Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Kenedy Health & Rehabilitation during CMS and state inspections, most recent first.
Improperly Sealed Frozen Biscuits in Kitchen Freezer: The facility failed to store food in accordance with professional standards when a clear plastic bag of frozen biscuits was observed in the reach-in freezer with an opening between two knots, leaving the contents exposed to ambient air. The DFN stated the bag was not sealed properly and should have been, and the facility policy and Food Code required food to be wrapped or sealed and protected from contamination.
Failure to notify the LMHA/LIDDA after a PASRR positive resident had a significant change in mental and physical status. A resident with schizoaffective disorder, psychotic disorder with delusions, and mild ID had a significant change MDS showing severe cognitive impairment, decline in eating, toileting, and walking, and new frequent incontinence. The MDS LVN said the notification was missed as an oversight, the MDS LVN Regional Director confirmed the authority was not contacted, and the DON stated she was unaware of the notification requirement.
Incomplete Care Plan for Self-Managed Catheter Care: A cognitively intact resident with an indwelling catheter had a care plan that addressed catheter maintenance and UTI monitoring, but it did not include that he performed his own catheter care and emptied his own drainage bag. The resident stated he had done all of his catheter care himself since admission, and the DON and MDS LVN acknowledged this information should have been included in the care plan.
Care plan not updated for hearing change: A resident with dementia, COPD, and chronic atrial fibrillation had a Significant Change MDS showing severe cognitive impairment and minimal hearing difficulty, but the comprehensive care plan did not include a communication or hearing focus area. The MDS LVN and DON both stated the hearing issue should have been included so staff would know how to adjust communication methods.
A resident with dementia, COPD, and Parkinson's disease had current tobacco use documented and was care planned for supervised smoking and vaping. His record showed the last safe smoking assessment was completed over a year earlier, despite a history of dropping cigarettes and burning his clothes and a need for direct supervision and a fire-resistant smoking apron. The DON and AD stated the AD was responsible for quarterly smoking assessments, and the AD acknowledged the assessments were missed.
A resident with bowel/bladder incontinence, cognitive impairment, and total care needs did not receive complete peri care during incontinent care. A CNA observed providing care did not clean between the buttocks or the anal area and stated she did not fully separate the buttocks because she thought she had cleaned enough. The DON stated staff must clean the anal area to help prevent skin irritation and infection, and the facility policy required gentle care to the buttocks and anal area.
Hand Hygiene Not Performed Before Incontinent Care: A resident with cerebral infarction, HTN, depression, hyperlipidemia, and irritant contact dermatitis due to incontinence was observed receiving incontinent care when a CNA did not wash or sanitize hands before starting care after touching the bed remote, did not change gloves before care, and did not sanitize between the fingers during hand hygiene. The CNA stated she forgot to sanitize and did not know the bed remote was considered dirty; the DON stated staff were required to perform hand hygiene before care and between glove changes.
The facility failed to maintain a safe and homelike environment, with issues such as missing floor molding, a non-functioning overhead light in a shower room, and a scratched clothes closet in resident rooms. The Maintenance Director was unaware of these issues, and both he and the Administrator acknowledged the need for repairs to improve the residents' living conditions.
The facility failed to secure hazardous items in a shower room, leaving the door and a cabinet containing a razor, shaving cream, and toxic wipes unlocked. Staff confirmed the oversight, acknowledging the risk posed to ambulatory residents with mental illness or dementia. The facility's policy requires secure storage of hazardous materials, which was not followed.
A resident's privacy was compromised during catheter and incontinent care when two CNAs did not fully close the privacy curtain, leaving the resident exposed. The resident, who required extensive assistance due to multiple health conditions, was visible from the room's door, and the roommate was present. The CNAs acknowledged the oversight, and the facility's policy requires privacy to be maintained during such care.
A resident with a history of urinary tract infections did not receive proper incontinent care, as a CNA failed to clean the buttocks and rectal area thoroughly. Despite having received training, the CNA admitted to the oversight, which was confirmed by the DON. The resident had multiple medical conditions, including cognitive impairment, requiring assistance with ADLs. The facility's policy emphasized proper cleaning to prevent contamination, but this was not followed, leading to a deficiency.
