Inspection Reports for
Kingsley Manor

The complaint involved two allegations: 1) Staff threatening resident #1 with eviction if payment was not made, and 2) Staff having resident #1 sign a document without an authorized representative present. The investigation included interviews, document reviews, and observations. The allegations were found unsubstantiated due to lack of evidence.

The investigation found no evidence to support the allegations. Staff and residents denied the claims of threats and improper document signing. Resident #1 was found to be self-responsible and able to sign documents without a representative. The eviction notice issued complied with regulations. The allegations were unsubstantiated.

Resident 1 alleged that staff 1 inappropriately touched them on 2025-09-07. Licensing Program Analysts interviewed resident 1 and reviewed relevant records as part of the investigation.

The Licensing Program Analysts conducted a physical plant tour and did not observe any health or safety risks to residents. They reviewed records of resident 1 and staff 1 and interviewed resident 1 regarding the allegation.

The complaint alleged that Resident #1 pushed Resident #5, became aggressive, yelled at other residents, hit the table, and threw a soda at another resident. Interviews with staff, residents, and review of documentation found no corroborating evidence. Staff were reported to have intervened appropriately and residents denied the allegations. The complaint was unsubstantiated.

The investigation included interviews with residents, staff, and review of records. The evidence was insufficient to substantiate the allegation that staff failed to intervene appropriately during incidents involving residents. The allegations were determined to be unsubstantiated.

The facility was found to have appropriate infection control plans, operational requirements, physical plant safety, staffing, personnel training, resident rights information, food service, medical and dental care, and disaster preparedness. No deficiencies were cited, but a technical violation was issued.

The complaint alleged that the facility charged a resident for additional services without informing or obtaining consent from the resident's responsible party. The investigation included interviews with staff and the resident, document review, and observations. The allegation was determined to be unsubstantiated.

The investigation found that the resident was receiving services as identified by a health reassessment following an incident of eloping. Documentation and interviews indicated that the additional fees were related to these services, and the allegation was unsubstantiated due to lack of preponderance of evidence.

The Licensing Program Analyst conducted a health and safety check and interviews, reviewed relevant documents, and found no signs of neglect, abuse, or other immediate health and safety threats during the visit.

The complaint investigation was unsubstantiated. Allegations included staff not properly positioning a resident, not meeting toileting needs, and a resident developing pressure injuries. Interviews with eight residents and staff, as well as record reviews, did not support these claims.

The investigation found no corroboration for the allegations after interviews with residents and staff, record reviews, and observations. Staff were found to assist residents appropriately, and no pressure injuries were identified. The allegations were determined to be unsubstantiated due to lack of evidence.

The facility was found to be in compliance with no deficiencies observed. The inspection covered multiple domains including infection control, physical plant safety, staffing, personnel records, client rights, food service, and disaster preparedness. Fire clearance was approved and emergency drills were up to date.

The complaint involved allegations that staff did not keep the facility free of obstructions, spoke inappropriately to residents, did not treat residents with respect and dignity, and failed to safeguard resident property. After investigation, all allegations were determined to be unsubstantiated.

The investigation included interviews with staff and residents, a tour of the facility, and document reviews. All allegations including staff not keeping the facility free of obstructions, speaking inappropriately to residents, not treating residents with respect and dignity, and not safeguarding resident property were found to be unsubstantiated due to lack of preponderance of evidence.

Personnel records were reviewed including criminal background clearance and training for nine staff members. Health related services include assistance with self-administration of medications and proper storage of centrally stored medications. Emergency preparedness was verified with a posted Emergency Disaster Plan and recent emergency drill and fire alarm checks documented.

The complaint alleged that resident (R1) was being financially exploited by resident (R2), who requested a transfer of stock shares owned by R1. The investigation included interviews with 16 residents, 4 staff, private caregiver, and family members, as well as review of resident files and physician reports. Resident (R1) denied abuse and was oriented to person, place, and situation. Resident (R2) denied abuse and stated the transfer was a mutual decision. No financial interests had been transferred due to lack of authorization. The allegation was unsubstantiated due to insufficient evidence.

The investigation found insufficient evidence to substantiate the allegation of financial abuse between residents. Interviews with residents, staff, and family members, as well as document reviews, indicated that the alleged financial transfer had not occurred and the resident denied abuse. The allegation was determined to be unsubstantiated.

The complaint alleged that staff were not following a resident's dietary needs. The investigation included interviews with residents and staff, review of dietary menus, and a kitchen tour. The allegation was found to be unsubstantiated.

The investigation found no preponderance of evidence to substantiate the allegation. Interviews with residents and staff indicated that dietary needs were being met, including special menus and replacement meals. The allegation was determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included inappropriate speech by staff, failure to treat residents with dignity and respect, and failure to provide a comfortable environment. Interviews and evidence did not support the allegations.

The investigation included interviews with the administrator, staff, and residents, and review of rosters. The allegations were found to be unsubstantiated as most residents reported respectful treatment and a comfortable environment, and staff denied inappropriate behavior.

The complaint alleged financial abuse of a resident. The Power of Attorney reported withdrawals over $1250 in two months, but stated the facility did not do any wrongdoing. The resident confirmed the facility did not touch his money and spends money at casinos. The allegation was unsubstantiated.

The investigation included interviews with the resident, staff, and administrator, as well as a review of relevant documents. It was found that the resident spent his own money gambling and the facility did not have access to his funds. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included a resident injury from a fall, a resident exhibiting threatening and aggressive behavior leading to eviction, and staff performing duties without proper qualifications. Interviews, document reviews, and observations did not provide sufficient evidence to prove violations occurred.

