Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
125% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
66 residents
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 66
Deficiencies: 13
Jul 10, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey of The Healthcare Resort of Kansas City to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, prevent resident-to-resident abuse, ensure timely lab work and follow-up, apply prescribed braces, maintain a safe environment, provide appropriate nutrition and dialysis care, secure medications, implement infection control, and provide adequate staff training.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Potential for minimal harm: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to provide wheelchair pedals for Resident 39 when staff pushed her wheelchair, leaving her vulnerable to injury. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent resident-to-resident abuse when Resident 31 threw hot coffee on Resident 40. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure timely physician-ordered STAT labs for Resident 45 and failed to notify physician of delay. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to apply Resident 39's leg/ankle brace as ordered, risking worsening contractures and decreased mobility. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a safe environment free from hazards including unsecured oxygen tanks, chemical exposure, and fall prevention interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care for Resident 39's urinary incontinence and peri care, increasing risk of UTIs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to consistently communicate Resident 6's medical condition pre- and post-hemodialysis, risking adverse outcomes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post daily nurse staffing information with required data and failed to retain posted staffing data. | Level of Harm - Potential for minimal harm |
| Failed to adequately meet Resident 46's behavioral health needs, resulting in repeated behavioral episodes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident 41's blood pressure and pulse were monitored as ordered prior to administration of antihypertensive medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to secure medication and treatment carts, placing residents at risk for medication errors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow sanitary infection control standards related to handling soiled laundry, medication administration, and PPE disposal. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure agency direct care staff received required training in communication, resident rights, dementia care, and nurse aide in-service training. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents in census: 66
Sample residents reviewed: 19
Weight loss percentage: 11.74
Weight loss percentage: 7.35
Weight loss percentage: 8.13
Weight loss in pounds: 11.74
Weight in pounds: 155
Weight in pounds: 136.8
Weight in pounds: 251
Weight in pounds: 350
Pressure in PSI: 200
Medication dose: 25
Medication dose: 300
Medication dose: 400
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple statements regarding facility policies, deficiencies, and investigations |
| Certified Nurse's Aide M | Certified Nurse's Aide | Interviewed regarding wheelchair pedals, fall prevention, and resident care |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding wheelchair pedals, abuse incident, and medication administration |
| Administrative Staff A | Administrative Staff | Provided statements regarding abuse policies, staffing, and agency training |
| Licensed Nurse H | Licensed Nurse | Interviewed regarding nutrition monitoring and medication administration |
| Certified Nurse's Aide O | Certified Nurse's Aide | Observed and interviewed regarding peri care and brace application |
| Certified Medication Aide T | Certified Medication Aide | Observed failing to perform hand hygiene during medication administration |
| Consultant GG | Consultant | Interviewed regarding communication about weight loss and enteral feeding |
| Licensed Nurse F | Licensed Nurse | Interviewed regarding oxygen storage and safety |
| Licensed Nurse J | Licensed Nurse | Observed and secured medication carts |
| Certified Nurse's Aide P | Certified Nurse's Aide | Agency staff lacking required training |
| Certified Nurse's Aide Q | Certified Nurse's Aide | Agency staff lacking required training |
| Certified Nurse's Aide LL | Certified Nurse's Aide | Agency staff lacking required training |
Inspection Report
Routine
Census: 66
Deficiencies: 14
Jul 10, 2024
Visit Reason
Routine inspection of The Healthcare Resort of Kansas City nursing home to assess compliance with regulatory requirements including resident care, safety, medication administration, infection control, and staff training.
