Inspection visit
Inspection
14 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 14 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure residents have a right to
personal privacy; personal privacy includes accommodations, medical treatment, written and telephone
communications, and personal care, for 1 of 4 residents (Resident #40) reviewed for privacy, in that:
Residents Affected - Few
CNAs A and B did not completely close Resident #40's privacy curtain while providing catheter/incontinent
care.
This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.
The findings include:
Record review of Resident #40's face sheet, dated 08/30/2024, revealed an admission date of 11/02/2022
and, a readmission date of 01/02/2023, with diagnoses which included: Dementia (decline in cognitive
abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Major depressive disorder (mental
disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or
pleasure), Hypertension (high blood pressure) and, Peripheral vascular disease (abnormal narrowing of
arteries reducing blood flow to the arms or legs).
Record review of Resident #40's Quarterly MDS assessment, dated 08/20/2024, revealed the resident had
a BIMS score of 15, indicating he had no cognitive impairment. Resident #40 was always incontinent of
bowel and had a urinary catheter and, required extensive assistance with most of his ADLs.
Record review of Resident #40's care plan, dated 11/02/2022, revealed a problem of ADLS: The resident
has an ADL Self Care Performance Deficit Limited Mobility -Bilateral Below the Knee Amputation, with an
intervention of TOILET USE: the resident is totally dependent on staff for toilet use. Incontinent of bowel checked every 2 hours and as needed and incontinent/ perineal care rendered per nursing staff as needed
Observation on 08/30/24 at 09:23 a.m. revealed CNA A and CNA B did not completely close the privacy
curtains while they provided catheter/incontinent care for Resident #40, exposing the resident who could be
seen from the room's door. Further observation revealed Resident #40's roommate was sitting on his bed
and was ambulatory as indicated by the walker next to him. After finishing cleaning Resident #40, CNA B
collected the soiled supply and opened the door to put it in the barrel outside the room while Resident #40
was still fully exposed.
During an interview with CNA A and CNA B on 08/30/2024 at 9:30 a.m., CNA A and CNA B stated the
privacy curtain was not completely closed while they provided care for Resident #40 but it should have
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
676173
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kenedy Health & Rehabilitation
7882 S Hwy 181 (No Mail Service)
Kenedy, TX 78119
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0583
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
been. CNAs A and B stated Resident #40's roommate was ambulatory and could have stood up and seen
Resident #40 exposed during care. CNA B stated opening the room's door while the resident was still
exposed. CNAs A and B stated they had received resident rights training within the year.
During an interview with the DON on 08/30/2024 at 9:39 a.m., the DON stated privacy must be provided
during nursing care and Resident #40's privacy curtains should have been closed completely. The DON
confirmed the staff had received training on resident rights within the year and the training was provided by
herself, and they also checked the staff skills annually and as needed. The DON further stated that she,
ADON, and the weekend RN supervisor did skills spot checks as well.
Review of the facility's policy titled Perineal care, dated 5/11/2022, revealed, Procedure content [ .[ 7/
Provide privacy and modesty by closing the door and/or curtain.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676173
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kenedy Health & Rehabilitation
7882 S Hwy 181 (No Mail Service)
Kenedy, TX 78119
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure residents have a right to a safe, clean,
comfortable and homelike environment, including but not limited to receiving treatment and supports for
daily living safely, for 1 of 2 shower rooms (Shower room [ROOM NUMBER]) and 2 of 26 resident rooms
(Rooms #17 and #24) reviewed for safe, clean, and comfortable environment.
The facility failed to repair missing and detached floor molding in a resident's room, replace a broken
overhead light in a resident's shower room, and repair a scratched standing clothes closet in a resident's
room.
This deficient practice could place residents at risk of a diminished quality of life due to exposure to an
environment that is unpleasant, unsanitary, and unsafe.
The findings included:
During an observation on 08/29/24 from 1:40 p.m. to 1:50 p.m. with the Maintenance Director. revealed the
following:
a. Resident room [ROOM NUMBER] had a 3.5 ft x 4 inch section of missing floor molding along the bottom
surface of the wall adjoining to the floor surface. There was also a 4 x 4 inch section of floor molding in the
bedroom proper that was detached from the wall.
b. Resident Shower room [ROOM NUMBER] had 1 of 2 overhead lights which measured approximately 3 ft
in length that was not working.
c. Resident room [ROOM NUMBER] had a standing clothes closet that had an approximate 2 x 2 ft surface
area on the front and side that contained multiple scratch marks that were ingrained into the wood surface.
