Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Kingdom Care Senior Living during CMS and state inspections, most recent first.
Facility staff failed to maintain and implement a comprehensive, annual facility-wide assessment to determine necessary resources for competent resident care during routine operations and emergencies. The only available assessment lacked required information on staffing for day-to-day and emergency situations. An LPN responsible for scheduling reported staffing based on census rather than resident acuity and was unaware of any staffing direction from the facility assessment. The corporate finance director, temporarily assisting after the prior administrator’s abrupt departure, did not know required update frequency for the assessment. During this period, the facility had no DON, a planned DON hire withdrew before starting, and the Assistant DON (an RN) had only recently returned and was being placed into the DON role, while the facility census was 26 residents.
Facility staff did not maintain a separate accounting of resident personal funds and allowed commingling with operating funds, resulting in multiple residents' funds being held in the facility account without timely refunds. Administrative staff and the DOO confirmed that refunds were not processed within the required timeframe due to corporate-level delays and financial constraints, and there was no written authorization to retain these funds after discharge.
The facility failed to maintain a homelike environment, with multiple resident rooms showing unpainted drywall patches, gouges, and scrapes. Despite policies requiring a safe and clean environment, staff interviews revealed a lack of communication and follow-through in reporting maintenance issues. The maintenance director did not receive work orders for the damages, and the administrator was unaware of unpainted repairs, highlighting a breakdown in the facility's maintenance process.
Facility staff failed to implement Enhanced Barrier Precautions (EBP) for two residents requiring feeding tubes, as staff did not wear gowns during high-contact care activities. Observations showed a lack of EBP signage and PPE stations, and interviews revealed staff were unaware of EBP guidelines. The Director of Nursing and administrator acknowledged the oversight, indicating a gap in infection control practices.
Facility staff failed to update care plans for two residents regarding meal assistance and bed rail usage. One resident struggled to eat due to a hand contracture and required assistance, which was not documented in the care plan. Another resident had swallowing issues requiring nectar thick liquids and supervision, yet the care plan inaccurately documented independence with eating. Staff interviews confirmed the need for care plan updates to reflect the residents' current needs.
Facility staff failed to obtain a physician's order and update the care plan for a resident receiving oxygen therapy. The resident's Physician Orders Sheet lacked an order for oxygen, despite continuous use documented in the care plan. Observations showed varying oxygen levels administered without a corresponding order or care plan update. Interviews with staff revealed inconsistencies in oxygen administration and a lack of awareness regarding correct settings, with the DON acknowledging responsibility for ensuring proper documentation.
The facility failed to post complete nurse staffing information, missing details such as the number of licensed staff and total hours worked for various shifts. Observations over several days showed incomplete postings, and interviews with staff revealed a lack of awareness and responsibility for ensuring the forms were filled out correctly. The DON and administrator were unaware of the deficiencies, despite the facility's policy requiring accurate and timely postings.
Failure to Maintain and Implement Comprehensive Facility-Wide Assessment for Staffing
Penalty
Summary
Facility staff failed to conduct and document a comprehensive, annual facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. Review of the Facility Assessment Report dated July 2024 showed it did not contain required information on staffing for routine operations and emergency situations. The July 2024 assessment was identified as the only facility assessment available. The corporate director of finance, who was temporarily assisting at the facility after the abrupt departure of the previous administrator, stated not knowing how often the assessment needed to be updated or why the previous administrator had not maintained it. Interviews further showed that staffing practices were not guided by the facility assessment. An LPN responsible for the nursing staff schedule reported scheduling staff based on census rather than resident acuity and stated not knowing what the facility assessment directed for staffing. The corporate director of finance confirmed that the LPN handled the staffing schedule. Additionally, the facility had been without a DON since mid-December, and a planned DON hire had declined the position before starting. The corporate administrator reported that the Assistant DON, an RN, had only recently returned to work and would be placed in the DON role until a new DON was hired. The facility census at the time of the survey was 26 residents.
Failure to Maintain Separate Accounting and Timely Refunds of Resident Funds
Penalty
Summary
Facility staff failed to prevent the commingling of personal funds belonging to nine residents with the facility's operating funds. Record review showed that the facility's admission assessment policy requires a system that ensures separate accounting of resident funds, prohibits commingling with facility or other individuals' funds, and mandates timely refunds within 30 days of discharge. Despite these requirements, the Accounts Receivable (AR) Aging report revealed that significant amounts of resident funds were held in the facility's operating account, totaling $22,759.25 for the nine residents. There was no written permission to hold these funds after discharge. Interviews with the administrator and Director of Operations (DOO) confirmed that the process for issuing refunds and updating the AR Aging report is managed at the corporate level, and the facility administrator cannot issue refunds directly. Both the administrator and DOO acknowledged awareness of outstanding credits owed to residents, with refunds not being issued within the required 30-day timeframe. The DOO stated that financial constraints sometimes delayed approval for refunds, and that refund checks and updates to the AR Aging report were not consistently communicated to the facility. The facility did not have written authorization to retain resident funds after discharge.