Kingswood Nursing Center (SFF) Abuse and Neglect Attorneys

Both the Centers for Medicare and Medicaid Services (CMS) and the state of North Carolina conduct routine investigations, inspections and surveys of every nursing facility statewide. Their efforts help to identify serious deficiencies and violations that harm or could harm the home’s residents. In some incidences, the violations are so egregious that regulators designate the nursing center as a Special Focus Facility (SFF) and add the Home to the federal Medicare watch list.

In 2017, regulators designated Kingswood Nursing Center as a Special Focus Facility. Now that the Home is added to the Medicare watch list, they must make significant improvements promptly to ensure the health and well-being of every resident are safeguarded against abuse, neglect, and mistreatment. Likely, the facility will remain on the watch list for many years to come as investigators evaluate the permanency of positive changes and how corrections have significantly improved the lives of the Home’s residents. Some egregious violations and serious concerns involving this facility are listed below.

Kingswood Nursing Center

This Long-Term Care Center is a 90-certified bed ‘for profit’ Home providing services to residents of Aberdeen and Moore County, North Carolina. The Facility is located at:

915 Pee Dee Road
Aberdeen, NC 28315
(910) 944-8999

Nearly $600,000 in Monetary Penalties

Both the State of North Carolina and the CMS have the legal authority to impose monetary penalties on any nursing home found in violation of protective rules and regulations. These fines are meant to alert the nursing facility that changes must be made immediately to ensure the health and well-being of every resident.

Over the last three years, Kingswood Nursing Center has received four monetary penalties including a fine of $37,013 on March 26, 2015, a $159,322 fine on February 4, 2016, $120,810 fine on September 23, 2016, and a $280,194 fine on March 3, 2017. Medicare also denied a payment request on September 23, 2016, for services the facility provided residents due to substandard care. During the same time, the North Carolina State Agency received 21 filed formal complaints concerning this facility that after investigations resulted in citations.

Current Nursing Home Resident Safety Concerns

The federal government and North Carolina care home regulatory agencies routinely update their statewide nursing facility database system. The website contains historical details of filed complaints, safety concerns, opened investigations, health violations, incident inquiries and dangerous hazards of every facility statewide.

Currently, Kingswood Nursing Center maintains an overall one out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, four out of five stars for staffing issues, and one out of five stars for quality measures. Some serious concerns, deficiencies, and violations listed for this facility include:

  • Failure to Notify the Resident’s Doctor and Family Member of a Change in Their Condition
  • In a summary statement of deficiencies dated March 3, 2017, the state investigator noted the facility’s failure “to notify the physician of an incident until the next day which resulted in a delay of a physician’s assessment and [physician] orders.”

    A facility’s Occurrence Investigation revealed that “during incontinence care, a foreign cloth object was taken out of [the resident’s] rectum with the bowel movement.” The object was “believed to be a piece of a washcloth. Treatment provided was to monitor balm movement output and bowel sounds, [an abdominal x-ray] and frequent rounds. The resident was observed at times chewing or gnawing on bed linen when in bed. The resident was unable to verbalize what happened.”

    A review of the records revealed a 24-hour summary board occurrence report and notification of the Director of Nursing. “The root cause determined to be the resident’s dimension confusion, and the resident was known to attempt to eat foreign objects.” The investigator breached interviewed the resident’s physician who stated “he discussed this incident with the Administrator believe that the washcloth was in the rectum. If the cloth was inside the rectum, this type of care was a violation of how residents are cleaned.” The physician also stated that “consequences would not be an obstruction.”

    However, the resident “was constipated [and the physician] stated that ‘the consequences of having a cloth in the rectum was pain-and-suffering.’” The physician stated that “he believed the cloth was placed in the rectum, possibly during dis-impaction, which was unusual.” The physician then stated that they “could not remember if he spoke to the Director of Nursing” The Director revealed that she had “instructed a nurse at the facility to complete the Incident Report and said that the physician’ was not notified of the incident [until a later date].’” The resident has since expired.

