Inspection Reports for Kentmere Rehabilitation and Healthcare Center
1900 Lovering Avenue, DE, 19806
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 14
Nov 22, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Delaware, Department of Health and Social Services, Division of Health Care Quality. The survey was conducted from 11/19/24 to 11/22/24 to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in compliance with 42 CFR 483 subpart B. Deficiencies were identified related to residents' rights to be informed and make treatment decisions, freedom from abuse and neglect, accuracy of assessments, quality of care, pharmacy services, food safety, and safe operating conditions of equipment. Several residents were placed at risk due to failures in medication administration, abuse investigations, self-administration of medications, and care planning.
Complaint Details
The complaint investigation was substantiated with findings of abuse, neglect, misappropriation of property, and failure to protect residents. Specific incidents included physical abuse, verbal intimidation, theft of resident property, and failure to report allegations timely. Staff disciplinary actions and terminations were noted.
Severity Breakdown
SS=D: 12
SS=F: 3
SS=E: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to ensure residents were informed of risks and benefits of psychotropic medications, placing residents at risk of uninformed care decisions. | SS=D |
| Failure to ensure one resident was allowed to self-administer cough drops per physician order, violating resident rights. | SS=D |
| Failure to ensure three residents were free from abuse, neglect, and exploitation, including physical abuse and misappropriation of property. | SS=D |
| Failure to report alleged violations of abuse, neglect, exploitation, or mistreatment immediately and within required timeframes. | SS=D |
| Failure to protect residents from misappropriation of property, including theft of credit card and money. | SS=D |
| Failure to ensure accuracy of resident assessments, leading to inaccurate federal reimbursements and care planning. | SS=D |
| Failure to provide consistent activities of daily living (ADLs) care, including oral hygiene and showers, placing residents at risk of diminished quality of life. | SS=D |
| Failure to ensure proper foot care and podiatry consults for residents, risking mobility and health complications. | SS=D |
| Failure to ensure quality of care, including skin care, medication administration, and wound care, resulting in untreated wounds and risk of infection. | SS=D |
| Failure to ensure sufficient staff competencies and training in dementia care, resulting in resident harm and inadequate care. | SS=D |
| Failure to provide pharmacy services including narcotic count accuracy and medication storage, risking drug diversion. | SS=F |
| Failure to ensure menus and nutritional adequacy, including proper portion sizes and diet consistency, risking resident nutrition. | SS=E |
| Failure to maintain safe operating condition of patient care equipment, including broken wheelchair, risking resident safety. | SS=D |
| Failure to ensure food safety practices including staff hygiene and food preparation, risking contamination. | SS=F |
Report Facts
Survey Census: 94
Sample Size: 40
Supplemental Residents: 10
Deficiencies cited: 16
Plan of Correction Completion Dates: Dates range from 2025-01-29 to 2025-01-29 for various deficiencies
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide CNA12 | Named in verbal intimidation and abuse allegations | |
| Licensed Practical Nurse LPN7 | Confirmed allegations and participated in investigation | |
| Certified Nurse Aide CNA16 | Terminated following investigation of theft and misappropriation | |
| Director of Nursing DON | Director of Nursing | Interviewed regarding abuse allegations and investigation |
| Social Services Director SSD | Social Services Director | Provided statements regarding resident interactions and abuse |
| Licensed Practical Nurse LPN1 | Documented skin tear and participated in investigation | |
| Certified Nurse Aide CNA1 | Reported skin tear and resident abuse incident | |
| Registered Nurse RN5 | Observed wound care and participated in resident care | |
| Certified Nurse Aide CNA2 | Reported on resident care and abuse incidents | |
| Dietary Manager DM | Dietary Manager | Interviewed regarding food portion sizes and meal service |
| Registered Dietician RD | Registered Dietician | Interviewed regarding nutritional adequacy and meal portions |
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 11
Oct 12, 2023
Visit Reason
An unannounced annual and complaint survey was conducted at Kentmere Rehabilitation And Healthcare Center from October 9 through October 12, 2023, to assess compliance with federal and state regulations including emergency preparedness and long-term care requirements.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified in personnel documentation, transfer and discharge notices, bed rail safety, medication management, food safety, resident assessments, and binding arbitration agreements among others. No residents were harmed by the deficient practices noted.
