Kingwood Healthcare Center

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a clean, safe and comfortable homelike environment for the residents. The surveyors observed various maintenance issues and items requiring cleaning. Resident identifiers: #7, #29, #50, and #111. Census: 116.

Inspectors wroteBased on observation and staff interview. The facility failed to ensure items for resident meal use are air dried prior to use. This was found during the annual facility survey process. This failed practice had the potential to affect more than a limited number of residents. Facility census 116.

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to ensure a safe and sanitary environment was provided to prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #3, #111. Facility Census: 116. a) Resident #111 On 05/11/26 at 11:19 AM, during an interview with Resident # 111, staff observed a hole in the bottom edge of his walker seat's plastic cover, exposing the inner padding. During a facility walkthrough with the Assistant Director of Nursing (ADON), on 05/12/26 at 1:55 PM, she acknowledged Resident #111's walker seat with the hole and exposed inner padding and stated she would report it so the seat cover could be repaired. [...]

Inspectors wroteBased on record review, observation, staff interview and resident interview, the facility failed to ensure a resident's call light was within reach. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #117. Facility Census: 116.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to provide dental services for Resident #110. Resident Identifier #110. Facility Census 116.

Inspectors wroteBased on observation and staff interviews, the facility failed to store garbage and refuse in a proper manner to prevent rodents, vermin and pests. The dumpsters were in disrepair. This had the potential to affect all residents that reside in the facility. Facility census: 117.

Inspectors wroteBased on record reviw and staff interview, the facility failed to keep a resident's Health Care Surrogate / legal decision-maker informed of her health status and medical condition. The deficient practice prevented the legal decision-maker from being informed, in advance, of the care to be furnished. This was true for one (1) of 24 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #74. Facility census: 117.

Inspectors wroteBased on observation, and interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment, with housekeeping, and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was a random opportunity for discovery. Bathroom identifiers: room [ROOM NUMBER], #114, #107, #112. Resident identifier: #94. Facility Census:

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a written Notice of Transfer / Discharge was provided to residents/resident representatives for four (4) of five (5) residents reviewed for hospitalizations during the long-term care survey process. This had the potential to affect all residents being transferred or discharged . Resident identifier: #167, #74, and #28. Facility census: 117.

Inspectors wroteBased on record review, and staff interview, the facility failed to follow physician orders related to insulin. This was true for one (1) of five (5) residents reviewed for the unnecessary medication review during the annual long-term care survey process. Resident identifier: #56. Facility census: 117.

Inspectors wroteFollowing record review and interviews, the facility failed to obtain an order to utilize a pain scale for the administration of pain medication. Additionally, facility staff did not assess residents after administering pain medication, to ensure effective pain management, as per professional standards of practice. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #103 and #319. Facility census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to complete annual performance reviews for Nurse Aides (NA). This was true for five (5) of five (5) reviewed for staffing during the Long-Term Survey Process (LTCSP). Facility census: 117.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure the physician documented the actions or rational if no action taken to monthly drug regimen reviews. This was true for four (4) of five (5) reviewed for unnecessary medications and the pharmacist failed to identify clinically significant risks associated with concurrent use of a Benzodiazepines and opioids. Resident identifiers: #22, #77, #101 and #17. Facility census: 117.

Inspectors wroteBased on observation and staff interviews, the facility failed to keep unit refrigerators free from medical supplies that could contaminate food and store food and supplies in accordance with professional standards for food service safety. This has the ability to affect more than a limited number of Residents. Facility census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain accurate records on four (4) out of 24 sampled residents in the Long-Term Care Survey Process. Resident identifiers: #71, #68, #110, and #93. Facility census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to facilitate the inclusion of the resident representative in person-centered care planning. This was true for one (1) of 24 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #74. Facility census: 117.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident's legal representative of a change in health status and transfer to the hospital. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #74. Facility census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to issue the required Notification of Medicare Non-Coverage (NOMNC) in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: #269. Facility census: 117.

Inspectors wroteBased on random observations and interviews, the facility failed to ensure a Resident's medical and health information was protected during MDS Interviews. Resident identifiers: #18 and #77. Facility census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the appropriate information was communicated to the receiving health care institution when the facility transferred Resident #167 to the hospital. This deficient practice was true for one (1) of five (5) residents reviewed under the hospitalization pathway. Resident identifier: #167. Facility census: 117.

Inspectors wroteBased on record review, outside agency interview, and staff interview, the facility failed to allow a resident to return to the facility following a brief hospitalization. When the facility did not allow the resident to return, the facility failed to initiate a discharge and did not comply with transfer and discharge requirements at 42 CFR 483.15(c). This was true for one (1) of two (2) residents reviewed under the discharge pathway throughout the survey process. Resident identifier #167. Facility census: 117.

Inspectors wroteBased on record review, and staff interview, the facility failed to provide physician-ordered treatment and services to a resident admitted with limited range of motion. This deficient practice affected potential one (1) of one (1) residents reviewed for position/mobility. Resident identifier: #1. Facility census: 117. a) Resident #1 Review of Resident #1's progress notes showed a therapy note from 09/30/24 at 5:59 PM that stated, Patient given [NAME] air short opponens orthosis this date to gradually lift flexed digits in R [right] hand. Nurse and aide instructed to keep it on for an hour and then to remove d/t [due to] newness. Patient to wear as tolerated. Review of Resident #1's physicians' orders showed the following order written on 10/01/24, [NAME] air short opponens orthosis to right hand on for an hour and the remove, to wear as tolerated. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the environment remained as free of accident hazards as is possible and assistance devices to prevent accidents for Resident #101. This was true for one (1) of five (5) residents reviewed for accident hazards. Resident identifier: #101. Facility census: 47.

