Klondike Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Klondike Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF657Jan 23, 2024

  Based 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. […]

• Actual harm, isolatedF689Jan 23, 2024

  Based 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. […]

• No harm, potential for more than minimal, isolatedF554Dec 20, 2024

  Based 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. The findings included: Review of the facility policy titled, Self-Administration of Medication Policy, effective 08/04/2024, revealed, Residents have the right to self-administer medication if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. […]

• No harm, potential for more than minimal, isolatedF640Dec 20, 2024

  Based 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. The findings included: Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, indicated, Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment Summary and all tracking or correction information. […]

• No harm, potential for more than minimal, isolatedF600Jan 23, 2024

  Based 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. The findings include: Review of the facility's policy titled, Abuse Prohibition, dated 10/24/2022, revealed the facility prohibited abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients. […]