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F0921
D

Unsecured and Inaccessible Spa Room Toilets Affect Resident Safety

Kansas City, Missouri Survey Completed on 06-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain several spa room toilets in a safe and operable condition, as observed and confirmed through interviews and record reviews. Specifically, the toilets in the 100 and 300 Hall Spa Rooms were not securely bolted in place and could be moved easily, while the 200 Hall Spa Room toilet was inaccessible due to being blocked by stored equipment. The 400 Hall Spa Room was also inaccessible, and the toilet in one resident's room was inoperable for a period of time. These deficiencies were directly observed during facility rounds and confirmed by staff interviews, with staff expressing surprise and concern upon discovering the unsecured toilets. A resident with hemiplegia and hemiparesis following a stroke was unable to use their own bathroom due to the inoperable toilet and reported feeling unsteady and fearful when attempting to use the unsecured spa room toilets. The resident also noted that other toilets in the facility were not bolted down. Staff interviews revealed a lack of awareness regarding the unsecured toilets and the blocked or inaccessible spa rooms, and maintenance staff had not received prior reports or work orders related to these issues, except for the clogged toilet. The facility census at the time was 89 residents, and the issues potentially affected all residents utilizing the spa bathroom toilets.

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