Inspection Reports for
Rehab of Kansas City South

The complaint investigation included a family member reporting strong body odor smells of feces and urine on the 300 Hall, and an allegation from Resident #2's family about a $300 unauthorized charge on the resident's CashApp. The facility failed to timely investigate the financial allegation and did not report it to authorities as required. Multiple staff interviews confirmed awareness but lack of proper reporting and investigation.

The facility failed to control pervasive odors on the 300 Hall, did not timely investigate an allegation of misappropriation of resident funds, and had multiple spa room toilets that were unsecured, blocked, inaccessible, or inoperable, posing safety risks to residents.

The complaint investigation involved physical abuse incidents between residents #2 and #3, and residents #4 and #5. The abuse was substantiated with video footage, witness statements, and interviews. Resident #5 punched Resident #4, and Resident #2 allegedly pushed Resident #3 to the ground. Behavioral monitoring was noted as lacking for Resident #2 prior to the incidents.

The facility failed to prevent physical abuse for two sampled residents out of nine reviewed. Multiple altercations were documented involving residents, with video evidence and witness statements confirming physical abuse incidents. Staff were educated post-incident to mitigate future occurrences.

The facility was found deficient in multiple areas including failure to provide timely written notification prior to resident transfer, improper storage and lack of physician orders for respiratory equipment, incomplete dialysis documentation and monitoring, inadequate nurse staffing posting, unsecured and unsanitary medication storage, medications left unattended at bedside, and failure to implement and educate staff on Enhanced Barrier Precautions for infection control.

The complaint investigation found substantiated issues with showering accommodations for three residents and a transportation safety incident involving Resident #3, who was not properly strapped in during van transport and sustained a head injury from tipping over.

The facility failed to accommodate three sampled residents' showering preferences, resulting in inadequate shower frequency and hygiene concerns. Additionally, the facility failed to properly secure one resident's wheelchair during transport, causing the resident to tip and hit their head, though no serious injury occurred.

The facility was found to have deficiencies related to providing appropriate pressure ulcer care and preventing new ulcers from developing, with a level of harm classified as minimal harm or potential for actual harm affecting some residents.

The facility failed to provide consistent pressure ulcer wound dressing changes and prevent acquired pressure injuries for some residents, with documented noncompliance and inadequate wound care documentation. Additionally, the facility failed to ensure adequate nursing staff to meet resident needs, particularly for residents requiring mechanical lifts for transfers, resulting in residents not being assisted to get out of bed as desired.

The facility failed to maintain a safe, clean, and homelike environment due to multiple water leaks affecting residents and poor cleanliness in resident rooms, including grime and debris buildup. The facility lacked a specific policy for water leaks in resident rooms and delayed appropriate response to leaks, causing discomfort and safety concerns for residents.

Complaints included residents' call lights going unanswered for extended periods (up to 40 minutes), resulting in residents being left incontinent and in pain. One resident reported being left in fecal matter overnight and having an untreated pressure injury on the right heel. Grievances were made to social services but remained unresolved at the time of inspection.

The facility failed to ensure call lights were answered promptly for three sampled residents, resulting in residents being left incontinent and in pain. Additionally, the facility failed to document and provide appropriate wound care treatment for one resident's pressure injury.

The complaint involved an allegation that CMT A threw water on Resident #1 on 8/31/23. The investigation included interviews with the resident, CMT A, the charge nurse, Director of Nursing, Admissions Coordinator, and a Certified Nurses Aide. The incident was not substantiated as abuse but was related to customer service/dignity. CMT A was suspended and terminated. The resident was provided care and linens were changed after the incident.

The investigation found that the alleged incident could not be verified as abuse but was related to customer service and dignity issues. The CMT was suspended and later terminated, and the deficiency was corrected on 8/31/23. The resident reported feeling shocked and outraged by the altercation.

Complaint # MO 2014989 involved allegations of inadequate bathing, oral care, pain management, food temperature issues, and infection control deficiencies.

The facility failed to provide adequate bathing, oral care, and timely incontinence care to multiple residents. Pain medication was not consistently available or documented. Hot food was served at unsafe temperatures. Infection prevention and control practices were deficient, including improper hand hygiene, glove use, and lack of ongoing infection surveillance documentation.

Complaint MO 2014989 involved concerns about pain medication availability and management for Resident #50.

The facility was found deficient in multiple areas including failure to honor resident self-determination, maintain cleanliness, provide timely bed hold notices, update care plans accurately, provide adequate bathing and oral care, properly manage pressure ulcers, ensure safe medication administration and storage, maintain infection control practices, and post accurate staffing information. Several residents reported dissatisfaction with care, including delays in assistance and inadequate hygiene.

The facility was found deficient in providing adequate assistance to residents requiring mechanical lifts, ensuring supervision and safety for residents who smoke, maintaining adequate staffing levels to meet resident needs, and properly storing and handling food in the kitchen. Several equipment and sanitation issues were also noted in the kitchen.