Inspection Reports for
Kingston Care Center of Fort Wayne

The investigation was triggered by complaints regarding missed medication doses leading to seizures and sanitation issues causing pest infestations in the kitchen.

The facility failed to follow physician orders for antiseizure medication for one resident, resulting in seizures. Additionally, the facility failed to maintain proper sanitation in the kitchen, leading to pest infestations and inadequate cleaning of food carts.

This citation is related to complaint IN00459756.

The facility failed to ensure that a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents. Specifically, a secured exit door was found to be disarmed or delayed in locking, allowing Resident 98 to exit the building unsupervised.

The facility was found deficient in multiple areas including failure to provide required bed hold policy documentation prior to resident discharge, inadequate facial hair and nail care for a resident, failure to follow physician's oxygen orders, lack of communication with dialysis facilities, employment of a staff member with an expired license, and failure to maintain proper sanitization parameters in the kitchen.

This citation relates to Complaint IN00458140. The grievance involved Resident Q who was rushed and handled roughly during personal care by a Certified Nurse Aide. The facility did not use grievance forms properly and lacked follow-up documentation after the complaint was raised.

The facility failed to ensure grievances were thoroughly investigated, documented, and corrective actions taken for one of three residents reviewed. Specifically, a grievance about rough handling during personal care was not properly followed up or documented.

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.

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 IN00454446 was substantiated with federal/state deficiencies cited at F684 related to surgical wound care.

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.

This citation refers to Complaint IN00454446.

The facility failed to ensure that Resident P's surgical wound was assessed and monitored appropriately from admission through follow-up. Documentation and care plans for surgical wound assessment, monitoring, and infection signs were lacking, with only one documented wound assessment during the review period.

This citation relates to Complaint IN00444543.

The facility failed to maintain complete and accurate medical records for one resident, including inadequate documentation of medication changes and failure to recognize the resident's edentulous status, resulting in inappropriate food service. There was also no policy regarding documentation available at the time of exit.

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.

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.

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.

The facility failed to ensure a dignified dining experience, proper formulation of advanced directives, completion of Minimum Data Set (MDS) sections, trauma-informed care planning, preparation of pureed food according to guidelines, and maintenance of sanitary conditions in the dining room.

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.

This tag relates to Complaint IN00431781. The complaint involved inadequate pain management for a resident, including delayed medication administration and lack of non-pharmacological interventions.

The facility failed to provide timely and effective pain management for one resident (Resident Q) experiencing pain after a fall. Pain medications were delayed and non-pharmacological interventions were not consistently offered, leading to the resident's early discharge due to uncontrolled pain.

Complaint IN00431781 was substantiated with federal/state deficiencies cited related to pain management. Complaints IN00431135 and IN00431174 had no deficiencies related to the allegations.

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 IN00422127 was substantiated with federal/state deficiencies cited at F692 and F812 related to nutrition/hydration documentation and food safety sanitation.

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.

This citation relates to Complaint IN00422127.

The facility failed to ensure meal consumption percentages were documented for 4 residents over multiple dates. Additionally, sanitation procedures were not properly followed, including use of wet dishes and improper glove hygiene by dietary staff.

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.

The facility failed to provide adequate pain management for one resident, failed to date opened medications on multiple medication carts, and failed to ensure denture care and replacement for one resident. Non-pharmacological pain interventions were infrequently documented and opioid medications were heavily used. Several medications were found opened without dates, and a resident's broken denture was not replaced timely.

Two complaints (IN00412674 and IN00413266) were investigated with no deficiencies found regarding the allegations.

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 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.

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.

This Federal citation is related to Complaint IN00408892. The complaint involved allegations of verbal abuse by CNA 4 toward Resident B, which was substantiated by interviews and record reviews.

The facility failed to ensure freedom from verbal abuse for 1 of 3 residents reviewed. The CNA was found to have made disrespectful and derogatory comments to Resident B, causing emotional distress.

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.

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 IN00393206 - Substantiated with deficiencies cited at F804. Complaint IN00394465 - Substantiated with no deficiencies cited. Complaint IN00394521 - Substantiated with deficiencies cited at F656 and F804.

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.

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.

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.

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.