Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Foxwood Springs Living Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and on hospice care did not have their physician-ordered oxycodone accurately documented or reconciled between the narcotic sheet and MAR. Staff failed to consistently document administration, altered medication counts without proper notation, and left required fields blank on medication count sheets, resulting in discrepancies that were only identified during an audit.
The facility failed to maintain cleanliness in the kitchen, with observations revealing food debris, grime, and grease on floors, equipment, and surfaces. Interviews with staff indicated a lack of updated cleaning schedules and oversight, contributing to the deficiency in food service safety.
The facility's QAPI Committee failed to include the Medical Director and Infection Control Preventionist in three out of six meetings, as required by policy. The absence of these key members was confirmed by the ADON, who was new to coordinating the meetings and unaware of the attendance requirements.
The facility failed to maintain a clean and safe environment for residents on the 200 Hall and in shared areas. Observations revealed unclean carpeting, misplaced personal items, and trash in resident rooms. The shared lounge area had dirt, dust, and cobwebs, and the ice machine was unclean. The facility lacked documented cleaning procedures, relying on insufficient spot checks by the Housekeeping Supervisor.
An RN Charge Nurse left a treatment cart unlocked in a lounge area used by residents, containing medicated creams, ointments, sprays, and scissors. This oversight occurred when the nurse was called away and did not secure the cart, posing a potential hazard to residents nearby.
A facility failed to involve a resident in the Care Plan process despite the resident not being determined by a physician to lack decision-making capacity. The resident had a moderate cognitive impairment and a DPOA for Health Care Decisions, which was misinterpreted by social workers as being effective immediately, rather than upon a physician's determination of incapacity.
A facility failed to ensure a resident was informed of a Medicare non-coverage determination. The resident, with moderate cognitive impairment, had a DPOA for health care decisions. Social workers assumed the resident lacked capacity without documented physician assessment, leading to the DPOA's involvement without proper notification to the resident.
A facility failed to update a resident's Comprehensive Care Plan within the required timeframe after the resident experienced an unwitnessed fall resulting in a right hip replacement and pubic bone fracture. The Care Plan was updated beyond the seven-day requirement, despite the resident's complex medical history, including conditions like dementia and diabetes. The delay was confirmed by the ADON.
A resident with dementia was prescribed Memantine without notifying their DPOA, despite instructions to do so. The charge nurse failed to inform the DPOA of the new medication order, leading to the administration of the drug without consent. The DPOA discovered the issue upon receiving a pharmacy bill and requested discontinuation.
A resident was forcibly showered by an LPN and three CNAs despite their refusal and expressed fear of water. The resident was visibly upset and had multiple bruises. Staff interviews confirmed they proceeded with the shower despite the resident's protests, violating the facility's policies on resident care and rights.
A resident was transferred by four staff members from a wheelchair to a shower chair without a gait belt, resulting in bruising. The facility's policy mandates the use of gait belts for all transfers, but staff did not adhere to this policy, leading to the resident's injury. Interviews confirmed that gait belts should be used for all transfers unless a mechanical lift is required.
Failure to Accurately Document and Reconcile Narcotic Medication Orders and Administration
Penalty
Summary
The facility failed to ensure accurate and consistent documentation and administration of a physician-ordered narcotic medication for one resident. Specifically, the physician's order for oxycodone was not accurately reflected on both the narcotic sheet and the Medication Administration Record (MAR). The narcotic record showed a different dosage and frequency than the physician's order and the MAR, and the number of tablets received from the pharmacy was altered on the narcotic record without proper documentation. Additionally, the MAR did not show administration of the medication on certain dates, even though the narcotic record indicated it had been given. Nursing staff did not consistently document the administration of narcotic medications on the MAR as required by facility policy. On several occasions, the nurse signed out the medication on the narcotic sheet but failed to document it on the MAR. There were also instances where the quantity of medication administered was altered on the narcotic sheet without explanation, and the required information on the medication count sheets, such as nurse initials and verification, was left blank. The orders on the narcotic sheet, MAR, and physician's order sheet did not match, and discrepancies were not promptly identified or corrected. The resident involved had multiple complex medical conditions, including chronic pain, kidney failure, heart disease, and was receiving hospice services. Despite the facility's policies outlining the steps for safe administration and documentation of oral and narcotic medications, these procedures were not followed. Staff interviews confirmed that the expected protocols were not adhered to, and the errors in documentation and order reconciliation were only discovered during an audit.
