Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 13, 2025
Visit Reason
A facility reported incident investigation for #2665252-I was conducted on November 13, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to a reported incident identified as #2665252-I; the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 8, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance certification.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective September 6, 2025. No specific deficiencies are detailed in the report.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 11
Aug 7, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigations of complaints #128092-C, 129673-C, and 2563590-C from August 4 to August 7, 2025.
Findings
The survey identified multiple deficiencies related to resident rights, discharge planning, accuracy of assessments, medication administration, food safety, staffing, and infection control. Some complaints were substantiated, and the facility failed to meet several regulatory requirements.
Complaint Details
Complaint #128092-C was substantiated with a cited deficiency. Complaints #129673-C and 2563590-C were not substantiated with deficiencies related to those allegations.
Severity Breakdown
D: 6
E: 3
F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Resident Rights/Exercise of Rights - failure to respond timely and with dignity to resident call light. | D |
| Discharge Planning Process - failure to properly document and manage resident discharges and appeals. | D |
| Accuracy of Assessments - inaccurate data entered in Minimum Data Set (MDS) assessments. | D |
| Professional Standards (medications) - medication administered outside ordered parameters. | D |
| Free of Medication Error - medication orders updated to contain words versus symbols; medication administration reviewed. | D |
| Food and Drink - failure to provide food at safe and appetizing temperatures to residents. | E |
| Food Procurement, Store, Prepare, Serve - failure to store food in accordance with professional standards; expired food found. | E |
| Food Storage - failure to discard expired food and properly label food items. | E |
| Payroll Based Journal (PBJ) Staffing Data - failure to meet staffing requirements in all three metrics. | F |
| Infection Prevention and Control - failure to provide proper hand hygiene and infection control practices. | D |
| Linens - failure to provide proper hygiene and care of linens. | D |
Report Facts
Census: 31
Deficiencies cited: 10
Medication error rate: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) / Certified Medication Assistant (CMA) | Observed interacting with Resident #7 regarding call light and personal care. |
| Staff C | Certified Nursing Assistant (CNA) / Certified Medication Assistant (CMA) | Observed entering Resident #7's room and explaining need for assistance. |
| Director of Nursing | Observed and interviewed regarding Resident #7's care and medication administration audits. | |
| Staff D | MDS Coordinator / Infection Preventionist (IP) / Registered Nurse (RN) | Observed medication administration and infection control practices. |
| Staff E | Registered Nurse (RN) | Observed medication administration and infection control practices. |
| Staff F | Licensed Practical Nurse (LPN) | Observed medication administration and infection control practices. |
| Staff K | Certified Nursing Assistant (CNA) | Observed performing hand hygiene and PPE use. |
| Staff I | Registered Dietitian | Provided statements regarding food preparation and diet modifications. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 15, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance, certifying the facility in compliance with health requirements effective January 15, 2025.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification of compliance with health requirements.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Jan 9, 2025
Visit Reason
A complaint investigation was conducted from 2024-01-07 to 2024-01-09 for complaints #124776-C and #124793-C. Complaint #124776-C was substantiated while complaint #124793-C was not substantiated.
Findings
The facility failed to revise and update care plans to include appropriate interventions to prevent repeated falls and injuries for 3 residents reviewed. The facility also failed to provide adequate fall interventions and communicate these via care plans, resulting in injuries. The facility reported a census of 34 residents at the time of the investigation.
Complaint Details
Complaint #124776-C was substantiated. Complaint #124793-C was not substantiated.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to revise and update care plans to include appropriate interventions for residents to prevent repeated falls and injuries. | SS=D |
| Failure to provide adequate fall interventions and communicate interventions via the care plan to prevent falls that resulted in injury. | SS=D |
Report Facts
Resident census: 34
Number of residents reviewed: 3
Number of falls for Resident #2: 4
Number of falls for Resident #3: 6
Fall risk score for Resident #1: 13
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 11, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on October 11, 2024.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction, resulting in certification of compliance effective October 11, 2024.
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 12
Sep 13, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #122770-C and facility reported incident #123337-I from September 9 to September 13, 2024.
Findings
The facility was found to have multiple deficiencies including failure to respect resident dignity, failure to notify representatives of hospitalizations, inadequate bed hold notices, incomplete comprehensive care plans, failure to meet professional standards of care, inadequate infection prevention and control, and issues with food safety and staffing data submission. Several residents' care plans and assessments were incomplete or not properly implemented.
Complaint Details
Complaint #122770-C was substantiated. Facility reported incident #123337-I was substantiated.
