Inspection Reports for New Mark Rehab and Healthcare Center
11221 NORTH NASHUA DR, KANSAS CITY, MO, 64155-1159
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
161 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 161
Deficiencies: 2
Date: Dec 31, 2025
Visit Reason
The inspection was conducted due to an alleged allegation of sexual abuse of Resident #1 by another resident, which was reported to the facility and family members. The investigation focused on whether the facility timely reported and appropriately responded to the allegation.
Complaint Details
The complaint involved an alleged sexual abuse incident on 11/29/25 where Resident #2 allegedly put his/her hands down Resident #1's pants. The facility census was 161. The allegation was reported by family members and hospice staff. The facility reviewed camera footage and concluded the allegation was untrue and did not report to authorities or hospice agency as required. Resident #2 was placed on one-to-one supervision for making inappropriate sexual comments to other residents. The facility did not conduct a proper investigation or timely reporting as required by their Abuse Prevention and Prohibition Program policy.
Findings
The facility failed to timely report the alleged sexual abuse to law enforcement and the state survey agency within two hours and failed to conduct a proper investigation of the allegation. The facility determined the allegation was untrue based on camera footage review and did not notify the hospice agency or authorities as required by policy.
Deficiencies (2)
Failed to timely report suspected abuse of Resident #1 to law enforcement and the state survey agency within two hours.
Failed to respond appropriately by conducting a thorough investigation of the alleged sexual abuse involving Resident #1.
Report Facts
Facility census: 161
BIMS score Resident #1: 0
BIMS score Resident #2: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Notified family of Resident #1 about the alleged sexual abuse and conducted assessment on Resident #1 |
| LPN A | Licensed Practical Nurse, Unit Manager | Informed family of Resident #1 about the facility's review of camera footage and status of the allegation |
| Administrator | Reviewed camera footage, determined allegations were untrue, did not report to authorities, and spoke with involved residents | |
| Hospice RN | Hospice Registered Nurse | Assessed Resident #1 after family reported the incident to hospice; attempted to gather information from facility |
| Hospice Director | Received report of alleged sexual abuse from Resident #1's family member | |
| Corporate Nurse Consultant | Reviewed camera footage and stated the incident did not occur as reported |
Inspection Report
Annual Inspection
Census: 158
Deficiencies: 3
Date: Nov 21, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident dignity, activities of daily living care, and pressure ulcer prevention at New Mark Rehab and Healthcare Center.
Findings
The facility failed to treat residents with dignity and respect, particularly regarding a resident who frequently yelled, which affected other residents. The facility also failed to provide timely incontinence care and maintain residents clean, dry, and free of odor for multiple residents. Additionally, the facility failed to prevent pressure ulcers in a resident with an open area on the buttocks due to inadequate care and staffing.
Deficiencies (3)
Failed to treat residents with dignity and respect when staff allowed Resident #7 to scream and yell in the halls and dining room, affecting other residents.
Failed to provide basic Activities of Daily Living (ADLs) care, including timely incontinence care, resulting in residents being unclean, wet, and having offensive body odor.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing; Resident #10 had an open area on the buttocks due to inadequate incontinence care.
Report Facts
Facility census: 158
Residents affected: 2
Residents affected: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Mentioned in relation to care deficiencies and observations of resident yelling and incontinence care |
| CNA A | Certified Nurse Aide | Mentioned in relation to care deficiencies and observations of resident yelling and incontinence care |
| LPN B | Licensed Practical Nurse | Mentioned in relation to care deficiencies and observations of resident yelling |
| Director of Nursing | Interviewed regarding expectations for resident care and dignity | |
| Administrator | Interviewed regarding facility expectations and family contact about resident care | |
| Unit Manager A | Reported resident had loose stools and open area on buttocks | |
| Nurse Practitioner A | Notified of resident's loose stools and moisture breakdown; ordered treatment | |
| LPN A | Licensed Practical Nurse | Interviewed about awareness of resident's open areas |
| Certified Nurse Aide B | Certified Nurse Aide | Mentioned in relation to incontinence care observations |
Inspection Report
Complaint Investigation
Census: 152
Deficiencies: 2
Date: Sep 26, 2025
Visit Reason
The inspection was conducted due to complaints regarding wound care management and resident safety incidents at New Mark Rehab and Healthcare Center.
