Inspection Reports for
New Mark Rehab and Healthcare Center
11221 NORTH NASHUA DR, KANSAS CITY, MO, 64155-1159
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
14.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
165% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
81% occupied
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate 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
Plan of Correction
Census: 161
Deficiencies: 4
Date: May 2, 2025
Visit Reason
The inspection was conducted to evaluate compliance with discharge process regulations and related requirements at New Mark Rehab and Healthcare Center.
Findings
The facility failed to provide an appropriate discharge notice including required information such as date, location, appeal rights, and contact information for the State Long Term Care Ombudsman for one sampled resident. The facility's census at the time was 161 residents.
Deficiencies (4)
F628 Discharge Process: The facility failed to provide written notice of discharge that included the date and location the resident would be discharged to, statement of appeal rights, and contact information for the State Long Term Care Ombudsman for one resident.
A4119 Records Required for Transfer: The resident was not accompanied by required transfer forms including medical history and nursing summary.
A8015 30 Day Notice-Transfer/Discharge: The facility failed to provide at least 30 days advance notice of transfer or discharge to the resident and responsible parties.
A8017 Discharge Appeal Rights: The resident was discharged without full and adequate notice of the right to a hearing before the department's Administrative Hearings Unit.
Report Facts
Resident census: 161
Deficiencies cited: 4
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
Complaint Investigation
Census: 153
Deficiencies: 2
Date: Mar 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation related to allegations of abuse and neglect at New Mark Rehab and Healthcare Center.
Complaint Details
The complaint investigation substantiated physical abuse of Resident #2 by Resident #1. The injuries and incident were confirmed through record reviews, staff interviews, and resident progress notes.
Findings
The facility failed to protect a resident from physical abuse by another resident, resulting in injuries including scratches, redness, and bruising. The facility's abuse prevention policies and procedures were found deficient, and staff interviews confirmed the injuries and incident.
Deficiencies (2)
F600: The facility failed to protect residents from physical abuse, as Resident #1 hit and restrained Resident #2 causing scratches and bruises. The facility's abuse prevention and reporting policies were inadequate to prevent or address the incident.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents, including reporting requirements to the department and mental health authorities.
Report Facts
Facility census: 153
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse B | Registered Nurse | Interviewed regarding resident agitation and medication changes following the abuse incident |
| Director of Nursing | Director of Nursing | Interviewed and confirmed accuracy of injury report for Resident #2 |
| Administrator | Administrator | Interviewed and confirmed injuries fit the definition of physical abuse 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
Capacity: 99
Deficiencies: 13
Date: Apr 11, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC, on behalf of the State of Missouri, Department of Health and Senior Services.
Complaint Details
The survey was complaint-related and substantiated as evidenced by multiple findings including failure to inform residents about medication risks, failure to maintain a safe environment, failure to protect residents from abuse, and failure to report and investigate alleged violations.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to residents' rights to be informed, safe environment, freedom from abuse and neglect, reporting of alleged violations, care planning, quality of care, medication storage and administration, food safety, and essential equipment maintenance.
Deficiencies (13)
F552 Right to be Informed/Make Treatment Decisions. The facility failed to ensure one resident and/or representative was informed of the risks and benefits of a physician ordered antipsychotic medication prior to initiation.
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain a clean and comfortable environment for one resident, including heavy buildup of dirt, dust, and ants in the resident's room.
F600 Freedom from Abuse and Neglect. The facility failed to protect one resident from physical abuse by another resident and failed to investigate and report the incident timely.
F609 Reporting of Alleged Violations. The facility failed to report an injury of unknown origin and a resident-to-resident altercation to the State Survey Agency and adult protective services within required timeframes.
F610 Investigate/Prevent/Correct Alleged Violation. The facility failed to conduct a thorough investigation for an injury of unknown origin and a resident-to-resident altercation for two residents reviewed for abuse.
F657 Care Plan Timing and Revision. The facility failed to revise the care plan of two residents to reflect current clinical conditions and needs.
