Inspection Reports for
Kingsland Walk Senior Living
868 KINGSLAND AVENUE, UNIVERSITY CITY, MO, 63130-3181
Back to Facility Profile8 Reports
Inspection Report — Apr 30, 2025
Complaint Investigation
Date: Apr 30, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding protective oversight and proper care of residents exhibiting aggressive behaviors and other care concerns at Kingsland Walk Senior Living.
Complaint Details
The complaint investigation substantiated that Resident #1 exhibited aggressive behaviors leading to physical assault of Resident #2, resulting in serious injuries requiring hospitalization. The facility failed to notify medical staff and update care plans accordingly. The violation was determined to be at an imminent danger Class I level initially, later lowered to Class II after corrective actions.
Findings
The facility failed to provide 24-hour protective oversight and proper care for a resident exhibiting increased agitation and aggression, resulting in physical assault and serious injury to another resident. The facility also failed to notify appropriate medical personnel and update individualized service plans accordingly.
Deficiencies (5)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide 24-hour protective oversight and did not notify the physician or psychiatric nurse practitioner when Resident #1 exhibited increased agitation and aggression, resulting in physical assault and serious injury to Resident #2.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: The facility failed to provide proper care for Resident #1 as defined in the individualized service plan, which lacked documentation of behaviors or interventions related to agitation.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: The facility failed to follow abuse and neglect policies and complete an investigation for Resident #1's injury of unknown origin.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: The facility failed to provide proper care for Resident #8 by not updating the individualized service plan to include known behaviors, contributing to the resident's death after pulling out a dialysis port.
19 CSR 30-86.047(47)(A) Physicians Orders Followed: The facility failed to follow physician's orders for Resident #4's medication administration and failed to notify the physician of medication requests outside ordered parameters.
Report Facts
Deficiencies cited: 5
Inspection Report — Nov 13, 2024
Plan of Correction
Date: Nov 13, 2024
Visit Reason
This document is a Plan of Correction submitted by Kingsland Walk Senior Living in response to deficiencies cited during a state survey conducted on 11/13/2024.
Findings
The facility failed to meet multiple regulatory requirements including individualized evacuation plans, tuberculosis screening, community based assessments, individualized service plans, protective oversight, resident record maintenance, medication administration, food safety, toxic material storage, and personal clothing/possessions management. Deficiencies were documented for multiple residents and staff files.
Deficiencies (14)
19 CSR 30-86.045(3)(A)(5) Individual Evacuation Plan - The facility failed to ensure residents needing more than minimal assistance had individualized evacuation plans in their service plans for three residents. The census was 48.
19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan-Staff Requirements - The facility failed to provide responsibilities of specific staff members in emergency evacuation plans for three residents. The census was 48.
19 CSR 30-86.047(19) TB Screen Residents & Staff - The facility failed to ensure two-step tuberculosis tests were completed prior to admission for three of five sampled staff and two of six sampled residents. The census was 48.
19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day - The facility failed to ensure all residents had a completed community based assessment within five days of admission for five of six sampled residents. The census was 48.
19 CSR 30-86.047(28)(F)(2) Community Based Assessment - DHSS Form - The facility failed to use the approved Community Based Assessment form for two of six sampled residents. The census was 48.
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop - The facility failed to develop individualized service plans including resident needs, preferences, and goals for four of six sampled residents. The census was 48.
19 CSR 30-86.047(35) Protective Oversight - The facility failed to provide protective oversight for a resident who fell and was helped by a care partner before evaluation by a licensed nurse. The census was 48.
19 CSR 30-86.047(58)(A) Resident Record Admission Info - The facility failed to maintain complete admission records including contact information and preferred providers for six of six sampled residents. The census was 48.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review - The facility failed to maintain monthly summaries and medication reviews for three of six sampled residents. The census was 48.
19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety - The facility failed to ensure adequate staffing levels and failed to ensure administration of medication was properly documented for one resident. The census was 48.
19 CSR 30-87.020(5) Toxic Material Storage - The facility failed to ensure poisonous or toxic materials were stored securely and separately from residents for one day of observation. The census was 48.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS - The facility failed to ensure food was protected from contamination and stored at proper temperatures during observation. The census was 48.
19 CSR 30-87.030(20) Frozen Food at Zero Degrees F or Below - The facility failed to maintain proper freezer temperature and ensure food was stored properly. The census was 48.
19 CSR 30-88.010(36) Personal Clothing/Possessions - The facility failed to maintain inventory lists of personal items for six of six sampled residents. The census was 48.
Report Facts
Deficiency counts: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in interviews related to evacuation plans and medication administration. |
| Administrator | Administrator | Named in interviews related to evacuation plans, community based assessments, and medication administration. |
| Director of Wellness | Director of Wellness | Named in interviews related to individualized service plans and medication administration oversight. |
| Level One Medication Aide (LIMA) C | Level One Medication Aide | Named in resident fall history and medication administration. |
| Care Partner (CP) J | Care Partner | Named in resident fall history and assessments. |
Inspection Report — Oct 30, 2024
Plan of Correction
Date: Oct 30, 2024
Visit Reason
The inspection was conducted to assess compliance with fire safety and electrical wiring regulations, including the functionality of communication systems and the completion of required inspections and certifications.
Findings
The facility failed to ensure a two-way communication system in the areas of refuge was functional, did not have annual fire alarm system inspections and certifications, and failed to have electrical wiring inspected every two years by a qualified electrician. These deficiencies potentially affect all 46 residents.
