The King's Daughters & Sons Nursing Home

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the advanced and planned menu was available for review for 32 residents who received meals from the facility kitchen. A revised facility policy titled Menus dated October 2017, read in part, 2. Menus for regular and therapeutic diets are written at least two (2) weeks in advance, and are dated and posted in the kitchen at least one (1) week in advance.11. Copies of menus are posted in at least two (2) resident areas, in positions and in print large enough for residents to read them. On 06/17/25 at 11:39 a.m., it was observed no weekly menus were posted for resident to review. On 06/18/25 at 9:08 a.m., the dietary manager stated according to company policy the menu's were supposed to be posted in places throughout the building for residents to review. [...]

Inspectors wroteBased on record review and interview, the facility failed to administer the 2024 influenza vaccine and the pneumococcal vaccine for 1 (#27) of 5 residents whose records were reviewed for immunizations. The facility's policy Influenza Vaccine, dated March 2022, and the facility's policy Pneumococcal Vaccine, dated October 2023, showed the date of the vaccine, lot number, expiration date, person administering, and the site of vaccination were documented in the resident's medical record. Resident #27's immunization record was missing their 2024 influenza and their pneumoccocal immunization. On 06/19/25 at 12:25 p.m., the infection preventionist stated there was no documentation of Resident #27 receiving their 2024 influenza or their pneumococcal immunization.

Inspectors wroteOn 02/01/24 an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who had fallen had interventions in place to prevent the recurrence of falls. The facility failed to monitor and evaluate the effectiveness of the interventions and modify the care plan with each fall. The facility failed to conduct a root cause analysis and/or evaluate the cause for each fall. The facility did not have a fall prevention program, nor have the staff received education regarding falls and fall prevention in the last 12 months. Res #36 had 26 falls from 05/17/23 to 01/27/24. Res #36 had 19 falls prior to sustaining a left hip fracture on 11/19/23 and six falls after sustaining the fracture. 13 of the 26 falls did not have updated interventions to help prevent future falls. [...]

Inspectors wroteBased on record review and interview, the facility failed to follow their abuse policy and ensure background checks were completed for new hires. The administrator identified 42 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to have an effective administration to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident. The facility failed to ensure: a. to follow their abuse policy and ensure background checks were completed for new hires; b. MDS assessments accurately reflected the residents' status; c. care plans were updated and revised; d. physician orders were followed; e. supervision was provided to help prevent accidents, falls were thoroughly investigated to determine root causes, fall interventions were modified/revised, and to monitor effectiveness of interventions to prevent falls; f. staff demonstrated competency in skills to care for residents; g. a registered nurse served as the DON; h. [...]

Inspectors wroteBased on record review and interview, the facility failed to implement their Legionnaires prevention policy. The administrator identified 42 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure MDS assessments accurately reflected the residents' status for three (#1, 6, and #14) of 15 residents whose assessments were reviewed. The administrator identified 42 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to follow physician orders for two (#10 and #27) of five sampled residents reviewed for unnecessary medications. The administrator identified 42 residents resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were able to demonstrate competency in skills necessary to care for residents' needs for one (CMA #1) of six staff reviewed for competency skills. The administrator identified 42 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was a registered nurse serving as the DON on a full time basis. The administrator identified 42 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure significant medication errors did not occur for four (#1, 14, 24, and #27) of six sampled residents whose medications were reviewed. The administrator identified 42 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure certifications were not expired for one (CMA # 1) of six employee files reviewed for certifications/licenses. The administrator identified 42 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were updated and revised for two (#31 and #36) of 15 residents whose care plans were reviewed. The administrator identified 42 residents resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document required daily staffing information. The administrator identified 42 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician responded to or dated the MRRs for two (#10 and #14) of five sampled residents reviewed for unnecessary medications. The administrator identified 42 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to lock unattended treatment and medication carts. The Resident Census and Conditions of Residents documented a census of 45.

Inspectors wroteBased on record review, observation, and interview the facility failed to develop a comprehensive person centered care plan for one (# 3) of three residents reviewed for care plans. The Resident Census and Conditions of Residents, dated 01/03/23, documented a census of 45.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide services to have a hearing aid repaired for one (#9) of one residents reviewed for hearing aids.