Inspection Reports for
Silverado Lee‘s Summit

19 CSR 30-88.010(29) Dignity/Privacy: The surveyor found the facility failed to ensure dignity and respect when staff raised their voice, clapped hands, and held the resident's hands and legs during care, and the resident became upset, yelling, kicking and swinging at staff.

19 CSR 30-88.010(25) Report A/N to DHS/DMH When Needed: Based on interview and record review, the facility failed to conduct a thorough investigation to determine if a report to the State Agency was warranted regarding an allegation that Resident #2 entered Resident #1's room uninvited and kissed Resident #1.

19 CSR 30-86.032(9) Temperatures In Resident Areas: Based on observation, interview and record review the facility failed to ensure temperatures in the facility and resident rooms/resident areas were maintained above 68 degrees Fahrenheit, with multiple resident rooms and common areas registering temperatures below that threshold and residents reporting they were cold. The deficient practice affected all residents in the facility (facility census 49).

19 CSR 30-86.022(10)(A) Hazardous Area Requirements: Based on observation, interview and record review, the facility failed to ensure that an open kitchen with an operable stove was separated by construction providing at least a one-hour fire resistive rating from resident living areas. The surveyor noted this had the potential to affect all residents.

19 CSR 30-86.032(22) Furniture/Equip, Provide Comfort & Safety: Based on observation and interview, facility staff failed to ensure prompt repair of broken laundry equipment, resulting in multiple bags of residents' dirty laundry and delays in returning laundry to residents.

19 CSR 30-86.047(35) Protective Oversight: Based on observation, interview and record review, facility staff failed to provide protective oversight and supervision for sampled residents, including inadequate elopement prevention and lack of timely updates to individualized service plans and post-fall analyses.

19 CSR 30-87.030(7) Food Prep & Storage Separate From Other Areas: Based on observation, interview and record review, the facility failed to ensure that an open kitchen with an operable stove was separated from the open living area, potentially affecting all residents.

19 CSR 30-86.047(5) Administrator - Licensed: Based on interview and record review, the facility failed to designate an individual licensed by the Missouri Board of Nursing Home Administrators to act as the facility administrator; records and interviews indicated the former administrator had left and no active administrator was designated.

19 CSR 30-86.047(28)(J) Plan to Safeguard Residents: Based on interview and record review, the facility failed to ensure a plan was in place for one sampled resident of four sampled residents who had a history of displaying aggressive behaviors; Resident #1 forcefully grabbed another resident and staff and interventions were not put in place to ensure the safety of other residents.

19 CSR 30-86.045(4)(A) Staffing Ratio, Resident Care & Fire Safety: Based on observation, interview, and record review, the facility failed to provide an adequate number of staff to provide oversight for one sampled resident who required one-on-one monitoring, and the facility relied on the resident's family/private caregiver; the facility census was 53 residents.

19 CSR 30-86.047(46) Safe & Effective Medication System: Based on interview and record review, the facility failed to implement a safe and effective medication administration system when medications for a newly admitted resident were unavailable for the first 10 days of admission and the facility did not ensure continuous supply for the resident.

19 CSR 30-88.010(22) Free From Abuse: Based on observation, interview, and record review, the facility failed to ensure sampled residents were free from sexual abuse when Resident #2 was observed engaging in inappropriate physical contact with other residents between 12/25/22 and 12/27/22, affecting multiple residents.

19 CSR 30-88.010(23) Develop/Implement A/N Policies: Based on interview and record review, the facility failed to implement and follow its abuse, neglect and exploitation policies by not completely and thoroughly investigating allegations of sexual abuse for multiple residents.

19 CSR 30-86.047(35) Protective Oversight: Based on observation, interview, and record review, the facility failed to ensure the facility's fall policy was followed and appropriate post-fall monitoring was completed for one sampled resident (Resident #1) who was found on the floor on two separate occasions and later had a depressed skull fracture; the facility also failed to have a licensed nurse assess sampled residents (Resident #2 and Resident #3) who after a fall had significant injury.

19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety: Based on interview and record review, the facility failed to ensure the appropriate type of staff were employed to ensure protective oversight for residents after falls and to ensure those employed did not work outside of their scope of practice, a deficient practice that negatively affected three residents who sustained falls with major injury.

19 CSR 30-88.010(29) Dignity/Privacy: Based on interview and record review, the facility failed to ensure residents were treated with dignity and respect by allowing a caregiver to be rude and disrespectful to residents. The deficient practice had the potential to affect all residents.

19 CSR 30-86.047(19) TB Screen Residents & Staff: Based on interview and record review, the facility failed to administer TB skin tests to two of three sampled newly hired employees and had no documentation of TB testing for other staff.

