Complete Care at Kimberly Hall North

In the surveyor’s words

From the most serious findings on record at Complete Care at Kimberly Hall North, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Dec 12, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for a change in condition, the facility failed to ensure a comprehensive care plan was developed timely for a resident with dysphagia and who required staff assistance with meals, which resulted in the finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included oropharyngeal phase dysphagia (difficulty initiating a swallow), hypertension (high blood pressure), hyperlipidemia (high cholesterol and triglycerides), pseudobulbar affect (sudden uncontrollable and inappropriate laughing or crying), contractures (shortening of muscles), and dementia with behavioral disturbance (impaired ability to think with behaviors). […]

• Immediate jeopardy, isolatedF684Dec 12, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure staff education was provided timely for a resident at risk of aspiration when discharged from Speech Therapy, which resulted in the finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included oropharyngeal phase dysphagia (difficulty initiating a swallow), hypertension (high blood pressure), hyperlipidemia (high cholesterol and triglycerides), pseudobulbar affect (sudden uncontrollable and inappropriate laughing or crying), contractures (shortening of muscles), and dementia with behavioral disturbance (impaired ability to think with behaviors). […]

• Immediate jeopardy, isolatedF689Dec 12, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision was provided for a resident with dysphagia and who required staff assistance with meals. The resident was left unattended during a meal and was found unresponsive. This failure resulted in the finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included oropharyngeal phase dysphagia (difficulty initiating a swallow), hypertension (high blood pressure), hyperlipidemia (high cholesterol and triglycerides), pseudobulbar affect (sudden uncontrollable and inappropriate laughing or crying), contractures (shortening of muscles), and dementia with… […]

• Immediate jeopardy, isolatedF684May 26, 2022

  Based on review of the clinical record, review of facility documentation, and interviews for one of three sampled residents (Resident #127) who experienced a change in condition that required a hospitalization , the facility failed to ensure that readmission physician's orders were transcribed accurately resulting in the resident missing 12 doses of medications (6 days) and not receiving the accurate dosages of another medication culminating in the resident being re-hospitalized . These failures resulted in the finding of Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF760May 26, 2022

  Based on review of the clinical record, review of facility documentation, and interviews for one of three sampled resident (Resident #127) reviewed for a change in condition, the facility failed to ensure the resident was free of significant medication errors related to critical medications (Metformin, Metoprolol, Eliquis) not administered for six days for a total of 36 mixed doses as well as the incorrect dosage of Prednisone administered for a total of three days. The failures resulted in a finding of Immediate Jeopardy. […]