Deficiencies (last 7 years)
Deficiencies (over 7 years)
6.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
71% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 51
Deficiencies: 1
Date: Feb 3, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to allegations of staff raising their voice and inappropriate interaction with a resident during care.
Complaint Details
Complaint # MO 00248840 was substantiated. The complaint involved allegations of a caregiver raising their voice and inappropriate interaction with a resident during care, which was confirmed through interviews and witness statements.
Findings
The facility failed to ensure dignity and respect for a resident during care, as evidenced by a caregiver raising their voice and the resident exhibiting distress and combative behavior. The investigation included interviews, witness statements, and review of care plans and behavioral management training.
Deficiencies (1)
19 CSR 30-88.010(29) Dignity/Privacy: Facility staff failed to ensure dignity and respect during care when a caregiver raised their voice and restrained a resident who was upset and combative. The resident exhibited yelling, kicking, and swinging at staff during care.
Report Facts
Facility census: 51
Complaint number: 248840
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Oct 7, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of potential resident-to-resident abuse involving two sampled residents.
Complaint Details
The complaint investigation was substantiated. The incident involved Resident #2 entering Resident #1's room uninvited, getting into bed, and kissing Resident #1. The facility failed to investigate or report the incident properly.
Findings
The facility failed to conduct a thorough investigation and report the alleged resident-to-resident abuse to the State Agency as required. Documentation and communication regarding the incident were incomplete or missing.
Deficiencies (1)
19 CSR 30-88.010(25) - The facility failed to report to the Department of Health and Senior Services or the Department of Mental Health when there was reasonable cause to suspect resident abuse. The facility did not conduct a thorough investigation or report the incident involving resident-to-resident abuse.
Report Facts
Facility census: 52
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Jan 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to maintain resident and common area temperatures above 68 degrees Fahrenheit during cold weather conditions.
Complaint Details
The complaint investigation found the violation to be an imminent danger Class I level due to the effect on residents. The deficiency was substantiated based on observation, interviews, and record review.
Findings
The facility failed to maintain temperatures in resident rooms and common areas above 68 degrees Fahrenheit, resulting in discomfort for residents. The deficiency affected all residents, and corrective actions were initiated during the investigation.
Deficiencies (1)
19 CSR 30-86.032(9) Temperatures In Resident Areas: The facility failed to ensure temperatures in resident rooms and common areas were maintained above 68 degrees Fahrenheit, causing discomfort to residents. The facility census was 49 residents.
Report Facts
Facility census: 49
Temperature readings: 56.1
Temperature readings: 67.6
Date of survey completion: Jan 17, 2024
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 4
Date: Jun 20, 2023
Visit Reason
Annual survey conducted to assess compliance with state regulations for Silverado Lee's Summit Memory Care facility.
Findings
The facility was found deficient in multiple areas including hazardous area requirements, furniture and equipment maintenance, protective oversight, and food preparation separation. Several residents exhibited behaviors requiring increased supervision and fall risk management, with incomplete documentation and follow-up noted.
Deficiencies (4)
19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The facility failed to ensure that an open kitchen with an operable stove was separated by at least a one-hour fire resistive rating. This deficiency potentially affected all residents. The facility census was 44 residents.
19 CSR 30-86.032(22) Furniture/Equip, Provide Comfort & Safety: Facility staff failed to ensure prompt repair of broken laundry equipment, causing delays in returning residents' laundry. The facility census was 44 residents.
19 CSR 30-86.047(35) Protective Oversight: Facility staff failed to provide protective oversight and supervision for residents exhibiting exit seeking behaviors, including failure to update individualized service plans and ensure resident safety. The facility census was 44 residents.
19 CSR 30-87.030(7) Food Prep & Storage Separate From Other Areas: The facility failed to ensure that an open kitchen with an operable stove was separated from the open living area, potentially affecting all residents. The facility census was 44 residents.
Report Facts
Facility census: 44
Inspection Report
Plan of Correction
Census: 40
Deficiencies: 2
Date: Feb 2, 2023
Visit Reason
The document is a Plan of Correction submitted by Silverado Lee's Summit following a survey completed on February 2, 2023. It addresses deficiencies cited during the inspection related to administrator licensing and resident safety plans.
Findings
The facility failed to designate a licensed administrator as required and did not have a plan in place to safeguard a resident with a history of aggressive behaviors. The facility census was 40 residents at the time of inspection.
