6 Reports
Inspection Report — Aug 20, 2025
Routine CMS
Date: Aug 20, 2025
Visit Reason
Routine inspection of Life Care Center of Kansas City to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to ensure wheelchair foot pedals were used, call lights were within reach, privacy of medical records, discharge documentation, mouth care for tube-fed residents, pressure ulcer prevention, range of motion exercises, securing oxygen tanks, medication security, medication monitoring, food safety, antibiotic stewardship, and vaccination documentation.
Deficiencies (13)
F 0558: The facility failed to ensure Resident R2's wheelchair foot pedals were used and Resident R43's call light was within reach, placing residents at risk for preventable accidents.
F 0583: The facility failed to secure protected health information for Resident R31, risking decreased psychosocial well-being due to lack of privacy.
F 0628: The facility failed to provide a final summary of discharge status for Residents R64 and R1, risking delayed or uncommunicated care needs.
F 0677: The facility failed to provide mouth care for Resident R43 who required assistance, risking complications from poor hygiene.
F 0686: The facility failed to ensure pressure-reducing boots were applied to Resident R58's heels, increasing risk for pressure ulcer development.
F 0688: The facility failed to provide range of motion exercises for Resident R54, risking further decline in mobility.
F 0689: The facility failed to secure 44 oxygen tanks in a locked area and failed to ensure fall interventions were in place for Resident R2, risking accidents and injuries.
F 0756: The facility failed to ensure the consultant pharmacist identified and reported lack of monitoring for antihypertensive medication for Resident R10, risking adverse medication effects.
F 0757: The facility failed to follow pharmacist recommendations for monitoring antihypertensive medications for Resident R10, risking adverse effects and unnecessary medications.
F 0761: The facility failed to secure medications at the nurse's station, risking unnecessary medication and administration errors.
F 0812: The facility failed to follow sanitary dietary standards including sticky kitchen floor, unlabeled and undated food, and overflowing trash, risking food-borne illness.
F 0881: The facility failed to implement an effective antibiotic stewardship program including tracking and trending infections and antibiotic use.
F 0883: The facility failed to offer or document pneumococcal vaccinations or declinations for Residents R1, R7, and R29, increasing risk for pneumonia complications.
Report Facts
Medication review period: 111
Oxygen tanks unsecured: 44
Residents reviewed: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statements regarding medication monitoring, fall interventions, and medication security |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding fall interventions, medication monitoring, medication security, and vaccination tracking |
| Certified Nurse Aide M | Certified Nurse Aide | Provided statements regarding wheelchair foot pedal use, call light placement, mouth care responsibility, and oxygen room security |
| Administrative Nurse E | Infection Preventionist | Provided statements regarding antibiotic stewardship program and infection control tracking |
| Licensed Nurse H | Licensed Nurse | Provided statements regarding computer screen locking and oxygen room security |
| Licensed Nurse LN | Licensed Nurse | Mentioned in privacy breach observation |
| Dietary Staff BB | Dietary Staff | Provided statements regarding kitchen cleanliness and food labeling |
Inspection Report — Jul 10, 2024
Complaint Investigation CMS
Date: Jul 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent a cognitively impaired resident (R1) from exiting the building without staff knowledge, posing a risk of accidents or injuries.
Complaint Details
The complaint investigation was substantiated. The facility failed to prevent Resident R1, who had impaired safety awareness and was at risk for elopement, from leaving the facility unattended. Witness statements confirmed multiple incidents of R1 exiting through unsecured gates and doors.
Findings
The facility failed to ensure adequate supervision and appropriate interventions to prevent Resident R1 from eloping. Multiple witness statements and observations confirmed that R1 exited the building unsupervised through an unsecured gate, placing the resident at risk.
Deficiencies (1)
F 0689: The facility failed to ensure that the nursing home area was free from accident hazards and did not provide adequate supervision to prevent Resident R1 from exiting the building without staff knowledge. This placed R1 at risk for accidents or injuries.
Report Facts
Residents present: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Provided notarized witness statement regarding R1's elopement incident and checked WanderGuard functionality |
| CMA R | Certified Medication Aide | Provided notarized witness statement about responding to door alarm and retrieving R1 from outside the gate |
| Administrative Nurse D | Directed staff to check WanderGuard and provided instructions following elopement incident | |
| CNA M | Certified Nurse Aide | Recalled incidents of R1 exiting the building unsupervised |
| Administrative Staff B | Reported door alarms frequently go off and confirmed R1 exited to parking lot | |
| Housekeeper U | Reported gate leading out of courtyard could be easily opened |
Inspection Report — Apr 15, 2024
Annual Inspection CMS
Date: Apr 15, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident assessments and dental services.