  • Failure to Report and Investigate Acts or Allow Allegations of Abuse, Neglect or Mistreatment of Residents
  • In a summary statement of deficiencies dated March 3, 2017, the state investigator noted the facility had “hired an employee who had a substantiated allegation of neglect of a resident on the Nursing Assistant Registry, which resulted in an employee with substantiated-neglect behavior providing care to the residents.” It was also documented that the facility had “failed to report an injury of an unknown source to the Health Care Personal Investigations which resulted in the facility reporting non-compliance [involving one resident].”

    A part of the investigator’s findings included a review of the Nurses Aide Registry that substantiated “finding of neglect of a resident, which occurred while [a nurse aide] was employed in a nursing facility. The information was entered into the Registry on October 8, 2015.”

    The investigator interviewed the Health Care Personal Registry Supervisor who stated that she was familiar with the Nurse Aide who “had a substantiated allegation of neglect of a resident on October 8, 2015, and was on the [Registry] when she was hired at [this] facility on November 22, 2016.”

  • Failure to Develop Policies That Prevent Mistreatment, Neglect or Abuse of Residents
  • In a summary statement of deficiencies dated March 3, 2017, the state surveyor noted the facility’s failure “to screen a potential new hire which resulted in a Nursing Assistant hired a substantiated allegation of neglect of a resident on The Nursing Assistant Registry.” The investigator reminded the facility of their Administrative Policy and Procedure for Abuse Reporting and Investigations dated March 11, 2004” that reads in part:

    • The facility will complete a thorough investigation of an alleged incident to the appropriate staff. The Administrator or designee will provide notice to the corporate staff and all appropriate state and regulatory agencies. The Director of Nursing or designee will initiate the investigation along with notifying the Department of Health and Human Services.”
    • “A verification of the current license and certification status, including the Nurse’s Aide Registry will be obtained to include whether any disciplinary action has been taken against them.”

    The incident involved a resident when it was found to expel a partial washcloth from their rectum during a bowel movement. The facility Administrator was not immediately notified of the problem, by any of the nursing staff, including the Director of Nursing who “had not informed the Administrator.” The Administrator stated that “she expected staff to report incidents to her immediately [but] did not consider the incident abuse [therefore] the 24 hour and five-day reports [required by law to be sent to the State Agency] were not completed.

  • Failure to Ensure That Every Resident Receives an Accurate Assessment by a Qualified Health Professional
  • In a summary statement of deficiencies dated March 3, 2017, the state investigator noted the facility’s failure “to accurately code the Minimum Data Set (MDS) assessment in the area of pressure ulcers… and in the area of hospice…”

    In one incident, the investigator reviewed a severely impaired resident’s MDS Assessment who had “an unstageable pressure ulcer that was present on admission. The dimension of the unhealed pressure ulcer section of the assessment was not completed in width, length or depth of the pressure ulcer.” The state investigator interviewed the facility Director of Nursing who stated that “she expected the MDS assessments to be accurate.”

    In a separate incident, a review of a resident’s medical records indicated that the resident “had memory and decision-making problems and he had received hospice services while… at the facility. The prognosis section of the MDS assessment was coded not indicating that the resident did not have a condition or chronic condition with the life expectancy of less than six months.”

    The Director of Nursing was interviewed concerning this incident and said that “she expected the MDS to be coded accurately. The facility MDS coordinator was also interviewed and stated that “she had not completed the MDS for this resident but revealed that was inaccurate based on the medical record.”

  • Failure to Provide a Level of Care and Services That Meets Professional Standards of Quality
  • In a summary statement of deficiencies dated March 3, 2017, the state investigator noted the facility’s failure “to follow physician’s orders for [the patient’s medication (insulin)] and blood glucose monitoring.” It was also documented that the facility had failed to “follow physician’s orders [for anxiety medication, antidepressant medications, and appetite stimulant drugs] and resource (nutritional supplement)” for a resident.