Complaint Details
Complaint 2622612 related to wound care management and Complaint 2610018 related to resident elopement and injury.
Findings
The facility failed to ensure appropriate wound dressing orders were in place for a resident with a negative pressure wound dressing, resulting in excessive bleeding and hospital transfer. Additionally, the facility failed to protect another resident's safety who eloped and sustained a laceration in the parking lot. Corrective actions and staff education were implemented following these incidents.
Deficiencies (2)
Failed to ensure appropriate wound dressing orders were obtained and in place for one resident, causing excessive bleeding and hospital transfer.
Failed to protect a resident's safety when he/she eloped from the facility and was found with a laceration to the forehead.
Report Facts
Facility census: 152
Number of sampled residents affected: 1
Date range wound vac left in place: 2025-09-09 to 2025-09-19
Date of resident elopement incident: Sep 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner A | Primary Care Provider | Interviewed regarding wound vac dressing adherence and wound care orders. |
| Licensed Practical Nurse (LPN) B | Licensed Practical Nurse | Assessed wound vac dressing and called EMS during wound bleeding incident. |
| Physician Assistant (PA) | Physician Assistant | Examined resident after wound vac dressing change bleeding incident. |
| LPN A | Licensed Practical Nurse | Documented resident elopement incident and care following injury. |
| Administrator | Facility Administrator | Provided statements regarding wound care orders and resident safety expectations. |
Inspection Report
Routine
Census: 162
Deficiencies: 4
Date: Jun 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, respiratory care, trauma-informed care, and food safety in the facility.
Findings
The facility was found deficient in providing adequate personal hygiene care to dependent residents, proper respiratory care including oxygen equipment maintenance, trauma-informed care planning for a resident with PTSD, and food safety practices including storage, labeling, cleanliness, and temperature monitoring.
Deficiencies (4)
Failed to ensure dependent residents received necessary perineal care to maintain good personal hygiene.
Failed to provide proper respiratory care by not documenting cleaning dates and improper storage of oxygen accessories.
Failed to provide trauma-informed care by not developing a care plan addressing PTSD and related interventions.
Failed to store, prepare, and serve food in accordance with professional standards, including disposing expired food, labeling, wearing hairnets, and maintaining cleanliness.
Report Facts
Facility census: 162
Sampled residents: 32
Residents affected: 3
Residents affected: 3
Residents affected: 1
Expired food items: 5
Observation date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nurses Aide | Named in hygiene care deficiency and interviews regarding resident care |
| CNA G | Certified Nurses Aide | Named in hygiene care deficiency and interviews regarding resident care |
| LPN I | Licensed Practical Nurse | Interviewed regarding resident care and trauma-informed care |
| Director of Nursing | Interviewed regarding resident care, respiratory care, and trauma-informed care expectations | |
| Administrator | Interviewed regarding facility expectations for resident care and food safety | |
| CMT A | Certified Medication Technician | Interviewed regarding oxygen equipment cleaning and storage |
| Social Services Designee | Interviewed regarding trauma assessments and care planning | |
| Interim Dietary Manager | Dietary Manager | Interviewed regarding kitchen cleanliness and food safety practices |
| Registered Dietician | Interviewed regarding food safety and cleaning protocols | |
| Dietary Aide A | Dietary Aide | Observed and interviewed regarding food preparation and hygiene |
Inspection Report
Complaint Investigation
Census: 161
Deficiencies: 1
Date: May 2, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide appropriate discharge notice and documentation to a resident, including written notice of discharge with appeal rights and bed-hold policies.
Complaint Details
The complaint investigation found that the facility did not provide written notice of discharge including appeal rights and bed-hold policy to Resident #1. The resident was transferred to a hospital without proper discharge planning or family notification. The resident's DPOA and family members were not properly informed, and the resident experienced physical and psychosocial harm. The hospital was not informed that the resident would not be accepted back, and the hospital is not equipped for long-term care.