A resident with severe cognitive impairment and multiple diagnoses, including hypoxia, was found to have an unclean oxygen concentrator with dust and a sticky substance on the intake air grill. The DON admitted that staff should have cleaned the concentrator's exterior, as per the facility's policy, which was not followed.
A facility failed to maintain accurate medical records for a resident's oxygen concentrator maintenance. The resident's physician orders incorrectly stated that the filter should be changed or cleaned weekly, but the concentrator did not require an outside filter. Staff signed off on the task as completed, despite the absence of a filter. The resident had multiple diagnoses, including dementia and hypoxia, and was severely cognitively impaired.
A CNA in a LTC facility failed to change gloves or wash hands after providing incontinent care to a resident with multiple health conditions, including dementia and hypertension. This breach in infection control was confirmed by the CNA and the DON, despite the CNA having received infection control training. The facility's policy requires hand hygiene before and after resident contact and after exposure to body fluids.
A resident with dementia and schizophrenia eloped from a facility due to inadequate supervision and faulty magnetic locks on a patio gate. The resident, who required moderate assistance for mobility, was last seen in the TV room before being found in a vehicle on a neighboring property. The facility's failure to maintain secure locks and provide adequate supervision led to this incident.
Improperly Sealed Frozen Biscuits in Kitchen Freezer
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. During observation on 12/02/2025 at 11:35 AM in the reach-in freezer, a clear plastic bag of frozen biscuits was found closed at the top with two knots, but there was an opening between the knots that exposed the contents of the bag to the ambient air in the freezer. During interview on 12/02/2025 at 11:36 AM, the DFN stated the bag of biscuits was not sealed properly and should have been. Record review showed the facility's policy required food to be wrapped or sealed and covered in clean containers, and the Food Code required food to be protected from contamination by storing it in packages, covered containers, or wrappings and in a clean, dry location where it is not exposed to splash, dust, or other contamination.
Failure to Notify Mental Health and Intellectual Disability Authorities After Significant Change
Penalty
Summary
The facility failed to notify the state mental health authority or state intellectual disability authority promptly after a significant change in the mental or physical condition of a PASRR positive resident. Resident #47 was a male admitted with diagnoses including schizoaffective disorder, psychotic disorder with delusions, and mild intellectual disabilities. His significant change MDS showed a BIMS score of 07/15, indicating severe cognitive impairment, and documented a decline in eating, toileting, and walking abilities compared with the quarterly MDS. The resident also changed from always continent of bladder and bowel to frequently incontinent of both. Resident #47’s care plan identified him as PASRR positive for mental illness and intellectual disability, and his EHR showed he had been assessed by the Local Mental Health Authority for both MI and IDD in 2023. During interviews, the MDS LVN stated she did not notify the state mental health authority or state intellectual disability authority after the significant change in the resident’s physical condition and described it as an oversight. The MDS LVN Regional Director confirmed the authority was not notified and should have been contacted so the resident could be assessed for additional services. The DON stated she was unaware of the requirement to notify the local state mental health or intellectual disability authority when a PASRR positive resident had a significant change and a significant change MDS was submitted.
Incomplete Care Plan for Self-Managed Catheter Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #5 that included measurable objectives and timeframes to meet the resident’s identified needs. Resident #5 was admitted with diagnoses including chronic respiratory failure with hypercapnia, retention of urine, and obstructive and reflux uropathy. The admission MDS showed a BIMS score of 15/15, indicating the resident was cognitively intact, and also indicated that the resident had an indwelling catheter. The comprehensive care plan, updated 12/02/2025, included a focus area for the resident’s indwelling catheter with interventions related to catheter size, tubing and bag placement, catheter changes as ordered, checking for kinks, keeping the drainage bag off the floor, anchoring tubing, monitoring intake and output, monitoring pain or discomfort, and monitoring and reporting signs and symptoms of UTI. However, the care plan did not mention that the resident performed his own catheter care or emptied his own drainage bag. During interview, the resident stated he performed 100% of his catheter care himself and had done so since admission. The DON and MDS LVN both stated the resident performed his own catheter care and that this information should have been included in the care plan.
