Kyakameena Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) care plans was revised and updated. The facility also failed to complete post-fall assessment risk and conduct an IDT meeting following each fall. This failure resulted in Resident 1's fall care plan not being updated to include post-fall interventions, which placed Resident 1 at increased risk for accidents and injuries. During a review of Resident 1's admission Record (AR), dated 01/13/26, the AR indicated, Resident 1 had a diagnosis of Adreno myeloneuropathy (condition that makes a person's muscles weak and have walking difficult), muscle weakness, and difficulty in walking. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and revise individualized fall-prevention interventions for one of three sampled residents (Resident 1), with severe cognitive impairment, impaired mobility, and a documented history of recurrent falls. This failure resulted in Resident 1 sustaining a fall and without additional individualized fall-prevention interventions following recurrent falls, placed Resident 1 at continued risk for additional falls, accidents and injuries. During a review of Resident 1's admission Record (AR), dated 01/13/26 with original admission date on 7/23/2024, the AR indicated, Resident 1 had a diagnosis of Adreno myeloneuropathy (condition that makes a person's muscles weak and have walking difficult), muscle weakness, and difficulty in walking. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) received a written notification about the room change when Resident 1 was moved to another room. This failure resulted in violation of Resident 1's rights to receive written notice of the room change, including the reason for the change, before the resident's room in the facility was changed. During a review of Resident 1's admission Record, dated 12/17/25, the admission Record indicated Resident 1 was admitted in the facility on 10/10/25. [...]

Inspectors wroteBased on interview and record review, for four (Resident 1,10, 19, and 27) of five sampled residents, the facility failed to ensure quarterly Minimum Data Set assessments (MDS - a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) were completed not less frequently than once every three months according to the regulation. This failure had the potential to result in delayed assessment of residents' needs, goals of care and inability to monitor each residents' progress over time. During a review of resident 1,10, 19, and 27's MDS assessment records the following quarterly MDSs were not completed every three months:Resident 1' MDS assessment indicated the last quarterly MDS assessment was completed on 10/28/25 over 120 days. [...]

Inspectors wroteBased on interview and record review, for four (Resident 1,10,19, and 27) of five sampled residents, the facility failed to electronically transmit accurate and complete Minimum Data Set (MDS -a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), data to the CMS system within 14 days after completion of resident's assessment. Definition: CMS - The Centers for Medicare & Medicaid Services provides health coverage through Medicare and Medicaid-a government national health insurance program that provided health insurance for adults and children with limited income and resources. These failures had the potential to result in the delay of assessment of residents' needs, goals of care and inability to monitor each resident's progress over time. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately code three out of four sampled resident's (Resident 27, 31 and 49) Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) when:1. For Resident 49 section B was not coded accurately for vision.2. Facility inaccurately coded No to No natural teeth or tooth fragments when Resident 27 has no natural teeth. This failure resulted in inaccurate reflection of Resident 27's oral/dental status and had the potential to affect Resident 27's nutrition, oral care, and dietary needs.3. Resident 31's hospice care item was incorrectly coded on MDS to reflect Resident 31's choice. These failures resulted in an inaccurate reflection of Resident 27 and 49's clinical condition which had the potential to affect their health care outcomes. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to complete and update the care plan in a timely manner to reflect residents' care needs for two of two investigated residents when:1. For Resident 48 facility did not update care plan to accurately reflect the resident's required transfer method. This failure resulted in Resident 48 being transferred incorrectly and sustained a left lower leg fracture.2. For Resident 29 facility did not develop comprehensive care plan within 7 days of completion of assessment to address risks of elopement and Interdisciplinary Team did not review Resident 29 episodes of elopement from the facility with appropriate interventions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 30 and 48) were provide toenails care and treatment, in accordance with professional standards of practice, when: 1. For Resident 30, facility did not provide appropriate toenails care and treatment for thick, long, brownish black toenails.2. For Resident 48, facility did not provide toenail fungal treatment and toenail trimming for 15 months. This failure resulted in Resident 30 and 48's overgrowth of toenails and increased risk for injury and infection.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 29) received adequate supervision to prevent accident hazards when: Resident 29 eloped from the facility and was found by the police in another town. Resident 29's incidents of elopements were not reported to the state department as required by federal or state regulations. Elopement is a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision. This failure caused Resident 29 to continue to elope and had the potential to result in heat or cold exposure, dehydration or struck by motor vehicle. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a performance review for three out of three certified nursing assistants (CNA 2, 3, 4) at least once every 12 months. This failure had the potential for a lack of training for any potential deficiencies identified during the performance review process. During a review of personnel files, indicated CNA 2, 3, 4, hired 3/25, 2/22, 11/24 respectively, had no performance review for year 2025. During a concurrent interview and record review on 11/20/25 at 9:02 a.m. with the Director of Staff Development (DSD), CNA 2, 3, 4's CNA annual skills checklist dated 9/11/25, 10/16/25 and 11/4/25 respectively was reviewed, the DSD stated CNA 2, 3, 4 only had annual skills check list. The DSD stated there was no other form the facility had provided for the performance review. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its Legionella Water Management Program policy and procedures when facilitydid not have a water management program. This failure had the potential risk for Legionnaires' disease, and unsafe water usage. During an interview on 11/21/25 at 8:55 a.m. with Administrator (Admin), Admin stated facility did not have a program for managing water systems to prevent Legionnaires' disease and had not tested water for legionella. During a review of the facility's policy and procedure (P&P) titled, Legionella Water Management Program, revised September 2022, the P&P indicated, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella.

