Complete Care at Kensington

In the surveyor’s words

From the most serious findings on record at Complete Care at Kensington, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jan 30, 2024

  Based 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 roiagnom on [DATE] after staff identified what appeared to be frostbite to R1's fingers. […]

• Immediate jeopardy, isolatedF689Jan 30, 2024

  Based on observation, interview, and record review, the facility did not ensure each resident's environment was as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents for 4 (R1, R6, R2, & R5) of 6 Residents. *On Friday 1/12/24, the facility became aware of poor weather conditions due to a snowstorm. The facility was aware of R1's frequent smoking noting he would often sit outside and smoke several cigarettes in a row. The Social Worker (SW) spoke to the Med Tech regarding the need to monitor R1 going outside to smoke due to the weather and gave the Med Tech R1's cigarettes to keep in the medication cart. […]

• Actual harm, isolatedF686May 21, 2025

  2.) R32 was admitted to the facility on [DATE] with diagnoses which includes fracture of T11-T12 vertebra, chronic kidney disease (characterized by progressive damage and loss of kidney function), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), morbid obesity, anxiety disorder and depression. R32's hospital Discharge summary dated [DATE] includes under discharge diagnoses pressure injury. Under hospital course pressure injury wound care consulted. R32's nurses note dated 4/18/25 at 15:18 (3:18 p.m.) and written by Licensed Practical Nurse (LPN)-W documents New admit head to toe: Resident was brought into facility from [hospital's initials] for rehabilitation around 1230. […]

• Actual harm, isolatedF686Jul 19, 2021

  Based on observation, record review and interview, the facility did not thoroughly assess, document and provide services consistent with professional standards of practice to prevent development or worsening of pressure injuries for 3 (R42, R14, R56) of 7 residents reviewed for pressure injuries. * R42 had no pressure injuries upon admission but was assessed to be at risk for pressure injuries. R42's care plan did not address providing pressure relief between R42's contracted lower legs nor did it address providing pressure relief in R42's chair. On 6/7/21 R42 developed an unstagable pressure injury to the right inner calf. On 6/7/21 the facility updated R42's care plan to include placing a pillow between R42's legs/knees at all times. […]

• Actual harm, isolatedF689Jul 19, 2021

  Based on observation, record review and interviews, the facility did not ensure 3 (R59, R79, and R46) of 3 residents reviewed for accidents received care and services to prevent accidents. * R59 fell off a shower bed and received staples to their scalp. The resident was assessed as needing assist of two staff for bed mobility and care planned to have two staff while using the shower bed/gurney. The facility did not ensure the agency certified nursing assistant (CNA)-AA was aware of the equipment safety warnings prior to use and resident care plan/Kardex information prior to proving cares to R59. R59 indicated to the Surveyor the staff had not used the cart appropriately when the fall occurred because they did not have the pins in place to have the side rails in place. […]