Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Healthcare Resort Of Kansas City during CMS and state inspections, most recent first.
A resident receiving enteral nutrition experienced an 11.74% weight loss due to the facility's failure to consistently monitor her weight and adjust her nutritional regimen. Despite being at risk, the resident's nutritional needs were not adequately assessed or addressed, and there was a lack of communication and documentation among staff regarding her condition.
The facility failed to ensure agency direct care staff received required communication training, risking impaired care and decreased quality of life for residents. A review revealed that three CNAs lacked evidence of completed communication training. Administrative Staff A assumed the staffing agency ensured completion of required in-services, which was not the case. The curriculum covered various topics but omitted communication, resident rights, and dementia training.
The facility failed to ensure agency CNAs received required resident rights training, as revealed by a review of training records. Administrative Staff A assumed the staffing agency handled this training, but it was not completed, risking impaired care and decreased quality of life for residents.
The facility did not ensure agency CNAs received required dementia training, risking resident care quality. Training records for three CNAs lacked evidence of completed in-service training. Administrative Staff A assumed the staffing agency handled this, leading to missing training in communication, resident rights, and dementia care.
The facility failed to maintain a safe environment by leaving cleaning chemicals accessible, an unsecured CO2 canister, and an unlocked oxygen storage room. Additionally, fall prevention interventions were not followed for two residents, leading to a fall incident. An unsecured oxygen canister was also left in a resident's room, posing a risk for injury.
The facility failed to secure medication and treatment carts, leaving medicated lotions and medications like Cefdinir and Junuvia unsecured. An LN confirmed that carts should be locked when unsupervised, and the facility's policy required safe storage of medications. This deficiency placed residents at risk for medication errors.
The facility failed to follow infection control standards, risking resident safety. Observations showed improper handling of soiled laundry and PPE, with items left on floors and carts. CMAs and CNAs neglected hand hygiene during medication administration and personal care. Staff interviews confirmed these practices violated the facility's infection control policy, which requires routine training.
A resident with a complex medical history, including hemiparesis and cognitive impairment, was not provided with foot pedals for her wheelchair, leaving her vulnerable to injury. Staff interviews confirmed that pedals should have been used when the resident was being pushed by staff, as per the facility's policy on accommodating individual needs.
A resident with a history of hemiplegia and intact cognition threw hot coffee on another resident during a seating disagreement in the dining room. The incident was reported, but no immediate further action was taken to prevent future harm. The facility's policy on abuse prevention was not adequately followed, resulting in a deficiency in protecting residents from abuse.
A resident with intact cognition and mobility impairments threw hot coffee on another resident during a disagreement over seating in the dining room. The facility failed to fully investigate the incident or implement interventions to prevent further occurrences, despite having policies on abuse prevention. This inaction placed residents at risk of harm.
A resident with a UTI and other conditions experienced a delay in care due to the facility's failure to obtain STAT labs as ordered and notify the physician of the delay. Despite multiple attempts to contact the lab, the labs were not collected promptly, and the resident's condition was not adequately monitored or documented. Staff interviews revealed a lack of communication and follow-up, contributing to the delay in treatment.
A resident with multiple medical conditions, including hemiparesis, did not have her leg/ankle brace applied as ordered when out of bed, risking worsening contractures. Despite a physician's order and no documented refusals, staff failed to apply the brace, with a CNA admitting lack of knowledge on how to do so. Interviews confirmed the brace should have been applied, highlighting a deficiency in following care protocols.
A resident with a history of UTIs did not receive proper perineal care due to inadequate hand hygiene by a CNA. The CNA failed to wash hands between glove changes while assisting the resident, contrary to facility procedures. Staff interviews revealed a lack of ongoing hand hygiene training, contributing to the deficiency.
A facility failed to consistently communicate a resident's medical condition before and after hemodialysis, risking adverse outcomes. The resident, with multiple health issues including end-stage renal disease, was not properly assessed on several occasions. Despite a care plan requiring daily checks and communication with the dialysis center, the facility's process was inadequate, leading to incomplete documentation.
A resident with cognitive impairment and aggressive behaviors was not provided with adequate non-pharmacological interventions, as documented in the facility's records. Despite having a care plan and staff training, the facility failed to document or implement strategies to manage the resident's refusal of care and aggression, and did not notify the medical provider of these behaviors.
