Kingswood Senior Living

In the surveyor’s words

From the most serious findings on record at Kingswood Senior Living, in the surveyor’s own words.

• Immediate jeopardy, isolatedF690Jul 23, 2026

  Based on interview and record review, the facility failed to meet the medical needs of one sampled resident (Resident #1) out of four sampled residents, who admitted to the facility on [DATE] from the hospital with an indwelling foley catheter (a tube placed to drain the bladder). On 07/09/26, the resident's Urologist (medical doctor and surgeon specializing in diagnosing and treating conditions of the urinary tract) removed the indwelling foley catheter and ordered the resident to be monitored for urinary retention. The facility failed to document any monitoring for post void retention (PVR - urinary output) per policy and as ordered. […]

• Immediate jeopardy, isolatedF689Mar 5, 2025

  Based on interview and record review, facility staff failed to follow facility policy for using mechanical lifts for one sampled resident, (Resident #1) out of five sampled residents. Facility staff failed to use two staff to transfer the resident using a Hoyer lift (a medical device used to assist lifting and transferring individuals with limited mobility) and failed to inspect the lift sling for safety on 2/26/25. During the transfer, the sling strap broke and the resident fell to the floor. The resident sustained a subdural hematoma (a type of bleeding that occurs inside the skull in the outermost membrane surrounding the brain) and a fractured right hip and was admitted to the hospital intensive care unit (ICU). […]

• No harm, potential for more than minimal, widespreadF812Sep 29, 2023

  Based on observation and interview, the facility failed to maintain the ceiling tiles, light fixtures, and sprinkler heads, which were over the food preparation table and the dishwasher area, free of a dust buildup. This practice potentially affected all residents who ate food prepared in the kitchen. The facility census was 58 residents. 1. Observation on 9/25/23 at 9:42 A.M., showed a buildup of dust on the sprinkler head on the ceiling close to the food preparation area. Observation on 9/25/23 at 9:43 A.M., showed a dust buildup on the ceiling tiles and on the light fixtures over the food preparation table. Observation on 9/25/23 at 9:47 A.M., showed a buildup on the ceiling tiles and on the light fixtures over the dishwasher area. […]

• No harm, potential for more than minimal, widespreadF880Sep 29, 2023

  Based on observation, interview, and record review, the facility failed to ensure they followed infection control practices by performing hand hygiene between glove changes for three sampled residents (Residents #13, #44, and #19) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's policy, titled Hand washing/Hand Hygiene dated August 2019, showed: -Staff were to perform hand hygiene with soap and water or an alcohol-based hand rub before and after coming on duty, before and after direct contact with residents, after contact with a resident's intact skin, and after removing gloves. 1. […]

• No harm, potential for more than minimal, patternF812Jun 18, 2025

  Based on observation, interview and record review, the facility failed to maintain the cleanliness of the floors around and under equipment in the main kitchen and around the counters in Satellite Kitchen #3; failed to ensure in the main kitchen the bins that contained dried items (sugar, flour, and cereal) did not have grime and debris on them; failed to ensure in Satellite Kitchen #3 there was not a black substance potentially mold in the juice machine around the tops of the juice nozzles, coffee debris around the coffee nozzles, and dried spills on both sides of the serving station walls. This practice potentially affected all residents. The facility census was 56 residents. The facility did not provide a sanitation policy. 1. […]