F684 Quality of Care. The facility failed to ensure two residents received treatment and care in accordance with professional standards, including proper wheelchair headrest placement and dermatology appointment scheduling.
F688 Increase/Prevent Decrease in ROM/Mobility. The facility failed to ensure one resident received appropriate services to maintain or improve mobility and prevent decline.
F695 Respiratory/Tracheostomy Care and Suctioning. The facility failed to ensure a resident's respiratory equipment was properly stored and maintained to minimize infection risk.
F758 Free from Unnecessary Psychotropic Meds/PRN Use. The facility failed to ensure psychotropic medications were used appropriately and with proper documentation for residents reviewed.
F761 Label/Store Drugs and Biologicals. The facility failed to properly store and label medications, including insulin pens and psychotropic drugs, and failed to maintain secure storage.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. The facility failed to maintain sanitary conditions in the kitchen and properly store food items, affecting 98 of 99 residents.
F908 Essential Equipment, Safe Operating Condition. The facility failed to maintain the reach-in refrigerator properly, resulting in water leakage and potential contamination of food.
Report Facts
Total licensed capacity: 99
Residents sampled: 25
Residents involved in abuse incident: 4
Residents involved in medication review: 5
Residents affected by food safety issue: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David McCleary | Administrator | Signed the initial statement of deficiencies on page 1 and interviewed regarding ant infestation and abuse reporting. |
| Unit Manager 1 | Interviewed regarding medication consent and resident behavior. | |
| Licensed Practical Nurse 1 | LPN | Interviewed about resident behavior and abuse incident. |
| Certified Medication Technician 1 | CMT | Interviewed about resident behavior and medication administration. |
| Certified Nursing Assistant 1 | CNA | Interviewed about resident behavior and abuse incident. |
| Director of Nursing | DON | Interviewed about medication adjustments and abuse reporting. |
| Assistant Director of Nursing | ADON | Interviewed about restorative care and abuse reporting. |
| Dietary Director | DD | Interviewed about kitchen sanitation and food safety. |
| Social Services Director | SSD | Interviewed about resident behavior and abuse reporting. |
Inspection Report
Life Safety
Census: 101
Capacity: 193
Deficiencies: 7
Date: Apr 10, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for existing health care occupancy.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including discharge from exits, emergency lighting, vertical openings enclosure, sprinkler system maintenance and testing, corridors open to corridor, utilities gas and electric, and maintenance, inspection and testing of doors.
Deficiencies (7)
K271 Discharge from Exits: The facility failed to ensure the exterior sidewalk was free of cracks and holes, creating a trip hazard near the South exit door by room 229.
K291 Emergency Lighting: The facility failed to provide emergency lighting at the emergency generator transfer switch, and emergency lighting was not present at the electrical room transfer switch.
K311 Vertical Openings - Enclosure: The facility failed to ensure two of four fire rated stairway exit doors were equipped with approved fire exit hardware.
K353 Sprinkler System - Maintenance and Testing: The facility failed to ensure sprinkler system control valves, water flow alarms, and tamper switches were inspected quarterly and semiannually as required.
K361 Corridors - Areas Open to Corridor: The facility failed to ensure smoke detectors were installed in rooms open to the corridor, specifically the gaming room next to the nurses' station.
K511 Utilities - Gas and Electric: The facility failed to ensure Ground Fault Circuit Interruption (GFCI) protection was provided within six feet of sinks in the assisted dining room.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to ensure fire doors were inspected annually and lacked required inspection tags on fire doors.
Report Facts
Current occupied beds: 101
Total licensed beds: 193
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and confirmed observations related to deficiencies |
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
Census: 105
Deficiencies: 2
Date: Feb 13, 2024
Visit Reason
The inspection was conducted to investigate and document deficiencies related to accident hazards, supervision, and devices at New Mark Care Center, following an incident involving a resident with a fracture.
Findings
The facility failed to provide adequate supervision and protective oversight to prevent accidents, resulting in a resident sustaining an acute oblique fracture of the right femur. The investigation included review of resident records, staff interviews, and internal facility investigations.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) The facility failed to ensure the resident environment remained free of accident hazards and did not provide adequate supervision and assistance devices to prevent accidents, evidenced by a resident's acute oblique fracture of the right femur.