Deficiencies (2)
19 CSR 30-86.047(5) Administrator - Licensed: The facility failed to designate an individual licensed by the Missouri Board of Nursing Home Administrators to act as the administrator. The facility census was 40 residents.
19 CSR 30-86.047(28)(J) Plan to Safeguard Residents: The facility failed to ensure a plan was in place for a resident with a history of aggressive behaviors who forcibly grabbed another resident and required staff intervention to ensure safety. The resident was discharged on January 18, 2023.
Report Facts
Facility census: 40
Deficiency tags cited: 2
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 4
Date: Jan 4, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Silverado Lee's Summit, detailing regulatory deficiencies found during a survey completed on January 4, 2023.
Findings
The facility was found deficient in staffing levels, medication administration, and prevention of abuse, neglect, and exploitation. Specific issues included inadequate staffing for one resident requiring 1:1 supervision, failure to implement a safe medication system, and failure to ensure residents were free from sexual abuse.
Deficiencies (4)
19 CSR 30-86.045(4)(A) Staffing Ratio, Resident Care & Fire Safety. The facility failed to provide adequate staff oversight for one resident requiring 1:1 monitoring and private caregiver services. The facility census was 53 residents.
19 CSR 30-86.047(46) Safe & Effective Medication System. The facility failed to implement a safe medication system ensuring medications were available for the first 10 days of admission for a newly admitted resident. The facility census was 53 residents.
19 CSR 30-88.010(22) Free From Abuse. The facility failed to ensure five sampled residents were free from sexual abuse, including one resident observed with inappropriate sexual contact by another resident. The facility census was 53 residents.
19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility failed to fully implement abuse and neglect policies, including thorough investigation and reporting of suspected abuse incidents involving residents.
Report Facts
Facility census: 53
Sampled residents: 16
Residents affected by abuse deficiency: 5
Inspection Report
Plan of Correction
Census: 31
Deficiencies: 1
Date: May 31, 2022
Visit Reason
The inspection was conducted to investigate and document deficiencies related to dignity and privacy violations at Silverado Lee's Summit nursing facility.
Findings
The facility failed to ensure residents were treated with dignity and respect, allowing a caregiver to be rude and disrespectful to residents. The incident was substantiated and corrective actions including staff suspension and training were implemented.
Deficiencies (1)
19 CSR 30-88.010(29) Dignity/Privacy: The facility failed to ensure residents were treated with dignity and respect, allowing a caregiver to be rude and disrespectful to residents during care and meal times.
Report Facts
Facility census: 31
Inspection Report
Plan of Correction
Census: 24
Deficiencies: 2
Date: Sep 29, 2021
Visit Reason
The inspection was conducted to identify deficiencies related to tuberculosis screening of residents and staff, and compliance with community based assessment requirements for assisted living facilities.
Findings
The facility failed to administer required TB skin tests to newly hired employees and did not ensure staff were certified to complete Community Based Assessments. Three residents were affected by deficient admission practices related to the assessment process.
Deficiencies (2)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to administer required TB skin tests to two of three newly hired employees. Documentation of TB testing was incomplete or missing.
19 CSR 30-86.047(28)(F)(3) Community Based Assessment - Other Form: The facility failed to ensure a staff member was certified to complete Community Based Assessments. This affected three newly admitted residents.
Report Facts
Facility census: 24
Residents affected: 3
Inspection Report
Plan of Correction
Census: 29
Capacity: 30
Deficiencies: 2
Date: Mar 25, 2021
Visit Reason
The inspection was conducted to investigate deficiencies related to the facility's failure to notify family members about a resident's change in condition and death, and to assess protective oversight and elopement risk for residents.
Findings
The facility failed to notify the responsible party for a resident who was found unresponsive and subsequently passed away. Additionally, the facility failed to provide adequate protective oversight for a resident who eloped twice, including failure to implement consistent 1:1 staffing and proper documentation.
Deficiencies (2)
19 CSR 30-88.010(11) Inform Medical Cond. - Access to Med Records. The facility failed to notify the responsible party for one resident when the resident was found unresponsive and subsequently passed away.
19 CSR 30-86.047(35) Protective Oversight. The facility failed to provide adequate protective oversight for a resident who eloped twice, including failure to implement consistent 1:1 staffing and proper documentation.
Report Facts
Facility census: 29
Facility census: 30
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 1
Date: Dec 5, 2019
Visit Reason
The inspection was conducted to investigate compliance with discharge requirements within five days and to address a deficiency related to refunding overpayments to discharged residents.
