Kenwood Manor (SFF) Abuse and Neglect Attorneys

The Centers for Medicare and Medicaid Services (CMS) and the state of Oklahoma conduct routine inspections, surveys, and investigations at every nursing facility statewide. Their efforts can identify serious violations, deficiencies, and health concerns. When problems are detected, surveyors provide the facility the opportunity to make significant improvements to the level of care they provide residents and changes to policies and procedures.

Some facilities are found to have serious underlying problems that make improving care extremely challenging. When these nursing homes are identified, regulators will often designate the Center as a Special Focus Facility (SFF) and add the Center to the Medicare deficiency watch list. If changes are not made over months and years and verified by additional investigations and inspections, the nursing home can lose their contract to provide care to Medicaid and Medicare-funded patients.

In 2017, regulators designated Kenwood Manor as a Special Focus Facility. Now that the Home has been added to the national watch list, the nursing staff and administration must make significant improvements and undergo additional inspections and surveys of every year. Some of the serious concerns, violations, and deficiencies identified at this facility are detailed below.

Kenwood Manor (SFF)

This Long-Term Care Facility is a 45-certified bed ‘for profit’ Home providing services and cares to residents of Enid and Garfield County, Oklahoma. The Center is located at:

502 West Pine
Enid, OK 73701

In addition to providing 24-hour skilled nursing care, the facility also offers:

  • IV (intravenous) therapy
  • Tube feeding
  • Pain management
  • Wound management
  • Wound VAC therapy
  • Ostomy care
  • Trach care
  • Complex diabetes treatment care
  • Post-surgical care and rehabilitation
  • Neurological disorder care
  • Post-surgical recovery care
  • Orthopedic care
  • Multiple-trauma care
  • Physical, occupational and speech/language therapies
  • Nutritional therapy
  • Dementia disorder and behavioral-specialized services

Over $175,000 in Monetary Penalties

Federal and state nursing home regulatory agencies have the legal authority to impose monetary penalties against any skilled nursing facility identified with deficiencies and violations. These fines are meant to discourage substandard care while encouraging improvements to policies and procedures.

Over the last three years, regulators have levied two monetary penalties against Kenwood Manor. These penalties include an $82,672 fine on April 22, 2015, and a $93,759 fine on June 15, 2016. Additionally, Medicare refused three requests for payments to cover care provided residents on three separate occasions. These payment denials occurred on April 22, 2015, February 5, 2016, and June 15, 2016. Also, during the same time, state regulators received five formally filed complaints that after investigations all resulted in citations.

Current Nursing Home Resident Safety Concerns

The federal government and Oklahoma care home regulatory agencies routinely update their statewide nursing facility database system. The publically accessible website information contains historical details of incident inquiries, safety concerns, health violations, dangerous hazards, filed complaints, and opened investigations of every facility statewide.

Currently, Kenwood Manor maintains an overall one out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, and two out of five stars for quality measures. Some violations, deficiencies and safety concerns involving this facility include:

  • Failure to Treat Residents with Dignity and Respect of Individuality
  • In a summary statement of deficiencies dated April 22, 2015, the state surveyor noted the facility’s failure “to ensure [a resident] was provided transfer assistance on to a bedside commode [promptly] to prevent the resident from soiling herself and suffering embarrassment.” The incident involved a resident who “requires total staff assistance with transfers, extensive staff assistance with toileting, has balance problems with moving from seated to a standing position, with service to surface transfers, it was not able to stabilize yourself without physical assistance from staffed.”

    The state surveyor interviewed two family members of the resident who were “asked if the resident was treated with dignity and respect of the staff. They both stated that there had been problems with the resident getting assistance when needed to get up to the bedside commode. The [family members] stated there had been times when the resident had to wait for as long as thirty minutes to an hour to receive assistance when she needed to use the bathroom. They further stated the resident was unable to hold her urine on one occasion and wound up wetting herself, causing the resident to be embarrassed.”

  • Failure to Assist Residents Who Require Assistance with Activities of Daily Living
  • In a summary statement of deficiencies dated April 22, 2015, state investigator noted the facility’s failure “to ensure residents received assistance with activities of daily living. The deficient practice by the nursing staff affected two residents where run resident “did not receive assistance with toileting [and] was left soiled and [the other resident] did not receive assistance with bathing and did not [receive] three showers a week” as Care Planned.