Deficiencies (3)
19 CSR 30-86.022(7)(D)(1-8) The facility failed to ensure a two-way communication or intercom system in the areas of refuge and the main communication panel phone were functioning. Six call boxes failed to function and the main master communication phone did not have a dial tone.
19 CSR 30-86.022(9)(D) The facility failed to have annual inspections and written certifications of the complete fire alarm system by an approved qualified service representative. The last annual inspection was on October 25, 2023.
19 CSR 30-86.032(13) The facility failed to have electrical wiring inspected every two years by a qualified electrician. The last bi-annual electrical wiring certification was completed on September 15, 2022.
Report Facts
Call boxes failed: 6
Call button activation failures: 2
Call button activation failures: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Manager | Interviewed regarding call system issues and scheduling inspections | |
| Executive Director | Responsible for reviewing monthly fire drill documentation and ensuring compliance | |
| Maintenance Director | Responsible for ensuring communication systems and electrical wiring inspections and maintenance |
Inspection Report — Jul 3, 2024
Plan of Correction
Date: Jul 3, 2024
Visit Reason
The inspection was conducted to identify deficiencies related to combustible materials storage, individualized service plans, and physician orders compliance at Kingsland Walk Senior Living.
Findings
The facility failed to properly secure combustible materials, did not update individualized service plans for residents with falls, and failed to follow physician orders for medication administration. The census during the inspection was 44 residents.
Deficiencies (3)
19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of. The facility failed to keep unnecessary combustibles properly secured, posing a hazard to residents.
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop. The facility failed to update a resident's individualized service plan after several falls, missing documentation of fall prevention services.
19 CSR 30-86.047(47)(A) Physicians Orders Followed. The facility failed to follow physician orders for medication administration for a resident, including missing documentation and improper medication handling.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Woods | Executive Director | Signed the inspection report and plan of correction |
Inspection Report — Jun 8, 2023
Plan of Correction
Date: Jun 8, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Kingsland Walk Senior Living following a survey completed on 06/08/2023. The visit was to assess compliance with state and federal regulations related to staff orientation, resident dignity, abuse/neglect information, safe transfers training, and abuse/neglect policies.
Findings
The facility failed to ensure agency staff received proper orientation and training on job responsibilities, resident dignity, abuse/neglect reporting, and safe transfer techniques. Deficiencies were noted in staff training documentation, agency binder usage, and adherence to abuse and neglect policies. The facility also failed to properly investigate and document incidents involving resident care.
Deficiencies (5)
19 CSR 30-86.047(62)(A) Orientation - job responsibilities. The facility failed to ensure agency staff received orientation training on job responsibilities prior to or on the first day of work. The census was 45.
19 CSR 30-86.047(62)(E) Orientation - resident dignity. The facility failed to ensure agency staff received orientation training on preservation of resident dignity prior to or on the first day of employment. The census was 45.
19 CSR 30-86.047(62)(F) Orientation - Abuse/Neglect info. The facility failed to ensure all agency staff received information regarding abuse/neglect and how to report it for one day of observation. The census was 45.
19 CSR 30-86.047(65)(A) Safe Transfers Training Requirements. The facility failed to develop a system to ensure all staff were properly trained in transferring residents when an agency worker failed to use proper techniques for one of two sampled residents. The census was 45.
19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility failed to follow their abuse and neglect policy when an incident occurred and did not complete a thorough investigation regarding the incident for one of two sampled residents. The census was 45.
Report Facts
Inspection Report — May 23, 2022
Plan of Correction
Date: May 23, 2022
Visit Reason
The inspection was conducted to assess compliance with proper care per individualized service plans for residents, focusing on incidents involving two residents and their care plans.
Findings
The facility failed to ensure proper care as defined in individualized service plans for two of three sampled residents, resulting in behavioral incidents and inadequate documentation of interventions and staff responses.
Deficiencies (1)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. The facility failed to ensure residents received proper care based on individualized service plans, as evidenced by incidents involving two residents with dementia and behavioral issues.
Report Facts
Inspection Report — Jul 22, 2021
Plan of Correction
Date: Jul 22, 2021
Visit Reason
The inspection was conducted to evaluate compliance with individual evacuation plans, individualized service plans, inspection rights, and medication self-control requirements at Kingsland Walk Senior Living.
Findings
The facility failed to ensure residents who required more than minimal assistance had individualized evacuation plans and service plans. The facility also failed to prevent fire hazards related to oxygen tanks, provide proper care per individualized service plans, and obtain physician orders for self-administered medications.
Deficiencies (6)
19 CSR 30-86.045(3)(A)(5) Individual Evacuation Plan - The facility failed to ensure residents needing more than minimal assistance had individualized evacuation plans in their service plans. This was observed for two of five sampled residents.
19 CSR 30-86.045(3)(A)(6)(C) Individual Evacuation Plan - The facility failed to develop individualized evacuation plans that included risk of resistance, response to alarms and fire drills, and location within the facility for one of five sampled residents.
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard - The facility failed to ensure staff did not transfill oxygen tanks in resident use areas and failed to store an excessive amount of oxygen tanks in a resident's room, creating a fire hazard.
19 CSR 30-86.047(28)(G) Individual Service Plan - The facility failed to ensure individualized service plans included resident preferences and specific services to be provided for three of five sampled residents.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan - The facility failed to provide proper care per individualized service plans for three of five sampled residents, including assistance with transfers and fall prevention.
19 CSR 30-86.047(40) Self-Control of Medication Requirements - The facility failed to obtain a physician's order for a resident to self-administer medication and failed to ensure proper medication management and administration for one of five sampled residents.
Report Facts
Report — Apr 22, 2026
Apr 22, 2026
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