The investigation found insufficient evidence to substantiate the allegations. The resident injury allegation was unsubstantiated due to lack of preponderance of evidence. The resident threatening safety allegation involved documented incidents and eviction, but was also unsubstantiated. The allegation that staff did not meet qualifications was unsubstantiated as staff received appropriate training and residents felt staff were qualified.

The complaint investigation was unsubstantiated. Allegations included staff not providing proper assistance to a resident, failure to mitigate pest spread, and not following COVID-19 protocols. Interviews with staff, residents, pest control technician, and public health nurse supported that the facility addressed these concerns adequately.

The investigation found no preponderance of evidence to substantiate the allegations. Staff were reported to assist residents appropriately, pest control measures were in place and effective, and COVID-19 protocols were generally followed with some resident non-compliance.

The facility was found to be in compliance with all applicable regulations, including fire safety, staffing, medication management, and environmental conditions. No deficiencies were observed during the visit.

The complaint investigation was unsubstantiated. Allegations included staff failing to return resident's personal belongings, treating residents without dignity and respect, engaging in verbal altercations, and failing to meet residents' needs. Interviews with seven residents and eight staff members did not corroborate any of the allegations.

The investigation included interviews with staff and residents, record reviews, and a facility tour. All allegations were found to be unsubstantiated as interviews and evidence did not corroborate the complaints.

The complaint involved a resident who fell and sustained injuries including a fractured left knee and right wrist. The resident was found promptly by nursing staff, and the investigation concluded no neglect or lack of supervision.

The investigation found no signs of neglect or lack of supervision related to the resident's fall. The resident was independent with a 1:1 caregiver and had access to emergency alert devices. No deficiencies were issued.

The complaint alleged that staff were not meeting residents' showering needs. The investigation included interviews with the resident, staff, and administrator, and review of relevant schedules and agreements. The allegation was found unsubstantiated.

The investigation found that staff assisted the resident with all showering needs on 11/13/2022 and that the resident prefers showering once a week on Sundays. A meeting was scheduled to discuss the matter further. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged illegal eviction of resident #1. Interviews with residents and staff, as well as document reviews, showed that eviction procedures followed required regulations and that the resident had not complied with payment requests since November 2021. The allegation was unsubstantiated due to lack of preponderance of evidence.

The investigation found that the eviction notices issued to the resident were lawful and in compliance with regulations. Despite the resident's claim, there was insufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.

The complaint investigation was unsubstantiated. Allegations included neglect/lack of care regarding assistance with showering and medication administration. Interviews, record reviews, and evidence showed no preponderance to prove the alleged violations occurred.

The investigation found that Resident #1 was independent in self-care and medication management, refused facility care services, and had left the facility following hospitalization. There was insufficient evidence to substantiate the allegations, and both were found to be unsubstantiated.

The complaint involved an allegation by Resident #1 that someone entered their room and touched their private part, but the resident could not identify the person or the time of the incident. Subsequent interviews indicated a misunderstanding and no substantiated memory of the event by the resident.

Interviews and investigation revealed that Resident #1 did not remember the alleged incident and no other allegations were reported. The Licensing Program Analyst found no deficiencies cited during the visit.

The visit was triggered by the incident and death of a resident on June 26, 2022. The resident was pronounced dead at the scene after falling from the 5th floor balcony. The facility was instructed to submit the Death Certificate and Coroner's report.

The resident was found deceased after falling from the 5th floor balcony. The facility provided notification to the licensing division and relevant documents were obtained for review.

The resident was found deceased outside the building after falling from the 5th floor balcony. The balcony railing was approximately 36 inches high. The facility notified the Community Care Licensing Division and provided relevant documents for review.

The complaint involved allegations that staff failed to prevent a resident from engaging in inappropriate behaviors and failed to provide a safe environment. The resident was physically violent, damaged property, and caused distress among other residents. Staff and management reported efforts to manage the resident's behavior, including police involvement and attempts to evict the resident. Interviews with staff, residents, and family members supported that staff acted appropriately. The complaint was unsubstantiated due to lack of sufficient evidence.

The investigation found that although a resident (R4) exhibited aggressive and inappropriate behaviors causing concern among residents, staff took actions to redirect and keep residents safe, including calling police when necessary. Interviews with staff, residents, and family members indicated that the facility provides a safe environment and prevents inappropriate behaviors. There was insufficient evidence to substantiate the allegations, and the complaint was determined to be unsubstantiated.

The complaint alleged that a resident was raped by a staff member. Interviews revealed cognitive impairment of the resident and no corroborating evidence was found. Family members and staff denied neglect or abuse. Hospital records showed no trauma or complaints. The allegation was unsubstantiated due to lack of evidence.

The investigation included interviews with residents, family members, caregivers, and review of hospital medical records. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.

The facility was inspected and toured with no deficiencies observed. COVID-19 infection control practices, signage, PPE supply, social distancing, and food supplies were all found adequate and in compliance with regulations.

The inspection found that COVID-19 infection control practices were properly observed throughout the facility, including signage, social distancing, PPE availability, and medication supply. No deficiencies were observed and no citations were issued.

The complaint alleged that staff did not protect a resident from financial abuse. The investigation found no preponderance of evidence to prove the alleged violation occurred, resulting in an unsubstantiated finding.

The investigation included interviews with residents, caregivers, and the administrator, as well as a review of relevant logs and policies. All residents denied unauthorized withdrawals or transfers of money, and no evidence was found to substantiate the allegation. The complaint was determined to be unsubstantiated with no deficiencies cited.