Complete Care at Kensington

Inspectors wroteBased on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered an alert for excessively low weekend staffing. This has the potential to affect all 70 residents residing in the facility. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 6 (R14 and R3) residents reviewed for pressure injuries. R14 did not have care plan interventions of a pillow under her legs while in chair implemented during survey. R3 had a delay of comprehensive assessment of her pressure injury upon return from an appointment.

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 (R76) residents observed during medication pass. R76's prescribed Lorazepam was not available at the facility, and the nurse was unable to remove it from the facility contingency supply because there was no handwritten prescription (script) provided by the physician for the medication. The handwritten script is provided to the pharmacy who in turn supplies the facility with a code which allows the facility to remove the medication from their contingency supply.

Inspectors wroteBased on observation, interview and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficient practice had the potential to affect 4 (R3, R18, R24 and R56) of 4 residents residing on the unit that require blood sugar testing. The glucometer that is shared between residents was not cleaned between resident use.

Inspectors wroteBased on observations, interviews and record review, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect 33 residents. * Garbage was observed in the personal protective equipment (PPE) storage. * Dirty linen and used tissues were observed in the basket for the vital signs machine, the machine was brought into R2's room and used on R2. The machine is shared on the unit with potential to affect 33 residents. * R3 was on Enhanced Barrier Precautions (EBP), proper Personal Protective Equipment (PPE) was not worn during cares. * R1, R2, and R4 were observed to not have appropriate hand hygiene during personal care observations. * The mechanical lift was not disinfected after being used for R1, R3, R4, R5, R7, and R8.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 4 (R9, R32, R64, R49) of 8 residents reviewed for pressure injuries. * R9's unstageable pressure injury to the left posterior thigh reopened on 2/24/25. The facility states it is due to noncompliance with repositioning and offloading. Four Minimum Data Set (MDS) assessments were completed in 2025 and none document rejection of care or refusals by R9. R9 has an air mattress and no documentation for inflation setting guidance was found. The day after the pressure injury was discovered an intervention was added to the care plan related to refusals. [...]

Inspectors wrote3.) R62 was transferred to the hospital on 2/7/25 after experiencing a change of condition. R62 was discharged from the hospital and returned to the facility on 2/18/25. Surveyor conducted a review of R62's medical record and could not locate any evidence that R62 or their representative were given the required bed hold notice information in writing to identify the reserve bed payment rate for all payer sources for R62's bed hold after 15 days. The Ombudsmen was not notified of 62's transfer and discharge on [DATE]. No additional information was provided. Based on interview and record review, the facility did not ensure 10 (R16, R50, R62, R23, R33, R9, R12, R40, R58, & R72) of 10 residents reviewed were notified of the reason for transfer/discharge in writing to the resident & their representative. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during 5 (R12, R44, R32, R50 & R9) of 8 resident care and treatment observations. * Surveyor observed a staff member empty R12's ileostomy bag (small abdominal opening to allow waste discharge from the small bowel). After empting the ileostomy bag, Surveyor observed the staff member not remove their gloves and did not wash their hands prior to turning on R12's radio. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R50) of 1 injury of unknown origin that was reviewed was submitted to the State survey agency. On 4/22/25, R50's daughter informed the facility of a bruise on R50's left eyelid of R50's left eye. The facility did not report this injury of unknown source to the State survey agency.

Inspectors wroteBased on interview and record review, the facility did not have evidence that an injury of unknown source was thoroughly investigated for 1 (R50) of 1 residents. On 4/22/25, R50 was observed to have a bruise to the left eye. This injury of unknown source was not thoroughly investigated.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents received proper treatment and care to maintain mobility and good foot health for 2 (R50 & R64) of 2 residents. * R50 & R64's toenails were very long and in need of trimming.