19 CSR 30-86.047(28)(F)(3) Community Based Assessment - Other Form: Based on interview and record review, the facility failed to ensure there was staff certified to complete Community Based Assessments; this deficient practice affected three newly admitted residents.

19 CSR 30-88.010(11) Inform Medical Cond. - Access to Med Records: The facility failed to notify the responsible party/family when Resident #1 was found unresponsive and subsequently passed, notifying only hospice and not the family.

19 CSR 30-86.047(35) Protective Oversight: Based on interview and record review the facility failed to provide adequate protective oversight for Resident #1 who eloped on 5/11/21 and 5/24/21, failing to identify elopement risk, update the individualized service plan, and consistently implement 15-minute checks and required one-to-one monitoring.

19 CSR 36-88.020(10) Discharge Requirement Within 5 Days: Based on record review and interview, the facility failed to refund an overpayment paid by a former resident within five days of discharge for one resident out of three sampled residents; a refund was not issued for the remaining two weeks.

19 CSR 30-86.022(5)(B)(1 - 10) Fire Drill/Evacuation Plan Requirements: The facility failed to maintain the facility Disaster manual as required; the manual lacked required written evacuation instructions and did not instruct staff to call 911, affecting twenty-five of twenty-five residents.

19 CSR 30-86.045(4)(A) Staffing Ratio, Resident Care & Fire Safety: The facility failed to maintain the staffing pattern and required minimum on-duty staff and to ensure at least one staff member was certified in CPR on each shift; facility census was 32 residents.

19 CSR 30-86.022(2)(C) Fire Notification to DHSS: The facility failed to report and submit a written fire report to the state agency after a toaster fire incident and was unaware the toaster had smoked; the event was not promptly reported.

19 CSR 30-86.022(2)(E) Fire-24hr Monitor, Hourly Checks: The facility failed to monitor and document the kitchen/toaster area for 24 hours after a smoking incident and failed to ensure hourly visual checks were completed.

19 CSR 30-86.022(5)(B)(1-10) Fire Drill/Evacuation Plan Requirements: The facility's written disaster manual was incomplete and did not include required contact numbers, maps, and individualized evacuation instructions for all residents.

19 CSR 30-86.022(10)(A) Fire Drill/Evacuation Plan Requirements (Area of Refuge/Plan): The facility failed to ensure the Area of Refuge/evacuation plan was complete and accessible and staff could not identify the facility's disaster manual or area of refuge layout.

19 CSR 30-86.022(10)(A) (trash service/poison control info) (A2215/A2216 related): The facility failed to maintain required emergency contact and poison control information and did not have accurate disaster/evacuation resource information readily available.

19 CSR 30-86.022(10)(?) (A2216) Fire/24hr Monitor (Hazardous Areas Requirements): The facility failed to ensure hazardous area protections and separation requirements were met for identified hazardous areas.

19 CSR 30-86.032(16) Night Lights Provided: The facility failed to ensure night lights were provided for corridors and resident bathrooms so that residents had light in their rooms as required.

19 CSR 30-86.032(33) Call Systems Requirement: The facility failed to ensure all resident rooms were equipped with functioning call lights and that call light cords/units were provided and accessible.

19 CSR 30-86.047(5) Administrator - Licensed (A4703): The facility failed to ensure there was a licensed administrator/temporary coverage in accordance with Missouri Board of Nursing Home Administrators rules; documentation did not show a valid license on file.

19 CSR 30-86.047(6) Operator/Administrator Responsibilities (A4704): The operator failed to maintain required clinical laboratory improvement (CLIA) documentation and medication administration oversight as required.

19 CSR 30-86.047(13)(A) Criminal Background Check Requirements (A4711): The facility failed to obtain or document criminal background checks for some employees prior to hire or as required.

19 CSR 30-86.047(19) TB Screen Residents & Staff (A4724): The facility failed to ensure all required tuberculosis screening (two-step PPD or equivalent) and annual testing documentation were current for staff and residents.

19 CSR 30-86.047(28)(E) Premove-in Screening Requirements (A4748): The facility failed to complete pre-move-in screening for several residents prior to admission as required.

19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day (A4749): The facility failed to complete required community based assessments within the required timeframes for newly admitted residents.

19 CSR 30-86.047(28)(G) Individual Service Plan - Develop (A4754): The facility failed to develop individualized service plans (ISP) and document resident preferences and needs for sampled residents upon admission and thereafter.

19 CSR 30-86.047(34)(A) Disease/Infection Control/Report Category III (A4775): The facility failed to follow appropriate infection control procedures and failed to report suspected communicable disease events as required.

19 CSR 30-86.047(35) Protective Oversight (A4776): The facility failed to provide consistent protective oversight for residents with elopement/exit-seeking behavior and failed to implement required supervision and documentation.

