Kirkland Court Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Kirkland Court Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 13, 2025

  Based on observations, interviews, and record reviews the facility failed to ensure the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 (Resident #2 and Resident #3) of 5 resident's reviewed for abuse.1. The facility failed to protect Resident #2 from mental and verbal abuse by Resident #3 when he threatened to cut off her foot with a hand saw and proceeded to saw a groove in the center of her top, front, walker bar.2. The facility failed to protect Resident #3 from neglect when he was able to obtain a hand saw from an unlocked maintenance closet.These failures could place residents at risk of abuse and neglect.An Immediate Jeopardy (IJ) was identified on 09/12/25. […]

• Immediate jeopardy, isolatedF607Sep 13, 2025

  Based on observations, interviews, and record reviews the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 (Resident #2 and Resident #3) of 5 residents reviewed for abuse/neglect policy implementation.The facility failed to implement their abuse policy when Resident #3 obtained a hand saw from an unlocked maintenance closet and used it to threaten Resident #2 and to saw a groove into the top, front bar of Resident #2's walker.This failure could place residents at risk of abuse and neglect occurring and/or continuing.An Immediate Jeopardy (IJ) was identified on 09/12/25. The IJ template was provided to the facility on [DATE] at 01:00 PM. […]

• Immediate jeopardy, isolatedF689Sep 13, 2025

  Based on observations, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and Resident #3) of 5 residents reviewed for accidents and hazards.1. The facility failed to ensure Resident #1 did not elope on 08/21/25 in his manual wheelchair 8 days after he had cranioplasty surgery .5 of a mile from the facility on his way to the hospital.2. The facility failed to ensure Resident #3 did not have access to a hand saw from the unlocked maintenance office.These failures could place residents at risk of injury or death.An Immediate Jeopardy (IJ) was identified on 09/12/25 at 01:00 PM. […]

• No harm, potential for more than minimal, widespreadF812Apr 26, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled and dated. 2. The facility failed to ensure walk-in refrigerator items were stored, labeled, and dated. 3. The facility failed to ensure pantry foods were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the walk-in pantry on 04/24/24 at 8:16 AM revealed the following: 1. […]

• No harm, potential for more than minimal, widespreadF851Apr 26, 2024

  Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information, for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS for 1 of 4 FY quarters (FY Quarter 1 2024 (October 1-December 31)) reviewed for administration. The facility failed to submit staffing data to CMS for FY Quarter 1 (October 1-December 31). […]