Findings
The facility was found deficient in multiple areas including failure to provide wheelchair pedals and leg/ankle brace for Resident 39, failure to prevent resident-to-resident abuse, failure to obtain timely physician-ordered labs for Resident 45, failure to follow fall prevention interventions, failure to communicate dialysis information for Resident 6, failure to post and retain daily nurse staffing data, failure to provide appropriate care for urinary incontinence, failure to monitor medication parameters for Resident 41, failure to meet behavioral health needs for Resident 46, failure to identify dementia-related behaviors for Resident 29, failure to secure medication carts, failure to follow infection control standards, and failure to ensure agency staff received required training.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Level of Harm - Potential for minimal harm: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Facility failed to provide wheelchair pedals for Resident 39 when staff pushed her wheelchair, leaving her vulnerable to injury. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure residents were free from resident-to-resident abuse when Resident 31 threw hot coffee on Resident 40. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to obtain physician-ordered STAT labs timely for Resident 45 and failed to notify physician of delay, risking delayed care. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to apply Resident 39's leg/ankle brace when out of bed, risking worsening contractures and decreased mobility. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure a safe environment free from hazards and failed to follow fall prevention interventions for Residents 29, 58, and 6. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure timely and consistent communication of Resident 6's medical condition pre- and post-hemodialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to post daily nurse staffing data with required information and failed to retain posted staffing data. | Level of Harm - Potential for minimal harm |
| Facility failed to provide appropriate care for Resident 39's urinary incontinence and failed to follow proper peri care procedures. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to monitor blood pressure and pulse as ordered prior to administration of antihypertensive medication for Resident 41. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to secure medication and treatment carts, leaving medications unattended and unsecured. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to follow sanitary infection control standards related to handling soiled laundry, medication administration, and PPE disposal. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to adequately meet Resident 46's behavioral health needs resulting in repeated behavioral episodes. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to identify a pattern of dementia-related behaviors for Resident 29 and implement meaningful interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure agency direct care staff received required communication, resident rights, dementia, and nurse aide training. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 66
Sample size: 19
Weight loss percentage: 11.74
Weight loss percentage: 7.35
Weight loss percentage: 8.13
Weight: 155
Weight: 136.8
Weight: 251
Weight: 143.6
Weight: 142.4
Weight: 145.2
Weight: 155.1
Weight: 251
BIMS score: 8
BIMS score: 15
BIMS score: 13
BIMS score: 14
BIMS score: 14
BIMS score: 9
BIMS score: 11
BIMS score: 9
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Interviewed regarding multiple deficiencies including wheelchair pedals, abuse incident, lab delays, fall prevention, dialysis communication, medication administration, infection control, and staff training. |
| Certified Nurse's Aide M | Certified Nurse's Aide | Interviewed regarding wheelchair pedals, fall prevention, behavioral health interventions, safe transfer of Resident 58, and infection control. |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding wheelchair pedals, abuse incident, peri care, medication administration, dialysis communication, fall prevention, and infection control. |
| Certified Nurse's Aide O | Certified Nurse's Aide | Observed and interviewed regarding failure to apply leg brace and improper peri care for Resident 39. |
| Licensed Nurse H | Licensed Nurse | Interviewed regarding wheelchair brace application, weight monitoring, medication administration, and behavioral health interventions. |
| Certified Medication Aide T | Certified Medication Aide | Observed failing to perform hand hygiene during medication administration. |
| Certified Medication Aide S | Certified Medication Aide | Observed failing to perform hand hygiene during medication administration. |
| Licensed Nurse J | Licensed Nurse | Observed unsecured medication carts and secured them. |
| Administrative Staff A | Administrative Staff | Interviewed regarding staffing data posting, agency staff training, and medication cart security. |
| Consultant GG | Consultant | Interviewed regarding concerns with communication related to weight loss and enteral feedings. |
Inspection Report
Routine
Census: 55
Deficiencies: 1
Mar 28, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards related to wound care and treatment for residents, specifically focusing on Resident 1 who had diabetes and amputations.
