Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 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 on interview and record review, the facility failed to ensure residents were able to
organize and participate in the Resident Council meeting at a location that was large
enough to accommodate all the residents who wanted to attend the resident council meeting;
to communicate with the resident council on where they would like to have the resident
council meetings during the renovations and to have a coffee stand on the first floor for
the residents who arise early and during the day to enjoy during the renovations. Seven
residents attended the resident group meeting. The facility census was 68 residents.
Record review of the facility’s titled Resident Rights Policy Statement dated (MONTH) 2009
showed the employees shall treat all residents with kindness, respect and dignity.
Record review of facility’s policy titled Interpretation and Implementation dated (MONTH)
2009 showed:
-Federal and state laws guarantee certain basic rights to all residents of the facility,
and these rights include the resident’s right to:
-Be informed about what rights and responsibilities he or she has;
-Residents are entitled to exercise their rights and privileges to the fullest extent
possible and
-Our facility will make every effort to assist each resident in exercising his/her rights
to assure that the resident is always treated with respect, kindness, and dignity;
Resident Council Policy Statement dated (MONTH) (YEAR) showed the facility supports
resident’s rights to organize and participate in the Resident Council;
-.The purpose of the Resident Council is to provide a forum for;
– Residents, families and resident representative to have input in the operation of the
facility;
– Discussion of concerns and suggestions for improvement;
– Consensus building and communication between residents and facility staff;
-Disseminating information and gathering feedback from interested residents;
-All residents are eligible to participate in the Resident Council;
-The facility staff encourages residents who are willing to participate;
-A resident council response form will be utilized to track issues and their resolution
and
-The facility department related to any issues will be responsible for addressing the item
of concern.
1. During the group interview on 3/11/19 at 10:45 A.M., the residents shared they enjoyed
having their monthly Resident Council Meeting in the first floor dining room. The
residents said they were abruptly moved from the first floor dining room to a room on the
second floor. The room space on the second floor was not big enough to conduct their
monthly meetings;
-After the recent renovation efforts the residents wanted to continue to have there
monthly meetings in the first floor dining area;
-The residents expressed they would like to have the coffee stand back on the first floor
so that the residents who were early risers would have their coffee to drink prior to
their breakfast hour;
-The Activities Director had not been as attentive to their needs during the Resident
Council group due to the recent building renovations at the facility;
-The residents said the Activities Director gets pulled on the floor a great deal to help
with providing baths to the residents and other assigned duties;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
-The residents talked about how important the resident council meeting was and this was
their opportunity to be a voice for the other residents and
– The residents were not provided with updates regarding how the renovation efforts would
interfere or interrupt their monthly meetings.
During an interview on 3/14/19 at 9:15 A.M.,Certified Nursing Assistant (CNA) C said:
-He/she had five early risers on the second floor who had enjoyed going down to the first
floor to get a cup of coffee to drink prior to the breakfast meal;
-He/she had confirmed one year ago the facility had a coffee stand for the residents and
the facility guests and
-He/she was waiting to see how soon the other floors would be remodeled and how it would
affect those residents.
During an interview on 3/14/19 at 12:30 P.M. the Director of Nursing (DON) said:
-He/she would alert the facility Administrator on the communication concerns expressed
during the resident group meeting on 3/11/19;
-He/she admitted they had not communicated well with the residents during the recent
facility renovation project efforts;
-He/she believed the residents misunderstood what the management team was trying to
achieve in terms of enhancing the building to make it look more attractive and user
friendly for guest, family, friends, community and the residents;
-He/she would be responsible for communicating and reassuring the residents that they
would be able to continue to meet on the floor dining room, and
-He/she would work on locating safe places in the building to have appropriate coffee
stands for the residents.
During an interview on 3/14/19 at 1:30 P.M., the Administrator said he/she will be working
on making the necessary changes for the residents regarding the needs and concerns they
had expressed during the resident group meeting regarding the coffee stands and the other
concerns the resident’s expressed during the resident group meeting.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain the second and third
floors free from persistent and strong urine odors; to maintain mattresses in rooms 331,
329, 330, 319, 305 free from damage; to maintain the floors in resident rooms 324, 309,
303, free from damage; to maintain the floors of the third floor dining room, shower room
[ROOM NUMBER] and in resident rooms 321, 309, 308, 305, 303, 234, and 220, free from a
buildup of debris and grime; to have a regular cleaning schedule for fans in resident
rooms [ROOM NUMBER], and the second floor nurse’s station; to maintain two lifts free of a
dust and debris buildup; and to prevent two slings (a flexible strap or belt used in the
form of a loop to support or raise a hanging weight) that were severely damaged, from
making it back to the second floor Central Supply room. This practice potentially affected
57 residents who resided on the second and third floors. The facility census was 68
residents.
1. Observations on 3/7/19, showed the following:
-At 9:09 A.M. there was a strong urine odor on the third floor that could be detected to
the elevator;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
-At 9:23 A.M., the mattress in bed two of resident room [ROOM NUMBER], had worn spots in
the middle and at the head part of the mattress and
-At 12:20 P.M., there was a strong urine odor in the the third floor dining room during
the lunch meal.
2. Observations and interviews on 3/8/19, showed the following:
-At 10:14 A.M., strong urine odors emanated from the south and west wall of the second
floor dining room;
– At 10:16 A.M., a strong urine odor was detected in the second floor hallway, close to
resident room [ROOM NUMBER];
– At 10:35 A.M., the Housekeeping Director said he/she has had to do more cleaning on the
third floor because the floors get dirty more frequently;
– At 10:39 A.M, a strong urine odor was detected on the third floor between rooms [ROOM
NUMBERS] in the hallway;
– At 10:38 A.M., the mattress in resident room [ROOM NUMBER] showed a sunken area that was
faded out in the middle part of that mattress and
– At 10:39 A.M., a strong urine smell was detected in resident room [ROOM NUMBER].
3. Observations and interviews with the Maintenance Director and the Housekeeping Director
during the Life safety Code /Environmental Tour showed:
– At 10:09 A.M., there was a persistent, pungent, urine odor in the third floor hallway,
between resident rooms 323 and the third floor dining room;
– At 10:15 A.M., several rips were present in the Bed A mattress in resident room and a 29
inch (in.) diameter section of damage in the bed B mattress of 331;
– At 10:16 A.M., Certified Nurse’s Assistant (CNA) A said if they see mattresses in that
condition, they should inform the nurse;
– At 10:20 A.M., a 19 in. of the bed B mattress in resident room [ROOM NUMBER], was
damaged, and a strong urine odor was present in that room;
– At 10:22 A.M., a damaged mattress was present in resident room [ROOM NUMBER];
– At 10:26 A.M., a 2 in. rip was present in the seat of the shower lift in Shower room
[ROOM NUMBER];
– At 10:26 A.M., the Maintenance Director said a new seat was on order;
– At 10:27 A.M., Licensed Practical Nurse (LPN) A said none of the CNAs informed him/her
of the damaged mattress;
– At 10:36 A.M., there was the presence of food crumbs and food debris behind the armoire
in the third floor dining room;
– At 10:36 A.M., the Housekeeping Director said the housekeepers need to clean behind the
armoire every other day;
– At 10:39 A.M., a strong urine odor emanated from resident room [ROOM NUMBER];
-At 10:41 A.M., a 4 in. section of the floor was damaged floor and grime was present in
the restroom of resident room [ROOM NUMBER];
-At 10:43 A.M., there was a strong urine odor in the restroom of resident room [ROOM
NUMBER] with the presence of brown stains on the wall paper of that restroom;
-At 10:56 A.M., the floor in the restroom in room [ROOM NUMBER] had grime present on
portions of the floor;.
– At 11:00 A.M., in resident room [ROOM NUMBER] the mattress was damaged;
– At 11:11 A.M., a portion of the floor in the therapy area had stains;
-At 11:03 A.M., a heavy dust buildup and several pieces of tissue papers were present on
the base of a lift that was stored in the alcove towards the 3rd floor soiled utility
room;
-At 11:05 A.M., there was a buildup of dust on the fan in resident room [ROOM NUMBER];
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-At 11:18 A.M., debris and human hair was found under the blue shower mat in Shower room
[ROOM NUMBER];
-At 11:17 A.M., Certified Medication Technician (CMT) A said the person who used that mat
to give a shower, should clean under that blue mat every time they give a shower;
-At 11:23 A.M., a buildup of dust on the fan and a 5.5 in. section of the floor in the
restroom in resident room [ROOM NUMBER] was damaged;
-At 11:24 A.M., in resident room [ROOM NUMBER] portion of the floor in the restroom had
grime on it;
-At 11:25 A.M., the Housekeeping Director said they try to use a scraper to scrape away
the grime every two days but agreed the floor in resident room [ROOM NUMBER] has not been
scraped in that time frame of the last two days;
-At 11:33 A.M., strong urine odor was present in resident room [ROOM NUMBER];
-At 11:33 A.M., the Housekeeping Director acknowledged the presence of the urine odor in
resident room [ROOM NUMBER];
-At 11:34 A.M., a 10 in. rip was present in the mattress in resident room [ROOM NUMBER];
-At 11:35 A.M., there was a buildup of dust in the fan in resident room [ROOM NUMBER];
-At 11:38 A.M., in resident room [ROOM NUMBER] the floor in the restroom was damaged;
-At 11:39 A.M., there was a buildup of dust in the fan in resident room [ROOM NUMBER];
-At 12:49 P.M., in resident room [ROOM NUMBER] the restroom floor was sticky;
-At 12:50 P.M., the Housekeeping Director acknowledged the presence of urine residue on
the floor which caused that floor to be sticky;
-At 12:55 P.M., the base of the stand-up lift stored in resident room [ROOM NUMBER], had a
heavy buildup of dust on it;
-At 12:56 P.M., CNA B said that lift was not used on the second floor because there were
no residents on the second floor, who used stand up lifts;
-At 1:12 P.M., a heavy buildup of dust was present on the fan at the second floor nurse’s
station;
-At 1:13 P.M., the second floor Unit Manager said that fan has been used at the nurse’s
station since around the middle of last month;
-At 1:16 P.M., in resident room [ROOM NUMBER] the restroom floor had grime on it;
-At 1:17 P.M., a pungent urine odor was present in the restroom of resident room [ROOM
NUMBER];
-At 1:25 P.M., two damaged slings, one with a 5 in. rip and the other with a 4 in. rip,
were observed handing on a rack in the 2nd floor Central Supply storage room;
-At 1:26 P.M., CNA C said he/she did not know about those slings were damaged;
and he/she did not think those slings should have been brought to the unit;
-At 1:27 P.M., the Housekeeping Director said the laundry staff did not check the slings
as closely as they should;
-At 1:29 P.M., in resident room [ROOM NUMBER] the restroom floor had grime on it;
-At 1:40 P.M., The presence of debris including numerous pieces of paper towels, were
present on the floor of shower room [ROOM NUMBER];
– At 1:41 P.M., the Maintenance Director acknowledged that the shower room floor needed to
be cleaned, and
– At 2:47 P.M, A heavy buildup of dust was present on the fan in resident room [ROOM
NUMBER].
During an interview on 3/8/19 from 3:01 P.M. through 3:07 P.M., the Regional Director of
Housekeeping services said:
-When the new company took over operations at the facility towards the end of (MONTH)
(YEAR), they did a full audit of all the rooms on the 2nd and 3rd floor;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
-They attempt to do a deep clean of two rooms per day;
-The housekeeping staff use a disinfectant/cleaner and rectangular scrubbers to remove the
grime from the floor, and
– The housekeepers should spray the floor cleanser on the floors, then use the rectangular
scrubbers to remove the grime.

F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Based on interview and record review, the facility failed to ensure criminal background
checks (CBC) were completed on newly hired staff and re-hired staff per facility policy
for seven out of 16 sampled employees. The facility census was 68 residents.
Record review of the facility’s undated Abuse, Neglect and Exploitation policy and
procedure showed it is the policy of the company to take appropriate steps to prevent the
occurrence of abuse, neglect, injuries of unknown origin, and misappropriation of resident
property, and to ensure that all alleged violations of federal or state laws which involve
mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of personal
property are reported immediately to the Administrator. Violations will also be reported
to state agencies in accordance with state law. The screening process showed all
applicants for employment in the company shall, at a minimum, have the following:
-Reference checks with the current and/or past employer;
-Appropriate licensing board or registry check;
-Criminal background check pursuant to company policy or state law;
-The Director of Nursing, or Human Resources is responsible for the initial licensing
and/or registry check, the Administrator of Human Resources must ensure that all screening
is completed and
-No applicant shall be considered for employment unless all screenings are completed, and
the applicant’s license is unrestricted.
1. Record review of the following Employee records showed:
-Certified Nursing Assistant (CNA) J was hired on 9/25/18 and there was no documentation a
criminal background check was requested or received;
-CNA L was hired on 2/5/19 and there was no documentation that a criminal background check
had been requested or received;
-Certified Medication Technician (CMT) C was hired on 11/28/18 and there was no
documentation that a recent criminal background check was requested or received (the
employee was re-hired);
-CMT D was hired on 8/15/18 and there was no documentation that a criminal background
check had been requested or received;
-Licensed Practical Nurse (LPN) E was hired on 7/25/18 and there was no documentation that
a criminal background check had been requested or received and
-There were no employee files for CNA H or CNA K to review.
During an interview on 3/13/19 at 9:03 A.M., the Staffing Coordinator said:
-He/she did not complete background checks for new employees;
-They should complete a background check when they hire or re-hire a potential employee
and
-They were unable to find any employee records for CNA H and CNA K (also chosen in the
sample are no longer employees at the facility).

