Inspection Reports for
Kennybrook Village
200 SW Brookside Dr, Grimes, IA 50111, United States, IA, 50111
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
35 residents
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 6, 2025
Visit Reason
A complaint investigation for complaint #129210-C was conducted on October 6, 2025.
Complaint Details
Complaint #129210-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 31, 2025
Visit Reason
The document serves as a Plan of Correction following a Recertification Survey, indicating acceptance of credible allegation of substantial compliance.
Findings
The facility will be certified in compliance effective January 31, 2025, with the Health portion of the Recertification Survey based on acceptance of the Plan of Correction.
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 4
Date: Jan 9, 2025
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification survey and investigation of Facility Reported Incidents #123505-I and #125723-I from January 06, 2024 to January 09, 2024.
Findings
The facility was found deficient in meeting nutritional needs and menu preparation, food temperature maintenance, food procurement and storage safety, and quality assurance and performance improvement (QAPI) program implementation. Multiple repeat deficiencies were noted related to menu compliance and food safety practices.
Deficiencies (4)
Menus did not meet nutritional needs and were not properly prepared in advance or followed, including failure to serve appropriate diet and portions for residents on pureed diets.
Food and drink were not maintained at safe and appetizing temperatures during meal service.
Food procurement, storage, preparation, and serving practices were not sanitary, including improperly labeled and stored food items.
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program to address previously identified quality deficiencies.
Report Facts
Facility census: 35
Facility Reported Incidents: 2
Food temperature readings: 123.5
Food temperature readings: 117
Food temperature readings: 124.8
Food temperature readings: 122
Food temperature readings: 124
Food temperature readings: 120
Portion sizes: 6
Portion sizes: 2
Portion sizes: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B Cook | Cook | Observed preparing pureed pork and handling food without proper measurement or hygiene |
| Staff C Dietary Aide | Dietary Aide | Observed placing serving utensils and measuring food portions |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Provided information on facility policies and training related to food service and temperature monitoring |
| Administrator | Administrator | Provided statements on facility policies and corrective actions |
| Culinary Manager | Culinary Manager | Conducted education, audits, and in-service training for dietary staff as part of plan of correction |
| Executive Director | Executive Director | Reeducated leadership team on QAPI process and involved in monitoring plan performance |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 4
Date: Jan 9, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey to assess compliance with nutritional, food safety, and quality assurance standards.
Findings
The facility failed to follow appropriate diet and portion sizes for residents on pureed diets, failed to maintain safe food temperatures during meal service, and did not maintain sanitary food storage and handling practices. Additionally, the facility's Quality Assurance Performance Improvement (QAPI) process was ineffective, with repeated deficiencies and lack of documented follow-up on corrective actions.
Deficiencies (4)
Failed to follow appropriate diet and serve correct portions for residents on pureed diets and gravy servings.
Failed to provide food served at safe and appetizing temperatures during meal service.
Failed to maintain sanitary practices by improperly storing and serving food, including unlabeled and undated food items and poor hand hygiene.
Failed to ensure an effective QAPI process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies.
Report Facts
Census: 35
Serving size discrepancy: -3.73
Serving size discrepancy: -1.07
Serving size discrepancy: -1
Food temperatures: 123.5
Food temperatures: 117
Food temperatures: 124.8
Food temperatures: 122
Food temperatures: 124
Food temperatures: 120
Repeat deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Cook | Named in findings related to pureed diet preparation and food handling |
| Staff B | Cook | Named in findings related to pureed diet preparation and food handling |
| Staff C | Dietary Aide | Named in findings related to meal service and food temperature observations |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Named in findings related to dietary policies and QAPI process |
| Administrator | Administrator | Named in findings related to food safety and QAPI process |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 14, 2024
Visit Reason
A complaint investigation for Complaint #120965-C was conducted from August 13, 2024 through August 14, 2024.
Complaint Details
Complaint #120965-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 20, 2023
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, leading to certification in compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective October 20, 2023.
