Inspection Reports for
Life Care Center of Grandview
6301 EAST 125TH ST, GRANDVIEW, MO, 64030-1884
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
15.9 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
189% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
62% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 2
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to multiple resident-to-resident abuse incidents reported at the facility, including physical altercations and inappropriate behaviors among residents.
Complaint Details
The complaint investigation was substantiated. Multiple resident-to-resident abuse incidents occurred on 10/10/25, 10/16/25, and 10/23/25 involving slapping, punching causing injuries, and throwing hot sauce. The facility also involuntarily discharged a resident involved in altercations without allowing return, which was not compliant with regulations.
Findings
The facility failed to protect residents from abuse, as evidenced by three separate incidents involving physical aggression and harmful behaviors between residents. The facility also failed to ensure safe transfer/discharge procedures for a resident involved in altercations.
Deficiencies (2)
F 0600: The facility failed to protect residents from all types of abuse, including physical abuse, as three residents were involved in incidents of hitting, slapping, punching, and pouring hot sauce on another resident's face.
F 0627: The facility failed to ensure the transfer/discharge met the resident's needs and preferences, as one resident was involuntarily discharged and not allowed back after hospital transfer related to behavioral issues.
Report Facts
Residents in sample: 13
Facility census: 106
Residents affected: 3
Resident-to-resident altercations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide A | Witnessed resident altercations and reported observations | |
| Licensed Practical Nurse (LPN) A | LPN | Reported observations during dining room altercation |
| Director of Nursing (DON) | Director of Nursing | Provided statements on abuse incidents and facility response |
| Facility Physician A | Physician | Provided medical opinions on resident behaviors and incidents |
| Certified Nursing Assistant (CNA) B | CNA | Responded to calls for help during resident altercations |
| Nurse Practitioner (NP) A | Nurse Practitioner | Provided clinical input on resident behavioral history |
| Social Services Designee (SSD) | Social Services Designee | Handled discharge notices and referrals for resident involved in altercations |
| Administrator | Administrator | Provided oversight and statements regarding incidents and resident discharge |
Inspection Report
Follow-Up
Census: 104
Deficiencies: 1
Date: Sep 25, 2024
Visit Reason
The visit was a follow-up inspection to verify correction of a previous deficiency related to medication administration errors.
Findings
The facility failed to ensure one sampled resident was free of significant medication errors, specifically related to the administration of Lamotrigine Extended Release. The deficiency was corrected by 9/19/24 after staff in-service and medication administration observations.
Deficiencies (1)
F 760 Residents are free of significant medication errors. The facility failed to ensure one resident did not receive an ordered dose of Lamotrigine Extended Release and received incorrect doses on multiple days.
Report Facts
Facility census: 104
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 1
Date: Sep 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a significant medication error involving a resident who did not receive the correct dose of seizure medication upon admission.
Complaint Details
The complaint investigation found that the resident did not receive the correct seizure medication dose due to pharmacy delivery errors and staff failing to use the Omnicell medication dispensing system properly. The medication errors were substantiated with a root cause analysis conducted by the facility.
Findings
The facility failed to ensure one resident was free from significant medication errors when the resident did not receive the ordered dose of Lamotrigine on admission and received incorrect doses on subsequent days. The medication errors were linked to pharmacy delivery issues and staff not following medication administration policies.
Deficiencies (1)
F0760: The facility failed to ensure residents were free from significant medication errors when one resident did not receive the ordered dose of Lamotrigine on 9/14/24 and received incorrect doses on 9/16/24 and 9/17/24.
Report Facts
Residents present: 104
Medication doses missed or incorrect: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Interviewed regarding medication order processing and error detection |
| LPN F | Licensed Practical Nurse | Interviewed about order entry and medication verification procedures |
| LPN B | Licensed Practical Nurse | Interviewed about medication administration and error |
| Director of Nursing | Director of Nursing | Interviewed about medication administration policies and error investigation |
| LPN C | Licensed Practical Nurse | Interviewed about medication administration and order verification |
| LPN D | Licensed Practical Nurse | Interviewed about medication administration and order verification |
| Administrator | Administrator | Interviewed about nursing staff expectations and medication error follow-up |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 2
Date: Jun 7, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of resident-to-resident abuse and a separate investigation into the missing narcotic medication at the facility.
Complaint Details
The complaint investigation substantiated that Resident #507 struck Resident #508 causing injury. The facility's investigation found the incident was due to Resident #507 being startled and not intentional abuse. The narcotic medication loss was confirmed after a delivery was signed for but medications were not verified or counted, leading to missing narcotics.
