Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

Based upon observation and interview, the facility failed to treat each resident with
respect and dignity and, care for each resident in a manner and in an environment that
promotes maintenance or enhancement of his or her quality of life while dining by avoiding
daily use of disposable dishware during meals. The facility census was 46 residents.
1. Observations on 1/27/19 at 9:10 A.M. and 5:58 P.M. in the dining room during breakfast
and dinner, showed all of the residents were eating from disposable, styrofoam dishware.
During an interview on 1/27/19 at 9:10 A.M., Resident #18 said the facility staff told
him/her that the dishwasher had broken for over a month and that was why they were eating
on disposable dishware.
During an interview on 1/29/19 at 6:55 A.M., the Dietary Manager said:
-The dishwashing machine had been working on and off for the last month and they had been
having to improvise with disposable plates and cups;
-The maintenance person had requested parts for the machine, but has had a hard time
obtaining them because of the age of the machine.
Observations on 1/31/19 at 8:02 A.M. in the dining room during breakfast, showed all of
the residents were eating with disposable, styrofoam dishware.
During an interview on 1/31/19 at 8:09 A.M., Resident #41 said:
-The facility staff told him/her that they used to use real dishes, but lately it was
styrofoam;
-I’d rather use real dishes.
During an interview on 1/31/19 at 8:25 A.M., Resident #47 said:
-The facility staff told him/her that they were using styrofoam because the dishwasher had
been out of order;
-They have had problems with it for a long time, but he/she didn’t know for sure how long.
During an interview on 1/31/19 at 11:49 A.M., Resident #14 said:
-The facility had been serving meals and drinks on styrofoam plates and cups for about
three weeks and this was ridiculous;
-The facility had plates and cups to use;
-He/She would not eat breakfast because this was not homelike to eat off styrofoam;
-He/She liked to drink hot tea, but did not want it out of a styrofoam cup;
-He/She used his/her own cup in his/her room for hot tea, because there were no regular
cups available.
During an interview on 1/31/19 at 11:59 A.M., Social Services Designee (SSD) said:
-The facility was using styrofoam cups and plates due to the dishwasher not working;
-The dishwasher had not been working for at least a couple of months;
-The styrofoam plates and cups did not enhance the residents homelike environment and
promote dignity.
During an interview on 1/31/19 at 1:01 P.M., Licensed Practical Nurse (LPN) A said:
-The Maintenance Director (MD) had been repairing the dishwasher off and on;
-It would work for a short period of time and then would break down;
-This has been on-going for a couple of months;
-Not a very homelike environment;
-The residents have voiced concerns about the styrofoam plates and cups.
During an interview on 1/31/19 at 1:33 P.M., the MD said:
-The residents had been eating on disposable dishware for over a month since the kitchen
dishwashing machine had been leaking and in need of repair;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
-The dishwashing machine was scheduled to be repaired in a couple of weeks.

F 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Reasonably accommodate the needs and preferences of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident had the necessary equipment available and operating properly, and to keep fully
charged batteries in order to operate a mechanical lift needed to get a resident into and
out of bed for one sampled resident (Resident #47) out of 12 sampled residents. The
facility census was 46 residents.
Record review of the facility policies showed the facility did not have a policy related
to mechanical lifts and battery charging.
1. Record review of Resident #47’s Face Sheet showed the resident was admitted to the
facility on [DATE] and last readmitted on [DATE] and had a [DIAGNOSES REDACTED]. A person
is considered morbidly obsess if 100 pounds or more over their ideal weight or has a Body
Mass Index (BMI – A measurement of body fat based on height and weight of 40 or more).
Record review of the resident’s Physician order [REDACTED].
-Orders beginning 1/10/19 for Skilled Occupational Therapy (OT – therapy based on
engagement in activities to maintain or improve functional skills related to Activities of
Daily Life (ADLs – dressing, grooming, toileting, and transfers) three times weekly for 30
days for therapeutic exercise, neurological re-education (Neuro re-ed – exercises to
improve balance, coordination and posture), and self-care training;
-Orders beginning 1/10/19 for Physical Therapy (PT -treatment of [REDACTED].
Record review of the resident’s PT Evaluation and Plan of Treatment, dated 1/10/19, and
accompanying Treatment Encounter and PT Progress Notes, also dated 1/10/19 showed:
-The resident was referred for exacerbation of decrease in abilities related to transfers,
functional skills, postural alignment, balance, mobility, strength, and range of motion
(ROM – full movement potential of a joint);
-The resident was evaluated for his/her ability to benefit from a sit to stand lift device
(a standing and raising aid used by caregivers to transfer a resident between two seated
postures such as the edge of the bed to a wheelchair);
-It was determined the resident required a mechanical lift (a device used to transfer
individuals who are unable to stand or whose weight makes it unsafe for other methods of
transfer) for safe transferring.
Record review of the resident’s OT Evaluation and Plan of Treatment, dated 1/10/19 and
accompanying OT Progress Note, dated 1/10/19, showed:
-The resident was referred due to his/her decrease in functional mobility and impaired
balance;
-It was determined the standing lift was not a viable transfer option and a mechanical
lift would be safer for the resident and staff.
Record review of the resident’s quarterly Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning purposes), dated
1/22/19, showed the resident:
-Was cognitively intact;
-Was totally dependent upon two or more staff for transfers.
Record review of the resident’s comprehensive Care Plan, dated 1/24/19, showed:
-The resident was limited in his/her ability to perform ADLs and transfers due to [MEDICAL

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
CONDITION];
-The resident would be transferred with the use of a mechanical lift.
Observations showed the resident was lying in bed awake on the following dates and times:
-1/27/19 at 10:15 A.M.;
-1/27/19 at 12:28 P.M.;
-1/27/19 at 8:09 P.M.
During an interview on 1/29/19 at 12:42 P.M., the resident said:
-He/She normally got up between 10:30 and 11:00 A.M. and sat in the common area where
he/she made phone calls and read magazines;
-He/She was told a couple of weeks prior by OT that he/she would need to be transferred
with a mechanical lift;
-He/She hadn’t been able to get out of bed for approximately two weeks, because the
mechanical lift that could lift him/her wouldn’t lift all the way above the bed surface;
-Only day shift staff got him/her up and put him/her to bed, because the evening shift
hadn’t been trained on getting him/her into and out of bed;
-On the weekends, he/she didn’t get out of bed, because a lot of the staff working
weekends were newbies who hadn’t been trained on how to get him/her out of bed;
-He/She would have preferred to get out of bed some of the days within the past week or
two.
Observation on 1/30/19 at 8:15 A.M., showed the resident was lying in bed awake.
During an interview on 1/30/19 at 9:03 A.M., the Director of Therapy/PT Assistant (PTA)
said there was a problem a couple of weeks prior with the mechanical lift used to lift the
resident and he/she was not sure if the problem had been fixed.
Observation on 1/30/19 at 11:35 A.M., showed the resident was lying in bed asleep.
During an interview on 1/30/19 at 1:06 P.M., in the resident said Certified Nurse
Assistant (CNA) D told him/her the mechanical lift hadn’t been fixed yet, so CNA D gave
him/her a bed bath earlier in the day instead of a shower.
During an interview on 1/30/19 at 1:10 P.M., Licensed Practical Nurse (LPN) A said:
-The facility had a 450 pound and a 600 pound capacity mechanical lift;
-The 600 pound capacity lift had been in and out of repair. It was fixed once and the last
time it had been out of repair three or four weeks due to getting off balance;
-He/She didn’t know if another lift or lift part was on back order.
During an interview on 1/30/19 at 1:28 P.M., CNA A said:
-On 1/28/19 in the afternoon, he/she checked with the resident who told CNA A he/she was
willing to get out of bed;
-He/She went to get the 600 pound capacity mechanical lift to get the resident out of bed
and Therapy told him/her the lift was broken.
During an interview on 1/31/19 at 9:08 A.M., LPN B said:
-A couple of weeks prior when the resident was put to bed and the mechanical lift was
raised to the top, staff had to pull on it to lower it;
-Therapy said the previous week the mechanical lift could still be used with the resident;

-Maintenance might know what had to be done to fix the lift.
During an interview on 1/31/19 at 9:30 A.M., the Director of Therapy/PTA said:
-The mechanical lift was appropriate for the resident’s weight and three to four staff
were required during a transfer for the resident’s safety;
-Approximately one and a half to two weeks ago, the mechanical lift raised only to a
certain height and staff had to use the manual lever to complete the transfer. The lift
worked smoothly in the manual mode;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
-The lift needed to be fixed before it was used with the resident;
-The resident had been doing therapy exercises he/she could do while lying in bed instead
of in the therapy room.
During an interview on 1/31/19 at 9:50 A.M., CNA D said:
-We normally get the resident up around 10:30 to 11:00 A.M., which is his/her preference,
and have been told to lay the resident down and make sure he/she was clean before 3:00
P.M. when the day shift staff leaves;
-He/She didn’t know why the resident needed to be in bed when the day shift left;
-It took four CNA’s to get the resident out of bed and sometimes the nurse helped;
-The mechanical lift broke two months prior and was fixed and broke again two weeks ago.
The lift raised all the way to the top, but the controller wouldn’t work to lower the
resident into bed, so they had to use the emergency lever which was not smooth so it
wasn’t considered safe;
-Therapy staff saw the problem two weeks ago and the resident hadn’t been out of bed
since.
During an interview on 1/31/19 at 10:52 A.M., the Maintenance Director said:
-The facility used a rented mechanical lift that had a 600 pound capacity and the facility
owned three 450 pound capacity lifts all in good working order;
-The scale on the 600 pound capacity lift was acting up, but the lift itself was working;
-Every time the mechanical battery was fully charged the 600 pound capacity lift worked;
-He/She recently purchased two battery testers. Mechanical lift batteries required four to
six hours to fully charge;
-The testers were not available to nursing staff and the only way for staff to know if a
battery was fully charged was to document when the battery was placed on the charger;
-He/She had seen the batteries sitting in resident rooms or the break room not on a
charger;
-There were three chargers in the medication room, two in the employee break room and one
in the Restorative Aide room on the Rehabilitation side;
-The staff had been instructed on keeping the batteries charged;
-There was no maintenance schedule for monitoring the function and safety of the
mechanical lifts or for checking that the battery cells to the mechanical lift batteries
were good.
Observation on 1/31/19 at 11:40 A.M., showed:
-Three battery chargers on the wall in the medication room, two with batteries on them and
two chargers with batteries on them in the employee break room. Additionally, one battery
was sitting out in the break room not being charged;
-There was no way to determine the charge level of the batteries without a battery tester.
During an interview on 2/1/19 at 10:25 A.M., the Director of Therapy/PTA said the 600
pound capacity mechanical lift was working without any problems and that staff were
getting ready to get the resident out of bed.
Observation on 2/1/19 at 10:43 A.M., showed:
-Five staff in the resident’s room, including the Director of Therapy/PTA;
-The resident was lifted from his/her bed and lowered into his/her wheelchair with no
noticeable problems with the functioning of the lift.
During an interview on 2/1/19 at 11:00 A.M., the Director of Nursing (DON) said:
-If a resident who uses a mechanical lift wants out of bed and the lift was working
Nursing should accommodate the resident’s wishes and get him/her out of bed;
-If a device such as a mechanical lift was not working correctly there should be a note
posted on the device and the problem should be written in the Maintenance log to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
communicate the problem.

F 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure residents have reasonable access to and privacy in their use of communication
methods.

