Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kensington At Anna Maria during CMS and state inspections, most recent first.
Medication administration errors exceeded the 5% threshold, with an 8.82% error rate during observation. An LPN failed to prime three insulin KwikPens before giving Humulin 70/30 and Lispro insulin to a resident with DM2 and severe cognitive decline, and also omitted a scheduled Midodrine dose even though the resident’s BP was below the hold parameter. The DON verified the insulin pens should have been primed and the Midodrine dose should have been administered.
The facility failed to ensure a safe transfer for a resident using a Hoyer lift, resulting in a fall and injury, and did not implement a physician-ordered fall intervention for another high-risk resident, leading to increased risk of falls.
The facility failed to serve food at palatable temperatures, affecting all residents except one. Interviews revealed food was often cold and bland. A test tray evaluation confirmed lukewarm temperatures, and the Certified Dietary Manager acknowledged complaints. The facility lacked heated transportation units to maintain proper food temperatures.
The facility failed to ensure all meals were served in a sanitary manner. A Dietary Cook was observed handling a cooked hamburger patty with gloved hands, cutting it into pieces, and scooping the pieces onto a plate using the same gloves. The cook acknowledged the improper handling during an interview.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
Medication administration errors exceeded the facility’s 5 percent threshold, with four errors observed in 34 opportunities for an 8.82 percent total error rate. The deficiency involved one resident out of three residents observed for medication administration. The resident had diagnoses including spinal stenosis, type 2 diabetes, chronic kidney disease, gastro-esophageal reflux disease, overactive bladder, atrial fibrillation, adult failure to thrive, and hyperlipidemia. The quarterly MDS showed a BIMS score of 8 out of 15, indicating severe cognitive decline, and the functional assessment showed the resident needed supervised assistance with grooming and maximum assistance with toileting, transferring, and wheelchair mobility. During observation of morning medication administration, the resident’s blood glucose was 209, and the ordered sliding scale required 4 units of Lispro insulin before breakfast. The LPN administered Humulin 70/30 insulin in two doses, 30 units from one KwikPen and 24 units from a second KwikPen, and then administered 4 units of Lispro insulin, but did not prime any of the three insulin pens before use. The LPN also omitted the morning dose of Midodrine 5 mg even though the resident’s blood pressure was 127/84 and the order directed the medication to be held only if systolic blood pressure was greater than 130. The LPN confirmed not priming the pens and stated she forgot, and the DON verified that the pens should have been primed and that the Midodrine dose should have been given based on the recorded blood pressure.
Failure to Ensure Safe Transfers and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure Resident #27 was safely transferred using a Hoyer lift, resulting in actual harm. On the evening of 10/30/23, STNA #520 attempted to transfer Resident #27 from her wheelchair to her bed using a Hoyer lift without the assistance of another staff member, contrary to facility policy. The Hoyer pad was incorrectly positioned, causing Resident #27 to slide through the pad and fall to the floor. This incident led to Resident #27 being transferred to the emergency room, where she was diagnosed with a closed non-displaced fracture of her left clavicle and a hematoma to her left ear. The investigation revealed that STNA #520 was aware of the two-person requirement but proceeded alone due to the resident's distress, and the incident was not accurately documented in initial reports and witness statements. The facility also failed to implement a physician-ordered fall intervention for Resident #48. Resident #48, who had a history of falls and was at high risk for further falls, was observed sitting in her wheelchair without the required Dycem mat above and below her wheelchair cushion. Despite the physician's order and the resident's care plan specifying the use of Dycem to prevent sliding, the mat was found on the nightstand in her room. Interviews with staff revealed a lack of awareness and adherence to the intervention, with one STNA confirming the absence of the Dycem on the wheelchair cushion and another staff member providing a new Dycem during the observation. These deficiencies highlight significant lapses in the facility's adherence to safety protocols and care plans, directly leading to harm and increased risk for the residents involved. The failure to follow established procedures for mechanical lift transfers and fall prevention interventions underscores the need for improved staff training and compliance monitoring to ensure resident safety.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure food was served at palatable temperatures, affecting all residents except one who received nothing by mouth. Interviews with five residents revealed that food was often served cold and tasted bland. Observation of tray line service showed that food was placed on plates, covered with thermal lids, and then placed in a metal, enclosed food cart. A test tray evaluation revealed that the pureed lasagna was 113 degrees Fahrenheit and the pureed vegetable was 107.6 degrees Fahrenheit, both of which were lukewarm. The Certified Dietary Manager confirmed these findings and acknowledged hearing food complaints from residents. The facility had ordered thermal plate bottoms but did not have heated transportation units to keep the food warm during tray pass. The facility's Room Test Tray Evaluation form indicated acceptable delivery temperatures for hot foods should be between 135 to 160 degrees Fahrenheit.
Unsanitary Meal Service
Penalty
Summary
The facility failed to ensure all meals were served in a sanitary manner. During an observation of tray line meal service, a Dietary Cook (DC) was seen opening a steamer with gloved hands, removing a cooked hamburger patty, and setting it onto the steamtable. The DC then cut the hamburger into bite-sized pieces and scooped the pieces onto a plate using her gloved hands. The DC subsequently changed her gloves and continued serving. This meal tray was then taken to the dining room for a resident. The DC acknowledged the improper handling of the hamburger patty during an interview, confirming that she knew she should not have used her hands to scoop the food.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anna Maria Of Aurora | 0.1 mi | ★★★★★ | 12 | 0 |
| Aurora Manor Special Care Cent | 2.2 mi | ★★★★★ | 14 | 1 |
| Avenue At Aurora | 2.7 mi | ★★★★★ | 7 | 0 |
| Canterbury Of Twinsburg | 3.6 mi | ★★★★★ | 0 | 0 |
| Twinsburg Post Acute | 4.7 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.