Kensington Place Nrsg & Rehab

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to monitor the temperature in the walk-in refrigerator cooler; failed to ensure food in the freezer is 6 inches off the floor; failed to label prepared foods; failed to test and record dishwasher sanitation; and failed to clean kitchen equipment used to prepare food. These failures have the potential to cause foodborne illnesses for all 139 residents receiving oral nourishment in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one resident (R10) who depends on staff's assistance for ADL (Activities of Daily Living) care received incontinence care. This failure affected one (R10) out of three residents reviewed for quality of care.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow their medication administration policy for one resident (R1) of three reviewed in a sample of four.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide comfortable and safe temperature levels for the residents by not following their policy to maintain consistent temperatures at 71 degrees or greater. This failure affected all 147 residents that reside at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to distribute and serve food to two residents (R1 and R6) in accordance with professional standards for satisfactory food consumption. This failure affected two residents reviewed for dietary services.

Inspectors wroteBased on observation, interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R9) of 10 residents reviewed for abuse. This failure resulted in R10 hitting R9 on the face in the dining room, resulting in R9 sustaining superficial scratches to R9's face. Findings Include: R9's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Cerebrovascular disease, type 2 diabetes mellitus without complications, idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, unspecified, hyperlipidemia, hypertensive heart disease without heart failure, gastro-esophageal reflux disease without esophagitis, history of falling, benign prostatic hyperplasia without lower urinary tract symptoms. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent resident to resident physical abuse for one of four residents (R2) reviewed for abuse in a total sample of nine residents.

Inspectors wroteBased on interview and record review, the facility failed to complete performance evaluations for certified nursing assistants and failed to ensure 12-hours of in-servicing was completed for certified nursing assistants annually. This failure affects all 127 residents that reside within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to post required staffing information in a high visibility area. This failure affects all 127 residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all kitchen staff have active food handler certifications to provide safe and competent food and sanitation service to residents which has the potential to affect all 127 residents receiving oral diets in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and date an opened refrigerated food item; kitchen staff failed to perform appropriate hand hygiene in the kitchen; failed to sanitize the thermometer probe in between obtaining temperature readings of each hot food item; failed to properly clean food processor equipment; failed to allow food processor equipment to fully air dry before use; failed to ensure that kitchen staffs' personal belongings are not stored on kitchen equipment where resident food is prepared; and failed to ensure that kitchen staffs' food and drink items are not stored in the facility kitchen dedicated for resident food and drinks. These failures affect all 127 residents receiving oral diets in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete an accurate facility assessment. This failure has the potential to affect all 127 residents that reside within the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to wear personal protective equipment (PPE) while performing gastrotomy (G-tube) care for one resident (R104) on enhanced barrier precautions (EBP). This failure affected one resident (R104) in a total sample size of 54 residents. The facility also failed to do hand hygiene while performing laundry duties. This failure has the potential to affect all 127 residents residing in the facility.

Inspectors wroteBased on observation and interview the facility failed to clean the lint screen thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 127 residents that reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff were trained on Quality Assurance (QA)and Performance Improvement (QAPI). This failure affects all 127 residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure preadmission screening assessments were completed as needed for residents identified to have a mental illness. This failure affects 4 residents (R10, R33, R40, and R46) reviewed for pre-admission screening in the sample list of 54 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 4 out of 18 residents who are prescribed controlled substances from the second-floor long hall medication cart.

Inspectors wroteBased on interview and record review, the facility failed to follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice. The facility failed to vaccinate eligible residents with the pneumococcal vaccine. The facility failed to document the refusal and/or the benefits and side effects in the resident's electronic medical records. This deficient practice affected 9 residents (R21, R25, R33, R39, R64, R68, R69, R102, R115) sampled in a total sample size of 54 and has the potential to affect all eligible residents that reside at the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain confidentiality of personal and medical information for two residents (R225 and R69) out of the 54 residents reviewed for privacy and confidentiality of records.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident was free of confinement to bed with all four side rails up. This failure has the potential to affect 1 resident (R40) of 1 resident reviewed in a sample size of 54 residents.

Inspectors wroteBased on interview and record review, the facility failed to refer residents with possible serious mental disorders for Screening and Resident Review to the appropriate state-designated authority for further assessment as required. This failure affects 2 residents (R106 and R110) reviewed for pre-admission screening in the sample list of 54 residents.

Inspectors wroteBased on observation and interview, the facility failed to have signage posted identifying a resident who has oxygen in use in the resident's room to prevent a possible hazard. This affected one resident (R69) in a total sample of 54 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents remain free of abuse for one of three residents (R5) reviewed for abuse in the sample of eight.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the required information for [NAME] Program information in areas where it is easily accessible to the residents. This failure has the potential affect all the 125-residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility temperature in residents' rooms, common area hallways, and dining area on the 1st, 2nd, and 3rd floor meet the required temperature of 71-degree Fahrenheit to 80-degree Fahrenheit. This failure has the potential all the 120-resident residing in the facility. The facility aslo failed to ensure that residents sinks were functioning properly for two (R1 and R3) of five residents reviewed for physical environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were free from physical abuse from fellow residents. This failure affected two residents R3(who was physically abused by R2) and R5(who was physically abused by R4), that were reviewed for resident versus resident physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow their own policy in reporting incident and accident. This failure affected 1 (R1) resident reviewed for reporting of incident and accident in the total sample of 3 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an incident was investigated thoroughly. This failure affected 1 (R1) resident reviewed for incident and accident investigation in the total sample of 3 residents.

