Cooney Healthcare and Rehabilitation

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure baseline care plans were completed within 48 hours, to meet the residents' ADL needs, for 2 (#s 20 and 21) of 25 sampled residents. This deficient practice resulted in a delay in ADL cares for residents #20 and 21.

Inspectors wroteBased on interviews and record review, the facility failed to provide ADL cares to meet the needs of dependent residents for 2 (#s 20 and 21) of 25 sampled residents. This deficient practice resulted in resident #20 fearing her safety during transfers and walking and resident #21 to be found by family wet and still in bed at 12:30 p.m.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free from abuse and neglect, psychosocial harm, and deprivation of services, for 10 (#s 3, 4, 5, 6, 7, 12, 13, 14, 15, and 16) residents, out of 19 sampled residents. These failures contributed to three new wound areas for resident #3, several residents were left all night in urine-soaked briefs/bedding, were subjected to verbal abuse or neglect, #5 was left on the commode for an extended period of time, #12 was left unclothed and soiled, and was not assisted out of bed, #16 had items taken away from him and staff were verbally abusive after he fell, and residents filed grievances and were afraid to use their call lights.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a comprehensive grievance process was operationalized and followed effectively by staff for the resolution of grievances received, for 9 (#s 2, 3, 4, 5, 12, 13, 14, 15, and 16) of 19 sampled residents. This deficiency resulted in multiple grievances being mishandled, including ones not reported to the State Survey Agency, about abuse or neglect of care.

Inspectors wroteBased on interviews and record reviews, staff member B, a licensed nurse, failed to uphold professional standards of practice for nursing care, and falsified medical record documentation and health information related to resident treatments and monitoring, when she was not working in the facility to complete the tasks personally, for 10 (#s 3, 5, 7, 8, 9, 10, 11, 17, 18, and 19) of 19 sampled residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to have sufficient nursing staff available and working with the appropriate competencies and skills sets to provide nursing related services, taking the resident care needs and diagnoses of the facility's resident population into consideration, for 6 (#s 3, 5, 6, 10, 12, and 16) of 19 sampled residents. This deficient practice resulted in residents not receiving necessary ADL care and nursing services.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident or representative was provided written notifications of room changes, for 1 (#2) of 19 sampled residents, and room changes reportedly caused the resident frustration and anxiety, which the representative wanted to avoid, but she was not provided the opportunity to be present to assist the resident with the room changes.

Inspectors wroteBased on interviews and record review, the facility failed to investigate and report to the State Survey Agency verbal abuse for 1 (#16) of 19 sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to provide care for a resident, who was identified to be at risk for pressure ulcers, in accordance with her comprehensive person-centered care plan, and the resident's choice, and the resident had skin breakdown due to the lack of staff assistance for incontinence, for 1 (#3) of 19 sampled residents. These failures contributed to three new painful wound areas for resident #3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer wounds were identified, closely monitored, treated, and prevented so they did not develop in the facility or worsen; and, it was found pressure wounds were not treated per the physician orders; the wound care nurse was not informed of new wounds, failed to follow safe infection control processes during wound care, or have the necessary skillset for wound care services and oversight of the wound program; licensed nursing staff were documenting wound care was completed when not done; nursing staff failed to reposition residents with wounds as needed; and the cumulative effect of this failure was the wound development or wound worsening for 4 (#s 2, 6, 8 and 9), of 7 residents sampled for wounds. Resident #2 had a Stage II wound that developed in-house. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who left the facility unattended was monitored and supervised sufficiently for elopement prevention, and the resident left the facility again, unattended and without staff knowledge, for 1 (#6) of 26 sampled residents, and resident #6 sustained minor injuries when he had a fall. Staff failed to follow the identified safety interventions for elopement prevention, and the facility classification of an elopement allowed the resident to exit the facility and be in an unsafe environment unattended.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that timely pain management was provided for a resident who was exhibiting significant pain that was reportedly unbearable. consistent with professional standards of practice, for 1 (#11) of 26 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to have sufficient staff to meet the needs of the residents for 3 (#s 2, 11, and 54) of 26 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a registered nurse was on duty for at least eight consecutive hours a day, seven days a week.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were implemented during the transportation of dirty laundry to prevent transmission of communicable diseases, and failed to ensure enhanced barrier precautions and aseptic technique were followed while performing a wound dressing change for 3 (#s 2, 8, and 53).

