Kensington Gardens Rehab and Nursing Center

Inspectors wroteBased on record reviews and interviews the facility failed to implement an effective Antibiotic Stewardship program as evidence by the lack of tracking of infections and not ensuring antibiotic use met infection criteria.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to staff performing hand hygiene between providing care for two (#27 and #28) resident's and failed to ensure an enhanced barrier precaution sign was posted for one (#29) of thirteen residents diagnosed with a infectious disease.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop a comprehensive grievance policy and procedure, failed to implement the grievance procedure to investigate customer care concerns for two residents (#8 and #2), and failed to have evidence of informing the results of grievance investigation for four residents (#9, #8, #10, and #2) of four residents sampled for grievances.

Inspectors wroteBased on interview and record review the facility failed to provide quality of care related to resident assessments for a change in condition of vascular wounds for two residents (#4 and #11) of six sampled residents.

Inspectors wroteBased on interview and record review the facility failed to provide assessments post falls including vital signs and neurological checks for one resident (#3) of three sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an Quality Assessment and Assurance (QAA) practice that demonstrated identification, monitoring, and implementation of an effective action plan to correct previously cited deficient practice at F689 in regards to: 1) preventing a vulnerable resident with severe cognitive impairment from exiting the facility for one resident (#26) out of two residents reviewed for elopement risk; and 2) ensuring elopement risk binders were updated/accurate to ensure staff knew who was at risk for four out of four binders reviewed.

Inspectors wroteBased on interview and record review the facility failed to provide notice of change in condition related to informing the resident's family regarding a fall and failed to follow-up with the Primary Provider after a fall for one resident (#3) of five sampled residents.

Inspectors wroteBased on observations and interviews the facility failed to ensure a safe and clean environment related to soiled/stained privacy curtains in two resident rooms (#206 and #325) out of three rooms observed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to effectively implement the Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) policy and procedure for 2 (#2 and #8) of fifteen sampled residents. Resident #8 complained on 12/11/25 about customer service which was not investigated or reported; subsequently Resident #2 reported an allegation of mental / verbal abuse on 12/27/2025 which was verified.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an allegation of neglect regarding untimely care and services was investigated and reported within 24 hours to the State Survey Agency and adult protective services for one resident (#8) of fifteen sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure updates of care plans for two out of four residents reviewed (Resident #1 and #231B).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure ADLs (activities of daily living) related to nail care was provided for two residents (#1, #13) out of four residents sampled.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure equipment was safe, sanitary and operational, and failed provide a safe, functioning, sanitary and comfortable environment in resident's rooms for six residents (#5, #6, #7, #11, #12 and #13) out of 15 residents sampled, and in common areas to include food storage areas.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident (#3) out of four residents sampled.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate a resident-to-resident allegation of abuse involving two residents (#14 and #15) out of four reportable events sampled.

Inspectors wroteBased on observations, interviews and record review, the facility did maintain an effective pest control program related to roaches for their residents.

Inspectors wroteBased on observation, record review, interviews, and review of the Plan of Correction (PoC) the facility failed to ensure it had a functioning Quality Assurance Performance Improvement (QAPI) plan. The facility was actively involved in the creation, implementation, and monitoring of their PoC for deficient practice identified during a complaint survey on 05/13/2025. The plan was ineffective resulting in citation F908 being recited related to ensuring timely repairs of essential equipment, for one roof-top Air-Conditioning (A/C) unit (#11) of 19 roof- top A/C units and F908 being recited related to failure to ensure equipment was safe, sanitary and operational, and failure to provide a safe, functioning, sanitary and comfortable environment in resident's rooms for six residents (#5, #6, #7, #11, #12 and #13) out of 15 residents sampled, and in common areas to include food storage areas.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure timely repair of essential equipment, two (#5 and #19) roof top air-conditioning units of 19 roof top air-conditioning units.

Inspectors wroteBased on observations and interviews, the facility failed to ensure one pantry (South Wing) of three pantries and one of five eye wash stations, was maintained in a safe and sanitary manner.

Inspectors wroteBased on observations and interviews, the facility failed to post the nurse staffing data to ensure the information was readily accessible to all residents and visitors during three of four days of survey.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) Level I for six (#61, #43, #5, #342, #48, and #45) of fifty-seven residents reviewed; and failed to ensure a PASARR Level II was completed for one (#100) of fifty-seven residents reviewed.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure all grievances were tracked through to their conclusions for two residents (#56 and #16) of seven sampled residents for choices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one resident (#120) out of four residents reviewed for falls had the comprehensive care plan revised with additional interventions after a fall.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide care and services related to accessible emergent tracheostomy supplies at the bedside and providing oxygen as ordered for one resident (#109) out of one resident reviewed for tracheostomy care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a clean, comfortable, home-like environment in three of four community shower rooms, one of one dining rooms, and resident rooms in two of three units, on four of four days observed (1/29/2024, 1/30/2024, 1/31/2024 and 2/1/2024) during the survey.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one resident (#106) out of three residents reviewed received scheduled dialysis treatments as ordered in accordance with professional standards.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Forty-three medication administration opportunities were observed, and twenty errors were identified for three residents (#30, #65, and #101) out of five residents observed. These errors constituted a 46.51% medication error rate.