Inspectors wroteBased on interview and record review the facility failed to ensure one (Resident 4) of seven sampled residents' rights was free from misappropriation of property and exploitation when Resident 4's missing pants and tops were not replaced or reimbursed. This failure had the potential to cause Resident 4 emotional distress. During a review of Resident 4's admission Minimum Data Set (MDS- a federally mandated resident assessment and care guide tool), dated 7/13/25, the MDS indicated Resident 4's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 4's score was 13 meaning intact cognition. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 3 and Resident 4) Preadmission Screening and Resident Review (PASRR) were screened accurately and referred to the appropriate state mental authority for Level II PASRR evaluation and determination when Resident 3 and 4 with diagnosis of schizophrenia, bipolar and major depression were screened and documented as not having serious mental illness.(PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care). This failure had the potential to prevent residents from receiving appropriate required mental health services. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure one of three sampled residents (Resident 49) was provided appropriate treatment and services to maintain or improve functional mobility to carry out the activities of daily living, when: For Resident 49 facility did not provide Restorative Nursing Services (RNA) treatment for decline in functional mobility as ordered by the physician. RNA is restorative nursing care consisting of nursing interventions to help promote optimal safety and independence. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 49) was assisted to receive proper vision treatment to maintain vision when Resident 49 was not assisted with referral for cataract surgery as ordered by the doctor. This failure had the potential to cause Resident 49 decline in vision, blindness and emotional distress. During a review of Resident 49's Minimum Data Set (MDS- a federally mandated resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 8/21/25, the MDS indicated Resident 49's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). [...]

Inspectors wroteBased on interview and record review, for three of three sampled residents (Resident 9, 19, and 55) the facility failed to have a formal written agreement with dialysis provider for residents needing dialysis (a treatment for kidney failure to remove waste products and excess fluids by external filtration of blood), that outline responsibilities for care coordination, communication, and emergency preparedness. This failure had the potential for Residents 9, 19 and 55 to not receive consistent care that meets professional standards. During a review of Resident 19's admission Record (AR) dated 11/21/25, the AR indicated Resident 19 was admitted on [DATE] with principal diagnosis of end stage renal disease (ESRD- is the final stage of kidney failure, where the kidneys are no longer able to function adequately to keep the body healthy). [...]

