Deficiencies (last 4 years)
Deficiencies (over 4 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
64% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Occupancy
Latest occupancy rate
71% occupied
Based on a November 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 39
Deficiencies: 1
Date: Nov 28, 2023
Visit Reason
The inspection was conducted to assess compliance with protective oversight regulations, specifically regarding the use of side rails and related safety measures for residents.
Findings
The facility failed to ensure proper assessments, physician orders, and staff training related to the use of side rails for multiple residents. Several residents lacked physician orders for side rails, and staff had not been trained on side rail or Low Air Loss Mattress (LALM) settings.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight by not ensuring side rail assessments, physician orders, and staff training for four sampled residents. The facility census was 39 residents at the time of inspection.
Report Facts
Facility census: 39
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in interview regarding side rail use and training |
| Certified Medication Technician | Certified Medication Technician | Interviewed about side rail and LALM training |
| Certified Nursing Assistant | Certified Nursing Assistant | Interviewed about side rail use and training |
| Nurse Practitioner | Nurse Practitioner | Interviewed about orders for side rails |
| Hospice Registered Nurse | Hospice Registered Nurse | Interviewed about hospice orders for side rails and LALMs |
Inspection Report
Plan of Correction
Census: 50
Deficiencies: 1
Date: Aug 24, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Cross Creek at Lee's Summit following an inspection completed on 08/24/2022. The plan addresses a deficiency related to safeguarding residents, specifically regarding a resident who fell from a wheelchair.
Findings
The facility failed to ensure a plan was developed to protect the safety of one resident who required staff assistance with mobility. The resident fell from a wheelchair when his/her feet hit the floor, causing injury and requiring emergency room evaluation.
Deficiencies (1)
19 CSR 30-86.047(28)(J) requires a plan to protect the rights, privacy, and safety of residents. The facility failed to develop a plan to ensure the safety of a resident who required assistance with wheelchair mobility and fell, sustaining injuries.
Report Facts
Facility census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Benefiel | Executive Director | Signed the plan of correction document |
| Licensed Practical Nurse (LPN) | Interviewed regarding resident falls | |
| Activities Director | Interviewed regarding resident mobility and fall | |
| Case Manager | Interviewed regarding resident care and condition | |
| Director of Nursing (DON) | Interviewed regarding resident care and hospice admission |
Inspection Report
Life Safety
Census: 44
Deficiencies: 4
Date: Sep 12, 2019
Visit Reason
The inspection was a fire safety inspection conducted to assess compliance with fire drills, fire alarm system maintenance, and sprinkler system requirements.
Findings
The facility failed to provide documentation of an annual local fire department consultation, failed to perform required fire drills every three months on each shift, failed to provide semi-annual fire alarm system inspection documentation, and failed to provide monthly sprinkler system check documentation as required by NFPA standards.
Deficiencies (4)
19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan was not met as the facility failed to provide documentation of a current annual local fire department consultation. The deficiency affected all 44 residents.
19 CSR 30-86.022(5)(D) Fire Drill Requirements were not met as the facility failed to perform fire drills at least once every three months on each shift. The deficiency affected all 44 residents.
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain was not met as the facility failed to provide documentation of semi-annual fire alarm inspections. The deficiency affected all 44 residents.
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13 was not met as the facility failed to provide documentation of monthly sprinkler system checks. The deficiency affected all 44 residents.
Report Facts
Facility census: 44
Fire drills performed: 5
Fire drills performed: 4
Fire drills performed: 3
Inspection Report
Plan of Correction
Census: 39
Deficiencies: 2
Date: Sep 26, 2018
Visit Reason
The inspection was conducted as a fire safety inspection to assess compliance with sprinkler system maintenance and electrical wiring regulations.
Findings
The facility failed to provide documentation of monthly sprinkler system pressure checks and electrical wiring inspections every two years by a qualified electrician. These deficiencies affected all 39 residents present during the inspection.
Deficiencies (2)
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing. The facility failed to provide documentation of monthly sprinkler system pressure checks being performed. This deficiency affected all 39 residents.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to provide documentation of electrical wiring inspections every two years by a qualified electrician. This deficiency affected all 39 residents.
Report Facts
Facility census: 39
Residents affected: 39
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