Klondike Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that one (Resident (R) 54) of two sampled residents who were reviewed for respiratory care were assessed for the ability to self-administer medications. Nursing staff left medication out for R54 to self- administer without an inter-disciplinary team first determining that the practice was clinically appropriate.

Inspectors wroteBased on interview, record review, and document review, the facility failed to transmit quarterly Minimum Data Set (MDS) assessments in a timely manner for two (Resident (R) 22 and R14) of two sampled residents reviewed for resident assessment. The MDS assessments were not transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of the MDS completion date.

Inspectors wroteBased on interview, record review, review of the facility's investigation, and the facility's policies, it was determined the facility's interdisciplinary team (IDT) failed to review and revise the comprehensive care plan with each assessment, including both the comprehensive and quarterly review assessments, to prevent falls for one (1) of twenty-two (22) sampled residents (Resident 9 (R9). R9 sustained twenty-two (22) falls in 2023, one (1) of which resulted in the resident experiencing a subdural hematoma, and a rib fracture during another one (1) of the falls. Review of Resident 9's Comprehensive Care Plan (CCP) revealed the facility care planned R9 for his/her risk for falls related to a history of falls prior to admission. The current interventions included staff to encourage R9 to keep his/her walker at a safe distance when ambulating throughout facility; [...]

Inspectors wroteBased on interview, record review, review of the facility's investigation and policies, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (2) of twenty-two (22) sampled residents (Residents 9 (R9) and Resident 10 (R10)). 1. R9 sustained twenty-two (22) falls in 2023, seventeen (17) of which were either unwitnessed, or the witness was not identified. The facility had incomplete information/documentation to help determine the root cause of R9's numerous falls. Three (3) of R9's falls in 2023 occurred between the hours of 12:00 AM and 4:00 AM, and were documented as related to R9's toileting needs. [...]

Inspectors wroteBased on interview, record review, review of the facility's investigation, and the facility's policies, it was determined the facility failed to protect residents from sexual abuse, for two (2) of twenty-two (22) sampled residents (Resident 3 (R3) and Resident 5 (R5)). On 08/07/2023 Resident 4 (R4) told R3 (his/her) stuff does not work, and R4 touched R3's knee. On 09/12/2023 R4 was observed with his/her hand on R5's buttock. On 11/15/2023 Resident 6 (R6) was observed with his/her hand on R5's breast.

Inspectors wroteBased on interview, record review, review of the facility's investigations and policies, it was determined the facility failed to implement the comprehensive person-centered care plan for one (1) of twenty-two (22) sampled residents (Resident #10 (R10). The facility care planned R10 with an intervention for using a mechanical stand-alone lift when being transferred from the bed to the wheelchair. However, on 06/20/2023, facility staff transferred R10 from the bed to the wheelchair without using a mechanical stand-alone transfer lift. As a result R10 sustained a laceration to his/her lower right leg which required transfer to a higher level of care for emergent treatment.

Inspectors wroteBased on interview, record review, and review of the facility's policy and nursing standards of practice, it was determined the facility failed to ensure care and services were provided in accordance with accepted standards of clinical practice for one (1) of twenty-six (26) sampled residents, Resident #6. On the morning of 10/04/2023, Certified Nursing Assistant/Certified Medication Technician (CNA/CMT) #1 and Registered Nurse (RN) #2 were administering residents' medications at the same time and might have administered Resident #19's medication to Resident #6. Resident #6 was transferred to the hospital Emergency Department (ED) for evaluation and observation of possible adverse effects.

Inspectors wroteBased on observation, record review, and interview it was determined the facility failed to ensure a comprehensive care plan was implemented for three (3) of the thirty-seven (37) sampled residents, Residents #10, #37, and #45. Resident #45 did not have a nutrition care plan related to a therapeutic diet. In addition the facility failed to initiate a comprehensive care plan for an identified area to the right heel and the left foot under the little toe for Resident #10 and the call light for Resident #37 was not working.

Inspectors wroteBased on observation, record review, and interview it was determined the facility failed to ensure that a resident who acquired a pressure sore on the foot received proper treatment to facilitate wound healing and not worsening of the wound for one (1) resident out of the thirty-seven (37) sampled residents. Resident #10 had a blistered on the right heel that had worsened and an unidentified pressure area on the bottom of the left foot under the little toe.

Inspectors wroteBased on observation, record review, and interview it was determined the facility failed to notify the physician of a worsening blister and the development of a new pressure area for one (1) out of the thirty-seven (37) sampled residents. Resident #10 had a blister on the right heel that had worsened and an unidentified pressure area on the bottom of the left foot under the little toe.

Inspectors wroteBased on interview, record review, and facility policy review it was determined the facility failed to ensure the activity department provided community outings to meet the interests of residents.

Inspectors wroteBased on interview, record review, and facility policy review it was determined the facility failed to ensure advance directives were in the clinical record for two (2) of thirty-seven (37) sampled residents, Resident #10 and #45.

Inspectors wroteBased on observation, interview, and facility policy review it was determined the facility failed to ensure a homelike environment for one (1) of thirty-seven (37) sampled residents, Resident #25. The plastic covering on Resident #25's over bed table was partially peeled off and exposed bare particle board surface underneath. In addition, observations of the Resident's smoking area revealed an unkept area containing cigarette butts and trash.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid REsident Assiessment Instrument 3.0 Manual, it was determined the facility failed to ensure the discharge Minimum Data Set (MDS) was transmitted within fourteen (14) days of completion for one (1) of thirty-seven (37) sampled residents, Resident #1.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a baseline care plan for one (1) of thirty-seven (37) sampled residents, Resident #3. Record review discovered no baseline care plan for Resident #3 initiated within forty-eight (48) hours of admission.

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to ensure one (1) of six (6) sampled residents was served thickened liquids according to the physician's order, Resident #45.

Inspectors wroteBased on record review and interview it was determined the facility failed to provide two (2) of three (3) Certified Nursing Aides (CNA) with a performance evaluations annually for Employee #2 and #3.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure the daily staffing information was posted for public view. Observations revealed the facility failed to post the staffing post on 09/06/19. Interviews with the Unit Manager and the Director of Nursing (DON) revealed the posted staff information was not completed for the week on 09/02/19 through 09/06/19.

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to ensure infection control policies were followed during a dressing change for one (1) of thirty-seven (37) sampled residents, Resident #10. Observations revealed staff failed to sanitize or provide a barrier to a table surface prior to placing dressing change supplies on the surface. Additionally, staff's hair fell into a soiled dressing just removed from Resident #10's buttock area.

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to ensure the call light was accessible and functional for one (1) of thirty-seven (37) sampled residents, Resident #37.