Kirkland Court Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided with such care consistent with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for respiratory care. The facility failed to store Resident #1's nasal cannula properly. Resident #1's nasal cannula was left on the floor for 4 hours. This failure could place resident at risk for complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.

Inspectors wroteBased on interviews and records reviews, the facility failed to permit 1 (Resident #1) of 1 resident reviewed for discharge, to remain in the facility and not transfer or discharge the resident from the facility. The facility discharged Resident #1 and did not allow Resident #1 to return to the facility after being denied admittance by an acute care facility on 06/06/2026. This failure could result in residents' needs not being met, decline in resident safety, and a violation of resident's rights. Findings Include: Record review of Resident #1's face sheet, dated 06/29/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #1) of 5 residents reviewed for advanced directives. Resident #1 had a DNR in her record that was not dated by the physician. The facility's failure could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes.

Inspectors wroteBased on observation, interview, and record review the facility failed to review the risks and benefits of bed rails with 1 of 5 (Resident #1) residents or their resident representatives and obtain informed consent prior to installation of bed rails, in that:Resident #1 had (1) one-half length bed rail installed on the right side of her bed without a physician order, without documented informed consent from the resident or resident representative and without inclusion of bed rail use in the resident's comprehensive care plan. This failure placed the residents at risk for injury, including entrapment of bedrails, hindered the resident's' ability to independently exit the bed and could negatively impact the resident's' ability to engage in activities of daily living.

Inspectors wroteBased on observation, interview, and record review the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments for 1 (west wing medication cart) of 4 medication carts reviewed for medication storage. The facility failed to ensure RN locked the west wing medication cart when it was unattended. This failure could place residents at risk of injury due to ingesting non-prescribed medications and/or ingesting prescribed medications at incorrect doses or times.

Inspectors wroteBased 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. The IJ template was provided to the facility on [DATE] at 01:00 PM. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated for 2 (Resident #2 and Resident #3) of 5 residents reviewed for allegation investigation. The facility failed to investigate an incident from 09/10/25 when Resident #3 threatened Resident #2 with a hand saw and then cut a groove in the center of the top, front bar of Resident #2's walker. This failure could place residents at risk of continued abuse or neglect. Findings Included:1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 (Resident #40) of 15 residents, 1 (hall 200 medication cart) of 4 medication carts, and 1 (east wing treatment cart) of 2 treatment carts reviewed for medication storage. 1. The facility failed to ensure Resident #40 did not have access to nasal decongestant spray. 2. The facility failed to ensure LVN D locked the hall 200 medication cart when it was unattended. 3. The facility failed to ensure LVN E locked the east wing treatment cart when it was unattended. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure foods were properly stored, labeled, and dated. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Include: Observation of the walk-in refrigerator on 06/09/2025 at 5:55 AM revealed the following: 1. 2 bags of yellow colored cream, the packaging was not labeled or dated. 2. 10 lbs. of ground beef on a flat pan. The pan was labeled: beef-use by 06/07/2025 3. 2 turkeys on a flat pan. The pan was labeled: turkey- use by 06/07/2025 4. 25 small glasses of milk covered-no label or date 5. 26 small glasses of orange juice covered-no label or date 6. [...]

Inspectors wroteBased on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #30) of 15 residents reviewed for PASRR. The facility failed to perform a new PASRR level 1 assessment on Resident #30 due to diagnoses of bipolar disorder and PTSD. This failure could place residents at risk of not receiving needed services and support. Findings Included: [...]

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #103) of 15 residents reviewed for care planning. The facility failed to develop a baseline care plan for Resident 103 within 48 hours of her admission. This failure could place newly admitted residents at risk of not receiving effective, person-centered care. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #26, Resident #45, and Resident #46) of 17 residents reviewed for infection control. -LVN D failed to use the proper disinfecting wipes when disinfecting equipment used on residents. This deficient practice had the potential to place residents at risk by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Residents #1) of 6 residents reviewed for care plans. The facility failed to implement Resident #1's care plan to ensure Resident #1 was transferred and toileted with the assistance of 2 staff in order to ensure resident's safety. Resident #1 was transfered from her bed to wheelchair using a gait belt with the assistance of one person. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure in accordance with accepted professional standards and practices, the facility maintained medical records on each resident that were complete, accurately documented, and readily accessible for 2 of 5 residents (Residents #1 and #2) reviewed for clinical records. The facility failed to ensure the altercation that occurred on 12/4/2024 between Resident #1 and Resident #2 was documented in their clinical records. This failure could place residents at risk for incorrect or omitted treatment, duplicated treatments, poor self-esteem and self-worth, and a failure to ensure continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (CNA B and CNA C) of 4 staff and 1 of 1 resident (Resident #1) observed for resident care. CNA B and CNA C did not wear the proper PPE when performing catheter care on Resident #1 per Enhanced Barrier Precautions increasing risk of MDRO contamination. This deficient practice has the potential to affect residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representatives when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention or a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #1) of 5 residents reviewed for notification. The facility failed to ensure Resident #1's resident representative was immediately notified when the resident had a change in condition that required he be transported via ambulance to the hospital. This failure could result in residents not having the comfort and company of their families during traumatic times.

Inspectors wroteBased 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.

