The King's Daughters & Sons Nursing Home

In the surveyor’s words

From the most serious findings on record at The King's Daughters & Sons Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 6, 2024

  On 02/01/24 an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who had fallen had interventions in place to prevent the recurrence of falls. The facility failed to monitor and evaluate the effectiveness of the interventions and modify the care plan with each fall. The facility failed to conduct a root cause analysis and/or evaluate the cause for each fall. The facility did not have a fall prevention program, nor have the staff received education regarding falls and fall prevention in the last 12 months. Res #36 had 26 falls from 05/17/23 to 01/27/24. Res #36 had 19 falls prior to sustaining a left hip fracture on 11/19/23 and six falls after sustaining the fracture. […]

• No harm, potential for more than minimal, widespreadF607Feb 6, 2024

  Based on record review and interview, the facility failed to follow their abuse policy and ensure background checks were completed for new hires. The administrator identified 42 residents who resided in the facility. Findings: The Abuse Prohibition/Unusual Occurrence Policy and Procedure policy, undated, read in part, .Screening All potential employees will be screened for a history of abuse, neglect or mistreatment of residents as defined by the applicable requirements .Nursing Home will obtain OSBI checks, attempt to obtain information from prior employers, current employers and licensing boards and registries . The Employee Seniority Report, dated 01/30/24, documented the following: a. CNA #1 was hired on 02/11/23. b. […]

• No harm, potential for more than minimal, widespreadF835Feb 6, 2024

  Based on observation, record review, and interview, the facility failed to have an effective administration to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident. The facility failed to ensure: a. to follow their abuse policy and ensure background checks were completed for new hires; b. MDS assessments accurately reflected the residents' status; c. care plans were updated and revised; d. physician orders were followed; e. supervision was provided to help prevent accidents, falls were thoroughly investigated to determine root causes, fall interventions were modified/revised, and to monitor effectiveness of interventions to prevent falls; f. […]

• No harm, potential for more than minimal, widespreadF880Feb 6, 2024

  Based on record review and interview, the facility failed to implement their Legionnaires prevention policy. The administrator identified 42 residents who resided in the facility. Findings: A Legionella Water Management Program dated September 2022, read in parts, .Our facility is committed to prevent, detection and control of water-borne contaminants, including Legionella .As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team .The water management team consists of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; and e. […]

• No harm, potential for more than minimal, patternF641Feb 6, 2024

  Based on record review and interview, the facility failed to ensure MDS assessments accurately reflected the residents' status for three (#1, 6, and #14) of 15 residents whose assessments were reviewed. The administrator identified 42 residents resided in the facility. Findings: 1. Res #1 had diagnoses which included atherosclerotic heart disease, old myocardial infarction, and cerebral infarction. A physician order, dated 12/20/23, documented Brilinta (an antiplatelet medication) administer 90 mg BID for MI/CVA prevention. An admission assessment dated [DATE], documented the resident was severly impaired with cognition and required extensive assistance with ADLs. The assessment did not document the resident was receiving an antiplatelet medication. […]