Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Kensington during CMS and state inspections, most recent first.
The facility did not ensure accurate PBJ staffing data was submitted to CMS, and the report triggered an alert for excessively low weekend staffing. Survey review found RN/LPN coverage on each shift and CNAs assigned for each shift and unit, while interviews showed the weekend schedule was set the same as weekdays and agency staff were used for call-ins. The Scheduler did not know why the report showed low weekend staffing, and the Director of Labor Management stated the facility had difficulty capturing agency hours, especially on weekends, because documentation was not always sufficient.
A resident with prior skin issues and reduced mobility was repeatedly observed in a Broda chair without the ordered pillow under her legs, despite the care plan and TAR calling for it to prevent friction-related skin injury. Another resident with dementia, hemiplegia, diabetes, and a left arm wound after ORIF returned from ortho with daily dressing orders, but the facility did not document a comprehensive wound assessment until two days later; staff acknowledged the assessment was expected sooner and that the resident’s arm had been difficult to view while the splint was in place.
A resident admitted with anxiety had orders for scheduled and PRN lorazepam, but the medication was not available in the cart or contingency supply because the pharmacy had not received a handwritten script needed to release it. An LPN and other staff documented repeated calls to pharmacy and the provider, while the resident reported repeatedly asking for the medication and being told it was not available. The MAR showed multiple missed scheduled doses before the medication was eventually obtained and administered.
An infection prevention and control deficiency occurred when a shared glucometer was not cleaned and disinfected between resident blood sugar checks. An LPN used the same glucometer for two residents and wiped it with an alcohol wipe for only a few seconds after each use, despite the facility policy requiring cleaning and disinfection after each use with EPA-registered disinfectant wipes.
Surveyors identified that the facility failed to maintain an effective infection prevention and control program, including improper storage of garbage in PPE carts, use of a shared vital signs machine containing dirty linen and used tissues without disinfection, and inconsistent implementation of Enhanced Barrier Precautions for a resident on EBP orders. Staff entered and exited rooms and performed personal care and transfers without appropriate PPE or hand hygiene, including reusing gloves across tasks, contaminating clean linens during peri care, and leaving rooms without washing hands. Mechanical and Hoyer lifts used to transfer multiple residents were repeatedly returned to hallways or the shower room without being sanitized between residents, despite staff and leadership stating they should be cleaned after each use.
Several residents with existing or high risk for pressure injuries did not receive timely and comprehensive skin and wound assessments upon admission or when new wounds developed. In multiple cases, LPNs performed initial assessments without prompt RN follow-up, and wound documentation was delayed or incomplete. Staff failed to consistently implement or communicate offloading interventions, and air mattress settings were not properly adjusted. There was also confusion in wound care documentation and a lack of care plan updates for refusals, resulting in missed opportunities for effective pressure injury prevention and management.
Surveyors found that the facility did not provide required written notices to residents or their representatives regarding bed-hold policies, transfer/discharge reasons, or appeal rights during hospital transfers. Staff interviews revealed confusion about responsibilities, and documentation was inconsistent, with missing information about bed-hold payment rates and lack of written notification. The facility also failed to notify the Ombudsman of resident transfers or discharges, affecting multiple residents with complex medical needs.
Surveyors observed multiple failures in infection control practices, including staff not removing gloves or performing hand hygiene after providing incontinence care or emptying ostomy bags, and not wearing gowns during high-contact care for residents on enhanced barrier precautions. Staff also failed to change gloves and perform hand hygiene between dirty and clean tasks during wound care. These deficiencies were observed during care of residents with significant medical needs, such as indwelling catheters, chronic wounds, and severe cognitive impairment.
A resident with multiple medical conditions was found with a large bruise on the left eyelid, which was not witnessed by staff and could not be explained by the resident. Despite facility policy requiring reporting of injuries of unknown source, the incident was not reported to the State survey agency. Leadership relied on assumptions about the cause, such as difficulty with glasses, and did not complete required documentation or follow reporting protocols.
