Kent County Nursing Home

In the surveyor’s words

From the most serious findings on record at Kent County Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, patternF600Nov 20, 2024

  Based on observation, interview and record review, the facility failed to ensure the rights of the residents to be free from abuse and neglect for 1 of 7 residents (Resident #2) reviewed for abuse A. The facility failed to keep Resident #2 safe from Resident #1 on an unknown date when Dietary Aide B reported that Resident #1 had touched Resident #2's breast in the dining room on an unknown date to the Interim DON and to Regional Director J on an unknown date multiple times between May 2024-November 2024). An Immediate Jeopardy (IJ) was identified on 11/19/24 at 2:48 PM. The IJ template was provided to the facility on [DATE] at 2:48 PM. […]

• Immediate jeopardy, patternF607Nov 20, 2024

  Based on interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 5 of 7 residents (Resident #1, #2, #3, #4, and #5) reviewed for abuse. A. The Interim DON failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to HHSC and documenting her investigation measures regarding Resident #1 and Resident #2 reported by Dietary Aide B on an unknown date. B. The Former ADM failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to HHSC and documenting her investigation measures regarding Resident #1 and Resident #2 reported by Dietary Aide B on an unknown date. C. […]

• Immediate jeopardy, patternF610Nov 20, 2024

  Based on interviews and record review the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action were taken, for 5 of 7 residents (Resident #1, #2, #3, #4, and #5) reviewed for abuse. A. […]

• Immediate jeopardy, patternF689Oct 4, 2023

  Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards for 3 of 3 residents (Resident #1, Resident #2 and Resident #3) reviewed for quality of care in that: CNA A failed to operate the Hoyer lift with 2 staff per facility policy when transferring Resident #1 from the wheelchair to the bed. As a result Resident #1 sustained a head injury and was sent to the hospital. Resident #2 stated that staff (unknown) lifted him majority of the time with 1 staff using the Hoyer lift. Uncertified Nurses aides (NA B and NA C) admitted to using the Hoyer lift to transfer residents. […]

• No harm, potential for more than minimal, widespreadF727Jul 12, 2023

  Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 7 out of 30 (06/17/23, 06/18/23, 06/23/23, 07/01/23, 07/02/23, 07/03/23, and 07/07/23) days reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 06/17/23, 06/18/23, 06/23/23, 07/01/23, 07/02/23, 07/03/23, and 07/07/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster undated revealed there were four RNs employed at the facility. […]