Kings Daughters Community Health & Rehab

Inspectors wroteBased on staff interviews, resident interviews and record reviews, the facility failed to protect residents from neglect. The facility failed to ensure licensed nursing services were available on the [NAME] Wing nursing unit from approximately 7:47 p.m. on 1/31/26 until 7:00 a.m. on 2/1/26. During this period, 39 residents were without access to licensed nursing assessment, medication administration, monitoring, physician notification, and nursing intervention. As a result, Resident #6 (R6), Resident #7 (R7), and Resident #8 (R8) experienced untreated pain, delayed or missed medications, anxiety, insomnia, and psychosocial distress. This deficient practice constituted neglect and resulted in Immediate Jeopardy. Following validation of corrective actions, the Immediate Jeopardy was removed and the deficiency remained cited at Level 2, Pattern noncompliance.

Inspectors wroteBased on staff interviews, resident interviews, and facility documentation reviews, the facility staff failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident affecting 39 residents on the [NAME] Wing. Specifically, the facility failed to ensure licensed nurse coverage on the west wing, resulting in one of the three nursing units operating without a licensed nurse available to administer medications or provide nursing oversight for approximately 12 hours. This deficient practice resulted in the identification of immediate jeopardy (IJ), and subsequent substandard care. Following the removal of the IJ, the scope and severity was lowered to a level 3 widespread noncompliance.

Inspectors wroteBased on staff interviews, resident interviews, clinical record reviews, and facility documentation reviews the facility staff failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This deficient practice resulted in harm for three residents, Resident #6 (R6), Resident #7 (R7), and Resident #8 (R8) out of a survey sample of nine residents.

Inspectors wroteBased on observations, clinical record reviews, staff interviews, resident interview, and facility documentation the facility staff failed to ensure adequate interventions were implemented and followed to prevent the development and or worsening of pressure ulcers for one resident, resident #2 (R2) out of a survey sample of nine residents This failure resulted in harm as R2 developed in house acquired pressure ulcers.

Inspectors wroteBased on staff interviews, resident interviews, and facility documentation the facility staff failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident which resulted in harm to several residents, who had untreated pain, residing on one unit out of three units.

Inspectors wroteBased on staff interviews, resident interviews, clinical record reviews, and facility documentation reviews, the facility staff failed to ensure quality nursing care was provided to meet resident needs on one of three nursing units. Specifically, the facility failed to ensure licensed nurse coverage on the west wing nursing unit, resulting in no licensed nurse being available to administer medications, assess residents, respond to change in condition, provide treatments, or ensure resident safety. This deficient practice resulted in harm to residents #6, 7, and 8.

Inspectors wroteBased on observation, staff interviews, and facility documentation the facility staff failed to maintain an infection prevention and control program designed to provide residents with a safe, sanitary and comfortable environment for one of ten residents (Resident #10).

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation review the facility staff failed to notify the physician when ordered laboratory tests were not obtained as prescribed for one resident, Resident #102(R102) out of a survey sample of eight residents.

Inspectors wroteBased on staff interviews, resident interviews, clinical record reviews, and facility documentation reviews the facility staff failed to follow the facility's abuse, neglect, and exploitation policy after allegation of neglect were reported, resulting in residents not being adequately protected form potential ongoing harm.

Inspectors wroteBased on staff interviews, resident interviews, and facility documentation reviews the facility staff failed to follow their abuse policy and report an allegation of neglect.

Inspectors wroteBased on staff interviews, resident interviews, and facility documentation the facility staff failed to investigate an allegation of neglect that was reported, resulting in residents not being adequately protected from potential ongoing harm.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation review, the facility staff failed to complete required post-fall assessments and neurological checks following an unwitnessed fall for one resident, Resident #102 out of a survey sample of eight residents.

Inspectors wroteBased on clinical record reviews, staff interviews and facility documentation review, the facility staff failed to review and revise the comprehensive person-centered care plan for two residents, Resident #1 (R1) and Resident #2(R2), out of a survey sample of nine residents.

Inspectors wroteBased on staff interviews, clinical record reviews, and facility documentation reviews the facility staff failed to ensure that professional standards of quality care were met for one resident, Resident #5 out of a survey sample of nine residents.

Inspectors wroteBased on facility documentation review, and staff interview the facility staff failed to ensure complete nurse staffing information was available for review.

Inspectors wroteBased on staff interviews, resident interviews, clinical record reviews, and facility documentation review the facility staff failed to ensure residents were provided pharmaceutical services that included administration of medications to meet the needs of each resident.