A resident with dementia exhibited behaviors such as throwing food and pouring hot food on herself, resulting in a burn injury. Despite having a care plan noting her behavioral history, the facility failed to identify a pattern of these behaviors and implement effective interventions. Staff interviews indicated awareness of the behaviors, but the facility lacked a specific dementia care policy, leading to inadequate supervision and intervention during mealtimes.
A facility failed to monitor a resident's blood pressure and pulse as ordered by a physician before administering metoprolol succinate, an antihypertensive medication. The resident, with a history of congestive heart failure and other conditions, was at risk of unnecessary medication administration due to the lack of monitoring. Interviews with staff confirmed that monitoring should have occurred, but the facility's policy was not followed, as shown by missing records in April, May, and June 2024.
The facility did not post daily nurse staffing data with the required information and failed to retain these records as required. Observations showed outdated postings and missing census numbers. Staffing sheets from earlier months were incomplete, and recent sheets lacked census data. Responsibility for posting was divided among staff, but no specific policy was in place, leading to unawareness of the omissions.
A resident with diabetes and amputations did not receive timely and appropriate wound care, leading to a severe infection and the surgical removal of a toe. The facility failed to monitor and treat the wound promptly, resulting in the resident's condition worsening.
Failure to Monitor and Adjust Enteral Nutrition Leads to Significant Weight Loss
Penalty
Summary
The facility failed to consistently monitor the weight of a resident, identified as R27, who was receiving enteral nutrition through a PEG tube due to severe cognitive impairment and medical conditions such as aphasia, dysphagia, and hemiplegia. Upon admission, R27 weighed 155 pounds and was dependent on staff for all activities of daily living. Despite being at risk for complications related to her PEG tube, the facility did not trigger a Nutrition Care Area Assessment upon her admission, and her care plan did not adequately address her nutritional needs. R27 experienced a significant, unplanned weight loss of 11.74% over 37 days, dropping to 136.8 pounds. The facility's records showed a lack of consistent weight monitoring and documentation, with no follow-up from the medical provider or registered dietician despite the resident's continued weight loss. The facility's policy required weekly weigh-ins for at-risk residents, but this was not adhered to, and the resident's nutritional regimen was not adjusted in response to the weight loss. Interviews with staff revealed that there was a breakdown in communication and documentation regarding R27's nutritional status and weight loss. The registered dietician was on maternity leave, and a temporary dietician was not adequately informed of the resident's condition. The facility's failure to monitor and adjust R27's enteral nutrition regimen in a timely manner led to the significant weight loss, highlighting deficiencies in the facility's nutritional management practices.
Lack of Communication Training for Agency Staff
Penalty
Summary
The facility failed to ensure that agency direct care staff received the required communication training, which placed residents at risk for impaired care and decreased quality of life. During a review of the training records for agency CNAs, it was found that the credentialing files for three CNAs lacked evidence of completed communication training. Administrative Staff A acknowledged that during orientation, the curriculum covered various topics such as timekeeping, meal breaks, smoking policy, cell phone and social media use, dress code, dietary services, fall prevention, infection control, abuse, customer service, and information related to protected health information and electronic medical records. However, it was assumed that the staffing agency ensured the completion of required in-services for nurse aides, which was not the case. Administrative Staff A stated that communication, resident rights, and dementia training would be added to the curriculum for agency staff.
Deficiency in Resident Rights Training for Agency Staff
Penalty
Summary
The facility, with a census of 66 residents, failed to ensure that agency direct care staff received the required training on resident rights. This deficiency was identified through a review of the training records for agency CNAs P, Q, and LL, which revealed a lack of evidence that these staff members completed the necessary resident rights training. During an interview, Administrative Staff A acknowledged that the orientation for agency employees covered various topics, including timekeeping, meal breaks, smoking policy, cell phone and social media use, dress code, dietary services, fall prevention, infection control, abuse, customer service, and information related to protected health information and electronic medical records. However, it was assumed that the staffing agency ensured the completion of required in-services for nurse aides, which was not the case. This oversight placed residents at risk for impaired care and decreased quality of life.
Deficiency in Dementia Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that agency direct care staff received the required dementia training for nurse aides, which placed residents at risk for impaired care and decreased quality of life. During a review of the training records for agency CNAs, it was found that the credentialing files for three CNAs lacked evidence of completed in-service training. Administrative Staff A acknowledged that the orientation for agency employees covered various topics, but assumed that the staffing agency ensured the completion of required in-services for nurse aides. This oversight resulted in the absence of necessary training in communication, resident rights, and dementia care for agency staff.