  • Failure to Provide Necessary Care and Services to Maintain a Resident’s Highest Well-Being
  • In a summary statement of deficiencies dated June 24, 2015, the state investigator identified a serious facility failure. The facility failed to “obtain a specialty physician consult for persistent complaints of ringing in the ears and intervened for a resident who both verbalized intent and attempted to harm himself, as a re-direct result of the ringing in his ears.” It was documented that the deficiency by the nursing staff “resulted in actual harm to the residents. This [failure] had the potential to affect all thirty-five residents.”

    The state investigator interviewed the facility Administrator who said that “the resident was admitted to the facility with this problem of ‘ringing’ and his ears and he knew the resident had the same complaint while residing in another facility.” The Administrator “was asked what was done for the complaint at the other facility.” The Administrator responded that “he was sure that [a neurologist has seen the resident].” When asked to provide documentation of the consultation with a neurologist the Administrator said he would “try to locate it.”

  • Failure to Notify the Resident’s Doctor and the Resident’s Responsible Party Immediately of the Serious Decline in Their Medical Condition That Jeopardizes Their Health
  • In a summary statement of deficiencies dated June 15, 2016, the state investigator noted that the facility failed to “notify the physician and obtain a treatment order for [a resident] for at least twelve days when a pressure ulcer was first identified in the resident’s left heel.” The deficiency by the nursing staff “resulted in harm to the resident.” The surveyor also noted that the facility had failed to “notify the physician of all the multiple pressure ulcers [another resident had] acquired in the facility. This [failure] resulted in actual harm. There is no documentation to show they were unavoidable. The facility identified no additional residents who have pressure ulcers.”

  • Failure to Ensure That Every Resident Receives an Accurate Assessment by a Qualified Health Professional
  • In a summary statement of deficiencies dated June 15, 2016, the state surveyor noted the facility’s failure “to ensure assessments were accurate for [two residents] with pressure ulcers.” One resident was admitted to the facility with “pressure ulcers on her right lateral ankle.” However, the resident’s Admission Minimum Data Set assessment dated February 4, 2016 “contains no documentation that the resident had an existing pressure ulcer on her right ankle at the time of admission or that pressure relieving devices and treatments had been implemented.” A January 29, 2016, Nurses Note revealed that the resident had a Stage II ulcer measuring approximately 1.5 cm in diameter on her right lateral ankle.”

  • Failure to Ensure Residents Receive Proper Treatment to Prevent New Bedsores or Heal Existing Pressure Sores
  • In a summary statement of deficiencies dated June 15, 2016, the state investigator noted that the facility had failed to “ensure that [a resident] did not develop an unavoidable Stage IV pressure ulcer and [other medical conditions] to her left heel. The facility failed to notify the physician and obtain a treatment order for at least twelve days when the pressure ulcer was first identified on the resident’s left heel.”

    In a separate incident, another resident “develop multiple pressure ulcers all over his body with one [sore] on the left foot becoming severely infected. The physician was not notified of all the pressure ulcers. There was no documentation to show they were unavoidable.” The state investigator notified the Director of Nursing, the Corporate Register Nurse, and the Assistant Administrator that an Immediate Jeopardy existed.

  • Failure to Provide an Environment Free of Accident Hazards
  • In a summary statement of deficiencies dated June 15, 2016, the state investigator noted the facility had failed to “provide adequate supervision to prevent falls for [one resident] was clinical records were reviewed for falls. This [failure] resulted in actual harm to [the resident]. The facility identified four residents who were on the fall watch program.”

    One incident was identified in a facility Incident Report that documents that “the resident was found sitting on the floor mat next to the bed. The mat alarm had been activated. The Incident Report documented no new interventions were implemented. The Care Plan had not been updated to reflect this fall. There is no documentation [to show that] the unobserved fall had been investigated.”

