King Health and Rehabilitation Center

Based on observations, record review and staff interviews, the facility failed to implement their policies and procedures for hand hygiene when NA #1 failed to perform hand hygiene after handling dirty linens and NA #2 failed to perform hand hygiene while handling residents water cups and passing fresh ice and water. This was for 2 of 5 staff members observed for infection control practices (NA #1 and NA #2).Findings included:A review of the facility policy titled Hand Washing Requirements with effective date of 2/6/20 stated in part: Hand hygiene should be performed after handling soiled equipment or utensils, after removing gloves or aprons, and after any contact with potentially contaminated objects. There was no mention of how to handle soiled linens in the policy.a. A continuous observation was completed on 6/21/26 from 11:33AM to 11:40AM. NA #1 came out of a resident's room and removed her gloves and threw them in the trash bin in the hallway. She did not perform hand hygiene, and a wall mounted hand sanitizer dispenser was observed nearby on the wall in the hallway. NA #1…

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 observations, policy review and staff interviews, the facility failed to maintain kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean under the shelf of 1 of 1 steam tables observed. This practice had the potential to affect residents. The findings included: A review of the Live Well Healthcare Solutions Food Service Closing Checklist read as: All plate warmers, pellet warmers, tray racks and steam tables cleaned and turned off. During the kitchen observation on 04/15/25 at 3:09 PM the steam table was observed. The 5-foot steamtable shelf was observed with dark brown dried food debris. On 4/16/25 at 10:18 AM the 5-foot steamtable shelf was observed with dark brown dried food debris and was sticky to touch. In an interview on 4/16/25 at 10:20 AM the Corporate Dietary Supervisor stated staff should clean the steamtable shelf. In an interview on 4/16/25 at 12:10 PM the Administrator stated the kitchen staff would scrub the steamtable shelf clean. He reported they would add the shelf to the daily sanitation checklist and…

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 record review and staff interviews, the facility failed to refer a resident with a newly identified serious mental illness for a Level II Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident reviewed for PASRR (Resident #55). Findings included: Resident #55 was admitted to the facility on [DATE]. A Level I PASRR determination notification letter dated 3/9/20 indicated No further PASRR screening is required unless a significant change occurs with the individual's status which suggest a diagnosis of mental illness or mental retardation or, if present, suggests a change in treatment needs for those conditions. A review of Resident #55's medical record indicated on 6/25/24 the diagnosis of bipolar disorder was added and on 12/24/24 the diagnosis of major depressive and generalized anxiety disorders was added. There was no evidence indicating a Level II PASRR referral had been completed for Resident #55 after the new diagnoses of serious mental illnesses had been identified. An interview…

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 record review and staff interviews, the facility failed to develop a comprehensive care plan from 12/27/24 through 3/13/25 for 1 of 1 resident reviewed for urinary catheter (Resident #37). The facility also failed to update the care plan to reflect the change in the dialysis schedule for 1 of 2 residents reviewed for dialysis (Resident #48) and failed to update the care plan to reflect the change in dietary status for 1 of 2 residents reviewed for tube feeding (Resident #79). The findings included: Resident #37 was readmitted to the facility on [DATE] with diagnoses which included obstructive and reflux uropathy. She was hospitalized from [DATE] through12/4/24 and 3/11/25 through 3/13/25. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #37 was cognitively intact and was coded as frequently incontinent of bladder. The Admission/readmission Nursing Collection Tool dated 12/4/24 and completed by Nurse #1 revealed that Resident #37 returned to the facility with an indwelling…

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, record review, and staff interviews, the facility failed to obtain physician orders for the management of an indwelling urinary catheter for 1 of 1 resident reviewed for urinary catheter (Resident #37). The findings included: Resident #37 was readmitted to the facility on [DATE] with diagnoses which included obstructive and reflux uropathy. She was hospitalized from [DATE] through 12/4/24 and 3/11/25 through 3/13/25. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #37 was cognitively intact and was coded as frequently incontinent of bladder. The care plan for Resident #37 was created on 12/4/24 and resolved on 12/27/24 revealed that the resident requires a urinary catheter. Interventions included: maintain catheter anchor, maintain catheter privacy bag, observe for signs and symptoms of infection such as dark or cloudy urine or blockage and notify md as indicated, and provide catheter care each shift. The Admission/readmission Nursing Collection Tool dated…

