Inspection Reports for
The Kensington

The visit was triggered by a complaint involving an incident report about duplicate narcotic medication administration to a resident. The complaint was substantiated by record review and interviews.

The facility was found to have administered duplicate doses of a narcotic medication to a resident, contrary to physician orders, posing a potential health and safety risk. A Type B deficiency was cited for failure to administer medication according to physician directions.

The complaint investigation was triggered by multiple Unusual Incident Reports received on 12/09/2025, 11/20/2025, 10/20/2025, and 07/03/2025, documenting medication errors including wrong medication administration, missed medications, and medication given to a guest by mistake. Some incidents involved staff training errors and staffing shortages due to COVID-19.

The inspection found multiple medication administration errors involving several residents, including wrong medication given, missed medications, and medication given inappropriately. Deficiencies were cited under California Code of Regulations, Title 22, related to failure to administer medications according to physician's directions.

The complaint investigation was substantiated. Allegations included staff mismanaging medications, falsifying medication records, and improper training of staff administering medications. The investigation included interviews, record reviews, and observations confirming these issues.

The investigation substantiated all allegations, finding that staff missed medication doses, falsified medication administration records, and that Medication Technicians administered insulin injections and performed blood glucose checks without appropriate training, posing potential health and safety risks to residents.

The complaint investigation (#15-AS-20241029121159) was triggered by an incident where Resident 1 fell on or about 07/01/2024, was assisted by a witness, but emergency services were not called. The resident was found unresponsive and pronounced deceased on 07/02/2024. The investigation substantiated that emergency medical services were not activated following the fall.

The investigation found that the facility failed to activate emergency medical services following a resident's fall with head impact, and there was no documentation of ongoing monitoring or reassessment of the resident's condition. The resident was later found deceased with bruising noted. A Type B deficiency was cited for failure to immediately telephone 9-1-1 in an apparent life-threatening medical crisis.

The visit was triggered by a complaint involving an unusual incident report received on 01/02/2025 concerning a medication error on 12/01/2024 where R1 was assisted with the wrong medication by a Med Tech. The Med Tech no longer works at the facility. The complaint was investigated during the visit.

The inspection found that the facility did not comply with medication administration requirements, specifically failing to administer medication for resident R1 according to the physician's directions, posing a potential health and safety risk. Deficiencies were cited under California Code of Regulation, Title 22.

The inspection found multiple deficiencies including unsafe hot water temperatures exceeding regulatory limits, unsecured prescription medications accessible to a resident, incomplete staff training records, and missing required postings. Plans of correction were requested with specific due dates.

Complaint investigation #15-AS-20241029121159 was conducted. The deficiency was substantiated based on observation and record review.

Two staff members (S2 and S5) were found not fingerprinted and associated with the facility, violating Title 22 California Code of Regulations, posing a potential health and safety risk to persons in care.

The visit was triggered by a complaint regarding a resident eloping from the Memory Care unit on 10/19/2024. The complaint was substantiated by observations and interviews confirming the incident and deficiencies.

The facility failed to maintain egress doors properly and did not have sufficient trained staff to prevent resident elopement, posing an immediate health and safety risk. Two Type B deficiencies were cited related to maintenance and staff supervision.

The facility had not cleared two deficiencies related to annual medical assessments for residents with dementia and required staff training. The Plan of Correction submissions were incomplete, and the Executive Director requested additional time to complete staff training by the end of the year.

The inspection identified multiple deficiencies including missing current medical assessments for residents, lack of TB tests, incomplete health screenings and annual training for staff, and failure to conduct quarterly disaster drills. Plans of correction were agreed upon to address these issues by 08/30/2024.

The complaint investigation was substantiated for staff mismanagement of residents' medication, specifically failure to administer insulin Lispro injections for multiple days without documentation. The allegation that staff did not keep an accurate medication log was unsubstantiated.

The investigation substantiated the allegation that staff mismanaged residents' medication, including failure to administer insulin Lispro injections as prescribed, posing a potential health and safety risk. The allegation regarding inaccurate medication logs was unsubstantiated as records were found to be complete and accurate.

The visit was complaint-related based on an Unusual Incident Report regarding a resident leaving memory care unsupervised. The complaint was substantiated by observations and interviews confirming the resident could force open windows and remove screens.

The licensee failed to secure the windows and window screens in memory care, posing an immediate health and safety risk to residents. The resident was able to force open a window and remove the screen, which was confirmed by observation and interview.