A resident with multiple medical conditions was found with a significant bruise to the left eyelid, first noticed by a family member. Although staff discussed possible causes, such as difficulty with glasses and use of a hoyer lift, the facility did not conduct a thorough investigation as required by policy, failing to interview all relevant staff or fully document the investigative process.
Two residents with significant medical needs were found to have excessively long toenails due to the facility's failure to ensure timely podiatry services, despite having signed consents and a policy requiring proper foot care. Staff interviews and record reviews revealed that both residents were not included on the podiatrist's list, and communication lapses with the podiatry group contributed to the deficiency.
Two residents did not receive appropriate bowel and bladder care, including lack of timely assessment, documentation, and intervention for incontinence and constipation. One resident experienced a decline in continence without a comprehensive assessment or individualized toileting plan, while another went several days without a bowel movement and did not receive interventions as outlined in the facility's protocol. Staff interviews revealed inconsistent documentation and lack of clarity regarding care protocols.
Three medication errors were identified, resulting in a medication error rate above 5%. Two residents did not receive medications as ordered: one did not receive Glimepiride before breakfast and was given the wrong eye drops, while another was administered a different eye drop product than prescribed. Nursing staff confirmed that medications should be given according to physician orders, but this was not followed in these cases.
The facility did not accurately submit required PBJ staffing data to CMS for a quarter, omitting agency staff hours and resulting in a one-star staffing rating and a flag for low weekend staffing. Review of schedules showed actual staffing was adequate, but the data submission process failed to capture all hours worked, potentially affecting all residents.
Inaccurate PBJ Staffing Submission Triggered Low Weekend Staffing Alert
Penalty
Summary
The facility did not ensure accurate reporting of mandatory staffing information submitted to CMS through the Payroll Based Journal system. The report states that the facility entered inaccurate PBJ data, which triggered an alert for excessively low weekend staffing for the fiscal quarter of October 1 through December 31, 2025. The deficiency was identified through review of the CMS PBJ Staffing Data Report and the facility’s schedules for weekend shifts during that quarter. Surveyor review of the schedules showed that a RN or LPN was assigned on each shift, along with CNAs designated for each shift and unit. The facility assessment, last reviewed and updated on 1/27/26, listed direct care staffing levels including RNs, LPNs, medical aides/technicians, CNAs, an infection preventionist, and an MDS staff member. During interviews, the Scheduler stated the weekend schedule was made the same as weekdays and that agency staff would be used for call-ins, but she did not know why the report showed low weekend staffing or who submitted it. The Director of Labor Management acknowledged the low weekend staffing alert and stated the facility struggled to enter agency staff, especially on weekends, because the office was closed and documentation was not always sufficient to reconcile punches and capture agency hours. The facility was not able to provide additional information explaining the inaccurate staffing submission by the end of the survey.
Pressure Injury Care and Wound Assessment Deficiencies
Penalty
Summary
The facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice. For one resident with a history of MASD, prior DTI, reduced mobility, incontinence, refusals of care, and a care plan intervention to use a pillow behind her legs while up in a Broda chair, surveyors repeatedly observed her sitting in the Broda chair without the pillow in place. The resident was observed in the dining room and later in the same chair position with her legs elevated and turned to one side, while wearing heel protective boots. The care plan and TAR documented the pillow intervention as ordered, and staff later acknowledged that the resident had been provided new protective boots and a pillow under her legs to prevent further rubbing, but the intervention was not observed in place during the survey observations. For another resident with dementia, hemiplegia, diabetes with polyneuropathy, and impaired mobility, the facility did not complete a comprehensive wound assessment promptly after the resident returned from an orthopedic appointment. The resident had sustained a fall with left humerus fracture and underwent ORIF, followed by a non-removable splint that remained in place for weeks. After the orthopedic follow-up, the splint was discontinued and daily dressing changes with Xeroform, gauze, and ace wrap were ordered for the left arm wound. Survey review found no comprehensive wound assessment documented until two days after the resident returned with the new orders, despite staff stating the expectation was generally within 24 hours of discovery. During interview, the unit manager stated the resident had not been able to have the arm fully viewed since the non-removable splint was placed and that she attempted an evaluation when the resident returned, but the resident declined and this was not documented. The DON later acknowledged that the comprehensive assessment was completed later, after surveyor concern was raised. The record also showed wound care documentation dated before the facility stated it had first performed wound care, and surveyors observed the wound care being completed with the resident’s left arm wound measuring 1 x 1 cm and 100% granulation at the time of observation.