Findings
The facility failed to provide written discharge notice including date, location, appeal rights, and contact information for the State Long Term Care Ombudsman to one resident. The resident was transferred to a hospital without proper discharge planning or family notification, resulting in physical and psychosocial harm. The hospital was not informed the resident would not be accepted back, and the resident remains hospitalized in an inappropriate care setting.
Deficiencies (1)
Failed to provide required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Report Facts
Facility census: 161
Dates: Apr 8, 2025
Dates: Apr 23, 2025
Dates: Apr 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Notified family member of resident transfer and hospital choice; did not know resident would not be accepted back |
| Director of Nursing | Director of Nursing | Called 911 for resident transfer; involved in decision not to accept resident back due to aggression and refusal of treatment |
| Social Services Director | Social Services Director | Signed Notice of Proposed Discharge/Transfer and Bed Hold Policy; had little involvement with transfer; notified family via Carefeed |
| Admissions Coordinator | Admissions Coordinator | Handled resident screening and admission status; no communication with family about discharge plans |
| Administrator | Facility Administrator | Provided information on transfer decision and discharge process |
Inspection Report
Complaint Investigation
Census: 153
Deficiencies: 1
Date: Mar 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a physical abuse incident where Resident #1 hit and restrained Resident #2, causing injuries.
Complaint Details
The complaint investigation found that Resident #1 hit and restrained Resident #2 causing physical injuries. The incident was substantiated by staff interviews, resident progress notes, and facility incident reports. The injuries were confirmed by the Director of Nursing and Administrator, who classified the incident as physical abuse.
Findings
The facility failed to protect Resident #2 from physical abuse by Resident #1, resulting in multiple injuries including a scratch, redness, abrasion, and bruising. The facility's abuse prevention program and care plans were reviewed, and interviews with staff confirmed the incident and injuries.
Deficiencies (1)
Failed to protect residents from physical abuse resulting in actual harm to Resident #2.
Report Facts
Medication dosage: 2
Medication dosage: 125
Medication dosage: 500
Medication dosage: 1
Facility census: 153
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse B | Registered Nurse | Interviewed regarding the abuse incident involving Resident #1 and Resident #2 |
| Director of Nursing | Director of Nursing | Confirmed accuracy of injuries sustained by Resident #2 |
| Administrator | Administrator | Confirmed the injuries fit the definition of physical abuse as per facility policy |
Inspection Report
Routine
Deficiencies: 12
Date: Apr 11, 2024
Visit Reason
Routine inspection of New Mark Rehab and Healthcare Center to assess compliance with healthcare regulations including resident care, safety, medication management, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to inform residents about medication risks, maintaining a clean environment, protecting residents from abuse, timely reporting and investigating incidents, revising care plans, providing appropriate treatment and care, respiratory care, medication management, food safety, and equipment maintenance.
Deficiencies (12)
Failed to ensure one resident was informed of the risks and benefits of a physician ordered antipsychotic medication.
Failed to maintain a clean and comfortable environment for one resident, including dirt, grime, and ants in the resident's room.
Failed to protect a resident from physical abuse by another resident and failed to monitor and manage aggressive behaviors.
Failed to timely report suspected abuse and resident-to-resident altercation to the State Survey Agency and Abuse Coordinator.
Failed to conduct a thorough investigation for an injury of unknown origin and a resident-to-resident altercation.
Failed to revise care plans for two residents to include diagnosis of PTSD and use of specialized wheelchair.
Failed to provide appropriate treatment and care for two residents, including proper wheelchair support and timely dermatology appointment.
Failed to provide appropriate care to maintain or improve range of motion for one resident with contractures.
Failed to ensure nebulizer tubing and pipe were placed in a covered bag to minimize spread of pathogens for one resident.
Failed to remove an insulin pen from medication cart after 28 days, risking ineffective medication for one resident.
Failed to ensure air vents were clean, stored food was dated and sealed, and staff wore hair restraints in the kitchen, risking contamination.