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed follow physician’s
orders to administer one sampled resident’s (Resident #38) [MEDICATION NAME] (a medication
used to treat mental disorders, including [MEDICAL CONDITION] and [MEDICAL CONDITION]
disorder) at bedtime as ordered to help minimize his/her Dementia (a group of thinking and
social symptoms that interferes with daily functioning) with behavioral disturbance and to
stay and watch the residents take their medications to ensure that the medications are
swallowed for two sampled residents (Resident #11 and Resident #3) out of 17 sampled
residents. The facility census was 68 residents.
Record review of the facility’s policy titled Documentation of Medication Administration
dated (MONTH) 2007 showed:
-The facility shall maintain a Medication Administration Record [REDACTED]
– Nurse or Certified Medication Technician (CMT) (where applicable) shall document all
medication administered to each resident on the resident’s MAR;
– Administration of medication must be documented immediately after (never before it is
given).
-Documentation must include, as a minimum:
– Name and strength of the drug;
– Dosage;
– Method Administration e.g. oral, injection (and site);
– Date and time;
– Reason(s) why a medication was withheld, not administered, or refused (as applicable)
and
– Signature and title of the person administering the medication;
Record review of the facility’s policy for Medication Administration Procedure showed:
-The purpose was to administer all medications safely and appropriately to aid the
resident to overcome illness, relieve, and prevent symptoms, and help in [DIAGNOSES
REDACTED].>-The person administering the medications to the resident must remain with
the resident to ensure that the medication is swallowed.
1. Record review of Resident’s #38’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Dementia with Behavioral Disturbance; and
-Major [MEDICAL CONDITION] – (A mental health disorder characterized by persistently
depressed mood or loss of interest in activities causing impairment of daily life).
Record review of the resident’s quarterly Minimum Data Set (MDS – a federally mandated
assessment tool to be completed by the facility staff for care planning) dated 8/23/18,
showed the resident:
-Was mild to moderately cognitively impaired which means the resident was not cognitive
alert and oriented;
-Was incapable of communication beyond answering either yes or no closed questions;
-Did not respond at all to the staff attempts to talk about his/her physical and spiritual
needs;
-Was unable to have meaningful conversations with others;
-Continued to walk the halls constantly with fidgeting behaviors and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-Was frequently redirected out of the resident’s rooms by the nursing staff.
Record review the resident’s Care Plan for Activities of Daily Living (ADL’s) dated
8/23/18 showed:
-He/she used [MEDICAL CONDITION] medications to aid with his/her behavior management;
-He/she was to remain free of drug related complications, including movement disorder,
discomfort, [MEDICAL CONDITION] (low blood pressure), gait disturbance and cognitive
behavior impairment;
-The resident had an ADL Self Care Performance Deficit related to progressing [DIAGNOSES
REDACTED] (is an umbrella term that includes Parkinson disease dementia;
-The resident was totally dependent on staff for ADL’s such as bathing, bed mobility,
dressing, eating, personal hygiene and transfers;
-The staff was required to monitor, document the side effects and the effectiveness of
medications ordered by his/her physician;
-The resident had impaired cognitive function/dementia or impaired thought processes;
-He/she was to maintained current level of cognitive function;
-The staff was to administer the resident’s medications as ordered;
-Discussed concerns about confusion, disease process;
-Was to keep the resident’s routine consistent and provide consistent caregivers as much
as possible to decrease stress level and confusion;
-Was to monitor, document, and report to the resident’s physician any changes in cognitive
function, especially changes in: decision-making ability, recall and general awareness,
difficulty expressing self, difficulty in understanding others;
-The resident was dependent on staff and family for all decision – making;
-The resident was to maintain involvement in cognitive stimulation, social activities as
desired and
-The resident needed one to one bedside/in-room visits and activities if unable to attend
out of room events.
Record review of the resident’s Physician’s Order Summary Report dated 9/6/18 showed the
resident had a physician’s order for [MEDICATION NAME] 5 milligrams (mg) one tablet by
mouth at bedtime for [MEDICAL CONDITION] related to unspecified Dementia with Behavioral
Disturbance.
Record review of the resident’s Consulting Pharmacy note dated 11/19/18 showed he/she was
receiving [MEDICATION NAME] which required a specific [DIAGNOSES REDACTED]. Please
indicate the appropriate [DIAGNOSES REDACTED].
-[MEDICAL CONDITION] – A disorder that affects a person’s ability to think, feel and
behave clearly;
-Schizo-affective disorder – A mental health condition including [MEDICAL CONDITION];
-Delusional disorder – Is generally rare mental illness in which a patient present
delusions;
-Mood Disorder – A group of mental health disorders that affect emotional state;
-[MEDICAL CONDITION] – A mental disorder characterized by a disconnected from reality;
-[MEDICAL CONDITION]’s Disorder – A nervous system disorder involving repetition movement
to or unwanted sounds;
-[MEDICAL CONDITION]’s Disease – An inherited condition in which nerve cells in the brain
breakdown over time;
-Medical illnesses or [MEDICAL CONDITION] with manic or psychotic symptoms/treatments and
-Behavioral or psychological symptoms of Dementia.
Record review of the resident’s Consulting Pharmacy note dated 12/11/18 showed a
physician’s order for [MEDICATION NAME] 5 mg one tablet every night for Dementia with
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
behavioral disturbances.
Record review of the resident’s MAR indicated [REDACTED].
Record review of the resident’s MAR indicated [REDACTED].
During an interview on 3/14/19 at 9:35 A.M., CMT C said:
-The resident had a physician’s order to take his/her [MEDICATION NAME] medication nightly
at bedtime,
-He/she worked until 6:00 P.M. and after he/she left it was the responsibility of the
evening Nurse to give the resident his/her [MEDICATION NAME] medication, and
-The resident typically does not leave the nursing home facility, and there was no record
of the resident leaving the facility in recent months.
During an interview on 3/14/19 at 9:40 A.M., Licensed Practical Nurse (LPN) C said the
evening Nurse was responsible for giving the [MEDICATION NAME] medication to the resident
at night between the hours of 8:00 P.M. and 9:00 P.M.
During an interview on 3/14/19 at 12:30 P.M., the Director of Nursing (DON) said:
-He/she expected the nurses to give the resident their medication and
-He/she expected the nurses to provide an explanation on the MAR indicated [REDACTED].
2. Record review of Resident #3’s Quarterly MDS dated [DATE] showed he/she:
-Was mildly cognitively impaired and with disorganized thinking and
-Was usually able to understand others and make his/her needs known.
Observation on 3/13/19 at 8:44 A.M. of the medication administration on the 3rd floor by
CMT A showed:
-CMT A had entered the resident’s room and gave seven medications to the resident to take
that included:
– [MEDICATION NAME] Hcl (pain) 50 mg one tablet by mouth two times a day;
– [MEDICATION NAME] (a medication used to remove excess fluid from the body by the
kidneys) 40 mg one tablet a day;
– [MEDICATION NAME] (blood pressure)10 mg one tablet by mouth daily;
– ASA ( blood thinner) 81 mg one tablet daily;
– Carvedilol ( is used to treat high blood pressure and heart failure) 6.25 mg 1 tablet by
mouth two times a day;
– [MEDICATION NAME] (heartburn/sour stomach)150 mg one tablet daily;
– [MEDICATION NAME] (high blood pressure and heart failure) 25 mg 1/2 tablet every
morning.,
-CMT A went into the resident’s bathroom to wash his/her hands and did watch to see if the
resident took those seven medications and
– Then CMT A exited the resident’s room.
3. Record review of Resident #11’s quarterly MDS dated [DATE] showed he/she:
-Was cognitively intact and
-Was usually able to understand others and make his/her needs known;
Observation on 3/13/19 at 8:50 A.M. during the medication administration by CMT A showed:
-CMT A entered the resident’s room and handed six medications to the resident to take
which included:
– [MEDICATION NAME] (allergy medication) 10 mg 1 tablet by mouth;
– [MEDICATION NAME] 2.5 mg 1 tablet by mouth daily;
– [MEDICATION NAME] succ ER ([MEDICAL CONDITION]-heart issue) 25 mg 1 tablet by mouth
daily;
– [MEDICATION NAME] 25 mg one tablet by mouth twice a day;
-Vitamin D3 two tablets by mouth daily;
-Tums (heartburn) one tablet mouth three times a day;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
-CMT A then turned and exited the resident’s room and
-CMT A did not watch to ensure the resident had safely taken his/her medication.
4. During an interview on 3/13/19 at 10:30 A.M., CMT A said :
– You should make sure the resident had taken their medications before leaving the
resident’s room and
-Was aware he/she did not watch to ensure the resident had safely taken his/her
medications during medication pass with Resident #11 and Resident #3 ,
During an interview on 3/14/19 at 11:00 A.M. the DON said:
-He/she expected the nursing staff and the CMT’s to watch the residents take their
medications to ensure the resident’s had taken all their medications before leaving the
resident’s room and
-The DON provided the facility’s policy for Medication Administration Procedure and point
out the person administering medication is to remain with the resident to ensure that the
medication is swallowed.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure an
activity plan of care and care plan goals and objectives were identified and documented to
ensure the resident’s activities were individualized and according to the resident’s
abilities and interests, and to ensure activity updates were documented at least quarterly
to show the resident’s activity progress for a resident who required total care and had
communication challenges for one sampled resident (Resident #27) out of 17 sampled
residents. The facility census was 68 residents.
1. Record review of Resident #27’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].), [MEDICAL CONDITION] (difficulty speaking),
dysphagia (difficulty swallowing), cognitive communication deficit, [MEDICAL CONDITION] (a
surgical procedure to create an opening through the neck into the trachea (windpipe)-a
tube is most often placed through this opening to provide an airway and to remove
secretions from the lungs) and a gastrostomy tube ([DEVICE] – a tube inserted through the
abdomen that delivers nutrition directly to the stomach).
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 9/20/18, showed
he/she:
-Was severely cognitively impaired and had a communication deficit;
-Was totally dependent for bathing, dressing, toileting, transferring and mobilizing, and
eating;
-Was unable to answer questions regarding activity preferences and
-Staff assessment of the resident’s daily activity preferences showed the resident had
family involvement in care planning and he/she liked music.
Record review of the resident’s Medical Record showed he/she did not have any activity
notes documented to show the resident’s participation in activities and progress with
his/her activity plan/goals.
Record review of the resident’s comprehensive Care Plan dated 12/15/18 showed:
-The resident had a communication problem and would respond appropriately to yes/no
questions and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
-There was no documentation showing the resident had an activity care plan, goals or
interventions.
Record review of the resident’s Activity Log dated (MONTH) 2019 showed:
-The resident had participated in voluntary activity check-in and TV/radio daily, and had
one to one with family nine times during the month;
-The Activity Director completed one to one activities five times during the month (the
activity was not identified);
-The resident had nail care twice during the month, a movie once and other activities
twice during the month and
-It showed the resident preferred independent activities and had good family support.
Record review of the resident’s Activity Log dated (MONTH) 2019, showed:
-The resident showed he/she participated in voluntary activity check-in and TV/radio
daily, and had one to one with family seven times during the month to date.;
-The Activity Director completed one to one activities twice during the month (the
activity was not identified) to date and
-The resident had a music room visit, participated in a music program and nail care once
so far during the month and had one other activity (unidentified).
Observation on 3/8/19 at 10:00 A.M., showed the resident was laying in his/her bed with
the head of his/her bed up 30 degrees. The resident had an oxygen mask over his/her
[MEDICAL CONDITION] and was connected to his/her [DEVICE]. He/she was alert and was
looking around. He/she could not talk. He/she was dressed in a hospital gown with a pad
alarm within his/her reach. The resident looked clean and was groomed. The television was
on in his/her room. The resident had contractures (a permanent shortening of a muscle or
joint) at his/her wrists, fingers and one knee. The resident was unable to move without
assistance.
During an interview on 3/13/19 at 8:56 A.M., Licensed Practical Nurse (LPN) B said:
-They try to get the resident up for at least two hours if the resident tolerates it;
-His/Her daughter comes to visit regularly, at least two to three times a week;
-The resident can communicate and respond by knocking his/her hand against your hand when
asked yes/no questions;
-The nurses spent a significant amount of time with the resident due to his/her care needs
and when he/she was with the resident he/she talked to the resident about current events,
his/her family, the resident’s family recently came in to decorate the resident’s room and
celebrate his/her birthday and he/she talks to the resident about that;
-When the resident’s daughter comes to visit and she will turn on music for the resident
for short periods of time. She comes two to three times per week and
-He/She did not see any one to one activities for the resident other than what nursing
staff does when they are in the room with the resident providing care.
During an interview on 3/13/19 at 1:47 P.M., the Activity Director said:
-He/She was an assistant to the activity director at this facility before becoming the
Activity Director;
-He/She has been the Activity Director for four to five months and had not gone to the
Activity Director training;
-He/She did not know he/she was supposed to develop activity goals and directives for the
residents and had not been trained on writing care plans and did not know he/she was
supposed to document activity notes;
-He/She does one to one activities with the resident at least weekly;
-He/she will go into the resident’s room and play music, perform nail care and will
sometimes do massage with oils to his/her hands, legs and feet;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
-He/She kept an activity log showing the activities he/she did with the resident weekly;
-He/She completed the activity assessment (on the MDS) in the computer on each resident
and the activity log, but did not complete activity quarterly notes;
-He/She participated in the quarterly and annual care plan meetings but has never been
told to complete an activity care plan and
-He/she would start documenting activity notes to show what the resident is doing on a
quarterly basis and develop a care plan.
During an interview on 3/13/19 at 2:57 P.M., the Director of Nursing (DON) said:
-The Activity Director is responsible for completing the activity assessment, setting
activity goals and interventions for the residents;
-The MDS Coordinator was assisting with care planning, but may not have gotten to all of
the resident’s care plans and may not have a care plan for activities;
-The Activity Director is expected to make quarterly notes regarding each resident’s
activities or progress toward their activity goal and
-They have planned to send the Activity Director to training.

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow
physician’s order for ongoing weekly skin assessment and to have detail documentation on
any skin issues reported or found; to follow physician’s orders to apply topical
medication to the resident’s skin issues, and to transcribe physician’s orders for a
topical medication to the resident’s Treatment Administration Record (TAR) which caused
the resident not to receive that medication in (MONTH) for one sampled resident (Resident
#58) out or 17 sampled residents. The facility census was 68 residents.
1. Record review of Resident #58 Admission Face Sheet showed he/she was admitted to the
facility on [DATE] with the following [DIAGNOSES REDACTED].>-Lumbosacral root disorder
(causes pain in the leg rather than in the lumbar spine) and
-Swelling of lymph nodes and [MEDICAL CONDITION].
Record review of the resident’s Quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 2/5/19 showed he/she:
-Was severely cognitively impaired and had short term and long term memory problem;
-He/she was usually able to understand others and make his/her needs known;
-Required limited assistance from staff for all cares and transfers and
-Had a treatment for [REDACTED].
Record review of the resident’s medical record showed there was no Weekly Skin Assessment
documentation found for (MONTH) (YEAR).
Record review of the resident’s Physician’s Order Sheet (POS) dated (MONTH) 2019 and
(MONTH) 2019 showed the resident had a physician’s order for the nursing staff to complete
a Weekly Skin Assessments every Wednesday during the evening shift.
Record review of the resident’s TAR dated 2/1/19 to 2/28/19 showed;
-Ammonium [MEDICATION NAME] Cream 12% was not documented as applied on 2/2/19,
2/3/19,2/7/19, 2/11/19, 2/13/19, 2/14/19 and 2/25/19 during the day shift;
-The staff put their initials in the box to show the Weekly Skin Assessments were
completed on every Wednesday during the evening shift on 2/6/19, 2/13/19, 2/20/19, and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
2/27/19, and
-The Weekly Skin Assessment documentation was not found in the resident’s medical record
for the dates the staff put their initials in the box to show the assessment was completed
for (MONTH) 2019.
Record review of the resident’s progress note dated 2/27/19 at 10:43 P.M. showed:
-The resident was out of facility to a dermatology appointment;
-He/she returned with orders for [MEDICATION NAME] 2.5 % topical cream to be applied to
the affected skin on the resident’s face and [MEDICATION NAME] cream to be used on
affected areas on his/her body and
-The resident’s physician’s orders was updated and faxed to the pharmacy,
Record review of the resident’s POS dated (MONTH) 2019, showed the resident had
physician’s order for:
-[DIAGNOSES REDACTED].
-[MEDICATION NAME] Cream 2.5% apply to face only two times a day for skin plaques with
Lichenification (is when your skin becomes thick and leathery);
-[MEDICATION NAME] Cream 0.1% (is a topical corticosteroid medication prescribed to
relieve skin inflammation, itching, dryness, and redness) to apply to face, torso, groin
topically during the day and evening shift for Psoriasis;
-Ammonium [MEDICATION NAME] Cream 12% apply to both upper extremities, both lower
extremities topically during the day and evening shifts for skin itching and
-Weekly Skin Assessments to be completed every Wednesday during the evening shift.
Record review of the resident TAR for (MONTH) 2019 showed a physician’s order for
[MEDICATION NAME] Cream 0.1% to apply to face, torso, groin topically during the day and
evening shift for Psoriasis was not written on the (MONTH) 2019 TAR.
Record review of the resident’s TAR dated 3/1/19 to 3/28/19 showed Ammonium [MEDICATION
NAME] Cream 12% was not documented as given during the day shift on 3/1/19, 3/3/19,
3/4/19, and 3/6/19.
Record review of the resident’s weekly skin assessment started on 3/6/19 showed;
-The resident’s skin was intact and he/she had no open areas and
-The staff did not document the resident skin issues caused by his/her Psoriasis on on
3/6/19.
Record review of the resident’s Bath Sheet dated 3/6/19 showed the resident:
-On the body diagram that shows the from part of the body there were three areas marked
with a circle and on the body diagram that shows the back part of the body there were
three areas marked with a circle;
-There were no detail documentation found for any of the resident’s areas that were
circled and
-The bath sheet had been signed off by the charge nurse and the Certified Nursing
Assistant (CNA).
Observation on 3/8/19 at 8:16 A.M. showed the resident was lying in his/her bed and had
patches of discolored skin and very dry skin on his/her legs, arms, and face.
Record review of the resident’s weekly skin assessment dated [DATE] showed:
-The resident’s skin was intact and he/she had no open areas and
-During the evening shift, the staff applied cream to the resident’s areas as ordered.
During an interview on 3/14/19 at 9:10 A.M., CNA D said:
-He/she would document on the resident’s bath sheet any issues by marking the yes by the
question and then by circling the area on the body figure and document the issue at the
site circled;
-Would notify the charge nurse to come and observe the issue and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
The resident has a chronic skin condition that is ongoing.
During an interview on 3/14/19 at 9:30 A.M., Licensed Practical Nurse (LPN) B said:
-He/she was not aware of the new treatment ordered for the resident and
-The resident’s skin assessment are done on the evening shift and he/she had not been
notified of any skin issues.
During an interview on 3/14/19 at 10:41 A.M., Director of Nursing (DON) said he/she
expected the nursing staff to complete a weekly skin assessment and to follow-up on any
skin issues.

