Inspection Reports for
John Knox Village
1001 NW Chipman Rd, Lee's Summit, MO 64081, United States, MO, 64081
Back to Facility Profile10 Reports
Inspection Report — Jan 14, 2025
Routine
Date: Jan 14, 2025
Visit Reason
CMS-2567 (federal health) and Missouri Department of Health and Senior Services State Form were included; the survey type is not stated in the documents.
Findings
There are 4 federal health deficiencies and 3 Missouri state licensure deficiencies addressing failure to provide required Medicare/Medicaid beneficiary notices, failure to review/revise a care plan for a pressure injury, improper cleaning/storage/handling of respiratory and oxygen equipment, and failures in infection prevention and control including hand hygiene and enhanced barrier precautions. State citations mirror concerns for nursing care, infection control, and informed services/Alzheimer's disclosure.
Deficiencies (3)
19 CSR 30-85.042(66) Nursing Care per Res Condition: Refer to F695.
19 CSR 30-85.042(77) Infection Control/Communicable Disease: Refer to F880.
19 CSR 30-88.010(8) Informed Services/Charges - Alz Disclosure: Refer to F582.
Report Facts
residents sampled: 23
residents affected by lack of SNF ABN: 2
Inspection Report — Jul 5, 2023
Routine
Date: Jul 5, 2023
Visit Reason
CMS-2567 federal health survey pages and Missouri Department of Health and Senior Services State Form pages; the survey type is not stated (routine).
Findings
Fourteen deficiencies were cited: six federal health tags addressing resident transfer/safety, respiratory/oxygen management, pharmacy/narcotic administration and counts, medication storage and labeling, food safety, and infection prevention; and eight Missouri State Form citations referencing medication storage and reconciliation, nursing care, infection control, and multiple food-service and food-contact requirements.
Deficiencies (8)
19 CSR 30-85.042(55) Medication Storage: Medication Storage: See the deficiency cited at F755 and F761.
19 CSR 30-85.042(62) Controlled Substance Reconcile/Record: Controlled Substance Reconcile/Record: See the deficiency cited at F755.
19 CSR 30-85.042(66) Nursing Care per Res Condition: Nursing Care per Res Condition: See the deficiency cited at F689 and F695.
19 CSR 30-85.042(77) Infection Control/Communicable Disease: Infection Control/Communicable Disease: See the deficiency cited at F880.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Food-Protected, Temp, Need to Contact DHSS: See the deficiency cited at F812.
19 CSR 30-87.030(26) Hazardous Food Cooking Temperatures: Hazardous Food Cooking Temperatures: See the deficiency cited at F812.
19 CSR 30-87.030(46) Safe Plastic/Rubber Items, Food Contact: Safe Plastic/Rubber Items, Food Contact: See the deficiency cited at F812.
19 CSR 30-87.030(63) Food-Contact Surfaces Washed/Rinsed/Sanitized: Food-Contact Surfaces Washed/Rinsed/Sanitized: See the deficiency cited at F812.
Report Facts
residents_sampled: 21
residents_sampled_for_TB: 5
Inspection Report — Jul 5, 2023
Life Safety
Date: Jul 5, 2023
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CMS-2567 Life Safety (LSC) survey (federal K-tag deficiencies) and Missouri Department of Health and Senior Services State Form (state A-tag deficiencies); Life Safety Code inspection.
Findings
There are 13 Life Safety (K-tag) deficiencies and 10 Missouri state licensure (A-tag) deficiencies. The findings address emergency lighting and generator testing, fire alarm notification devices, sprinkler installation and maintenance, portable fire extinguishers, heating/fireplace hazards, dryer lint/firebox cleaning, fire drill documentation, fire door operation, electrical system inspection/annunciator/generator monitoring, and improper use of power strips/extension cords.
Deficiencies (10)
19 CSR 30-85.022(2)(E) No Fire Hazard: Refer to K522 and K700.
19 CSR 30-85.022(2)(H) Electrical Appliances UL/FM Good Repair: Refer to K920.
19 CSR 30-85.022(8)(D) Fire Extinguisher UL/FM, Monthly Check: Refer to K355.
19 CSR 30-85.022(10)(A) Complete Fire Alarm System Requirements: Refer to K343.
19 CSR 30-85.022(11)(B) No Complete Sprinkler System Prior to 8/28/07: Refer to K351.
19 CSR 30-85.022(11)(C) Sprinkler System-Test/Maintain: Refer to K353.
19 CSR 30-85.022(25) Emergency Lighting: Refer to K291.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K761.
19 CSR 30-85.022(33)(F) Fire Drill Records: Refer to K712.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K914, K916, K918, and K920.
Report Facts
facility smoke zones: 36
Inspection Report — Dec 9, 2021
Complaint Investigation
Date: Dec 9, 2021
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Federal health survey (CMS-2567) and Missouri State Form; complaint investigation. Complaint number MO00194233 is cited in the file.
Complaint Details
MO00194233; substantiation not stated in the forms.
Findings
Two deficiencies were cited: one federal health deficiency regarding failure to maintain a resident environment free of accident hazards (unlocked chemicals leading to a resident ingesting cleaning solution and hospitalization), and one Missouri state licensure deficiency for protective oversight/voluntary leave referencing the federal finding.
Deficiencies (1)
19 CSR 30-85.042(66) Protective Oversight, Voluntary Leave: Refer to F689.
Report Facts
residents sampled: 5
Inspection Report — Aug 30, 2021
Routine
Date: Aug 30, 2021
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Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) for John Knox Village Care Center; the survey type is not stated in the forms.
