Kingdom Care Senior Living

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store and serve food at temperatures adequate to prevent food-borne illness and in a manner to prevent contamination and outdated use. Facility staff also failed to allow mechanically washed dishes to air-dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. These failures have the potential to affect all residents. The facility census was 27.1. Review of the facility's policy titled Record of Food Temperatures, undated, showed it is the policy of the facility to record food temperatures to ensure food is at the proper serving temperatures. Review showed potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit (dF). Review showed the policy directed staff to measure and record temperatures for each food product and milk at all meals. [...]

Inspectors wroteBased on record review and interview, facility staff failed to document a thorough facility-wide assessment to include specific staffing needs for each resident unit in the facility and consider specific staffing needs for each shift, such as day, evening, night or include active involvement in the process from direct care staff, including but not limited to: Registered Nurses (RN), Licensed Practical Nurses (LPN), Nurse Aides (NA), and representatives of the direct care staff, if applicable, and/or solicit and consider input received from residents, resident representatives, and family members. The facility census was 27.1. Review of the facility's Facility Assessment policy, dated October 2018, showed the residents, representatives and family members may be asked to participate in the review of the care and services provided to meet the needs of our residents. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for four (Resident #1, # 9, #17, and #23) of twelve sampled residents. The facility census was 27.1. Review of the facility's Comprehensive Care Plan policy, dated March 2022, showed: -The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment;-The comprehensive, person-centered care plan:-Includes measurable objectives and timeframes;-Describes services to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being;-Includes resident stated goals and outcomes;-Builds on resident strengths;-Reflects current recognized standards of practice for problem areas and conditions. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the comprehensive care plan for five residents (Resident #2, #8, #13, #19, and #23) out of twelve sampled resident care plans. The facility census was 27.1. Review of the facility's Comprehensive, Care Plan policy, dated March 2022, showed: -The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan: -Includes measurable objectives and timeframes; -Describes services to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being; -Includes resident stated goals and outcomes; -Builds on resident strengths; -Reflects current recognized standards of practice for problem areas and conditions. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide an environment free from accident hazards, when staff failed to lock medication carts when unattended and not in use and store chemicals when not in use. The facility census was 27.1. Review of the facility's Medication Storage policy, dated 2026, showed: -All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls;-Only authorized personnel will have access to the keys to locked compartments;-During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 2. [...]

Inspectors wroteBased on record review and interview, facility staff failed to educate and offer Coronavirus disease 2019 (COVID-19), a respiratory disease that can cause severe illness, immunizations to residents as required for four residents (Residents #8, #13, #15, and #25) of five sampled residents. The facility census was 27.1. Review of the facility's policy COVID-19 Vaccination dated 2025, showed the facility will educate and offer the COVID-19 vaccine to residents, resident representatives and staff and maintain documentation of each. A copy of the Vaccine Information Statement will be given to staff, residents and resident representatives prior to administration. Review of Resident #8's medical record showed the record did not contain documentation of education, administration or refusal of the COVID-19 vaccination for the 2025-2026 season. [...]

Inspectors wroteBased on interview and record review, facility staff failed to perform a significant change in status (SCSA) Minimum Data Set (MDS) assessment, a federally mandated assessment tool, for two (Resident #8 and #23) of three residents who elected hospice services and one (Resident #19) of four sampled residents who had a change in activities of daily living. The facility census was 27.1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to obtain orders for an indwelling urinary catheter and catheter care for one resident (Resident #2) out of one sampled resident, failed to obtain an order for hospice for one (Resident #23) out of three sampled residents, and failed to notify the physician when one (Resident #17) of four sampled residents did not receive his/her medication as ordered. The facility census was 27.1. [...]

