Inspection Reports for Kingston Care Center of Fort Wayne
1010 W WASHINGTON CENTER RD, IN, 46825
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
Moderate
Low
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 25, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure Survey.
Findings
Kingston Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Annual Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 10, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00458140.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Complaint Details
Complaint IN00458140 was investigated and corrected as of May 15, 2025.
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 1
May 14, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00456678, IN00458140, and IN00458555 at Kingston Care Center of Fort Wayne.
Findings
The facility was found deficient in ensuring grievances were thoroughly investigated, documented, and corrective actions taken for one of three residents reviewed (Resident Q). No deficiencies were cited for complaints IN00456678 and IN00458555. The grievance process lacked proper documentation and follow-up, and grievance forms were not readily available.
Complaint Details
Complaint IN00458140 was substantiated with federal/state deficiencies cited at F585 related to grievance investigation failures. Complaints IN00456678 and IN00458555 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure grievances were thoroughly investigated, contained required documentation, and appropriate corrective actions taken for 1 of 3 residents reviewed with grievances (Resident Q). | SS=D |
Report Facts
Census: 103
Medicare residents: 13
Medicaid residents: 70
Other residents: 20
SNF/NF beds: 71
SNF beds: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Holifield | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Social Services Director | Interviewed regarding grievance process and lack of documentation | |
| Administrator | Interviewed and provided facility grievance policy | |
| Director of Nursing | Interviewed regarding care concerns of Resident Q and grievance follow-up |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Mar 14, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454446 regarding federal and state deficiencies related to surgical wound care.
Findings
The facility failed to ensure a surgical wound was properly assessed and monitored for one resident (Resident P). Documentation and monitoring of the surgical wound, including signs of infection and staple removal, were inadequate or missing during the review period.
Complaint Details
Complaint IN00454446 was substantiated with federal/state deficiencies cited at F684 related to surgical wound care.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a surgical wound was assessed and monitored for one resident. | SS=D |
Report Facts
Census: 111
SNF/NF beds: 70
SNF beds: 41
Medicare residents: 25
Medicaid residents: 54
Other payor residents: 32
Deficiency completion date: Mar 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Holifield | Laboratory Director's or Provider/Supplier Representative | Signed the report |
| Registered Nurse 2 | Registered Nurse | Interviewed regarding surgical wound assessment and documentation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding surgical wound care policies and monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 14, 2025
Visit Reason
Investigation of Complaint IN00454446 was conducted to review compliance with regulatory requirements.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Complaint Details
Complaint IN00454446 was investigated and corrected as of March 14, 2025.
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Feb 7, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452475 and IN00452879 at Kingston Care Center of Fort Wayne.
Findings
No deficiencies were cited related to the allegations in both complaints. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Investigation of Complaints IN00452475 and IN00452879 found no deficiencies related to the allegations.
Report Facts
Census: 107
Census Bed Type SNF: 38
Census Bed Type SNF/NF: 69
Census Payor Type Medicare: 22
Census Payor Type Medicaid: 53
Census Payor Type Other: 32
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Jan 31, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00451137 and IN00452135 at Kingston Care Center of Fort Wayne.
Findings
No deficiencies related to the allegations in complaints IN00451137 and IN00452135 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00451137 and Complaint IN00452135 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 68
Census Bed Type - SNF: 41
Total Census: 109
Census Payor Type - Medicare: 21
Census Payor Type - Medicaid: 56
Census Payor Type - Other: 32
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Dec 3, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00447153.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Investigation of Complaint IN00447153 with no deficiencies related to the allegations cited.
Report Facts
Census Bed Type Total: 104
Census Bed Type SNF/NF: 69
Census Bed Type SNF: 35
Census Payor Type Medicare: 20
Census Payor Type Medicaid: 63
Census Payor Type Other: 21
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 21, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00444543.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00444543 was investigated and corrected as of October 21, 2024.
Inspection Report
Complaint Investigation
Census: 108
Capacity: 108
Deficiencies: 1
Oct 18, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00444040 and IN00444543 at Kingston Care Center of Fort Wayne.
Findings
The facility failed to ensure complete and accurate medical records were maintained for 1 of 3 residents reviewed (Resident D), including documentation of medication changes and oral status. Deficiencies related to complaint IN00444543 were cited, while no deficiencies were found related to complaint IN00444040.