Findings
Sixteen deficiencies were cited: eight federal F-tags addressing assessment and timing (comprehensive, quarterly, baseline), gastrostomy tube care, posted staffing information, medication storage/labeling and security, food safety and sanitation, and facility assessment; and eight Missouri state citations (19 CSR) mostly referencing employee TB screening, medication storage, nursing care and multiple food-safety requirements. Many federal findings cite failures in timely MDS assessments, baseline care plans, medication cart security, and kitchen sanitation.
Deficiencies (8)
19 CSR 30-85.042(27) Communicable Disease-Employees: The facility failed to properly screen new employees for tuberculosis, not completing required two-step TSTs within required timeframes for sampled employees.
19 CSR 30-85.042(56) Medication Storage: See the deficiency cited at F761.
19 CSR 30-85.042(67) Nursing Care per Res Condition: See the deficiency cited at F693.
19 CSR 30-87.030(3) Clean Clothing, Hair Restraints: See the deficiency cited at F812.
19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources: See the deficiency cited at F812.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: See the deficiency cited at F812.
19 CSR 30-87.030(46) Safe Plastic/Rubber Items, Food Contact: See the deficiency cited at F812.
19 CSR 30-87.030(64) Grills/Griddles/Microwaves/Other-Clean Daily: See the deficiency cited at F812.
Report Facts
residents selected for review: 27
residents with incomplete quarterly MDS: 5
residents lacking baseline care plan within 48 hours: 4
sampled resident with gastrostomy care issues: 1
Inspection Report — Aug 30, 2021
Life Safety
Date: Aug 30, 2021
Visit Reason
Federal CMS-2567 life safety and emergency preparedness survey (CMS-2567) and Missouri Department of Health and Senior Services State Form licensure pages; the survey type is not stated.
Findings
Fourteen federal life-safety/emergency preparedness deficiencies primarily involved emergency preparedness (water/shelter), exit signage, kitchen/hood grease buildup, fire alarm/notification, sprinkler/fire-watch procedures, fire extinguishers, fire drills, smoking/ashtray management, door fire-resistance labeling, electrical/generator systems, power strips, and oxygen cylinder storage. Fourteen Missouri state deficiencies mirror many life-safety and fire/gas storage issues and refer to the federal K/E findings.
Deficiencies (14)
19 CSR 30-85.012(36) Oxygen Storage Room: 1. Refer to K 923.
19 CSR 30-85.022(2)(E) No Fire Hazard: 1. Refer to K324.
19 CSR 30-85.022(8)(D) Fire Extinguisher UL/FM, Monthly Check: 1. Refer to K355.
19 CSR 30-85.022(9) Range Hood Certification: 1. Refer to K324.
19 CSR 30-85.022(10)(A) Complete Fire Alarm System Requirements: 1. Refer to K343.
19 CSR 30-85.022(11)(E) Sprinkler System Out of Service More Than 4hr: 1. Refer to K354.
19 CSR 30-85.022(22) Exit Sign Requirements: 1. Refer to K293.
19 CSR 30-85.022(32) Ashtrays Noncombustibles/Safe/Disposal: 1. Refer to K741.
19 CSR 30-85.022(33)(A) Fire Drill/Emergency Preparedness - Plans: 1. Refer to E0015.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation: 1. Refer to K712.
19 CSR 30-85.022(40)(B) Exterior Premises-Fire Safety: 1. Refer to K741.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: 1. Refer to K916. 2. Refer to K918. 3. Refer to K920.
19 CSR 30-85.032(37) Extension Cords/Duplex Receptacles: 1. Refer to K920.
19 CSR 30-85.042(13) Policies/Procedures-Operational: 1. Refer to E0022.
Report Facts
staff count: 75
smoke compartments: 36
oxygen cylinders: 12
Inspection Report — May 3, 2019
Life Safety
Date: May 3, 2019
Visit Reason
Federal CMS-2567 Life Safety and Emergency Preparedness forms and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
There are 11 federal life-safety/emergency preparedness deficiencies addressing emergency preparedness planning, emergency lighting, fire protection/penetrations, portable fire extinguishers, evacuation/fire watch and fire drills, door maintenance and fire-resistive ratings, and multiple electrical and gas storage issues. There are 13 Missouri state licensure deficiencies mostly referencing the same topics and directing to the corresponding K/E findings.
Deficiencies (13)
19 CSR 30-85.012(36) Oxygen Storage Room: Refer to K923.
19 CSR 30-85.012(128) Emergency Lights, Generator for Life Support: Refer to K291.
19 CSR 30-85.022(2)(E) No Fire Hazard: Refer to K761.
19 CSR 30-85.022(8)(D) Fire Extinguisher UL/FM, Monthly Check: Refer to K355.
19 CSR 30-85.022(10)(B) Fire Alarm System-Test/Maintain: Refer to K711.
19 CSR 30-85.022(10)(C) Fire Alarm System-Inspections/Certifications: Refer to K711.
19 CSR 30-85.022(10)(H) Fire Alarm System-Out of Service > than 4hrs: Refer to K711.
19 CSR 30-85.022(29) Smoke Section Walls/Doors: Refer to K761.
19 CSR 30-85.022(33)(F) Fire Drill Records: Refer to K712.
19 CSR 30-85.032(2) Substantially Constructed/Maintained: Refer to K300.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K914 and K918.
19 CSR 30-85.032(37) Extension Cords/Duplex Receptacles: Refer to K920.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E0001.
Report Facts
smoke_zones: 36
double_smoke_door_sets: 32
Inspection Report — Jun 7, 2018
Complaint Investigation
Date: Jun 7, 2018
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CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form; complaint investigation is cited (MO00143412).