Based on interview and record review, the facility failed to ensure residents had the
opportunity to consistently receive mail, magazines and packages that were delivered to
the facility on Saturdays on the day of delivery for residents who receive personal mail.
The facility census was 46 residents.
Record review of the facility policies showed the facility did not have a policy related
to the delivery of mail.
Record review of the Resident Council Meeting minutes for the months of (MONTH) (YEAR),
(MONTH) (YEAR) and (MONTH) (YEAR), showed there were no recent discussions related to
delivering mail to residents on Saturdays.
1. During discussion at the Resident Council Group Meeting on 1/28/19 at 1:30 P.M., the
eight cognitively intact residents in attendance were asked if they received mail on
Saturdays. The residents said:
-The Activity Director gave them their mail on the Saturdays he/she worked, which was
normally every other Saturday;
-The mail came late in the day at approximately 4:00 P.M.;
-If the Activity Director didn’t work on a Saturday they received their mail on the
following Monday.
During an interview on 1/31/19 at 8:34 A.M., the Activity Director said:
-On the Saturdays he/she didn’t work, the Activity Assistant worked at the facility and
was supposed to pass out personal mail such as magazines, cards and letters to the
residents before leaving for the day;
-The Activity Assistant usually left work around 3:30 P.M.;
-The mail came between 3:00 and 4:00 P.M.;
-When he/she was made aware the Activity Assistant left the faciity on a Saturday before
the mail was passed out to residents, he/she called the Certified Medication Technician
(CMT) and asked the CMT to pass out the resident’s mail or came in to work and did so
him/herself.
During an interview on 1/31/19 at 10:34 A.M., the Activity Assistant said:
-He she/worked half of the Saturdays and the Activity Director worked the other half;
-If the mail arrived on Saturday before he/she left for the day, he/she delivered personal
mail to residents;
-Approximately half the Saturdays he/she worked, the mail was delivered before he/she left
for the day;
-He/She usually left the faciity on Saturdays between 3:00 and 4:00;
-If the Saturday mail hadn’t been delivered before he/she left for the day, he/she thought
Nursing held the residents’ personal mail in the Medication Room until the following
Monday;
-When working on Saturday, he/she let the charge nurse know if he/she was leaving before
3:00 P.M. and did not let anyone know if the mail had been delivered to the residents
before he/she left.
During an interview on 2/1/19 at 11:00 A.M., the Director of Nurses (DON) said:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
-There should be a way for residents to get personal mail on Saturdays;
-He/She assumed the Activity Director and Activity Assistant consistently passed out mail
on Saturdays;
-If the Activity Assistant got off work before the mail was passed on Saturdays, the
Activity Director would have to ensure the residents’ personal mail got passed that day.

F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to request, refuse, and/or discontinue treatment, to
participate in or refuse to participate in experimental research, and to formulate an
advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure advanced directives
were in place for one sampled resident (Resident #47) out of 12 sampled residents who
wanted to appoint someone as Durable Power of Attorney (DPOA – a person previously
identified to make decisions for an individual in the event the person becomes unable to
make his/her wishes known should he/she become incapacitated). The facility census was 46
residents.
Record review of the facility’s Advanced Directive policy, revised 9/25/06, showed:
-Upon admission, the nurse and social worker should verify if the resident has an advanced
directive (written instruction such as a Living Will or Durable Power of Attorney for
Health Care) in place;
-Advanced directives recognized the resident’s wishes and should be known and followed by
facility staff;
-Advanced directives must be revised and updated as the resident indicates with the annual
Minimum Data Set (MDS – a federally mandated assessment instrument completed by facility
staff for care planning purposes).
1. Record review of Resident #47’s Face Sheet showed he/she:
-Was originally admitted to the facility on [DATE] and last readmitted on [DATE];
-Was his/her own responsible party;
-Had no person(s) listed as DPOA.
Record review of the resident’s Care Plan Conference Summary, dated 10/29/18, showed Care
Plan discussion that the resident’s wishes were to have two of his/her family members
acting as DPOAs.
Record review of the resident’s Physicians Orders Sheet (POS), dated (MONTH) 2019, showed
the resident had the following Diagnoses: [REDACTED]. A person is considered morbidly
obsess if 100 pounds or more over their ideal weight or has a Body Mass Index (BMI – A
measurement of body fat based on height and weight of 40 or more);
-History of [MEDICAL CONDITION] ([MEDICAL CONDITION] – a blood clot in a deep vein).
Record review of the resident’s quarterly MDS, dated [DATE], showed he/she was cognitively
intact.
Record review of the resident’s Care Plan, updated 1/24/19, showed:
-The resident had advanced directives for Do Not Resuscitate status should he/she be found
unresponsive without breath or heartbeat;
-The resident’s wishes related to his/her choice for DPOA were not mentioned.
Record review of the resident’s medical record on 1/29/19, showed no advanced directives
related to DPOA.
During an interview on 1/30/19 at 8:13 A.M., the Social Services Designee (SSD) said:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
-He/She asks residents upon admission if they have a DPOA;
-He/She has DPOA forms, but there has not been a notary working at the facility for
several months, so residents must go to their bank to notarize legal paperwork;
-The resident was unable to leave the facility in a van;
-The resident wanted two family members to be his/her DPOA;
-Arrangements had not been made for notarizing the resident’s DPOA paperwork.
During an interview on 1/30/19 at 1:55 P.M., the SSD said he/she called a sister company
and learned they have a notary who could come to the facility in two days to get the DPOA
paperwork signed.
During an interview on 1/31/19 at 9:59 A.M., the resident said:
-He/She was asked upon admission and during quarterly Care Plan meetings who he/she wanted
as DPOA;
-He/She told the facility since his/her admission, he/she wanted two family members to
share DPOA responsibilities if he/she became incapacitated.
During an interview on 2/1/19 at 11:00 A.M., the Director of Nursing (DON) said:
-Upon admission all residents should be asked if they have advanced directives and be
provided any needed assistance in filling out advanced directives paperwork;
-Residents who want to appoint someone as DPOA should have advanced directives completed
within a week of admission.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and the
resident’s representative(s) in writing of a transfer or discharge to the hospital,
including the reason for the transfer/discharge for three sampled residents (Resident #
22, #43, and #7) out of 12 sampled residents. The facility census was 46 residents.
Record review of the facility’s Policies showed:
-Acute Care Transfer Policy dated 9/26/06, revised 10/1/12;
-Discharging a Resident Policy dated 5/6/05, revised 10/1/12;
–Neither policy included notifying the resident and resident’s representative in writing
of a resident’s transfer/discharge.
Record review of the facility’s Notice of Transfer or Discharge sheet showed:
-Date; Resident Name; Reason of Discharge; Date Resident Family notified; Verbal Review
Completed; Resident’s family contact, including Name, Relationship and Phone number of
said person;
-The facility must notify the resident and the resident’s representative(s) of the reasons
for the move in writing.
1. Record review of Resident #22’s Face Sheet showed the resident was admitted to the
facility on [DATE], was readmitted on [DATE], and 1/9/19 with the following Diagnoses:
[REDACTED].
-Tracheotomy (surgical opening into the wind pipe into which a tube is inserted to allow
passage of air and removal of secretions).
Record review of the resident’s nurse’s notes dated:
-11/20/18 at 11:25 P.M., showed the resident was transferred to the hospital with labored
breathing and audible congestion;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
-1/1/19 at 8:00 A.M., showed the resident was transferred to the hospital with labored
breathing and congestion.
Record review of the Discharge Minimum Data Set (MDS – a required, federally mandated
assessment tool completed by facility staff for care planning) showed discharge of the
resident from the facility on:
-11/20/18; and
-1/1/19.
Record review of the resident’s medical record showed no documentation the facility
notified the resident and resident’s representative(s) in writing of the resident’s
transfer/discharge to the hospital on:
-11/20/18; and
-1/1/19.
Record review of the resident’s medical record showed the resident returned to the
facility on :
-12/20/18; and
-1/9/19.
2. Record review of Resident #43’s Face Sheet showed the resident was admitted to the
facility on [DATE], was readmitted on [DATE], and 1/4/19 with the following Diagnoses:
[REDACTED].
-Altered level of consciousness.
Record review of the resident’s nurse’s notes dated 10/31/18 at 8:30 A.M., showed the
resident was transferred to the hospital with chest pain and increased confusion.
Record review of the resident’s nurse’s notes for 12/29/18 showed no documentation the
resident was transferred to the hospital.
Record review of the Resident Transfer Form dated 12/29/18, showed the resident was
transferred to the hospital for altered level of consciousness and weakness.
Record review of the Discharge MDS showed discharge of the resident from the facility on:
-10/31/18; and
-12/29/18.
Record review of the resident’s medical record showed no documentation the facility
notified the resident and resident’s representative(s) in writing of the resident’s
transfer/discharge to the hospital on:
-10/31/18; and
-12/29/18.
Record review of the resident’s medical record showed the resident returned to the
facility on :
-11/8/18; and
-1/4/19.
During an interview on 1/27/19 at 10:15 A.M., the resident said he/she:
-Didn’t get any paper work before he/she went to the hospital;
-Got the paper work after he/she had returned from the hospital.
3. Record review of Resident #7’s Face Sheet showed:
-He/She was admitted to the facility on [DATE] and last readmitted on [DATE];
-The resident had [DIAGNOSES REDACTED].
-The resident was his/her own responsible party;
-The resident had a Durable Power of Attorney (DPOA – a person identified in advance to
act on behalf of the resident should the resident become incapacitated).
Record review of the resident’s Discharge MDS showed the resident was discharged from the
facility to an acute care hospital on [DATE] with return to the facility anticipated.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
Record review of the resident’s nursing note, dated 10/12/18, showed the resident was sent
to the emergency roiagnom on [DATE] due to a change in the resident’s level of
consciousness.
Record review of the resident’s medical record showed no documentation the facility
notified the resident and resident’s representative in writing of the resident’s transfer
to the hospital on [DATE].
Record review of the resident’s Entry Tracking Record MDS, dated [DATE] showed the
resident returned to the facility from the acute care hospital on [DATE].
4. During an interview on 1/28/19 at 3:30 P.M. Licensed Practical Nurse (LPN) C said:
-If the resident was their own person:
–He/She gave the resident the Notice of Transfer with the reason for transfer;
–Did not send one to the resident’s representative.
-If the resident was not their own person:
–The notice was placed into the Emergency Medical Technician’s (EMT) envelope;
–A copy of the Notice of Transfer was kept in the resident’s chart for the DPOA to sign;
–He/She did not give/send a copy to the DPOA.
During an interview on 1/29/19 at 11:32 P.M., the Social Services Designee (SSD) said:
-The nurse gives the resident written notification of transfers and discharges;
-He/She sent the State Ombudsman a copy of the notification of transfers and discharges on
a monthly basis;
-The resident’s DPOA’s or legal representatives were not sent written notifications of the
resident’s transfer or discharge.
During an interview on 1/31/19 at 8:57 A.M., LPN A said:
-If the resident was their own person:
–He/She gave the resident the Notice of Transfer with the reason for transfer;
–Did not send one to the resident’s representative.
-If the resident was not their own person:
–The notice was given to the Emergency Medical Technician (EMT);
–A copy of the Notice of Transfer was kept in the resident’s chart for the DPOA to sign;
–He/She didn’t give/send a copy to the Durable Power of Attorney (DPOA).
During an interview 1/31/19 at 9:48 A.M., LPN B said he/she:
-Gave the Notice of Transfer to residents;
-Placed a copy in the resident’s chart for the DPOA to sign when a resident is
transferred;
-Contacted resident’s DPOA when transferred;
-Said, if the Notice of Transfer form is mailed, Social Services handled it.
During an interview on 02/01/19 at 7:51 A.M., the Director of Nursing (DON) said he/she
expected:
-The Notice of Transfer to be given to the resident at time of transfer/discharge by the
charge nurse;
-The facility notified the residents’ representatives by phone of a pending
transfer/discharge;
-He/She was uncertain if the residents or resident representatives received a letter from
the facility explaining the reason for the transfer/discharge;
-There was no written notification sent to resident representatives, only a phone call.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Notify the resident or the resident’s representative in writing how long the nursing
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and
resident representative of the facility’s Bed Hold Policy in writing at the time of
transfer/discharge for two sampled resident (Resident #22 and #43) out of 12 sampled
residents. The facility census was 46 residents.
Record review of the facility’s Bed Hold Policy showed:
-Policy was undated and unsigned;
-A copy of the facility’s bed hold policy will accompany this notice;
-Any questions regarding the bed hold policy should be addressed with the facility
administrator.
1. Record review of Resident #22’s Face Sheet showed the resident was admitted to the
facility on [DATE], was readmitted on [DATE], and 1/9/19 with the following Diagnoses:
[REDACTED].
-Tracheotomy (surgical opening into the wind pipe into which a tube is inserted to allow
passage of air and removal of secretions).
Record review of the resident’s nurse’s notes dated, (MONTH) (YEAR) through (MONTH) 2019,
showed staff documented:
-11/20/18 at 11:25 P.M., showed the resident was transferred to the hospital with labored
breathing and audible congestion;
-1/1/19 at 8:00 A.M., showed the resident was transferred to the hospital with labored
breathing and congestion.
Record review of the Discharge Minimum Data Set (MDS – a required, federally mandated
assessment tool completed by facility staff for care planning) showed discharge of the
resident from the facility on:
-11/20/18; and
-1/1/19.
Record review of the resident’s medical record showed no documentation the facility
notified the resident and resident’s representative(s) in writing of the facility’s bed
hold policy at time of transfer/discharge:
-11/20/18; and
-1/1/19.
Record review of the resident’s medical record showed the resident returned to the
facility on :
-12/20/18; and
-1/9/19.
2. Record review of Resident #43’s Face Sheet showed the resident was admitted to the
facility on [DATE], was readmitted on [DATE], and 1/4/19 with the following Diagnoses:
[REDACTED].
-Altered level of consciousness.
Record review of the resident’s nurse’s notes, dated 10/31/18 at 8:30 A.M., showed
resident was transferred to the hospital with chest pain and increased confusion.
Record review of the resident’s nurse’s notes, dated 12/29/18, showed no documentation the
resident was transferred to the hospital.
Record review of the Resident Transfer Form, dated 12/29/18, showed the resident was
transferred to the hospital for altered level of consciousness and weakness.
Record review of the Discharge MDS showed discharge of the resident from the facility on:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
-10/31/18; and
-12/29/18.
Record review of the resident’s medical record showed no documentation the facility
notified the resident and resident’s representative(s) in writing of the facility’s bed
hold policy at time of transfer/discharge:
-10/31/18; and
-12/29/18.
Record review of the resident’s medical record showed the resident returned to the
facility on :
-11/8/18; and
-1/4/19.
During an interview on 1/27/19 at 10:15 A.M., Resident #43 said he/she:
-Did not get any paper work before he/she went to the hospital; and
-Got the paper work after he/she had returned from the hospital.
3. During an interview on 1/28/19 at 3:30 P.M., Licensed Practical Nurse (LPN) C said:
-If the resident was their own person:
–He/She gave the resident the Bed Hold Policy;
–Did not send one to the resident’s representative.
-If the resident was not their own person:
–The notice was placed into the Emergency Medical Technician’s (EMT) envelope;
–A copy of the Bed Hold Policy was kept in the resident’s chart for the DPOA to sign;
–He/She didn’t give/send a copy to the Durable Power of Attorney (DPOA).
During an interview on 1/31/19 at 8:57 A.M., Licensed Practical Nurse (LPN) A said:
-If the resident was their own person:
–He/She gave the resident the Bed Hold Policy;
–Did not send one to the resident representative.
-If the resident was not their own person:
–The notice was given to the Emergency Medical Technician (EMT);
–A copy of the Bed Hold Policy was kept in the resident’s chart for DPOA to sign; and
–He/She did not give/send a copy to the DPOA.
During an interview 1/31/19 at 9:48 A.M., LPN B said he/she:
-Gave the Bed Hold Policy to the residents;
-Placed a copy in the chart for the DPOA to sign;
-Contacted the DPOA;
-Said, if the form needed to be mailed, Social Services handled it.
During an interview on 02/01/19 07:51 A.M., the Director of Nursing (DON) said he/she
expected:
-The Bed Hold Policy to be given to the resident at time of transfer/discharge by the
nurse;
-There was no written notification sent to the resident’s representative, only a phone
call;
-There was confusion if the form was an in-house only form or not.

