Kingsbrook Lifecare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: Review of the facility's policy titled, Resident Rights, revised 10/2022, revealed the resident had the right to a dignified existence, self-determination, including privacy and the right to participate in decisions and care planning. 1. Review of R117's admission Record revealed the facility admitted her on 04/01/2025 with diagnoses of acute kidney failure, congestive heart failure, and hyponatremia. Review of R117's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/07/2025, revealed the facility assessed the resident to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; and staff, after performing fingersticks to measure blood glucose levels, did not clean and disinfect two glucometers according to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: Review of the facility's policy titled, Continuum of Care with Dialysis Center, revised 10/2017, revealed the facility's intent was to maintain effective communication with the dialysis center to provide the best continuum of care and outcomes for all residents receiving hemodialysis. Additional review revealed nursing would provide the dialysis center with a current medication list. Further review revealed the dialysis center would send labs, diet, and weight sheets back to the facility following treatment for nursing to review and place in the resident's medical record. Review of the facility's agreement with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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 . The findings include: Review of the facility's policy titled, Medication Storage in the Facility, not dated, revealed medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: Review of the kitchen document titled Weekly Cleaning Schedule undated, revealed it did not include a schedule for cleaning dust on the ceiling. Review of the facility Policy titled Refrigerated Storage dated 05/2006, revealed a variety of foods are stored under refrigeration and the temperatures are low enough to safely keep perishable foods. Per Policy, each refrigerator contains a thermometer and temperature charts are to be documented daily. Review of the Refrigerated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: Review of the facility's Policy titled, Social Services Resident Rights, revised 11/2017 revealed the facility recognized each resident's right to a dignified existence and self-determination. Further review revealed it was the policy of the facility to ensure resident's rights were promoted and protected. Continued policy review revealed the facility would provide Resident Rights education to staff annually. Review of Resident #29's clinical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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]. The findings include: Review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, revised May 2011, revealed under Chapter 3, Section J1800, if this is not the first assessment, review period from the day after the Assessment Reference Date (ARD) of the last MDS Assessment to the ARD of the current Assessment. Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Review nursing home…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. However, there was no documented evidence during January, February or Mach of 2019, of ongoing monitoring for efficacy and adverse consequences of Haloperidol Lactate Concentrate which was prescribed for a diagnosis of Unspecified Dementia without Behavioral Disturbance, on 06/29/18. (Refer to F-758) The findings include: Review of facility's Policy, titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: Review of facility's Policy, titled Comprehensive Plan of Care, revised November 2002, revealed the comprehensive care plan must describe services to be furnished to attain or maintain the resident's highest physical, mental, and psychosocial well-being. Further review revealed the care plan will be updated quarterly, whenever significant changes occur, or annually. 1. Review of Resident #64's medical record revealed the facility admitted the resident on 10/30/18 with diagnoses which included Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. In addition, there was no documented evidence the facility addressed Resident #35's hoarding behavior through behavioral management to ensure necessary person-centered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: Review of the facility's Psychotropic Medication Management Program Policy, revised October 2017, revealed the facility would monitor behaviors and adverse consequences of psychotropic medication for residents receiving psychotropic medications. Further, all residents on psychotropic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The nurse further mixed the contents with vanilla pudding, and administered the preparation as a bolus. However, there was no documented evidence of a Physicians' Order to crush the medications or to administer the medications in a bolus for this resident. This observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: Review of the facility's Policy titled, Medication Administration-General Guidelines, effective 04/2002, revealed it was the policy of the facility to provide resident medications as ordered. Further policy review revealed the facility would administer medications according to the Five (5) Rights of medication administration that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: Review of the facility's Policy titled, Handwashing, dated 12/2001 and revised 02/2003, revealed the facility recognized handwashing as the most basic yet most effective means of preventing and controlling the spread of infection. Further review of the facility's Handwashing Policy revealed, Every staff member had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.