Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kingsley Specialty Care during CMS and state inspections, most recent first.
A resident with heart failure, HTN, renal failure, DM, and COPD requested CPR and was found unresponsive with no pulse. Staff began some compressions, but the RN left to get O2, staff searched for code status, and CPR was not continued until EMS arrived. EMS reported the resident was cyanotic and started CPR on arrival, while the facility’s crash cart, Ambu bag, O2, and AED supplies were not used during the event.
Failure to Notify Physician of Abnormal Blood Sugars and Missed Insulin: A resident with DM, HF, HTN, renal failure, and COPD had ordered insulin and accuchecks, but the MAR lacked documentation for missed insulin and missing BG results. Several BG readings were outside ordered parameters, yet there was no documentation that the physician was notified, and the DON could not find an explanation for the omitted insulin or missing BG checks.
Failure to report misappropriation of resident medication. An LPN/charge nurse self-administered a resident’s PRN Zofran after becoming ill while on duty, and another LPN reported seeing the medication taken. The Administrator confirmed the incident but did not report it to the state agency, stating it was not a controlled substance, despite facility policy requiring suspected misappropriation to be reported immediately.
Failure to follow insulin and BG orders: A resident with DM, HF, HTN, renal failure, and COPD had MAR gaps showing missing BG checks and missing documentation for Insulin Lispro administration. The record also showed multiple BG results outside ordered parameters, with no documentation that the physician was notified or that the ordered insulin was given as prescribed.
A resident with heart failure, HTN, renal failure, DM, and COPD required hemodialysis and needed a hoyer sling to transfer at the dialysis center. The resident arrived without the sling, could not transfer on her own, and the dialysis center waited over an hour for the LTC facility to bring it; by then, the resident declined treatment because she was uncomfortable and in pain. The dialysis records also noted missed treatments and fluid overload concerns.
A resident with pain, HF, PNA, DM, and no cognitive impairment had an inaccurate narcotic record for Oxycodone/APAP when more doses were signed out than were prescribed. Review found two nurses had access to the med cart, an attempted forged signature on the narcotic record, and multiple missing or illegible signatures on the controlled drug count record when keys were exchanged, contrary to facility policy.
Incomplete Dialysis Documentation: A resident with heart failure, HTN, renal failure, DM, and COPD had a care plan for hemodialysis several times each week, but the clinical record did not document a missed dialysis treatment as reported by the family member. The DON stated that missed dialysis should be documented when it occurs.
Incorrect PBJ staffing data was submitted to CMS, with weekend staffing reported as excessively low and the facility failing to meet staffing requirements in all three metrics. Review of staffing showed Nurses and CNAs were scheduled similarly on weekdays and weekends, while the Administrator stated she was newly hired and unaware of how the incorrect data had been reported.
Cold and Improperly Held Meals Served to Residents: Several residents reported that meals delivered to their rooms were routinely cold, including breakfast and lunch trays served cool or cold. During observation, a dietary staff member plated mechanically altered ham at 114 degrees, then microwaved it to 170 degrees after the surveyor questioned the temperature. The DON, RD, and Administrator stated food should be held and served at a minimum of 135 degrees, and the facility policy required hot foods and mechanically altered foods to remain above that temperature or be reheated appropriately.
Incorrect Food Consistency Served to Residents on Mechanical Soft Diets: A facility served whole brussels sprouts to six residents ordered mechanical soft diets, despite meal tickets and menu directions calling for chopped brussels sprouts. Staff observed the lunch meal being plated with regular brussels sprouts, and the Dietary Manager, Dietary Aide, lead cook, Administrator, and RD all acknowledged the food was not prepared in the ordered consistency.
Food Storage Lacked Dating and Proper Coverage: Surveyors found multiple open food items in the kitchen that were undated, uncovered, or expired, including refrigerated broccoli dated beyond the facility’s stated leftover timeframe, open cheese, noodles, frozen foods, and meats. The Dietary Manager stated open items should be dated and the expired broccoli should have been discarded, and the Administrator stated open food should be covered and labeled with an open date.
A resident with moderate cognitive impairment, hemiplegia/hemiparesis, unsteadiness, and generalized weakness required substantial to maximal assist for toileting and was dependent for toileting hygiene. Staff repeatedly turned off his call light after he said he needed the bathroom and later needed his brief changed, but care was delayed while staff said they were busy or needed another staff member. The resident was observed sobbing, and the DON and Administrator acknowledged the delay and that the resident did not receive appropriate dignity and respect.
A resident was not permitted to return after a hospital stay, despite an MDS showing return was anticipated. Facility interviews and records showed conflicting statements about a bed hold, past-due balance, and whether the resident could come back, and the hospital case manager documented that the resident could not return to the facility or other company-owned facilities.
Inaccurate MDS Documentation of Insulin Use: A resident’s MDS incorrectly documented insulin injections during the assessment period even though the EHR and MAR/TAR showed no active insulin order and no insulin administration. The resident stated he was not on insulin, and the MDS Coordinator and DON acknowledged the MDS was completed in error and was not accurate.
A resident with diagnoses including essential hypertension and unspecified hypotension received midodrine even though the order required the medication to be held if SBP was above 110. Staff obtained a BP of 140/70 before the medication pass, but the RN still removed the midodrine and gave it with the resident’s other medications. Staff and the DON acknowledged the medication should have been held based on the physician’s parameters.
Medication error rate exceeded 5 percent when 2 of 37 medications were not administered as ordered. A resident with hypotension received midodrine even though the SBP was 140 and the order said to hold it if SBP was above 110. Another resident with DM received NovoLog insulin incorrectly when an LPN administered part of the dose, left 2 units in the pen, and another staff member gave the remainder with a new needle. The DON stated the midodrine should have been held and the insulin should have been given as ordered.