Inspectors wroteBased on observation, resident interviews, staff interviews, and facility documentation the facility staff failed to ensure resident furnishings and equipment were maintained in good repair and safe condition for one resident, Resident #7 (R7) out of a survey sample of nine residents.

Inspectors wroteBased staff interview and facility document review, the facility staff failed to provide services of a registered nurse (RN) for at least 8 consecutive hours per day on three of seventeen days in December 2025 (12/7/25, 12/13/25 and 12/14/25).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to follow physician orders for medication administration for four of eleven residents in the survey sample (Residents #1, #4, #7 and #8).

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to follow professional standards of care during medication administration for one of eleven residents (Resident #11).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of eleven residents in the survey sample (Resident #5).

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to follow infection control practices during a medication pass on one of two units (East unit).

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure medication was available for administration for one of 26 residents, Resident #124, during the medication pass and pour observation.

Inspectors wroteBased on staff interview, resident interview, and facility documentation review, the facility staff failed to prevent further potential abuse, neglect, or mistreatment, while investigations were in progress, and the facility staff lacked the knowledge of the need to protect the resident if abuse is reported and/or witnessed. The facility conducted inadequate investigations and removed protective measures that were implemented following the allegation prior to a conclusion being reached regarding the abuse allegations, which had the potential to expose residents on 3 of 3 nursing units to abuse. Immediate Jeopardy and substandard quality of care were identified.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement interventions to ensure that 4 residents (Resident #14, Resident #13, Resident #3, and Resident #12), in a survey sample of 48 residents, maintained an acceptable parameter of nutritional status and as a result, all 4 experienced insidious, severe weight loss that was unplanned resulting in immediate jeopardy being identified.

Inspectors wroteBased on clinical record review, resident interview, facility documentation review, and facility documentation review, the facility failed to protect the resident's right to be free from abuse and neglect from staff, for two residents (Resident #1 & Resident #44) in a survey sample of 48 residents, which resulted in harm for both residents.

Inspectors wroteBased on observation, staff interviews, resident interviews, clinical record review and facility documentation review it was determined that the facility staff failed to identify pressure wounds until they were an advanced stage for two residents (Resident #4, R4 and Resident #17, R17) in a survey sample of four residents reviewed for pressure wounds. This constitutes harm for both residents.

Inspectors wroteBased on resident interview, staff interviews, clinical record review and facility documentation review, the facility staff failed to provide incontinence care for one resident (Resident #44), in a survey sample of 48 residents, resulting in psychosocial harm.

Inspectors wroteBased on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to have sufficient nursing staff to meet the resident care needs on 2 of 3 nursing units, which affected many residents and resulted in psychological harm for one resident (Resident #44).

Inspectors wroteBased on observation and staff interviews, the facility staff failed to post in a readily accessible place, inspection reports with a plan of corrections in effect, with respect to any surveys conducted during the past 3 years. The facility's non-compliance has the potential to impact all 112 Residents and their family's ability to make informed decisions with knowledge of the facility's regulatory compliance history.

Inspectors wroteBased on resident interview, staff interview and facility documentation review, the facility staff failed to respond to resident council grievances, which had the potential to affect many residents on 3 of 3 nursing units.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to report allegations of abuse, neglect, and mistreatment to the required regulatory agencies, which involved 26 resident allegations of abuse and/or mistreatment, in a sample of 33 allegations reviewed.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review the facility staff failed to ensure residents receive treatment and care in accordance with professional standards of practice for numerous residents residing on 2 of 3 nursing units.

Inspectors wroteBased on observations, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure 3 Residents (Resident #36, #35, and #31) who received dialysis services received care and treatment consistent with professional standards of practice, in a survey sample of 3 residents reviewed for dialysis services.

Inspectors wroteBased on observation, resident interviews, staff interviews and facility documentation review the facility staff failed to prepare and serve meals in accordance with the menu, which had the potential to affect residents on 3 of 3 nursing units.

Inspectors wroteBased on observations, staff interviews, resident interviews, and facility documentation review it was determined that staff failed to provide meals based on resident preferences, failed to provide nutritionally equivalent substitutions, and failed to serve foods that accommodate resident allergies, affecting multiple residents residing on 3 of 3 nursing units.

Inspectors wroteBased on observations, staff interviews, resident interviews, and facility documentation review, it was determined the staff failed to provide care and services for therapeutic diets for ten residents (Resident #2- R2, Resident #6- R6, Resident #7- R7, Resident #9-R9, Resident #12-R12, Resident #4-R4, Resident #14- R14, Resident #33- R33, Resident #40- R40 and Resident #36-R36), in a survey sample of 48 residents.