Severity Breakdown
SS=D: 6
SS=E: 4
SS=F: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to respect each resident's dignity throughout all care and services provided (Resident #32). | SS=D |
| Failure to notify resident's representative of hospitalization for 1 of 3 residents reviewed (Resident #7). | SS=D |
| Failure to ensure bed hold notices were signed by residents or responsible persons for 4 of 4 residents reviewed. | SS=E |
| Failure to develop and implement comprehensive care plans addressing high risk medications and side effects for 2 of 5 residents reviewed. | SS=D |
| Failure to provide professional standards of care by not initiating physical therapy as ordered for 1 of 12 residents reviewed (Resident #9). | SS=E |
| Failure to provide bathing assistance twice weekly for 3 of 3 residents reviewed (Residents #4, #23, #35). | SS=D |
| Failure to provide restorative nursing services for mobility concerns for 1 of 1 resident reviewed (Resident #4). | SS=D |
| Failure to ensure dialysis assessments and interventions were completed for 1 of 2 residents reviewed (Resident #37). | SS=D |
| Failure to ensure food was stored and prepared under sanitary conditions. | SS=E |
| Failure to submit accurate payroll based staffing data to CMS. | SS=F |
| Failure to establish and maintain an infection prevention and control program. | SS=F |
| Failure to maintain a safe, functional, sanitary, and comfortable environment for residents and staff. | SS=E |
Report Facts
Resident census: 33
Residents reviewed: 12
Residents reviewed: 5
Residents reviewed: 3
Residents reviewed: 4
Residents reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in follow-up and education related to bed hold notices and high risk medication care plans. | |
| Administrator | Reported expectations for staff responses and infection control program. | |
| Staff C, Registered Nurse (RN) | Reported on bed hold documentation and restorative therapy refusals. | |
| Staff B, Infection Preventionist | Interviewed regarding Legionella water program. | |
| Staff A, Maintenance Director | Interviewed regarding Legionella water program. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 20, 2024
Visit Reason
A complaint investigation was conducted for complaints #120940-C, #120959-C, and #121385-C from July 19, 2024 to July 20, 2024.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Complaint investigation for complaints #120940-C, #120959-C, and #121385-C; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 14, 2024
Visit Reason
A complaint investigation for complaints #119786-C, #120172-C, #120511-C, and #120665-C was conducted from May 8, 2024 to May 14, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation for complaints #119786-C, #120172-C, #120511-C, #120665-C; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 17, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Kingsley Specialty Care, certifying the facility in compliance based on acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was found to be in compliance effective July 17, 2023, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 6
Jun 29, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints and incidents from June 26, 2023 to June 29, 2023.
Findings
The facility was found to have deficiencies related to Medicaid/Medicare coverage notices, accuracy of assessments, activities meeting resident interests, qualified dietary staff, food procurement and storage, and resident records. Some complaints were substantiated while others were not.
Complaint Details
Complaint #113308-C was substantiated. Complaints #113665-C, #113622-C, #113133-C, #113819-C and incident #109482-I were not substantiated.
Deficiencies (6)
| Description |
|---|
| The facility failed to properly complete the Centers of Medicare & Medicaid form #10055 for sampled residents, lacking required information on the ABN form. |
| The facility failed to accurately code the Minimum Data Set (MDS) assessments for residents, including incorrect documentation of feeding tubes and catheters. |
| The facility failed to assure activity preferences of residents were provided and documented. |
| The facility failed to employ sufficient qualified dietary staff with appropriate competencies and skills. |
| The facility failed to store food in accordance with professional standards; freezer temperatures were not maintained properly and old freezer was removed. |
| The facility failed to maintain accurate and complete medical records for residents, including documentation of choking incidents. |
Report Facts
Census: 40
Residents reviewed for ABON notice: 2
Residents reviewed for MDS accuracy: 15
Residents reviewed for medical records: 15
Residents reviewed for choking incident: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged areas on ABN form and medical record documentation expectations |
| Staff A | Activity Director | Provided information on activity calendars and resident participation |
| Staff B | Dietary Staff | Revealed lack of certification for dietary manager |
| Staff E | Certified Nurse Assistant (CNA) | Witnessed staff performing Heimlich Maneuver on Resident #98 |
| Staff D | Licensed Practical Nurse (LPN) | Reported response to choking event on Resident #98 |
| Administrator | Administrator | Revealed expectations for dietary manager certification and audit plans |
| Regional Nurse Consultant | Regional Nurse Consultant | Acknowledged medical record documentation requirements |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 28, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction, indicating acceptance of a credible allegation of compliance and plan of correction for certification.
Findings
The facility was certified in compliance effective June 28, 2022, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies are detailed in the report.
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 3
Jun 9, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #103963-C, which was not substantiated.
Findings
The facility failed to meet requirements related to coordination of PASARR and assessments, care plan timing and revisions, and food procurement and sanitary conditions. Deficiencies included failure to incorporate PASARR Level II recommendations, incomplete care plans addressing medication usage, and multiple food safety violations such as unlabeled or expired food items and poor kitchen hygiene.
Complaint Details
Complaint #103963-C was investigated and found to be not substantiated.