Deficiencies (11)
| Description |
|---|
| Facility failed to provide documentation verifying annual influenza immunization or refusal for 6 out of 10 employees reviewed. |
| Personnel records lacked evidence of criminal background checks, mandatory drug testing, and adult abuse registry checks for 6 out of 10 employees reviewed. |
| Facility failed to ensure one employee received pre-employment tuberculosis screening. |
| Facility failed to ensure two of three residents and/or their representatives were provided with timely and complete transfer/discharge notices. |
| Facility failed to ensure bed rail safety assessments and informed consents were completed for two residents. |
| Facility failed to ensure performance reviews were completed every 12 months for five nurse aides. |
| Facility failed to ensure medication carts were free of loose pills and properly secured. |
| Facility failed to ensure regular in-service education for nurse aides was completed annually. |
| Facility failed to ensure food safety requirements were met, including proper labeling, storage, and dishwasher temperature monitoring. |
| Facility failed to maintain accurate and timely resident assessments and care plans for multiple residents. |
| Facility failed to ensure binding arbitration agreements were properly executed and explained to residents and representatives. |
Report Facts
Facility census: 99
Sample size: 28
Supplemental residents: 24
Employees reviewed for influenza documentation: 10
Employees lacking background checks: 6
Residents reviewed for transfer notices: 3
Nurse aides reviewed for performance evaluations: 5
Residents reviewed for assessments: 28
Residents signed arbitration agreements: 99
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 4
Apr 25, 2022
Visit Reason
An unannounced complaint and extended survey was conducted from April 13, 2022 to April 25, 2022 by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection.
Findings
The facility was found out of compliance with staffing requirements and failed to provide adequate staffing levels for at least three days. Additionally, the facility failed to report an alleged violation of neglect immediately and failed to perform CPR on a resident who was a Full Code. Deficiencies included failure to maintain minimum staffing hours, failure to report incidents timely, and failure to provide basic life support including CPR.
Complaint Details
The complaint investigation found that one resident (R1) was not provided CPR despite being a Full Code and unresponsive. The facility failed to report the incident to the State Survey Agency within the required timeframe. The allegation of neglect was substantiated as the facility failed to ensure timely reporting and appropriate emergency response.
Severity Breakdown
SS=D: 2
SS=J: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to provide staffing at a level of at least 3.28 hours of direct care per resident per day for three days. | — |
| Failure to report alleged violation of neglect immediately, but not later than 2 hours after the allegation was made. | SS=D |
| Failure to provide basic life support including CPR to a resident who was a Full Code. | SS=J |
| Failure to ensure licensed nurses had the skill sets necessary to provide care when a resident had a change of condition and was unresponsive. | SS=D |
Report Facts
Facility census: 98
Survey sample size: 5
Staffing hours per resident per day: 3.28
Staffing hours recorded: 2.69
Staffing hours recorded: 3.15
Staffing hours recorded: 3.09
Time to report incident: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E5 | Registered Nurse (RN) | Named in failure to perform CPR and failure to report incident |
| E8 | Physician/Medical Director | Named in failure to perform CPR and incident reporting |
| E6 | Licensed Practical Nurse (LPN) | Named in failure to assess resident and check code status |
| E7 | Certified Nurse Assistant (CNA) | Named in notifying nursing staff of resident unresponsiveness |
| E4 | Infection Control/Staff Development | Involved in education and monitoring corrective actions |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference and review of findings |
| E2 | Director of Nursing (DON) | Participated in exit conference and review of findings |
Inspection Report
Follow-Up
Census: 86
Deficiencies: 0
Jan 27, 2022
Visit Reason
An unannounced follow-up survey was conducted for the annual and complaint survey ending December 9, 2021, to assess compliance at the facility.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities as of January 7, 2022. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 9
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 12
Dec 9, 2021
Visit Reason
An unannounced annual, complaint, and emergency preparedness survey was conducted at the facility from December 1, 2021 through December 9, 2021 to assess compliance with federal and state regulations.
Findings
The survey identified multiple deficiencies related to resident care, infection control, emergency preparedness, and facility administration. Key issues included failure to notify maintenance of a broken call bell, inadequate resident self-determination processes, failure to post required information, grievances handling deficiencies, abuse and neglect reporting failures, respiratory care shortcomings, food safety violations, and infection control lapses during a COVID-19 outbreak.