Inspectors wroteBased on interview and record review, the facility failed to implement and educate staff on an antibiotic stewardship program in order to promote the appropriate use of antibiotics. This deficient practice increased the risk for residents to develop drug-resistant organisms and/or complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure MDS assessments were submitted timely. This deficient practice was corrected in August 2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff member F received the appropriate and sufficient education prior to starting a position as a wound care nurse. This deficient practice resulted in staff member F not following enhanced barrier precautions or aseptic technique while performing wound dressing changes for 2 (#s 2, and 8) of 7 sampled residents with wounds; and medication errors for 3 (#s 12, 27, and 32) of 36 medications observed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medication error rates remained below five percent, administering medications with the correct dose for 2 (#s 12 and 32); and the correct route for 1 (#27) of 36 sampled medications. The medication error rate was 11 percent.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure medications stored for use were not expired. The failures could affect any resident using medications or supplies from the storage area.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident catheter bags were covered in public areas for 1 (#25) of 2 sampled residents with catheters.

Inspectors wroteBased on interview and record review, the facility exceeded the required two hour window for reporting alleged sexual abuse to the State Survey Agency for 1 (#59) of 26 sampled residents. This deficient practice increased the risk for all residents to be unprotected from the alleged sexual abuse perpetrator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to put effective measures in place to ensure further potential abuse did not occur while an investigation was in process for 1 (#59) of 26 sampled residents. This deficient practice allowed the alleged perpetrator to have continued access to the alleged victim and/or other vulnerable residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident or the resident's representative, in writing, of the facility's bed hold policy when transferring a resident to the hospital; and failed to provide all pertinent information to the receiving hospital for 1 (#5) of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident care plans were updated with relevant care information for 1 (#4) of 26 sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a resident who was incontinent of bowel received appropriate services to restore as much normal bowel function as possible for 1 (#11) of 26 sampled residents. This deficient practice resulted in resident #11 feeling humiliated and frustrated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had fluids readily available for 1 (#55) of 26 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications were used with appropriate diagnoses and behavioral monitoring for 1 (#72) of 26 sampled residents.

Inspectors wroteBased on observations, interview and record review, the facility failed to assist a resident in making appointments and transportation to and from the dental services for dentures, for 1 (#2) of 26 sampled residents. This deficient practice prevented a resident from eating her preferred diet.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 (#1) of 3 sampled residents was kept safe while using her motorized wheelchair in the [Entity Name] parking lot while coming from an appointment. This deficient practice resulted in a resident falling outside of the facility and suffering from multiple fractures, which resulted in hospitalization; and the residents using motorized wheelchairs did not feel safe when being transported due to the type of transport offered or used, for 2 (#s 1 and 2) out of three sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to fully investigate, have a consistent process of investigating, and document the investigations for four Facility Reported Incidents (FRI) that were reviewed during the time of survey for 4 (#s 1, 3, 4, and 5) residents out of the 5 sampled, and resident injuries occurred for some of those residents. This deficient practice had the potential to result in a higher occurrence of similar incidents, as the root cause may have never been identified.

Inspectors wroteBased on interview and record review, the facility failed to ensure new and existing staff: were properly educated concerning the transportation of residents; yearly evaluations were completed and documented; and written job titles and duties were located in the staff files. This deficient practice had the potential to result in staff feeling unprepared and potentially not knowing their roles.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was in place for 2 residents (#s 1 and 2) of 3 sampled residents. This resulted in one resident falling in the parking lot while using her motorized wheelchair while she was outside of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety by providing the appropriate competencies to all staff regarding transportation services when staff were assisting outside the facility. This deficient practice resulted in a resident falling in the parking lot, being ejected from their motorized wheelchair, and this resulted in 1 (#1) resident being transferred to the hospital.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide oversight to ensure the nursing scope of practice was being followed appropriately for 1 (staff member C) of 5 staff sampled, and failed to uphold disciplinary action for an LPN license on probation, and there were restrictions on the license staff member C.

Inspectors wroteBased on interviews and record review, the facility failed to ensure staff were performing cares within their scope of practice and without necessary training, for 1 (#12) of 3 sampled residents. This practice increased the risk of negative outcomes for those residents who received care from staff member C.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to report an incident of potential abuse for two residents (#s 1 and 2) to the State Survey Agency, or the resident's representative, of 5 sampled residents. This failure increased the risk of other events occurring related to the two residents, due to preventive measures not being taken, and one resident displayed overly attentive behavior towards males.

