Courage Kenny Rehabilitation Institutes Trp

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide respect and dignified treatment for 1 of 3 residents (R3) reviewed for dignity. R3 was given a bed alarm that R3 stated he did not consent to. The alarm limited his freedom of movement when he was in bed due to feeling startled by the loud sound of the alarm. In addition, he was anxious because he was concerned his alarm would bother residents near his room.Findings include: The facilities Consent Form for Restraints dated 2/2/26 indicated R3 signed giving consent for the medication trazodone and side rails on his bed. The bed alarm was not on the consent form. R3's admission minimum data set (MDS) dated [DATE] indicated R3's BIMS score was a 14 indicating he was cognitively intact. R3 required moderate assistance for dressing and personal hygiene. He was dependent for toileting hygiene and transfers. He could roll from side to side in bed with moderate assistance. R3's pertinent diagnoses were cerebral infarction, dysphagia,…

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 interview and document review, the facility failed to implement a process to assess for, determine medical symptoms, obtain an order prior to use, assess for use of the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for 3 of 3 residents (R1, R2, R3) reviewed for use of physical restraints.Findings include: Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 dated October 2025 Section P: Restraints and Alarms indicated physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The important consideration is the effect of the device on the resident, and not the purpose for which the device was placed on the resident. Residents who are cognitively…

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, interview and record review the facility failed to develop a person-centered care plan that included all the medical devices in use and develop interventions for the safe use of the devices for 3 of 3 residents (R1, R2, and R3) who were reviewed for care plan development.Findings include: Upon observation and interview on 4/7/26 at 12:17 p.m. R1 was observed to have bilateral quarter side rails at the head of his bed and three-quarter length side rails at the foot of his bed. R1 was seated in his wheelchair with an alarmed seat belt around his waist on the back of his chair he had a wander guard bracelet attached to his wheelchair. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 6 indicating he was significantly cognitively impaired. R1 required moderate assistance with dressing, sitting to standing, chair to bed transfer, toilet transfer, walking 150 feet. R1 used a wheelchair. R1 was always continent of bowel and…

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, interview, and record review the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as a part of the regular maintenance program to identify areas of possible entrapment for 3 of 3 residents (R1, R2, and R3) reviewed for side rails. The facility did not provide any documentation of inspection or entrapment assessments.Findings include: Recommendations for Health Care Providers Using Adult portable Bed Rails dated 2/27/2023 retrieved on 4/13/26 from https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/hospital-beds indicated, when evaluating the safe use of a hospital bed, component or accessory, manufacturers and caregivers should recognize that the risk for entrapment may increase if a hospital bed system is used for purposes, or used in a care https: Evaluating the dimensional limits of gaps in hospital beds may be one component of a bed safety program which includes a comprehensive plan for patient and bed assessment. Bed…

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 interview and document review, the facility failed to comprehensively reassess pressure ulcer interventions and develop and implement new interventions to prevent pressure injuries for 1 of 1 resident (R1) who was identified as refusing repositioning on the overnight and acquired a new pressure sore. Findings Include:Definitions of pressure ulcer types according to National Pressure Ulcer Advisory Panel (NPUAP):Unstageable Pressure Ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed.R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated diagnoses of traumatic spinal cord dysfunction, neurogenic bladder (condition where nerve damage from the brain, spinal cord, or peripheral nerves leads to a loss of bladder control) and quadriplegia (paralysis that affects all of a person's limbs…

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 interview and document review, the facility failed to comprehensively reassess pressure ulcer interventions and develop and implement new interventions to prevent pressure injuries for 1 of 2 residents (R1) who was identified as refusing repositioning on the overnight and acquired a new pressure sore. Findings include: Definitions of pressure ulcer types according to National Pressure Ulcer Advisory Panel (NPUAP): Unstageable Pressure Ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. Braden Pressure Ulcer Risk assessment dated [DATE] indicated a score of 16, low. (The Braden Scale is a tool used to assess a patient's risk for pressure ulcers, with lower scores indicating higher risk. Scores between 15 and 18 are considered at mild risk). R1's admission Minimum Data Set (MDS) dated [DATE],…

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 observation, interview, and document review, the facility failed to ensure food was stored in accordance with professional standards for food service safety. The facility failed to: remove expired food from food storage areas; label and date food; assure proper hand hygiene while preparing resident meal trays; and storing resident food in an employee break room refrigerator. These practices had the potential to affect all residents, staff and visitors consuming food at the facility. Findings include: During an observation and interview with the dietary manager (DM) on 12/11/23 at 3:01 p.m., a container of Mrs. Gerry's premade coleslaw was noted to have been dated as opened on 11/2/23, and a discard date of 11/25/23. There was also noted to be pre-cooked chicken pieces in a plastic bag with no label or dates. The DM stated once a week refrigerators were checked for expired food. Expired food could cause illness. During an observation and interview on 12/12/23 at 10:49 a.m., dietary aid (DA)-A was wearing gloves while preparing resident trays. DA-A left the serving area with…

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, interview, and document review, the facility failed to ensure compression socks were applied to 1 of 1 resident (R238) reviewed for quality of care. Findings include: R238 Diagnosis report printed 12/14/23, indicated diagnosis included cerebral infarction (stroke). R238 Order dated 11/29/23, directed to apply TEDS (compression socks) in AM before getting out of bed. R238 baseline care plan dated 11/29/23, and caresheet undated, identified R238 wore compression socks During interview on 12/11/23 at 6:43 p.m., R238 stated she did not have compression socks since admission on [DATE] but wore them prior to admission. R238 asked two staff about compression socks and was told they needed to be reordered. R238 stated she was worried about her left foot swelling. During observation on 12/13/23 at 7:37 a.m., R238 was observed wearing white non compression socks on both legs. During observation on 12/14/23 at 10:01 a.m., R238 was wearing fuzzy socks and canvas tennis shoes. Compression socks were not…

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.