Inspection Reports for Seasons Rehab and Healthcare Center
15600 WOODS CHAPEL RD, KANSAS CITY, MO, 64139-1261
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
74 residents
Based on a January 2025 inspection.
Census over time
Inspection Report
Routine
Census: 74
Deficiencies: 4
Date: Jan 31, 2025
Visit Reason
The inspection was conducted to assess compliance with Medicare/Medicaid regulations including resident notification of Medicare coverage, provision of activities to meet residents' needs, nurse staffing postings, and psychotropic medication management.
Findings
The facility failed to provide proper Medicare Non-Coverage notices with QIO contact information to residents, did not provide adequate individualized activities or documentation for residents with cognitive impairments, failed to post nurse staffing hours per shift as required, and did not adequately document behaviors or care plans related to psychotropic medication use for a resident.
Deficiencies (4)
Failed to provide Quality Improvement Organization (QIO) contact name and toll-free phone number on Notice of Medicare Non-Coverage (NOMNC) forms for residents with benefit days remaining.
Failed to provide an ongoing program of activities tailored to meet the needs of residents who did not like group activities and failed to maintain accessible daily activity participation documentation.
Failed to post actual nurse staffing hours worked per shift for RNs, LPNs, CNAs, and CMTs in locations visible to residents, family, and visitors.
Failed to document target behaviors and non-pharmacological interventions in care plan for a resident prescribed psychotropic medication; behavioral documentation was incomplete and progress notes lacked detail.
Report Facts
Residents affected: 2
Residents affected: 2
Facility census: 74
Behavior occurrences: 8
Behavior occurrences: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse Consultant A | Provided updated CMS-10123 form and education on QIO contact information | |
| Social Services Director | Unaware of missing QIO contact info on NOMNC forms; received updated forms and education | |
| Certified Nursing Assistant A | CNA | Provided observations and comments on resident activities and behaviors |
| Certified Nursing Assistant B | CNA | Provided observations and comments on resident activities and behaviors |
| Activities Director | Provided information on activities program, documentation, and resident participation | |
| Director of Nursing | DON | Provided information on staffing postings and psychotropic medication monitoring |
| Staffing Coordinator | Responsible for completing and posting staffing sheets | |
| Licensed Practical Nurse A | LPN | Provided information on psychotropic medication monitoring and documentation |
| MDS Coordinator | Provided information on psychotropic medication monitoring and care planning |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 1
Date: Aug 26, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to properly assess a resident who had fallen before moving him/her and the delay in calling Emergency Medical Services (EMS) for timely hospital transfer.
Complaint Details
The complaint investigation focused on Resident #1 who fell on 8/20/24. The resident was moved by staff before nurse assessment, EMS was not called promptly, and the resident was transported to the hospital nearly two hours after the fall. The family requested hospital transfer multiple times. Video evidence confirmed the timeline and staff actions. Interviews with staff and family corroborated the findings.
Findings
The facility failed to assess Resident #1 after a fall before moving him/her and delayed notifying EMS for hospital transfer. The resident was moved by staff before nurse assessment, experienced pain, and was eventually sent to the hospital nearly two hours after the fall. Staff education on fall protocols was provided but not followed during the incident.
Deficiencies (1)
Failure to assess a resident who had fallen before moving him/her and delay in calling EMS for hospital transfer.
Report Facts
Residents at facility during inspection: 77
Resident falls: 4
Resident fall dates: Resident #1 had falls on 6/5/24, 6/10/24, 8/5/24, and 8/20/24
Time of fall: 617
Time EMS arrived: 803
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Night nurse who assessed resident after fall and documented assessment but did not call 911 |
| LPN B | Licensed Practical Nurse | Day shift nurse who assessed resident and called for hospital transfer |
| CNA D | Certified Nursing Assistant | Notified nurse of resident on floor and assisted resident to chair |
| RA/CNA A | Restorative Aide/Certified Nursing Assistant | Assisted resident after fall and moved resident to chair |
| CNA B | Certified Nursing Assistant | Interviewed about fall response and notification procedures |
| CNA C | Certified Nursing Assistant | Reported on shift change and fall notification procedures |
| DON | Director of Nursing | Provided interview on expected fall response and assessment procedures |
| Administrator | Notified of past non-compliance and involved in staff education |
Inspection Report
Annual Inspection
Census: 76
Capacity: 78
Deficiencies: 5
Date: May 23, 2023
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements including staff background checks, medication administration, food safety, restorative care, infection control, and other standards.
Findings
The facility was found deficient in multiple areas including failure to complete criminal background checks and nurse aide registry checks for new hires, failure to ensure safe medication administration parameters and practices, unsanitary food service conditions, failure to provide timely restorative care after therapy discharge, and inadequate infection prevention and control program including tuberculosis screening and hand hygiene during medication pass.
Deficiencies (5)
Failed to complete Criminal Background Checks (CBC) and Nurse Aide Registry checks for all new staff prior to hire.
Failed to ensure parameters were in place and followed for safe administration of Metoprolol and Digoxin medications for supplemental residents.
Failed to maintain sanitary food preparation areas and equipment, safeguard against foreign material contamination, and properly document food temperatures.
Failed to provide restorative care following discharge from therapy services in a timely manner.
Failed to implement a comprehensive infection prevention and control program including proper tuberculosis screening for new employees and proper hand hygiene during medication pass.
