Inspection Reports for
Kingswood Senior Living Community
10000 Wornall Rd, Kansas City, MO 64114, MO, 10000
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
64% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
64% occupied
Based on a May 2025 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 1
Date: May 22, 2025
Visit Reason
The visit was conducted to address a deficiency related to resident rights and dignity following an incident involving a resident and a Registered Nurse (RN) on 5/14/25.
Findings
The facility failed to ensure a resident was treated with dignity and respect, resulting in a skin tear caused by an RN grabbing the resident's arm during resistance to care. The incident was investigated, and corrective actions including staff in-service and termination of the RN were taken.
Deficiencies (1)
F 550 Resident Rights/Exercise of Rights. The facility failed to treat a resident with dignity and respect, resulting in a moon-shaped skin tear caused by an RN grabbing the resident's arm during care resistance.
Report Facts
Facility census: 55
Incident date: May 14, 2025
Termination date: May 16, 2025
Inspection Report
Plan of Correction
Census: 59
Deficiencies: 1
Date: Mar 5, 2025
Visit Reason
The inspection was conducted to investigate a deficiency related to the facility's failure to follow policy for using mechanical lifts, resulting in a resident injury. The document is a Statement of Deficiencies and Plan of Correction.
Findings
The facility failed to ensure the resident environment was free of accident hazards and did not follow policy requiring two staff to use a mechanical lift, leading to a resident fall and injury. The resident sustained a subdural hematoma and fractured hip after a sling strap broke during transfer. The facility census was 59 at the time.
Deficiencies (1)
F 689: The facility failed to follow policy for using mechanical lifts, resulting in a resident fall when a sling strap broke. The resident sustained a subdural hematoma and fractured hip and was admitted to the ICU.
Report Facts
Facility census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in mechanical lift error incident and interviews |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Assessed resident after incident |
| Director of Nursing (DON) | Director of Nursing | Notified of incident and assessed resident |
| LPN B | Licensed Practical Nurse | Interviewed regarding incident and staffing |
| CNA B | Certified Nurse Aide | Interviewed regarding staffing and incident |
| LPN C | Licensed Practical Nurse | Interviewed regarding resident condition and incident |
| Maintenance Staff A | Maintenance Staff | Interviewed regarding sling inspections |
| Nurse Practitioner A | Nurse Practitioner | Interviewed regarding resident evaluation and incident |
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 4
Date: Jan 22, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident care, including notification of changes, care plan timing and revision, pressure sore prevention and treatment, and staffing requirements. The document includes a plan of correction responding to cited deficiencies.
Findings
The facility was found deficient in notifying physicians and families of significant changes in residents' conditions, updating and revising care plans timely, conducting and documenting pressure injury risk assessments and treatments, and employing a qualified dietitian. Several residents had pressure injuries that were not properly documented or treated, and care plans did not reflect current conditions.
Deficiencies (4)
F580 Notification of Changes: The facility failed to notify the resident's physician, administrator, Director of Nursing, or resident representative of changes in a resident's skin condition, resulting in delayed treatment and lack of family notification.
F657 Care Plan Timing and Revision: The facility failed to ensure care plans were reviewed, updated, and revised for two sampled residents in a timely manner, with care plans not reflecting current pressure injuries or treatments.
F686 Treatment/Services to Prevent/Heal Pressure Ulcers: The facility failed to ensure weekly skin and wound assessments were conducted and documented, including measurements and physician notifications for pressure ulcers for one sampled resident.
F801 Qualified Dietary Staff: The facility failed to employ a qualified dietitian to perform dietary assessments and consult with dietary staff, affecting two sampled residents who needed dietary assessments.
