Kent County Nursing Home

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for one of one kitchen reviewing for food and nutrition services. A. Residents #12, #15, and #49 complained the food was served cold. B. 7 of the 9 foods sampled on the meal tray were cold. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and food borne illnesses.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure resident had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 2 of 4 residents (Resident #3 and #48) observed for physical restraints. Resident #3 and #48 failed to have physician orders for position change alarm (chair alarm) for fall prevention. This failure puts residents at risk of being restrained without justification of the need for a restraint.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 2 of 22 residents (Residents #3 and Resident #48) reviewed for care plans. Residents #3 and 48 did not have a care plan for position change alarm (chair alarm). This failure could place residents at risk of not receiving the care required to meet their individual needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and maintained in accordance with currently accepted professional standards for 1 of 2 medication carts (Medication Cart 2) reviewed. The facility failed to ensure 11 loose pills in Medication Cart 2 were properly labeled or stored. This failure could place residents at risk for medication errors and drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the rights of the residents to be free from abuse and neglect for 1 of 7 residents (Resident #2) reviewed for abuse A. The facility failed to keep Resident #2 safe from Resident #1 on an unknown date when Dietary Aide B reported that Resident #1 had touched Resident #2's breast in the dining room on an unknown date to the Interim DON and to Regional Director J on an unknown date multiple times between May 2024-November 2024). An Immediate Jeopardy (IJ) was identified on 11/19/24 at 2:48 PM. The IJ template was provided to the facility on [DATE] at 2:48 PM. While the IJ was removed on 11/20/24 at 1:28 PM, the facility remained out of compliance at a severity level of actual harm and a scope of widespread due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 5 of 7 residents (Resident #1, #2, #3, #4, and #5) reviewed for abuse. A. The Interim DON failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to HHSC and documenting her investigation measures regarding Resident #1 and Resident #2 reported by Dietary Aide B on an unknown date. B. The Former ADM failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to HHSC and documenting her investigation measures regarding Resident #1 and Resident #2 reported by Dietary Aide B on an unknown date. C. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress and reported 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 was verified appropriate corrective action were taken, for 5 of 7 residents (Resident #1, #2, #3, #4, and #5) reviewed for abuse. A. [...]

