Family Care Center Of Kingston

Based on observation, record review, and interview, the facility failed to provide dignity for 1 (#1) of 1 sampled resident reviewed an indwelling urinary catheter. The DON identified three residents with indwelling urinary catheters. Findings: On 07/28/25 at 2:23 p.m., Res #1 was observed lying in bed with their eyes closed. The resident's indwelling urinary catheter bag was hanging from the bedside uncovered. On 07/29/25 at 9:53 a.m., Res #1 was observed lying in bed watching television. The resident's indwelling urinary catheter bag was hanging from the bedside and did not have a privacy cover. On 07/30/25 at 12:21 p.m., Res #1's indwelling urinary catheter bag was observed hanging from the bedside uncovered and was in full view from the resident's doorway. A facility policy titled Quality of Life - Dignity, revised 08/2009, read in part, Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered An undated transfer/discharge report…

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 interview, the facility failed to ensure residents were offered the opportunity to create an advance directive for 2 (#38 and #43) of 3 sampled residents reviewed for advanced directives.The administrator identified 38 residents resided in the facility.Findings: An Advance Directive policy, revised 12/2016, read in part, Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.Written information will include a description of the facility's policies to implement advance directives.Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directive.Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical…

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 record review and interview, the facility failed to complete a significant change assessment for 1 (#30) of 12 sampled residents whose assessments were reviewed. The administrator identified 38 residents resided in the facility.Findings:An undated discharge/transfer report showed Res #30 had diagnoses which included acute kidney failure, dementia, and disorder of the skin and subcutaneous tissue. A physician order, dated 06/13/25, showed Res #30 had an order to admit to hospice service for a diagnosis of heart disease with heart failure. The electronic record for Res #30 showed a significant change assessment, dated 06/18/25, was in progress. On 08/04/25 at 11:22 a.m., the MDS coordinator was interviewed regarding a significant change assessment still in progress dated 06/18/25 for Resident #30. The MDS coordinator stated a significant change assessment was to be completed 14 days after a resident was admitted for hospice services. The MDS coordinator stated a significant change assessment was not completed in the required time frame and was an oversite.

Based on record review and interview, the facility failed to ensure care plans were revised for 2 (#3 and #25) of 12 sampled residents reviewed for care plans.The administrator identified 38 residents resided in the facility.Findings:1. A physician's order for Resident #3, dated 04/16/25, showed to admit the resident to hospice for diagnosis of dementia.A review of Resident #3's care plan showed no documentation of the resident being on hospice.On 07/30/25 at 1:22 p.m., the MDS coordinator stated Resident #3's care plan did not reflect the resident was on hospice.2. Resident #25's Order Summary Report, dated 07/31/25, showed the resident had diagnosis of gastro-esophageal reflux disease.A review of Resident #25's electronic health record showed the resident weighed 190 pounds on 05/29/25 and 163.4 pounds on 07/30/25. This was a 14% weight loss in two months.A review of Resident #25's care plan showed no documentation or interventions for Resident #25's weight loss.On 08/04/25 at 11:24 a.m., the MDS coordinator stated Resident #25's care plan had not been updated to reflect 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 observation, record review, and interview, the facility failed to implement their policy for enhanced barrier precautions and hand hygiene for 1 (#19) of 1 sampled resident reviewed for enhanced barrier precautions.The DON identified seven residents on enhanced barrier precautions. Findings:On 07/31/25 at 10:34 a.m., LPN #1 was observed providing wound care for Resident #19. No signage was posted at the door for enhanced barrier precautions. LPN #1 gathered wound care supplies per the physician orders and placed them on the barrier on the bedside table. LPN #1 donned a pair of gloves and removed the old dressing. LPN #1 did not wash their hands prior to donning gloves. LPN #1 changed their gloves and used gauze with wound wash to clean the wound. LPN #1 placed the calcium alginate dressing (wound dressing) on the wound to the right foot. LPN #1 did not wash their hands with each glove change. LPN #1 was not wearing a gown.An undated facility form titled Enhanced Barrier Precautions (EBP) Decision Making-Algorithm showed if a resident had a wound or indwelling medical device…

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, and interview, the facility failed to maintain the ice machine in a safe and sanitary manner. The Administrator reported 34 residents resided in the facility. Findings: On 03/19/24 at 11:15 a.m., the ice machine in the main hallway near the facility dining room was observed to be unlocked. The ice machine was observed to remain unlocked throughout the day. On 03/20/24 at 9:54 a.m., the ice machine was observed to remain unlocked. A scoop was observed to be kept in a holder mounted on the wall beside the machine. The surveyor used a white paper towel and wiped along the upper inside of the ice machine. A jelly-type, brownish-orange substance was observed on the paper towel. The substance on the paper towel was shown to the dietary manager and maintenance staff. The dietary manager reported dietary staff were responsible for cleaning the scoop. She stated there was a lock and key for the ice machine but she didn't know where it was located. Maintenance staff reported the ice machine was maintained by an outside company and that he usually scheduled…

