Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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 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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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 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 | — | 7 | 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 | — | 0 | 0 |
| Heartland Care Center | 18 mi | — | 1 | 0 |
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