Kenwood Terrace Healthcare Center

Inspectors wroteBased on medical record review, staff interview, observations and policy review, the facility failed to investigate the allegation of missing dentures. This affected one Resident (#35) of three reviewed for dental appliances. The facility census was 87.

Inspectors wroteBased on medical record review, hospice documentation, staff interview, hospice staff interview, review of the contract between the hospice provider and the facility, and review of the facility policy, the facility failed to ensure collaboration between the hospice provider and the facility was documented in the medical record. Additionally, the facility failed to retain copies of hospice provider progress notes at the facility. This affected two (Residents #35 and #7) of three residents reviewed for hospice services. The facility census was 87 residents.

Inspectors wroteBased on observation, interviews, and review of facility water temperatures, the facility failed to maintain a comfortable hot water supply to ensure a comfortable environment. This affected four (#33, #34, #43 and #52) out of four residents review for hot water temperatures and had the potential to affect 59 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58 and #59) residents residing on the 100, 200, 300, 400, 500 and part of the 600 hallway. The facility census was 79.

Inspectors wroteBased on closed medical record review, observations, mechanical lift users manual, and interviews, the facility failed to properly maintain and inspect mechanical lifts to prevent injuries for residents being transported. This affected one resident (Resident #46) out of four reviewed that required the use of mechanical lifts. The facility census was 78.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored in a safe manner and failed to ensure kitchen equipment was kept in a clean and sanitary manner. This had the potential to affect all 82 residents residing in the facility. The facility census was 82.

Inspectors wroteBased on medical record review and resident and staff interview, the facility failed to promote and honor a resident's choice for bathing. This affected one (#21) of two residents reviewed for activities of daily living (ADLs). The facility census was 82.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete discharge Minimum Data Set (MDS) assessments in a timely manner. This affected two (#63 and #82) of three residents reviewed for resident assessments. The facility census was 82.

Inspectors wroteBased on medical record review, resident and staff interviews, and policy review, the facility failed to ensure care conferences were held as required for residents and their representatives. This affected two (#12 and #38) of three residents reviewed for care conferences. The facility census was 82.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to ensure residents were administered antipsychotic medications for appropriate indications. This affected two (#84 and #241) of the five residents reviewed for unnecessary medications. The facility census was 82.

Inspectors wroteBased on medical record review, staff interview, review of a facility policy, the facility failed to a physician was notified promptly of a critical laboratory value. This affected one (#16) of three residents reviewed for change in condition. The facility census was 82.

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to ensure residents were provided with prompt and appropriate dental services upon the discovery of a resident with missing dentures. This affected one (#62) of six residents reviewed for personal property. The facility census was 82.

Inspectors wroteBased on resident and staff interview, observation, record review, and policy review, the facility failed to develop comprehensive care plans for pain management to include indwelling medical devices. This affected one (Resident #69) of ten residents reviewed for care plans. The facility census was 87.

Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to ensure medications were stored in appropriate containers in the medication cart. This had the potential to affect three (Residents #59, #61, and #62) of three residents prescribed iron on the 500-Hall. The facility census was 87.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure staff prepared food in a sanitary manner. This affected one (Resident #3) of one resident reviewed during tray line service. The facility census was 87.

Inspectors wroteBased on observations, interviews, medical record review, and policy review, the facility failed to implement appropriate infection prevention procedures during medication administration. This affected two (Residents #63 and #79) of five residents reviewed for medication administration. The facility census was 87.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to notify residents of Medicaid account balances. This affected three residents (#28, #29 and #61) out of three residents reviewed for notification of Medicaid account balances. The facility census was 94.

Inspectors wroteBased on record review, interview and policy review, the facility failed to properly investigate grievances and provide a summary of the findings to the resident or resident representative. This affected two residents (#55 and #8601) out of three residents reviewed for grievances. The facility census was 94.

Inspectors wroteBased on medical record review, observations, interviews and policy review, the facility failed to ensure medications were securely stored. This affected three (#56, #24 and #54) residents of three reviewed for medication storage. The facility census was 86.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to accommodate resident food preferences. This affected one (#30) out of three residents reviewed for food preferences. The census was 89.

Inspectors wroteBased on medical record review, staff and resident interview, and policy review, the facility failed to ensure physician orders were followed correctly. This affected one (#17) out of three residents reviewed for medications. The facility census was 100.

Inspectors wroteBased on medical record review and staff and resident interviews, the facility failed to ensure their pharmacy services provided resident's medication in a timely manner. This affected one (#17) out of three residents reviewed for medication administration. The census was 100.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to ensure residents who were unable to carry out activities of daily living, received the necessary services to perform them when Resident #4 did not receive showers twice a week. This affected one (Resident #4) of three residents reviewed for showers. The facility census was 86.

