Kensington Gardens Rehab and Nursing Center

In the surveyor’s words

From the most serious findings on record at Kensington Gardens Rehab and Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF732Feb 1, 2024

  Based 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. Findings included: An observation on 01/29/24 at 9:00 a.m., revealed no nurse staffing data was posted in the facility. An observation on 01/30/24 at 6:00 p.m., revealed no nurse staffing data was posted in the facility. An observation on 01/31/24 at 3:00 p.m., revealed no nurse staffing data was posted in the facility. During an interview on 01/31/24 at 3:00 p.m., the Administrator stated normally the staffing coordinator would be responsible for posting the staffing numbers, however, the daily staff posting had not been getting posted with the absence of the staffing coordinator.

• No harm, potential for more than minimal, patternF684Aug 27, 2026

  Based on observations, interviews, and record review, the facility failed to provide wound care in accordance with professional standards for two residents (#1 and #3) of three residents sampled. Findings included: On 8/27/26 at 9:21 a.m. Resident #1 was observed sitting in a wheelchair, eyes closed, shaking, breathing rapidly, and non-responsive to verbalizations. Staff B, Licensed Practical Nurse (LPN) responded to the resident room and was unable to elicit a response from the resident. As the staff member left the room, the resident opened eyes saying (pronoun) was fine. Staff C, Licensed Practical Nurse/Unit Manager came into room and resident informed the staff member they were okay. […]

• No harm, potential for more than minimal, patternF881Feb 18, 2026

  Based 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. Findings included: Review of the facility December 2025 Infection and Antibiotic Tracking Tool showed symptoms related to antibiotic use as urinary tract symptoms. The tool revealed Resident #42 was diagnosed with an urinary tract infection (UTI) with symptoms of urinary tract symptoms and leukocytosis, an urine test was obtained with no documentation of white blood cell count (WBC), colony count, or culture results. The documentation showed the resident was treated with Ceftriaxone for 7 days (12/20-12/27/25) and the urinalysis (UA) was negative (neg). […]

• No harm, potential for more than minimal, patternF585Jan 16, 2026

  Based 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.Findings included: A review of the facility's Grievances - Resident Rights policy and procedure, last revised 07/2024, documented the guideline: The Administrator and staff will make prompt efforts to resolve grievance so the satisfaction of the resident and / or representative.The Procedure:Any resident, family member, or appointed resident representative may file a grievance or complaint… […]

• No harm, potential for more than minimal, patternF684Jan 16, 2026

  Based 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. Findings included: 1. Resident #4 was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. Review of the admissions record showed diagnoses included but not limited to diabetes, acquired below knee amputation, Chronic Obstructive Pulmonary Disease (COPD), Peripheral vascular disease, muscle weakness, permanent atrial fibrillation, Chronic systolic congestive heart failure, and pulmonary hypertension. Review of the Minimum Data Set, dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 or cognitively intact. […]