Inspectors wroteBased on observation and record review, the facility had six resident rooms (room [ROOM NUMBER], 27, 29, 31, 33, and 35) that accommodated more than four residents in each room. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings.

Inspectors wroteBased on observation, interview and record review, the facility had six resident rooms (room [ROOM NUMBER], 25, 27, 29, 31 and 33) with multiple beds that provided less than 80 square feet 9sq ft) per resident who occupied these rooms. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of the residents' belongings. During an observation on 11/20/25 at 11:11 a.m. the following rooms had corresponding square footage (sq. ft.0 per bed were identified: Room Activity Room Size Floor Area23 Rt room [ROOM NUMBER].3 sq. ft 78.42 sq. ft/bed25 Rt room [ROOM NUMBER].3 sq. ft 78.42 sq. ft/bed27 Rt room [ROOM NUMBER].6 sq. ft 77.59 sq. ft/bed29 Rt room [ROOM NUMBER].6 sq. ft 77.59 sq. ft/bed31 Rt room [ROOM NUMBER].6 sq. ft 77.59 sq. ft/bed33 Rt room [ROOM NUMBER].6 sq. ft 77.59 sq. [...]

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to act upon the Consultant Pharmacist's recommendation for 2 (Resident #2 and Resident #32) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, interview, document review, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. The facility had 4 medication errors out of 26 opportunities, which yielded a medication error rate of 15.38% for 1 (Resident #40) of 4 residents observed for medication administration.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to transcribe a physician's order for wound care for 1 (Resident #2) of 14 sampled residents.

Inspectors wroteBased on observation, record review, interview, and document review, the facility failed to ensure enhanced barrier precautions were implemented for 1 (Resident #26) of 14 sampled residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure 6 (Rooms 26, 27, 29, 31, 33, and 35) of 16 resident bedrooms in the facility did not have more than four residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 6 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 16 resident rooms in the facility.

Inspectors wroteBased on interview and record review, the facility failed to administer the medication Tramadol 50 mg (medication used to help relieve moderate to moderately severe pain) as per physician ' s order for one (Resident 1) of three sampled residents. This failure resulted in Resident 1 receiving a double dose of medication within 12 hours and placed Resident 1 ' s health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision and maintain safety to prevent an avoidable accident for one of three sampled residents (Resident 1) when Certified Nurse Assistant (CNA) 1 provided Resident 1 two instant hot packs (a chemically activated disposable pack squeezed to pop an inner fluid bag and shaken to produce heat) without a physician order or protective barrier. Resident 1 placed the hot packs directly on her abdomen and was not supervised or reassessed during the application. This failure caused a second-degree burn (a burn that damages the outer layer [dermis] and second layer [epidermis] of skin) on Resident 1's lower abdomen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards for care for one of three residents (Resident 1) when Certified Nurse Assistant (CNA) 1 provided Resident 1 two instant hot packs (a chemically activated disposable pack squeezed to pop an inner fluid bag and shaken to produce heat) without a physician order or protective barrier. Resident 1 placed the hot packs directly on her abdomen and was not supervised or reassessed during the application. This failure caused a second-degree burn (a burn that damages the outer layer [dermis] and second layer [epidermis] of skin) on Resident 1's lower abdomen.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures (P&P) that prevent abuse, neglect, and exploitation of residents when registry Certified Nursing Assistants (CNAs) were not given abuse training/orientation prior to working with residents. This failure had the potential to result in abuse of residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to serve two residents (Resident 51 and 49) of 57 sampled residents diets prescribed by a physician. This failure had the potential for two residents, Resident 51 and 49, to receive inadequate calories and/or nutrients contraindicated for a prescribed diet leading to nutritional related health issues.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to store food, brought into the facility by visitors, safely for residents. The facility also failed to have a policy to show food would be stored safely for residents upon request. This failure had the potential for decreased food intake by residents who preferred to eat food brought in from outside sources for 56 residents who were able to eat food by mouth out of a facility census of 57.

