Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bishop Spencer Place, Inc, The during CMS and state inspections, most recent first.
Infection control practices were not maintained when the facility had no infection records for several months and no infection mapping completed for multiple months, and staff stated the tracking system did not meet regulatory standards. During wound care for a resident with osteomyelitis and a Stage II coccyx pressure ulcer, an MDS coordinator touched and repositioned the dressing with dirty gloves while handling soiled linens, and staff stated the dressing should not have been touched and the treatment should have been redone.
No Active Antibiotic Stewardship Program: The facility failed to have an active ASP in place despite a policy requiring review of antimicrobial use, screening of residents receiving antimicrobials, and communication of recommendations to providers. The IP, an LPN, the MDS Coordinator, and the DON all stated they were unsure whether an ASP existed or how it was being maintained, and the DON was unaware the program was inactive.
The facility failed to ensure its background check policy included NA Registry screening for all applicants, and three of five sampled employee files lacked NA Registry checks before hire. An Activity Coordinator, an LPN, and a Housekeeper were hired without this screening, while staff interviews confirmed the CEC team was only completing NA Registry checks for CNA applicants and not for all employees.
The facility failed to keep resident care plans current and individualized for several residents. One resident with MDD, Bipolar Disorder, and Anxiety Disorder had no specific care plans for those diagnoses, another resident admitted for knee replacement lacked pain goals and detailed pain interventions, and a resident with dementia and depression had documented agitation, refusal of care, and physical aggression without a behavioral care plan or clear depression-related symptoms and interventions. Staff and the DON stated care plans should be specific, up to date, and reflect each resident’s current status.
A resident on hospice had multiple MDS assessments that marked hospice care in section O but incorrectly marked section J1400 as “no” for prognosis of less than 6 months to live. The MDS Coordinators said they believed a physician order specifically stating a 6-month prognosis was required and did not realize the hospice certification signed every 6 months was enough to mark J1400 “yes”; the DON said the MDS Coordinators were responsible for the assessments and expected them to be accurate.
A resident’s PASRR was not reviewed for accuracy or updated after admission despite later diagnoses of MDD, bipolar disorder, and anxiety disorder. The original PASRR stated the resident had no major mental disorder, while the MDS, admission record, and care plan documented mental health diagnoses and psychotropic medication use. Staff interviews showed unclear responsibility for PASRR updates, and the facility reported prior audits only checked that PASRRs were present, not accurate.
A resident with a Stage II coccyx pressure ulcer and osteomyelitis had wound care orders for normal saline cleansing and a mepilex border foam dressing, but an RN instructed an LPN and the MDS Coordinator to apply zinc barrier paste even though it was not ordered. Staff later acknowledged the paste should not have been used and that the wound care was not completed as ordered.
A resident with dementia, repeated falls, and impaired mobility did not have a bed assist device installed in a timely manner after therapy identified a need for bilateral bed assist rails. The physician order later specified only a right-side grab bar, and the care plan did not clearly identify the exact equipment needed for bed mobility and transfers. Staff reported the device process should move quickly, but the resident’s bed assist bar was not installed until after the resident fell out of bed, and the resident said the rail had been missing for weeks before the fall.
A resident with an indwelling catheter, ESRD, and a UTI had ordered catheter care every shift, but the TAR showed multiple missed documentation opportunities and there was no progress note documenting refusal of care. Staff stated that blank TAR entries meant the care was not done and that refusals should have been documented with a progress note and education.
Infection Control Program and Wound Care Practices Not Maintained
Penalty
Summary
The facility failed to maintain an appropriate infection prevention and control program for residents, staff, volunteers, visitors, and others. Review of the infection control log showed no records for infections from January 2025 through September 2025, and no infection mapping was completed for October, November, or December 2025. The Infection Preventionist stated he/she had taken over the program in October 2025, had to build the system because prior records could not be accessed, was not educated on how the program had previously tracked infections, and was unaware that infection mapping also had to be completed. The DON stated the current infection tracking log did not meet regulatory standards and needed to include mapping and CDC-recommended elements. The facility also failed to maintain appropriate infection control practices during wound care for a resident readmitted with osteomyelitis and a Stage II pressure ulcer to the coccyx. The resident’s order was to cleanse the wound with normal saline, pat dry, and cover with a mepilex border foam dressing, with changes every other day and as needed for soiling. During observation of wound care, RN A performed the treatment while LPN B and the MDS Coordinator assisted with positioning and bed linen changes. After the wound care was completed, the resident’s coccyx dressing slipped from its original position while dirty linens were being pulled from underneath the resident. The MDS Coordinator, while wearing dirty gloves used to handle the linens, readjusted the dressing back into place and patted it down before removing the linens and washing hands. RN A, LPN B, the MDS Coordinator, and the DON all stated the MDS Coordinator should not have touched the dressing and should have verbalized that it had moved so the treatment could be redone.
