Deficiencies (last 6 years)
Deficiencies (over 6 years)
15.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
259% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
31 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 13, 2025
Visit Reason
A facility reported incident investigation for #2665252-I was conducted on November 13, 2025.
Complaint Details
Investigation was related to a reported incident identified as #2665252-I; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
Deficiencies (11)
Resident Rights/Exercise of Rights - failure to respond timely and with dignity to resident call light.
Discharge Planning Process - failure to properly document and manage resident discharges and appeals.
Accuracy of Assessments - inaccurate data entered in Minimum Data Set (MDS) assessments.
Professional Standards (medications) - medication administered outside ordered parameters.
Free of Medication Error - medication orders updated to contain words versus symbols; medication administration reviewed.
Food and Drink - failure to provide food at safe and appetizing temperatures to residents.
Food Procurement, Store, Prepare, Serve - failure to store food in accordance with professional standards; expired food found.
Food Storage - failure to discard expired food and properly label food items.
Payroll Based Journal (PBJ) Staffing Data - failure to meet staffing requirements in all three metrics.
Infection Prevention and Control - failure to provide proper hand hygiene and infection control practices.
Linens - failure to provide proper hygiene and care of linens.
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
Census: 31
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
The inspection was conducted based on a review of the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report from Fiscal Quarter 2, 2025, to assess compliance with staffing requirements.
Findings
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.
Deficiencies (1)
Failure to meet staffing requirements in all three metrics based on PBJ Staffing Data Report.
Report Facts
Census: 31
Inspection Report
Routine
Census: 31
Deficiencies: 10
Date: Aug 7, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility standards, including resident rights, care quality, medication administration, food service, staffing, and infection control.
Findings
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.
Deficiencies (10)
Failure to provide dignity and respect to Resident #7, including delayed personal care and ignoring call lights.
Failure to permit Resident #39 to return to the facility after hospitalization due to outstanding balance and bed hold policy.
Inaccurate Minimum Data Set (MDS) assessment for Resident #7 regarding insulin use.
Medication administration error for Resident #8 by administering midodrine despite systolic blood pressure above physician's hold parameter.
Medication administration error for Resident #26 by incomplete insulin dose administration.
Failure to serve food at safe and appetizing temperatures to Residents #3, #5, #8, and #25.
Failure to prepare food in a form designed to meet individual needs; mechanical soft diets served with regular brussels sprouts for 6 residents.
Failure to date open food items and dispose of expired food items in kitchen storage areas.
Failure to electronically submit accurate direct care staffing information to CMS; reported staffing data was excessively low and inaccurate.
Failure to perform proper hand hygiene after resident care for 2 residents, including after glove removal and before touching surfaces.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 4
Residents Affected: 6
Census: 31
Medication error rate: 5.41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Non Certified Aide (NA) | Named in dignity and respect deficiency for Resident #7 |
| Staff B | Activities Director | Named in dignity and respect deficiency for Resident #7 |
| Staff C | Certified Nursing Assistant (CNA) / Certified Medication Assistant (CMA) | Named in dignity and respect deficiency for Resident #7 and infection control observation |
| DON | Director of Nursing | Acknowledged deficiencies in dignity, medication administration, and infection control |
| Staff D | MDS Coordinator / Infection Preventionist (IP) / Registered Nurse (RN) | Acknowledged MDS error, medication errors, and insulin administration error |
| Staff E | Registered Nurse (RN) | Observed medication administration error for Resident #8 |
| Staff F | Licensed Practical Nurse (LPN) | Observed insulin administration error for Resident #26 |
| Staff G | Lead Dietary Staff | Acknowledged food temperature and consistency deficiencies |
| Staff H | Dietary Manager | Acknowledged food temperature and storage deficiencies |
| Staff I | Registered Dietitian | Acknowledged food temperature and consistency deficiencies |
| Staff J | Dietary Aide | Acknowledged food consistency deficiency |
| Staff K | Certified Nursing Assistant (CNA) | Observed failure to perform hand hygiene after resident care |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
Complaint #124776-C was substantiated. 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.
Deficiencies (2)
Failure to revise and update care plans to include appropriate interventions for residents to prevent repeated falls and injuries.
Failure to provide adequate fall interventions and communicate interventions via the care plan to prevent falls that resulted in injury.
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
Complaint Investigation
Census: 34
Deficiencies: 2
Date: Jan 9, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to revise and update care plans with appropriate fall interventions to prevent repeated falls and injuries for residents.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to revise and update care plans to include appropriate interventions for residents to prevent repeated falls and injuries for 3 out of 3 residents reviewed.
Failed to provide adequate fall interventions and communicate interventions via the care plan to prevent falls that resulted in injury for 1 of 3 residents reviewed.