Inspectors wroteBased on observation, staff interviews, and facility documentation review, the facility staff failed to ensure the facility staff provided meals daily at regular times having affected residents on 3 of 3 nursing units.

Inspectors wroteBased on observations, resident interviews, staff interviews and facility document it was determined that the staff failed to prepare and store food in a safe and sanitary manner with regards to food temperatures on the service line and to keep holding temperatures adequate for serving the food to residents, having the potential to affect many residents on 3 of 3 nursing units.

Inspectors wroteBased on observation, staff and resident interviews, clinical record reviews and facility documentation reviews, the facility staff failed to provide effective administration regarding resident's right to be free from abuse, neglect and exploitation and the protection of residents and insidious weight loss, resulting in the identification of two immediate jeopardy situations and substandard quality of care being identified, which had the potential to affect multiple residents on all 3 of the nursing units.

Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to maintain an effective quality assurance program with regards to maintain ongoing compliance with food and nutrition services, which resulted in immediate jeopardy being identified, which had the potential to affect many residents on three of three nursing units.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to maintain a quality assessment and assurance committee consisting of the minimum members being present for 4 of 6 meetings reviewed for compliance.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review the facility staff failed to ensure residents receive services with reasonable accommodation of resident needs and preferences affecting 9 residents (Resident #21, 3, 10, 24, 25, 26, 19, 28, and 38) on 2 of 3 nursing units.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review the facility staff failed to uphold resident rights for visitation for two residents (Resident #14, R14 and Resident #15, R15) of 48 residents.

Inspectors wroteBased on resident interview, staff interviews, and facility documentation review, the facility staff failed to make prompt efforts to resolve grievances involving one resident (Resident #14- R14), in a survey sample of 48 residents.

Inspectors wroteBased on staff interview and employee record reviews and facility documentation review, the facility failed to implement their abuse policy for 2 employees (CNA #12 and CNA #1 ) in a survey sample of 25 staff records reviewed.

Inspectors wroteBased on observation, resident interviews, staff interviews and clinical record review, it was determined that the facility staff failed to accurately code an assessment for two residents (Resident #13- R13, and Resident #3- R3) in a survey sample of 48 residents.

Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to review and revise care plans of residents following each assessment for 2 Residents (Resident #4 & Resident #3) in a survey sample of 48 Residents.

Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing practice with regards to carrying out physician orders for one resident (Resident #35) (R35) in a survey sample of 48 residents.

Inspectors wroteBased on observations, staff interview, resident interview and facility documents it was determined that the facility staff failed to provide activity of daily living (ADL) care for three residents (Resident #4, R4, Resident #14, R14, Resident #15, R15) out of 48 residents in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure a resident who had Alzheimer's dementia had a dementia care plan with interventions to ensure dementia appropriate treatment and services were provided for one resident (Resident #6- R6) in a survey sample of 48 residents.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure medication was available for administration for one of 26 residents, Resident #124, during the medication pass and pour observation.

Inspectors wroteBased on observations, resident interviews, staff interviews and facility documentation review, it was determined that the facility staff failed to provide appetizing food with palatable temperatures and appearance to residents on one of three units (400 unit).

Inspectors wroteBased on observation, resident interviews, staff interviews and clinical record review, it was determined that the facility staff failed to maintain an accurate and complete clinical record for four residents (Resident #14, R14, Resident #15, R15, Resident #17, R17, and Resident #39, R39) in a survey sample of 48 residents.

Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, the facility staff failed to employ sufficient kitchen/dietary staff to ensure palatable food and timely meals.

Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, the facility staff failed to provide daily meals at regular times and according to posted schedules.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure accurate meal tickets for eleven of fourteen residents in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, the facility staff failed to provide appetizing food with palatable temperatures on one of three units (300-unit).

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store, prepare, and distribute food in a sanitary manner from the main kitchen.

Inspectors wroteBased on observation and staff interview, the facility staff failed to maintain essential kitchen equipment in good working order.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to include the medical record as part of a monthly medication regimen review for four of twenty-two residents in the survey sample (Residents #7, #13, #64 and #75).

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to prepare food in a sanitary manner in the main kitchen. The Findings Include: The kitchen staff were thawing 5 bags of chicken pieces using improper technique. On 1/31/23 at 11:15 AM, during an initial tour of the kitchen, 5 bags containing approximately 20 pieces of chicken per bag was submerged in water without water running over the chicken. At this time, the dietary manager (other staff, OS #2), who also observed the chicken in the sink, was interviewed. OS #2 verbalized that the sink had gotten clogged up so the water was cut off. OS #2 was asked how is the chicken supposed to be thawed. OS #2 verbalized that chicken and frozen meat can be thawed in submerged water with water running over the meat. [...]

