Deficiency Records for Kingston Rehabilitation and Nursing Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Kingston Rehabilitation and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-09-22 | 2023-10-31 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-09-22 | 2023-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-22 | 2023-10-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-09-22 | 2023-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-22 | 2023-10-31 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide or obtain dental services for each resident. | Health | 2023-09-22 | 2023-10-31 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-22 | 2023-10-31 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-09-22 | 2023-10-31 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-13 | 2023-10-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-13 | 2023-10-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-13 | 2023-10-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-06 | 2023-07-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-06 | 2023-07-31 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-05-30 | 2023-07-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-30 | 2023-07-06 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-05-30 | 2023-07-06 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-30 | 2023-07-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-30 | 2023-07-06 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-05-02 | 2023-07-06 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-03-10 | 2023-07-06 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-02 | 2023-05-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-02 | 2023-05-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-02 | 2023-05-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-10 | 2023-05-30 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-10 | 2023-05-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-10 | 2023-05-30 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-04 | 2023-05-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-04 | 2023-05-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-04 | 2023-05-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-04 | 2023-05-09 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-04-04 | 2023-05-09 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-04-04 | 2023-05-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-10 | 2023-05-02 | N |
| Respond appropriately to all alleged violations. | Health | 2023-03-10 | 2023-05-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-10 | 2023-05-02 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-03-10 | 2023-05-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-10 | 2023-05-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-10 | 2023-05-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-10 | 2023-05-02 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-03-10 | 2023-05-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-10 | 2023-05-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-10 | 2023-05-02 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-03-10 | 2023-05-02 | N |
| Post nurse staffing information every day. | Health | 2023-03-10 | 2023-05-02 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-03-10 | 2023-05-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-10 | 2023-05-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-10 | 2023-05-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-10 | 2023-05-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-10 | 2023-05-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-10 | 2023-05-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-10 | 2023-05-02 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-10 | 2023-05-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-10 | 2023-05-02 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-10 | 2023-05-02 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-10 | 2023-05-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-10 | 2023-05-02 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-12-28 | 2023-01-17 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-12-28 | 2023-01-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-09 | 2022-10-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-09 | 2022-10-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-09 | 2022-10-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-09 | 2022-10-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-09 | 2022-10-14 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-09-09 | 2022-10-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-09 | 2022-10-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-09 | 2022-10-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-09 | 2022-10-14 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-09-09 | 2022-10-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-09 | 2022-10-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-09 | 2022-10-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-09 | 2022-10-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-09-09 | 2022-10-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-09 | 2022-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-09 | 2022-10-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-09 | 2022-10-14 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-09-09 | 2022-10-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-09-09 | 2022-10-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-09 | 2022-10-14 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-21 | 2022-10-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-21 | 2022-10-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-21 | 2022-10-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-02 | 2022-06-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-02 | 2022-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-02 | 2022-06-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-02 | 2022-06-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-02 | 2022-06-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-02 | 2022-06-17 | Y |
| Report COVID19 data to residents and families. | Health | 2022-06-02 | 2022-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-04 | 2022-06-17 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-05-04 | 2022-06-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-04 | 2022-06-02 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-17 | 2022-03-10 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-02-17 | 2022-03-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-20 | 2022-03-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-20 | 2022-03-10 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-01-20 | 2022-03-10 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-20 | 2022-03-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-20 | 2022-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-20 | 2022-03-10 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-01-20 | 2022-03-10 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-01-20 | 2022-03-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-20 | 2022-03-10 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-01-20 | 2022-03-10 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-01-20 | 2022-03-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-21 | 2022-03-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-21 | 2022-03-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-21 | 2022-03-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-30 | 2022-03-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-17 | 2022-03-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-21 | 2022-01-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-21 | 2022-01-20 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-21 | 2022-01-20 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-12-21 | 2022-01-20 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-17 | 2022-01-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-30 | 2021-12-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-30 | 2021-12-21 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-11-30 | 2021-12-21 | Y |
| Provide or obtain dental services for each resident. | Health | 2021-11-30 | 2021-12-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-17 | 2021-12-21 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-17 | 2021-12-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-17 | 2021-12-21 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-17 | 2021-12-21 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-11-17 | 2021-12-21 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-11-17 | 2021-12-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-13 | 2021-11-17 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-13 | 2021-11-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-08 | 2021-10-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-08 | 2021-10-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-17 | 2021-10-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-07 | 2021-10-05 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-08-17 | 2021-09-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-17 | 2021-09-08 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-08-17 | 2021-09-08 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-08-17 | 2021-09-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-17 | 2021-09-08 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-08-17 | 2021-09-08 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-07-07 | 2021-09-08 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-07-07 | 2021-08-17 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2021-07-07 | 2021-08-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-07 | 2021-08-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-07 | 2021-08-17 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-07-07 | 2021-08-17 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-07-07 | 2021-08-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-14 | 2021-08-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-14 | 2021-07-07 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-05-14 | 2021-07-07 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-05-14 | 2021-07-07 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-05-14 | 2021-07-07 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-04 | Not Fixed | Y |
