Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Platte County Legacy Home during CMS and state inspections, most recent first.
Failure to provide adequate supervision to prevent resident injury. A resident with dementia, memory impairment, and wandering was found on the floor near a plant after staff heard a crashing sound, but no staff witnessed the fall. Staff reported residents were being assisted out of the dining room at the time, and the resident representative said the fall involved a head strike on a planter. The resident later returned from the hospital with a facial fracture and bruising.
Unlabeled Tubersol Vial and Expired Acetaminophen in Medication Storage. Surveyors found a partially used PPD Tubersol vial in the south med room without a use-by date and expired acetaminophen suppositories still available for use. An RN confirmed the vial was in use and should have been labeled, and confirmed the expired suppositories should have been discarded.
Failure to monitor psychotropic medications: Two residents receiving psychotropic meds, including antipsychotic, antidepressant, and lorazepam therapy, had no resident-specific or medication-specific target symptoms identified in the medical record. One resident had dementia with behavioral symptoms on MDS, while the other had severe cognitive impairment, dementia, Parkinson's disease, anxiety, and depression with no behavioral symptoms present. The DON confirmed the missing target symptoms for both residents.
A resident was transferred for urgent medical needs after emesis and subsequent hospital admission for SBO, GI bleed, sepsis, and SVT. The transfer notice stated the bed-hold policy was attached, but no policy was attached, and there was no evidence the resident or resident representative received the written bed-hold policy at the time of transfer.
A resident with PTSD had an inaccurate PASRR Level I that did not list a primary psychiatric diagnosis and stated that a Level II was not indicated. The social services director confirmed the diagnosis was identified after admission and that a significant change was not completed, even though a new PASRR should have been completed after the diagnosis was received.
The facility did not submit the required PBJ data for the 4th quarter of 2023. This was confirmed during a review and an interview with the business office manager, who stated that she began submitting PBJ data in January, while another staff member was previously responsible. The data for the specified quarter was not submitted.
A facility failed to label insulin pens with an open date on a medication cart. An RN confirmed the insulins were undated and considered expired. The administrator stated insulin should be dated when removed from the refrigerator. Facility policy requires recording expiration dates on new vials, and manufacturer guidelines indicate a 28-day expiration at room temperature.
Two residents in the facility did not receive scheduled bathing services, with one resident going up to 17 days without a bath. A resident with severe cognitive impairment and another with multiple sclerosis were both affected. Staff interviews revealed that CNAs were sometimes unavailable to provide bathing, leading to missed care.
A facility failed to provide restorative services to a resident with limited ROM due to a history of CVA and hemiplegia. The resident was not receiving restorative care due to refusals, which were not documented. The resident was observed without a splint for contractures, and there were no physician orders for restorative care or splint placement. The administrator confirmed that the lack of documentation indicated non-implementation of the care plan.
A facility failed to ensure proper hand hygiene during wound care for a resident. An LPN changed dressings on a resident's shoulder and arm without performing hand hygiene between glove changes. The LPN believed she had done so, but the facility's policy required hand hygiene before and after glove use. The administrator confirmed this expectation.
Failure to Provide Adequate Supervision to Prevent Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision was provided to prevent resident injuries for 1 of 4 sampled residents reviewed for accident hazards. Resident #10 had short-term and long-term memory impairment, a diagnosis of non-Alzheimer's dementia, physical and verbal behaviors directed toward others, other behavioral symptoms not directed toward others, and wandering during the look-back period. The resident representative reported that the resident recently fell and hit his/her head on a planter, and stated the incident was being investigated. The representative also said there were 2 other residents in the room with Alzheimer's dementia and it was unclear how the fall occurred. A facility incident report documented that after staff completed shift briefing, a nurse heard a crashing sound and found resident #10 lying on the floor near a plant in the family room. LPN #1 and CNA #1 were assigned to the unit and responded to the incident. CNA #1 stated she had answered a call light and, when she returned, heard the resident yelling and learned the resident had been walking around before the incident. LPN #1 stated residents had just finished dinner and CNAs were assisting residents out of the dining room when she heard a loud noise and found the resident on the floor. The social services director confirmed there were no staff present who observed the incident and that there were no actual witnesses other than residents with cognitive impairment. A later progress note stated the resident had been re-admitted from the hospital after a fall that caused a facial fracture and bruising, and noted diagnoses including HTN, memory loss, and osteoporosis.
Unlabeled Tubersol Vial and Expired Acetaminophen in Medication Storage
Penalty
Summary
Drugs and biologicals in the south medication room were not labeled in accordance with accepted professional principles because a partially used PPD Tubersol vial had been opened and was not marked with a use-by date, and over-the-counter acetaminophen suppositories were available for use even though they had expired in 1/2026. During observation at 8:45 AM, surveyors found the Tubersol vial in general stock without a date indicating when it should be discarded, and they found the expired acetaminophen suppositories still present in the medication storage area. RN #1 confirmed that the Tubersol vial was in use and should have been labeled with a use-by date, and also confirmed that the expired suppositories were available for resident use and should have been discarded. The facility policy stated that discontinued, outdated, or deteriorated drugs or biologicals shall not be used, and the manufacturer’s insert for Tubersol stated that a vial entered and in use for 30 days should be discarded.