Failure to perform hand hygiene after resident care was observed for two residents. A CNA provided catheter and incontinence care, removed soiled PPE, handled the trash receptacle and soiled PPE, and then continued arranging the resident’s sheet and bedside table without hand hygiene. In another observation, an LPN administered NovoLog insulin to a resident with severe cognitive impairment and DM2, then handled insulin supplies, the resident’s wheelchair, and the med cart before completing hand hygiene. The IP/RN and DON stated hand hygiene should have been done immediately after glove removal and before contaminating surfaces.
The facility failed to update care plans for three residents to include fall prevention interventions, despite multiple falls and injuries. Residents with cognitive impairments and high fall risk experienced repeated falls without timely updates to their care plans, contrary to facility policy. The administrator expected immediate intervention after falls, which was not implemented.
A resident with dementia and high fall risk experienced multiple falls resulting in injuries due to the facility's failure to update the care plan with appropriate interventions. Despite the facility's protocol requiring review and revision of care plans after falls, staff interviews revealed a lack of communication and coordination, leading to repeated incidents.
The facility failed to implement a Legionella water management program, as interviews revealed a lack of testing, monitoring, and documentation. The Administrator, responsible for the program, could not provide specifics on preventive measures and admitted to not having educated staff or implemented the program. Despite having a policy, the facility did not flush water lines, and key staff were unaware of their roles in the program.
The facility did not meet staffing requirements as it failed to submit staffing data for Fiscal Quarter 3, 2024, had low weekend staffing, and lacked 24-hour licensed nursing coverage for several days. Staffing for nurses and CNAs was scheduled similarly for weekdays and weekends, contributing to the deficiency. The Administrator was aware of the CMS data submission requirement but did not comply.
The facility failed to obtain proper signatures for bed hold notices when residents were transferred out, affecting four residents with various medical conditions. Verbal confirmations were used without securing necessary signatures, and a resident signed a form retroactively. Staff interviews revealed reliance on phone authorizations without proper documentation, which the administrator deemed unacceptable.
The facility was found to have deficiencies in food storage and preparation, with expired items in the dry storage area and unlabeled open items in the kitchen fridge. The facility's policy requires all foods to be labeled and dated, which was not adhered to, as confirmed by the Dietary Manager.
The facility failed to maintain a clean and orderly environment, with boxes stacked around the nurses' station and wheelchairs blocking an emergency exit. Observations over several days showed persistent clutter, and staff interviews revealed no designated person to manage freight, contrary to the facility's policy for a homelike environment.
A facility failed to notify a resident's power of attorney about the resident's hospitalization. The resident, with moderate cognitive impairment, was hospitalized without the son's knowledge, who is rarely informed about her care. The facility lacked documentation of notifying the son for bed hold authorization and did not provide a policy on family notification.
The facility failed to include high-risk medication usage and side effects in the care plans for two residents. One resident, with no cognitive impairment, was prescribed Latuda and Nucynta, but their care plan lacked details on these medications. Another resident, with moderate cognitive impairment, was prescribed Morphine Sulfate and Hydrocodone-Acetaminophen, but their care plan also lacked necessary information. The facility's policy did not provide guidance on including medication usage and side effects in care plans.
A resident with cancer, renal insufficiency, and Parkinson's Disease did not receive ordered physical therapy for shoulder pain. Although the written Physician Orders documented the therapy order, it was not entered into the electronic system, and the resident was not added to the physical therapy case load. Interviews with staff confirmed the oversight, and the facility did not provide a policy on handling physician orders.
A facility failed to provide a restorative program for a resident with mobility concerns, despite recommendations in the Physical Therapy Discharge Summary. The resident, with no cognitive impairment, reported not receiving restorative therapy due to staff unavailability, affecting her leg mobility. Interviews revealed a lack of documentation and implementation of restorative services, contrary to facility policy.
A facility failed to provide appropriate dialysis care for a resident with renal insufficiency, Diabetes Mellitus, and coronary artery disease. The nursing staff did not complete required dialysis evaluations on multiple occasions, despite physician orders specifying the need for evaluations before and after dialysis on certain days. The facility's policy required staff training on assessment data collection, but evaluations were missed on several dates. The Administrator expected nurses to complete these assessments as ordered.
A resident with a urinary catheter experienced a dignity violation when a nurse failed to address a leaking catheter, prioritizing her shift end over the resident's care. The resident, with no cognitive impairment and diagnosed with renal insufficiency, diabetes, and peripheral vascular disease, spent the night soaked in urine, leading to embarrassment and distress. The facility's dignity policy was not followed, and the administrator expected staff to respond promptly to residents' concerns.
The facility failed to provide scheduled bathing assistance to three residents, leading to extended periods without baths. A resident with hypertension and diabetes reported sporadic shower schedules due to staff shortages, while another with severe cognitive impairment was observed with unkempt hair. Documentation showed significant gaps in bathing schedules, contrary to the facility's policy to promote cleanliness and comfort.
A resident with multiple diagnoses, including renal insufficiency and DM, returned from the hospital requiring skilled care. The facility failed to perform daily skilled assessments on several occasions, contrary to its policy. The administrator confirmed the expectation for daily assessments.