Care Plan Not Updated for Hearing Change
Penalty
Summary
The facility failed to ensure Resident #7’s comprehensive care plan was reviewed and revised by the interdisciplinary team after assessment findings showed a change in hearing status. Resident #7 was an [AGE]-year-old male with diagnoses including dementia, COPD, and chronic atrial fibrillation. His Significant Change MDS showed a BIMS score of 07/15, indicating severe cognitive impairment, and Section B for Hearing, Speech, and Vision indicated minimal difficulty hearing. However, the comprehensive care plan updated 10/24/2025 did not include a focus area addressing communication or hearing deficiency. During interview, the MDS LVN stated the comprehensive care plan should have addressed the resident’s hearing difficulty and that it was omitted in error. The DON also stated the hearing difficulty was not noted in the care plan and should have been included so appropriate accommodations could be made. The facility policy stated the resident’s care plan would be reviewed after each Admission, Quarterly, Annual, and/or Significant Change MDS assessment and revised based on changing goals, preferences, needs, and current interventions.
Missed Smoking Risk Assessments for Resident Using Tobacco
Penalty
Summary
The facility failed to complete quarterly smoking risk assessments for a resident with a history of tobacco use. The resident was a male admitted and readmitted to the facility with diagnoses including dementia with agitation, COPD, and Parkinson's disease. His annual MDS showed a BIMS score of 5, indicating severe cognitive impairment, and the record identified current tobacco use. His comprehensive care plan noted that he smoked and also vaped with supervision, with an intervention to perform smoking assessments according to facility policy. The resident's electronic health record showed the last safe smoking assessment was completed on 04/30/2024. That assessment documented that he had a history of dropping cigarettes and burning his clothes, and that he required direct supervision while smoking and a fire-resistant smoking apron. During interviews, the DON stated the resident was supervised by the AD when using his vape and that the AD was responsible for completing quarterly smoking assessments for all residents who smoked or vaped. The AD stated she supervised residents who smoked or vaped, acknowledged she was responsible for completing safe smoking assessments on all residents who used tobacco in any form, and said she must have missed completing assessments for this resident.
Incomplete Perineal Care During Incontinent Care
Penalty
Summary
The facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and service to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents reviewed for incontinent care. Resident #53 was admitted on 11/29/2024 and had diagnoses including cerebral infarction, hyperlipidemia, depression, hypertension, and irritant contact dermatitis due to incontinence. The resident also had memory problems, required reminders, cues, and supervision in planning, organizing, and correcting daily routines, was rarely understood, and required total care. The resident’s care plan identified bowel incontinence and directed staff to provide peri care after each incontinent episode. During observation on 12/04/2025 at 12:47 a.m., CNA A provided incontinent care but did not clean between the resident’s buttocks and did not clean the anal area. During interview, CNA A stated she did not fully separate the resident’s buttocks to clean the anal area and thought she had cleaned enough. The DON stated staff must clean the anal area and, for a male resident, the underside of the perineal area to prevent skin irritation and infection. The facility’s perineal care policy stated to gently perform care to the buttocks and anal area.