Deficiencies (3)
| Description |
|---|
| Failure to coordinate assessments with PASARR program, including failure to incorporate Level II recommendations into residents' care plans. |
| Care plans were not revised timely or comprehensively to address opioid and antipsychotic medication usage and side effects for sampled residents. |
| Food procurement, storage, preparation, and sanitary conditions did not meet food safety requirements, including unlabeled and expired food items, poor hand hygiene, and contaminated kitchen environment. |
Report Facts
Census: 38
Residents reviewed for PASARR: 2
Residents reviewed for care plans: 3
Residents sampled for care plan review: 12
Residents with deficient care plans: 3
Dates of survey: Survey conducted June 6, 2022 to June 9, 2022.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Operations | Interviewed regarding PASARR completion and facility status. | |
| Director of Nursing | Interviewed regarding care plan expectations and food handling concerns. | |
| Staff A Cook | Cook | Observed during meal service with poor hand hygiene and food handling practices. |
| Administrator | Interviewed regarding thickened liquids and facility concerns. |
Inspection Report
Re-Inspection
Census: 30
Deficiencies: 12
Aug 30, 2021
Visit Reason
A recertification survey and investigation of complaints #97805-C, #98408-C, and incident #98144-I completed August 23-30, 2021.
Findings
The survey substantiated complaints #97805-C and #98408-C but did not substantiate self-report #98144-I. Deficiencies were found related to resident rights, notification of changes, baseline care plans, comprehensive care plans, professional standards, medical services, bowel/bladder incontinence care, respiratory/tracheostomy care, administration, food procurement and sanitation, infection prevention and control, and pest control.
Complaint Details
Complaints #97805-C and #98408-C were substantiated. Self-report #98144-I was not substantiated.
Deficiencies (12)
| Description |
|---|
| Facility failed to provide privacy during toileting for residents #2 and #12. |
| Facility failed to notify physician of abnormal blood sugar readings for residents #34 and #85. |
| Baseline care plans not completed within 48 hours for residents #5 and #26. |
| Comprehensive care plans not developed for residents #5, #12, and #19. |
| Facility failed to meet professional standards related to medication administration and weight monitoring for resident #34. |
| Resident #2 incontinent care plan and procedures not properly followed. |
| Respiratory/tracheostomy care and suctioning not provided according to professional standards for resident #25. |
| Physician services not properly supervised or documented for residents #8, #25, #33. |
| Nurse aides lacked proper training and certification documentation. |
| Food procurement and kitchen sanitation deficiencies including grime buildup and pest presence. |
| Infection prevention and control program deficiencies including failure to maintain isolation and hand hygiene. |
| Facility failed to maintain effective pest control program; evidence of rodents in kitchen. |
Report Facts
Resident census: 30
Deficiency count: 12
Inspection Report
Routine
Census: 30
Deficiencies: 0
Aug 31, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 30
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 1
Jun 19, 2020
Visit Reason
A COVID-19 focused infection control survey was conducted by the Department of Inspection and Appeals on 6/19/2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found not in compliance with infection prevention and control practices, specifically failing to maintain proper infection control after resident contact for 2 of 3 residents reviewed. Deficiencies included improper use of contaminated gloves and failure to follow isolation protocols.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure infection control practices were maintained after direct resident contact for 2 of 3 residents reviewed. | SS=D |
Report Facts
Total residents: 37
Residents reviewed: 3
Residents with infection control failures: 2
BIMS score: 8
BIMS score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Observed providing care with contaminated gloves and improper infection control |
| Tanner Mackey | Administrator | Signed plan of correction letter |
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 8
Jan 16, 2020
Visit Reason
The inspection was a recertification survey conducted from January 13 to January 16, 2020, to assess compliance with federal regulations for Kingsley Specialty Care.
Findings
The facility was found to have multiple deficiencies related to resident rights, resident/family group participation, notification of changes, accuracy of assessments, accident prevention, bowel/bladder incontinence care, and food service. Specific issues included failure to maintain dignity and respect, inadequate response to resident grievances, failure to notify physicians of significant weight loss, inadequate supervision to prevent accidents, improper catheter care, and failure to serve appropriate diets.
Severity Breakdown
SS=D: 7
SS=G: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to assure a resident with incontinence did not have soiled linens in view of others. | SS=D |
| Facility failed to consider views of resident group and act promptly on grievances and recommendations. | SS=D |
| Facility failed to notify physician and family of significant weight loss for 1 of 2 residents reviewed. | SS=D |
| Facility failed to accurately reflect resident's status on Minimum Data Set assessment for 1 resident. | SS=D |
| Facility failed to provide adequate supervision to prevent accidents for 1 of 2 residents reviewed. | SS=G |
| Facility failed to provide appropriate catheter care to prevent infection for 1 of 2 residents reviewed. | SS=D |
| Facility failed to serve mechanical soft diets in appropriate form for 2 of 4 residents reviewed. | SS=D |
| Facility failed to report and notify with major injury involving a resident. | SS=D |
Report Facts
Census: 33
Residents reviewed: 12
Residents with mechanical soft diets: 4
Residents with deficiencies: 2
Residents with accident prevention deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant (CNA) | Named in findings related to resident care and catheter site care |
| Staff E | Certified Nursing Assistant (CNA) | Named in findings related to resident care and catheter site care |
| Staff C | Certified Nursing Assistant (CNA) | Named in findings related to resident care and catheter site care |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding assessments and fall reporting |
| Administrator | Administrator | Interviewed regarding resident council meeting issues |
| Activities Director (AD) | Activities Director | Interviewed regarding resident council meetings |
| Nurse Consultant | Nurse Consultant | Interviewed regarding weight loss notifications and catheter care |
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