Failure to Provide Continuous CPR for a Full-Code Resident
Penalty
Summary
The facility failed to provide adequate CPR for a resident who had requested CPR and was found not breathing with no pulse. The resident had a BIMS score of 15 and diagnoses including heart failure, hypertension, renal failure, diabetes, and COPD. The resident had signed a CPR/DNR declaration indicating a preference for CPR and AED use to prolong life when biological death was not imminent. According to the progress notes and staff interviews, the resident complained of shortness of breath and was being cleaned up after loose stools when staff noticed her breathing slow down and then become unresponsive. Staff began some chest compressions, but the nurse left the room to obtain oxygen and later could not find all the working parts. Staff then called for help, and one CNA called 911 while another attempted CPR. Staff reported that they were unsure of the resident’s code status at first and searched for it in the facility records before finding that she was a full code. Multiple staff and EMS accounts described that CPR was not continuously performed until EMS arrived. Staff stated that compressions were stopped when the ambulance arrived, and EMS then initiated CPR. EMS reported that the resident was cyanotic and that they began CPR after entering the room. The facility had a crash cart, Ambu bag, oxygen, AED pads, and a backboard available, but staff did not use the crash cart during the event. The DON stated that CPR should begin right away for a resident who wants CPR and has no respirations or pulse, and that CPR should continue until EMS takes over.
Failure to Notify Physician of Abnormal Blood Sugars and Missed Insulin
Penalty
Summary
The facility failed to notify the physician when a resident’s blood sugars were outside ordered parameters and when insulin was not given as ordered for one of four residents reviewed. The resident had diagnoses including heart failure, hypertension, renal failure, diabetes, and chronic obstructive pulmonary disease, and the MDS assessment showed a BIMS score of 15, indicating no cognitive impairment. The care plan identified the resident as using insulin and hypoglycemic medications for diabetes, with interventions to administer insulin as ordered and monitor blood glucose as ordered. The MAR for March 2026 showed Insulin Lispro 10 units three times daily with instructions to hold if blood sugar was less than 100, but there was no blood sugar reading or insulin administration documented on 3/27/26. The DON could not find blood sugar results or an explanation for why the Insulin Lispro was not given. The MAR for May 2026 included accuchecks before meals and at bedtime, but there were no p.m. results on 5/4 and 5/6/26, and the record lacked documentation for blood sugars that were outside the ordered parameters, including readings of 67, 405, 377, 379, and 434. The record also lacked documentation that the physician was notified of the abnormal blood sugars or the missed insulin doses, and the physician stated she would expect to be notified when blood sugars were not within parameters or insulin was not received as ordered.
Failure to Report Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report suspected misappropriation of resident medication to the Department of Inspections, Appeals and Licensing for one resident. Resident #6 had a BIMS score of 15, indicating no cognitive impairment, and diagnoses that included heart failure, COPD, and respiratory failure. The resident had an order for ondansetron disintegrating oral tablet every 8 hours as needed for nausea. Staff D, an LPN in training, stated that Staff E, an LPN and charge nurse, removed a Zofran tablet and took it herself. Staff D reported the incident to the Administrator the next morning. An email from the Administrator identified that Staff E took Resident #6's Zofran tablet, and a disciplinary form documented that Staff E became physically ill while on duty and self-administered the resident's PRN Zofran medication. The Administrator stated she did not self-report the incident to DIAL because it was not a controlled substance, despite facility policy stating that suspected misappropriation of resident property must be reported immediately to the administrator and other officials according to state law, including the state licensing/certification agency.
Failure to Follow Insulin and Blood Sugar Orders
Penalty
Summary
The facility failed to follow the physician’s orders for medication administration and blood sugar monitoring for one resident with no cognitive impairment who had diagnoses including heart failure, hypertension, renal failure, diabetes, and COPD. The care plan identified the resident’s use of insulin/hypoglycemic medications and directed staff to administer insulin as ordered and monitor blood glucose as ordered. The March 2026 MAR showed Insulin Lispro 10 units three times daily with a hold parameter for blood sugar less than 100, but the MAR lacked blood sugar readings and insulin administration documentation for 3/27/26. The DON reviewed the record and could not find blood sugars or an explanation for why the Insulin Lispro was not given, and stated physician orders should be followed and the physician should be notified if something was not done. The May 2026 MAR also showed accuchecks before meals and at bedtime, but there were no p.m. results documented on 5/4 and 5/6/26. Blood sugar results were outside the ordered parameters on multiple occasions, including 67 before lunch on 5/2/26, 405 on 5/4/26, 377 and 379 on 5/6/26, and 434 before breakfast on 5/7/26. The MAR included Insulin Lispro per sliding scale, but there was nothing documented on 5/5 or 5/6/26. The clinical record lacked documentation explaining why the blood sugars and Insulin Lispro were not completed as ordered, and it also lacked documentation that the physician was notified of the out-of-parameter blood sugars. The administrator stated there was nothing to indicate the insulin was completed as ordered or that the physician was notified, and the physician stated she would expect to be notified when blood sugars were not within parameters or when insulin was not given per order.
Dialysis Resident Sent Without Needed Lift Sling
Penalty
Summary
The facility failed to ensure a resident who required dialysis had the needed equipment available for treatment. The resident had diagnoses including heart failure, hypertension, renal failure, diabetes, and COPD, and the MDS indicated no cognitive impairment. Dialysis care coordination documents noted the resident needed to be in a hoyer sling because she was unable to transfer or shift position in her chair, and another facility dialysis form specifically asked that a lift sling be provided. On the day of the missed dialysis treatment, the resident arrived at the dialysis center without a sling under her in her wheelchair. Because she could not transfer on her own, the dialysis center called the nursing home to bring a sling. The nursing home took over an hour to return with it, and by then the resident no longer wanted treatment because she had been sitting and waiting so long and was in pain and uncomfortable. The dialysis facility administrator documented that the resident had missed prior treatments and had left above her estimated dry weight on completed treatments, and the DON acknowledged the dialysis center's note that she needed a lift sling for dialysis.