Complaint Details
MO00143412; substantiation not stated in the document.
Findings
2 deficiencies: one federal quality-of-care deficiency concerning failure to ensure and monitor ordered supplemental oxygen for a hospice resident, and one Missouri state licensure deficiency for nursing care that references the federal finding.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Res Condition: Refer to F684.
Inspection Report — Mar 23, 2018
Routine
Date: Mar 23, 2018
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Federal health survey (CMS-2567) with accompanying Missouri State Form licensure survey; the survey type is not stated in the forms.
Findings
Fifteen deficiencies were cited (eleven federal F-tags and four Missouri state citations). Deficiencies cover resident care planning and comprehensive care plans, transfer/bed‑hold and discharge/transfer notice practices, medication management and labeling, food preparation/serving practices, infection prevention and control (isolation/hand hygiene/wound and catheter care), respiratory/oxygen therapy care, accident/transfer procedures and overall quality of care.
Deficiencies (4)
19 CSR 30-85.04(2)(6) Medication Storage: Refer to F761.
19 CSR 30-85.04(...) (Clinical Records/assessments/interventions): Refer to F656.
19 CSR 30-85.05(2)(3) Foods - Nutritive Value/Flavor/Appearance: Refer to F804.
19 CSR 30-85.04(...) Residents Informed Services/Charges (Bed-hold/transfer disclosures): Refer to F625.
Report Facts
residents sampled: 38
Inspection Report — Mar 23, 2018
Life Safety
Date: Mar 23, 2018
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CMS-2567 federal health and life safety surveys and Missouri State Form; the survey type is not stated.
Findings
Fourteen deficiencies were cited: nine federal (E- and K- tags) involving emergency preparedness, emergency plan review and testing, HVAC, fire drills, and multiple electrical issues including receptacles, circuit breaker testing, and improper use of extension cords/surge protectors; and five Missouri state (19 CSR) deficiencies concerning fire drill records, toilet room accessibility/ventilation/locks, electrical wiring/equipment maintenance, extension cords/duplex receptacles, and operational policies/procedures.
Deficiencies (5)
19 CSR 30-85.022(33)(F) Fire Drill Records: Refer to K712.
19 CSR 30-85.032(16) Toilet Rim-Accessible, Ventilated, Locks: Refer to K521.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained: Refer to K914, K918 and K921.
19 CSR 30-85.032(37) Extension Cords/Duplex Receptacles: Refer to K920.
19 CSR 30-85.042(13) Policies/Procedures-Operational: Refer to E004, E031, and E039.
Report Facts
residents potentially affected: 14
total facility smoke zones: 36
locations with extension cords or outlet adapters observed: 20
27 CMS Surveys
Inspection Report — Apr 30, 2025
Complaint Investigation
Date: Apr 30, 2025
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Federal health survey (CMS-2567); complaint investigation with complaint number MO00253421.
Complaint Details
MO00253421; substantiation not stated in the document.
Findings
One federal deficiency was cited related to resident rights/informed consent. The finding involved the application of barrier cream that caused burning and a resident reporting feeling 'violated'; past noncompliance was noted.
Deficiencies (1)
F 552 Right to be Informed/Make Treatment Decisions: Based on interview and record review, the facility failed to ensure one sampled resident was fully informed of his/her care prior to receiving the care; the resident reported barrier cream was applied by a CNA, the cream burned and the resident felt "violated."
Report Facts
residents sampled: 3
residents affected: 1
Inspection Report — Jan 14, 2025
Life Safety
Date: Jan 14, 2025
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CMS-2567 federal Life Safety and Emergency Preparedness survey. The Initial Comments identify this as a Life Safety Code Survey.
Findings
Three federal deficiencies were cited addressing emergency preparedness subsistence needs, exit signage illumination/placement, and missing or undocumented fire drills and alarm transmissions; all federal deficiencies were cited with severity SS=F.
Deficiencies (3)
E015 Subsistence Needs for Staff and Patients: Based on record review and interview, the facility failed to develop policies and procedures to ensure the subsistence needs of staff and residents when they shelter in place; the deficient practice could affect all 113 residents.
K293 Exit Signage: Based on observation and interview, the facility failed to ensure all exit signs were displayed with continuous illumination in accordance with NFPA 101; the deficient practice had the potential to affect all 113 residents.
K712 Fire Drills: Based on record review and interview, the facility failed to conduct and document fire drills and fire alarm activations/transmissions in accordance with NFPA 101 requirements; the deficient practice had the potential to affect all 113 residents.
Report Facts
residents potentially affected: 113
Inspection Report — Jan 14, 2025
Routine
Date: Jan 14, 2025
Visit Reason
CMS-2567 (federal health) and Missouri Department of Health and Senior Services State Form were included; the survey type is not stated in the documents.
Findings
There are 4 federal health deficiencies and 3 Missouri state licensure deficiencies addressing failure to provide required Medicare/Medicaid beneficiary notices, failure to review/revise a care plan for a pressure injury, improper cleaning/storage/handling of respiratory and oxygen equipment, and failures in infection prevention and control including hand hygiene and enhanced barrier precautions. State citations mirror concerns for nursing care, infection control, and informed services/Alzheimer's disclosure.
Deficiencies (4)
F582 Medicaid/Medicare Coverage/Liability Notice: Based on interview and record review, the facility failed to ensure the SNF Advanced Beneficiary Notice (SNF ABN) was provided to two residents whose Medicare Part A benefits ended, so residents were not informed of potential noncoverage and financial liability.
F657 Care Plan Timing and Revision: Based on interview and record review, the facility failed to review and revise a resident's person-centered care plan to address a pressure injury for one sampled resident.
