Above 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 John Knox Village Care Center during CMS and state inspections, most recent first.
A resident who was cognitively intact and recently admitted after pacemaker placement was not fully informed before a CNA, who was not regularly assigned to them, applied barrier cream to their perineal area. The resident experienced discomfort and distress, reporting that they had not previously received this care and were not told why it was being done. Staff interviews confirmed that residents are expected to be informed of all care, and that this protocol was not followed in this case.
A facility failed to follow infection control standards during wound care and catheter care for two residents. An RN did not perform proper hand hygiene during wound care, and an LPN did not use Enhanced Barrier Precautions (EBP) while changing a Foley catheter. Staff interviews revealed inconsistencies in training and understanding of infection control protocols.
The facility failed to provide a SNF ABN to two residents, informing them of potential non-coverage by Medicare Part A, financial liability, and appeal rights. A former SSA responsible for issuing these notices did not provide them, as they were unaware of the requirement. The Administrator confirmed the necessity of the SNF ABN when Medicare Part A services were expected to end, and residents continued to reside in the facility.
A resident with moderate cognitive impairment and Stage III pressure injuries on both buttocks did not have these conditions addressed in their care plan. Interviews with staff revealed confusion about responsibility for updating care plans, despite facility policy requiring updates for changes in health status.
The facility failed to maintain sanitary conditions for respiratory equipment for two residents. A resident's CPAP mask was repeatedly left uncovered, contrary to policy, while another resident's oxygen tubing and nebulizer mask were found on the floor and unbagged. Staff interviews revealed confusion over responsibility for equipment storage, leading to non-compliance with facility policies.
A resident with mobility issues was improperly transferred using a large hygiene sling instead of the correct small sling, leading to a fall. Despite facility guidelines requiring verification of sling size, two CNAs used the incorrect sling already under the resident, resulting in the incident.
Failure to Inform Resident Prior to Application of Barrier Cream
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had recently been admitted following a pacemaker placement, was not fully informed prior to the application of barrier cream to the perineal area. The resident required partial to moderate assistance with toileting and was at risk for skin problems, but there was no physician order for barrier cream documented in the resident's records. On the day of the incident, a CNA who was not regularly assigned to the resident responded to a call light and, upon noticing reddened skin and the presence of barrier cream in the bathroom, applied the cream without adequately informing the resident of the intended care. The resident reported feeling violated by the application, stating that no care staff had previously used barrier cream on them and that the CNA did not answer when asked about the reason for its use. The resident experienced a burning sensation from the cream and required assistance from a nurse to remove it. Multiple staff interviews confirmed that the resident was not appropriately informed prior to the application, and that informing residents of care is an expected protocol and a resident right. The CNA involved stated that they believed they had informed the resident, but other staff and the DON acknowledged that the explanation was insufficient. Facility policy requires that residents be informed of all aspects of their care, including participation in planning and any changes in treatment. Staff interviews consistently indicated that all residents should be informed of care prior to its delivery, and that this expectation was not met in this instance. The lack of clear communication and failure to obtain informed consent for the application of barrier cream led to the resident's distress and the subsequent deficiency finding.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to adhere to infection control standards during wound care for a resident with multiple pressure injuries and cognitive impairment. The Registered Nurse (RN) involved did not perform proper hand hygiene at several critical points during the wound care process, such as before and after touching the resident, between handling different wounds, and after touching potentially contaminated surfaces. The RN also failed to sanitize scissors used during the procedure, which were placed back into the treatment cart without cleaning. The RN admitted to not having received recent in-service training on wound care and acknowledged the lapses in hand hygiene. Another deficiency was observed in the facility's failure to implement Enhanced Barrier Precautions (EBP) for a resident with a Foley catheter. The Licensed Practical Nurse (LPN) did not wear a gown while performing catheter care, despite the presence of an EBP sign outside the resident's room indicating the requirement for gown and glove use. The resident confirmed that staff did not wear a gown during previous catheter changes. The LPN believed they had performed the care correctly, indicating a lack of understanding or training regarding EBP protocols. Interviews with staff revealed inconsistencies in the understanding and implementation of EBP and hand hygiene protocols. While some staff members reported receiving training on these procedures, others indicated a lack of education or awareness. The facility administrator acknowledged the expectation for staff to follow hand hygiene and EBP protocols but noted that the facility was still in the process of planning and educating staff on EBP procedures.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, Form CMS-10055) to two residents, informing them that skilled services might not be covered by Medicare Part A, the potential financial liability if they chose to continue receiving services, and their claim appeal rights. This deficiency was identified during a review of the facility's SNF Liability Notice Policy and interviews with facility staff. The policy required that if the facility believed Medicare would not cover certain services, residents or their legal representatives should be notified in writing using the SNF ABN form. However, for two residents, there was no documentation that they were asked if they wanted to continue services or that the SNF ABN was provided. Interviews revealed that a former Social Services Associate (SSA) was responsible for providing these notices but failed to do so, as they were unaware of the requirement to present the SNF ABN to residents who remained in the facility after Medicare Part A services were expected to end. The current SSA confirmed that the previous SSA, who had not worked long at the facility, was trained by a now-retired Social Worker and did not provide the SNF ABN form as required. The Administrator acknowledged that the SNF ABN was necessary when Medicare Part A services were expected to end, and the resident continued to reside in the facility.