Findings
The facility failed to protect residents from abuse when Resident #507 struck Resident #508 causing injury. Additionally, the facility failed to ensure safe storage and accountability of controlled substances, resulting in the loss of 30 tablets of Oxycodone for Resident #500. Both issues were addressed with staff education and corrective actions.
Deficiencies (2)
F 0600: The facility failed to protect residents from abuse when Resident #507 hit Resident #508 causing injury to the lip and bruising. The incident was investigated and staff were educated on abuse prevention.
F 0761: The facility failed to ensure safe storage and accountability of controlled substances, resulting in the missing 30 tablets of Oxycodone 10 mg for Resident #500. Staff failed to verify and sign for medication delivery properly.
Report Facts
Residents present: 115
Missing narcotic tablets: 30
Residents sampled: 19
Residents sampled for medication: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Signed for narcotic medication delivery but failed to verify contents, implicated in medication loss |
| CNA A | Certified Nursing Assistant | Witnessed and intervened in resident abuse incident |
| CNA C | Certified Nursing Assistant | Witnessed resident abuse incident and intervened |
| CMT A | Certified Medication Technician | Witnessed resident abuse incident and assisted |
| Administrator | Facility Administrator | Interviewed regarding abuse incident and medication loss |
| Pharmacy General Manager | Pharmacy General Manager | Provided in-service training on medication security and delivery verification |
| Former Director of Nursing | Director of Nursing | Reported missing narcotic medication and conducted search |
Inspection Report
Routine
Census: 115
Deficiencies: 14
Date: May 9, 2024
Visit Reason
Routine inspection of Life Care Center of Grandview to assess compliance with healthcare regulations including resident care, infection control, medication management, and facility safety.
Findings
The facility had multiple deficiencies including failure to coordinate mental health assessments, incomplete care plans, inadequate dental services, improper use of braces, incomplete fall investigations, inadequate nutrition monitoring, improper oxygen equipment maintenance, failure to implement infection control protocols including Enhanced Barrier Precautions, incomplete medication regimen reviews, and failure to provide required vaccinations and tuberculosis screenings.
Deficiencies (14)
F0644: The facility failed to coordinate assessments with the Pre-admission Screening and Resident Review program and failed to refer one resident with a newly diagnosed mental disorder to a level two review.
F0645: The facility failed to complete a Preadmission Screening and Resident Review for one resident, missing required screening within 72 hours of admission.
F0657: The facility failed to develop and revise comprehensive care plans addressing dental issues and refusals of care for two residents.
F0688: The facility failed to ensure a resident's brace was applied as ordered and documented, resulting in lack of proper support for limited range of motion.
F0689: The facility failed to complete comprehensive fall investigations including documentation of fall prevention measures and root cause analysis for one resident at risk for falls.
F0692: The facility failed to ensure a resident with a feeding tube was weighed regularly and oral intake was documented to maintain adequate nutrition.
F0695: The facility failed to maintain oxygen equipment in a sanitary condition, failed to change oxygen tubing weekly, and failed to provide water in humidifiers for three residents on oxygen therapy.
F0699: The facility failed to assess and provide trauma-informed care including identification of triggers and interventions for a resident with PTSD.
F0756: The facility failed to ensure timely physician response to consultant pharmacist medication recommendations for one resident.
F0791: The facility failed to provide dental services for two residents with broken or missing teeth and failed to provide a dental consultation for one resident with an order for oral surgery.
F0812: The facility failed to maintain sanitary food service conditions including unclean dry storage and freezer floors, lack of thermometers in refrigerators, and failure to change deep fryer oil timely.
F0880: The facility failed to establish and maintain a comprehensive infection prevention and control program including waterborne pathogen management, failed to ensure proper hand hygiene and Enhanced Barrier Precautions during wound and catheter care, and failed to prevent cross-contamination.
F0883: The facility failed to provide education, obtain signed consent or refusal, and document pneumococcal vaccinations for multiple residents.
F0887: The facility failed to provide education, obtain signed consent or refusal, and document COVID-19 vaccinations for multiple residents.
Report Facts
Facility census: 115
Deficiencies cited: 13
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 2
Date: Feb 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation and exploitation of a resident's property by a Certified Nurses Aide (CNA).
Complaint Details
The complaint was substantiated based on evidence including resident bank statements, interviews with staff and family, and a police report. The CNA was suspended and the matter was referred to the Prosecutor's Office.
Findings
The facility failed to protect a resident from misappropriation when a CNA used the resident's debit card for personal charges totaling $4,607.20. The investigation included interviews, record reviews, and a police report confirming fraudulent charges and employee suspension.