F695 Respiratory/Tracheostomy Care and Suctioning: Based on observation, interview, and record review, the facility failed to ensure respiratory equipment (including CPAP masks) and oxygen tubing were cleaned, stored, and kept covered when not in use for sampled residents, and observed tubing and masks were left uncovered or on the floor.
F880 Infection Prevention & Control: Based on observation, interview, and record review, the facility failed to ensure infection control practices including hand hygiene and use of enhanced barrier precautions during wound and Foley catheter care for sampled residents, risking transmission of infection.
Report Facts
residents sampled: 23
residents affected by lack of SNF ABN: 2
Inspection Report — Jul 16, 2024
Routine
Date: Jul 16, 2024
Visit Reason
Federal health survey (CMS-2567); the survey type is not stated.
Findings
One federal health deficiency for failure to follow mechanical lift and sling procedures resulting in a resident slipping from a Hoyer lift. The deficiency concerns staff practice during transfers and sling selection/use.
Deficiencies (1)
F 689 Free of Accident Hazards/Supervision/Devices: Based on interview and record review, the facility staff failed to follow the facility guidelines for using mechanical lifts by transferring one sampled resident (Resident #1) out of three sampled residents using an incorrect sling for this resident on a Hoyer lift, which caused him/her to slip from the sling onto the floor without injury.
Report Facts
residents sampled: 3
residents affected: 1
Inspection Report — Jul 5, 2023
Routine
Date: Jul 5, 2023
Visit Reason
CMS-2567 federal health survey pages and Missouri Department of Health and Senior Services State Form pages; the survey type is not stated (routine).
Findings
Fourteen deficiencies were cited: six federal health tags addressing resident transfer/safety, respiratory/oxygen management, pharmacy/narcotic administration and counts, medication storage and labeling, food safety, and infection prevention; and eight Missouri State Form citations referencing medication storage and reconciliation, nursing care, infection control, and multiple food-service and food-contact requirements.
Deficiencies (6)
F689 Free of Accident Hazards/Supervision/Devices: Based on interview and record review, the facility failed to ensure physician orders and to update resident transfer status/profile following a sit-to-stand transfer injury for one sampled resident.
F695 Respiratory/Tracheostomy Care and Suctioning: Based on observation, interview, and record review, the facility failed to ensure oxygen and related equipment were stored and managed in a sanitary, appropriate manner and did not clarify or carry out oxygen orders as intended for sampled residents.
F755 Pharmacy Srvs/Procedures/Pharmacist/Records: Based on observation, interview, and record review, the facility failed to ensure narcotic medications were documented and the narcotic counts were accurately verified at the beginning and end of each shift.
F761 Label/Store Drugs and Biologicals: Based on observation, interview, and record review, the facility failed to ensure medications were stored in a secure, sanitary, temperature-appropriate environment and that medication refrigeration temperatures and storage practices were monitored and documented.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: Based on observation and interview, the facility failed to maintain dry storage, walk-in refrigerator and freezer cleanliness, retain operable thermometers in refrigeration units, and maintain sanitary food preparation equipment and proper food-handling/temperature practices.
F880 Infection Prevention & Control: Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program, including appropriate hand hygiene, glove use and wound-care practices for sampled residents and required TB testing procedures.
Report Facts
residents_sampled: 21
residents_sampled_for_TB: 5
Inspection Report — Jul 5, 2023
Life Safety
Date: Jul 5, 2023
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CMS-2567 Life Safety (LSC) survey (federal K-tag deficiencies) and Missouri Department of Health and Senior Services State Form (state A-tag deficiencies); Life Safety Code inspection.
Findings
There are 13 Life Safety (K-tag) deficiencies and 10 Missouri state licensure (A-tag) deficiencies. The findings address emergency lighting and generator testing, fire alarm notification devices, sprinkler installation and maintenance, portable fire extinguishers, heating/fireplace hazards, dryer lint/firebox cleaning, fire drill documentation, fire door operation, electrical system inspection/annunciator/generator monitoring, and improper use of power strips/extension cords.
Deficiencies (13)
K291 Emergency Lighting: The facility failed to ensure all emergency lighting was comprehensively inspected and tested for the required 90-minute annual duration; weekly/generator runs and records showed varied and often shorter run times.
K343 Fire Alarm System - Notification: The facility failed to ensure all components of the fire alarm notification system (audio and visual devices) were properly installed and operable; surveyors observed audible alarms/strobes that were nonfunctional or very dim in several areas.
K351 Sprinkler System - Installation: The facility failed to ensure sprinklers were installed to provide adequate coverage in all areas; inspections found at least one closet/area without a properly installed ceiling sprinkler head and other areas with insufficient coverage.
K353 Sprinkler System - Maintenance and Testing: The facility failed to perform complete weekly and monthly sprinkler inspections and to maintain required documentation; observations included dislodged or offset sprinkler head flanges and missing evidence of routine valve/gauge checks.
K355 Portable Fire Extinguishers: The facility failed to complete and document all monthly portable fire extinguisher checks; observations found extinguishers with outdated or missing monthly check tags.
K522 HVAC - Any Heating Device: The facility failed to properly safeguard heat-producing electric fireplaces, resulting in combustible exposure and excessive surface temperatures near residents; measurements and observations showed high temperatures at appliance slots and combustible proximity concerns.
K700 Operating Features - Other: The facility failed to adequately clean dryer lint traps and fireboxes, resulting in heavy lint accumulation in commercial dryer fireboxes; inspectors observed significant lint buildup in multiple dryers.
