Kensington Place NRSG & Rehab

In the surveyor’s words

From the most serious findings on record at Kensington Place NRSG & Rehab, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 7, 2024

  Based on observation, interviews, and record review the facility failed to protect the resident's right (R2) to be free from physical abuse by another resident (R1) out of six residents reviewed for abuse in the sample. This failure resulted in R2 sustaining a laceration to the right center of the head requiring four sutures to close the wound. Findings include: R1's medical record face sheet documented that R1 was admitted on [DATE] and latest admission was on 10/25/24. Listed diagnoses includes but not limited to type 2 diabetes mellitus with other specified complications, other schizoaffective disorders, and other symptoms and signs involving appearance and behavior. […]

• Actual harm, isolatedF600Dec 22, 2022

  Based upon record review and interview the facility failed to ensure that one of three residents (R2) in the sample remained free from physical abuse and failed to assess (R1) prior to hospital transfer. On 11/9/22, R1 struck R2 in the eye. R1 sustained a fracture of the right 5th distal metacarpal and R2 sustained discoloration to the right eye. Findings include: The initial facility incident report states on 11/10/22 at approximately 8:45am, staff observed (R2) with discoloration to right eye. When asked what occurred (R2) alleged (R1) hit her on 11/10/22 afternoon [per R2's 11/10/22 statement the incident occurred 11/9/22 after lunch]. She (R2) is just now reporting it to staff. Body assessment was conducted by Nurse on duty. R1 was observed with discoloration to right eye. […]

• Actual harm, isolatedF600Jun 23, 2022

  Based on interview and record review, the facility failed to ensure that residents were free from physical abuse/assault from staff and fell ow residents. This failure affected four residents (R1, R5, R13, and R14) of six residents reviewed for physical abuse/assault. As a result, R14 sustained a facial and arm injury from a physical assault by staff. Findings include: 1. R14's Resident Face Sheet documents that R14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's BIMS (Brief Interview for Mental Status) dated 5/16/22 documents, in part, The BIM score is considered to be on a continuum with a score of 9 or less indicating some level of cognitive impairment and a 10 or greater being an indicator of intact cognitive function. R14 scored a 12. […]

• Actual harm, isolatedF689Apr 20, 2021

  Based upon observation, interview and record review the facility failed to ensure that staff are aware of resident fall prevention interventions, failed to score fall risk assessments properly for (R1, R2, R3), failed to provide timely response to (R2's) call light, and failed to implement fall prevention interventions for three of three residents (R1, R2, R3) reviewed for falls. These failures resulted in R1 sustaining a (3/30/21) fall and laceration requiring 13 sutures. R2 sustained a (3/4/21) fall and abrasion with facial swelling/redness. […]

• No harm, potential for more than minimal, widespreadF812Jul 11, 2026

  Based on observations, interviews and record reviews, the facility failed to monitor the temperature in the walk-in refrigerator cooler; failed to ensure food in the freezer is 6 inches off the floor; failed to label prepared foods; failed to test and record dishwasher sanitation; and failed to clean kitchen equipment used to prepare food. These failures have the potential to cause foodborne illnesses for all 139 residents receiving oral nourishment in the facility. Findings include: On 7/10/26 V4 (Dietary Supervisor) presented a list of 139 residents who were receiving an oral diet in the facility. […]