Inspectors wroteBased on observation, staff interview, and resident interview, 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. Residents were not given the opportunity to clean/sanitize their hands prior to eating lunch in their rooms. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #105, #68 and #46. Facility census: 111.

Inspectors wroteBased on record review, family interview and staff interview, the facility failed to make prompt efforts to resolve a grievance and make restitution for a lost cell phone. This is true for one of three phones lost in the facility. Resident identifier: #201. Facility census: 111.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to establish and maintain an effective 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. [...]

Inspectors wroteBased on Resident Council meeting, review of Resident Council minutes, resident and staff interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life in regards to privacy, meal costs and meal services. This was by a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #1, #24, #46, and #71. Census: 109. a) Resident Council During Resident Council on 12/14/22 at 3:30 PM, the members voiced their concern about the cutbacks on food and snacks. They stated that the staff keep telling them they are unable to have certain food items that was previously available because they cost too much. [...]

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility failed to ensure each resident had the right to personal privacy during care and treatments and failed to ensure confidentiality of resident's personal and medical information. Facility staff failed to provide privacy during a treatment/personal care for Resident #30 and Resident #162. The facility staff failed to safeguard confidential information related to residents on the 400 hall, by leaving out assignment sheets in plain view. These failed practices were identified through a random observation for discovery during the Long-Term Care Survey Process (LTCSP), and had the potential to affect more than limited number of residents. Resident identifiers: Resident #30 and Resident # 162. Census: 109.

Inspectors wroteBased on operation policy review, observation, and staff interview, the facility failed to report an alleged violations related to neglect and/or abuse, and report the results of all investigation to the proper authorities within the prescribed time frames. This was true for two (2) of three (3) allegations of abuse. Resident identifier: #34. Facility census: 109. Record review of the facility's policy titled, Abuse, Neglect, Exploitation, showed: -The abuse coordinator will report allegations or suspected abuse, neglect, or exploitation immediately to the Administrator, other officials in accordance with state law, and State survey and certification agency through established procedures.

Inspectors wroteBased on operation policy review, resident interview, and staff interview, the facility failed to take actions to thoroughly investigate an alleged violation related to, sexual and physical abuse and accurately documenting a follow up . Resident identifiers: #34, #73. Facility census: 109. Record review of the facility's policy titled, Abuse, Neglect, Exploitation, showed: - Once a patient is cared for and initial reporting has occurred, an investigation should be conducted, - identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation. - Providing complete and thorough documentation of the investigation. - Responding immediately to protect the alleged victim and integrity of the investigation. [...]

Inspectors wroteBased on record review, staff and resident interview, the facility failed to develop and implement a baseline care plan within 48 hours of the resident's admission, which included goals and interventions for immediate health and safety needs and failed to provide the resident or resident's representative a summary of the baseline care plan. This was true for one (1) of seven (7) newly admitted residents reviewed during the LTCSP. Resident identifier: Resident #164. Census:

Inspectors wroteBased on resident and staff interviews, observations and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services. This was true for 1 of 1 resident interviewed. This failed practice had the potential to affect a limited number of residents that currently reside at the facility. Resident identifier: #18. Facility census: 109. Findings Included: Resident #18 on 12/12/22 at 1:31 PM stated that the facility was doing nothing for the increased limited motion in her right hand. She stated that she had therapy for her arm but has never been given therapy for her hand. Resident #18 reports that she is unable to properly ambulate in the wheelchair or able to do things she did to due to the limited range of motion in her hand. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the attending physician documented a rationale for no action taken when reviewing monthly Medication Regimen Review recommendations from the licensed pharmacist. This was true for one (1) of five (5) residents reviewed under the unnecessary medication pathway. Resident identifier #92. Facility census: 109.

Inspectors wroteBased on record review, staff and resident interview, the facility failed to ensure a resident was not administered a psychotropic drug unless, based on a comprehensive assessment of the resident, the drug was medically necessary to treat a specific condition as diagnosed and documented in the resident's medical record. Resident #164 was receiving an anti-psychotic medication without a specific diagnosed behavior, behavior monitoring did not contain a documented specific behavior to be observed and was incomplete. The resident was unaware and had not signed a consent for the administration of the medication. This failed practice was identified in one (1) of five (5) residents reviewed for unnecessary medications during the LTCSP. Resident identifier: Resident #164. Census:

Inspectors wroteBased on observation and staff interview the facility failed to secure Marinol (Dronabinol) a Schedule III narcotic in a separately locked permanently affixed compartment. This is true for one of two medication rooms reviewed. Resident identifier: 314. Facility census: 109.

Inspectors wroteBased on observation, resident interview, record review and facility documentation review, the facility failed to ensure a reasonable effort was put forth when providing food items to residents to meet the individual needs and preferences of the resident. This was identified in one (1) of two (2) residents reviewed for food during the LTCSP. The facility failed to provide Resident #1 food items during meals based on an assessed and identified food preference. Resident identifier: Resident #1. Census:109.

Inspectors wroteBased on policy review, observation, and staff interview, the facility failed to ensure food items kept in the north nourishment room were labeled and dated. This had the potential to affect all residents receiving nourishment from the refrigerator on the north side of the facility. Resident identifier: 34. Facility census: 109.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate medical record for one (1) of four (4) sampled residents reviewed for Advance Directives during the Long-Term Care Survey process. Resident identifier: #312. Facility census: 109.