEAR) by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In (YEAR), the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiologic considerations for healthcare facilities are described in this toolkit. Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. TB Testing Record review of the employee health files on 2/2/18 revealed two staff had not received an annual [MEDICAL CONDITION] (TB) test. Specifically, the Dentist was due for his/her TB test on 8/31/17 and Licensed Nurse #5 was due for his/her TB test on 12/8/17. During an interview on 2/2/18 the facility's Administrator stated these should have been done on an annual basis. | 2020-09-01 |
| 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 three sections of screen, would not stay locked in position. Every time the section folded in, Resident #2 was fully exposed to Resident #6, in the other bed. Resident #13 Record review on 1/30/18 revealed Resident #13 was admitted to the facility with medical [DIAGNOSES REDACTED]. Observation during care on 1/29/18 at 10:30 am, CNA #s 2 and 3 provided personal care to Resident #13. Both CNA's positioned the privacy screen so it was blocking the view from the door. The Resident was exposed to his/her roommate's side of the room (Resident #3). Review of the facility's admission packet, received from the facility on 1/31/18, revealed the facility's Residents Rights information included: Is treated with consideration, respect and full recognition of the resident's dignity . including privacy and confidentiality in treatment and care for the resident's personal needs. | 2020-09-01 |
| 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 | 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 have addressed it with the CNA because staff were expected to maintain the Resident's dignity. During an interview on 2/28/20 at 1:27 pm, the Director of Nursing (DON) stated that prior to transporting the resident from the bedroom to the shower, staff should have checked to ensure that residents were completely covered by the linens. LNs should have overseen the tasks to ensure resident dignity was maintained. Gait Belt Resident #4 During an observation on 2/24/20 at 2:04 pm of the 300 unit common area revealed Resident #4 had their gait belts wrapped around the back of their WC with their names written in black, visible to people on the unit. Resident #4 was admitted to the facility with a [DIAGNOSES REDACTED]. The Resident used a WC for mobility. Resident #6 During an observation on 2/24/20 at 2:04 pm of the 300 unit common area revealed Resident #6 had their gait belts wrapped around the back of their WC with their names written in black, visible to people on the unit. Record review on 2/24-28/20 revealed Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 2/25/20 at 3:39 pm, Resident #6 was sitting in his/her wheelchair in the dining room. The gait belt was wrapped around the back of the Resident's wheelchair. During an observation on 2/26/20 at 11:02 am, Resident #6 was sitting in his/her wheelchair in the dining room with two other Residents eating breakfast. The gait belt was wrapped around the back of the Resident's wheelchair. During an interview on 2/28/20 at 3:09 pm, LN #2 stated that there was no standard practice for the storage of the gait belts. LN #2 further stated that the staff put the gait belts on the back of the Resident's wheelchairs to have them handy when they are needed. Resident #7 During an observation on 2/24/20 at 2:04 pm of the 300 unit common area revealed Resident #7 had their gait belts wrapped around the back of their WC with their names written in black, visible to people on the unit. Record review on 2/24-28/20 revealed Resident #7 was admitted to the facility with a [DIAGNOSES REDACTED]. The blood collection can be within the brain tissue or underneath the skull, pressing on the brain.) During an observation on 2/25/20 at 9:12 am, Resident #7 sitting in his/her WC at the dining table with his/her gait belt wrapped around the back of the WC with his/her name written in black and visible to read. During an observation on 2/26/20 at 9:54 am Resident #7 was sitting in his/her WC with a gait belt attached around back of WC with full name of Resident # 7 written in black and visible to those who walk by. During an interview on 2/26/20 at 9:54 am, Resident #7's family was sitting at a table in dining area with the Resident. When asked about the belt being on Resident #7's WC back, the family member stated he/she did not know why that was on the chair. The family member further stated they have seen other residents with the belt on their WC's with names visibly written on them. Resident #12 During an observation on 2/24/20 at 2:04 pm of the 300 unit common area revealed Resident #12 had their gait belts wrapped around the back of their WC with their names written in black, visible to people on the unit. Record review on 2/24-28/20 revealed Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 2/26/20 at 11:04 am, Resident #12 was sitting in a recliner in the dayroom. The Resident's wheeled walker was nearby, with his/her gait belt rolled up and placed on the seat area of the walker. During an observation on 2/27/20 at 11:16 am, Resident #12 was seated at the dining room table eating breakfast. The Resident's wheeled walker was nearby, with his/her gait belt draped over the walker. During an observation on 2/27/20 at 1:25 pm, Resident #12 was seated at the dining room table eating lunch. The Resident's wheeled walker was nearby, with his/her gait belt draped over the walker. During an interview on 2/28/20 at 12:11 pm, LN #2 stated that the Resident's gait belt was placed on his/her walker for easy access by staff. LN #2 further stated that he/she would not have to go look for the gait belt when it was needed by the Resident. Resident #13 During an observation on 2/24/20 at 2:04 pm of the 300 unit common area revealed Resident #13 had their gait belts wrapped around the back of their WC with their names written in black, visible to people on the unit. Record review on 2/24-28/20 revealed Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 2/27/20 at 3:06 pm Resident #13 was sitting at the dining table with his/her gait belt wrapped around the back of the WC he/she was sitting in. During an observation on 2/28/20 at 11:09 am, Resident #13 was transferred from his/her WC to a recliner using their gait belt by CNA's #7 and #8. CNA #8 removed the gait belt from the Residents abdomen and placed it on the back of the Resident's WC. Resident #16 During an observation on 2/24/20 at 2:04 pm of the 300 unit common area revealed Resident #16 had their gait belts wrapped around the back of their WC with their names written in black, visible to people on the unit. Record review on 2/24-28/20 revealed Resident #16 was admitted to the facility with [DIAGNOSES REDACTED].) A continuous observation on 2/28/20 from 10:39-11:09 am, revealed Resident #16 sitting in his/her WC by the dining table with his/her gait belt wrapped around the back of the WC with the Resident's first and last name was written on it in black and visible to all on the unit. Resident #16 was moved to a recliner from the WC by CNA #7. Resident #16's gait belt remained on the back of his/her WC with their name visible throughout the transfer by the CNA. The WC was then placed next to the TV with the gait belt remaining on the WC. During an interview on 2/28/20 at 11:30 am, CNA #8, when asked about use of the Residents' gait belts, stated when they were done using the belt they were to leave them on the back of the WC. During an interview on 2/28/20 at 12:00pm LN #1 was asked about leaving the gait belts with/without residents' names on the residents WC or walkers, LN#1 replied they were probably left there for the staff to use and that was a dignity issue especially those having the names visible on them. Review of the facility policy entitled, Resident's Rights and Responsibilities, last reviewed 2/2/2020 revealed, I. POLICY: It is the policy of the [ENTITY] to respect the rights of individuals served to receive the utmost care within its programs, within its capability, mission, and applicable laws and regulations, and to respect the resident's ability to perform his/her responsibilities. II. PURPOSE: To safeguard each resident's rights and dignity while receiving treatment and to support the resident's recognition and exercise of his/her ability to act responsibly. | 2020-09-01 |
| 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 | 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) stated the only rights information provided to Residents was the Ombudsman pamphlet. The SW further stated that he/she had not provided any additional follow up information on rights, written or verbal, or in a second language. The SW stated he/she was unaware the rights were not posted on the units. During an interview on 2/28/20 at 1:20 pm, the Director of Nursing (DON) stated there were no additional efforts to inform Residents, guardians, or their families of their rights, orally or in writing, other than the Ombudsman pamphlet. Review of facility's procedure entitled, on Resident's Rights and Responsibilities, last reviewed 2/2/20 revealed an abbreviated list of Resident Rights. The procedure did not address how the Residents receive information on their rights at admission or an ongoing process of communicating the rights and responsibilities to Residents, guardians, or their families. Review of the facility's policy entitled, Resident's Rights and Responsibilities, last reviewed 2/2/20 revealed no information in the policy on when or how Resident rights information would be communicated to Residents, guardians, or their families. Review of the facility's policy entitled, LTC Grievance Policy, effective date 10/1/13 revealed, .III. PROCEDURE: A. The Social Worker will assure that residents or legal representative(s) receive a review of their rights and responsibilities on admission. | 2020-09-01 |
| 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 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 assure that residents or legal representative(s) receive a review of their rights and responsibilities on admission. B. The Activities Director/Designee will complete a grievance form when a global issue is raised at a Resident Council Meeting. C. The Social Worker or ANY staff member will assist concerned resident(s), legal representative, other family member(s), or advocate that have issues or concerns to complete a Grievance/Concern Form. (Note- if the person with the concern does not to complete a Grievance Form, any format will be accepted.) D. The Social Worker will log all concerns/grievances receive onto the facility grievance log. E. The concern/grievance should be reviewed and assigned to the appropriate department head at the facility daily stand up meeting or as appropriate. Review of facility procedure entitled, . on Resident's Rights and Responsibilities, last reviewed 2/2/20, revealed an abbreviated list of Resident Rights. The procedure did not include the GO name, the grievance process, or contact information for external agencies. Review of the facility policy entitled, Resident's Rights and Responsibilities, last reviewed 2/2/20 revealed, I. POLICY: It is the policy of the [ENTITY] to respect the rights of individuals served to receive the utmost care within its programs, within its capability, mission, and applicable laws and regulations, and to respect the resident's ability to perform his/her responsibilities. II. PURPOSE: To safeguard each resident's rights and dignity while receiving treatment and to support the resident's recognition and exercise of his/her ability to act responsibly. | 2020-09-01 |
| 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 through Work Hub for repair. LN #1 and a Surveyor entered Resident #12's room. LN #1 observed the wall damage and stated that yes, the wall damage should have been reported. LN #1 further stated that he/she would put in a work order because the wall was in need of repair. During an observation and simultaneous interview on 2/28/20 at 10:42 am, the Administrator (AD) observed Resident #12's room and stated she was not aware of the damage to the wall until the work order was placed. The AD further stated that the damage to the wall needed to be fixed. | 2020-09-01 |
| 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 assure that residents or legal representative(s) receive a review of their rights and responsibilities on admission. B. The Activities Director/Designee will complete a grievance form when a global issue is raised at a Resident Council Meeting. C. The Social Worker or ANY staff member will assist concerned resident(s), legal representative, other family member(s), or advocate that have issues or concerns to complete a Grievance/Concern Form. (Note- if the person with the concern does not to complete a Grievance Form, any format will be accepted.) D. The Social Worker will log all concerns/grievances receive onto the facility grievance log. E. The concern/grievance should be reviewed and assigned to the appropriate department head at the facility daily stand up meeting or as appropriate. F. The assigned Department Head/Designee investigates the concern and takes action to correct the issue within 48 hours. [AGE] hours if on a Friday evening or Saturday. G. The Department Head/Designee will complete the grievance form to resolution and returns the completed for to the Social Service Director/Designee. H. Grievances must be completed with appropriate actions as well, within 5 days from submission. I. The Social Worker/Department Head or Designee shall notify the person with the concern of the resolution. If it is not to their satisfaction they may be given the phone number to the local Ombudsman as applicable. J. The Social Worker/Designee will keep a running log of concerns voiced and their resolution as well a copy of the completed grievance forms . | 2020-09-01 |
| 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 | 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 dizziness, [MEDICAL CONDITION], palpitations, prolonged hiccups, and chest pain. If noted, monitor vital signs while symptomatic and notify physician of potential pacemaker failure . Resident #13 Record review on 2/24-28/20 revealed Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, a quarterly assessment dated [DATE], revealed Resident #13 was coded as having had dementia. During an interview on 2/25/20 at 2:40 pm, Licensed Nurse (LN) #1 stated Resident #13 had the neurostimulator when he/she came into the facility with for tremors from [MEDICAL CONDITION]. During an interview on 2/27/20 at 12:04 pm, the DON stated Resident #13 had a stimulator implanted in his/her head for his/her [MEDICAL CONDITION] tremors. Review of Resident #13's Care Plan, last revised 1/8/20, and revealed no problem or approaches related to the neurostimulator. During an interview on 2/27/20 at 3:49 pm, the DON stated the neurostimulator was not in Resident #13 care plan and it needed to be in the care plan. | 2020-09-01 |