Findings
The facility failed to refund an overpayment to a discharged resident within five days as required by regulation. The resident was discharged to a skilled nursing home, and no refund was issued for the remaining two weeks of service.
Deficiencies (1)
19 CSR 36-88.020(10) Discharge Requirement Within 5 Days was not met as the facility failed to refund an overpayment to a discharged resident within five days.
Report Facts
Facility census: 27
Refund amount: 3294.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding resident discharge and refund | |
| Director of Nursing | Interviewed regarding resident transfers |
Inspection Report
Annual Inspection
Census: 32
Capacity: 32
Deficiencies: 18
Date: Mar 22, 2019
Visit Reason
Annual survey conducted to assess compliance with state regulations and federal requirements for Autumn Leaves of Lee's Summit facility.
Findings
The facility was found to have multiple deficiencies including staffing issues, fire safety violations, medication administration errors, incomplete resident assessments, and inadequate infection control practices. Corrective actions and plans of correction were required.
Deficiencies (18)
A4513 Staffing Requirements: The facility failed to maintain adequate staffing levels and ensure staff were trained in CPR and emergency procedures, affecting all 32 residents.
A2201 Fire Notification to DHSS: The facility failed to report and submit a fire incident report after a toaster fire, affecting all 32 residents.
A2203 Fire-24hr Monitor, Hourly Checks: The facility failed to monitor the kitchen toaster for 24 hours after the fire incident, risking resident safety.
A2215 Fire Drill/Evacuation Plan Requirements: The facility's disaster plan was incomplete and lacked proper instructions and documentation for evacuation and fire safety.
A2256 Hazardous Area Requirements: The facility failed to separate hazardous areas properly and ensure fire safety compliance, affecting all 32 residents.
A3217 Night Lights Provided: The facility failed to ensure night lights were provided in resident restrooms, affecting all 32 residents.
A3234 Call Systems Requirements: The facility failed to ensure all call systems were functional and accessible to residents, affecting all 32 residents.
A4703 Administrator - Licensed: The facility lacked a licensed administrator during the survey period, affecting all 32 residents.
A4711 Criminal Background Check Requirements: The facility failed to obtain timely criminal background checks for new employees, risking resident safety.
A4724 TB Screen Residents & Staff: The facility failed to ensure tuberculosis screening was completed for new employees and residents, affecting all 32 residents.
A4748 Premove-in Screening Requirements: The facility failed to complete required pre-move-in screenings for new residents, risking infection control.
A4754 Individual Service Plan Development: The facility failed to complete individualized service plans for sampled residents, affecting care quality.
A4775 Protective Oversight: The facility failed to provide adequate protective oversight for residents at risk of elopement and injury.
A4776 Medication System Safe & Effective: The facility failed to ensure safe medication administration and documentation, risking resident health.
A4827 Resident Condition/Medication Review: The facility failed to conduct timely medication regimen reviews for residents, risking medication errors.
A5201 Food Prep & Services: The facility failed to ensure food was prepared and served safely and in accordance with dietary needs, affecting 32 residents.
A8002 Noncompliance/Inspection Reports Posted: The facility failed to post required inspection reports in a visible location for residents and visitors.
A8024 Staff Trained on Reporting A/N: The facility failed to ensure all staff were trained on reporting abuse and neglect, risking resident safety.
Report Facts
Facility census: 32
Total licensed capacity: 32
Deficiency count: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gary Holmes | Executive Director | Named in relation to plan of correction and signature on multiple pages |
Inspection Report
Plan of Correction
Census: 31
Deficiencies: 7
Date: Dec 21, 2018
Visit Reason
The document is a Plan of Correction related to deficiencies identified during a facility inspection conducted on 12/21/2018 at Autumn Leaves of Lee's Summit.
Findings
The facility was found deficient in staffing ratios, individual service plans, admission criteria, menu planning, grievance processes, and posting of inspection reports. The census was 31 residents at the time of inspection.
Deficiencies (7)
19 CSR 30-86.045(4)(A) Staffing Ratio, Resident Care & Fire Safety. The facility failed to ensure adequate staffing based on resident acuity, with staffing records incomplete and observations showing insufficient staff assistance during meals.
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop. The facility failed to develop and maintain individualized service plans with required signatures, goals, and timely updates for residents.
19 CSR 30-86.047(29)(E) Not Admit/Care For-More > 1 staff to Assist. The facility admitted a resident requiring more than one person for assistance without appropriate care provisions.
19 CSR 30-86.052(6) Menus, Substitutes. The facility failed to follow planned menus and document substitutions, affecting all residents who ate food prepared by the facility.
