Blue Springs Wellness & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Blue Springs Wellness & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF584Aug 24, 2023

  Based on observation, interview, and record review, the facility failed to maintain a comfortable environment with air temperatures at or below 81 F (degrees Fahrenheit) on 8/21/23 and 8/22/23 in the following resident use areas: the 100 Hall, 200 Hall, 300 Hall, 400 Hall, 500 Hall corridors, the South and North Dining Rooms; Resident rooms 408, 405, 406, 403, 404, 402, 507, 512, 513, 514, 204, 201, 206, 208, 206, 208, 207, 109, 108, 107, 106, 105, and 102; failed to implement its plan to monitor temperatures when the temperatures went above 81 F; and to evacuate residents from those rooms or cease using the common spaces when the temperatures were above 81 F. […]

• Immediate jeopardy, isolatedF689Oct 3, 2024

  Based on observation, interview, and record review, the facility failed to ensure staff used a gait belt (a device that helps prevent falls) during transfers and ambulation for one sampled resident (Resident #1) out of eight sampled residents. CNA A assisted the resident into the shower room to provide incontinence care. CNA A assisted the resident into a standing position without the use of a gait belt. The resident slid to floor, which resulted in the resident being impaled by his/her wheelchair break lever, causing a penetrating wound (trauma that occurs when a foreign object enters the body) and laceration (a wound produced by the tearing of skin and underlying soft tissue) and was hospitalized for three days. The facility census was 65 residents. […]

• Actual harm, isolatedF600Nov 18, 2025

  Based on observation, interview and record review, the facility failed to ensure two sampled residents (Resident # 8 and #9), out of 10 sampled residents, were free from abuse when on 8/31/25 Resident #7 pushed Resident #8 out of his/her wheelchair resulting in Resident #8 sustaining a laceration to his/her midforehead; and on 9/2/25 Resident #7 punched Resident #9 in the arm and began pulling on his/her arm causing immediate and residual arm pain and feelings of being attacked. The resident census was 92 residents. On 9/16/25 the Administrator was notified of the past noncompliance which occurred on 8/31/25. The facility had completed interventions for residents and training for all staff prior to state agency investigation. The deficiency was corrected on 9/6/25. […]

• No harm, potential for more than minimal, widespreadF880Jul 21, 2023

  Based on observation, interview, and record review, the facility failed to have an adequate Infection Surveillance Program for all residents; to perform a yearly tuberculosis (TB-a potentially serious infectious bacterial disease that mainly affects the lungs and is spread by coughing and/or sneezing) test and/or screening for two sampled residents (Resident #26 and #32); to provide care in a manner to prevent infection by using soiled gloves to perform clean tasks during incontinence care for two sampled residents (Residents #25 and #48) and one supplemental resident (Resident #47), to ensure a mechanical lift (used for transferring residents that are not able to assist in their own transfer) was cleaned after being contaminated for one supplemental resident (Resident #47); and to ensure… […]

• No harm, potential for more than minimal, widespreadF881Jul 21, 2023

  Based on observation, interview and record review, the facility failed to have a process to ensure the antibiotic (an antimicrobial [an agent that kills microorganisms or stops their growth] medication) ordered for each resident was appropriate for the treatment of the infection, that excessive antibiotics were not used, and to monitor antibiotic use trends. This had the potential to affect all residents at the facility. The facility census was 77 residents. Review of the facility's policy, dated 3/20/23, titled Assessment of Infections and Antimicrobial Usage showed: -Assessing antimicrobial use was essential for determining antimicrobial trends. -Staff were to perform a monthly review of antibiotics ordered and the clinical documentation for why the medication was ordered. […]