Kerens Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans. Resident #1's comprehensive care plan did not reflect Resident #1's mechanical soft texture diet. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: A record review of Resident #1's face sheet dated 04/30/2025, reflected a [AGE] year-old male who was re-admitted to the facility on [DATE]. Resident #1's diagnoses included: unspecified dementia (a condition that causes a decline in thinking, memory, and reasoning abilities), seizures (sudden, temporary disruption of the brain's normal…

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 observations, interviews, and record review the facility failed to ensure each resident's bedside, toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 3 of 10 residents (Resident #20, Resident #28, and Resident #31) reviewed for the resident call system . The facility failed to provide a working communication system, which was easily at reach, which would allow Resident #20, Resident #28, and Resident #31 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Findings included: Record review of Resident #20's face sheet dated 04/09/2025 reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included metabolic…

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 interviews, and record review the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for five of five residents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present. Findings included: During an interview on 04/08/2025 at 10:20 am, with the Activity Director revealed the Resident Council meetings were held in the dining room. She stated there was not another area for the residents to meet in private. She stated she would close the doors and place signs on the doors. She stated she would notify staff before the meeting not to come in or out of the dining room until after the resident group meeting. The Activity Director offered to move the Resident Council meeting to a bedroom so it would be private since it was a few…

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 interviews and observations, the facility failed to provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible for 1 of 1 memory care units (10 total residents) reviewed for homelike environment. The facility failed to provide a homelike environment inside the rooms (by hanging pictures, having decor present, or having color present) for the residents who lived in the memory care unit of the facility. This deficient practice could lead to regression and/or a feeling of institutionalization for the residents. Findings included: In an observation on 4/09/2025 at 09:33 AM in the facility's secured unit revealed a few paintings hung in the hallway as well in the dining room and dayroom. Observations of all 5 rooms (2 residents per room) revealed grey colored walls that were barren of any decorations. No personal or homelike decorations were observed in any of the 5 rooms. Each room contained 2 beds, 2 dressers, televisions, blinds on the window, over-bed lights, a privacy curtain between beds,…

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, interviews, and record review the facility failed to provide, based on the comprehensive assessment and care plan, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being in the 1 of 1 memory care units (10 residents) reviewed for activities. The facility did not provide the memory care unit residents with individual or group activities. Findings included: In an observation on 04/09/25 at 9:35 AM in the memory care unit revealed the residents all sitting in the day room with a television on and 1 staff member present with them. Some residents were looking at the television and some were looking around and mumbling to themselves. There was no activity calendar posted in the memory care unit. There was no evidence of activities (puzzles, books, baby dolls, toys, coloring books, pencils, crayons) within the memory care unit. In an observation and interview on 04/09/25 at 2:09 PM with CNA D she stated they did not do activities back there [in…

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 observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 4 of 4 resident (Resident #13, #14, #24, and #39) and 1 of 1 laundry carts reviewed for infection control. The facility failed to ensure MA B performed proper hand hygiene and sanitize contaminated medication cart and blood pressure equipment when passing medications on Resident #13, #14, #24, and #39. The facility failed to ensure laundry staff handled and stored linens in a manner to ensure cleanliness and protect from dust and soil to prevent cross-contamination and the spread of infections for 1 of 1 laundry carts. This failure could place residents at risk for development of communicable diseases and infections. Findings included: Record review of Resident 13's undated face sheet, revealed he was a [AGE] year-old male…

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 observations, interviews, and record review the facility failed to protect and promote an environment that ensured the resident's right to a dignified existence for 2 of 2 residents (Resident #24 and #3) reviewed for resident rights. The facility failed to to address Resident #3's eating restrictions in a dignified manner and protect confidentiality related to incontinence care needs on Resident #24. This failure could place residents at risk for shame and loss of dignity that could negatively impact their quality of life. Findings included: Record review of Resident #3's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of pneumonitis, epilepsy (seizures), stroke, malnutrition, right side muscle weakness related to stroke, dementia, and anxiety. Record review of Resident #3 's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 99, which indicated the resident's cognitive ability could not be determined due to other medical conditions. Record review of…

