Kingston Court Skilled Nursing and Rehabilitation

Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that, in accordance with professional standards and practices, the facility failed to ensure that the resident's medical record was complete and accurately documented for one of the three resident records reviewed (Resident 2). Findings Include: Review of the facility's policy, titled Code Status Orders, effective [DATE], read, Code status communicates to the clinical staff whether the patient desires cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. [...]

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure residents are treated with respect and dignity and cared for in a manner and in an environment that promotes dignity for one of one meals observed (lunch on September 9, 2025).

Inspectors wroteBased on observations, policy review, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment in resident rooms on two of six nursing units (Heritage and A station).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the care plan for two of 27 residents reviewed (Resident 7 and 135).

Inspectors wroteBased on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen area and two of three nourishment pantries (stations A and B).

Inspectors wroteBased on facility policy, review of the clinical record, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that meet each resident's physical, mental, and psychosocial needs for one of 27 residents reviewed (Resident 101).

Inspectors wroteBased on review of the clinical record, policy review, and resident and staff interviews, it was determined that the facility failed to ensure pain management is provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of 30 residents reviewed (Resident 143).

Inspectors wroteBased on review of select food service committee meeting minutes, staff and resident interviews, observation, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures.

Inspectors wroteBased on clinical record review and staff interviews, it was determined the facility failed to ensure pain management was provided that was consistent with professional standards of practice for two of 23 residents reviewed (Residents 9 and 14). This failure resulted in actual harm to Residents 9 and 14, whose pain was not properly relieved and managed and continued to experience uncontrolled pain.

Inspectors wroteBased on clinical record review, staff interview, and Resident's written statement, it was determined that the facility failed to follow accepted professional standards and principles for administering medications to ensure the prevention of significant medication errors for three of 24 residents reviewed (Resident 9, 10 and 14). This failure resulted in harm to Resident 9 and 14 who suffered pain from the omission of mediations.

Inspectors wroteBased upon clinical record review and staff and resident interviews, it was determined the facility failed to provide transfer out of bed services per preference for one of 23 residents reviewed (Resident 1).

Inspectors wroteBased on clinical record review, policy review, and staff interview, it was determined that the facility failed to provide the highest practicable care and follow professional standards of practice for wound care for one of 23 residents reviewed (Resident 9), and failed to follow scheduled medication times based on the documented administration time for 21 of 23 residents reviewed (Residents 1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, and 23).

Inspectors wroteBased on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one of five residents reviewed (Resident 5). Findings Include: A review of the facility's policy, titled Transportation and Escort: Patient, effective April 1, 2003, read, in part, Centers will arrange for ambulance and other appropriate transportation services to provide transportation of patients/residents (hereinafter 'patient') for scheduled appointments as well as emergencies. The policy continued, Center staff will provide assistance in scheduling transportation for patients who need transportation outside of the Center (doctor's appointments, etc.). [...]

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident receives adequate supervision to prevent accidents for one of five residents reviewed (Resident 2). Findings Include: A review of the facility's policy, titled Transportation and Escort: Patient, effective April 1, 2003, read, in part, Centers will arrange for ambulance and other appropriate transportation services to provide transportation of patients/residents (hereinafter 'patient') for scheduled appointments as well as emergencies. The policy continued, Center staff will provide assistance in scheduling transportation for patients who need transportation outside of the Center (doctor's appointments, etc.). Staff may escort patients, if needed . [...]

Inspectors wroteBased on observation, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a skin tear to the posterior right lower extremity for one of 27 residents reviewed (Resident 46). Findings Include: Review of Resident 46's clinical record revealed diagnoses that included multiple sclerosis (a chronic progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord; symptoms include numbness, impaired speech, muscle coordination, blurred vision, and severe fatigue), muscle weakness, and unsteadiness on feet. Review of select facility report detailing the incident that occurred on August 5, 2024, read, in part; [...]

Inspectors wroteBased on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two of three residents reviewed (Residents 8 and 60).

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards, and failed to maintain complete and accurate records related to dialysis communication for one of three residents reviewed for dialysis (Resident 93).

Inspectors wroteBased on review of personnel training records and staff interview, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for five of five nurse aide employee records reviewed (Employees 6, 7, 8, 9, and 10); failed to provide annual training that included dementia management and resident abuse prevention for one of five nurse aide employee records reviewed (Employee 7); and failed to provide annual training that included abuse prevention for one of five nurse aide employee records reviewed (Employee 6). Findings Include: Review of personnel information revealed Employee 6's hire date was November 28, 2014; Employee 7's hire date was March 9, 2023; Employee 8's hire date was February 1, 2023; Employee 9's hire date was April 4, 2023; [...]

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage appropriately, in advance of changes for Medicare covered services, to one of three residents reviewed whose Medicare coverage was discontinued (Resident 341).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment for one of three dining areas and four of 77 resident rooms observed (Resident 60, 71, 94, and 114).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 30 residents reviewed (Residents 36 and 119).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to coordinate the resident assessment for one of four discharged residents reviewed (Resident 110).