| 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 2/24/20 at 2:08 pm, revealed Resident #7 self-propelled himself/herself in the WC on unit and voiced the desire to go home and be with his/her family to staff on the unit. Continuous observation on 2/25/20 from 8:00 -10:21 am revealed the Resident self-propelling his/her WC on unit from his/her room to a table for a morning meal, throughout the unit. Resident # 7 stated to the Activities Coordinator (AC) he/she wanted to go home. Resident # 7 further stated to the AC he/she was going to go to Anchorage, come back to the facility and then he/she wanted to go home. Record review on 2/26/20 at 2:28 pm of Resident #7's care plan last updated 12/30/19 and 1/20/20, revealed elopement was in the Resident's care plan. The care plan stated, when the resident wants to go off the unit, staff may take him/her off the unit and when staff were not able to do this and the Resident wanted to leave the unit/facility to redirect the Resident to another activity or topic. The care plan further stated to arrange to take the resident off the unit with staff. During an interview on 2/28/20 at 11:16am, Licensed Nurse (LN) #1 stated he/she was working the day Resident # 7 got out of the facility. LN #1 stated the facility had a lot of people coming in/out of the unit. The LN further stated Resident # 7 was exit seeking often that day. The Resident had been on the phone with his/her child who was in town and wanted to leave the facility and go see the son/daughter. The facility had an Audiologist who was at the facility seeing residents during that day. This staff had a security badge to let themselves into/out of the locked units. When the Audiologist left the unit using her badge to release the locked door, Resident # 7 followed the staff through the door just as the door was about to close. The Resident next followed an Environmental Services (EVS) staff who was exiting the building as he/she left the front double doors of the facility to get completely outside. In the gathering room the Activity Coordinator (AC) whom was setting the room for an activity saw the Resident outside the facility, called for help and exited the building to assist the Resident in returning to the building as the EVS staff member was returning to the building as he/she had noticed the resident outside the facility came back to bring the resident into the facility. Resident #7 was brought back into the facility safely. He/she had been out of the facility for a total of 2 minutes. Review of the facility investigation, completed 2/5/20 at 9:45 am revealed on 1/17/20 at 3:30 pm, The nurse on the unit swiped her badge to allow the visiting audiologist off of the unit to leave. This was between 1510-1520 because she received a phone call at 1505 taken by the nurse and given to the audiologist, and then finished up her tasks and left. After swiping her badge to allow the audiologist out, the nurse went to assist another resident in (his/her) room. The door (took) a total of 30 seconds to engage the lock after badging out and we believe that (Resident #7) exited in this manner. He/she is able to self-propel his/her wheelchair. At 1524, (Resident #7) can be seen via lobby camera, exiting the building following out (Staff name), EVS manager. (EVS manager) realized that (Resident #7) was following him and immediately ran back into the facility to get nursing staff. During this time (Activity Coordinator (AC) name), saw (Resident #7) through the window and ran outside to redirect him/her back into the building. (Resident #7) was assisted back into the building within 2 minutes of his/her exit. When asked why he/she was leaving, (Resident # 7) stated that he/she wanted to catch a cab to AC (local store) to see his/her (adult child) to give money to his/her (adult child) who he/she had just talked with on the phone and watch the sled dog races. (Resident #7) continues to insist that he/she had to go to AC to see his/her (adult child)upon his/her return, so CNA accompanied him/her on a trip to AC and his/her son was there waiting for his/her (parent) to give him/her money. The (adult child), CNA and (Resident #7) returned to LTC later that afternoon .Upon return into the facility after elopement, there were no injuries noted and there has been no injury or issues noted since . Further review of the facility investigation revealed, Risk Mitigation Poll & Recommendation, Staff to ensure that the lock on the doors re-engages after they badge out and no residents are nearby the vicinity of the doors that could elope. For (Resident #7) specifically, staff to have eyes (on) the common area at all times during shift and provide as much activity to (Resident #7) and all residents as possible. (Resident #7) care plans reviewed and elopement risk plan initiated. Door locking times dropped from 30 seconds to 15 seconds . Review of an email on 2/28/20 provided by the facility dated January 27, 2020 at 2:13 pm, revealed .Please change the door timer to 15 seconds on the wings . The facility had requested the automatic door shutting mechanism be lowered from 30 seconds to 15 seconds this is in the process of this being done. When staff badge out of the unit they were now watching to ensure the door was securely closed and residents were on the unit and not coming out of the unit unsupervised. | 2020-09-01 |
| 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 | 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 Pharmacist further added, he/she was not sure how it just dropped off the MAR, user error? The Pharmacist stated the medication had been still available in bubble pack in the medication cart. During a phone interview on 2/28/20 at 2:06 pm, when asked what had changed to prevent this from re-occurring, the Pharmacist stated he/she started entering a longer date so it does not drop off the MAR, and had sent a memo out to the Director of Nursing (DON) and nursing staff to investigate anytime they had a bubble pack with a medication that is not showing up on the MAR. The Pharmacist further stated the staff were to make sure the physician had actually discontinued the medication. During an interview with the DON on 2/28/20 at 3:00 pm, when asked about the missed doses of Quetiapine for Resident #13, the DON replied, she thought the missed doses were due to the timing with different staff working, as it occurred on a weekend. During a second interview with the DON on 2/28/20 at 3:37 pm, when asked if the DON had received a memo from the Pharmacist regarding notification process for preventing missed doses, she stated, No memo was received, but the Pharmacist did speak with each nurse after the incident. Review on 2/28/20 of the facility's policy LTC (Long Term Care) - Stop Orders, dated 03/01/18, revealed, When implementing the Stop Order for routine medications, the prescriber is notified before the administration of the last dose to allow the alternative of continuing the medication without interruption of the medication regimen . Certain medications should not be discontinued before consulting with provider and determining a taper schedule. Review of [MEDICATION NAME] (Quetiapine): Package insert and Label information, Dated 2/28/20, from https://druginserts.com/lib/rx/meds/[MEDICATION NAME]-13/, revealed on page 7 Never stop an antidepressant medicine without first talking to your healthcare provider. Stopping an antidepressant medicine suddenly can cause other symptoms. | 2020-09-01 |
| 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, pieces and partially used were undated; Biscuits in a Ziplock bag were not sealed or dated; Brownies in plastic wrap were undated; Double chocolate cake in an opened box, unsealed with no date opened or use by date; and Berries in an unsealed, unlabeled Ziplock bag. Unit Refrigerators During an observation on 2/24/20 at 2:47 pm, of the 200 wing refrigerator revealed packages of smoked salmon, opened, undated, and unlabeled in the drawer. During an interview on 2/24/20 at 2:49 pm, Licensed Nurse (LN) #2 stated that all the food in the unit refrigerator belonged to the Residents and further stated that all food items should have been labeled with the Residents name, date opened, and in sealed packages. During on observation on 2/24/20 at 3:02 pm of the 300 wing refrigerator revealed the following: 1 carton of nectar thick cranberry cocktail with an expiration date of 2/20/20; 1 carton of nectar thick orange juice with an expiration date of 2/2/20; 2 peach yogurt cups with the expiration date of [DATE]; 2 packages of smoked salmon, opened, undated, and unlabeled in the drawer. During an interview on 2/24/20 at 3:10 pm, Certified Nurse Assistant (CNA) #5 stated nurses were responsible for the items in the unit refrigerator. During an interview on 2/24/20 at 3:11 pm, LN #3 stated that the kitchen staff were responsible for the unit refrigerators and they were checked daily by the kitchen staff. During an interview on 2/25/20 at 11:30 am, DA #1 stated the DAs were responsible for weekly refrigerator checks on the units but the DA who was responsible to complete the checks was no longer employed at the facility. Review on 2/26/20 at 1:00 pm of the Quality Assurance Performance Improvement plan meeting minutes, dated 10/17/19, revealed that 2 new employees were added to the kitchen staff, bringing the kitchen to full staff. During an interview on 2/27/20 at 2:12 pm, the DM stated that the backup cook quit because he/she had to work all meals for the entire kitchen because scheduled DAs did not come to work. The cook had to make all meals, serve, clean, and wash dishes according to standards. The DM further stated as a result of the insufficient staffing, other kitchen tasks were incomplete. The DM stated that retention had been a big issue. He/she spent significant time and energy training new staff, but staff did not stay long or were sometimes not dependable employees. During an interview on 2/28/20 at 1:04 pm, the Director of Nursing (DON) stated that it was an ongoing problem to keep the kitchen sufficiently staffed. The DM covered all the shifts/meals and was responsible for all the duties when assistant staff were not available. Review of the facility's policy entitled, LTC_Safe Food Procurement, Handling, and Storage, last reviewed 11/7/18 revealed, .All YKHC Food Service Workers (FSW) and Cooks at YKHC will follow Policies, Procedures, and Guidance of the State of Alaska Food Safety & Sanitation Program, the United States Department of Agriculture (USDA), the U.S. Food and Drug Administration (FDA), and the Centers for Disease Control and Prevention (CDC). Review of the USDA guidelines for food storage stated, .use ready-to-eat foods as soon as possible, refrigerated ready-to-eat foods such as luncheon meats should be used as soon as possible. The longer they're stored in the refrigerator, the more chance Listeria, a bacterium that causes foodborne illness, can grow .store refrigerated foods in covered containers or sealed storage bags .Check expiration dates. A use by date means that the manufacturer recommends using the product by this date for the best flavor or quality . | 2020-09-01 |
| 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, 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, pieces and partially used were undated; Biscuits in a Ziplock bag were not sealed or dated; Brownies in plastic wrap were undated; Double chocolate cake in an opened box, unsealed with no date opened or use by date; and Berries in an unsealed, unlabeled Ziplock bag. Unit Refrigerators During an observation on 2/24/20 at 2:47 pm, of the 200 wing refrigerator revealed packages of smoked salmon, opened, undated, and unlabeled in the drawer. During an interview on 2/24/20 at 2:49 pm, Licensed Nurse (LN) #2 stated that all the food in the unit refrigerator belonged to the Residents and further stated that all food items should have been labeled with the Residents name, date opened, and in sealed packages. During on observation on 2/24/20 at 3:02 pm of the 300 wing refrigerator revealed the following: 1 carton of nectar thick cranberry cocktail with an expiration date of 2/20/20; 1 carton of nectar thick orange juice with an expiration date of 2/2/20; 2 peach yogurt cups with the expiration date of [DATE]; 2 packages of smoked salmon, opened, undated, and unlabeled in the drawer. During an interview on 2/24/20 at 3:10 pm, Certified Nurse Assistant (CNA) #5 stated nurses were responsible for the items in the unit refrigerator. During an interview on 2/24/20 at 3:11 pm, LN #3 stated that the kitchen staff were responsible for the unit refrigerators and they were checked daily by the kitchen staff. During an interview on 2/25/20 at 11:30 am, DA #1 stated the DAs were responsible for weekly refrigerator checks on the units but the DA who was responsible to complete the checks was no longer employed at the facility. Review on 2/26/20 at 1:00 pm of the Quality Assurance Performance Improvement plan meeting minutes, dated 10/17/19, revealed that 2 new employees were added to the kitchen staff, bringing the kitchen to full staff. During an interview on 2/27/20 at 2:12 pm, the DM stated that the backup cook quit because he/she had to work all meals for the entire kitchen because scheduled DAs did not come to work. The cook had to make all meals, serve, clean, and wash dishes according to standards. The DM further stated as a result of the insufficient staffing, other kitchen tasks were incomplete. The DM stated that retention had been a big issue. He/she spent significant time and energy training new staff, but staff did not stay long or were sometimes not dependable employees. During an interview on 2/28/20 at 1:04 pm, the Director of Nursing (DON) stated that it was an ongoing problem to keep the kitchen sufficiently staffed. The DM covered all the shifts/meals and was responsible for all the duties when assistant staff were not available. Review of the facility's policy entitled, LTC_Safe Food Procurement, Handling, and Storage, last reviewed 11/7/18 revealed, .All YKHC Food Service Workers (FSW) and Cooks at YKHC will follow Policies, Procedures, and Guidance of the State of Alaska Food Safety & Sanitation Program, the United States Department of Agriculture (USDA), the U.S. Food and Drug Administration (FDA), and the Centers for Disease Control and Prevention (CDC). Review of the USDA guidelines for food storage stated, .use ready-to-eat foods as soon as possible, refrigerated ready-to-eat foods such as luncheon meats should be used as soon as possible. The longer they're stored in the refrigerator, the more chance Listeria, a bacterium that causes foodborne illness, can grow .store refrigerated foods in covered containers or sealed storage bags .Check expiration dates. A use by date means that the manufacturer recommends using the product by this date for the best flavor or quality . | 2020-09-01 |
| 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 | 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, revealed the CNA was hired on 1[DATE]. Further review of the CNA's education file revealed no dementia training. During an interview on 2/27/20 at 5:15 pm, the DON stated the facility was deficient in dementia training for the CNAs. A review on 2/28/20 at 9:43 am, of a facility provided email dated 11/30/19 at 6:19 pm, revealed the DON emailed the facility's Licensed Nurses (LNs) and CNAs offering the required dementia training. A review on 2/28/20 at 9:43 am, of a facility provided email dated [DATE] at 1:53 pm, revealed the DON contacted CNA #2 and requested the dementia training be completed by 1/10/19. A review on 2/28/20 at 9:43 am, of a facility provided email dated 2/5/20 at 3:08 pm, revealed the DON contacted CNA #2 and CNA #6 and requested staff attend in person dementia trainings. During an interview on 2/28/20 at 2:18 pm, The DON stated that some of the contract staff have not yet completed the required dementia training. | 2020-09-01 |
| 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 observation on 11/6/18 at 8:26 pm, CNA #5 was observed placing a clothing protector on Resident #16 without asking. During an observation on 11/6/18 at 9:02 am, CNA #5 placed a clothing protector on Resident #5 without asking. During an observation on 11/8/18 at 8:24 am, LN #3 was observed placing a clothing protector on Resident #17 without asking. During an observation on 11/8/18 at 8:35 am, CNA #7 was observed placing a clothing protector on Resident #12 without asking. Provide Feeding Assistance in a Dignified Manner During an observation on 11/5/18 from 5:24 pm - 5:40 pm, revealed CNA #1 occasionally using Resident #12's clothing protector to wipe the Resident's mouth. During an observation on 11/5/18 at 5:36 pm, Resident #15 was having difficulty eating his/her roll. CNA #5 picked the roll up off the Resident's plate and tore it into pieces without asking. Observation on 11/7/18 at 12:30 pm, revealed LN #2 spoon fed Resident #12. LN #2 wiped the Resident's mouth with the spoon immediately after spooning food into his/her mouth for a total of 22 times during the meal. LN #2 did not use a napkin to wipe the Resident's mouth. Inquire Prior to Ending a Meal During an observation on 11/6/18 at 9:35 am, CNA #3 was observed to remove a clothing protector from Resident #11 and move him/her away from breakfast without asking the Resident if he/she was done eating. The Resident had only eaten about 5% of the meal, the rest of the food was untouched. During an interview on 11/9/18 at 9:52 am, the Director of Nurses (DON) stated the clothing protectors should not be placed on Residents without asking cognitive Residents permission or explaining to less cognitive Residents that they are placing a clothing protector over the Residents clothing. The DON further stated a clothing protector and spoon should not have been used as a napkin. Exercise Rights as a Citizen During an interview on 11/7/18 at 3:00 pm, the Activities Coordinator (AC) stated he transported Resident #s 15 and 17 to the voting location but was told the Residents were not registered for the [NAME]el district and were unable to vote. He further stated he was unaware of a facility policy regarding Resident voting. During an interview on 11/7/18 at 3:15 pm, the Social Worker stated all Residents except Resident #5 had been registered for the [NAME]el district last year and they had voted in past elections. She further stated she did not have a copy of the Resident's voter registration. During an interview on 11/7/18 at 3:43 pm, the Interim Administrator stated the AC had told her the Residents did not have their identification with them and that was why they could not vote. Review of the facility policy LTC Voting Policy dated 10/1/13, revealed it is the center's policy that each resident has the freedom to exercise their right to vote .[NAME] the activity Coordinator is responsible for ensuring resident voting in local, regional, state and national elections .E. The Activity Coordinator will conduct voter registration annually in the center for those residents who wish to register to vote. | 2020-09-01 |
