Kings Healthcare & Wellness Center LP

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data by the required deadline. This failure resulted in CMS not knowing how many direct care staff provided daily care and services for 61 residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for three of 11 sampled residents (Resident 34, Resident 76, and Resident 78) when:1. Resident 34's oxygen therapy (a colorless, odorless, tasteless gas essential to living organisms) was not administered according to the physician order (a set of instructions written by a doctor for clinicians to follow when caring for a resident). This failure resulted in Resident 34 not receiving her oxygen therapy as ordered by the physician, which had the potential to result in shortness of breath, and respiratory distress (difficulty breathing).2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of nine sampled residents (Resident 43) was assessed to safely store and self-administer medication at bedside when Resident 43 had a bottle of [brand name C 1000mg (over the counter vitamin C medication supplement)] medication bottle stored at bedside for self-administration without a physician's order or Medication Self-Administration Assessment Form (MSA- an assessment form to determine if a resident is clinically appropriate to safely and securely store and self-administer their own medication at bedside). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) was developed and implemented for one of three sampled residents (Resident 81), when Resident 81 did not have a care plan for the use of Cervical Collar (C-Collar -a neck brace used to support and immobilize a person's neck) for cervical spinal cord injury (damage to the uppermost part of the spine located in the neck area). This failure had the potential for Resident 81 to not receive the necessary care required for cervical collar, increasing the risk for skin breakdown, improper alignment, and compromised airway. During an observation on 6/1/26 at 9:35 a.m. during initial tour in Resident 81's room, Resident 81 was observed lying in bed, eyes opened, and C-Collar in place. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure daily nurse staffing information contained all required information when the total number and actual hours worked by Registered Nurses (RN), Licensed Vocational Nurses (LVN), and Certified Nursing Assistants (CNA) were not posted for 61 residents and visitors to view. This failure resulted in 61 residents and visitors not knowing how many direct care hours were actually provided daily for each resident by licensed and unlicensed staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to ensure controlled substance medications (is a drug that is strictly regulated by the government because of high risk of misused and abused) are administered and recorded accurately in accordance with the facility's policies and procedures for one of two sampled residents (Resident 39) when Licensed Vocational Nurse (LVN) 2 failed to accurately document Resident 39's controlled substance medication on the controlled substance log to accurately reflect the controlled substance administration. This failure placed Resident 39 at potential risk for medication errors, duplicated dosing and undetected controlled substances diversion (theft or illegal redirecting of a regulated drug). During a medication administration observation on 6/3/26 at 8:28 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and served safely in accordance with professional standards of food service safety for 57 out of 57 residents eating at the facility when 4 single serve pre-prepared ice cream cups and an opened box of kielbasa rope sausage were in the freezer past the use by date. This failure resulted in food items being retained past the use by date which could lead to the serving of expired food items and foodborne illness. During a concurrent observation and interview on 6/1/26 at 9:02 am with the Certified Dietary Manager (CDM), in the kitchen, 4 single serve pre-prepared ice cream cups were observed with a use by date of 5/29/26. The label indicated the 4 single serve pre-prepared ice cream cups were 3 days past the use by date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program to help prevent the development and transmission of infections when, two of two licensed nurses (Licensed Vocational Nurse [LVN] 3 and LVN 4), failed to follow the manufacturer's instructions for use (IFU- the official step by step directions provided by the maker of a product) by not maintaining the required germicidal disposable wipes dwell time (the exact amount of time a disinfectant must stay visibly wet on a surface to completely kill germs) during the disinfection (chemical process that kills harmful germs) of a glucometer (a medical device used for determining the amount of sugar in the blood) after use on Resident 13, Resident 21, Resident 40, Resident 65, and Resident 85. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' room measured at least 80 square (sq) feet (ft) per resident in 16 (Rooms 101 - 104 and Rooms 110 - 121) of 29 resident rooms in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse for one of five sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 hit Resident 1 in the shoulder during transfer from the bed to the wheelchair. This failure violated Resident 1's right to be free from abuse.

