Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Kingswood Senior Living during CMS and state inspections, most recent first.
A resident with hemiplegia, major depressive disorder, and aphasia, who was severely cognitively impaired, was subjected to care against their wishes when an RN and CNA attempted to get the resident out of bed despite repeated refusals. The RN forcibly removed the resident's hand from the bed rail and held the resident's arms down, resulting in a skin tear. The resident communicated distress and indicated the encounter was rough, confirming a failure to respect the resident's dignity and right to self-determination.
A resident with significant mobility impairments and on anticoagulant therapy was transferred using a Hoyer lift by a CNA without the required second staff member and without proper inspection of the lift sling. During the transfer, the sling strap broke, causing the resident to fall and sustain a head injury and hip fracture. Staff interviews confirmed that the two-person transfer policy and sling inspection requirements were not followed at the time of the incident.
A resident with severe cognitive impairment developed multiple wounds that were documented by LPNs over several days, but neither the physician nor the family was notified as required by facility policy. Staff interviews confirmed that notifications were not made or documented, and the family only learned of the wounds after the resident was transferred to the hospital. This failure resulted in a delay in treatment for the resident's wounds.
The facility did not update care plans for two residents to reflect current pressure injuries and related interventions, despite established procedures requiring timely revisions when residents' conditions change. Staff interviews confirmed that care plans were not revised to include new or existing wounds, and that updates should have occurred within one week of changes.
A resident with severe cognitive and mobility impairments developed multiple pressure injuries that were not consistently assessed, measured, or staged by nursing staff. There was a lack of timely physician and family notification, and treatment orders for wounds were significantly delayed. Staff interviews revealed inconsistent documentation, poor communication, and failure to follow facility protocols for wound care and reporting.
The facility did not ensure a RD was available to perform dietary assessments and consult with dietary staff for several weeks, resulting in two residents with complex medical needs not receiving required RD evaluations or documentation, despite significant weight loss, pressure wounds, and specialized dietary requirements.
Failure to Honor Resident's Right to Dignity and Self-Determination During Care
Penalty
Summary
A resident with hemiplegia following a stroke, major depressive disorder, reduced mobility, and aphasia was involved in an incident where their right to dignity and self-determination was not honored. The resident was severely cognitively impaired, rarely or never understood by others, but able to understand others and communicate needs through gestures. The care plan specified the need to avoid restraints, respect the resident's decisions, and allow for alternative communication methods. On the day of the incident, the resident refused to get out of bed multiple times, verbally and physically indicating their refusal. Despite the resident's clear refusal, a registered nurse (RN) and a certified nurse aide (CNA) entered the resident's room to get the resident up for lunch. The RN insisted that the resident needed to get up, and when the resident resisted by grabbing the bed rail and flailing their arm, the RN forcibly removed the resident's hand from the rail and held the resident's arms down. This resulted in a moon-shaped skin tear on the resident's left arm. The CNA reported that the RN did not offer the resident the option to remain in bed and did not respect the resident's expressed wishes. Interviews and documentation confirmed that the resident was upset by the encounter, indicated pain from the injury, and expressed a desire for the RN to stay out of their room. The administrator acknowledged that the resident had the right to remain in bed and that the RN should have walked away, as the resident was safe. The incident was identified as a failure to treat the resident with dignity and respect, and to honor their right to self-determination and communication.
Failure to Follow Mechanical Lift Policy Results in Resident Fall and Injury
Penalty
Summary
Facility staff failed to follow established policy for the use of mechanical lifts when transferring a resident with significant mobility impairments. On the day of the incident, a certified nurse aide (CNA) attempted to transfer a resident using a Hoyer lift without the required assistance of a second staff member, despite being aware of the facility's policy mandating two staff for such transfers. The CNA proceeded alone because other staff were occupied, and did not wait for help, even though there was no emergency or urgency. The CNA also did not thoroughly inspect the lift sling for signs of wear or damage prior to use, as required by policy. During the transfer, the sling strap broke while the resident was being lifted, resulting in the resident falling to the floor. The resident, who had a history of cerebral palsy, spinal stenosis, prior falls, and was on anticoagulant therapy, sustained a hematoma on the back of the head and a left hip fracture. The resident was initially assessed and sent to the hospital, where a CT scan was performed and the resident was returned to the facility. Later that evening, the resident exhibited altered mental status and was sent back to the hospital, where further imaging revealed a subdural hematoma and a left femoral neck fracture. Interviews with staff revealed that the responsibility for inspecting the sling prior to use was understood, but not always performed. The CNA involved admitted to not inspecting the sling and to not following the two-person transfer policy. Other staff confirmed that training on mechanical lift use and sling inspection had been provided, but some could not recall the last time they received such training. Maintenance staff were not involved in sling inspections prior to the incident, and the CNA's orientation checklist did not include lift device use. The resident's care plan clearly indicated the need for two-person Hoyer lift transfers due to extensive assistance needs and fall risk.