Inspectors wroteBased on interview and record review the facility failed to provide necessary treatment and services to promote healing and prevent infection for one (Resident 51) of six sample residents when the facility staff did not provide the wound treatment on multiple shifts for Resident 51's multiple wounds. This deficient practice could result in worsening of Resident 51's existing pressure ulcers.

Inspectors wrote2. During a concurrent observation and interview on 6/8/21, at 12:20 p.m., with the Director of Nursing (DON), in the Medication Storage Room, an uncapped and undated multi-dose vial (MDV) of Aplisol (used in skin tests to help diagnose tuberculosis) was found in the refrigerator. During an observation, on 6/8/21, at 12:30 p.m., with the DON, the uncapped and undated MDV of Aplisol was compared side-by-side to the capped MDV of Aplisol. The fluid level was lower in the uncapped and unlabeled MDV compared to the capped MDV, which indicated the vial had been opened. During an interview on 6/9/21, at 4 p.m., the DON stated she cannot find a facility policy and procedure for dating opening MDV. [...]

Inspectors wroteBased on observation, interview and facility document review, the facility failed to: 1. Ensure the Registered Dietitian (RD) supported the Dietary Supervisor (DS) in maintaining a clean and safe kitchen environment; 2. Ensure the Dietary Supervisor (DS) maintained a clean kitchen and clean equipment on a day-to-day basis; and 3. Involve the RD in the quality assurance and performance improvement (QAPI; a data driven and proactive approach to quality improvement), when food and nutrition services was involved. This failure had the potential for contamination of food leading to foodborne illness for a highly susceptible population of 56 residents who received food from the kitchen out of a facility census of 57.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure competency of staff in the functions of the food and nutrition service when: 1. [NAME] 2 did not follow and properly document cooldown procedures for a time temperature control for safety (TCS) food (food that is more likely to grow harmful bacteria if not stored appropriately leading to foodborne illness); 2. [NAME] 1 did not appropriately demonstrate how to check the quaternary ammonia strength to clean food contact and nonfood-contact surfaces; 3. [NAME] 1 did not follow the menu for residents on a renal diet; and 4. Dietary Assistant 2 (DA2) did not appropriately demonstrate how to check the chlorine strength for the dish machine. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe and sanitary environment for four (Residents 21, 26, 36, and 255) of 57 sampled residents, as evidenced by: 1) Nurse did not disinfect and clean BP cuff between using the BP cuff on residents 26, 36, 255 2) Nurses did not follow manufacturer's directions for SaniWipe use on medication baskets 3) Certified Nursing Assistant did not perform hand hygiene after doffing gloves and assisting a resident 4) The facility did not screen staff members for COVID-19 symptoms on 6/6/21 prior to providing care for the residents. . These failures had the potential to result in cross contamination and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident 6) of two sampled residents needs were accommodated when administrator (Adm) told him he was not allowed to smoke. This failure caused Resident 6 psychological distress.

Inspectors wroteBased on the observation, interview and record review the facility failed to provide a homelike environment when three (Resident 36, 51 and Resident 255) of five sample residents were complaining about the noise level at night. This failure had the potential to result in Resident 36 and 255 inability to sleep and feeling tired.

Inspectors wroteBased on observation, interviews and record review, the facility failed to follow its Grievances/Complaint policy and procedure to make prompt efforts to resolve a complaint for one (Resident 40) of 15 sampled residents when the facility did not follow up and resolve Resident 40's concerns regarding cold food. This deficient practice had the potential to cause emotional distress.

Inspectors wroteBased on interviews and record review the facility failed to ensure one (Resident 3) of six sampled residents received treatement to prevent further decline of range of motion when restorative nursing exercise was not provided as ordered by the physician. This deficient practice had the potential for Resident 3's range of motion to further decline.

Inspectors wroteBased on observation and interview, the facility had seven resident's rooms (Rooms A, B, C, D, E, F, G and H) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. This deficient practice had the potential to result inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings.