Kingwood Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jun 3, 2025

  Based on observations, interviews and record reviews the facility failed to ensure 4 (CR#2, CR#3 R#1 and R#2) of 9 resident reviewed was free from abuse and neglect The facility failed to prevent neglect and failed to provide the required structures and processes in order to meet the needs of CR#2 when interventions were not implemented: WCD orders for changing bandages, turning, and repositioning, and getting CR#2 in the chair twice daily. As a result, CR#2 did not receive proper treatment to prevent wound deterioration and infection, which resulted in hospitalization with severe sepsis and required surgical wound debridement. An Immediate Jeopardy (IJ) was identified on 5.28.2025. The IJ template was provided to the facility on 5.28.2025 at 1:15p.m. […]

• Immediate jeopardy, patternF607Jun 3, 2025

  Based on Interviews and record review the facility failed to implement the facility's abuse policy ensuring 1 (CR#3) of 9 residents was free from abuse reviewed for developing/implementing abuse policies. The facility failed to implement their abuse policy when CR #3 made an allegation of physical and verbal abuse. The allegation was not reported to the abuse coordinator or investigated and the alleged abuser had access to CR#3 after an allegation of abuse was made. An Immediate Jeopardy (IJ) was identified on 5.30.2025. The IJ template was provided to the Administrator and DON on 5.30.2025 at 1:27p.m. […]

• Immediate jeopardy, patternF610Jun 3, 2025

  Based on interviews and record review the facility failed to immediately investigation, report and protect 1 (CR#3) of 9 residents reviewed for abuse and neglect. The facility failed to immediately investigate, report, and protect CR#3 when he reported being stabbed in the arm with an insulin needle and scratched on the nose by LVN B. They facility failed to prevent further potential abuse when the facility failed to remove CR#3 from LVN B care after the report of abuse. An Immediate Jeopardy (IJ) was identified on 5.30.2025. The IJ template was provided to the Administrator and DON on 5.30.2025 at 1:27p.m. […]

• Immediate jeopardy, patternF686Jun 3, 2025

  Based on interviews and record review the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual ' s clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (CR2, R#1, R#2) of 9 residents reviewed for Treatment/Services to Prevent/Heal Pressure Ulcers in that: The facility failed to ensure CR #2's wound interventions were implemented: WCD orders for changing bandages, turning, and repositioning, and getting CR#2 in the chair twice daily. […]

• Immediate jeopardy, patternF689Jun 3, 2025

  Based on, interviews and record review the facility failed to ensure resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (CR #1) reviewed for accidents and supervision, in that: The facility failed to ensure CR#1 was transferred properly per therapy assessments and instruction, by CNA B. CR#1, a bedbound resident, who was totally dependent on staff for care sustained an unexplained head injury and hip fracture in her room alone. The facility failed to ensure precautionary interventions in place for CR#1, who was a known fall risk. An Immediate Jeopardy (IJ) was identified on 5.22.2025. […]