Findings
The facility failed to provide appropriate wound care and monitoring for Resident 1, resulting in progressive infection and eventual surgical amputation of the left third toe. Documentation and follow-up care were inadequate, placing the resident at risk for increased pain and decreased mobility.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident 1 received appropriate wound care and monitoring for a diabetic foot ulcer, leading to infection and surgical amputation. | Level of Harm - Actual harm |
Report Facts
Census: 55
Antibiotic dosage: 800
Antibiotic duration: 14
Wound measurement: 1.4
Wound measurement: 2
Wound measurement: 0.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Reported initial observation and care of Resident 1's toe wound and communication with physician |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding notification and treatment procedures for Resident 1's wound |
| Administrative Nurse E | Administrative Nurse | Described wound care and monitoring practices for Resident 1's toe |
| Consultant GG | Consultant Nurse Practitioner/Physician Assistant | Documented Resident 1's foot ulcer and provided expert opinion on wound care |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
Mar 20, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's physician of a change in condition and failure to administer medications as ordered, placing the resident at risk for health complications.
Findings
The facility failed to notify Resident 1's physician of elevated blood pressures during a seven-day admission and failed to administer the medication Carvedilol as ordered, resulting in a significant medication error. The facility also lacked policies for physician notifications and medication reconciliation.
Complaint Details
The investigation was complaint-related, focusing on failure to notify the physician and medication errors. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to inform Resident 1's physician of a change in condition related to elevated blood pressures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer medications as ordered, specifically Carvedilol, resulting in a medication error. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident census: 64
Blood pressure readings: 206
Blood pressure readings: 113
Medication tablets received: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Stated procedures for physician notification and medication order entry | |
| Administrative Nurse D | Described blood pressure thresholds for physician notification and audit processes |
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 10
Nov 2, 2022
Visit Reason
The inspection was conducted as part of an annual survey of The Healthcare Resort of Kansas City to assess compliance with regulatory requirements and evaluate the quality of care provided to residents.
Findings
The facility was found deficient in multiple areas including failure to notify a resident's physician timely about medication administration issues, failure to develop a comprehensive care plan for hypertension medication, failure to provide scheduled bathing, failure to provide a safe environment to prevent falls, failure to accurately monitor fluid intake for a resident on fluid restriction, failure to provide timely pain medication, failure to ensure nursing staff competency in medication administration via feeding tube, failure to reconcile controlled medications properly, failure to ensure medication availability, failure to label and secure medications properly, and failure to implement adequate infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to notify Resident 29's physician of medications not administered in a timely manner. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a comprehensive care plan for hypertension medication for Resident 29. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide scheduled bathing for Resident 16, placing the resident at risk for skin problems and poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a safe environment and resident-centered interventions to prevent falls for Resident 46. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately monitor fluid intake for Resident 16 on a 2000 ml per day fluid restriction. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely pain medication for Resident 172, placing the resident at risk for further pain and discomfort. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure licensed nursing staff possessed necessary knowledge and skills when administering Resident 41's medication via feeding tube, administering by mouth instead. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure reconciliation of controlled medications at shift changes and failed to ensure Resident 29's medications were available as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label insulin pen when opened and failed to ensure medication cart was locked when unattended. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to transport clean clothing in a sanitary manner and failed to adequately disinfect a glucometer. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 63
Medication unavailable days for gabapentin: 9
Medication unavailable days for atorvastatin: 4
Medication unavailable days for spironolactone: 8
Medication unavailable days for bisoprolol fumarate: 12
Bathing interval: 29
Fluid restriction: 2000
Fluid intake recorded: 658
Fluid intake recorded: 731
Pain medication delay: 20
Medication cart shift changes without reconciliation: 14
Medication cart shift changes without reconciliation: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse J | Licensed Nurse | Contacted pharmacy about Resident 29's medication coverage and VA medication |
| Administrative Nurse D | Administrative Nurse | Commented on failure to notify physician and medication issues for Resident 29 and others |
| Licensed Nurse I | Licensed Nurse | Administered Resident 41's medication by mouth instead of feeding tube |
| Certified Medication Aide S | Certified Medication Aide | Reported Resident 172 did not receive pain medication on admission day due to lack of authorization code |
Inspection Report
Routine
Census: 43
Deficiencies: 14
Jun 16, 2021
Visit Reason
Routine inspection of The Healthcare Resort of Kansas City nursing home to assess compliance with regulatory requirements across multiple care areas including discharge communication, personal hygiene assistance, treatment implementation, pressure ulcer care, range of motion support, fall prevention, catheter care, respiratory care, dialysis communication, medication regimen review, unnecessary medication use, and infection control.