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a resident with a

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
mental disorder had a DA-124 Level I screen (used to evaluate for the presence of
psychiatric conditions to determine if a preadmission screening/resident review (PASARR)
level II screen is required) as required, for one sampled resident (Resident #14) out of
12 sampled residents. The facility census was 46 residents.
Record review of the facility policy’s showed the facility did not have a policy related
to PASARRs.
Record review of the Missouri Department of Health and Senior Services (DHSS) guide
titled, PASARR Desk Reference, dated 3/3/08, showed:
-The PASARR is a federally mandated screening process for any person for whom placement in
a Medicaid Title (XIX) certified bed is being sought. This is a Level I screening
(completion of the DA124C form). (In this facility, all beds are Medicaid certified);
-A Level II assessment is completed on those persons identified at Level I who are known
or suspected to have a serious mental illness (such as [MEDICAL CONDITION], dementia,
[MEDICAL CONDITION], etc., MR or related MR condition to determine the need for
specialized service (completion of the DA124A/B form). The facility responsible for
completing the DA124A/B and/or DA124C forms is also responsible for submitting completed
form(s) to DHSS, Division of Regulation and Licensure, Section for Long Term Care
Regulation, Central Office Medical Review Unit (COMRU);
-PASARR screening is required: To assure appropriate placement of persons known or
suspected of having a mental impairment;
-To assure that the individual needs of mentally impaired persons can be and are being met
in the appropriate placement environment;
-To be compliant with the OBRA/PASARR federal requirements, see 42 CFR 483.Subpart C; and
-To assure Title XIX funds are expended appropriately and in accordance with Legislative
intent.;
-To comply with PASARR requirements, the facility must maintain a legible copy on file of
the DA124C and Level II Screening Report for each resident until the resident is
transferred. If a legible copy is not maintained, the facility must complete and submit a
new set of DA124A/B and C forms to COMRU;
-If a resident is discharged to a new nursing home, the receiving facility is responsible
for assuring the DA124C and Level II screening results are included in the transfer
packet; and
-Should the DA124C not be included in the packet, admission should not be completed. The
DA124C and Level II screening results should be requested from the prior facility by the
receiving facility;
-The Guide To Intensive Psychiatric Treatment Guidelines, (instructions that are included
with the DA124 forms), dated 9/07, showed the following: Definition – inpatient
psychiatric hospitalization and/or any intensive mental health service provided by mental
health professionals that is required to stabilize or maintain a person experiencing major
mental disorder;
-Services may be rendered within their current residence; and
-The services are not merely medication changes, weekly counseling sessions or routine
outpatient visits.
1. Record review of Resident #14’s Face Sheet showed the resident was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED]. People who have [MEDICAL
CONDITION] disorder can have periods in which they feel overly happy and energized and
other periods of feeling very sad, hopeless, and sluggish);
-[MEDICAL CONDITION] (usually results from a violent blow or jolt to the head or body);
-Had a court appointed legal guardian as his/her responsible party.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
Record review of the resident’s annual Minimum Data Set (MDS-a federally mandated
assessment tool required to be completed by facility staff for care planning), dated
12/8/18, showed:
-The resident was cognitively intact;
-A PASARR was not completed for the resident.
Record review of the resident’s Care Plan, dated 1/19/18, showed the resident:
-Had a [DIAGNOSES REDACTED].
-Needed medications for his/her mood and anxiety;
-Manifested his/her condition through tearfulness, anger, anxiety, manipulation, feelings
of hopelessness and negative thinking.
Record review of the resident’s Geriatric Psychiatric Services assessment dated [DATE]
showed the resident:
-Had a [DIAGNOSES REDACTED].
-Had an increase in behaviors and paranoia;
-Made medication changes and discussed this with the resident’s legal guardian.
Record review of the resident’s medical record on 1/27/19 at 5:12 P.M., showed no record
of a PASARR.
During an interview on 1/30/19 at 9:47 A.M., the Social Services Designee (SSD) said:
-The resident came from another facility;
-He/She did not think a resident needed a PASARR if they had come from another facility.
During an interview on 1/30/19 at 12:02 P.M., the SSD said:
-The DA124 usually was done in the hospital, but the resident came to the facility from a
previous facility after a hospital stay;
-Normally, if a new resident was admitted to the facility, he/she obtained the Level I and
then would go further to request a Level 2 if needed;
-If the resident came from another facility, he/she utilized the exiting DA124;
-He/She did not obtain one for this resident upon admission, but should have.
During a telephone interview on 1/31/19 at 10:50 A.M., DHSS (Central Office Medical Review
Unit) COMRU Employee A said:
-The facility was responsible for obtaining the PASARR DA124 upon admission to determine
if the resident had or needed a Level II;
-This was needed to determine if a specialized plan of care was required for the resident;
and
-Resident #14 had a Level I assessment in 2007 and did not require a Level II.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a Bed
Rail Care Plan was developed for three sampled resident’s (Resident #47, #7, and #25) out
of 12 sampled residents. The facility census was 46 residents.
1. Record review of Resident #47’s Face Sheet showed the resident was admitted to the
facility on [DATE] and last readmitted on [DATE] and had a [DIAGNOSES REDACTED]. A person
is considered morbidly obsess if 100 pounds or more over their ideal weight or has a Body
Mass Index (BMI – A measurement of body fat based on height and weight of 40 or more).
Record review of the resident’s Bed Rail/Assist Bar Evaluations, completed 3/7/18 and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
1/21/19, showed the resident had poor balance and trunk control due to his/her body size
and used bed rails or assist bars for positioning and support.
Record review of the resident’s comprehensive Care Plan, dated 1/24/19, showed:
-The resident had an Activity of Daily Living (ADL) Care Plan showing he/she required
quarter ( ¼) assist rails to aid in transfers;
-There was no Bed Rail Care Plan showing the resident needed the rails for positioning,
the number of bed rails needed or any risks associated with having bed rails.
Observations of the resident lying in his/her bed showed the resident had one-half side
rails in use on both sides of his/her bed on the following dates and times:
-1/27/19 at 10:15 A.M.;
-1/27/19 at 12:28 P.M.;
-1/29/19 at 12:42 P.M.;
-1/30/19 at 11:35 A.M.;
-1/31/19 at 9:59 A.M.
During an interview on 2/1/19 at 9:42 A.M., the Minimum Data Set (MDS – a federally
mandated assessment tool completed by facility staff for scare planning) Coordinator
acknowledged the resident did not have a Bed Rail Care Plan that showed the resident
required bed rails for positioning, the number of bedrails needed or any risks related to
the bed rails.
2. Record review of Resident #7’s Face Sheet showed he/she was admitted to the facility on
[DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s Bed Rail/Assist Bar Evaluations completed on 6/7/18
showed:
-The resident did not use bed rails for positioning or support or to rise from a supine
(lying) to a sitting position;
-1/2 bed rails were to be used on the right and left sides of the resident’s bed.
Record review of the resident’s comprehensive Care Plan, revised 11/13/18 showed there was
no Bed Rail Care Plan showing the number and type of rails the resident needed, why the
resident needed the rails and any associated risks.
Observations of the resident lying in his/her bed showed the resident had side rails in
use on both sides of his/her bed on the following dates and times:
-1/27/19 at 11:07 A.M.;
-1/27/19 at 1:03 P.M.;
-1/27/19 at 2:29 P.M.
-1/30/19 at 11:04 A.M.;
-1/31/19 at 9:29 A.M.
During an interview on 2/1/19 at 9:42 A.M., the MDS Coordinator said he/she could not find
a Bed Rail Care Plan for the resident.
3. Record review of Resident #25’s Face Sheet showed the resident was admitted to the
facility on [DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s Bed Rail/Assist Bar Evaluations, completed on 9/27/18,
showed the resident requested 1/2 side rails to assist with mobility.
Record review of the resident’s Comprehensive Care Plan, dated 10/19/18, showed no Side
Rail Care Plan showing the need for the bed rails and any associated risks related to bed
rail use.
Observations of the resident lying in his/her bed showed the resident had 1/2 side rails
in use on both sides of his/her bed on the following dates and times:
-1/27/19 at 11:10 A.M.;
-1/27/19 at 8:10 P.M.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
-1/30/19 at 11:34 A.M.;
-1/31/19 at 9:29 A.M.
During an interview on 2/1/19 at 9:42 A.M., the MDS Coordinator said he/she could not find
a Bed Rail Care Plan for the resident.
4. During an interview on 2/1/19 at 9:42 A.M., the MDS Coordinator said:
-Nursing or Therapy verbally communicated resident needs such as bed rails in morning
meetings and as needed and he/she incorporated the information into resident Care Plans.
During an interview on 2/1/19 at 11:00 A.M. the Director of Nursing (DON) said:
-A comprehensive Care Plan should include all needs and cares of the resident such as
Activities of Daily Living (ADLs – eating, grooming, toileting, and dressing), transfers,
diets, medical needs, and bed rail use;
-Nursing and Therapy should discuss the need for side rails and Therapy should determine
what the resident needs;
-The resident’s needs should be assessed quarterly and the resident’s Care Plan updated
quarterly and as needed with changes in the resident’s care requirements.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to update a care plan to reflect
the resident’s current status for two sampled residents (Residents #8 and #20) out of 12
sampled residents. The facility census was 46 residents.
1. Record review of Resident #8’s face sheet showed he/she re-admitted to the facility on
[DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s Significant Change Minimum Data Set (MDS a federally
mandated assessment tool to be completed by the facility staff for care planning), dated
11/9/18, showed the resident:
-Had a Brief Interview of Mental Status (BIMS) score of 13 that indicated he/she was
cognitively intact;
-Was totally dependent on one staff member for toileting;
-Had an indwelling catheter (a tube inserted into the bladder to remove urine).
Record review of the resident’s indwelling catheter care plan, dated 11/14/18, showed the
resident had an indwelling catheter in place for [MEDICAL CONDITION]. Further review of
the resident’s care plan showed it had not been updated.
Record review of the resident’s Physician order [REDACTED].
2. Record review of Resident #20’s face sheet showed he/she admitted to the facility on
[DATE] with [DIAGNOSES REDACTED].>-[MEDICATION NAME] (inflammation of the urinary
bladder);
-[DIAGNOSES REDACTED] (inflammation of bone or bone marrow, usually due to infection).
Record review of the resident’s Admission MDS, dated [DATE], showed the resident:
-Had a BIMS score of 13 indicating he/she was cognitively intact;
-Had an indwelling catheter in place.
Record review of the resident’s indwelling catheter care plan, dated 7/6/18, showed:
-The resident had an indwelling catheter in place;
-The care plan had not been updated.
Record review of the resident’s quarterly MDS, dated [DATE], showed the resident:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
-Had a BIMS score of 14 indicating he/she was cognitively intact;
-Did not have an indwelling catheter.
Record review of the resident’s quarterly MDS, dated [DATE], showed the resident:
-Had a BIMS score of 15 indicating he/she was cognitively intact.
-Did not have an indwelling catheter.
Record review of the resident’s POS, dated 12/26/18, showed the resident:
-Had an order for [REDACTED].>-Had an order for [REDACTED].
Record review of the resident’s care plans showed the resident did not have a care plan
for the IV antibiotic.
3. During an interview on 1/30/19 at 9:17 A.M., the Director of Nursing (DON) said:
-He/She expected care plans to be updated any time there was a change;
-Licensed nurse’s, the Assistant Director of Nursing (ADON), the MDS Coordinator, and
himself/herself could update care plans;
-Resident #8 should not have had the indwelling catheter care plan in his/her chart since
the catheter had been discontinued;
-Resident #20 should have had an IV antibiotic care plan;
-Resident #20 should have had an indwelling catheter care plan.
During an interview on 2/1/19 at 9:56 A.M., the MDS Coordinator said:
-He/She read the nurse’s notes to obtain information;
-When he/she was made aware of changes, he/she would update/discontinue care plans;
-He/She was not aware the Resident #8 had the catheter discontinued;
-Resident #8 did not have a catheter and still had the catheter care plan in his/her
medical record;
-He/she did not develop or implement an IV antibiotic care plan for Resident #20;
-He/She did not update the catheter care plan for Resident #20.