F 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that feeding tubes are not used unless there is a medical reason and the
resident agrees; and provide appropriate care for a resident with a feeding tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure physician
order included coordination of the resident’s bolus tube feeding (Bolus feeding is a type
of feeding method using a syringe to deliver formula through your feeding tube-a medical
device used to provide nutrition to patients who cannot obtain nutrition by swallowing)
and pleasure feeding meals to maintain adequate nutrition intake; and to ensure to have
detail care plan for the resident bolus tube feedings and pleasure feeding, for one sample
resident (Resident #35) out of 17 sampled residents. The facility census was 68 residents.
1. Record review of Resident #35’s Admission Record showed he/she was admitted to the
facility on [DATE] and had a [DIAGNOSES REDACTED].
Record review of the resident’s Admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 12/31/18 showed
he/she:
-Was not cognitively impaired and no issue with short term and long term memory problems;
-Was able to understand others and make his/her needs known;
-Required limited assistant from staff for all cares and transfer and
-Had a feeding tube for all nutritional needs.
Record review of the resident’s Physician’s Order Sheet (POS) dated 2/1/19 to 2/28/19
showed physician’s orders for:
-Pleasure feedings for a regular mechanical soft diet with thin liquids consistency;
-[MEDICATION NAME] 1.5 calorically (Cal, is a calorically dense liquid food with a
patented fiber blend that provides complete, balanced nutrition) of 237 milliliter (ml) of
supplement, to be administered through the feeding tube, to be given by bolus tube
feedings (or gravity feeding, is a type of feeding method using a syringe to deliver
formula through a feeding tube) four times a day at 8:00 A.M., 12:00 P.M., 4:00 P.M., and
8:00 P.M.,
–For a total volume of 948 ml in a 24 hour period;
-Every shift to check and record the residual (the amount of fluid remaining in the
stomach at a point of time during enteral tube feedings) If residual is greater than 150
ml, hold tube feeding and call the resident’s physician;
-There were no physician’s orders guide the staff on what to do if the resident eats a
sufficient amount of food and does not need his/her bolus feeding and
-The resident bolus feedings are at the same time as the meals are being served at 8:00
A.M., 12:00 P.M., 4:00 P.M. there were no guidance for the staff if the resident wants to
eat.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
Record review of the resident’s Care Plan dated 2/11/19, showed he/she:
-Did not have a care plan related to his/her bolus tube feedings and
-Did not have a care plan related to the coordination and monitoring of his/her bolus tube
feedings and his/her pleasure feedings, including fluid intake by mouth.
Record review of the resident’s Weight Change Progress notes dated 2/11/2019 at 2:52 P.M.,
showed:
-The resident had a 7.5% loss of body weight;
-The resident frequently refuses his/her bolus tube feeding;
-The resident is also on a regular mechanical soft diet with thin liquids;
-The plan to offer the resident snacks between meals and
-The resident had been eating his/her meals well.
Record review of the resident’s Dietary progress notes dated 2/28/2019 at 12:57 P.M.,
showed a late entry was made for the resident:
-Was on a mechanical soft diet with thin liquids for pleasure feedings;
-Had been attending many meals in the dining room and he/she had been eating fair
according to the staff;
-Continues be on [MEDICATION NAME] 1.5 cal supplemental via bolus tube feedings of 237 ml,
four times a day;
-Frequently refuses his/her bolus tube feedings;
-Receives water flushes for medications only;
-Had a recommendation from the [MEDICAL TREATMENT] clinic ,that his/her 175 ml of water
flush to be stopped since the resident was consuming fluids by mouth;
-Weight was 174.8 pounds and was down 6.8% in 30 days;
-Weight fluctuates due to [MEDICAL TREATMENT], but his/her refusal of bolus feedings could
be contributing to the weight loss and
-The facility staff will continue to encourage the resident to take his/her bolus feeding
or to eat better at meal times.
Record review of the resident’s POS dated 3/1/19 to 3/31/19 showed a physician’s order
for:
-Pleasure feedings, and for a regular mechanical soft diet with thin liquids consistency;
-[MEDICATION NAME] 1.5 cal of 237 ml of supplement, to be given by bolus tube feedings
four times a day at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M., for a total of 948 ml
in a 24 hour period;
-There were no physician’s orders guide the staff on what to do if the resident eats a
sufficient amount of food and does not need his/her bolus feeding and
-The resident bolus feedings are at the same time as the meals are being served at 8:00
A.M., 12:00 P.M., 4:00 P.M. there were no guidance for the staff if the resident wants to
eat.
Observation on 3/11/19 at 8:28 A.M., showed the resident:
-Was eating his/her meals in 3rd floor dining room;
-The resident had to clear his/her throat several times;
-The Speech Therapist was present and was monitoring the resident and other residents and
-The resident was able to feed himself/herself, and ate about 50-75% of his/her meal.
Record review of the resident’s Treatment Administration Record (TAR) dated 3/1/19 to
3/12/19 showed a physician’s orders for:
– [MEDICATION NAME] 1.5 cal of 237 ml of supplement, to be given by bolus feedings four
times a day at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. for a total of 948 ml in a
24 hour periods;
-From 3/9/19-3/12/19 at 4:00 P.M. the resident refused his/her bolus tube feedings;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
-From 3/9/19-3/12/19 the staff documented the resident received his/her bolus tube
feedings or the resident refused his/her bolus tube feedings;
-The staff did not document on 3/6/19 at 4:00 P.M. if the resident received or refused
his/her bolus tube feedings and
-The staff did not document on 3/1/19 and 3/6/19 if the resident refused or received
his/her 8:00 P.M. bolus tube feeding.
Record review of the resident’s food intake sheet dated 3/1/19 to 3/13/19 showed he/she:
-Had eaten 76% to 100% of his/her breakfast meal on 3/5/19, 3/10/19 and 3/13/19;
-Had eaten 51% to 75% of his/her breakfast meal on 3/6/19, 3/7/19 and 3/8/19;
-Had eaten 76% to 100% of his/her lunch on 3/6/19, 3/10/19 and 3/13/19, and ate 76% to
100% of his/her supper on 3/8/19;
-Had a snack on 3/1/19, 3/6/19, 3/7/19, 3/8/193/12/19 and 3/13/19 and
-The staff did not document the resident’s dietary intake and snack intake from 3/1/19 to
3/13/19.
Record review of the resident’s most recent bolus tube feeding Care Plan dated 3/12/19,
showed the resident:
– Was dependent on tube feeding for his/her nutrition and received water flushes, see
physician’s order for current tube feeding orders;
-[MEDICATION NAME] 1.5 supplement to be given by bolus tube feedings four times a day;
-Did not document the resident’s non-complaint with the bolus tube feeding and
-Did not have a care plan related to the coordination and monitoring of his/her bolus tube
feedings and his/her pleasure feedings at meal time.
Record review of the resident’s meal intake for (MONTH) 2019 showed the staff did not
document the resident’s meal intake for all meals from 3/1/19-3/4/19 and did not document
the meal intake for the evening meal on 3/5/19, 3/6/19, 3/9/19 and 3/10/19. ,
During an interview on 3/14/19 at 9:24 A.M., Licensed Practical Nurse (LPN) B said:
-The resident has physician orders for bolus tube feeding four times a day and for
pleasure feeding;
-The Registered Dietician (RD) and the resident’s physician are aware of the resident
refusing his/her bolus tube feedings;
-They do not always document the resident meal intake;
-Do not have specific order related coordination of bolus feedings and the pleasure
feeding and
-Should have detail physician’s order tailored to the resident current nutritional choices
to include if eating certain percentage of oral meals what the recommendation would be for
the resident.
During an interview on 3/14/19 at 11:29 A.M., the Director of Nursing (DON) said;
-The facility staff had discussion about all residents on tube feeding supplements during
morning meeting;
-The resident did not have a Care Plan for his/her bolus tube feeding until 3/12/19;
-The care team should had been coordinating and monitoring the resident’s bolus tube
feedings and his/her pleasure feedings to include a tailored nutritional plan for the
resident due to his/her current nutritional choices and
-His/her expectations were for the staff to obtain a detail physician’s order for the
coordination and monitoring the resident’s bolus tube feedings and his/her pleasure
feedings.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 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
coordination of care between the facility and the [MEDICAL TREATMENT] (a process for
removing waste and excess water from the blood, and is primarily used to provide an
artificial replacement for lost kidney function in people with [MEDICAL CONDITION]) center
was maintained to ensure the continuum of care for one sampled resident (Resident #163);
to ensure monitoring and detail documentation of the resident’s [MEDICAL TREATMENT], and
to obtain physician’s order for the monitoring of the resident’s [MEDICAL TREATMENT] for
two sampled residents (Resident #35 and #163) out of 17 sampled residents. The facility
census was 68 residents.
Record review of the facility’s [MEDICAL TREATMENT] Access Care policy and procedure dated
10/2020, showed:
-Care involves the primary goals of preventing infection and maintaining patency of the
catheter (preventing clots);
-To prevent infection and/or clotting, keep the access site clean at all times, Check for
signs of infection at the access site when performing care and at regular intervals, do
not use the arm to check blood pressure, advise the resident not to sleep on, wear tight
jewelry or lift heavy objects with the access arm; check the color and temperature of the
fingers, and the radical pulse of the access arm when performing routine care and at
regular intervals; check the patency of the site at regular intervals. Palpitate (feel)
the site to check the thrill (vibration) or use a stethoscope to hear the bruit (swooshing
sound caused by blood moving through the access site);
-Care immediately following [MEDICAL TREATMENT] (the clinical purification of blood as a
substitution for the function of the kidneys) treatment: the dressing change is done in
the [MEDICAL TREATMENT] center post treatment. If the dressing becomes wet, dirty, or not
intact, the dressing should be changed by a licensed nurse trained in this procedure. Mild
bleeding from the site is expected. Apply pressure to the insertion site and notify the
[MEDICAL TREATMENT] center. If there is major bleeding, apply pressure to the insertion
site and contact emergency services and the [MEDICAL TREATMENT] center and
-The nurse should document in the resident’s medical record the location of the [MEDICAL
TREATMENT] site, condition of the dressing, if [MEDICAL TREATMENT] was done during the
shift, any part of report from the [MEDICAL TREATMENT] center post-[MEDICAL TREATMENT]
being given and observations post [MEDICAL TREATMENT].
1. Record review of Resident #163’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED]., [MEDICAL CONDITION] (increased pressure in the eye
causing a gradual loss of eyesight), amputation of bilateral legs below the knee, high
blood pressure, [MEDICAL CONDITION] (formation of blood clots in the veins, particularly
in the lower legs) and sleep disorders.
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 2/13/19, showed
he/she:
-Was alert and oriented;
-Needed moderate to extensive assistance with mobility and transfer, bathing and dressing;
-Needed supervision with eating;
-Was continent and
-Had [MEDICAL CONDITION] diagnosis ([MEDICAL TREATMENT]).
Record review of the resident’s Physician’s Order Sheet (POS) dated 3/2019, showed a
physician’s orders for:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
-[MEDICAL TREATMENT] on Tuesday, Thursday and Saturday;
-On every day shift, clarify the specific days and chair time of [MEDICAL TREATMENT]
(2/12/2019). Remove fistula (an artificial connection between the vein and an artery)
dressing 24 hours after [MEDICAL TREATMENT] treatment and
-There was no physician’s orders for monitoring and checking the resident’s [MEDICAL
TREATMENT] site or for monitoring his/her weight or vital signs (blood pressure,
temperature, pulse and respirations).
Record review of the resident’s Skin observation tool showed:
-3/7/19-no skin issues;
-3/5/19-no skin issues;
-2/26/19-no skin issues;
-2/21/19-documentation regarding the resident’s wounds healing from an amputation and
-On all of the skin documentation, there was no documentation showing the resident’s
[MEDICAL TREATMENT] site was being checked or monitored.
Record review of the resident’s Nursing Screening Tool dated 2/16/19 showed he/she:
-Was oriented to person place and time with some Dementia;
-Needed assistance due to [MEDICAL TREATMENT] and his/her bilateral [MEDICAL CONDITION];
-Received [MEDICAL TREATMENT] three times per week;
-Had a [MEDICAL TREATMENT] fistula/catheter to his/her left chest wall for [MEDICAL
TREATMENT] and
-Had no open wounds.
Record review of the resident’s Nursing Notes showed:
-on 2/14/19 the nurse received a call from the [MEDICAL TREATMENT] center stating the
resident fell while at [MEDICAL TREATMENT] and hit his/her head and was sent to the
hospital for follow up treatment (the resident was admitted for observation) and
-There were no additional notes referring to the resident’s ongoing [MEDICAL TREATMENT]
treatments, any changes in treatments or medications, vital signs or weights taken before
or after [MEDICAL TREATMENT] treatments or any additional communication between the
[MEDICAL TREATMENT] center and the facility to show a coordination of care and services
was continual.
Record review of the resident’s [MEDICAL TREATMENT] Communication Sheet showed:
-An area at the top of the form where the nursing staff was to complete pre and post
[MEDICAL TREATMENT] weights, vital signs, any medication changes, social issues and
concerns the [MEDICAL TREATMENT] staff should be aware of and
-At the bottom of the form it showed the [MEDICAL TREATMENT] staff should complete
information showing the resident’s weight before and after [MEDICAL TREATMENT], vital
signs before and after [MEDICAL TREATMENT], report on the [MEDICAL TREATMENT] treatment
and occurrences during the resident’s [MEDICAL TREATMENT] treatment.
Record review of the resident’s [MEDICAL TREATMENT] Treatment forms showed:
-The form was only completed on 2/9/19, 2/14/19 and 2/19/19;
-On 2/9/19 and on 2/14/19, the facility did not document the resident’s vital signs after
returning from [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] center completed the residents
weights and vital signs before and after his/her [MEDICAL TREATMENT] treatment;
-On 2/19/19 the facility did not document the resident’s vital signs and weights before or
after [MEDICAL TREATMENT] and there was no documented response from the [MEDICAL
TREATMENT] center. The facility documented the resident had a fall and sustained a bruise
to his/her head and was sent to the hospital and
-There were no [MEDICAL TREATMENT] communication forms documented after 2/19/19.
Record review of the resident’s Treatment Administration Record (TAR) showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
-On (MONTH) 2019 showed a physician’s order to remove the resident’s fistula dressing 24
hours after his/her [MEDICAL TREATMENT] treatment. Documentation showed the nursing staff
followed the orders everyday except on 2/11/19, 2/14/19 (due to hospitalization ),
2/18/19-2/20/19. There was no documentation showing the nursing staff checked the site for
thrill or bruit and
-On (MONTH) 2019-showed a physician’s order to remove the resident’s fistula dressing 24
hours after his/her [MEDICAL TREATMENT] treatment. Documentation showed the nursing staff
followed the orders. There was no documentation showing the nursing staff checked the site
for thrill or bruit.
Record review of the resident’s Care Plan showed there was no care plan regarding [MEDICAL
TREATMENT] treatment and interventions in the resident’s electronic or paper record. The
Care Plan was requested from staff on 3/12/19 at 1:00 PM. and was received on 3/13/19.
Record review of the resident’s Care Plan dated 3/12/19, showed the resident required
[MEDICAL TREATMENT] due to a history of [MEDICAL CONDITION]. Interventions instructed
facility staff to:
-Check and change the resident’s dressings daily at his/her access site;
-Do not draw blood or take blood pressure in the resident’s arm with the graft;
-Encourage the resident to go for the scheduled [MEDICAL TREATMENT] appointments;
-Monitor the resident for dry skin and apply lotion as needed;
-Monitor the resident’s labs and report to the physician as needed;
-Monitor, document and report to the resident’s physician as needed any signs and symptoms
of depression, and obtain an order for [REDACTED].>-Monitor, document and report to the
physician any signs and symptoms of infection to the resident’s access site;
-Monitor, document and report to the resident’s physician any sign and symptom of [MEDICAL
CONDITION];.
-Notify the nephrologist or [MEDICAL TREATMENT] center immediately in case of no pulse,
vibration (thrill) in the fistula or graft, pus draining from the fistula, redness or
swelling in the accessed arm, enlarging hematoma or pain in the accessed arm, coldness,
numbness aching or weakness of the accessed arm;
-Obtain vital signs and weight per protocol. Report significant changes in pulse, blood
pressure and respirations immediately and
-Work with the resident to relieve discomfort for side effects of the disease and
treatment.
Observation and interview on 3/7/19 at 11:28 A.M., showed the resident:
-Was sitting in his/her wheelchair;
-Was alert, oriented, was dressed for the weather and was groomed appropriately;
-Had bilateral amputations to his/her lower legs and did not have prosthetics and
-Said he/she was blind and could not see, went to [MEDICAL TREATMENT] three times weekly
on Tuesday, Thursday and Saturday, and he/she had been going to [MEDICAL TREATMENT] for
several years. The resident said the nursing staff set up his/her transportation and they
also checked his [MEDICAL TREATMENT] site (he/she had no issues with the nursing staff
care).
During an interview on 3/13/19 at 9:18 A.M.,Licensed Practical Nurse (LPN) B said:
-The resident has [MEDICAL TREATMENT] three times weekly;
-He/she sends the [MEDICAL TREATMENT] communication paperwork with the resident every time
he/she went to [MEDICAL TREATMENT], but the [MEDICAL TREATMENT] center does not always
send it back or if it comes back, they don’t always fill it out;
-Sometimes the resident forgets to or does not give the sheet to the [MEDICAL TREATMENT]
center;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
-He/she has had to call the [MEDICAL TREATMENT] center to request the information (vital
signs, weights changes in medications etc.) when they have not sent the form back or
completed it;
-He/she had not called to request the information every time the resident did not return
with the form;
-The only time the [MEDICAL TREATMENT] center has called is when something has happened at
[MEDICAL TREATMENT]-for example, when they had to send the resident out after he/she fell
while at [MEDICAL TREATMENT];
-The facility used a different [MEDICAL TREATMENT] center for other residents, and they do
not have the same issues with getting the return paperwork or information;
-When the resident leaves for [MEDICAL TREATMENT], it is at the time when his/her shift is
ending and he/she did not see the resident when he/she returned to be able to check to see
if he/she brought the form back or if the [MEDICAL TREATMENT] center filled the
information out;
-The facility nursing staff was supposed to weigh the resident and enter his/her vital
signs and any pertinent information on the form to communicate to [MEDICAL TREATMENT] and
after the resident returned from [MEDICAL TREATMENT] they were supposed to weigh the
resident and completed vital signs. All of this information should be documented on the
[MEDICAL TREATMENT] communication form;
-He/she was not sure if the nursing staff weigh him/her or take his/her vital signs once
he/she returned but it should be documented on the communication form;
-When the resident comes back to the facility, the nursing staff is supposed to file the
[MEDICAL TREATMENT] communication log in the resident’s file;
-Record review of the resident’s medical record showed the resident had three [MEDICAL
TREATMENT] communication logs that were not completely filled out;
-There should be a [MEDICAL TREATMENT] communication log filled out every time the
resident goes to [MEDICAL TREATMENT] and they had not been ensuring that occurred and
-They check the resident’s [MEDICAL TREATMENT] site, on the days he/she comes from
[MEDICAL TREATMENT] and remove his/her dressing, but they did not check the site daily.
During an interview on 3/13/19 at 2:57 P.M., The Director of Nursing (DON) said:
-The nurse was supposed to send the [MEDICAL TREATMENT] communication sheet (with the
resident to [MEDICAL TREATMENT]) in hopes that the [MEDICAL TREATMENT] center will send
back information regarding what occurred at [MEDICAL TREATMENT] (the resident’s labs,
vitals and weights);
-They seldom receive this information from the [MEDICAL TREATMENT] center;
-The [MEDICAL TREATMENT] center will call if there is an issue but that was it;
-He/She does not expect nursing staff to call the [MEDICAL TREATMENT] center to obtain the
resident’s vital signs weights;
-He/She expects the facility nurse to complete the resident’s vital signs and weights (and
to fill out the top of the [MEDICAL TREATMENT] communication form) before and after
[MEDICAL TREATMENT];
-The facility nursing staff are supposed to monitor the resident’s [MEDICAL TREATMENT]
site-observe the site and check the thrill and bruit after the resident comes back from
[MEDICAL TREATMENT];
-Documentation that they are checking and monitoring the resident’s fistula site should be
on the resident’s orders and TAR and the nursing staff should document that they checked
it on the TAR;
-The DON reviewed resident’s POS and TAR and said he/she did not see orders to check the
thrill and bruit on either document and did not see where the nurses had been checking the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
resident’s thrill and bruit. He/she said he/she will correct that. and
-He/she looked at the resident’s care plan and did not see a care plan for [MEDICAL
TREATMENT] so he/she developed it on 3/12/19.
2. Record review of Resident #35’s Admission Record showed he/she was admitted to the
facility 12/21/18 and had a [DIAGNOSES REDACTED].>-Acute Kidney failure;
-[MEDICAL CONDITION] and
-Dependence on [MEDICAL TREATMENT]
Record review of the resident’s Progress note dated 12/28/2018 at 2:06 P.M. showed;
-The resident’s Tussio catheter ([MEDICAL TREATMENT]) was secured on his/her right
shoulder;
-Had no bleeding, irritation or redness of the site and
-The resident denied any pain or other complaints voiced.
Record review of the resident’s Admission MDS dated [DATE] showed he/she:
-Was not cognitively impaired and no issue with short term and long term memory problems;
-Was able to understand others and make his/her needs known;
-Required limited assistant from staff for all cares and transfer and
-Was receiving [MEDICAL TREATMENT] services.
Record review of the resident’s nursing Weekly Skin Assessment showed;
-The staff documented the resident had a [MEDICAL TREATMENT] Access site in place on
2/28/18, 1/4/19, 1/18/19, 1/25/19, 2/1/19 and 2/8/19;
-The documentation did not include a detail nursing assessment of the resident’s [MEDICAL
TREATMENT] and
-Documentation did not describe where the placement of the [MEDICAL TREATMENT] or what
type of [MEDICAL TREATMENT] access the resident had.
Record review of the resident’s POS for (MONTH) 2019 showed:
-The resident’s had a physician’s order for [MEDICAL TREATMENT] at a local clinic on every
Tuesday, Thursday, and Saturday, pickup was by a community transportation at 10:00 A.M.
and
-Had no physician orders for the monitoring of the resident’s [MEDICAL TREATMENT] central
venous catheter (CVC,
that is place in a large vein usually at the clavicle area).
Record review of the resident’s Care Plan dated 2/11/19 showed:
-The resident needs [MEDICAL TREATMENT];
—Check and change the [MEDICAL TREATMENT] access dressing daily and to document
findings;
—Obtain the resident’s vital signs and weight per protocol;
—Monitor/document for [MEDICAL CONDITION];
—Report significant changes in pulse, respirations and BP immediately and
—Monitor, document and report to the resident’s physician as needed any signs and
symptoms of infection to the [MEDICAL TREATMENT]: Redness, swelling, warmth or drainage.
Review of the resident’s progress notes dated 2/28/2019 at 12:57 P.M., Dietary Note Late
Entry showed the resident:
-Continues on [MEDICAL TREATMENT] services and at times refuses to go;
-Receives water flushes for medications only;
-[MEDICAL TREATMENT] clinic had recommended that the 175 mililiters (ml) flush to be
stopped since he/she was consuming fluids by mouth;
-Weight was 174.8 pounds and had a weigh loss of 6.8% in 30 days and
-Weight fluctuates due to [MEDICAL TREATMENT], but refusal of bolus tube feedings could be
contributing to the resident’s weight loss.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
Record review of the resident’s Physician’s Progress Note dated 2/18/2019 at 9:26 P.M.
showed the resident:
-Had a [DIAGNOSES REDACTED].
-Continues go to [MEDICAL TREATMENT] clinic three times a week, but he/she has missed on
occasion.
Record review of the resident’s POS for (MONTH) 2019 showed the resident did not have a
physician’s order for the monitoring of the resident’s [MEDICAL TREATMENT] Central Venous
Catheter and for the monitor the resident before or after his/her [MEDICAL TREATMENT]
visit.
Observation on 3/11/19 8:28 A.M. showed the resident had [MEDICAL CONDITION] in his/her
feet and ankles and had a dressing on the right upper shoulder chest area that covered
his/her [MEDICAL TREATMENT] access port.
Record review of the resident’s hard chart and electronic medical record showed:
– The nursing staff did not document in detail the monitoring of the resident or of
his/her [MEDICAL TREATMENT] after returning from [MEDICAL TREATMENT] and
-The nursing staff did not document the monitoring of the resident’s [MEDICAL TREATMENT]
on non-[MEDICAL TREATMENT] clinic days.
During an interview on 3/13/19 at 9:24 A.M., LPN B said:
-The facility sends a [MEDICAL TREATMENT] communication sheet with the resident and
-The resident should be monitored when returns from [MEDICAL TREATMENT] to include vital
signs, weight, monitoring of the [MEDICAL TREATMENT] shunt on the communication sheet and
in the resident’s medical record.
During an interview on 3/13/19 at 11:25 A.M., Certified Medication Technician (CMT) C and
Certified Nursing Assistant (CNA) C said:
-When the resident returns from the [MEDICAL TREATMENT] clinic, they offer the resident a
sandwich, to lay down, [MEDICAL TREATMENT] have taken the vital sings before the resident
left the clinic;
-CNAs would check the resident’s vital and weight before the resident leaves the facility
for [MEDICAL TREATMENT] and
-Unsure if nursing staff check the resident when the residents returns from [MEDICAL
TREATMENT].
During an interview on 3/13/19 at 11:45 P.M., LPN D said:
-The [MEDICAL TREATMENT] residents vital signs are taken before they leave and after they
return to the facility;
-When the resident returns from [MEDICAL TREATMENT] the nursing staff should check
[MEDICAL TREATMENT] access dressing, the fistula or the resident’s [MEDICAL TREATMENT] for
the thrill and bruit and
-Would document the findings in the resident’s MAR indicated [REDACTED].
During an interview on 3/14/19 at 10:41 A.M., with DON, related to the assessment and
physician order for [REDACTED].>-Nursing staff are expected to have detail
documentation in the resident’s nurses MARs and TARs and in the nursing progress notes for
the findings of the assessment and monitoring of the resident’s [MEDICAL TREATMENT] access
fistula site or CVC and monitor of the resident’s vital signs; and
-Should have obtained a physician’s order for the assessment and the monitoring of the
resident’s [MEDICAL TREATMENT] Central Venous Catheter or the fistula for the thrill and
bruit and monitor the resident’s vital signs after the resident returns from [MEDICAL
TREATMENT] and on the days the resident does not go to [MEDICAL TREATMENT].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0740