Inspectors wroteBased on observation, interviews and record review, facility staff failed to ensure arrangements were made for nephrology (services that provide care for kidney related conditions) services outside of the facility for one resident (Resident #35) of one sampled resident with kidney disease. The facility census was 27.1. Review of the facility's admission Agreement, undated, showed if a resident chose a physician who does not have privileges at the facility, the resident must travel, at their own expense, to the healthcare provider to receive services from that provider. The agreement did not contain direction or guidance on assistance to set up transportation for ordered services or assistance in set up for the appointments. Review of Resident #35's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/01/26, showed staff assessed the resident as: [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide a clean, comfortable and homelike environment for residents, when staff failed to maintain one of one shower rooms free of an excessive buildup of foreign material. This failure has the potential to affect all residents. The facility census was 27. F1. Review of the facility's policy titled Safe and Homelike Environment, dated 2025, showed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Review showed the policy did not contain specific guidance related to the resident shower room. Observation on 04/14/26 during the Life Safety Code tour showed the facility equipped with one shower room for use by all residents. [...]

Inspectors wroteBased on interview and record review, facility staff failed to conduct and document an annual facility-wide assessment to determine what resources are necessary to care for facility residents competently during both day-to-day operations and emergencies as required. The facility census was 26. 1. Review of the facility's Facility Assessment Report, dated July 2024, showed the assessment did not contain information on staffing for day-to-day operations and emergencies as required. During an interview on 1/6/25 at 10:02 A.M., Licensed practical Nuse (LPN) A said he/she is responsible for the nursing staff schedule. He/She said he/she schedules a consistent schedule based on the census and not according to resident acuity. He/She said he/she does not know what the facility assessment directs for staffing. [...]

Inspectors wroteBased on interview and record review, facility staff failed to prevent the commingling of nine residents (Resident #6, #7, #8, #9, #10, #11, #12, #13, and #14) personal funds with the facility operating funds out of 13 sampled residents. The facility census was 28.1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a clean, safe, and comfortable home-like environment when staff failed to adequately maintain doors and keep walls in resident rooms free of gouges in the drywall and scrapes in the paint. The facility census was 26. 1. Review of the facility's policy titled Quality of Life-Homelike Environment, dated May 2017, showed residents are provided with safe, clean, comfortable and homelike environment. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, to include clean, sanitary and orderly environment. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of bacteria and other infection causing contaminants during the provision of care for two residents (Residents #9 and #28) of a sample of two residents. The facility census was 26. 1. Review of the facility's titled Enhanced Barrier Precautions, undated, showed EBP are an infection control intervention designed to reduce the transmission of Multidrug-Resistant Organisms (MDROs) in nursing homes. EBP expands upon Standard Precautions by requiring the use of gowns and gloves during specific high-contact resident care activities. High-contact resident care activities are activities that have been demonstrated to result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to update the care plans for meal assistance for two residents (Resident #3 and #24) and for bed rail usage for one resident (Resident #3) of 19 sampled residents. The facility census was 26. 1. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centers dated, December 2016 says; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain a physician's order for and failed to update the plan of care for one resident (Resident #23) out of two sampled residents who received oxygen therapy. The facility census was 26. 1. Review of the facility's policy titled, Oxygen Administration, dated October 2010, showed staff are directed to verify there is a physician's order. Review the physician's order or facility protocol for oxygen administration. Review the care plan to assess for any special needs of the resident. 2. Review of Resident #23's admission Minimum Data set (MDS), a federally mandated assessment tool, dated 07/07/24, showed staff assessed the resident used oxygen. Review of the resident's Physician Orders Sheet (POS), dated September 2024, showed it did not contain an order for oxygen. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility census was 26. 1. Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, dated August 2022, showed staff were directed to do the following: -Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents; [...]

Inspectors wroteBased on interview and record review, facility staff failed to check the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) as directed in their policy. The facility census was 29. 1. Review of the facility's policy, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed staff were directed to conduct employee background checks and not knowingly employ or otherwise engage any individual who has a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; [...]

