Kensington Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect 74 of the facility's 74 residents who consumed food from the kitchen. Observation of the kitchen on 03/23/2025, revealed unlabeled, undated, unsealed, and expired food items in the walk-in refrigerator and the dry pantry storage area.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure proper storage of biologicals for 1 of 2 treatment carts. Observation of the 100 hall treatment cart on [DATE], revealed 28 packages of Hydrogel which expired in 2023 and 2024.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service Review of the facility Census and Condition, dated 10/15/19, revealed seventy-three (73) of seventy-six (76) residents received meals from the kitchen. A food tray line observation on 10/15/19 at 11:15 AM, revealed the day shift cook did not know the correct food temperatures of cold food.

Inspectors wroteBased on observation, interview and review of the facility policy, it was determined the facility failed to ensure it must have food prepared by methods that conserve nutritive value, flavor, and appearance and food and drink that is palatable, attractive, and at a safe and appetizing temperature. Review of the facility Census and Condition, dated 10/15/19, revealed seventy-three (73) of seventy-six residents received meals from the kitchen.

Inspectors wroteBased on observation, interview and review of the facility's policy, it was determined the facility failed to ensure it must prepare, distribute, and serve food in accordance with professional standards for food service safety. Review of the facility Census and Condition, dated 10/15/19, revealed seventy-three (73) of seventy-six (76) residents received their meals from the kitchen. Observation of a lunch meal service on 10/15/19 revealed dietary staff was not washing their hands in between glove changes or before donning gloves.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents had a right to make choices about aspects of his or her life in the facility that were significant to the resident (Resident #30). Resident #30 wanted to get out of bed after breakfast daily; however, staff failed to assist the resident out of bed.

Inspectors wroteBased on observation, interview, record review, and facility's policy review, it was determined the facility failed to implement a comprehensive person-centered care plan one (1) of twenty-five (25) sampled residents (Resident #22). Resident #22 sustained falls on 09/18/19, 09/26/19, 10/12/19, and 10/13/19 due to the facility not ensuring staff not leave the resident alone in his/her room or dining room without staff supervision per care plan.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for two (2) of twenty-five (25) sampled residents (Resident #35 and #66) The facility failed to revise the care plan per facility policy for Resident #35 related to skin breakdown and Resident #66 related to receiving showers three (3) time a week.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (1) of twenty-five (25) sampled residents (Resident #65). Staff failed to provide sterile technique per facility policy when providing Tracheostomy Care for Resident #66.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one (1) of twenty-five (25) sampled residents (Resident #2). Therapy wrote an order on 10/09/19 for Resident #2 to be up in a Broda Chair for two (2) hours a day, seven (7) days a week because the resident enjoyed getting out of bed; however, staff were not getting the resident out of bed daily.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of twenty-five (25) sampled residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene (Resident #32 and #66). Resident #66 had a physician order to receive bath/shower three (3) times a week for Seborrhea treatment, and Resident #32 was to receive two (2) showers a week; however, staff failed to ensure the residents received their baths and/or showers.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, based on the comprehensive assessment (Resident #219) Resident #219 had an order to put on right elbow brace in the AM and take off in the PM, but multiple observations revealed the resident was not wearing it.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #22). Resident #22 was care planned to encourage resident to be up at nursing station while awake, for resident to be in TV room across from nurses station when not in restorative dining, and to encourage the resident to come out of dining room when finished with breakfast, to lay down after meals, and do not have resident in dining room alone. However, Resident #22 sustained falls on 09/18/19, 09/26/19, 10/12/19, and 10/13/19 due to being left alone in the dining room or his/her bedroom without supervision of staff.

Inspectors wroteBased on observation, interview, record review and facility policy review, it was determined the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for one (1) of twenty-five (25) sampled residents (Resident #3). Certified Nurse Aide (CNA) #2, while performing catheter care on 10/18/19 at 9:10 AM, failed to wash the catheter tubing per facility policy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents was offered sufficient fluid intake to maintain proper hydration and health (Resident #3).

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide respiratory care, consistent with professional standards of practice, for one (1) of twenty-five (25) sampled residents (Resident #3). Resident #3 had orders for Oxygen (02) at two (2) liters per minute via nasal cannula continuously; however, observation revealed Resident #3 was not receiving oxygen.

Inspectors wroteBased on observation, interview and review of the facility policy, it was determined the facility failed to ensure drugs and biological's used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observations of one (1) of four (4) medication carts revealed two (2) insulin pens and one (1) bottle of insulin were not dated when opened.

Inspectors wroteBased on observation, interview and facility policy review, it was determined the facility failed to ensure suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care for (1) of twenty-five (25) sampled residents (Resident #3).

Inspectors wroteBased on observation, interview and review of the facility's policy, it was determined the facility failed to ensure it must 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. Licensed staff failed to clean the over bed table prior to placing a clean barrier on table to prepare for wound care for Residents Residents #30 and #35. In addition, staff failed to wash hands or remove dirty gloves after providing wound care or handling dirty linen, prior to touching a bathroom door handle.