Complaint Details
Complaint IN00444040 had no deficiencies related to the allegations. Complaint IN00444543 had federal/state deficiencies cited at F842 related to incomplete and inaccurate resident medical records.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain complete and accurate medical records for Resident D, including lack of documentation of medication changes and oral status. | SS=D |
Report Facts
Census: 108
Total Capacity: 108
Medicare Census: 21
Medicaid Census: 67
Other Payor Census: 20
Lithium blood level: 1.6
Deficiency cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding documentation policies and facility procedures related to resident medical records |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Involved in medication orders and interviewed regarding medication changes for Resident D |
| Medical Nurse Practitioner | Medical Nurse Practitioner | Provided lab results and communicated with psychiatric NP regarding Resident D's elevated lithium levels and tremors |
Inspection Report
Re-Inspection
Census: 100
Capacity: 137
Deficiencies: 0
Oct 10, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/05/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. The building is fully sprinklered except for a detached un-sprinklered storage building used for mowing equipment.
Report Facts
Facility capacity: 137
Census: 100
Emergency generator power: 300
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 9, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Kingston Care Center of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 117
Capacity: 137
Deficiencies: 4
Sep 5, 2024
Visit Reason
The survey was conducted as an Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included unsealed holes in fire-rated rooms, incorrect fire alarm panel time, outdated sprinkler gauges, and unsealed penetrations in smoke barriers affecting multiple areas of the facility.
Severity Breakdown
SS=E: 3
SS=C: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 hazardous soiled linen rooms were separated by smoke resistant partitions due to unsealed screw size holes. | SS=E |
| Failed to ensure fire alarm system was continuously in proper operating condition; fire alarm panel time was incorrect. | SS=C |
| Failed to ensure 7 of 7 sprinkler riser's gauges were replaced or tested every 5 years as required. | SS=E |
| Failed to ensure penetrations through 1 of 8 smoke barrier walls were protected to maintain smoke resistance. | SS=E |
Report Facts
Facility capacity: 137
Census: 117
Unsealed holes: 11
Sprinkler gauges: 7
Smoke barrier walls: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and acknowledged deficiencies related to unsealed holes, fire alarm panel time, sprinkler gauges, and smoke barrier penetrations | |
| Administrator | Participated in exit conference reviewing findings | |
| Facilities Maintenance Supervisor | Interviewed regarding unsealed penetration in 300-hall smoke barrier |
Inspection Report
Renewal
Census: 108
Capacity: 108
Deficiencies: 6
Aug 26, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 20 to 26, 2024.
Findings
The facility was found deficient in several areas including failure to ensure a dignified dining experience, incomplete advanced directive documentation, incomplete Minimum Data Set (MDS) assessments, failure to provide trauma-informed care, improper preparation of pureed food, and inadequate infection prevention and control practices related to sanitation during dining.
Severity Breakdown
SS=E: 3
SS=D: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure a dignified dining experience for 5 of 20 residents reviewed, including serving residents at the same time at each table. | SS=E |
| Failed to ensure formulation of an advanced directive after admission for 1 of 1 resident reviewed. | SS=D |
| Failed to ensure all Minimum Data Set (MDS) sections were completed for 2 of 32 residents reviewed. | SS=D |
| Failed to identify and initiate plans to mitigate trauma informed care for 1 of 1 resident reviewed. | SS=D |
| Failed to ensure pureed food was prepared to guideline specifications for 5 of 5 residents requiring pureed diets. | SS=E |
| Failed to ensure a sanitary environment for dining in the crown dining room, including failure to maintain hand hygiene and proper sanitation when residents assisted with bussing tables. | SS=E |
Report Facts
Census: 108
Total Capacity: 108
Residents reviewed for dignified dining: 20
Residents requiring pureed diets: 5
Quality Assurance Audits frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Holifield | Laboratory Director/Provider/Supplier Representative | Signed the report |
| Cook 8 | Named in findings related to meal service delays, pureed food preparation, and dining sanitation | |
| Cook 7 | Referenced regarding recipe availability for pureed food | |
| Director of Nursing | Director of Nursing | Interviewed regarding dining service and advanced directive issues |
| Dietary Aide 7 | Interviewed regarding meal service procedures | |
| Director of Rehab | Director of Rehabilitation | Interviewed regarding MDS completion issues |
| MDS Coordinator 6 | Interviewed regarding MDS completion issues | |
| Social Services Director | Social Services Director | Interviewed regarding trauma-informed care deficiencies |
| Resident 77 | Resident involved in dining sanitation and behavior findings |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Jun 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434938.
Findings
No deficiencies were cited related to the allegations, and the facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00434938 found no deficiencies related to the allegations.