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, safe, and comfortable home-like environment for its residents, as evidenced by multiple observations of damaged and unmaintained areas within resident rooms. The facility's policy on Quality of Life-Homelike Environment, dated May 2017, mandates that residents are provided with a safe, clean, comfortable, and homelike environment. However, observations revealed numerous instances of unpainted drywall patches, gouges, and scrapes in the paint across various resident rooms. These deficiencies were noted in several rooms, with issues such as peeled paint, unpainted patched areas, and damaged drywall being prevalent. The facility's Maintenance Service policy, dated December 2009, outlines the responsibility of the maintenance department to maintain the building in a safe and operable manner. Despite this, the maintenance director reported not receiving any work orders for the observed damages during the week of the survey. Interviews with staff, including a CNA and an RN, indicated a lack of communication and follow-through in reporting maintenance issues. The CNA mentioned being too busy to notice cosmetic issues, while the RN expressed uncertainty about whether damage had already been reported, leading to inaction. The maintenance director stated that repairs require a work order before entering resident rooms and acknowledged the absence of a set schedule for painting patched drywall. The administrator confirmed that staff should notify maintenance of any damage, with aides reporting to nurses and nurses emailing maintenance. Despite having paper requests available at the nurses' station, the administrator had not noticed unpainted drywall repairs. This lack of effective communication and follow-up resulted in the failure to maintain a homelike environment as required by facility policies.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of infection-causing contaminants during care for two residents. The facility's EBP guidelines, which are designed to reduce the transmission of Multidrug-Resistant Organisms (MDROs), require the use of gowns and gloves during high-contact resident care activities. However, observations revealed that staff did not adhere to these guidelines, as evidenced by the lack of EBP signage and Personal Protective Equipment (PPE) stations outside the residents' rooms, and staff not wearing gowns during care activities. Resident #9, who had a severe cognitive impairment and required a feeding tube, was observed receiving care without the necessary EBP measures in place. Staff members, including a Licensed Practical Nurse (LPN), Certified Nurse Aide (CNA), and Registered Nurse (RN), were seen providing care such as tube feeding, medication administration, and personal hygiene without wearing gowns. Similarly, Resident #28, who also required a feeding tube, was observed receiving care without EBP signage or PPE stations, and staff did not wear gowns during care activities. Interviews with staff, including CNAs, RNs, and the Director of Nursing (DON), revealed a lack of awareness and training regarding EBP. Staff members admitted to not knowing what EBP was or that it should be used for residents with feeding tubes and catheters. The DON and the facility administrator acknowledged the failure to implement EBP and the absence of necessary equipment and signage, indicating a significant gap in infection control practices at the facility.
Failure to Update Care Plans for Meal Assistance and Bed Rail Usage
Penalty
Summary
The facility staff failed to update the care plans for meal assistance and bed rail usage for two residents. Resident #3's care plan did not include documentation regarding the resident's need for meal assistance and the use of side rails, despite observations showing the resident struggled to eat due to a partial contracture of the right hand and required assistance. The resident's care plan inaccurately documented independence with meals after setup assistance, and there was no mention of the resident's use of bed rails for positioning with staff assistance. Resident #24's care plan also lacked necessary interventions for choking concerns, despite the resident being assessed as having difficulty swallowing and requiring nectar thick liquids with supervised assistance during meals. Observations showed the resident coughed and choked while eating and drinking, yet the care plan documented the resident as independent with eating. Staff interviews confirmed the resident's need for supervision during meals due to swallowing issues, which was not reflected in the care plan. Interviews with facility staff, including a CNA, RN, and the DON, revealed a lack of awareness and adherence to the care plans, with staff acknowledging the need for updates to reflect the residents' current needs. The MDS coordinator, responsible for care plan development, was on leave, and the DON had been updating care plans but failed to include critical information for these residents. The administrator also confirmed the necessity for care plans to address the residents' swallowing issues and meal assistance needs.
Failure to Obtain Physician's Order and Update Care Plan for Oxygen Therapy
Penalty
Summary
The facility staff failed to obtain a physician's order and update the care plan for a resident receiving oxygen therapy. The facility's policy requires staff to verify a physician's order for oxygen administration and review the care plan for any special needs. However, the resident's Physician Orders Sheet did not contain an order for oxygen, despite the resident using oxygen continuously as documented in the care plan. Observations showed varying oxygen levels administered to the resident, ranging from three to five liters per minute, without a corresponding physician's order or care plan update. Interviews with facility staff, including a CNA, RN, and the DON, revealed inconsistencies in the oxygen administration and a lack of awareness regarding the correct oxygen settings. The CNA mentioned that the oxygen use should be on the care plan, and the RN confirmed that there should be an order for oxygen. The DON acknowledged the responsibility for ensuring oxygen is listed on the physician's orders and care plan, especially in the absence of the Assistant Director of Nursing. The administrator admitted to confusion and changes in the resident's oxygen use upon admission, highlighting a lapse in communication and documentation.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information, which includes the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff responsible for resident care, per shift, and on a daily basis. The facility's policy, dated August 2022, mandates that staffing data be posted within two hours of the beginning of each shift in a prominent location. However, observations over several days revealed that the postings were incomplete, missing details such as the number of licensed staff and total hours worked for various shifts. Interviews with facility staff, including an LPN, the Director of Nursing (DON), and the administrator, highlighted a lack of awareness and responsibility regarding the completion of the staffing forms. The LPN responsible for putting out the forms each night was unaware that they were not being filled out correctly. The DON and the administrator both acknowledged that the forms should be completed during shift reports and monitored for accuracy, but neither was aware of the ongoing deficiencies. The administrator indicated that the DON should ensure the forms are completed accurately during floor rounds.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 88 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fulton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fulton Nursing & Rehab | 0.5 mi | ★★★★★ | 4 | 0 |
| Fulton Manor Care Center | 1.1 mi | ★★★★★ | 2 | 0 |
| Riverview Nursing Center | 12.3 mi | ★★★★★ | 0 | 0 |
| Lenoir Health Care Center | 18.9 mi | ★★★★★ | 0 | 0 |
| Neighborhoods Rehabilitation And Skilled Nursing B | 19.3 mi | ★★★★★ | 4 | 2 |
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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.