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 observations, record review, and staff interviews, the facility failed to label a new tube feeding formula bottle when it was hung for 1 of 2 residents with a feeding tube (Resident #245). The findings included: Resident #245 was admitted to the facility on [DATE] with diagnoses which included failure to thrive, dysphagia, and gastrostomy status (surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage). Gastrostomy, feeding tube, and enteral tube feeding are interchangeable descriptions. Review of Resident #245's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and was dependent on staff with most activities of daily living (ADL). Resident #245 received all nutrition and hydration through the feeding tube. Review of Resident #245's care plan dated 4/3/25 revealed she was at risk for complications related to the need for a feeding tube. Interventions included: administer tube feedings and…

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, record review, staff interview, and the facility policy, the facility failed to ensure a staff member followed facility policy to sign off a controlled medication immediately after administering on the controlled medication count sheet. This occurred for 1 of 4 staff observed during medication administration (Nurse #1). The findings included: Review of the facility policy entitled: Pharmacy Preparation and General Guidelines: IIA6 -Controlled Substances Policy read in part: When a controlled substance is administered, the licensed nurse immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration 2) Amount administered 3) Remaining quantity 4) Initials of the nurse administering the dose, completed after the medication is actually administered. During an observation of medication pass on 4/15/25 at 8:40 AM, Nurse #1 was observed administering one controlled medication to Resident #57: Oxycodone 10mg - Give 1 tablet by mouth every 12 hours as needed for pain. Nurse #1…

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 observations and staff interviews, the facility failed to discard expired medications 2 of 3 medication carts (D Hall Medication Cart and E Hall Medication Cart) reviewed for medication storage. The findings included: a. An observation of the D Hall medication cart with Medication Aide #1 on 04/16/25 3:55 PM revealed an opened box of Bisacodyl Suppositories (medication used to cause a bowel movement) with an expiration date of 3/31/25. An interview with Medication Aide #1 on 4/16/25 at 4:01 PM revealed she thought the nurses were responsible for checking the medication carts for expired medications. b. An observation of the E Hall medication cart with Nurse #2 on 4/16/25 at 4:06 PM revealed: an opened bottle of CoQ10 (a dietary supplement used in some people with certain conditions)100 with an expiration date of 2/2025 and an opened bottle of Antacid Antigas liquid (medication used to help sooth or relieve heartburn, acid indigestion and sour stomach) with an expiration date of 2/2025. An interview with Nurse #2 on 4/16/25 at 4:09 PM revealed the nurse assigned 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to protect the rights of 1 of 2 residents (Resident #2) to be free from misappropriation of a narcotic medication (Oxycodone) prescribed to treat pain. Findings included: Resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses which included: surgical aftercare following surgery on the nervous system, spinal stenosis, osteoarthritis, chronic pain, and post-traumatic stress syndrome (PTSD). Review of the quarterly Minimum Data Set, dated [DATE] indicated Resident #2 was cognitively intact and received opioid medication. Review of Resident #2's physician cumulative orders included an order dated 2/2/24 for Oxycodone hydrochloride, immediate release 5 milligrams (mg), one tablet every four hours as needed for pain for seven days (stop date 2/9/24). On 2/29/24 the Administrator was away from the facility and unavailable for interview. During an interview with the Director of Nursing (DON) on 2/29/24 at 3:00 p.m.…

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 observations, resident and staff interviews and record review, the facility failed to secure medications for 1 of 1 resident (Resident #44) observed with medications at bedside. Findings Included: Resident #44 was admitted to the facility on [DATE]. Her diagnoses included, in part, dementia, psychotic disturbance, mood disturbance, anxiety and major depressive disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had mild cognitive impairment. A review of the medical record revealed there was no order for Resident #44 to self-administer medication. An observation and interview with Resident #44 were conducted on 01/21/24 at 12:13 PM. The Resident was alert and sitting up in bed. A medication cup that contained eight pills was clearly visible on the overbed table next to the Resident's bed. There were four white pills. two blue pills, and two pink pills in the cup. She revealed the nurse often leaves her pills for her to take when she is ready. She further revealed she…

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 observations, record review, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey completed on 9/2/22. This was for 1 deficiency that was cited in the area of Label and Medication Storage (F761) and recited on the current recertification and complaint survey of 1/24/24. The QAA committee additionally failed to maintain implemented procedures and monitor interventions the committee put in place following the onsite revisit following the recertification on 10/19/22. This was evident for 1 deficiency in the area of Label and Medication Storage (F761) originally cited on the recertification and complaint survey on 9/2/22 and recited on the current recertification and complaint survey of 1/24/24. The continued failure of the facility during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This citation is…

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.