Inspectors wroteBased on clinical record review, and staff interview, the facility staff failed for one of 22 residents in the survey sample (Resident # 10) to ensure an accurate Minimum Data Set. Resident #10 was inaccurately identified on a Significant Change Minimum Data Set (MDS) as not receiving hospice services.

Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to develop a baseline care plan for immediate care upon admission for one of 22 residents, Resident # 293.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure drugs and biological's were labeled appropriately on one of two nursing units medication room.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide a therapeutic diet for one of twenty-two residents in the survey sample (Resident #193).

Inspectors wroteBased on clinical record review, and staff interview, the facility staff failed for one of 22 residents in the survey sample (Resident # 38) to ensure a complete and accurate clinical record. The reason for a room change was not included in Resident # 38's clinical record.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to perform hand hygiene during a medication pass on one of two units (East).

Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to accurately complete an MDS assessment for one of 21residents, Resident #83. Resident #83's discharge status was incorrectly coded as acute hospitalization.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care for one of 21 residents in the survey sample. Resident #33 was administered the medication alendronate (Fosamax) without following manufacturer recommendations to maximize effectiveness and prevent side effects such as esophagus injury.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide nail care for one of 21 residents in the survey sample. Resident #33 was observed with long, thick, distorted toenails described by the resident as causing discomfort.

Inspectors wroteBased on observation, staff interview, and clinical record review the facility failed to accurately complete an admission and weekly skin assessment for one of 21 Residents, Resident #242.

Inspectors wroteBased on medication pass observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 percent. There were five observed medication errors out of 35 opportunities resulting in 14.2% error rate.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not readily available for distribution on one of 3 units, the 400 unit.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to follow infection control protocols for hand hygiene on one of three nursing units. A nurse on East wing failed to don gloves and perform hand hygiene between residents when obtaining fingerstick blood samples for glucometer testing.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to attempt appropriate alternatives prior to the use of side/bed rails, failed to assess residents for risk of entrapment prior to use, failed to review the risks/benefits of side/bed rails with the resident and/or resident representative and failed to obtain informed consent prior to use, failed to have a system in place to ensure residents beds were appropriate for the resident's size and weight, and failed to have a system in place for assessment and ongoing monitoring/supervision of side/bed rails in use. One resident (Resident #1) in the survey sample was identified as having his legs entrapped in the side/bed rails. [...]

Inspectors wroteBased on survey findings and staff interviews, the facility administrator failed to ensure that resources regarding the use of side rails were used effectively and efficiently to maintain the highest practicable well-being of each resident. Information regarding the 2017 regulatory requirements for side rails was available to the facility administrator but not implemented.

Inspectors wroteBased on an overview of the facility's Quality Assurance and Performance Improvement (QAPI) Program, staff interview, and the identification of Immediate Jeopardy and Substandard Quality of Care in the area of Quality of Care, specifically Federal Tag F-700 (Bedrails), the facility's QAPI Program failed to identify a systemic problem with the use of bedrails, and failed to develop a mitigation program to address the problem.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to perform a pressure ulcer dressing change per physician's order for one of 24 residents, Resident #67. LPN (licensed practical nurse) #2 was observed providing incorrect treatments to two pressure ulcer sites on Resident #67's hips.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to provide supervision for one of 24 residents in the survey sample, Resident #89. Resident #89 was observed seated in a wheelchair with her toes pointing downward and her feet not flat on the floor. Resident #89 was attempting to self propel in her wheelchair but was unable to do so using only her toes. Resident #89 was then pulling at the door of another resident's room and in the living room of the unit, leaning forward and getting cups out of the trash cans; she was observed putting the cups to her lips and spitting into them.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure two of 24 residents in the survey sample (Residents # 48 and 97) were free of unnecessary psychotropic medications. Residents # 48 and 97 both had an as needed (PRN) psychotropic medication ordered for more than 14 days without a stop date.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not available for administration in two of two medication rooms, and also failed to ensure insulin was properly labeled on one of 6 medication carts. 1. The medication room refrigerators on the East hall and [NAME] hall contained three bottles each of Lorazepam (an antianxiety medication) which were expired and available for administration. 2. The medication cart on the 400 unit contained two vials of improperly labeled insulin.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of 24 residents in the survey sample: Resident # 84.