Inspectors wroteBased on interview and record review, the facility staff, failed to update and revise care plans with the interdisciplinary team (IDT) for three residents (Resident #1, #2, and #8). The facility census was 29. 1. Review of the facility's policies showed staff did not provide a policy for care plan meetings. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated, showed staff assessed the resident as: -Moderate cognitive impairment; -Required limited one person assistance for bed mobility, transfers, toileting, and personal hygiene; -Diagnosis of Depression (a depressed mood or loss if pleasure or interest in activities for long periods of time). Review of the resident's care plan signature sheet, dated 06/16/23, showed the sheet did not consist of an IDT team. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to ensure safe propulsion for three residents (Resident #4, #8, #12, and #15) in wheelchairs in a manner to prevent accidents. The facility census was 29. 1. Review of the facility's Manual Wheelchair safety and Maintenance policy, undated, showed the following: -No pedals-No push; -Always propel a resident in a forward position; -Always ensure leg rests and foot pedals are in the correct position and in use when propelling a resident in a wheelchair. 2. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/03/23, showed staff assessed the resident as: -Severe cognitive impairment; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to accurately complete entrapment assessments, side rails assessments, obtain informed consent and a physician order for the use of side rails and/or grab bars for four residents (Residents #4, #9, #18, and #25). The facility census was 29. 1. Review of the facility's Bed Safety, revised December 2007, directed staff as follows: -Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; -Review of the gaps within the bed system are within the dimensions established by the FDA (Note: the review shall consider situations that could be caused by the resident's weight, movement or bed position); [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during perineal care, when staff failed to perform appropriate hand hygiene, and glove changes for two residents (Resident #8 and #12), when staff failed to change oxygen tubing for three residents (Resident # 1, #17 and #178), and prevent one resident's (Resident #11) catheter tubing from laying on the ground. Additionally the facility failed to ensure the two-step purified protein derivative (PPD) (skin test for Tuberculosis (TB)) was completed and on file in accordance with their policy for four employees (Certified nursing assistant (CNA) E, F and G, and housekeeper A). The facility census was 29. 1. [...]

Inspectors wroteBased on interview and record review the facility staff failed to document residents' code status consistently, Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) for one resident (Resident #1). The facility census was 29. 1. Review of the facility's Do Not Resuscitate Order Policy, revised [DATE], showed staff are directed as follows: -Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record; -The Interdisciplinary Care Planning Team will review advance directives with the resident during quarterly care planning sessions to determine the resident wishes to make changes in such directives. [...]

Inspectors wroteBased on interview and record review facility staff failed to implement dietician recommendations after an acute illness and change in appetite to prevent weight loss for one of one sampled resident (Resident #21). The facility census was 29. 1. Review of the facility's Nutritional Assessment Policy revised October 2017, showed as part of the comprehensive assessment, a nutritional assessment including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietician, in conjunction with the nursing staff and healthcare practioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one (Resident #20) of one sampled residents received care and services for the provision of hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) consistent with professional standards of practice when staff failed to obtain orders for dialysis and provide ongoing assessments of the resident's condition, and monitoring for complications after dialysis treatments. The facility census was 29. 1. Review of the policies provided by the facility showed no direction for staff in regard to dialysis care for residents. 2. Review of Resident #20's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/21/23, showed facility staff assessed the resident as: -Moderate cognitive impairment; -Received dialysis; [...]

Inspectors wroteBased on observation and interview and record review, the facility staff failed to post, in a form and manner accessible to the residents and resident representatives, the Department of Health and Senior Services (DHSS) Elder Abuse hotline information (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SA). The facility census was 29. 1. Review of the facility's Resident's Rights Policy, revised 03/01/2023, showed: -The facility must post, in a form and manner accessible and understandable to residents, and resident representatives: -A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the state survey agency, the state licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for three residents (Resident #9, #14, and #179) out of three sampled residents. The facility's census was 29. 1. Review of the facility's policies showed staff did not provide a policy for bed holds. 2. Review of Resident #9's medical record showed the following: -Cognitively intact; -discharged from the facility on 06/18/23 and readmitted to the facility on [DATE]; -Did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 3. Review of Resident #14's medical record showed the following: -Cognitively intact; -discharged from the facility on 07/04/23 and readmitted to the facility on [DATE]. [...]