Report Facts
Census: 107
Census Bed Type - SNF: 39
Census Bed Type - SNF/NF: 68
Census Payor Type - Medicare: 17
Census Payor Type - Medicaid: 66
Census Payor Type - Other: 24
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 0
May 15, 2024
Visit Reason
This visit was conducted to investigate Complaints IN00433121 and IN00433398 at Kingston Care Center of Fort Wayne.
Findings
No deficiencies related to the allegations in Complaints IN00433121 and IN00433398 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00433121 and IN00433398 found no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 105
Census Payor Type Total: 105
SNF/NF Beds: 74
SNF Beds: 31
Medicare Residents: 4
Medicaid Residents: 67
Other Payor Residents: 34
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 16, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00431781.
Findings
Kingston Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00431781 completed on April 16, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 113
Capacity: 113
Deficiencies: 1
Apr 15, 2024
Visit Reason
This visit was for the investigation of complaints IN00431135, IN00431174, and IN00431781. Complaints IN00431135 and IN00431174 had no deficiencies related to the allegations, while complaint IN00431781 resulted in federal/state deficiencies cited.
Findings
The facility failed to ensure adequate pain management for one resident (Resident Q) who experienced unrelieved pain during her stay, leading to early discharge. Pain medications were not given timely, non-pharmacological interventions were not consistently offered, and the facility lacked a comprehensive pain assessment form. The facility implemented corrective actions including staff education, audits, and policy reinforcement.
Complaint Details
Complaint IN00431781 was substantiated with federal/state deficiencies cited related to pain management. Complaints IN00431135 and IN00431174 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure pain management for 1 of 3 residents experiencing pain, including untimely administration of pain medications and lack of non-pharmacological interventions. | SS=D |
Report Facts
Census: 113
Total Capacity: 113
Medicare Residents: 29
Medicaid Residents: 68
Other Payor Residents: 16
Pain medication administration times: 9
Audit frequency weeks: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Holifield | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Director of Nursing | Provided interview regarding pain management policies and corrective actions | |
| Administrator | Provided education to therapy employees regarding pain management policies | |
| Director of Rehab | Conducted therapy records review and audits related to pain management |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 113
Deficiencies: 0
Feb 28, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00426121, IN00426651, and IN00428765.
Findings
No deficiencies were cited related to any of the three complaints investigated. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00426121, IN00426651, and IN00428765 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 43
Census Bed Type - SNF/NF: 70
Total Census: 113
Census Payor Type - Medicare: 24
Census Payor Type - Medicaid: 65
Census Payor Type - Other: 24
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Jan 11, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00424917.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00424917 - No deficiencies related to the allegations are cited.
Report Facts
Census: 117
Census Bed Type - SNF/NF: 68
Census Bed Type - SNF: 49
Census Payor Type - Medicare: 16
Census Payor Type - Medicaid: 64
Census Payor Type - Other: 37
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 2
Dec 22, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422127 regarding federal and state deficiencies related to nutrition/hydration status maintenance and food safety.
Findings
The facility failed to ensure meal consumption percentages were documented for 4 residents on multiple dates and failed to follow proper sanitation procedures in food service, including use of wet dishes and improper glove hygiene.
Complaint Details
Complaint IN00422127 was substantiated with federal/state deficiencies cited at F692 and F812 related to nutrition/hydration documentation and food safety sanitation.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to document meal consumption percentage for 4 residents on multiple dates. | SS=E |
| Failed to ensure food procurement, storage, preparation, and serving were conducted in a sanitary manner, including use of wet dishes and improper glove hygiene. | SS=E |
Report Facts
Census: 110
Residents reviewed for meal documentation: 4
Residents receiving meals from kitchen: 108
Dates with missing meal documentation: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Grabbe | RN-DON | Signed the report as Laboratory Director or Provider/Supplier Representative |
| Cook 4 | Interviewed regarding moisture between dishes | |
| Dietary Aide 7 | Observed handling wet dishes and cups | |
| Dietary Aide 5 | Interviewed about use of wet cups | |
| Dietary Manager | Interviewed about dish drying and sanitation policies | |
| Cook 6 | Observed using wet plates and improper glove hygiene; interviewed about practices | |
| Registered Nurse 2 | Interviewed about meal consumption documentation procedures | |
| CNA 3 | Interviewed about meal consumption documentation procedures | |
| Administrator | Interviewed about meal consumption documentation and department monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 22, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00422127 completed on December 22, 2023.
