Complete Care At Kensington

Penalties

• Jan 30, 2024 — Fine ($66,632)

Inspection findings

1. Apr 29, 2026 Health · 4 findings
   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected May 22, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 22, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected May 22, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 22, 2026 · CMS health inspection

2. Feb 23, 2026 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 20, 2026 · CMS health inspection

3. May 21, 2025 Fire Safety · 11 findings
   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Jun 12, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jun 12, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jun 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jun 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Jun 12, 2025 · CMS health inspection

   • Serious Scope/severity G

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jun 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0687 Quality of Life and Care Deficiencies

     Provide appropriate foot care.

     Corrected Jun 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Jun 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jun 12, 2025 · CMS health inspection

   • Not serious Scope/severity C

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Jun 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 12, 2025 · CMS health inspection

4. Feb 22, 2024 Fire Safety · 12 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Mar 13, 2024 · CMS fire safety

   • Not serious Scope/severity D Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity C

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Mar 15, 2024 · CMS health inspection

5. Jan 30, 2024 Health · 5 findings
   • Serious Scope/severity J Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jan 15, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 31, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0868 Administration Deficiencies

     Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

     Corrected Feb 13, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0946 Administration Deficiencies

     Provide training in compliance and ethics.

     Corrected Feb 13, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0949 Administration Deficiencies

     Provide behavior health training consistent with the requirements and as determined by a facility assessment.

     Corrected Feb 13, 2024 · CMS health inspection

6. Oct 6, 2023 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Oct 17, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Oct 17, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• CULP, KAREN — adp of the snf, NOT APPLICABLE, since 02/03/2020
• CULP, KAREN — operational/managerial control, NOT APPLICABLE, since 02/03/2020
• HELLMAN, YOSEF — adp of the snf, NOT APPLICABLE, since 08/01/2017
• HELLMAN, YOSEF — operational/managerial control, NOT APPLICABLE, since 08/01/2017
• KLEKAMP, CHRISTINE — operational/managerial control, NOT APPLICABLE, since 04/13/2020
• KLEKAMP, CHRISTINE — adp of the snf, NOT APPLICABLE, since 04/13/2020
• KLUGMAN, JACOB — adp of the snf, NOT APPLICABLE, since 08/01/2017
• REED, RACHEL — adp of the snf, NOT APPLICABLE, since 11/20/2022
• REED, RACHEL — operational/managerial control, NOT APPLICABLE, since 11/20/2022
• SIDHU, SARFRAZ — adp of the snf, NOT APPLICABLE, since 08/01/2017
• SIDHU, SARFRAZ — operational/managerial control, NOT APPLICABLE, since 07/28/2020
• STEIN, SHALOM — adp of the snf, NOT APPLICABLE, since 08/01/2017
• STEIN, SHALOM — indirect ownership interest, NOT APPLICABLE, since 08/01/2017
• STEIN, SHALOM — managing control - governing body, NOT APPLICABLE, since 08/01/2017
• STEIN, SHALOM — corporate officer, NOT APPLICABLE, since 08/01/2017
• STEIN, SHALOM — trustee of the snf, NOT APPLICABLE, since 08/01/2017
• STERNBUCH, DANIEL — adp of the snf, NOT APPLICABLE, since 08/01/2017
• DES CAPITAL LLC — adp of the snf, NOT APPLICABLE, since 08/01/2017
• JRK INVESTMENTS LLC — adp of the snf, NOT APPLICABLE, since 08/01/2017
• PEACE CAPITAL HOLDINGS II LLC — adp of the snf, NOT APPLICABLE, since 08/01/2017
• PEACE CAPITAL LLC — 5% or greater direct ownership interest, 100%, since 05/03/2024
• SMS 2021 TRUST — adp of the snf, NOT APPLICABLE, since 08/01/2017
• WAKESHA PROPCO LLC — adp of the snf, NOT APPLICABLE, since 08/01/2017
• WI 6 PROPCO HOLDCO LLC — adp of the snf, NOT APPLICABLE, since 08/01/2017
• WI 6 PROPCO TOPCO LLC — adp of the snf, NOT APPLICABLE, since 08/01/2017