Controlled Substance Count and Narcotic Record Discrepancies
Penalty
Summary
The facility failed to ensure an accurate account of controlled medications for Resident #3, who had a BIMS score of 15 indicating no cognitive impairment and diagnoses including heart failure, pneumonia, diabetes, and bilateral knee pain. The care plan identified pain related to the resident’s diagnosis and included interventions for opioid use, administration per physician order, and monitoring for side effects. During review of the resident’s narcotic record, a discrepancy was identified when 5 doses of Oxycodone/APAP were removed on 4/7/26 even though only 3 doses were prescribed. The facility’s internal review found that two nurses had access to the medication cart when the doses were signed out, and documentation irregularities were noted on the individual narcotic record, including an attempted forged nurse signature. Staff A stated she did not do a narcotic count, and Staff E stated she did not do a narcotic count. Review of the controlled drugs count record also showed multiple gaps in required signatures when keys were exchanged on several dates, including missing on-duty and off-duty nurse signatures and illegible entries. The facility policy required both nurses to sign the controlled substance count record and to verify the count when exchanging keys.
Incomplete Dialysis Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident who received dialysis. The resident’s MDS assessment showed a BIMS score of 15 with no cognitive impairment, and the resident’s diagnoses included heart failure, hypertension, renal failure, diabetes, and COPD. The care plan stated the resident received hemodialysis on Monday, Tuesday, Wednesday, and Friday each week at the dialysis center and included an intervention to encourage attendance at scheduled dialysis appointments. Progress notes documented the resident was sent by ambulance to the hospital, and the resident’s family member told surveyors that the resident did not have dialysis on 5/8/26. The clinical record did not contain documentation that the resident missed dialysis on that scheduled day, and the DON stated it should be documented if the resident did not have dialysis on the scheduled day.
Incorrect PBJ Staffing Data Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data. Review of the CMS PBJ Staffing Data Report for Fiscal Quarter 2, 2025 showed that the facility reported staffing data that triggered excessively low weekend staffing within the quarter, and the facility failed to meet staffing requirements in all three metrics. The facility reported a census of 31 residents. Facility staffing review showed Nurses and CNAs were scheduled similarly for weekdays and weekends, which did not match the low weekend staffing data submitted to CMS. During an interview, the Administrator stated she had recently been hired and was not aware of how incorrect data was reported to CMS, and said she expected the data to be reported correctly and would look into the matter. The facility policy stated staffing and census information would be reported electronically to CMS through the PBJ system in compliance with the Affordable Care Act.
Cold and Improperly Held Meals Served to Residents
Penalty
Summary
The facility failed to provide food at an appetizing temperature for 4 of 20 residents reviewed, including residents who were cognitively intact and able to report their concerns. Resident #3 stated that food was delivered cold to the room every day and that meals were not served at a particular time, including lunch that was cold on the day of interview. Resident #5 stated that after telling the Administrator the food was cold, the evening meal began to get hotter, but lunch was almost always cold. Resident #25 stated that nearly all meals were served cool and that she would like the food served warmer. During a continuous lunch observation, Staff G removed mechanically altered ham from the steam table, processed it, and plated it for residents. The surveyor requested the temperature of the mechanical ham, and Staff G obtained a temperature of 114 degrees. Staff G then removed the ham from the plated meals, placed it in a microwave, and retook the temperature at 170 degrees. Staff H, the Dietary Manager, acknowledged the mechanically soft ham should not have been served at 114 degrees and stated the expected serving and holding temperature was a minimum of 135 degrees. The Administrator and the Registered Dietitian also stated that food should have been served at a minimum of 135 degrees, and that the mechanically soft ham should have been reheated to 135 degrees before serving. Resident #8, who consumed all meals in her room, had breakfast delivered outside the room while care was being provided. After care ended, staff retrieved the tray from an uninsulated cart and served it to the resident. Resident #8 stated the breakfast was cold and reported that meals were cold six out of seven days, with all three meals cold on those days. The Administrator stated staff should have provided a new breakfast tray for the resident. The facility policy stated that hot foods must be maintained above 135 degrees, mechanically altered hot foods must remain above 135 degrees during preparation or be reheated to 165 degrees for at least 15 seconds, and steam tables are never used to reheat foods.
Incorrect Food Consistency Served to Residents on Mechanical Soft Diets
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs by serving incorrect consistency items to 6 of 6 residents reviewed who were ordered mechanical soft diets. Resident #7, #9, #10, #11, #13, and #22 each had EHR orders for a regular/no added salt diet with mechanical soft texture, and the MDS documented varying levels of cognitive impairment and, for some residents, diagnoses including hemiplegia and hemiparesis following cerebral infarction, unsteadiness on feet, and generalized muscle weakness. Despite these orders, the lunch meal tickets for all six residents on 8/6/25 documented mechanical soft diets with 1/2 cup of chopped brussels sprouts. During continuous observation of lunch service, Staff G, Lead [NAME], removed ham from the steam table, processed it in a food processor to ground consistency, and plated it, but served whole brussels sprouts on the plates for all six mechanically soft diets. No mechanical soft brussels sprouts were prepared for the meal. Staff H, the Dietary Manager, acknowledged the brussels sprouts were not chopped and should have been. The Administrator stated the brussels sprouts should have been chopped if that was how the menu read. Staff J, Dietary Aide, acknowledged the residents on mechanical soft diets received regular brussels sprouts and stated he depended on the cook to serve the correct consistency. Staff G later acknowledged none of the residents on a mechanical diet received chopped brussels sprouts and stated he thought the brussels sprouts were soft enough. The Registered Dietitian stated mechanical soft brussels sprouts should be chopped or fork tender and that cooks should follow the menu when it states the brussels sprouts are chopped.
