The Healthcare Resort of Kansas City

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents remained free from staff-to-resident verbal and/or mental abuse when Resident (R)9 reported during the resident council meeting attended by staff in 11/2025 that Licensed Nurse (LN) K and Certified Nurse Aide (CNA) QQ made fun of him. The abuse resulted in feelings of shame, sadness, and anger for R9, who further felt fear of retaliation from staff for bringing up the abuse.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff reported Resident (R)9's allegation of verbal/mental abuse to the administrator and State Agency (SA) as required, leaving R9 and all the other residents at risk for ongoing abuse. (Refer to F600 and F610)

Inspectors wroteBased on record review and interview, the facility failed to investigate an allegation of verbal/mental abuse and further failed to implement protective measures after Resident (R) 9's alleged Licensed Nurse (LN) K verbally and mentally abused him, which permitted LN K to continue to have access to R9 and all residents in the facility. (Refer to F600 and F609).

Inspectors wroteBased on record review and interview, the facility failed to ensure four of the four Certified Nurse Aide (CNA) and one Certified Medication Aide (CMA) staff reviewed had yearly performance evaluations completed.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to implement adequate infection control practices when staff failed to store Resident (R)13's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) in a sanitary manner when not in use. The facility failed to ensure wet briefs were not left in R28's trash can and failed to ensure clean linen was not placed on a Personal Protective Equipment (PPE) cart. The facility failed to ensure dirty laundry bags were not placed on the residents' floor and failed to ensure a sanitary barrier was placed under a blood glucose monitor. The facility failed to ensure R86's nasal canula was stored in a sanitary manner when not in use. The facility further failed to ensure clean laundry was stored in a sanitary manner.

Inspectors wroteBased on record review and interviews, the facility failed to ensure agency staff received the required communication training.

Inspectors wroteBased on record review and interviews, the facility failed to ensure agency staff received the required resident rights training.

Inspectors wroteBased on record review and interviews, the facility failed to ensure agency staff received the required behavioral health training.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the facility provided a safe and clean homelike environment for the residents when staff failed to ensure the walkway/sidewalk into the building did not have missing tiles/blocks on the walkway. The facility failed to ensure the east resident dining area was free from ants. The facility failed to ensure the ceiling light in Resident (R) 19's room was working properly.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents received the necessary activities of daily care (ADL) care needed when staff failed to provide consistent bathing to dependent Residents (R) 47, R6, and R77.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the medication error rate did not exceed five percent (%) when staff administered seven of Resident (R) 1's 14 medications outside of the 60 minutes before or 60 minutes after window. This resulted in a medication error rate of 21.88%.

Inspectors wroteBased on observation, record review, and interview, the facility failed to keep the facility free from pests and maintain an effective pest control program when ants were seen in the east dining room.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident (R)6 and R43's call light was within his reach to enable him to call for staff assistance.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure a discharge summary was completed and a recapitulation of Resident (R) 83's stay at the facility. The facility also failed to notify the state ombudsman of his discharge from the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement and activities program to support Resident (R)6's social needs with involvement in both individual and group activities in order to support his highest psychosocial wellbeing when staff failed to offer and provide one on one activity or diversions from his red bag of activities in his room.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide adequate care and services to promote the healing of pressure ulcers (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) for Resident (R) 4, and R43 when staff failed to provide their heel boots.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide care and services to prevent further decline in range of motion when staff failed to place Resident (R)6's hand splint on his left hand for contracture (abnormal permanent fixation of a joint or muscle) prevention. [...]

Inspectors wroteBased on interviews, observation, and record review the facility failed to secure pressurized supplemental oxygen tanks in a safe, locked area, and out of reach of the cognitively impaired, independently mobile residents. The facility additionally failed to ensure fall interventions were in place for Resident (R) 53 and R16, which placed the residents at risk for preventable accidents and injuries.

Inspectors wroteBased on interviews, observation, and record review the facility failed to ensure Resident (R)43 received treatment and services for enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) to prevent complications or adverse consequences when staff did not position R43 to prevent potential aspiration.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide services consistent with the standards of care related to the care of Resident (R) 4's peripherally inserted central line (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) when staff failed to follow the physicians order for the in-facility removal of the PICC line when the intravenous antibiotic was finished for three days, failed to document the full removal of the line including the tip and failed to adequately monitor the site for complications after removal.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide adequate respiratory care and services for Resident(R) 77's. bilevel positive airway pressure (BiPAP- a noninvasive ventilator that helps breathing), and her nasal cannula, when staff failed to ensure the equipment was stored in a sanitary manner when not in use.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide effective pain management, including ongoing assessment and monitoring for effectiveness of pain relief, for Resident (R)16, who had pain. Findings Included:- R16's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (HTN-elevated blood pressure), contracture (abnormal permanent fixation of a joint or muscle) of muscle, muscle weakness, and lupus (an autoimmune disease that damages the immune system damage organs and tissue throughout the body. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R16 received pain medication and received as needed (PRN) medications or was offered and declined during the observation period. [...]

