Kenedy Health & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, meet professional standards of quality for 1 of 5 residents (Residents #1) reviewed for following physician orders. The facility failed to obtain a specialty care follow up appointment to the urologist for Resident #1 ordered post hospitalization on 1/7/26 after the insertion of a supra pubic catheter. Resident #1 was transferred to the hospital on 6/23/26 related to a change in condition and was diagnosed with sepsis and a urinary tract infection while at the hospital. These failures could place the residents at risk of not having their individual needs met and of not receiving adequate care and medical interventions to maintain their health and prevent worsening health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure a bag of biscuits was properly sealed in the reach in freezer. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review for one of one PASRR positive resident (Resident #47) who had a significant change in mental or physical condition. The facility failed to notify the LMHA of Resident #47's significant change in mental and physical status after submitting a significant change MDS on 10/22/2025. This failure could potentially result in PASRR positive residents receiving services of not having their needs evaluated to determine if additional services were required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment, for 1 of 18 residents (Residents #5) reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan that addressed Resident #5's self-care of his indwelling catheter. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 18 residents (Residents #7) reviewed for care plans, in that: The facility failed to revise Resident #7's comprehensive care plan to reflect the resident's change in hearing status. This deficient practice could place residents with a decline at risk of receiving proper care.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's environment was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent avoidable accidents for 1 of 6 residents (Resident #3) whose care was reviewed for accidents and hazards, in that: The facility failed to complete quarterly smoking risk assessments for Resident #3. This deficient practice could affect residents who used tobacco and could result in avoidable accidents from improper supervision during tobacco use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and service to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 (Resident #53) residents reviewed for incontinent care. The facility failed to ensure CNA A thoroughly cleaned Resident #53's buttocks and anal area during incontinent care. This deficient practice could place residents at-risk for infection and/or skin breakdown.

Inspectors wroteBased on observation, interview, 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 development and transmission of communicable disease and infection for 1 of 5 resident (Resident #53) reviewed for infection control, in that: 1. The facility failed to ensure CNA A washed her hands before starting to provide incontinent care for Resident #53. 2. The facility failed to ensure CNA A sanitized between her fingers while she provided incontinent care for Resident #53. These deficient practices could place residents at-risk for infection due to improper care practices. Record review of Resident #53's face sheet, dated 12/04/2025, revealed an admission date of 11/29/2024. Resident #53 had diagnoses which included: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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: 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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: 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to ensure Resident #1 did not elope from the facility without staff knowing on the evening of 4/8/2024. The noncompliance was identified as PNC. The IJ began on 4/8/2024 and ended on 4/9/2024. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at-risk of harm, serious injury, or death.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide an MDS assessment that accurately reflected the resident's status for one resident (#41) of 8 residents reviewed for accurate assessments in that: Resident #41's chronic pain and cardiac pacemaker were not listed as active diagnoses on his MDS assessment. This deficient practice could affect residents who receive MDS assessments and could result in missed care.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for one resident (#4) out of 5 residents reviewed for accident hazards in that: LVN A disposed of the lancet she used to check Resident #4's blood glucose level in the regular trash container on the medication cart and not the sharps container. This deficient practice could affect residents and could result in injury.

Inspectors wroteBased on observations, interviews and record reviews. the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for one resident (#29) of three residents reviewed for oxygen therapy, in that: Resident #29's oxygen was set to 4L/NC instead of 3L/NC as ordered by the physician. This deficient practice could affect residents who receive oxygen therapy and could result in respiratory distress.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure all drugs and biologicals are stored locked compartments and permit only authorized personnel to have access to the keys for 1 of 5 residents (Resident #19) reviewed for storage of medications, in that: Resident #19 had what appeared to be and smelled like cough medicine at his bedside in a specimen cup and an empty brown pill container without a label. This deficient practice could place residents at risk of ingesting unknown medications not ordered by their physicians in an unsupervised manner.