Inspection Reports for
Kensington Health and Rehabilitation
550 Congress Street, Mobile, AL, 36603
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
103% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Deficiencies: 0
Date: Jul 21, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Kensington Health and Rehabilitation, summarizing the findings of a regulatory survey completed on July 21, 2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 21, 2023
Visit Reason
Annual inspection survey of Kensington Health and Rehabilitation conducted to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 3
Date: Feb 18, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to medication monitoring and administration, specifically focusing on the use of psychotropic medications and medication error rates.
Findings
The facility failed to ensure adequate monitoring of Resident Identifier #75 for behaviors and side effects related to antipsychotic and antidepressant medications. Additionally, the facility had a medication error rate of 9.09%, exceeding the acceptable threshold of 5%, with errors involving medication administration to Residents #62 and #20.
Deficiencies (3)
Failure to monitor Resident #75 for behaviors related to antipsychotic medication (Zyprexa).
Failure to monitor Resident #75 for side effects of antipsychotic (Zyprexa) and antidepressant (Zoloft) medications.
Medication error rate exceeded 5% with 3 errors in 33 opportunities involving Residents #62 and #20.
Report Facts
Medication error rate: 9.09
Medication errors: 3
Medication administration opportunities: 33
Dosage error: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | EI #6 stated no orders were present to monitor behaviors or side effects for Resident #75 | |
| Director of Nursing | EI #2 stated expectation for monitoring residents on antipsychotic and antidepressant medications every shift and reviewed medication error reports | |
| Administrator | EI #1 stated expectation for nursing staff to monitor target behaviors and side effects of psychotropic medications | |
| Psychiatric Nurse Practitioner | EI #16 stated expectation for monitoring residents on antipsychotic and antidepressant medications for behaviors and side effects | |
| Licensed Practical Nurse | EI #4 observed administering incorrect medications to Resident #62 | |
| Licensed Practical Nurse | EI #5 observed administering incorrect dosage of lactulose to Resident #20 |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 18, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations related to medication monitoring, administration, and error rates in the nursing home.
Findings
The facility failed to adequately monitor Resident Identifier #75 for behaviors and side effects related to antipsychotic and antidepressant medications, resulting in minimal harm potential. Additionally, the facility had a medication error rate of 9.09%, exceeding the allowed 5%, due to errors in medication administration for Residents #62 and #20.
Deficiencies (3)
Failure to monitor Resident #75 for behaviors related to antipsychotic medication (Zyprexa).
Failure to monitor Resident #75 for side effects of antipsychotic (Zyprexa) and antidepressant (Zoloft) medications.
Medication error rate exceeded 5% with 3 errors in 33 opportunities involving Residents #62 and #20.
Report Facts
Medication error rate: 9.09
Medication errors: 3
Medication administration opportunities: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #6 | Licensed Practical Nurse | Interviewed regarding lack of orders to monitor behaviors and side effects for Resident #75 |
| EI #2 | Director of Nursing | Interviewed about expectations for monitoring residents on antipsychotic and antidepressant medications and medication error rate |
| EI #1 | Administrator | Interviewed about expectations for monitoring target behaviors and side effects and informed of medication errors |
| EI #16 | Psychiatric Nurse Practitioner | Interviewed about expectations for monitoring residents on antipsychotic and antidepressant medications |
| EI #4 | Licensed Practical Nurse | Observed and admitted medication errors during medication pass involving Residents #62 |
| EI #5 | Licensed Practical Nurse | Observed and admitted medication error during medication pass involving Resident #20 |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jul 11, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation (#AL00036326) regarding failure to notify resident's guardian or sponsor of significant events and other care concerns.
Complaint Details
Investigation of complaint/report #AL00036326 regarding failure to notify family members of significant resident events and other care concerns.
Findings
The facility failed to notify Resident #74's guardian of a hospital visit and Resident #105's sponsor of a smoking restriction. Environmental deficiencies were noted including peeling paint, splintered doors, torn ceiling tiles, and missing drawer in resident rooms. Additional findings included inaccurate resident assessments, failure to update care plans with smoking restrictions, unsafe oxygen therapy practices, unlocked medication cart during administration, and infection control lapses during resident care.
