Inspection Reports for
Baptist Homes of Independence

The complaint investigation found that the facility failed to provide appropriate hospice care to Resident #29, including medication order management and administration. Additionally, the facility failed to inspect mechanical lift slings properly, leading to a fall of Resident #24 when a sling strap broke during transfer, causing head injury. Both incidents involved minimal harm and affected few residents.

The facility failed to provide adequate hospice care to a resident on hospice, including failure to timely enter and administer hospice medication orders. Additionally, the facility failed to properly inspect mechanical lift slings, resulting in a sling strap breaking and a resident falling and hitting their head. Staff training and procedures related to sling inspection and medication administration were found deficient.

Complaint investigation focused on failure to notify family of change in condition, injury reporting, infection control, bathing and hygiene care, wound care, fall investigation, staffing adequacy, medication administration, diet orders, and infection prevention practices.

The facility failed to notify the family timely about a resident's arm fracture, failed to maintain cleanliness and odor control in certain areas, failed to report an injury of unknown origin timely, failed to investigate injuries and bruises, failed to provide adequate bathing and hygiene care to several residents, failed to complete wound care assessments and treatments, failed to ensure follow-up appointments, failed to investigate a resident fall properly, failed to provide sufficient nursing staff during a winter storm, failed to ensure proper medication administration, failed to follow infection prevention protocols including Enhanced Barrier Precautions, and failed to ensure proper diet orders and discontinuations.

The facility was found deficient in multiple areas including failure to maintain authorization forms for resident trust funds, incomplete and untimely financial reconciliations, inconsistent documentation of advanced directives and code status, failure to notify family of resident condition changes, poor environmental cleanliness and odor control, incomplete and inaccurate resident care plans and assessments, inadequate wound care and pain management, medication administration errors, insufficient staffing during inclement weather, lack of infection preventionist and antibiotic stewardship program, failure to provide immunizations, and unsafe emergency equipment maintenance.

The complaint investigation revealed that the Business Office Manager wrote and cashed a check for $7,279.74 from a deceased resident's account to himself, after altering the payee name and forging a signature. The resident's family had not received the refund within 30 days as required. The manager admitted to the act and was terminated and arrested. The facility failed to follow policies for resident funds and check signing.

The facility failed to return funds owed to the family of a deceased resident within the required 30 days and allowed a Business Office Manager to write a check to himself from the resident trust account, which was cashed improperly. The check was altered and forged, leading to police involvement and termination of the employee. The facility's policies on resident funds and check signing were not followed, and oversight was inadequate.

The complaint investigation was substantiated by video evidence showing CNA A physically aggressive with Resident #1 by pushing him/her into a recliner with too much force. The local police department was notified. The family chose not to press charges. The Administrator plans to terminate the CNA regardless of the investigation outcome.

The facility failed to provide care in a respectful and dignified manner when CNA A forcefully pushed Resident #1 into a recliner. The incident was confirmed by video evidence and family observation. The facility administration conducted staff in-service training on abuse, neglect, and resident rights, and planned to terminate the CNA involved.

The facility failed to maintain an effective infection control program including proper hand hygiene and perineal care, and failed to implement an antibiotic stewardship program. Observations and interviews revealed improper handling of soiled linen and inadequate infection monitoring and training.

The complaint investigation focused on the facility's failure to thoroughly investigate a resident's injury of unknown origin, potential abuse and neglect, inadequate staff training on mechanical lifts, infection control deficiencies during a COVID-19 outbreak, and failure to notify families of COVID-19 positive residents.

The facility failed to properly investigate a resident injury, ensure staff competency in mechanical lift use, follow infection prevention and control protocols including proper hand hygiene and COVID-19 testing procedures, prevent cross-contamination, and notify families of COVID-19 positive residents. Deficiencies were noted in investigation completeness, staff training, infection control practices, and communication with families.

Complaint MO00219381 related to infection prevention and control deficiencies including COVID-19 outbreak management, testing, PPE use, and family notification.

The facility had multiple deficiencies including failure to maintain proper resident fund authorization and ledger accuracy, inadequate assessment and monitoring of physical restraints, incomplete investigations of alleged abuse, failure to notify residents of bed hold policies, incomplete significant change assessments, incomplete care plans, inadequate assistance with activities of daily living, improper catheter care, unsafe medication storage, improper food temperature control, incomplete staff training on mechanical lifts, failure to submit payroll based journal data, and lapses in infection prevention and control practices including COVID-19 protocols.

The facility was found deficient in multiple areas including improper catheter care practices risking infection, failure to post daily nurse staffing information visibly, missing pharmacist medication regimen review documentation, incomplete annual tuberculosis screenings for several residents, and inadequate maintenance and monitoring of AED machines.