Inspectors wroteBased on interviews and record review and facility failed to ensure allegations of neglect involving one resident (#106) out of one sampled resident for dialysis was reported immediately to the governing agency in accordance with State law and thoroughly investigated.

Inspectors wroteBased on observations, interviews, and record review the facility failed to evaluate and analyze hazards and risks, implement interventions to reduce hazards and risk, monitor for the effectiveness of the interventions, and ensure neurological monitoring was completed after a head injury for one resident (#48) out of two residents sampled.

Inspectors wroteBased on record review and interview, the facility failed to convey and provide a final accounting of personal funds within 30 days of discharge for three (#5, #7, and #8) of three residents reviewed. Resident #5 was discharged from the facility on 10/29/2023, as of 12/13/2023, Resident #5's patient trust account had $4,442.73 in it and his room and board bill documented he was due a refund of $736.80. Resident #7 was discharged from the facility on 01/20/2023, as of 12/13/2023, Resident #7's patient trust account had $1249.69 in it. Resident #8 was discharged from the facility on 04/26/2023, as of 12/13/2023, Resident #8's patient trust account had $45.00 in it.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure personal funds were accurately billed or adjusted for Room and Board (Care Cost) for one (#2) of six sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement the grievance policy and procedure for one (Resident #2) of ten sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a safe, clean, comfortable and homelike environment by not ensuring 1. resident closet room doors in three rooms (228, 231 and 328) were functioning, 2. HVAC (Heating, Ventilation, and Air Conditioning) system filters in 12 resident rooms (303, 304, 306, 307, 309, 311, 319, 320, 323, 324, 325, and 326) were free of dust and debris, 3. walls, floors, closet ceiling (resident room [ROOM NUMBER]), handrail, an electrical outlet, resident room furniture and trim molding were maintained in two units (300 and 200) of three units to include nine resident rooms (317, 309A and 217P, 326, 328, 330, 332, 333, and 334), and 4. An overhead wall light and cover worked and had a light pull cord for use for one resident (#56) for a total of four days (4/11/2022 to 04/14/2022) four days observed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident smoking supplies were secured and residents adhered to designated smoking times for seven residents (#40, #9, #57, #4, #68, #78, and #81), on four (4/11/2022, 4/12/2022, 4/13/2022, and 4/14/2022) of four days observed

Inspectors wroteBased on observations, interviews and record review, the facility 1. failed to store medications securely and appropriately in five medication carts (East Hall Medication Cart #1, North Hall Medication Cart #2, East Hall Medication Cart #3, South Hall Medication Cart #1, and South Hall Medication Cart #2 ) of seven medication carts and one of one treatment cart on the South Hall, and 2. failed to ensure controlled substances were stored in a permanently attached container in two refrigerators (East Hall and North Hall) of three refrigerators used for storage of medications; and 3. failed to appropriately secure medications for four residents (#98, #85, #46 and #40) of 61 sampled residents.

Inspectors wroteBased on observation, interviews and record review the facility failed to maintain an effective pest control program for two units (300 and 200) of three units related to small flying insects, ants, and wasp like insects for four days (4/11/2022, 4/12/2022, 4/13/2022, and 4/14/2022) of four days observed.

Inspectors wroteBased on record review, observations and interviews, the facility failed to implement care plan interventions with relation to bed rail use and bed rail monitoring for seven of sixty-one sampled residents (#64, #43, #40, #62, #38 and #56, and #55), during four of four days observed (4/11/2022, 4/12/2022, 4/13/2022, and 4/14/2022).

Inspectors wrote3. According to the clinical record, Resident #22 was admitted on [DATE] and included diagnoses of hypertension and pneumonia. An observation was conducted at 9:25 a.m. on 4/11/22 of Resident #22's nebulizer equipment. The observation indicated a nebulizer mask with an attached medication cup was lying on top of electronic equipment on the resident's bedside dresser, uncovered. The medication cup had droplets of residual liquid in it. On 4/12/22 at 9:17 a.m., an observation of Resident #22 identified nebulizer equipment lying on top of the resident's bedside dresser. The nebulizer mask was not in a protective bag and had liquid residual in the attached medication cup. Resident #22 was observed, on 4/13/22 at 9:35 a.m., lying in bed. A nebulizer mask was lying on the bedside dresser with liquid residue in the medication cup. [...]

Inspectors wroteBased on observation, interview and policy review the facility failed to ensure Nursing Staffing Information was posted for three days (04/08/22, 04/09/22 and 04/10/22).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and two medication errors were identified for two (Residents #98, and #275) of seven residents observed. These errors constituted an 8.00% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure the wound care for one (#44) of twelve residents with wounds was completed in a sanitary manner to promoted healing.