Mar. 16, 2019

Tiffany Springs Rehab & Health Care Center, Kansas City, MO:

The facility failed to provide supervision and protective oversight for one resident who was assessed as needing a staff member present while he/she was in the whirlpool. Staff left the resident in a whirlpool tub unsupervised for approximately one hour.

Swope Ridge Geriatric Center, Kansas City, MO: The facility failed to maintain a comfortable environment when the facility lost power for approximately 30 hours during a winter storm. The air temperatures were not maintained above 68 degrees and the facility failed to evacuate residents when it was determined that the required temperature could not be maintained.

Gaslight Manor, Lebanon, MO: A complaint investigation was conducted. The facility staff failed to provide protective oversight for one resident with a diagnosis of wandering and paranoid schizophrenia. The resident left the facility while on 30 minute visual checks by staff. The resident was not missed by staff for approximately four hours and was located five days later approximately 54 miles from the facility.

Four Seasons Living Center, Sedalia, MO: A complaint investigation was conducted. The facility failed to ensure one resident was free from physical abuse, when the resident and the administrator got into a physical altercation that resulted in the administrator pushing the resident about 15feet, and then “taking down” the resident to the floor. The facility failed to implement interventions known to help de-escalate one resident’s behavior when the resident had increased agitation. Facility staff planned to allow one resident to smoke when his/her behaviors escalated in an effort to calm the resident. However, staff instead removed smoke breaks as a result of escalating behaviors for the resident. The behavior escalated over several days and resulted in the facility staff “taking down” and injecting anti-psychotic and anti-anxiety medication into the resident prior to sending the resident out for an inpatient psychiatric evaluation.

Edgewood Manor Center for Rehab and Healthcare, Raytown, MO: The facility failed to ensure the resident environment was free of accident hazards by not maintaining water temperatures between 105 and 120 degrees F. in an occupied resident room, sinks, and community bath houses. This put residents at increased risk for burns caused by scalding. The facility failed to respond to reports of out of range/fluctuating water temperatures and investigate the cause. The facility further failed to have a policy in place for maintaining safe water temperatures.

Adrian Manor Health & Rehabilitation Center: The facility failed to provide protective oversight and adequate supervision for one resident who exhibited multiple instances of wandering into other resident rooms, disrobing, and getting into bed with other residents on the night shift. The facility did not accurately assess and identify the behaviors and did not have a care plan in place to initiate appropriate interventions and ensure appropriate supervision was provided.