Inspectors wroteBased on observation, record review and staff interviews, the facility did not ensure that 2 (R16 & R6) out of 3 residents reviewed for bowel and bladder incontinence received the appropriate treatment and services to restore continence to the extent possible. * R16 did not have a documented bowel movement for 6 days in February, 2025. The facility did not provide interventions to assist with proper bowel function nor did they notify R16's physician of R16's constipation. R16 was sent out to the hospital for an unrelated change of condition and was found to have a small bowel obstruction. * R6 had a decline in incontinence status without a comprehensive assessment completed to help maintain or restore bladder / bowel functioning.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 3 medication errors in 28 opportunities which resulted in a medication error rate of 10.71%. Medication errors were identified for R54 & R47. * R54 did not receive Glimepiride 4 mg before breakfast according to physician orders and received the incorrect eye drop medication. * R47 received the incorrect eye drop medication.

Inspectors wroteBased on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). Staffing information for Quarter 1 (October 1 - December 31) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS. This deficient practice has the potential to affect all 69 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not maintain a system of surveillance, tracking and trending of infections and identifying possible communicable diseases or infections before they can spread to other persons in the facility potentially affecting 75 of 75 residents. ~ The facility had an Infection Control Program that did not accurately track, trend or analyze the infection rate and data to help decrease the rates, numbers and spread of infections in the facility. No maps were completed to identify monthly infections on units. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents at risk for pressure injuries or those admitted with pressure injuries received care consistent with professional standards of practice for 4 (R20, R29, R5, and R72) of 10 residents reviewed for pressure injuries. *R20 developed a Stage 4 pressure injury to the left lateral ankle. The wound was not comprehensively assessed weekly. *R29 was admitted to the facility with a chronic right heel Unstageable pressure injury that was not comprehensively assessed on admission and readmission, a wound treatment was not ordered for three days after readmission, and the wound was not comprehensively assessed weekly. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 2 (R13 and R48) 2 residents reviewed for accommodation of needs. R13 reported he needed his incontinence brief changed. Facility staff did not respond to his request for a period of over 1 hour. R48 reported he was uncomfortable and wanted to get out of bed. His call light was not answered for an extended period time.

Inspectors wroteBased on interview and record review, the Facility did not ensure adequate supervision to prevent accidents for 1 (R59) of 2 residents reviewed for accidents. R59 had an unwitnessed fall outside in the Facility courtyard on 11/23/23. The fall resulted in a hematoma to the left side of the face. The Facility did not complete a thorough investigation to identify the root cause of the fall and implement interventions to prevent future falls.

Inspectors wroteBased on interview and record review, the facility did not comprehensively assess 1 (R43) of 1 resident reviewed for bowel and bladder. The facility did not ensure that a resident who is incontinent of bowel and bladder receives appropriate treatment, services and monitoring to restore as much normal bowel and bladder function as possible. R43 was admitted to the facility 1/22/24 with orders for a bowel and bladder assessment that was not fully completed per order. The data collected was not comprehensively assessed and resident had continued loose stools while at the facility. During visits by Nurse Practitioners on 2/1/24, 2/9/24 and 2/16/24 instructions were to monitor bowel irregularities and patterns which was not completed. Resident ended up needing a stool sample sent out for C. Diff testing that was not followed up on.

Inspectors wroteBased on observations, interviews and record review the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 5 (R59) residents reviewed for nutrition and weight loss. *R59 was identified to have weight loss one month after admission and the Facility initiated interventions. R59 continued to have documented weight loss in the following three months and the Facility did not revise or implement new interventions.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that its medication error rate was not 5 percent or greater. During observation of medication administration, the facility staff made medication errors with 1 (R37) of 3 residents observed for medication administration for a total of 5 errors of 30 opportunities for an error rate of 16.67%. R37 was administered a Sodium Bicarbonate 650 mg tablet that expired 12/2023. R37 was administered a Simethicone 850 mg chewable tablet instead of the ordered Simethicone 125mg Oral Capsule. R37 was not administered her Losartan Potassium Tablet 100 mg with her 8:00 AM medications because it was not available in the cart and was leaving for an MD (Medical Doctor) appointment. The medication was administered 2 hours later around 10:00 AM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R37) of 3 residents reviewed for medication administration were free of significant medication errors. R37 was going to be administered Losartan with a blood pressure of 106/66 when MD (Medical Doctor) orders document Hold if systolic blood pressure (SBP) < or = 120. R37 was going to be administered Amlodipine Besylate with a blood pressure of 106/66 when MD orders document Hold if systolic blood pressure (SBP) < or = 120.

Inspectors wroteBased on observation, interview, and record review, the facility did not assure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable in 2 of 2 Medication Carts reviewed for compliance. Surveyor observed undated, opened eye drops in both medication carts. Surveyor observed undated, unopened eyedrops that should have been stored in the refrigerator until use in the Rehab medication cart. Surveyor observed undated and unlabeled medications in both carts. Surveyor observed expired medications in both carts. Surveyor observed medications with illegible expiration dates in Rehab medication cart. Surveyor observed loose medications in both carts. Surveyor observed single dose contingency medications loose in both medication carts.

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure 1 (R46) of 5 Residents reviewed for unnecessary medications met the criteria for the use of antibitiotics. The facility uses the McGreers criteria to define wound/skin infections. *R46 was given an antibiotic for Methicillin-Resistant Staphylococcus Aureus (MRSA) without meeting the McGreer's criteria.

Inspectors wroteBased on staff interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 75 residents residing in the facility. Staffing information for Quarter 4 (July 1-September 30) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.

Inspectors wroteBased on record review and interviews, the facility did not ensure treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 (R1) of 6 residents. On 1/14/24, R1 was outside from 1:16:49 am until 3:28 am. Review of video footage found R1 was stuck in the snow and unable to propel his wheelchair inside. R1 was brought in from the outside on 1/14/24 at 3:28am; there was no assessment of R1's vital signs including temperature until six hours later. R1 was sent to the emergency room on 1/14/24 after staff identified what appeared to be frostbite to R1's fingers. The emergency department clinical impression documents: Atrial fibrillation, unspecified type, Acute congestive heart failure, unspecified heart failure type, pneumonia of right lower lobe due to infectious organism and frostbite, initial encounter. [...]

Inspectors wrote3. R2 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Morbid Obesity, Type 2 Diabetes, Chronic Pulmonary Edema, Cervicalgia, Hypertensive and Chronic Kidney Disease with Heart Failure, and Hyperlipidemia. R2 is his own person. R2's Annual Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score of 15, indicating R2 is cognitively intact for decision making. The MDS documents that R2 has no behaviors. R2's MDS also documents that R2 requires supervision for upper body dressing, substantial/maximum assist for lower body dressing. R2 requires supervision for rolling left to right and sit to lying, and lying to sitting. R2 is total dependent for sit to stand and transfers. Surveyor reviewed R2's Care Area Assessment (CAA) dated 1/5/24 which documents that R2 is a hoyer transfer on the unit and is non-ambulatory. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure there was a QAPI (Quality Assurance Performance Improvement) meeting held at least quarterly with the required committee members in order to identify issues through the committee. This deficient practice had the potential to effect all 73 residents currently in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 3 of 8 staff chosen at random received annual training on the facility's compliance and ethics program. CNA (Certified Nursing Assistant)-W, LPN (Licensed Practical Nurse)-X, & Housekeeping-Y did not receive training on the facility's compliance and ethics program. This has the potential to affect 73 residents as CNAs rotate throughout the facility and LPN-X who works PRN (as needed) is assigned throughout the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 3 of 8 staff chosen at random received behavioral health training. CNA (Certified Nursing Assistant)-W, LPN (Licensed Practical Nurse)-X, & Housekeeping-Y did not receive behavioral health training. This has the potential to affect 73 residents as CNAs rotate throughout the facility and LPN-X who works PRN (as needed) is assigned throughout the facility.

Inspectors wroteBased on interview and observation, the facility failed to ensure food was served palatably warm on two test tray observations conducted due to food complaints from three out of three residents and/or family members (Resident (R) 18, R24, and R14) out of a total sample of 28 residents. This failure had the potential to adversely affect the meal intake/nutrition of any of the 79 residents that receive meal trays from the kitchen.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure two out of 28 sampled residents (Resident (R) 9 and R10) were provided with home-like accommodations and an individualize physical environment according to their needs.