Missed Scheduled Lorazepam Due to Missing Prescription
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident who was admitted with generalized anxiety disorder and had orders for Lorazepam 0.5 mg by mouth twice daily scheduled and every 8 hours as needed for anxiety. During a medication pass, the LPN could not locate the resident’s Lorazepam in the medication cart and then checked the other cart, where it was also not found. The LPN stated the medication would need to be removed from contingency supply and that pharmacy would be called. Record review showed the resident’s Lorazepam was not available because the pharmacy had not received a handwritten prescription needed to provide a code for release from contingency supply. Facility documentation showed repeated entries stating the medication was not available, that pharmacy did not have a script, and that the medication was waiting on pharmacy or a new script was needed. The resident’s April 2026 MAR documented five missed scheduled doses of Lorazepam before the medication was finally signed as given later in the month. Facility notes and staff interviews showed the issue persisted over several days while staff contacted pharmacy and the physician/PA about the missing script. The DON stated the facility could not take medication from contingency until an authorization code was received from pharmacy, which required a script. The resident stated she kept asking for the medication and was told it was not available, and she said she could tell she had not been receiving it and was frustrated because she needed it for anxiety.
Glucometer Not Properly Disinfected Between Resident Uses
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficiency involved 4 residents on the unit who required blood sugar testing, identified as R3, R18, R24, and R56. The facility policy for glucometer disinfection stated that glucometers used for resident testing are to be cleaned and disinfected after each use and according to manufacturer instructions, using EPA-registered disinfectant wipes effective against HIV, HCV, and HBV. During observation, an LPN gathered a glucometer, lancet, and alcohol wipes, entered R24's room, performed blood sugar testing, and wiped the glucometer with an alcohol wipe for about 5 seconds. The same glucometer was then taken into R56's room and used again after hand hygiene and glove use, and it was again wiped with an alcohol wipe for about 5 seconds before being placed on the medication cart. When asked what is used to clean the glucometer, the LPN stated she used an alcohol wipe and also noted bleach wipes were in the med cart. The DON stated the expectation was to use bleach wipes to clean the glucometer, and the surveyor verified there were no residents on the unit requiring blood sugar testing with bloodborne pathogens.
