Kensington Place

Based on record review and interview the facility failed to take immediate and proper steps following a change in Resident #11's health status to ensure the resident received appropriate and proper care and to prevent complications. The facility failed to timely address, monitor, and treat the resident's urinary tract infection. This affected one resident (#11) of three resident changes in condition reviewed. The census was 106.

Findings Include:

Record review revealed Resident #11 was admitted to the facility on 06/02/21 with diagnoses including basil cell carcinoma, actinic keratosis, polymyalgia rheumatica, hypertrophic osteoarthropathy, atrial fibrillation, major depressive disorder, osteoarthritis, and vitamin D deficiency.

Review of the assisted living wellness assessment, dated 06/06/24, revealed the resident was cognitively intact.

Review of Resident #11 urinalysis lab test and results revealed a urine sample for testing was obtained on 09/11/24 and submitted that day to the laboratory. On 09/12/24, the results were available which revealed the resident had a urinary tract infection (UTI).

Review of Resident #11's physician's orders, dated 09/19/24 (seven days after the urine test was completed), revealed the resident was prescribed the antibiotic, Fosfomycin Tromethamine three grams with an order to take one packet by mouth one time only for her urinary tract infection. There was no medical documentation to support she was treated or monitored for her UTI from the time the results were read on 09/12/24, and when the first medication was ordered to treat her UTI on 09/19/24.

Interview with Assistant Director of Nursing (ADON) #153 on 10/10/24 at 1:45 P.M. and 3:30 P.M. revealed Resident #11 was deemed to be independent and they didn't order/prescribe or administer any of her medications. She confirmed the facility ordered Resident #11's urinalysis to determine if she had a UTI, but she stated she had no information as to who would get the results and/or order any medication for the UTI. She stated again Resident #11 was independent and would be able to do all of this herself. She confirmed she was able to get the urinalysis results online.

Interview with Director of Nursing (DON) on 10/10/24 at 3:50 P.M. confirmed the dates of when the UTI results were available (09/12/24) and the date in which they added medication to treat the resident's UTI was put into her medical record (09/19/24). She stated she was not sure if medications or treatment were ordered prior to 09/19/24, or if Resident #11 had seen the urinalysis results between 09/12/24 to 09/19/24, because Resident #11 was independent with her medical care.

Interview with Resident #11 on 10/10/24 at 4:00 P.M. revealed she was not aware of the urinalysis results until 09/19/24. She stated she was not feeling well on 09/11/24 and went to the nurse's station to ask for a urine sample collection kit so she could be tested for a UTI. She stated she collected her sample and gave it back to the nurse's for them to send to the lab for analyzing. She revealed she did not hear anything from the facility about the results, until she asked about them on 09/19/24, when she was told she was positive for a UTI. The resident stated she was very frustrated about this, because she was told she would get the results from the nurses. She confirmed she did not start medication or treatment for the UTI until 09/19/24.

Review of documentation on file with the State agency as part of the facility residential care facility license revealed the room Resident #11 resided in was a licensed residential care facility bed.

This violation represents non-compliance investigated under Complaint Number OH00157937.

Based on record review and staff interview, the facility failed to ensure the falls assessment was completed for all residents upon admission. This affected one (Resident #6) of seven residents for initial health assessments. The facility census was 103.

Findings include:

Review of the medical record for Resident #6 revealed an admission date of 04/23/24 with diagnoses including cellulitis of right lower limb, localized edema, and dyspnea.

Review of Resident #6's assessments from 04/23/24 to 08/05/24 revealed the initial falls assessment was not completed.

Review of Resident #6's progress notes from 04/23/24-08/05/24 revealed Resident #6 had falls on 06/30/24, 07/23/24, and 08/03/24

Interview on 08/05/24 at 2:45 P.M. with the Director of Nursing (DON) verified all residents should have a falls assessment upon admission and verified Resident #6 did not have a completed falls assessment.

Based on record review and staff interview, the facility failed to complete the Tuberculosis (TB) Mantoux testing for State Tested Nursing Assistant (STNA) #58 prior to providing care for residents. This had the potential to affect all 103 residents residing in the facility.

Findings include:

Review of STNA #58's personnel record revealed a hire date of 04/25/24. STNA #58's TB Mantoux test was initially conducted on 04/25/24 without a second step completed. STNA #58 had a Mantoux test first step on 05/21/24 and second step on 05/31/24.

Interview on 08/05/24 at 4:50 P.M. with Human Resource (HR) #225 verified STNA #58 started providing care prior to the completed Mantoux testing.

Based on record review and staff interview, the facility failed to ensure ostomy bag changes were evaluated every seven days and comprehensively assessed. This affected one resident (Resident #3) out of one resident reviewed for skilled care. The facility census was 103.

Findings include:

Record review revealed Resident #3's admission date was 08/05/23 with diagnosis including malignant neoplasm.

Review of Resident #3's progress notes from 10/01/23 to 08/05/24 revealed no skilled charting documentation for the resident receiving ostomy care.

Interview on 08/05/24 at 1:32 P.M. with the Director of Nursing (DON) verified Resident #3 had ostomy care provided for skilled care and verified there was no documentation or assessments every seven days for Resident #3.

Based on record review and staff interview, the facility failed to ensure resident evacuations occurred during at least two fire drills a year on each shift. This had the potential to affect all 103 residents residing in the facility.

Findings include:

Review of the fire drills revealed there were no evacuations of residents during the third-shift fire drills in the past year. The third-shift fire drills occurred on 11/30/23, 02/29/24, 05/31/24, and 07/31/24.

Interview on 08/05/24 at 9:36 A.M. with Maintenance Director #132 verified there were no evacuation of residents during the four third-shift fire drills in the past year.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure that medications were administered safely and in accordance with accepted standards of practice. This affected eight residents (#13, #14, #15, #16, #20, #29, #65, #76) of eight residents reviewed for medication administration. The facility census was 105.

Findings include:

Review of the medical record for Resident #20 revealed an admission date of 04/23/18. Medical diagnoses included hypertension, hypothyroidism, and depression.

Review of the medical record for Resident #14 revealed an admission date of 07/07/23. Medical diagnoses included cerebral infarction, atherosclerotic heart disease, and hyperlipidemia.

Review of the medical record for Resident #65 revealed an admission date of 01/30/23. Medical diagnoses included hypothyroidism, hypertension, depression, and atrial fibrillation.

Review of the medical record for Resident #76 revealed an admission date of 03/27/23. Medical diagnoses included Alzheimer's disease, hypertension, and repeated falls. Review of physician's orders dated 11/03/23 revealed an order for hydrochlorothiazide (a diuretic) 25 milligrams (mg) one tablet daily at bedtime and an order for amlodipine 10 mg one tablet daily at bedtime.

Review of the medical record for Resident #16 revealed an admission date of 09/29/22. Medical diagnoses included osteoarthritis, hyperlipidemia, anxiety, and depression.

Review of the medical record for Resident #29 revealed an admission date of 11/02/21. Medical diagnoses included dementia, hypertension and hypothyroidism.

Review of the medical record for Resident #15 revealed an admission date of 09/29/22. Medical diagnoses included emphysema, hypotension, and muscle weakness.

Review of the medical record for Resident #13 revealed an admission date of 09/17/22. Medical diagnoses included Chronic Obstructive Pulmonary Disease (COPD), chronic pulmonary embolism, and depression.

Observation on 11/07/23 at 8:07 A.M. revealed Licensed Practical Nurse (LPN) #201 stood at the medication cart on the second floor. On top of the cart was a gray basket with six cups of medications labeled with room numbers.

Interview on 11/07/23 at 8:08 A.M. with LPN #201 confirmed she had prepared multiple residents' medications ahead of time, and it was her practice to sign the medications off as administered on the Medication Administration Record (MAR) immediately after she had prepared them.

Observation on 11/07/23 from 8:09 A.M. to 8:23 A.M. of medication administration per LPN #201 revealed the nurse prepared morning medications for Resident #20, Resident #14, Resident #65, Resident #76, Resident #16, and Resident #29. LPN #201 placed a hydrochlorothiazide tablet and an amlodipine tablet in the cup with Resident #76's morning medications, although the physician had ordered these medication to be given at bedtime.

Interview on 11/07/23 at 8:23 A.M. with LPN #201 confirmed Resident #76 routinely took his hydrochlorothiazide and amlodipine in the morning even though the physician had ordered these medications to be given at bedtime.

Observation on 11/07/23 at 8:24 A.M. revealed LPN #201 attempted to deliver Resident #20's medications, but Resident #20 was not in her room. LPN #201 then returned to the cart and prepared morning medications for Resident #15.

Observation on 11/07/23 at 8:26 A.M. revealed LPN #201 entered Resident #15 and Resident #16's room. Resident #15 was seated in a chair in the living room area. LPN #201 sat down her basket containing seven resident's medications on a table next to Resident #15 and filled a cup with water at Resident #15's sink. LPN #201 assisted Resident #16 from a lying position in bed to a seated position on the edge of the bed prior to administering his medications. LPN #201 did not perform hand hygiene and then administered medications to Resident #15. LPN #201 did not perform hand hygiene after administering medications to Resident #15.

Observation on 11/07/23 at 8:43 A.M. revealed LPN #201 entered Resident #14's room and handed the resident a cup of medications. As Resident #14 began to take her morning pills, a red capsule fell onto the floor. LPN #201 picked the dropped pill off the floor with her ungloved hand and handed the pill to the resident. Resident #14 took all of the medications, including the pill that had dropped to the floor. LPN #201 did not offer to replace the medication. LPN #201 did not perform hand hygiene after administering medications to Resident #15.