Report Facts
Resident census: 34
Fall risk score: 13
Number of falls: 4
Number of falls: 6
BIMS score: 9
BIMS score: 8
BIMS score: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Reported past non-compliance actions and forms completed for lack of fall interventions being updated on care plans |
| Staff A | Licensed Practical Nurse (LPN) | Reported expectations for nurses to initiate fall interventions immediately after a fall and place interventions on care plans |
| Staff B | Certified Nursing Assistant (CNA) | Reported following nurse instructions for interventions and described where fall interventions are documented |
| Staff C | Certified Nursing Assistant (CNA) | Reported charge nurses develop interventions after falls and described injuries to Resident #1 |
| MDS/Care Plan Nurse | Reported process for initiating interventions after falls and communication failures leading to care plan update omissions | |
| Administrator | Reported expectations for fall interventions initiation and described communication breakdowns between DON and MDS regarding care plan updates |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
Complaint #122770-C was substantiated. Facility reported incident #123337-I was substantiated.
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.
Deficiencies (12)
Failure to respect each resident's dignity throughout all care and services provided (Resident #32).
Failure to notify resident's representative of hospitalization for 1 of 3 residents reviewed (Resident #7).
Failure to ensure bed hold notices were signed by residents or responsible persons for 4 of 4 residents reviewed.
Failure to develop and implement comprehensive care plans addressing high risk medications and side effects for 2 of 5 residents reviewed.
Failure to provide professional standards of care by not initiating physical therapy as ordered for 1 of 12 residents reviewed (Resident #9).
Failure to provide bathing assistance twice weekly for 3 of 3 residents reviewed (Residents #4, #23, #35).
Failure to provide restorative nursing services for mobility concerns for 1 of 1 resident reviewed (Resident #4).
Failure to ensure dialysis assessments and interventions were completed for 1 of 2 residents reviewed (Resident #37).
Failure to ensure food was stored and prepared under sanitary conditions.
Failure to submit accurate payroll based staffing data to CMS.
Failure to establish and maintain an infection prevention and control program.
Failure to maintain a safe, functional, sanitary, and comfortable environment for residents and staff.
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
Routine
Census: 33
Deficiencies: 4
Date: Sep 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, dignity, bathing assistance, skilled nursing assessments, and staffing based on observations, interviews, and record reviews.
Findings
The facility failed to respect residents' dignity, provide bathing assistance as scheduled for multiple residents, complete required skilled nursing assessments for one resident, and meet staffing requirements in three metrics based on payroll data. Deficiencies were noted with minimal harm and affected few to many residents.
Deficiencies (4)
Failed to respect resident's dignity related to catheter care resulting in resident being soaked and embarrassed.
Failed to provide bathing assistance twice weekly for 3 residents as scheduled.
Failed to complete all required skilled nursing assessments for 1 of 12 residents reviewed.
Failed to electronically submit complete and accurate direct care staffing information and failed to meet staffing requirements in three metrics.
Report Facts
Residents affected: 33
Bathing missed dates: 11
Skilled assessments missed: 7
Residents reviewed for bathing: 3
Residents reviewed for skilled assessments: 12
Inspection Report
Routine
Census: 33
Deficiencies: 13
Date: Sep 13, 2024
Visit Reason
Routine inspection of Kingsley Specialty Care nursing home to assess compliance with regulatory standards including resident care, safety, and facility operations.
Findings
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.
Deficiencies (13)
Failed to respect resident's dignity related to catheter care resulting in resident being soaked and embarrassed.
Failed to notify resident's representative of hospitalization and bed hold authorization.
Failed to notify resident or representative in writing about bed hold policies and obtain signatures.
Failed to develop care plans addressing high-risk medication usage and side effects.
Failed to initiate ordered physical therapy for shoulder pain.
Failed to provide bathing assistance twice weekly as scheduled for multiple residents.
Failed to complete required skilled nursing assessments daily for a resident on skilled level of care.
Failed to provide restorative therapy program for resident with mobility concerns.
Failed to complete dialysis evaluations as ordered for resident requiring dialysis.
Stored expired food items and unlabeled opened beverages in kitchen.
Failed to electronically submit complete and accurate direct care staffing information to CMS.
Failed to implement and maintain a legionella water management program.
Maintained cluttered and unsafe environment with boxes stacked around nurses station and wheelchairs blocking emergency exit.
Report Facts
Residents affected: 33
Boxes stacked: 26
Expired food items: 23
Bathing missed days: 8
Physical therapy order date: Jul 18, 2024
Medication start dates: Aug 21, 2023
Medication start dates: Sep 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN), MDS Coordinator | Reported care plan expectations and restorative therapy refusals |
| Staff B | Administrator | Reported expectations for staff response, bed hold forms, dialysis assessments, and legionella program responsibility |
| Staff A | Maintenance Director | Interviewed regarding legionella water program responsibilities |
| Staff C | Registered Nurse, Infection Preventionist | Interviewed regarding legionella water program knowledge |
| Dietary Manager | Interviewed regarding food storage and labeling practices | |
| Nurse Consultant | Reported physical therapy case load issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: 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.