Inspectors wroteBased on interviews, observation, and record review, the facility failed to provide dementia (a progressive mental disorder characterized by failing memory, and confusion) related care and services for Resident (R) 10 to promote his highest practicable level of well-being when staff failed to provide diversions and one to one attention per his plan of care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to store medication and biologicals adequately when staff failed to lock and secure an unattended medication cart.

Inspectors wroteBased on record reviews and interviews, the facility failed to offer and administer or obtain an informed declination for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) and influenza (highly contagious viral infection) vaccination for Resident (R)3.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the daily nurse staffing data was posted and failed to ensure the daily posted nursing staffing included the required information.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents with six reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to monitor weights consistently in order to identify loss and immediately involve the registered dietician and physician to evaluate if nutritional needs were met for Resident (R) 27's enteral nutrition regimen (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew or swallow food) to prevent a significant, unplanned weight loss of 11.74 percent (%) within two months. Findings Included: [...]

Inspectors wroteThe facility identified a census of 66 residents. Based on record review and interviews, the facility failed to ensure agency direct care staff had received the required communication training. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 66 residents. Based on record review and interviews, the facility failed to ensure agency direct care staff had received the required resident's rights training. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 66 residents. Based on record review and interviews, the facility failed to ensure agency direct care staff had received the required dementia training for nurse aides. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility had a census of 66 residents. The sample included 19 residents with five reviewed for accidents. Based on observation, record review and interview the facility failed to ensure a safe environment free from potential hazards out of reach of the five cognitively impaired, independently mobile residents. The facility additionally failed to follow the fall prevention interventions care planned for Residents (R)29 and R58. The facility additionally failed to ensure R6's room was free from physical hazards. These deficient practices placed the residents at risk for preventable accidents and injuries. Findings Included: -On 07/08/24 at 07:09 AM an inspection of the main lobby's kitchenette next to the receptionist revealed an accessible kitchenette entrance with a cleaning chemical bottle and Microkill wipes. [...]

Inspectors wroteThe facility reported a census of 66 residents. The facility identified one medication room and four medication carts. Based on observations, record reviews, and interviews, the facility failed to secure its medication and treatment carts. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included- - On 07/08/24 at 07:06 AM an inspection of the East Hall nursing station revealed an unlocked skin treatment cart. The cart contained assorted medicated lotions with the avoid ingestion and contact poison control warnings. At 07:20 AM an inspection of the [NAME] Hall station revealed an unsecured medication cart. The cart contained R39's Cefdinir (medication used to treat bacterial infections) and Junuvia (medication used to lower blood glucose) pill packs left unsecured on top of the cart. The medication cart was not secured. [...]

Inspectors wroteThe facility identified a census of 66 residents. The facility identified eight residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control standards related to the handling of soiled laundry, medication administration, and disposal of personal protective equipment (PPE). These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R)39 foot pedals for her wheelchair. This deficient practice left R39 vulnerable to possible injury due to unmet care needs.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents with two residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure that residents were free from resident-to-resident abuse when Resident (R) 31 threw hot coffee on R40. This placed R40 and other residents on the west hall at risk of possible harm and or injury and impaired quality of life.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents with two residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure a resident-to-resident altercation was fully investigated and interventions implemented to prevent further abuse after R31 threw hot coffee on R40. This placed the residents on the west hall at risk of possible harm and or injury and impaired quality of life.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents. Based on observation, record review and interview the facility failed to ensure staff obtained physician-ordered labs for Resident (R) 45 and the facility failed to notify the physician of the delay in R45's labs being obtained. This placed R45 at risk of delayed care and related complications.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents with two residents reviewed for position and mobility. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 39's leg/ankle brace was applied to her right leg when she was out of bed to prevent her contractures (abnormal permanent fixation of a joint or muscle) from worsening. This deficient practice left R39 at risk for further decline and decreased range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). or mobility.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents with two residents observed for bowel and bladder. Based on observation, record reviews, and interviews the facility failed to ensure the standard of care was provided for Resident (R)39, who had a history of urinary tract infection (UTI-an infection in any part of the urinary system). This deficient practice placed R39 at risk of complications and further UTIs.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents with two residents reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to consistently communicate Resident (R) 6's medical condition prior to and post-hemodialysis. This deficient practice placed R6 at risk of potential adverse outcomes and physical complications related to dialysis.