19 CSR 30-86.052(8)(B) Modified Diets-Diet/Food Qrtly Review. The facility failed to ensure meal preparation, service, menus, and recipes were reviewed quarterly by a qualified dietitian.
19 CSR 30-88.010(2) Noncompliance/Inspection Reports Posted. The facility failed to post noncompliance notices and inspection reports in a conspicuous location as required.
19 CSR 30-88.010(20) Exercise Rights/Voice Grievances. The facility failed to fully investigate and follow up on family grievances in a timely manner and lacked an official grievance process.
Report Facts
Facility census: 31
Deficiency counts: 7
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 3
Date: Nov 14, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding protective oversight failures for residents with histories of elopements and exit-seeking behavior.
Complaint Details
The complaint investigation found the violation to be immediate and serious (Class I) related to protective oversight and elopement risk. The facility implemented corrective action and began staff training during the initial onsite visit.
Findings
The facility failed to provide adequate protective oversight and supervision for residents at risk of elopement, resulting in multiple elopement incidents. Staff failed to accurately assess elopement risk, develop interventions, and update Individual Service Plans accordingly.
Deficiencies (3)
19 CSR 30-86.047(35) Protective Oversight: Facility staff failed to provide protective oversight and supervision for residents with histories of elopements and exit-seeking behavior, resulting in multiple elopements. Staff did not accurately assess elopement risk or update Individual Service Plans to guide care.
19 CSR 30-88.010(23) Develop/Implement A/N Policies: The facility failed to implement written policies and procedures to report incidents of possible resident to resident abuse or neglect for one resident. The facility census was 31 residents.
19 CSR 30-88.010(15) 30 Day Notice-Transfer/Discharge: The facility failed to provide a proper discharge notice to a resident's legal representative outlining appropriate time frames and rights to appeal. This affected one resident of two sampled.
Report Facts
Facility census: 31
Missed 30-minute checks: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver A | Interviewed regarding resident elopement on 10/24/18 | |
| Caregiver B | Interviewed regarding resident elopement and door alarms on 11/7/18 | |
| Caregiver C | Interviewed regarding resident elopement and monitoring on 11/13/18 | |
| Caregiver D | Interviewed regarding resident elopement on 11/14/18 | |
| Caregiver E | Interviewed regarding training and resident monitoring on 11/14/18 | |
| Caregiver F | Interviewed regarding resident exit-seeking behavior on 11/14/18 | |
| Director of Nursing | DON | Interviewed about resident elopement and staff response on 10/24/18 |
| Executive Director | ED | Interviewed about resident elopement and staff training |
| Licensed Practical Nurse | LPN | Interviewed about resident work schedule and monitoring on 11/14/18 |
| CMT A | Certified Medication Technician | Observed resident elopement and monitoring on 11/2/18 |
| CMT B | Certified Medication Technician | Interviewed about door alarms and resident monitoring on 11/5/18 |
| CMT C | Certified Medication Technician | Interviewed about resident elopement and door alarms on 10/24/18 and 11/9/18 |
| Culinary Manager | Interviewed about resident elopement on 11/5/18 |
Inspection Report
Plan of Correction
Census: 21
Deficiencies: 1
Date: Jul 6, 2018
Visit Reason
The inspection was conducted due to a protective oversight deficiency related to a resident elopement incident. The report documents the facility's failure to provide adequate protective oversight for a resident at risk of elopement.
Findings
The facility failed to provide protective oversight and supervision for one resident at known elopement risk, resulting in the resident leaving the facility without staff knowledge. Multiple missed checks and delayed responses to door alarms were noted.
Deficiencies (1)
19 CSR 30-88.047(35) Protective Oversight: The facility failed to provide protective oversight and supervision for one resident at elopement risk, resulting in the resident leaving the facility without staff knowledge or timely response to alarms.
Report Facts
Facility census: 21
Missed 15-minute checks: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 6/21/18 regarding resident elopement | |
| Certified Medication Technician (CMT) | Interviewed on 6/21/18 and 6/25/18 regarding resident elopement and alarm response | |
| Administrator | Interviewed on 6/26/18 regarding facility response and family refusal of 1:1 sitter service | |
| Caregiver #A | Interviewed on 6/25/18 regarding resident elopement and pager alarm |
Document
Deficiencies: 0
Date: Sep 24, 2019
Visit Reason
The document does not contain any readable content to determine the visit reason.
Findings
No findings or content are available due to lack of readable text.
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