Failure to Maintain a Safe Environment and Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to maintain a safe environment free from potential hazards for its residents, particularly those who are cognitively impaired and independently mobile. During an inspection, it was observed that cleaning chemicals and Microkill wipes were left accessible in the main lobby's kitchenette, posing a risk to residents. Additionally, a pressurized carbon dioxide canister was found unsecured under a sink, and an oxygen storage room was left unlocked with several pressurized canisters inside. Furthermore, a large leak in the west dining hall was covered with soiled wet towels without a 'Wet Floor' sign, creating a slip hazard. The facility also failed to follow fall prevention interventions for two residents, R29 and R58. R29, who has moderate cognitive impairment and is at risk for falls, was found with a low air-loss mattress that was supposed to be discontinued due to safety concerns. Despite the care plan indicating the removal of this mattress, it remained in place, and staff were unable to verify if it was supposed to be there. Similarly, R58, who requires two-person assistance for transfers due to weakness, experienced a fall during a shower transfer when only one staff member was assisting him. This incident highlights the failure to adhere to the care plan interventions designed to prevent falls. Additionally, the facility did not ensure R6's room was free from physical hazards. R6, who is legally blind and has multiple medical conditions, had an unsecured oxygen canister left in his room. The canister was not in a holder or secured, contrary to the facility's policy on oxygen handling and storage. This oversight placed R6 at risk for injuries, as unsecured oxygen tanks can pose significant hazards. The facility's failure to secure the oxygen canister and adhere to its own policies contributed to the unsafe environment.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to secure its medication and treatment carts, which placed residents at risk for unnecessary medication and administration errors. During an inspection on the East Hall nursing station, an unlocked skin treatment cart was found containing assorted medicated lotions with warnings to avoid ingestion and contact poison control. Additionally, at the [NAME] Hall station, an unsecured medication cart was observed with pill packs of Cefdinir and Junuvia left on top of the cart. These medications were not secured, and the cart stored both stock and prescription medications for residents in the [NAME] Hall. Licensed Nurse J verified the unsecured medications and carts, acknowledging that they should be locked when unsupervised and that medication should never be left unattended. Administrative Nurse D confirmed that the facility's policy required medication carts to be locked when not in use or supervised. The facility's Medication Access and Storage policy indicated that all medications and biologicals should be stored safely, following the manufacturer's storage recommendations, and properly labeled with expiration dates. The failure to adhere to these protocols resulted in the deficiency noted in the report.
Infection Control Deficiencies in Handling Laundry and Hand Hygiene
Penalty
Summary
The facility failed to adhere to sanitary infection control standards, which placed residents at risk for infectious diseases. Observations revealed multiple instances of improper handling of soiled laundry, such as soiled towels and bed linens being placed on the floor in various locations, including a kitchenette and resident rooms. Additionally, used personal protective equipment (PPE) was found discarded improperly, such as a soiled glove and broken facemask left on an Enhanced Barrier Precautions (EBP) cart, and used PPE on the floor of a resident's room. These actions indicate a lack of compliance with infection control protocols regarding the proper disposal of contaminated materials. Further deficiencies were noted in the administration of medications and hand hygiene practices. Certified Medication Aides (CMAs) failed to perform hand hygiene during medication preparation and administration, increasing the risk of contamination. A Certified Nurse's Aide (CNA) was observed not performing hand hygiene between glove changes and after providing personal care to a resident, despite acknowledging the importance of hand hygiene. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed that hand hygiene should be performed frequently and that soiled laundry should not be placed on the floor. The facility's Infection Control and Surveillance policy, revised in October 2023, mandates routine infection control training, yet staff reported a lack of recent education on hand hygiene practices.