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure heel
float boots (an air cavity for zero pressure while providing air circulation to aid
healing of existing ulcers) were placed on one sampled resident (Resident #36) out of 12
sampled residents, who had existing pressure ulcers (localized injury to the skin and/or
underlying tissue usually over a bony prominence, as a result of pressure, or pressure in
combination with shear and/or friction) to his/her heels. The facility census was 46
residents.
Record review of the facility’s Wound and Skin Care Policy, revised 2/1/2011, showed:
-The purpose was to prevent pressure ulcer formation and to develop appropriate
interventions;
-To promote a systematic approach and monitoring process for the care of residents with
existing pressure ulcers and those who are at risk for pressure ulcers;
–The policy did not have specific interventions listed to aid in the healing of pressure
ulcers.
1. Record review of Resident #36’s Face Sheet showed the resident was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Muscle weakness.
Record review of the resident’s care plan, dated 11/5/18, showed the resident:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
-Had the potential for skin integrity related to decreased mobility and incontinence;
-Updated on 11/24/18: Pressure reduction boot to the right foot while in bed;
-Updated on 1/17/19: Pressure reduction boot to the right foot while in bed.
Record review of the resident’s Nurses Notes, dated 1/24/19, showed the resident had an
unstageable pressure ulcer to his/her left heel.
Record review of the resident’s quarterly Minimum Data Set (MDS – a federally mandated
assessment tool required to be completed by the facility staff for care planning) dated
1/9/19, showed the resident:
-Was moderately cognitively impaired;
-Needed the extensive assistance of two staff members for transfers;
-Had one unstageable pressure ulcer (Full thickness tissue loss in which the base of the
ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown
or black) in the wound bed).
Record review of the resident’s physician’s orders [REDACTED].
Record review of the resident’s Treatment Administration Record (TAR), dated 1/24/19,
showed the following physician’s orders [REDACTED].>-Protective boots on the resident’s
bilateral lower extremities at all times;
–This was documented as not being completed three times out of ten times from 1/24/19
through 1/28/19.
Observation on 1/29/19 at 8:38 A.M., showed:
-The resident was in the common area in his/her wheelchair;
-The resident had on yellow slipper socks and his/her feet/heels were on the floor.
Observation on 1/29/19 at 10:15 A.M., showed:
-The resident was in his/her wheelchair in his/her room;
-The resident had on yellow slipper socks and his/her feet/heels were on the floor.
During an interview on 1/29/19 at 10:25 A.M., the resident said:
-The staff did not keep his/her heel float boots on at all times;
-The staff had trouble locating the heel float boots sometimes.
Observation on 1/29/19 at 12:30 P.M., showed:
-The resident was in his/her wheelchair in the dining room;
-The resident had on yellow slipper socks and his/her feet/heels were on the floor.
Observation of the resident’s room on 1/29/19 at 12:32 P.M., showed:
-There was one light blue heel float boot on the floor by the resident’s bed;
-No other heel float boot was observed.
Observation on 1/29/19 at 12:57 P.M., showed:
-The resident was in his/her wheelchair in the dining room;
-A staff member assisted the resident out of the dining room;
-The resident had yellow slipper socks on;
-The staff member pushed the resident’s wheelchair from the dining room to the nurses
station;
-The resident’s feet/heels were both flat on the floor and glided over the floor while
being pushed in his/her wheelchair;
-The resident continued down the hall using his/her feet and hands to self-propel down the
hall.
During an interview on 1/31/19 at 9:49 A.M., Certified Nurses Assistant (CNA) A said:
-The resident had wounds on his/her heels;
-The resident had blue boots that float the heels;
-The resident should have his/her boots on at all times when up in his/her wheelchair;
-The resident should also have his/her boots on when lying in bed;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
-This was to ensure the resident’s heel wounds do not worse.
During an interview on 1/31/19 at 9:54 A.M., CNA F said:
-The resident had wounds on both of his/her feet and one was a recent wound;
-The resident needed to have his/her boots on at all times when up and when in bed.
During an interview on 1/31/19 at 1:01 P.M. LPN A said:
-The resident had heel wounds on both heels and the left heel wound was new;
-He/She should have protective boots on at all times;
-This should be documented on the TAR;
-The CNAs should not be pushing the resident in his/her wheelchair without boots on and
should have wheelchair foot rests;
-The resident’s feet should not be touching the floor and should always have boots on.
During an interview on 1/31/19 at 1:42 P.M., LPN B said:
-If the resident’s heel float boots were not on, he/she expected the CNAs to put the boots
on the resident;
-The CNAs were responsible for ensuring the resident’s boots were on his/her feet;
-On 1/29/19, he/she noticed later in the day the boots were not on the resident;
-He/She had been unable to locate the resident’s heel float boots;
-Not all staff knew the resident had heel float boots;
-The resident’s heels should not be touching the floor and not be gliding on the floor
when being pushed by staff in his/her wheelchair.
During an interview on 2/1/19 at 11:00 A.M., the Director of Nursing (DON) said:
-The resident had heel lift boots and he/she expected the staff, nurses and CNAs, to
ensure the boots were on at all times;
-The resident tended to slide his/her feet on the floor;
-The boots were used to prevent further damage to the resident’s heels and to aide in
healing.

F 0689

Level of harm – Immediate jeopardy

Residents Affected – Some

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure the
resident environment was free of accident hazards by not maintaining water temperatures
between 105 degrees Fahrenheit (F) to 120 degrees F in occupied resident room sinks and
community bathhouses, which put the residents at increased risk [MEDICAL CONDITION] by
scalding; failed to respond to reports of out of range/fluctuating water temperatures and
investigate the causes; and failed to have a policy in place for maintaining safe water
temperatures. This had the potential to affect the residents residing on the 100, 500 and
600 halls. The facility also failed to transfer one sampled resident (Resident #36) out of
12 sampled residents in a safe manner. The facility census was 46.
Record review of the Burn Foundation website, www.burnfoundation.org, showed the
following:
-Hot Water Causes Third [MEDICAL CONDITION](full [MEDICAL CONDITION] go through the skin
and affect deeper tissue resulting in white or blackened, charred skin) .
— .in 1 second at 156 degrees F;
— .in 2 seconds at 149 degrees F;
— .in 5 seconds at 140 degrees F;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0689

Level of harm – Immediate jeopardy

Residents Affected – Some

(continued… from page 18)
— .in 15 seconds at 133 degrees F.
1. Record review of the Hot Water Temps facility log completed by the Maintenance Director
dated 9/2018, 10/2018, 11/2018, 12/2018 and 1/2019 showed:
-For the dates of 9/5/18, 9/15/18, 9/20/18, 9/26/18, 10/4/18, 10/9/18, 10/17/18, 10/23/18,
10/30/18, 11/6/18, 11/14/18, 11/20/18, 11/19/18, 12/5/18, 12/13/18, 12/20/18, 12/28/18,
1/2/19, 1/10/19, and 1/16/19:
–Two rooms on each hall (100, 200, 300, 400, 500 and 600 halls) had water temperature
checks and were documented to be in a safe range between 105 degrees F to 120 degrees F;
–There was no documentation that showed the community bathhouses had water temperature
checks.
Observation on 1/27/19 at 10:43 A.M., showed the following water temperatures taken by the
surveyor:
-In room [ROOM NUMBER], the sink temperature measured 126.5 degrees F;
-In room [ROOM NUMBER], the sink temperature measured 126.2 degrees F.
Observation on 1/27/19 at 11:07 A.M., showed the following water temperatures taken by the
surveyor:
-In room [ROOM NUMBER], the sink temperature measured 130.0 degrees F;
-In room [ROOM NUMBER], the sink temperature measured 127.9 degrees F;
-In room [ROOM NUMBER], the sink temperature measured 129.4 degrees F;
-In room [ROOM NUMBER], the sink temperature measured 126.6 degrees F.
Observation on 1/27/19 at 11:10 A.M., showed the following water temperatures taken by the
surveyor:
-In room [ROOM NUMBER], the sink temperature measured 123.4 degrees F;
-In room [ROOM NUMBER], the sink temperature measured 124.6 degrees F;
-In room [ROOM NUMBER], the sink temperature measured 123.0 degrees F;
-In room [ROOM NUMBER], the sink temperature measured 123.6 degrees F.
During an interview on 1/27/19 at 11:05 A.M., Certified Nurses Assistant (CNA) B said:
-The water temperatures in the sinks on the 100 hall did get hot at times, but then the
temperature would go down;
-He/she had noticed the water temperature was hot a few times, but that was not normal.
During an interview on 1/27/19 at 11:06 A.M., Licensed Practical Nurse (LPN) D said:
-He/she had not noticed any hot water issues where water can be too hot;
-The resident in room [ROOM NUMBER] was cognitively impaired and could use his/her sink
independently;
-He/she was not aware if water temperatures were monitored.
During an interview on 1/27/19 at 11:24 A.M., the Maintenance Director said:
-He/she checked the water temperatures on the halls weekly;
-He/she checked the temperatures in the resident room sinks;
-He/she checked the resident room the furthest away from the hot water heater and both
sides of the hallway closest to the hot water heater on all of the halls.
Observation on 1/27/19 at 12:28 P.M., showed the water temperatures taken by the surveyor
in room [ROOM NUMBER] was 135.5 degrees F at the sink.
During an interview on 1/27/19 at 12:29 P.M., Resident #47 said when he/she washed his/her
hands, the hot water tap at first feels warm and then it gets hotter and he/she adds cold
water to the hot.
Observation on 1/27/19 at 12:40 P.M., the water temperatures were:
-room [ROOM NUMBER], the sink was 122.9 degrees F;
-room [ROOM NUMBER], sink was 120.3 degrees F and
-The 100/300 hall community bath house sink was 143.1 degrees F.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0689