Severity Breakdown
SS=D: 6
SS=E: 4
SS=F: 2
SS=K: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to notify maintenance staff of a broken call bell and failure to provide frequent checks on the call bell. | SS=D |
| Failure to ensure resident self-determination rights were upheld, including making choices about activities and care. | SS=D |
| Failure to post required information including names and contact information of state agencies and grievance procedures. | SS=E |
| Failure to maintain survey results and complaint investigation reports for the past three years in a binder accessible to residents and representatives. | SS=E |
| Failure to implement a grievance policy that includes procedures for filing grievances anonymously and identifying a grievance official. | SS=E |
| Failure to identify and report allegations of neglect and abuse timely and failure to provide appropriate education to staff. | SS=D |
| Failure to provide adequate assistance with toileting and failure to report allegations of neglect related to toileting. | SS=D |
| Failure to provide appropriate respiratory care and ensure oxygen tubing and humidifier bottles were changed weekly. | SS=D |
| Failure to ensure food was stored, prepared, and served in a sanitary manner, including ice machine covered with biofilm. | SS=E |
| Failure to administer the facility in a manner that enables effective infection control practices during a COVID-19 outbreak. | SS=F |
| Failure to maintain attendance at Quality Assurance meetings and failure to correct attendance issues. | SS=D |
| Failure to maintain an effective infection prevention and control program including staff education and PPE usage during COVID-19 outbreak. | SS=K |
Report Facts
Facility census: 93
Survey sample size: 45
Deficiency completion dates: Various completion dates listed for plans of correction, e.g., 1/7/2022, 12/30/2021
Number of staff fit tested: 7
Number of residents audited: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E11 | Nursing Home Administrator (NHA) | Interviewed during exit conference and involved in findings review |
| E2 | Director of Nursing (DON) | Interviewed during exit conference and involved in findings review |
| E6 | Director of Social Services (DSS) and Grievance Officer | Interviewed regarding grievances and complaint investigations |
| E26 | Maintenance Director | Interviewed regarding broken call bell maintenance |
| E27 | Certified Nurse Aide (CNA) | Interviewed regarding call bell issues |
| E4 | RN Infection Control Practitioner (ICP) | Interviewed regarding infection control and COVID-19 outbreak |
| E20 | Certified Nurse Aide (CNA) | Observed wearing surgical mask and involved in COVID-19 unit observations |
| E14 | Certified Nurse Aide (CNA) | Observed residents and infection control compliance |
| E15 | RN Unit Manager | Interviewed regarding resident care and shower preferences |
| E16 | Licensed Practical Nurse (LPN) | Interviewed regarding resident care and shower preferences |
| E17 | Certified Nurse Aide (CNA) | Interviewed regarding resident shower frequency |
| E18 | Director of Rehabilitation | Attended interdisciplinary care plan meeting |
| E21 | Staff Educator | Involved in infection control education and COVID-19 outbreak response |
| E31 | Licensed Practical Nurse (LPN) | Interviewed regarding N95 training and fit testing |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 3
Aug 26, 2021
Visit Reason
An unannounced COVID-19 Focused Infection Control and Complaint surveys were conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from August 23, 2021 through August 26, 2021.
Findings
The facility was found to not be in compliance with 42 CFR §483.80 infection control regulations and had not implemented the CMS and CDC recommended practices to prepare for COVID-19. Deficiencies were identified related to comprehensive care plans for residents with urinary catheters and infection prevention and control practices.
Complaint Details
The survey was complaint-related and focused on infection control and urinary catheter care. The facility failed to implement recommended infection control practices and did not have adequate policies or procedures related to urinary catheter maintenance and infection prevention.
Deficiencies (3)
| Description |
|---|
| Failure to develop comprehensive care plans for residents with urinary catheters, including measurable objectives and interventions to prevent urinary tract infections. |
| Failure to ensure appropriate treatment and services to prevent urinary tract infections for residents with indwelling catheters. |
| Failure to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. |
Report Facts
Survey sample residents: 9
Facility census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eileen Nodle | Administrator | Signed the initial statement of deficiencies on 9/17/2021 |
Inspection Report
Routine
Census: 95
Deficiencies: 0
Jul 7, 2021
Visit Reason
An unannounced COVID-19 Focused Infection Control Survey was conducted by the State of Delaware Division of Health Care Quality from July 6, 2021 through July 7, 2021.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 7
Inspection Report
Annual Inspection
Census: 102
Deficiencies: 7
Jan 21, 2020
Visit Reason
An unannounced annual, complaint, and emergency preparedness survey was conducted at the facility from January 8, 2020 through January 21, 2020.
Findings
The survey identified multiple deficiencies related to grievance procedures, comprehensive care plans, quality of care, fall prevention, nutrition/hydration status maintenance, pain management, and labeling/storage of drugs and biologicals. Some deficiencies were cited as past noncompliance with no plan of correction required.
Complaint Details
The inspection included complaint investigation as part of the annual and emergency preparedness survey.
Severity Breakdown
SS=F: 1
SS=D: 4
SS=G: 1
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to establish a system of filing grievance reports including lost and missing personal items and belongings. | SS=F |
| Failed to develop comprehensive care plans for residents including measurable objectives and timeframes. | SS=D |
| Failed to meet professional standards of quality in services provided or arranged by the facility. | SS=D |
| Failed to ensure resident received care and services that are resident centered and meet professional standards regarding leave of absence policy. | SS=D |
| Failed to ensure adequate supervision and assistance devices to prevent accidents for residents. | SS=G |
| Failed to ensure pain management was provided consistent with professional standards of practice. | SS=D |
| Failed to label drugs and biologicals in accordance with accepted professional principles and failed to remove expired medications. | SS=E |
Report Facts
Facility census: 102
Survey sample size: 43
Deficiency count: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Named in discussions of findings and exit conference. |
| E2 | Director of Nursing (DON) | Named in discussions of findings and exit conference. |
| E23 | Assistant Director of Nursing (ADON) | Named in discussions of findings and exit conference. |
| E24 | Staff Educator | Named in discussions of findings and exit conference. |
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