Failure to Provide Wheelchair Pedals for Resident
Penalty
Summary
The facility failed to provide a resident, identified as R39, with foot pedals for her wheelchair, which left her vulnerable to possible injury. R39 has a complex medical history, including dysarthria, a pacemaker, transient ischemic attack, diabetes mellitus, hemiparesis/hemiplegia, difficulty in walking, cerebral infarction, depression, and cerebrovascular accident. Her cognitive function is moderately impaired, as indicated by a BIMS score of eight, and she is dependent on staff for certain activities, such as putting on and taking off footwear. The care plan for R39 notes a contracture of her right upper and lower extremity, which further complicates her mobility. On a specific morning, R39 was observed rolling herself to breakfast using her left hand, without wearing her foot/ankle brace, and her right foot hit the floor twice while being propelled by a CNA. Interviews with staff, including a CNA, a Licensed Nurse, and an Administrative Nurse, confirmed that wheelchair pedals should have been provided to prevent injury when staff were pushing R39. The facility's policy on accommodating needs states that residents have the right to receive services with reasonable accommodation of individual needs, which was not adhered to in this instance.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect residents from abuse when a resident, identified as R31, threw hot coffee on another resident, R40. R31, who has a history of hemiplegia, diabetes, hypertension, and peripheral vascular disease, was documented to have intact cognition and was independent in his functional abilities, using a motorized wheelchair for mobility. The incident occurred in the dining room when R31 became upset over a seating disagreement with R40, leading to R31 throwing coffee on R40's abdomen and thighs. R40 was assessed by a licensed nurse, who noted wet clothing but no immediate injury, although tiny raised areas were observed on R40's thigh the following day. The facility's investigation revealed that R31 had a history of becoming upset if he felt his prayer group time was impeded upon, and staff were instructed to approach him calmly and redirect him if necessary. However, during the incident, R31 expressed that the coffee spill was accidental, although he later made a comment suggesting intentionality. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and the importance of staff intervention to protect residents' rights and safety. Despite this, no immediate further action was taken with R31 following the incident, as it was believed he posed no further threat. Interviews with staff indicated that the incident was reported immediately, but there was a lack of immediate intervention to prevent further harm. The facility's policy requires oversight and monitoring to prevent abuse, yet the actions taken were insufficient to ensure the safety and well-being of all residents. The failure to implement appropriate interventions and monitor residents with behaviors that might lead to conflict resulted in a deficiency in protecting residents from abuse.
Failure to Investigate and Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to fully investigate and implement interventions following a resident-to-resident altercation, where one resident threw hot coffee on another. The incident involved a resident with intact cognition and a history of hemiplegia, diabetes, hypertension, and peripheral vascular disease, who used a motorized wheelchair for mobility. This resident became upset when another resident did not move from a preferred spot in the dining room, leading to the altercation. Despite the incident, the facility did not take further action to address the behavior of the resident who threw the coffee. The facility's investigation report documented that the incident was reported to administrative staff, and the affected resident was assessed for injuries, which were minimal. However, the facility did not implement any interventions to prevent further incidents or address the behavior of the resident who initiated the altercation. The staff involved did not witness the incident directly but were informed by other staff members. The resident who threw the coffee claimed it was an accident, and no further actions were taken by the facility to ensure the safety of other residents. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and the importance of taking action to prevent such incidents. Despite this policy, the facility did not take adequate steps to investigate the incident thoroughly or implement measures to prevent future occurrences. This lack of action placed residents at risk of harm and did not align with the facility's stated policies on abuse prevention and resident safety.
Failure to Obtain STAT Labs and Notify Physician
Penalty
Summary
The facility failed to ensure that staff obtained physician-ordered labs for a resident, identified as R45, and did not notify the physician of the delay in obtaining these labs. R45 had diagnoses of hypertension, a urinary tract infection, and a compression fracture of the lumbar vertebra. The resident required partial assistance for functional abilities and was dependent on staff for toileting and bathing. On a specific date, R45 presented with an altered mental status and heavy sweating, prompting an order for immediate labs, including urinalysis, a complete metabolic panel, and a complete blood count with differential. However, the labs were not obtained in a timely manner, and there was no documentation of further monitoring of R45's condition from the time the labs were ordered until they were eventually reviewed. The nursing notes indicated that staff attempted to contact the lab company multiple times to request a STAT lab draw, but the labs were not collected until several days later. During this period, R45's condition was not adequately monitored or documented, and the physician was not informed of the delay in obtaining the lab results. When the lab results were finally reviewed, they showed abnormal findings, and an order for an antibiotic was placed. However, there was a lack of documentation regarding the resident's condition and any signs or symptoms from the time the labs were ordered until the results were reviewed. Interviews with facility staff revealed a lack of communication and follow-up regarding the delay in obtaining the STAT labs. A licensed nurse acknowledged that the resident had not been followed up on appropriately, and the administrative nurse admitted to being unaware of the delay and the lack of physician notification. The facility did not provide a policy regarding quality of care, and the failure to obtain the STAT labs as ordered resulted in a delay in care and treatment for R45's urinary tract infection.
