Kentmere Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Kentmere Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Dec 9, 2021

  Based on observations, interviews, reviews of facility documentation and resources from national and state public health agencies as indicated, the facility failed to maintain a safe environment by not implementing the appropriate infection control practices as directed by the Centers for Disease Control and Prevention (CDC), the State of Delaware's Division of Public Health (DPH) and the State Health Operations Center (SHOC) during a COVID-19 outbreak in the facility. As a result of the facility's noncompliance, the likelihood of a serious adverse outcome of COVID-19 spreading to additional residents could have occurred if not corrected. The facility was notified of the Immediate Jeopardy (IJ) on Friday, 12/3/21, at 3 PM with an additional finding on Monday, 12/6/21 at 1:35 PM. […]

• Immediate jeopardy, isolatedF678Apr 25, 2022

  Based on interviews, review of clinical records and facility documentation as indicated, it was determined that for one (R1) out of five residents reviewed for death in the facility, the facility failed to ensure that Nursing personnel provided basic life support (CPR) to a resident who was a Full Code. On [DATE] at 11 PM, R1 was found unresponsive in his room and nursing personnel failed to check R1's code status, failed to call a Code Blue, failed to initiate CPR and failed to activate the Emergency Response System (EMS) by calling 911. R1 expired and the RN pronounced R1 as deceased . […]

• Actual harm, isolatedF689Dec 13, 2025

  Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to:1. Provide supervision to prevent a fall for 1 (Resident #110) of 3 residents reviewed for falls. While providing care to Resident #110 on [DATE], Certified Nurse Aide (CNA) #16 turned her back to the resident and the resident jerked and fell to the floor. Initially, the resident was transferred to a hospital and received four sutures for a skin tear to the left side of their forehead. Two days later, on the morning of [DATE], CNA #16 noted swelling to resident #110's left hip and thigh and the resident had limited range of motion (ROM) to the left leg. […]

• No harm, potential for more than minimal, widespreadF812Dec 13, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure foods items stored in the walk-in refrigerator and freezer were covered, labeled and dated and expired food items were discarded. The facility further failed to ensure wash dishes as directed by the facility policy. Lastly, the facility failed to ensure hot foods were held on the tray line at a temperature of at least 135 degrees Fahrenheit. These deficient practices had the potential to affect residents who received food from the kitchen. Findings included:1. A policy titled, Food Receiving and Storage, revised 10/2017, indicated, Policy Statement Food shall be received and stored in a manner that complies with safe food handling practices. Per the policy, 8. […]

• No harm, potential for more than minimal, widespreadF755Nov 22, 2024

  Based on interviews, record review, and review of the facility policy, the facility failed to ensure the narcotic count sheets on each medication cart for the oncoming nurse and off going nurse were documented prior to finishing the narcotic count to ensure accuracy of the narcotics for five of five medication carts reviewed of 40 sample residents. This failure had the potential for drug diversion. Findings include. Review of an undated facility's policy titled, Controlled Medication Storage and Accountability, revealed .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations . 1. […]