Kemp Care Center

Inspectors wroteBased on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response for 3 of 3 confidential resident council meetings reviewed (04/18/25, 05/13/25, and 06/10/25) for grievances. The facility failed to ensure there was documentation of the facility's efforts to resolve concerns collected at the resident council meetings on 04/18/25, 05/13/25, and 06/10/25. This failure could place residents at risk of not having their concerns and grievances followed through, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 3 of 24 residents (Resident #53, Resident #40 and Resident #29) reviewed for ADL care. 1. The facility failed to ensure Resident #53 was showered or offered a shower as scheduled for June 2025. 2. The facility did not ensure Resident #40 received her shower as scheduled for June 2025. 3. The facility failed to provide Resident #29's showers as scheduled for June 2025. These failures could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 5 of 24 residents (Residents #1, #10, #29, #48, and #53) and 1 of 1 lunch meal reviewed for palatability. The facility did not provide palatable food served at an appetizing temperature or taste to residents who complained the food was cold and not seasoned. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the provider investigation report was turned into the state survey agency (HHSC) within 5 working days of the reported incident for Resident #1 This failure could place residents at risk for abuse and neglect. Findings Included: Record review of Resident #1's face sheet, dated 06/30/25, indicated he was a [AGE] year-old male, initially admitted to the facility on [DATE] and most recently re-admitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 24 residents (Resident #1) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #1's discharge MDS assessment dated [DATE] as return not anticipated instead of return anticipated. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to coordinate assessments with the PASARR program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 6 residents (Resident #32) reviewed for PASARR. The facility failed to ensure a Form 1012 Mental Illness/Dementia Resident Review was completed for Resident #32 after he was initially admitted to the facility on [DATE] to determine if he required further evaluation due to his mental illnesses. This failure could place residents at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 4 (Resident #44) residents reviewed. The facility failed to care plan Resident #44's oxygen (which is vital for the human body as it is used by cells to produce energy) therapy. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #51) of 1 resident reviewed for enteral nutrition. The facility failed to follow physician orders for Resident #51's enteral feeding tube to be administered at 53 ml/hr. This failure could place residents who had gastrostomy tube at risk for fluid overload.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 3 residents (Resident #48) reviewed for respiratory care. The facility failed to ensure Resident #48's CPAP (a device that keeps breathing airways open while sleeping) mask was stored properly. This failure could place residents requiring respiratory care at risk for shortness of breath, respiratory distress, or complications.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 5 residents (Resident #6) reviewed for pharmacy services. The facility failed to ensure ADON H administered Resident #6's Magdelay (magnesium chloride, combination medication used as a supplement for minerals lacking in diet) as ordered on 06/30/25. This failure could place the residents at risk of not receiving the intended therapeutic benefits of prescribed medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 24 residents (Resident #20) reviewed for medications at their bedside. The facility did not ensure Resident #20's Ayr Nasal Solution (nasal spray), and biotene dry mouth moisturizing spray were not left on his bedside table. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs for 1 of 2 residents (Resident #19) reviewed for dietary needs and preferences. The facility failed to ensure Resident #19 received small, frequent meals as recommended by her physician. This failure placed residents at risk for altered nutritional status and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility did not ensure:1. The ham was discarded after the use by date of 06/26/25.2. The potatoes were labeled and dated. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #44) reviewed for infection control. The facility failed to ensure CNA N performed hand hygiene while providing incontinent care for Resident #44 on 06/29/25. This failure could place any resident at the facility at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to implement written policies that prohibit and prevent abuse, neglect, misappropriation of resident property, and exploitation for 1 of 69 (Resident #1) residents reviewed for abuse and neglect. The facility failed to implement the abuse and neglect policy and procedure regarding reporting misappropriation of property for Resident #1. This failure could place the residents at increased risk for abuse and neglect.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 69 (Resident #1) residents reviewed for abuse and neglect. [...]

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure in response to allegations of abuse, neglect, or mistreatment, have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse, neglect, or mistreatment while the investigation was in progress. And report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1of 69 (Resident #1) residents reviewed for Abuse and Neglect. The facility's Administrator failed to ensure on Resident #1's misappropriation of property was thoroughly investigated. This failure could place residents at risk for ANE.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 5 of 6 residents (Resident #14, Resident #36, Resident #47, Resident #115, and Resident #218) reviewed for pressure ulcers. 1. The facility failed to ensure weekly ulcer assessments were performed and measurements were obtained for Resident #47's left outer ankle stage 4 pressure injury, Resident #218's pressure injuries to her buttocks, fluid filled blister to great toe, ulcer to right foot, Resident #14's pressure injury to his left buttock, Resident #115's stage 3 pressure injury to his left buttock. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 4 of 14 residents (Residents #42, #165, #58, and 115) reviewed for accident hazards. 1. The facility failed to ensure safety measures were in place after Resident #42 received a first-degree burn (an injury that affects the first layer of your skin) from hot coffee. An Immediate Jeopardy (IJ) situation was identified on 05/01/24. The IJ template was provided to the facility on [DATE] at 11:41 a.m., While the IJ was removed on 05/02/24 at 5:15 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. 2. The facility failed to ensure Resident #165 was supervised while smoking. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient staff to provide nursing related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, for 2 of 22 residents (Resident #54 and Resident #219) and 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient staff to provide prompt and proper incontinent care for Resident #54 and Resident #219. This failure could place residents at risk of an unsafe environment, new pressure injuries, worsening of pressure injuries, falls, and exacerbations of disease processes. Findings Included: 1. Record Review of Time Sheets between 04/14/2024-05/02/2024 indicated number of CNAs worked: 04/14/20224: 1 CNA from 1:31pm- 9:56pm; 1 CNA from 6:19am-6:02 pm, 1 CNA from 6 pm-6:18am. [...]

