Clara Manor Nursing Home

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

-This was the first experience he/she had with an abuse allegation and did not know what he/she was supposed to do other than notify the Administrator.-LPN B was the charge nurse upstairs so he/she didn't know anything about sending CMT A home. During an interview on 11/19/25 at 3:33 P.M., CNA A said:-He/She didn't see Resident #1 by the medication cart during the evening shift (on 11/12/25).-Sometime after dinner on 11/12/25, he/she came out from giving a resident a shower when CMT

A told him/her that he/she just put Resident #1 to bed and asked CNA A to check on Resident #1 to see if he/she was still in bed.-When he/she went into Resident #1's room, he/she was in his/her wheelchair and was getting in bed.-Resident #1 had blood on his/her pants and shirt.-It looked like the blood came from his/her face.-He/She asked Resident #1 what happened and he/she did not want to tell him/her what happened.-He/She told the resident that he/she had to tell the nurse.-The resident told him/her not to worry about it.-He/She reported the bleeding to LPN A. During an interview on 11/17/25 at 11:23 A.M., the Administrator said:-Resident #1 told Resident #2 on 11/12/25 about the incident with CMT A and they both went to the AIT the evening of 11/12/25 to report it. -The AIT reported the incident with CMT A to him/her by text on 11/12/25 around 6:00 P.M. and he/she read the text around 7:30 P.M.-He/She called CMT A soon

after 7:30 P.M. and told CMT A he/she needed to clock out and leave.-CMT A timed out at 9:07 P.M. on 11/12/13, probably after finishing the medication pass.-CMT A was gone on 11/13/25, so he/she knew Resident #1 was safe.-The DON called him/her on 11/13/25 between 8:30 A.M. and 9:00 A.M. and said he/she saw bruising on Resident #1's face.-He/She arrived after 9:00 A.M. on 11/13/25.-He/She knows the abuse happened.-Resident #1 initially said he/she was too scared to tell the Administrator.-He/She interviewed Resident #1 and Resident #1 said he/she was going to the medication cart to steal some cigarettes and the CMT came out of nowhere and grabbed his/her face hard and scared him/her to death.-When the AIT interviewed CMT A, he/she denied anything happened.-He/she told CMT A to leave over the phone. The charge nurse reported it to the AIT, the AIT said it was his/her first experience and did not know he/she was supposed to do other than notify the Administrator. No one made CMT A go home.

During an interview on 11/18/25 at 10:20 A.M., the DON said:-He/She did the skin assessment on the resident as part of his/her investigation on the morning of 11/13/25.-He/She did not know the resident reported the incident to the AIT on 11/12/25.-CMT A should have been sent home immediately when the allegation of abuse was first reported on 11/12/25.-Putting a hand over the resident's mouth and causing a scratch and bruising was abuse.-When he/she saw the scratch/bruising the next morning (11/13/25), it was

the first time he/she knew anything about the incident. -He/She called the Administrator on 11/13/25 after he/she saw the resident and reported the scratch and bruising on the resident. During an interview on 11/18/25 at 1:19 P.M., the Administrator said:-He/She did not keep a phone log to show when he/she called CMT A because it took up too much space.-Dinner was usually served around 5:00 P.M. and the incident was after dinner.-He/She concluded that CMT A abused the resident. During an interview on 11/18/25 at 8:13 A.M., Resident #1's primary care physician said she would expect the staff to not put their hand over

the resident's face and abuse the resident. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to

the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). 2668352 and Event ID:

Facility ID:

26A293

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

26A293

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clara Manor Nursing Home

3621 Warwick Boulevard Kansas City, MO 64111

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

cm and a scratch on his/her right side of his/her face.--The Director of Nursing (DON) called the Administrator to inform him/her of the bruises he/she saw on Resident #1. Review of CMT A's timecard report dated 11/6/25-11/19/25 showed he/she worked 2:55 P.M. to 9:06 P.M. on 11/12/25. Observation on 11/17/25 at 10:10 A.M., showed the resident had a red scratch on his/her right cheek that was about a 3 cm long and a circular bruise on the left side of his/her face that was 2 cm in length and 2 cm in width and demonstrated how CMT A placed his/her right hand over his/her face. During an interview on 11/17/25 at 11:23 A.M., the Administrator said:-He/She knew CMT A abused Resident #1.-They did not notify the police of CMT A abusing Resident #1.-Resident #1 told Resident #2 on 11/12/25 about the incident with CMT A and they both went to the AIT the evening of 11/12/25 to report it. -The AIT reported the incident with CMT

A to him/her by text on 11/12/25 around 6:00 P.M. and he/she read the text around 7:30 P.M.-He/She called CMT A soon after 7:30 P.M. and told CMT A he/she needed to clock out and leave.-CMT A timed out at 9:07 P.M. on 11/12/13, probably after finishing the medication pass. During an interview on 11/18/25 at 10:20 A.M., the DON said he/she did not think about notifying the police. During an interview on 11/18/25 at 1:19 P.M., the Administrator said:-He/She concluded that CMT A abused the resident.-It was his/her responsibility to complete the investigation per the facility policy.

Event ID:

Facility ID:

26A293

If continuation sheet