Findings
Kingston Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00422127; paper compliance review completed and found in compliance.
Inspection Report
Re-Inspection
Census: 100
Capacity: 137
Deficiencies: 0
Oct 19, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 08/21/23.
Findings
At this PSR survey, Kingston Care Center of Fort Wayne was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
Oct 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00418077 and IN00418473.
Findings
No deficiencies related to the allegations in Complaints IN00418077 and IN00418473 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00418077 and IN00418473 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 100
Census Payor Type - Medicare: 15
Census Payor Type - Medicaid: 61
Census Payor Type - Other: 24
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 29, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey, as well as the investigation of complaints IN00413266 and IN00412674.
Findings
Kingston Care Center of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the recertification, state licensure survey, and complaint investigations.
Complaint Details
The investigation of complaints IN00413266 and IN00412674 was completed and found to be in compliance.
Inspection Report
Life Safety
Census: 99
Capacity: 137
Deficiencies: 0
Aug 21, 2023
Visit Reason
A Life Safety Code and Environmental Preoccupancy Survey was conducted for the new addition of a locked unit with multiple resident rooms and support areas.
Findings
The locked wing and new support and common areas were found in compliance with Medicare/Medicaid participation requirements, Life Safety Code, and Indiana's Health Facilities Rules. The facility was fully sprinklered and had appropriate fire alarm and emergency generator systems.
Report Facts
Rooms in new locked unit: 13
Facility capacity: 137
Census: 99
Emergency generator power: 300
Inspection Report
Life Safety
Census: 99
Capacity: 137
Deficiencies: 13
Aug 21, 2023
Visit Reason
An Emergency Preparedness and Life Safety Code Recertification Survey was conducted by the Indiana Department of Health to assess compliance with federal and state regulations including 42 CFR 483.73 and NFPA 101 standards.
Findings
The facility was found not in compliance with Emergency Preparedness training and testing requirements, Life Safety Code exit door hardware, exit signage, sprinkler system maintenance, portable fire extinguisher condition, corridor door latching, electrical panel security, HVAC combustion air intake, and improper use of extension cords and power strips. Corrective actions and plans of correction were implemented.
Severity Breakdown
SS=F: 2
SS=E: 9
SS=D: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to conduct annual emergency preparedness staff knowledge quiz and document staff knowledge. | SS=F |
| Failed to complete facility drill/event reports for emergency preparedness exercises. | SS=F |
| One exit discharge door on 200 hall required excessive force to open, not free of impediments. | SS=E |
| Exit signage on 400 hall had incorrect directional arrow knock-outs. | SS=E |
| Failed to document monthly testing and annual battery changes for battery-operated smoke alarms in resident rooms. | SS=E |
| Missing or improperly installed sprinkler escutcheon plate leaving annular space around sprinkler head. | SS=E |
| Sprinkler heads in laundry, kitchen, and dining hall were loaded with dust, lint, or corroded. | SS=E |
| K-class fire extinguisher nozzle showed corrosion and was not in operable condition. | SS=E |
| Resident room door (room 111) did not latch properly to resist passage of smoke. | SS=D |
| Electrical panels in 100-Hall were unsecured and accessible to unauthorized personnel. | SS=E |
| Fuel-fired water heater room intake air vent was blocked with lint and dirt, restricting combustion air. | SS=E |
| Extension cords and power strips were used improperly as substitutes for fixed wiring and for high current draw equipment. | SS=E |
| Flexible power cord in HR office was not secured and was dangling, risking damage. | SS=E |
Report Facts
Facility capacity: 137
Census: 99
Deficiencies cited: 12
Date of survey: Aug 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Holifield | Maintenance Director | Named in relation to findings on emergency preparedness training, sprinkler maintenance, and other facility maintenance deficiencies |
| Regional Maintenance Director | Named in relation to findings on emergency preparedness training, sprinkler maintenance, and other facility maintenance deficiencies |
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 3
Aug 8, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of two complaints (IN00412674 and IN00413266).
Findings
The facility was found deficient in pain management for one resident, medication labeling and dating for multiple medication carts, and dental services for one resident. Complaints investigated were found to have no deficiencies regarding allegations.