Report Facts
Facility census: 67
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON B | Assistant Director of Nursing | Named in findings related to pressure injury assessments and care plan responsibilities |
| DON | Director of Nursing | Named in findings related to notification failures and care plan updates |
| LPN B | Licensed Practical Nurse | Named in findings related to documentation and notification of pressure injuries |
| LPN D | Licensed Practical Nurse | Named in findings related to wound notification expectations |
| LPN E | Licensed Practical Nurse | Named in findings related to wound documentation and notification |
| RN A | Registered Nurse | Named in findings related to wound assessments and documentation |
| RN B | Registered Nurse | Named in findings related to wound care and notification |
| NP | Nurse Practitioner | Named in findings related to wound assessments and notifications |
Inspection Report
Life Safety
Census: 58
Capacity: 86
Deficiencies: 12
Date: Sep 29, 2023
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with fire safety regulations and related requirements at Kingswood nursing facility.
Findings
The facility failed to meet several provisions of the 2012 Life Safety Code, including issues with means of egress, exit signage, cooking facilities range hood inspections, fire alarm system testing and maintenance, sprinkler system maintenance, fire drills, emergency preparedness, and electrical system maintenance. These deficiencies potentially affected residents and staff across multiple smoke zones.
Deficiencies (12)
K211 Means of Egress - The sliding door at the main entrance did not open easily during the fire alarm test and had conflicting signage, potentially confusing residents and staff.
K293 Exit Signage - The facility failed to place an EXIT sign at or above the door from the kitchen to the corridor, potentially confusing dietary employees about exit locations.
K324 Cooking Facilities - The facility failed to ensure timely semiannual range hood inspections, affecting one smoke zone in the kitchen.
K345 Fire Alarm System - The facility failed to obtain fire alarm system inspections on a semiannual and annual basis, affecting all residents in 12 smoke zones.
K353 Sprinkler System - The facility failed to prevent paint and corrosion on sprinkler heads in resident rooms and failed to obtain an annual inspection of its backflow system.
K354 Sprinkler System Out of Service - The facility failed to include required information in the fire watch plan when the sprinkler system was impaired, affecting all residents and staff.
K372 Smoke Barrier - The facility failed to maintain smoke barrier walls free of penetrations, affecting approximately 25 residents in four smoke zones.
K374 Smoke Barrier Doors - The smoke barrier door at the therapy department failed to close completely and was missing an astragal, affecting at least 30 residents.
K712 Fire Drills - The facility failed to maintain records of four fire drills, including signatures and documentation of simulated conditions, affecting all residents and staff.
K918 Electrical Systems - The facility failed to maintain and test the emergency generator and transfer switches according to NFPA standards, potentially affecting all residents and staff.
K919 Electrical Equipment - The facility failed to prevent storage of combustibles near electrical panels in the kitchen, affecting one non-resident smoke zone and unknown residents.
E015 Subsistence Needs - The facility failed to maintain required emergency water temperatures and failed to update emergency water location labeling, affecting all residents and staff during severe weather.
Report Facts
Facility census: 58
Licensed capacity: 86
Number of smoke zones: 12
Days between range hood inspections: 208
Days between range hood inspections: 202
Days since last fire alarm inspection: 444
Number of fire drills missing records: 4
Generator kWh rating: 125
Inspection Report
Routine
Deficiencies: 0
Date: Feb 27, 2023
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 2
Date: Jan 23, 2023
Visit Reason
This document is a plan of correction submitted by the facility Kingswood in response to deficiencies cited during a survey conducted on 2023-01-23.
Findings
The facility was found not free from misappropriation and exploitation of resident property, with multiple residents affected by fraudulent charges on their credit/debit cards and missing cash. The facility failed to keep or hold residents' valuables securely and had inadequate policies and procedures regarding resident funds management.
Deficiencies (2)
F 602: The facility failed to ensure residents were free from misappropriation and exploitation of resident property, including fraudulent charges on credit/debit cards and missing cash for multiple residents. The facility also failed to keep or hold residents' valuables securely and lacked adequate policies for resident funds management.
A8023: The facility did not develop and implement written policies and procedures prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds, as required by regulation.