Failed to ensure the reach-in refrigerator was properly maintained, resulting in water leakage and potential food contamination.
Report Facts
Residents sampled: 25
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 98
Residents affected: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager 1 | Unit Manager | Interviewed regarding medication consent and AIMS assessment |
| Licensed Practical Nurse 1 | LPN | Interviewed regarding resident behavior and abuse incident |
| Certified Medication Technician 1 | CMT | Interviewed regarding resident behavior |
| Certified Nursing Assistant 1 | CNA | Interviewed regarding resident behavior and abuse incident |
| Registered Nurse 1 | RN | Documented abuse incident and interviewed about incident |
| Unit Manager 1 | Unit Manager | Interviewed regarding resident behavior and abuse incident |
| Director of Nursing | DON | Interviewed regarding abuse reporting, investigations, and medication management |
| Activity Director | AD | Interviewed regarding housekeeping and resident room cleaning |
| Social Services Director | SSD | Interviewed regarding care plan and resident skin concerns |
| Licensed Practical Nurse 3 | LPN | Interviewed regarding medication orders and respiratory care |
| Certified Nursing Assistant 2 | CNA | Interviewed regarding wheelchair foot pedal |
| Rehabilitation Director | Rehab D | Interviewed regarding wheelchair support |
| Maintenance Staff | MS | Interviewed regarding kitchen vent cleaning and refrigerator maintenance |
| Dietary Director | DD | Interviewed regarding kitchen cleanliness and food safety |
| Consultant Pharmacist | Pharmacist | Interviewed regarding medication order issues |
| Dietary Staff 1 | D1 | Observed and interviewed regarding beard restraint use |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 11, 2024
Visit Reason
The inspection was conducted due to complaints regarding resident-to-resident abuse and failure to report and investigate incidents of abuse and injuries of unknown origin at the facility.
Complaint Details
The complaint involved allegations of resident-to-resident physical abuse, failure to report injuries and altercations timely to the State Survey Agency, and failure to investigate incidents thoroughly. The incidents involved residents R96 and R51, both with dementia and behavioral issues. The facility delayed reporting a black eye injury and a biting incident, and did not investigate the causes of injuries or altercations adequately.
Findings
The facility failed to protect a resident from physical abuse by another resident, failed to timely report suspected abuse and injuries to the State Survey Agency, and failed to conduct thorough investigations into injuries of unknown origin and resident-to-resident altercations. The incidents involved two residents with dementia and aggressive behaviors, and the facility did not adequately monitor or respond to these events.
Deficiencies (3)
Failed to protect a resident from physical abuse by another resident.
Failed to timely report suspected abuse and injuries to the State Survey Agency within required timeframes.
Failed to conduct a thorough investigation for injuries of unknown origin and resident-to-resident altercations.
Report Facts
Residents reviewed for abuse: 4
Sample size: 25
Incident report date: Oct 24, 2023
Incident report date: Mar 20, 2024
Incident report date: Mar 21, 2024
Incident report date: Mar 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Documented biting incident and reported it to night nurse. |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Provided interview about resident R96's behavior and incident. |
| Certified Medication Technician 1 | Certified Medication Technician | Provided interview about resident R96's behavior. |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Provided interview about resident R96 and incident circumstances. |
| Unit Manager 1 | Unit Manager | Provided interview about resident R96's behavior and monitoring. |
| Director of Nursing | Director of Nursing | Provided interview about reporting and investigation failures. |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Reported resident-to-resident altercation to unit manager. |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Date: Feb 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision and protective oversight for a resident who sustained an acute oblique fracture to the right femur.
Complaint Details
The investigation was complaint-related, focusing on the circumstances leading to Resident #1's fracture. The complaint was substantiated based on observations, record reviews, and staff interviews confirming inadequate supervision and improper handling of the resident's injured leg.
Findings
The facility failed to provide adequate supervision and protective oversight for Resident #1, who was found with an acute oblique fracture of the right femur. The investigation revealed that staff transferred the resident despite the resident's leg appearing abnormal, and staff attempted to straighten the leg causing pain. The facility's internal investigation and staff interviews confirmed these findings.