Hand Hygiene Not Performed Before Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident reviewed for infection control. During observation of incontinent care for a resident admitted on 11/29/2024 with diagnoses including cerebral infarction, hyperlipidemia, depression, hypertension, and irritant contact dermatitis due to incontinence, CNA A did not wash or sanitize her hands before starting care after touching the resident’s bed remote. CNA A also did not change her gloves or sanitize her hands before providing incontinent care, and she did not sanitize between the fingers of her hands during hand hygiene. The resident’s skilled nursing note indicated the resident required reminders, cues, and supervision in planning, organizing, and correcting daily routines, had memory problems, and was rarely understood. The resident’s Section GG indicated total care, and the care plan identified bowel incontinence with an intervention to provide peri care after each incontinent episode. During interview, CNA A stated she had not sanitized her hands and changed gloves before starting care, did not know the bed remote was considered dirty, and forgot to sanitize between her fingers while sanitizing her hands. She stated she knew how to practice hand hygiene and that it was important to prevent infection for residents, and that she received infection control training at least once a year. The DON stated staff had to wash their hands before providing care and had to use sanitizer or wash their hands between glove changes and sanitize between their fingers to prevent the spread of infection. The facility policy on Fundamentals of Infection Control Precautions stated hand hygiene was required after handling soiled equipment or utensils and included rubbing hands together and covering all surfaces of the hands and fingers until dry.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as observed in one of the two shower rooms and two of the 26 resident rooms reviewed. Specifically, in one resident's room, there was a missing section of floor molding measuring 3.5 feet by 4 inches, and another section of molding that was detached from the wall. In the shower room, one of the two overhead lights, approximately 3 feet in length, was not functioning. Additionally, a standing clothes closet in another resident's room had multiple ingrained scratch marks over a 2 by 2-foot surface area. During interviews, the Maintenance Director acknowledged that he was not informed by the staff about these issues and agreed that addressing these repairs would enhance the residents' living environment. The Administrator also concurred that fixing these deficiencies would contribute to a more positive home environment. The facility's policy on Preventative Maintenance/Work-Order Request, dated 2003, states that the facility will repair or replace damaged or broken equipment or building amenities as needed, indicating a lapse in adherence to this policy.
Failure to Secure Hazardous Items in Shower Room
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards in one of the two shower rooms reviewed. During an observation, it was noted that the door to the shower room was left open, and a wall cabinet inside the room was unlocked. The cabinet contained hazardous items, including a razor, three bottles of shaving cream, and a bottle of Micro kill one wipes. The safety data sheet for the wipes indicated they have acute toxicity, are flammable, and can cause serious eye damage, posing a risk to residents. Interviews with staff confirmed the oversight. A CNA acknowledged that the door and cabinet were left unlocked and that the hazardous items were accessible to residents. The Director of Nursing (DON) also confirmed that the items could be hazardous, especially considering the presence of ambulatory residents with mental illness or dementia who might misuse these products. The facility's policy on hazardous communication, dated 2003, requires that hazardous materials be stored securely, which was not adhered to in this instance.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during catheter and incontinent care. Two CNAs, while attending to a resident with a urinary catheter and bowel incontinence, did not completely close the privacy curtain, leaving the resident exposed. This exposure was visible from the room's door, and the resident's ambulatory roommate was present in the room. Additionally, one of the CNAs opened the door to dispose of soiled supplies while the resident was still exposed, further compromising the resident's privacy. The resident involved had a BIMS score indicating no cognitive impairment and required extensive assistance with activities of daily living due to conditions such as dementia, diabetes, major depressive disorder, hypertension, and peripheral vascular disease. The facility's policy on perineal care mandates providing privacy by closing the door and/or curtain, which was not adhered to in this instance. Both CNAs acknowledged the lapse in privacy and confirmed they had received training on resident rights within the year. The Director of Nursing also confirmed that privacy should have been maintained and that staff had been trained on resident rights.
Inadequate Incontinent Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a deficiency in preventing urinary tract infections. During an observation, it was noted that a CNA did not thoroughly clean between the buttocks or the rectal area of a resident who was incontinent of bladder. This oversight occurred despite the CNA having received training in infection control and incontinent care within the past year. The resident in question had a history of urinary tract infections and required assistance with activities of daily living due to mild to moderate cognitive impairment. The resident's medical history included conditions such as hypothyroidism, anxiety disorder, hyperlipidemia, dementia, schizoaffective disorder, major depressive disorder, and hypertension. The facility's policy on perineal care clearly outlined the need to clean the buttocks and anal area from front to back to prevent contamination. However, the CNA admitted to not cleaning the rectal area, which was confirmed by the Director of Nursing, who also stated that staff skills are checked annually and as needed. This failure in care practice was identified as a risk for infection and skin breakdown.