Deficiencies (2)
F602 Free from Misappropriation/Exploitation: The facility failed to protect a resident from misappropriation when a CNA used the resident's debit card for personal charges totaling $4,607.20. The resident's family reported unusual charges, and the CNA was suspended pending investigation.
A8023 Develop/Implement Abuse/Neglect Policies: The facility did not develop and implement policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds. This deficiency was classified as Class II due to the extent and effect on residents.
Report Facts
Resident census: 119
Fraudulent charges: 4607.2
Dates of charges: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ron Hicks | Executive Director | Signed and approved the plan of correction |
| CNA A | Certified Nurses Aide implicated in misappropriation of resident funds | |
| Director of Nursing | Director of Nursing | Interviewed regarding CNA employment and knowledge of misappropriation |
| Administrator | Administrator | Interviewed about notification of fraudulent charges and police report |
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's debit card and checks at the facility.
Complaint Details
The complaint was substantiated. The resident's debit card and checks were missing and used without authorization. The facility reported the incident to police and conducted an internal investigation. The resident was assisted in recovery and staff were educated on abuse and neglect policies.
Findings
The facility failed to protect one resident from misappropriation of property involving unauthorized use of the resident's debit card and cashed checks. The facility initiated an investigation, notified authorities, and provided staff education on abuse and neglect policies.
Deficiencies (1)
F 0602: The facility failed to protect a resident from misappropriation of property when the resident's debit card was used for unauthorized purchases and checks were cashed without consent.
Report Facts
Residents present: 121
Unauthorized debit card purchase: 60
Declined debit card purchase: 11.6
Check cashed: 875
Check cashed: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Reported missing debit card and checkbook to Director of Nursing |
| SSA | Social Service Assistant | Assisted resident to bank and reported missing debit card and checks |
| DON | Director of Nursing | Notified of missing debit card and checkbook, led investigation |
| Administrator | Facility Administrator | Notified of incident and involved in investigation |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 1
Date: May 3, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected sexual abuse between residents on 4/30/2023.
Complaint Details
The complaint investigation was substantiated. The facility failed to report suspected sexual abuse immediately as required. Multiple staff including Agency CNA B, Agency CNA C, and LPN D did not report the incident on 4/30/23. The Administrator acknowledged the policy but did not initially consider the allegation credible. Staff were educated after the incident.
Findings
The facility failed to ensure that all alleged allegations of sexual abuse were reported immediately, but not later than two hours, involving Agency CNAs and an LPN who did not report suspicious activity between residents. The facility educated staff on abuse reporting policy following the incident.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. The failure involved delayed reporting of alleged sexual abuse between residents on 4/30/23.
Report Facts
Facility census: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency Certified Nurse Aide (CNA) B | Failed to report suspicious activity between residents on 4/30/23 | |
| Agency Certified Nurse Aide (CNA) C | Failed to report suspicious activity between residents on 4/30/23 | |
| Licensed Practical Nurse (LPN) D | Failed to report suspicious activity between residents on 4/30/23 | |
| Director of Nursing (DON) | Interviewed regarding the incident and reporting policy | |
| Administrator | Interviewed regarding the incident and reporting policy |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 2
Date: Dec 30, 2022
Visit Reason
The inspection was conducted in response to allegations of abuse and neglect involving a Certified Nursing Assistant (CNA) and a resident at Life Care Center of Grandview.
Complaint Details
The complaint investigation substantiated that improper actions and unprofessional physical contact by the CNA occurred. The facility failed to report the abuse immediately as required. The deficiency was corrected on 12/29/22.
Findings
The facility failed to prevent abuse when a CNA grabbed a resident's left ankle and pushed him/her backwards in bed, causing skin tears and bruising. The facility also failed to report the alleged abuse immediately as required by regulations.
Deficiencies (2)
F600: The facility failed to ensure a resident was free from abuse when a CNA grabbed the resident's left ankle and pushed him/her backwards in bed, resulting in skin tears and bruising. The facility census was 120 residents at the time.
F609: The facility failed to report an alleged abuse incident immediately, reporting it more than two hours after the event occurred, violating reporting requirements. The facility census was 120 residents at the time.
Report Facts
Facility census: 120
Sampled residents: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in abuse incident involving resident |
| RN B | Registered Nurse | Responded to abuse incident and involved in investigation |
| Ron Hicks | Executive Director | Administrator notified of noncompliance and involved in corrective actions |
Inspection Report
Life Safety
Census: 112
Capacity: 172
Deficiencies: 7
Date: Aug 8, 2022
Visit Reason
An Emergency Preparedness portion of a Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid emergency preparedness requirements and life safety code provisions.
