Lee's Summit Place

Inspectors wroteOn 5/26/26, the Administrator was notified of the past noncompliance which took place on 5/11/26. The resident's physician was notified of the error. The Director of Nursing (DON) provided facility staff training on 5/11/26 with return demonstration provided. The deficiency was corrected on 5/11/26. Review of facility policy entitled Medication Administration revised 2/7/24 showed:-Medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. -Identified resident by photo in the Medication Administration Record (MAR).-Review MAR to have identified medication to be administered. -Compare medication with MAR to have verified resident name, medication name, form, dose, route, and time. -Observed resident consumption of medication. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility's policies; failed to ensure prevention and treatment of pressure injuries (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction); failed to identify individuals at risk for developing pressure injuries; failed to assess, monitor, and measure the wounds at least weekly and document the findings; failed to observe for changes in the pressure injury that could indicate a change in the treatment; failed to implement the interventions on the residents plan of care; and failed to follow physician's orders for the treatment of pressure injuries for two sampled residents (Resident #26 and #307) out of 12 sampled residents. The facility census was 48 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were given as ordered when a staff member administered Lorazepam Intensol (a scheduled IV controlled substance medication was used for the management of anxiety disorders (a feeling of fear, dread, and uneasiness) without a physician's order for one supplemental resident (Resident #14) out of 12 residents. The facility census was 48 residents. Review of the facility policy titled Medical Provider Orders, dated 4/7/22, showed: -The facility shall use uniform guidelines for the ordering and following of medical provider orders. -Medications should be administered only upon the signed order of a person lawfully authorized to prescribe. -Documentation of medication if using electronic medication record, should be input in the electronic health record (EHR) with instructions per facility policy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess the resident's ability and capacity for self-care of his/her catheter (a tube passed through the urethra into the bladder to drain urine); failed to provide the resident with infection control education for self-administration of his/her catheter to help prevent infection; failed to capture the resident's self-catheter care on his/her admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning); and failed to include the resident's self-care on his/her baseline care plan for one sampled resident (Resident # 307), out of 12 sampled residents. The facility census was 48 residents. A policy was requested and not received at the time of exit. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate documentation on the narcotic count sheets; and failed to dispose of Lorazepam Intensol (a controlled substance used to treat anxiety) per professional standards and facility policy for one supplemental resident (Resident #14). The facility census was 48 residents. Review of the facility policy titled Controlled Substance Administration & Accountability, dated [DATE], showed: -It was the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. -The facility would have safeguards in place in order to prevent loss, diversion, or accidental exposure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the kitchen and Dry Storage (DS) room floors clean; to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food; and to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination), in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 13 residents with a licensed capacity for 60 residents at the time of the survey. 1. Review of the meal times provided by the Dietary Manager (DM) on 9/5/23 at 8:48 A.M. showed that breakfast was served at 8:00 A.M., lunch at 12:00 P.M., and dinner at 5:30 P.M. Observation on 9/5/23 between 8:48 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an annual dental exam for two sampled residents (Resident #2 and Resident #5) and to provide a dental consult for one sampled resident (Resident #12) who wanted to be evaluated for possible extractions of his/her teeth so he/she could obtain dentures out of nine sampled residents. The facility census was 13 residents. Review of the facility's dental services policy revised on 9/1/22 showed: -It was the policy of the facility to assist residents in obtaining routine and emergency dental care. -The dental needs were to be identified through the physical assessment and Minimum Data Set (MDS-a federally required assessment tool completed by facility staff for care planning) assessment process and addressed in each resident's plan of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to perform hand hygiene during cares for one sampled resident (Resident #12); to ensure nursing staff were cleansing their hands during medication pass, did not sanitize a pair of scissors used to open an sealed package counting a narcotic, and picked a tray lid up off of the floor without cleansing hands for one sampled resident (Resident #10) out of nine sampled residents and to follow their policy to complete testing to screen new employees and residents for tuberculosis (TB- a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for two out of ten sampled new employees. The facility census was 13 residents. Review of the facility's hand hygiene policy dated 9/1/21 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' private records were kept private during a medication pass by not ensuring the computer screen was not visible to anyone walking by the computer on top of the medication cart while the nurse administered medications inside of the residents' room for two sampled residents (Resident #5 and Resident #11) and one supplemental resident (Resident # 10) out of nine sampled residents. The facility census was 13 residents. Review of the facility's policy, Medication Administration, dated 9/1/22 showed: -Medications were to have been administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. -Provide privacy. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide continuity of resident care by not reviewing and revising resident comprehensive care plans (a document that specified health care and supported needs and outlined how the facility met resident requirements) for one sampled resident (Resident #269) out of nine sampled residents. This practice had the potential to effect the resident's safety and physical well-being. The facility census was 13 residents. Review of the facility's Comprehensive Care Plans Policy, dated 9/1/2021, showed: -It was the facility's policy to develop and implement a comprehensive person-centered care plan for each resident. -The comprehensive care plan described the services that were furnished to attain or maintain the resident's highest practicable physical well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to document information regarding the resident's personal belongings for one sampled closed record resident (Resident #15) out of two sampled closed records. The facility census was 13 residents. Review of the facility's resident personal belongings policy revised 9/1/22 showed: -All resident personal belongings would be inventoried at the time of admission and documentation kept in the medical record. -Additional possessions brought in during the duration of the individual's stay would be added to the existing personal belongings inventory listing. -Following the discharge of a resident, all personal belongings would be given to the designated resident representative. -The inventory of personal belongings should be reviewed at time of discharge by Social Services and the resident's representative. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders by not providing supervision for one sampled resident (Resident #269) out of nine sampled residents while the resident was alone in his/her wheelchair in his/her room. The facility census was 13 residents. Review of the facility's Medical Provider Orders policy, dated 4/7/22, showed: -The facility used uniform guidelines for the ordering and following of medical provider orders. -Medical provider orders were reviewed prior to administration of medication and/or treatment to validate the orders contained all required elements. -Staff should follow all valid medical provider orders timely unless there was an emergency that temporarily delayed the implementation of the order. Review of the facility's Incidents and Accidents policy, dated 9/1/22, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one sampled resident (Resident #68) who was the only resident receiving dialysis that resided at the facility. The facility census was 13 residents. Review of the facility's dialysis policy revised 9/1/22 showed: -There should be ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. -The facility staff should coordinate and collaborate with the dialysis facility to assure that documentation requirements were met to assure that treatments are provided as ordered. 1. Review of Resident #68's all-inclusive admission with baseline care plans dated 9/3/23 showed the reason for the resident's admission was to receive therapy, cares and dialysis. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal (lung inflammation caused by bacterial or viral infection) vaccines for one sampled resident (Resident #268) out of five residents sampled for immunizations. The facility census was 13 residents. Review of the facility's Pneumococcal Vaccine Policy, dated 9/1/2021, showed: -It was the facility's policy to offer residents immunizations against pneumococcal disease in accordance with current Center for Disease Control (CDC-the nation's health protection agency responsible for controlling the introduction and spread of infectious diseases) guidelines and recommendations. -Each resident was assessed for pneumococcal immunization upon admission. -Each resident was offered the pneumococcal immunization unless medically contraindicated or the resident was already immunized. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post required nurse staffing information, which included the total and actual hours worked by both licensed and unlicensed staff directly responsible for resident care, per shift on a daily basis and visible for residents, visitors, and staff to view. The facility census was 14 residents. Record review of the facility policy Nurse Staffing Posting Information revised 5/1/22 showed: -The daily staffing sheet would be posted on a daily basis and contain the following information: --The facility name. --The current date. --The census. --The total number of hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift including Registered Nurses (RN's), Licensed Practical Nurses (LPN's) and Certified Nurses Assistants (CNA's). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the dry storage floor clean; failed to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food and/or beverages; to keep trash and garbage receptacles lidded; and to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards. These deficient practices potentially affected all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 14 residents with a licensed capacity for 60 residents. 1. Observations during the initial kitchen inspection on 5/2/22 between 9:26 A.M. and 10:18 A.M. showed the following: -The dry storage room had numerous plastic lids, dried drips, paper debris, and a leaf on the floor under storage racks. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a Facility Assessment to determine resources necessary to meet the needs of the residents, such as assessment of the resident population, staff competencies needed to provide resident care, physical plant requirements, services needed, technology resources and facility and community-based risk assessment updated annually and complete to show the current resident population and needs. A total of 8 residents were sampled. The facility census was 14 residents. Record review of the facility's Facility Assessment policy revised 5/1/22 showed: -The facility conducted and documented a facility wide assessment to determine what resources were necessary to care for the residents competently during both day-today operations and emergencies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, sanitary, well graded driving surface to prevent the pooling of water, in the event of an evacuation of residents, and/or for emergency and transport vehicles. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who reside, visit, use, or work in the facility. The resident census was 14 residents with a licensed capacity for 60 residents. 1. Record review of the facility's disaster manual entitled Master Emergency Book, last reviewed and updated on 12/12/18 and obtained from the nurse's station, showed the following: -On the page entitled Evacuation Considerations, under point #4, which was a list of evacuation terms, at part c, it stated, Complete/Outside Evacuation: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for the use of supplemental oxygen, as needed pain medication including non-pharmacological interventions, anticoagulant use and diuretic use for three sampled residents (Resident #7, #4, and #13) out of eight sampled residents. The facility census was 14 residents. 1. Record review of Resident #7's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's care plan dated 9/25/20 and last revised on 4/12/22 showed no care plan for the resident's supplemental oxygen, or for his/her diuretic (fluid removing medication) use. His/Her pain care plan did not include non-pharmacological interventions for pain management. Record review of the resident's May 2022 Physician's Order Sheet (POS) showed: -Check oxygen saturation every shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Acetaminophen (an over the counter pain medication) orders were clarified to include parameters for maximum dose per day for four sampled residents and to provide and document non-pharmacological interventions prior to administering as needed pain medication for four sampled residents (Residents #7, #8, #4, and #13) out of eight sampled residents. The facility census was 14 residents. A policy for the use of non-pharmacological interventions prior to administering as needed pain medications and a policy for medication parameters, including Acetaminophen was requested and not received at the time of exit. Record review of Micromedex on 5/3/22 showed: -The maximum dose for Extra Strength Acetaminophen is 3000 milligrams (mg) in 24 hours. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were free from medication administration error rate of less than five percent (5%). A total of three medication errors out of 31 opportunities were observed for a medication error rate of 9.67% affecting three residents (Residents #12, #165, and #13). The facility census was 14 residents. Record review of the facility Medication Administration Policy dated 5/1/22 showed: -Staff were directed to administer medications as ordered by the physician in accordance with professional standards of practice. -Compare the medication with the resident's Medication Administration Record (MAR) to verify the resident, the medication, and the time the medication was to be administered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled correctly, expired medications were properly disposed of, and medications were stored at the appropriate temperature. This deficient practice potentially affected all residents who received medications from the medication cart and medication storage room. The facility census was 14 residents. 1. Observation on 5/4/22 at 7:42 A. M., of the resident's medication administration with Agency Licensed Practical Nurse (LPN) A showed: -Acidophilus (a probiotic supplement) was pulled from the medication cart. --The bottle was opened on 4/23/22. --The bottle was the same temperature as all other over-the-counter (OTC) medications in the medication cart. --The bottle of Acidophilus showed it must be refrigerated after opening. During an interview on 5/4/22 at 8:41 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or family were notified when a staff or resident in the facility tested positive for COVID (a new disease caused by a novel (new) coronavirus) for one sampled resident (Residents #8) out of one sampled resident who resided at the facility between November 2021 through January 2022 when the facility reported having positive cases in the building. The facility census was 14 residents. 1. Record review of Resident #8's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's medical record from 11/21/21 to 1/20/22 showed no documentation the resident or the resident's family was notified of positive COVID staff or residents. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure provision and documentation of education regarding the benefits, risks and potential side effects associated with the COVID-19 (a new disease caused by a novel (new) coronavirus) vaccine for unvaccinated residents upon admission to the facility for two sampled residents (Residents #265 and #117) out of eight sampled residents. The facility census was 14 residents. Record review of the facility COVID-19 Vaccination policy dated 11/5/21 showed: -The facility will follow guidance from the Centers of Disease Control and Prevention (CDC) and any additional State and local guidelines and regulations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard trash and garbage disposal practices to mitigate the presence of common household pests, specifically ants, and to maintain an effective pest control program with adequate measures to eradicate those pests when present. These deficient practices potentially affected all residents, visitors, volunteers, and staff who ate food from the kitchen and/or resided, visited, used, or worked in the facility. The facility's census was 14 residents with a licensed capacity for 60 residents. 1. Observations during the initial kitchen inspection on 5/2/22 between 9:26 A.M. and 9:52 A.M. showed the following: -There were three ants crawling inside a microwave and numerous ants on its outer top and sides. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident in writing of a transfer or discharge to a hospital, including the reasons for the transfer and to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for one sampled resident (Resident #6) out of eight sampled residents. The facility census was 14 residents. Record review of the facility's Transfer and Discharge policy revised 5/1/22 showed the staff were to provide a transfer notice upon transfer to the resident and/or the residents' representative as soon as practical. 1. Record review of Resident #6's admission Record showed he/she: -Was admitted to the facility on [DATE] for a skilled rehabilitation stay and was his/her own responsible party. -Had the following diagnoses: --Stroke. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident in writing of the facility bed hold policy at the time of transfer for one sampled resident (Resident #6) out of eight sampled residents. The facility census was 14 residents. Record review of the facility's policy Bed Hold Upon Transfer revised 5/1/22 showed before a resident was transferred to the hospital, the facility would provide a written notice which specified the duration of the bed hold policy. 1. Record review of Resident #6's admission Record showed he/she: -Was admitted to the facility on [DATE] for a skilled rehabilitation stay and was his/her own responsible party. -Had the following diagnoses: --Stroke. --Dysphagia (inability or difficulty swallowing). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a recapitulation of stay was completed and to document the disposition of medications upon discharge for one sampled resident (Resident #15); and to ensure a recapitulation of stay was completed and to document the disposition of medications and belongings for one sampled resident (Resident #16) who was discharged after a skilled therapy stay out of two sampled closed records. The facility census was 14 residents. A policy was requested but not received from the facility. 1. Record review of Resident #15's admission Record showed he/she: -Was admitted to the facility on [DATE] for a skilled therapy stay. -Had the following diagnoses: --Pneumonia (inflammation of one or both lungs with consolidation). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident had a current, valid physician's order for supplemental oxygen who was utilizing as needed supplemental oxygen for one sampled resident (Resident #7) out of eight sampled residents. The facility census was 14 residents. 1. Record review of Resident #7's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's May 2022 Physician's Order Sheet (POS) showed: -Check oxygen saturation every shift. If below 90 percent (%), may use oxygen as ordered as needed. --NOTE: The resident did not have an active order for the use of supplemental oxygen. The resident had a previous order for oxygen as needed at 2 Liters (L) that was discontinued on 3/5/21. Observation on 5/2/22 at 5:31 A.M. showed the resident was lying in bed asleep. [...]