Johnson County Care Center

In the surveyor’s words

From the most serious findings on record at Johnson County Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 14, 2023

  Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #7) was free from physical abuse. On 2/25/23, Resident #9 struck Resident #7 in the face, resulting in him/her sustaining a broken nose and facial bruising out of seven sampled residents. The facility census was 82 residents. On 3/14/23, the Administrator was notified of the past noncompliance which occurred on 2/25/23. The facility administration was notified on the same day of the incident and the investigation was started. Facility staff were educated on abuse and neglect policy, resident intervention and behaviors before the start of the next shift. […]

• Actual harm, isolatedF600Jan 19, 2023

  Based on interview and record review, the facility failed to protect two sampled residents (Resident #3 and #4) from physical abuse when Resident #4 hit Resident #3, then Resident #3 hit Resident #4 back and Resident #4 fell and acquired a cut and skin tear, out of six sampled residents. The facility census was 76 residents. Record review of the facility's policy, Abuse and Neglect, dated 2016 showed: -Abuse was the willful infliction of injury, with resulting physical harm, pain or mental anguish. -The use of physical force that might result in bodily injury, physical pain, or impairment. -It would include hitting, slapping, pinching or kicking. […]

• No harm, potential for more than minimal, widespreadF908Aug 4, 2026

  Based on observation and interview, the facility failed to maintain functioning elevators when on 8/3/26 the front elevator was nonfunctioning impacting all residents who use the elevators for meals and activities. The facility census was 82 residents.1. Observation on 8/3/26 at 10:30 A.M. showed the front elevator of the facility was posted out of service. During an interview on 8/3/26 at 2:00 P.M. the Administrator said:-He/She was aware the elevator being inoperable.-He/She did not know when someone would be there to fix the elevator.-The elevator broke down over the weekend, 8/1/26. Review of Resident #21's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) dated 5/18/26 showed the resident was cognitively intact. […]

• No harm, potential for more than minimal, widespreadF727Oct 14, 2025

  Based on interview and record review, the facility failed to provide sufficient proof of the Registered Nurse (RN) eight consecutive hours a day coverage during the Fiscal Year (FY) Quarter Four 2024 Payroll Based Journal (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for all the dates triggered within the quarter equaling nine total days; during FY Quarter One 2025 PBJ for all the dates triggered within the quarter equaling two total days; during FY Quarter Two 2025 PBJ for all the dates triggered within the quarter equaling 18 total days; and during FY Quarter Three 2025 PBJ for all the dates triggered within the quarter equaling 45 total days. […]

• No harm, potential for more than minimal, widespreadF880Oct 14, 2025

  Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. […]