Deficiency in Kitchen Sanitation and Cleanliness
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the kitchen, as observed during two separate tours. The kitchen floors were found to have food debris, black grime, and grease under various equipment such as the stove, grill, ovens, steamers, and preparation tables. Food preparation tables, shelves, and drawers contained food debris and crumbs. The stove, grill, and grill area had accumulated grease and grime, while the ovens had black food debris built up inside and on the doors and sides. The deep fat fryer had yellow grease buildup, and the refrigerators contained dried food substances and sticky debris on the handles. The tilt skillet and steamer/convection ovens had black food debris inside, and the glass doors were discolored with gunky handles. A sign on the steamer indicated cleaning responsibilities, but these were not adequately followed. Interviews with Chef #3 and the Director of Dining Services (DDS) revealed that the kitchen cleaning schedule was not updated, and the responsibility for ensuring cleanliness was not adequately managed. Chef #3 acknowledged the importance of cleaning to prevent illness and pests, while the DDS admitted to not being in the kitchen as often as necessary. Both agreed that the kitchen items were not clean, highlighting a lapse in maintaining professional standards for food service safety. The lack of proper oversight and adherence to the sanitization policy contributed to the deficiency in food service safety.
QAPI Committee Lacks Required Participation
Penalty
Summary
The facility failed to maintain a Quality Assessment and Performance Improvement (QAPI) Committee with the required participation of the Medical Director and Infection Control Preventionist for three out of six quarterly meetings. The facility's policy mandates that the QAPI Committee includes the Administrator, Director of Nursing Services, Medical Director, and Infection Preventionist. However, the review of QAPI committee meeting attendance sheets revealed that the Medical Director did not attend the meetings on December 21, 2023, and December 19, 2024, while the Infection Control Preventionist was absent on September 19, 2024, and December 19, 2024. Both the Medical Director and Infection Control Preventionist were absent from the December 19, 2024 meeting. The Assistant Director of Nursing, who was new to coordinating the QAPI Committee Meetings, confirmed the absence of these key members and was unaware of the required attendance.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents on the 200 Hall and in shared areas. Observations revealed that the carpeting on the 200 Hall was consistently unclean, with debris such as paper trash and gauze fragments scattered throughout the hallway. In the semi-private room shared by two residents, trash was found on the floor, including cotton balls and paper trash, and personal items like pillows and cushions were misplaced under furniture. These conditions persisted over multiple days of observation. In the shared lounge area, which serves residents from both the 100 and 200 Halls, several cleanliness issues were noted. A disposable exam glove was found under a medication cart, and there were accumulations of dirt and dust in various areas, including corners, chair rails, and baseboards. Cobwebs were present in the sunroom area, and the doorknob to a supply room was loose and missing a screw. The ice machine near the nursing station was also found to be unclean, with lime build-up and dust accumulations. The facility lacked documented policies and procedures for cleaning resident rooms and common areas. The housekeeping staff had a checklist on their carts, but it was not filled out or retained, and there was no verification process to ensure tasks were completed as specified. The Facilities Director acknowledged the need for additional monitoring in light of the findings, as the current system relied on spot checks by the Housekeeping Supervisor, which proved insufficient to maintain cleanliness standards.
Unsecured Treatment Cart Poses Hazard
Penalty
Summary
The facility staff failed to maintain a safe environment free from accident hazards by not securing the contents of an unattended treatment cart. The cart, which contained medicated creams, ointments, topical sprays, and bandage scissors, was left unlocked in a lounge area used by residents on the 100 and 200 Halls. This oversight occurred when a Registered Nurse (RN) Charge Nurse was called away to assist someone and did not lock the cart before leaving it unattended. The unlocked cart posed a potential hazard to all residents in the vicinity, as multiple residents were observed to be within six feet of the cart.
Failure to Involve Resident in Care Planning Due to Misinterpretation of DPOA
Penalty
Summary
The facility failed to ensure that a resident, who was not determined by a physician to lack the ability to make informed healthcare decisions, was provided with opportunities to participate in the Care Plan process. The resident, identified as having a moderate cognitive impairment with a BIMS score of nine, had a Durable Power of Attorney (DPOA) for Health Care Decisions document that specified the agent's authority would only be activated when the resident could not make decisions or communicate their wishes. However, the facility did not have documentation from a physician indicating that the resident lacked decision-making capacity. Interviews with two social workers revealed that the resident's DPOA representative was notified of healthcare concerns and asked to acknowledge changes in care and services, while the resident was not involved in the planning of their care. Social Worker #1 admitted there was no documentation of a decline in the resident's decision-making capacity, nor could they provide the physician's documentation about such a change. Social Worker #2 incorrectly stated that the DPOA representative's authority was effective from the date of the resident's signature on the DPOA document, rather than after a physician's determination of the resident's incapacity.
