Kennybrook Village

Based on observation, staff interview, and policy review, the facility failed to serve food within appropriate temperature ranges for one of one meals observed. The facility reported a resident census of 39.Findings include:On 1/21/26 at 12:05 PM, a lunch food check revealed the following preservice temperatures:Chicken parmesan - 142.3 deg FSpaghetti noodles - 149 deg FVegetables - 177 deg FBread - 153.4 deg FSpaghetti sauce - 173.6 deg FBeef pot pie - 161 deg FChicken noodle soup - 196 deg FMechanical soft (MS) chicken parmesan - 159.1 deg FMechanical soft (MS) beef pot pie - 173 deg FPureed chicken parmesan - 189 deg FPureed noodles - 175.8 deg FPureed bread - 179 deg FPureed vegetables - 154.5 deg FAt 1:06 PM, the food temperatures revealed the MS chicken parmesan temperature was 125.2 deg F and the Pureed chicken parmesan temperature was 126.3 deg F which indicated they did not maintain a safe temperature of at least 135 deg F throughout lunch service. All other food items' post-service temperatures exceeded 135 deg F.At 1:10 PM, the Dietician stated the MS and pureed foods are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy review, the facility failed to maintain sanitary practices by touching food with contaminated, gloved hands during food service for one of one meal services observed. The facility reported a census of 39 residents.Findings include:On 1/20/2026 at 11:17 AM, a continuous meal service observation revealed Staff A, Culinary Aide (CA) placed his right oven mitt covered thumb inside the pan of peas and directly touched the food.At 11:34 AM, Staff A put on gloves, packed up a food thermometer, grabbed the temperature logbook, placed them both on the back counter, and returned to serving resident food. During service, he grabbed Tostitos chips with the same gloved hands and put them on a resident's plate.At 11:46 AM, Staff B, CA put on gloves, handled plates, ladles, and scoops then returned to serving resident food. During food service, she grabbed Tostitos chips with the same gloved hands and put them on a resident's plate. She did it four (4) times.At 11:15 AM, Staff A stated he received Infection Prevention training upon hire in March…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 2 of 3 residents reviewed (Resident #35 and Resident #4). The facility failed to ensure use of Enhanced Barrier Precautions (EBP) when required for Resident #35 and failed to perform hand hygiene and infection control practices during wound care for Resident #4. The facility reported a census of 39 residents. Findings include: 1.The Minimum Data Set (MDS) for Resident #35, dated 12/31/2025, included diagnoses of Non-Alzheimer's Dementia and pressure- induced damage of sacral region (buttocks). The MDS identified the resident was dependent on staff for transfers. The MDS identified the resident had a Stage 2 pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer). The MDS indicated the resident had a BIMS score of 5, indicating severe cognitive impairment. The Care Plan with initiated date of 10/24/25 for Resident#35 documented a Deep Tissue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, review of the facility's Provider History Profile reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies. This resulted in multiple repeat deficiencies identified on the facility's current recertification and complaint survey. The facility reported a census of 35 residents. Findings include: Review of the facility's Provider History Report revealed the facility received the same deficiency for three (3) consecutive recertification surveys. The deficiency category was for failing to accurately follow resident menus. On 1/09/25 at 2:50 PM, the Certified Dietary Manager (CDM) stated she assigned all staff to watch a video on diet portion sizes as part of the QAPI Performance Improvement Plan (PIP). At 2:55 PM, the Administrator stated the CDM held monthly in-services and the administrative team held a skills fair twice yearly. She stated the video was provided to staff on 4/30/24 and 5/02/24. She stated all staff should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to follow the appropriate diet and serve the appropriate portions for (2) residents (#11, #18) who received pureed diets and failed to follow the menu diet for all residents who received gravy. The facility reported a census of 35 residents. Findings include: On 1/08/25 at 10:40 AM, Staff B, Cook, began making the pureed pork. He placed six (6) small pieces of pork into the blender and added 2 ounces (oz) of beef base. He blended the contents. He emptied the contents into a steam table bowl. Some of the contents was observed still in the blender when rinsed. The total volume was not measured and the Dishers Scoop Sizes, Colors and Yields chart was not used to determine the appropriate serving size prior to being served. At 11:37 AM, Staff C, Dietary Aide (DA), placed serving utensils in each menu item pan. She stated a #20 disher (1.6 fluid oz) was used for the pureed pork and pureed vegetable serving sizes, and a black handled scoop was used for gravy. She was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature for one of one meal service observed. The facility reported a census of 35 residents. Findings include: On 1/08/23 at 11:37 AM, a continuous lunch service observation revealed Staff C, Dietary Aide (DA), obtained the temperature of one (1) food item, Salmon croquettes, prior to service and noted the temperature of 123.5° Fahrenheit (F). All other lunch menu items met acceptable temperatures. At 12:20 PM, Staff C obtained the temperatures of remaining lunch menu items after meal service ended. The results were: 1) Salmon croquettes - 117° F 2) Mashed potatoes - 124.8° F 3) Vegetable egg rolls - 122° F 4) Pureed pork - 124° F 5) Mechanical Soft egg rolls - 120° F A policy titled Food Preparation and Service revised 10/2018 indicated food held at temperatures between 41° F and 135° F promoted the rapid growth of pathogenic organisms that cause foodborne illness and must be maintained above 135° F. On 1/09/25 at 2:03 PM, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility policy review, the facility failed to maintain sanitary practices by improperly storing and serving food. The facility reported a census of 35 residents. Findings include: On 1/06/25 at 10:20 AM, an initial kitchen observation identified the following findings: A [NAME] refrigerator contained: 1) Two (2) undated, unlabeled, sealed packs of long, round, hot-dog looking items. 