Failure to Notify Physician and Family of Resident's Change in Skin Condition
Penalty
Summary
The facility failed to notify the physician, Director of Nursing (DON), Administrator, and the resident's representative of a resident's changes in skin condition, resulting in a delay in treatment. The resident, who was admitted with diagnoses including altered mental status, acute kidney failure, cellulitis of the lower limbs, and mobility issues, was documented as being severely cognitively impaired. Multiple entries in the interdisciplinary notes by LPNs indicated the presence of new wounds over several days, but there was no documentation of notification to the physician or family during this period. Interviews with staff revealed that although wounds were observed and documented by several LPNs, none of them notified the physician or the family as required by facility policy. Some staff reported notifying the DON or wound nurse verbally, but these notifications were not documented, and the family was not informed. The nurse practitioner and DON confirmed that they were not notified of the wounds until much later, and the family only became aware of the wounds after the resident was sent to the hospital for an unrelated issue. Family members stated they were not informed of any wounds prior to the resident's hospital transfer, and staff interviews confirmed a lack of communication regarding the resident's skin condition. The facility's policy required prompt notification of significant changes in a resident's condition to the physician and family, but this was not followed, resulting in a delay in both notification and treatment for the resident's wounds.
Failure to Update Care Plans for Residents with Pressure Injuries
Penalty
Summary
The facility failed to ensure that care plans were reviewed, updated, and revised for two out of four sampled residents, as required by facility policy and regulatory standards. Specifically, the care plans for these residents did not reflect current conditions, including newly acquired or existing pressure injuries and the interventions being provided. The facility's own procedures require that comprehensive, person-centered care plans be developed and implemented for each resident, with measurable objectives and timetables, and that these plans be revised as residents' conditions change. For one resident, the care plan included risk factors for pressure ulcers and listed several interventions such as use of pressure-reducing devices, turn and repositioning programs, and skin assessments. However, the care plan did not directly address any current acquired pressure injuries, despite the resident being at risk and having relevant diagnoses such as altered mental status, acute kidney failure, cellulitis, and mobility issues. The care plan also failed to document specific treatments and interventions for the pressure injuries that had developed. Another resident's care plan did not reflect a facility-acquired deep tissue injury (DTI) to the right heel. Interviews with facility staff, including the ADONs and DON, confirmed that care plans were not updated to reflect these changes in the residents' conditions. Staff acknowledged that care plans should have been updated within one week of any noted changes, but this was not done for the affected residents.
Failure to Provide Timely Pressure Ulcer Assessment and Physician Notification
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident with significant risk factors, including severe cognitive impairment, impaired mobility, incontinence, and a history of skin issues. Upon admission, the resident was identified as being at risk for pressure injuries, and care plans included interventions such as a low air loss mattress, pressure-reducing devices, and regular skin assessments. However, documentation shows that weekly skin and wound assessments were not consistently performed, and when pressure injuries were identified, there was a lack of detailed descriptions, measurements, and staging of the wounds. Additionally, there was no timely notification to the resident's physician or family regarding the development of new pressure ulcers, and treatment orders were not promptly obtained. Multiple entries in the resident's medical record indicated the presence of pressure injuries to the heels, ankle, knees, and sacrum, but these were often not accompanied by adequate documentation or follow-up. Nursing staff failed to document the required details of the wounds, such as size, stage, and condition, and did not consistently notify the physician or family as required by facility policy. There were also significant delays in obtaining treatment orders for the wounds, with some wounds going untreated for up to 21 days after initial identification. Interviews with staff revealed confusion about reporting procedures, lack of awareness of standing orders, and inconsistent communication between nursing staff, wound care nurses, and providers. The resident's condition deteriorated during the stay, with the development of multiple open wounds that were not properly assessed or treated in a timely manner. Family members reported that the resident had no open wounds upon admission, but was later found to have multiple untreated wounds that led to infection and subsequent hospitalization. The lack of consistent wound assessment, documentation, and timely intervention contributed to the resident's decline, as confirmed by interviews with nursing staff, the wound care nurse, and the nurse practitioner.
Failure to Provide Registered Dietitian Services for Resident Assessments
Penalty
Summary
The facility failed to ensure the presence of a Registered Dietitian (RD) to perform dietary assessments and consult with dietary staff, as required by their own policy and regulatory standards. Review of facility records and interviews revealed that there was no RD in the facility from early November through early December, and there was a lack of consistent RD coverage for several weeks. During this period, two residents who required dietary assessments did not receive RD evaluations or consultations, as evidenced by the absence of RD notes or assessments in their medical records. The Director of Nursing and the Administrator both confirmed the lack of RD presence and documentation for the affected residents. One resident was admitted with multiple diagnoses, including altered mental status, acute kidney failure, and cellulitis, and experienced significant weight loss, development of pressure wounds, and required a specialized diet and fluid restriction. Despite these needs and a care plan indicating the necessity for RD evaluation, no RD assessment was documented. Another resident with diabetes, anemia, and other conditions, also required dietary management and had care plan interventions referencing RD recommendations, but similarly lacked RD assessment or documentation. Staff interviews confirmed that RD consults were expected but not provided during the period in question.
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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.
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Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Resort Carondelet Llc | 0.9 mi | ★★★★★ | 34 | 0 |
| Hilltop At Blue River, The | 2.1 mi | ★★★★★ | 3 | 0 |
| Hope Care Center | 2.1 mi | ★★★★★ | 14 | 0 |
| Bridgewood Health Care Center | 2.2 mi | ★★★★★ | 28 | 3 |
| Armour Oaks Senior Living Community | 2.4 mi | ★★★★★ | 19 | 1 |
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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.