Inspectors wroteBased on interview and record review the facility failed to protects a resident's right to be free from physical abuse. This failure affected one (R1) resident reviewed for abuse in a total sample of 3 residents.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their Nursing Service Policy to identify and assess a resident's needs, musculoskeletal status, need for assistive devices, and safety needs for one (R1) of three residents reviewed for accidents.

Inspectors wroteBased on observation, interviews, and record review the facility failed to protect the resident's right (R2) to be free from physical abuse by another resident (R1) out of six residents reviewed for abuse in the sample. This failure resulted in R2 sustaining a laceration to the right center of the head requiring four sutures to close the wound.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that medication was locked up safely in the treatment cart when not in use and when not in proximity of the nurse, to prevent tampering and accidental hazard. This failure has the potential to affect all the residents residing on the 1st and 2nd floor of the facility.

Inspectors wroteBased on interview and record review the facility failed to immediately report an allegation of verbal abuse for one resident (R5) out of six residents reviewed for abuse in the sample.

Inspectors wroteBased on interview and record review the facility failed to meet professional standard of medication administration and failed to follow their facility policy on medication administration for one resident (R5) in the sample. This failure affected R5 whose medication was prepared by one nurse but administered by a different nurse putting R5 at risk for medication error.

Inspectors wroteBased on interview and record review, the facility failed to schedule sufficient staff to meet the behavioral needs of one resident (R1) out of out of six residents reviewed for sufficient staffing in the sample of six.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from physical abuse. This failure affected one resident (R1) of seven residents reviewed for abuse. Findings Include: Facility's Investigation Report (dated 09/13/2024) notes, on 09/06/2024, (R1) engaged in an altercation with (R2), staff immediately intervened and separated the residents. Body assessment conducted. (R1) was noted with a laceration. MD (Medical Doctor) aware and emergency contacts made aware. (Local Police Department) contacted, administration. (R1) stated she was sitting down at a table eating her snacks and watching television while in the 3rd floor dining room when (R2) approached her and became aggressive. She indicated no precipitating factors that led to the altercation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents have privacy curtains which extend around the bed. This failure affected seven residents (R21, R22, R23, R24, R25, R26, and R27) reviewed for residents' privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a functioning call light in the community shower rooms on the second floor and third floor of the facility. This failure has the potential to affect all 38 residents on the second and all 48 residents on the third floor.

Inspectors wroteBased on observation , interview and record review the facility fails to maintain an effective pest control program so that the facility is free of insect pests in 1 of 4 facility levels in one residents room.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one resident (R1) and failed to protect a resident's right to be free from physical abuse by another resident for two residents (R2 and R3) reviewed for abuse in the sample of 5 residents.

Inspectors wroteBased on the interview and record review, the facility failed to report abuse in a timely manner for two residents (R2 and R3) reviewed for abuse out of the sample of 5 residents. R3 is [AGE] years old, initially admitted in the facility on 9/19/2018 with the following diagnosis schizophrenia, hallucinations, conduct disorder, bipolar disorder, and depressive disorder. R2 is [AGE] years old, initially admitted in the facility on 9/20/2018 with the following diagnosis chronic obstructive pulmonary disease (COPD), anxiety disorder. Facility reported incident dated 6/19/2024 involving R2 and R3 are as follows: Incident description by V4 (Licensed Practical Nurse) documents that on 6/19/2023 at 11:42 AM, it was reported to staff by a resident that R2 and R3 engaged in a physical altercation that occurred on 6/18/2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to (a) ensure incontinence care is provided in a timely manner for one (R1) resident who needed assistance with toileting; and (b) provide a shower as scheduled for one (R1) resident who needed assistance with shower / bathe. These failures affected one (R1) of three residents reviewed for improper nursing care.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one (R1) resident out of five residents reviewed for abuse in a sample of five. Findings Include: The facility's incident final report shows incident date of 4/15/24 with description of occurrence that reads in part: On 4/15/2024 at approximately 6:25PM, staff observed (R1) hit (R2) unprovoked in facial area with chair. Staff immediately intervened and separated both residents. (R2) was assessed by NOD [Nurse on Duty], with injury noted. R1's progress notes written by V5 (Licensed Practical Nurse/LPN) dated 4/15/24 at 5:14 PM documents in part that during dinner time V5 was informed that R1 had thrown a chair at another resident, hitting the resident in the lower eye causing laceration with light bleeding. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were locked and secured while unattended, remove and discard expired medication, and label liquid medications that had been opened in five of five medication carts reviewed for medication labeling and storage. These failures have the potential to affect all 113 residents residing in the facility. Findings Include: On 03/12/2024 at 9:39AM, surveyor located on the first floor of the facility. Surveyor observes a medication cart (identified as the First Floor medication cart) unlocked and unattended. Surveyor observes five pills inside of an unlabeled clear medication cup on top of the unattended medication cart with the following pills inside: [...]