Level of harm – Immediate jeopardy

Residents Affected – Some

(continued… from page 19)
During an interview on 1/27/19 at 12:46 P.M., Certified Medication Technician (CMT) A
said:
-He/she had not noticed hot water temperatures on the 500 hall;
-None of the residents had complained of hot water temperatures on the hall;
-He/she was unaware of any hot water issues at the facility and
-He/she would report any hot water issues to the Maintenance Director or the charge nurse.
During an interview on 1/27/19 at 12:48 P.M., LPN E said:
-He/she had not noticed hot water temperatures on the 500 hall;
-None of the residents had said there were issues of hot water temperatures on the hall;
-He/she was unaware of any hot water issues at the facility and
-He/she would report any hot water issues to the Maintenance Director.
Observation on 1/27/19 starting at 12:49 P.M. showed the following water temperatures
taken by the surveyor:
-In room [ROOM NUMBER], the sink was 124.4 degrees F;
-In room [ROOM NUMBER], the sink was 123.3 degrees F;
-In room [ROOM NUMBER], the sink was 124.7 degrees F and
-In room [ROOM NUMBER], the sink was 124.2 degrees F.
During an interview on 1/27/19 at 12:51 P.M. LPN D said:
-Residents from the 100 & 300 halls take showers in the community shower/bath house
and
-He/she has not received complaints of the water being too hot.
During an interview on 1/27/19 at 12:58 P.M., the Director of Nursing (DON) said the
facility did not have a written policy on how often to check water temperatures.
Observation on 1/27/19 at 1:16 P.M. showed:
-The Maintenance Director and surveyor completed rounds for water temperatures throughout
the building;
-The water temperatures were taken by the Maintenance Director and by the surveyor;
-The water temperatures were as follows as taken by the Maintenance Director:
–In room [ROOM NUMBER], the sink was 123.6 degrees F and the shower was 122.5 degrees F;
–In room [ROOM NUMBER], the sink was 124.5 degrees F and the shower was 124.5 degrees F;
–In the bathhouse on 500 hall: the sink was 106 F to 118 F and the temperature kept
fluctuating; the shower was 122.3 degrees F;
–In room [ROOM NUMBER], the sink was 123.2 degrees F;
–In room [ROOM NUMBER], the sink was 124.3 degrees F;
–In room [ROOM NUMBER], the sink was 123.5 degrees F;
–In room [ROOM NUMBER], the sink was 123.4 degrees F;
–In the bathhouse on 600 hall: the sink was 129.4 F and the shower was 130.8 F;
–In room [ROOM NUMBER], the sink was 140.2 degrees F;
–In room [ROOM NUMBER], the sink was 138.6 degrees F;
–In room [ROOM NUMBER], the sink was 138.7 degrees F;
–In room [ROOM NUMBER], the sink was 136.7 degrees F;
–In room [ROOM NUMBER], the sink was 135.2 degrees F and
-During the above observations, the water temperatures would fluctuate from hot to cold.
During an interview on 1/27/19 at 1:16 P.M., while taking the above temperatures, the
Maintenance Director said:
-He/she would check the water temperatures on the halls weekly and sometimes more than
weekly;
-The facility had re-circulator water pumps;
-The facility had chemical dispensers and this could change the water temperatures and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0689

Level of harm – Immediate jeopardy

Residents Affected – Some

(continued… from page 20)
make the temperatures jump up;
-He/she had battled the water heaters since he/she had been employed here;
-He/she had been here for about three months;
-He/she had brought the issues up in the Interdisciplinary Team Meeting (IDT) meetings in
the morning to the Administrator, the DON, and the Assistant Director of Nursing (ADON);
-During the daily IDT meetings, he/she had stated the water temperatures were too hot and
too cold and he/she was having trouble maintaining the water temperatures;
-He/she expressed the water temperature issues all of the time but nothing was done by
administration;
-The water temperatures should be maintained between 105 degrees F and 120 degrees F;
-The water temperatures could cause injury to a resident by scalding the resident;
-He/she had taken temperatures during the last three months and had temperatures on the
halls at 138 degrees F;
-He/she would adjust the water heater then write on the temperature log the temperature
when he/she got the temperature in a safe range;
-He/she did not write down high or low water temperatures on the weekly log or what he/she
did to try to correct the water temperatures and
-He/she made adjustments all of the time because he/she could not maintain a safe water
temperature on the halls.
During an interview on 1/27/19 at 1:22 P.M. CMT A said:
-He/she normally used hand sanitizer rather than washing his/her hands at resident sinks;
-He/she had never noticed the residents’ water was too hot unless it was turned on full
blast on 600 hall;
-He/she always added cold water to the hot and
-If he/she noticed the water scalding hot he/she would report it to the Maintenance
Director.
Observation on 1/27/19 at 2:11 P.M. showed the following water temperatures taken by the
surveyor:
-In room [ROOM NUMBER], the sink was 134 degrees F;
-In room [ROOM NUMBER], the sink was 132.8 degrees F;
-In room [ROOM NUMBER], the sink was 131 degrees F and
-In room [ROOM NUMBER], the sink was 132 F.
During an interview on 1/27/19 at 1:31 P.M. CNA C said:
-He/she worked as needed, usually 16 hours per week;
-No resident had ever complained to him/her about water temperatures and
-If he/she noticed the water was so hot he/she couldn’t stand it he/she would report it to
the Maintenance Director.
During an interview on 1/29/19 at 11:29 A.M. CNA A said if a resident complained about hot
water, he/she would tell the charge nurse.
During an interview on 1/31/19 at 8:57 A.M. LPN A said:
-CNAs should let the charge nurse know of any complaints about water temperatures and
-He/she has not received notification of the water being too hot.
During an interview on 1/27/19 at 2:15 P.M., the DON said:
-He/she had been told by the Maintenance Director about water temperature issues;
-During the IDT team morning meeting, the Maintenance Director said the water temperatures
were too high on the 600 hall;
-The Maintenance Director took care of the hot water temperature issues;
-He/she did not really pay attention to the water temperature issues because the
Maintenance Director was handling it;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0689

Level of harm – Immediate jeopardy

Residents Affected – Some

(continued… from page 21)
-He/she would pay more attention to care issues during the meetings and
-The Maintenance Director stated he/she was doing micro adjustments to the water
temperatures to fine tune them.
During an interview on 1/27/19 at 3:08 P.M. the ADON said:
-On a daily basis during the IDT meeting, the Maintenance Director would talk about
needing to adjust the water temperatures;
-The Maintenance Director had trouble maintaining temperatures in range on different halls
in the facility;
-The Maintenance Director had found the water temperatures out of range and had to adjust
them;
-The Maintenance Director would bring the issue up about the water temperatures two to
three times per week.
During an interview on 1/28/19 at 11:08 A.M., the Regional Director of Operations said:
-Monitoring was expected weekly by the Maintenance Director and all staff should watch for
hot water temperatures;
-He/she expected the staff to report discrepancies in temperatures to the Administrator;
-The Maintenance Director should be checking temperatures in bath houses also;
-He/she expected the Maintenance Director to log the correct high temperatures on the log,
bring it to the attention of the Administrator, and try to correct the hot water issue;
-If brought to the attention of the Administrator, he/she should have acted upon the
issues.
During an interview on 2/1/19 at 8:29 A.M., the Administrator said:
-Issues were brought to his/her attention daily in the IDT meeting;
-The hot water heater had recently been replaced on the 400 hall;
-The Maintenance Director had only brought cold water temperatures to his/her attention in
the IDT meetings;
-He/she had reviewed the water temperature logs and no water temperatures were out of
range;
-The Maintenance Director should have been documenting the actual temperatures on the
logs, not the corrected temperatures.
2. Record review of Resident #36’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Muscle weakness.
Record review of the resident’s Care Plan dated 11/6/18 showed he/she required transfers
to be completed with a sit-to-stand lift (a mechanical lift used to assist residents when
they were unable to transition from a sitting position to a standing position on their
own).
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool required to be completed by the facility staff for care planning) dated
1/9/19 showed he/she:
-Was moderately cognitively impaired;
-Needed the extensive assistance of two staff members with the sit-to-stand lift for
transfers.
Observation on 1/29/19 at 10:15 A.M., showed:
-CNA D and CNA E transferred the resident from his/her wheelchair to the toilet;
-The resident was placed in the sit-to-stand lift;
-The belt buckle and Velcro were not properly secured around the resident;
-The belt was under the resident’s arm pits, which made the resident’s shoulders go upward
during the transfer;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0689

