Kensington at Anna Maria

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 4, 2024

  Based on record review, interview, observation, and review of witness statements, facility investigation, mechanical lift policy and fall policy and procedure the facility failed to ensure Resident #27 was safely transferred with a Hoyer (mechanical) lift to prevent a fall with injury and failed to ensure a physician ordered fall intervention was implemented for Resident #48. This affected two residents (#27 and #48) of three residents reviewed for falls. The facility census was 95. Actual Harm occurred on 10/30/23 at 7:45 P.M. when State tested Nurse Aide (STNA) #520 attempted to transfer Resident #27 without another staff member from her wheelchair to her bed using a Hoyer lift with the Hoyer pad in the incorrect position. […]

• No harm, potential for more than minimal, widespreadF804Apr 4, 2024

  Based on observation, interview, and record, and review of the sample room test tray evaluations, the facility failed to ensure food was served at palatable temperatures. This had the potential to affect all residents except one resident (#65) who received nothing by mouth. Facility census was 95. Findings include: Interviews on 04/01/24 from 9:41 A.M. to 11:00 A.M. with Resident #12, #28, #29, #66, and #147 revealed the food was often served cold and tasted bland. Observation of tray line service on 04/02/24 at 12:12 P.M. revealed the food was served on plates that were then placed on a food tray and covered with a thermal lid. The food tray was then placed in a metal, enclosed food cart. Completion of a test tray on 04/02/24 at 1:57 P.M. […]

• No harm, potential for more than minimal, isolatedF759Dec 18, 2025

  Based on record review, observation, interviews, review of the manufacturer's instruction for insulin flex pens and facility policy, the facility failed to ensure a medication error rate of less than 5 percent (%). There were four errors observed of 34 opportunities, resulting in an 8.82 % total error rate. This affected one Resident (#21) out of three residents observed for medication administration. The facility census was 88.Findings include:Review of the medical record for Resident #21 revealed an admission date of 04/28/25 with diagnoses of spinal stenosis, type two diabetes, chronic kidney disease, gastro-esophageal reflux disease, overactive bladder, atrial fibrillation, adult failure to thrive, and hyperlipidemia.Review of the quarterly Minimum Data Set (MDS) assessment dated… […]

• No harm, potential for more than minimal, isolatedF812Apr 4, 2024

  Based on observation and interview, the facility failed to ensure all meals were served in a sanitary manner. This affected one (#63) of one resident who received the alternate meal selection. The facility census was 95. Findings included: Observation of tray line meal service on 04/02/24 at 12:17 P.M. revealed Dietary Cook (DC) #609 opening the steamer with gloved hands, removing a cooked hamburger patty and setting the hamburger patty onto the steamtable. DC #609 closed the steamer door and obtained a knife and cut the hamburger into bite sized pieces. DC #609 obtained a plate, scooped the cut up hamburger patty with gloved hands and placed the hamburger on the plate. At 12:19 P.M., DC #609 changed her gloves and continued serving. […]