Kings Harbor Multicare Cente

Inspectors wroteNumber of residents sampled: 39Number of residents cited: N/A Based on interviews and record reviews conducted during the Recertification survey, the facility failed to ensure that the direct care staffing information based on payroll data was submitted based on the schedule specified by the Centers for Medicare and Medicaid Services. Specifically, the facility failed to submit the direct care staffing data for fiscal year Quarter 1 2026 (10/01/2025 - 12/31/2025) timely.

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 1 Based on observation, record review, interview, the facility failed to ensure that resident was assessed by an interdisciplinary team to determine their ability to safely self-administer medication when clinically appropriate. This was evident for one (1) of three (3) residents (Resident #439) reviewed for Respiratory Care. Specifically, there were multiple observations of a Ventolin HFA inhaler left unsecured at Resident #439's bedside, and there was no evidence Resident #439 had been assessed by the interdisciplinary team, and a determination made that they could safely self-administer the medication. In addition, there was no documented evidence of a physician's order for this medication.

Inspectors wroteNumber of residents sampled:5Number of residents cited:1Based on record review and interviews, the facility failed to ensure they immediately informed the resident, consulted with the resident's physician and notified the resident's representative when there was a need to alter treatment significantly. This was evident for one (1) of five (5) residents (Resident #630) reviewed for Pain Management out of 39 sampled residents. Specifically, there was no documented evidence that Resident #630 or their designated representative was informed when Dilaudid was initiated and added to their pain management regimen.

Inspectors wroteBased on observation, interview, and record review conducted during the survey the facility failed to ensure that a resident was free from physical restraints for purposes of discipline or convenience and that are not required to treat the resident's medical symptom. This was evident for one (1) of two (2) residents (Resident #642) reviewed for Physical Restraints out of 39 total sampled residents. Specifically, Resident #642 was observed, on multiple occasions, in bed with two (2) upper half side rails raised on both sides. The siderail assessments were incomplete, the physician order documented use of a one (1) half side rail as an enabler, there was no documentation of the medical necessity for use of the side rails, and Resident #642 was not able to lower the bed rails voluntarily.

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 1Based on record review and interviews conducted during the survey 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, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the state agency. This was evident for one (1) of three (3) residents (Resident #273) reviewed for Accidents out of total 39 sampled residents. [...]

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 1Based on record review and interviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This was evident for one (1) of three (3) residents (Resident #696) reviewed for Hospitalization out of 39 sampled residents. Specifically, Resident #696 had a change of condition and Urinalysis/Polymerase Chain Reaction testing (method to detect and identify pathogens (things that cause disease) was ordered on 02/09/2026 and results were not received until 02/19/2026 which confirmed that Resident #696 had a urinary tract infection. In addition, there was no documented evidence that the Medical Doctor and Resident #696's representative were notified when Resident #696 refused to provide a urine sample.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident on one (1) of 17 resident units (Unit 5 East), and one (1) of five (5) residents (Resident #683) reviewed for Pressure Ulcer/Injury out of a total sample of 39 residents. Specifically, 1). Housekeeping Aide #1 was observed in the room of a resident on contact/droplet precaution clostridium difficile (bacterial infection that affects the colon) and was not wearing a gown and did not perform hand washing before exiting the room, and 2). [...]

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 3 Based on record review and staff interview conducted during the survey, the facility failed to ensure that residents and/or their designated representatives were fully informed of their right to an expedited review of a service termination. This was evident for three (3) of three (3) sampled residents (Resident #635, Resident #637, and Resident #701) reviewed for Beneficiary Protection Notification out of 39 sampled residents. Specifically, there was no documented evidence that written notices were mailed to the designated representatives of Resident #635, Resident #637, and Resident #701 on the same day that telephone notification was made.

Inspectors wroteBased on record reviews, and interviews conducted during a survey, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice. This was evident in one (1) of three (3) residents sampled (Resident #1). Specifically, facility's investigation dated 02/17/2026 at 5:04 PM, documented Resident #1 vomited undigested foods and there was no documented evidence that Resident #1's vital signs were done, or the Registered Nurse Supervisor #1 or the medical doctor were notified that Resident #1 vomited after dinner.