Failure to Maintain Effective Infection Control Practices for PPE, Hand Hygiene, and Shared Equipment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including proper hand hygiene, PPE management, and cleaning and disinfection of shared resident care equipment. Surveyors observed multiple PPE carts outside residents’ rooms containing garbage, including balled-up paper from used straws and cookie packaging stored in drawers with clean gowns and other PPE. A rolling vital signs monitor shared among 33 residents was found with dirty linen and used tissues with a dried red substance in its basket, with the blood pressure cuff, thermometer, and pulse oximeter resting on top of these soiled items. An LPN used this vital signs machine on a resident without noticing or removing the dirty linen and tissues and did not disinfect the blood pressure cuff before or after use; the LPN also used a manual blood pressure cuff from the nurse’s cart on the same resident and returned it without cleaning. The facility did not consistently implement Enhanced Barrier Precautions (EBP) and PPE use as ordered and as outlined in its policies. One resident with a history including infected left knee prosthesis, type 2 diabetes, primary hypertension, vitamin D deficiency, and stage 3 chronic kidney disease had a physician order for EBP, but there was initially no EBP signage or PPE storage outside the room, and the resident’s Kardex contained no indication of EBP or other precautions. The Infection Preventionist and a CNA exited this resident’s room without any discarded PPE evident, and the Infection Preventionist later acknowledged not knowing at the time that the resident was on EBP and that signage and a PPE cart were not in place until after the issue was recognized. CNAs subsequently transferred this resident with a mechanical lift without donning PPE, stating they were unaware of the precautions and did not see signage or PPE storage before entering; they also stated they did not believe transferring was a high-contact care activity requiring PPE, despite the EBP sign listing transferring as such. Hand hygiene and glove use practices during personal care were inconsistent with the facility’s handwashing policy. One CNA was observed entering a resident’s room wearing the same gloves used previously, touching environmental surfaces and equipment, assisting with clothing changes and transfers, leaving the room with the same gloves to obtain linens, and only later removing gloves and performing hand hygiene. During peri care for the same resident, the CNA contaminated clean linen by placing it in the sink, turning on the faucet, and using the soap dispenser pump with gloved hands before using the linen for the resident’s face. The same CNA was also seen exiting another resident’s room wearing gloves, retrieving clean linens from a hallway cart, and returning to the room without removing gloves or performing hand hygiene. In another case, during incontinence care for a resident with multiple sclerosis, diabetes, morbid obesity, and hypertension, one CNA removed gloves and left the room without hand hygiene, and the other CNA completed perineal care, applied barrier cream, and handled linens and equipment before removing gloves and leaving the room to retrieve a Hoyer lift without performing hand hygiene. The facility also failed to ensure proper cleaning and disinfection of mechanical lifts between residents, contrary to its policy that multiple-resident-use equipment be cleaned and disinfected after each use. Surveyors repeatedly observed CNAs using mechanical or Hoyer lifts to transfer several residents, including those dependent on chair/bed-to-chair transfers, and then placing the lifts in hallways or in the bath/shower room without sanitizing them. This occurred after transfers for multiple residents, including those with significant comorbidities such as diabetes, atrial fibrillation, and hypertensive heart disease with heart failure. Staff interviews revealed inconsistent understanding and practice: some CNAs stated lifts are only wiped down after use in rooms with precautions, others stated lifts are washed at night, while several staff members, including the Infection Preventionist and DON, stated that lifts should be sanitized after every use or when leaving the room. Despite these stated expectations, surveyor observations documented that lifts used for multiple residents were not disinfected between uses.
Failure to Provide Timely and Comprehensive Pressure Injury Assessment and Prevention
Penalty
Summary
Multiple deficiencies were identified in the facility's management of pressure injuries for several residents. In one case, a resident was admitted with a history of vertebral fractures, chronic kidney disease, heart failure, morbid obesity, and visual impairment. The hospital discharge summary indicated the presence of pressure injuries, but upon admission, only a Licensed Practical Nurse performed the initial skin assessment, noting abrasions and bruising. A comprehensive assessment by a Registered Nurse did not occur until five days later, despite the resident having two unstageable pressure injuries. Observations revealed that the resident's heels were not being offloaded as required, and the air mattress was set incorrectly for the resident's weight. Staff did not consistently communicate or implement offloading interventions, and there was a lack of timely and thorough wound assessment and documentation. Another resident with dementia, malnutrition, and spinal stenosis, who was also receiving hospice care, developed an open area on the right buttock. The hospice aide documented the wound, but no nursing assessment was completed for a week. The care plan included interventions such as offloading heels and using an alternating pressure mattress, but repeated observations showed the resident's heels were not being offloaded. There was also confusion and inconsistency in wound care documentation and dressing application, with a deep tissue injury on the sacrum being discovered without prior documentation or physician orders. The resident's care plan did not reflect refusals of care, despite documentation of resistance to repositioning and treatments. A third resident was admitted with a stage 4 sacral wound, but the initial admission assessment lacked a comprehensive description of the wound, including staging, wound bed, and surrounding tissue. The first detailed assessment was not completed until five days after admission by the wound doctor. Facility staff, including the wound nurse and unit manager, acknowledged that a comprehensive assessment should have been completed upon admission. Across all cases, the facility failed to ensure prompt and thorough assessment, documentation, and implementation of pressure injury prevention and management interventions, as required by their own policy and professional standards of practice.