Failure to Apply Leg Brace for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident's leg/ankle brace was applied when she was out of bed, which was necessary to prevent the worsening of her contractures. The resident, identified as having multiple medical conditions including hemiparesis and a history of cerebrovascular accident, was dependent on staff for assistance with activities of daily living, including the application of her leg brace. Despite a physician's order for the brace to be applied every shift when the resident was out of bed, observations revealed that the brace was not applied, and the resident reported that the CNA did not know how to put it on. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the brace should have been applied and that there were no documented refusals from the resident regarding the application of the brace. The facility's policy on contracture documentation emphasized the importance of providing appropriate treatment to prevent a decrease in range of motion. However, the failure to apply the brace as ordered placed the resident at risk for worsening contractures and decreased mobility.
Deficient Perineal Care and Hand Hygiene Practices
Penalty
Summary
The facility failed to provide the standard of care for a resident with a history of urinary tract infections (UTIs). The resident, who had multiple medical conditions including moderately impaired cognition, was dependent on staff for all toileting hygiene. During an observation, a Certified Nurse's Aide (CNA) did not perform proper hand hygiene while assisting the resident with toileting. The CNA did not wash hands between changing gloves after cleaning the resident's back and front peri areas, which is against the facility's procedure for perineal care. This lack of proper hand hygiene placed the resident at risk for further UTIs. Interviews with staff revealed that the CNA acknowledged the mistake and admitted that the facility had not provided hand hygiene education since her hiring. A Licensed Nurse confirmed that the CNA should have washed her hands when transitioning from cleaning the back to the front peri area. An Administrative Nurse also stated that staff had not received follow-up in-service training on hand hygiene, only initial check-offs at hiring. The facility's failure to ensure proper hand hygiene during perineal care was a deficiency that increased the resident's vulnerability to UTIs.
Failure to Communicate Dialysis Condition
Penalty
Summary
The facility failed to consistently communicate a resident's medical condition prior to and post-hemodialysis, which placed the resident at risk of potential adverse outcomes and physical complications related to dialysis. The resident, who had a history of diabetes mellitus, hypotension, end-stage renal disease requiring dialysis, peripheral vascular disease, hypertension, muscle weakness, repeated falls, cognitive communication deficit, difficulty in walking, unsteadiness on feet, and dysphagia, was not properly assessed before and after dialysis sessions on multiple dates. The resident's care plan required nursing staff to check the dialysis fistula daily, monitor for signs of infection, and obtain pre- and post-dialysis vitals, but these assessments were not consistently documented. The facility's process for handling dialysis communication sheets was inadequate, as evidenced by the lack of completed pre- and post-dialysis assessments in the resident's clinical record. Licensed Nurse G and Administrative Nurse D acknowledged issues with obtaining communication sheets from the dialysis center, which were supposed to be filled out and returned to the facility. Despite attempts to improve the process by sending sheets in a binder, the facility's policy to assist residents in maintaining homeostasis and ensuring ongoing communication with the dialysis center was not effectively implemented, leading to the deficiency.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to adequately meet the behavioral health needs of Resident 46, who was diagnosed with metabolic encephalopathy, cognitive-communication disorder, and other conditions that contributed to her moderate cognitive impairment. The resident exhibited verbal and physically aggressive behaviors, which were documented in her Minimum Data Set (MDS) and Behavioral Symptoms Care Area Assessments (CAA). Despite these assessments indicating a need for interventions, the care plan lacked specific strategies to address her continued refusal or resistance to care. Throughout the report, multiple instances were noted where the resident displayed aggressive and verbally abusive behavior towards staff, including refusing medications and treatments. Progress notes in the Electronic Medical Records (EMR) repeatedly lacked documentation of non-pharmacological interventions being offered or attempted to calm the resident. Additionally, there was no evidence that the medical provider was notified of the resident's behaviors, which is a critical step in managing such situations. Interviews with staff, including a Certified Nurse Aide (CNA), a Licensed Nurse (LN), and an Administrative Nurse, revealed that while there were care-planned interventions and mandatory training for handling behaviors, these were not consistently documented or followed. The facility's Behavioral Health Services policy emphasized the need for non-pharmacological interventions, yet the failure to implement these effectively placed the resident at risk for continued behavioral episodes and unmet care needs.