A4075 19 CSR 30-85.042(66) Nursing Care per Resident Condition Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the findings under F689.
Report Facts
Facility census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn McCord | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Director of Nursing | Interviewed regarding staff expectations on resident leg abnormalities |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 28, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with related CMS and CDC requirements.
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
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
Deficiencies: 0
Date: May 5, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 5/5/23 to assess compliance with CMS and CDC recommended practices and federal 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
Life Safety
Census: 109
Capacity: 199
Deficiencies: 4
Date: Nov 28, 2022
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents, focusing on building construction, sprinkler systems, smoke barriers, and fire damper inspections.
Findings
The facility failed to meet several Life Safety Code requirements including sprinkler system coverage, maintenance of fire dampers, and smoke barrier construction. Deficiencies included water-damaged ceilings, missing ceiling tiles, lack of fire damper inspection records, and failure to maintain fire dampers according to code.
Deficiencies (4)
K161: The facility failed to maintain sprinklered stories with an approved automatic system and had water damaged drywall ceilings and missing ceiling tiles affecting fire rating. Multiple rooms had water-stained or missing ceiling tiles compromising fire barriers.
K372: The facility failed to maintain fire dampers according to code and lacked records of fire damper inspections. The Maintenance Director had no specific training to complete inspections and the facility was unable to find qualified inspectors.
A2054: Smoke sections were not separated by one-hour fire-rated walls with self-closing doors as required by regulation. This deficiency was uncorrected as of the survey date.
A3001: The building was not substantially constructed and maintained in good repair as required. The facility failed to comply with physical plant requirements per NFPA 101, 2000 edition.
Report Facts
Facility capacity: 199
Resident census: 109
Inspection date: Nov 28, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding ceiling tile damage and fire damper inspections; noted lack of training for fire damper inspections | |
| Administrator | Interviewed about fire damper inspection vendor issues and ceiling tile repairs |
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 |
Inspection Report
Annual Inspection
Census: 108
Deficiencies: 4
Date: May 17, 2022
Visit Reason
Annual inspection survey conducted to assess compliance with professional standards and regulatory requirements at New Mark Care Center.
Findings
The facility failed to meet professional standards related to narcotic medication storage, auditing, and destruction. Deficiencies included unsecured narcotic medications, lack of auditing policies for the Stat-Safe system, and improper destruction of medications by the former Director of Nursing.
Deficiencies (4)
F658: The facility failed to ensure narcotic medications were stored securely behind two locks and did not follow proper auditing and destruction procedures, resulting in missing medications and improper handling by the former Director of Nursing.
A4063: Medication storage regulations were not met as medications were not secured properly, violating safe storage requirements.
A4067: Medication destruction was not performed by a pharmacist or two licensed nurses as required, with improper destruction by the former Director of Nursing.
A4070: The facility failed to establish an accurate system for receipt and disposition of controlled drugs, lacking proper reconciliation and record maintenance.
Report Facts
Facility census: 108
Tablets destroyed: 29
Tablets destroyed: 15
Tablets destroyed: 1
Inspection Report
Routine
Deficiencies: 0
Date: Oct 8, 2021
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 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 129
Capacity: 199
Deficiencies: 2
Date: Jun 23, 2021
Visit Reason
The inspection was conducted to assess compliance with life safety and exit requirements, specifically focusing on means of egress and emergency exit accessibility.
Findings
The facility failed to keep emergency exits free of obstructions, including sandbags blocking an emergency exit door and a concrete curb forming a semi-circle around the door. The facility was cited for not meeting exit requirements related to unobstructed exits and fire-rated separation in a multi-story facility.
Deficiencies (2)
K211 Means of Egress - General: The facility failed to ensure emergency exits were continuously free of obstructions, including sandbags blocking an emergency exit door and a concrete curb around the door. Emergency exit signs were present but flooding issues caused obstruction concerns.
