Kenansville Rehabilitation and Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to provide visual privacy when a buttock wound dressing was changed in the presence of another resident without the privacy curtain being pulled for 1 of 18 residents reviewed for concerns with privacy (Resident #17). Findings included: Nurse #1 was observed on 6/10/25 at 2:30 PM providing wound care to Resident #17's left buttock wound without pulling the privacy curtain between Resident #17's bed and Resident #17's roommate (Resident #35) closest to the window in the room. Nurse #1 was already at bedside ready to complete wound care and was positioned on Resident #17's left side of the bed facing Resident 17's backside. Resident #17 was positioned with her backside turned away from Resident #35's bed with her blankets pulled down, gown pulled up and incontinence brief straps unfastened pulled down on her backside but covering her front. Resident #35 was seated on a wheelchair next to her bed close to the foot of her bed eating a…

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 record review and staff interviews the facility failed to ensure Resident # 9 had transportation arrangements for her podiatry appointments as requested by her husband resulting in Resident #9 missing podiatry appointments for one of one resident reviewed for medically related social services. The findings included: Resident # 9 was admitted into the facility on 7/28/2023 with the diagnoses of diabetes mellites, nontraumatic ischemic infarction of muscle of left lower leg, unspecified atherosclerosis of native arteries of extremities, right leg, cellulitis of left lower limb, acquired absence of other left toe(s). A review of her hospital discharge orders dated 7/28/2023 indicated an order for antibiotic ointment to ulcer to left posterior leg covered with a dressing daily. There was no order for follow-up appointments for podiatry noted. The admission Minimum Data Set, dated [DATE] revealed that Resident #9 was severely cognitively impaired, had no behaviors, had 1 stage 2 pressure ulcer, and was at…

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 record review and staff interviews, the facility failed to staff Registered Nurse (RN) coverage for at least 8 consecutive hours a day for six (6) of the past 38 consecutive days reviewed (10/01/22, 10/02/22, 10/15/22, 10/16/22, 10/29/22, and 10/30/22). Findings included: A review of 10/01/22 through 11/07/22 staff assignment sheet was conducted on 11/07/22. The assignment sheets for 10/01/22, 10/02/22, 10/15/22, 10/16/22, 10/29/22, and 10/30/22 did not indicate a registered nurse was on duty. The daily staff posting sheets for 10/01/22, 10/02/22, 10/15/22, 10/16/22, 10/29/22, and 10/30/22 indicated no data (zero) for the RNs on duty. An interview was conducted with the Scheduler on 11/08/22 at 1:30 PM. The Scheduler explained the staff posting sheets were correct and there was no RN coverage on 10/01/22, 10/02/22, 10/15/22, 10/16/22, 10/29/22, and 10/30/22 due to staff shortages. The Scheduler explained if she did not have enough staff to cover the call roster people would be called. The call roster included the treatment nurse (Licensed Practical Nurse (LPN), 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.

Based on staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the 3/19/21 recertification and complaint investigation survey and the 8/18/21 focused infection control and complaint investigation survey. This was for a recited deficiency on the current recertification survey in the area of infection control. The continued failure during three federal surveys shows a pattern of the facility's inability to sustain an effective QAA program. Findings included: This tag is cross referenced to: F880: Based on observation and record review, the facility failed to implement a Legionella prevention program. This had the potential to effect 51 residents. During the recertification and complaint investigation survey of 3/19/21, the facility was cited for failing to implement their procedures for Personal Protective Equipment (PPE) and hand hygiene. During a focused infection control and complaint investigation survey of 8/18/21, 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.

Based on observation and record review, the facility failed to implement a Legionella prevention program. This had the potential to effect 51 residents. Findings included: Review of the Emergency Preparedness and Infection Control Programs revealed the facility did not have a procedure or program for water safety management for Legionella. Review of the facility water safety plan policy dated 01/27/2022 revealed the following: Water Safety Team shall meet regularly to review water safety program including - Review of monitoring logs - Review of any corrective actions - Review validation results - Review if any changes to plan is required. In an interview on 11/10/2022 at 10:45AM, the Maintenance Supervisor (MS) revealed he had not conducted a Legionella risk assessment of the facility water system. MS stated he will only conduct the risk assessment if there was an outbreak of Legionella at the facility. In an interview on 11/10/22 at 10:50 AM, the Administrator revealed the facility had not conducted a risk assessment for Legionella. She believed assessment was optional unless there…

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, record review, and staff interviews, the facility failed to provide Resident #42 with a pureed diet as ordered by the physician due to a history of difficulty swallowing when a peanut butter and jelly sandwich was served to the resident by Nurse Aide (NA) #1 and the failed to provide pureed ham of a smooth consistency for 11 of 11 residents on a pureed diet. Findings included: 1. Review of the facility's recipe for Baked Ham included instructions to prepare the ham according to the regular recipe, measure out desired number of servings into the food processor and blend until smooth using milk or broth to thin as needed. An observation occurred on 11/9/22 at 11:40 AM of the lunch meal with the regional dietary manager present. He indicated the foods on the tray line were ready for service. The pureed ham on the tray line had a chunky consistency with visible pieces of ham. The regional dietary manager confirmed it was the pureed ham. During an interview at 11/9/22 at 11:40 AM, the Regional…

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 interviews, and record review, failed to date leftover food stored for use in one of one (300 hall) nourishment room refrigerator. This had the potential to affect food served to residents. Findings included: A tour was conducted on 11/7/22 at 10:15 AM of the facility's nourishment room with Dietary Aid #1. The refrigerator revealed a to-go box of food with a resident's name and no date, a plastic lidded container with a resident's name and no date, a plastic to-go container with a resident's name and no date, and a gallon jug of tea with no date. During an interview on 11/7/22 at 10:17 AM, Dietary Aid #1 revealed she checked the refrigerator daily and discards foods with no name or date. She revealed she had checked the refrigerator that morning. During an interview on 11/8/22 at 1:45 PM, the Dietary Manager revealed the dietary aids checked the refrigerators daily and should discard food with no name or date. He indicated he checked the refrigerators most days as well. During an interview on 11/9/22 at 3:25 PM, the Administrator revealed she expected…

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, record review, and staff interviews, the facility failed to develop a comprehensive care plan to address a resident's behavior of putting non-food items in his mouth for 1 of 13 (Resident #42) residents reviewed for comprehensive care plans. Findings included: Resident #42 was admitted to the facility on [DATE] with diagnoses that included dementia. A physician's order dated 4/28/22 for Resident #42 indicated remove potentially dangerous objects from resident including drinking straws every shift included directions resident puts objects in his mouth and chews on them. Resident #42's annual Minimum Data Set (MDS) dated [DATE] indicated he had severe cognitive impairment. A nursing progress note dated 8/6/22 indicated Resident #42 was found in his room chewing on his bed sheet. A nursing progress note dated 8/9/22 indicated Resident #42 was found chewing on his oxygen tubing several times. A nursing progress note dated 8/28/22 indicated Resident #42 was found in his room with a piece of…

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.