Cooney Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Cooney Healthcare and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684May 2, 2024

  Based on interview and record review, the facility failed to provide quality care services to a skilled care resident admitted for rehabilitation services and nursing care; failed to identify a severe weight loss totaling 21.8% and implement nutritional interventions for prevention of further loss; failed to obtain, document, and assess vital signs as ordered by the physician; failed to follow physician orders; and failed to assess and identify behavioral care needs, to include pain, and ensure documentation was included in the EHR; Prior to his ER transfer, nursing staff failed to sufficiently assess and address a significant change in condition and provide oxygen for a decline in respiratory status, for 1 (#1) of 4 sampled residents. […]

• Actual harm, widespreadF838Sep 1, 2022

  Based on observation, interview, and record review, the facility failed to ensure the Facility Assessment identified appropriate staffing levels to provide basic care needs for residents, which caused mental anguish for 1 (#49), and caused 3 (#s 60, 64, and 70) of 7 sampled residents to voice concerns about staffing due to care needs not being met; and failed to update the Facility Assessment to include COVID-19 care and services. These failures increased the risk of a negative outcome for residents residing at the facility. Findings include: 1. Basic Care Needs: a. During an interview on 8/30/22 at 10:29 a.m., resident #49 stated he had not had a shower in two weeks and had made requests. Resident #49 said, I am a grown man and I have an issue with wetting the bed. […]

• Actual harm, isolatedF600Dec 4, 2025

  Based on interviews and record reviews, the facility failed to ensure residents were free from abuse and neglect, psychosocial harm, and deprivation of services, for 10 (#s 3, 4, 5, 6, 7, 12, 13, 14, 15, and 16) residents, out of 19 sampled residents. These failures contributed to three new wound areas for resident #3, several residents were left all night in urine-soaked briefs/bedding, were subjected to verbal abuse or neglect, #5 was left on the commode for an extended period of time, #12 was left unclothed and soiled, and was not assisted out of bed, #16 had items taken away from him and staff were verbally abusive after he fell, and residents filed grievances and were afraid to use their call lights. Findings include:1. […]

• Actual harm, isolatedF686Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure pressure ulcer wounds were identified, closely monitored, treated, and prevented so they did not develop in the facility or worsen; and, it was found pressure wounds were not treated per the physician orders; the wound care nurse was not informed of new wounds, failed to follow safe infection control processes during wound care, or have the necessary skillset for wound care services and oversight of the wound program; licensed nursing staff were documenting wound care was completed when not done; nursing staff failed to reposition residents with wounds as needed; and the cumulative effect of this failure was the wound development or wound worsening for 4 (#s 2, 6, 8 and 9), of 7 residents sampled for wounds. […]

• Actual harm, isolatedF689Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure a resident who left the facility unattended was monitored and supervised sufficiently for elopement prevention, and the resident left the facility again, unattended and without staff knowledge, for 1 (#6) of 26 sampled residents, and resident #6 sustained minor injuries when he had a fall. Staff failed to follow the identified safety interventions for elopement prevention, and the facility classification of an elopement allowed the resident to exit the facility and be in an unsafe environment unattended. Findings include: Review of resident #6's EHR showed a nursing note, dated 8/20/25, which included, This nurse called on call provider. […]