Kingsbrook Lifecare Center

Inspectors wroteBased on observation, interview, record review, review of the facility's investigation report, and review of the facility's policy, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 26 sampled residents, Resident (R) 99, R110, R117, and R130.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, 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 development and transmission of communicable diseases and infections affecting 4 of 26 sampled residents, Residents (R) 57, R60, R87, and R132. Observations on 06/02/2025 and 06/04/2025 revealed opened packages of resident items, clothing, and equipment that were stored in unclean areas; staff providing direct care for residents in Enhanced Barrier Precautions (EBP) that did not wear appropriate personal protective equipment (PPE), dispose of PPE properly, and perform required hand hygiene; staff holding clean linen against their person; [...]

Inspectors wroteBased on interview, record review, review of the facility's agreement with the dialysis center, and review of the facility's policy, the facility failed to ensure that residents requiring dialysis received services consistent with professional standards of practice by failing to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 2 of 3 residents receiving dialysis, Resident (R) 64 and R123.

Inspectors wroteBased on observation, interview, record review, review of the website www.drugs.com, and review of the facility's policy, the facility failed to ensure drugs and biologicals were stored according to professional standards for 1 of 3 medication room refrigerators and 3 of 4 medication carts. Proper temperature control for the medication room refrigerator on the Forest Heights Unit was not maintained, and staff failed to notify the Maintenance Director of the equipment failure. Staff failed to write the expiration date on three insulin pens (two in the medication cart on the Forest Heights Unit and one in the medication cart on the Garden View Unit) based on the date they were removed from refrigeration. Staff failed to discard two tramadol pills in the medication cart on the Shoreline Unit after the packaging was damaged .

Inspectors wroteBased on interview, record review, review of the Kentucky Medicaid Nurse Aide Testing Procedures Manual and Study Guide, and review of the facility's policy, the facility failed to ensure residents received care planning to meet the resident's physical, mental, and psychosocial needs for 1 of 26 residents reviewed for care planning (Resident (R) 99). The facility failed to develop care plan interventions to address care of R99's uncircumcised penis, resulting in worsening of an infection of the resident's penis that required surgical intervention.

Inspectors wroteBased on interview, record review, review of the Kentucky Medicaid Nurse Aide Testing Procedures Manual and Study Guide, and review of Mosby's Textbook for Nursing Assistants, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs for 1 of 3 residents assessed for skin care (Resident (R) 99). Staff failed to re-assess identified redness under R99's penile foreskin, even though the resident was complaining of pain during urination, which resulted in worsening of an infection that required surgical intervention.

Inspectors wroteBased on observation, interview and review of facility Policy, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation during initial tour on 03/26/19 of the kitchen, revealed there was an accumulation of dust on the dish room ceiling, above the kitchen production area and on the ceiling in the refrigerator walk-in. In addition, the temperature logs for the walk-in refrigerator, freezer and dry storage were incomplete. Additionally, Resident #35 was observed to have multiple perishable food items in his/her room.

Inspectors wroteBased on observation, interview and review of the facility's Policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (1) of twenty-five (25) total sampled residents (Resident #29). Observation of staff member with residents in the Parlor Dining Room located on The Forest Heights Unit, on 03/27/19, revealed State Registered Nursing Assistant (SRNA) #1 obtaining vital signs for one (1) of twenty-five (25) total sampled residents, Resident #29.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for one (1) of twenty-five (25) sampled residents (Resident #64). Although Resident #64 sustained a fall on 01/26/19, this fall was not reflected on the Quarterly MDS assessment dated [DATE].

Inspectors wroteBased on interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to implement Comprehensive Care Plans for each resident, to meet a resident's medical, nursing, and mental and psychosocial needs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being related to ongoing psychotropic medication monitoring for one (1) of twenty-five (25) sampled residents (Resident #56). Resident #56's Comprehensive Care Plan, dated 08/14/18, revealed interventions to observe for effectiveness of medications; and observe for side effects of medication. [...]

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure the Comprehensive Care Plan was revised for one (1) of twenty-five (25) sampled residents (Resident #64). Resident #64, sustained a fall on 01/26/19, and the facility conducted aRoot Cause Analysis with corrective action including interventions for a Reacher/Grabber and to Keep the resident in populated areas; however, the Comprehensive Care Plan was not revised with the new interventions.

Inspectors wroteBased on observation, interview, record review and review of facility Policy, it was determined the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of twenty-five (25) sampled residents (Resident #35). Resident #35 exhibited hoarding behaviors including hoarding of papers which were stacked against the walls of the resident's room and were all over the resident's bed. In addition, there was hoarding of left over food and perishable foods. Although there was a Physician's Order received on 08/23/17, which stated may have psychiatric evaluation as needed, there was no documented evidence the facility attempted to provide psychiatric services as ordered. [...]

Inspectors wroteBased on interview, record review, and review of facility Policy, it was determined the facility failed to ensure residents who use psychotropic drugs receive adequate monitoring for efficacy and adverse consequences, to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one (1) of two (2) residents reviewed for psychotropic medications out of (25) sampled residents (Resident #56). Resident #56 was prescribed scheduled Haloperidol Lactate Concentrate (antipsychotic psychotropic drug) related to Unspecified Dementia without Behavioral Disturbance, on 06/29/18; however, there was no documented evidence during January, February or Mach of 2019, of ongoing monitoring for efficacy and adverse consequences for the psychotropic drug.

Inspectors wroteBased on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure that its medication error rates were not five percent (5%) or greater. Observation of medication pass, on 03/28/19 at 9:01 AM, for Resident #277, revealed the nurse crushed one (1) Potassium Chloride Extended Release (ER) twenty (20) Milliequivalents (MEQ) Tablet, crushed three (3) Metoprolol Succinate ER twenty-five (25) Milligram (MG) tablets, crushed one (1) Amiodarone Hydrochloride (HCL) 100 Milligram (MG) Tablet, and crushed one (1) Methocarbamol 500 mg Tablet. Then, the nurse opened one (1) Omeprazole 20 mg Delayed-Release (DR) Capsule and opened one (1) Duloxetine 30 mg DR Capsule and placed the contents of each crushed tablet and each opened capsule into a medication cup. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility's Policies, it was determined the facility failed to ensure residents were free of significant medication errors for one (1) of twenty-five (25) sampled residents (Resident #277). Observation of medication administration, on 03/29/19 at 9:01 AM, on Forest Heights Unit, A-Hall, revealed Licensed Practical Nurse (LPN) #8 crushed Potassium Chloride Extended-Release (ER) and Metoprolol Succinate Extended Release (ER) and administered the medication to Resident #277. Potassium Chloride Extended-Release (ER) and Metoprolol Succinate Extended Release (ER) were two (2) medications that were listed on the facility's Oral Dosage Forms That Should Not Be Crushed List.

Inspectors wroteBased on observation, interview, and review of the facility's Policies, it was determined 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 development and transmission of communicable diseases and infections for one (1) of five (5) residents reviewed for infections out of a total of twenty-five (25) sampled residents (Resident #277). Observation of medication administration on 03/28/19 revealed staff failed to perform proper hand hygiene prior to preparation of medications, before entering resident's room and during administration of eye medication for one (1) of twenty-five (25) sampled residents, Resident #277.