Inspectors wroteBased on observation, staff interview, and record review the facility failed to ensure med error rate was less than 5% when Resident #55 and Resident #53 did not receive their medications as ordered. This affected two (Resident #53, and #55) of four residents reviewed for medication administration. There was 29 opportunities for error with five errors for a 17.24% error rate. The facility census was 86.

Inspectors wroteBased on observation, staff interview, manufactures directions, and record review the facility failed to ensure they were free from significant medication errors when the nurse did not prime the insulin pen prior to administering the dosage to Resident #34. This affected one (Resident #34) of four residents reviewed for medication administration. The facility census was 86.

Inspectors wroteBased on observation, staff interview and record review the facility failed to store medications appropriately when Resident #47 had medications in her room and Resident #55 had medications and multiple eye drops in her room. This affected two (Resident #47 and #55) of four reviewed for medication administration. The facility census was 86.

Inspectors wroteBased on observation, staff interview, blood glucose machine reference manual, and record review the facility failed to failed to follow infection control procedures when they did not appropriately clean the blood glucose machine after use for Resident #34. This affected one (Resident #34) of four residents reviewed for medication administration. The facility identified five residents (Resident #1, #34, #46, #63, and #70) on the 600 hallway with blood sugar checks. The facility census was 86.

Inspectors wroteBased on observation, staff interview, and review of the facility's policy, the facility failed to maintain a sanitary kitchen and acceptable food storage practices. This had the potential to affect 67 residents who received food from the kitchen. The facility census was 68.

Inspectors wroteBased on observations, and resident and staff interviews, the facility failed to provide a safe, clean comfortable and homelike environment. This affected four (Residents #2, #12, #21, and #52) of 18 residents reviewed for a homelike environment. The facility census was 68.

Inspectors wroteBased on record review, observation, resident interview, staff interview, and review of the facility's policy, the facility failed to offer a resident a choice in method of bathing. This affected three (Residents #2, #47, and #419) of three residents reviewed for choices. The facility identified 65 residents who required staff assistance or were dependent on staff with bathing. The facility census was 68.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the residents were informed in writing of being cut from Medicare services. This affected two (Residents #117 and #118) of three residents reviewed for beneficiary notice. The facility census was 68.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the residents who discharged to the hospital received a transfer/discharge notice. This affected two (Residents #8 and #68) of two residents reviewed for hospitalization. The facility census was 68.

Inspectors wroteBased on record review, family interview, and staff interview, the facility failed to ensure a care conference was provided for the residents and/or family member. This affected two (Residents #12 and #51) of three residents reviewed for care planning. The facility census was 68.

Inspectors wroteBased on staff interviews, medical record review, review of the hospice contract, and review of the facility's policy, the facility failed to coordinate hospice services with the facility for Resident #14. This affected one (#14) of one resident reviewed for hospice services. The facility identified five residents receiving hospice care. The facility census was 68.

Inspectors wroteBased on record review, observation, staff interview, review of the facility's policy, and review of a professional wound care resource, the facility failed to ensure preventative devices were in place to prevent further skin breakdown as ordered by the physician. This affected one (Resident #15) of nine facility-identified residents with pressure ulcers. The facility census was 68.

Inspectors wroteBased on record review, observation, resident interview, staff interview, and review of the facility's policy, the facility failed to implement treatment measures and devices to prevent and minimize the risk of further contractures. This affected one (Resident #15) of two residents reviewed for contractures. The facility identified five residents with contractures. The facility census was 68.

Inspectors wroteBased on review of the facility's policy, staff interview, and record review, the facility failed to provide tube feeding equipment required for tube feeding administration for Resident #366 upon admission. This resulted in Resident #366's hospitalization. This affected one (Resident #366) of one resident reviewed for tube feeding administration. The facility identified two residents who receive tube feeding. The facility census was 68.

Inspectors wroteBased on observation, staff interview, review of the facility's policy, and record review, the facility failed to date oxygen tubing per physician orders for Resident #48. This affected one (#48) of nine residents reviewed for oxygen administration. The facility identified 15 residents receiving respiratory treatments. The facility census was 68.

Inspectors wroteBased on record review, resident and staff interview, observation, and review of the facility's policy, the facility failed to maintain a physician-ordered fluid restriction for a resident dependent on hemodialysis. This affected one (Resident #59) of one resident reviewed for dialysis. The facility-identified one resident (#59) who was dialysis with a fluid restriction. The facility census was 68.