Failure to Monitor Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring of psychotropic medications for 2 residents reviewed for unnecessary medications. One resident had short-term and long-term memory impairment, a diagnosis of non-Alzheimer's dementia, and MDS findings of physical and verbal behaviors directed toward others and other behavioral symptoms on 1 to 3 days during the look-back period. That resident was receiving antipsychotic and antidepressant medications, as well as lorazepam 0.5 mg by mouth daily for pain and agitation, but the medical record did not show resident-specific or medication-specific target symptoms had been identified. The second resident had severe cognitive impairment, diagnoses including non-Alzheimer's dementia, Parkinson's disease, anxiety, and depression, and no behavioral symptoms were present on the MDS assessment. That resident was receiving fluoxetine 20 mg by mouth daily for depression and olanzapine 2.5 mg in the morning for anxiety and 5 mg in the evening for dementia without behavioral disturbance, but the medical record also did not show resident-specific or medication-specific target symptoms. The DON stated that residents receiving psychotropic medications should have target symptoms identified and monitored, and confirmed there were no target symptoms identified for either resident.
Failure to Provide Written Bed-Hold Policy at Transfer
Penalty
Summary
The facility failed to ensure that a written bed-hold policy was provided at the time of transfer for resident #46. Medical record review showed the resident had emesis during the shift, an order was obtained to transport the resident to the emergency department, and the resident was later admitted to the hospital with a small bowel obstruction, gastrointestinal bleed, sepsis, and supraventricular tachycardia. A Nursing Home Transfer and Discharge Notice documented that the resident was transferred for urgent medical needs that could not be met in the facility and indicated that the bed-hold policy was attached, but no bed-hold policy was attached in the record. Review of the medical record found no evidence that the resident or resident representative received the written bed-hold policy at the time of transfer, and the administrator confirmed there was no evidence it had been provided.
Inaccurate PASRR Screening for Resident with PTSD
Penalty
Summary
The facility failed to ensure preadmission screening was performed accurately for resident #3, who had diagnoses including post-traumatic stress disorder. Review of the quarterly MDS assessment showed the resident had PTSD, but the PASRR Level I completed on 7/30/23 listed no primary psychiatric diagnosis and indicated that a PASRR Level II was not needed because there was no evidence of mental illness or intellectual disability. During interview, the social services director stated that the resident’s PTSD was identified after admission and that a significant change was not completed, and he confirmed that a new PASRR should have been completed after the diagnosis was received.
Failure to Submit PBJ Data for 4th Quarter 2023
Penalty
Summary
The facility failed to submit the required Payroll Based Journal (PBJ) data for the 4th quarter of 2023, covering the period from July 1, 2023, to September 30, 2023. This deficiency was identified during a review of the facility's quarterly PBJ submissions and confirmed through an interview with the business office manager. The manager revealed that she began submitting PBJ data in January, and prior to that, another staff member was responsible for entering the data. However, it was confirmed that the data for the 4th quarter of 2023 was not submitted.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly labeled with an open date on one of the medication carts, specifically the 300 - 400 medication cart. During an observation, it was found that a Novolog flex pen and a Lantus Solostar pen, both 100 unit/milliliter, were not dated. RN #1 confirmed that these insulins were for resident use and acknowledged that they were not dated, thus considered expired. The facility's administrator stated that insulin should be dated when removed from the refrigerator and disposed of if not dated. The facility's policy on insulin administration requires recording the expiration date and time on a new vial, following manufacturer recommendations. Manufacturer guidelines indicate that both the NovoLog pen and Lantus insulin expire 28 days after being kept at room temperature.
Failure to Provide Scheduled Bathing for Residents
Penalty
Summary
The facility failed to ensure that residents received adequate personal hygiene services, specifically bathing, for two residents. Resident #11, who is severely cognitively impaired with a BIMS score of 3 out of 15, requires extensive assistance for daily living activities, including bathing twice a week. However, the resident experienced significant gaps between scheduled bathing days, going up to 17 days without a bath. These missed bathing sessions were documented as 'Not Applicable,' and the resident expressed dissatisfaction with the frequency of bathing. Resident #24, who is cognitively intact with a BIMS score of 15 out of 15, also experienced similar issues. This resident, who is totally dependent on two staff members for bathing due to multiple sclerosis, went several days without a bath, contrary to the scheduled twice-weekly bathing. The resident reported sometimes receiving only one shower per week. Interviews with staff revealed that there are days when a CNA is not available for bathing, and floor CNAs do not have time to provide this care, leading to residents going without baths.
Failure to Provide Restorative Services and Document Refusals
Penalty
Summary
The facility failed to provide appropriate restorative services to a resident with limited range of motion due to a history of cerebrovascular accident (CVA) and hemiplegia. The resident, who is severely cognitively impaired, was dependent on staff for various activities of daily living and had completed therapy, transitioning to a restorative nursing assistant (RNA) program. However, there were no physician orders for restorative care or splint placement, and the resident was observed not wearing a splint for contractures, despite stating that they do wear one. Interviews with staff revealed that the resident was not receiving restorative care due to refusals, which were not being documented. The administrator confirmed that staff were expected to follow physician orders and the care plan, and acknowledged that the lack of documentation indicated that the restorative care and splint use were not being implemented. Additionally, the restorative CNA had recommended discontinuing the restorative program and splint, but the care plan had not been revised to reflect this change.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident. During an observation, an LPN changed the dressing on a resident's right upper shoulder and then proceeded to change the dressing on the left lower arm without performing hand hygiene between doffing and donning gloves. The LPN believed she had performed hand hygiene between these actions. The facility's policy and procedure for hand hygiene clearly stated that hand hygiene should be performed before applying and after removing gloves. An interview with the administrator confirmed that staff were expected to follow these hand hygiene protocols.
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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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