Failure to Provide Required Written Bed-Hold Notices and Ombudsman Notification During Resident Transfers
Penalty
Summary
Surveyors identified that the facility failed to provide required written documentation and notifications related to bed-hold policies, transfer/discharge reasons, and appeal rights to residents and their representatives during hospital transfers or discharges. In all ten cases reviewed, there was no evidence that residents or their representatives received written notices specifying the reason for transfer/discharge or the facility's bed-hold policy, including the reserve bed payment rate for all payer sources after 15 days. Additionally, the facility did not notify the Ombudsman of these transfers or discharges as required by regulation and facility policy. The review of medical records and interviews with facility staff revealed inconsistent and unclear processes for completing and distributing transfer/discharge notices and bed-hold information. Staff members, including the Social Services Director, Medical Records Director, and Unit Secretary, provided conflicting accounts of their responsibilities, and there was confusion regarding who was responsible for notifying the Ombudsman. Documentation practices were inconsistent, with verbal consent often noted in place of written notification, and the required bed-hold payment rates were not included on the forms provided to residents or their representatives. In several instances, staff indicated that forms were only sent to representatives upon request, and there was no documentation that written notices were provided. The deficiency affected residents with a range of complex medical conditions, including seizures, neurogenic bowel, hemiplegia, diabetes, heart failure, chronic kidney disease, and others. Despite multiple hospital transfers for acute changes in condition, there was no evidence that the facility provided the necessary written information to residents or their representatives regarding their rights, the reason for transfer, or the financial implications of bed-hold policies. The facility also failed to maintain documentation of notifications to the Ombudsman for any of the reviewed cases.
Infection Control Deficiencies: Hand Hygiene, PPE, and Enhanced Barrier Precautions
Penalty
Summary
Multiple deficiencies were identified in the facility's infection prevention and control practices, particularly regarding hand hygiene, glove use, and adherence to enhanced barrier precautions (EBP). Staff were observed failing to remove gloves and perform hand hygiene after providing incontinence care, emptying ostomy bags, and before touching clean surfaces or equipment. For example, after emptying a resident's ileostomy bag, a staff member did not remove gloves or perform hand hygiene before turning on the resident's radio. In another instance, a staff member did not remove gloves or wash hands after providing incontinence care, only performing hand hygiene at the end of the care process. There were also failures to use appropriate personal protective equipment (PPE) as required by the facility's EBP policy. Staff were observed not wearing gowns when providing high-contact care activities, such as transferring, changing linens, and providing hygiene to residents on EBP, including those with indwelling urinary catheters or chronic wounds. In one case, a staff member entered a resident's room on EBP, delivered meal trays, and left the room without performing hand hygiene as required by posted signage and facility policy. Additionally, a nurse was observed performing wound care without changing gloves and performing hand hygiene between dirty and clean tasks, contrary to accepted standards and state guidance. The residents involved had significant medical needs, including severe cognitive impairment, incontinence, indwelling urinary catheters, chronic wounds, and pressure ulcers. The observed lapses in infection control occurred during routine care activities such as incontinence care, wound care, catheter care, and assistance with activities of daily living. These actions and inactions were directly observed by surveyors and confirmed through interviews with facility staff, who acknowledged the required procedures were not followed in these instances.