Deficiencies (1)
Failure to provide supervision and protective oversight resulting in an acute oblique fracture to the right femur of a resident.
Report Facts
Facility census: 105
Date of fracture: Jan 31, 2024
Resident passed away: Feb 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Assisted with transfer and reported resident's leg turned inward and yelling in pain |
| CMT B | Certified Medication Technician | Observed staff transferring resident and noted resident did not yell out at that time |
| Director of Nursing | Director of Nursing (DON) | Provided expectations regarding handling of resident's abnormal leg |
| Administrator | Administrator | Provided expectations regarding staff actions when resident's leg appeared abnormal |
| CNA A | Certified Nursing Assistant | Reported resident squirming and yelling out in pain during transfer |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 5, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a survey completed on 05/05/2023 for New Mark Rehab and Healthcare Center.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Census: 110
Deficiencies: 11
Date: Sep 29, 2022
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, care standards, medication management, infection control, safety, and food service in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to honor resident meal preferences and dignity during feeding, improper management of resident funds, unsafe and unsanitary food storage and preparation, medication administration errors, lack of proper infection control practices including incomplete tuberculosis testing, and failure to assess and document safety risks related to bed rails and cane rails for residents.
Deficiencies (11)
Failure to honor resident rights related to meal preferences, feeding assistance, and oral care.
Failure to provide reasonable accommodation for residents to access the courtyard independently.
Failure to properly hold, secure, and manage resident personal funds separate from facility operating accounts.
Failure to maintain a safe, clean, and homelike environment including broken tiles, damaged walls, and unsanitary conditions.
Failure to notify resident or representative in writing of bed hold policy upon hospital transfer.
Failure to meet professional standards of quality in medication administration including missed doses and lack of physician orders for bed cane rails.
Failure to ensure drugs and biologicals are labeled and stored properly including loose pills in medication carts and expired medications.
Failure to provide and implement an effective infection prevention and control program including incomplete tuberculosis testing and lack of qualified infection preventionist.
Failure to regularly inspect bed frames, mattresses, and bed rails for safety and to perform entrapment assessments for residents using bed rails.
Failure to ensure food is served at safe and appetizing temperatures and to prepare pureed food to appropriate consistency.
Failure to procure food from approved sources and store, prepare, and serve food in a sanitary manner.
Report Facts
Residents affected: 22
Facility census: 110
Missed medication doses: 11
Expired medication count: 50
Resident funds in operating account: 4142.5
Resident funds in operating account: 830.4
Resident funds in operating account: 2790.84
Resident funds in operating account: 1215
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Observed feeding residents while standing and unable to read insulin vial dates |
| CMT A | Certified Medication Aide | Observed feeding resident while standing |
| Director of Nursing | Director of Nursing | Acknowledged staff standing while feeding residents and lack of bed cane rail assessments |
| Assistant Director of Nursing | Assistant Director of Nursing | Described dietary meal ticket process and infection prevention training status |
| Dietary Manager | Dietary Manager | Unaware of resident meal preferences and described food temperature standards |
| Business Office Manager | Business Office Manager | Explained resident funds in operating account and refund process |
| Staffing Coordinator | Staffing Coordinator | Responsible for employee TB testing and described testing procedures |
| Administrator | Administrator | Discussed expectations for bed hold notices, infection preventionist, and food service |
| LPN D | Licensed Practical Nurse | Explained medication delay and communication with pharmacy |
| RN A | Registered Nurse | Reviewed medication administration records and noted lack of documentation for missed meds |
| Unit 1 Nurse Manager | Unit 1 Nurse Manager | Discussed medication storage and bed cane rail practices |
| Dietary Staff C | Dietary Staff | Described pureed food preparation and consistency |
| Dietary Staff D | Dietary Staff | Described food temperature and pureed food standards |
| Maintenance Director | Maintenance Director | Described maintenance request process and lack of complaints |
| Housekeeping | Housekeeping Staff | Reported contacting maintenance for bed cane rail needs |
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