Report Facts
Facility census: 76
Total licensed capacity: 78
Number of sampled new staff without CBC: 10
Number of sampled new staff without NA registry check: 7
Number of residents affected by medication administration deficiency: 3
Number of residents affected by food safety deficiency: 76
Number of residents affected by infection control deficiency: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Named in deficiency for lack of CBC and NA registry check | |
| Employee B | Named in deficiency for lack of CBC and NA registry check | |
| Employee C | Named in deficiency for lack of CBC and NA registry check | |
| Employee D | Named in deficiency for lack of CBC and NA registry check | |
| Employee E | Named in deficiency for lack of CBC and NA registry check | |
| Employee F | Named in deficiency for lack of CBC and NA registry check | |
| Employee G | Named in deficiency for lack of CBC and NA registry check | |
| Employee H | Named in deficiency for lack of CBC and NA registry check | |
| Employee J | Named in deficiency for lack of CBC and NA registry check | |
| Employee K | Named in deficiency for lack of CBC and NA registry check | |
| Human Resources Director | Human Resources Director | Interviewed regarding CBC and NA registry check deficiencies and TB screening |
| Administrator | Administrator | Interviewed regarding CBC, NA registry check, medication administration, and infection control deficiencies |
| LPN C | Licensed Practical Nurse | Observed and interviewed regarding medication administration deficiencies |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding medication administration parameters |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and infection control deficiencies |
| Dietary Manager | Dietary Manager | Interviewed regarding food service deficiencies |
| Certified Nursing Assistant A | Certified Nursing Assistant | Interviewed regarding restorative care deficiency |
| Restorative Aide | Restorative Aide | Interviewed regarding restorative care deficiency |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed and observed regarding restorative care and infection control deficiencies |
| Director of Rehab | Director of Rehabilitation | Interviewed regarding restorative care deficiency |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding TB screening and water management program |
| Director of Maintenance | Director of Maintenance | Interviewed regarding water management program |
Inspection Report
Routine
Census: 73
Capacity: 78
Deficiencies: 11
Date: Jun 23, 2021
Visit Reason
Routine inspection of Seasons Rehab and Healthcare Center to assess compliance with healthcare regulations including resident care, medication management, infection control, and facility safety.
Findings
The facility had multiple deficiencies including failure to accommodate resident needs for appropriate equipment sizing, incomplete documentation of Do Not Resuscitate (DNR) orders, inadequate privacy and dignity for residents, failure to check Nurse Aide Registry for new hires, failure to prepare a resident properly for surgery, incomplete physician orders follow-up, failure to complete weekly weights and diagnostic testing, inadequate supervision to prevent falls and ensure medication administration, failure to obtain ordered lab tests, medication storage and labeling issues, incomplete tuberculosis screening, failure to wash hands between glove changes during wound care, and lack of a comprehensive Legionella water management program.
Deficiencies (11)
Failed to ensure low air loss mattress settings and appropriate sizing of Broda chair for a resident.
Failed to accurately document wishes of a resident to be Do Not Resuscitate (DNR).
Failed to maintain resident dignity by allowing exposure during cares and inadequate privacy when resident removed clothing.
Failed to check Nurse Aide Registry for two employees to ensure no Federal Indicator prohibiting employment.
Failed to prepare resident for surgery by not ensuring resident was kept NPO resulting in surgery rescheduling.
Failed to complete weekly weights as ordered and to schedule CT scan as ordered for residents.
Failed to provide adequate supervision to prevent near falls and ensure medication administration.
Failed to obtain physician ordered laboratory tests for a resident.
Failed to ensure medications were kept in clean, sanitary, and secured medication carts or rooms; expired medications were discarded; opened medications were dated; no food or cleaning supplies stored with medications; medications removed upon resident discharge; and medications labeled and matched physician orders.
Failed to ensure residents were tested or screened for tuberculosis as required and failed to wash or sanitize hands between glove changes during wound care.
Failed to establish and maintain a comprehensive, facility-specific infection prevention and control program for waterborne pathogens including Legionella, and failed to provide documented assessments for such an outbreak.
Report Facts
Facility census: 73
Total capacity: 78
Weight: 189
Weight loss percentage: 14
Weight: 107
Weight: 124.6
Weight: 111.2
Weight: 109.8
Weight: 110.6
Weight: 117
Weight: 126.2
Weight: 107
Weight: 107
Height: 64
Medication doses: 10
Expired medication date: May 4, 2021
Expired medication date: Nov 18, 2018
Expired medication date: Nov 24, 2019
Expired medication date: Mar 31, 2020
Expired medication date: Aug 31, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in medication storage and wound care hand hygiene findings |
| LPN C | Licensed Practical Nurse | Named in resident supervision, wound care, and medication administration findings |
| CNA B | Certified Nursing Assistant | Named in resident supervision and medication administration findings |
| CNA D | Certified Nursing Assistant | Named in medication storage and resident walker inspection |
| LPN A | Licensed Practical Nurse | Named in medication storage and wound care hand hygiene findings |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding deficiencies and facility policies |
| Administrator | Administrator | Named in interviews regarding facility policies and deficiencies |
| Dietary Manager | Dietary Manager | Named in food safety and kitchen inspection findings |
| Restorative Aide | Restorative Aide | Named in weekly weights and resident care findings |
| Human Resources employee | Human Resources employee | Named in Nurse Aide Registry check findings |
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