Inspectors wroteBased on staff observation, interviews and record review conducted during an abbreviated survey (NY00333408), the facility did not ensure that pain management was provided to a resident who required such services consistent with professional standards of practice. This was evident in one out three residents (Residents #1) sampled. Specifically, Resident #1 reported to Certified Nursing Assistant #1 on 02/09/2024 at 10:10 AM that they were unable to stand and that they had pain. Resident #1 was transferred, by Licensed Practical Nurse #1 and Certified Nursing Assistant #1, before being assessed by Registered Nurse Supervisor #1 and before pain medication was administered. Resident #1 was transferred to the hospital on [DATE] and was diagnosed with an acute Pelvic fracture. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification/Complaint survey (NY00349608) from 12/02/2024 to 12/09/2024, the facility did not ensure all alleged violations involving resident to resident physical abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident for 2 (Resident # 193 and # 325) of 5 residents reviewed for Abuse out of sample size 38 residents. Specifically, the facility did not report Resident # 325 hit Resident # 193 on the right shoulder with a grabber to the New York State Department of Health within 2 hours after the allegation was made

Inspectors wroteBased on Record reviews and interviews during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that all completed resident assessments were submitted and transmitted into the Quality Improvement Evaluation Assessment Submission and Processing in a timely manner. Specifically, 9 (Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #493, and Resident #572) of 9 Minimum Data Set submissions reviewed for Resident Assessments were not submitted to Centers for Medicaid and Medicare Services system within 14 days of completion.

Inspectors wroteBased on observations, interviews, and record review during the Abbreviated Survey (NY 00351995), the facility failed to protect residents' rights to be free from physical abuse by nursing home staff. This was evident in one out of six residents (Resident #1) reviewed for abuse. Specifically, on 08/20/2024 at approximately 4:45 PM, Certified Nursing Assistant #2 reported to Registered Nurse Supervisor #1 that at 6:53 AM, Certified Nursing Assistant #2 assisted Certified Nursing Assistant #1, in the care of Resident #1. During care, Resident #1 held on tightly to Certified Nursing Assistant #1's hand, sinking their fingers into Certified Nursing Assistant #1's arm. Certified Nursing Assistant #1 raised their hand and with a deliberate, forceful slap to Resident #1's face between their forehead and eyes.

Inspectors wroteBased on record review and interviews conducted during the abbreviated survey (NY00341680) on 08/27/2024-08/29/2024, the facility failed to ensure the resident was free of significant medication errors. This was evident for one out of five sampled residents (Resident #2). Specifically, on 05/08/2024 at approximately 10:50 PM, Registered Nurse # 1 administered 24 units of insulin Lantus (long-acting insulin) to Resident #2, who was not on insulin therapy. The Medical Doctor was made aware and immediately ordered dextrose 5 % and 0.45 % sodium chloride intravenous solution to be infused at 70 ml/hour for 24 hours. Fingerstick Blood Sugar and vital signs (blood pressure, pulse, and temperature), monitor every four hours for 24 hours.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification and Complaint (NY00312479) survey from 04/27/23 to 05/04/23, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet resident needs. This was evident for 3 (Residents #193, #513, and #936) of 41 total sampled residents. Specifically, 1) a CCP related to abuse prevention was not developed for Resident #193 following a substantiated abuse allegation, 2) a CCP related to dialysis treatment was not developed for Resident #513 who receives dialysis, and 3) a CCP related to fractures was not developed for Resident #936 following a left rib fracture.

Inspectors wroteBased on interviews and record review conducted during an abbreviated survey (NY00307515), the facility did not ensure that all alleged violation of abuse, including injuries of unknown source, were thoroughly investigated. This was evident in 1 (Resident #936) of 41 sampled residents. Specifically, Resident #936 was found to have multiple left rib fractures of unknown origin without evidence of an investigation to rule out abuse.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification and Complaint (NY00311511) survey from 04/27/23 to 05/04/23, the facility did not ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene. This was evident for 1 (Resident #402) of 6 residents reviewed for ADLs out of 41 total sampled residents. Specifically, Resident #402 was not provided with incontinent care after having a bowel movement.

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated survey (#NY00308148) from 4/27/23 to 5/4/23, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evidenced for 1 (Resident #475) of 41 total sampled residents. Specifically, Resident #475 was not assessed after a a family member reported swelling and discoloration to their right hand.