Inspectors wroteThe facility reported a census of 66 residents. The sample included 19 with one reviewed for behavioral health services. Based on record review, observations, and interviews, the facility failed to adequately meet Resident (R)46's behavioral health needs related to utilizing non-pharmacological care approaches resulting in repeated behavioral episodes. This deficient practice placed R46 at risk for continued behavioral episodes and unmet care needs. Findings Included: - The Medical Diagnosis section within R46's Electronic Medical Records (EMR) included diagnoses of metabolic encephalopathy (brain disorder resulting in confusion, agitation, and thought dysfunction), cognitive-communication disorder, unsteadiness on her feet, muscle weakness, insomnia (difficulty sleeping), and a need for assistance with personal cares. [...]

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 with one reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record review, and observations, the facility failed to identify a pattern of dementia-related behaviors for Resident (R)29 and implement meaningful interventions to promote quality of life. This deficient practice placed R29 at risk for preventable injuries and the inability to maintain her highest practicable level of functioning. Findings Included: - The Medical Diagnosis section within R29's Electronic Medical Records (EMR) included diagnoses of dementia, cognitive communication deficit, insomnia (difficulty sleeping), and dysphagia (difficulty swallowing). [...]

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure staff followed physician-ordered parameters for Resident (R) 41 's antihypertensive (class of medication used to treat high blood pressure) medication monitoring. This placed the resident at risk of unnecessary medication administration and possible adverse side effects.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to ensure nurse staffing data was posted daily with the required information and failed to ensure the facility retained the posted daily staffing data as required.

Inspectors wroteThe facility identified a census of 55 residents. The sample included three residents reviewed for foot care. Based on record review and interviews, the facility failed to ensure Resident (R) 1, who had a history of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin) and amputations of his right leg and his left fifth toe related to DM, received appropriate wound care and services to prevent complications from his medical conditions. As a result, R1's toe wound became progressively worse and infected and ultimately required surgical removal. This also placed R1 at risk for increased pain and decreased mobility.

Inspectors wroteThe facility had a census of 63 residents. The sample included 19 residents. Based on observation, record review, and interview the facility failed to ensure a reconciliation of controlled medications at the end of daily work shifts. The facility further failed to ensure Resident (R)29's medications were available for administration as ordered by the physician. This placed residents at risk for misappropriation of medications by staff and ineffective medication regimen.

Inspectors wroteThe facility had a census of 63 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to transport clean clothing in a sanitary manner and failed to adequately disinfect a glucometer (blood sugar reading machine). This placed the residents at risk for infectious disease processes.

Inspectors wroteThe facility had a census of 63 residents. The sample included 19 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify Resident (R)29's physician of medications not administered in a timely manner. This placed the resident at risk for physical decline.

Inspectors wroteThe facility had a census of 63 residents. The sample included 19 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for hypertension (high blood pressure) medication with signs and side effects of antihypertensive medications for one sampled resident, Resident (R) 29. This placed the resident at risk for physical decline and complications related to high blood pressure.

Inspectors wroteThe facility had a census of 63 residents. The sample included 19 residents, with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide scheduled bathing for one sampled resident, Resident (R) 16. This placed the resident at risk for skin problems and poor hygiene.

Inspectors wroteThe facility had a census of 63 residents. The sampled included 19 residents, with seven reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment and failed to implement resident centered interventions for one sampled resident, Resident (R) 46. This placed the resident at risk for further falls and injury.

Inspectors wroteThe facility had a census of 63 residents. The sample included 19 residents. Based on observation, record review, and interview the facility failed to accurately monitor the fluid intake for a 2000 milliliter (ml) per day fluid restriction for one sampled resident, Resident (R) 16. This placed the resident at risk for dehydration.

Inspectors wroteThe facility had a census of 63 residents. The sample included 19 residents with three reviewed for pain. Based on observation, record review, and interview, the facility failed to provide pain medication for one sampled resident, Resident (R) 172. This placed R172 at risk for further pain and discomfort.

Inspectors wroteThe facility had a census of 63 residents. The sample included 19 residents, with one reviewed for tube feeding. Based on observation, record review, and interview, the facility to ensure licensed nursing staff possessed the necessary knowledge and skills when staff administered Resident (R) 41's medication by mouth though the order read, and the licensed nurse was aware, the medications were ordered via percutaneous endoscopic gastrostomy (PEG) feeding tube (a feeding tube placed through the skin and stomach wall to allow nutrition, fluids and/or medication to be put directly into the stomach bypassing the mouth) by the physician. This deficient practice placed the resident at risk for aspiration.

Inspectors wroteThe facility had a census of 63 residents and five medication carts. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to label and store drugs and biologicals for two of five medication carts. This placed the affected residents at risk for ineffective medication regimens.