2) Three (3) opened, undated bags of grapes in a single labeled box. 3) One (1) undated, previously opened 2-liter bottle of A&W root beer. 4) Three (3) undated, unlabeled, clear dispensers with a clear liquid and round, orange, disk shaped items. 5) Four (4) unlabeled, loaf shaped packages of a dark pink substance. A [NAME] freezer 1) One (1) undated, unlabeled, clear plastic bag with round, yellow items. 2) One (1) undated, unlabeled, clear plastic bag with a pink, meat-looking item on a cookie pan. The kitchen area contained: 1) A white bin labeled sugar had 1 sealed bag of sugar, 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing, preparing, and serving food. The facility reported a census of 39 residents. Findings include: During an initial kitchen observation on 9/25/23 at 9:35 AM, the following findings were identified: -Observed all of the Heating, Ventilation, and Air-Conditioning diffusers (HVAC vents) missing and two (2) ducts blowing air directly on a pan of barbeque (BBQ) chicken located on the food preparation table. Another exposed duct blowing air directly on the area designated for newly washed dishware. -Observed a serving scoop stored inside a bin of flour in direct contact with the contents. -Observed Staff A, Cook, did not have his facial hair covered while preparing food and Staff B, Dietary Aide (DA), did not cover the back of her hair while handling food. -The [NAME] refrigerator contained an undated bag of previously opened dinner rolls, a partially covered tray of vegetable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and facility policy review, the facility failed to maintain a clean, comfortable and homelike environment for 2 out of 8 resident rooms. The facility reported a census of 39 residents. Findings include: 1. On 09/25/23 at 11:00 AM observation of the carpeted floor in room [ROOM NUMBER] revealed excessive stains of various sizes and colors. A urine odor noted in the room. A second observation on 09/26/23 at 09:00 AM of room [ROOM NUMBER] revealed no changes to the stained carpet and continued to have a strong urine odor. A third observation on 09/27/23 at 10:00 AM of room [ROOM NUMBER] showed stained carpet and urine odor remained unchanged. During an interview on 09/27/23 at 12:20 PM the Housekeeping Supervisor and the Maintenance Supervisor both confirmed the carpet was excessively stained and the urine odor noted but could not provide a date of the last time the carpet was shampooed. 2. On 09/26/23 at 10:10 AM observation of the carpeted floor in room [ROOM NUMBER]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview and staff interviews, the facility failed to provide restorative activities for 1 of 1 sampled resident in order to maintain a functional range of motion and prevent a decline in activities of daily living (Residents #3). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 had diagnoses that included anemia (low blood count), arthritis, Alzheimer's Disease, muscle weakness, and abnormal gait and mobility. The MDS revealed the resident required limited assistance of one for bed mobility, transfers, dressing, personal hygiene, and toileting. The MDS indicated no range of motion (ROM) impairment to the upper and lower extremities. The MDS revealed the resident had Occupational Therapy (OT) services from 4/10/23 - 5/31/23 and was actively receiving Physical Therapy (PT) services that began 7/2/23. The Electronic Health Record (EHR) for the resident recommended for Restorative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve the appropriate portions for the last five (5) residents who received green beans or mashed potatoes. The facility reported a census of 39 residents. Findings include: On 9/27/23 at 12:53 PM, observed Staff C, Dietary Aide (DA) partially fill a #8 (4-oz) scoop for a serving of potatoes and a 4-oz ladle for a serving of green beans for the last 5 resident servings. At 12:59 PM, the Registered Dietician stated the serving size of vegetables is 4 oz. but less dense starches required larger portion servings. A review of the Week 5 Wednesday menu indicated a serving size of mashed potatoes was a #8 scoop and a serving size of green beans was four (4) ounces. A document titled Diet Type Report provided by the Dietary Manager revealed no resident was ordered half-portion sizes for meals. On 9/28/23 at 10:25 AM, the Dietary Manager stated staff should provide serving sizes according to the guidelines. A policy titled Kitchen Weights and Measures revised 10/2018…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interview, and facility policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 39. Findings include: During a continuous observation on 9/27/23 beginning at 11:33 AM, Staff C, Dietary Aide (DA), obtained the temperatures of two (2) foods that were noted to be below the acceptable holding temperature. The mechanical soft turkey had a temperature of 131.4° Fahrenheit (F) and the pureed turkey had a temperature of 93° F. At 12:32 PM, Staff C prepared a resident plate containing the mechanical soft turkey but was asked to recheck the temperature of the mechanical soft turkey before serving it. The temperature observed to be 129° F and it was subsequently reheated to 190° F before being served to a resident. The pureed turkey was served to the resident without rechecking the temperature or being reheated. A policy titled Food Preparation and Service revised 10/2018 indicated food held at temperatures between 41° F and 135° F promoted the rapid growth of pathogenic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.