Kahl Home for the Aged & Infirmed

Based on observations, facility policy review, cleaning schedules, and staff interviews, the facility failed to label and date opened food items, clean equipment in the kitchen, and clean flooring in kitchen and dining areas to help prevent contamination and foodborne illness. The facility reported a census of 105 residents. Findings include:1. The following revealed during a continuous observation on 03/9/2026 from 9:45 AM to 10:30 AM: a. Walk-in refrigerator: 1. Open 5 oz (ounce) container of blue cheese crumbles2. Open bag of parmesan cheese.3. Open, undated green 5-gallon bucket of pickles. b. Stand-alone Freezer1. Open, undated bag of chicken tenders2. Open, undated bag of tater tots.c. The inside of a Victory stand-alone freezer had area of residue build up, and spilled items on the bottom shelf. Spilled items included a chicken tender, French fries and tater tots. d. Three large trays of breadsticks sat uncovered on a kitchen table.e. The outside of the fryer noted to have a buildup of a sticky grease-like substance. f. The outside of the microwave had a build up of dirt/food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, the facility failed to offer updated pneumococcal vaccinations (given to protect against infections which can cause pneumonia, a serious lung infection) for 4 of 5 residents reviewed for immunizations (Residents #3, #10, #12, and #32). The facility reported a census of 105 residents.Findings:1. Resident #3's admission Record listed an admission date of 5/22/22. The record listed her age as 94.The resident's Immunization Report documented she received the Pneumovax 23 (a type of pneumococcal vaccine) on 11/3/14 and the Prevnar 13 (a type of pneumococcal vaccine) on 11/10/15. A 5/2/22 Information/Permission form asked if the resident wished to receive the Pneumovax vaccine if there was no record of previous immunizations of Prevnar 13 and Pneumovax 23. The form indicated the resident previously received Prevnar 13 and Pneumovax 23. The form did not include information regarding updating the resident's pneumococcal vaccinations per current Centers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review and staff interviews, the facility failed to follow dietician recommendations and weigh a resident at least monthly for 1 of 11 reviewed for nutrition (Resident #112). The facility reported a census of 106 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #112 did not have a Brief Interview for Mental Status (BIMS) exam completed due to resident rarely or never understood. The MDS indicated resident required set up or clean up assistance with eating. The list of diagnoses included non-Alzheimer's dementia and depression. The MDS indicated no known weight loss of more than 5% in a month and the need for a mechanically altered diet. The Care Plan revealed a Focus area, revised on 10/20/25, to address at risk for malnutrition due to weight loss related to energy needs greater than energy intake related to difficulty chewing, holding food in mouth, possibly being a vegetarian diet for 5 months,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, clinical record review, and staff interviews, the facility failed to cover clean laundry during transport to resident rooms during 2 out of 2 observations, failed to keep a urinary drainage bag off the floor and failed to keep the graduated cylinder used to empty urine form a catheter collection bag off the floor for 1 out of 1 resident reviewed (Resident#35). The facility reported a census of 105 residents.Finding include:1. During an observation on 03/09/2026 at 1:09 PM, Staff I, Laundry Aide pushed an uncovered laundry cart, which contained hung clean laundry, from North 210 to North 203. 2. During an observation on 03/11/2026 at 11:42 AM, Staff J, Laundry Aide pushed an open hanging cart, half full of clean clothes on hangers, past three residents in the lounge on the South 3rd floor. Staff J left the cart open while she delivered clothing to five resident rooms. 3. Review of the Minimum Data Set (MDS) assessment for Resident #35, dated 2/11/26, list of diagnoses included of stoke, obstructive uropathy ( blockage in the urinary system that prevents urine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interviews, the facility failed to implement a physician order given after a low lab result for 1 of 5 residents (Resident #1) in the sample. The facility reported a census of 104 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS list of diagnoses included malignant neoplasm of the colon (colon cancer), arthritis and aphasia (difficulty speaking). The MDS indicated Resident #1 required substantial/maximal staff assistance with toileting, partial/moderate assistance with showers, dressing, putting on and removing footwear and repositioning.Review of the electronic health record (EMR) revealed an admission Record which indicated Resident #1 admitted to the facility on [DATE] and discharged on 12/19/25.Review of a 12/8/25 Progress note -routine written by a Nurse Practitioner (NP) revealed a 12/5/25 lab result…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interviews, the facility failed to utilize isolation gowns when providing resident care that require the use of Enhanced Barrier Precautions (EBP) for 1 of 3 residents (Resident #3) in the sample. The facility reported a census of 104 residents.Findings include:Review of the Minimum Data Set (MDS), dated [DATE] identified Resident #3 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS list of diagnoses included pressure ulcer to the sacral region. The MDS indicated Resident #3 dependent on staff for assistance with toileting and transfers in and out of bed/chair, and required substantial/maximal assistance with showers.Review of Resident #3 Care Plan, dated 2/12/25, the Care Plan revealed a Problem to address The resident requires enhanced barrier precautions (EBP) to reduce the spread or potential spread of multi-drug resistant organisms R/T (related to) a pressure injury. Interventions included, in part:a.