Kenwood By Senior Star The

Based on medical record review, review of online medication resources, and staff interview, the facility failed to ensure resident medical records included documentation of the medical condition being treated by resident medications. This affected two (Residents #22, #19) of three residents reviewed for medications. The facility census was 76 residents.

Findings include:

1.Review of medical record for Resident #22 revealed an admission date of 09/30/25 with diagnoses including dementia, metabolic encephalopathy, diabetes, and hypertension.

Review of the Medication Administration Record (MAR) for Resident #22 dated January 2026 revealed an order for Seroquel 25 milligram (mg) one time per day for treatment of altered mental status.

Review of an online resource at pdr.net revealed appropriate indications for use for use of Seroquel included schizophrenia, bipolar disorder, acute depressive episodes and as a maintenance therapy (adjunct to lithium or valproate).

2.Review of medical record for Resident #19 revealed an admission date of 08/13/25 with diagnoses including dementia, protein calorie malnutrition, and Alzheimer's Disease.

Review of the MAR for Resident #19 dated January 2026 revealed an order for Risperdal 0.25 mg one tablet by mouth one time a day for behaviors and an order for Haldol concentrate 50 milliliters (ml) by mouth every four hours as needed for agitation/ behaviors.

Review of the online medication resource at pdr.net revealed Risperdal was used for treatment of schizophrenia, as an adjunctive therapy to lithium or valproate for treatment of acute mania or mixed episodes associated with bipolar disorder, or treatment of irritability associated with autistic disorder. Haldol was used for psychotic disorders, Tourette's disorder and control of tics in children and adults. Risperdal and Haldol had black box warnings indicating there was a risk of increased mortality in elderly patients with dementia-related psychosis

Interview on 02/02/26 at 2:36 P.M with the Director of Nursing (DON) confirmed Resident #22 and #18's medical records did not include documentation regarding the indications/diagnoses being treated by the medications.

Interview on 02/03/26 at 3:32 P.M. with Pharmacy Director of Operations (PDO) #176 confirmed pharmacy staff enter all orders for the facility which they receive through their interface with the facility's electronic medical record or via fax directly from facility. PDO #176 confirmed pharmacy staff only enter what is on the actual order they receive from the facility and do not add any additional information, including diagnosis or indication of use.

Interview on 02/03/26 at 3:50 P.M. with Registered Nurse (RN) #117 confirmed the medications for Residents #22 and #18 did not have correct or appropriate accompanying diagnoses or indications as part of the medication orders.

Interview on 02/03/26 at 4:21 P.M with Medical Director (MD) #197 confirmed some changes need to be made to the facility's documentation process to ensure proper diagnoses are paired with resident medications.

This violation represents noncompliance investigated under Complaint Number OH00169207.

Based on observation, staff interview and review of the facility policy, the facility failed to maintain a working call system. This affected one (Resident #20) of three residents reviewed for call lights. The facility census was 76 residents.

Findings include:

Observation on 02/03/26 at 1:23 P.M. of Resident #20's room revealed a bathroom call light was activated and sounded until 1:37 P.M.

Interview on 02/03/26 at 1:37 P.M. with Licensed Practical Nurse (LPN) #179 confirmed there had been no notification to staff that Resident #20's bathroom call light had been activated.

Observation on 02/03/26 at 1:38 P.M. revealed LPN #179 activated Resident #20's bathroom call light again but there was no notification to staff the call light had been activated.

Interview on 02/03/26 at 2:54 P.M. with Compliance Director (CD) #198 confirmed the facility had a new system and staff were not fully up to speed with how the system worked. CD #198 confirmed daily notifications were to be sent to the facility if a battery was low in any of the pendants supplied to each resident or if there was a missing pendant. CD #198 was not sure how the system notified facility staff if bathroom call systems were not functioning.

Interview with Executive Director (ED) on 02/03/26 at 4:25 P.M. confirmed he did not know Resident #20's bathroom call light was not working. The ED confirmed the maintenance staff conducted semiannual audits of the call light system, but this was not sufficient to maintain resident safety.

Review of the facility policy titled Preventive Maintenance Program dated 08/27/25 revealed a semi-annual check was done of all call system devices (pendant, pull cords) by maintenance staff.

Review of the facility policy titled Pendant Assignment, Monitoring and Alarm Escalation undated revealed the front desk clerk, the Environmental Service Director (ESD), the Assistant Executive Director (AED) and the Executive Director (ED) received daily alerts via email regarding any call pendant with low battery or if a pendant was missing. The Executive Director or AED should monitor daily emails and address pendants with a low battery or missing status greater than 48 hours.

This violation represents noncompliance investigated under Complaint Number OH00169207.

Based on personnel file review and staff interview, the facility failed to ensure employees were examined by a physician or other health care professional acting within their scope of practice within 30 days before beginning work or on the first day of work. This had the potential to affect all 80 residents residing in the facility. The census was 80.

Findings include:

1. Review of the personnel file for Care Partner (CP) Certified Nurse Aide (CNA) #52 revealed a hire date of 02/18/25. Further review revealed CP CNA #52 had a health care examination completed, however, there was no date documented for when the physician or nurse practitioner completed the examination.

Interview on 04/22/25 at 3:48 P.M. with the Executive Director (ED) confirmed CP CNA #52 did not have a date documented on the health care examination to determine when it was completed.

2. Review of the personnel file for CP CNA #86 revealed a hire date of 02/18/25. Further review revealed CP CNA #86 had a health care examination completed that was dated 02/20/25 which was two days after the first day of work.

Interview on 04/22/25 at 3:59 P.M. with the ED confirmed CP CNA #86's health care examination was not completed within the required time frame.

Based on observation and staff interview, the facility failed to store food in a manner to protect against contamination and spoilage. This had the potential to affect all 80 residents residing in the facility. The census was 80.

Findings included:

Observation and interview on 04/22/25 at 10:07 A.M. during tour of the kitchen with Food and Beverage Director (FBD) #107 revealed the walk-in freezer had a box containing a large bag of frozen corn that was opened and unsecured. Upon further investigation a bag of two vegetable burger patties were opened to air and were undated. FBD #107 confirmed the frozen corn and the frozen vegetable burger patties were open to air and the vegetable burger patties had no date.

Observation on 04/22/25 at 10:15 A.M. revealed the walk-in refrigerator had a bag of Romaine lettuce opened and undated which was confirmed by FBD #107. Further observation revealed an open container of cottage cheese which was undated and confirmed by FBD #107. FBD #107 was unaware the cottage cheese needed to be dated but later confirmed it needed to be dated as of the day of opening.

Based on observation and staff interview, the facility failed to maintain tightfitting lidded garbage cans within the kitchen area as required. This had to potential to affect all 80 residents in the facility. The census was 80.

Findings included:

Observation on 04/22/25 at 10:22 A.M. during tour of the kitchen with Food and Beverage Director (FBD) #107 revealed two large garbage cans in the kitchen area with one noted near the food preparation area and the other close to the dishwashing area. Both garbage cans did not have lids on them and there were no lids in sight.

Observation and interview with FBD #107 on 04/22/25 at 10:22 A.M., revealed FBD #107 was able to retrieve one lid, placed it on one garbage can, and confirmed the garbage cans should be covered.