Interview on 11/07/23 at 8:45 A.M. with LPN #201 confirmed she should not have let Resident #14 take the medication that had been on the ground, nor should she touch medications with her ungloved hand.

Observation on 11/07/23 at 8:46 A.M. revealed LPN #201 entered Resident #65's room. Resident #65 was lying in bed on top of an incontinent pad. LPN #201 touched Resident #65's legs and back with an ungloved hand while she assisted the resident to a seated position on the edge of the bed. LPN #201 then administered medications to Resident #65. LPN #201 did not perform hand hygiene after administering medications to Resident #65.

Observation on 11/07/23 at 8:52 A.M. revealed LPN #201 administered medications to Resident #20. LPN #201 did not perform hand hygiene after administering medications to Resident #20.

Observation on 11/07/23 at 8:55 A.M. revealed LPN #201 administered medications to Resident #76. LPN #201 did not perform hand hygiene after administering medications to Resident #65.

Observation on 11/07/23 at 8:57 A.M. revealed LPN #201 return to the medication cart on the second floor and retrieved a cup of medications she stated were for Resident #13. LPN #201 administered medications to Resident #13. LPN #201 did not perform hand hygiene after administering medications to Resident #13.

Interview on 11/07/23 at 8:57 A.M. with LPN #201 confirmed she had prepared Resident #13's medications earlier in the shift and had already signed out the medications in the MAR.

Interview on 11/07/23 at 9:01 A.M. with LPN #201 confirmed she had prepared Resident #29's medication earlier in the shift and needed to go to a different unit to administer the medications. LPN #201 confirmed she did not perform hand hygiene following resident care for the previous medications passed.

Observation on 11/07/23 at 9:04 A.M. revealed LPN #201 entered the memory care unit and administered medications to Resident #29.

Interview on 11/07/23 at 10:45 A.M. with LPN #201 confirmed she administered Resident #76's hydrochlorothiazide and amlodipine in the morning even though the medications were ordered by the physician to be administered at bedtime.

Interview on 11/07/23 at 11:08 A.M. with the Director of Nursing (DON) confirmed that at no time should the nurse touch medications with bare hands or allow a resident to ingest a medication after it had fallen onto the floor. Additionally, the DON confirmed LPN #201 should have performed hand hygiene immediately after medication administration to each resident. Further interview confirmed nurses should not pre-pour medications and should document medication administration at the time the medications are given. Interview with the DON confirmed the actions of LPN #201 did not align with the standards of nursing practice.

Review of the policy titled Medication Administration Documentation undated revealed when administering a medication, documentation must include the date, time, medication and dosage on the MAR, and name of the individual administering the medication.

Review of the policy titled Administration of Medication undated revealed medications should be administered to the resident for whom they are prescribed and shall be given in accordance with the directions on the prescription or the physician's orders and shall be recorded on the resident's record.

This violation represents non-compliance investigated under Complaint Number OH00146925.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure no smoking signage was posted on the doors of resident rooms in which oxygen is in use. This affected two residents (#15 and #13) of two reviewed for appropriate no smoking signage. Additionally, the facility failed to ensure a portable oxygen cylinder was stored in a safe and secure manner. This had the potential to affect all residents within the facility. The facility census was 105.

Findings include:

1. Review of the medical record for Resident #15 revealed an admission date of 09/29/22. Medical diagnoses included emphysema, hypotension, and muscle weakness.

Observation on 11/07/23 at 8:36 A.M. revealed Resident #15 was sitting in a chair in his room and was wearing supplemental oxygen per concentrator via nasal cannula with oxygen tubing visible from the bedroom area to the living room area. There was no signage placed outside of Resident #15's room which indicated oxygen was in use.

Interview on 11/07/23 at 8:42 A.M. with LPN #201 confirmed there was no signage place outside of Resident #15's room which indicated oxygen was in use.

2. Review of the medical record for Resident #13 revealed an admission date of 09/17/22. Medical diagnoses included Chronic Obstructive Pulmonary Disease (COPD), chronic pulmonary embolism, and depression.

Observation on 11/07/23 at 8:57 A.M. revealed LPN #201 delivered Resident #13 was sitting on the couch and was wearing supplemental oxygen per concentrator via nasal cannula. There was no signage placed outside of Resident #13's room which indicated oxygen was in use.

Interview on 11/07/23 at 9:00 A.M. with LPN #201 confirmed there was no signage place outside of Resident #13's room which indicated oxygen was in use.

3. Observation on 11/07/23 at 8:25 A.M. of the hallway across from the activity office revealed a portable oxygen cylinder was propped up against the medication cart. The oxygen cylinder was not in a rack, cart, or holder.

