May 25, 2019

Sunrise of Chesterfield, Chesterfield, MO: A complaint investigation was conducted. The facility failed to provide acceptable nursing care to one resident. The resident’s physician ordered transfers by a full mechanical lift. Staff transferred the resident with the use of a gait belt. The facility also failed to assess and treat the resident’s pain in a timely manner. The resident was later found to have a fracture.

North Village Park, Moberly, MO: A complaint investigation was conducted. The facility failed to ensure residents with mental health disorders received appropriate person-centered and individualized treatment to meet their needs. One resident had a history of physical aggression. This resident was involved in an altercation with another resident. The victim sustained a severe head injury which required surgical intervention, including a craniectomy (a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand) and a tracheostomy (a tube placed through a surgical procedure in the neck to provide an airway) mechanical ventilation and feeding tube placement. The facility failed to adequately assess the residents’ specific needs and develop resident specific interventions as appropriate to address these needs.

Garden Valley Healthcare Center, Kansas City, MO: A complaint investigation was completed. The facility failed to protect one resident from verbal abuse and neglect, when the resident fell out of bed and staff did not respond when the resident cried for help for eight minutes. Once observed on the floor, the staff failed to get the resident off the floor for over 10 minutes and verbally abused the resident while the resident begged for help.

Bridgewood Health Care Center, Kansas City, MO: A complaint investigation was conducted. The facility failed to ensure residents with mental health disorders received appropriate person-centered and individualized treatment to meet the needs for two sampled residents. The facility also failed to ensure there were enough staff to adequately monitor the residents on the eight census dementia unit; to complete registered nurse investigations when aggressive behaviors occurred to determine the ongoing behavioral needs of the resident; to update the care plan to ensure the staff knew the individualized interventions of the residents when aggressive behaviors occurred, and to ensure the residents were kept from harm. One resident had a history of physical aggression towards staff and residents. This resident had a physical altercation with another resident. One of these residents sustained a severe head injury with a diagnosis of subdural head bleed and was placed on a mechanical ventilator, listed in critical condition at the hospital, and then passed away at the hospital.

Autumn Leaves of Lee’s Summit, Lee’s Summit, MO: The facility failed to provide protective oversight to one resident, when facility staff failed to complete a fall risk assessment; failed to develop and implement a comprehensive individualized ISP that addressed the resident’s fall risk and outlined preventative measures; failed to document falls; failed to complete an assessment of the resident’s condition after a fall; failed to perform neurological checks after a fall; and failed to update the resident’s ISP and implement interventions after falls for one resident who sustained a C6 vertebrae fracture.