| 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 interview on 11/7/18 at 9:00 am, the SW stated Resident #10 did not have an advance directive on file. She further stated there is no documentation that the Resident was offered assistance in making an advance directive. Resident #12 Record review on 11/5-9/18 revealed Resident # 12 was admitted with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. During an interview on 11/6/18 at 3:15 pm, the SW stated advanced directives are done in the hospital before admission to the Elder's Home long term care. She further stated the Residents or their Representatives are not asked if they would like assistance to complete an advanced directive since it should have been done in the hospital. The SW further stated the form in the Yukon Kuskokwim Elders Home admission packet only asks if the Resident has an advanced directive and does not ask if the Resident would like assistance to formulate an advanced directive. | 2020-09-01 |
| 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 | 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 stand and moved out of his/her wheel chair to a chair at the table. LN #3 noticed that the Resident was seated in the dining chair and assisted him/her back into the wheelchair and wheeled Resident #7 to the bedroom. During an interview on 11/6/18 at 3:15 pm, Resident #7's power of attorney (POA) stated that he/she didn't visit as much because the Resident's mental status had declined and he/she didn't talk to him/her or interact like he/she had in the past. He/she had been concerned about him/her. During an interview on 11/07/18 at 1:00 pm, the MDS nurse stated that he/she was unfamiliar with the MDS process of recognizing and implementing a significant change MDS. Interview on 11/9/18 at 9:55 am, Licensed Nurse (LN) #5 stated that Resident #7 had been getting weaker. He/she stated that the Resident had not regained strength since his/her past hospitalization on [DATE] for pneumonia. LN #5 additionally stated that Resident #7 no longer had the strength to walk around the unit. Interview on 11/9/18 at 10:15 am with Certified Nursing Assistant #2 stated that Resident #7 had severe cognitive issues that limit his/her judgement and had demonstrated increased weakness. Review of the facility policy entitled Long Term Care MDS-Quarterly Assessment-Care Plan Review last updated 10/1/13 revealed, .Residents will be re-assessed no less frequently than quarterly .to ensure that the care plan is reflective of the resident's current needs. This review will also identify if there have been significant change in the resident's condition, which may warrant a comprehensive assessment .The (Resident Care Manager) will then review the MDS to identify if there has been a significant change. If so, procedures for significant change condition will be followed. | 2020-09-01 |
| 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 responsible for filling out the cognitive section of the MDS assessment. During an interview on 11/7/18 at 10:50 am, the Social Worker stated she was unaware that none of the Residents had a BIMs score completed in the MDS assessment. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.15, (MONTH) (YEAR)(currently used by the facility), revealed .These items are crucial factors in many careplanning decisions .Most residents are able to attempt the Brief Interview for Mental Status .A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance .Without an attempted structured cognitive interview, a resident might be mislabeled based on his or her appearance or assumed diagnosis .will enhance good care. | 2020-09-01 |
| 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 | 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 illegible. Record review on 11/5-9/18 of the annual MDS dated [DATE] triggered the Care Area Assessment (CAA) to include cognitive loss/dementia, vision, mood state, pressure ulcers, and behaviors. The CAA further stated the triggered areas were addressed in the care plan. Record review on 11/5-9/18 of Resident #15's care plan revealed no goals or interventions for cognitive loss/dementia, vision, mood state, pressure ulcer prevention, or behaviors. During an interview on 11/5/18 at 4:00 pm, the MDS nurse stated that he/she was trying to get all the care plans up to follow care areas identified in the MDS assessments. Review of the facility policy entitled Comprehensive Care Plan for LTC (Long Term Care) last updated 11/1/15 revealed under section II, :Purpose: The purpose of the . facility if to provide individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing, limitations, and goals. Results of the resident's assessment shall be used to develop, review, and revise the resident's comprehensive plan of care. The care plan shall describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial wellbeing as required . Additionally under section III, Procedure revealed within 7 days of the completion of the comprehensive assessments, all residents shall have a computerized plan of care .The interdisciplinary team should show evidence in the Care Area Assessment (CAA) summary or clinical record the following: [NAME] The resident's status triggered in CAA areas. C. Evidence that the facility considered the development of care planning interventions for all CAA's triggered by the MDS . | 2020-09-01 |
| 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 under his/her fitted mattress sheet, keeping the Resident in the center of the mattress. The resident was able to turn himself side to side. During an interview on 11/9/18 at 9:55 am, the Director of Nursing (DON) stated the wedges were used for positioning and safety not a restraint as the resident was unable to stand on his own. Review of Resident #5's Care Plan dated 11/3/18, did not reveal any interventions utilizing bed wedges for positioning. Call Light Observation on 11/8/18 at 8:21 am revealed Resident #5 calling out repeatedly while lying in his bed. During an interview on 11/8/18 at 8:30 am, Resident #5 stated he/she wanted juice. When asked he/she knew how to call the nurse he had a confused look on his/her face and did not answer. The call light attached to the bed was hanging off the right side of the bed (Resident's blind side). This surveyor handed the call light to the Resident and the Resident put the call light to his/her ear. The Resident was observed to have had difficulty holding the call light. During an interview on 11/8/18 at 8:40 am, Licensed Nurse (LN) #5 stated Resident #5 rattled his/her bed rails when he/she wanted something instead of using his/her call light. Review of Resident #5's long term care admission history dated 10/19/18, revealed the Resident was blind in his/her right eye and had opacities ([MEDICAL CONDITION]) in his/her left eye. During an interview on 11/8/18 at 3:23 pm, the Director of Nursing (DON) stated she was unaware Resident #5 rattled his/her bed rail to call nursing staff. The DON further stated the facility did have soft call lights that might be easier for Resident #5 to use. Review of Resident #5's Care Plan on 11/8/18, dated 11/3/18, did not reveal the Resident used his/her bed rails to call staff. Further review revealed objects should be placed close to the Resident and in his/her line of vision. Observation on 11/9/18 at 8:52 am, revealed the large call light had not been replaced with a lighter soft call light. Resident #11 Record review on 11/5-9/18 revealed Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. 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% of the time. The hash fell off the side of the plate as Resident attempted to scoop the hash onto the fork. The Resident tried to put the food back on the plate several times. The Resident lifted the empty fork to his/her mouth several times again as more and more food fell off the plate. - The Resident stopped eating, in total the Resident ate about 5% of the hash. - At 9:44 am, CNA #3 moved the Resident from the table and his/her breakfast. CNA #3 did not ask if he/she was done eating. The Resident's cream of wheat or diced fruit was left untouched. During an observation of lunch on 11/07/18 at 12:15 pm, the Resident ate lunch with a spoon, which aided in amount of food per bite. CNA #6 assisted to load the spoon with food, cued the Resident to keep eating, and at times, fed the Resident. During an observation of breakfast on 11/9/18 at 9:15 am, revealed LN #4 set up meal for the Resident and left him/her unassisted. The Resident did not take his/her first bite of the meal until 9:24 am. Further observation revealed the Resident sat alone until 10:00 am, when LN #4 sat to give the Resident morning medication. LN #4 assisted the Resident with a couple of bites of the meal, then left. Review of Resident's quarterly nutrition assessment, performed on 10/4/18, revealed: Summary of Feeding Ability: Extensive assist per (Activities of Daily Living) (evaluation) on 9/21/18. Feeding ability varies, will feed (himself/herself), needs cueing, and sometimes need fed. Record review of Resident's provider note, dated 7/6/18, revealed: I met with the Speech therapist today, who tells me the (Resident) doesn't have difficulty swallowing but difficulty (getting) the food cut up and it takes to much energy for (him/her) to eat meaning put (his/her( utensils to (his/her) mouth. Also, (Speech Therapist) tells me that (Resident) focuses only on specific spoke on (his/her) plate, which I did notice when I was sitting with (him/her) at lunch this afternoon. With the addition of (his/her) increased weakness, (he/she) is leaning more to the right and (his/her) glance focuses on between 10 o'clock and one o'clock. Anything outside of that range, (he/she) neglects and that is why (he/she) is likely not eating it. Further review revealed Impression and Plan: .(Speech Therapist) recommended that (his/her) plate be moved around so (he/she) can see there is more food, also (his/her) spoon can be loaded for (him/her) .encouraged nursing to use techniques suggested by (Speech Therapist) to help with eating. Review of Resident #11's care plan revealed an identified problem of Nutritional Status, last updated 10/6/18. Further review of the outcomes and interventions revealed no documentation of Resident's energy expenditure that could affect Resident's ability to eat; need for extensive assistance to eat; or the technique to turn Resident's plate to view food to aid in eating. During an interview on 11/8/18 at 2:05 pm, the MDS Nurse could not comment on why the interventions to aide in Resident #11's nutritional intake were not on the care plan. During an interview on 11/09/18 at 10:10 am, CNA #6 stated the Resident will have some days where he/she has no problems eating, other days he/she struggles. During an interview on 11/09/18 at 10:20 am, LN #2 stated Resident #11 does tire out fast when feeding himself/herself and think it's necessary for staff to assist him/her or he/she won't get adequate nutrition. During an interview on 11/9/18 at 10:30 am, both CNA #6 and LN #2 stated they were unaware of the plan to rotate Resident #11's plate. They further stated a more detailed plan to assist Resident to eat is needed so all staff are using the same interventions. Resident #17 Record review on 11/5-9/18 revealed Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, a quarterly assessment dated [DATE], revealed the Resident was coded as: 1) sometimes makes self understood; 2) being severely cognitively impaired and never/rarely made decisions ; 3) has hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality); and 4) as having no participation for his/herself in the assessment and goal setting process. Review of Resident #17's Medication Administration Record [REDACTED]. Review of Resident #17's provider note, dated 9/6/18, revealed a notation under the [DIAGNOSES REDACTED]. Record of Resident #17's care plan revealed no problem; goals; or interventions for [MEDICAL CONDITION] drug use. During an interview on 11/7/18 at 11:44 am, the MDS Nurse stated the Resident originally had the problem identified in the care plan for [MEDICAL CONDITION] medication use, however this was discontinued on 3/9/18 when a gradual dose reduction (GDR) and discontinuation of [MEDICATION NAME] had been attempted. The medication was restarted on 5/26/18. The MDS Nurse further stated the care plan problem was not reinitiated and should have been. Review of the facility's policy (Long Term Care) Care Conference, dated 10/1/13, revealed: - During the interdisciplinary team review, care plans developed, goals dates and interventions will be reviewed to ensure they reflect the resident's current status. - A separate care conference will be scheduled with the resident and/or responsible party to review care plan goals and interventions. - The care plan review with resident and/or responsible party may include 1 or more interdisciplinary team members and may be completed in person, by telephone, or letter. - Review of the care plan with resident and/or responsible party shall be documented on the care conference sign-in sheet . Review of the facility's policy Comprehensive Care Plan for (Long Term Care), last revised 8/2/14, revealed: .Care planning shall be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable. The interdisciplinary team should show evidence in the Care Area Assessment (CAA) summary or clinical record (of) the following .H. regular review and revising the plan of care, treatment, and services. I. The plan of care shall be individualized to the needs of the resident .O. The care plan shall be periodically reviewed by a team of qualified persons after each assessment. Review of the facility's policy (Long Term Care) (Minimum Data Set) Quarterly Assessment Care Plan Review, dated 10/1/13, revealed: D. Revisions in the care plan will be completed to identify the resident's current needs. | 2020-09-01 |
| 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 resident to be sent to (emergency room ) for (x-ray) and further treatment. Review of Resident #11's care plan revealed the identified problem of Respiratory, last updated 5/27/18. Interventions for this problem include: evaluate vital signs, breath sounds for variations; evaluate effectiveness of (oxygen) and respiratory therapy; and consult with Physician for variations in evaluation findings. Review of Resident #11's physician's notes revealed no documentation of collaborations with nurses prior to 5/4/18 about the Resident's respiratory symptoms. Review of Resident's emergency room and hospitalization notes revealed an abnormal urinary analysis (UA) with an E. Coli infection which required intravenous antibiotics to treat. Resident #11 returned to the long term care facility on 5/7/18. During an interview on 11/8/18 at 4:11 pm, the Director of Nursing (DON) stated there was no documentation in the 4/30/18 note to indicate any treatment was given or if collaboration with the medical doctor occurred about the Resident's respiratory symptoms. The DON further stated, after review of the subsequent notes, that there was not adequate documentation to show that Resident #11 received care or treatment that could have prevented his/her hospitalization . Review of the online facility policy and procedures revealed no policy in regards to nursing documentation standards or procedures for variations in Resident base line status. Review of an American Association of Nurse Assessment Coordination article entitled: The Importance of Documentation in Long-Term Care for Chronic Medical Conditions, dated (MONTH) 20, (YEAR), accessed at https://www.aanac.org/Today-in-Long-Term-Care/post/the-importance-of-documentation-in-long-term-care-for-chronic-medical-conditions/2017-06-20 on 11/15/18, revealed: The documentation in the medical record must also support what is in the care plan that addresses the medications and treatments provided to the resident and must demonstrate the involvement of licensed nurse in the assessment, evaluation, and observation of symptoms; the needs for treatments that are not routine; and the efficacy of treatments provided. Further review revealed: Documentation should also reveal that care and treatment interventions for symptoms are effective and, if not, that the resident has been further evaluated and the treatment plan adjusted, with additional evaluation. | 2020-09-01 |
