Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse,
physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
supervision, monitoring and preventive measures remained in place after a resident to
resident altercation occurred to prevent the recurrence of another resident to resident
altercation between two sampled residents (Resident #30 and #67), who both had behaviors
that were known by the facility; to complete a comprehensive investigation of the
incidents that showed the circumstances of each incident, what occurred, what the
facility’s response was, witness statements and the facility’s plan of action to prevent
the recurrence after each incident; and to follow the behavior care plan for one sampled
resident (Resident #30) that may have prevented the second incident, out of 20 sampled
residents. The facility census was 100 residents.
Record review of the facility’s undated Abuse Prevention and Prohibition policy and
procedure showed the facility will immediately remove any alleged perpetrator from any
further contact with any resident. It showed:
-When another resident is the alleged perpetrator of the abuse, a licensed professional
shall immediately evaluate the resident’s physical and mental status, care plan, monitor
behaviors and notify the physician for a determination regarding treatment and/or
discharge options;
-Residents will be referred for behavior management when indicated;
-Changes in room assignments and seating arrangements will be recommended as needed and
-The safety of other residents and employees of the facility is of primary concern.
1. Record review of Resident #67’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED]., anxiety, or fear that are strong enough to
interfere with one’s daily activities), mental disorder (a wide range of conditions that
affect mood, thinking and behavior), cognitive communication deficit (in which a person as
difficulty communicating because of injury to the brain that controls the ability to
think) and cognitive social and emotional deficit (the inability to adjust to changes)
following cardiovascular disease (stroke).
Record review of Resident #67’s admission Minimum Data Set (MDS), a federally mandated
assessment tool to be completed by facility staff for care planning dated 4/10/18, he/she:
-Had significant cognitive impairment with long and short-term memory loss;
-Had no mood symptoms during the assessment period;
-Had verbal and physical behaviors toward others during the assessment period that did not
put himself/herself at risk of injury or cause injury to others, did not intrude on
privacy or activity of others.
-Was independent with ambulation and transfers and
-Received no psychological therapies.
Record review of the resident’s physician’s orders [REDACTED]. for delusional behaviors
(ordered 4/26/18), [MEDICATION NAME] 100 mg in the evening for mental disorder and
Namzaric 14-10 mg once daily for dementia.
Record review of the resident’s Care Plan dated 4/4/18, showed the resident had a dementia
care plan that addressed his cognitive deficits, behaviors, [MEDICAL CONDITION] and
[MEDICAL CONDITION] medication use. There was an update on 4/9/18, that showed he/she
struck another resident and the intervention was to move Resident #67 to his room and away
from other residents. It showed on 4/26/18, the psychiatrist changed his medication (anti
depressant and anti psychotic). On 6/8/18, it showed he/she slapped another resident
twice, and was separated from the resident. Interventions showed staff was to determine

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
the cause of his/her aggression and attempt to alleviate the cause and to take the
resident to his room and put on country music because this calms him.
Record review of the resident’s Nursing Notes showed:
-6/8/18 At 4:00 P.M. and 4:20 P.M., Resident #67 and another resident were in the dining
room when Resident #67 walked over to the other resident, stood over him/her and proceeded
to strike him/her in the face. Immediately after the first time (he/she struck the
resident) staff separated the two residents, then 20 minutes later the incident repeated
itself. The residents were physically separated again and also distracted. Resident #67
voiced no complaints. The nurse notified the resident’s physician and responsible party.
There were no further incidents and staff will continue to monitor.
-On 6/9/18 (late entry),There were no behaviors displayed by the resident on this shift
and he/she had no further complaints. The nurse took the resident’s vital signs (blood
pressure, temperature, pulse and respirations, which were within normal limits).
-On 6/10/18, Follow up from displayed behavior on the previous shift. There were no
further incidents to report. The resident’s mood was pleasant and voiced no complaints.
Vital signs were documented.
-On 6/10/18 at 11:36 A.M., the resident had continuously been monitored during the shift
with no disruptive behaviors. He/she was currently in bed with eyes closed. Staff will
continue to monitor. At 10:16 P.M., nursing staff documented the resident was resting
comfortably.