A2037 Exit Requirements: The facility did not meet the requirement for at least two unobstructed exits remote from each other in a multi-story facility, lacking proper fire-rated separation and exit pathways.
Report Facts
Facility capacity: 199
Resident census: 129
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen McClard | Administrator | Named in relation to the inspection and plan of correction |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 22, 2021
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CDC and CMS guidelines.
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
Abbreviated Survey
Deficiencies: 0
Date: Feb 3, 2021
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and federal 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
Complaint Investigation
Census: 108
Deficiencies: 2
Date: Jan 19, 2021
Visit Reason
The inspection was conducted as a COVID-19 focused emergency preparedness survey and to investigate complaints related to resident falls and supervision.
Complaint Details
The complaint investigation was substantiated based on findings related to inadequate supervision and fall prevention for Resident #4, who experienced 20 falls in 25 days with injuries.
Findings
The facility was found in compliance with COVID-19 emergency preparedness requirements but failed to provide adequate supervision and interventions to prevent falls for one resident, resulting in multiple falls and injuries. The facility also failed to follow its fall prevention policy and update care plans after falls.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide supervision and interventions to prevent one resident from multiple falls and failed to follow fall prevention policy and update care plans after falls.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the fall prevention deficiencies.
Report Facts
Resident census: 108
Resident falls: 20
Inspection Report
Routine
Deficiencies: 0
Date: Nov 6, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from October 30 to November 6, 2020.
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
Abbreviated Survey
Deficiencies: 0
Date: Oct 16, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted from October 14 to October 16, 2020.
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
Deficiencies: 0
Date: Jul 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted to assess compliance with CMS and CDC recommended practices and federal 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
Deficiencies: 0
Date: Jun 25, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on June 24 and June 25, 2020.
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
Complaint Investigation
Census: 148
Deficiencies: 2
Date: May 26, 2020
Visit Reason
The inspection was conducted to investigate infection prevention and control deficiencies related to COVID-19 precautions and compliance with infection control policies.
Complaint Details
The visit was complaint-related focusing on infection control deficiencies during the COVID-19 pandemic. The complaint was substantiated based on observations and interviews.
Findings
The facility failed to maintain social distancing, proper mask usage, and hand hygiene among staff and residents. Multiple observations showed staff and residents not wearing masks properly, lack of hand hygiene, and failure to follow CDC guidelines for infection control.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to maintain social distancing, proper mask use, and hand hygiene among staff and residents, increasing risk of COVID-19 transmission.
A4085 Infection Control/Communicable Disease: The facility did not report communicable diseases as required by state regulations.
Report Facts
Facility census: 148
Residents observed without facial masks: 28
Residents observed in main dining: 16
Inspection Report
Life Safety
Census: 160
Capacity: 199
Deficiencies: 4
Date: Sep 5, 2019
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and electrical system regulations at New Mark Care Center.
Findings
The facility failed to maintain the sprinkler system with monthly checks, did not maintain corridor doors to resist smoke passage, failed to perform annual inspection and testing of resident room electrical receptacles, and did not assure safe use of power strips in resident rooms. The Emergency Preparedness portion of the survey did not result in any deficiencies.
Deficiencies (4)
K353 Sprinkler System - The facility failed to conduct or document monthly sprinkler system main checks, affecting the system's ability to function properly in an emergency.
K363 Corridor Doors - The facility failed to maintain corridor doors resistive to smoke passage, with open gaps and damaged doors in multiple rooms, affecting six of thirteen smoke compartments.
K914 Electrical Systems - The facility failed to perform and document annual inspection and testing of resident room electrical receptacles, potentially affecting all residents.
K920 Electrical Equipment - The facility failed to assure safe use of power strips when refrigerators and an oxygen concentrator were plugged into resident room electrical outlets, affecting three of thirteen smoke compartments.
Report Facts
Deficiency cited capacity: 199
Deficiency cited census: 160
Inspection Report
Annual Inspection
Census: 160
Deficiencies: 10
Date: Sep 5, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations at New Mark Care Center in Kansas City, MO.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity, inadequate call light response, improper medication storage and administration, insufficient infection control practices, and lack of proper notification for transfers and discharges. The facility census was 160 during the survey.