No Active Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure an antibiotic stewardship program was in place. Review of the facility policy titled "Antimicrobial Stewardship in Senior Living Communities" showed the facility was to establish and maintain an Antimicrobial Stewardship Program to ensure optimal use of antimicrobials, review appropriateness of antimicrobial regimens for residents, screen and review all residents receiving antimicrobials, and communicate recommendations to providers. However, during review of the facility's antibiotic stewardship program, the facility did not have an antibiotic stewardship program currently in place. During interviews, the Infection Preventionist said he/she was not sure whether the facility had an antibiotic stewardship program and did not have records from the previous IP showing one had been in place. An LPN said the Medical Director was responsible for overseeing antibiotic usage but was unsure whether the facility had an antibiotic stewardship program or what it entailed. The MDS Coordinator was also unsure if a program was in place, and the DON said he/she was unaware the facility did not have an active antibiotic stewardship program and expected the IP to maintain it.
Missing NA Registry Background Checks for New Hires
Penalty
Summary
The facility failed to ensure its Criminal Background Investigations policy included a check of the Nurse Aide (NA) Registry for all potential employees and volunteers. Review of the policy showed criminal background checks, the Employee Disqualification List, and other screening processes, but it did not state that NA Registry checks would be completed for all new applicants. Federal regulation cited in the report stated that certified long-term care facilities are required to check the NA Registry before allowing a person to work or volunteer, and the OIG website review showed that the LEIE does not include NA Registry findings. Record review showed three of five sampled employee files did not contain NA Registry background screenings prior to hire. An Activity Coordinator, an LPN, and a Housekeeper were hired without NA Registry checks. During interviews, the Candidate Experience Coordinator manager stated the team completed FCSR, EDL, and criminal background checks prior to hire but was not doing NA Registry checks on all employees. The Human Resources Business Partner stated the CEC team handled background checks and only completed NA Registry checks for CNA applicants, not for other applicants. The Facility President and Administrator stated OIG screenings were completed prior to hire and monthly thereafter on all employees, but NA Registry checks were only completed for CNA candidates and were not being completed on all facility employees.
Incomplete and Outdated Care Plans
Penalty
Summary
The facility failed to ensure comprehensive care plans were current and reflected the residents’ status for three sampled residents. The facility policy stated that service/care plans should include measurable goals, objectives, and timetables, and should reflect identified problem areas, risk factors, treatment goals, professional services, and recognized standards of practice. Interviews with CNA staff, an LPN, the MDS Coordinator, and the DON confirmed that care plans were expected to be up to date, specific to each resident, and available to staff responsible for care, but there was no designated person identified to verify completion of care plans. For one resident with diagnoses of MDD, Bipolar Disorder, and Anxiety Disorder, the quarterly MDS and admission record showed multiple mental health diagnoses, but the care plan only addressed psychotropic medication use for anxiety and depression. The care plan did not include a specific care plan for Bipolar Disorder, did not include a specific care plan for Anxiety Disorder, and did not include a specific care plan for MDD. The MDS Coordinator stated that all of the resident’s mental health diagnoses, medications, interventions, and behaviors should have been included on the care plan, and the DON agreed that care plans needed to be specific and up to date. For another resident admitted for aftercare following right knee replacement surgery, the resident was discharged before an admission MDS was completed. The care plan on review showed only one intervention related to pain control and did not include goals for effective pain management or the resident’s pain management techniques. For a third resident with dementia and depression, progress notes documented repeated episodes of agitation, verbal abuse, refusal of medications and care, physical aggression, wandering, and other behaviors, but the comprehensive care plan did not include a behavioral care plan or interventions describing when behaviors were likely to occur and what staff should do when they occurred. The resident’s psychotropic medication orders and MAR/TAR also did not identify symptoms related to depression for monitoring, and staff interviews confirmed that the care plan lacked the resident’s typical depression symptoms, target behaviors, and non-pharmacological interventions.
Incorrect MDS Documentation for Hospice Prognosis
Penalty
Summary
The facility failed to accurately document Resident #54’s MDS by not marking section J1400 for prognosis of less than six months to live, even though the resident was on hospice services. Record review showed the resident was admitted to the facility, had an order to admit to hospice for end-of-life care, and was care planned as being on hospice services. Multiple MDS assessments, including quarterly, significant change, and comprehensive assessments, showed section J1400 marked “no” while section O was marked “yes” for hospice care. During interviews, both MDS Coordinators stated that hospice care was documented in section O and that they did not mark section J1400 because they believed a doctor had to write an order stating the resident had six months or less to live. They said they did not realize the hospice certification signed by physicians every six months would be enough to mark section J1400 “yes.” The DON stated the MDS Coordinators were responsible for the assessments and that the MDS RN verified the MDS was correct and accurate.
