Kenwood Vlge NRSG and RHB CTR

In the surveyor’s words

From the most serious findings on record at Kenwood Vlge NRSG and RHB CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 1, 2022

  Based on interviews and record review, the facility failed to provide the necessary monitoring and supervision to ensure a safe environment for a resident and provide a quick response to assess a resident's injury or physical condition to give medical treatment for a resident who experienced an unwitnessed fall. This applies to 1 of 3 residents (R1) reviewed for falls. R1 is a physically and cognitively impaired resident (R1) who was found on the floor in a cold room unresponsive. As a result of this failure R1 became hypothermic (below normal body temperature), which required emergency medical treatment. This was identified as an Immediate Jeopardy situation. The immediate jeopardy began on 1/5/22 and was identified on 1/27/22. The Administrator was notified on 1/27/22. […]

• Actual harm, isolatedF600Mar 27, 2026

  Based on observation, interview and record review, the facility failed to protect residents from verbal aggressions which affected two residents (R37, R66) of seven residents reviewed for abuse in a total sample of 28 residents. The escalating verbal aggressions resulted in verbal and physical assault which caused R37 to suffer psychosocial harm exhibited by increased depression, increased feeling of mania and feeling unsafe in her private space. Findings include: R66'S medical record documents, in part, the following medical diagnoses: Schizophrenia and Major Depressive Disorder. A Minimum Data Set (MDS) dated [DATE] documents that R66 is Cognitively Intact. R66's care plans include concerns with behavioral symptoms, physical and verbal aggressions towards others and depression. […]

• Actual harm, isolatedF600Oct 18, 2025

  Based on interviews and record reviews, the facility failed to affirm the right of their residents to be free from verbal and mental abuse and failed to prevent potential further abuse by failing to remove the alleged perpetrator (R2) from interacting with R1. These failures affected two (R1, R2) out of four residents reviewed for abuse. These failures resulted in R1 feeling unsafe and scared for her safety, was unable to sleep, and felt like no one was doing something to protect her. Findings Include: On 10/17/25 at 9:39 AM, Surveyor observed R1 sitting by the side of her bed alert and oriented to time, place, and situation. R1 stated, There is one gentleman his name is [R2]. He [R2] lives on the same floor as me. He [R2] is two rooms down from my room. He [R2] is black. […]

• Actual harm, isolatedF610Oct 18, 2025

  Based on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse and failed to prevent potential further abuse by failing to remove the alleged perpetrator (R2) from interacting with R1. These failures affected two (R1, R2) out of four residents reviewed for abuse. These failures resulted in R1 feeling unsafe and scared for her safety, was unable to sleep, and felt like no one was doing something to protect her. Findings Include: On 10/17/25 at 9:39 AM, Surveyor observed R1 sitting by the side of her bed alert and oriented to time, place, and situation. R1 stated, There is one gentleman his name is [R2]. He [R2] lives on the same floor as me. He [R2] is two rooms down from my room. He [R2] is black. He [R2] has prosthetics on both legs. […]

• Actual harm, isolatedF692Jul 25, 2025

  Based on interviews and record reviews the facility failed to evaluate and address a resident's continued poor appetite for adequate nutrition and hydration, failed to follow the dietary's recommendation, and failed to consistently implement interventions, monitor the effectiveness of interventions and revising them as necessary for one (R1) out of four residents reviewed for nutritional services. These failures resulted in R1 being hospitalized due to hypovolemic shock, malnutrition, and dehydration.Findings Include:R1's clinical records revealed R1 was admitted in the facility on 6/23/25 and was discharged home on 7/9/25. […]