July 24, 2021
Analogy of the Plaza, Kansas City, MO: A complaint investigation was completed. The facility failed to ensure coordination of mental health services or to address a change in condition for one resident when approximately two weeks prior the resident started displaying paranoid behavior and having auditory hallucinations which was a change in his/her base line condition. The resident was found in his/her room with a self-inflicted gunshot wound to the head.
The Bishop Spencer Place, Inc., Kansas City, MO: A complaint investigation was completed. The facility failed to notify the resident’s physician of a change of condition, failed to respond to a resident’s elevated blood glucose, and failed to continue to assess or monitor the resident’s elevated blood glucose. The resident was discharged to home and the resident’s family member took the resident to the hospital where he/she was admitted to the intensive care unit with Diabetic Ketoacidosis ( a serious diabetes complication).
The Sheridan at Laumeier Park, Sunset Hills, MO: A complaint investigation was completed. The facility failed to provide proper care per the individualized service plan for a resident diagnosed with COVID-19 who had a significant change, and the resident’s physician was not notified. The resident expired.
Parkside Manor, Columbia, MO: The facility failed to maintain the dry sprinkler system by failing to make needed repairs. This had the potential for system failure in the event of an emergency.
Levering Regional Health Care Center, Hannibal, MO: The facility failed to ensure two residents did not obtain illegal drugs, including methamphetamine and cannabis, while in the facility. Further, the facility failed to ensure the residents could not obtain contaminated needles to inject the illegal drug, which they had done five or six times in the last two months.
Heritage Village of Gladstone, Gladstone, MO: The facility failed to provide protective oversight for one resident who left the facility without staff knowledge. The resident wondered approximately two miles from the facility at night, in the rain, and was found by staff of a local business. Facility staff was not aware the resident was missing until approximately 6 hours after he/she was last seen.
Pioneer Skilled Nursing Center, Marceline, MO: A complaint investigation was completed. The facility failed to provide proper CPR to one resident who had a tracheotomy and was a full code. The resident expired. The facility had several nurses and three other staff whose CPR certification had lapsed. The facility further failed to ensure care staff was proficient in the care of a tracheotomy prior to accepting the resident.
Silex Residential Home, LLC, Silex, MO: A complaint investigation was conducted. The facility failed to ensure an adequate number of personnel on duty on the day shift met the requirements for fire safety and care of residents.
Independence Manor Care Center, Independence, MO: A complaint investigation was completed. The facility failed to provide basic life support, including cardiopulmonary resuscitation, and failed to call emergency medical services in a timely manner for one resident with a full code order. The resident was found not breathing and without heartbeat.
Willow Creek Memory Care At Lee’s Summit, Lee’s Summit, MO: A complaint investigation was conducted. The facility failed to provide adequate protective oversight for one resident who eloped from the facility. The facility failed to identify the resident as an elopement risk after he/she routinely voiced a desire to go home. The facility failed to update the resident’s service plan and failed to do 15 minute checks.
Big Bend Woods Healthcare Center. Valley Park, MO: The facility failed to have a process to ensure CNAs reported new or worsening skin conditions and soaked or missing dressings to the nurse when identified. In addition, the facility failed to ensure nurses applied treatments to wounds with soiled or missing dressings in a timely manner. Thirteen residents were identified with pressure ulcers.
Carnegie Village Senior Living Community, Belton, MO: A complaint investigation was completed. The facility failed to promptly put interventions in place for two residents, when the residents voiced suicidal ideations with plans and made subsequent attempts.