The Healthcare Resort of Kansas City

In the surveyor’s words

From the most serious findings on record at The Healthcare Resort of Kansas City, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 3, 2022

  The facility identified a census of 69 residents. The sample included three residents reviewed for falls. Based on record review, interview, and observations, the facility failed to provide adequate supervision and implement interventions aimed to prevent falls for Resident (R) 1, who was at high risk for falls and had a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. R1 admitted to the facility on [DATE] with a diagnosis of traumatic subdural (collection of blood on the surface of the brain due to injury) hemorrhage (an escape of blood from a ruptured blood vessel) due to a fall at home. On 07/14/22 R1 fell in the facility and staff implemented nonskid socks. […]

• Immediate jeopardy, isolatedF689Dec 15, 2021

  The facility identified a census of 50 residents. The sample included seven residents identified at risk for elopement (when a cognitively impaired resident leaves the facility without staff knowledge). Based on record review, observation, and interview the facility failed to provide adequate supervision and appropriate interventions to prevent an elopement. Resident (R)1, who mobilized independently in a wheelchair, with poor cognition and identified at high risk for elopement, exited the facility on 12/12/21 at 5:50 PM without staff knowledge or supervision. A facility visitor alerted facility staff that R1 was outside the facility, alone in the parking lot. This deficient practice placed R1 in Immediate Jeopardy. […]

• Actual harm, isolatedF600May 14, 2026

  Based 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. Findings included:- The Electronic Medical Record (EMR) for R9 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), blindness in the right eye, posttraumatic stress disorder (PTSD- a… […]

• Actual harm, isolatedF692Jul 10, 2024

  The 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. […]

• Actual harm, isolatedF684Mar 28, 2024

  The 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. […]