| 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% of the time. The hash fell off the side of the plate as Resident attempted to scoop the hash onto the fork. The Resident tried to put the food back on the plate several times. The Resident lifted the empty fork to his/her mouth several times again as more and more food fell off the plate. - The Resident stopped eating, in total the Resident ate about 5% of the hash. - At 9:44 am, CNA #3 moved the Resident from the table and his/her breakfast. CNA #3 did not ask if he/she was done eating. The Resident's cream of wheat or diced fruit was left untouched. During an observation of lunch on 11/07/18 at 12:15 pm, the Resident ate lunch with a spoon, which aided in amount of food per bite. CNA #6 assisted to load the spoon with food, cued the Resident to keep eating, and at times, fed the Resident. During an observation of breakfast on 11/9/18 at 9:15 am, revealed LN #4 set up meal for the Resident and left him/her unassisted. The Resident did not take his/her first bite of the meal until 9:24 am. Further observation revealed the Resident sat alone until 10:00 am, when LN #4 sat to give the Resident morning medication. LN #4 assisted the Resident with a couple of bites of the meal, then left. Record review of Resident's provider note, dated 7/6/18 (4 months prior), revealed: I met with the Speech therapist today, who tells me (Resident) .takes to much energy for (him/her) to eat meaning put (his/her) utensils to (his/her) mouth. Also, (Speech Therapist) tells me that (Resident) focuses only on specific spoke on (his/her) plate, which I did notice when I was sitting with (him/her) at lunch this afternoon. With the addition of (his/her) increased weakness, (he/she) is leaning more to the right and (his/her) glance focuses on between 10 o'clock and one o'clock. Anything outside of that range, (he/she) neglects and that is why (he/she) is likely not eating it. Further review of the provider note revealed Impression and Plan: .(Speech Therapist) recommended that (his/her) plate be moved around so (he/she) can see there is more food, also (his/her) spoon can be loaded for (him/her) .encouraged nursing to use techniques suggested by (Speech Therapist) to help with eating. Additional review revealed no recommendation or plan for a restorative dining program. Additional review of the Resident's medical record 11/5-9/18 revealed no speech therapy documentation. Review of Resident #11's care plan revealed an identified problem of Nutritional Status, last updated 10/6/18. The outcomes and interventions revealed no documentation of Resident's energy expenditure that could affect Resident's ability to eat; need for extensive assistance to eat; or the technique to turn Resident's plate to view food to aid in eating. Further review revealed no documentation of a restorative dining program. During an interview on 11/8/18 at 2:05 pm, the MDS Nurse could not comment on why the interventions to aide in Resident #11's nutritional intake were not on the care plan. During an interview on 11/09/18 at 10:10 am, Certified Nursing Assistant (CNA) #6 stated the Resident will have some days where he/she has no problems eating, other days he/she struggles. During an interview on 11/09/18 at 10:20 am, Licensed Nurse (LN) #2 stated Resident #11 does tire out fast when feeding himself/herself and think it's necessary for staff to assist him/her or he/she won't get adequate nutrition. During an interview on 11/9/18 at 10:30 am, both CNA #6 and LN #2 stated they were unaware of the plan to rotate Resident #11's plate. They further stated a more detailed plan to assist Resident to eat is needed so all staff are using the same interventions. They further felt a restorative dining program with a scoop plate would be appropriate for the Resident. Attempts to contact the dietician via phone were unsuccessful. Review of the facility's policy (Long Term Care) Restorative Nursing, dated 10/1/13, revealed: - If the (MDSC -Minimum Date Set Coordinator) or licensed staff determines the resident has the ability to improve in .eating .a therapy referral or RESTORATIVE NURSING REFERRAL will be initiated. - If the MDSC or licensed staff determines the resident has the need to maintain current function in .eating .a RESTORATIVE NURSING REFERRAL will be initiated. - The RESTORATIVE NURSING REFERRAL documents the resident's current functional status, need to improve or maintain functional status, recommended goals, approaches and plan for periodic re-evaluation of the program. Restorative nursing programs should also be added to the appropriate nursing care plan . Review of the facility's policy (Long Term Care) Restorative Dining Program, dated 10/1/13, revealed: - Using the assessment process described in the RESTORATIVE NURSING policy and procedure, residents appropriate for participation in a Restorative Dining Program will be identified. - Resident with the following symptoms might benefit from a Restorative Dining Program .pushes food off plate .poor sitting balance or posture .visual problems with inability to locate food . - Refer Restorative Dining candidates to Speech Therapy and/or Occupational therapy for evaluation and treatment as indicated. | 2020-09-01 |
| 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 | 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 credit card account issues; vendor discrepancies with Alaska Native Medical Center in Anchorage (where the hearing aids were ordered); and miscommunications. As the facility attempted to correct these problems, the Social Worker stated the hearing aids were forgotten about and the facility failed to follow up to attempt to purchase them again. The hearing aids were successfully purchased during the course of this survey on 11/8/18. During an interview on 11/8/18 at 4:02 pm, the Director of Nursing (DON) stated if staff are aware of missing resident item(s), they should bring this to the attention of the DON, Social Worker, and the Long Term Care Administrator to correct the problem. The DON further stated there is no documentation from (MONTH) (YEAR) to (MONTH) (YEAR) to indicate staff informed administration about Resident #11's missing hearing aid. There was no occurrence report filled out by staff, nor is there documentation of an investigation prior to (MONTH) (YEAR). Review of the facility's policy (Long Term Care) Personal Items, effective date 10/1/13, revealed: If any personal item is lost during a resident's stay, an investigation will be completed by the facility and the results will be communicated to the resident and/or family/responsible party. The Administrator/designee will discuss the method of replacement for lost items with the resident and/or family/responsible party. | 2020-09-01 |
| 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 meals and keep (his/her) wheelchair within (his/her) reach in (his/her) room. Resident #6 Record review on 11/5-9/18 revealed Resident # 6 was admitted with [DIAGNOSES REDACTED]. Record review on 11/5-9/18 revealed in Resident #6's care plan that he/she had impaired physical mobility due to neuromuscular impairment and limited ROM. A goal was for Resident #6 to maintain or increase mobility and strength of muscles. Record review of Resident's PT evaluation, dated 8/27/18, revealed: -Chief Complaint: Deconditioning, muscle weakness; -Assessment: Resident #6 is dependent on physical assistance and adaptive devices for all ADLs. He/she was able to propel his/her wheelchair. He/she is at risk for deconditioning, decreased awareness due to dementia, and a fall risk; and -Additional information recommended 1) daily self-propulsion of wheel chair to/from meals with least restrictive amount of assistance from staff and 2) 1-2 days of AROM and upper and lower extremities to decrease contractures and improve strength. Resident #9 Record review on 11/5-9/18 revealed Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Resident's PT evaluation, dated 3/15/18, revealed: - Chief Complaint: decreased functional mobility and failure to thrive; - Assessment: needs assistance for all activities, had residual muscle weakness; - Summary of needs: daily self-care to maintain quality of life; and - Additional Information: Daily gentle Passive ROM (PROM) to all joints. Review of Resident's care plan revealed an identified problem of Activities of Daily Living Function Rehab, last updated on 11/5/18. Further review revealed the PT evaluation recommendations are not included in the interventions for this problem. Resident #10 Record review on 11/5-9/18 revealed Resident # 10 was admitted with [DIAGNOSES REDACTED]. During an interview on 11/6/18 at 1:50 pm, Resident #10 stated, Staff never have time to help me exercise. Record review of Resident's PT evaluation, dated 7/30/18, revealed: -Chief Complaint: Deconditioning, decreased functional mobility; -Assessment: Resident #10 was difficult to assess as his/her strength was variable depending on mood, status and time of day but that he/she was able to performs functional tasks such as sit to stand, pivot using grab bars, and push with arms and scoot with feet in wheel chair; and -Summary of needs recommended for restorative care include 1) AROM (Active ROM) 2-3 times per week of bilateral upper and lower extremities within available range; 2) bed mobility training by staff to encourage patient to participate in self-care as much as possible; 3) skilled care approximately 1 time per week to ambulate within bars and progress ambulation status; 4) daily self-propulsion of wheel chair within the facility; and 5) Use of NuStep 3-5 times per week. Record review of Resident #10's care plan revealed no care planning task to maintain physical functioning. Resident #11 Record review on 11/5-9/18 revealed Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident's PT evaluation, dated 8/2/18, revealed: - Chief Complaint: deconditioning; impaired posture; impaired functional mobility; - Assessment: Impairments/limitations: Abnormal tone (muscle tone); ambulation deficits; balance deficits; ROM deficits; cognitive (mental) deficits; coordination/proprioception (the sense of the relative position of one's own body parts and strength of effort being used in movement) deficits; endurance deficits; strength deficits; transfer deficits; wheelchair mobility deficits; - Summary of needs: PROM and AROM exercises as tolerated 2-3 days per week; Daily sit to stand attempts with transferring; frequent pressure relief repositioning from staff when in geri chair (large padded reclining chair on wheels); frequent repositioning from staff to avoid contractures/discomfort; and - Additional Information: Bed PROM and AROM (as (Resident) is able) 2-3 days per week of upper and lower extremities. Review of Resident's care plan revealed an identified problem of Activities of Daily Living Function Rehab, last updated on 10/29/18. Further review revealed the intervention: schedule restorative program per needs. No ROM program is documented in the care plan. Resident #12 Record review on 11/5-9/18 revealed Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Resident's PT Evaluation, performed on 8/6/18, revealed: - Chief Complaint: Deconditioning, decreased strength, posture impairment; - Assessment: Homebound/Facilitybound Reasons 1) Needs assistance for all activities 2) Muscle weakness 3) Nonambulatory / Total dependence for mobility 4) Confusion 5) Dependent on adaptive devices/positioning devices; - Summary of needs: Daily gentle PROM with end range stretch of all joints, including encouragement of patient active contribution to ROM when appropriate; and - Recommendations for Restorative Care: Daily PROM to all joints to improve flexibility. Daily AROM (when patient is cooperative and able) of legs and arms in bed. Review of Resident #12's care plan dated 8/11/18, revealed a goal (Resident #12) will not develop any new contractures and an intervention .has joint pain with PROM - use gentle repositioning. Further review of the care plan revealed a problem of Long Term ADL Function Rehab with none of the PT recommendations for daily PROM and AROM included. Resident #15 Record review on 11/5-9/18 revealed Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of falls documentation on 11/8/18 revealed Resident #15 had at least 18 documented falls between 01/2018 and 11/2018, some of which resulted in broken bones. Record review of Resident's PT evaluation, dated 8/30/18, revealed: -Chief Complaint: Deconditioning, fall risk, confusion, gait impairment; -Assessment: Resident #15 was difficult to assess as he/she has difficulty understanding but has approximately 75% strength and range of motion in upper and lower extremities; and -Summary of needs recommended for restorative care include 1) NuStep 1 time per week or as tolerated. Record review of Resident #15's care plan revealed no care planning task to maintain physical functioning. Resident #17 Record review on 11/5-9/18 revealed Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Resident's PT Evaluation, dated 3/16/18, revealed: - Chief Complaint: Reduced functional mobility, [MEDICAL CONDITION], and fall risk; - Assessment: Residual muscle weakness, requires assistance to ambulate; - Summary of needs: One on one care for accommodation to the new facility, daily ambulation the unit with the use of a 4 wheeled walker, daily aerobic activity; and - Recommendations for Restorative Care: 3-5 times use the Nu-step machine in the PT office, Level 1-7, as tolerated by the resident for up to 15 minutes each time, ambulate around the unit to and from the room to dining area and living area with supervision as needed. Review of Resident's care plan revealed an identified problem of Activities of Daily Living Function Rehab, last updated on 10/29/18. Further review revealed the PT evaluation recommendations are not included in the interventions for this problem. During random observations on 11/5-9/18 revealed no CNA-led restorative exercise groups (to include all able Residents) occurred. Interview on 11/7/18 at 12:41 pm, MDS nurse stated that there was no restorative activities being performed in the facility because no staff were trained for perform the task. During an interview on 11/9/18 at 9:14 am, Licensed Nurse (LN) #2 stated ROM and exercises are not done because the facility has told staff a Restorative Aid is needed. He/she further stated there are no ROM exercises listed out for staff to follow with Residents. During an interview on 11/9/18 at 9:18 am, LN # 2 stated the Residents do not use the Nu-step machine unless he/she is with the PT. During an interview on 11/9/18 at 10:15 am, CNA #6 stated he/she used to do PROM with Residents when he/she first started working here, on his/her own, to help loosen Resident's extremities but cannot anymore. He/she further stated Residents do not use the Nu-step machine on their own. During an interview on 11/9/18 at 11:53 am, Certified Nursing Assistant (CNA) #6 stated none of the CNAs do ROM because the facility does not have a restorative aid program and ROM was taken off the Caretracker (electronic task list) and the CNAs were told not to do ROM on the Residents. During an interview on 11/9/18 at 12:16 pm, the PT stated he/she and administration have attempted to develop a more regular program to get a restorative aide in the facility. He/she further stated when ROM is recommended it is not something CNAs can do. He/she had the expectation that a Restorative Aide would be hired to complete these recommendations. The PT stated he/she was aware these recommendations are not able to be completed at this time due to not having restorative aides. Review of the facility's policy (Long Term Care) Restorative Nursing, dated 10/1/13, revealed: - Based on a comprehensive assessment of the resident's current functional status related to .mobility, range of motion, performance of ADLs .the (MDSC - Minimum Data Set Coordinator) will determine appropriateness for participation in restorative nursing programs. - If the MDSC or licensed staff determines the resident has the ability to improve in .mobility, range of motion, ADL performance .a therapy referral or RESTORATIVE NURSING REFERRAL will be initiated. - If the MDSC or licensed staff determines the resident has the need to maintain current function in .mobility, range of motion, ADL performance .a RESTORATIVE NURSING REFERRAL will be initiated. - The RESTORATIVE NURSING REFERRAL documents the resident's current functional status, need to improve or maintain functional status, recommended goals, approaches and plan for periodic re-evaluation of the program. Restorative nursing programs should also be added to the appropriate nursing care plan . Review of the facility's policy (Long Term Care) Restorative Exercise Group, dated 10/1/13: - It is the policy of this facility to ensure that a resident's strength and range of motion does not deteriorate .Residents assessed with [REDACTED]. - The Restorative Exercise Group will meet at least 6 days per week for a minimum of 15 minutes. - The Restorative Exercise Group will be led by a facility CNA in an area large enough to allow for placement of wheelchairs and unrestricted movement of arms and legs. | 2020-09-01 |
