Inspection Reports for
Kings Harbor Multicare Center

One isolated Level 2 deficiency in pain management corrected by February 14, 2025.

The facility failed to provide appropriate pain management and assessment for Resident #1 prior to transferring them to the hospital. There was no documented evidence of pain assessment or administration of pain medication before the transfer. The investigation ruled out abuse or neglect and identified that Resident #1 was independent and could have fractured their pelvis during an unassisted transfer.

Multiple isolated Level 2 deficiencies in resident assessments and reporting of alleged violations; life safety code deficiencies related to electrical equipment, receptacles, and sprinkler system with pattern scope; all corrected by February 2025.

The facility failed to ensure timely submission of all completed resident Minimum Data Set assessments to the Centers for Medicare and Medicaid Services within 14 days of completion. Specifically, 9 resident assessments were not submitted on time due to an administrative error involving batch submission.

Isolated Level 2 deficiencies in abuse and neglect and medication errors; corrected by November 18, 2024.

The visit was complaint-related, investigating allegations of physical abuse and medication errors. The abuse allegation was substantiated with witness reports and staff termination. The medication error involved a nurse administering insulin to the wrong resident, also resulting in termination.

The facility failed to protect residents from physical abuse by staff and failed to prevent significant medication errors. One resident was physically abused by a Certified Nursing Assistant who was subsequently terminated. Another resident was mistakenly administered insulin by a Registered Nurse, who was also terminated.

The complaint investigation included allegations of neglect in providing incontinence care to Resident #402, failure to notify family of significant changes for Resident #936, substantiated abuse of Resident #193 by CNA #1, failure to report abuse and injury of unknown origin to authorities, lack of care plans for multiple residents, and failure to provide appropriate treatment and assessments.

The facility was found deficient in multiple areas including failure to provide timely incontinence care, failure to notify resident representatives of significant changes, substantiated abuse with failure to report to authorities, lack of adequate care plans for residents with fractures, dialysis, and abuse prevention, failure to document hospital transfer reasons, and failure to provide appropriate treatment and care according to professional standards.

Widespread Level 2 deficiency in reporting to national health safety network; not corrected at time of report.

The facility was found deficient in maintaining resident dignity related to catheter privacy, failure to review advance directives with resident representatives, improper posting of nurse staffing data, and inadequate infection control practices with Foley catheter care.