Deficiencies (8)
Failure to notify Resident #74's guardian of hospital visit on 5/26/19.
Failure to notify Resident #105's sponsor of smoking restriction starting 6/28/19.
Resident rooms observed with peeling paint, splintered doors, torn ceiling tiles, missing drawer, broken blinds, and scuffed baseboards.
Resident #111's admission MDS assessment was coded incorrectly regarding range of motion.
Resident #93's care plan was not updated to reflect smoking restriction.
Oxygen tubing and humidifier bottle for Resident #102 were not dated; Resident #97's oxygen tubing found on floor and mask not replaced properly.
Medication cart left unlocked and unattended during medication administration.
Soiled linens placed in Resident #97's closet; CNAs used soiled washcloths for bed bath and touched clean items with soiled gloves.
Report Facts
Residents affected: 2
Resident rooms observed with environmental issues: 19
MDS assessments reviewed: 23
Nurses observed during medication administration: 5
Days smoking restriction for Resident #93: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #7 | Social Service Director | Failed to notify Resident #105's sponsor of smoking restriction and failed to update Resident #93's care plan |
| EI #2 | Director of Nursing | Interviewed regarding notification policies and infection control |
| EI #12 | Maintenance Director | Observed environmental deficiencies and rounds documentation |
| EI #9 | MDS Coordinator | Acknowledged error in Resident #111's MDS assessment |
| EI #10 | Certified Nursing Assistant | Observed using soiled washcloths and gloves during Resident #97's care |
| EI #6 | Licensed Practical Nurse | Observed leaving medication cart unlocked and unattended |
| EI #17 | Respiratory Therapist | Initiated oxygen therapy for Resident #102 and acknowledged failure to date tubing and humidifier |
| EI #3 | Registered Nurse | Observed oxygen tubing and mask on floor for Resident #97 |
| EI #1 | Administrator | Interviewed regarding smoking policy and environmental concerns |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jul 11, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation (#AL00036326) regarding failure to notify resident guardians or sponsors of significant events and other care concerns.
Complaint Details
Investigation of complaint/report #AL00036326 regarding failure to notify family/sponsors of resident condition changes and smoking restrictions.
Findings
The facility failed to notify resident #74's guardian of a hospital visit and resident #105's sponsor of a smoking restriction. Environmental deficiencies were noted including peeling paint, splintered doors, torn ceiling tiles, and missing drawer in resident rooms. Additional findings included inaccurate resident assessments, incomplete care plans for smoking restrictions, unsafe oxygen therapy practices, unlocked medication cart during administration, and infection control breaches during resident care.
Deficiencies (8)
Failure to notify resident #74's guardian of hospital visit on 5/26/19.
Failure to notify resident #105's sponsor of smoking restriction starting 6/28/19.
Resident rooms observed with peeling paint, splintered doors, torn ceiling tiles, missing drawer, broken blinds, and scuffed baseboards.
Resident #111's admission MDS assessment was coded incorrectly regarding range of motion.
Resident #93's care plan was not updated to reflect smoking restriction.
Oxygen tubing and humidifier bottle for resident #102 were not dated; resident #97's oxygen tubing found on floor and mask not replaced properly.
Medication cart left unlocked and unattended during medication administration.
Soiled linens placed in resident #97's closet; CNAs used soiled washcloths for bed bath and touched clean items with soiled gloves.
Report Facts
Residents affected: 2
Resident rooms observed with environmental issues: 19
MDS assessments reviewed: 23
Sampled residents identified as smokers: 5
Nurses observed during medication administration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #7 | Social Services Director | Failed to notify resident #105's sponsor of smoking restriction and failed to update care plan for resident #93 |
| EI #2 | Director of Nursing | Interviewed regarding notification policies and infection control practices |
| EI #12 | Maintenance Director | Reported environmental issues and lack of documentation |
| EI #10 | Certified Nursing Assistant | Observed using soiled washcloths and gloves during resident care |
| EI #6 | Licensed Practical Nurse | Observed leaving medication cart unlocked |
| EI #17 | Respiratory Therapist | Initiated oxygen therapy for resident #102 and failed to date tubing and humidifier |
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