Failure to Update Care Plan for Pressure Injuries
Penalty
Summary
The facility failed to review and revise a resident's person-centered care plan to address pressure injuries for one resident out of 23 sampled. The resident, who was readmitted to the facility, had moderate cognitive impairment and was at risk for pressure injuries. The resident's quarterly Minimum Data Set (MDS) indicated the presence of Stage III pressure injuries on both buttocks, yet these were not addressed in the care plan as problems, nor were there any goals or interventions specified. Interviews with facility staff revealed a lack of clarity and responsibility regarding updating the care plan. The Certified Nurse Assistant (CNA) indicated that the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were responsible for updates. The MDS Coordinator and the facility wound care nurse both acknowledged that pressure injuries should be reflected in the care plan, but there was confusion about who was responsible for making these updates. The facility's policy required the care plan to be updated as conditions changed, but this was not adhered to in the case of the resident's pressure injuries.
Failure to Maintain Sanitary Conditions for Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment, specifically CPAP masks, were cleaned and stored in a sanitary condition for Resident #18. Observations on multiple occasions showed the resident's CPAP mask was left uncovered on the dresser, contrary to the facility's policy that required such equipment to be stored in a plastic bag when not in use. Interviews with staff, including a CNA and an LPN, revealed a lack of awareness and adherence to the proper storage policy for CPAP equipment, with the responsibility for storage being unclear among staff members. For Resident #412, the facility failed to maintain respiratory face masks and tubing in a sanitary condition. Observations indicated that the resident's oxygen tubing was frequently found lying on the floor, and the nebulizer mask was left unbagged on the heat register. The facility's policy required that oxygen supplies be replaced weekly and stored in a dated zip lock bag when not in use. Interviews with LPN B and the Administrator confirmed that the responsibility for changing and storing the equipment was assigned to the nursing staff, but the equipment was not consistently managed according to the policy. Both residents had significant respiratory conditions requiring careful management of their respiratory equipment. Resident #18 had obstructive sleep apnea and used a CPAP machine, while Resident #412 had multiple respiratory diagnoses, including emphysema and acute respiratory failure, necessitating continuous oxygen therapy. The facility's failure to adhere to its own policies for storing and maintaining respiratory equipment compromised the sanitary conditions required for these residents' care.
Incorrect Sling Use Leads to Resident Fall
Penalty
Summary
The facility staff failed to adhere to the guidelines for using mechanical lifts, resulting in an incident involving a resident who was transferred using an incorrect sling size. The resident, who had a history of abnormal posture, lack of coordination, generalized muscle weakness, and was non-ambulatory, was transferred using a large hygiene sling instead of the small sling specified in their profile. This incorrect use of the sling led to the resident slipping through the sling and falling to the floor, although no injury was reported. The incident occurred when two CNAs attempted to transfer the resident from a recliner to a bed using a Hoyer lift. The hygiene sling, which was not appropriate for the resident, was already under the resident, and the CNAs did not verify its size or appropriateness before proceeding with the transfer. The hygiene sling, designed for toileting purposes with a large opening, was not suitable for the resident's needs, leading to the fall. Interviews with staff revealed that there was a lack of verification of the sling size and type before use, despite the facility's guidelines and training. The CNAs involved were relatively new and did not check the resident's profile for the correct sling size. The facility's guidelines clearly stated the importance of using the correct sling size, which was not followed in this instance, resulting in the deficiency.
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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 Lees Summit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lee's Summit Place | 1 mi | ★★★★★ | 1 | 0 |
| Jefferson Health Care | 1.9 mi | ★★★★★ | 2 | 2 |
| University Health Lakewood Medical Center | 4 mi | ★★★★★ | 12 | 0 |
| Edgewood Manor Health Care Center | 4.1 mi | ★★★★★ | 6 | 0 |
| Seasons Rehab And Healthcare Center | 4.3 mi | ★★★★★ | 2 | 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.