Kensington Nursing and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Mar 26, 2025

  Based 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 [DATE], revealed unlabeled, undated, unsealed, and expired food items in the walk-in refrigerator and the dry pantry storage area. The findings include: Review of the facility policy titled, Policy and Procedure Manual, Food Storage, dated 2019, [NAME] and Associates, Inc. Chapter three: Food Production and Food Safety ,d+[DATE], revealed foods should be dated as it is placed on the shelves if required by state regulation. […]

• No harm, potential for more than minimal, isolatedF761Mar 26, 2025

  Based 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. The findings include: Review of the facility's policy titled, Medication Storage, effective [DATE], revealed medications were stored in carts and nursing staff was responsible for maintaining medication storage in a safe manner. Observation with Licensed Practical Nurse (LPN)9, on [DATE] at 1:25 PM, revealed the 100 hall treatment cart contained twenty-eight individually wrapped packages of Hydrogel, which expired 2023 and 2024. […]

• No harm, potential for more than minimal, isolatedF656Jul 29, 2022

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet the resident's safety needs for one (1) of five (5) sampled residents (Resident #1). On 06/26/2022, Certified Nursing Assistant (CNA) #1 found a box labeled [NAME]. CNA #1 notified Licensed Practical Nurse (LPN) #2, who discovered a handgun in the box. The Assistant Director of Nursing (DON) removed the weapon from Resident #1's room. On 07/08/2022, five (5) days later, the Comprehensive Care Plan (CCP) was developed to include a focus stating the resident expressed fear related to watching the news and current events. […]

• No harm, potential for more than minimal, isolatedF689Jul 29, 2022

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as possible for one (1) of five (5) sampled residents (Resident #1). The census was seventy-six (76) residents. On 06/26/2022, Certified Nursing Assistant (CNA) #1 discovered a box labeled [NAME] and notified Licensed Practical Nurse (LPN) #2. The nurse found a handgun in the box and notified the Assistant Director of Nursing (ADON). Resident #1's room was immediately searched for other dangerous weapons/items. However, the facility failed to search other residents' rooms for dangerous items, until after the State Survey Agency (SSA) entered the building the next afternoon, on 06/27/2022. […]