Findings
The facility was found not in compliance with several Life Safety Code requirements including discharge from exits, cooking facilities maintenance, sprinkler system maintenance, smoke barrier doors, smoking regulations, electrical equipment safety, and gas equipment qualifications. Multiple deficiencies potentially affected residents in various smoke zones.
Deficiencies (7)
K271 Discharge from exits was not maintained free of obstructions and all-weather surfaces were damaged, potentially affecting 62 residents in three smoke zones.
K324 Cooking facilities failed to have a grease drip tray on the range hood, potentially affecting 25 residents in one smoke zone.
K353 Sprinkler heads outside the south entrance and in the kitchen showed green corrosion, potentially affecting two smoke zones.
K374 Smoke barrier doors failed to maintain astragal seals, causing doors not to close completely during fire alarm tests, potentially affecting 45 residents in two smoke zones.
K741 Smoking regulations were not enforced; cigarette butts were improperly disposed of in outdoor areas, affecting outdoor areas of the facility.
K919 Electrical equipment safety was compromised by cracked outlet covers, frayed cords, and improper storage of cardboard boxes, potentially affecting at least 20 residents in four smoke zones.
K926 Oxygen cylinders were not stored properly with supports or chained in the oxygen storage room, potentially affecting at least 20 residents in one smoke zone.
Report Facts
Residents present: 112
Licensed capacity: 172
Residents potentially affected by discharge from exits deficiency: 62
Residents potentially affected by cooking facilities deficiency: 25
Residents potentially affected by smoke barrier doors deficiency: 45
Residents potentially affected by electrical equipment deficiency: 20
Residents potentially affected by oxygen storage deficiency: 20
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 21
Date: Aug 8, 2022
Visit Reason
Complaint investigation triggered by allegations of misappropriation, inadequate care, and regulatory compliance issues.
Complaint Details
Multiple complaints including misappropriation of resident funds, inadequate care, environmental cleanliness, staffing shortages, and food service delays.
Findings
The facility was found deficient in multiple areas including resident funds notification, advance directive transcription, Medicaid/Medicare beneficiary notification, environmental cleanliness, resident rights violations, medication administration, catheter and ostomy care, feeding tube management, respiratory care, dialysis care, staffing adequacy, food service timeliness and safety, call light availability, and pest control.
Deficiencies (21)
F 0569: Facility failed to notify residents timely about spend down plans and failed to send Third Party Liability forms within 30 days of resident deaths.
F 0578: Facility failed to transcribe and verify advance directive orders correctly for one resident, resulting in conflicting code status orders.
F 0582: Facility failed to provide Medicaid/Medicare beneficiary notification to one resident discharged from Medicare.
F 0584: Facility failed to maintain a safe, clean, and homelike environment including torn transfer pole grips, buildup of grime and dust, damaged mattress, and stained bed sheets.
F 0602: Facility failed to prevent misappropriation of resident property when a CNA used a resident's debit card for unauthorized purchases totaling $278.97.
F 0657: Facility failed to update care plans to reflect pressure ulcer development and failed to include resident or representative in care plan development for sampled residents.
F 0677: Facility failed to ensure residents unable to perform ADLs had call lights answered timely and received necessary personal hygiene care.
F 0678: Facility failed to maintain current CPR certification for staff and failed to monitor CPR certification status and availability on all shifts.
F 0686: Facility failed to provide appropriate pressure ulcer care including repositioning every 2 hours for a resident with a Stage III pressure ulcer.
F 0689: Facility failed to ensure infection control during suprapubic catheter care and failed to monitor catheter drainage bags timely for sampled residents.
F 0690: Facility failed to ensure complete physician orders and monitoring for feeding tube care, failed to document nutritional intake adjustments, and failed to check gastric residual volume prior to flushing for sampled residents.
F 0695: Facility failed to ensure safe and appropriate respiratory care including oxygen therapy and breathing treatments, and failed to maintain oxygen equipment and supplies properly.
F 0698: Facility failed to ensure dialysis orders included access site monitoring and failed to consistently document dialysis site monitoring and communication with dialysis center.
F 0725: Facility failed to provide sufficient nursing staff to meet resident needs including timely answering of call lights and providing care.
F 0802: Facility failed to ensure sufficient dietary staff to serve meals timely, resulting in late meal delivery.
F 0803: Facility failed to provide recipes for seafood casserole and pureed carrots for dietary staff to follow.
