Kensley Care LLC dba Kensley Care South

During the walkthrough conducted on 6/13/25, several maintenance and safety concerns were observed. Specifically, a broken kitchen cabinet, damaged curtain rods in a common area, visible cracks in a dining room window, chipped paint around a bedroom window, a missing light switch cover in one of the bedrooms and exposed screws in a bedroom wall were noted.

During the inspection conducted on 6/13/25, it was determined that the operation failed to document accurate circumstances surrounding a child's discharge.

Four individuals hired after September 1,2023 were missing the Pre-Employment Affidavit in their personnel file.

During the inspection conducted on 6/13/25, it was determined that the discharge documentation for a child in care was incomplete and did not include who the child was discharged to .

During the inspection, the opertion failed to provide documented records verifying that required severe weather drills are being conducted.

All employees files reviewed did not have a photo copy of the actual drug test results.

Information gathered and obtained throughout the investigation determined a staff member used inappropriate language towards a child in care.

A child in care physically assaulted another child in care by punching the victim in the head several times. This resulted in the victim being taken to an urgent care center. The child was diagnosed with a mild concussion.

During a review of the operation's current inspection, the fire inspection has not yet been completed and expired on 3/19/2025. The facility has already purchased the necessary items for the inspection. They are currently just awaiting completion.

A caregiver failed to intervene and take appropriate action to separate a child from other aggressive children after a physical altercation.

Multiple discrepancies were discovered in the active child records for discharge summaries, safety plans, and admission assessments. The discharge summaries for 3 children were verbatim copy and pasted information, including another child's name. A safety plan implemented after a physical altercation included contradictory information about the incident and resolution. Admission Assessments included contradictions regarding the medical care for each child. The assessments also include blanket, copy and pasted statements.

3 of 3 discharge forms did not document when the child was informed of the discharge.

A treatment team staff for the operation did not delegate or provide the appropriate direct supervision for a child in care with history of suicidal behaviors after the child expressed suicidal ideations and scored high on suicide screening.

A child was involved in 3 serious incidents that were not documented fully as required by 748.311(1-11). One incident was not documented at all. Two incidents did not include all required information about the incident, witness, or resolution to the incidents.

748.457(a) - Unauthorized Absence - Triggered Review of childs unauth absences must occur ASAP, but no later than 30 days after third absence within 60-days

There was meat observed in the kitchen sink defrosting and there was food not properly stored in the pantry.

A serious incident report was completed for both children on 3/7/2025 at 5:40pm. The intake came in on 3/08/2025 at 7:24am which was about 14 hours after the children had gone AWOL and almost 8 hours past the time frame in which the facility was to report to licensing.

It was reported that a victim child was injured during AWOL, however, the serious incident report completed reports that there were np injuries upon return.

748.1113(b) - Child Rights searches-Search a child, his possessions, or his room only when reasonable suspicion exists

Staff did not document the results of the search conducted on their debriefing form. Staff confiscated a knife from a child in care.

A child was not properly supervised and was able to maintain a knife in their possession without the knowledge of staff.

Three staff files were reviewed and were missing drug test results.

During a review of the operation's current inspections. It appears that the fire inspection has not been completed as of yet and expired on 11/23/2023.

At the time of the monitoring inspection, there was not proof of a current health inspection.

During the course of the investigation this standard was found to be deficient when a caregiver threatened to physically harm a child in care and pulled him by his hoodie.

The bathroom window inside of room 3 was observed uncovered.

During the course of this investigation this standard was found to be deficient due to the operation failing to complete and report an incident where on child in care choked another child in care.

The Admissions policy must include all genders that the operation will be excepting.

Policy states that they can use emergency medication for PMN kids. Also says they can use mechanical restraints.

The form was missing a spot for what occurred while the child was away.

Need to add time medication occurred to the form.