Inspectors wrote9. During an observation on 04/29/2024 at 10:52 p.m., PVC plastic clean linen cart sitting in the hallway with cover was open. During an interview on 04/29/2024 at 11:03 p.m., NA Q stated the PVC plastic linen cart cover should always be closed. NA Q stated it was his responsibility to make sure he closed the cover. NA Q stated it was important to keep the cover closed so microorganisms in the hallway would not get on the liens. NA Q stated the failure would be the supplies and linens getting contaminated and cause infection. During an interview on 04/29/2024 at 11:20 p.m., LVN T stated the linen cart cover should be closed. LVN T stated it was the CNAs responsibility to close the cover when they were done. LVN T stated she would do an in-service. LVN T stated the charge nurse was responsible for making sure the CNAs did their jobs. [...]

Inspectors wroteBased on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response for 8 of 8 confidential residents reviewed for resident council. The facility failed to ensure there was documentation of the facility's efforts to resolve concerns collected at the resident council meetings on 10/10/23, 11/14/23, 12/12/23, 01/09/24, 02/13/24, and 03/12/24. This failure could place residents at risk of not having their concerns and grievances followed through and a diminished quality of life.

Inspectors wrote2. Record review of Resident #31's face sheet dated 05/02/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses heart disease, congestive heart failure, kidney disease, high blood pressure and depression. Record review of Resident #31's quarterly MDs assessment dated [DATE] indicated he had a BIMS score of 08 which indicated he had moderately impaired cognition. The MDS also indicate he required limited assistance for bed mobility, extensive assistance for toileting, bathing, and transfers, and setup for eating. Record review of Resident #31's undated care plan indicated he required supervision of 1 staff for bathing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 5 of 6 residents (Resident #12, Resident #26, Resident #39, Resident #165, and Resident #218) reviewed for pharmacy services. 1. The facility failed to ensure Resident #26's buspirone (anxiety medication), gabapentin (medication for nerve pain), duloxetine (medication for depression), and metoprolol succinate (blood pressure medication) were administered timely. 2. The facility failed to ensure Resident #218's spironolactone (medication used to treat fluid buildup), metoprolol (blood pressure medication), venlafaxine hydrochloride (medication for depression), and pregabalin (used to treat nerve pain) were administered timely. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 5 medication carts (Hall 200 medication cart, Treatment medication cart) and 1 of 22 residents (Resident #36) reviewed for pharmacy services. 1. The facility failed to ensure Resident #36 did not have prescribed and OTC medications at bedside. 2. The facility failed to ensure the treatment nurse ensured the medication cart, used for treatments, was locked when it was left unattended. 3. The facility failed to ensure LVN M ensured the 200 Hall medication cart was locked when it was left unattended. These failures could place residents at risk of injury from medication misuse or drug diversion. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents had the right to a safe, clean, comfortable, and homelike environment for 1 of 6 resident rooms (room [ROOM NUMBER]) reviewed for the homelike environment. The facility failed to ensure Resident #4's room was without urine odor during the surveyors observation 04/28/24 through 05/02/24. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept and clean environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 22 residents (Resident #219) reviewed for abuse and neglect. The facility failed to ensure CNA G and SNA H provided incontinent care every two hours as required for Resident #219 on 04/30/24, which resulted in a strong urine odor and wet, brown stains to her sheets and mattress. This failure could result in pressure injuries, infections, psychosocial harm, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures to prohibit neglect and abuse for 1 of 22 residents (Resident #11 and Resident #219) reviewed for abuse and 1 of 21 staff (LVN K) reviewed for abuse training. The facility failed to ensure the Social Worker followed the facility's policy when he did not immediately report Resident #11's allegation of verbal abuse by Resident #219 to the Administrator on 04/28/24. The facility failed to follow its policy when LVN K did not complete abuse training upon hire on 03/05/24. These failures could place residents at risk of abuse, neglect, and decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 22 residents (Resident #11 and Resident #219) reviewed for abuse and neglect reporting. The facility failed to ensure the Social Worker reported Resident #11's allegation of verbal abuse by Resident #219 immediately to the Administrator on 04/28/24. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interviews and record review , the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 4 (Resident #54) residents reviewed for comprehensive person-centered care plans. The facility failed to care plan Resident #54's interventions, diagnoses, and medication use of Trazodone (an antidepressant medication used to help with her sleep). This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 22 residents (Resident #219) reviewed for incontinence. 