F 0812: Facility failed to maintain kitchen and storage areas clean and free from contamination including grime, stained cutting boards, unclean dishwasher nozzles, damaged refrigerator gaskets, and moldy produce.
F 0813: Facility failed to have a policy and practice to ensure safe storage and labeling of foods brought by family or visitors in resident refrigerators.
F 0814: Facility failed to ensure trash container in kitchen was closed when not in use.
F 0919: Facility failed to provide accessible call light systems in resident rooms for residents who needed them, including residents in dementia unit where call lights were removed due to safety concerns.
F 0925: Facility failed to prevent pest infestation including presence of gnats, flies, dead insects in kitchen and storage areas, and sprinkler room.
Report Facts
Residents affected: 112
Unauthorized purchases: 278.97
Call light wait time: 58
Meal delay: 61
Temperature: 109.9
Temperature: 108.8
Urine volume: 4000
Dialysis treatments: 3
Tube feeding rate: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nurse Assistant | Named in misappropriation of resident property finding |
| RN B | Registered Nurse | Named in dialysis communication and staffing shortage findings |
| DM | Dietary Manager | Named in dietary staffing and food preparation findings |
| DON | Director of Nursing | Named in multiple findings including staffing, dialysis communication, and medication administration |
Inspection Report
Routine
Deficiencies: 0
Date: Jan 7, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 2
Date: Jan 27, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding verbal abuse by a housekeeper toward a resident and improper storage of medications.
Complaint Details
The complaint investigation was substantiated with findings of verbal abuse by Housekeeper A and improper medication storage leading to missing medications.
Findings
The facility failed to prevent verbal abuse by a housekeeper toward a resident and failed to secure medications properly, resulting in missing medications. The facility took corrective actions including terminating the housekeeper and providing staff training.
Deficiencies (2)
F600 Freedom from Abuse and Neglect: The facility failed to prevent verbal abuse by Housekeeper A toward a resident. The housekeeper was terminated and staff received abuse training.
F761 Label/Store Drugs and Biologicals: The facility failed to secure medications properly, leaving medication and treatment carts unlocked, resulting in missing medications for one resident.
Report Facts
Facility census: 95
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Named in verbal abuse finding and termination | |
| Director of Nurses (DON) | Director of Nurses | Notified of deficiencies and involved in investigation and corrective actions |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Involved in medication storage deficiency and investigation |
| Regional Nurse | Regional Nurse | Involved in medication count and investigation |
Inspection Report
Routine
Deficiencies: 0
Date: Dec 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 6
Date: Oct 9, 2020
Visit Reason
The inspection was conducted as a complaint investigation focusing on resident fund management and enteral tube feeding practices.
Complaint Details
Complaint investigation related to resident fund management and PEG tube care. Complaints MO 00167253, MO 00167828, and MO 00172833 were referenced. The higher classification was merited due to the extent of the violations.
Findings
The facility was found noncompliant with regulations regarding the management of residents' personal funds, including failure to obtain proper authorization signatures for withdrawals. Additionally, the facility failed to accurately assess and verify placement of residents' PEG tubes and maintain proper food temperature standards.
Deficiencies (6)
F567 Resident fund management was deficient as the facility failed to ensure resident authorizations for withdrawals and proper documentation for two residents. The facility census was 87 residents.
F693 The facility failed to accurately assess and verify placement of residents' PEG tubes for multiple residents, including failure to follow policy and physician orders.
F804 The facility failed to maintain hot breakfast foods at the required temperature, affecting at least 10 residents in the 400 hall.
A4074 Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by deficiencies in PEG tube care and resident fund management.
A5005 The facility failed to assure that hot food is served hot and cold food is served cold, impacting resident satisfaction and safety.
A9002 The operator failed to use residents' personal funds exclusively for their use and only with proper authorization, as evidenced by unauthorized withdrawals.
Report Facts
Facility census: 87
Residents affected by hot food temperature: 10
Unauthorized withdrawal amount: 417.85
Unauthorized withdrawal amount: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Smith | Director of Nursing | Named in interview regarding PEG tube placement verification |
Inspection Report
Routine
Deficiencies: 0
Date: Aug 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jul 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Apr 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 4/23/20 to assess compliance with CMS and CDC recommended practices and relevant regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Routine
Census: 119
Deficiencies: 16
Date: Oct 4, 2019
Visit Reason
Routine inspection of Life Care Center of Grandview to assess compliance with regulatory requirements related to resident rights, safety, care planning, medication administration, environment, and food safety.