K712 Fire Drills: The facility failed to provide thorough and complete documentation of fire drills, including simulated conditions and confirmation from the monitoring/receiving activity reports; several drills lacked required documentation and some months' drill records were missing.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to ensure all fire doors completely closed when released from electromagnetic holders; an observed fire door (room C202) was caught on the floor and did not fully close.
K914 Electrical Systems - Maintenance and Testing: The facility failed to provide itemized annual inspection records and required documentation for bedside receptacles and other electrical outlets; resident room outlet inspections were not itemized as required.
K916 Electrical Systems - Essential Electric System Alarm Annunciator: The facility failed to ensure an annunciator or monitoring was provided and readily observable for the generator alarm conditions; staff were not aware of the requirement for an alarm monitor showing generator faults.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to provide comprehensive documentation of annual inspections and testing of electrical main and feeder circuit breaker panels, including itemized inspection lists and evidence of required testing practices.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to prevent use of non-UL-listed surge protectors and to avoid overloading power strips in multiple locations; observers found several devices and work areas using surge protectors that were not UL listed and multiple items plugged into single surge strips.
Report Facts
facility smoke zones: 36
Inspection Report — Dec 9, 2021
Complaint Investigation
Date: Dec 9, 2021
Visit Reason
Federal health survey (CMS-2567) and Missouri State Form; complaint investigation. Complaint number MO00194233 is cited in the file.
Complaint Details
MO00194233; substantiation not stated in the forms.
Findings
Two deficiencies were cited: one federal health deficiency regarding failure to maintain a resident environment free of accident hazards (unlocked chemicals leading to a resident ingesting cleaning solution and hospitalization), and one Missouri state licensure deficiency for protective oversight/voluntary leave referencing the federal finding.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards when chemicals were left unlocked and accessible, resulting in a sampled resident obtaining and ingesting cleaning solution and being sent to the hospital.
Report Facts
residents sampled: 5
Inspection Report — Aug 30, 2021
Routine
Date: Aug 30, 2021
Visit Reason
Federal health survey (CMS-2567) and Missouri state licensure survey (State Form) for John Knox Village Care Center; the survey type is not stated in the forms.
Findings
Sixteen deficiencies were cited: eight federal F-tags addressing assessment and timing (comprehensive, quarterly, baseline), gastrostomy tube care, posted staffing information, medication storage/labeling and security, food safety and sanitation, and facility assessment; and eight Missouri state citations (19 CSR) mostly referencing employee TB screening, medication storage, nursing care and multiple food-safety requirements. Many federal findings cite failures in timely MDS assessments, baseline care plans, medication cart security, and kitchen sanitation.
Deficiencies (8)
F636 Comprehensive Assessments & Timing: The facility failed to complete an annual Minimum Data Set assessment for Resident #5 as required.
F638 Qtrly Assessment at Least Every 3 Months: The facility failed to complete required quarterly Minimum Data Set assessments for multiple sampled residents.
F655 Baseline Care Plan: The facility failed to develop and/or provide written baseline care plans within 48 hours of admission for multiple sampled residents.
F693 Tube Feeding Mgmt/Restore Eating Skills: The facility failed to provide required gastrostomy tube site care/cleansing and related documentation for a sampled resident with a G-tube.
F732 Posted Nurse Staffing Information: The facility failed to post the actual hours worked by licensed and unlicensed nursing staff per shift and failed to develop a policy addressing posting of staffing data.
F761 Label/Store Drugs and Biologicals: Medication and treatment carts were observed unlocked and accessible with loose pills, tacks and scissors present in medication drawers.
F812 Food Procurement,Store/Prepare/Serve-Sanitary: Multiple food safety and sanitation failures were observed in kitchen and food storage areas, including dirty equipment, missing thermometers, poor fryer/oil maintenance and unsanitary food-contact surfaces.
F838 Facility Assessment: The facility failed to complete and update a comprehensive facility-wide assessment that included required components and staff competencies.
Report Facts
residents selected for review: 27
residents with incomplete quarterly MDS: 5
residents lacking baseline care plan within 48 hours: 4
sampled resident with gastrostomy care issues: 1
Inspection Report — Aug 30, 2021
Life Safety
Date: Aug 30, 2021
Visit Reason
Federal CMS-2567 life safety and emergency preparedness survey (CMS-2567) and Missouri Department of Health and Senior Services State Form licensure pages; the survey type is not stated.
Findings
Fourteen federal life-safety/emergency preparedness deficiencies primarily involved emergency preparedness (water/shelter), exit signage, kitchen/hood grease buildup, fire alarm/notification, sprinkler/fire-watch procedures, fire extinguishers, fire drills, smoking/ashtray management, door fire-resistance labeling, electrical/generator systems, power strips, and oxygen cylinder storage. Fourteen Missouri state deficiencies mirror many life-safety and fire/gas storage issues and refer to the federal K/E findings.
Deficiencies (14)
E015 Subsistence Needs for Staff and Patients: The facility failed to develop consistent, well-known emergency preparedness policies and procedures to ensure subsistence needs (notably emergency water supply) for residents and staff during an outage; contracts and supplies were outdated and inadequate.
E022 Policies/Procedures for Sheltering in Place: The facility failed to establish and maintain a comprehensive emergency preparedness program including policies and procedures for sheltering in place under various emergency conditions.
K293 Exit Signage: The facility failed to ensure doors had clear, non-conflicting exit/"Not an Exit" signage; multiple doors were missing or had confusing signage which could mislead evacuees.
K324 Cooking Facilities: The facility failed to ensure the range hood/flue and fire suppression elements were maintained free of excessive grease build-up and were properly serviced, creating a potential fire hazard in the cooking area.