1. The facility failed to ensure Resident #219 was provided prompt and proper incontinent care. 2. The facility failed to ensure CNA C properly cleaned the peri area, changed gloves, and used hand hygiene before going from dirty to clean while providing incontinent care to Resident #54. These failures could place residents at risk for urinary tract infections, skin breakdown, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 4 residents (Residents #19 and Resident #8) reviewed for respiratory care. 1. The facility failed to ensure Resident #19's handheld nebulizer was properly stored. 2. The facility failed to properly store Resident #8's nasal cannula. 3. The facility failed to properly clean Resident #8's oxygen concentrator. These failures could place residents requiring respiratory care at risk for respiratory infections or complications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were given psychotropic medications to treat specific diagnoses for 1 (Resident #46) of 5 Residents, reviewed for pharmacy services. The facility failed to ensure that Resident #46 did not receive an antipsychotic (Seroquel/Quetiapine Fumarate) that was not necessary to treat Vascular Dementia. This failure could place residents at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free of medication error rates of 5 percent or greater. The facility had a medication error rate of 10.0%, based on 4 errors out of 40 opportunities, which involved 2of 6 residents (Resident #165 and Resident #12) reviewed for medication administration. 1. The facility failed to ensure RN A administered the correct dose of Aspirin 81 MG and Omeprazole 40 MG, (Aspirin and omeprazole combination is used in patients who need aspirin to prevent heart and blood vessel problems (e.g., heart attack, stroke). RN A failed to administer Lyrica 75MG (used to treat pain caused by nerve damage due to diabetes) on 04/29/24 as ordered. 2. The facility failed to ensure RN A administered the correct dose of Aspirin 81MG (a type of NSAID that can treat mild to moderate pain and inflammation. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure laboratory services were obtained to meet the needs for 1 of 5 (Resident #1) residents reviewed for laboratory services. The facility did not ensure Resident #1 had weekly CBC (complete blood count-used to look at overall health and find a wide range of conditions including anemia (condition in which the blood does not have enough healthy red blood cells) and infection and BMP (basic metabolic panel-test that checks the body's fluid balance and levels of electrolytes) lab tests as ordered. Resident #1 was lethargic and requested to be sent to the hospital on 2/20/24 where she was admitted for hyponatremia (decreased sodium with symptoms including fatigue, lethargy, and mental confusion), dehydration and AKI (acute kidney injury-a condition in which the kidneys suddenly cannot filter waste from the blood. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 (Resident #2) residents reviewed for quality of care. 1. The facility failed to ensure Resident #2's venous stasis ulcer (a wound on the leg or ankle caused by abnormal or damaged veins) treatment was performed daily as ordered. 2. The facility failed to ensure the nurses initialed and dated wound dressings when wound care was performed on Resident #2 . These failures could result in residents with venous stasis ulcer of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 5 (Resident #1) residents reviewed for pressure injuries. The facility failed to ensure Resident #1's wound care was performed daily as ordered . These failures could place residents at risk for worsening of existing pressure injuries, infection, pain, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 1 (Resident #1) residents reviewed for incontinence care. The facility failed to ensure Resident #1's discharge order for a urinary straight catheter (also called an intermittent catheter, is a soft, thin tube used to pass urine from the body) four times a day was initiated upon re-admission to the facility . This failure could place residents at risk for urinary retention (difficulty urinating and completely emptying the bladder), pain, and urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with personal privacy and confidentiality of his or her personal and medical records.for 2 of 5 (Resident #2 and Resident #3) residents reviewed for resident rights. 1. The facility did not ensure the door was closed during wound care on Resident #2 resulting in another resident trying to enter the room to speak with the nurse during Resident #2's wound care . 2. The facility failed to prevent RN A from discussing Resident #3 with Resident #2. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on interview the governing body failed to appoint an administrator who was Licensed by the State, where licensing was required; responsible for management of the facility; and reports to and was accountable to the governing body for 1 of 1 facilities reviewed for having an Administrator. The facility failed to appoint a Licensed Administrator while having an Administrator in Training in the facility . This failure could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 9 (Resident #1) residents reviewed for pharmacy services. The facility failed to only administer medication prescribed by the physician to Resident #1. The noncompliance was identified as PNC. The noncompliance began on 9/05/23 and ended on 9/07/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for adverse reactions. Findings Include: [...]