Kirkwood Wellness & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Kirkwood Wellness & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 29, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (skin damage caused by prolonged pressure usually occurring over boney areas) when staff failed to report a new skin issue to the Wound Nurse in a timely manner, and when staff failed to implement pressure-reducing interventions timely upon identification of a new skin integrity issue for one resident (Resident #505). The census was 66. The sample was 33. […]

• Actual harm, isolatedF692Jan 29, 2026

  Based on observation, interview, and record review, the facility failed to follow physician orders pertaining to the nutritional requirements for one resident, which included no monthly weight since September 2025 and not administering a nutritional supplement as ordered. The resident had a 5.49% weight loss in four months (Resident #27). The sample was 21. The census was 91.Review of the facility's Weight Variance policy, dated July 2025, showed:-All residents who experience significant, insidious and/or unintentional/unplanned weight loss or gains shall be assessed for nutritional status by Registered Dietitian (RD). […]

• Actual harm, isolatedF745Jan 29, 2026

  Based on observation, interview, and record review, the facility failed to provide medically related social services to assist a resident (Resident #507) lacking decision-making capacity in obtaining a legal representative, despite hospital documentation identifying the need for guardianship. The facility failed to ensure admission agreements and Do Not Resuscitate (DNR, no life saving measures) code status was signed upon admission and in the medical record for two residents (Resident #507 and Resident #505). The facility failed to ensure care plan meetings were conducted quarterly and updated with the goals, medical needs, and daily living support of one resident (Resident #94). The sample size was 33. The census was 66. […]

• No harm, potential for more than minimal, widespreadF620Jan 29, 2026

  Based on observation, interview and record review, the facility failed to update records of residents' personal possessions per facility policy for two sampled residents (Residents #44 and #12). The facility failed to ensure one resident received an admission packet (Resident #124). In addition, the facility failed to ensure that residents were provided an accurate admission agreement that reflected financial terms related to refundable deposits following a change in management (Resident #129). The sample size was 21. […]

• No harm, potential for more than minimal, widespreadF835Jan 29, 2026

  Based on observation, interview and record review, the facility failed to ensure payments were issued or issued in a timely manner, to the facility's food supplier, staffing agency, dietician, and other necessary vendors utilized to provide services for the needs of residents, placing residents at risk for interruption of services and inadequate care. This deficient practice had the potential to affect all residents. The census was 91. Review of the facility's Facility Assessment, undated, showed:-Purpose: The facility assessment is a complete review of internal human and physical resources required by the facility to care for residents competently during day to day (including nights and weekends) and emergency operations. […]