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 5
Date: Sep 28, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #111359-C and facility reported incident #111556-I.
Complaint Details
Complaint #111359-C was substantiated. Facility reported incident #111556-I was not substantiated.
Findings
The facility was found deficient in maintaining a safe, clean, comfortable, and homelike environment, activities of daily living, menus meeting resident needs, food safety and preparation, and food procurement and storage. Complaint #111359-C was substantiated, while incident #111556-I was not substantiated.
Deficiencies (5)
Failed to maintain a clean, comfortable, and homelike environment; stained carpet and urine odor in resident rooms; temperature issues in resident rooms.
Failed to provide necessary care and services to ensure residents' abilities in activities of daily living were maintained or improved.
Failed to meet nutritional needs of residents; inappropriate serving sizes of vegetables.
Failed to provide food that is palatable, attractive, and at a safe and appetizing temperature; food served below acceptable holding temperature.
Failed to maintain sanitary practices in food procurement, storage, and preparation; missing HVAC vents, improper food storage, and staff not following hair and glove protocols.
Report Facts
Census: 39
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Dietary Aide (DA) | Observed partially filling serving scoops and improper food handling. |
| Staff B | Dietary Aide (DA) | Did not cover hair while handling food. |
| Staff A | Cook | Did not have facial hair covered while preparing food. |
| Assistant Director of Nursing | ADON | Stated resident had not received restorative program services due to staffing shortages. |
| Dietary Manager | Provided information on serving sizes and food storage policies. | |
| Rehabilitation Director | Stated resident should be on restorative program services. |
Inspection Report
Census: 39
Deficiencies: 1
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to evaluate compliance with nutritional standards regarding menu preparation, portion sizes, and dietary needs of residents.
Findings
The facility failed to serve appropriate portion sizes of green beans and mashed potatoes to the last five residents observed, despite menu guidelines and dietary policies specifying correct serving sizes.
Deficiencies (1)
Failed to serve the appropriate portions for the last five residents who received green beans or mashed potatoes.
Report Facts
Residents affected: 5
Census: 39
Inspection Report
Routine
Census: 39
Deficiencies: 5
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident environment, restorative services, nutrition, food safety, and sanitary practices at Kennybrook Village nursing home.
Findings
The facility was found deficient in maintaining a clean and comfortable environment in resident rooms, providing restorative activities for a resident, serving appropriate food portions, maintaining safe food temperatures, and following sanitary food handling practices. All deficiencies were cited with minimal harm or potential for actual harm affecting a few or some residents.
Deficiencies (5)
Failed to maintain a clean, comfortable and homelike environment for 2 out of 8 resident rooms, including stained carpets and urine odor, and a room temperature outside the expected range.
Failed to provide restorative activities for 1 sampled resident to maintain functional range of motion and prevent decline in activities of daily living.
Failed to serve appropriate portions of green beans or mashed potatoes for the last five residents served.
Failed to maintain safe and appetizing food temperatures; mechanical soft turkey served below acceptable temperature and pureed turkey served without reheating.
Failed to maintain sanitary food handling practices including missing HVAC diffusers blowing air on food, improper storage of food, uncovered hair, and improper glove use during food service.
Report Facts
Residents census: 39
Room temperature: 86
Food temperature: 131.4
Food temperature: 93
Food temperature after reheating: 190
Number of residents affected by food portion deficiency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Dietary Aide | Observed serving food below temperature and improper glove use during food service |
| Staff A | Cook | Observed not covering facial hair while preparing food |
| Staff B | Dietary Aide | Observed not covering back of hair while handling food |
| Staff D | Certified Nurse Aide | Reported resident had not received restorative services in previous 3-4 weeks |
| Rehabilitation Director | Stated resident should be on restorative program services | |
| Assistant Director of Nursing | ADON | Stated resident had not received restorative program services due to staffing shortages |
| Housekeeping Supervisor | Confirmed stained carpet and urine odor in resident room | |
| Maintenance Supervisor | Confirmed stained carpet, urine odor, and room temperature issues | |
| Dietary Manager | Confirmed food temperature issues and expectations for food storage and serving | |
| Registered Dietician | Provided information on serving sizes for vegetables | |
| Therapy Assistant | Stated facility did not have a routine Restorative Aide |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
A focused COVID-19 infection survey was conducted ending on 2/23/23, and an investigation of complaint #110060-C was conducted from 2/20 to 2/23/23.