-On 6/11/18 at 10:44 A.M., the nursing staff documented the resident voiced no complaints
and has had no further incidents. Staff will continue to monitor.
At 12:41 P.M., the resident had no complaints. There had been no further incidents. The
resident was resting in his/her bed quietly with eyes closed. Staff will continue to
monitor.
-The notes did not show, after the initial incident what interventions (other than
separating the residents and Resident #67 going to his/her room) were put in place to show
how the nursing staff was monitoring Resident #67 in order to prevent him/her from coming
back into contact with Resident #30 to repeat the first incident.
-There was no documentation showing that after the first incident occurred, how Resident
#67 ended up back in the same location with Resident #30 or how the second incident
occurred.
Record review of the resident’s Occurrence Report dated 6/14/18, showed:
-On 6/8/18, the residents were in the dining room when Resident #67 walked over to the
other resident (unidentified) and struck (him/her) in the face. The two residents were
immediately separated in order to gain composure before the incident repeated itself 20
minutes later. The nurse documented the resident stated he/she was angry he/she also
documented the resident was confused prior to and after the incident occurred). There was
no witness statement;
-The nurse documented the incident occurred in the dining room and there were no witnesses
to the incident;
-The nurse notified the resident’s physician at 4:00 P.M. and notified his/her responsible
party at 6:40 P.M;
-The nurse completed a physical assessment of the resident to include vital signs (pulse,
temperature, blood pressure and respirations). and reported no injuries and
-The nurse documented the resident was kept under continuous supervision.
Record review of the resident’s Follow Up Occurrence Report dated 6/14/18, showed:
-On 6/8/18, Resident #67 became agitated at the other resident due to the other resident
making loud remarks. At that time, Resident#67 walked over to the other resident and hit
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
the resident in the face. Resident #67 was immediately separated from the other resident
and educated on the proper response when feeling upset at another resident. Due to
Resident #67’s dementia diagnosis, he/she was unable to discuss what happened. At
Approximately 20 minutes later, Resident #67 was observed (no witness identified) walking
over to the resident again and hit the same resident. At that time, Resident #67 was
separated again from the other resident and staff was assigned to Resident #67 until
he/she was calm;
-The root cause showed the incident was due to resident action or internal risk factors;
-The recommendation was that staff would monitor the resident for aggressive behaviors
towards other residents and immediately separate the resident for safety to self and
others;
-The occurrence report did not identify what monitoring measures the facility staff put in
place after Resident #67 first hit the other resident, in order to prevent the second
occurrence 20 minutes later;
-The occurrence report did not explain the circumstances of how the second incident
occurred in detail, and what interventions were implemented after the second incident to
ensure monitoring was occurring to prevent Resident #67 from aggressing on Resident #30
again;
-The occurrence report did not identify the witness of the second incident and what
efforts they made to stop the resident from hitting the other resident, and there was no
witness statement showing what the eyewitness saw attached to the report and
-The report was not comprehensive.
Record review of Resident #30’s Face Sheet showed he/she was admitted on [DATE], with
[DIAGNOSES REDACTED].
Record review of the resident’s quarterly MDS dated [DATE], showed he/she:
-Had significant cognitive impairment;
-Had no mood or behaviors displayed during the assessment period;
-Needed extensive assistance with all personal care to include transfers and mobility and
-Used a wheelchair for mobility.
Record review of the resident’s POS dated (MONTH) (YEAR), showed physician’s orders
[REDACTED].
Record review of the resident’s Care Plan showed the resident has a [DIAGNOSES REDACTED].
It showed the resident can be verbally abusive at times and can become physically abusive
toward peers. Interventions showed:
-Targeted behaviors for verbally abusive behaviors showed staff should notify the charge
nurse, remove the resident from the area, remind him/her that he/she cannot speak to
others in an inappropriate way or touch others at any time (revised 10/12/15);
-Monitor and record the occurrence for targeted behaviors to include violence/aggression
towards staff and others and document per facility protocol and
-There was an update on 6/8/18, that showed that the resident was slapped twice by another
resident. The resident was not injured and had no skin discoloration. He/she was separated
from the other resident.