Level of harm – Immediate jeopardy

Residents Affected – Some

(continued… from page 22)
-The resident hung from the straps that were under his/her shoulders;
-The clasp of the belt buckle was broken;
-The Velcro did not attach due to wear;
-The transfer was completed for the resident;
-A second sit-to-stand sling in good repair was in the resident’s room.
During an interview on 1/29/19 at 11:00 A.M.:
-CNA D said the resident’s lift belt had been broken for at least one year;
-CNA E said the resident’s lift belt had been broken since he/she started at the facility
about three months ago;
-If a lift belt was broken it should be reported to the charge nurse or Maintenance
Director;
-CNA D and CNA E had not reported the lift belt was broken to the charge nurse or
Maintenance Director.
During an interview on 1/31/19 at 1:01 P.M., LPN A said:
-He/she was not aware of the sit-to-stand lift being in poor repair;
-He/she expected the CNAs to bring this to nurses’ attention if the lift belts were in bad
repair;
-He/she expected the CNAs not to perform a transfer with buckles and straps in poor
repair;
-The CNAs should not complete a transfer with a broken lift belt;
-This could cause damage to the resident’s shoulders.
During an interview on 1/31/19 at 1:42 P.M., LPN B said:
-He/she was not aware of the sit-to-stand lift being in poor repair;
-The CNAs had not reported any issues, but should report equipment in poor repair to the
charge nurse;
-He/she expected the CNAs to not continue a transfer with a resident when the lift belt
was broken.
During an interview on 2/1/19 at 11:00 A.M., the DON said:
-If a lift was in poor repair, he/she expected the staff not to use the lift on the
resident;
-He/she expected the staff to take the sit-to-stand lift out of service and add it to the
maintenance log;
-He/she expected the staff to obtain another lift belt and not use one in poor repair that
would not buckle;
-The staff should not have used the bad sling and held the resident up by his/her arms.
NOTE: At the time of the survey, the violation was determined to be at an imminent danger
Immediate Jeopardy K level. Based on observation, interview and record review completed
during the onsite visit, it was determined the facility had implemented corrective action
to address and lower the violation at the time. During the onsite visit, the facility
began immediately training the staff on the hot water notification process, had a company
come to the facility to reset and repair/replace the hot water tanks, implemented an
on-going water temperature monitoring system to ensure safe temperatures of the water by
the Maintenance Director, which included notification of any out of range temperatures to
the facility’s Regional Manager. A 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 E level.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure complete
physician’s orders for [MEDICAL TREATMENT] (process of cleansing the blood by passing it
through a special machine – necessary when the kidneys are not able to filter the blood)
and failed to ensure an effective communication system between the [MEDICAL TREATMENT]
clinic and the facility for one sampled resident (Resident #46) out of 12 sampled
residents. The facility census was 46 residents.
Record review of the facility’s [MEDICAL TREATMENT] policy, revised 2/1/11, showed:
-The policy did not include information related to the [MEDICAL TREATMENT] Communication
Sheet or how often to monitor the resident.
1. Record review of Resident #46’s Face Sheet showed the resident was admitted to the
facility on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s Physician’s Orders Sheet (POS), dated 1/14/19, showed the
following physician’s orders:
-[MEDICAL TREATMENT]: Tuesday, Thursday, and Saturday at 10:45 A.M.;
-There were no physician’s orders that showed how often to monitor the resident’s fistula
(a creation of a vascular communication by suturing a vein directly to an artery) or how
often to check the resident’s bruit (turbulent blood flow through the blood vessel) and
thrill (a vibration felt in the blood vessel).
Record review of the resident’s admission care plan, dated 1/14/19, showed:
-The resident required [MEDICAL TREATMENT] three times per week;
-The staff were to check the resident’s bruit and thrill at the fistula site each shift
and as needed;
-Observe the fistula site upon return from [MEDICAL TREATMENT] for bleeding;
-Observe and report signs of localized infections at the fistula site;
-Report any adverse signs to the physician.
Record review of the resident’s Treatment Administration Record (TAR), dated 1/14/19,
showed there was no record the resident’s fistula was being monitored.
Record review of the resident’s [MEDICAL TREATMENT] Communication Sheets showed:
-On 1/15/19, 1/20/19 and 1/22/19, there was no documentation from the facility nurse that
showed the resident’s fistula was checked for signs of bleeding upon return from [MEDICAL
TREATMENT];
-There were no [MEDICAL TREATMENT] Communication Sheets for 1/17/19, 1/24/19, and 1/27/19.
Observation on 1/29/19 at 8:52 A.M., showed the resident had a fistula in the right upper,
inner arm with no redness.
During an interview on 1/29/19 at 9:24 A.M., Licensed Practical Nurse (LPN) C said:
-There were no physician’s order for bruit and thrill or how often to monitor the fistula
site;
-He/She would check the bruit and thrill then would document it in the nurses notes when
he/she was working;
-The nurses were responsible for obtaining physician’s orders so all nurses know to check
the thrill, bruit and monitor the fistula site.
During an interview on 1/31/19 at 9:04 A.M., the Assistant Director of Nursing (ADON)
said:
-The nurses were responsible for sending the [MEDICAL TREATMENT] Communication Sheet with
the resident to [MEDICAL TREATMENT];
-The resident brought it back from [MEDICAL TREATMENT] and the nurse was responsible for
reviewing the information and weights;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 24)
-If there were any issues with the weights the nurses were responsible for notifying ADON;
-The [MEDICAL TREATMENT] Communication Sheets for 1/17/19, 1/24/19, and 1/27/19 were not
located;
-The nurses were responsible for obtaining physician’s orders to check the thrill, bruit
and monitor the fistula site.
During an interview on 1/31/19 at 1:01 P.M., LPN A said:
-The nurses were responsible to obtain physician’s orders for monitoring the site for
bleeding and how often to check the thrill and bruit;
-The nurses would send a [MEDICAL TREATMENT] Communication Sheet every time they go to
[MEDICAL TREATMENT];
-Most of the time the resident would bring the form back;
-He/She reviewed the communication form to ensure weights were consistent and if any
issues arose with [MEDICAL TREATMENT],
-He/She would check the dressing/fistula upon return of the resident from [MEDICAL
TREATMENT]; and
-The bottom of the [MEDICAL TREATMENT] Communication Sheet had an area to document the
condition of the fistula/dressing site when the resident came back from [MEDICAL
TREATMENT] and the nurses were responsible for completing this part of the form.
During an interview on 1/31/19 at 1:42 P.M., LPN B said:
-The nurses were responsible to obtain physician’s orders for monitoring the site for
bleeding and how often to check the thrill and bruit;
-This should be monitored and documented on the resident’s TAR;
-The nurses would send a [MEDICAL TREATMENT] Communication Sheet with the resident to the
[MEDICAL TREATMENT] clinic;
-Upon return, he/she would review the resident’s weights and ensure there were no issues
with [MEDICAL TREATMENT];
-He/She was unaware he/she was supposed to check the fistula/dressing site upon return and
document this on the [MEDICAL TREATMENT] Communication Sheet.
During an interview on 2/1/19 at 11:00 A.M., the (Director of Nursing) DON said:
-The nurses were responsible for filling out the [MEDICAL TREATMENT] sheets and sending it
with the resident to [MEDICAL TREATMENT];
-The facility rarely got the [MEDICAL TREATMENT] communication sheet back from the
[MEDICAL TREATMENT] clinic;
-He/She expected the nurses to the check the dressing site and document the assessment on
the [MEDICAL TREATMENT] Communication Sheet;
-The [MEDICAL TREATMENT] Communication Sheet were used to get the resident’s weights or
anything significant that happened at [MEDICAL TREATMENT];
-Usually the form would come back blank from the [MEDICAL TREATMENT] clinic;
-He/She expected the charge nurse to obtain the orders for [MEDICAL TREATMENT], how often
to check the thrill and bruit and how often to check the fistula site.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Try different approaches before using a bed rail. If a bed rail is needed, the
facility must (1) assess a resident for safety risk; (2) review these risks and benefits
with the resident/representative; (3) get informed consent; and (4) Correctly install and
maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
Based on observation, interview, and record review, the facility failed to assess
appropriateness of side rail use for residents on a quarterly basis and obtain informed
consent, to include showing alternates attempted that failed to meet resident needs prior
to the use of side rails for four residents (Residents #47, #7, #25, and #6) out of 12
sampled residents. The facility census was 46 residents.
The facility did not have a policy on the use of side rails.
1. Record review of Resident #47’s Face Sheet showed the resident was admitted to the
facility on [DATE] and last readmitted on [DATE] and had a [DIAGNOSES REDACTED]. A person
is considered morbidly obsess if 100 pounds or more over their ideal weight or has a Body
Mass Index (BMI – A measurement of body fat based on height and weight of 40 or more).
Record review of the resident’s Bed Rail/Assist Bar Evaluations completed within the past
twelve months showed:
-The resident was assessed for bed rail and/or assist bar use on 3/7/18 and 1/21/19 with
the following findings:
–The resident had never expressed a desire to have a bed rail or assist bar for his/her
safety or comfort;
–The 3/7/18 assessment showed a history of falls and the rails/assist bars helped the
resident rise to a sitting and/or standing position. The 1/21/19 assessment showed no
history of falls and the rails/assist bars were not used to help the resident sit or
stand;
–The resident had poor balance and trunk control due to his/her body size and used the
rails or assist bars for positioning and support;
–The resident was on medication which could pose safety risks;
–The form did not comprehensively show specific risks for entrapment, the number and type
of bed rails or assist bars recommended and alternates attempted prior to the use of the
bed rails or assist bars. Additionally, there was no documentation that risks and benefits
of side rail use and appropriate alternates were discussed with the resident.
Record review of the resident’s Physician order [REDACTED].
Record review of the resident’s Quarterly Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning purposes), dated
1/22/19, showed the resident:
-Was cognitively intact;
-Was totally dependent upon staff and required two or more staff for transfers (moving
from one surface such as a bed to another surface such as a wheelchair);
-Required two-person extensive assistance with bed mobility.
Record review of the resident’s comprehensive Care Plan, dated 1/24/19, showed:
-The resident had an Activities of Daily Living (ADL) Care Plan showing he/she required
quarter (¼ ) assist rails to aid in transfers;
-There was no Bed Rail Care Plan showing the resident needed the rail for positioning, the
number of bed rails needed or any risks associated with having bed rails.
Observations of the resident lying in his/her bed showed the resident had one-half (1/2)
side rails in use on both sides of his/her bed on the following dates and times:
-1/27/19 at 10:15 A.M.;
-1/27/19 at 12:28 P.M.;
-1/29/19 at 12:42 P.M.;
-1/30/19 at 11:35 A.M.; and
-1/31/19 at 9:59 A.M.
During an interview on 1/30/19 at 9:03 A.M. the Director of Therapy/Physical Therapist
Assistant (PTA) said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
-Therapy was working with the resident on upper and lower strengthening exercises that
he/she can learn to do independently, bed mobility and positioning;
-Therapy had not made a recommendation for the one-half bed rails which might have come
with the bed.
2. Record review of Resident #7’s Face Sheet showed he/she was admitted to the facility on
[DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s Bed Rail/Assist Bar Evaluations completed within the past
twelve months showed:
– The resident was assessed for bed rail and/or assist bar use on 6/7/18 with the
following findings:
–The resident had never expressed a desire to have a bed rail or assist bar for his/her
safety or comfort;
–The resident had fluctuations in consciousness or cognition and poor balance or trunk
control due to Cerebral-vascular Accident ([MEDICAL CONDITION] – a stroke);
–At the time of the assessment the resident was considered severely cognitively impaired;

–The resident did not use bed rails for positioning or support or to rise from a supine
(lying) to a sitting position;
–One-half bed rails were to be used on the right and left sides of the resident’s bed;
–The form did not show specific risks for entrapment and alternates attempted prior to
the use of the bed rails. Additionally, there was no documentation showing the resident or
his/her Durable Power of Attorney (a person established prior to incapacitation that acts
on behalf of the resident should the resident become unable to make decisions) was made
aware of the risks and benefits of using a one-half side rail and appropriate alternates
attempted prior to use.
Record review of the resident’s Significant Change MDS, dated [DATE], showed the resident:
-Was moderately cognitively impaired;
-Required one person extensive assistance for transfers and one person limited assistance
with bed mobility.
Record review of the resident’s comprehensive Care Plan, revised 11/13/18 showed there was
no Bed Rail Care Plan showing why the resident needed the rails and any risks associated
with having bed rails.
Record review of the resident’s POS for (MONTH) 2019, showed no orders related to bed
rails.
Observations of the resident lying in his/her bed showed the resident had side rails in
use on both sides of his/her bed on the following dates and times:
-1/27/19 at 11:07 A.M.;
-1/27/19 at 1:03 P.M.;
-1/27/19 at 2:29 P.M.
-1/30/19 at 11:04 A.M.; and
-1/31/19 at 9:29 A.M.
During an interview on 1/31/19 at 9:40 A.M., the Director of Therapy/PTA said:
-The resident leaned to the left;
-Therapy was working on passive (the therapist moves the joint) Range of Motion (ROM) on
the right side and active (the resident moves his/her own joints) ROM on the left, trunk
strength and hand therapy;
-Therapy had not assessed the resident for alternatives to side rails.
During an interview on 2/1/19 at 9:42 A.M., the MDS Coordinator said:
-Nursing verbally communicates needs such as bed rails in morning meetings and at other