Findings
The facility failed to document discharge recapitulation for a resident, provide adequate personal hygiene assistance, implement physician orders for treatments and catheter care, ensure timely wound care and pressure ulcer prevention, provide appropriate range of motion support, investigate and intervene for falls, maintain proper respiratory care orders and equipment sanitation, ensure effective communication with dialysis center, act on consultant pharmacist recommendations, monitor psychotropic medication use and behavior, properly store and date medications, and enforce infection control precautions for residents on isolation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Level of Harm - Actual harm: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to document a recapitulation of stay for Resident 33 upon discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide needed assistance with personal hygiene for dependent Resident 15. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement physician order for urinalysis with culture and sensitivity for Resident 15. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide pressure ulcer treatments as ordered and delayed preventative measures for Resident 92. | Level of Harm - Actual harm |
| Failed to provide appropriate treatment and services to increase range of motion and/or prevent further decrease for Resident 28. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to investigate causative factors and implement interventions for prevention of falls for Resident 8. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident 39 received suprapubic catheter care orders after hospital return and failed to ensure physician ordered urinalysis for Resident 17 was completed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide oxygen and Bi-Pap use orders upon reentry from hospital for Resident 16 and failed to change oxygen tubing for Residents 16 and 30. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to utilize an effective system for communication to and from dialysis center for Resident 25. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Consultant Pharmacist recommendations were identified, reported, and acted upon for Residents 39, 16, 8, 28, and 17; failed to recognize and report missing behavior monitoring documentation for Resident 17 on psychotropic medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident 39's medication orders were reinstated with necessary administration instructions after hospital stay. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure PRN clonazepam had a physician ordered duration and failed to attempt gradual dose reduction for scheduled clonazepam for Resident 8; failed to monitor behaviors for Resident 17 on psychotropic medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store and date two tuberculin purified protein derivative vials and three insulin pens; failed to properly store medications; failed to discard expired medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure standard infection control practices with Residents 193 and 197 on droplet precautions. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 14
Census: 43
Medication administration documentation gaps: 15
Medication administration documentation gaps: 5
Medication administration documentation gaps: 3
Medication administration documentation gaps: 1
Medication administration documentation gaps: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Stated nursing provided discharge instructions but did not document recapitulation of stay |
| Administrative Nurse D | Administrative Nurse | Stated nursing reviewed discharge instructions but did not document discharge summary; verified lack of wound care orders; stated expectation for fall investigations and interventions; stated expectation for hand hygiene and PPE use; stated CP recommendations sent to physician and nursing staff |
| Licensed Nurse G | Licensed Nurse | Stated fingernails should be checked during baths; stated new orders placed on shift report; stated fall packet completed after falls; stated oxygen tubing changed weekly; stated CP recommendations sent to physician and nursing staff |
| Certified Nurse Aide R | Certified Nurse Aide | Described bath book use and nail trimming process; described fall interventions for Resident 8 |
| Licensed Nurse I | Licensed Nurse | Verified lack of wound care orders; stated new orders placed on shift report |
| Medical Consultant II | Medical Consultant | Described wound care assessment and order process |
| Certified Medication Aide R | Certified Medication Aide | Stated therapy responsible for applying braces |
| Therapy Consultant HH | Therapy Consultant | Stated therapy occasionally applied brace; nursing responsible for brace application and removal |
| Consultant Physician Assistant II | Consultant Physician Assistant | Notified of UA results; stated antibiotic treatment could have prevented sepsis |
| Licensed Nurse H | Licensed Nurse | Stated medications were dated; ADON checked medication carts and rooms |
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