Inspectors wroteBased on interviews 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, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) for 4 of 7 residents (Resident #1, #2, 3, and #5) reviewed for abuse. A. The Interim DON failed to follow the facility's abuse policy by not reporting the incident involving Resident #1 and Resident #2's involvement in inappropriate sexual touching reported by Dietary Aide B on an unknown date to HHSC. B. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 7 residents (Resident #1 and #4) reviewed for comprehensive care plans. Resident #1's comprehensive care plan did not include his known behavior for sexual inappropriateness (kissing residents hands and the alleged touching of the breast) and flirtatious behavior towards female residents and specifically Resident #2. Resident #4's comprehensive care plan did not include her known behavior for sexual inappropriateness (masturbating on the outside of her clothing) in common areas. This failure could place residents at risk for not having their individualized needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 16 residents (Resident #27) reviewed for care plans. The facility failed to ensure Resident #27's care plan reflected the resident's current code status. This failure could place residents at risk of not receiving appropriate care to meet their current needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 16 residents (Resident #31) reviewed for care plans. The facility failed to ensure Resident #31's care plan reflected the resident's current code status. This failure could place residents at risk of not receiving appropriate care to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 1 of 2 medication carts (medication cart for hall 100-200) in that: 1. The medication cart assigned to hall 100-200 contained expired medications. This failure could place residents at risk of not receiving prescribed medications as ordered, receiving medications that are less effective or have altered composition, and drug diversions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 dining rooms reviewed for dietary services, in that: The facility failed to ensure foods were served under sanitary conditions. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interviews and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of controlled medications for 2 of 6 residents (Residents #1 and #2) reviewed for pharmaceutical services. The facility failed to ensure that the MA accurately documented the narcotic count sheet for Resident #1's scheduled pain medication administration for Norco 5-325 mg. The facility failed to ensure the MA followed the physician's orders for Resident #1's scheduled pain medication administration for Norco 5-325 mg. The facility failed to ensure that LVN B documented the narcotic count sheet for Resident #2's scheduled pain medication for Norco 7.5-325mg. These failures could place residents at risk of having their medications diverted or missing.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for medication administration. The facility failed to ensure the MA followed the physician's orders for Resident #1's scheduled pain medication administration for Norco 5-325 mg when she administered a dose one hour after Resident #1 received the previous dose. This failure could place residents at risk of receiving incorrect amounts of medication prescribed by their physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards for 3 of 3 residents (Resident #1, Resident #2 and Resident #3) reviewed for quality of care in that: CNA A failed to operate the Hoyer lift with 2 staff per facility policy when transferring Resident #1 from the wheelchair to the bed. As a result Resident #1 sustained a head injury and was sent to the hospital. Resident #2 stated that staff (unknown) lifted him majority of the time with 1 staff using the Hoyer lift. Uncertified Nurses aides (NA B and NA C) admitted to using the Hoyer lift to transfer residents. The Director of Nurses (DON) and the Director of Rehabilitation (DOR) did not ensure that staff were trained according to their lifting policy to use the Hoyer. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure licensed nurses and certified nurses Aides had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 3 of 3 Residents (Resident #1, #2, and #3) reviewed for nursing services. In that: The facility failed to ensure all clinical staff had physical competencies showing they were capable of utilizing the Hoyer lift. CNA A operated the Hoyer lift with on staff transferring Resident #1 which resulted in Resident #1 sustaining a head injury and being sent to the hospital. Uncertified Nurse Aides (NA B and C) admitted to operating the Hoyer lift to transfer residents. Resident #3 said that staff transfer him using the Hoyer lift with one staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 7 out of 30 (06/17/23, 06/18/23, 06/23/23, 07/01/23, 07/02/23, 07/03/23, and 07/07/23) days reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 06/17/23, 06/18/23, 06/23/23, 07/01/23, 07/02/23, 07/03/23, and 07/07/23 This failure could place residents at risk for inconsistency in care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1)The facility failed to ensure foods were processed under sanitary conditions, 2) The facility failed to ensure Dietary staff dated and labeled foods as required, 3) The facility failed to ensure Dietary staff maintained chlorine sanitizer levels within acceptable ranges in wiping cloth solutions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in the kitchen, dining room, 2 of 2 sunrooms, auxiliary hall, 4 of 14 rooms (room [ROOM NUMBER], 200, 202 and 401) and rotunda, in that: 1)Live Flies were observed flying and crawling in kitchen, dining room, 2 of 2 sunrooms, auxiliary hall, 4 of 14 rooms (room [ROOM NUMBER], 200, 202 and 401), and 2) The pest control program was further compromised due to having limited fly deterrents placed in and around the facility. These failures could place residents at risk for foodborne illness and infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 2 of 14 residents (Residents #7, and #11) reviewed for PASRR screening, in that: 1. Resident #7 did not have an accurate PASRR Level 1 assessment when he had a new diagnosis of Psychotic disorder with delusions due to known physiological condition - Onset Date, 1/26/22 and Major depressive disorder, recurrent severe without psychotic features - Onset Date, 1/21/21 2. Resident #11 did not have an accurate PASRR Level 1 assessment when she had a new diagnosis of schizoaffective on 03/09/23. These failures could place residents with an inaccurate PASRR Level 1 evaluation at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I screening accurately reflected the resident's status for 3 of 14 residents (Residents #7, #26, and #143) reviewed for PASRR services. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Residents #7, #26, and #143. This failure could place residents who have a mental illness at risk of not receiving individually specialized services to meet their needs. The findings was: Resident #7 Record review of the face sheet for Resident #7, dated 7/10/23 revealed that the male resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had listed diagnoses of: [...]

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 5 of 14 residents (Residents #19, #21, #30, #40, and #143) reviewed for care plans as follows: The facility failed to prevent the following: 1. Resident #19 did not have a care plan for delirium and dehydration. 2. Resident #21 did not have a care plan for dehydration/fluid maintenance and dental care. 3. Resident #30 did not have a care plan for risk for pressure ulcer. 4. Resident #40 did not have a care plan for psychosocial well-being, nutrition, and dehydration/fluid maintenance. 5. Resident #143 did not have a care plan for urinary incontinence, nutrition, and psychotropic medications. These failures could place residents at risk of not receiving the care required to meet their Individualized needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 2 residents fed by gastrostomy tube (Resident #8), in that: 1)The facility failed to ensure nursing staff provided G-tube (gastrostomy tube) care in a sanitary manner for Resident #8, and 2) The facility failed to ensure nursing staff accurately labeled G-tube feedings and flushing containers for Resident #8. These failures could result in the spread of resident infections and cause miscommunication and confusion between nursing staff regarding G-tube feedings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 4 residents receiving respiratory treatments (Resident #34), in that: The facility failed to ensure staff effectively monitored Resident #34 during and after respiratory treatments. This failure could result in the exacerbation of resident respiratory issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual for 3 of 3 residents with orders for puréed diet (Residents #10, 20 and 37); in that: The facility failed to provide pureed food in a form to meet resident needs for 3 of 3 meals observed (7/10/23 - Lunch and Supper and 7/11/23 - Lunch) for 3 of 3 residents with the orders for puréed diets (Residents #10, 20 and 37). This failure could place residents at risk of decreased food intake and choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 2 residents fed by gastrostomy tube (Resident #8), in that: The facility failed to ensure nursing staff provided G-tube (gastrostomy tube) care in a sanitary manner for Resident #8. This failure could result in the spread of resident infections.