Findings
The facility had multiple deficiencies including failure to protect resident funds from negative balances, improper management of resident personal money, unsafe and unclean equipment and environment, inaccurate resident assessments and care plans, lack of physician orders for catheter use, inadequate fall prevention interventions, failure to monitor and encourage food intake for residents with weight loss, improper use of psychotropic medications, insulin administration errors, poor food safety and sanitation practices, failure to label and date visitor food, unsafe environmental conditions, and pest control issues.
Deficiencies (16)
F 0567: The facility failed to protect resident fund balances from going negative due to withdrawal mechanisms that did not separate resident accounts from outside financial institutions.
F 0568: The facility failed to properly account for change returned when residents signed out money for shopping trips.
F 0584: The facility failed to maintain commode risers free from rust and failed to notify therapy and maintenance about damaged wheelchair cushions and handles.
F 0584: Communication breakdown between departments regarding equipment needs and maintenance issues was noted.
F 0625: The facility failed to provide written bed hold policy information to residents or their representatives during hospital transfers or therapeutic leaves.
F 0641: The facility failed to ensure accuracy of assessments for one resident, marking restraint use on the MDS without evidence of restraint use.
F 0656: The facility failed to develop comprehensive care plans reflecting current health care needs for two residents, missing key diagnoses and interventions.
F 0658: The facility failed to obtain a physician's order for an indwelling urinary catheter and failed to care plan the resident's catheter needs.
F 0689: The facility failed to implement fall interventions and adequate supervision for a resident at high risk for falls with multiple recent falls.
F 0692: The facility failed to monitor a resident with significant weight loss during meals to ensure physician ordered supplements were given and encouragement to eat was provided.
F 0758: The facility failed to ensure psychotropic medication was clinically indicated and supported by documented rationale and care planning for a resident prescribed antipsychotic medication without appropriate diagnosis.
F 0760: The facility failed to prime insulin pens with 2 units of insulin before administration for two residents, contrary to policy and training.
F 0812: The facility failed to maintain kitchen and food preparation areas free of grease buildup, food debris, gnats, and unclean equipment, and failed to follow proper infection control practices.
F 0813: The facility failed to ensure visitor brought-in food was labeled and dated in resident refrigerators.
F 0921: The facility failed to maintain a safe and sanitary environment including dust buildup on fans, damaged doors, and unsafe equipment in resident rooms and common areas.
F 0925: The facility failed to maintain pest control, with presence of gnats, ants, mouse droppings, and dead insects in kitchen, dining, and resident areas.
Report Facts
Facility census: 119
Resident weight loss percentage: 7.29
Resident weight loss percentage: 9.38
Resident weight loss percentage: 18.3
Fall risk score: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager A | Business Office Manager | Interviewed regarding resident fund management and personal money accounting |
| Director of Nursing | Director of Nursing | Interviewed regarding wheelchair maintenance, bed hold policy, care plans, fall interventions, insulin administration, and medication reviews |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding bed hold policy, fall interventions, insulin pen priming, and resident care |
| Certified Nurse's Assistant D | Certified Nurse's Assistant | Interviewed regarding catheter care and resident fall risk |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen cleanliness, pest control, and food safety |
| Dietary Aide A | Dietary Aide | Interviewed regarding kitchen cleanliness and pest control |
Inspection Report
Annual Inspection
Census: 119
Deficiencies: 15
Date: Oct 4, 2019
Visit Reason
Annual inspection of Life Care Center of Grandview to assess compliance with federal and state regulations for nursing homes.
Findings
The facility was found to have multiple deficiencies including failure to protect residents' personal funds, maintain accurate accounting records, ensure a safe and clean environment, implement effective care plans, and maintain proper food safety and pest control. Several residents were affected by these deficiencies.
Deficiencies (15)
F567 Protection/Management of Personal Funds: The facility failed to protect the resident fund balance for two sampled residents from negative balances due to withdrawal mechanisms outside the facility.
F568 Accounting and Records of Personal Funds: The facility failed to maintain a full and complete accounting of residents' personal funds and failed to account for change returned to residents.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain commode risers free from rust and failed to maintain a wheelchair in good repair.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to provide written notice of the bed hold policy to sampled residents during hospital stays or therapeutic leave.
F641 Accuracy of Assessments: The facility failed to ensure the accuracy of assessments for one sampled resident.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive care plans reflecting residents' needs for two sampled residents.
F658 Services Provided Meet Professional Standards: The facility failed to obtain a physician's order for an indwelling urinary catheter and failed to provide care consistent with professional standards for one sampled resident.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure fall prevention interventions for one sampled resident at risk for falls.