Inspectors wroteBased on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 27 residents reviewed (Residents 6 and 94).

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to provide respiratory care and services consistent with professional standards of practice for one of five residents reviewed for respiratory care/oxygen services (Resident 58).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to provide a record of the pharmacist's recommendation along with the physician's response for one of five residents reviewed for unnecessary medications (Resident 119), and failed to act upon a pharmacy recommendation appropriately or in a timely manner for one of five residents reviewed for unnecessary medications (Resident 46).

Inspectors wroteBased on observation, facility policy, product information, and staff interviews, it was determined that the facility failed to store medication in accordance with professional principles for one of three medication storage rooms observed (Heritage Medication Storage Room). Findings Include: Review of facility provided policy, Medication Administration General Guidelines, effective [DATE], revealed, No expired medication will be administered to a resident. Observation of the Heritage Medication Storage Room on [DATE], at 9:15 AM, revealed one single-dose vial of Aranesp (medication used to treat low red blood cell count) 40mcg/1ml. The vial was open with the cap removed and no opened date on the vial. Review of Aranesp product information on [DATE], revealed that Aranesp is only available in single dose vials. Further review revealed once opened Aranesp should only be used one time. [...]

Inspectors wroteBased on clinical record review, facility document review, and staff interviews, it was determined that the facility failed to document education regarding the influenza vaccination at the time of refusal for two of five residents reviewed for immunizations (Residents 46 and 85).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for three of 5 residents reviewed (Residents 1, 3, and 4).

Inspectors wroteBased on facility policy review, job description review, staff and resident interviews, and clinical record review, it was determined that the facility failed to implement post-discharge needs, including therapy services, nursing services, and medical equipment. This failure resulted in a lack of post-discharge services provided in the community for seven out of 15 discharged residents reviewed (Residents 1, 2, 4, 6, 10, 12, and 15) and placed current residents with active discharge plans in an immediate jeopardy situation (Residents 16-20). Findings Include: Review of the facility's policy, titled Discharge Planning Process, revised November 15, 2022, read, in part, The Center must develop and implement an effective discharge planning process that focuses on the patient's/resident's .discharge goals . and effectively transfer them to post-discharge care. [...]

Inspectors wroteBased on document review and staff and other interviews, it was determined that the facility 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 psychological well-being of each resident by failing to employ a qualified Social Worker to deliver medically related social services to all its residents for one of one employee record review (Employee 1). Findings Include: Review of the facility's Job Description titled Social Services Specialist 1, revised November 17, 2020, described the position as non-exempt and Bachelor's Degree in Social Work or Human Services required. The Job Description continued, Special Educational and Vocational Requirements: * Must possess any certifications/licensure's as required by State of employment to practice in long term care. [...]

Inspectors wroteBased on document review, interviews with staff, and other interviews, it was determined that the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis for one of one staff person's credentials reviewed (Employee 1). Findings Include: Review of the facility's Job Description, titled Social Services Specialist 1, revised November 17, 2020, described the position as non-exempt and Bachelor's Degree in Social Work or Human Services required. The Job Description continued, Special Educational and Vocational Requirements: * Must possess any certifications/licensure's as required by State of employment to practice in long term care. * 1-3 years of supervised social work experience in health care setting working directly with individuals preferred. [...]

Inspectors wroteBased on policy review, observation, resident and staff interviews, clinical record review, and other document review, it was determined that the facility failed to ensure sufficient nursing staff to provide nursing care to all residents in accordance with the resident care plans to attain and maintain the highest practicable physicial, mental, and psychosocial well-being of each resident for two of seven residents reviewed (Residents 1 and 7), two Grievance Forms reviewed (December 18 and 21, 2023), and review of two months of Resident Council Meeting Minutes (December 2023-January 2024). Findings Include: [...]

Inspectors wroteBased on clinical record review, facility policy review, hospital document review, and staff interviews, it was determined that the facility failed to initiate interventions to prevent wound deterioration and promote wound healing, failed to ensure a wound assessment was conducted weekly, and failed to ensure a worsening wound was assessed by a physician in a timely manner, resulting in harm as evidenced by the worsening of a pressure ulcer for one of four residents reviewed for pressure ulcers (Resident 44). Further, based on observation, clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to provide care and services to promote healing and prevent infections for one of four residents reviewed for pressure ulcers (Resident 74).