Inspectors wroteBased on observation, interview, and record review, the facility licensed nursing staff failed to follow physician wound care orders; failed to complete wound treatments; and failed to document the wound status/severity sufficiently, for 1 (#23), and failed to follow physician orders; complete wound dressing changes properly; licensed nursing staff used improper aseptic technique with a dressing change; and licensed nursing staff failed to follow the facility policy and procedures for wound care services, for initialing wound dressings, adding times, or dates, for 1 (#32) of 3 sampled residents requiring wound care. These failures made it more difficult to accurately determine the status of wounds, locations of wounds, and severity, for ongoing treatment/needs to be met, for both residents who had wounds being treated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate staffing resulting in residents not recieving scheduled showers for 1 (#132) of 31 sampled residents, call lights not answered in an adequate timeframe for 5 (#s 11, 12, 27, 37, 132) of 31 sampled residents, increased risk of dehydration in residents, and negative impact on resident's wound treatments and services. These failures increased the risk of negative outcomes of psychosocial harm due to residents feeling embarrassed and their needs not being met from missed showers and long call light wait times.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and date food items in the refrigerator located in the A-hall; and failed to ensure food stored in the walk-in freezer was stored at a temperature to keep the food frozen solid. This deficient practice increased the risk of residents receiving contaminated food due to improper food storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices while in a COVID-19 outbreak for 3 (#s 21, 70 and 74) of 31 sampled residents; failed to provide notification and a screening process for visitors entering the facility; failed to train staff on the proper PPE process for transmission based precautions; failed to encourage residents to wear facemask's while out of their rooms; and failed to properly dress a wound with aseptic technique for 1 (#32) of 1 sampled resident. The facility was in Covid-19 outbreak status during the survey with 10 active resident cases of Covid-19.

Inspectors wroteBased on interview and record review, the facility failed to ensure the current Do Not Resuscitate order was reflected in the code status of the electronic health record and care plan for 2 (#49 and #57) of 31 sampled residents. This deficient practice increased the risk of the individual choices not being honored for the Do Not Resuscitate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise individualized comprehensive care plans to reflect the bathing preference for 1 (#132) of 3 sampled residents for baths and to reflect current transfer methods for 2 (#s 35 and 55) of 3 sampled residents for transfers.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment while using a lift, and anticipate and assess the residents needs related to transfers, for 1 (#35) of 3 sampled residents. This resulted in the resident being transferred with the wrong lift and the lift failing, and the resident was dropped from the lift to the bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient hydration for 1 (#50) of 31 sampled. This failure had the potential to affect all of the residents with a BIMS less than 7 in the facility and required encouragement from staff to drink a sufficient amount of fluids throughout the day.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication regimen reviews were completed monthly and documented in the electronic health record for 2 (#42 and 74) of 3 sampled residents for medication review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. The observed error rate was 20.69% for 3 (#s 73, 74, and 101) of 4 residents sampled for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure the designated infection preventionist was qualified through an approved certification program, prior to assuming the role, of the infection preventionist. The deficient practice increased the risk of infection control concerns not being identified or addressed for all residents and staff within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place the call light button within reach for 2 (#18 and #46) of 31 sampled residents. This deficient practice caused resident #18 to call out for help and resident #46 to feel panicked and afraid.

Inspectors wroteBased on interview and record review, the facility failed to provide quality care services to a skilled care resident admitted for rehabilitation services and nursing care; failed to identify a severe weight loss totaling 21.8% and implement nutritional interventions for prevention of further loss; failed to obtain, document, and assess vital signs as ordered by the physician; failed to follow physician orders; and failed to assess and identify behavioral care needs, to include pain, and ensure documentation was included in the EHR; Prior to his ER transfer, nursing staff failed to sufficiently assess and address a significant change in condition and provide oxygen for a decline in respiratory status, for 1 (#1) of 4 sampled residents. Resident #1 expired the same day he was transferred to the local hospital after his change in condition. [...]

Inspectors wroteBased on interview and record review, facility nursing staff failed to provide supplemental oxygen for a resident's saturation level of 75%, with standing orders to apply oxygen two liters via nasal cannula for saturations less than 89%, for 1 (#1) of 8 sampled residents, and the resident had a decline in status and was sent to the ER.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff followed professional standards of practice for identifying a resident's change in condition, for the assessment and implementation of supplemental oxygen for a resident's saturations of 75%, for the assessment and implementation of interventions for non-verbal indicators of pain, for the assessment of intake and output for weight loss, monitoring of vital signs, and accuracy of, per physician orders, and monitoring of bowel movements for abnormalities, for 1 (#1) of 8 sampled residents. These cumulative failures, which occurred over multiple shifts and included various staff disciplines, contributed to the residents negative outcomes identified in F684 - Quality of Care, and the Immediate Jeopardy announced on 5/2/24.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received a weekly head to toe skin assessment, to assess for any new skin issues and to evaluate existing wounds, for 3 (#s 1, 4 and 5) of 4 sampled residents for skin concerns.