F692 Nutrition/Hydration Status Maintenance: The facility failed to ensure adequate nutrition and hydration for one sampled resident.
F758 Free from Unnecessary Psychotropic Medications/PRN Use: The facility failed to ensure proper use and documentation of psychotropic medications for one sampled resident.
F760 Residents are Free of Significant Medication Errors: The facility failed to ensure residents were free of significant medication errors for two sampled residents.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to maintain sanitary conditions in food preparation and storage areas, affecting approximately 110 residents.
F813 Personal Food Policy: The facility failed to follow the visitor foods policy, resulting in unlabeled and undated food items in refrigerators.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain a safe and sanitary environment, including dust buildup and damaged equipment in resident areas.
F925 Maintains Effective Pest Control Program: The facility failed to maintain an effective pest control program, with presence of ants, gnats, and mouse droppings.
Report Facts
Facility Census: 119
Residents Sampled: 33
Residents Affected: 2
Residents Affected: 4
Residents Affected: 4
Residents Affected: 2
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 2
Residents Affected: 110
Inspection Report
Life Safety
Census: 119
Capacity: 172
Deficiencies: 14
Date: Oct 4, 2019
Visit Reason
An Emergency Preparedness portion of a Life Safety Code Survey was conducted to assess compliance with emergency preparedness and fire safety regulations.
Findings
The facility was found not in compliance with emergency preparedness requirements including tracking of staff and patients during evacuation, maintaining updated contact lists, communication plans, and fire safety measures such as means of egress, fire alarm testing, sprinkler system maintenance, and door locking mechanisms.
Deficiencies (14)
E018 CFR(s): 483.73(b)(2) Procedures for tracking of staff and patients: The facility failed to include a plan on how to keep track of residents and staff at other locations during evacuation, potentially affecting all residents.
E026 CFR(s): 483.73(b)(8) Roles under a waiver declared by Secretary: The facility failed to include a policy regarding procedures for applying for and implementing 1135 waivers during emergencies, affecting all residents and staff.
E030 CFR(s): 483.73(c)(1) Names and contact information: The facility failed to maintain an updated list of facility staff, including those no longer employed, potentially affecting timely contact of off-duty personnel.
E032 CFR(s): 483.73(c)(3) Primary/Alternate means of communication: The facility failed to include specifications of backup communication devices such as walkie-talkies, affecting all employees.
E041 CFR(s): 483.73(e) Hospital CAH and LTC emergency power: The facility failed to obtain a letter from the local natural gas company demonstrating reliability during emergencies, potentially affecting all residents.
K211 CFR(s): NFPA 101 Means of Egress: The facility failed to maintain clear egress paths in corridors, with obstructions affecting 74 residents in three smoke zones.
K222 CFR(s): NFPA 101 Egress Doors: The facility failed to ensure locks on doors to storage and kitchen areas were not secured with padlocks, affecting at least 15 dietary employees in one smoke zone.
K321 CFR(s): NFPA 101 Hazardous Areas: The facility failed to maintain the area around clothes dryers free of lint buildup and failed to install a self-closing device on a door, affecting at least 30 residents in two smoke zones.
K345 CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance: The facility failed to ensure semi-annual fire alarm inspections were conducted, affecting all residents and staff.
K354 CFR(s): NFPA 101 Sprinkler System - Out of Service: The facility failed to develop a fire watch plan during sprinkler system impairment lasting over 10 hours, affecting all residents and staff.
K363 CFR(s): NFPA 101 Corridor - Doors: The facility failed to maintain door latching hardware and failed to keep the East Assist dining room door closed, potentially affecting residents in two smoke zones.
K372 CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barriers between nurse stations and dining rooms, affecting 54 residents in four smoke zones.
K741 CFR(s): NFPA 101 Smoking Regulations: The facility failed to maintain the area under the walk-in refrigerator compressor free of dried leaves and cigarette butts, affecting all residents.
K919 CFR(s): NFPA 101 Electrical Equipment - Other: The facility failed to prevent use of frayed cords and improperly plugged electrical equipment in administrative and resident areas, potentially affecting residents in four smoke zones.
Report Facts
Facility census: 119
Total licensed capacity: 172
Employees no longer working: 19
Employees terminated in 2019: 20
Lint buildup: 4
Lint buildup: 7
Fire alarm inspections: 1
Sprinkler system impairment duration: 10
Residents affected by egress obstruction: 74
Dietary employees affected by padlock issue: 15
Residents affected by lint buildup: 30
Residents affected by smoke barrier issues: 54
Inspection Report
Plan of Correction
Census: 114
Deficiencies: 18
Date: Sep 28, 2018
Visit Reason
The document is a Plan of Correction submitted by Life Care Center of Grandview following a regulatory inspection conducted on 09/28/2018. It addresses deficiencies identified during the inspection.