Failure to Address Dementia-Related Behaviors in Resident
Penalty
Summary
The facility failed to identify a pattern of dementia-related behaviors for a resident, referred to as R29, and implement meaningful interventions to promote her quality of life. R29 had a medical diagnosis of dementia, cognitive communication deficit, insomnia, and dysphagia. Her Minimum Data Set (MDS) indicated moderate cognitive impairment and required substantial assistance with daily activities. Despite having a care plan that noted her history of behaviors such as verbal aggression and banging on things, the facility did not effectively address her behaviors during mealtimes, which included throwing food, spitting food down her shirt, and pouring hot food on herself, resulting in a burn injury. Interviews with staff revealed that while they were aware of R29's behaviors and the need for supervision during meals, the facility did not have a specific policy related to dementia care. The facility's Behavioral Health Services policy emphasized the need for non-pharmacological interventions, but there was no evidence of a consistent approach to managing R29's behaviors. The lack of a structured plan and failure to monitor and intervene appropriately during mealtimes placed R29 at risk for preventable injuries and hindered her ability to maintain her highest practicable level of functioning.
Failure to Monitor Antihypertensive Medication Parameters
Penalty
Summary
The facility failed to ensure that staff followed physician-ordered parameters for monitoring a resident's antihypertensive medication, specifically metoprolol succinate. The resident, who had a history of congestive heart failure, myocardial infarction, diabetes mellitus, and chronic kidney disease, was at risk of unnecessary medication administration due to the lack of proper monitoring. The resident's care plan did not include specific directions for antihypertensive medications, and the medication administration records for April, May, and June 2024 showed a lack of blood pressure and pulse monitoring prior to administering the medication. Interviews with licensed nurses and administrative staff revealed that blood pressure and pulse should have been monitored before administering the medication, and the medication should have been held if the parameters were not met. However, the facility's policy on medication administration was not followed, as evidenced by the absence of monitoring records. This oversight placed the resident at risk for unnecessary medication administration and potential adverse side effects.
Failure to Post and Retain Daily Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily with the required information and did not retain the posted daily staffing data as mandated. During an initial tour, it was observed that the staffing hours posted were outdated, and the facility census number was missing. Upon request, the facility could only provide staffing sheets from December 2023 onwards, with notable gaps in March and April 2024. Additionally, the sheets from May 2024 onwards lacked the daily facility census number. Interviews revealed that the responsibility for posting staffing hours was divided between front desk staff and the floor charge nurse on weekends. However, there was no specific policy in place for daily posted staffing hours, and the administrative staff was unaware of the omissions in the census number.
Failure to Provide Appropriate Wound Care for Resident with Diabetes and Amputations
Penalty
Summary
The facility failed to ensure that a resident with a history of diabetes mellitus (DM) and amputations received appropriate wound care and services to prevent complications from his medical conditions. The resident, who had severe cognitive impairment and required assistance with various activities, developed a wound on his left third toe that was not properly monitored or treated in a timely manner. Despite the resident's known risk factors, including DM and peripheral vascular disease (PVD), the facility did not follow its own policies for skin and wound monitoring and management. The resident's electronic medical record (EMR) documented that on 02/15/24, the resident's second toe on his left foot had moist, loose skin, which was cleaned and wrapped with gauze by a nurse. However, there was no evidence of follow-up monitoring, treatment orders, or physician notification until 02/21/24, when the resident was seen by a physician for a new open area on the third toe with a possible infection. The physician ordered antibiotics and wound care, but the delay in addressing the initial concern allowed the wound to worsen. By the time the resident was transferred to the hospital on 03/14/24, the wound had become severely infected, leading to the surgical removal of the third toe. Interviews with facility staff revealed inconsistencies in documentation and communication regarding the resident's wound care. The facility's failure to adhere to its policies and promptly address the resident's wound contributed to the deterioration of the resident's condition and the need for surgical intervention.
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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) |
|---|---|---|---|---|
| Providence Place | 0.1 mi | — | 0 | 0 |
| Riverbend Post Acute Rehabilitation | 1.4 mi | — | 15 | 0 |
| Willow Point Rehabilitation And Nursing Center | 3.1 mi | — | 0 | 0 |
| Life Care Center Of Kansas City | 3.7 mi | — | 0 | 0 |
| Kaw River Care And Rehab | 5.2 mi | — | 0 | 0 |
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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 August 2026) and official state health department websites.