Deficiencies (10)
F550 Resident Rights: The facility failed to ensure staff treated residents with dignity and responded to call lights timely, affecting six of 32 sampled residents. The facility census was 160.
F584 Safe Environment: The facility failed to protect residents' personal belongings from loss or theft, affecting three of 32 sampled residents. The facility census was 160.
F623 Notice Before Transfer/Discharge: The facility failed to provide written notices of transfer or discharge to residents or their representatives, affecting two of 32 sampled residents. The facility census was 160.
F658 Services Meet Professional Standards: The facility failed to administer Flonase nasal spray correctly, affecting one of 32 sampled residents. The facility census was 160.
F677 ADL Care for Dependent Residents: The facility failed to provide complete perineal care and morning care for two of 32 sampled residents. The facility census was 160.
F689 Free of Accident Hazards: The facility failed to ensure proper use and maintenance of sit to stand lifts and side rails, affecting multiple residents. The facility census was 160.
F693 Tube Feeding Management: The facility failed to provide appropriate care and monitoring for residents with feeding tubes, affecting one of 32 sampled residents. The facility census was 160.
F759 Free of Medication Errors: The facility had a medication error rate of 12%, exceeding the 5% threshold, affecting three of 32 sampled residents. The facility census was 160.
F761 Labeling of Drugs and Biologicals: The facility failed to properly label and store medications in locked compartments, affecting multiple residents. The facility census was 160.
F880 Infection Prevention and Control: The facility failed to maintain effective infection control practices including hand hygiene and environmental cleanliness, affecting multiple residents. The facility census was 160.
Report Facts
Facility Census: 160
Sampled Residents: 32
Medication Error Rate: 12
Medication Opportunities: 25
Medication Errors: 3
Medication Observations: 60
Nasal Spray Observations: 20
Topical Medication Observations: 20
Call Light Audit Observations: 100
Resident Surveys: 60
Inspection Report
Plan of Correction
Census: 167
Deficiencies: 1
Date: Apr 12, 2019
Visit Reason
The inspection was conducted to assess compliance with care plan timing and revision requirements following incidents of resident falls and related care plan deficiencies.
Findings
The facility failed to revise residents' comprehensive care plans after falls, affecting two residents. Multiple reviews of care plans, nurses' notes, and fall committee reports showed lack of updated fall prevention strategies and timely care plan revisions.
Deficiencies (1)
F 657 Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii) The facility failed to revise residents' comprehensive care plans within required timeframes after falls, affecting two residents. Fall prevention strategies were not updated or implemented as required.
Report Facts
Facility census: 167
Number of residents affected: 2
Number of falls in 90 days: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David DeBoard | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Interviewed on 4/12/19 regarding care plan updates after falls | |
| Unit Manager | Interviewed on 4/12/19 regarding care plan updates after falls |
Inspection Report
Annual Inspection
Census: 174
Deficiencies: 9
Date: Jul 26, 2018
Visit Reason
Annual survey conducted to assess compliance with federal and state regulations at New Mark Care Center in Kansas City, MO.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents' rights to grooming and dignity, timely notification and conveyance of personal funds, development and implementation of comprehensive care plans, adherence to professional standards in medication administration, provision of perineal care, and infection prevention and control. The facility census was 174 at the time of the survey.
Deficiencies (9)
F550 Resident Rights/Exercise of Rights: The facility failed to ensure residents were groomed in a manner consistent with dignity, as five of 37 sampled residents had unsightly facial hair.
F569 Notice and Conveyance of Personal Funds: The facility failed to complete and send a Third Party Liability form timely for two discharged residents, affecting their personal funds.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop comprehensive care plans reflecting residents' personal conditions and preferences for five of 37 sampled residents.
F658 Services Provided Meet Professional Standards: The facility failed to ensure staff followed physicians' orders for medication administration, resulting in a medication error affecting one resident.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide perineal care in a manner to prevent infection for three residents and failed to provide appropriate care for one resident with a history of urinary tract infection.