Complaint Details
Two complaints (IN00412674 and IN00413266) were investigated with no deficiencies found regarding the allegations.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure pain was controlled in 1 of 1 resident reviewed (Resident 249), including inadequate documentation and use of non-pharmacological interventions. | SS=D |
| Failure to date medications when opened in 4 of 4 medication carts reviewed, risking improper medication labeling and storage. | SS=E |
| Failure to ensure denture care and replacement was provided for 1 of 3 residents reviewed (Resident 66), including lost broken denture and delayed replacement. | SS=D |
Report Facts
Census: 105
Medications administered: 30
Non-pharmacological interventions documented: 3
Medication carts reviewed: 4
Residents with dentures reviewed: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 14, 2023
Visit Reason
The visit was conducted as a paper compliance review related to the Investigation of Complaint IN00408892 completed on May 30, 2023.
Findings
Kingston Care Center of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00408892 completed on May 30, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 1
May 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408892 regarding allegations of verbal abuse at Kingston Care Center of Fort Wayne.
Findings
The facility failed to ensure freedom from verbal abuse for 1 of 3 residents reviewed (Resident B). The investigation found that a Certified Nursing Aide (CNA 4) made disrespectful and verbally abusive comments to Resident B, which caused the resident emotional distress. The facility took immediate corrective actions including separating the employee involved and implementing staff re-education and ongoing monitoring.
Complaint Details
Complaint IN00408892 was substantiated with federal/state deficiencies cited related to verbal abuse allegations. The resident was verbally abused by CNA 4, who made derogatory comments and yelled at the resident. The facility conducted an investigation, took immediate corrective action, and separated the employee involved.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure freedom from verbal abuse for 1 of 3 residents reviewed (Resident B). | SS=D |
Report Facts
Census: 114
SNF beds: 48
SNF/NF beds: 66
Medicare residents: 33
Medicaid residents: 63
Other payor residents: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Holifield | Laboratory Director's or Provider/Supplier Representative | Signed the report |
| RT 3 | Respiratory Therapist | Reported and intervened in verbal abuse incident involving Resident B |
| CNA 4 | Certified Nursing Aide | Employee who verbally abused Resident B and was separated from employment |
| RN 7 | Registered Nurse | Witnessed and reported CNA 4's behavior toward Resident B |
| CNA 6 | Certified Nursing Aide | Heard CNA 4 yelling at Resident B |
| CNA 8 | Certified Nursing Aide | Provided interview about abuse definitions and staff conduct |
| Director of Nursing | Reported CNA 4's verbal abuse to Resident B |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 109
Deficiencies: 0
Apr 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00405000.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00405000 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 33
Medicaid census: 57
Other payor census: 19
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 0
Mar 21, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00403604.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00403604 - No deficiencies related to the allegations are cited.
Report Facts
Census: 105
Census Bed Type - SNF/NF: 62
Census Bed Type - SNF: 43
Census Payor Type - Medicare: 22
Census Payor Type - Medicaid: 57
Census Payor Type - Other: 26
Inspection Report
Re-Inspection
Census: 113
Deficiencies: 0
Feb 28, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00400348 and IN00401079 completed on February 9, 2023.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of Complaints IN00400348 and IN00401079. Both complaints were corrected.
Complaint Details
This visit was related to the investigation of complaints IN00400348 and IN00401079. Both complaints were corrected.
Report Facts
Census: 113
Census Bed Type Total: 113
Medicare Census: 33
Medicaid Census: 58
Other Payor Census: 22
Inspection Report
Complaint Investigation
Census: 106
Capacity: 106
Deficiencies: 3
Feb 8, 2023
Visit Reason
The visit was conducted for the investigation of two substantiated complaints (IN00400348 and IN00401079) regarding quality of care and medication errors at Kingston Care Center of Fort Wayne.
Findings
The facility failed to assess and monitor a resident following a significant medication error that resulted in respiratory distress and emergent treatment. Additionally, the facility failed to provide a therapeutic diet to a resident with dietary needs and failed to ensure residents were free from significant medication errors.
Complaint Details
Complaint IN00400348 and IN00401079 were substantiated. The medication error complaint resulted in immediate jeopardy due to a morphine overdose causing respiratory distress and need for emergent treatment. The nutrition complaint involved failure to provide a therapeutic diet as ordered.
Severity Breakdown
SS=J: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to assess and monitor a resident following a significant medication error involving morphine overdose. | SS=J |
| Failed to provide a therapeutic diet for a resident with a nutritional problem as ordered by the health care provider. | SS=D |
| Failed to ensure residents were free from significant medication errors, resulting in immediate jeopardy due to a morphine overdose. | SS=J |
Report Facts
Census: 106
Total Capacity: 106
Medication error dose: 100
Medication error multiplier: 20
Date of survey completion: Feb 9, 2023
Inspection Report
Complaint Investigation
Census: 108
Capacity: 108
Deficiencies: 0
Jan 19, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399283.