Report Facts
Facility census: 52
Fraudulent charges amount: 1914.47
Fraudulent charges amount: 391.08
Fraudulent charges amount: 59.98
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 8
Date: Apr 22, 2022
Visit Reason
The document is a Plan of Correction submitted by Kingswood following a survey completed on 04/22/2022. It addresses deficiencies cited during the inspection.
Findings
The facility was found deficient in multiple areas including failure to provide timely and complete transfer/discharge notices, bed hold policy notifications, treatment and prevention of pressure ulcers, medication administration and labeling, and food safety practices. Several residents were affected by these deficiencies.
Deficiencies (8)
F623 Notice Before Transfer/Discharge: The facility failed to notify residents and their representatives of transfers or discharges in writing and did not provide required notices to the Ombudsman. The facility census was 52 residents.
F625 Notice of Bed Hold Policy: The facility failed to notify residents and representatives in writing of the bed hold policy at the time of transfer for sampled residents. The facility census was 52 residents.
F686 Treatment/Services to Prevent/Heal Pressure Ulcers: The facility failed to ensure completion of treatment for a resident's pressure ulcer and proper documentation of treatments. The facility census was 52 residents.
F755 Pharmacy Services: The facility failed to ensure accurate narcotic counts and proper medication administration documentation, resulting in a medication error rate of 19.23%. The facility census was 52 residents.
F759 Medication Errors: The facility failed to maintain a medication error rate of less than 5 percent. Five errors were observed out of 26 medication opportunities.
F760 Residents are Free of Significant Medication Errors: The facility failed to ensure residents were free from significant medication errors, including insulin pen administration errors. The facility census was 56 residents.
F761 Label/Store Drugs and Biologicals: The facility failed to properly label and store medications, including eye drops and inhalers, and failed to maintain accurate medication refrigerator temperature logs. The facility census was 52 residents.
F812 Food Procurement, Storage, Preparation, and Sanitary Conditions: The facility failed to maintain proper food safety practices including labeling, storage, cleaning, and sanitation of food-contact surfaces. The facility census was 52 residents at the time of survey.
Report Facts
Facility census: 52
Medication error rate: 19.23
Medication error opportunities: 26
Medication errors observed: 5
Facility census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Murphy | Administrator | Signed the Plan of Correction and referenced in corrective actions |
Inspection Report
Routine
Deficiencies: 0
Date: Jul 27, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jan 15, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 15, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess the facility's compliance with related CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparation and infection control.
Inspection Report
Plan of Correction
Census: 56
Deficiencies: 8
Date: Sep 3, 2019
Visit Reason
The document is a Plan of Correction submitted by Kingswood following a survey conducted on September 3, 2019, addressing deficiencies found during the inspection.
Findings
The facility was found deficient in multiple areas including failure to ensure accurate resident code status on Physician's Order Sheets, failure to provide required Medicaid notices, inadequate discharge summaries, lack of CPR certified staff on all shifts, improper assessment and use of bed rails, medication errors exceeding acceptable rates, and deficiencies in pharmacy services related to controlled substances and medication disposal.
Deficiencies (8)
F578 The facility failed to ensure the resident's current code status was accurate and clear on the Physician's Order Sheet for one sampled resident. The resident's POS showed conflicting code statuses of DNR and Full Code.
F582 The facility failed to provide a completed Skilled Nursing Facility Advance Beneficiary Notice at Medicare Part A termination for one sampled resident. The facility also failed to inform residents of Medicaid coverage changes in writing.
F661 The facility failed to ensure a discharge summary was completed upon planned discharge for one sampled resident. The discharge summary did not include required recapitulation and final status.
F678 The facility failed to ensure CPR certified staff were available on all shifts. No CPR certified staff were scheduled for the night shift on the reviewed date.
F700 The facility failed to assess and document risks and benefits of bed rails and obtain informed consent prior to installation for one sampled resident. Side rails were used without proper assessment or consent.
F755 The facility failed to ensure proper disposal and documentation of Fentanyl patches for three sampled residents. Staff did not witness or sign destruction of patches as required.
