Kenwood View Healthcare and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Jan 24, 2023

  The facility identified a census of 69 residents with three residents reviewed for wounds. Based on record review, observation, and interview the facility failed to identify and provide appropriate intervention to prevent pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and failed to involve the physician, implement treatment orders, and consistently monitor wound status to promote healing, and prevent infection. Resident (R) 1, who was severely cognitively impaired, required extensive staff assistance for activities of daily living (ADL) and had contractures (abnormal fixed tightening of muscle, tendons, ligaments, or skin) developed a skin alteration on her right knee on 11/01/22. […]

• Actual harm, isolatedF686May 4, 2023

  The facility had a census of 60 residents. The sample included 17 residents, with four reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to prevent ulcers for two sampled residents: Resident (R) 54, who obtained a facility acquired stage 3 (full thickness tissue loss) and R208, who obtained a facility acquired stage 2 (shallow with a reddish base) pressure ulcer. The facility further failed to ensure weekly monitoring of skin conditions to assess wound status including wound bed, healing, and effectiveness of treatments for R54 and R208. […]

• Actual harm, isolatedF689May 4, 2023

  The facility had a census of 60 residents. The sample included 17 residents, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to supervise cognitively impaired Resident, R 36, who exited the North Court Yard door, fell , and obtained a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on her forehead. This deficient practice placed R36 at risk for further falls and avoidable injuries. Findings included: - The Electronic Medical Record (EMR) for R36 recorded diagnoses of Alzheimer disease (a progressive mental deterioration characterized by confusion and memory failure), muscle weakness, anxiety (a feeling of worry, nervousness, or unease about something), and abnormality of gait. […]

• Actual harm, isolatedF689Apr 11, 2022

  The facility had a census of 67 residents. The sample included two residents reviewed for accidents. Based on record review and interview, the facility failed to ensure that a Hoyer lift (a mechanical device used to assist in transferring a resident) full body sling strap (a fabric device used to help suspend and attach to the Hoyer lift when transferring a resident) was fully attached to the hook on the lift arm of the Hoyer lift. As a result, Resident (R) 1 slipped from the sling and was lowered to the floor, which resulted in a fractured seventh rib and complications related to internal injuries. […]

• Actual harm, isolatedF684Nov 15, 2021

  The facility had a census of 59 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide the necessary care and services to ensure the resident wore her leg immobilizer (a leg brace is a device used to immobilize a joint or body segment, restrict movement in a given direction, reduce weight bearing forces, or correct the shape of the body) during transfers as physician ordered for Resident (R) 33. Findings included: - R33's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition, required extensive assistance of two staff for bed mobility, and dependent upon two staff for transfers. […]