K343 Fire Alarm System - Notification: The facility failed to ensure adequate audible/visible fire alarm notification coverage in certain areas (notably kitchen/main food prep), with devices not clearly visible or providing effective visual signals.
K354 Sprinkler System - Out of Service: The facility's fire watch/sprinkler outage procedures lacked required notification/contact information and specific fire watch duties and procedures when a sprinkler system was impaired.
K355 Portable Fire Extinguishers: The facility failed to ensure complete, accurate documentation and maintenance of portable fire extinguishers and had extinguishers that were inaccessible or obstructed (including a Class K extinguisher not located along a normal path of travel).
K712 Fire Drills: The facility failed to ensure monthly fire drills were thoroughly documented and scheduled at varied/unexpected times for all shifts, with missing required details and several months without required drills.
K741 Smoking Regulations: The facility failed to ensure approved ashtrays, self-closing disposal devices and appropriate signage were present in smoking areas; outdoor ashtray locations and signage were inadequate or missing.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to provide accurate documentation for annual fire/smoke door inspections and some fire/smoke doors were missing legible fire-resistance rating (FRR) labels.
K916 Electrical Systems - Essential Electric System Alarm Annunciator: The facility failed to ensure the generator had a remote alarm annunciator located outside the generator enclosure that would alert operating personnel to generator malfunctions.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to maintain required clear working space and cover plates on electrical panels and junction boxes; several panels were blocked or had missing covers.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to ensure appropriate use of power strips/ surge protectors and outlet adapters, with non-UL or overloaded surge protectors and multiple items plugged into single adapters.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to properly maintain oxygen/gas cylinder storage areas (including proper enclosure, FRR labeling, ventilation, and signage); cylinders were stored in a service hallway and storage rooms lacked required features.
Report Facts
staff count: 75
smoke compartments: 36
oxygen cylinders: 12
Inspection Report — Jul 1, 2021
Complaint Investigation
Date: Jul 1, 2021
Visit Reason
Federal health survey (CMS-2567); complaint investigation. Missouri complaint numbers MO00173557 and MO00187427 are cited in the file.
Complaint Details
Complaint numbers MO00173557 and MO00187427 are cited; the file does not state whether the complaint allegation was officially substantiated.
Findings
One federal health deficiency citing failure to protect a resident from financial exploitation (misappropriation). The survey notes past noncompliance.
Deficiencies (1)
F 602 Free from Misappropriation/Exploitation: Based on record and interview, the facility failed to assure one sampled resident (Resident #3) was free from misappropriation when a Health Services Associate accepted a blank signed check from the resident which was later cashed for $5,000.
Report Facts
residents affected: 1
residents sampled: 6
amount misappropriated: 5000
Inspection Report — Mar 9, 2021
Routine
Date: Mar 9, 2021
Visit Reason
CMS-2567 federal survey (health/infection control and emergency preparedness); the form states a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted on 03/09/2021.
Findings
No deficiencies were cited; the COVID-19 focused emergency preparedness and infection control surveys found the facility in compliance with applicable guidance.
Inspection Report — Jan 11, 2021
Complaint Investigation
Date: Jan 11, 2021
Visit Reason
Federal health survey (CMS-2567); complaint investigation. Complaint number MO00180192 is cited in the file.
Complaint Details
MO00180192; substantiation not stated in the file.
Findings
1 federal health deficiency was cited for failure to prevent physical abuse/neglect of a resident. The survey notes past noncompliance.
Deficiencies (1)
F600 Free from Abuse and Neglect: The facility failed to ensure a resident was free from physical abuse when a certified nurse aide pushed and held the resident by the shoulders, resulting in bruising and blood on the resident.
Report Facts
residents_affected: 1
residents_sampled: 3
Inspection Report — Dec 15, 2020
Routine
Date: Dec 15, 2020
Visit Reason
Federal CMS-2567 form for a COVID-19 Focused Emergency Preparedness and Infection Control survey; the survey type is stated as COVID-19 focused.
Findings
No deficiencies were cited; the facility was found in compliance with COVID-19 emergency preparedness and infection control requirements.
Inspection Report — Nov 20, 2020
Routine
Date: Nov 20, 2020
Visit Reason
CMS-2567 federal health survey containing a COVID-19 Focused Emergency Preparedness and a COVID-19 Focused Infection Control survey as stated on the form; no complaint numbers are listed.
Findings
No deficiencies were cited. The survey documents the facility was found in compliance with COVID-19 focused emergency preparedness and infection control requirements.
Inspection Report — Nov 2, 2020
Routine
Date: Nov 2, 2020
Visit Reason
Federal CMS-2567 health and emergency preparedness pages; a COVID-19 Focused Infection Control and Emergency Preparedness survey is stated and no complaint number is shown.
Findings
No deficiencies were cited on this CMS-2567; Initial Comments state the facility was found to be in compliance with COVID-19 infection control and emergency preparedness practices.
Inspection Report — Oct 15, 2020
Routine
Date: Oct 15, 2020
Visit Reason
Federal CMS-2567 health and emergency preparedness survey; the Initial Comments state a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control survey were conducted.
Findings
No deficiencies were cited; the facility was found in compliance with the COVID-19 focused emergency preparedness and infection control requirements.
Inspection Report — Sep 21, 2020
Routine
Date: Sep 21, 2020
Visit Reason
Federal CMS-2567 (health and emergency preparedness); COVID-19 Focused Infection Control Survey and COVID-19 Focused Emergency Preparedness survey were conducted as stated on the form.
Findings
No deficiencies were cited; the COVID-19 Focused Infection Control and Emergency Preparedness surveys found the facility in compliance.