Record review of the resident’s Nursing Notes showed:
-On 6/8/18, an incident occurred on this shift where this resident was struck by another
resident while in the dining room twice at 4:00 P.M., and again at 4:20 P.M. The nurse
documented there was no bruising, skin tears or cuts were located on the resident upon
assessment. Both residents were separated. Nursing staff performed range of motion
assessment on the resident and took the resident’s vital signs after each incident. At
this time (9:21 P.M.) the resident was in his/her bed resting. He/she had no complaints
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
and there have been no further incidents.
-On 6/9/18-(late entry), follow up charting from the incident on 6/8/18 showed the
resident had no further complaints and no further incidents. The nurse documented the
resident’s vital signs.
-On 6/10/18 the resident documented the resident was on follow up charting from the
incident on 6/8/18 and there were no further incidents. The resident had no complaints and
the nurse documented the resident’s vital signs. At 10:03 P.M., the nurse documented the
resident was continuously being monitored during the shift and had no disruptive
behaviors.
-On 6/11/18 at 6:12 A.M., the nurse documented the resident has had no incidents or
behaviors and staff would continue to monitor the resident.
At 10:37 A.M. the nurse documented the remained on monitoring after the incident on
6/8/18, and there were no new conditions to develop. The resident voiced no complaints.
At 9:33 P.M., the nurse documented the resident was being monitored after the incident on
6/8/18, and there were no further incidents, the resident voiced no complaints and the
resident was in his/her bed resting. Staff would continue to monitor.
Record review of the resident’s Occurrence Report dated 6/8/18, showed:
-On 6/8/18, the residents were in the dining room. Resident #30 was verbally aggressive
with another resident (unidentified) and the other resident came over to Resident #30 (who
was sitting in the dining room) and struck him/her in the face twice, once at 4:00 P.M.,
and again at 4:20 P.M. The residents were separated and counseled;
-Resident #30 said, he hit me. There were no witness statements;
-The nurse documented the resident’s physician was notified at 4:25 P.M. and the resident
did not have a responsible party;
-The nurse conducted a physical assessment of the resident and began neurological checks.
There were no injuries noted, the resident had full range of motion and did not complain
of pain and
-The nurse documented the resident was confused prior to and after the incident occurred.
Record review of the resident’s Follow Up Occurrence Report dated 6/14/18, showed:
-Resident #30 was known to have loud outbursts against other residents and staff. The
other resident walked up to Resident #30 due to Resident #30 yelling, and hit him/her in
the face. Both residents were immediately separated. There were no injuries at this time;
-No staff interviews were available;
-Recommendations showed staff will continue to monitor the resident for inappropriate
interactions towards other residents;
-The report did not show what interventions staff put in place after the resident was hit
to prevent a reoccurrence and to protect the resident and how they monitored this resident
after the first incident occurred;
-The report did not show what interventions were in place for the resident once the
facility staff became aware that the resident was being verbally aggressive in the dining
room (after the first incident occurred) and whether any attempt was made to follow the
resident’s care plan when he/she exhibits this behavior;
-The report did not show the circumstances, in detail, showing how the resident managed to
be hit again, by the same resident, 20 minutes after the first incident occurred (after
the nursing staff separated the residents) and what monitoring, or lack thereof, was being
provided to Resident #30 to ensure his/her safety;
-The report did not show what the facility staff implemented for this resident after the
second incident occurred to ensure the resident’s safety and keep him/her out of harms
way;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-There was no documentation on the report showing where the nursing staff was at the time
of each incident. There were no witness statements attached to the report showing the
facility thoroughly investigated the incidents and
-This complaint investigation was not comprehensive to show a thorough investigation of
the incidents had been completed.