Food Storage Lacked Dating and Proper Coverage
Penalty
Summary
The facility failed to store food in accordance with professional standards by not dating open food items and by not disposing of expired food items. During an initial kitchen observation, surveyors found broccoli in the refrigerator dated 7/25/25, an open and undated bag of shredded cheese in the 3-door refrigerator, an open and undated 5-lb bag of egg noodles and an open undated 5-lb bag of tri color spiral noodles in dry storage, an open and undated bag of hush puppies in the 2-door freezer, an open and undated bag of frozen chicken breasts in the [NAME] freezer chest, and an open undated bag of pork chops plus a bag of pork sausages that were dated but not covered in the 2-door stand up freezer. The Dietary Manager stated that all open food items should have the date the item was opened and that the broccoli dated 7/25/25 should have been thrown away, explaining that leftovers were expected to be discarded after 3 days. The Administrator later stated that all open food should be covered and labeled with an open date. The facility policy stated that dry foods not stored in bins must be removed from original packaging, labeled and dated, and that all foods stored in the refrigerator or freezer must be covered, labeled, and dated.
Failure to Provide Dignity During Delayed Toileting and Personal Care
Penalty
Summary
The facility failed to provide dignity and respect to one resident with moderate cognitive impairment, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, unsteadiness on feet, and generalized muscle weakness. The resident’s MDS documented that he required substantial to maximal assistance for transfers on and off the toilet and was completely dependent on staff for toileting hygiene. During observation, the resident repeatedly stated he needed to use the bathroom and later stated he needed to be changed because his brief was wet, but staff shut off his call light and told him they could not help him alone or would return later. The resident remained waiting while multiple staff members entered the room, turned off the call light, and said they were busy or needed another staff member to assist. The resident was observed audibly and visually sobbing while waiting for personal care. The DON later acknowledged the resident was upset because he wanted to be changed and had been waiting, and the resident stated he felt staff had not provided him dignity because the light was turned off twice without his wet brief being changed. The Administrator also acknowledged there was a delay in care and that a person in a similar situation would feel appropriate dignity and respect was not provided.
Failure to Permit Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization for 1 of 1 residents reviewed. Resident #39 had an MDS assessment documenting an unplanned short-term general hospital stay with return anticipated. Clinical progress notes showed the resident was admitted to the hospital on 3/10/25 at 9:01 PM, but there was no documentation of readmission to the facility. The hospital case manager documented that the facility social worker stated the patient did not do a bed hold and had other issues with the facility, and that the patient could not return to the facility or other facilities owned by the company. Interviews showed conflicting information about whether the resident could return and whether outstanding debt affected the decision. The OSLTCO reported the BOM said the resident owed a substantial balance and was told he could not just stay without paying. The BOM stated bed hold notices were not provided if debt was owed and referenced the admission agreement. Later interviews showed Staff L said the resident signed a bed hold form but the bed hold was stopped during an extended hospital stay to prevent further billing, while Staff M stated a bed hold was allowed even with a past due amount and that the resident wanted to let the bed hold go to prevent further billing. The current Administrator stated that if a resident's account is past due, the resident should be permitted to return from the hospital to the facility. The admission agreement stated the resident could hold the bed indefinitely, but not during a temporary absence if the account was past due, and the discharge summary and plan did not address readmissions.
Inaccurate MDS Documentation of Insulin Use
Penalty
Summary
The facility failed to ensure an accurate assessment of Resident #7’s status during the MDS observation period by incorrectly documenting insulin use. The MDS dated [DATE] recorded a BIMS score of 12, indicating moderate cognitive impairment, and also documented that the resident received insulin injections during the last 7 days, even though there was no current order for insulin in the EHR. Review of the resident’s EHR showed no active insulin order, and the MAR/TAR for May, June, and July also showed no insulin orders. During interview, Resident #7 stated on 8/4/25 at 1:21 PM that he was not on insulin. Staff D, the MDS Coordinator/IP/RN, acknowledged on 8/6/25 that the MDS completed for Resident #7 on 5/15/25 was entered in error when documenting insulin use and stated the MDS would be updated. Staff D also acknowledged that the resident did not have an insulin order and was not receiving insulin at the time the MDS was completed. The DON later stated that the expectation was for the MDS to be completed accurately and acknowledged that Resident #7’s MDS was not accurately completed.
