Kerens Care Center

Inspectors wroteBased on interview, and record review, the facility failed to ensure personnel provided basic life support, which included CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to relative physician orders and the Resident's advanced directives for 1 (Resident #1) of 6 residents reviewed for cardio-pulmonary resuscitation. RN A failed to initiate life-saving measures (CPR) when Resident #1, who had a code status of full code was found unresponsive and expired. This failure could place residents at risk of death from not receiving life-saving measures if required. The immediacy began on [DATE] and ended on [DATE]: The noncompliance was identified as PNC. The JT began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on observation, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, 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 1 of 6 residents (Resident #1) reviewed for comprehensive care plans. Resident #1's comprehensive care plan did not reflect Resident #1's mechanical soft texture diet. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident's bedside, toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 3 of 10 residents (Resident #20, Resident #28, and Resident #31) reviewed for the resident call system . The facility failed to provide a working communication system, which was easily at reach, which would allow Resident #20, Resident #28, and Resident #31 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.

Inspectors wroteBased on interviews, and record review the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for five of five residents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present.

Inspectors wroteBased on interviews and observations, the facility failed to provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible for 1 of 1 memory care units (10 total residents) reviewed for homelike environment. The facility failed to provide a homelike environment inside the rooms (by hanging pictures, having decor present, or having color present) for the residents who lived in the memory care unit of the facility. This deficient practice could lead to regression and/or a feeling of institutionalization for the residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide, based on the comprehensive assessment and care plan, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being in the 1 of 1 memory care units (10 residents) reviewed for activities. The facility did not provide the memory care unit residents with individual or group activities.

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 transmission of communicable diseases and infections for 4 of 4 resident (Resident #13, #14, #24, and #39) and 1 of 1 laundry carts reviewed for infection control. The facility failed to ensure MA B performed proper hand hygiene and sanitize contaminated medication cart and blood pressure equipment when passing medications on Resident #13, #14, #24, and #39. The facility failed to ensure laundry staff handled and stored linens in a manner to ensure cleanliness and protect from dust and soil to prevent cross-contamination and the spread of infections for 1 of 1 laundry carts. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to protect and promote an environment that ensured the resident's right to a dignified existence for 2 of 2 residents (Resident #24 and #3) reviewed for resident rights. The facility failed to to address Resident #3's eating restrictions in a dignified manner and protect confidentiality related to incontinence care needs on Resident #24. This failure could place residents at risk for shame and loss of dignity that could negatively impact their quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #36) of five residents reviewed for ADL care. The facility failed to shave Resident #36's facial hair all along the under side of her chin that was approximately 1 cm in length This deficient practice could place residents at risk of a decline in their sense of well-being and level of satisfaction with life.

Inspectors wroteBased on observations, interviews and record review, 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 each resident for 7 of 18 residents (Resident #5, #8, #9, #10, #11, #12, #14) reviewed for medications and pharmaceutical services, in that: The facility failed to ensure narcotic audits were properly conducted on or about 2/6/2025, through 2/8/2025, per the facility's policies and procedures, resulting in unaccounted for, misplaced, and/or misappropriated medications, including (2) tablets of Lorazepam 1mg, (1) tablet of Tylenol #3 (Codeine), (2) tablets of Lorazepam .5mg, (1) tablet of Phenobarbital 60mg, and (1) tablet of Amoxicillin 500mg. [...]

Inspectors wroteBased on interview, and record review the facility failed to implement a policy that is in accordance with the State Medicaid Plan to allow a resident to return to his previous room upon discharge from the hospital for 1 of 1 resident reviewed for discharges. The facility failed to ensure Resident #1 received the services required when they failed to allow Resident #1 to return to the facility after his hospitalization and they failed to appropriately notify the resident, his representative, and the LTC Ombudsman of the discharge. This failure placed residents at risk of an extended, unnecessary hospitalization and a traumatic psychosocial adjustment to a new facility.

Inspectors wroteBased on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 1 resident (resident #2) reviewed for care plans. The facility failed to ensure Resident #2 had a care plan to reflect the accurate diet she was on. Resident #2 was care planned for pureed textured diet when she was receiving regular diet. This failure could place residents at risk of getting insufficient nutrition with the wrong diet order which could have diminished her physical and psychosocial well-being.

Inspectors wroteBased on interview, and record review the facility failed to ensure medical records were complete and accurate in accordance with accepted professional standards and practices when the facility to maintain a correct medical record for 1of 1 resident (resident #2) reviewed for diet orders. Evidence supports the resident medical record was not accurate. The facility failed to ensure Resident #2 had an accurate medical record when the physician signed an incorrect diet order for a pureed diet that the resident wasn't getting and did not need. This failure could place residents at risk of getting insufficient nutrition with the wrong diet order which could have diminished her physical and psychosocial well-being.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #7) of seven residents reviewed for quality of care. The facility failed to ensure Resident #7 was transferred using a gait belt on 03/11/2024 that resulted in a 10th rib fracture and pneumothorax This failure could place residents at risk of accidents and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 2 residents (Resident #5) and 1 of 2 staff (CNA A) reviewed for incontinent care as indicated by: The facility failed to ensure CNA A washed or sanitized her hands while going from a dirty to clean surface when performing incontinent care on Resident #5. This deficient practice placed residents at risk for cross contamination and the spread of infection.