F759 The facility failed to maintain medication error rates below 5%. Five medication errors were detected out of 28 observed medication opportunities, resulting in a 17.86% error rate.
F760 The facility failed to ensure residents were free of significant medication errors. One resident had a significant medication error related to insulin pen priming.
Report Facts
Facility census: 56
Medication error rate: 17.86
Medication errors detected: 5
Medication opportunities observed: 28
Inspection Report
Life Safety
Census: 56
Capacity: 86
Deficiencies: 4
Date: Sep 3, 2019
Visit Reason
An Emergency Preparedness portion of a Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid emergency preparedness requirements and life safety code provisions.
Findings
The facility was found in compliance with emergency preparedness requirements but failed to meet the applicable provisions of the 2012 Life Safety Code related to fire alarm system testing and maintenance, sprinkler system installation, fire drills, and fire door inspections. Multiple deficiencies were cited regarding incomplete or outdated fire alarm inspections, lack of sprinkler coverage in the kitchen, inadequate fire drill documentation, and failure to conduct annual fire door inspections.
Deficiencies (4)
K345 Fire Alarm System - The facility failed to provide and maintain current annual fire alarm inspection documentation and did not conduct required semi-annual testing of the fire alarm system components and battery testing.
K351 Sprinkler System - The facility failed to have a sprinkler head in the main kitchen refrigerated walk-in unit, creating a hazardous situation affecting all residents and staff.
K712 Fire Drills - The facility failed to conduct quarterly fire drills on one shift and lacked required documentation and components for completed fire drills, potentially affecting staff preparedness.
K761 Maintenance, Inspection & Testing - Doors - The facility failed to conduct annual visual and functional assessments of smoke barrier and fire resistive doors, risking malfunction during a fire.
Report Facts
Facility census: 56
Licensed capacity: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Murphy | Administrator | Signed the report and plan of correction |
| Director of Operations | Interviewed regarding fire alarm inspection and sprinkler system deficiencies | |
| Director of Operations Assistant | Interviewed regarding fire drill discrepancies and door inspections |
Inspection Report
Plan of Correction
Census: 31
Capacity: 86
Deficiencies: 9
Date: Aug 31, 2018
Visit Reason
The document is a Plan of Correction submitted by Kingswood SNF following a survey conducted on 08/31/2018. It addresses deficiencies identified during the inspection.
Findings
The facility was found non-compliant with several regulatory requirements including respect and dignity of residents, notice requirements before transfer/discharge, comprehensive care plans, infection control, medication labeling, food safety, and others. Specific issues involved resident dignity related to clothing, failure to notify Ombudsman on transfers, incomplete care plans, inadequate infection control procedures, and improper medication labeling.
Deficiencies (9)
F557 Respect, Dignity/Right to have Personal Property: The facility failed to ensure resident dignity by not providing adequate clothing and care for one resident. The resident was non-compliant with changing clothes and bathing, and staff did not document or address this properly.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide discharge notification to the Ombudsman and responsible party for three sampled residents. The facility census was 31 residents.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to provide a copy of the bed-hold policy to the resident's representative for one sampled resident. The facility census was 31 residents.
F657 Care Plan Timing and Revision: The facility failed to develop and revise comprehensive care plans timely for one resident. The care plan did not accurately reflect current needs or use of assistive devices.
F658 Services Provided Meet Professional Care Plans: The facility failed to obtain physician's orders for monitoring a resident's pacemaker and cardiologist check-ups. Documentation of ongoing monitoring was incomplete.
F688 Increase/Prevent Decrease in ROM/Mobility: The facility failed to provide restorative services to maintain or improve mobility for one resident. The facility census was 31 residents.
F761 Label/Store Drugs and Biologicals: The facility failed to label medications with resident names and dates opened for multiple residents. Medication carts were not properly audited.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to maintain sanitary conditions in the kitchen including buildup of food debris and dust, damaged utensils, and improper cleaning schedules. The facility census was 31 residents in certified beds and 24 in licensed beds, total capacity 86 beds.