Medication Given Outside Blood Pressure Parameters
Penalty
Summary
The facility failed to provide services in accordance with professional standards when a resident with diagnoses of essential hypertension and unspecified hypotension received midodrine despite blood pressure parameters that required the medication to be held. The resident’s order directed midodrine HCl 10 mg by mouth three times daily for hypotension, with instructions to hold the medication if systolic blood pressure was greater than 110. During observation, staff obtained a blood pressure of 140/70 before medication administration, yet the nurse removed midodrine from the drawer and bubble pack and presented it to the resident along with the other medications, which the resident self-administered. The resident’s EHR and MAR-TAR both documented the midodrine order with the hold parameter, and the EHR blood pressure summary documented a blood pressure of 140/70 shortly after the medication pass. Staff acknowledged that the midodrine should have been held because the systolic blood pressure was above 110 and stated the medication was given outside the physician’s parameters. The DON stated the expectation was that the medication would have been held at a systolic blood pressure of 140 and that the nurse should have followed the medication checks prior to administration.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with 2 of 37 medications not provided as ordered for a calculated error rate of 5.41. For one resident with diagnoses of essential hypertension and unspecified hypotension, the MDS and EHR documented a BIMS of 15 and an order for midodrine HCl 10 mg by mouth three times daily, to be held if systolic blood pressure was greater than 110. During observation, the resident’s blood pressure was 140/70, yet the nurse removed midodrine from the drawer, reviewed it with the MAR, removed it from the bubble pack, and gave the medication to the resident. Staff D stated the medication should have been held because the systolic blood pressure was above 110, and the DON stated the nurse should have followed the medication checks prior to administration. For another resident with a BIMS of 2 and a diagnosis of type 2 diabetes mellitus with other specified complications, the MAR and orders documented NovoLog insulin 6 units subcutaneously three times daily. During observation, an LPN drew up 2 units of NovoLog, primed the pen with 2 units, administered 6 units into the back of the right upper arm, and then removed the needle while the pen continued clicking outside the arm. The surveyor observed that 2 units remained in the insulin pen, and another staff member then administered the remaining 2 units with a new needle into the left abdomen. Staff D stated the insulin did not appear to have been administered appropriately, and the DON stated all 6 units should have been given in one dose and that the facility expected medications to be administered according to the physician’s orders.
Failure to Perform Hand Hygiene After Resident Care
Penalty
Summary
The facility failed to provide proper hand hygiene after resident care for 2 of 2 residents reviewed. During an observation on 08/06/2025 at 8:02 AM, Staff K, a CNA, and Staff C, a CNA, performed hand hygiene, donned a gown and gloves, and provided care for a catheter and bowel movement incontinence. After finishing care, Staff K removed the soiled gown and gloves, used the left hand to hold the trash receptacle, used the right hand to place soiled PPE into the trash, then placed the right hand on top of the soiled PPE and pushed it further into the trash receptacle. Staff K then arranged the resident’s sheet and bedside table without performing hand hygiene. The Administrator stated on 08/07/2025 at 3:34 PM that staff were expected to complete hand hygiene immediately after removing soiled gloves. For Resident #26, the MDS documented a BIMS score of 2, indicating severe cognitive impairment, and a diagnosis of type 2 diabetes mellitus with other specified complications. During an observation on 08/06/2025 at 8:38 AM, Staff F, an LPN, completed hand hygiene, applied gloves, drew up NovoLog insulin, cleansed the resident’s upper arm with an alcohol wipe, and administered the insulin. After removing gloves, Staff F picked up insulin supplies, placed hands on the handles of the resident’s wheelchair, wheeled the resident down the hall to the medication cart, retrieved keys, unlocked the cart, and placed supplies in the cart before completing hand hygiene and wheeling the resident to the dining room table. Staff D, the MDS Coordinator/IP/RN, stated hand hygiene should have been completed after glove removal before contamination of surfaces, before pushing the resident up the hall, and before returning supplies to the medication cart. The DON stated the same expectation on 6/7/25 at 4:00 PM.
Failure to Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to revise and update care plans to include appropriate interventions for residents to prevent repeated falls and injuries. This deficiency was identified for three residents who experienced multiple falls without corresponding updates to their care plans. The facility's policy requires care plans to be reviewed and revised by a team of health professionals, but this was not adhered to, resulting in a lack of fall interventions for the affected residents. Resident #2, with diagnoses including a neurological disorder and stroke, fell four times between November and December 2024. Despite these incidents, the care plan for Resident #2 did not include any focus area or interventions for falls during this period. Similarly, Resident #3, who has coronary artery disease, diabetes, and arthritis, fell six times from October to November 2024. The care plan for Resident #3 lacked fall interventions for several of these incidents, indicating a failure to address the resident's fall risk adequately. Resident #1, diagnosed with dementia and other conditions, was identified as high risk for falls. Despite multiple falls resulting in injuries, the care plan interventions were not timely or adequately updated. The facility's failure to implement appropriate fall interventions after each incident, as required by their policy, contributed to the repeated falls and injuries experienced by these residents. The administrator acknowledged the expectation for immediate intervention following a fall, which was not met in these cases.
Failure to Update Care Plan Leads to Repeated Falls
Penalty
Summary
The facility failed to provide adequate fall interventions and communicate these interventions via the care plan to prevent falls that resulted in injury for a resident. The resident, who had a history of dementia, blindness, cerebral infarction, and heart failure, was assessed to be at high risk for falls. Despite this, the care plan did not include appropriate interventions to mitigate this risk, leading to multiple incidents where the resident fell and sustained injuries. The resident experienced several falls, including one where they were found sitting on the floor with bruises and another where they attempted to stand without assistance, resulting in a fall and a forehead laceration. These incidents highlighted the facility's failure to update the care plan with necessary interventions after each fall. Staff interviews revealed a lack of communication and coordination among the nursing staff, with some staff members unsure of their responsibilities in updating the care plan. The facility's protocol required that all falls be reviewed during daily quality assurance meetings and that care plans be revised with additional interventions. However, this process was not followed, as evidenced by the repeated falls and injuries sustained by the resident. The lack of timely updates to the care plan and inadequate communication among staff contributed to the ongoing risk of falls and injuries for the resident.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to implement a Legionella water management program, as evidenced by interviews and a lack of documentation. The Maintenance Director indicated that the Administrator was responsible for the program, but no testing or monitoring had been conducted. The Infection Preventionist was unaware of who was in charge of the program. The Administrator admitted to not having specifics on testing and acknowledged that the facility planned to educate staff on the program but had not yet done so. Despite having a 20-page plan, the Administrator could not explain the current measures in place to prevent Legionella growth. Further interviews revealed that the facility had not been flushing water lines, a key preventive measure, and lacked documentation to confirm such actions. The Administrator initially claimed certainty about flushing the lines but later admitted uncertainty after being informed of the Maintenance Director and Infection Preventionist's statements. The facility's policy, revised in July 2017, outlined a water management team that included the Infection Preventionist, Administrator, Medical Director, Director of Maintenance, and Director of Environmental Services. However, the Administrator conceded that a Legionella program had not been implemented.