Inspection Report — Aug 17, 2020
Routine
Date: Aug 17, 2020
Visit Reason
Federal CMS-2567 health survey and emergency preparedness survey (COVID-19 focused infection control and emergency preparedness) as stated in the initial comments; the survey type is COVID-19 focused.
Findings
No health (F) or emergency preparedness (E) deficiencies were cited; the facility was found to be in compliance with COVID-19 focused infection control and emergency preparedness practices.
Inspection Report — Jul 22, 2020
Routine
Date: Jul 22, 2020
Visit Reason
CMS-2567 federal health survey (CMS-2567) documenting a COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control survey; no complaint numbers are stated.
Findings
No deficiencies were cited. The surveyor documented the facility was found in compliance with the COVID-19 focused emergency preparedness and infection control surveys.
Inspection Report — Jun 25, 2020
Routine
Date: Jun 25, 2020
Visit Reason
Federal CMS-2567 infection control and emergency preparedness survey. The form states it was a COVID-19 Focused Emergency Preparedness and Infection Control Survey.
Findings
No federal health or emergency preparedness deficiencies were cited. The surveyor found the facility in compliance with infection control and emergency preparedness requirements during the COVID-19 focused survey.
Inspection Report — May 27, 2020
Routine
Date: May 27, 2020
Visit Reason
Federal CMS-2567 forms for infection control (F) and emergency preparedness (E); the survey is a COVID-19 Focused Infection Control and Emergency Preparedness survey as stated in the Initial Comments.
Findings
No deficiencies were cited. The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 and in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Jan 28, 2020
Complaint Investigation
Date: Jan 28, 2020
Visit Reason
CMS-2567 federal health survey; complaint investigation (complaint numbers M000165984 and M000166014).
Complaint Details
Complaint numbers M000165984 and M000166014; determination of substantiation not stated.
Findings
One federal health deficiency for failure to prevent resident abuse/neglect resulting in resident bruising. Past noncompliance was noted.
Deficiencies (1)
F600 Free from Abuse and Neglect: Based on observation, interview and record review, the facility failed to keep one sampled resident free from physical abuse when a staff member forced the resident to bed resulting in bruising to the resident's left upper arm, left lower flank, and right outer arm. Staff suspended the employee, conducted an investigation, notified appropriate parties, and placed a do-not-return status with the staffing agency.
Report Facts
residents sampled: 3
residents affected: 1
Inspection Report — May 3, 2019
Complaint Investigation
Date: May 3, 2019
Visit Reason
CMS-2567 federal health survey (annual) and Missouri state licensure form (Licensure Inspection/Complaint); a complaint investigation is stated in the file.
Findings
No federal health deficiencies (0) were cited and no state licensure deficiencies (0) were cited.
Inspection Report — May 3, 2019
Life Safety
Date: May 3, 2019
Visit Reason
Federal CMS-2567 Life Safety and Emergency Preparedness forms and Missouri Department of Health and Senior Services State Form; the survey type is not stated.
Findings
There are 11 federal life-safety/emergency preparedness deficiencies addressing emergency preparedness planning, emergency lighting, fire protection/penetrations, portable fire extinguishers, evacuation/fire watch and fire drills, door maintenance and fire-resistive ratings, and multiple electrical and gas storage issues. There are 13 Missouri state licensure deficiencies mostly referencing the same topics and directing to the corresponding K/E findings.
Deficiencies (11)
E001 Establishment of the Emergency Program (EP): The facility failed to establish and maintain a comprehensive emergency preparedness program; the plan lacked procedures for evacuation of bariatric residents, monitoring extreme temperatures during outages, identification of facility roles under federal waivers, and a process for training staff in EP.
K291 Emergency Lighting: The facility failed to ensure emergency lighting was inspected and tested per NFPA standards; exit lights did not illuminate when tested and maintenance records lacked an itemized list of emergency light locations.
K300 Protection - Other: The facility failed to ensure ceilings and penetrations resisted the passage of smoke in numerous locations, including holes in ceilings, cable penetrations not properly fire-caulked, and unsealed piping creating potential smoke paths.
K355 Portable Fire Extinguishers: The facility failed to ensure monthly inspections of portable fire extinguishers were documented for all months; inspection tags were blank for April 2019 and a consistent quick-inspection program was not evidenced.
K711 Evacuation and Relocation Plan: The facility failed to provide a complete, comprehensive policy and documentation for procedures such as fire watch and impairment actions, resulting in missing procedures and documentation to guide staff and notify authorities.
K712 Fire Drills: The facility failed to ensure fire drills were thoroughly documented with varying simulated conditions and verifications of successful alarm signal transmission; drill records were incomplete or missing required elements.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to annually conduct and document visual, functional and technical assessments of smoke barrier and corridor doors and to ensure fire-resistive rating (FRR) labels were legible and present on smoke and corridor doors.
K914 Electrical Systems - Maintenance and Testing: The facility failed to maintain complete, itemized records for electrical receptacles and annual assessments, and failed to replace broken or missing receptacle covers in multiple resident rooms.
K918 Electrical Systems - Essential Electric System: The facility did not provide complete, verifiable documentation of annual maintenance and testing of the electrical main and circuit breaker panels and failed to document required generator testing and controls (including a remote stop location).
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to prevent use of noncompliant power strips/adapters and to prevent cords from being pinched or stressed, with multiple observations of surge protectors, three-plex adapters and pinched printer cords in various units.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to ensure the oxygen storage room door and frame had a fire resistance rating (FRR) label and to ensure the oxygen storage room met required fire-resistive qualities.