Inadequate Respiratory Care Due to Unclean Oxygen Concentrator
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required continuous oxygen therapy. The resident, who was severely cognitively impaired and had multiple diagnoses including dementia, aphasia, and hypoxia, was observed to have an oxygen concentrator with an intake air grill partially covered with gray dust and a sticky substance. This observation was made during a survey, and it was noted that the concentrator should have been cleaned according to the manufacturer's recommendations. During an interview, the Director of Nursing (DON) acknowledged that the concentrator did not require an outside filter as it had an internal filter changed every two years during manufacturer maintenance. However, the DON admitted that the staff should have cleaned the outside of the concentrator. The facility's policy on oxygen administration, dated March 2023, indicated that the concentrator should be cleaned according to manufacturer recommendations, which was not adhered to in this instance.
Inaccurate Medical Records for Oxygen Concentrator Maintenance
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident who was observed for accuracy of medical records. The deficiency involved the lack of an appropriate order regarding the maintenance of the resident's oxygen concentrator. Specifically, the resident's physician orders indicated that the filter of the oxygen concentrator should be changed or cleaned every Sunday night shift. However, upon observation, it was found that there was no apparent filter on the back air intake grill of the oxygen concentrator in the resident's bedroom. During an interview, the Director of Nursing (DON) revealed that the concentrator did not require an outside filter, as it had an internal filter that was changed every two years by the manufacturer. The order to change or clean the filter was incorrect, and staff had erroneously signed off on the task as completed. This discrepancy in the medical records could place residents at risk for errors in care and treatment. The resident involved had multiple diagnoses, including dementia, aphasia, hypoxia, schizoaffective disorder, hyperlipidemia, and hypothyroidism, and was severely cognitively impaired, as indicated by a BIMS score of 6.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) who did not adhere to proper hygiene protocols during incontinent care for a resident. The CNA did not change gloves or wash hands after providing care and before handling a clean brief, which is a breach of infection control practices. This incident was observed during a survey, and the CNA confirmed the lapse in protocol during an interview, despite having received infection control training within the year. The resident involved had multiple diagnoses, including hypothyroidism, anxiety disorder, hyperlipidemia, dementia, schizoaffective disorder, major depressive disorder, and hypertension. The resident's care plan indicated a need for incontinence care due to occasional bladder and frequent bowel incontinence. The Director of Nursing (DON) confirmed the requirement for glove changes and hand hygiene to prevent cross-contamination, as outlined in the facility's infection control policy. The facility's policy, dated 2019, specifies the necessity of hand hygiene before and after direct resident contact and after contact with body fluids or excretions.
Resident Elopement Due to Inadequate Supervision and Faulty Security Measures
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in a resident eloping from the facility without staff knowledge. The incident involved a male resident with diagnoses including unspecified dementia, paranoid schizophrenia, and type 2 diabetes mellitus. The resident had a BIMS score indicating moderate cognitive impairment and required partial/moderate assistance for mobility. Despite being assessed as a low wander elopement risk earlier in the year, the resident was able to leave the facility unsupervised. On the evening of the incident, the resident was last seen in the TV room by CNAs before being discovered missing during a medication round. Staff conducted a search of the facility and its perimeter but were unable to locate the resident. The Director of Nursing (DON) and Administrator were notified, and emergency services were called. The resident was eventually found sitting in a vehicle on a neighboring property, approximately 500 feet from the facility, without any injuries. The investigation revealed that the resident exited through a door leading to a fenced-in patio area, where the magnetic locks on the gate had failed due to misalignment. Interviews with staff indicated that the magnetic locks had not been functioning properly, allowing the resident to leave the facility. The DON confirmed that the locks had become misaligned, causing them to fail. The resident was taken to the emergency room for evaluation and returned to the facility without injury. The facility's failure to maintain secure locks and provide adequate supervision contributed to the resident's elopement, highlighting a deficiency in ensuring a safe environment for residents.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kenedy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| John Paul Ii Nursing Home | 0.3 mi | ★★★★★ | 5 | 0 |
| Bluebonnet Nursing And Rehabilitation | 10.5 mi | ★★★★★ | 38 | 0 |
| Yorktown Nursing And Rehabilitation Center | 23.4 mi | ★★★★★ | 13 | 0 |
| Frank M. Tejeda Texas State Veterans Home | 28.1 mi | ★★★★★ | 12 | 0 |
| Harmony Care At Floresville | 28.6 mi | ★★★★★ | 18 | 0 |
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