Findings
The facility failed to accurately complete Minimum Data Sets (MDS) for Resident 1, particularly regarding oral and dental status, and failed to identify and respond to Resident 1's dental needs, resulting in untreated tooth pain and dental issues.
Deficiencies (2)
F0641: The facility failed to accurately and thoroughly complete Minimum Data Sets for Resident 1, particularly the oral and dental status, placing the resident at risk for unidentified care needs.
F0791: The facility failed to identify and respond to Resident 1's dental needs, resulting in tooth pain and untreated dental issues, placing the resident at risk for pain and other complications.
Report Facts
Sample size: 4
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Interviewed regarding oral and dental status assessment of Resident 1 |
| LN G | Licensed Nurse | Interviewed regarding Resident 1's dental pain complaints and dental appointment |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding Resident 1's dental assessment and facility dental services policy |
Inspection Report — Feb 22, 2024
Complaint Investigation CMS
Date: Feb 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to accommodate Resident 1's need and preference for a transfer pole to assist with bed transfers.
Complaint Details
The complaint investigation found that Resident 1 was vocal about wanting a transfer pole, but the facility staff did not provide one. The transfer pole brought in was unsafe and removed, and staff did not follow up with Resident 1 about providing another. Resident 1 reported speaking with administrative staff who denied the request. Staff interviews confirmed lack of communication and follow-up regarding the transfer pole.
Findings
The facility failed to provide a safe and usable transfer pole for Resident 1, despite the resident's expressed need and preference. This failure placed Resident 1 at risk of decreased mobility and impaired autonomy.
Deficiencies (1)
F 0558: The facility failed to accommodate Resident 1's need and preference for a transfer pole to assist with bed transfers. The transfer pole installed was deemed unsafe and subsequently removed, and no alternative was provided.
Report Facts
Residents present: 69
Inspection Report — Jan 4, 2024
Routine CMS
Date: Jan 4, 2024
Visit Reason
Routine state inspection of Life Care Center of Kansas City to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to ensure resident dignity, inadequate care planning, insufficient assistance with activities of daily living, inconsistent weight monitoring, medication errors, unsafe medication storage, inadequate infection control, and lack of certified activity personnel. Several residents were at risk for adverse outcomes due to these deficiencies.
Deficiencies (24)
F 0550: The facility failed to ensure residents R13 and R24 were treated with dignity, leaving them uncovered and exposed in their rooms with doors open.
F 0558: The facility failed to accommodate R42's mobility needs and failed to provide R65 a call light, placing them at risk for decline in activities of daily living.
F 0580: The facility failed to notify R13's physician and representative regarding significant weight loss and change in health condition.
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment, with strong urine odors and maintenance issues noted.
F 0623: The facility failed to provide timely written notification of hospital transfers to residents, representatives, and ombudsman for R6 and R28.
F 0657: The facility failed to revise R42's care plan to reflect use of personal knee braces, risking impaired care due to uncommunicated needs.
F 0676: The facility failed to provide necessary assistance to R65 during mealtime, risking impaired nutrition and decline in ADLs.
F 0677: The facility failed to provide consistent bathing for R46, risking complications related to poor hygiene and impaired dignity.
F 0679: The facility failed to provide consistent weekend activities and a certified activity professional, risking decreased psychosocial well-being.
F 0680: The facility failed to ensure appropriate pressure ulcer care for R8 and R60, including wound assessments and proper mattress settings.
F 0689: The facility failed to secure hazardous materials in a sharps container and failed to ensure R53's portable urinal was within reach, resulting in a fall.
F 0690: The facility failed to assess ongoing bowel and bladder incontinence patterns for R53, risking complications related to incontinence.
F 0692: The facility failed to complete weekly weight monitoring for R60 and failed to monitor R13's weight per standards, risking complications related to weight loss.
F 0695: The facility failed to maintain and store R42's CPAP equipment in a sanitary manner, risking respiratory infections.
F 0698: The facility failed to monitor R55's dialysis access site for infection and bleeding and failed to obtain communication from the dialysis center.
F 0727: The facility failed to provide RN coverage for at least eight consecutive hours a day seven days a week, risking decreased quality of care.
F 0732: The facility failed to post daily nurse staffing data and maintain records for 18 months as required.
F 0756: The facility failed to ensure the consultant pharmacist identified and reported lack of blood pressure and pulse monitoring for R32 and R28, and failed to identify inappropriate antipsychotic use for R55.
F 0757: The facility failed to ensure R32 and R28's blood pressure and pulse were monitored as ordered, risking unnecessary medications and adverse effects.
