A list of the most recent deficiencies for Lee's Summit Place. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-08 | 2023-10-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-08 | 2023-10-09 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-09-08 | 2023-10-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-08 | 2023-10-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-08 | 2023-10-09 | N |
| Provide or obtain dental services for each resident. | Health | 2023-09-08 | 2023-10-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-08 | 2023-10-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-08 | 2023-10-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-08 | 2023-10-09 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| Have an externally vented heating system. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-08 | 2023-10-09 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-03 | 2023-05-31 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-05 | 2022-06-18 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-05-05 | 2022-06-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-05 | 2022-06-18 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-05-05 | 2022-06-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-05 | 2022-06-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-05 | 2022-06-18 | N |
| Post nurse staffing information every day. | Health | 2022-05-05 | 2022-06-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-05 | 2022-06-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-05 | 2022-06-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-05 | 2022-06-18 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-05-05 | 2022-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-05 | 2022-06-18 | N |
| Report COVID19 data to residents and families. | Health | 2022-05-05 | 2022-06-18 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-05-05 | 2022-06-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-05 | 2022-06-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-05-05 | 2022-06-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-05 | 2022-06-18 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-08-16 | 2021-09-22 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-16 | 2021-09-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-27 | 2019-11-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-09-27 | 2019-11-11 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-09-27 | 2019-11-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-27 | 2019-11-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-27 | 2019-11-11 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2019-09-27 | 2019-11-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-09-27 | 2019-11-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-27 | 2019-11-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-27 | 2019-11-11 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-09-27 | 2019-11-11 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-09-27 | 2019-11-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-27 | 2019-11-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-27 | 2019-11-11 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-09-27 | 2019-11-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-27 | 2019-11-11 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-27 | 2019-11-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-09-27 | 2019-11-11 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-09-27 | 2019-11-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-09-27 | 2019-11-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-27 | 2019-11-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-27 | 2019-11-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-27 | 2019-11-11 | N |
