Kabul Nursing Homes Inc

Inspectors wroteBased on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative for the ombudsman (resolves complaints for residents of long term care facilities) contact information, the contact information for the agency responsible for protective and advocacy of individuals with mental disorders, contact information for the protection and advocacy of individuals with development disabilities, and appeal information for two residents (Residents #5 and #10) out of two sampled residents. The facility also failed to provide a discharge summary to the resident which includes a recapitulation of the resident's stay, and a final summary of the resident's status for one resident (Resident #48) out of one sampled resident. The facility's census was 39. Review of the facility's policy titled, Bed Hold Policy, dated 11/08/22, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff utilized safe transfer techniques for one resident (Resident #28) out of one sampled resident when staff failed to use a gait belt (an assistive device placed around a person's waist to provide caregivers with a secure grip when lifting or moving) appropriately when lifting and repositioning one resident in wheelchair. The facility census was 39. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for one resident (Resident #15) out of three sampled residents. The facility census was 39. The facility did not provide a policy regarding dementia care.1. Review of Resident #15's medical record showed:- admission date of 07/02/25;- Diagnoses of vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), moderate, with other behavioral disturbance, and senile degeneration of the brain (progressive decline in cognitive functions associated with old age). [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records for the receipt and disposition of all controlled medications in sufficient detail to enable an accurate reconciliation of the controlled medications to ensure nursing staff signed at the beginning and the end of each shift for two medication carts out of three sampled medication carts. The facility's census was 39. The facility did not provide a policy regarding the reconciliation of narcotics. 1. Review of the North Hall Medication Cart Controlled Medication Package Count Log, dated July 2025, showed: - No documented narcotic quantity for 26 missed opportunities out of 93 opportunities; - No signature and/or initials by the nurse or Certified Medication Technician (CMT) for 46 opportunities out of 186 opportunities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in a safe and effective manner when staff left the medication cart unlocked and unattended. This had the potential to affect all residents. The facility census was 39. Review of the facility's policy, Medication Administration, dated 04/25/24, showed:- Medication will be administered safely and accurately to residents for whom they are prescribed in accordance with current standards of practices;- Medication carts must be kept locked when not in use or in plain sight.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #17) out of one sampled resident. The facility failed to to follow physician's orders for one resident (Resident #20) out of 20 sampled residents. The facility failed to obtain a physician's order, evaluate and assess the resident's abilities and provide education for self-care of a colostomy (a surgical procedure where the colon is diverted to an artificial opening in the abdomen) for one resident (Resident #31) out of two sampled residents. The facility also failed to obtain a physician's order and provide trapeze (a bar above the bed designed to assist the patient with a means of self-help to change positions in bed) assessments for one resident (Resident #34) out of one sampled resident. The facility census was 43. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were administered. There were 26 opportunities with three errors made, for an error rate of 11.54%. This practice affected three residents (Resident #2, #20, and #29) of the seven sampled residents. The facility census was 43. Review of the facility's policy titled, Medication Administration, last reviewed 04/25/24, showed: - Medication will be administered safely and accurately to residents for whom they are prescribed in accordance with current standards of practices; - Staff will observe the seven rights in giving each medication: right resident, right time, right medication, right amount, right method/route, right documentation, and right to refuse treatment; - Read medication label three times before administering medications: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications in a safe and effective manner when staff left the medication cart unlocked and unattended. This had the potential to affect all residents. The facility census was 43. Review of the facility's policy titled, Medication Administration, last revised 04/25/24, showed: - Medication will be administered safely and accurately to residents for whom they are prescribed in accordance with current standards of practices; - Medication carts must be kept locked when not in use or in plain sight. 1. Observation on 06/26/24 at 11:17 A.M., of the insulin administration for Resident #31 showed: - Licensed Practical Nurse (LPN) D locked the medication cart, entered the resident's room, and performed the blood sugar reading; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain adequate infection control practices to prevent the transmission of infection by failing to ensure proper infection control practices during a medication pass when the staff touched medication with their bare finger and allowed medication to touch the top of the unclean medication cart for two residents (Resident #2 and #20) out of seven sampled residents. The facility failed to ensure the appropriate placement of an indwelling catheter (a flexible tube inserted into the bladder to drain urine) tubing and drainage bag for two residents (Resident #24 and #95) out of three sampled residents. The facility failed to maintain proper infection control practices during incontinent care for one resident (Resident #34) out of four sampled residents. [...]

Inspectors wroteBased on observation, and interview, the facility failed to provide a safe environment for the residents and staff by not removing miscellaneous items on top of the overbed light fixtures. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 43. The facility did not provide a policy regarding a safe environment. 1. Observation on 06/25/24 at 10:04 A.M., of room [ROOM NUMBER] showed three 12 inch (in.) stuffed animals on top of the light fixture on the wall near the window and three stuff animals on the light fixture near the door. 2. Observation on 06/25/24 at 10:15 A.M., of room [ROOM NUMBER] showed one 8 in. x 10 in. picture frame on top of the light fixture above the bed next to the window. 3. Observation on 06/28/24 at 8:20 A.M., of room [ROOM NUMBER] showed four 10 in. and four 6 in. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for one resident (Resident #57). The facility census was 45. Record review of the facility's policy entitled Discharge to Hospital or Other Facility, dated 3/31/22, showed the following information: -Order received from attending physician indicating discharge destination and mode of transportation; -Resident/Responsible Party to be notified of order of discharge. Social Service Representative to be notified to assist with discharge; -Complete a Transfer Form to include resident's name, social security number, Medicare/Medicaid numbers, condition of resident's skin, personal belongings being sent with resident. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's choice of code status (the level of medical interventions a person wishes to have started if their heart or breathing stops) was clearly and consistently noted throughout the resident's medical record for one resident (Resident #40). The facility census was 45. Record review of the the facility's policy titled Do Not Resuscitate Order, revised [DATE], showed the following: -Upon admission of a resident to the facility, the social service designee will obtain written wishes regarding cardiopulmonary resuscitation; -A copy of the code information form will be placed in the residents chart; -A physician's order will be obtained; -A red dot sticker will be placed on the resident's name tag at the resident's door; [...]