Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kennybrook Village during CMS and state inspections, most recent first.
Food was not maintained at a safe temperature during lunch service when mechanical soft and pureed chicken parmesan dropped below 135 deg F while being served from a warming oven instead of the usual steam table. A Dietician stated the items were moved because of the number of lunch items, and the DM said staff should have checked temperatures periodically when the warming location changed. Facility policy identified improper holding temperatures as a critical factor in foodborne illness and defined the danger zone as 41 deg F to 135 deg F.
Contaminated Gloved Hands Used During Meal Service: During meal service, a CA touched peas with an oven mitt covered thumb and later used the same gloved hands to handle chips and serve a resident after handling a thermometer and logbook. Another CA also handled plates, ladles, and scoops with gloved hands and then used the same gloves to serve chips to a resident multiple times. The DM stated staff should have used appropriate equipment such as tongs, and the facility policy prohibited bare hand contact with food and required glove changes between tasks.
Infection control practices were not maintained for two residents. One resident with a wound and EBP requirements was transferred by CNAs wearing gloves only, without the gown and gloves required for high-contact care. Another resident with multiple wounds received dressing changes from an LPN who repeatedly removed gloves without hand hygiene, used the same scissors for dirty and clean tasks without sanitizing them, and touched a trash can lid during care without sanitizing hands afterward.
The facility failed to effectively implement a QAPI process to address repeat deficiencies related to following resident menus, as identified in consecutive surveys. Despite assigning staff to watch a video on diet portion sizes, there was no documentation of follow-up to assess the efficacy of the Performance Improvement Plan (PIP).
The facility did not follow dietary guidelines for two residents on pureed diets and all residents receiving gravy. Staff failed to measure and use appropriate scoop sizes, resulting in incorrect portion sizes. The facility's policy on portion sizes was not adhered to, leading to discrepancies in serving sizes for pureed pork, vegetables, and gravy.
The facility failed to maintain food at a safe and appetizing temperature during a lunch service. A Dietary Aide recorded the temperature of salmon croquettes at 123.5°F before service, below the required 135°F. After the meal, several items, including salmon croquettes, mashed potatoes, and egg rolls, were below the required temperature. The facility's policy states food must be above 135°F to prevent foodborne illness. The Administrator acknowledged the need for staff to ensure correct temperatures and report discrepancies.
The facility was found deficient in maintaining sanitary practices for food storage and handling. Observations revealed undated and unlabeled food items in the kitchen and improper hand hygiene by staff during food preparation. These actions violated the facility's policies on food safety and cross-contamination prevention.
Food Held Below Safe Temperature During Lunch Service
Penalty
Summary
The facility failed to serve food within appropriate temperature ranges for one of one meals observed. On 1/21/26 at 12:05 PM, a lunch food check showed multiple items at preservice temperatures, including chicken parmesan, spaghetti noodles, vegetables, bread, spaghetti sauce, beef pot pie, chicken noodle soup, mechanical soft chicken parmesan, mechanical soft beef pot pie, pureed chicken parmesan, pureed noodles, pureed bread, and pureed vegetables. At 1:06 PM, the mechanical soft chicken parmesan measured 125.2 deg F and the pureed chicken parmesan measured 126.3 deg F, which 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 mechanical soft and pureed foods are routinely placed on the steam table but were placed in the warming oven because of the number of items being served for lunch. On 1/22/26 at 1:47 PM, the Dietary Manager stated staff should have checked the food temperatures periodically since it was being served from a warming location that was different than usual. Facility policies titled Preventing Foodborne Illness - Food Handling and Food Preparation and Service identified inadequate cooking and improper holding temperatures as critical factors in foodborne illness and stated the danger zone for food temperatures is between 41 deg F and 135 deg F.
Contaminated Gloved Hands Used During Meal Service
Penalty
Summary
The facility failed to maintain sanitary practices during meal service by allowing food to be touched with contaminated gloved hands. During a continuous meal service observation on 1/20/2026, Staff A, a Culinary Aide, placed his right oven mitt covered thumb inside a pan of peas and directly touched the food. Later in the same meal service, Staff A put on gloves, handled a food thermometer and temperature logbook, set them on the back counter, and then returned to serving resident food. While serving, he used the same gloved hands to grab Tostitos chips and place them on a resident's plate. Staff B, also a Culinary Aide, was observed putting on gloves, handling plates, ladles, and scoops, and then returning to serve resident food. During that service, she used the same gloved hands to grab Tostitos chips and place them on a resident's plate four times. Staff A stated he had received Infection Prevention training upon hire in March 2025 and confirmed hand hygiene and proper glove use were included, but he was not aware his thumb touched the peas and admitted he should have changed his gloves before touching the chips. The Dietary Manager stated staff should have been more aware of food handling equipment and should have used appropriate equipment such as tongs. The facility policy stated bare hand contact with food is prohibited and gloves must be changed between tasks when contaminated or soiled.