Inspectors wroteBased on observation, interview and review of records, facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. This failure has the potential to affect all 113 residents in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure controlled substances were counted and documented at the beginning and end of each shift for 26 out of 34 shifts and failed to keep an accurate count of all narcotic medications for one (R24) resident. These failures have the potential to affect 72 residents residing in the facility.

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow their policy on Resident rights for one (R36) of six residents reviewed for clean comfortable and homelike environment in a sample of 24.

Inspectors wroteBased on observations, interview and review of records, facility failed to follow their policy to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints for one (R51) of three residents reviewed for restraints in a sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had an individualized comprehensive care plan to meet the residents' medication need for one (R3) of four residents reviewed for care plans in a sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion by not applying/maintaining a left hand splint. This failure affects one (R21) of four residents reviewed for limited range of motion in a total sample of 24 residents.

Inspectors wroteBased upon record review and interview the facility failed to ensure that required medical records were provided to EMS (Emergency Medical Service) for one of three residents (R1) reviewed for transfer.

Inspectors wroteBased upon record review and interview the facility failed to follow policies/procedures, failed to timely follow-up on x-ray results, failed to timely notify the physician of serious injury, and failed to provide timely care for one of three residents (R3) reviewed for injury of unknown origin. R3 had an acute fracture to the distal right fibula. R3 went 5 days without treatment or care for the fracture.

Inspectors wroteBased on interviews and records review, the facility failed to protect resident's right (R3) to be free from physical abuse by another resident (R2). These failures affect 2 residents (R2 and R3) out of 4 residents reviewed for abuse.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide a sanitary environment by failing to ensure that resident rooms were free of pests, failing to implement cleaning of resident drawers, and failing to notify the appropriate department of the presence of pests detected. The facility also failed to ensure a functional environment by failing to notify maintenance about equipment that needed repair. As a result, roaches were found in a resident's room and a broken faucet that needed repair was not fixed in a timely manner. This failure affected two residents (R1 and R5) of the 4 residents reviewed.

Inspectors wroteBased interviews, and review of records the facility failed to provide a person-centered care plan for refusal of care for 1 out of 3 residents (R1) for a total of 3 residents reviewed for plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow procedure for sanitizing cook/service ware in three-compartment sink according to manufacturing guidelines, failed to follow the procedure for cleaning dishware, and failed to perform hand hygiene. These deficient practices have the potential to affect all 101 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage and refuse were disposed of properly by not closing the lids of the dumpsters outside the facility. This deficient sanitation practice has the potential to affect all 102 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the residents were treated with respect and dignity by not passing out meals to all residents sitting at a table at the same time. These failures affected 11 residents (R11, R12, R24, R25, R39, R82, R84, R86, R99, R255, and R306) reviewed during dining in a total sample of 21 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the menus for pureed diet consistency for 4 residents (R9, R15, R26, and R53) reviewed for special diets. Findings Include: On 01/31/23 after initial kitchen tour, V7 (Food Service Manager) provided document titled, Client List Report printed 01/31/23 at 10:13 AM. Five residents receive pureed diets prepared in the facility however one of the residents listed on the diet census was transferred to the hospital (01/29/23) and therefore was not included in this review. On 02/01/23 at 09:30 AM, observed V9 (Kitchen Cook) use an industrial blender to pureed lima beans. V9 did not measure the amount of lima beans added into the blender. V9 then added 1 large scoop of food thickener to the blender and then a large amount of chicken broth (unmeasured) from a pitcher. [...]

Inspectors wroteBased on interviews and records review and interviews the facility failed to document code status preference in the resident profiles for 2 residents (R14, R255) in a sample of 21 residents reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the appropriate equipment for residents with contractures to prevent further decrease in range of motion for one of three residents (R9) reviewed for range of motion in the sample of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to label, date, and store oxygen tubing for 1 (R8) resident out of 5 reviewed for oxygen therapy out of a total sample of 21. Findings Include: R8 has diagnosis not limited to Chronic Obstructive Pulmonary Disease, Dementia, Hypertensive Heart Disease with Heart Failure, Shortness of Breath. R8's MDS (Minimum Data Set) from 11/10/22 BIMS (Brief Interview for Mental Status) score is 08 indicating moderately impaired cognition. R8's Physician Order Report dated 01/01/2023-02/01/2023 documents, in part oxygen with nasal cannula rate at 2L oxygen per minute as needed with start date from 12/02/2022. On 01/31/23 at 12:48 PM, surveyor observed R8 in R8's room with oxygen concentrator at bedside with nasal cannula tubing wrapped in a ball around the outside of the oxygen concentrator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure a resident received and consumed liquids in the appropriate consistency according to physician orders for one(R9) of three residents who was on nectar thickened liquids.