Interview on 11/07/23 at 8:25 A.M. with LPN #201 confirmed there was an oxygen cylinder propped against the medication cart. LPN #201 further confirmed the oxygen cylinder should have been placed in a proper storage rack.

Review of the facility policy titled Oxygen Storage revised August 2017 revealed that oxygen should be secured and stored in a safe environment. The policy identified that oxygen cylinders should be stored in racks or secured by chains.

Based on observation and resident and staff interviews the facility failed to provide residents with appetizing meals. This affected six residents (#5, #27, #28, #34, #62, and #98) interviewed during mealtimes. This had the potential to affect all 105 residents residing in the facility.

Findings include:

An interview conducted on 10/05/23 at 9:41 A.M. with Resident #5 and Resident #34 revealed Resident #5 stated they repeat the same menu; breakfast was their best meal of the day; their lunch and evening menus are both horrible. There were no seasonings in the food provided to residents. Resident #34 stated the meals they serve were not palatable, and feels the menu was not appropriate because the food served resembles what would be served at a nursing home.

An interview conducted on 10/05/23 at 9:47 A.M. with Resident #98 stated the food from the facility was a disaster and dreadful. All the fruit and vegetables residents received came from cans, and residents are not given adequate protein. Resident #98 said meals served were very poor quality, and something needed to be done about the food.

An interview conducted on 10/05/23 at 12:12 P.M. with Resident #62 stated the food did not taste good. Resident #62 avoided coming down to the dining room area because the food tasted terrible and would rather prepare meals in the apartment.

An interview conducted on 10/05/23 at 12:30 P.M. with Server #23 stated he has had multiple complaints from residents regarding the taste of the food.

An interview conducted on 10/05/23 at 12:40 P.M. with Resident #27 and Resident #28 revealed Resident #27 stated they provide us the same thing every day and repeat the menu. Resident #28 agreed, and stated they do a terrible job with making the food taste good.

An interview was conducted on 10/05/23 at 3:30 P.M. with the Administrator and Resident #98. Resident #98 voiced his concern regarding the food quality at the facility. The Administrator acknowledged Resident #98's complaint stating she was an active member of the facility food service committee. The committee, which consisted of residents and staff in the facility, was making an effort to improve resident meals, and the Administrator explained the menu had improved over the last few months.

A lunch tray was ordered on 10/05/23 at 12:30 P.M. This tray consisted of seasoned mustard greens, butternut squash soup, tomato soup, and steamed rice. Initial observation of the lunch side items resembled the appearance of a mechanical soft diet and did not appear appetizing. The mustard greens were mushy and lacking in flavor. The tomato soup had a dull, tomato juice-like flavor. No complaints were noted on the butternut squash soup and steamed rice.

An interview on 10/05/23 at 12:40 P.M. with Resident #27 stated salt and pepper needed to be added to the mustard greens because they lacked flavor. Resident #27 stated the facility does not add any seasonings because of other residents' special diets.

Based on observation and staff interview, the facility failed to have lids on their garbage cans. This had the potential to affect all 105 residents residing in the facility.

Findings include:

Observation of the kitchen on 10/05/23 at 7:55 A.M. revealed four garbage cans without lids located in the food preparation area during breakfast prep and service.

Interview on 10/05/23 at 8:45 A.M. with Food Services Director (FSD) #58 stated they have never had lids for the garbage cans. The FSD #58 asked Cook #40 if they had any since she started employment at the facility. Cook #40 stated they have not had trash cans with lids in the kitchen since she started employment on 01/10/23.

Based on fire drill record review, staff interview, and facility policy review, the facility failed to vary the times of fire drills. This had the potential to affect 121 of 121 residents in the facility.

Findings Include:

Review of first shift facility fire drills revealed the following dates and times they were executed: 03/30/22 at 1:30 P.M. and 06/30/22 at 2:00 P.M..

Review of second shift facility fire drills revealed the following dates and times they were executed: 01/31/22 at 3:22 P.M., 04/29/22 at 3:30 P.M., 07/29/22 at 3:40 P.M., and 10/31/22 at 3:30 P.M.

Review of third shift facility fire drills revealed the following dates and times they were executed: 02/28/22 at 5:38 A.M., 05/31/22 at 5:41 A.M., 08/31/22 at 6:16 A.M., and 11/30/22 at 6:11 A.M.

Interview with Property Management Staff #106 on 12/27/22 at 2:35 P.M. confirmed the times that the fire drills were completed. He confirmed they are to vary the times for the fire drills, and confirmed the fire drills that were completed could have been varied more in times.

Review of facility Fire Drills policy, dated 10/08/15, revealed fire drills shall be conducted monthly on alternating shifts, at a minimum each shift per quarter to familiarize facility personnel with the signs and emergency action required under varied conditions.