F 0760: The facility failed to prevent a significant medication error when R24 received twice the ordered dose of Eliquis, risking adverse effects including bleeding.
F 0761: The facility failed to ensure safe storage and handling of R55's insulin medication, risking diversion and ineffective medication regimen.
F 0812: The facility failed to maintain sanitary dietary standards related to food storage, with multiple unlabeled and undated food items observed.
F 0880: The facility failed to implement infection control practices including Legionella monitoring, respiratory equipment sanitation, laundry temperature, hand hygiene, and infection tracking.
F 0881: The facility failed to develop and implement core elements of antibiotic stewardship to ensure safe and effective antibiotic use.
Report Facts
Weight loss percentage: 9.36
Medication error count: 67
RN coverage missing days: 25
Blood pressure monitoring missed: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple statements regarding care expectations, policies, and deficiencies |
| Licensed Nurse H | Licensed Nurse | Provided statements regarding resident care, medication monitoring, and deficiencies |
| Certified Nurse Aide M | Certified Nurse Aide | Provided observations on resident care and assistance |
| Licensed Nurse G | Licensed Nurse | Provided statements on resident care and medication monitoring |
| Administrative Nurse E | Infection Preventionist | Provided statements on infection control practices and deficiencies |
Inspection Report — Apr 6, 2022
Routine CMS
Date: Apr 6, 2022
Visit Reason
Routine state inspection of Life Care Center of Kansas City to assess compliance with healthcare regulations including resident rights, care planning, medication management, infection control, and safety.
Findings
The facility had multiple deficiencies including failure to respect residents' rights and dignity, inadequate care planning especially for dementia and behavioral health, inconsistent bathing and activity provision, improper medication monitoring and administration, failure to prevent falls and elopement, inadequate wound care and infection control, and improper respiratory equipment maintenance.
Deficiencies (15)
F 0550: The facility failed to ensure residents' rights and dignity were respected during meals and personal care, including failure to offer dining options, provide drinks, obtain permission for clothing protectors, and maintain privacy during care.
F 0558: The facility failed to ensure Resident 13's call light was within reach, placing her at risk for not receiving timely assistance with personal care.
F 0644: The facility failed to complete a Level II PASRR screening for Resident 42, risking inadequate care for his mental health and intellectual disabilities.
F 0656: The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents including R13, R205, R30, R44, and R49, risking inadequate care and increased confusion or decline.
F 0677: The facility failed to provide consistent bathing per residents' preferences and schedules for multiple residents, risking poor hygiene and impaired psychosocial well-being.
F 0684: The facility failed to adequately assess and prevent skin injuries for Resident 27, omitted physician-ordered wound treatments, resulting in wound deterioration, infection, and surgical repair.
F 0686: The facility failed to prevent cross-contamination during wound care for Resident 3 and failed to ensure Resident 21 wore heel protectors as ordered, risking wound infection and pressure ulcers.
F 0689: The facility failed to ensure a safe environment for Resident 42 who eloped from the facility, and failed to implement fall prevention interventions and thorough fall investigations for Residents 225 and 205.
F 0690: The facility failed to provide consistent incontinence care for Residents 30 and 44 and failed to provide consistent catheter care for Resident 225, risking infections and impaired psychosocial well-being.
F 0695: The facility failed to provide necessary respiratory care and services for Residents 6, 23, and 49 by failing to properly date, clean, and store oxygen equipment, risking respiratory infection or illness.
F 0740: The facility failed to provide needed dementia care and services for Resident 13, lacking person-centered care plans and direction to staff on managing dementia-related behaviors.
F 0756: The facility failed to ensure the Consultant Pharmacist identified and reported lack of behavior monitoring for Residents 39, 13, and 27 receiving psychotropic medications and lack of indication for diuretic administration for Resident 13.
F 0761: The facility failed to ensure nursing staff properly dated insulin pens when opened, risking adverse consequences or ineffective treatment.
F 0780: The facility failed to provide consistent behavior monitoring for Residents 13, 27, and 39 receiving psychotropic medications, risking unnecessary medication use and physical complications.
F 0880: The facility failed to maintain sanitary wound care, properly date and store oxygen equipment, perform hand hygiene when serving meals, transport clean laundry properly, and sanitize mechanical lifts after use, risking infection and disease transmission.
Report Facts
Bathing not occurred: 32
Incontinent episodes: 12
Incontinent episodes: 63
Missed catheter care: 2
Missed urine output documentation: 5
Undated insulin pens: 5
Carvedilol given outside ordered parameters: 15
Bowel incontinent episodes: 12
Bowel incontinent episodes: 63
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