| 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 straight catheterization revealed: - No sterile field was used, supplies were placed on the Resident's bed leaning against non-sterile objects (like dirty clothes, blankets, and baby wipes container) and - Cleaning of the perineum before catheterization was not completed appropriately. A review of the initial department orientation check off list for LNs revealed no competencies on policy or procedures for straight catheterizations. During an interview on 11/9/18 at 1:54 pm, the Director of Nursing (DON) stated the Infection Preventionist had misspoke on 11/8/18. She clarified that there had been no competency training for LNs on female straight catheterizations. A review of the facility's procedures Intermittent (Straight) Catheter Insertion in Female Adult, copyright date (YEAR), from the facility's DynamicHealth training website, revealed: - Create a sterile field, if not using a prepackaged kit, within easy reach, and open all supplies onto the sterile field using ANTT (aseptic non-touch technique) - Clean the external urethral orifice (where urine exits the body) with an antiseptic agent, maintaining general ANTT - Do not allow the external urinary orfice to close, once it is exposed, especially after the antiseptic cleaning agent has been applied. It the labia close after cleaning, the skin is contaminated and must be recleaned. - (Intermittent catheterization) is performed using aseptic technique to minimize the transfer of healthcare-related microorganisms into the urinary tract. - In healthcare institutions, nurses who perform (intermittent catheterization) use general ANTT due to the increased risk for exposure to microorganisms in the healthcare environment and resultant healthcare-associated infection. | 2020-09-01 |
| 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 daily activities or meaningful interactions with staff. During an interview attempted interview with Resident #15 on 11/5/18 at 3:30 pm, CNA #7 stated 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 illegible. Record review on 11/5-9/18 of the annual MDS dated [DATE] revealed Resident #15 was coded as 1) being rarely/never understood verbally; 2) being severely impaired- never/rarely making decisions; 3) as having no participation for his/herself, family or legally authorized representative in the assessment and goal setting process. Further review of the MDS Care Area Assessment (CAA) revealed Resident #15 triggered for cognitive loss/dementia, mood state, and behavioral symptoms. The CAA revealed these areas were addressed in the care plan. Record review on 11/5-9/18 of Resident #15's care plan revealed no goals or interventions for cognitive loss/dementia, mood state, or behaviors. During an interview on 11/07/18 at 1:00 pm, the MDS nurse stated that he/she was unfamiliar with the MDS processes regarding CAAs and required follow up. Review of the facility policy entitled Comprehensive Care Plan for LTC (Long Term Care) last updated 11/1/15 revealed under section II, :Purpose: The purpose of the . facility if to provide individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing, limitations, and goals. Results of the resident's assessment shall be used to develop, review, and revise the resident's comprehensive plan of care. The care plan shall describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial wellbeing as required . Additionally under section III, Procedure revealed within 7 days of the completion of the comprehensive assessments, all residents shall have a computerized plan of care .The interdisciplinary team should show evidence in the Care Area Assessment (CAA) summary or clinical record the following: [NAME] The resident's status triggered in CAA areas. C. Evidence that the facility considered the development of care planning interventions for all CAA's triggered by the MDS . | 2020-09-01 |
| 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 | 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 caribou legs stored in black garbage bags. Not sealed, one leg sticking out of the garbage bag exposing meat on lower aspect of leg to the elements. Slight freezer burn on this exposed meat. Loose strands of caribou hair can be seen on over 40% of the meat on the leg. 3) Walk-in Refrigerator - 3 - 48oz. boxes of Cream Cheese with an expiration date of 18 (MONTH) (YEAR); - 1 - 5lbs. container of Sour Cream with mold on the inner rim of the lid; - Half gallon of Butter Milk with a best by date of 10/4/18; - Tartar sauce stored in a 5lbs. sour cream container, no date, a plastic spoon was stored within the container; - 1 - 5lbs. container of Beef Base, no open date, a plastic spoon was stored within the container; - 1 - 5lbs. container of Chicken Base, no open date, a plastic spoon was stored within the container; - 1 - 32oz. container of Garlic, no open date, a plastic spoon was stored within the container; - 1 - large container of Sweet Relish, no open date, 1/4 full; and - 1 - large container of Dill Relish, no open date, 1/4 full. 4) Small Refrigerator - 2 unopened canned drinks that belong to the cook within the resident food refrigerator. During an interview on 11/5/18 at 1:10 pm, the Cook stated the large dry goods bins contained panko, rice, flour, and sugar. He could not state when then bins were last filled. During an interview on 11/5/18 at 1:18 pm, the Cook stated the large black tool chest-type container in the freezer was staff's personal food. During an interview on 11/5/18 at 1:20 pm, the Cook stated buttermilk should be discarded 2 weeks after the best by date. During an interview on 11/5/18 at 1:25 pm, the Cook stated that when a product is opened it should be labeled with an open dated before being stored in the refrigerator. During an interview on 11/5/18 at 1:30 pm, the Cook stated the canned drinks in the small refrigerator were staff's personal drinks. An observation of the 200 wing kitchen on 11/5/18 at 2:20 pm, revealed: 1) Cupboards: - 1 - 4.5lbs. container Think & Easy Pureed Bread and Dessert Mix, a plastic spoon and a plastic cup was stored within the container; - 3 sandwich-size Ziploc bags half full of white powders, all different consistencies, no labels, no dates; and - 1 sandwich-size Ziploc bag labeled Sugar 1 1/2 C, no date. 2) Freezer: - Resident's Personal Food: Dry Fish, (Resident #6), no date. 3) Refrigerator: - Rubbermaid container with a whole tomato and a cooked hamburger patty, no name, no date. An observation of the 300 wing kitchen on 11/5/18 at 2:45 pm, revealed: 1) Cupboards: - Small plastic cup with light brown, nontransparent, granulated substance, half full, no lid, no label, no date; - 1 can Bushes Black Beans, Best by Feb (YEAR); - [MEDICATION NAME] instant protein powder, use by 11 APR (YEAR), plastic scoop stored within the container; and - 4.5lbs. Think & Easy Pureed Bread and Dessert Mix, plastic scoop stored within the container. 2) Refrigerator: - Bubble gum plastic container with smoked salmon strips, not covered, fish exposed to the elements. No name, no date. During an interview on 11/5/18 at 3:25 pm, Licensed Nurse (LN) #1 stated food brought into the facility from family should be labeled with the resident's name and dated. He/she further stated the smoked salmon in the bubble gum container should not be stored in that manner. During an observation in the kitchen on 11/5/18 at 3:35, a sign on the walk-in refrigerator read: Is it labeled? Dated? No? Turn around and go do it. No food goes in the walk in without a date and label. During a telephone interview on 11/6/18 at 12:00 pm, the Department of Environmental Conservation Representative stated donated game meat should be taken out of garbage bags immediately due to the possibility of chemicals within the bags contaminating the meat. During an interview on 11/8/18 at 3:15 pm, the Long Term Care Administrator stated garbage bags should not be used to store any kind of food within the facility. Review of the online facility policies on 11/5-7/18 revealed no policies or procedures for the kitchen or food handling and storage. During the survey, the facility initiated a policy, (Long Term Care) - Safe Food Procurement, Handing, and Storage, original effective date: new, reviewed date: 11/7/18. Review of this new policy revealed: Unsafe food handling practices represent a potential source of pathogen exposure. Review of the facility's draft of a policy on traditional native foods/donated foods, written on 11/28/17 and reviewed (MONTH) (YEAR), revealed: 4. Food brought in from outside the Elder Home will be checked by the RN Charge Nurse to .c. The food will be labeled with the resident's name, content, and date the food was brought to the facility . Further review revealed: 5. Storing Traditional Native Foods .c. Food must be kept in covered and closed containers. | 2020-09-01 |
| 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 catheterization by LN #2 for the Resident revealed sterilization was again breached at the initiation of supply set up. Observation of the straight catheterization revealed: - No sterile field was used, supplies were placed on the Resident's bed leaning against non-sterile objects (like dirty clothes, blankets, and baby wipes container) and - Cleaning of the perineum before catheterization was not completed appropriately. A review of the initial department orientation check off list for LNs revealed no competencies on policy or procedures for straight catheterizations. During an interview on 11/9/18 at 1:54 pm, the Director of Nursing (DON) stated the Infection Preventionist had misspoke on 11/8/18. She clarified that there has been no competency training for LNs on female straight catheterizations. Bladder Scans During an observation on 11/8/18 at 9:30 am, LN #3 performed a bladder scan on Resident #4. Once complete he/she wiped the scanner off with a paper towel and returned it to the bladder scanner cart. Further observation revealed LN #3 returned the bladder scanner to the medication room without cleaning/disinfecting the scanning device. During an observation on 11/9/18 at 9:28 am, LN #2 performed a bladder scan on Resident #4. Once complete he/she wiped the scanner off with a paper towel and returned it to the bladder scanner cart. Further observation revealed LN #2 returned the bladder scanner to the medication room without cleaning/disinfecting the scanning device. During an interview on 11/9/18 at 1:35 pm, LN #2 stated the bladder scanner should be cleaned with a Cavi-wipe (disinfectant cleaner) after each use. He/she further stated this is something forgotten after the morning scan. During an interview on 11/9/18 at 1:45 pm, the Director of Nursing (DON) stated the bladder scanner should be cleaned with antimicrobial wipes after each use. A review of the facility's procedures Intermittent (Straight) Catheter Insertion in Female Adult, copyright date (YEAR), from the facility's DynamicHealth training website, revealed: - Create a sterile field, if not using a prepackaged kit, within easy reach, and open all supplies onto the sterile field using ANTT (aseptic non-touch technique) - Clean the external urethral orifice (where urine exits the body) with an antiseptic agent, maintaining general ANTT - Do not allow the external urinary orifice to close, once it is exposed, especially after the antiseptic cleaning agent has been applied. It the labia close after cleaning, the skin is contaminated and must be recleaned. - (Intermittent catheterization) is performed using aseptic technique to minimize the transfer of healthcare-related microorganisms into the urinary tract. - In healthcare institutions, nurses who perform (intermittent catheterization) use general ANTT due to the increased risk for exposure to microorganisms in the healthcare environment and resultant healthcare-associated infection. Review of the facility's policy Cleaning and Disinfecting of Patient Care Equipment, last revised 11/1/16, revealed it will, .provide guidelines for the standardized processing of reusable patient care equipment (PCE) in order to minimize the risk of Healthcare Associated Infections (HAIs) related to the reprocessing of these items. Further review revealed a bladder scanner is considered a Non-critical equipment/device that .touches only intact skin . and is cleaned with low level disinfection. | 2020-09-01 |
| 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 | 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 | 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 | 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 | 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 | 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 | 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, revealed .In case of actual missing person or elopement .Call to notify the Nursing Facility Licensing Unit (State Survey Agency) . unsigned. Review of a second facility policy, LTC Elopement-Wandering, Category: Patient Functions .with an effective date of 10/1/13 revealed, .Procedure: . B. If a resident is identified as an elopement risk .The resident will also be placed in Line of sight (LOS) while awake and Care planned accordingly . F. Upon return to the facility .document the occurrence, update interventions, and notify the state agency as appropriate . Signed and dated 1/14/14. | 2020-05-01 |
| 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 | 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 and Techniques to Meet Needs; Offer (Resident) Activity Choices; Encourage Active Participation for Physical, Cognitive Stim; Encourage Passive Participation Socialization, Religious Spiritual Needs . There was no specific information that directed staff on how to implement specific techniques needs and what adaptive material was needed. Review of Social Work Note dated 9/15/16 revealed, a discussion the facility wanted to implement using an I Pod for the Resident to listen to music in the common area. No I Pod was observed being used by the Resident or in his/her room during the survey. Random observations from 1/31/17 to 2/3/17 during the survey, Resident #2 was observed aimlessly wandering on the unit, occasionally stopping to watching TV independently. The Resident did not engage in any specific activities during the observations. During an interview with LN #1 on 2/1/17 at 2:30 pm when asked about Resident individual activities stated, the staff know the Residents well and know what they like. Next giving the example of Resident #2 likes singing Silent Night and will sing it with staff. No staff observed during the survey singing with Resident #2. 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, 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 1/13/17, revealed Offer activity of choices, encourage participation for physical, cognitive stimulation. No Resident specific activities, likes or dislikes, had been care planned. Resident #5 Record review from 2/1-3/17 revealed Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #5's care plan dated 1/31/17, revealed under Activities revealed Offer Activity Choices .Encourage Active Participation for Physical, Cognitive Stim; Social Interaction Needs; Religious Spiritual Needs. Encourage Passive Participation in Cognitive Stimulation; Socialization; Religious Spiritual Needs. Offer 1:1 activities if unable or unwilling to participate in group activities. (Resident) enjoys going to church, being read to. Random observations from 1/31/17-2/3/17 revealed, no nursing staff or Certified Nurse Assistant (CNA)'s reading to the resident, nor any person centered activities observed being done with the Resident. Resident #7 Record review from 1/31 - 2/4/17 revealed Resident #7 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the Residents most current care plan, dated 12/13/16, revealed Offer Activity Choices .Encourage Active Participation for Physical, Cognitive Stim; Social Interaction Needs; Religious Spiritual Needs. Encourage Passive Participation in Cognitive Stimulation; Socialization; Religious Spiritual Needs. No Resident specific activities, likes or dislikes, had been care planned. During an interview on 1/31/17 at 2:30 pm when asked what activities were provided to the Residents, CNA # 2 stated, I don't know the residents well. During an interview with the Director of Nursing (DON) on 1/31/17 at 4:00 pm when asked about activities stated staff know the residents well and know what they like. During an interview on 2/3/17 at 4:00 pm, the Activities Coordinator (AC) stated s/he had a log of each resident's likes and dislikes, but had not shared the information with the nursing staff. In addition, the AC stated s/he had been working on individualizing the activity care plans for resident, but s/he didn't have the time to get the activity care plans completed and provide the daily activities. Record review of the Activity Coordinators job description on 2/3/17 at 10:30 am, dated 6/10/14, revealed Position description .designs a creative and exciting life enrichment program to meet group and individual needs and interests of the residents .participates in the review of Resident Care Plans and documents life enrichment progress . During the survey, CNA and nursing staff observed did not engage residents in individualized activities. Review of the facility's policies revealed a policy was listed, but not produced by the end of the survey. | 2020-05-01 |