Failure to Notify Resident of Non-Coverage Determination
Penalty
Summary
The facility failed to ensure that the Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage were acknowledged by a resident. This deficiency was identified for a resident who had a Durable Power of Attorney (DPOA) for Health Care Decisions. The resident had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. Despite this, there was no documentation to support that the resident's physician had determined the resident was unable to make informed healthcare decisions, which would necessitate the involvement of the DPOA. Interviews with social workers revealed that the resident was not notified of the non-coverage determination due to an assumption of incapacity to make informed decisions. However, there was no documented evidence of a decline in the resident's cognitive status or a physician's determination of incapacity. The social workers indicated that the DPOA's decision-making authority was activated based on the date of the resident's signature on the DPOA document, rather than a physician's assessment of the resident's decision-making capacity.
Failure to Timely Update Care Plan After Resident's Significant Change
Penalty
Summary
The facility failed to develop a Comprehensive Care Plan following a significant change in the status of a resident. This deficiency was identified when a resident experienced an unwitnessed fall resulting in a major injury, specifically a right hip replacement and pubic bone fracture. Despite the incident occurring on 7/24/24, the Care Plan was not revised within the required seven-day timeframe. The Care Plan was only updated on 8/19/24, which was beyond the stipulated period for ensuring a timely, person-centered comprehensive assessment. The resident's medical history included conditions such as Senile Degeneration of Brain, Major Depressive Disorder, Hypertension, Dementia, and Type II Diabetes. An interview with the Assistant Director of Nursing confirmed the delay in updating the Care Plan.
Failure to Notify DPOA of New Medication
Penalty
Summary
The facility failed to notify the responsible party of a resident before starting a new medication, Memantine, which was prescribed for dementia-related behaviors. The resident had a Durable Power of Attorney (DPOA) who had specified that they should be contacted for any medication changes. Despite this, the resident was administered Memantine without the DPOA's consent. The resident's medical records indicated severe cognitive impairment and a diagnosis of dementia, necessitating careful communication with the DPOA regarding treatment decisions. The deficiency occurred because the charge nurse did not notify the DPOA when a new physician's order was given for Memantine. The psychiatrist provided verbal orders to the charge nurse, who was responsible for contacting the DPOA but failed to do so. The DPOA only became aware of the new medication upon receiving the resident's pharmacy bill, at which point they expressed disapproval and requested the medication be discontinued. This oversight highlights a lapse in communication and adherence to the resident's care plan regarding medication changes.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from intimidation and physical abuse. On the specified date, an LPN and three CNAs forcibly made the resident take a shower despite the resident's refusal and expressed fear of water. The resident was visibly tearful and upset while recounting the event and had multiple bruises on their arms as a result of the incident. The resident's care plan indicated that they were resistive to care and preferred to wash themselves at the sink in their room. The care plan also specified that if the resident resisted ADLs, staff should reassure the resident, leave, and return later to try again. However, the staff involved did not follow these guidelines and instead forced the resident to shower, causing physical and emotional distress. Interviews with the staff involved revealed that they were aware of the resident's refusal but proceeded with the shower anyway. The LPN and CNAs admitted to physically assisting the resident to stand and disrobe, despite the resident's protests and physical resistance. The facility's policies clearly state that residents have the right to refuse care and should not be coerced or forced, yet these policies were not followed in this instance.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to provide safe transfer assistance for a resident who was transferred by four staff members from a wheelchair to a shower chair without the use of a gait belt. The resident physically resisted the transfer, and staff grabbed the resident by the arms to lift them, resulting in bruising on the back of the right upper arm, left lower arm below the elbow, and right upper outer arm. The resident had diagnoses including morbid obesity, unspecified osteoarthritis, low back pain, and required assistance with personal care. The facility's policy on Safe Lifting and Movement of Residents, revised in 2017, mandates the use of appropriate techniques and devices, including gait belts, for lifting and moving residents. However, during the incident, staff did not use a gait belt and instead lifted the resident by the arms, contrary to the care plan that required assistance by two staff for transfers. Interviews with various staff members, including LPNs, CNAs, and therapists, confirmed that gait belts should be used for all transfers unless a mechanical lift is required. Despite the facility's policy and staff training on the use of gait belts, the staff involved in the incident did not adhere to these guidelines. The resident's care plan and the facility's policy were not followed, leading to the resident sustaining bruises during the transfer. Interviews with the staff revealed a lack of consistent understanding and application of the policy regarding the use of gait belts during transfers.
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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 Raymore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carnegie Village Rehabilitation & Health Care Cent | 2 mi | ★★★★★ | 0 | 0 |
| Sunrise Nursing & Rehabilitation | 2.3 mi | ★★★★★ | 1 | 0 |
| Beautiful Savior Home | 2.6 mi | ★★★★★ | 2 | 0 |
| Raintree Village | 5.6 mi | — | 1 | 0 |
| Life Care Center Of Grandview | 6.2 mi | ★★★★★ | 23 | 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.