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident must receive and the facility must provide necessary behavioral
health care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to do a initiate a
follow up evaluation and treatment when the resident began exhibiting behaviors that were
identified by the facility and to care plan interventions in response to the resident’s
behaviors, once the behaviors were identified, timely for one sampled resident (Resident
#163) out of 17 sampled residents. The facility census was 68 residents.
1. Record review of Resident #163’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED]., [MEDICAL CONDITION] (increased pressure in the eye
causing a gradual loss of eyesight), amputation of bilateral legs below the knee, high
blood pressure, [MEDICAL CONDITION] (formation of blood clots in the veins, particularly
in the lower legs) and sleep disorders.
Record review of the resident’s Preadmission Screening and Resident Review (PASSAR) level
I screening dated [DATE], showed he/she had no history of a major mental disorder and no
signs of a mental disorder at the time of the screening. It showed the resident had no
serious problems in functioning and had no psychiatric treatment in the past two years. No
level II screening was warranted.
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated [DATE], showed
he/she:
-Was alert and oriented;
-Needed moderate to extensive assistance with mobility and transfer, bathing and dressing;
-Needed supervision with eating;
-Was continent;
-Had [MEDICAL CONDITION] diagnosis ([MEDICAL TREATMENT]) and
-Did not have any psychiatric [DIAGNOSES REDACTED].
Record review of the resident’s Physician’s Order Sheet (POS) dated ,[DATE] showed there
were no physician’s orders for any anti-psychotic, anti-hypnotic, anti-anxiety or
anti-depressant medications.
Record review of the resident’s Social Service Notes showed:
-On [DATE], the resident was wheeled to this writer’s office insisting on getting a cab to
run errands. (He/she) demanded this writer to call a cab to pick (him/her) up. This writer
stated that lunch is being served in less than 30 min. and (he/she) is diabetic, plus it
is raining outside and (there are) concerns with (his/her) vision problems. (The resident)
irritably said, I don’t care. This writer then asked if (he/she) wanted (his/her) sisters
to be called to pick (him/her) up. (He/she) stated no, a cab was called and the resident
left and
-On [DATE], Admit Note: The resident was admitted to the facility on [DATE], from home and
is in the facility for long term care. The resident wouldn’t participate in the interview
process. He/she said that he/she didn’t want to answer any questions. He/she doesn’t have
glasses, and has difficulty seeing. He/she doesn’t wear dentures or hearing aids. They
discussed advanced health care directives and the resident is a Full Code. The resident
was insisting to go to the bank today but he/she did not want to talk to anyone. He/she
was rude to staff. The Social Service Director explained that if the resident wanted to
leave, he/she would have to sign out of the building.
Record review of the resident’s Nursing Notes showed:
-On [DATE] the resident’s lab results were reported to the Nurse Practitioner and there

