Kimwell Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Kimwell Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 7, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who became unsteady during a transfer and was lowered to the floor by staff, the Facility failed to ensure staff provided quality of care consistent with professional standards of practice, when on 08/30/25, after Resident #1 was lowered to the floor, two Certified Nurse Aides (CNAs) transferred him/her up off the floor without informing and having the nurse assess him/her first for the potential for physical injury, Resident #1 exhibited a sudden change in his/her condition, with signs and symptoms of severe pain, was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a fracture of his/her left hip.Findings include:Review of the Facility's Policy, titled… […]

• No harm, potential for more than minimal, widespreadF880Dec 30, 2021

  Based on observation, staff interview, and policy review, the facility failed to ensure that all staff adhered to its infection control policy regarding quarantined residents and the proper use of personal protective equipment (PPE) during a COVID-19 outbreak. In addition, the facility failed to ensure staff were fit tested for an N-95 (filtering, facepiece respirator), required to be worn by all staff during the outbreak. Findings include: During an interview on 12/30/21 at 8:00 A.M., the Director of Nursing (DON) said that the facility had experienced a recent staff outbreak of COVID-19 (19 staff members reportedly infected with the Coronavirus since 12/9/21) necessitating quarantine of the residents on the K-2 and K-3 units. […]

• No harm, potential for more than minimal, widespreadF886Sep 1, 2021

  Based on interviews and record reviews, the facility failed to conduct COVID-19 testing based on parameters set forth by the Secretary including testing frequency during an outbreak, for three Residents (#1, #2, and #3), out of a sample of five residents, and for four Staff (#1, #2, #3, and #4), out of a sample of five staff. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) memorandum, revised 4/27/21, and titled Interim Final Rule, CMS -3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care Facility Testing Requirements and Revised COVID-19 Focused Survey Tool indicated the following: -An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any… […]

• No harm, potential for more than minimal, patternF584Mar 16, 2026

  Based on observations and interviews, the facility failed to ensure residents had a homelike environment on three of three units. Specifically, the facility failed to: 1. Repair water damaged ceiling tiles on the K3 unit; 2. Ensure Resident #18 had a bedroom with walls, blinds, and durable medical condition in good repair; and 3. Ensure residents' bedrooms were homelike and free from holes and damaged window treatments on the K1 and K2 units.Findings include:Review of the facility's policy titled Homelike Environment, dated 2001, indicated but was not limited to the following:-the facility staff and management maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. […]

• No harm, potential for more than minimal, patternF880Mar 16, 2026

  Based on interview and document review, the facility failed to implement a comprehensive infection control program to include timely surveillance data and a comprehensive analysis which identified interventions when patterns and trends were identified. Specifically, the facility failed to ensure timely and accurate surveillance data for all infection types to identify a pattern of E-Coli Urinary Tract Infections (UTI) (bacterial infection, caused by E-Coli bacteria, typically originating from the gut, entering the urinary tract, and causing inflammation, often due to improper wiping/perineal care) and implement interventions to decrease the risk of residents developing E-Coli UTIs. […]