F679 Activities Meet Interest/Needs Each Resident: The facility failed to provide stimulating activities for two of 37 sampled residents at risk for social isolation.
F759 Free of Medication Error Rates 5 Percent or More: The facility failed to ensure staff administered medications with less than a 5% error rate, resulting in a 12.82% error rate affecting two residents.
F761 Label/Store Drugs and Biologicals: The facility failed to properly label medications, discard expired medications, and store medications securely, affecting multiple residents.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program to prevent transmission of communicable diseases and infections.
Report Facts
Facility census: 174
Sampled residents: 37
Medication error rate: 12.82
Medication errors: 5
Medication opportunities for error: 39
Inspection Report
Life Safety
Census: 174
Capacity: 199
Deficiencies: 7
Date: Jul 26, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and emergency preparedness requirements at New Mark Care Center.
Findings
The facility failed to meet several Life Safety Code requirements including installation and maintenance of fire alarm systems, portable fire extinguishers, fire drills, emergency power generator maintenance, and oxygen storage. The emergency preparedness program was also found deficient in multiple areas.
Deficiencies (7)
K341 Fire Alarm System - Installation: The facility failed to provide horns or strobes in the courtyard as required by NFPA 70 and 72, affecting staff and residents' safety.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to test and maintain the fire alarm system according to NFPA standards, with no semi-annual inspections completed in the last 18 months.
K355 Portable Fire Extinguishers: Fire extinguishers were installed more than 5 feet above the floor, violating NFPA 10 standards.
K712 Fire Drills: The facility failed to conduct fire drills at varied times within shifts, affecting staff readiness.
K918 Electrical Systems - Essential Electric System: The emergency power generator lacked a remotely located emergency power shut-off switch, risking building-wide power failure.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to properly identify and store oxygen cylinders in accordance with NFPA 99 standards.
E001 Establishment of the Emergency Program (EP): The facility lacked a comprehensive emergency preparedness plan covering all required elements and staff training.
Report Facts
Facility capacity: 199
Resident census: 174
Deficiencies cited: 7
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 2
Date: Apr 4, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding bowel/bladder incontinence, catheter care, and urinary tract infections (UTIs) at New Mark Care Center.
Complaint Details
The investigation was triggered by a credible allegation of noncompliance related to catheter care and urinary tract infections. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure proper catheter care and positioning, timely administration of antibiotics for UTIs, and adequate communication with physicians regarding resistant infections. Deficiencies were found in staff adherence to catheter care policies and documentation of physician notifications.
Deficiencies (2)
F690: The facility failed to ensure proper positioning of tubing and drainage bags for residents with catheters, leading to recurrent urinary tract infections. The facility also failed to administer antibiotics timely and document physician notifications for resistant infections.
A4074: The facility did not provide personal attention and nursing care consistent with residents' conditions, as evidenced by the failure to meet catheter care standards referenced in F690.
Report Facts
Facility census: 169
Medication dosage: 500
Medication dosage: 500
Inspection Report
Plan of Correction
Census: 169
Deficiencies: 2
Date: Mar 7, 2018
Visit Reason
The inspection was conducted to investigate deficiencies related to accident hazards, supervision, and devices following incidents involving residents at New Mark Care Center.
Findings
The facility failed to follow its investigation policy for incidents involving residents, resulting in inadequate supervision and documentation. Resident #1 sustained a bruising injury after Resident #2 ran over their foot with a wheelchair, and the facility did not complete required incident reports or assessments.
Deficiencies (2)
F689: The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision to prevent accidents. Incident investigations and documentation were incomplete and did not follow facility policy.
A4074: The facility did not provide personal attention and nursing care consistent with current acceptable nursing practice, as evidenced by the issues noted in F689.
Report Facts
Facility census: 169
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | LPN | Named in failure to complete incident investigation and assessment |
| Director of Nursing | DON | Assessed resident injury and interviewed regarding incident documentation |
| Physician A | Physician | Interviewed regarding expectations for staff to follow facility policies |
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