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0740

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
were no new orders but noted the resident was a fall risk and can be non-compliant at
times;
-On [DATE] at 3:42 P.M. of the resident’s Behavior Note Text showed the resident:
– Resident requested pain medicine for a headache from this nurse;
-This nurse assessed pain levels and gave the resident his/her prn (as needed) medication
as ordered; -The resident held (his/her pain medication) without taking it, stating, I’m
going to give these to my son. He works for the DEA. I know all of you f–king nurses are
f–king me around on these pills. I know they’re not the [MEDICATION NAME] and [MEDICATION
NAME] I’m asking for;
-This nurse attempted to educate resident, stating, . you do not have an order for
[REDACTED]. to keep medication at your bedside. So, if you don’t want your medicine,
please give them back to me for proper disposal;
-This nurse will write down what you are taking and you can give that list to your son;
-The resident then became belligerent with this nurse, screaming and cursing about You
stupid b—h! Other people give me [MEDICATION NAME]! Borrow it from someone else! And I
ain’ t giving you back this Tylenol; I’m giving them to my son!
-This nurse continued to try to reason with resident in a calm manner, but resident
continued to scream and curse;
-This nurse did not engage in any further verbal arguments, but attempted to reach for the
Tylenol that was sitting on the resident’s bedside table;
-The resident then reached out and punched this nurse in the stomach, in the leg, and near
the ribs;
-The resident then grabbed this nurse’s wrist and forcibly twisted it, cutting open
nurse’s wrist in the process (the resident wears multiple rings on nearly every finger and
the sharp edges of the jewelry sliced open nurse’s wrist) drawing blood;
-This nurse told the resident to let go and that was assaulting the staff and that was
highly inappropriate and
-The resident continued to yell and attempted to swing on nurse, so this nurse stated, .I
am walking out of your room now. This nurse walked away and alerted other staff members
that if they need to go into (his/her) room to pass medications, provide care, answer call
lights, etc., that they need to take two staff members in at all times for any reason.
Staff stated they understood.
-Record review of the resident’s Nursing Notes showed there was no documentation showing
the facility notified the resident’s family or physician of the resident’s refusal of
care, rude behaviors or physical assault on the nurse. There was no documentation showing
the resident received a referral for behavioral management or assessment once he/she
exhibited aggressive verbal and physical behaviors.
Record review of the resident’s Medical Record showed there was no documentation showing
that a referral was made to the facility’s psychiatrist or psychologist for follow up
evaluation for treatment after the resident exhibited verbal and physical aggression
toward staff.
Record review of the resident’s electronic and paper record showed there was no Care Plan
in the resident’s medical records. The resident’s care plan was requested on [DATE] at
1:00 PM.
Record review of the resident’s Care Plan showed the initial care plan was dated [DATE].
The resident’s comprehensive care plan showed there was a behavioral care plan that showed
the resident had mood problems that fluctuated throughout the day, and had behaviors as
evidenced by yelling, cursing and hitting staff. The initiation of the care plan for mood
and behavior interventions was dated [DATE]. The interventions showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0740

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 23)
-Allow the resident time to verbalize feelings, thoughts without rushing him/her and
listen attentively;
-Discuss with the physician and family regarding his/her ongoing need for medication;
-Monitor/document/report to the nurse and physician ongoing signs/symptoms of depression
unaltered by antidepressant medications;
-Monitor/document/report to the physician when the resident is at risk for harming others;
-Observe for signs and symptoms of mania, racing thoughts, euphoria, increased
irritability, frequent mood changes, pressured speech, flight of ideas, marked change in
need for sleep, agitation or [MEDICAL CONDITION];
-The resident needs encouragement, assistance and support to maintain as much independence
and control as possible;
-Administer medications as ordered and document/monitor for side effects and
effectiveness;
-Monitor behavior episodes and attempt to determine underlying cause-consider location,
time of day, persons involved and situations. Document behavior and potential causes;
-Provide a program of activities that interest the resident and accommodate his/her needs;
-Anticipate and meet the resident’s needs;
-Intervene as necessary to protect the rights and safety of others. Approach and speak to
the resident in a calm manner. Divert his/her attention. Remove the resident from the
situation and take him/her to an alternate location as needed;
-Explain all procedures to the resident before starting and allow the resident time to
adjust to changes.
-If reasonable, discuss the resident’s behaviors. Explain/reinforce why behaviors are
inappropriate and/or unacceptable;
-Minimize potential for the resident’s disruptive behaviors by offering tasks which divert
attention and
-Praise any indication of the resident’s progress/improvement in behavior.
Observation and interview on [DATE] at 11:28 A.M., showed the resident was sitting in
his/her wheelchair in his/her room. He/she was alert and oriented, dressed for the weather
and was groomed appropriately. He/she had bilateral amputations to his/her lower legs and
did not have prosthetics. The resident said that he/she was blind and could not see.
He/she said that his/her only concern was that he/she thought the nursing staff had given
him/her outdated medication, but upon further interview, the resident was unable to say
what medication was given, dosage, when the expiration date was or how he/she knew the
medication was expired. The resident could not state when this incident had occurred.
During this interview, the resident said that his/her son was a Drug Enforcement Agency
(DEA) agent, another son was a Central Intelligence Agency (CIA) agent, his/her
brother-in-law was the Mayor of Kansas City and he/she had a nephew who worked for CBS
(television station) and CBS had come to the facility and investigated the issue with
his/her medication and it was on the news (on television). He/she did not state any
additional concerns about the facility or staff that he was able to express at this time.
He/she did not discuss his/her behaviors while at the facility.
During an interview on [DATE] at 9:05 A.M., Licensed Practical Nurse (LPN) B said:
-The resident had not been in the facility for very long;
-He/she was a new admission (since [DATE]);
-Since his/her admission they have found that he/she does have behaviors and can be very
derogatory towards staff, very verbally abusive (name calling, short tempered) and has
been physically abusive toward a nurse once (documented in the nursing notes);
-The resident is not on any [MEDICAL CONDITION] medications and did not know if he had a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0740

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 24)
psychiatric history;
-The facility had a Psychiatrist who visited every three months and as needed and a
Psychologist who visited every two weeks and as needed;
-The resident had not been seen by the Psychiatrist or Psychologist and was not on the
list to see either person;
-When the resident has behaviors they try to redirect the resident, leave the resident
alone and call the Social Service Director to speak with the resident;
-The resident is his/her own responsible party;
-The resident stays in his/her room most of the time and does not want to come out even
though they try to get him/her to come out for activities and meals;
-The resident has not been verbally or physically abusive to any of the residents. He/she
stays in his/her room most of the time and does not interact with other residents;
-He/she had not had any verbal or physical aggression toward his/her roommate outside of
normal occasional disagreements;
-He/she was not working on the day when the resident hit the nurse, but he/she found out
about the incident in report and
-The resident has had no further incidents of physical aggression.
During an interview on [DATE] at 2:57 P.M., the Director of Nursing (DON) said:
-The behaviors the resident has exhibited started last week, when he/she threatened and
kicked a nurse;
-He/she has been refusing cares and was angry about his/her health status;
-He/she did not receive the report that the resident kicked the nurse until well after the
incident occurred (the nurse did not immediately inform him/her of the incident when it
occurred);
-The resident was admitted to the facility from home, so they did not have any prior
history of his/her behaviors;
-He/she remembered that initially, he/she thought the facility’s licensed Psychologist saw
the resident but he/she did not know if there was any documentation of that;
-He/she wrote the resident’s behavioral care plan yesterday because he/she saw that there
was no care plan in his/her medical record;
-They would notify the resident’s family and physician of the resident’s behaviors and try
to have the resident seen by the psychiatrist at the facility or transferred to have a
psychiatric evaluation completed;
-They would have sent the resident out after the incident occurred if he/she had been
informed that the resident had hit and kicked the nurse and
-The current plan is to have the resident evaluated for possible psychiatric treatment
since they have no record of the resident having a psychiatric history and is not
prescribed any [MEDICAL CONDITION] medications.

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 to
monitor for out dated medical supplies; to ensure the medication room door was kept closed
and locked when unattended by authorized licensed staff and to store, label and date

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
medications correctly in two out of the three medications rooms and in one out of the four
sampled medication carts. The facility census was 68 residents.
1. Observation on [DATE] at 12:15 P.M., of the first floor medication room with Registered
Nurse (RN) C showed:
-Had six boxes of Glucose Control that had expired on [DATE];
-Had five Foley insertion tray kits with a 5 centimeter (cc) catheter that had expired on
,[DATE] and
-Had a open bottle of [MEDICATION NAME] Purified Protein Derivative (TB) bottle dated
[DATE], which was past 30 day date.
Observation on [DATE] at 12:15 P.M., of the first floor medication cart with RN C showed;
-Resident #164 had a vial of Humalog (insulin) 100 unit/milliliters (ml), the vial did not
have date on the bottle when was opened and
-Resident #1001 [MEDICATION NAME] HFA(used treatment for [REDACTED].
During an interview on [DATE] at 12:30 P.M. ,with RN C said:
-The nursing staff had just went through the medication rooms and the medication carts;
-The main floor has the facility’s electronic dispensing medication cart (is the most
secure technology to manage controlled medications, STAT/first doses and emergency
medication/supplies-kits) and in the 3rd floor keeps the refrigerator that has a E-Kit
box;
-The nursing staff check the medication carts every shift and
-The unit manger check the medication room and carts every month for any out dated
medications and supplies.
2. Observation on [DATE] at 5:03 A.M. of the Medication Room on the 1st floor showed:
-The medication room door was propped open with trash can;
-Was unable to locate the licensed nursing staff or the Certified Nursing Assistants
(CNA);
-At 5:06 A.M. the CNA was around the corner but not insight of the medication room or the
entrance to the unit;
-At 5:11 A.M., Licensed Practical Nurse (LPN) D came out of a resident’s room, after the
CNA found him/her in the resident’s room and
-The medication room remain open, unlocked and unattended for 30 minutes.
Observation and interview on [DATE] at 5:33 A.M. of the Medication Room on the 3rd floor
showed:
-The medication room door was propped open with trash can;
-The unlocked black box emergency Kit (e-Kit) tag # 934 was sent from pharmacy on [DATE];
-The box that stored the house stock medication had a broken red tag # 5. This box stored
antibiotics, antipsychotic’s , anti-anxiety medications, and pain medications;
-The medication room remained opened and there was no staff near or within eye-site of the
medication room;
-Then CNA M saw that the medication door was left opened and went over closed the door and
said the the medication room door should not be left open;
-An unsupervised medication cart had a bottle of [MEDICATION NAME] (Tylenol) 500 mg on
top, that had been opened on [DATE] and
-The unit had one resident in the hallway, three CNA’s staff that was in and out of the
resident’s room, while the medication room door was left propped open and with the
medication visible and unsupervised on top the medication carts.
3. Observation on [DATE] at 8:30 A.M., of the 3rd floor medication room with LPN B showed:

-The black E-Kit box was unlocked with the broken E-Kit tag # 934;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
-The box that stored the house stock medication had broken red tag # 5 and was unlocked.
The house stock medication box had antibiotics, anti-psychotics , anti-anxiety
medications, controlled substance pain medications stored in it;
– Inside the house stock medication box was a was faxed sheet that listed the medications
that were stored in that box;
– Resident #9 had a bottle of [MEDICATION NAME] 2 milligram (mg) per milliliter (ml),
which did not have a date on the bottle when was opened or the resident’s name and the box
did not have a date on when it was open;
-Had an open bottle of [MEDICATION NAME] Purified Protein Derivative (TB) bottle dated
[DATE], which was past 30 day date;
-Had unwrapped items in a box, one was an enteral feeding gravity bag, and other was
unwrapped [MEDICATION NAME] locked syringe and
-Had two Non conductive connective tubing packages that had expired on ,[DATE] and other
one on expired [DATE].
4. During an interview on [DATE] at 8:39 A.M., with LPN B said:
-The medication room are monitored nightly by the nursing staff for expired medication and
monthly by the pharmacy during the medication review;
-There should not be any E-Kits any more, since the facility has a electronic dispensing
medication cart for an E-kit;
-He/she was going to call the pharmacy about the open unlocked medication E-kit and
-Medication room doors are not to be left open when not in use.
During an interview on [DATE] at 10:41 A.M., Director of Nursing (DON) said:
-The central supply staff are also responsible for monitoring the medication rooms for
expired over the counter medication and medical supplies;
-The nursing staff are responsible for cleaning the medication rooms monthly and should
check for expiration dates at that time;
-The nursing staff and the CMT’s are to check the expiration date of the stock medication
before administration and should the medication carts are clean every day;
-The TB testing done is by the education nurse and he/she will check for expired TB vials;
-The medication room doors should not be propped open and secure and
-Medication e-kit tags that had been broken need to be replaced with new a one, and the
staff should ensure the E-Kit box is secured and locked at all times when not in use.
During an interview on [DATE] at 4:30 P.M. ,with RN C said:
-The charge nurse are responsible for monitoring the medication rooms and the medication
carts to ensure secure during rounds;
-It not normal practice for nursing staff to leave the medication room door open;
-On [DATE], he/she had found the medication room door open during the morning shift
change;
-He/she had address the concern about the open medication room with the night nurse LPN D,
-It was not the practice of the facility to leave medication room prop open and
-All nursing staff are aware they not to prop the medication room doors open and not to
left unattended.
During an interview on [DATE] at 4:40 P.M. , DON said:
-He/she was not aware the nursing staff had left the medication room door prop open during
the night shift;
-He/she was not aware how long the medication rooms door had been left open on the 3rd
floor or the 1st floor;
-The facility had camera in the medication rooms, but they do not face the doors;
-The night/evening RN supervisor are responsible for making rounds on each floor, and to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
ensure the safe storage of the medication rooms and medication carts, and the safety of
the resident;
-The RN supervisor on night shift on [DATE] was not aware of the medication room being
left prop open and was not aware that the Black medication E-kit was not secure with a
safety tag;
-During DON rounds of the units, he/she has witness nursing staff in past, leaving the
medication room door open for a few minutes, while they were away at the nursing
medication cart, (within eyesight);
-He/she had correct the issue and educate nursing staff at that time on the importance
keep the medication room door shut and securing at all times;
-Charge nurses or unit manger are responsible for ensure the security of the medication
room including the black box e-kit and
-The Black box E-kit had been sent back to the pharmacy.

F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide each resident with a nourishing, palatable, well-balanced diet that meets his
or her daily nutritional and special dietary needs.

Based on observation, interview and record review, the facility failed to check the
temperature of a Potentially Hazardous Food (PHF- a term used by food safety organizations
to classify foods that require time-temperature control to keep them safe for human
consumption, typically these foods contain moisture, protein and neutral to slightly
acidic) chicken after it was cooked. This practice potentially affected at least 64
residents who ate food from the kitchen on 3/7/19. The facility census was 68 residents.
1. Observations on 3/7/19, showed the following:
– At 9:15 A.M., the Dietary Cook (DC) cooked battered chicken in the deep fryer;
– At 9:17 A.M., the DC took out the 1st batch of chicken and did not check the
temperature;
– At 9:18 A.M., the DC placed the 2nd batch of chicken in the deep fryer;
– At 9:21 A.M. the DC took out that batch of chicken and placed on a pan to place in the
oven to keep the chicken pieces warm;
– At 9:35 A.M., the DC placed the 3rd batch of chicken into the deep fryer, and
– At 9:38 A.M., the DC took out the third batch of chicken up without measuring the
temperature of the cooked batch.
During an interview on 3/7/19 at 12:06 P.M., the DC said he/she should have checked the
temperature of the chicken, after it was cooked.
During a phone interview on 3/11/19 at 8:27 A.M., the Registered Dietitian (RD) said
he/she had not done any training with the facility dietary staff in checking the
temperatures of PHFs after they are cooked.
Record review of the 2013 Food and Drug Administration (FDA)
Chapter 3-401.11 Raw Animal Foods, showed:
(A) Except as specified under paragraphs B, C, and D of this section, raw animal FOODS
such as EGGS, FISH, MEAT, POULTRY, and FOODS containing these raw animal FOODS, shall be
cooked to heat all parts of the FOOD to a temperature and for a time that complies with
one of the following methods based on the FOOD that is being cooked:
1) 145ºF (degrees Fahrenheit) or above for 15 seconds for
Raw EGGS that are broken and prepared in response to a CONSUMER’S order and for immediate

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
service,
2) 155 ºF or above for for 15 seconds or the temperature specified in the following chart
that corresponds to the holding time for MECHANICALLY TENDERIZED, and INJECTED MEATS; the
following if they are COMMINUTED: FISH, MEAT, GAME ANIMALS commercially raised for FOOD as
specified under Subparagraph 3-201.17(A)(1), and raw EGGS that are not prepared as
specified under Subparagraph (A)(1)(a) of this section, and
3) 165 ºF or above for 15 seconds for POULTRY, wild GAME ANIMALS as stuffed MEAT, stuffed
pasta, stuffed POULTRY, or stuffing containing FISH, MEAT, POULTRY.

