Yukon Kuskokwim Elder's Home

Inspectors wroteBased on record review and interview, the facility failed to honor the rights of 17 residents (#s 1-17) out of 18 residents (total census) to be informed of, to participate in, or refuse the facility's decolonization program (a medical intervention aimed at eliminating antimicrobial-resistant microorganisms). Specifically, the facility did not notify the residents and/or their representatives of the decolonization program, the rationale and risks and benefits of the use of the following interventions: Chlorhexidine as a soap substitute used during showers, andMupirocin 2% topical ointment (used to treat bacterial skin infections) nasal swab for five days every other week. These failed practices denied all residents and their representatives, the opportunity to be informed of treatments applied to them and placed them at potential risk for adverse effects

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1) accurate grievance officer contact information was available to residents and representatives through required postings or individual notice, and2) clear instructions were provided on how to file and submit grievances, as grievance forms and admission information did not include submission instructions. These failed practices resulted in all residents (based on a census of 18) and resident representatives not having reliable access to the grievance process due to inaccurate grievance officer identification and unclear submission instructions. This placed residents at risk for delayed reporting and resolution of concerns and created a facility-wide system failure that limited residents' ability to access and utilize the grievance process

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was stored, labeled, and prepared in accordance with professional standards of practice for food safety. Specifically, the facility failed to ensure: 1) foods were properly labeled and dated; 2) expired foods were removed and discarded; and 3) food items were stored in a manner that maintained the required clearance from sprinkler heads to promote temperature distribution. These failed practices had the potential of causing or spreading foodborne illness to all residents (based on a census of 18), who received food from the kitchen .

Inspectors wroteBased on interview and record review, the facility failed to monitor the effectiveness of its performance improvement activities to ensure that improvements were sustained. Specifically, the facility had no evidence of tracking, trending or monitoring the decolonization (a medical intervention aimed at eliminating antimicrobial-resistant microorganisms) program. This failed practice placed all residents (based on a census of 18) at risk of receiving an ineffective decolonization intervention and at potential risk for adverse effects .

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide an ongoing program of individualized, meaningful activities designed to meet the interests and needs of residents for 2 of 18 sampled residents (Residents #7 and #10). Specifically, the facility failed to: 1. implement activities consistent with residents' assessed preferences and care plan goals,2. ensure activities were actually provided as scheduled, and3. maintain effective oversight and evaluation of the activity program. These deficient practices placed residents at risk for social isolation, decreased psychosocial well-being, and diminished quality of life

Inspectors wroteBased on interview and record review, the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Specifically, from the end of March 2024 through the end of May 2024, there was no full-time DON for the facility. This failed practice of not providing a full-time DON to oversee daily management and the monitoring of care practices, had the potential to place all residents (based on a census of 18) at substantial risk for subquality of care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that food was stored, labeled, and prepared foods in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) foods were labeled and dated; and 2) expired foods were discarded. These failed practices had the potential of causing or spreading foodborne illness to residents, based on a census of 18, who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed. Specifically, the facility failed to: 1) provide hand hygiene to 7 residents (#s 1, 5, 6, 9, 11, 12, and 13), out of 8 residents observed for hand hygiene before meals; and 2) ensure clean laundry of all (census of 18) residents was transported with appropriate measures to prevent contamination. This failed practice had the potential for the transmission of infectious disease and place residents at risk of acquiring communicable diseases.

Inspectors wroteBased on record review, observation, and interview, the facility failed to obtain the residents' consent for bedrails use and conduct accurate risks and benefits assessments for 7 residents (#'s 1, 2, 5, 6, 8, 12, and 167), out of 8 sampled residents and 2 unsampled residents (#s 11 and 13), reviewed for bedrails use. This failed practice had the potential to place the residents at risk of falls, entrapment, and other preventable accidents and potentially place residents at risk of feelings of isolation and helplessness.

Inspectors wroteBased on record review and interview, the facility failed to ensure 5 residents (#s 3, 5, 8, 9, and 14), out of 8 sampled residents, were examined in person by a medical provider within the required interval of at least 60 days, or no later than 10 days after the date the visit was required. This failed practice placed the residents at risk for substandard medical care. This further placed the residents at risk for exacerbation of health conditions.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the staff received education and training of the Q-Straint QRT-1 Series Wheelchair Restraint. This securement system was used to secure wheelchair bound residents during transport in the facility vehicle. Specifically, 1 resident (#67) out of 2 closed records obtained a superficial injury after his/her wheelchair tipped over in the facility's vehicle. This failed practice had the potential to affect all 8 out of 8 sampled residents and 2 unsampled residents who utilized wheelchairs for mobility at risk for injury during transportion in the facility's vehicle.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Monthly Regimen Review (MRR) were completed for 3 Residents (#s 3, 8, and 12), out of 8 sampled residents. This failed practice placed residents at risk for adverse consequences related to medication therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medical supplies in 1 medical supply storage room (room [ROOM NUMBER]), out of 2 medical supply storage rooms were removed. This failed practice placed all residents (based on census of 18) at risk for adverse effects and/or complications from receiving expired medical supplies.

Inspectors wroteBased on record review, interview, and observation, the facility failed to revise the care plan for 2 residents (#'s 6 and 117), out of 8 sampled residents. Specifically, the facility failed to: 1) include interventions to address edema (swelling of the legs) for Resident #6; and 2) include interventions to address a urinary tract infection (bladder infection) for Resident #117. This failed practice placed the Resident #6 at risk of exacerbation of edema and discomfort; and Resident #117 at risk for not receiving the necessary and/or appropriate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1) food was stored and/or labeled properly; and 2) food was stored away from chemicals. These failed practices had the potential of causing or spreading food-borne illnesses to all residents, based on a census of 17, who utilized the kitchen services.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident Council meetings were held regularly for those who wished to attend. Specifically, Resident Council meetings were not held for 12 consecutive months, citing declination without rationale for each month. This failed practice had the potential to limit the voicing of the residents' collective concerns, based on a census of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all medical supplies stored in the facility were not expired. This failed practice had the potential to affect all residents, based on a census of 17, with the potential to receive expired medical supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control protocols were followed for 3 residents (#'s 2, 3, and 15), out of 17 residents observed. These failed practices had the potential to place all residents, based on a census of 17, at increased risk for the development and transmission of communicable diseases and infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure a copy of 1 Resident's (#11) transfer to the hospital on 8/25/23 was sent to the Office of the State Long Term Care (LTC) Ombudsman, out of 1 resident reviewed for hospitalization. This failed practice had the potential to deny the resident access to an advocate who could have informed him/her of their rights and options after transfer or discharge with hospitalization.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 resident (#13), out of a 8 sampled residents, was assessed per the physician's orders after a fall with a potential head injury. This failed practice had the potential to delay treatment if the resident had a change in status.