PASRR Not Updated for Resident With New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) for one resident was reviewed for accuracy and updated after admission when the resident’s condition changed. Resident #57’s original PASRR Level One Screening, completed before admission, stated the resident had no signs or symptoms of a major mental disorder and had never been diagnosed with one. However, the resident’s later records showed diagnoses of Major Depressive Disorder, Bipolar Disorder, and Anxiety Disorder, and the quarterly MDS also documented depression, anxiety disorder, and bipolar disorder. The resident’s admission record showed a diagnosis of Major Depressive Disorder, Recurrent, Mild, and the care plan noted psychotropic medication use for anxiety and depression. The care plan did not include specific plans for bipolar disorder, anxiety disorder, or MDD. Staff interviews showed confusion about who was responsible for updating PASRRs, and the facility stated that prior audits only confirmed PASRRs were present in records and did not verify accuracy. Staff also stated there was no one specifically responsible for ensuring new PASRRs were completed when indicated, and the updated PASRR requested for the resident was not received prior to exit.
Wound Care Order Not Followed for Coccyx Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident’s wound care orders were followed during treatment of a Stage II pressure ulcer to the coccyx. The resident had been readmitted with a diagnosis of osteomyelitis, and the January 2026 order summary directed staff to cleanse the coccyx wound with normal saline, pat dry, cover it with a mepilex border foam dressing, and change it every other day and as needed for soiling. There was no order for zinc barrier paste to be applied to the coccyx area. During observation of the wound care, an RN cleansed the wound and instructed an LPN and the MDS Coordinator to apply zinc barrier paste to the resident’s coccyx area before the mepilex border foam dressing was applied. In interviews, the RN said the paste should not have been applied and that the wound care order should have been followed as written. The LPN said he/she thought the treatment had been completed as ordered and did not realize the coccyx wound care had been done incorrectly. The MDS Coordinator also acknowledged that the zinc oxide paste was not part of the treatment order, and the DON stated that all wound care treatments needed to be followed as ordered by the physician.
Delayed Bed Assist Device Installation and Unclear Bed Mobility Equipment Orders
Penalty
Summary
The facility failed to ensure a resident with dementia, repeated falls, impaired mobility, and weakness had bed assist devices installed in a timely manner and failed to clarify whether the resident needed a right-side bed assist bar or bilateral bed devices. The resident’s care plan, initiated in late December 2024, stated the resident would have a positioning device on the bed to assist with bed mobility and transfers, but it did not specify the exact equipment needed or show that the device was no longer needed at any point afterward. Record review showed therapy identified a need for bed assist rails bilaterally to improve independence with bed mobility and transfers, while a physician order later specified a grab bar on the right side of the bed. Progress notes did not explain the difference between the bilateral therapy recommendation and the right-side order. A later bed rail assessment indicated a right-side side rail/bed assist bar was indicated to promote independence, but it still did not identify the exact type of device needed. Staff interviews showed the process depended on therapy recommendations, physician orders, consent, and a maintenance work order, and staff stated the device should generally be installed within a day or two after approval. The resident’s bed assist device was not installed until after the resident fell out of bed. The event record showed staff found the resident sitting on the floor in the middle of the room, and the resident reported that the bed rail or bar had been removed for weeks before the fall and that there was nothing to grab to try to prevent the fall. The resident also stated the call light was not working when the fall occurred. Maintenance and social work staff confirmed the facility had replaced the beds, removed the prior assist bars, and then had to reassess residents for new devices, but the resident’s device was not installed until after the fall event.
Missed and Undocumented Catheter Care
Penalty
Summary
The facility failed to provide catheter care, document catheter care, or document refusal of catheter care for one sampled resident with an indwelling catheter. Resident #33 was readmitted with diagnoses including UTI and ESRD, and the resident’s care plan directed catheter care every shift. Review of the TAR showed multiple missed documentation opportunities in November and December 2025, and the progress notes contained no documentation that catheter care was refused by the resident. The resident’s comprehensive MDS indicated an indwelling catheter, ESRD, and a UTI. Facility staff interviews confirmed that catheter care was expected to be documented on the TAR, that blank spaces meant the care was not done, and that refusals should have been documented in a progress note with education provided. The DON also stated it was his/her expectation that ordered catheter care be performed and documented, and that refusals be charted with a progress note, but acknowledged having just started as DON and not yet having things figured out.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summit, The | 0.8 mi | ★★★★★ | 1 | 0 |
| Clara Manor Nursing Home | 1.1 mi | ★★★★★ | 21 | 1 |
| Ignite Medical Resort Rainbow Boulevard, Llc | 1.8 mi | — | 0 | 0 |
| Parkway Health Care Center | 2.1 mi | ★★★★★ | 2 | 1 |
| Highland Rehabilitation & Health Care Center | 3.3 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.