During an interview on 6/12/18 at 9:55 A.M., Licensed Practical Nurse (LPN) A said:
-The incident between Resident #30 and Resident #67 occurred last week on 6/8/18 on the
3:00 P.M. to 11:00 P.M. shift;
-The residents had two incidents that occurred 20 minutes apart at 4:00 P.M. and at 4:20
P.M. and in both incidents, Resident #67 hit Resident #30 in the face;
-He/she was at the nursing station with the Assistant Director of Nursing (ADON) at the
time the incident occurred, but he/she did not witness either incident;
-Both residents were in the dining room with other residents. He/she heard a commotion and
got up to go over to see what had occurred. The ADON also walked over to the residents to
see what had happened;
-He/she saw Resident #67 standing over Resident #30 (who was sitting in his/her
wheelchair) and Resident #30 said that Resident #67 had hit him/her;
-He/she and the ADON stood between the residents and the ADON took Resident #67 to his/her
room;
-He/she stayed in the dining room with Resident #30 and asked him/her what happened and
Resident #30 said Resident #67 hit him/her (slapped him/her in the face). He/she said
he/she did not see any red areas, cuts, scratches or bruising on Resident #30;
-The ADON completed physical assessments on both residents and Neither resident had any
injuries nor complained of pain. They completed vital signs on both residents;
-He/she went back to the nursing station after the incident was over. Resident #30
remained in the dining room and Resident #67 was in his/her room;
-Upon investigation, residents in the area said that Resident #30 was yelling out
aggressive statements and was being verbally aggressive toward Resident #67 prior to the
incident;
-At 4:20 P.M., Resident #30 was sitting in the dining room and he/she heard another
commotion. When he/she looked up he/she again saw Resident #67 standing over Resident #30
and Resident #30 said Resident #67 had hit him/her again;
-This second incident was not witnessed and he/she had not seen Resident #67 come out of
his/her room;
-He/she notified the ADON of the second incident and the ADON came and assessed both
residents again;
-Resident #67 was taken back to his/her room and he/she put Resident #30 closer to the
nursing station so he/she could better monitor him/her;
-Neither resident sustained [REDACTED].
-He/she took the resident’s vital signs and notified the resident’s physician and
responsible party of Resident #67 and the physician of Resident #30 of the incident;
-Resident #67 remained in his/her room and the nursing staff provided monitoring to both
residents;
-Resident #30 was eventually was taken back to his/her room and put to bed;
-Resident #30 has a baseline behavior of being verbally aggressive to residents and staff.
They usually redirect the resident when he/she begins to be verbally aggressive through
distraction or talking with him/her about the behavior and asking him/her to stop.
Sometimes they are more successful than other times;
-Resident #67 has a history of physical aggression but had not had any problems that day,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
prior to the initial incident. Once the resident becomes aggressive, it takes a while for
him/her to calm down. He/she was counseled about hitting other residents after the
incident occurred;
-When a resident to resident physical incident occurs, they determine if they need to
provide one to one monitoring, but in this instance they did not think one to one
monitoring was necessary once Resident #67 was taken to his/her room. He/she said Resident
#67 usually will stay in his/her room and lay down and they did not expect him/her to get
back up;
-Usually, they are able to calm Resident #67 by taking him/her to his/her room, providing
distractions such as smoking, because he/she likes that;
-Had he/she known Resident #67 was back up ambulating, he/she would have re-directed the
resident back to his/her room and kept him/her away from Resident #30 and
-He/she documented the incident in both resident medical records and on the occurrence
forms.
Observation on 6/12/18 at 10:00 A.M., showed Resident #30 was laying in his/her bed
asleep. There were no signs or symptoms of pain or distress. His/her bed was low to the
ground. There were no bruising, scrapes scratches or other injury to the resident’s face
or head observed. LPN A said the resident was alert with confusion and significant memory
loss. He/she said the resident was not interviewable, but he/she can make his/her needs
known.
During an observation and interview on 6/13/18 at 10:45 AM, Resident #67 was laying down
in his bed. He was awake. Restorative Aide (RA) A said:
-The resident has mood swings and if he/she was not familiar with the person attempting to
provide care, he/she would not interact so he/she stayed in the resident’s room during the
interview because he/she said the resident may be more accepting to being interviewed;
-The resident can communicate his/her needs, but usually does not have much conversation
with others and
-Resident #67 said he/she did not remember Resident #30. When asked if he/she slapped or
hit the resident or any resident in the face, he/she said I don’t remember, I may have.
When asked if he/she remembered any of the resident’s yelling at him/her or threatening to
hit him/her he/she said, I don’t remember. He/she was unable to provide any information
regarding the incident.
Observation on 6/13/18 at 10:50 AM, Resident #30 was laying on top of his/her bed fully
dressed and was asleep. There were no signs of injury on the resident’s face and he/she
did not show any signs or symptoms of pain or discomfort.