F 0801

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Employ sufficient staff with the appropriate competencies and skills sets to carry out
the functions of the food and nutrition service, including a qualified dietician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure the
Registered Dietician (RD) was scheduled for monthly visits to the facility between the
dates of 6/11/18 and 8/6/18 and between 10/3/18 and 12/17/18. The facility also failed to
provide training to the dietary staff and have a qualified Dietary Manager (DM) in the
kitchen to provide training and leadership to dietary employees in the areas of processing
and tasting of the pureed food and checking temperatures of chicken a Potentially
Hazardous Food (PHF- a term used by food safety organizations to classify foods that
require time-temperature control to keep them safe for human consumption, typically these
foods contain moisture, protein and neutral to slightly acidic). This practice potentially
affected all residents in the facility. The facility census was 68 residents.
1. Record review of the RD Reports dated 4/18 through 2/19, showed the RD did not visit
the facility for a period of 55 days from 6/11/18 through 8/6/18, and for a period of 66
days from 10/3/8 through 12/7/18.
On 3/12/19 at 7:09 P.M., during a written response to a question about the length of time
when the visits did not occur, the RD wrote:
-The company he/she consulted for notified him/her that he/she could not go into a
facility since they had not received payment;
-The RD placed the facility on hold until he/she was told that he/she could go into the
facility, and
-If he/she did not go into a building for a whole month and nonpayment was the reason.
During a phone interview on 3/18/19 from 8:45 A.M. through 8:57 A.M., The owner of the
Registered/Consultant Dietitian’s group, said:
-There were problems with payment to his/her company, because the facility was behind on
payment;
-The times the RD did not go into the facility for nonpayment, training was delayed, and
-Once payment was made, his/her company would work to try and catch up with regular
visits.
During a phone interview on 3/20/19 at 8:39 A.M., the Administrator said:
-The previous dietary services company left the faciity on [DATE];
-When the RD did not visit the facility between 6/11/18 and 8/6/18, it was due to a
payment issue;
-He/she was not sure what the issue was during the RD’s absence between 10/3/18 and
12/7/18 and
-The previous dietary services company left the faciity on [DATE].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0801

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 29)
2. Observations on 3/7/19, showed the following:
– At 9:15 A.M., the Dietary Cook (DC) cooked battered chicken in the deep fryer;
– At 9:17 the DC took out the 1st batch of chicken and failed to check the temperature;
– At 9:18 A.M., the DC placed the 2nd batch of chicken in the deep fryer;
– At 9:21 A.M. the DC took out that batch of chicken and placed on a pan to place in the
oven to keep the chicken pieces warm;
– At 9:35 A.M., the DC placed the 3rd batch of chicken into the deep fryer and
– At 9:38 A.M., the DC took out the third batch of chicken up without measuring the
temperature of the cooked batch.
During an interview on 3/7/19 at 12:06 P.M., the DC said he/she should have checked the
temp of the chicken, after it was cooked.
3. Observation on 3/7/19 from 10:46 A.M. through 10:47 A.M., showed:
-Dietary Cook (DC) placed the battered chicken breast in the food processor and added
bread and plain water with no recipe book open and
-The DC poured the pureed mixture into a metal container to be placed into the oven to
keep it warm, without tasting it.
Observation during a taste test on 3/7/19 at 11:39 A.M., showed the pureed chicken had
bits of grain which were easily detected while the mixture was chewed.
During interviews on 3/7/19, the following was said:
-At 11:39 A.M, the DC said he/she did not puree the chicken to the [MEDICATION NAME]
he/she could,
-At 12:03 P.M., the DC said he/she had 1.5 months of training and he/she was not aware of
the recipe for pureed chicken calling for the use of milk instead of water, and
-At 12:05 P.M., the Interim Dietary Manager (DM) said he/she believed that he/she trained
the DC to taste the food after it was pureed and he/she did not know about documenting the
training of the employees.
Record review of the facility’s recipe book showed the absence of a recipe for pureed
pasta.
Observation on 3/7/19 from 10:53 A.M. through 10:55 A.M., showed:
-The Dietary Cook (DC) pureed the buttered pasta in the same unwashed container that the
chicken was pureed in just a few minutes earlier;
-The DC pureed the buttered pasta and he/she added water and pureed it;
-DC placed the pureed mixture in a metal container without tasting it, and
-The DC placed a metal cover on the metal container and placed it on steam table and did
not check the temperature.
During an interview on 3/7/19 at 11:49 A.M., the Interim DM said:
-He/she knew the recipe was not in the book and
-The pureed pasta did not have as much flavor as the regular.
During a phone interview on 3/11/19 from 8:25 A.M. through 8:41 A.M., the Registered
Dietician (RD) said:
-He/she had not done training in the kitchen;
-He/she did not know who to speak with when he/she went into the kitchen;
-He/she has not done any training with employees in the processing of pureed foods;
-He/she did not advise the dietary employees to taste the foods after the foods were
pureed;
-He/she had not done any training with the facility staff in checking the temperatures of
PHFs after they are cooked;
-He/she did not advise the dietary employees in checking the temperatures of PHFs after
they were cooked;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0801

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 30)
-The interim DM had not enrolled in classes and he/she did not want the job of being the
DM, and
-There was no documentation of training of dietary employees within the facility, and
-If there was documentation, no one would know where those records were located.
During a phone interview on 3/11/19 from 11:46 A.M. through 11:51 A.M., the Regional
Director of Dietary Services said:
-His/her company had not done a lot of training since they took over dietary operations at
the facility;
-They officially took over dietary operations at the facility at the beginning of 11/18,
and
-There was not a qualified Dietary Manager at that time.
During a phone interview on 3/20/19 at 8:51 A.M., the Administrator said:
-The current Interim DM was appointed by the Regional Director of Dietary Services;
-The current Interim DM did not have training, and
-In the past between 12/18 and 1/19, the 1st floor Unit Manager used to formulate the
computerized tickets for the dietary staff, because no one in the dietary department had
the training to complete the dietary tickets.

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be
followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, interview and record review, the facility failed to follow the menu
for two sampled residents (Residents #17 and #20) with pureed diets, by not serving those
residents pureed (cooked food, usually vegetables or legumes, that has been ground,
pressed, blended or sieved to the consistency of a creamy paste or liquid) side dishes of
garlic bread and vegetables. This practice affected 2 residents with pureed diets. The
facility census was 68 residents.
1. Record review of Resident #17’s care plan dated 10/7/14, showed he/she had Dementia and
was on a pureed diet.
2. Record review of Resident #20’s care plan dated 12/6/18, showed he/she received a
pureed diet and received honey thickened liquids.
3. Record review of the menu for the lunch meal on 3/7/19, showed chicken breast filet,
buttered pasta, tossed salad, bread sticks, Mandarin oranges, and coffee.
During an interview on 3/7/19 at 12:06 P.M., the Dietary Cook (DC) said he/she did not
pureed the garlic bread or the tossed salad or add any equivalent food for the residents
with pureed diets.
Observation on 3/7/19 at 12:09 P.M., showed Resident #17 and #20 did not receive their
sides of garlic bread and tossed salad or the equivalent.
During an interview on 3/7/19 at 12:10 P.M., the Staffing Coordinator who helped out in
the dining room that date, said Residents #17 and #20 did not receive their sides of
garlic bread and vegetables, during that lunch meal.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure food and drink is palatable, attractive, and at a safe and appetizing
temperature.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Based on observation, interview and record review, the facility failed to process pureed
(cooked food that has been ground pressed, blended or sieved to the consistency of a
creamy paste or liquid ) pasta to the same taste as the regular pasta and to have a recipe
for the pureed pasta. This practice potentially affected three residents with pureed diets
in the facility. The facility census was 68 residents.
1. Record review of the facility’s recipe book showed the absence of a recipe for pureed
pasta.
2. Observation on 3/7/19 from 10:53 A.M. through 10:55 A.M., showed:
-The Dietary Cook (DC) pureed the buttered pasta in the same unwashed container that the
chicken was pureed in just a few minutes earlier;
-The DC pureed the buttered pasta and he/she added water and pureed it;
-The DC placed the pureed mixture in a metal container without tasting it, and
-The DC placed a metal cover on the metal container and placed it on steam table and did
not check the temperature.
3. On 3/7/19 at 11:40 A.M., during a taste test with the Interim Dietary Manager (DM), the
pureed pasta was very bland compared to the non pureed buttered pasta.
During an interview on 3/7/19 at 11:49 A.M., the Interim DM said:
-He/she knew the recipe was not in the book, and
-The pureed pasta did not have as much flavor as the regular.
During a phone interview on 3/11/19 from 8:25 A.M. through 8:41 A.M., the Registered
Dietician (RD) said:
-He/she had not done training in the kitchen;
-He/she did not know who to speak with when he/she went into the kitchen;
-He/she has not done any training with employees in the processing of pureed foods, and
-He/she did not advise the dietary employees to taste the foods after the foods were
pureed.
During a phone interview on 3/11/19 at 11:52 A.M., the Regional Director of Dietary
Services agreed that the pureed food should be tasted after it was processed.

F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives and the facility provides food prepared in a form
designed to meet individual needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to puree (make
cooked food into a texture that is ground, pressed, blended or sieved to the consistency
of a creamy paste or liquid) the battered chicken breasts to have a smooth pudding like
consistency. This practice affected 2 residents (Residents #17 and #20) with pureed diets.
The facility census was 68 residents.
1. Record review of the undated recipe for 16 servings of pureed meat, showed:
-Two pounds of meat;
-3/4 quarts of whole warm milk, and
-14 3/8 slices of bread.
The directions for the pureed meat recipe showed to place hot meat and warmed milk into
the blender and mix until meat is pureed and seasoned appropriately, add bread to meat
mixture and blend at medium speed until a semi liquid consistency is reached and there are
no visible pieces of bread in the mixture. Test seasoning and adjust if necessary.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
2. Observation on 3/7/19 from 10:46 A.M. through 10:47 A.M., showed:
-Dietary Cook (DC) placed the battered chicken breast in the food processor and added
bread and plain water with no recipe book open and
-The DC poured pureed the mixture into a metal container to be placed into the oven to
keep it warm, without tasting it.
Observation during a taste test on 3/7/19 at 11:39 A.M., showed the pureed chicken had
bits of grains which were easily detected while the mixture was chewed.
During interviews on 3/7/19, the following was said:
-At 11:39 A.M, the DC said he/she did not puree the chicken to the [MEDICATION NAME]
he/she could;
-At 12:03 P.M., the DC said he/she had 1.5 months of training and he/she was not aware of
the recipe for pureed chicken calling for the use of milk instead of water and
-At 12:05 P.M., the Interim Dietary Manager (DM) said he/she believed that he/she trained
the DC to taste the food after it was pureed.
During a phone interview on 3/11/19 from 8:25 A.M. through 8:41 A.M., the Registered
Dietician (RD) said:
-He/she had not done training in the kitchen;
-He/she did not know who to speak with when he/she went into the kitchen;
-He/she has not done any training with the dietary employees in the processing of pureed
foods, and
-He/she did not advise the dietary employees to taste the foods after the foods were
pureed.
During a phone interview on 3/11/19 at 11:52 A.M., the Regional Director of Dietary
Services agreed that the pureed food should be tasted after it was processed.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation, interview and record review, the facility failed to maintain the fan
vent cover in the walk-in refrigerator free of grime; to ensure the food preparation area
at the toaster area was adequately illuminated; maintain utensils free of handles that
were not easily cleanable; to refrigerate a bottle of jelly according to the label;
maintain the ceiling vent above the food preparation table free of a black mildew like
substance; to maintain the mittens in good repair; to maintain the stove free of burnt on
grease and food deposits; to maintain two cutting boards in an easily cleanable condition;
to maintain the ice machine and an ice cooler on the 3rd floor free from damage; to store
condiment packets in an organized and a spill free manner and to ensure the nursing staff
used proper hand hygiene practices during the lunch meal and snack services for the
residents who were eating their meals in the dining room on the second floor. This
practice potentially affected at least 64 residents who ate food from the kitchen. The
facility census was 68 residents.
1. Observations and interviews on 3/7/19 from 8:49 A.M. through 12:59 P.M., during the
lunch preparation, showed:
-At 8:49 A.M. , grime on the fan vent cover of the walk-in refrigerator;
-At 8:49 A.M., the Interim DM said in 3 months no one has notified the maintenance
department about the grime on the fan vent cover;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 33)
-At 8:52 A.M., the area where the food processor and the toaster was located was very
dimly lit;
-At 9:04 A.M., one purple handled scoop and one white handled spatula with damaged
handles;
-At 9:24 A.M .,one 32 ounce jar of jelly was not refrigerated even though the label says
to refrigerate after opening;
-At 9:36 A.M., Dietary Aide (DA) A said with a different jelly in the past, they could
leave it out, but with the different kind of jelly, they have to refrigerate, and that
jelly was left out from the previous night;
-At 10:23 A.M., mildew like substance was on the vent cover above the food prep table;
-At 10:29 A.M., two mittens with damage one with a 2 inch rip and one with a 1.5 inch rip;
-At 11:23 A.M., a deposit of burnt on food, food debris and grease on top of the burners
and beneath the burners on the 6-burner stove;
-At 11:28 A.M., DA B said the stove had been cleaned within the month;
-At 12:39 P.M., there were 2 cutting boards a red and green, that had numerous nicks and
areas that were not easily cleanable;
-At 12:46 P.M., DA B said the Interim DM was just moved up and was not equipped with the
same kinds of tools as the previous manager;
-At 12:53 P.M., the Interim DM said he/she has been the Interim since November;
-At 12:59 P.M., 2 out of 6 cutting boards had numerous nicks and grooves which made them
not easily cleanable;
-At 1:01 P.M., The Interim DM said the cutting boards should be checked every month for
damage, and
-At 1:02 P.M., Interim DM acknowledged the damaged utensils in the storage containers.
2. Observations with the Maintenance Director and the Housekeeping Director on 3/8/19,
showed:
– At 10:28 A.M., a plethora of salt, sugar and sugar substitute packets, black pepper
packets whipped cream packets, syrup packets, scattered about in a drawer in in 3rd floor
dining room, that were not in separate containers;
-Several of the packets were damaged which allowed grains of salt, sugar substitutes, and
other assorted powders to be scattered about in that drawer;
-At 10:31 A.M., a damaged ice cooler with the cover not secured on that ice cooler, and
-At 10:31 A.M., damaged ice machine door with a 30 inch rip in it.
During interviews on 3/8/19 at the times of those observations, the Maintenance Director
acknowledged those observations.
3. Observation on 3/7/19 at 12:00 P.M., showed the Licensed Practical Nurse (LPN) C
standing behind the nursing station on the second floor and proceed to lift up his/her
hair a pulled his/her hand into a clipped pony tail and
-He/she proceed to get the utensils (fork, spoon and knife) out of the black utensil tray
and proceeded to place the utensils on the resident’s brown dining room table.
Observation on 3/7/19 at 12:15 P.M., showed the Clinical Nurse Educator carrying a bowl of
mandarin oranges to a resident. He/she placed his/her right thumb in the resident’s fruit
bowl and proceeded to place the bowl of fruit in the front of the resident on the brown
dining room table and
-He/she was wearing a red key ring and the key ring red cloth material almost touched a
piece of the mandarin oranges in the bowl.
4. During an interview on 3/13/19 at 9:15 A.M., Certified Nurses Aide (CNA) C said:
-He/she was expected to carry plates and bowls with his/her hands underneath the plates or
bowls;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 34)
-He/she was to grabbed the plate around the rim of the plate before proceeded to place the
plate or bowl in front of the resident;
-He/she was to pick up glasses from the bottom and was never touch the rim of the glass;
-He/she was to cut the resident’s sandwiches with a knife but never used his/her hands and
-He/she was to follow good hygiene food practices.
During an interview on 3/13/19 at 12:00 P.M., LPN C said he/she expected his/her staff to
used proper hand hygiene practices during all aspects of meal services.
During an interview on 3/13/19 at 12:30 P.M., Director of Nursing (DON) said:
– He/she expected her staff to use proper protocols of safe food handling practices during
meal services;
– He/she expected dietary and nursing staff to never touch the the rim of plates, bowls
and cups;
– He/she expected dietary and nursing to carry the resident’s plate with his/her hand
underneath the resident’s plate;
– He/she expected the glass or cup not to be touched by the employee;
– He/she expected dietary and nursing staff to pass out the resident’s utensil by touching
the middle or core area of the utensil to prevent foodborne illnesses and
– He/she expected the dietary and nursing staff to maintain a sense of cleanness prior to
offering meal services to the residents.
During an interview on 3/13/19 at 1:30 P.M., Administrator said:
– He/she expected the dietary staff to use proper and safe hygiene practices with the
residents;
– He/she was expected to have staff trained in best food practices in the dietary
department and
– He/she wanted to stabilize his/her dietary staff and then he/she would proceed with the
employees in Interim DM and the contracted food services company will be responsible to
train staff in all aspects of dietary services, in a collaborative manner.
Record review of the facility’s policy statement Preventing Foodborne Illness Employee
Hygiene and Sanitary Practices dated (MONTH) 2008 showed:
– Food Services employees shall follow appropriate hygiene and sanitary procedures to
prevent the spread of foodborne illness.
– All employees who handle, prepare or serve food will be trained in the practices of safe
food handling and preventing foodborne illness. Employees will demonstrate knowledge and
competency in these practices prior to working with food or serving food to residents.
-Employees must wash their hands (after engaging in other activities that contaminate the
hands).
– Contact between food and bare (ungloved) hands is prohibited
Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and
Missouri Food Codes, showed:
-In Chapter 3-202.11 Temperature.(A) Except as specified in paragraph B) of this section,
refrigerated, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be at a temperature of 5oC
(41oF) or below when received,
– In Chapter 3-305.14, During preparation, unPACKAGED FOOD shall be protected from
environmental sources of contamination,
-In Chapter 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.
A)Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under
3-502.12, and except as specified in paragraphs (E) and (F) of this section, refrigerated,
READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD
ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 35)
by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a
temperature of 41ºF or less for a maximum of 7 days. The day of preparation shall be
counted as Day 1,
– In Chapter 4-202.11, regarding Food-Contact Surfaces; Multi-use FOOD-CONTACT SURFACES
shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and
similar imperfections; (3) Free of sharp internal angles, corners, and crevices; and 4)
Finished to have SMOOTH welds and joints;
– In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to
scratching and scoring shall be resurfaced if they can no longer be effectively cleaned
and SANITIZED, or discarded if they are not capable of being resurfaced. Surfaces such as
cutting blocks and boards that are subject to scratching and scoring shall be resurfaced
if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not
capable of being resurfaced.
– In Chapter 4-601.11, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to
sight and touch.
– In Chapter 4-602.13, nonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a
frequency necessary to preclude accumulation of soil residues;
-In Chapter 6-303.11 Intensity: The light intensity shall be: At least 50 foot candles at
a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT
such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor.
– In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as
necessary to keep them clean.