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, facility policy review, and staff interviews, the facility failed to ensure the disposal of expired food items, and food items in a resident refrigerator were labeled with the name of the food item, date placed in refrigerator and the date item needed to be disposed in an effort to prevent the potential for foodborne illness. The facility reported a census of 104 residents. Findings include: 1. During the initial tour of the kitchen and dry storage room on 12/10/25 at 9:58 AM, the following food times were found to be expired: a. 1- Chocolate Cake Mix expired 11/16/21. b. 12- Apricot Nectar cans expired 9/1/22. c. 1 - Baking Powder container expired 1/6/23 and 2 additional cans expired 6/15/23. d. 1 - Poultry Seasoning canister expired 9/6/23. e. 2 - Ground Mustard canisters - 1 expired 10/27/23, the other expired 9/8/24. f. 11 - Cornbread Mix boxes - 4 expired 12/4/23, 7 expired 12/18/24. g. 1 - Whole Sesame Seeds canister expired 2/9/24. h. 1 - Nutmeg canister expired 6/5/24. i. 8 - Lemon Juice bottle- 1 expired 6/12/24 and 7 expired 1/19/25. j. 1 - Ground…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to utilize Enhanced Barrier Precautions for 4 of 6 residents observed (Residents #12, #41, #68 and #89) and failed to keep the tubing of indwelling catheter tubing off the floor for one of two residents observed (Resident #68). The facility reported a census of 104 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #12 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: fractures/multiple trauma, pneumonia and a urinary tract infection. The MDS indicated the resident dependent on staff for toileting and showers, repositioning and required substantial/maximal staff assist with transfers, lower body dressing and putting on footwear. The MDS also identified Resident #12 had an unhealed Stage IV pressure ulcer, A review of the Physician Orders revealed the following orders: a. 10/29/24 Enhanced Barrier Precautions b. 11/12/24 for Sacral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility policy review, staff, family and resident interviews, the facility failed to answer call lights within 15 minutes to meet resident needs for 1 of 3 residents reviewed (Residents #5). The facility reported a census of 104 residents. Findings include: Resident #5's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated moderate cognitive impairment. The MDS documented the resident admitted [DATE] and needed substantial to maximal assistance with toileting hygiene, toilet transfers, and lower body dressing. The Care Plan, initiated 1/8/25 documented the resident required 1:1 staff for toileting. During an interview on 02/10/25 at 12:56 PM Resident #5 shared that some call lights took a longer time to answer, maybe 15-20 minutes. He stated he knew staff were busy but he needed help to go to the bathroom. On 2/11/25 at 8:58 AM during a hallway observation the resident's call light was noted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family and staff interview, and policy review, the facility failed to safely transfer one of three residents reviewed with a mechanical lift (Resident #1). The facility reported a census of 99 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a BIMS of 13 out of 15, and had the following diagnoses: Heart Failure, Peripheral Vascular Disease and Renal Insufficiency (Kidney Failure). The MDS also identified Resident #1 was totally dependent on staff for assistance with toileting hygiene, upper and lower body dressing, help with footwear, and transfers. On 4/6/18, the Care Plan identified Resident #1 with the problem of having an ADL (Activities of Daily Living) self-care performance deficit related to Parkinson's with dementia and directed staff to have two staff assist with toileting with the Hoyer Lift to the Shower Chair. A review of the incident report dated 3/29/24 at 11:12 AM had documentation of the following:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure consistent documentation of code status for 1 of 8 resident reviewed for advanced directives (Resident #232). Documentation for Cardiopulmonary Resuscitation (CPR) found in the electronic record, a form in the chart directed Do Not Resuscitate (DNR) and another form in the chart directed CPR both signed by the provider on the same day. The facility reported a census of 83 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #232 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, indicating cognition intact. Diagnoses for Resident #232 included debility, cardio-respiratory conditions, heart failure, renal disease, pneumonia, diabetes, and pulmonary disease. The Care Plan focus initiated [DATE] documented Resident #232 had chosen specific advance directives, noted as Full Code. A document titled, Full Code Form, located in the chart for Resident #232 check…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and facility policy review the facility failed to follow physician orders to provide notification of elevated blood sugars for 1 of 5 residents reviewed for medications (Resident #72). The facility reported a census of 83 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 12/14/23, listed diagnoses for Resident #72 that included diabetes mellitus, heart disease, renal disease, anxiety, and depression. The Care Plan initiated 10/20/23 stated the resident would not have any complications related to diabetes. Staff to give medication as ordered by the doctor and to monitor, document for side effects and effectiveness. Review of the March 2024 Medication Administration Record (MAR) revealed the following: 1. 3/5/24 at 12:00 PM blood sugar result of 394 mg/dl 2. 3/14/24 at 12:00 PM blood sugar result of 384 mg/dl The Medication Administration Record (MAR) for March 2024 reflected a physician order (PO) started 3/6/24 that directed staff to administer extra units of Humalog insulin based on blood sugar, it directed if blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.