Inspectors wroteBased 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). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being for 3 of 7 anonymous residents reviewed for quality of life. The facility failed to ensure 3 of the 7 anonymous residents interviewed received adequate notification of activities. The facility failed to ensure activities that were provided met residents' needs or desires. This failure placed residents at risk of boredom and a decline in their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional. The facility failed to ensure the AD was qualified to serve as the director of the activities program. This failure placed residents at risk of not having stimulating, engaging activities that are beneficial and meaningful to the residents.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication carts reviewed for medication storage. The facility failed to prevent the following: -1 loose pill was found in medication cart for Hall 300 and part of Hall 200, -medication cart for Hall 300 and part of Hall 200 had 3 insulins with no open dates located on medications. -3 insulin medications were found in Hall 100 & and part of 200 Hall's medication cart that were past their expiration dates. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to prevent the following: -LVN B did not perform HH before performing blood sugar check. -LVN B did not perform HH before or after donning or doffing gloves to administer insulin to resident. -LVN A did not perform HH before preparing medication for resident. -LVN A did not clean bedside table before setting up medication administration for a resident with a gastrotomy tube. -CNA D did not perform HH or glove change after cleaning resident during incontinent care. -LVN A did not perform HH during incontinent care or wound care of resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails, and obtain informed consent prior to installation of bed rails with residents or their resident representatives for 1 of 13 (Resident #12) residents reviewed for quality of care in that: The facility failed to ensure Resident #12 did not have (2) one-quarter bed rails, on both sides of his bed with no documentation of physician orders, consent, or a safety assessment prior to installation. This failure could place residents at risk of injury, hindering residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being for 1 of 5 staff reviewed for nursing services. The facility failed to ensure the following: -LVN A used proper technique when providing wound care. -LVN A used proper technique when providing incontinent care. -LVN A used proper technique when administering medications via gastrotomy tube. This failure had the potential to affect residents receiving wound care and incontinent care by exposing them to infections resulting in poor healing, increased tissue damage, and deterioration in their wounds and health often resulting in IV antibiotic therapy and even hospitalization. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for one of 13 (Resident #10) residents reviewed for pharmacy services. -The facility failed to ensure LVN B did not administer insulin to Resident #10 that belonged to another resident. This failure could place residents who receive insulin medications at an increased risk for complications such as increased blood glucose levels, change in cognition, and an exacerbation of symptoms and disease process.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #1 and Resident #2) of 5 Residents reviewed for abuse and neglect. 1. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility observed for sanitation and infection control in that: The facility did not follow infection control policies when on 01/04/2023 staff failed to use hand hygiene while passing out food, leaving used COVID tests with bodily fluids left on a countertop in an easy accessed location, failed to utilize hand hygiene when entering and exiting resident's rooms, and a staff member not following infection prevention measures when experiencing symptoms This failure could place residents at risk for infections, contamination, and physical and mental decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess residents for risk of entrapment from bed rails prior to installation. The facility failed to review the risks and benefits of bed rails with 1 of 5 (Resident #2) residents or their resident representatives and obtain informed consent prior to installation of bed rails, in that: Resident #2 had (2) one-quarter bed rails, one on each side of her bed with no documentation of consent or safety assessment prior to installation. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living.

Inspectors wroteBased on observation, interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented for 1 of 5 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure Resident #1's physician orders for a bed alarm was documented in the care plan. The facility failed to ensure Resident #1's fall risk assessment was accurately documented in the care plan. The resident's fall risk assessment indicated Resident #1 was a high risk for falls but was inaccurately documented in care plan as a moderate risk for falls. These failures could place residents at risk of not receiving needed care or treatments or duplication of care or treatment by misleading care providers regarding what care or treatments residents have or have not received.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for three (Resident #1, Resident #32, and Resident #38) of 49 residents reviewed for misappropriation of property and exploitation. CNA H asked Resident #32 for money. Someone with the same first name as CNA H used Cash App to steal money from Resident #38. Someone with the same first name and half of the same last name as CNA H used Cash App to steal from Resident #1 at the same time Resident #1's wallet was opened and $100 went missing. This failure could place residents at an increased risk for misappropriation of their property.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #15, #27, and #44) of 18 residents reviewed for advanced directives. Resident #15 had a DNR in her record that was missing multiple required pieces of information. Resident #27 had a DNR is his record that was missing the date and printed signature for the Resident. Resident #44 had a DNR in her record that had no second witness. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 8 of 17 residents (Resident #12 and all ambulatory residents not residing in the locked unit) reviewed for accident hazards. 1. A razor blade was observed sitting on the countertop of the conference room of the facility. 2. Resident #12 had three towels positioned on the floor around the base of his toilet. He is visually impaired and needs an even floor free of clutter, according to his care plan. These failures could place residents at risk of injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings, for 1 (Resident #45) of 1 resident that was reviewed for feeding tubes, in that: -The facility staff failed to verify placement of the feeding tube prior to medication administration. [...]

Inspectors wroteBased on interview and record review, the facility failed to receive registry verification that the individual has met competency evaluation requirements before allowing the individual to serve as a nurse aide for one of 5 (CNA G) CNA's reviewed for licensure. CNA G was hired by the facility on 08/22/22 and was never certified as a certified nurse's aide despite her current employment as, and title of, CNA. This failure to ensure employee competency in training could affect all residents by exposing them to inadequate care resulting in deterioration of their condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare, and serve food in accordance with professional standards of food safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to make sure staff (Cook A) was wearing hair restraints while preparing food in the kitchen. This deficient practice could place residents at risk of food-borne illness, weight loss, and a diminished meal experience.