Failure to Meet Staffing Requirements and Data Submission
Penalty
Summary
The facility failed to meet staffing requirements as per the CMS Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Quarter 3, 2024. The report indicated that no staffing data was submitted for the quarter, there was excessively low weekend staffing, and the facility did not maintain licensed nursing coverage 24 hours a day for four or more days within the quarter. Additionally, the staffing for nurses and Certified Nursing Assistants (CNAs) was scheduled similarly for both weekdays and weekends, which contributed to the deficiency. The facility reported a census of 33 residents during this period. The Administrator acknowledged awareness of the requirement to submit staffing data to CMS but failed to do so for the specified quarter.
Failure to Obtain Proper Bed Hold Signatures
Penalty
Summary
The facility failed to ensure that bed hold notices were properly signed by residents or their representatives when residents were transferred out of the facility. This deficiency was identified for four residents, each with varying degrees of cognitive impairment and medical conditions such as cancer, hypertension, diabetes mellitus, respiratory failure, renal insufficiency, and heart failure. The facility's policy required that written information regarding bed hold rights and limitations be provided to residents and their representatives prior to a transfer. However, in several instances, verbal confirmations were obtained without securing the necessary signatures, and in one case, a resident signed a bed hold form retroactively at the staff's request. Interviews with staff revealed that the facility's practice involved contacting representatives by phone for bed hold authorizations, but the required documentation was not consistently completed. A registered nurse admitted to adding handwritten information and signing bed hold forms, assuming that floor nurses had contacted the representatives. The facility's administrator acknowledged that the bed hold forms should have been addressed before residents were transferred and that it was unacceptable for staff to sign forms or obtain signatures retroactively.
Sanitation Deficiency in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure food was stored and prepared under sanitary conditions, as observed during an initial kitchen tour. In the dry storage area, several items were found with expired dates, including a bottle of kiwi-lime sauce, a bottle of mango sauce, and multiple packages of tortilla shells. Additionally, the kitchen fridge contained open gallons of white and chocolate milk, thickened water, thickened apple juice, and a gallon of orange juice, all without open dates. A container of food thickener was also found open with no open date and a scoop inside. The facility's policy on food receiving and storage mandates that all foods stored in the refrigerator or freezer be covered, labeled, and dated, and that beverages be dated when opened and discarded after twenty-four hours. An interview with the Dietary Manager confirmed that the kitchen should not have expired food stored and all items should be labeled with an open date.
Facility Fails to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to maintain a clean, orderly, and homelike environment as evidenced by the presence of boxes stacked around the nurses' station and wheelchairs blocking an emergency exit door. Observations on multiple occasions revealed 16 to 26 boxes stacked along the wall by the nurses' station, with no designated staff assigned to put the freight away. This situation persisted over several days, indicating a lack of timely action to address the clutter. Additionally, two wheelchairs were observed parked at the end of the 300 hallway, blocking an exit door, which could impede emergency egress. Interviews with staff, including a Registered Nurse, revealed that there is no specific person responsible for putting away the freight, leading to the accumulation of boxes around the nurses' station. The facility's policy on maintaining a homelike environment emphasizes a clean, sanitary, and orderly setting, which was not upheld in this instance.
Failure to Notify Resident's Representative of Hospitalization
Penalty
Summary
The facility failed to notify the resident's representative of a hospitalization event for one of the residents, identified as Resident #7. The resident had a documented history of cancer, hypertension, anxiety, and depression, with a BIMS score indicating moderate cognitive impairment. The clinical record review showed that the resident was on hospital unpaid leave and later marked as active, but there was no documentation of the resident's son being contacted for bed hold authorization. Despite a bed hold being dated, the progress notes lacked evidence of communication with the son, who is the power of attorney for healthcare. During an interview, the resident's son expressed that he was not informed about the bed hold or the hospitalization, despite being the power of attorney. He mentioned that he was rarely contacted about his mother's care and was unaware of her hospitalization until he visited the facility and found her absent. The Director of Nursing informed him that his mother was at the hospital receiving blood. Staff B mentioned that the resident had expressed a desire not to have her family notified of changes, but was unsure if the resident could adequately advocate for herself. The facility did not provide a policy on family notification.
Failure to Include High-Risk Medication Usage and Side Effects in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans addressing the usage of high-risk medications and their side effects for two residents. Resident #4, who has diagnoses including hypertension, depression, bipolar disorder, and diabetes mellitus, was prescribed Latuda, an antipsychotic medication, and Nucynta, an opioid medication. Despite these prescriptions, Resident #4's care plan did not include information on the usage of these medications or the side effects to monitor. The Minimum Data Set (MDS) assessment indicated that Resident #4 had no cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 15. Similarly, Resident #33, with diagnoses of renal insufficiency, dementia, and a history of hip fracture, was prescribed Morphine Sulfate and Hydrocodone-Acetaminophen. However, the care plan for Resident #33 also lacked details on the usage of these medications and the side effects to watch for. The facility's Care Plan Process Policy, dated January 2015, did not include instructions for care plan expectations related to medication usage and side effects. Interviews with staff confirmed that the care plans should have included this information, but it was not present.
