Kingston Court Skilled Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Kingston Court Skilled Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF745Feb 2, 2024

  Based on facility policy review, job description review, staff and resident interviews, and clinical record review, it was determined that the facility failed to implement post-discharge needs, including therapy services, nursing services, and medical equipment. This failure resulted in a lack of post-discharge services provided in the community for seven out of 15 discharged residents reviewed (Residents 1, 2, 4, 6, 10, 12, and 15) and placed current residents with active discharge plans in an immediate jeopardy situation (Residents 16-20). […]

• Actual harm, isolatedF697Jan 9, 2025

  Based on clinical record review and staff interviews, it was determined the facility failed to ensure pain management was provided that was consistent with professional standards of practice for two of 23 residents reviewed (Residents 9 and 14). This failure resulted in actual harm to Residents 9 and 14, whose pain was not properly relieved and managed and continued to experience uncontrolled pain. Findings include: Review of the clinical for Resident 9 revealed diagnoses that included Polyneuropathy (peripheral nerve disorder that affects multiple nerves throughout the body simultaneously) and Chronic Pain Syndrome (persistent pain that lasts for weeks to years). […]

• Actual harm, isolatedF760Jan 9, 2025

  Based on clinical record review, staff interview, and Resident's written statement, it was determined that the facility failed to follow accepted professional standards and principles for administering medications to ensure the prevention of significant medication errors for three of 24 residents reviewed (Resident 9, 10 and 14). This failure resulted in harm to Resident 9 and 14 who suffered pain from the omission of mediations. Findings include: Review of Resident 9's quarterly Minimum Data Set (MDS-periodic assessment of needs) revealed a BIMS score (brief interview of cognitive status) of 12 indicating moderate cognitive impairment. In a grievance filed by Resident 9 on December 28, 2024, Resident 9 stated that he/she had to request his/he routine morning pain medications. […]

• Actual harm, isolatedF689Aug 29, 2024

  Based on observation, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a skin tear to the posterior right lower extremity for one of 27 residents reviewed (Resident 46). Findings Include: Review of Resident 46's clinical record revealed diagnoses that included multiple sclerosis (a chronic progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord; symptoms include numbness, impaired speech, muscle coordination, blurred vision, and severe fatigue), muscle weakness, and unsteadiness on feet. […]

• Actual harm, isolatedF686Oct 19, 2023

  Based on clinical record review, facility policy review, hospital document review, and staff interviews, it was determined that the facility failed to initiate interventions to prevent wound deterioration and promote wound healing, failed to ensure a wound assessment was conducted weekly, and failed to ensure a worsening wound was assessed by a physician in a timely manner, resulting in harm as evidenced by the worsening of a pressure ulcer for one of four residents reviewed for pressure ulcers (Resident 44). Further, based on observation, clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to provide care and services to promote healing and prevent infections for one of four residents reviewed for pressure ulcers (Resident 74). […]