Findings
The Plan of Correction outlines multiple deficiencies related to resident care, staff training, documentation, infection control, and regulatory compliance. The facility failed to meet several regulatory requirements including self-determination, Medicaid/Medicare coverage notices, abuse/neglect policies, transfer/discharge notices, accuracy of assessments, and care planning.
Deficiencies (18)
F 561 Self-determination: Resident #14 had care plan and care card updated to reflect preferred time to be gotten up in the morning. Staff will be educated on honoring residents' preferences.
F 582 Medicaid/Medicare Coverage/Liability Notice: Resident #169 was interviewed and found not to have been notified of discharge as required. SNFABN and NOMNC were issued.
F 607 Abuse/Neglect Policies: Staff background checks and Nurse Aide Registry checks were not consistently completed. New hires will be monitored to ensure compliance.
F 623 Notice Requirements Before Transfer/Discharge: Residents discharged to hospital were not provided proper notification or documentation of transfer/discharge.
F 625 Notice of Bed Hold Policy Before/Upon Transfer: Facility failed to provide written notice of bed hold policy to residents prior to transfer or discharge.
F 641 Accuracy of Assessments: Residents #99 and #57 did not have comprehensive MDS assessments completed with accurate information.
F 645 PASARR Screening for MD & ID: Facility failed to ensure PASARR screening was completed and documented for residents with mental disorders or intellectual disabilities.
F 655 Comprehensive Person-Centered Care Planning: Baseline care plans were not developed timely or updated to reflect residents' needs and preferences.
F 657 Care Plan Timing and Revision: Care plans were not updated after resident falls or significant changes in condition.
F 658 Services Provided Meet Professional Standards: Residents receiving tube feedings were not adequately monitored or documented for feeding tube care.
F 685 Treatment/Devices to Maintain Hearing/Vision: Residents who wear glasses were not properly assessed or provided with adequate care and documentation.
F 686 Skin Care/Pressure Sores: Residents with pressure ulcers did not receive adequate wound care or documentation. Facility failed to prevent pressure ulcers and provide appropriate treatment.
F 692 Nutrition/Hydration Status Maintenance: Facility failed to ensure adequate hydration and nutrition for residents, including monitoring and documentation.
F 725 Sufficient Nursing Staff: Facility was short staffed with licensed nurses and CNAs during the inspection period, impacting resident care.
F 730 Nurse Aide Perform Review-12 hrly In-Service: Facility failed to provide required in-service training for nursing staff, including dementia care.
F 741 Sufficient Competent Staff-Behav Health Needs: Facility failed to provide adequate training for staff on behavioral health and dementia care.
F 758 Free from Unnec Psychotropic Meds/PRN Use: Residents receiving psychotropic medications were not properly monitored or documented for side effects and indications.
F 880 Infection Prevention and Control: Facility failed to maintain an effective infection control program, including hand hygiene, isolation precautions, and staff training.
Report Facts
Facility census: 114
Plan of Correction completion date: Nov 7, 2018
Inspection Report
Life Safety
Census: 114
Capacity: 172
Deficiencies: 2
Date: Sep 28, 2018
Visit Reason
The inspection was conducted to evaluate the facility's compliance with the 2012 edition of the Life Safety Code and related fire safety regulations, including fire alarm system testing and maintenance, and fire drill requirements.
Findings
The facility failed to provide complete documentation and testing of the fire alarm system, including missing inventory and sensitivity reports. Additionally, the facility did not conduct quarterly fire drills at varying times as required and lacked documentation of fire alarm transmission signals to the monitoring company.
Deficiencies (2)
K345 Fire Alarm System - The facility failed to provide complete documentation of the annual fire alarm inspection, including inventory, sensitivity ranges, and locations of alarm devices. The semi-annual visual inspection of fire alarm components was not performed.
K712 Fire Drills - The facility failed to conduct quarterly fire drills at varying times on one of three scheduled employee shifts and lacked documentation on drill size, type, staff response time, and fire alarm transmission signals.
Report Facts
Facility census: 114
Licensed capacity: 172
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scott Harris | Administrator | Signed the inspection report and plan of correction |
| Maintenance Director | Interviewed regarding fire alarm inspection and fire drills |
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