Courage Kenny Rehabilitation Institutes TRP

In the surveyor’s words

From the most serious findings on record at Courage Kenny Rehabilitation Institutes TRP, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 13, 2026

  Based on observation, interview, and record review the facility failed to identify environmental risks for stairwell doors that had nonfunctioning alarms, disabled locks, and failed to adequately supervise 1 of 3 residents (R1) through the remote monitoring system. This resulted in immediate jeopardy for 1 of 3 residents (R1) who opened a stairwell access door, wheeled through the door, and fell down six stairs while secured by a lap belt in his wheelchair. R1 sustained a hematoma (localized collected of clotted or partially clotted blood outside causing swelling, pain, and skin discoloration) and was sent to the emergency department for evaluation. […]

• Immediate jeopardy, isolatedF689Jan 26, 2021

  Based on observation, interview and document review, the facility failed to thoroughly investigate, and reassess residents for elopement risk following a resident elopement for 1 of 1 residents (R1) reviewed for elopement. The survey resulted in an immediate jeopardy (IJ) to resident health and safety on 1/18/21, when staff opened the door and R1 exited the facility, was found approximately 1.5 miles from the facility on a busy road, was not dressed appropriately for the cold weather and was away from the facility for approximately 1 hour, when R1 was returned to the facility by a family member (F)-A. […]

• No harm, potential for more than minimal, widespreadF812Dec 14, 2023

  Based on observation, interview, and document review, the facility failed to ensure food was stored in accordance with professional standards for food service safety. The facility failed to: remove expired food from food storage areas; label and date food; assure proper hand hygiene while preparing resident meal trays; and storing resident food in an employee break room refrigerator. These practices had the potential to affect all residents, staff and visitors consuming food at the facility. Findings include: During an observation and interview with the dietary manager (DM) on [DATE] at 3:01 p.m., a container of Mrs. Gerry's premade coleslaw was noted to have been dated as opened on [DATE], and a discard date of [DATE]. […]

• No harm, potential for more than minimal, patternF812Mar 16, 2022

  Based on observation, interview and document review the facility failed to ensure appropriate hand hygiene and gloves usage was performed for 1 of 1 staff observed preparing sandwiches. This had the potential to affect 5 residents who would have received these sandwiches. Findings include: During an observation on 3/16/22, at 7:13 a.m. dietary director (DD) donned clean gloves and with a knife, sliced open plastic bags containing 20 lbs. of raw beef and poured into a large kettle. DD removed soiled gloves, donned clean gloves, and moved the raw beef around in the kettle with gloved hand. DD removed soiled gloves and donned one clean glove. With gloved hand, DD placed the soiled knife into a sink. DD removed the soiled glove and donned clean gloves without first performing hand hygiene. […]

• No harm, potential for more than minimal, isolatedF550Apr 13, 2026

  Based on observation, interview and document review, the facility failed to provide respect and dignified treatment for 1 of 3 residents (R3) reviewed for dignity. R3 was given a bed alarm that R3 stated he did not consent to. The alarm limited his freedom of movement when he was in bed due to feeling startled by the loud sound of the alarm. In addition, he was anxious because he was concerned his alarm would bother residents near his room.Findings include: The facilities Consent Form for Restraints dated 2/2/26 indicated R3 signed giving consent for the medication trazodone and side rails on his bed. The bed alarm was not on the consent form. R3's admission minimum data set (MDS) dated [DATE] indicated R3's BIMS score was a 14 indicating he was cognitively intact. […]