Complaint Details
Complaint investigation for complaints #120940-C, #120959-C, and #121385-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: 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.
Complaint Details
Complaint investigation for complaints #119786-C, #120172-C, #120511-C, #120665-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Census: 40
Deficiencies: 4
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to evaluate compliance with Medicare and Medicaid regulations, including proper completion of Medicare Advanced Beneficiary Notices, staffing qualifications in food and nutrition services, food storage standards, and accuracy of medical record documentation.
Findings
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.
Deficiencies (4)
Failed to properly complete the Centers of Medicare & Medicaid form #10055 for 2 of 3 sampled residents, lacking reason Medicare may not pay and estimated cost of services.
Failed to employ sufficient staff with appropriate competencies and skills sets to carry out food and nutrition service functions by not having a qualified professional as dietary manager.
Failed to store food in accordance with professional standards; freezer temperature was above acceptable range and food was defrosted and mushy.
Failed to maintain accurate medical records for a choking event involving one resident, lacking detailed documentation as required by policy.
Report Facts
Residents affected: 2
Residents affected: 40
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Dietary Manager | Interview revealed lack of certification and ongoing classes to become certified |
| Staff E | Certified Nurse Assistant | Witnessed Heimlich maneuver on Resident #98 during choking event |
| Staff D | Licensed Practical Nurse | Responded to Resident #98 during choking event |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 6
Date: 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.
Complaint Details
Complaint #113308-C was substantiated. Complaints #113665-C, #113622-C, #113133-C, #113819-C and incident #109482-I were not substantiated.
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.
Deficiencies (6)
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
Routine
Census: 40
Deficiencies: 6
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medical record accuracy, staffing qualifications, food safety, and activity provision at Kingsley Specialty Care.
Findings
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.
Deficiencies (6)
Failed to properly complete Medicare Advanced Beneficiary Notice form #10055 for 2 of 3 sampled residents, lacking reason Medicare may not pay and estimated cost of services.
Failed to accurately record Minimum Data Set assessments for 2 of 15 residents, incorrectly documenting feeding tube and indwelling catheter presence.
Failed to assure activity preferences were met for 3 of 4 residents reviewed, with low participation and dissatisfaction expressed.
Failed to employ a qualified dietary manager; current dietary manager lacked required certification.
Failed to store food in accordance with professional standards; freezer temperatures were above acceptable range and food was defrosted and mushy.
Failed to maintain accurate medical records for a choking incident, lacking detailed documentation as required by policy.
Report Facts
Residents reviewed: 15
Residents reviewed: 4
Residents affected: 2
Residents affected: 3
Residents affected: 1
Freezer temperature: 20
Freezer temperature: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Acknowledged need for estimated cost on Medicare ABN forms and complete documentation of choking event | |
| Regional Nurse Consultant | Acknowledged need for estimated cost on Medicare ABN forms and complete documentation of choking event | |
| MDS Coordinator | Confirmed inaccuracies in Minimum Data Set assessments | |
| Staff A, Activity Director | Described activity calendar distribution and documentation process | |
| Staff B, Dietary Manager | Revealed lack of certification and plans to become certified | |
| Administrator | Expressed expectations for activity offerings and dietary manager certification | |
| Staff E | Certified Nurse Assistant (CNA) | Witnessed Heimlich maneuver on Resident #98 during choking event |
| Staff D | Licensed Practical Nurse (LPN) | Responded to Resident #98 during choking event |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
Complaint #103963-C was investigated and found to be 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.
Deficiencies (3)
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
Date: 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.
Complaint Details
Complaints #97805-C and #98408-C were substantiated. Self-report #98144-I was not substantiated.
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.
Deficiencies (12)
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
Date: 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
Date: 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.
Deficiencies (1)
Failure to ensure infection control practices were maintained after direct resident contact for 2 of 3 residents reviewed.
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
Date: 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.
Deficiencies (8)
Facility failed to assure a resident with incontinence did not have soiled linens in view of others.
Facility failed to consider views of resident group and act promptly on grievances and recommendations.
Facility failed to notify physician and family of significant weight loss for 1 of 2 residents reviewed.
Facility failed to accurately reflect resident's status on Minimum Data Set assessment for 1 resident.
Facility failed to provide adequate supervision to prevent accidents for 1 of 2 residents reviewed.
Facility failed to provide appropriate catheter care to prevent infection for 1 of 2 residents reviewed.
Facility failed to serve mechanical soft diets in appropriate form for 2 of 4 residents reviewed.
Facility failed to report and notify with major injury involving a resident.
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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