| 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 1/13/17, revealed Offer activity of choices, encourage participation for physical, cognitive stimulation. No Resident specific activities, likes or dislikes, had been care planned. Resident #5 Record review from 1/31 - 2/4/17 revealed Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Resident's care plan dated 1/31/17, revealed Activities .Offer Activity Choices .Encourage Active Participation for Physical, Cognitive Stim; Social Interaction Needs; Religious Spiritual Needs. Encourage Passive Participation in Cognitive Stimulation; Socialization; Religious Spiritual Needs. Offer 1:1 activities if unable or unwilling to participate in group activities . No Resident specific activities, likes or dislikes, had been care planned. Random observations from 2/2/17 from 8:10 am - 10:15 am revealed no staff attempted to engage Resident #5 in individual or group activities. Resident #7 Record review from 1/31 - 2/4/17 revealed Resident #7 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the Residents most current care plan, dated 12/13/16 revealed, Offer Activity Choices .Encourage Active Participation for Physical, Cognitive Stim; Social Interaction Needs; Religious Spiritual Needs. Encourage Passive Participation in Cognitive Stimulation; Socialization; Religious Spiritual Needs. No Resident specific activities, likes or dislikes, had been care planned. During an interview on 2/3/17 at 4:00 pm, the Activities Coordinator stated she had a log of each resident's likes and dislikes. In addition, she stated had been working on individualizing the activity care plans for resident but lacked the time to get the activity care plans completed and provide the daily activities. Record review of the Activity Coordinators job description on 2/3/17 at 10:30 am, dated 6/10/14 revealed, Position description .designs a creative and exciting life enrichment program to meet group and individual needs and interests of the residents .participates in the review of Resident Care Plans and documents life enrichment progress . | 2020-05-01 |
| 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 placing the resident at significant risk of getting to a potentially dangerous place (e.g., .outside of the facility) and intrudes on the privacy or activities of others coded as yes. Change in behavior or other symptoms compared to prior assessments as Worse. Elopement Risk Review on 2/3/17 of nursing progress note, dated 8/27/16 at 8:13 pm, revealed Resident jumped out of his room's window and landed on his knees .resident trying to stand up and started to walk visibly frightened and shaking . Continuous observation on 1/31/17 from 12:50-1:07 pm revealed, Resident #2 walking throughout the unit, opening the door to another resident's room # 302, walking into the room and closing the door behind him/her. Nursing staff on the unit were in various resident rooms during this time. At 1:05 pm Housekeeper (HK) appeared to notice Resident #2 was no longer in the common area. The HK walked into room #301 through the open door then exited room 301. Next, the HK walked to room #302, knocked on the closed door and entered the room. The HK guided Resident #2 out of the room and back into the common area where the Resident was observed to continue to wander, back and forth through the TV area in and out of other Resident's rooms or occasionally sitting on the couch unsupervised. During an observation on 1/31/17 at 1:23 pm Resident #2 walked to room #304 opened the closed door where a Certified Nursing Assistant (CNA) was working with Resident #11. CNA #1 knocked on room # 304's door entered the room and guided Resident #2 out of the room back into the common area where s/he aimlessly wandered on the unit unsupervised. During an observation on 2/2/17 from 9:25-9:35 am Resident #2 walked unsupervised by staff on the unit, wandering through the dining and TV area picking up papers. The Resident walked to the closed door of Resident #10's room, opened the door, entered the room then closed the door behind him/her. HK walked to room #302 knocked on the door, entered the room and guided Resident #2 out of the room and back to the common area. Review of Resident #2's care plan, updated on 12/30/16, revealed problems including elopement risk. The identified interventions included .Preform frequent location checks if Exit-Seeking Behavior, Utilize Wander Alert Device, .If Resident Elopes, Find Resident and Return to Facility, Notify Authorities According to Policy. Under the listed Outcomes .Behavioral Symptoms, the identified Interventions included .Call family to talk to (Resident) when (s/he) is having behaviors .Redirect (Resident) with mega blocks when needed, Motion sensor (with chime) in (Resident's) doorway to alert staff of Resident's movement. There was no information that listed what staff should do when the Resident had exited the room. During an interview on 2/3/17 at 4:40 pm, when asked about Resident #2's elopement, the Administrator stated the staff heard Resident #2 talking, went into his/her room where the voice was coming from, but couldn't see him/her in the room. The staff approached the open window in Resident #2's room, looked out the window and saw the Resident outside of the building. By the time the staff got to the front entrance of the building Resident #2 was walking toward the front entrance. The Administrator further stated the facility had no idea how the Resident got out the window or how long the Resident was outside. During the interview the Administrator confirmed the windows in the other Resident's rooms were still able to open wide enough for the Resident to slip through. During an interview on 2/3/17 at 5:00 pm the Licensed Nurse (LN) #1 revealed the Residents door would chime sound when the Resident went in or out of his/her room. LN #1 further stated, when staff hear the chime, they are supposed to watch Resident #2 on the unit. Sexual/Aggressive Behaviors Review of Resident #2's care plan, updated 12/30/16, revealed problems including Behavioral Symptoms. The identified Interventions included .Call family to talk to (Resident) when (s/he) is having behaviors .Redirect (Resident) with mega blocks when needed, Motion sensor (with chime) in (Resident's) doorway to alert staff of Resident's movement. Identified outcomes included, .Interventions Used to Alter Behavior .The problem is sexual inappropriateness .Goal: (Resident) to have no sexually inappropriate behavior. There were no instructions on what staff was to do once the Resident had exited the room. Review of a Progress Note-Nursing, dated 2/14/16 at 7:51 pm, revealed (Resident #2) was found standing next to a woman in a Geri-chair (a reclining chair on wheels that can be pushed like a wheel chair and may have a removable tray), walked away when staff approached. Another resident stated that (Resident #2) had touched the woman in a Geri chair, she is nonverbal and appeared to still be asleep. Review of a Progress Note-Nursing, dated 8/8/16 5:54 pm, revealed At 9:30 while Resident was eating breakfast with a female Resident (s/he) tried to touch her breast. Review of a Social Work (SW) Note, dated 8/11/16 at 2:36 pm revealed, On 8/8/16 SW was notified by the staff that resident appeared to be attempting to touch a female resident inappropriately without her consent. A CNA and Activities coordinator witnessed the event. She then directed the (female/male) resident to another table. This incident occurred during breakfast. The CNA states that he saw the (female/male) resident reaching for the female resident that startled and confused her . Review of a Progress Note-Nursing, dated 9/12/16 at 11:27 pm, revealed .female resident was speaking on the phone to her daughter. She was sitting in the dining room while talking .In a few moments (s/he) repositioned (himself/herself) to be within reach of her then (s/he) placed (his/her) hands in her view, shaping the fingers in (his/her) left hand in a circle and placing (his/her) right forefinger in the circle of the left hand began pushing a retracting (his/her) finger quickly to simulate sexual copulation. At first she ignored (him/her) then (s/he) reached and touched her shoulder, when she looked up at (him/her), (s/he) pointed between her legs and made some undetermined statement. At this she looked at me and said 'Get this (Resident #2) away from me' . Review of a Progress Note-Nursing, dated 9/17/16 at 12:03 am, revealed .observed (Resident #2) place (his/her) hand on a female resident at her shoulder, slide (his/her) hand down her back near her sacrum (buttocks) and do a one arm embrace against her. The female resisted (his/her) advance by pushing (his/her) hand away and walking off. Review of a Progress Note-Nursing, dated 9/17/16, revealed At 0600 (6:00 am) .Yupik speaking female staff was called to interpret. Upon seeing her (Resident #2) suddenly became hypersexual and was asking her in Yupik to kiss (him/her), and (s/he) advanced her multiple times to embrace her. She walked at a distance to prevent this and (s/he) continued on attempting to enter other rooms. Yupik staff reported (s/he) was saying in Yupik that (s/he) was looking to leave . Review of a BH (Behavioral Health) Progress Note, dated 11/4/16, revealed (Resident #2) is occasionally refusing (his/her) night time medications. This happened twice in the last week. When (s/he) does this (s/he) tends to be up much of the night and tries to get into others' rooms. Review of a BH Progress Note, dated 1/20/17, revealed (Resident #2) .is frequently wandering around the unit until 3 - 4 am, trying to get into others' rooms. (Resident #2) has also been assaultive several times . Further review of the medical record revealed multiple observations of the Resident's insomnia and wandering around the unit and in and out of Resident's rooms at night. During an interview on 2/1/17 at 1:00 pm CNA #2 stated the other residents don't like Resident #2 because s/he touches them and goes into their rooms when s/he is wandering around. During a resident group interview on 2/1/17 at 2:30 pm Resident #12 stated, I don't like it when people come in (his/her room), especially (Resident #2), I don't like (him/her) touching me or my things. During an interview on 2/13/17 at 9:30 am, Resident #12 stated, s/he was scared to stay in his/her room because s/he has seen a man in his/her room at nighttime. Review on 2/4/17 of the facility's Abuse Policy effective date Feb (YEAR) .Definitions .Neglect means failure to provide goods and services to avoid physical harm, mental anguish or mental illness . Symptom identification .Behaviors that may lead to higher risks of abuse include; residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident's room . | 2020-05-01 |
| 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 have been given if needed for increased behaviors without notifying the physician. | 2020-05-01 |
| 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 | 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 | 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 | 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 | 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 | 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 | 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 statements, dated 12/31/15 showed 3 Resident's with account balances greater than the Medicaid resource limit. Resident #5's account showed a balance of $2253.81; Resident #10's account showed a balance of $2100.27; and Resident #11's account showed a balance of $2300.58. Record review on 1/14/16 of the facility's notice Medicaid and Long-Term Care (LTC), which was posted at the facility, stated the Medicaid LTC eligibility amount was $2130.00/month. During an interview on 1/14/16 at 12:10 pm, the Administrator stated he notified the Residents and/or their legal representatives by telephone when the Resident accounts were around $2000.00. During a subsequent interview on 1/14/16 at 2:30 pm, the Administrator confirmed he did not know the current Medicaid LTC eligibility amount, but notified Residents and/or their legal representatives when accounts were around $2000.00. During a follow up interview on 1/14/16 at 4:32 pm, the Administrator confirmed the SSI limit was around $2150.00. | 2018-12-01 |
| 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 | 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 different. Review of the first policy given to Surveyors, LTC (Long Term Care) Grievance Policy, dated 10/1/13, revealed The center will actively seek resolution to concerns .The Social Worker will log all concerns/grievances received onto the facility grievance log .The Social Worker/Designee will keep a running log of concerns voiced and their resolution as well . Review of the second policy given to Surveyors, LTC Grievance Policy , dated 10/1/13, revealed .Concerns/grievances may be presented verbally or in writing and may include .treatment, care, lost personal items .The assigned Department Head/Designee investigates the concern and takes action to correct the issue within 48 hours. 72 hours if on a Friday evening or Saturday .Grievances must be completed with appropriate actions as well, within 5 days from submission. | 2018-12-01 |
| 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 | 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 [DIAGNOSES REDACTED]. Review of the most recent annual MDS assessment, dated 8/28/15, revealed the Resident was triggered on the CAA for dehydration - fluid maintenance. The trigger also was checked by the facility for requiring a care plan. Review of the most recent comprehensive care plan, dated 11/5/15, revealed no care plan for dehydration - fluid maintenance. During an interview on 1/13/16 at 2:25 pm, the DON confirmed there was no care plan for dehydration - fluid maintenance as triggered on the CAA and there was no documentation as to the reason why it was not care planned. Record review on 1/14/16 at 2:00 pm of the facility's policy & procedure, LTC Fluid Enhancement with the effective date of 10/1/13, revealed, When a resident has been assessed that additional fluids are appropriate, the care plan will be developed to include a FEP (fluid enhancement program). Record review of the facility's policy and procedure for LTC (Long Term Care) MDS-Quarterly Assessment-Care Plan Review, with an effective date of 10/1/13, revealed Revisions in the care plan will be completed to identify the resident's current needs. Resident #8 Record review on 11/14/16 revealed Resident #8 was admitted to the facility on [DATE]. Further review revealed the Resident had [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, an admission assessment dated [DATE], revealed the Resident was interviewed for activity preferences. During an interview on 1/12/16 at 3:25 pm the Administrator stated activity assessments are done on the MDS. Review of the Resident's care plan on 1/14/16 revealed activities was not part of the plan of care. Record review of the facility's policy and procedure for LTC Activity Assessment & Care Plan, with an effective date of 10/1/13, revealed The Activity Coordinator will assess each resident within 14 days of admission .The Activity Coordinator will participate in Care Plans for the resident, these care plans will be held: 72 hours of admission, 30 days of admission, 90 days from admission, Quarterly, Annually and with any changes. | 2018-12-01 |