During an interview with the Maintenance Director on 08/29/24 at 1:55 p.m., the Maintenance Director
stated that he had not been made aware by staff of the noted areas needing to be repaired. The
Maintenance Director stated that fixing the noted repairs would promote a more positive home environment
for the residents.
During an interview with the Administrator on 6/5/24 at 2:00 p.m., the Administrator stated that fixing the
floor molding in room [ROOM NUMBER], replacing the broken light in Shower room [ROOM NUMBER],
and repairing the scratched clothes closet in room [ROOM NUMBER] would promote a more positive home
environment for the residents.
Record review of the facility's policy on Preventative Maintenance/Work-Order Request Section AD 03-12.0
dated 2003 stated The facility will repair or replace damaged/broken equipment or building amenities as
needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676173
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kenedy Health & Rehabilitation
7882 S Hwy 181 (No Mail Service)
Kenedy, TX 78119
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure the resident environment remains as
free of accident hazards as is possible for 1 of 2 shower rooms (Shower room [ROOM NUMBER]) reviewed
for accidents and hazards, in that
The facility failed to keep hazardous items out of reach of residents in a shower room.
This deficient practice could place residents at risk of a diminished quality of life due to exposure to an
environment that is unpleasant, unsanitary, and unsafe.
The findings included:
Observation on 08/27/24 at 11:30 a.m., revealed the door of Shower room was left open. Inside the room
was a wall cabinet also left unlocked. Inside the cabinet were a razor, 3 bottle of shaving cream and a bottle
of Micro kill one wipes.
Review of the safety data sheet for micro kill one wipe revealed ACUTE TOXICITY - INHALATION Category 4 FLAMMABLE LIQUIDS - Category 2 SERIOUS EYE DAMAGE /EYE IRRITATION - Category
2A
SPECIFIC TARGET ORGAN TOXICITY (Single Exposure) - Category
During an Interview with CNA A on 08/27/24 at 11:40 a.m., CNA A confirmed the door of the shower room
and the wall cabinet were kept unlocked. CNA A confirmed the wipes. razor and shaving cream were in the
cabinet. CNA A confirmed the cabinet should have been locked to prevent resident to get in contact with
hazardous materials.
During an interview with the DON on 08/27/24 at 12:05 p.m., the DON confirmed either the door of the
shower room or the doors of the wall cabinet should remain locked. The DON confirmed the wipes, razor
and shaving cream could be a hazard. The DON confirmed having several residents in the facility who are
ambulatory but have mental illness diagnostics and/or dementia who could misuse the hazardous products
and hurt themselves or others.
Review of the facility policy, titled Hazardous communication program, dated 2003, revealed [ .] The facility
will provide adequate and appropriate space and equipment for safe handling and storage of hazardous
materials and waste. The storage areas will have the capacity to be secured and meet the provision of the
Life Safety Code.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676173
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kenedy Health & Rehabilitation
7882 S Hwy 181 (No Mail Service)
Kenedy, TX 78119
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on observation, interview, and record review, the facility failed to ensure a resident who was
incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of
2 residents (Resident #41) reviewed for incontinent care, in that:
The facility failed to ensure CNA C thoroughly cleaned Resident #41 while providing incontinent care.
This deficient practice could place residents at-risk for infection and skin break down due to improper care
practices.
The findings were:
Record review of Resident #41's face sheet, dated 08/29/2024, revealed an admission date of 09/11/2022,
with diagnoses which included: Hypothyroidism (under active thyroid), Anxiety disorder (A group of mental
illnesses that cause constant fear and worry), Hyperlipidemia (Elevated level of any or all lipids(fat) in the
blood), Dementia (decline in cognitive abilities), Schizoaffective disorder (mental disorder characterized by
abnormal thought processes and an unstable mood), Major depressive disorder(mental disorder
characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or
pleasure) and, Hypertension (High blood pressure).
Record review of Resident #41's Significant change MDS assessment, dated 05/28/2024, revealed
Resident #41 has a BIMS score of 12, which indicated mild to moderate cognitive impairment. Further
review revealed Resident #41 required limited to extensive assistance with ADLs and was indicated to
occasionally be incontinent of bladder and frequently incontinent of bowel.