Report Facts
smoke_zones: 36
double_smoke_door_sets: 32
Inspection Report — Jun 7, 2018
Complaint Investigation
Date: Jun 7, 2018
Visit Reason
CMS-2567 federal health survey and Missouri Department of Health and Senior Services State Form; complaint investigation is cited (MO00143412).
Complaint Details
MO00143412; substantiation not stated in the document.
Findings
2 deficiencies: one federal quality-of-care deficiency concerning failure to ensure and monitor ordered supplemental oxygen for a hospice resident, and one Missouri state licensure deficiency for nursing care that references the federal finding.
Deficiencies (1)
F 684 Quality of Care: The facility failed to ensure a hospice resident received and was monitored on prescribed supplemental oxygen; a portable oxygen tank was found empty and the resident was hypoxic.
Inspection Report — Mar 23, 2018
Routine
Date: Mar 23, 2018
Visit Reason
Federal health survey (CMS-2567) with accompanying Missouri State Form licensure survey; the survey type is not stated in the forms.
Findings
Fifteen deficiencies were cited (eleven federal F-tags and four Missouri state citations). Deficiencies cover resident care planning and comprehensive care plans, transfer/bed‑hold and discharge/transfer notice practices, medication management and labeling, food preparation/serving practices, infection prevention and control (isolation/hand hygiene/wound and catheter care), respiratory/oxygen therapy care, accident/transfer procedures and overall quality of care.
Deficiencies (11)
F558 Responsible Accommodation Needs/Preferences: The facility failed to ensure residents received needed assistance with dining and beverages and failed to ensure call lights were within reach, as evidenced by multiple resident interviews and observations showing unmet assistance needs.
F623 Notice Before Transfer/Discharge: The facility failed to provide required notice and documentation to residents or their representatives prior to transfers/discharges, as shown by multiple resident records lacking required notification.
F625 Notice of Bed-Hold Policy Before/Upon Transfer: The facility did not ensure residents and/or their representatives were informed of the facility's bed‑hold policy at transfer, as evidenced by resident records and interviews.
F656 Comprehensive Care Plans: The facility failed to develop and maintain comprehensive, individualized care plans reflecting resident needs and interventions for several sampled residents, as shown in care plan and record reviews.
F684 Quality of Care: The facility failed to ensure timely and accurate physician orders and documentation related to hospital transfers and treatments and failed to ensure appropriate follow‑up for transferred residents.
F689 Accidents: The facility failed to ensure safe transfer and ambulation practices and to protect residents from accidental trauma during transfers, as observed and documented in resident transfer incidents.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure appropriate respiratory care and monitoring, including oxygen administration and ordered respiratory treatments, as documented in resident records and observations.
F744 Treatment/Service for Dementia: The facility failed to ensure residents with dementia had appropriate individualized care plans and interventions addressing behavioral and functional needs, based on record review and staff interviews.
F761 Labeling of Drugs and Biologicals: The facility failed to ensure medications and biologicals were stored and labeled appropriately in medication carts/rooms, with observations of unlabeled or undated medication containers and open vials.
F804 Food and Drink (Nutrition/Preparation): The facility failed to ensure safe food preparation and handling practices and appropriate service times/temperatures, as evidenced by kitchen observations and staff interviews.
F880 Infection Control: The facility failed to establish and maintain an effective infection prevention and control program, with multiple breaches observed including improper use of PPE, isolation procedures, wound and catheter care, and hand hygiene.
Report Facts
residents sampled: 38
Inspection Report — Mar 23, 2018
Life Safety
Date: Mar 23, 2018
Visit Reason
CMS-2567 federal health and life safety surveys and Missouri State Form; the survey type is not stated.
Findings
Fourteen deficiencies were cited: nine federal (E- and K- tags) involving emergency preparedness, emergency plan review and testing, HVAC, fire drills, and multiple electrical issues including receptacles, circuit breaker testing, and improper use of extension cords/surge protectors; and five Missouri state (19 CSR) deficiencies concerning fire drill records, toilet room accessibility/ventilation/locks, electrical wiring/equipment maintenance, extension cords/duplex receptacles, and operational policies/procedures.
Deficiencies (9)
E004 Develop EP Plan, Review and Update Annually: Based on record review and interview, the facility failed to develop and maintain a comprehensive emergency preparedness plan with documentation of an annual review and updates and lacked documented emergency water source and phone contact information.
E031 Emergency Officials Contact Information: The facility failed to include contact information for State and Federal emergency preparedness agencies in its emergency preparedness plan.
E039 EP Testing Requirements: The facility failed to conduct or document required emergency preparedness exercises, including participation in a community-based full-scale exercise and additional exercises such as tabletop drills.
K521 HVAC: Based on observation, interview, and record review, the facility failed to ensure the HVAC system operated properly in resident restroom areas, with absent negative airflow observed in multiple restrooms.
K712 Fire Drills: The facility failed to ensure that fire drills were thoroughly documented with simulated size and type and appropriate staff education, lacking documentation of simulated fire type/size for monthly drills.
K914 Electrical Systems - Maintenance and Testing: The facility failed to maintain records and perform required assessments of electrical receptacles at resident bed locations, and observed damaged receptacles.
K918 Electrical Systems - Essential Electric System: The facility did not maintain and test main and feeder circuit breaker panels annually and lacked documentation of locations and annual assessments.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to prevent inappropriate use of extension cords and surge protectors, with multiple resident rooms and facility areas observed using surge protectors and extension cords.
K921 Electrical Equipment - Testing and Maintenance: The facility failed to produce documentation of testing and assessment of surge protectors and other patient-care related electrical equipment, including lack of a location list and testing results.
Report Facts
residents potentially affected: 14
total facility smoke zones: 36
locations with extension cords or outlet adapters observed: 20
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