F 0814

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Dispose of garbage and refuse properly.

Based on observation, interview and record review, the facility failed to ensure the
dumpster’s on the north Side of the facility were closed on 3/7/19. This practice affected
the outdoor area on the north side of the facility. The facility census was 68 residents.
1. Observations on 3/7/19 at 8:08 A.M. 9:29 A.M., 10:05 A.M., 11:13 A.M., 2:35 P.M.,
showed two dumpster’s open on the north side of facility. One dumpster did not have a
cover and the other dumpster had lids and the lids were not closed.
During an interview on 3/7/19 at 2:36 P.M. the Maintenance Director said one of the
dumpster’s needed a lid.
Review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri
Food Codes, showed:
5-501.113 Covering Receptacles.
Receptacles and waste handling units for refuse, recyclables, and returnables shall be
kept covered:
(A) Inside the Food establishment if the receptacles and units contain food residue and
are not in continuous use; or
(2) After they are filled; and
B) With tight-fitting lids or doors if kept outside the Food Establishment
– In Chapter 5-501.15, receptacles and waste handling units for refuse, recyclable’s, and
returnables used with materials containing food residue and used outside the food
establishment shall be designed and constructed to have tight-fitting lids, doors, or
covers; and receptacles and waste handling units for refuse and recyclable’s such as an

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0814

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 36)
on-site compactor shall be installed so that accumulation of debris and insect and rodent
attraction and harborage are minimized and effective cleaning is facilitated around, and
if the unit is not installed flush with the base pad, under the unit.

F 0835

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Administer the facility in a manner that enables it to use its resources effectively
and efficiently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure the corporate
leadership coordinated with the facility to use resources effectively to pay the
Registered/Consultant Dietician’s group in a timely manner. This practice created a gap in
the Registered Dietician (RD) scheduled for monthly visits to the facility between the
dates of 6/11/18 and 8/6/18 and between 10/3/18 and 12/17/18 and the residents that needed
to be seen by the RD was not seen. This practice potentially affected the residents who
were scheduled to be seen by the RD during those months the RD was not at the facility.
The facility census was 68 residents.
1. Record review of the RD Reports dated 4/18 through 2/19, showed the RD did not visit
the facility for a period of 55 days from 6/11/18 through 8/6/18, and for a period of 66
days from 10/3/8 through 12/7/18.
Record review on 3/12/19 at 7:09 P.M., during a written response to a question about the
length of time when the visits did not occur, the RD wrote:
-The company he/she consulted for notified him/her that he/she could not go into a
facility since they had not received payment;
-The RD placed the facility on hold until he/she was told that he/she could go into the
facility, and
-If he/she did not go into a building for a whole month and nonpayment was the reason.
During a phone interview on 3/18/19 from 8:45 A.M. through 8:57 A.M., The owner of the
Registered/Consultant Dietician’s group, said:
-There were problems with payment to his/her company, because the facility was behind on
payment;
-The times the RD did not go into the facility for nonpayment, training was delayed, and
-Once payment was made, his/her company would work to try and catch up with regular
visits.
During a phone interview on 3/20/19 at 8:39 A.M., the Administrator said:
-The previous dietary services company left the faciity on [DATE];
-When the RD did not visit the facility between 6/11/18 and 8/6/18, it was due to a
payment issue;
-He/she was not sure what the issue was during the RD’s absence between 10/3/18 and
12/7/18 and
-The previous dietary services company left the faciity on [DATE].

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide and implement an infection prevention and control program.