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
times;
-He/She could not find a Bed Rail Care Plan for the resident.
3. Record review of the Resident #25’s Face Sheet showed the resident was admitted to the
facility on [DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s Bed Rail/Assist Bar Evaluations completed within the past
twelve months showed:
-The resident was assessed for bed rail and/or assist bar use once on 9/27/18 with the
following findings:
–The resident requested one-half side rails to assist with mobility;
–The resident had a history of [REDACTED].
–The form did not comprehensively show specific risks for entrapment and alternates
attempted prior to the use of the bed rails. Additionally, there was no documentation that
risks and benefits of side rail use and appropriate alternates were discussed with the
resident’s legal representative prior to use.
Record review of the resident’s Comprehensive Care Plan, dated 10/19/18, showed no Side
Rail Care Plan.
Record review of the resident’s Quarterly MDS, dated [DATE], showed:
-The resident was severely cognitively impaired;
-The resident was totally dependent on one person for bed mobility and did not transfer
out of bed.
Record review of the resident’s POS, dated (MONTH) 2019, showed no orders related to bed
rail use.
Observations of the resident lying in his/her bed showed the resident had one-half side
rails in use on both sides of his/her bed on the following dates and times:
-1/27/19 at 11:10 A.M.;
-1/27/19 at 8:10 P.M.;
-1/30/19 at 11:34 A.M.; and
-1/31/19 at 9:29 A.M.
During an interview on 1/30/19 at 1:10 P.M. Licensed Practical Nurse (LPN) A said:
-Nursing completed the bed rail assessments;
-Bedrail assessments should be completed for residents at the time of admission, upon
return from a hospital stay and quarterly;
-Bed rails are used when requested by the resident and/or their family or the physician,
and when Therapy made recommendations for bed rails;
-The facility explains risks of bed rail use to the resident and/or family verbally;
-The family doesn’t sign anything showing that risks and benefits of bed rail use were
explained or alternates attempted prior to the use of bed rails and does not receive
written information on risks and benefits of side rails use; and
-If an alternate to a bed rail or assist bar was attempted there would be a nursing note
describing what was attempted.
During an interview on 1/31/19 at 9:40 A.M. the Director of Therapy/PTA said the resident
refused therapy and Therapy had not assessed the resident for alternatives to side rails
During an interview on 2/1/19 at 9:42 A.M. the MDS Coordinator said he/she could not find
a Bed Rail Care Plan for the resident.
4. Record review of Resident #6’s face sheet showed he/she admitted to the facility on
[DATE] with [DIAGNOSES REDACTED].>-Difficulty in walking;
-Lack of coordination;
-Muscle weakness;
-History of falls;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
-Obesity.
Record review of the resident’s bed rail/assist bar evaluation, dated 8/4/18, showed:
-On 8/4/18 bed rails/assist bar was indicated and was to serve as an enabler to promote
independence with bed mobility;
-There was no other documentation showing the bed rail/assist bar evaluation had been
completed after 8/4/18.
Record review of the resident’s Physical Therapy Discharge Summary for services provided,
dated 8/7/18 to 9/13/18, showed the resident will safely perform bed mobility tasks with
stand by assist with the use of siderails in order to get in and out of bed.
Record review of the resident’s Significant Change MDS, dated [DATE], showed the resident:
-Had Brief Interview of Mental Status (BIMS) score of 8 indicating moderate cognitive
impairment;
-Was totally dependent on one staff member for bed mobility and transfers;
-Used a wheelchair for mobility.
Record review of the resident’s ADL care plan, dated 8/28/18, showed no documentation of
the use of side rails for mobility.
Record review of the resident’s POS, dated (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR),
and (MONTH) (YEAR), showed there was no order for side rails.
Record review of the resident’s Quarterly MDS, dated [DATE], showed the resident:
-Had a BIMS score of 11 indicating mild cognitive impairment;
-Required extensive assistance from one staff member for bed mobility and transfers;
-Used a wheelchair for mobility.
Record review of the resident’s Telephone Order’s, dated (MONTH) (YEAR) to (MONTH) 2019,
showed no order for side rails.
Observation on 1/27/19 at 10:00 A.M., 1/28/19 at 11:00 A.M., 1/29/19 at 1:00 P.M., and
1/30/19 at 9:30 A.M., showed the resident had quarter (1/4) side rails in the upright
position on the right side of his/her bed.
During an interview on 2/1/19 at 9:38 A.M., the MDS Coordinator said:
-The resident’s side rails should be care planned;
-The resident should have a risk and benefit letter about the use of side rails;
-The resident did not have a care plan that mentioned the use of side rails.
5. During an interview on 2/1/19 at 11:00 A.M., the Director of Nursing (DON) said:
-He/She did not realize how many residents used side rails;
-Residents must be assessed for the use of side rails;
-Maintenance should have a monitoring system for the side rails;
-Was unclear as to who was putting side rails up on the beds;
-Upon admission everyone is assessed for side rail use by the admitting nurse;
-Nursing should discuss the need for side rails and Therapy should determine what the
resident needs.

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Observe each nurse aide’s job performance and give regular training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to have a system in place to
ensure Certified Nurse Assistant (CNA’s) received the required 12 hours in-service
education and based on performance reviews annually including abuse and neglect training
and dementia care training. This had the potential to affect all residents at the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 29)
facility. The facility census was 46 residents.
The facility did not have a policy related to staff training and competencies.
1. Record review of the Facility Assessment, dated [DATE], showed:
-Staff competencies and annual training requirements per regulatory authority and/or
facility policy:
-Abuse, neglect, exploitation, and misappropriation;
-Advanced directives;
-Behavioral health;
-Communication;
-Compliance and ethics;
-Cardiopulmonary resuscitation (CPR);
-Dementia care and management;
-Equipment and assistive device (lifts) training;
-Infection control;
-Other areas identified as areas of weakness during annual performance reviews/competency
evaluations;
-Promoting resident’s independence;
-Quality assurance and performance improvement;
-Resident rights including confidentiality, right to dignity, privacy and property;
-Safety and emergency procedures;
-Job responsibilities and lines of authority;
-Emergency preparedness;
-Facility’s policies and procedures;
-Change in condition/reporting.
Record review of the facility’s in-service book on [DATE], showed the following trainings
were not completed since the last survey:
-Falling star program, walk to dine program on [DATE], including all staff;
-Abuse and neglect, and fall prevention on [DATE] including all staff; there was no sign
in sheet that showed who attended the in-service;
-There was no documentation that showed dementia training had been completed;
-There was no documentation that showed the CNA’s received 12 hours of training in the
past year.
During an interview on [DATE] at 9:59 A.M., the Director of Nursing (DON):
-He/She knew the facility had a dementia training for the staff, it may be in another
book;
-Proof of dementia training might be in the individual employee files;
-All trainings were one to one and one-half hours long and required readings were sent
home;
-Abuse and neglect (A/N) training was completed by the Social Services Designee (SSD);
-Abuse and neglect training was completed on [DATE] then a recent one on [DATE] for A/N;
-There were no sign in sheets to show the abuse and neglect training was completed;
-He/She was responsible for monitoring and ensuring staff training was completed;
-He/She had not completed a new training schedule based off the facility assessment
completed in (MONTH) (YEAR);
-Previously, the DON would do the training schedule;
-He/She started as the Assistant Director of Nursing (ADON) in (MONTH) (YEAR) and started
as the DON in Oct (YEAR);
-He/She was waiting on the new company to send a list of the training for the staff.
During an interview on [DATE] at 11:37 A.M., the Human Resources Director said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 30)
-Upon orientation, a packet was given to the staff member of training;
-Policies and procedures including abuse and neglect, fire watch, tornado, and dementia
were given to new employees during orientation;
-He/She did not do the abuse and neglect training with the new staff;
-The SSD completed the abuse and neglect training at the facility;
-He/She went over the human resource packet information and dementia training upon hire;
-The DON should have the dementia training information including the sign in sheets;
-A checklist was used to ensure everyone received dementia training, but he/she had thrown
it away;
-The DON completed all the in-services;
-Not aware if twelve hours of training was being tracked to ensure the hours the CNA’s
received were the required amount of training;
-He/She was not aware if abuse and neglect training and dementia training was completed
and tracked.
During an interview on [DATE] at 11:57 A.M., the SSD said:
-An in-service was done for abuse and neglect in Oct (YEAR);
-There was a sign in sheet for all employees;
-The DON kept all of the sign in sheets;
-He/She did not have a copy of the sign in sheet for the training;
-The training was for all staff members including dietary, housekeeping, and all nursing
staff.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
medication refrigerator’s temperatures were monitored daily and maintained within
acceptable parameters for two out of two medication rooms, failed to ensure stock
medications and supplies were disposed of prior to the expiration date for one out of two
medication rooms; and failed to ensure the narcotic count sheet was signed by both
oncoming and off going nurses/Certified Medication Technicians (CMT) to verify the correct
count of narcotics for two out of three medication carts. The facility census was 46
residents.
Record review of the facility’s policies showed there was no policy for:
-Monitoring the medication refrigerator temperatures;
-Expired Medications and supplies;
-Counting narcotics.
1. Record review on 1/30/19 of the facility’s Refrigerator Thermometer Readings log sheet
for (MONTH) (YEAR) and (MONTH) 2019 for the 100 and 300 hall medication room showed:
-Staff are expected to document nightly between 1:00 A.M. and 2:00 A.M., by the night
shift charge nurse;
-December (YEAR) was missing 16 times out of 31 opportunities for 51.6% of the time;
-January 2019 was missing 15 times out of 29 opportunities for 51.7% of the time.
Observation on 1/30/19 at 12:15 P.M., of the 100 and 300 hall medication room showed:
-77 [MEDICATION NAME] (medication which helps prevent the blood from clotting) prefilled

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
flush syringes that expired 11/30/18;
-Two Central line (a catheter placed into a large vein) sterile dressing packs that
expired 8/1/17.
Observation on 1/30/19 at 12:15 P.M., of the front medication room showed no medication
refrigerator temperature log in the medication room.
During an interview on 1/30/19 at 12:30 P.M., Licensed Practical Nurse (LPN) C said
he/she:
-Doesn’t check for expired supplies, it was the responsibility of the central supply
staff;
-Didn’t know who monitored the refrigerator temperatures.
2. Record review on 1/30/19 of the Narcotic Shift Sign-In/Sign-Out Sheet showed missing
signatures for:
-The nurse’s cart dated 1/5/19 through 1/25/19, 17 times out of 100 opportunities, 17% of
the time;
-The CMT’s cart dated 1/5/19 through 1/29/19, 60 out of 150 opportunities, 40% of the
time.
During an interview on 1/30/19 at 1:02 P.M., CMT A said:
-He/She didn’t document the medication refrigerator temperatures, the nurses do it;
-He/She checked his/her medication cart constantly for expired medications;
-He/She was unsure who checked for expired supplies in the medication room;
-Nurse’s worked 12 hour shifts;
-CMT’s worked eight hour shifts and there are no CMT on the night shift, (11:00 P.M. to
7:00 A.M.);
-He/She counted with the charge nurse if prior shift CMT or oncoming CMT was not
available;
-Then the charge nurse counted with the new CMT;
-The charge nurse’s didn’t always sign the narcotic signature sheet.
During an interview on 1/31/19 at 8:57 A.M., LPN A said:
-Nurses, CMT’s, and central supply staff checked for expired supplies;
-Expired medications, are logged and destroyed immediately;
-Other supplies, are disposed of properly, (sharps into the sharps container, sterile
supplies returned to company);
-The medication refrigerator temperature logs are located on the outside of the
refrigerators;
-Night shift nurse checked and recorded the medication refrigerator temperatures;
-Temperatures outside of parameters are brought to the attention of the Director of
Maintenance immediately;
-Narcotic counts occurred at the beginning and end of each shift;
–Nurse to nurse every 12 hours;
–CMT to CMT every eight hours;
—Day and evening CMT count;
—Evening CMT counted with night nurse;
—Night nurse counted with day CMT.
During an interview on 1/31/19 at 9:48 A.M. LPN B said:
-The nurses monitored the refrigerator temperatures;
-There were thermometers in the refrigerators, but no logs. They haven’t been there for
some time;
-He/She did not pay attention to expired central supply items;
-He/She guessed everyone should check for expired medications and supplies;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
-Nurses and CMT’s checked for expired medications;
-No one person was assigned to check medication rooms and carts;
-Expired medication are destroyed immediately;
-If not enough time available to destroy the medications, they would be placed into a box
and be destroyed later in the week;
-A signature is expected after counting narcotics;
-If a CMT wanted to leave early, he/she counted with the CMT, then counted with the
oncoming CMT;
-He/She never signed when counting with the CMT;
-He/She didn’t sign the narcotic signature sheet when counting with the CMT.
During an interview on 2/01/19 at 11:00 A.M. the Director of Nursing (DON) said he/she
expected:
-Nightly, checked and documented medication refrigerator temperatures by the nurses;
-Nurses and CMT’s constantly checked for expired items;
-Nurses and CMT’s checked medication carts at least every week for expired items, both
medications and central supply;
-Nurses checked the medication rooms at least monthly for expired items, both medications
and central supply;
-Nurses and CMT’s destroyed any and all expired items;
-Oncoming and off going nurses counted narcotics and signed the narcotic signature sheet;
-Oncoming and off going CMT’s counted narcotics and signed the narcotic signature sheet;
-Nurse and CMT counted narcotics and signed the narcotic signature sheet at 11:00 P.M. and
7:00 A.M.;
-Any time a nurse and CMT counted narcotics, both signed the narcotic signature sheet.

