Kensington Health and Rehabilitation

Inspectors wroteBased on record review, interviews, and review of facility policies titled, Behavioral Assessment, Intervention, and Monitoring, Mood and Behavior, and Antipsychotic Medication Use, the facility failed to ensure Resident Identifier (RI) #75 received adequate monitoring related to the use of antipsychotic and antidepressant medications. Specifically, the facility failed: 1. to ensure RI #75 was monitored for behaviors for which an antipsychotic medication (Zyprexa) was administered. This deficient practice affected RI #75, one of three sampled residents reviewed for unnecessary medications who received an antipsychotic medication; and 2. to ensure RI #75 was monitored for side effects of an antipsychotic (Zyprexa) and an antidepressant (Zoloft) medication. [...]

Inspectors wroteBased on record review, observations, interviews, and review of a facility policy titled, Administration of Medications, the facility failed to ensure a medication error rate less than 5%. There were 3 errors in 33 opportunities, which resulted in a 9.09% medication error rate involving Resident Identifier (RI) #62 and RI #20 during medication pass. Specifically, the facility failed to ensure: 1. RI #62 received a Senna tablet and a multivitamin with mineral tablet as ordered by the physician; and 2. RI #20 received 30 milliliters (mL) of lactulose solution as ordered by the physician. This deficient practice affected RI #62 and RI #20; two of six residents observed during medication pass.

Inspectors wroteBased on observation, interview, medical record review, review of a facility form titled, Smoking Guidelines and review of a facility policy titled, NOTIFICATION OF RESIDENT'S CHANGE IN CONDITION, the facility failed to ensure: 1. Resident Identifier (RI) #74's guardian was notified of a hospital visit on 5/26/19, and 2. RI #105's sponsor was notified of the resident's behavior during smoking, which resulted in him/her being placed on restriction. This affected RI #74 and RI #105, two of four sampled residents who were reviewed for notification. Findings Include: 1. A review of a policy titled, NOTIFICATION OF RESIDENT'S CHANGE IN CONDITION, with a revised date of 9/2016, revealed .POLICY STATEMENT Standards: [...]

Inspectors wroteBased on observations, interviews and review of the facility admission Agreement, the facility failed to ensure resident rooms were not observed with peeling paint, splintered doors, torn ceiling tiles, chest of drawers with a missing drawer, broken window blinds and missing or scuffed base boards. This was observed in Room Locators (RLs) 1-19, 19 of 66 RLs in the facility. Findings Include: A review of an undated facility documented titled, Resident Rights revealed: All Residents of the Healthcare Facility are granted a Federal Statutory [NAME] of Rights. The following outlines these Federal Resident's Rights .57. The resident has a right to a safe, clean comfortable and homelike environment . A review of a facility form titled, Environmental Rounds Check-List dated 6/24/19, revealed no identified issues with the following: [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policy titled, RESIDENT ASSESSMENT INSTRUMENT (RAI) POLICY, the facility failed to ensure Resident Identifier (RI) #111's admission Minimum Data Set (MDS) assessment, dated 6/27/19, was coded correctly. This affected RI #111, one of 23 sampled residents whose MDS assessments were reviewed. Findings Include: A review of a facility policy titled, RESIDENT ASSESSMENT INSTRUMENT (RAI) POLICY with an issue date of November 28, 2017, revealed: .STANDARD OF PRACTICE .3 .Each individual who completes a portion of the Minimum Data Set (MDS) must certify the accuracy of that portion of the assessment .7 . This information helps the interdisciplinary team to plan care that allows the resident to reach his/her highest level of practicable level of functioning . [...]

Inspectors wroteBased on interviews, review of the medical record, review of a facility policy titled, SMOKING POLICY FOR RESIDENTS, and review of a facility document titled, Behavior Management Team Meeting Guidelines, the facility failed to ensure the plan of care was updated with a smoking restriction for Resident Identifier (RI) #93. This affected RI #93, one of five sampled residents identified as smokers whose care plans were reviewed. Findings Include: A review of the SMOKING POLICY FOR RESIDENTS with an issue date of 8/22/17, revealed: . POLICY STATEMENT It is the policy of this facility to establish and maintain safe resident smoking policies . SAFETY RESTRICTIONS: 1. The Attending Physician, Director of Nurses, and the Care Plan Team shall have the authority to make determinations as to which residents are responsible . [...]

Inspectors wroteBased on observations, interview and review of a facility policy titled, OXYGEN THERAPY POLICY the facility failed to ensure O2 (Oxygen) tubing and the humidifier water bottle were dated while in use for Resident Identifier (RI) #102. The facility also failed to ensure RI #97's O2 tubing was not found on the floor and the nurse did not attempt to place the trach mask back on RI #97 without it being cleaned or changed. This affected RI #102, and RI #97, two of four sampled residents receiving oxygen therapy. Findings Include: 1. A review of a facility policy titled, OXYGEN THERAPY POLICY with an issue date of 11/28//17 revealed, . POLICY STATEMENT Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Action . 8. Change tubing weekly. 9. Date tube when changed (weekly). [...]

Inspectors wroteBased on observation, interview and review of a facility policy titled, ADMINISTRATION OF MEDICATIONS, the facility failed to ensure the medication nurse locked the cart when unattended. This was observed on 7/10/19, and affected one of five nurses observed during medication administration and had the potential to affect the resident observed in the hallway at that time. Findings Include: A review of a facility policy titled, ADMINISTRATION OF MEDICATIONS with a revised date of January 2019 revealed: .Action . 8. During administration of medications; the medication cart is kept closed and locked when out of sight of the medication nurse On 7/10/19 at 8:13 AM the surveyor observed Employee Identifier (EI) #6, Licensed Practical Nurse (LPN) push the medication cart up the hall. EI #6 stopped it at the nurses station. [...]

Inspectors wroteBased on observation, interview, record review and review of facility policies LAUNDRY AND BEDDING, SOILED, BED BATH, and PERINEAL (SKIN) CARE FOR INCONTINENT RESIDENT, the facility failed ensure: 1. soiled linen was not placed in Resident Identifier (RI) #97's closet, 2. Certified Nursing Assistants (CNA)s did not use wash cloths that had been used to clean bowel movement from RI #97 to give him/her a bed bath, including the groin area, and 3. a CNA did not touch a clean pad, Oxygen tubing, clean pillows and linens with the same soiled gloves which were used to clean bowel movement from RI #97. Findings Include: 1. A review of a facility policy LAUNDRY AND BEDDING, SOILED with a revised date of April 1, 2018, revealed: POLICY INTERPRETATION AND IMPLEMENTATION .2. Place contaminated laundry in a bag or container at the location where is is used . [...]