Inspectors wroteBased on document review and resident and staff interviews, it was determined that the facility failed to ensure each resident the right to manage his or her financial affairs for three of four residents reviewed for personal funds (Residents 66, 121, and 126). Findings Include: Review of Resident 66's clinical record revealed diagnoses that included Diabetes Mellitus Type II (A chronic condition that affects the way the body processes blood sugar [glucose]) and anemia (condition in which the blood doesn't have enough healthy red blood cells). Review of Resident 66's Quarterly Minimum Data Set (MDS - a tool used to assess all care areas specific to the resident), dated September 15, 2023, revealed under Section C- Cognitive Patterns, the Brief Interview for Mental Status (BIMS). Review of the BIMS revealed Resident 66 scored 15/15. This score denotes an intact cognitive status. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflects the resident status for four of 35 residents reviewed (Residents 44, 48, 70, and 135). Findings Include: Review of Resident 44's clinical record on October 17, 2023, at approximately 10:30 AM, revealed diagnoses including central cord syndrome (injury to the spine that results in decreased nerve function for motor and sensory function of the body), and Guillain-Barre syndrome (neurological disorder caused by the immune system attacking the peripheral nervous system that results possible weakness, paralysis, and sensory deficit). [...]

Inspectors wroteBased on observations, record review, policy review, and resident and staff interviews, it was determined the facility failed to implement a comprehensive person-centered care plan to maintain the highest practicable well-being for five of 35 residents reviewed (Residents 15, 71, 97, 99, and 122). Findings Include: Review of the facility's policy, titled OPS416 Person-Centered Care Plan, last revised April 2023, revealed that the care plan includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. [...]

Inspectors wroteBased on review of facility policy and procedure, review of product user manuals, observations, record reviews, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice of five of 35 residents reviewed (Resident 20, 71, 102, 110, and 391).

Inspectors wroteBased on observation, review of facility policy, product packaging review, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the main kitchen and for two of three nourishment pantries.

Inspectors wroteBased on observation, policy review, and staff interviews, it was determined that the facility failed to prepare and administer medications to residents in a manner that promoted infection control practices for one of three residents observed for medication administration (Resident 75); and failed to implement their Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia).

Inspectors wroteBased on policy review, resident clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure an effective compliance and ethics program that has been reasonably designed, implemented, and enforced so that it is likely to be effective in preventing and detecting criminal, civil, and administrative violations under the Act and in promoting quality of care for three of four residents reviewed for personal funds and the application for resident Social Security benefits (Residents 66, 121, and 126).

Inspectors wroteBased on observations, facility policy review, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for six of 35 residents reviewed and one of four shower rooms observed (Residents 8, 20, 27, 68, 71, and 110).

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to identify and monitor a device as a restraint for one of 35 residents reviewed (Resident 71).

Inspectors wroteBased on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to verify the standing of professional license prior to hire for one of five personnel files reviewed (Employee 13). Findings Include: Review of facility policy, titled OPS300 Abuse Prohibition, with a revision date of October 24, 2022, revealed, 3. The Center will screen potential employees for a history of abuse, neglect, or mistreating patients, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. Review of personnel file for Employee 13 (Licensed Practical Nurse [LPN]) revealed license verification with the Licensing board was completed October 17, 2023; [...]

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility bed-hold policy at the time of transfer for one of 35 residents reviewed (Resident 23).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for one of 35 residents reviewed (Resident 8).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 35 residents reviewed (Resident 68). Findings Include: Review of Resident 68's clinical record included diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), congestive heart failure (CHF - the heart doesn't pump blood as it should), hypertension (high blood pressure), and dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking). [...]

Inspectors wroteBased on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living (ADL) for one of 35 resident s reviewed (Resident 71).

Inspectors wroteBased on facility policy, review of the clinical record, and resident and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 35 residents reviewed (Residents 71).

Inspectors wroteBased on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure the resident environment is free from accident hazards for two of 35 residents reviewed (Resident 8 and 23). Findings Include: Review of Resident 8's clinical record revealed diagnoses that included muscle wasting, dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), benign prostatic hyperplasia (age associated prostate gland enlargement that can cause difficulty with urinating), and chronic diastolic heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body). [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure residents requiring dialysis services receive such services consistent with professional standards of practice for one of two residents reviewed for dialysis services (Resident 122). Findings Include: Review of Resident 122's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis, leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of Resident 122's physician orders revealed an order dated July 12, 2023, that read, Dialysis Tuesday, Thursday and Saturday @ 11:00 AM. [...]

Inspectors wroteBased on clinical record review, policy review, and staff interview, it was determined that the facility failed to act upon the licensed pharmacist's report of a medication irregularity for one of 35 residents reviewed (Resident 23).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 48).

Inspectors wroteBased on observations, policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on four medication errors out of 28 opportunities, which equated to an error rate of 14.29 percent.

Inspectors wroteBased on observations, facility policy review, and staff interview, it was determined that the facility failed to ensure medications were stored in a secure manner for one of three medication carts observed.

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained/processed timely as ordered by the physician for one of 35 residents reviewed (Resident 102).

Inspectors wroteBased on clinical record review, resident interview and staff interviews, and policy review, it was determined that the facility failed to ensure four of seven residents reviewed were provided care and services regarding hygiene and bathing (Residents 1, 2, 3, and 4).