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident who was found with a significant bruise covering almost the entire left eyelid. The incident was first brought to staff attention by the resident's daughter, who noticed the bruise and believed it may have been caused by the resident resting his face against a hoyer sling during transfers. Nursing staff documented the bruise, noting its size and location, and that the resident was cognitively intact, denied pain, and could not recall how the injury occurred. Multiple staff members and the resident's representative provided differing accounts regarding the possible cause, including difficulty with glasses and the use of the hoyer lift, but no definitive cause was established. Despite the facility's policy requiring the reporting of all injuries of unknown source to the State survey agency, the incident was not reported. The policy specifically lists physical injury of unknown source as a possible indicator of abuse and mandates reporting within specified timeframes. Interviews with facility leadership revealed that the Nursing Home Administrator did not consider the injury to be of unknown origin, citing the resident's use of glasses as a likely explanation, and did not complete the required injury of unknown source flowchart to document the decision-making process. Surveyor review confirmed that the injury was not observed by staff, the resident could not recall the cause, and the location of the bruise was not generally vulnerable to trauma. The facility did not provide additional documentation or policies to justify the decision not to report. The lack of reporting was based on subjective judgment rather than adherence to the facility's written policy and regulatory requirements.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an injury of unknown source for one resident. The resident, who had diagnoses including diabetes mellitus, urinary retention, metabolic encephalopathy, bladder cancer, hypertension, and depression, was observed with a bruise covering almost the entire left eyelid. The bruise was first brought to staff attention by the resident's daughter, who noticed it prior to staff awareness. Documentation indicated that the resident was cognitively intact and used a hoyer lift for transfers. Staff and family noted the resident sometimes rested his face against the hoyer sling and had difficulty putting on his glasses, often hitting his face in the process. Despite the facility's policy requiring immediate and thorough investigation of injuries of unknown source, the investigation into the resident's bruise was incomplete. While some staff, such as the LPN/Unit Manager, DON, and a Med Tech, were involved in discussions and provided statements, there was no evidence that all staff who provided care to the resident on the days surrounding the appearance of the bruise were interviewed. The investigation relied on verbal statements and did not include written statements from all relevant staff, nor did it document interviews with all potential witnesses or caregivers who may have had knowledge of the incident. The facility's documentation included notes from nursing staff, the interdisciplinary team, and the resident's representative, but lacked comprehensive evidence of a systematic investigation as outlined in facility policy. The surveyor found that the information provided did not demonstrate a thorough investigation into the cause of the injury, as required by the facility's own procedures for responding to alleged violations, including injuries of unknown source.
Failure to Provide Timely and Appropriate Foot Care
Penalty
Summary
Two residents were found to have excessively long toenails that required trimming, indicating a failure by the facility to provide appropriate foot care as outlined in their own policy. Both residents had signed podiatry consent forms on file, but there was no documentation that either had received podiatry services since admission. One resident had a diagnosis of diabetes mellitus, which can complicate foot care needs, while the other had dementia. Observations by the surveyor confirmed that both residents' toenails were very long and in need of attention. Interviews with staff revealed that the process for scheduling podiatry services was not consistently followed. The unit secretary explained that residents are added to the podiatrist's list after consent forms are signed, but acknowledged that both residents were not included on the list for podiatry visits. The podiatrist had previously visited the facility during early morning hours, and there were concerns that some residents were reported as seen when they were not, as confirmed by resident feedback. The unit secretary also reported communication issues with the podiatry group, including missed emails and lack of follow-up. Medical record review and staff interviews confirmed that despite the presence of signed consents, neither resident had documentation of receiving podiatry care. In one case, a nurse assessed a resident's toenails and determined they were too thick and difficult to trim safely, but no podiatry service had been provided up to that point. The lack of timely and appropriate foot care for both residents constituted a deficiency in meeting their care needs as required by facility policy.
