Inspection Reports for
Kingsley Specialty Care

Complaint #3041458

All deficiencies were corrected and no deficiency cited with complaint. The facility is in substantial compliance effective June 13, 2026.

Complaints #2970857-C, #2991730-C, and #3010400-C and self report #2991734-I were investigated.

The facility failed to provide adequate cardiopulmonary resuscitation (CPR) to a resident requiring emergency CPR prior to EMS arrival. The facility also failed to notify the physician of blood sugar levels outside parameters and failed to report misappropriation of medication for one resident. Additional deficiencies involved failure to follow physician orders for medication administration, failure to ensure accurate narcotic counts, failure to provide dialysis equipment and documentation, failure to maintain accurate resident records, and failure to report alleged violations timely.

The facility failed to provide adequate CPR to Resident #1, who was unresponsive and had no pulse, as staff did not perform airway resuscitation or continue compressions until EMS arrived. The facility also failed to report to the state agency the misappropriation of medication by Staff E, who self-administered a resident's prescribed medication without reporting it.

Investigation was related to a reported incident identified as #2665252-I; the facility was found to be in substantial compliance.

The facility was found to be in substantial compliance.

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.

Complaint #128092-C was substantiated with a cited deficiency. Complaints #129673-C and 2563590-C were not substantiated with deficiencies related to those allegations.

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.

The facility failed to meet staffing requirements in all three metrics according to the PBJ Staffing Data Report. Weekend staffing data was excessively low within the quarter, and staffing for Nurses and Certified Nursing Assistants (CNAs) was scheduled similarly for weekdays and weekends. The Administrator was recently hired and unaware of the incorrect data reporting to CMS.

The facility was found deficient in multiple areas including failure to provide dignity and respect to residents, inaccurate resident assessments, medication administration errors, serving food at unsafe temperatures and incorrect consistencies, improper food storage practices, inaccurate staffing data submission, and inadequate infection prevention practices.

Complaints #128092-C, #129673-C, and 2563590-C were investigated. A deficiency was cited related to complaint #128092-C. Complaints #129673-C and 2563590-C were not cited.

Deficiencies were cited related to resident rights, inappropriate discharge procedures, accuracy of assessments, professional standards for medications, medication errors exceeding 5%, food temperature and safety, food procurement and storage, staffing data submission, and infection prevention and control. The facility failed to meet multiple regulatory requirements in these areas.

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.

The complaint investigation found that the facility failed to initiate and update fall interventions on care plans after residents experienced falls, resulting in injuries including bruises, abrasions, skin tears, and a forehead laceration requiring emergency medical treatment. The facility's interdisciplinary team failed to update and monitor care plans appropriately, and communication breakdowns occurred between staff responsible for care plan updates.

The facility failed to update care plans with fall interventions for multiple residents who experienced repeated falls resulting in injuries. The facility did not place appropriate fall interventions on care plans after falls, leading to minimal harm or potential for harm to residents.

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.

Complaint #122770-C was substantiated. Facility reported incident #123337-I was substantiated.

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.

The facility was found deficient in multiple areas including failure to respect resident dignity, inadequate family notification, incomplete care plans for high-risk medications, failure to initiate ordered physical therapy, inconsistent bathing assistance, incomplete skilled nursing assessments, lack of restorative therapy, incomplete dialysis evaluations, improper food storage, failure to submit staffing data, lack of a legionella water management program, and unsafe, cluttered environment.

Complaint investigation for complaints #120940-C, #120959-C, and #121385-C; facility found in substantial compliance.

The facility was found to be in substantial compliance following the complaint investigation.

Complaint investigation for complaints #119786-C, #120172-C, #120511-C, #120665-C; facility found in substantial compliance.

The facility was found to be in substantial compliance.

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.

The facility was found deficient in properly completing Medicare Advanced Beneficiary Notices for two residents, employing a qualified dietary manager, storing food at appropriate temperatures, and maintaining accurate medical records for a choking incident involving one resident. All deficiencies were assessed as causing minimal harm or potential for actual harm.

Complaint #113308-C was substantiated. Complaints #113665-C, #113622-C, #113133-C, #113819-C and incident #109482-I were not substantiated.

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.

The facility was found deficient in multiple areas including incomplete Medicare Advanced Beneficiary Notices, inaccurate Minimum Data Set assessments, failure to meet resident activity preferences, insufficiently qualified dietary manager, improper food storage temperatures, and incomplete documentation of a choking incident.

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.

Complaint #103963-C was investigated and found to be not substantiated.

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.

Complaints #97805-C and #98408-C were substantiated. Self-report #98144-I was not substantiated.

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.

The facility failed to provide tracheostomy suctioning for Resident #25 from May 6 to August 18, 2021, despite orders and the resident's critical condition. This failure led to the resident being sent to the emergency room and hospitalized with pneumonia and ventilator support.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

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.

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.

The facility failed to provide adequate supervision to prevent a fall resulting in a serious hip fracture for Resident #9. Additionally, the facility failed to report the major injury accident to the Department of Inspections and Appeals as required.