19 CSR 30-86.047(46) Safe & Effective Medication System (A4797): The facility failed to ensure safe medication administration practices including supervised med passes, correct MAR documentation, and ensuring med tech competency.

19 CSR 30-86.047(54) Drug Regimen Review (A4827): The facility failed to ensure drug regimen reviews (DRR) or monthly reviews were completed as required for sampled residents.

19 CSR 30-86.047(58)(B) Resident Condition/Medication Review (A4837): The facility failed to ensure ongoing monthly/periodic review of resident condition and medication effectiveness and to document required monitoring.

19 CSR 30-86.047(62)(A) Orientation - job responsibilities (A4846): The facility failed to ensure new employees received orientation and job responsibility training prior to working unsupervised; orientation records were incomplete.

19 CSR 30-86.052(1) Food Prep & Services, As Ordered (A5201): The facility failed to ensure food preparation and service met sanitary procedures and that potentially hazardous foods were handled, stored and served at safe temperatures.

19 CSR 30-86.052(6) Menus, Substitutes (A5206): The facility failed to plan and document menus and substitutions to ensure servings were equivalent in nutritional value and meet resident needs.

19 CSR 30-88.010(2) Noncompliance/Inspection Reports Posted (A8002): The facility failed to post inspection results or maintain them in the required conspicuous location for residents/visitors as required.

19 CSR 30-87.020(5) Toxic Material Storage (A6005): The facility failed to ensure poisonous/toxic materials were stored in locked cabinets or separate storage and that chemicals were secured from resident access.

19 CSR 30-88.010(24) Staff Trained on Reporting A/N (A8024): The facility failed to ensure staff were trained on reporting abuse/neglect and to document required reporting training and procedures.

19 CSR 30-86.047(13)(A) EDL Inquiry (A4773): The facility failed to maintain required Employer Disqualifying List (EDL) documentation for newly hired staff and did not have EDL checks recorded for several employees.

19 CSR 30-86.045(4)(A) Staffing Ratio, Resident Care & Fire Safety: Based on observation, interview, and record review the facility failed to ensure adequate staffing based on resident acuity; records and observations showed insufficient staff during meal service and many residents required evacuation assistance.

19 CSR 30-86.047(28)(G) Individual Service Plan - Develop: Based on record review and interview the facility failed to ensure individualized service plans (ISPs) were developed, contained goals/trackable outcomes, documented responsible party signatures, or noted Individualized Evacuation Plans for multiple residents; the deficient practice affected five residents.

19 CSR 30-86.047(29)(E) Not Admit/Care For-More > 1 staff to Assist: Based on observation, interview, and record review the facility failed to ensure a resident who required more than one person to assist with activities of daily living had appropriate pre-screening/placement and continued in the facility without required supports in place.

19 CSR 30-86.052(6) Menus, Substitutes: Based on observation, record review and interview the facility failed to follow the planned menu and document substitutions; multiple actual meal provisions were missing or inconsistent with the posted/planned menus.

19 CSR 30-86.052(8)(B) Modified Diets-Diet/Food Qtrly Review: Based on observation, record review and interview the facility failed to ensure meal preparation, service and modified diets were reviewed and documented by a registered dietitian quarterly and lacked appropriate oversight/documentation.

19 CSR 30-88.010(2) Noncompliance/Inspection Reports Posted: Based on record review and interview the facility failed to post survey results in a clearly visible location and did not maintain correspondence and statements of deficiencies in the required, accessible manner.

19 CSR 30-88.010(20) Exercise Rights/Voice Grievances: Based on interview and record review the facility failed to fully investigate and follow up on family grievances and had no formal grievance tracking process in place to ensure concerns were addressed.

19 CSR 30-86.047(35) Protective Oversight: Based on observation, interview and record review, facility staff failed to provide protective oversight and supervision for residents with histories of elopements and exit-seeking behavior, resulting in residents eloping multiple times and staff not implementing adequate interventions or updates to Individual Service Plans.

19 CSR 30-88.010(15) 30 Day Notice-Transfer/Discharge: Based on record review and interview, the facility failed to provide a proper discharge notice to the resident's legal representative or designee outlining appropriate time frames for discharge and the right to appeal; this affected one resident of two sampled residents.

19 CSR 30-88.010(23) Develop/Implement A/N Policies: Based on interview and record review, the facility failed to implement written policies and procedures to report incidents of possible resident-to-resident abuse to the state agency for one resident out of seven sampled residents.

19 CSR 30-80.047(35) Protective Oversight: Record review, observation and interviews found the facility failed to provide protective oversight and supervision for one resident at known elopement risk, and the resident left the facility and was found approximately one block away. Record review and interviews also identified missed and incomplete staff checks and inconsistent staff response to door alarm notifications.