Infection Control Failures During Resident Transfers and Wound Care
Penalty
Summary
Infection prevention and control practices were not maintained for two residents. For one resident with non-Alzheimer's dementia, severe cognitive impairment, and a wound on the buttock, the MDS and care plan identified the resident as dependent for transfers and on Enhanced Barrier Precautions due to the wound. During observation, two CNAs entered the resident's room wearing gloves only and transferred the resident from a wheelchair to a recliner with a stand-up lift, without the gown and gloves expected for EBP. Staff interviews confirmed the resident was on EBP and that gown and gloves were required for transfers and care. For another resident with severe cognitive impairment, heart failure, renal insufficiency, respiratory failure, and multiple unhealed pressure injuries and skin wounds, wound care was observed for both forearms and the right shin. The LPN performing the care sanitized hands before gathering supplies and donned a gown and gloves, but then repeatedly removed gloves and did not sanitize hands before continuing care. The same scissors were used to remove old dressings and then to cut new Xeroform and gauze for multiple wounds without being sanitized between dirty and clean use. During the wound care, the LPN also touched the trash can lid with gloved hands and continued wound care without sanitizing hands afterward. The DON stated the expectation was for scissors to be cleaned between clean and dirty use and for staff to perform appropriate hand hygiene between clean and dirty tasks, after glove removal, and after touching a dirty surface such as a trash can lid. The facility policy stated hand hygiene is required after contact with blood, body fluids, or contaminated surfaces, before moving from a soiled body site to a clean body site on the same resident, and immediately after glove removal, and that gloves do not replace handwashing or hand hygiene.
Repeat Deficiencies in QAPI Process for Resident Menus
Penalty
Summary
The facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies during the current recertification and complaint survey. The facility had a census of 35 residents. The Provider History Report indicated that the facility received the same deficiency for three consecutive recertification surveys, specifically for failing to accurately follow resident menus. The Certified Dietary Manager (CDM) stated that all staff were assigned to watch a video on diet portion sizes as part of the QAPI Performance Improvement Plan (PIP). However, the Administrator acknowledged that there was no documentation of follow-up to assess the efficacy of the PIP, despite the facility's policy indicating that ongoing monitoring should be achieved using specific tools and that the Quality Assessment and Assurance (QAA) committee should monitor progress and provide input.
Failure to Follow Dietary Guidelines for Pureed Diets and Gravy Portions
Penalty
Summary
The facility failed to adhere to the prescribed dietary requirements for two residents on pureed diets and all residents receiving gravy. During meal preparation, Staff B, a cook, did not measure the total volume of pureed pork and failed to use the appropriate disher scoop size as per the facility's guidelines. Similarly, Staff C, a dietary aide, used a black handled scoop for gravy without knowing its size, which was later identified as a one-ounce scoop, resulting in under-serving. The menu specified a #6 scoop for pureed pork and a #12 scoop for pureed vegetables, but these were not followed, leading to significant discrepancies in portion sizes. The facility's policy on Kitchen Weights and Measures, revised in 2018, mandates that cooks and staff follow portion sizes per the menu using appropriate utensils. However, the staff did not comply with this policy, as evidenced by the incorrect serving sizes for pureed pork, vegetables, and gravy. The Certified Dietary Manager confirmed the use of a facility-specific conversion chart, but it was not effectively utilized by the staff. The administrator acknowledged that staff should adhere to the scoop diagram and menu serving sizes, indicating a lapse in following established procedures.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain food at a safe and appetizing temperature during a lunch service, as observed on January 8, 2023. Staff C, a Dietary Aide, recorded the temperature of salmon croquettes at 123.5°F before service, which is below the required 135°F to prevent the growth of pathogenic organisms. After the meal service, further temperature checks revealed that several menu items, including salmon croquettes, mashed potatoes, vegetable egg rolls, pureed pork, and mechanical soft egg rolls, were all below the required temperature. The facility's policy on food preparation and service, revised in October 2018, states that food must be maintained above 135°F to prevent foodborne illness. The Administrator acknowledged that staff should have ensured the food was at the correct temperature before serving and reported any discrepancies to the Certified Dietary Manager (CDM).
Sanitary Practices and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain sanitary practices in food storage and handling, as observed during a survey. In the kitchen, multiple items in the refrigerator and freezer were found undated and unlabeled, including packs of hot-dog looking items, bags of grapes, a bottle of root beer, and various other food items. Additionally, the kitchen area and dry goods storage contained unlabeled and undated items, such as sugar bins with a scoop lying on top of the sugar, and bags of flaky and grain-shaped items. These observations indicate a lack of adherence to the facility's policy on food receiving and storage, which requires all foods to be labeled and dated. Furthermore, staff members were observed not following proper hand hygiene and glove use protocols. Staff A used the same gloves to handle a spray can and egg rolls without changing gloves or performing hand hygiene. Similarly, Staff B handled various food items and utensils without changing gloves or washing hands, including touching a freezer door, bread loaf, lunch meat, and a mustard container. These actions demonstrate a failure to prevent cross-contamination, as required by the facility's policies. The administrator acknowledged that staff should adhere to these policies to ensure food safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Grimes
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brio Of Johnston, Llc | 3.2 mi | ★★★★★ | 12 | 0 |
| Royal Oaks Nursing And Rehabilitation Center | 4.9 mi | ★★★★★ | 15 | 1 |
| Deerfield Health Care Center | 5.1 mi | ★★★★★ | 0 | 0 |
| Granger Nursing & Rehabilitation Center | 5.2 mi | ★★★★★ | 4 | 0 |
| The Village Of Legacy Pointe Nursing Facility | 5.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.