Failure to Provide Appropriate Bowel and Bladder Care and Assessment
Penalty
Summary
Two residents did not receive appropriate treatment and services to restore or maintain bowel and bladder continence, as required by facility policy and regulatory standards. One resident experienced a significant decline in continence status without a comprehensive assessment or individualized toileting plan. Despite documentation in the care plan to conduct a three-day bladder diary and assessment on admission, quarterly, annually, and with significant change, there was no evidence that such assessments or a voiding pattern study were completed after the resident's decline. Staff interviews confirmed that there was no set toileting schedule beyond routine checks, and the LPN Unit Manager was unaware of the decline documented in the MDS. The resident was observed managing incontinence independently, sometimes without staff assistance, and at high risk for falls due to not locking wheelchair brakes and not using the call light. Another resident, with a history of neurogenic bowel, hemiplegia, and severe cognitive impairment, went six days without a documented bowel movement. The care plan included interventions such as monitoring and documenting bowel movements every shift and following a protocol for no bowel movement for three days, but these interventions were not implemented. Bowel documentation was inconsistent, with multiple shifts left blank and no PRN bowel medications administered during the period of constipation. The resident was eventually sent to the hospital for an unrelated change of condition and was diagnosed with a small bowel obstruction. Staff interviews revealed confusion about documentation codes and the bowel protocol, and the facility was unable to provide clear evidence of monitoring or interventions during the period of constipation. The facility's failure to follow its own policies and protocols for bowel and bladder management, including timely assessment, documentation, and intervention, resulted in residents not receiving appropriate care. The lack of comprehensive assessment and individualized care planning, as well as inconsistent documentation and unclear staff understanding of protocols, contributed to the deficiencies identified by surveyors.
Medication Error Rate Exceeds 5% Due to Incorrect Administration and Product Substitution
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with three medication errors identified out of 28 opportunities, resulting in a 10.71% error rate. Two errors involved one resident who did not receive Glimepiride 4 mg before breakfast as ordered by the physician and was also administered the incorrect eye drop medication. Specifically, the resident received artificial tears lubricant eye drops instead of the prescribed Systane Ophthalmic Solution, and the Glimepiride was not given prior to breakfast as directed in the physician's order. These errors were observed during medication administration and confirmed through review of the resident's medical records and physician orders. A third medication error involved another resident who was administered Visine dry eye relief lubricant instead of the prescribed Artificial Tears Solution 1.4% (Polyvinyl Alcohol). The error was observed during the medication pass and later verified by comparing the administered medication to the physician's order. Interviews with nursing staff confirmed that medications are expected to be administered according to physician orders, including timing and specific products, but these expectations were not met in the observed instances.
Failure to Accurately Submit Staffing Data to CMS
Penalty
Summary
The facility failed to ensure the complete and accurate electronic submission of direct care staffing information to CMS for Quarter 1 (October 1 - December 31) as required by federal regulations. The Payroll Based Journal (PBJ) data submitted did not accurately reflect all staffing hours, specifically omitting agency staff hours for the month of October. This omission resulted in the facility being flagged for excessively low weekend staffing and receiving a one-star staffing rating for the quarter. Review of the facility's weekend schedules and staffing ratios did not reveal discrepancies in actual staffing, indicating the issue was with the data submission rather than actual staffing levels. Interviews with the scheduler and the nursing home administrator revealed that staffing data is pulled directly from the timekeeping system and reported to CMS, but the omission of agency staff hours was not initially detected. The administrator confirmed that corporate oversight identified the missing data, and the director of nursing and unit managers were noted to assist with staffing when census was high. The deficiency had the potential to affect all 69 residents in the facility, as accurate staffing data is essential for regulatory compliance and quality monitoring.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 784 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waukesha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina Of Pewaukee | 1.2 mi | ★★★★★ | 5 | 0 |
| Lindengrove Waukesha | 1.4 mi | ★★★★★ | 20 | 1 |
| Aria Of Waukesha | 2.5 mi | ★★★★★ | 20 | 1 |
| Complete Care At Care Age | 5.8 mi | ★★★★★ | 1 | 0 |
| Aria Of Brookfield | 6.3 mi | ★★★★★ | 39 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Complete Care At Kensington.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.