Inspection Reports for Lee’s Summit Place
1501 SW 3RD ST, LEE'S SUMMIT, MO, 64081-2424
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
48 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 48
Deficiencies: 4
Date: Apr 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations related to medication administration, pressure ulcer care, catheter care, and controlled substance management at Lee's Summit Place.
Findings
The facility failed to ensure medications were administered as ordered, failed to provide appropriate pressure ulcer care and wound management, failed to assess and educate a resident on self-catheterization, and failed to maintain accurate controlled substance documentation and disposal procedures.
Deficiencies (4)
Failed to ensure medications were given as ordered when Lorazepam Intensol was administered without a physician's order for one resident.
Failed to provide appropriate pressure ulcer care, including assessment, monitoring, documentation, and treatment for two residents with pressure injuries.
Failed to assess and educate a resident on self-catheterization, and failed to document self-catheter care and infection prevention.
Failed to ensure accurate documentation on narcotic count sheets and failed to properly dispose of Lorazepam Intensol per policy for one resident.
Report Facts
Facility census: 48
Medication administration: 12
Pressure ulcer sample: 12
Controlled substance count sheet opportunities: 56
Controlled substance count sheet opportunities: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding medication administration, wound care, and controlled substance destruction |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration, wound care, catheter care, and controlled substance policies |
| Pharmacist | Interviewed regarding medication orders and administration | |
| Registered Nurse A | Registered Nurse | Observed providing wound care |
| Certified Nursing Assistant A | Certified Nursing Assistant | Interviewed regarding skin assessments and resident care |
| Medical Director | Medical Director | Interviewed regarding expectations for skin assessments and physician orders |
| Assistant Director of Nursing | Assistant Director of Nursing | Observed providing wound care |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Apr 7, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in two sampled residents.
Complaint Details
The complaint investigation found substantiated deficiencies related to pressure injury care for two residents (Resident #26 and Resident #307). The facility failed to assess, monitor, and treat pressure injuries timely and adequately, with some wounds untreated for 18 days and refusal of care not properly documented.
Findings
The facility failed to follow policies and physician orders related to pressure injury prevention and treatment, including failure to identify at-risk residents, perform and document weekly wound assessments, and implement timely wound care treatments. Two residents had multiple unaddressed pressure injuries, some untreated for up to 18 days, with inadequate documentation and refusal of treatments not properly recorded.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Report Facts
Residents affected: 2
Facility census: 48
Pressure injury measurements: 6
Days untreated: 18
Refused wound treatments: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Involved in wound care observations and interviews regarding wound care treatments and refusals. |
| RN A | Registered Nurse | Observed providing wound care and interviewed regarding wound care treatments. |
| ADON | Assistant Director of Nursing | Observed wound care and interviewed regarding wound care orders and treatments. |
| Medical Director | Interviewed about expectations for wound care assessments and physician orders. | |
| CNA A | Certified Nurse Assistant | Interviewed about responsibilities for skin assessments and reporting skin issues. |
| DON | Director of Nursing | Interviewed about responsibilities for skin assessments, wound care, care plans, and documentation. |
Inspection Report
Routine
Census: 13
Capacity: 60
Deficiencies: 9
Date: Sep 8, 2023
Visit Reason
Routine inspection of Lee's Summit Place nursing home to assess compliance with healthcare regulations including privacy, care planning, dental services, infection control, food safety, and immunizations.
Findings
The facility had multiple deficiencies including failure to maintain resident privacy during medication administration, incomplete care plan updates, lack of documentation of resident belongings at discharge, inadequate supervision of a resident at risk for falls, failure to ensure ongoing communication with dialysis providers, failure to provide annual dental exams and consults, unsanitary kitchen conditions, lapses in hand hygiene and infection control practices, incomplete tuberculosis screening for new employees, and failure to provide pneumococcal vaccinations to eligible residents.
Deficiencies (9)
Failed to ensure residents' private records were kept private during medication pass by not ensuring computer screens were not visible to others.
Failed to provide continuity of resident care by not reviewing and revising resident comprehensive care plans.
Failed to document information regarding resident's personal belongings at discharge.
Failed to provide adequate supervision to prevent accidents for a resident at risk of falls while in wheelchair.
Failed to ensure ongoing communication and collaboration with dialysis facility regarding dialysis care and services.
Failed to provide annual dental exams and dental consults for residents who requested or required them.
Failed to keep kitchen and dry storage room floors clean; maintain sanitary utensils and food preparation equipment; safeguard against foreign material in food; and maintain plastic cutting boards in good condition.
Failed to perform hand hygiene during cares, medication pass, and after handling contaminated items; and failed to follow policy for tuberculosis screening of new employees.
Failed to provide pneumococcal vaccines for an eligible resident.