Record review of Resident #41's care plan, dated 05/06/2024, revealed a problem of The resident has
Urinary Tract Infection, with an intervention of Provide incontinence care as needed.
Observation on 08/29/24 at 9:17 a.m. revealed, while providing incontinent care for Resident #41, CNA C
did not clean between the buttocks' cheeks or the rectal area of the resident.
During an interview on 08/29/2024 at 9:30 a.m. CNA C stated she did not clean between the resident's
buttocks' cheeks area. CNA C stated she should have cleaned the rectal area. CNA C stated she had
received training for infection control and incontinent care within the last year.
During an interview with the DON on 08/29/2024 at 3:15 p.m., the DON stated the buttocks and rectal area
had to be cleaned. The DON stated she was the one training the staff for infection control and incontinent
care and that the ADON, weekend RN supervisor and herself would check the staff skills annually and as
needed if a problem was noted.
Record review of facility policy, titled Perineal care, dated 95/11/2022, revealed [ .] Gently perform care to
the buttocks and anal area, working from front to back without contaminating the perineal area.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676173
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kenedy Health & Rehabilitation
7882 S Hwy 181 (No Mail Service)
Kenedy, TX 78119
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure that residents who needed respiratory
care were provided such care, consistent with professional standards of practice, the comprehensive
person-centered care plan and the residents' goals and preferences for 1 of 3 residents (Resident #8)
reviewed for respiratory care.
Residents Affected - Few
The facility failed to ensure Resident #8's oxygen concentrator was not dirty.
That failure could place residents who required respiratory treatments at risk of receiving inadequate
respiratory treatments and could result in a decline in health.
The findings were:
Record review of Resident #8's face sheet, dated 08/27/24, revealed Resident #8 was admitted to the
facility on [DATE] and, readmitted on [DATE], with diagnoses that included: Dementia (decline in cognitive
abilities), Aphasia (unable to comprehend or formulate language), Hypoxia (the body is deprived of
adequate oxygen supply), Schizoaffective disorder (mental disorder characterized by abnormal thought
processes and an unstable mood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood)and,
Hypothyroidism (under active thyroid).
Record review of Resident #8's quarterly MDS dated [DATE] revealed a BIMS of 6, indicating the resident
was severely cognitively impaired. Further review of this MDS revealed in Section O, Special Treatments
and Programs, that the resident received oxygen therapy.
Record review of Resident #8's physician orders for August 2024 revealed the following order: Continuous
Oxygen via nasal cannula at 4 Liter Per Minute due to low O 2 saturation every day and night shift for
Shortness of Breath related to RESPIRATORY FAILURE, UNSPECIFIED WITH HYPOXIA to begin on
4/19/2023.
Observation on 08/27/2024 at 11:20 a.m. revealed Resident #8's oxygen concentrator's intake air grill was
partially covered with gray dust and a sticky substance.
During an interview on 08/27/2024 at 12:05 p.m., the DON revealed the concentrator did not require a
outside filter since it had a filter inside that was changed every two years when the manufacturer does the
maintenance. Th eDON the staff should have cleaned the concentrator outside.
Record review of facility undated policy, Oxygen Administration,, dated 03/21/23 revealed: oxygen
concentrator should be cleaned according to manufacturer recommendations.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676173
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kenedy Health & Rehabilitation
7882 S Hwy 181 (No Mail Service)
Kenedy, TX 78119
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to maintain clinical records in accordance with
accepted professional standards and practices that are complete and accurately documented for 1 of 18
residents (Resident #8) observed for accuracy of medical records in that:
The facility failed to have an appropriate order regarding the maintenance of Resident #8's oxygen
concentrator.
This deficient practice could place residents at risk for errors in care and treatment.
The findings were:
Record review of Resident #8's face sheet, dated 08/27/24, revealed Resident #8 was admitted to the
facility on [DATE] and, readmitted on [DATE], with diagnoses that included: Dementia (decline in cognitive
abilities), Aphasia (unable to comprehend or formulate language), Hypoxia (the body is deprived of
adequate oxygen supply), Schizoaffective disorder (mental disorder characterized by abnormal thought
processes and an unstable mood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood)and,
Hypothyroidism (under active thyroid).