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 observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #36) of five residents reviewed for ADL care. The facility failed to shave Resident #36's facial hair all along the under side of her chin that was approximately 1 cm in length This deficient practice could place residents at risk of a decline in their sense of well-being and level of satisfaction with life. Findings included: Review of Resident #36's quarterly MDS assessment dated [DATE], reflected an [AGE] year-old-female that was admitted to the facility on [DATE] with diagnoses including high blood pressure, dementia, anxiety, depression, muscle wasting and atrophy, muscle weakness, and unsteadiness of feet. Her BIMS score was a 04, indicating severe cognitive impairment. She required substantial/maximal assistance to maintain personal hygiene. Review of Resident #36's care plan revealed…

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 observations, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 7 of 18 residents (Resident #5, #8, #9, #10, #11, #12, #14) reviewed for medications and pharmaceutical services, in that: The facility failed to ensure narcotic audits were properly conducted on or about 2/6/2025, through 2/8/2025, per the facility's policies and procedures, resulting in unaccounted for, misplaced, and/or misappropriated medications, including (2) tablets of Lorazepam 1mg, (1) tablet of Tylenol #3 (Codeine), (2) tablets of Lorazepam .5mg, (1) tablet of Phenobarbital 60mg, and (1) tablet of Amoxicillin 500mg. The facility failed to ensure medications, including controlled substances, were administered to Resident #5 and Resident #9 on 2/7/2025, at 1800 (6:00 PM), as ordered or scheduled, resulting in the delayed…

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 record review the facility failed to implement a policy that is in accordance with the State Medicaid Plan to allow a resident to return to his previous room upon discharge from the hospital for 1 of 1 resident reviewed for discharges. The facility failed to ensure Resident #1 received the services required when they failed to allow Resident #1 to return to the facility after his hospitalization and they failed to appropriately notify the resident, his representative, and the LTC Ombudsman of the discharge. This failure placed residents at risk of an extended, unnecessary hospitalization and a traumatic psychosocial adjustment to a new facility. Findings include: Record review of Resident #1's undated face sheet, reflected he was an [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of Alzheimer's, Urinary Tract Infection, Muscle Weakness, Bipolar (mental illness), and Restlessness and Agitation. He was discharged to the hospital on 6/23/24 to be evaluated for…

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 record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 1 resident (resident #2) reviewed for care plans. The facility failed to ensure Resident #2 had a care plan to reflect the accurate diet she was on. Resident #2 was care planned for pureed textured diet when she was receiving regular diet. This failure could place residents at risk of getting insufficient nutrition with the wrong diet order which could have diminished her physical and psychosocial well-being. Findings include: Review of Resident #2's undated face sheet reflected that she was a [AGE] year-old female admitted with diagnoses of Malnutrition, Encephalopathy, Chronic Ulcer of Right Calf, Chronic Kidney Disease, Dementia and Anemia. Review of 7/29/24 of Resident #2's Quarterly MDS reflected her BIMS score was 99, which indicates they could not fully evaluate her cognitive abilities. Review of resident #2's 7/5/24 Care Plan reflected she was on a pureed texture diet…

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 record review the facility failed to ensure medical records were complete and accurate in accordance with accepted professional standards and practices when the facility to maintain a correct medical record for 1of 1 resident (resident #2) reviewed for diet orders. Evidence supports the resident medical record was not accurate. The facility failed to ensure Resident #2 had an accurate medical record when the physician signed an incorrect diet order for a pureed diet that the resident wasn't getting and did not need. This failure could place residents at risk of getting insufficient nutrition with the wrong diet order which could have diminished her physical and psychosocial well-being. Findings include: Review of Resident #2's undated face sheet reflected that she was a [AGE] year-old female admitted with diagnoses of Malnutrition, Encephalopathy, Chronic Ulcer of Right Calf, Chronic Kidney Disease, Dementia and Anemia. Review of 7/29/24 of Resident #2's Quarterly MDS reflected her BIMS…

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 maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 2 residents (Resident #5) and 1 of 2 staff (CNA A) reviewed for incontinent care as indicated by: The facility failed to ensure CNA A washed or sanitized her hands while going from a dirty to clean surface when performing incontinent care on Resident #5. This deficient practice placed residents at risk for cross contamination and the spread of infection. Findings included: Record Review of Resident #5's face sheet dated 02/28/24 reflected Resident #5 was an [AGE] year-old female with an admission date of 08/16/23. Resident #5's diagnoses included dementia (disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease), cerebrovascular disease (a variety of medical conditions that affects the blood vessels of the brain and the cerebral…

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.