    The state investigator interviewed the Director of Nursing concerning the resident’s falls. The Director “was asked how staff identified residents who were at risk for falls.” The Director responded that “may be a dot on the floor for staff to identify residents. If someone is a fall risk, [it is] informed by mouth.” The Director was asked, “if the resident was capable of using a call light.” She responded that “she had not taken the resident to her room to see if she could use the call light [and] ‘I have personally answered her call light before. I think she can use.’”

    The Incident Report stated that the nursing staff performs frequent checks on the resident. When asked, “what frequent checks on the resident meant, [referring to] the Incident Report, [the Director responded] had meant every time staff walked by her room they were to look in.” The investigator asked the Director “if she thought the staff had walked by the resident’s room often since she was at the end of the home the next to the fire door.” The Director responded, “no.”

  • Failure to Ensure There Were Adequate Staff Members at the Facility to Maximize the Resident’s Well-Being
  • In a summary statement of deficiencies on June 15, 2016, was noted that the facility failed to “ensure there was a sufficient number of staff [members at work] to supervise residents and prevent multiple falls with injuries from one resident.” The deficiency by the nursing staff “resulted in actual harm [for a resident]. This [failure] had the potential to affect all twenty residents residing in the facility.” The incident involved a severely cognitively impaired resident who understood others and made yourself understood.

    The residence Incident Report documents that the “resident was found sitting on the floor mat next to the bed. The alarm had been activated,” but there was no documentation that any new “interventions were implemented.” The incident resulted in a “bruise on her right hip. The new intervention was for the resident to use the call light in weight for help for transfers.”

    The state investigator conducted an interview with a Certified Medication Aide who “was asked about staffing. She was asked if she thought there was enough staff to provide care for the residents. She stated she tried to help the Certified Nursing Aides as much as possible, but sometimes she was too busy.” A Certified Nursing Assistant in an interview stated, “she sometimes feels like she needs more help. She stated other people try to help her if they are not too busy.”

    The surveyor interviewed the facility’s Director of Nursing who “was asked who is responsible for the staffing. She stated she did the staffing. The Director was asked how she determines the number of staff required.” The Director responded that “the corporation told me to staff by state ratios. She stated she had been staffing according to acuity [keen thinking] and that staff was busy, and she thought there had been lots of falls.”

  • Failure to Ensure That the Drug Regimen of Every Resident Is Free of Unnecessary Medications to Promote Their Highest Well-Being
  • In a summary statement of deficiencies dated June 15, 2016, the state investigator noted the facility’s failure “to ensure side effect monitoring was conducted for four residents who were reviewed for unnecessary medications.” The Resident Census and Conditions of Resident’s Form dated June 6, 2016, documented that seventeen residents receive psychoactive medications.”

    The incident revealed in a Nurses Note documented that “the resident was admitted from the local hospital [and] was pleasant and confused due to believing he had been in Mexico.” Other records revealed that “he refused to go to bed till midnight [and] is short-tempered [and] experiences delusions as evidenced by thinking he still in the hospital. He presents with a negative attitude. He is difficult to distract and redirect. He is still awake at 2:30 AM.”

    The surveyor noted that the resident’s Monthly Behavior Monitoring Flowsheet dated December 2015, did not contain documentation of side effect monitoring.” The surveyor reviewed the resident’s Care Plan interventions dated January 20, 2015, that “documented to administer medications as ordered and monitor/document for side effects and effectiveness.” As a part of the investigation, the surveyor interviewed the Director of Nursing on June 14, 2016, who was “asked if she could find documentation to indicate the resident was being monitored for side effects of the medication.” The Director responded, “no, they are blank.”

Are You the Victim of Nursing Home Abuse or Neglect?

If your loved one was injured as a resident of Kenwood Manor or any other nursing facility, a personal injury lawyer could help resolve your compensation case quickly. An attorney working on your behalf can ensure that all the necessary documentation is filed in the appropriate Oklahoma county courthouse before the state statute of limitations expires. Your lawyer will build a case by conducting a thorough in-house investigation by gathering evidence and speaking to eyewitnesses.

No upfront payments are necessary because personal injury attorneys accept all nursing home abuse claims for compensation and wrongful death lawsuits through contingency fee agreements. This arrangement provides immediate legal representation without the need to make an upfront payment or retainer.


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