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 37)
control practices were performed to prevent cross contamination by failing to
appropriately wash hands during transfers and care for one sampled resident (Resident
#27); to keep resident’s catheter bag off of the floor for two sampled residents (Resident
#6 and Resident #212); to ensure to clean barrier during wound care for one sampled
resident (Resident #29) who had a history of [REDACTED]. This practice potentially
affected all residents. The facility sample was 17 residents. The facility census was 68
residents.
Record review of the facility’s Handwashing/Hand Hygiene policy and procedcure dated
(MONTH) 2012, showed the facility considers hand hygiene the primary means to prevent the
spread of infection. Employees must wash their hands for at least 15 seconds using
antimicrobial soap and water under the following conditions:
-When hands are visibly soiled;
-Before and after direct resident contact;
-Before and after performing any invasive procedure (finger stick, blood sampling);
-Before and after entering an isolation precaution setting;
-Before and after assisting a resident with personal care;
-Before and after changing a dressing, before and after handling invasive devices;
-Upon and after coming intact with a resident’s intact skin (when taking a pulse or blood
pressure and lifting a resident);
-After contact with a resident’s muscous membranes, body fluids and excretions;
-After handling soiled linens, dressings, bedpans, urinals and catheters, soiled equipment
or utensils;
-After removing gloves or aprons;
-If hands are not visibly soiled, use an alcohol based hand rub containing 60-05%
[MEDICATION NAME] or [MEDICATION NAME] (alcohol content) before and after direct care with
residents; before donning sterile gloves; before performing any non-surgical invasive
procedure;before preparing or handling medications; before handling clean or soiled
dressings, gauze pads etc,; before moving from a contaminated body site to a clean body
site during care; after contact with a resident’s intact skin; after handling used
dressings, contaminated equipment; after contact with objects in the resident’s vicinity
and after removing gloves and
-Hand hygiene is always the final step after removing and disposal of personal protective
equipment.
-The use of gloves does not replace handwashing.
1a. Record review of Resident #27’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED]. the abdomen that delivers nutrition directly to the
stomach).
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 9/20/18, showed
he/she:
-Was severely cognitively impaired and had a communication deficit and
-Was totally dependent upon staff for bathing, dressing, toileting, transferring and
mobilizing, and eating.
Observation on 3/8/19 at 10:00 A.M., showed Certified Nursing Assistant (CNA) F went into
the resident’s room with the hoyer lift. CNA G was already in the room with the resident.
CNA F said they had already completed pericare on the resident and were getting ready to
get the resident up. The resident was laying down in his/her bed with the head of the bed
up at least 30 degrees. The resident was dressed in a hospital gown. He/she had a [MEDICAL
CONDITION] with an oxygen mask over it delivering oxygen. The resident looked clean and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 38)
was groomed His/her mouth was moist and her skin was supple. The resident had contracted
wrists, fingers and also at one knee. He/she also had a feeding tube that was on and
running. The following occurred:
-Without washing or sanitizing his/her hands, CNA F left the resident’s room and said
he/she was going to get the nurse;
-At 10:08 A.M., Licensed Practical Nurse (LPN), B came into the resident’s room and washed
his/her hands, then took a syringe and placed it on a barrier on the resident’s tray
table. He/she said that he/she had just hung the resident’s liquid nutrition and was
coming back to unhook the tube feeding since the nursing staff was getting ready to get
the resident up;
-At 10:09 A.M., CNA F came back into the resident’s room, and without washing his/her
hands, took a pair of gloves from the box and put them on. Another nursing staff came into
the resident’s room and took the lift out of the room;
-CNA F and CNA G waited for LPN B to remove the resident’s tube feeding then they also
left the room without washing or sanitizing their hands;
-LPN B unhooked the resident’s tube feeding and clamped the tube. He/she took the syringe
and placed it into the end of the tube and said he/she was checking for residual. LPN B
used his/her stethoscope and placed it on the resident’s stomach and said he/she was
checking for placement of the tube. LPN B then used the syringe to put 30 milliliters of
water into the resident’s tube. He/she clamped the tube then degloved and washed his/her
hands before leaving the resident’s room;
-At 10:15 A.M., CNA F and CNA G re-entered the resident’s room with the Hoyer lift. Both
CNA F and CNA G put on gloves without washing their hands and went over to the resident to
begin to transfer him/her;
-Registered Nurse (RN) C entered the resident’s room and without washing his/her hands,
took a pair of gloves from a box and began to assist with attaching the sling to the lift.
Once they connected the sling to the lift, CNA F informed the resident they were going to
lift him/her and CNA G wheeled the resident’s specialized wheelchair closer to the bed;
-RN C asked CNA G to get LPN B so he/she could assist with disconnecting the resident’s
oxygen so they could transfer the resident and CNA G left the resident’s room without
washing his/her hands. CNA G re-entered the resident’s room with LPN B;
-LPN B went to bathroom and washed his/her hands while CNA G put on gloves without washing
his/her hands and went back over to assist with the resident;
-LPN B disconnected the resident’s oxygen so they could transfer the resident. After
repositioning the resident and moving the resident closer to the oxygen concentrator, LPN
B reconnected the resident’s oxygen to the resident’s [MEDICAL CONDITION]. CNA F and RN C
continued to place positioning pillows around the resident;
-CNA G bagged the resident’s trash, removed his/her gloves and left the resident’s room
without washing or sanitizing his/her hands;
-CNA F removed his/her gloves and washed his/her hands then re-gloved and lowered the
resident’s bed and placed the resident’s call light within the resident’s reach. CNA F
then degloved and left the resident’s room without washing or sanitizing his/her hands;
-RN C degloved and washed his/her hands;
-LPN B degloved and washed his/her hands then went back to the resident and using his/her
stethoscope, checked the resident’s feeding tube placement and added more water to the
resident’s feeding tube, then reconnected the tube to the liquid nutrition machine and
turned it on. LPN B then de-gloved, washed his/her hands and left the resident’s room;
-During this time, CNA F came back into the resident’s room with clean linens. Without
washing or sanitizing his/her hands, he/she placed the linen down and took a pair of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 39)
gloves out of a box, put them on and began putting a pillowcase on a foam wedge that was
placed between the resident’s legs;
-RN C assisted with positioning of the resident. RN C then degloved and washed his/her
hands before exiting the resident’s room and
-CNA F degloved and left the resident’s room without washing his/her hands, stating that
he/she was going to get toothpaste to perform oral care on the resident.
During an interview on 3/7/18 at 11:48 A.M., CNA F and CNA G, both CNAs said they were
supposed to wash their hands upon entering the resident’s room, before performing cares,
after performing cares, as often as needed and before leaving the resident’s room.
1b. Observation on 3/12/19 at 5:20 A.M., showed RN A entered Resident #27’s room and
without washing his/her hands he/she walked over to a shelf beside the resident’s bed, put
on a pair of gloves then went to the resident’s bedside and told the resident he/she was
going to perform [MEDICAL CONDITION] care. He/she then:
-Removed the resident’s oxygen mask, removed the resident’s [MEDICAL CONDITION] dressing
and inner cannula and discarded them. He/she then took cleansing wipes and cleansed the
resident’s skin around the [MEDICAL CONDITION], then cleansed the outside of the
resident’s [MEDICAL CONDITION] and discarded the wipes in the trash;
-Without de-gloving, washing or sanitizing his/her hands, he/she then opened the
resident’s bottled water that was sitting on a dresser next to his/her bed, filled the
resident’s humidifier bottle and placed it back on the dresser then without degloving,
washing or sanitizing his/her hands, went back over to the resident, took another
cleansing wipe and wiped the resident’s skin around his/her [MEDICAL CONDITION];
-Without de-gloving, washing or sanitizing his/her hands, he/she then placed a new neck
strap on to the resident’s [MEDICAL CONDITION], then took another cleansing wipe and wiped
the skin around the resident’s [MEDICAL CONDITION] again;
-Without de-gloving, washing or sanitizing his/her hands, he/she opened a container
containing sterile supplies and said he/she was going to cleanse the inside of the
[MEDICAL CONDITION]. He/she then cleansed the inner [MEDICAL CONDITION] area;
-Without de-gloving, washing or sanitizing his/her hands, he/she opened a new inner
cannula and tried to place it in the resident’s [MEDICAL CONDITION] opening. He/she could
not get it to fit and tried two additional inner cannulas. He/she turned on the resident’s
call light and asked the nursing aide to call for assistance. He/she removed and discarded
his/her gloves;
-Without washing or sanitizing his/her hands he/she put on a pair of gloves then began
looking in the resident’s drawers for supplies, then went back to the resident and placed
the resident’s oxygen mask over the resident’s [MEDICAL CONDITION] while the Director of
Nursing (DON) came in to provide assistance.
-The DON washed his/her hands and gloved before assisting with the resident;
-LPN D came into the resident’s room, washed his/her hands and gloved then came over to
assist with the resident and tried to place the inner cannula in the resident’s [MEDICAL
CONDITION];
-RN A degloved and went to the bathroom and washed his/her hands. He/she put on gloves;
-The DON tried to place the resident’s inner cannula. The DON de-gloved and washed his/her
hands and tried to place a different cannula in the resident’s [MEDICAL CONDITION]. The
DON then de-gloved, washed his/her hands and said he/she was going to check the resident’s
physician’s orders [REDACTED].
-RN A and LPN D assisted with removing the resident’s gown and placing a clean gown on
him/her;
-RN A then took the worn gown and said he/she was going to put it in the laundry bin.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 40)
He/she left the resident’s room without washing or sanitizing his/her hands;
-LPN D held the oxygen over the resident’s [MEDICAL CONDITION] site and began talking to
the resident;
-He/she asked if the resident was in pain and the resident blinked his/her eyes to
communicate;
-RN A re-entered the resident’s room and without washing his/her hands or gloving, he/she
placed the oxygen strap around the resident’s neck (so they no longer had to hold the mask
over his/her [MEDICAL CONDITION] site). He/she then took the resident’s oxygen level and
said it was at 95% saturation and
-LPN D and RN A washed their hands prior to leaving the resident’s room.
During an interview on 3/12/19 at 6:24 A.M., RN A said:
-If he/she goes into a resident’s room to complete a bed check, he/she did not wash
his/her hands, but when he/she is going in to perform care he/she will wash his/her hands
upon entry, then put on gloves and begin care;
-The resident’s [MEDICAL CONDITION] care was a sterile procedure and during his/her care
he/she will wash his/her hands after he/she removed the dressings and cleaned around the
resident’s [MEDICAL CONDITION];
-He/she would have washed his/her hands before leaving the resident’s room;
-When he/she left to take the residents gown to the laundry, he/she did not wash his/her
hands because he/she was taking the soiled gown to the laundry;
-He/she removed his/her gloves and discarded them after he/she put the resident’s gown in
the laundry bin;
-He/she did not remember if he/she washed his/her hands upon re-entering the resident’s
room, but thought he/she had rinsed them and
-If he/she did not wash his/her hands it was because he/she was busy and nervous but
he/she would pay more attention to handwashing when providing care to the residents.
During an interview on 3/13/19 at 9:40 A.M., LPN B said:
-The nursing staff was supposed to wash their hands upon entering the resident’s room,
before putting on gloves;
-Whenever they are performing a dirty task they are to remove their gloves and wash their
hands and glove before completing a clean task;
-They are supposed to wash their hands again before leaving the resident’s room for any
reason;
-When completing [MEDICAL CONDITION] care, the nurse should wash his/her hands upon
entering the resident’s room, put on gloves then remove the dressing. After cleansing the
skin and area around the [MEDICAL CONDITION] or cleaning the [MEDICAL CONDITION], the
nurse should discard his/her gloves and wash his/he hands before applying the new tubing.
The nurse should then deglove and wash his/her hands again before leaving the resident’s
room and
-Anytime nursing staff leave the resident’s room and re-enter, they should wash their
hands before putting gloves on.
During an interview on 3/13/19 at 2:57 P.M., the DON said:
-Nursing staff should wash their hands upon entering the room when they know they will be
providing care, whenever their gloves become soiled during a procedure to prevent cross
contamination, during a sterile procedure when their hands are outside of the field-if you
touch anything outside of the area you are working on, whenever going from a dirty process
to a clean one, and they should deglove and wash their hands before leaving the resident’s
room and
-If they leave the room with plans to re-enter, they should still wash their hands before
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 41)
leaving the room and again upon returning.
2. Record review of Resident #6’s Face Sheet showed he/she was admitted to the facility on
[DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s physician’s orders [REDACTED].
Record review of the resident’s MDS dated [DATE], showed the resident:
-Was alert and oriented;
-Needed moderate to extensive assistance for mobility, transfers, bathing, dressing and
toileting;
-Was incontinent of bowel and had a urinary catheter.
Record review of the resident’s Care Plan dated 2/12/19, showed the resident had a
catheter and interventions instructed staff to:
-Position the resident’s catheter bag and tubing below the level of the bladder and away
from entrance room door;
-Monitor and document intake and output as per facility policy and monitor for signs and
symptoms of discomfort on urination and frequency and
-Monitor/document for pain/discomfort due to catheter and monitor/record/report to the
physician any signs and symptoms of infection.
Observation on 3/8/19 at 11:29 A.M., showed the resident was sitting in his/her bed
working on a puzzle book. His/her call light was within reach and he/she had personal
items on tray tables beside his/her bed that were also within reach. The resident was
dressed in a hospital gown. The resident’s bed was low to the ground and his/her catheter
bag was laying on the floor beside his/her bed.
During an interview on 3/13/19 at 9:40 A.M., LPN B said:
-The catheter bag should be in a privacy bag, be kept below the resident’s waist at all
times and should never be on the floor and
-The resident’s catheter bag was on the floor today and he/she had picked it up and hung
it on the side of the resident’s bed.
During an interview on 3/13/19 at 2:57 P.M., the DON said the resident’s catheter bag
should never be on the floor and he/she expected staff to monitor to ensure that it was
hung below the resident’s bladder at the side of his/her bed.
3. Record review of Resident #29 Admission Face Sheet, showed he/she was readmitted on
[DATE] and was originally admitted on [DATE], with [DIAGNOSES REDACTED].>-Gangrene
(localized death and decomposition of body tissue, resulting in either obstructed
circulation or bacteria infection);
-Acquired absence of other toe and
-Infection of skin and subcutaneous tissue.
Record review of the resident’s POS dated (MONTH) 2019 showed:
-Cleanse the coccyx wound with Wound Cleanser or Normal Saline, apply Alginate AG in the
wound bed and secure with border foam dressing; Change every day and as needed until wound
is healed and
-Santyl Ointment ([MEDICATION NAME] wound [MEDICATION NAME] agent); Apply to right hip
wound topically daily on the day shift for wound care.
Observation on 3/8/19 at 2:00 P.M. of the resident’s wound care by LPN F and assisted by
CNA F showed:
-LPN F and CNA F washed their hands when entering the resident’s room and pot on gloves,
-Had barrier for the wound supplies;
;-Right hip wound was completed and LPN F removed his/her gloves washed his/her hands
between the dirty and clean processes;
-Did not have a clean barrier in place prior to the wound care process and did not place a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 42)
clean barrier after cleaning the wounds;
-Coccyx wound care was completed and did not have a clean barrier in place prior to the
wound care process and did not place a clean barrier after cleaning the wounds, then LPN F
and
-Removed his/her gloves and washed his/her hands.
Record review on 3/11/19 at 11:27 A.M., of resident’s Progress Note dated 3/7/2019 at 5:11
A.M. showed the resident continues on antibiotics for [MEDICAL CONDITION] and for an
urinary tract infection.
During an interview on 3/14/19 at 1:00 P.M., LPN G said he/she should had clean barrier
under the resident before wound care.
4. Record review of Resident #212’s Admission Face Sheet showed he/she was admitted to the
facility on [DATE].
Record review of the resident’s Social Service progress note dated 3/6/19 at 2:02 P.M.
showed:
-The resident was alert and oriented, was able to make his/her needs known and was able to
understand others;
-During the interview process the resident had a scored of 15 on his/her BIMS (cognitively
intact) and
-He/she has reading glasses but he/she does not have them here.
Record review of the resident’s POS dated (MONTH) 2019 showed the resident did not have
physician order [REDACTED].
Observation 3/07/19 at 9:48 A.M. showed the resident’s catheter bag and tubing was
touching the floor. The resident finger nails are long and appear to have dark substance
underneath them.
Observation on 3/07/19 at 9:30 A.M., showed the resident’s Foley catheter tubing was
dragging on the floor while the resident was self propelling his/her wheelchair.
Observation on 3/08/19 at 10:03 A.M. showed the resident’s Foley catheter tubing was
touching the floor and the resident’s urine was cloudy.
Observation on 3/11/19 at 8:11 A.M. of the resident’s room showed he/she had an isolation
cart outside his/her room.
During an interview with LPN B on 03/11/19 at 8:14 A.M., said the resident’s was on
isolation for influenza.
5. During an interview on 3/13/19 at 10:30 A.M., CMT A said if the resident’s Foley
catheter tubing and bag was touching the floor it should be wiped off and reposition off
the floor.
During interview on 3/13/19 at 11:45 A.M. ,LPN E said:
-The staff should complete the soiled process and change the soiled chuck before starting
the clean process;
-Catheter tubing should not be touching the floor and should be replaced and
-The staff should wash their hands, put on their gloves upon entering the resident’s room
and before leaving the resident’s room and in between dirty and clean process.
During an interview on 3/14/19 at 11:00 A.M., the DON said:
– He/she would expect the nursing staff to have a clean barrier placed under the resident
during wound care and
-The resident’s catheter bag should not be on the floor or touching the floor.
6. Record review of the facility’s disaster plan showed the absence of a
Legionella/waterborne illness plan which accounted for the following:
-A facility risk assessment for waterborne illness;
-The facility implemented a water management program that considered the American Society
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 43)
of Heating Refrigerating and Air Conditioning Engineers (ASHRAE) standards;
-The facility established a water management program identifying areas where waterborne
illness/Legionella could grow and spread, and
-The facility accounted for changes in the municipal and the facility’s water quality,
water main breaks and construction (including renovations and installation of new
equipment).

F 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Make sure that the nursing home area is safe, easy to use, clean and comfortable for
residents, staff and the public.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide a safe
environment for facility staff by not maintaining two faucets in the kitchen, one faucet
in resident room [ROOM NUMBER], and one faucet in the 2nd floor soiled utility room in
good repair; to maintain the floor of the 2nd floor medication room free of grime, and to
maintain the elevator pump operating mechanism in good repair to prevent hydraulic fluid
from splattering across the floor in the elevator machine room. The facility census was 68
residents.
1. Observations during the lunch meal preparation on 3/7/19 from 9:10 A.M. through 12:30
P.M., showed:
– A 2.5 inch (in.) crack in the stainless steel frame of the hand washing faucet which
contributed to that faucet being out of alignment;
– A glove that was wrapped around the faucet spout (the part where the water came out of)
to prevent a leak within the spout from dispersing water in multiple directions and
– At 10:34 A.M. the Maintenance Director said the hand washing sink fixture needed to be
replaced due to a 2.5 in. crack in the stainless steel part of the fixture.
2. Observations with the Maintenance Director on 3/7/19 at 3:01 P.M., showed hydraulic
fluid across the floor of the elevator machine room which made that floor very slick for
walking.
During an interview at the time of the observation, the Maintenance Director said the
leakage of the hydraulic fluid came from the pump every time the elevator operated and
he/she had to clean up the fluid every 2-3 days.
3. Observations with the Maintenance Director on 3/8/19, showed:
– At 10:54 A.M., there was a buildup of grime on the floor of the 3rd floor medication
room;
– At 10:55 A.M., the Housekeeping Director said neither he/she nor his/her staff has been
in that medication room to clean the floors;
– At 12:51 P.M., a heavy buildup of lime on the faucet at the handwashing sink in resident
room [ROOM NUMBER];
– At 12:52 P.M, the Maintenance Director said that faucet definitely needed to be
replaced;
– At 1:21 P.M., there was not a knob on the hot water side of the faucet in the 2nd floor
soiled utility room, and
– At 1:22 P.M., the Maintenance Director said the cabinet around that faucet also needed
to be replaced and he/she had tried to get that accomplished in the past.
4. During interviews on 3/11/19, the following was said:
– At 11:27 A.M., the Maintenance Director said the corporate entity sometimes take a long

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 44)
time to get some of the requests met;
– At 11:58 A.M., the Maintenance Director said the elevator oil leaks out of the pump
every time the elevator runs and he/she had to clean up the hydraulic fluid oil every 2
days from the floor;
– Record review of the label on the hydraulic fluid container showed it was a skin
irritant and
– At 1:06 P.M., Certified Medication Technician (CMT) said with the sink in the 2nd floor
soiled utility room beng broken, one cannot wash their hands, they have to step into the
oxygen room to wash their hands, the regular way is that they should be able wash their
hands after discarding their soiled waste, and the hot water was needed to help with
bacteria removal from their hands.
During an interview on 3/13/19 at 8:57 A.M., the Interim Dietary Manager (DM) said the
small faucet at the food prep area had been leaking for about two weeks .
During an interview on 3/13/19 at 9:00 A.M., the Maintenance Assistant said he/she was
only informed about repairing the small faucet at the food preparation area, that day.

F 0925

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Make sure there is a pest control program to prevent/deal with mice, insects, or other
pests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, observation, and interviews, the facility failed to prevent the
influx of roaches in the kitchen and adjoining dining room, the 2nd floor shower room
[ROOM NUMBER], and the 2nd floor dining room and in the 3rd floor dining room. This
practice potentially affected all the residents that utilize these areas. The facility
census was 68 residents.
1. Record review of the work order from the local pest control company dated:
-2/22/19, showed no findings of live roaches;
-2/28/19, showed roaches were found in the kitchen and findings which included grease
deposits on the floor, which provided food for roaches grease and organic deposits on
equipment, missing or damaged tiles, which permitted the accumulation of water, food
deposits, standing water or irrigation soaking walls, and the application of various
pesticides and
-3/6/19, showed live roaches found, the same conditions in the kitchen as on the 2/28/19
application, and the application of pesticides.
2. Observation and interview on 3/7/19 from 9:49 A.M. through 12:57 P.M, during the lunch
meal preparation, showed the presence of live roaches at the following areas:
-Under the dishwasher, on the wall next to the cart with silverware on it, the wall next
to the door from the kitchen into the dining room, a roach crawled across the food prep
table during the food prep observation, there was food debris present above steam table
here food was being served, around the cutting boards and crawling along the wall in the
1st floor dining room and
– At 1:00 P.M., the Interim Dietary Manager (DM) said he/she thought when they sprayed
last night, the roaches started running around.
3. Observations with the Maintenance Director and the Housekeeping Director on 3/8/19,
showed:
– At 12:56 P.M., the presence of roaches in Shower #5 under two foot rest on the floor of
that shower room;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265199

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

03/14/2019

NAME OF PROVIDER OF SUPPLIER

GRAND PAVILION AT THE PLAZA

STREET ADDRESS, CITY, STATE, ZIP

4330 WASHINGTON
KANSAS CITY, MO 64111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0925

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 45)
– From 12:59 P.M., through 1:01 P.M., numerous roaches which started scurrying when the
black refrigerator and the drawer were pulled out from the west wall of the 2nd floor
dining room, while two residents ate in the dining room at that time;
– At 1:02 P.M., the Maintenance Director said he/she needed to spray again and
– At 1:08 P.M., a dead roach was observed in the cabinet of the 2nd floor medication room,
and an open box of a 1000 pack of spoons were present.
4. Observation on 3/11/19 at 8:23 A.M., showed a live larger roach running on floor then
went up the wall going into the hallway of the fire door, and a smaller roach on the floor
by the entrance door in front of the nurse’s station in the 3rd floor dining area.
During an interview on 3/11/19 at 11:28 A.M., the Maintenance Director said the following
in response to a question about the main obstacles to getting rid of the roaches form that
2nd floor dining room. The housekeeping Director said trying to get the housekeeping
services company to clean that area of the 2nd floor dining room is an obstacle.
Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and
Missouri Food Codes, showed:
6-501.111 Controlling Pests.
The PREMISES shall be maintained free of insects, rodents, and other pests. The presence
of insects, rodents, and other pests shall be controlled to eliminate their presence on
the PREMISES by:
(A) Routinely inspecting incoming shipments of FOOD and supplies;
(B) Routinely inspecting the PREMISES for evidence of pests;
(C) Using methods, if pests are found, such as trapping devices or other means of pest
control as specified under §§ 7-202.12, 7-206.12, and 7-206.13; Pf and
(D) Eliminating harborage conditions.
6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests.
Dead or trapped birds, insects, rodents, and other pests shall be removed from control
devices and the PREMISES at a frequency that prevents their accumulation, decomposition,
or the attraction of pests.