Kendal at Ithaca

In the surveyor’s words

From the most serious findings on record at Kendal at Ithaca, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF656Dec 19, 2024

  Based on observations, record review, and interviews during the recertification survey conducted 12/16/2024-12/19/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 2 of 2 residents (Resident #7 and #37) reviewed. Specifically, Resident #7 did not have a care plan for oxygen use, and Resident #37's fall prevention care planned interventions were not consistent with the care instructions and point of care tasks. The facility policy, Fall Prevention Program, revised 1/19/2016, documented after each resident fall, the interdisciplinary team would update the resident's fall care plan and the nurse doing the incident report would add any interventions immediately to the resident's fall care plan. […]

• No harm, potential for more than minimal, isolatedF689Dec 19, 2024

  Based on observations, record review, and interviews during the recertification survey conducted 12/16/2024-12/19/2024, the facility did not ensure residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #146) reviewed. Specifically, Resident #146 had a stroke, was on comfort care measures, could not swallow, did not have a clear diet consistency order, and was assisted with eating food before a swallowing evaluation was performed to determine the appropriate diet consistency. […]

• No harm, potential for more than minimal, isolatedF695Dec 19, 2024

  Based on observations, record review, and interviews during the recertification survey conducted 12/16/2024-12/19/2024, the facility did not ensure residents received respiratory care consistent with professional standards of practice for 1 of 1 resident (Resident #7) reviewed. Specifically, Resident #7 had a physician order for oxygen at 2-3 liters per minute via nasal cannula to keep oxygen saturations (amount of oxygen in the blood stream) above 92%, the resident received continuous oxygen, oxygen saturation readings were consistently above 92% and taken while the resident was on oxygen. […]

• No harm, potential for more than minimal, isolatedF700Dec 19, 2024

  Based on observations, record review, and interviews during the recertification survey conducted 12/16/2024-12/19/2024, the facility did not to obtain informed consent (including risks and benefits) from the resident or the resident representative prior to the installation of bed rails (side rails) for 1 of 1 resident (Resident #6) reviewed. Specifically, there was no documented evidence informed consent was obtained for the placement of bilateral bed rails on Resident #6's bed. […]

• No harm, potential for more than minimal, isolatedF758Dec 19, 2024

  Based on record review and interviews during the recertification survey conducted 12/16/2024-12/19/2024, the facility did not ensure as needed orders for psychotropic drugs were limited to 14 days or had a prescribing provider order to extend beyond 14 days with documented rationale for 1 of 5 residents (Residents #26) reviewed. Specifically, Residents #26 had a physician order for lorazepam (a controlled antianxiety medication) as needed that was not re-evaluated for continued use after 14 days. Findings include: The facility policy, Psychotropic Medications, dated 12/16/2024, documented psychotropic medications would be used only when appropriate to treat a specific condition. […]