Inspectors wroteBased on interviews and record review, the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences related to religion and medical appointments for 1 (#1) of 7 sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to identify, investigate, and document grievances for 1 (#1) of 7 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents right to be free from physical and emotional abuse by staff members for 2 (#5 and #24) of 2 sampled residents, resulting in emotional and physical harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ordered supplements, and assistance with meals, for 1 (#52) of 4 sampled residents, and the resident had a severe weight loss of 11.64% over six months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have oxygen supplies available to a resident with low oxygen saturations for 1 (#52), resulting in the resident's inability to maintain oxygen levels above 89-94%; failed to maintain oxygen tubing for 2 (#s 18 and 45), and failed to properly maintain and clean a CPAP machine for 1 (#18) of 6 sampled residents, increasing the potential for respiratory infections and medical decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication labels matched the physician's orders for 2 (#s 3 and 32) of 5 sampled residents, increasing the risk for medication errors, and staff failed to remove expired medications and supplies from the medication room.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure residents were safe to self-administer medications, before leaving the medications at bedside, causing an increased potential for medications not being taken as the physician ordered, for 3 (#s 18, 32, and 71) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility staff failed to implement a baseline care plan within 48 hours of admission for 3 (#s 33, 87, and 247) of 10 sampled residents.

Inspectors wroteBased on observation, interview, and record review, facility licensed staff failed to set up and administer medications without errors, increasing the potential for medication side effects, for 5 (#s 5, 20, 21, 26, and 32) of 5 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control standards while administering insulin for 1(#32) of 5 sampled residents, perform hand hygiene during clean to dirty tasks (putting clean laundry away) in room #s 102 and 104, and have a water treatment plan or policy in place for Legionella's Disease, increasing the risk for infection to residents and staff.

Inspectors wroteBased on observation and interview, the facility staff failed to respect the residents dignity, by not knocking prior to entering a residents room, for 2 (#s 18 and 68) of 10 sampled residents, causing the residents to feel like they had no privacy; and by leaving a resident on a bedside commode for an extended period of time for 1 (#18) of 10 sampled residents, causing the resident to feel hopeless.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's responsible party of a significant weight loss for 1 (#8) of 1 sampled resident.

Inspectors wroteBased on interview and record review, the facility failed to provide freedom from misappropriation of property for 2 (#s 20 and 250) of 2 sampled residents, resulting in a loss of medication for 1 resident and exploitation of funds for 1 resident.

Inspectors wroteDuring observation, interview, and record review, the facility failed to assess the use of a restraint and obtain a consent for the use of it, causing an increased potential for injury, inability to get out of a wheelchair, and skin breakdown, for 1 (#45) of 7 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to submit the required final summary for investigations, within the required reporting timelines, for reportable events, for 2 (#s 24 and 248) of 5 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develope a complete, comprehensive care plan, that addressed resident care needs, for 2 (#s 18 and 45) of 10 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise individual care plans for 1 (#11) and failed to notify a resident's representative of care conferences for 1 (#8) of 8 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement physician orders for an existing catheter and care for it, for 1 (#83) of 3 sampled residents. This increased the risk of urinary tract infections for the resident.

Inspectors wroteBased on observation and interview, the facility failed to provide adequate staffing throughout the facility to ensure residents were assisted timely with toileting, causing a resident to feel hopeless, for 3 (#s 3, 18, and 68) of 11 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Monthly Regimen Review (MRR) and a Gradual Dose Reduction (GDR) was completed for a resident taking a psychotropic medication for 1 (#57) of 5 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a physician ordered diet for 1 (#52) of 8 sampled residents, increasing the risk for weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide or receive declinations for influenza and pneumococcal vaccines, increasing the risk of influenza or pneumonia, for 2 (#s 13 and 57) of 5 sampled residents.

Inspectors wroteBased on interview and record review, the facility staff failed to obtain a consent or declination for a Covid immunization, increasing the risk for Covid-19 in a vulnerable resident, for 1 (#13) of 5 sampled residents.