Inspectors wroteBased on record review, staff interview, and review of the facility's policy, the facility failed to implement an appropriate stop date for as needed anti-anxiety medication and failed to offer non-pharmacological medications prior to administration of as needed anti-anxiety medications. This affected one (Resident #64) of five residents reviewed for unnecessary medications. The facility identified eight residents with orders for anti-anxiety medications. The facility census was 68.

Inspectors wroteBased on observations, review of the medical record, and staff interviews, the facility failed to ensure residents received liquids according to their physician orders. This affected one (Resident #12) of four residents reviewed for nutrition. The facility identified two residents on thickened liquids. The facility census was 68.

Inspectors wroteBased on record review, observation, staff interview, review of the facility's policy, and review of online resources per the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore facemasks covering their nose, mouth, and chin in resident areas and within close proximity to residents in order to help prevent the spread of Coronavirus (COVID-19). This affected two (Residents #47 and #64) of 68 residents in the facility. The facility census was 68.

Inspectors wroteBased on medical record review, review of hospital records, review of a facility Self-Reported Incident (SRI), review of staff time card punches, observations, review of the facility abuse policy, and interviews with staff, residents, and a police detective, the facility failed to implement their abuse policy when one State Tested Nurse Aide (STNA) neglected to report that he had dropped a resident during an improper transfer, and one additional STNA who was aware the resident had been dropped also neglected to report the incident. This resulted in Immediate Jeopardy and serious life-threatening injuries when Resident #40 experienced increased pain and suffering due to the delayed identification of the extent of the injuries sustained by the resident during the improper transfer. [...]

Inspectors wroteBased on medical record review, review of hospital documentation, review of a facility Self-Reported Incident (SRI), review of facility investigations, review of written statements, observations, staff, resident, detective and ambulette personnel interviews and policy review, the facility failed to provide adequate supervision and/or assistance for each resident to ensure their safety. This resulted in actual harm to two residents (#40, #29) who both sustained multiple fractures when being transferred. Resident #40 sustained bilateral distal femur fractures when transferred from bed to a shower chair without appropriate assistance and Resident #29 sustained multiple rib fractures while being transferred off an ambulette without adequate supervision at the entrance to the facility. This affected two (#40 and #29) out of five residents were reviewed for accidents. [...]

Inspectors wroteBased on observation, review of the planned menus approved by the Registered Dietitian (RD), and staff interview, the facility failed to follow the planned menus for pureed and mechanically soft diets. This had the potential to affect 13 of 13 residents on pureed or mechanically soft diets (#50, #5, #70, #75, #65, #13, #57, #20, #18, #76, #35, #133, and #62). The facility census was 78.

Inspectors wroteBased on observation and staff interview the facility failed to ensure walls, floors, and ceilings were maintained in good condition. This affected 22 Residents (#3, #6, #11, #12, #17, #18, #19, #20, #26, #32, #35, #36, #42, #44, #45, #52, #57, #63, #64, #66, #68, #73) residing on the 300 hall. The facility census was 78.

Inspectors wroteBased on staff interview and records review, the facility failed to obtain resident or Power of Attorney signatures to manage resident funds. This affected three (#29, #40 and #138) of six residents reviewed. The facility identified 47 residents whose funds are managed by the facility. The census was 78.

Inspectors wroteBased on medical record review, review of a facility Self-Reported Incident (SRI), staff, resident, and detective interviews and police review, the facility failed to ensure that each resident's physician was notified when a significant change occurred in their physical status. This involved one (#40) of five residents reviewed for abuse and neglect. The facility census was 78.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure a resident that was discharged from Medicare Part A services was notified of the potential liability for payment. This affected one (#327) of three residents reviewed for beneficiary notices. The facility census was 78.

Inspectors wroteBased on medical record review, observations, review of facility Self-Reported Incident (SRI)/investigations, staff, resident, and detective interviews and policy review, the facility staff failed to immediately report allegations of abuse, neglect, or mistreatment to the Administration. This affected two (#40 and #55) out of five residents reviewed for abuse and neglect. The facility census was 78.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a written notice including reasons for transfer/discharge and appeal rights was provided to the resident, resident's representative, and ombudsman prior to transfer/discharge. This affected two (#52 and #77) of two Residents reviewed for hospitalization. The facility census was 78.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure a discharge Minimum Data Sets (MDS) assessments were transmitted to Centers for Medicare and Medicaid Services (CMS) system. This affected one (#2) out of one resident reviewed for resident assessment. The facility census was 78.