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 record review and interview, the facility failed to complete a significant change assessment, when the resident required hospice services, for one (#25) of one resident reviewed for significant change. The Administrator reported 34 residents resided in the facility. Findings: A Resident Assessment Instrument policy, dated September 2010, documented the assessment coordinator would be responsible for ensuring the interdisciplinary assessment team conducted timely resident assessments and reviews when there had been a significant change in the resident's condition. Resident #25 had diagnoses which included protein-calorie malnutrition and diabetes mellitus. A progress note, dated 09/18/23 at 5:51 p.m., documented staff had talked with the resident's son and it was agreed the resident would benefit from hospice services. The note documented the resident's primary care physician was notified of the resident's decline and the physician ordered a hospice evaluation. A physician's order, dated 09/19/23, documented the resident would receive hospice care for a diagnosis of…

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 interview, the facility failed to ensure the resident assessment was transmitted within seven days of completion for one (#19) of one sampled resident reviewed for discharge assessments. The Administrator identified 34 residents resided in the facility. Findings: A Submission and Correction of the MDS Assessments document, read in part, .All Medicare and/or Medicaid-certified nursing homes and swing beds or agents of those facilities, must transmit required (MDS) data records to CMS' Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system . On 03/20/24 at 4:32 p.m., the clinical record documented resident #19 was admitted on [DATE] and discharged on 11/27/23. The facility EMR showed a discharge, return anticipated, in progress and dated 11/20/23. On 03/21/24 at 3:45 p.m., the MDS coordinator reported the discharge assessment for resident #19 was completed on 11/22/23 but had not been signed by the registered nurse. On 03/21/24 at 3:45 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.

Based on record review and interview, the facility failed to develop a comprehensive care plan for one (#2) of 12 residents sampled for care plans. The Administrator identified 34 residents resided in the facility. Findings: The Resident Care Plan Policy, revised December 2016, read in part, .Each discipline will assess each resident starting from the time of admission and periodically thereafter until discharged from the facility. Through these progressive, serial assessments, the needs of the resident will be identified, monitored, and updated .Resident care plans will be reviewed at least every three months, with significant changes and as indicated to ensure that timely updating of problems, goals, and interventions are being done by the Multidisciplinary Team . The McGeer Criteria for Infection Surveillance Checklist for resident #2 read in part, .date of infection 2/27/24 .UTI without indwelling catheter .Acute dysuria or pain, swelling .New or marked increase in urgency .New or marked increase in frequency .Meropenem (antibiotic) 1 GM 3x daily for 10 days .ESBL…

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, and interview, the facility failed to revise the care plan to include fall interventions for one (#17) of five residents reviewed for care plans. The Administrator reported 34 residents resided in the facility. Findings: A Care Plan policy, dated December 2016, documented resident care plans would be reviewed at least every three months, with significant changes and as indicated, to ensure timely updating of problems, goals, and interventions were being done by the multidisciplinary team. Resident #17 was admitted with a history of falls, arthritis, and age-related cognitive decline. A quarterly MDS assessment, dated 02/07/24, documented the resident was severely impaired with cognition. The assessment documented no falls since admission. A discharge-return anticipated MDS assessment, dated 02/19/24, documented the resident had a fall with injury. Resident #17's care plan, dated 02/19/24, documented the resident was at high risk for falls and had a previous fall at home prior to admission. The care plan documented the resident ambulated with 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.

Based on record review, observation, and interview, the facility failed to follow the menu and provide pureed foods listed on the menu for one (#12) of one sampled resident reviewed for pureed foods. The Administrator identified one resident which required a pureed diet. Findings: Review of the facility policy titled Menus, revision date October 2017, read in parts .Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy . Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal .If a food group is missing from a resident's daily diet (e.g., dairy products), the resident is provided an alternate means of meeting his or her nutritional needs . Resident #12 was admitted with diagnoses of Alzheimer's disease and chronic obstructive pulmonary disease. The Care Plan, for resident #12, documented the resident had a chewing difficulty, which increased the risk of nutritional deficit related to the need for an altered…

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 record review, observation, and interview, the facility failed to date foods stored in the freezer with the received and/or use-by dates. The Resident Census and Condition of Residents form documented 31 residents received meals from the facility kitchen. Findings: A facility policy, Food Receiving and Storage, revised July 2014, documented in part .all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). On 01/30/23 at 2:29 p.m., a tour of the kitchen was conducted and the following foods were observed in the freezer, in sealed bags, undated: ~14 bags green beans ~8 bags yellow squash ~12 bags of corn ~2 bag zucchini ~4 bags mixed bell peppers ~17 bags mixed vegetables ~1 bag of breaded squash ~6 bags of sweet potato fries ~whole chicken 4 bags ~1 bag of pretzels On 01/30/23 at 2:45 p.m., cook #1 reported once the food was received in the kitchen, the food should be dated and placed in the freezer. On 02/01/23 at 10:37 a.m., the DM reported the frozen vegetables did not have use-by dates on them. The DM stated all food items should…

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.