  • Failure to Manage a Resident’s Pain to Ensure They Maintain Their Highest Well-Being
  • In a summary statement of deficiencies dated March 3, 2017, the state investigator noted the facility’s failure to “administer [a resident’s pain medication] which resulted in increased pain and increased need to request for ‘as needed’ pain medication.” The deficiency involved a moderately cognitively impaired resident with a Care Plan that “address Administrator and a pain medication use of other modalities. The Care Plan intervention was to administer pain medication as ordered and to evaluate for effect.”

    A review of the resident’s January 2017 Medication Administration Record (MAR) indicated that “the medication had not been given [as directed]. Further review of the MAR indicated [that some of the resident’s pain medication] was administered twice on January 20, 2017, twice on January 21, 2017, three times on January 22, 2017, and three times on January 23, 2017.”

    The surveyor interviewed the resident who stated that “she remembers that [her pain medication] was missed one-time last month. [The missed drugs were] discovered when the next [pain medication] was due. During this period, the resident stated she had a pain level of ten on a scale of one through ten (with ten being the worst pain) and had asked for as needed [pain medication] more often to relieve the pain. The resident stated she noted the pain was not relieved as usual.”

  • Failure to Provide Every Resident Environment Free of Accident Hazards
  • In a summary statement of deficiencies dated March 3, 2017, the state investigator noted the facility’s failure to “investigate the root cause for two falls and failed to monitor the delay complications related to a fall.” The deficiency involved one moderately cognitively impaired resident with no behaviors who had been coded “for supervision with ambulating in the halls, toileting, hygiene, and bathing. He was coded as continent of bladder and bowel and not coded for any falls.”

    However, the resident’s Care Plan dated September 14, 2016, indicated the resident “was a moderate risk for falls.” Additionally, the resident’s Fall Risk Assessment dated November 22, 2016, indicated that the resident “was a moderate risk for falls.” The resident’s updated Care Plan of January 25, 2017, included “actual falls with intervention to include frequent rounds, non-skits socks, re-education to call for assistance and a therapy referral.” The resident was receiving “physical therapy for muscle weakness and an unsteady gait.”

    Investigator reviewed the resident’s Incident Logs that revealed the resident had “sustained falls on January 23, 2017, January 25, 2017, February 6, 2017, and again on February 22, 2017.” One falling incident involved a resident who “was found on the floor in front of his recliner. He stated he was getting up from the recliner to get to his wheelchair when he slipped on the floor. There were no injuries. The root cause was indicated as poor safety awareness and unassisted transfer.”

    However, a review of the resident’s Paper Medical Record revealed that “nursing staff obtained a neurological check and monitored [the resident] as ordered for the fall that occurred on January 23, 2017, from his personal recliner. There was no mention of an assessment of how he transfers from his personal recliner as a potential fall hazard.”

  • Failure to Follow Policies and Procedures Conveyed the Resident’s Personal Funds to the Appropriate Party Responsible after the Resident’s Death
  • In a summary statement of deficiencies dated March 3, 2017, the state investigator noted that the facility had “failed to convey personal fund account balances within 30 days of the resident’s death.” This deficiency practice by the Administration involved four residents at the facility. In one incident, the responsible party in charge of the resident’s property after their death did not receive funds until 111 days after the resident expired.

Want to File a Nursing Home Abuse Compensation Claim?

If you suspect your loved one has suffered harm through abuse, neglect or mistreatment while a patient at Kingswood Nursing Center, contact a personal injury law office now. An attorney working on your behalf can ensure that your family receives the financial compensation they deserve. Your lawyer can file all the necessary documentation in the appropriate county courthouse, build your case, and negotiate an out the court settlement or present evidence at your lawsuit trial, if necessary.

No upfront payments are required because personal injury attorneys accept wrongful death lawsuits, nursing home abuse cases and medical malpractice for compensation claims using contingency fee agreements. This arrangement means all legal fees are paid only after the law firm has successfully resolved your case and obtain a monetary recovery on your behalf.


Client Reviews

Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric