Kenansville Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Kenansville Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 14, 2022

  Based on observations, staff interviews, and record review, the facility failed to provide supervision to prevent a cognitively impaired resident with a history of putting non-food items in his mouth from placing a plastic sandwich bag in his mouth for 1 of 4 residents (Resident #42) reviewed for accidents. In addition, the facility had fall interventions in place that were not effective for a resident with severly impaired cognition and poor impulse control, did not complete a root cause analysis to assist with determining new fall interventions, and did not evaluate the effectiveness of fall interventions for 1 of 3 residents (Resident #501) reviewed for falls. […]

• No harm, potential for more than minimal, widespreadF727Nov 14, 2022

  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. […]

• No harm, potential for more than minimal, widespreadF867Nov 14, 2022

  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. […]

• No harm, potential for more than minimal, widespreadF880Nov 14, 2022

  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. […]

• No harm, potential for more than minimal, patternF803Aug 27, 2026

  Based on record reviews and interviews with residents and staff, the facility failed to follow the planned menu and did not offer required substitutes for 1 of 1 breakfast meal. Forty residents with no dietary restrictions, who were scheduled to receive hash browns, did not receive the menu item as planned. Findings included: Review of the facility menu dated 08/27/2026 revealed hash browns were to be served during breakfast. Resident #42 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) for Resident #42, dated 06/01/2026, indicated that the resident's cognition was intact. Resident #64 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) for Resident #64, dated 08/07/2026, indicated that the resident's cognition was intact. […]