The Wybe and Marietje Kroontje Health Care Center

In the surveyor’s words

From the most serious findings on record at The Wybe and Marietje Kroontje Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF700Apr 13, 2026

  Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to assess the resident for risk of entrapment and attempt to use appropriate alternatives prior to the installation of a side rail and failed to ensure correct installation to assess for the seven zones of entrapment when side rails were added and/or bed components were changed for 6 of 26 sampled residents (Resident #41, Resident #5, Resident #1, Resident #3, Resident #25, and Resident #57). At the time of the survey, the facility staff member responsible for the installation and maintenance of side rails did not have the knowledge to ensure appropriate safety measurements of the seven zones of entrapment risk. […]

• No harm, potential for more than minimal, widespreadF657Apr 13, 2026

  Based on staff interview and clinical record review, the facility staff failed to revise and/or reassess the effectiveness of the interventions of the comprehensive person-centered activity care plan to meet the needs of facility residents. The findings included:A review of the clinical records for the current sampled facility residents did not disclose activity progress notes for resident quarterly care plan reviews. On 4/8/26 at 9:10 AM, the activity director (AD) was interviewed and asked if a quarterly activity progress note or activity assessment is completed for each resident. The AD stated they do a care plan note. The activity assistant (AA) agreed that a quarterly activity progress note is completed with review of the resident care plans. […]

• No harm, potential for more than minimal, patternF656Apr 13, 2026

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to develop a comprehensive person-centered activity care plan to address the resident's activity preferences, interests, and psychosocial needs for (5) five of (26) twenty-six current sampled residents, Resident #1, Resident #2, Resident #19, Resident #25, and Resident #7. The findings included: 1. For Resident #1 the facility staff failed to develop a comprehensive person-centered activity care plan to address the resident's activity preferences, interests, and psychosocial needs. […]

• No harm, potential for more than minimal, patternF756Apr 13, 2026

  Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure completion of monthly medication regimen reviews for 5 of 26 sampled resident, Resident #9, #39, #41, #8, and #2. The findings included: 1.For resident #9 the facility staff failed to ensure a monthly drug regimen review was completed by a pharmacist for May 2025. A facility policy entitled Drug Regimen Review (DRR) with an implementation date of 9/25/25 specified, A consultant pharmacist shall conduct a drug regimen review for each resident monthly in the Cove (long-term care center). Item 2. […]

• No harm, potential for more than minimal, patternF944Apr 13, 2026

  Based on staff interview and facility document review, the facility staff failed to provide evidence of staff training that outlines and informs staff of the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program for four of four sampled staff members, Certified Nursing Assistant (CNA) #3, Registered Nurse (RN) #1, Dining Server #1, and the facility Maintenance Director. The findings included: A facility policy titled, Quality Assurance and Performance Improvement (QAPI), reviewed 1/29/26, specified All facility staff, contracted staff, and volunteers will be educated about the QAPI plan and their role in development and implementation of interventions.The facility staff were unable to provide evidence of staff training regarding the facility's… […]