Findings
The complaint IN00399283 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00399283 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 108
Census Payor Type Medicare: 27
Census Payor Type Medicaid: 51
Census Payor Type Other: 30
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Dec 28, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00394655.
Findings
The complaint IN00394655 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00394655 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Census: 111
Census Bed Type - SNF: 47
Census Bed Type - NF: 64
Census Payor Type - Medicare: 31
Census Payor Type - Medicaid: 50
Census Payor Type - Other: 30
Inspection Report
Follow-Up
Census: 100
Capacity: 137
Deficiencies: 0
Nov 22, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The building was fully sprinklered except for a detached storage building used for mowing equipment.
Report Facts
Facility capacity: 137
Census: 100
Emergency generator power: 300
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 15, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00393206 and IN00394521.
Findings
Kingston Care Center of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00393206 and IN00394521 and was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 115
Capacity: 115
Deficiencies: 2
Nov 14, 2022
Visit Reason
This visit was for the investigation of three complaints (IN00393206, IN00394465, and IN00394521). Two complaints were substantiated with related federal/state deficiencies cited, and one was substantiated with no deficiencies cited.
Findings
The facility failed to ensure showers and medicated shampoo were provided per the care plan for one resident, and failed to provide food that was appealing and served at a palatable temperature for seven residents. Multiple residents reported food being cold, unappetizing, and served inconsistently. Deficiencies were cited related to care plan implementation and food service.
Complaint Details
Complaint IN00393206 - Substantiated with deficiencies cited at F804. Complaint IN00394465 - Substantiated with no deficiencies cited. Complaint IN00394521 - Substantiated with deficiencies cited at F656 and F804.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure showers and medicated shampoo were provided per the care plan for one resident. | SS=D |
| Failed to provide food that was appealing to eat and served at a palatable temperature for seven residents. | SS=E |
Report Facts
Census: 115
Total Capacity: 115
Residents interviewed with food concerns: 7
Residents reviewed for care plan deficiency: 3
Residents affected by care plan deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica McKinley | Administrator | Signed report and interviewed regarding food service issues |
| Director of Nursing | Director of Nursing | Interviewed regarding failure to provide showers and medicated shampoo as ordered |
Inspection Report
Life Safety
Census: 100
Capacity: 137
Deficiencies: 2
Oct 11, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements, specifically related to a broken handrail on an exit discharge stair and incomplete visual inspection documentation of the fire alarm system.
Severity Breakdown
SS=E: 1
SS=C: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 exit discharge stairs handrails was readily accessible and safe to use; handrails were broken and leaning against the building. | SS=E |
| Failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72; visual inspection lacked an itemized list of required items. | SS=C |
Report Facts
Facility capacity: 137
Census: 100
Deficiency completion date: Oct 28, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica McKinley | Administrator | Signed the report and participated in exit conference |
| Regional maintenance manager | Responsible for revising maintenance logs, in-servicing maintenance team, and reviewing audits | |
| Maintenance Director | Interviewed regarding handrail and fire alarm system deficiencies | |
| Administrator in Training | Participated in observations and exit conference |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Sep 23, 2022
Visit Reason
This visit was for the investigation of Complaint IN00389824.
Findings
Complaint IN00389824 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00389824 - Substantiated. No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type Total: 107
Census Payor Type Total: 107
Medicare Census: 30
Medicaid Census: 56
Other Payor Census: 21
SNF/NF Census: 64
SNF Census: 43
Inspection Report
Annual Inspection
Census: 109
Deficiencies: 1
Sep 2, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the investigation of two complaints (IN00385686 and IN00386757).
Findings
The complaint IN00385686 was unsubstantiated due to lack of evidence, and complaint IN00386757 was substantiated but no deficiencies related to the allegations were cited. One deficiency was identified related to failure to ensure a resident received showers or bed baths as scheduled.
Complaint Details
Complaint IN00385686 was unsubstantiated due to lack of evidence. Complaint IN00386757 was substantiated but no deficiencies related to the allegations were cited. Referral was made to the appropriate agency.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident received showers or bed baths as scheduled for 1 of 5 residents reviewed (Resident 32). | SS=D |
Report Facts
Census: 109
Scheduled showers/bed baths missed: 6
Residents reviewed: 5
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 2, 2022
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on September 2, 2022.
Findings
Kingston Care Center of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
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