Inspectors wroteBased on interview and record review, the facility failed to perform a resident comprehensive assessment and provide pain management services in accordance with professional standards of practice for one of three sampled residents (Resident 1) when Resident 1's left hip internally rotated (twisting movement of the thigh inward from your hip joint) and experienced severe pain with a pain scale level of eight out of 10 (is a tool that measures pain intensity to help assess a person's pain; 0- no pain, 1-3 mild pain, 4-7 moderate pain, 8-10 severe pain) and License Vocational Nurse (LVN) 3 did not perform a resident comprehensive assessment. LVN 3 did not reassess Resident 1's pain level an hour after LVN 3 administered pain medication to assess the medication effectiveness. These failures resulted in Resident 1 experiencing severe pain on 1/25/23 at 5:11 a.m. to 10:48 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 22 's fall care plan interventions were in place to prevent or minimize fall related injuries for one of three sampled residents (Resident 22) when Resident 22 was assessed as at risk for falls, had known behavior of leaning forward in her wheelchair and the care plan interventions to use tilt-back feature on the wheelchair was not implemented. This failure resulted in Resident 22 experiencing an unwitnessed fall from the wheelchair on 10/18/22 onto the floor at the facility's hallway, resulting in loss of consciousness, sustaining a laceration (skin tear) and the use of antibiotic. Resident 22 was sent to the general acute care hospital (GACH) for treatment of her fall related injuries on 10/18/22. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person centered care plan for three of 17 sampled residents (Residents 34, 50 and 2) when: 1. Resident 34 was identified as having a behavior of yelling, cursing and threatening staff on 12/1/22 and licensed nursing staff did not develop an individualized care plan and implement effective interventions. This failure had the potential for Resident 34 to not receive appropriate care and not meet his health, safety, psychosocial, and behavioral needs. 2. Resident 50 did not have an individualized care plan to identify his 1500 milliliters (ml- a unit of measurement) fluid restriction. This failure placed Resident 50's care needs to go unmet and had the potential to result in fluid overload. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1. The Controlled Carbohydrate Diet (a meal plan for diabetic residents) lunch dessert was provided for 17 (Resident 2, 3, 5, 15, 22, 23, 25, 29, 32, 36, 37, 38, 40, 48, 50, 51, 52) of 17 sampled residents who have a physician order to receive Controlled Carbohydrate Diet (CCHO) diet received a regular dessert for lunch on 12/14/22. 2. The fortified dessert was provided for one of one sampled resident (Resident 10) who have a physician order to receive fortified diet (diet with added extra nutrients to increase the calories and/or protein density to promote improvement residents' nutrition status) received a regular dessert for lunch on 12/14/22. These failures had the potential to negatively impact the residents' nutritional status and further compromising residents' medical status.

Inspectors wroteBased on observation and interviews, the facility failed to provide appetizing foods for eight of 65 sampled residents (Resident 24, 33, 34, 53, 209, 357, 359, 360). This failure placed Resident 24, 33, 34, 53, 209, 357, 359 and 360 at potential risk of decreased nutritional intake and affect the residents' nutrition status which could compromise their medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food safety when: 1. The fire hood and ventilators above the stove had black debris and had grease. This failure had the potential risk to cause foodborne illness (stomach illness acquired from ingesting contaminated food) for 65 of 65 sampled residents who received food from the kitchen. 2. The reach in refrigerator number (#) 1 and # 2 ventilators had black debris. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 3. The oven had black substance on the bottom and a yellow/brown discoloration around the knobs. This failure had the potential risk to cause foodborne illness for 65 of 65 sampled residents who received food from the kitchen. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage under sanitary conditions when trash dumpsters were left uncovered, and trash were found on the floor surrounding the trash dumpsters. This failure had the potential to attract rodents, insects and flies and could spread infection which placed residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. Nine of sixteen sampled residents' (Resident 4, 408, 53, 21, 17, 360, 359, 208 and 357) oxygen concentrator (a device that concentrates the oxygen from the ambient air) filters were found with lint and dust. This failure placed Residents 4, 408, 53, 21, 17, 360, 359, 208 and 357 at an increased risk to develop respiratory and healthcare-associated infections. 2. Five bags of wet, soiled mops and cleaning cloths were found on the floor in the laundry area. This failure had the potential to result in cross contamination and placed residents at risk to develop an infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 359) received information on their plan of care in a language they could understand when staff did not consistently provide an interpreter when communicating to Resident 359 in her preferred language. This failure violated Resident 359's rights to participate in the development and implementation of his plan of care in a language he could understand and placed Resident 359 at risk for not making informed decisions about his care and treatment decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality when: 1. Licensed Vocational Nurse (LVN 3) used an unapproved medication administration technique while using an insulin flex pen (a device used to inject insulin [hormone- regulatory substance made by the body to control blood sugar production]) for one of two sampled residents (Resident 25) during a medication pass observation. This failure placed Resident 25 at risk for dosing errors and had the potential for adverse side effects such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). 2. Licensed nurses did not administer oxygen per physician's order for two of three sampled residents (Resident 14 and 17) when physician ordered parameters for oxygen administration were not followed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are receiving dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) treatment received services consistent with professional standards of practice for one of two sampled residents (Resident 50) when Resident 50 received more than her physician prescribed 1500 milliliters (ml- a unit of measurement) of fluids per day during lunch on 12/13/22. (Cross Reference F 656). This failure placed Resident 50's care needs to go unmet and had the potential to result in fluid overload.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain all mechanical equipment in a safe operating condition for one of three sampled residents (Resident 2) when the low air loss (LAL- an air mattress with fluctuating air) digital control unit (pressure redistribution device to stimulate blood flow) was not powering on. This failure had the potential for Resident 2 to have ineffective pressure management surface for the prevention and treatment of pressure ulcer (an injury that breaks down the skin and underlying tissue).

Inspectors wroteBased on observation during the survey period of 12/13/22 through 12/19/22, the facility failed to maintain rooms that measured at least 80 square feet per resident in 16 of 29 resident rooms. This failure had the potential to place residents and families at risk for not having sufficient space to accommodate residents' needs, privacy, and comfort.