F880 Infection Prevention & Control: The facility failed to establish and maintain an effective infection control program including hand hygiene, use of gloves, wound care, and staff education. Several residents suffered no ill effects from the deficient practice.
Report Facts
Facility census: 31
Total capacity: 86
Sampled residents: 15
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristan Watters | Administrator | Signed the Plan of Correction and named in findings related to resident dignity and infection control |
| CNA D | Named in infection control and resident care findings | |
| CNA E | Named in infection control and resident care findings | |
| LPN B | Named in infection control and wound care findings | |
| LPN C | Named in infection control and wound care findings | |
| Director of Nursing | Named in multiple findings related to care plans, infection control, and monitoring |
Inspection Report
Life Safety
Census: 55
Capacity: 86
Deficiencies: 14
Date: Aug 31, 2018
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with emergency preparedness requirements and life safety code regulations.
Findings
The facility failed to maintain compliance with emergency preparedness requirements including development and maintenance of an Emergency Preparedness plan, training, and documentation. Several life safety deficiencies were identified including combustible material storage, sprinkler system outage, fire drill records, electrical system maintenance, and fire door inspections.
Deficiencies (14)
E004: The facility failed to develop and maintain an Emergency Preparedness plan that included current, signed documentation of annual reviews. This potentially affected all residents.
E007: The facility failed to have Emergency Preparedness documentation explaining provisions for residents with special needs under various emergencies, potentially affecting all residents using such equipment.
E022: The facility failed to establish and maintain a comprehensive Emergency Preparedness program including a procedural plan for sheltering in place, potentially affecting all residents, family, visitors, and staff.
E026: The facility failed to develop and implement policies and procedures describing its role in providing care under waivers in emergencies, potentially affecting all residents, visitors, and staff.
E031: The facility failed to develop and maintain an Emergency Preparedness communication plan that included contact information for federal emergency preparedness agencies, potentially affecting all residents, visitors, volunteers, and staff.
E037: The facility failed to maintain records of initial and annual Emergency Preparedness training for all new hires, existing staff, and volunteers, potentially affecting all residents, visitors, and staff.
E041: The facility failed to identify areas and lights powered by the emergency generator and failed to include contact information for a fuel supply entity for diesel tanks over 100 gallons, potentially affecting all residents.
K300: The facility stored combustibles (cardboard) more than one foot from the electric hot water heater in the Therapy office, potentially affecting at least 10 residents using the therapy area in one smoke zone.
K354: The sprinkler system was out of service for more than 10 hours in a 24-hour period and the facility failed to include contact information for the property’s insurance carrier, potentially affecting all residents and staff in nine of 16 smoke zones.
K500: The facility failed to provide documentation demonstrating 19 smoke dampers were exercised and inspected every four years, potentially affecting all residents and staff in nine of 16 smoke zones.
K712: The facility failed to ensure fire drills were thoroughly documented and scheduled on unexpected, staggered dates with concurrent verification of fire alarm signal transmission, potentially affecting all residents and staff in nine of 16 smoke zones.
K914: The facility failed to assess receptacles in 48 resident rooms and associated areas for integrity, grounding, circuit continuity, polarity, and retention force, potentially affecting all residents in nine of 16 smoke zones.
K918: The facility failed to maintain records of weekly generator testing and failed to document electrical inspections and maintenance, potentially affecting all residents and staff in nine of 16 smoke zones.
K920: The facility failed to prevent use of flexible cords and cables as substitutes for fixed wiring and failed to prevent electrical hazards, potentially affecting all residents and staff in nine of 16 smoke zones.
Report Facts
Facility census: 55
Total bed capacity: 86
Combustible material distance: 1
Sprinkler system outage duration: 10
Smoke zones affected: 9
Smoke dampers: 19
Resident rooms assessed for receptacles: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krista Walters | Administrator | Signed the plan of correction and named in findings related to emergency preparedness and life safety |
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