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)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
105% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
194% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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
Annual Inspection
Census: 74
Deficiencies: 6
Date: Jan 31, 2025
Visit Reason
The inspection was the annual survey of Seasons Rehab and Healthcare Center to assess compliance with Medicare and Medicaid regulations.
Findings
The facility was found deficient in Medicaid/Medicare coverage notices, activity programs, nurse staffing information posting, and psychotropic medication management. Deficiencies were documented with specific resident examples and policy reviews.
Deficiencies (6)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to ensure two sampled residents were properly notified of Medicare Part A coverage end dates and Quality Improvement Organization contact information.
F679 Activities Meet Interest/Needs Each Resident: The facility failed to provide an ongoing program of activities meeting the needs of two sampled residents and lacked documentation of daily participation.
F732 Posted Nurse Staffing Information: The facility failed to post nurse staffing data including actual hours worked by licensed and unlicensed nursing staff in a clear and readable format accessible to residents and visitors.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to document behaviors and develop a care plan for a resident on psychotropic medication and did not properly document medication administration and behavioral interventions.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. Deficiency referenced to F758.
A4101 Activity Program: The facility shall designate an employee responsible for the activity program and provide planned activities appropriate to residents' needs and interests. Deficiency referenced to F679.
Report Facts
Facility census: 74
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Berry | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Life Safety
Census: 77
Capacity: 78
Deficiencies: 3
Date: Jan 31, 2025
Visit Reason
A Life Safety Code Survey was conducted on behalf of the State of Missouri to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with fire alarm system installation, sprinkler system maintenance and testing, and utilities gas and electric requirements. Deficiencies involved low voltage wiring protection, incomplete sprinkler inspections, penetration around sprinkler heads, and exposed nonmetallic sheathed cable.
Deficiencies (3)
K341 Fire Alarm System - Installation. The facility failed to ensure low voltage wiring under seven feet was in conduit, exposing wiring in the mechanical room, potentially affecting all 77 residents.
K353 Sprinkler System - Maintenance and Testing. The facility failed to ensure quarterly sprinkler inspections were completed and to prevent penetration around sprinkler heads, affecting all 77 residents.
K511 Utilities - Gas and Electric. The facility failed to ensure nonmetallic sheathed cable was concealed within walls, floors, or ceilings providing a thermal barrier, exposing wiring in a mechanical room, potentially affecting all 77 residents.
Report Facts
Occupied beds: 77
Total licensed beds: 78
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Boyan | Administrator | Signed the plan of correction and involved in in-service training |
| Maintenance Director | Interviewed regarding wiring and sprinkler system deficiencies | |
| Regional Director of Maintenance | Interviewed regarding sprinkler inspection completion |
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
Complaint Investigation
Census: 77
Deficiencies: 1
Date: Aug 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall and the facility's failure to properly assess and respond to the incident.
Complaint Details
The complaint investigation was substantiated based on interviews, record reviews, and video evidence showing the resident fell and was not properly assessed or assisted in a timely manner. The facility census was 77 residents at the time of the incident.
Findings
The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not timely call Emergency Medical Services after a resident fall and failed to properly assess the resident before moving him.
Deficiencies (1)
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to assess a resident who had fallen and did not call Emergency Medical Services in a timely manner. The resident was moved before being assessed by a licensed nurse.
Report Facts
Facility census: 77
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
Plan of Correction
Census: 76
Capacity: 78
Deficiencies: 14
Date: May 23, 2023
Visit Reason
The document is a Plan of Correction submitted by Seasons Rehab and Healthcare Center following a survey conducted on May 23, 2023. It addresses deficiencies cited during the inspection.
Findings
The facility was found deficient in multiple areas including failure to complete criminal background checks for new hires, failure to ensure nursing staff met professional standards in medication administration, food safety violations, inadequate specialized rehabilitative services, and infection control program deficiencies. The facility census was 76 residents with a licensed capacity of 78.
Deficiencies (14)
F607: The facility failed to complete criminal background checks for 7 out of 10 sampled new staff and did not follow policy to check the Nurse Aide Registry for all new hires.
F658: The facility failed to ensure nursing staff had parameters in place to safely administer medications including Metoprolol and Digoxin for three sampled residents.
F812: The facility failed to maintain sanitary conditions in the kitchen, including unclean utensils, damaged cutting boards, and improper food storage temperatures.
F825: The facility failed to provide required specialized rehabilitative services and did not ensure restorative nursing care plans were properly implemented for sampled residents.
F880: The facility failed to establish and maintain an effective infection prevention and control program, including incomplete TB testing and inadequate water management.
A4013: The facility failed to develop policies and procedures to ensure resident health and safety, including communicable disease screening for employees.
A4075: The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A7013: The facility failed to obtain food from approved or satisfactory sources in accordance with laws and regulations.
A7015: The facility failed to protect food from contamination including temperature control and contacting the Department of Health and Senior Services when needed.
A7046: The facility failed to ensure equipment and utensils were constructed and maintained to prevent contamination.
A7048: The facility failed to ensure safe plastic and rubber items used in food contact met general requirements for repeated use.
A7065: The facility failed to properly wash, rinse, and sanitize food-contact surfaces and utensils at required intervals.
A8023: The facility failed to develop and implement policies for animal and pest control.
A9998: The facility failed to comply with state statutes regarding employee criminal background checks and screening for abuse and neglect.
Report Facts
Facility census: 76
Licensed capacity: 78
Number of sampled new staff: 10
Number of sampled residents for medication review: 3
Number of sampled residents for restorative care review: 18
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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