Failure to Initiate Ordered Physical Therapy
Penalty
Summary
The facility failed to provide professional standards of care by not initiating physical therapy as ordered for a resident. The resident, who had diagnoses of cancer, renal insufficiency, and Parkinson's Disease, reported that a physician had ordered physical therapy for shoulder pain, but the therapy was not initiated. A review of the electronic Physician Orders showed no order for physical therapy, while the written Physician Orders documented the order dated 7/18/24. Further chart review revealed no documentation related to physical therapy. Interviews with the Nurse Consultant and Administrator confirmed that the resident was not picked up on the physical therapy case load and that orders were expected to be entered into the electronic chart and initiated. The facility did not provide a policy regarding physician orders.
Failure to Provide Restorative Program for Resident with Mobility Concerns
Penalty
Summary
The facility failed to provide a restorative program for a resident with mobility concerns, as identified during a survey. The resident, who had diagnoses including hypertension, depression, bipolar disorder, and diabetes mellitus, was assessed with a BIMS score of 15, indicating no cognitive impairment. The resident reported not receiving restorative therapy anymore due to the absence of a staff member to conduct it, which was the only exercise her legs received. She noticed a difference in her legs since the cessation of the therapy. The Physical Therapy Discharge Summary recommended a restorative range of motion program and the use of a lower extremities omnicycle, but the resident's care plan lacked a restorative therapy program. Interviews with facility staff revealed inconsistencies in the documentation and implementation of restorative services. The MDS Coordinator mentioned that the resident had been refusing restorative services, leading to their discontinuation, but was unable to provide documentation of these refusals or any record of the resident receiving restorative therapy since the order date. The facility's policy stated that residents should receive restorative nursing care as needed to promote safety and independence, but the Director of Nursing acknowledged that the order for restorative therapy should have been completed for the resident.
Failure to Complete Required Dialysis Evaluations
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, identified as Resident #37, who required such services. The clinical record review revealed that the nursing staff did not complete all required dialysis evaluations for the resident. The Minimum Data Set (MDS) assessment indicated that Resident #37 had diagnoses of renal insufficiency, Diabetes Mellitus, and coronary artery disease, with no cognitive impairment as per a BIMs score of 14. The physician's order required dialysis evaluations to be completed before and after dialysis on specific days and once on other days. However, the facility did not complete these evaluations on multiple dates, including 8/2/24, 8/4/24, 8/5/24, and several others through 9/11/24. The facility's policy on the care of residents with end-stage renal disease, revised in September 2010, required staff education and training on the type of assessment data to be gathered about the resident's condition. During an interview, the Administrator stated that she expected nurses to complete dialysis assessments as ordered.
Failure to Address Resident's Dignity and Care Needs
Penalty
Summary
The facility failed to respect the dignity of a resident, identified as Resident #32, who had a urinary catheter. The resident, who had no cognitive impairment and was diagnosed with renal insufficiency, diabetes mellitus, and peripheral vascular disease, reported an incident where a nurse neglected to address a leaking catheter. The resident informed the nurse about the leak, but the nurse prioritized leaving at the end of her shift over addressing the issue. As a result, the resident spent the entire night soaked in urine, leading to feelings of embarrassment and distress. The incident was documented in a progress note, which confirmed that the resident, his bed, and dressings were wet with urine the following morning. The resident stated that the catheter had been leaking since the previous night and that the nurse on duty was aware but did not take action. A grievance was filed by the resident, and the facility's dignity policy emphasized the importance of caring for residents in a manner that promotes their well-being and self-esteem. The facility's administrator expected staff to respond promptly to residents' requests and concerns, which was not adhered to in this case.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to three residents, as evidenced by clinical record reviews, resident interviews, and staff interviews. Resident #4, who has diagnoses including hypertension and diabetes mellitus, reported sporadic shower schedules due to staff shortages. Documentation revealed that Resident #4 went without a bath for five days in August and eight days in September, despite being scheduled for baths twice weekly. The care plan for Resident #4 lacked specified bathing frequency. Resident #35, with severe cognitive impairment and diagnoses including cancer and heart failure, was observed with unkempt and oily hair, indicating a lack of regular bathing. Documentation showed that Resident #35 went without a bath for extended periods, including 14 days in July and 11 days in August. Similarly, Resident #23, who has no cognitive impairment and requires partial assistance for bathing, did not receive a bath for over a week in late August and early September. The facility's policy, which aims to promote cleanliness and comfort, was not adhered to, as evidenced by the lack of documentation and failure to bathe residents as scheduled.
Failure to Complete Skilled Assessments for a Resident
Penalty
Summary
The facility failed to complete necessary skilled assessments for a resident, leading to a deficiency. Clinical record review and staff interviews revealed that the nursing staff did not perform all required skilled assessments for one resident out of twelve reviewed. This resident, who had a diagnosis of renal insufficiency, Diabetes Mellitus, and coronary artery disease, returned from the hospital on a skilled level of care after a prolonged stay for sepsis, hypoxia, rhabdomyolysis, DM, COPD, and myocardial infarction. Despite the facility's policy requiring daily skilled assessments, the resident's evaluations were not completed on several specified dates. The facility's administrator confirmed the expectation for daily skilled assessments by nurses.
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What surveyors actually found near you
We read the 114 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Kingsley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Correctionville Specialty Care | 12.5 mi | ★★★★★ | 13 | 0 |
| Happy Siesta Health Care Center | 15.1 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Le Mars | 16.2 mi | ★★★★★ | 0 | 0 |
| Good Samaritan - Lemars | 17.1 mi | ★★★★★ | 3 | 0 |
| Heartland Care Center | 18 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.