| 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 | 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 finished breathing in, hold your breath as long as you comfortably can, up to 10 seconds . Review of the manufacturer's package insert, revised (MONTH) 2014, for [MEDICATION NAME] HandiHaler, provided by the Pharmacist on 1/13/16 at 10:00 am, revealed Remember: To get your full daily dose, you must again, breath out completely and for a second time, breath in .from the same [MEDICATION NAME] capsule. During a subsequent interview on 1/13/16 at 10:05 am, after reviewing the manufacturer's package insert for [MEDICATION NAME], the Pharmacist confirmed [MEDICATION NAME] should be inhaled 2 times to get the full dose. Review on 1/14/16 at 4:00 pm of the facility's policy and procedure for Medication Administration dated 10/1/13 revealed, Medications will be prepared and administered in accordance with: A. physician's orders [REDACTED]. | 2018-12-01 |
| 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 11/20-27/14, and for the calendar year of (YEAR) with various missing days. During an interview with the Administrator on 1/12/16 at 7:15 am, the Administrator stated the procedure was for the AA to pick up and keep the nursing staffing/resident census sheets. During an interview on 1/12/16 at 8:45 am, the AA confirmed the facility was missing 6 months of the posted nurse/staffing information. | 2018-12-01 |
| 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 observation confirmed, Tea Bunn is dirty. He added that they get cleaned once weekly usually on Wednesdays. Hair Net - 200 Unit Resident Kitchen: Observation on 1/12/16 at 7:25 pm revealed Certified Nursing Assistant (CNA) #4 preparing a peanut butter and jelly sandwich in the Resident kitchen on the 200 unit and was not wearing a hair net. During an interview on 1/12/16 at 7:40 pm, CNA #4 stated there were no hair nets available in the kitchen. During an interview on 1/14/16 at 10:45 am, the Director of Nursing (DON) stated she was unaware that staff needed to wear a hair net while preparing food in the Resident kitchen. | 2018-12-01 |
| 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, Temperatures in all vaccine storage units must be monitored .Temperature monitoring devices must be placed in each vaccine storage unit .Improper placement of the monitor may result in vaccine wastage. All other vaccine refrigerators/freezers (temporary or day use storage units) must be monitored by using a calibrated temperature monitoring device supplied by your facility. The facility did not provide the refrigerator temperature/alarm settings or the vaccine refrigerator manufacturer's information as requested prior to exit. Additionally, the facility did not provide the policy and procedures for vaccine storage as requested prior to exit. | 2018-12-01 |
| 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 (LN) #4, who was assisting the Resident with dining at this time, did not offer hand hygiene to the Resident. During this observation the Resident was seen holding bowl and spoon during the meal feeding his/her self with intermittent assistance by staff. Review on 1/20/16 of CDC's article Handwashing: Clean Hands Saves Life, last reviewed 9/4/15, retrieved at http://www.cdc.gov/handwashing/when-how-handwashing.htmlm revealed person should wash hands before eating. Review of the facilities policy index revealed no policies for resident hand hygiene practice before dining. Laundry: Observation on 1/11/16 at 9:19 am of the 200 unit washer room revealed multiple piles of laundry on the floor. During an interview on 1/11/16 at 9:19 am Environmental Services (ES) Staff #1 stated soiled linen is brought into the washer room and separated on the floor. Observation on 1/12/16 at 8:55 am revealed LN #2 carried soiled resident clothing from a Resident #3's room through corridor. The LN placed the clothing in an open soiled laundry cart located outside the unit's laundry room without wearing personal/staff clothing protection. During an interview on 1/12/16 at 7:05 pm CNA #1 stated when providing peri-care to a resident the soiled brief would be placed in the garbage can and the clothing removed would be placed on top of the garbage can. The CNA continued to state when cares are completed, he/she would carry the soiled clothing through the corridor to the soiled laundry containers located in the hallway of the unit without personal protective equipment (PPE). Observation on 1/13/16 at 10:32 am, ES Staff #1 transported an uncovered clean laundry cart to the folding room. During an interview on 1/13/16 at 10:32 am revealed ES Staff #1 stated he/she separated soiled laundry on the floor of the washer room and that staff place soiled laundry in the dirty laundry containers without bagging them first. In addition, stated staff only wore gloves and no clothing protection when handling soiled linen. Laundry Bin: Random observation from 1/11-14/16 revealed two soiled laundry containers with lids affixed in the upright position on both 200 and 300 unit. In addition, a large mobile blue laundry cart labeled dirty was uncovered with obviously soiled resident clothing exposed on both 200 and 300 unit. Observation during the initial tour on 1/11/16 from 8:30 am - 9:30 am revealed 2 upright linen containers in the back hallway of each unit, with the lids open. Written on the inside of the lids in large print, visible when the lids were open, were the words Dirty Linen Random observations revealed one large blue open bin without covers on each unit. Further observation on 1/11/16 at 12:39 pm of the 300 wing revealed, loose dirty linen was placed in one of the upright bins; the lid was opened. Observation of the large blue bin revealed both loose linen and linen wrapped in plastic bags were in the bin. Observation on 1/12/16 at 7:18 am of the 300 wing, revealed unwrapped linen in both upright bins with the lids open and loose dirty linen overflowing in the large blue bin. During an interview on 1/14/ 16 at 7:25 am the Administrator was asked for a policy on the handling and storage of dirty linens. No policy was provided by the time of exit. Medication Handling/Pass: Observation during a medication pass on 1/12/16 at 8:10 am revealed LN #3 removed a medication capsule from a blister pack ([MEDICATION NAME]) and placed the capsule in her bare hand. The LN then used her bare fingers to pick up the capsule and place it in a HandiHaler device (a medication device used for inhaling medication). Further observation revealed LN #3 then took the medication to Resident #2's room and administered the medication. During an observation on 1/13/16 at 8:30 am LN #1 opened a bottle of [MEDICATION NAME] by taking an ungloved hand and breaking the metallic-colored seal with index finger. The LN then ran an ungloved finger around in the inside rim of the bottle to remove remnants of the seal. Infection Control Program: During an interview on 1/14/16 at 10:17 am the Director of Nursing (DON) was asked who the Infection Preventionist for the facility was. The DON said she was responsible for infection control since (MONTH) (YEAR). The committee consisted of the Administrator, Kitchen Manager, Activities Coordinator, MDS (Minimum Data Set) Nurse, and the Social Worker, when the facility had one on staff, and the Medical Director attended the meetings sometimes on Wednesdays, as her schedule allowed. During an interview on 1/13/16 at 9:20 am, the Pharmacist stated s/he had never attended an Infection Control meeting at the long-term care facility. However, the Pharmacist stated s/he did receive a copy of the meeting minutes up until (MONTH) of (YEAR). During the interview the DON revealed she had no training in Infection Prevention. There had not been an Infection Control Risk Assessment (a multidisciplinary process that focuses on reducing risk from infection throughout a facility) done by the Infection Control Committee since 2013. This was confirmed by the Administrator. In addition, when asked for the infection control committee minutes she stated the facility did not have any minutes and stated there was no formal infection control program. | 2018-12-01 |
| 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 | 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 | 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 | 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 | 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 | 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 11/18/14 from 8:58 - 9:36 am revealed Resident #4 at the dining table sleeping with face lying in food and wearing a stained shirt. When the Resident sat up at the table her face was soiled with food. An observation in the dining room on 11/18/14 at 3:10 pm revealed Resident #4s face, clothing protector, and table were covered in pudding. During an interview on 11/18/14 at 9:45 am, LN #5 stated the facility encouraged Resident #4 to do daily tasks as independently as possible and confirmed the Resident needed assistance during meal times, especially to keep her face and surrounding eating area clean. During an interview on 11/19/14 at 9:00 am, LN #5 also stated Resident #4 was able to feed herself with some prompting. Resident #5 Record review on 11/17-20/14 revealed Resident #5 was admitted to the facility with a history of a stroke. Review of the most recent MDS assessment, an annual assessment, dated 10/3/14, revealed the Residents assessment was coded as having limitations in ROM on one side. Review of the CORP - Resident Plan Report, no date, revealed ADLS Assist with tray set-up .Assist with tray set-up and uses right arm to eat Observation on 11/17/14 at 12:15 pm, revealed Resident #5s lunch tray was placed on the table in front of the Resident. Applesauce, apple juice, and pudding were served in pre-packaged containers and had not been opened for the Resident. During the same observation period, the Resident was observed repeatedly attempting to open the apple juice, applesauce, and pudding. The Resident was not able to open the food items. During the observation on 11/17/14 at 12:24 pm, Resident #5 spoke out loud to anyone in the area for assistance with opening the food items. The Resident did not receive assistance. During the observation on 11/17/14 at 12:29 pm, 5 minutes after the Resident requested staff assistance with opening the food items and 14 minutes after the Resident received the lunch tray, the Resident received assistance with opening the food items. Resident #12 Record review revealed Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment, an admission assessment, dated 10/19/14, revealed the Residents assessment was coded as totally dependent on staff for eating. Observation of medication administration on 11/18/14 from 8:30 - 8:45 am, revealed LN #2 administered [MEDICATION NAME] (a laxative which can cause bloating) to Resident #12 during the breakfast meal. Administration of the medication halted the Resident's meal for 15 minutes. During the medication administration, LN #2 was observed using the Resident's clothing protector to wipe the Resident's face 4 times. During an interview on 11/18/14 at 9:05 am, LN #2 confirmed the Resident's meal was interrupted by giving the [MEDICATION NAME] and the administration of the medication could have waited until after the Resident finished the meal. The LN also stated the medication could have made the Resident feel full before the meal was finished. During an interview on 11/20/14 at 10:30 am, the DON confirmed Resident #12's laxative should not have been administered during the Resident's meal. Additional Observations Multiple observations from 11/17-20/14 of Resident #s 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 15, and 19 during breakfast and lunch meals revealed the Resident's meals were served on plastic food trays with plates on plate warmers and multiple prepackaged food items. The resident's plates were not removed from the trays, the plates were not removed from the plate warmers and the food was not removed from the manufacturer's packaging before being given to the residents. Record review from 11/17-20/14 of the facility policy Resident Rights and Responsibilities, dated 12/13, revealed These residents' rights . treated with consideration, respect, and full recognition of the resident's dignity and individuality . | 2018-05-01 |
| 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 the resident's dignity and individuality . | 2018-05-01 |
| 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 | 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 result from scooting. Although the Resident's clinical manifestations presented risk for skin integrity issue and the current skin integrity issue, the comprehensive care plan, most recently updated on 11/7/14, revealed no problems, outcomes, interventions or goals related to risk for or treatment of [REDACTED]. During an interview on 11/20/14 at 10:43 am, when asked about Resident #4s care plan related to skin integrity, the DON stated the Resident scoots often as a mode of mobility and could put her at risk for skin integrity issues. In addition, the DON confirmed there was no care plan related to the risk of skin integrity issues or current issues and one should be in place. Falls Fall #1 Record review of Resident #4s medical record on 11/18/14 at 11:03 am revealed a fall had occured on 8/8/14 as a result of climbing on a wheelchair. Record review of the Resident's Post Fall Evaluation, dated 8/8/14, revealed environmental safety planning was to ensure adequate lighting, non-slip footwear, and Patient specific safety measures . In addition, the evaluation stated additional intervention to prevent future falls would be frequent observations and move closer to the nurse's station for observation. Fall #2 Record review of Resident #4s medical record on 11/18/14 at 11:03 am revealed a fall occurring on 11/3/14 as a result of falling backward after an attempt to squat. Record review of the Resident's post fall evaluation, dated 11/3/14, revealed environmental safety planning was to ensure adequate lighting. In addition, the evaluation stated additional intervention to prevent future falls would be to remind the Resident not to walk unassisted. Fall #3 Record review of Resident #4s nursing progress Notes, dated 11/15/14 at 9:43 pm, revealed the Resident was ambulating with staff and stumbled on a fall mat causing the Resident to fall on her knees. Review of documents, dated 11/15/14, provided by the DON on 11/20/14 at 11:20 am revealed staff were to remind the Resident to step up on the mat when ambulating over fall mat. Review of the care plan, last updated 10/4/14, revealed of the identified interventions after the falls that occurred on 8/8/14, 11/3/14 or 11/15/14. During an interview on 11/20/14 at 11:20 am the DON confirmed the Resident's care plan had not been updated to include any of the identified interventions after the Resident experienced falls. Review of the facility policy entitled LTC Accident-Incident Policy, effective date 10/1/13, revealed .A Plan to prevent re-occurrence must be initiated at the time of the incident .Once the investigation is complete, update the care plan and in-room care plan with the interventions. | 2018-05-01 |
| 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 charts. The DON also stated due to the CNAs not documenting in the Resident's charts, the only way to identify failure to implement Resident care plan requirements would be for the DON to notice discrepancies during rounds. Resident #4 Record review on 11/17-20/14 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 11/18-20/14 of the Resident's comprehensive care plan revealed interventions of .Furniture removed from (Resident #4s) room except for bed and dresser for safety .Hipsters or padded bike shorts on while awake .Staff will remove obstacles from (Resident #4s) path when she is scooting . Review on 11/18-20/14 of Resident #4s CORP-Resident Plan Report, no date, revealed the staff were to remove any obstacles from the Resident's path when ambulating and items were to be removed from Resident's room except for bed and dresser. Record review on 11/18-20/14 of Resident #4s Progress Note - Nursing, dated 11/15/14, revealed the Resident was ambulating in her room with staff and stumbled on a fall mat, which was in front of her, causing the Resident to fall on her knees. Random observations of the Resident's room from 11/17-20/14 revealed a blue fall mat flat on the floor in various areas of the room. Random observations on 11/19/14 from 8:15 - 8:45 am in the Resident's room revealed Resident #4 was scooting with no hipsters or bike shorts in place. Further observation revealed the Resident had repeatedly bumped into a wheelchair and two laundry baskets located next to a dresser. During an interview on 11/19/14 at 9:00 am, LN #3 confirmed Resident #4's care plan stated nothing was to be in the room except a bed and dresser. The LN confirmed the presence of extra items impeded the Resident's mobility in the room. In addition, LN #3 confirmed the Resident was out of bed without the required hipsters as identified by the care plan. Resident #9 Record review on 11/17-20/14 revealed Resident #9 was admitted to the facility with a [DIAGNOSES REDACTED]. Record review on 11/17-20/14 of the Resident's comprehensive care plan, last updated 11/6/14, revealed outcomes .Alteration in communication r/t (related to) hearing loss .(Resident #9) will wear her hearing aid as tolerated while awake. Additional review revealed .Staff will assess (Resident #9) daily to ensure she is wearing her hearing aid . During an observation on 11/18/14 at 9:23 am, the DON attempted to introduce the Resident to the Surveyor. The Resident had difficulty hearing the DON because the Resident did not have a hearing aid in place. During an interview on 11/18/14 at 9:25 am, the DON confirmed the Resident should have been wearing a hearing aid. Policy review on 11/17-20/14 revealed Comprehensive Care Plan, dated 8/2/14, .The care plan shall describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . | 2018-05-01 |
