Kirkland Court Health And Rehabilitation Center

g.

The facility medical director. 3.

Immediately is defined as: a. within two hours of an allegation

jeopardy to resident health or involve abuse or result in serious bodily injury.

Upon receiving any allegations of abuse, neglect, safety exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for detem1ining what actions (if any) are needed for the protection of residents.

investigations. 2.

Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. 3.

The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. a.

Any evidence that may be needed for a criminal investigation is sealed, labeled and protected from tampering or destruction. 4.

The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. 5.

The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 6.

Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7.

The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have bad contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and I. documents the investigation completely and thoroughly.On 09/13/25 at 12:08 PM ADM, DON, and ADON were informed the IJ was removed as of 12:08 PM. An IJ was identified on 09/12/25.

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

While the IJ was removed, the facility remained out of compliance at a level of no actual harm potential for more than minimal harm not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

675336 09/13/2025

Kirkland Court Health and Rehabilitation Center 1601 Kirkland Dr Amarillo, TX 79106

involve abuse or result in serious bodily injury.

675336 09/13/2025

Kirkland Court Health and Rehabilitation Center 1601 Kirkland Dr Amarillo, TX 79106

mistreatment, or misappropriation of resident property. 9.

Investigate and report any allegations

Misappropriation - Reporting and Investigating and dated April 2021 revealed the following: . 6.

Upon

injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

Investigating Allegations 1.

All allegations are thoroughly investigated.

The administrator initiates investigations. 7.

The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have bad contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and I. documents the investigation completely and thoroughly.

675336 09/13/2025

Kirkland Court Health and Rehabilitation Center 1601 Kirkland Dr Amarillo, TX 79106

During an interview on 09/11/25 at 02:53 PM MS stated

jeopardy to resident health or hand saw because the maintenance office was locked. MS stated, I always lock the door behind me safety when I'm going out. If it happens to be I made a mistake-I have so much going on and I am always in a hurry-it is a possibility.

But there is no excuse for that, and it will not happen again. MS stated a

up. He could hurt someone else or hurt himself.

During an interview on 09/11/25 at 04:23 PM LVN G stated Resident #3 was agitated on 09/10/25 and was telling her his doctor had increased his Parkinson's medication.

She stated he was upset with her when she told him she could not increase his medication without an order and more upset when she called his doctor's office, and they said it was not to be increased.

She stated during this time she left Resident #3 at the nurses' station in his motorized wheelchair and she went to help another resident. LVN G stated when she came back to the nurses' station, she saw him with a hand saw cutting on the top, front bar of a female resident's walker and making fun with everyone who was in the common area that he could saw through the walker.

She stated she went to his side and asked him to put the saw down because it was not his.

LVN G stated he put the saw on the ground when she asked him to put it down.

She stated he was still agitated so she called the doctor for an order for something to calm him down and he was given Vistaril which seemed to help calm him down. LVN G stated, Someone could have been cut due to Resident #3 having access to the hand saw.During an observation on 09/11/25 at 05:04 PM Resident #3 was wheeling himself into the front door after smoking in the courtyard.

During an interview on 09/12/25 at 12:42 PM RN C stated she was told on 09/12/25 to keep a closer eye on Resident #3.On 09/12/25 at 01:00 PM ADM and ADON were notified that an Immediate Jeopardy had been identified, IJ templates were provided, and Plan of Removal was requested.The facility's Plan of Removal (as follows) was accepted on 09/12/25 at 08:12 PM.Plan of RemovalProblem: There is a need for immediate action due to the break in the facility's risk management process regarding abuse, neglect, and elopement.

Specifically, the facility staff will need to address corrective action to prevent future incidents of elopement from occurring in the facility, especially when residents are exhibiting signs and symptoms of elopement.

All residents who are high risk for elopement are at risk of the alleged defected deficiency.Interventions: The administrator notified the medical director of Immediate Jeopardy 9/12/25 & Ad HOC completed on 8/22/2025.

The following in-services were provided:o On 8/21/25 DON/ADON provided education to staff on Dementia Care: Mental Decline, elopement policy & exit seeking protocol, and wandering/elopement education prior to their next working shift.o On 8/21/25 DON/ADON provided education to charge nurses on wandering/elopement, dementia care: Mental Decline, elopement policy and exit seeking protocol prior to their next working shift.o All staff will be educated by DON/ADON prior to working their next shift with a completion date of 8/21/25.

All NEW staff will be educated prior to working their first shift.o On 8/22/25 Admin and DON/ADON provided education to staff on how to identify residents at risk/high risk. DON/ADON completed audit on 8/21/25 to ensure Elopement Assessments have been completed according to protocol.

Charge Nurses will complete an Elopement Risk Assessment quarterly, upon admit, and for exit seeking behaviors.

The assessment will provide a score to indicate if they are at risk or high risk for elopement. ADMIN/DON will be responsible for ensuring a resident has 1:1 supervision when required and will monitor that it is being followed.

For residents who score at risk/high risk for elopement on the elopement assessment, a shoe emblem will be placed above the name pla