Report Facts
Facility census: 13
Licensed capacity: 60
Residents sampled: 9
New employees sampled: 10
Residents sampled for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in findings related to privacy breach during medication pass, hand hygiene lapses, and resident care |
| LPN B | Licensed Practical Nurse | Named in findings related to resident supervision and care |
| LPN C | Licensed Practical Nurse | Named in findings related to dental care coordination |
| CMT A | Certified Medication Technician | Named in findings related to privacy, hand hygiene, and dental care |
| CNA B | Certified Nursing Assistant | Named in findings related to resident supervision and care |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including privacy, dental care, infection control, and tuberculosis screening |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in infection control and tuberculosis screening findings |
| Dietary Manager | Dietary Manager (DM) | Named in kitchen sanitation and food safety findings |
| Director of Maintenance | Director of Maintenance (DOM) | Named in kitchen sanitation and maintenance findings |
| Regional Maintenance Director | Regional Maintenance Director (RMD) | Named in kitchen sanitation and maintenance findings |
Inspection Report
Census: 18
Deficiencies: 1
Date: May 3, 2023
Visit Reason
The inspection was conducted due to issues related to the facility management company's failure to ensure timely payments to vendors providing necessary services such as utilities, lawn care, and snow removal.
Findings
The facility management company failed to issue or timely issue payments to Vendor B and Vendor C, resulting in utility shutoff notices and unpaid balances for lawn care and snow removal services. The facility had instituted a new payment approval program, but delays occurred due to lack of steady payment schedules and incomplete system setup or training.
Deficiencies (1)
Failure to ensure payments were issued or issued in a timely manner to Vendor B and Vendor C who provided necessary services to the residents and Vendor C who maintained the lawn care and snow removal services.
Report Facts
Outstanding balance: 3964.95
Outstanding balance: 10573
Facility census: 18
Payment made: 3964.95
Current balance: 1896.66
Outstanding balance: 1050
Last payment date: 2023.0313
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding billing and payment processes |
| Maintenance Director | Maintenance Director | Interviewed regarding lawn care services and vendor payments |
| Administrator | Administrator | Interviewed regarding utility notices and access to payment system |
| Vendor B | Interviewed regarding payments and balances | |
| Vendor A | Interviewed regarding lawn care and snow removal services and unpaid balance | |
| Third Party Accounts Payable | Interviewed regarding new payment approval program and payment delays |
Inspection Report
Routine
Census: 14
Capacity: 60
Deficiencies: 14
Date: May 5, 2022
Visit Reason
Routine inspection of Lee's Summit Place nursing home to assess compliance with regulatory requirements including resident care, medication management, infection control, facility safety, and staffing.
Findings
The facility had multiple deficiencies including failure to provide timely transfer and bed hold notifications, incomplete care plans for residents, medication errors, improper medication storage and labeling, inadequate infection control practices, incomplete tuberculosis testing for employees and residents, failure to post nurse staffing information, unsafe and unsanitary kitchen conditions, lack of a comprehensive facility assessment, and failure to notify residents/families of COVID-19 cases.
Deficiencies (14)
Failed to provide timely written notification to resident and Ombudsman of transfer or discharge to hospital.
Failed to notify resident in writing of facility bed hold policy at time of transfer.
Failed to develop and implement complete care plans addressing pain, diuretics, anticoagulants, and oxygen use for sampled residents.
Failed to ensure recapitulation of stay and disposition of medications and belongings upon discharge for sampled residents.
Failed to ensure medication error rate less than 5%; observed 3 errors in 31 opportunities (9.67%).
Failed to label medications correctly, dispose expired medications, and store medications at appropriate temperatures.
Failed to provide and implement infection prevention and control program including employee TB testing, infection control during medication pass, oxygen and nebulizer tubing storage, and resident TB screening.
Failed to post nurse staffing information daily in a visible location for residents, visitors, and staff.
Failed to maintain sanitary kitchen conditions including clean floors, utensils, equipment, and proper trash disposal.
Failed to conduct and document a complete facility-wide assessment to determine resources necessary to care for residents.
Failed to notify residents and families of COVID-19 positive cases in the facility.
Failed to educate and document education of residents regarding COVID-19 vaccination upon admission.
Failed to maintain safe, sanitary, and well-graded driving surface for evacuation and emergency vehicles.
Failed to maintain an effective pest control program and follow standard trash disposal practices to mitigate presence of ants.
Report Facts
Medication errors observed: 3
Facility census: 14
Facility licensed capacity: 60
Exterminator visits: 4
TB skin test timing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee D | Employee TB testing not completed according to standards. | |
| Employee E | Employee TB testing not completed according to standards. | |
| Employee F | Employee TB testing not completed according to standards. | |
| Registered Nurse A | RN | Named in medication administration errors and infection control deficiencies. |
| Agency Licensed Practical Nurse A | LPN | Named in medication administration and infection control deficiencies. |
| Certified Medication Technician A | CMT | Named in medication administration and infection control deficiencies. |
| Social Services Director | SSD | Named in transfer and discharge notification deficiencies. |
| Administrator | Named in multiple interviews regarding facility deficiencies and expectations. | |
| Dietary Manager | Named in kitchen sanitation and pest control deficiencies. | |
| Maintenance Director | Named in facility safety and infection control deficiencies. | |
| Regional Maintenance Director | Named in infection control documentation deficiencies. |
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