Complaint Details
Investigation of complaint #110060-C was conducted from 2/20 to 2/23/23. The complaint was not substantiated.
Findings
The facility was in compliance with CMS and CDC recommended practices to prepare for COVID-19. The complaint investigation was not substantiated.
Report Facts
Total residents: 35
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 11, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's certification compliance.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective 7/11/22.
Inspection Report
Routine
Census: 40
Deficiencies: 2
Date: Jun 23, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to accurate resident assessments and proper nutritional service for residents on special diets.
Findings
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident and failed to ensure proper serving sizes for residents on a pureed diet, resulting in minimal harm or potential for harm.
Deficiencies (2)
Failed to accurately complete a Minimum Data Set (MDS) assessment for one resident (Resident #14).
Failed to ensure proper serving size for 2 residents with a pureed texture diet (Resident #26 and Resident #32).
Report Facts
Residents on pureed diet: 2
Census: 40
Serving size for pureed meat: 3
Serving size for pureed vegetables: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Dietary Cook | Prepared pureed food with incorrect serving sizes |
| Staff B | Dietary Aide | Measured and served pureed food with smaller scoops |
| Administrator | Acknowledged need for dietary staff education on serving sizes | |
| Assistant Director of Nursing | ADON | Verified and corrected MDS assessment coding error |
| Dietary Director | DD | Identified scoop sizes used and verified serving sizes |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 2
Date: Jun 23, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint 99311-C from June 16, 2022 to June 23, 2022.
Complaint Details
Complaint #99311-C was investigated and found to be unsubstantiated.
Findings
The facility was found to have deficiencies related to the accuracy of assessments and menus meeting resident nutritional needs. Specifically, the Minimum Data Set (MDS) assessment for one resident was inaccurately completed, and staff failed to serve the proper portion sizes for residents on a pureed texture diet.
Deficiencies (2)
Accuracy of Assessments: The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident, misidentifying the resident's mental illness status.
Menus Meet Resident Needs/Preparation/Followed: The facility failed to ensure staff served the proper serving size for residents on a pureed texture diet.
Report Facts
Census: 40
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anyse Munro | Executive Director | Signed the report and attested to the findings |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 6
Date: Jul 28, 2021
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of complaints 98659-C, 91141-C, 89527-C, and 89045-C, which were not substantiated.
Findings
The facility was found deficient in multiple areas including failure to complete a Significant Change Minimum Data Set (MDS) assessment timely, coordination of PASARR and assessments, comprehensive care plan updates, nurse staffing information posting, food safety and sanitation, and infection prevention and control practices. The facility reported a census of 37-38 residents during the survey.
Deficiencies (6)
Failure to complete a Significant Change Minimum Data Set (MDS) assessment within 14 days for a resident placed on hospice care.
Failure to coordinate PASARR and assessments including timely Level II PASRR evaluation and determination for residents with newly evident mental disorders.
Failure to update comprehensive care plans timely and include required interdisciplinary team members and resident participation.
Failure to post nurse staffing data in a prominent location visible to residents and visitors.
Failure to maintain food safety standards including staff not wearing hair restraints and improper hand hygiene during food preparation and service.
Failure to establish and maintain an infection prevention and control program including improper mask use, inadequate hand hygiene, and failure to provide a sanitary environment.
Report Facts
Resident census: 38
Resident census: 37
Residents reviewed: 16
Residents reviewed: 1
Residents reviewed: 1
Inspection Report
Routine
Census: 37
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 37
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