F 0837

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Establish a governing body that is legally responsible for establishing and
implementing policies for managing and operating the facility and appoints a properly
licensed administrator responsible for managing the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to maintain a governing body, or
designated persons functioning as a governing body, that was legally responsible for
establishing and implementing policies regarding the management and operation of the
facility. This had the potential to affect all residents in the facility. The facility
census was 46 residents.
Record review of the Facility assessment dated [DATE] showed:
-The facility reviewed the following policies during the annual facility assessment:
–Abuse and neglect;
–Fire alarm system;
-There were no other documented policies listed that had been reviewed by the facility
administration to meet the current standards of practice.
Record review of the facility’s list of policies needed for the survey and requested of
the facility showed:
-The facility did not maintain and/or develop current policies including;
–[MEDICAL TREATMENT], last revised 2/1/11;
–Bed hold, not dated and no documented procedure for the staff;
–Wound care and skin policy, revised 2/1/11, no current practices for wounds and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0837

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 33)
references to the National Pressure Ulcer Advisory Panel (NPUAP);
–Staff posting requirements dated 1/5/06;
–Advanced directives dated 9/25/06;
–Care Plans dated 2/1/11;
–Emergency dishwashing dated 2011;
–Standard precautions (for infection control) revised 1/10/14;
-The facility did not have policies for:
–Sit-to-stand lift (a hydraulic used to assist mobility patients when they are unable to
transition from a sitting position to a standing position on their own) transfers;
–Medication refrigerator temperatures;
–Expired medications and expired supplies;
–Infection control program;
–Antibiotic stewardship program;
–Side rail use;
–Homelike environment;
–Mail delivery;
–Staff required annual training including, 12 hours of training and dementia training;
–Maintaining transfer (lift) equipment.
During an interview on 2/1/19 at 8:29 A.M., the Administrator and Director of Nursing
(DON) said:
-Administrator:
–He/She along with the DON, were responsible for the development of facility policies;
–He/She usually wrote policies here and sent them to the Regional Manager for review
before implementation;
–The facility had different ownerships at different times;
–He/She had been at the facility for about one year;
–He/She had been unaware they were missing facility policies until now;
-DON:
-The facility was missing many policies;
-There were no policies on homelike environment, medication storage, and many others;
-He/She could not locate many of the policies requested by the surveyors.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

Based on interview and record review, the facility failed to ensure a facility-wide
Infection Prevention, Control Program (IPCP) was established, and failed to ensure
surveillance logs were maintained for 12 consecutive months, to monitor, track, and
identify trends of infections in the facility. This had the potential to affect all
residents who had infections. The facility’s census was 46.
Record review of the facility’s policy’s showed the facility did not have an Infection
Prevention, Control Program Policy.
1. Record review of the facility’s Resident Census and Conditions of Residents (CMS 672)
worksheet completed by the Minimum Data Set (MDS a required, federally mandated assessment
tool completed by facility staff for care planning) Coordinator on 1/28/19 showed there
were nine residents receiving antibiotics when the survey team entered the facility on
1/27/19.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
Record review of the facility’s facility-wide Infection Control book and surveillance logs
showed:
-There was not twelve consecutive months worth of data collected, (MONTH) (YEAR) data was
missing;
-Incomplete (inconsistent) data collection missing some of the following:
–Resident admitted s;
–Onset dates;
–Infection sites;
–Infection related diagnosis;
–Whether a culture was obtained or not;
–Treated organisms;
–Antibiotics prescribed;
–If the resident was isolated;
–If the infection was facility acquired;
–Reculture date;
–Date infection was resolved.
-Did not use an evidence-based surveillance criteria;
-Did not have a list of reportable communicable diseases to the State of Missouri;
-Did not have tracking of employees with communicable diseases;
-Did not have tracking of non-antibiotic treated infections.
During an interview on 1/31/19 at 12:32 P.M. the Assistant Director of Nursing (ADON) said
he/she:
-Started in the position in (MONTH) (YEAR);
-He/She is responsible for IPCP;
-He/She was unsure what the IPCP should contain;
-Worked with the infection control book daily;
-Filled out the infection control log form;
-Had not started to do trending;
-Was learning about the infection control program;
-Had not documented the signs and symptoms of infection;
-Had not followed any evidence-based surveillance criteria;
-Was unsure of what was reportable to State of Missouri.
During an interview on 2/1/19 at 11:00 A.M., the Director of Nursing (DON) said:
-There should be an Infection Control Policy;
-The ADON is responsible for the IPCP;
-He/She is unsure what the IPCP should contain;
-The ADON had been in his/her position since 11/2018;
-The facility was in the process of a new change of ownership;
-He/She called their corporate office to obtain copies of all policies.

F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement a program that monitors antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish an antibiotic
stewardship program (ASP) that included antibiotic use protocols and a system to monitor
antibiotic use and failed to have a policy for the ASP. The deficient practice had the
potential to affect all residents in the facility who had infections. The facility census

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 35)
was 46 residents.
Record review of the facility’s policies showed there was not a policy for ASP.
Record review showed the facility had not developed or implemented an ASP that should
include:
-Protocols to optimize the treatment of [REDACTED].
-Protocols to review clinical signs and symptoms and laboratory results to determine if
antibiotics are indicated or adjusted and to identify an infection assessment tool used;
-Procedure to promote and implement a facility-wide system to monitor the use of
antibiotics including a system of reports related to monitoring antibiotic usage and
resistance data;
-Designate appropriate facility staff accountable for promoting and overseeing antibiotic
stewardship;
-Accessing pharmacists and others with experience or training in antibiotic stewardship;
-Implementation of a policy or practice to improve antibiotic use;
-Regular reporting on antibiotic use and resistance to relevant staff such as prescribing
clinicians and nursing staff;
-Educate staff and residents about antibiotic stewardship.
1. Record review on 1/31/19 at 9:00 A.M., of the facility infection tracking information
for (MONTH) (YEAR) through (MONTH) 2019 showed:
-Data compiled was resident names, onset date, infection site (respiratory tract, urinary
tract, gastrointestinal tract, wound, skin), the date the culture was collected, the name
of the organism, the antibiotic prescribed, the prescribed dosage, the duration of the
antibiotic, required isolation and whether the infection was community or facility
acquired;
-Data did not include:
–Resident room numbers for tracking purposes;
–Antibiotic start and stop dates;
–Consistently documented specimen collection;
–Resident symptoms and lab records and bacterial counts (important information needed in
decision making regarding antibiotic use) and antibiotic sensitivity results (information
that ensures the correct antibiotic is used to effectively treat the infection); and
–Evidence-based (a conscientious practice, problem-solving approach to clinical practice
that incorporates the best evidence from well-designed studies, patient values and
preferences, and a clinician’s expertise in making decisions about a resident’s care)
criteria collected regarding antibiotic use.
During an interview on 1/31/19 12:32 P.M., the Assistant Director of Nursing (ADON) said
he/she:
-Had been in this position since (MONTH) (YEAR);
-Did not have a good understanding of the ASP;
-Reviews antibiotics, ordered by the physician, during a daily administrative meeting;
-Filled out the infection control log form;
-Didn’t use an infection assessment tool to document signs and symptoms of infection;
-Didn’t document signs and symptoms of infection;
-Didn’t use McGreer’s criteria or Loeb criteria;
-Hadn’t started to trend infections yet;
-Didn’t monitor non-antibiotic treated infections;
-He/She knew the facility was required to have an ASP and he/she was in charge of it;
-Looked forward to learning more about the ASP.
During an interview on 2/01/19 at 11:00 A.M., the Director of Nursing (DON) said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 36)
-There was no policy for the ASP;
-He/She just printed things from the Center for Disease Control (CDC) regarding ASP.

F 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and
all bed rails and mattresses must attach safely to the bed frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to complete an
inspection of bed frames, mattresses, and bed rails as part of a regular maintenance
program to identify risk of possible entrapment for three sampled residents (Residents
#47, #7, and #25) out of 12 sampled residents. The facility census was 46 residents.
Record review of the facility’s, undated, Bed Rail Safety Check Guide showed:
-Several potential areas of entrapment to include within and under the rails; between two
rails; between the end of the rail and the side edge of the head and foot board; and
between the mattress edge and the rails, headboard and footboard;
-Side rail bars should be spaced to prevent the head from passing through the opening;
-There should not be extra space between the mattress edge and the rails, headboard and
footboard;
-Compression of the mattress sides should be checked to prevent a person from suffocation
(death from lack of air or inability to breath);
-Latches securing the bed ails should be stable; and
-Maintenance and monitoring of the mattresses, beds and bedside items should be ongoing.
1. Record review of Resident #47’s Face Sheet showed the resident was admitted to the
facility on [DATE] and last readmitted on [DATE] and had a [DIAGNOSES REDACTED]. A person
is considered morbidly obsess if 100 pounds or more over their ideal weight or has a Body
Mass Index (BMI – A measurement of body fat based on height and weight of 40 or more).
Observations of the resident lying in his/her bed showed the resident had one-half side
rail in use on both sides of his/her bed on the following dates and times:
-1/27/19 at 10:15 A.M.;
-1/27/19 at 12:28 P.M.;
-1/29/19 at 12:42 P.M.;
-1/30/19 at 11:35 A.M.; and
-1/31/19 at 9:59 A.M.
Record review of the resident’s Bed Rail/Assist Bar Evaluations completed within the past
twelve months showed:
-The resident was assessed for bed rail and/or assist bar use on 3/7/18 and 1/21/19 and
-The form did not comprehensively show specific risks for entrapment, the number and type
of bed rails or assist bars recommended and alternates attempted prior to the use of the
bed rails or assist bars. Additionally, there was no documentation that risks and benefits
of side rail use and appropriate alternates were discussed with the resident.
2. Record review of Resident #7’s Face Sheet showed he/she was admitted to the facility on
[DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED].
Observations of the resident lying in his/her bed showed the resident had a Low Air Loss
(LAL) Mattress (mattress comprised of multiple inflatable air tubes that alternately
inflate and deflate, taking pressure off of prominent bony body surfaces such as the heels
and end of the spine) and had side rails in use on both sides of his/her bed on the
following dates and times:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 37)
-1/27/19 at 11:07 A.M.;
-1/27/19 at 1:03 P.M.;
-1/27/19 at 2:29 P.M.
-1/30/19 at 11:04 A.M.; and
-1/31/19 at 9:29 A.M.
Record review of the resident’s Bed Rail/Assist Bar Evaluations completed within the past
twelve months showed:
-The resident was assessed for bed rail and/or assist bar use on 6/7/18 and
-The form did not show specific risks for entrapment and alternates attempted prior to the
use of the bed rails. Additionally, there was no documentation showing the resident or
his/her Durable Power of Attorney (a person established prior to incapacitation that acts
on behalf of the resident should the resident become unable to make decisions) was made
aware of the risks and benefits of using a one-half side rail and appropriate alternates
attempted prior to use.
3. Record review of Resident #25’s Face Sheet showed the resident was admitted to the
facility on [DATE] with [DIAGNOSES REDACTED].
Observations of the resident lying in his/her bed showed the resident had a LAL mattress
and had one-half side rails in use on both sides of his/her bed on the following dates and
times:
-1/27/19 at 11:10 A.M.;
-1/27/19 at 8:10 P.M.;
-1/30/19 at 11:34 A.M.; and
-1/31/19 at 9:29 A.M.
Record review of the resident’s Bed Rail/Assist Bar Evaluations completed within the past
twelve months showed:
-The resident was assessed for bed rail and/or assist bar use once on 9/27/18 and
-The form did not comprehensively show specific risks for entrapment and alternates
attempted prior to the use of the bed rails. Additionally, there was no documentation that
risks and benefits of side rail use and appropriate alternates were discussed with the
resident’s legal representative prior to use.
4. During an interview on 1/31/19 at 10:52 A.M. the Maintenance Director said:
-He/She had installed one trapeze (an enabler designed to hang over the bed for
repositioning) for one resident and side rails for another resident’s bed. The side rails
were made by the same manufacturer as the bed and were designed to go with the bed;
-He/She only installed rails and enabler’s if requested to do so by Nursing or Therapy;
-He/She had tightened a couple of bed rails when told by Nursing the rails were loose;
-Bed frames can become loose over time when a person repositions him/herself and if shaken
or used for weight-bearing support;
-He/She had been trained on installing LAL Mattresses while working at another facility;
-The facility owned two LAL mattresses and residents also used LAL mattresses delivered by
medical supply companies. He/She was responsible for strapping down LAL mattresses owned
by the facility, which took eight straps to secure to the bed. Nurses set the dial to the
LAL mattresses according to resident needs. If there was a problem with the inflation of a
LAL mattress Nursing would let him/her know;
-He/she was not provided a list of residents with side rails and the type of side rails
residents required;
-He/She did not inspect bed rails, beds and mattresses on a scheduled basis and did not
have a monitoring schedule for checking the function, fit, and side compression of LAL
mattresses.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265425

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/01/2019

NAME OF PROVIDER OF SUPPLIER

EDGEWOOD MANOR CENTER FOR REHAB AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

11900 JESSICA LANE
RAYTOWN, MO 64138

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 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 38)
During an interview on 2/1/19 at 11:00 A.M. the Director of Nursing (DON) said:
-Maintenance should have a monitoring system for the side rails, beds and mattresses and
document what has been monitored and maintained.