| 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 on 11/17-20/14 revealed Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of Resident #8s Nursing Progress Notes, dated 11/13/14 to 11/17/14 revealed the hot pads were utilized for the Resident on 11/13/14, 11/16/14 and 11/17/14. Hydrocollator Observation of the PT room on 11/19/14 at 2:00 pm revealed a hot pad system that heated pads to 165 degrees in water. One thick, blue cover made for the hot pad was present next to the machine. During an interview on 11/19/14 at 2:40 pm NA #1 stated the hot pads were used for residents comfort and could be wrapped in regular towels before being placed on the residents. During an interview on 11/19/14 at 2:55 pm the DON stated the process for the use of the hot pad system was: Use tongs to lift the hot pads from the machine; Place the pad on the blue cover made specifically to be used with the heated pads; Secure the 3 strips of Velcro around the edges (to ensure the hot pad does not fall out and touch the resident's skin); and Place on the resident as needed for comfort. The DON stated the hot pad should be wrapped in the thick blue cover prior to being placed on a resident and not just wrapped in a towel. During an interview on 11/19/14 at 2:56 pm LN #5 stated physical therapy, occupational therapy or restorative will order the hot pads to be used on the Residents. In addition, the LN confirmed that Resident #4 did not have an order for [REDACTED]. During an interview on 11/19/14 at 4:30 pm the DON stated the facility did not have documentation of education for staff regarding the use of the hot pad system or a written procedure for the safe use of the hot pad system. During an interview 11/19/14 at 4:32 pm LN #5 stated the pads should be applied for 30 minutes and a skin assessment should be conducted after the removal of the hot pad. During a demonstration on 11/19/14 at 4:50 pm the DON demonstrated the preparation of the hot pad for use on Residents. When placed on the arm of this Surveyor, the skin on the Surveyor's arm under the hot pad turned red in less than a minute. The RD used a thermometer to measure the temperature of the hot pad wrapped in the thick blue cover and the side placed against the Surveyor's arm registered 136 degrees. During examination of the hot pad wrapped in the blue cover, the Surveyors identified the hot pad easily slipped out between the velcro closures, leaving no coverage of the hot pad. The pad then had the potential to be placed directly on a resident's skin. During an interview on 11/19/14 at 5:30 pm, CNA #1 stated if the blue cover made for the hot pad system was not available, she would wrap the hot pad in a regular bath towel. The CNA stated she was unsure how long to leave the hot pad in place on a resident's skin. During an interview on 11/19/14 at 5:32 pm, NA #1 stated the hot pads could be wrapped in a regular bath towel and placed on the resident's skin. The NA stated she was unsure how long to leave the hot pad in place and did not document the appearance of the resident's skin the one time I did use (the hot pad) on a resident. Review of the Hydrocollator User Manual, not dated, revealed to Constantly monitor HotPac application to ensure that the skin is not becoming too hot. Damage to skin can occur from exposure to extreme heat .DO NOT apply over insensitive skin or in the presence of poor circulation . Review of the FDA website at http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDeviceSafety/ucm 8.htm, accessed on 12/01/14 , revealed Heating Devices: How to Avoid Burns By Joan Ferlo Todd, RN, BSN Nurse-ConsultantFood and Drug Administration Center for Devices and Radiological Health, Rockville, Md. Orginially Published: 1/10/1997 A patient with arthritis suffered a second-degree burn to the hip after receiving treatment with a heating pad for pain. Set at low, the heating pad was left on for less than 20 minutes with the patient lying on top of the pad. Later testing showed that the pad was working properly and met the manufacturer's specifications. What went wrong? Therapeutic heating devices, such as heating pads, microwavable hot pads, and hot-water bottles, although generally safe, can cause bums. Most burns result from improper use or use with inappropriate patients, such as infants and elderly patients. The severity of the burn is influenced by factors such as heat intensity, length of application, and the patient's age, medical history, and ability to sense pain. What precautions can you take? Follow these do's and don'ts to keep your patient safe when using heating devices: DO inspect the device before each use to ensure it's in proper condition. DO read directions and contraindications for use. DO use a protective cover. DO place the pad or pad on top of, not underneath, the patient. DO assess skin integrity frequently and adjust the therapy interval according to the patient's skin tolerance-no longer than 15 to 20 minutes. DON'T use the device on someone who's sleeping or unconscious, an infant, or a patient with altered mental status or decreased skin sensation (such as people with diabetes or compromised skin circulation). DON'T use pins to fasten the device in place. DON'T use with ointments or salve preparations containing heat-producing ingredients. DON'T use electrical heating devices in an oxygen-enriched environment or near oxygen-emitting equipment. In Summary 1) Review of the manufacturer's instructions revealed the facility failed to follow the instructions for using hot pads on an older population of residents with compromised skin integrity; 2) facility staff were not trained specifically on how to use the hot pads; and 3) facility staff were inconsistent in their individual use of the hot pads. These failed practices resulted in an Immediate Jeopardy to the health and safety of the facility's resident population. #2 Environmental Safety Activity Kitchen Observations during the initial tour on 11/17/14 between 8:45 am - 10:00 am in the activity kitchens on both the 200 and 300 side revealed, a toaster that was plugged in and when checked for heat, it was working. In addition, the oven on both sides began doing a pre-heat and felt warm to the hand when turned on. An interview during the initial tour on 11/17/14 with LN #3 stated Resident #s 2, 3, 4, 13, 15 wandered within the units. Observations on 11/17/14 at 9:50 am, of the 200 side, revealed an unlocked drawer below the fish tank that contained an open, 2 fluid ounce container of Clear Water. The product bottle listed the active ingredient potassium permanganate. Review on 12/5/14 of the FDA website revealed, Potassium permanganate is a strong oxidizing agent, a highly caustic, tissue-destroying chemical, and a poison. Random observations on 11/17-18/14 in the activity kitchens on the 200 and 300 unit, revealed half full containers of Kirkland, lemon fresh dishwasher soap pods, in the unsecured cupboards below the sink. The label on the container stated Caution harmful if swallowed. During an interview on 11/19/14 at 8:15 am the DON confirmed the findings of the unsecured Clear Water bottle used for the fish tank and the Kirkland dishwashing pods should be locked and not accessible to the Residents. In addition, she stated the ovens were supposed to be turned off with a key and the toaster was a risk to the residents for burns because the two activity kitchens did not have locked doors. Lint Random observations on 11/17-18/14 in the dryer room on both the 200 and 300 side, revealed the large commercial dryers had large layers of multicolored lint in the lint trap. There was lint build-up on the floor and behind the dryers in both the 200 and 300 side dryer rooms. During an interview on 11/18/14 at 9:55 am EVS #1 stated the lint screens on the large commercial dryer was supposed to be cleaned at the end of each day and the lint screen in the small dryer was supposed to be cleaned after each dryer load. During an interview on 11/19/14 at 2:15 pm the Administrator stated the lint traps on the large dryers should be free of lint at the end of each day because of the fire hazard. Trip Hazards Observations during the initial tour on 11/17/14 between 8:45 am - 10:00 am on the 300 side revealed the carpet transition strip had multiple splits and tears in addition to being high enough to create a trip hazard. Observations on 11/18/14 at 10:30 am on the 200 side revealed multiple attempts by Resident #3 to get the wheelchair over the carpet transition strip before being assisted by NA #1. In addition, the carpet transition strip on the 200 side was high enough to create a trip hazard. During an interview on 11/19/14 at 9:45 am NA #1 stated the carpet transition strips were too high and some residents did need help getting over them if they were in a wheelchair. During an interview on 11/19/14 at 2:15 pm the Administrator stated the carpet transition strips had been identified as being worn on the 300 side and created a trip hazard on both the 200 and 300 sides. | 2018-05-01 |
| 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 microwave, holding a spoon filled with soup from the bowl close to her face and then placing the bowl of soup in front of the Resident. During an interview on 11/19/14 at 8:25 am, LN #1 stated residents can be offered fish soup as an alternative when they do not want the entree provided at meal times. The LN was asked to describe the process if a resident wanted the fish soup. The LN stated the frozen soup would be taken from the activity kitchen freezer, heated in the microwave for 5 minutes, allowed to cool for 2 minutes and then given to the resident. The LN stated she would identify if the soup was too hot by placing it close to her face before giving the soup to a resident. When asked if a thermometer was available to check the temperature of the heated soup, the LN stated a thermometer should have been used when the soup was prepared for Resident #2 on 11/18/14, but was not available in the activity kitchen. During an interview on 11/20/14 at 10:00 am, the DON stated the facility did not have a policy or procedure for heating frozen soup for the residents. Record review on 11/19/14 at 11:50 am of the facility's Dietary Department General HACCP Plan, dated 5/14/11, revealed All cooked foods prepared by this facility will be monitored to see that they meet the commonly accepted safe temperatures for each particular product .When holding hot food for service you should check temp (temperature) regularly to leave time for corrective action if necessary .All hot foods on the serving line must be held at 135f (degrees Fahrenheit) or above . Review of the policy manual used by the dietician Idaho Diet Manual, dated 2010, revealed Ensure foods are served at the appropriate temperatures. Hot foods should be hot . Review of the Food and Drug Administration Food Code, dated 2013, revealed food received hot shall be at a temperature of 57 C (degrees Celsius) (135 F (degrees Fahrenheit)) or above . | 2018-05-01 |
| 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 |
| 975 | YUKON KUSKOKWIM ELDER'S HOME | 25037 | 1100 CHIEF EDDIE HOFFMAN HWY, PO BOX 528 | BETHEL | AK | 99559 | 2014-11-20 | 371 | F | 0 | 1 | 00JH11 | Food Procurement Based on observation, interview, and record review the facility failed to procure food given to residents from a Federal, State or local approved source. This failed practice placed all residents (base on a census of 18) eating food from the kitchen at risk for foodborne illnesses. Findings: Kitchen Based on observation and interview the facility failed to ensure: 1) the kitchen surfaces were clean and free of dust, dirt and food debris; and 2) food stored in the facility's refrigerator, freezer and dry storage was properly dated, labeled and/or sealed. These failed practices had the potential to place all residents (base on a census of 18) eating food from the kitchen at risk for food borne illness or contamination of food. Findings: Food Procurement Observations during a tour of the facility on 11/17/14 at 1:30 pm revealed posters on display entitled Donated Foods We Can Accept and Foods Not Allowed. During an interview on 11/18/14 at 2:50 pm the Administrator stated the facility had: Accepted fish from a community source that had not been approved by Federal, State or local authorities; Processed the fish in the facility kitchen; and Provided the fish to the residents of the facility. The Administrator stated the donated food was accepted for processing in the facility after examination by one of the kitchen staff. Record review on 11/17-20/14 of Donated Food Log, dated 6/16/2014, revealed 2 identified community donations of food to the facility for processing and use by the residents: fish on 6/17/14; and Fish (King & Silver) on 9/10/14. Neither entry included the Location food was killed and Date food was killed or gathered as required on the facility form. Main Kitchen Observations of the facility's main kitchen on 11/17/14 from 8:55 am to 9:09 am revealed: -Counters stained and soiled with food debris; -Black plastic tub storing pot lids contained a large amount of food debris in the bottom; -Blast chiller on the lower shelf and the overflow trap contained food debris; -Lower oven contained food debris on lower shelf; -Plate warmer contained brown sticky substance and food debris; and -One 4 liter container of instant mashed potatoes was unsealed and open to the air. During an interview on 11/17/14 at 9:11 am, EC confirmed the kitchen equipment should be clean and free from food debris. Observations of the facility's main kitchen refrigerator on 11/17/14 from 9:15 am to 9:30 am revealed: -Two 5 lb. bags of mozzarella cheese - expired 2/18/14; -One 5 lb. bag of parmesan cheese contained mold; -One 5 lb. bag of 3-cheese was unsealed and open to the air; -One block of American sliced cheese was unsealed and open to the air; and -Three green bell peppers were wrinkled and soft. Observations of the facility's main kitchen freezer on 11/17/14 at 9:30 am revealed large amounts of food debris on the freezer floor. Observations of the facility's dry storage on 11/17/14 on 9:40 am revealed a bag of cereal unsealed and open to the air and one large bag of rice unsealed and open to the air. During a second interview on 11/17/14, at 9:40 am, EC confirmed that food items stored and used by the facility should be sealed, free from mold and used before their expiration dates. During an interview on 11/18/14 at 3:48 pm, EC stated there was no cleaning schedule other than the 10 Commandments that were to be completed daily by the kitchen staff. Record review on 11/18/14 at 3:48 pm of the The 10 Commandments, not dated, revealed .sweep & mop floors .make sure all foods is labeled and dated! Additional review of the daily cleaning task list did not include the cleaning of the equipment. Record review on 11/19/14 at 11:50 am of the facility's Dietary Department General HACCP Plan, dated 5/14/11, revealed .Throw away food that is expired passed its expiration date .throw away food that has growth of mold . In addition, the plan continued to state Equipment .can be both dangerous and also have potential for causing food borne illness if not properly .cleaned. Further review of the Dietary Department General HACCP Plan on 11/19/14 revealed Daily and scheduled Cleaning .Proper cleaning is our first line of defense against food borne pathogens and other contamination. Therefore constant attention to cleanliness must be one of our highest priorities. Review of the Food and Drug Administration Food Code, dated 2013, revealed FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminates EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch .the NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. | 2018-05-01 |