Record review of Resident #8's quarterly MDS dated [DATE] revealed a BIMS of 6, indicating the resident
was severely cognitively impaired. Further review of this MDS revealed in Section O, Special Treatments
and Programs, that the resident received oxygen therapy.
Review of Resident #8's physician orders for August 2024 revealed the following order: Change or clean the
filter of the 02 concentrator every night shift every Sunday started on 4/23/23.
Review of Resident #8's Medication and Treatment administration record for August 2024, revealed the staff
had signed on Sundays for changing or cleaning the filter as done.
Observation of Resident #8's bedroom on 08/27/2024 at 11:20 a.m. revealed no apparent filter on the back
air intake grill at the back of the oxygen concentrator.
During an interview with the DON on 8/27/2024 at 12:05 p.m., the DON revealed the concentrator did not
require a outside filter since it has a filter inside that is change every two years when the manufacturer does
the maintenance. The order to change or clean the filter was incorrect. The staff should not have signed the
filter [NAME] as done.
Record review of facility's policy, titled purpose and requirements medical records, dated 2015, revealed
The medical record is a legal document that serves the purpose of: 1. providing an accurate assessment of
each resident's condition.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676173
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676173
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kenedy Health & Rehabilitation
7882 S Hwy 181 (No Mail Service)
Kenedy, TX 78119
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interviews, and record reviews, the facility failed to maintain an Infection prevention
and control program designed to provide a safe, sanitary and comfortable environment and to help prevent
the development and transmission of communicable disease and infection for 1 of 4 residents (Resident
#41) reviewed for infection control, in that:
Residents Affected - Few
CNA C did not change her gloves or wash her hands after providing incontinent care for Resident #41.
These deficient practices could place residents at-risk for infection due to improper care practices.
The findings included:
Record review of Resident #41's face sheet, dated 08/29/2024, revealed an admission date of 09/11/2022,
with diagnoses which included: Hypothyroidism (under active thyroid), Anxiety disorder (A group of mental
illnesses that cause constant fear and worry), Hyperlipidemia (Elevated level of any or all lipids(fat) in the
blood), Dementia (decline in cognitive abilities), Schizoaffective disorder (mental disorder characterized by
abnormal thought processes and an unstable mood), Major depressive disorder(mental disorder
characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or
pleasure) and, Hypertension (High blood pressure).
Record review of Resident #41's Significant change MDS assessment, dated 05/28/2024, revealed
Resident #40 has a BIMS score of 12, which indicated mild to moderate cognitive impairment. Resident
#40 required limited to extensive assistance with hid ADLs and was indicated to occasionally be incontinent
of bladder and frequently incontinent of bowel.
Review of Resident #41's care plan, dated 05/06/2024, revealed a problem of The resident has Urinary
Tract Infection, with an intervention of Provide incontinence care as needed.
Observation on 08/29/24 at 09:17 a.m., revealed, while providing incontinent care for Resident #41, CNA C
did not change her gloves or wash her hands after providing incontinent care for Resident #41 and before
touching and fastening the clean brief to Resident #41.
During an interview on 08/29/2024 at 09:27 a.m. CNA C confirmed she did not change her gloves or wash
her hands prior to touch the clean brief. She confirmed she received infection control training with the year.
During an interview with the DON on 08/29/2024 at 3:15 p.m., the DON confirmed gloves must be changed
after cleaning and before touching clean brief to prevent cross contamination. The DON revealed she was
the one training the staff for infection control and that the ADON, weekend RN supervisor and herself would
check the staff skills annually and as needed if a problem was noted.
Review of facility policy, titled Fundamental of infection control precautions, dated 2019, revealed [ .] the
following is a list of some situations that require hand hygiene: [ .] Before and after direct resident contacts
(for which hand hygiene is indicated by acceptable professional practice) [ .] after contact with a resident's
mucous membranes and body fluids or excretions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676173
If continuation sheet
Page 8 of 8
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Back to topCitations
14 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the August 30, 2024 survey of KENEDY HEALTH & REHABILITATION?
This was a inspection survey of KENEDY HEALTH & REHABILITATION on August 30, 2024. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at KENEDY HEALTH & REHABILITATION on August 30, 2024?
Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep residents' personal and medical records private and confidential."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.