During an interview on 6/13/18 at 10:50 AM, RA A said:
-He/she was not in the area on the date the incident took place but heard about it in
report;
-At the time of the incident, Resident #67 was a newer resident and they (facility staff)
weren’t very familiar with him/her or his/her behaviors;
-There were also new staff and agency staff working on the floor and some of the aides
working were pregnant.;
-When he/she heard about the incident he/she was surprised because Resident #67 was
usually quiet, stayed in his/her room, and did not bother other residents;
-In the dining room he/she really did not talk to the other residents and never had any
interactions with Resident #30. He/she said that Resident #67 sat in the front of the
dining room across from the nursing station and Resident #30 sat in the back of the dining
room by the patio;
-Resident #30 was a long term resident whose normal behaviors were yelling out things
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
like,I’ll hit you, not actually speaking to anyone in particular, and without intention
because he/she has never actually hit anyone. He/she said when Resident #30 begins to yell
out these statements, other residents either ignore him/her or tell him/her to be quiet,
but since Resident #67 was a new resident he/she may have thought the resident was
threatening him/her and this triggered resident #67 to hit him/her.;
-Now that they have more experience with Resident #67, they know that Resident #67 is
easily agitated and they have to be careful with him/her due to his/her mood swings and
-Since the incident, Resident #67 has had no further altercations with Resident #30 or any
of the residents.
During an interview on 6/15/18 at 12:10 P.M., the ADON said:
-He/she was at the nursing station when the incident occurred, but he/she did not witness
the incident;
-When he/she saw LPN A go into the dining room, he/she followed and saw that Resident #67
was standing over Resident #30. Resident #30 said Resident #67 hit him/her in the face;
-Resident #67 was not able to explain what occurred due to his/her dementia;
-He/she and LPN A separated the residents and completed vital signs on both;
-He/she took Resident #67 to his/her room and educated him/her about hitting other
residents;
-He/she assessed both of the residents for injury and did not see any injury on Resident
#30 or Resident #67;
– Resident #30 remained in the dining room;
-The did not begin one to one monitoring or 15 minute checks on either resident;
-LPN A went back to the nursing station to begin documenting the occurrence report and
making notifications to the residents physicians and responsible partys;
-He/she went down to the notify the Director of Nursing (DON) and Administrator of the
incident when LPN A called to say that Resident #67 had come out of his/her room, walked
into the dining room and hit Resident #30 again in the face;
-He/she went back to the unit and Resident #67 was in his/her room and Resident #30 was
sitting in his/her wheelchair at the nursing station;
-He/she assessed Resident #30 and took vital signs and saw a little red area on his/her
cheek that went away soon thereafter. He/she went to Resident #67’s room to assess him/her
and and saw no injuries;
-Neither resident could explain how the second incident occurred and none of the staff
said they witnessed the incident;
-He/she informed nursing staff to ensure that both of the residents were being observed at
all times and they were to be kept separated;
-When he/she asked Resident #67 about the second incident he/she said that Resident #30
just makes him/her mad, but could not explain what the resident had done or how the
incident occurred;
-Upon further investigation, he/she found out that Resident #67 came out of his/her room
to go out to smoke on the smoking patio and walked through the dining room, saw Resident
#30 and hit him/her again.
-When he/she asked Resident #30 what happened, he/she asked for a cigarette;
-After observing Resident #67, he/she has noticed that he/she becomes agitated with loud
noise and yelling and nursing staff said that this was a pattern for the resident;
-Since yelling out was one of Resident #30’s behaviors, the nursing staff were keeping the
residents apart.
-When they have a resident to resident physical altercation, they are supposed to separate
the residents, keep them separated and provide diversion or redirection to prevent
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
recurrence;
-They can provide one to one monitoring if they think it is necessary, but after the
initial incident, they did not think one to one monitoring was necessary for Resident #67
once he/she was in his/her room;
-Resident #30’s verbal aggression is a continuous behavior that they address through
redirection and talking with the resident. He/she will usually stop for a while but will
start the behavior again;
-He/she did not know why nursing staff did not take Resident #30 to his/her room after the
initial incident and if they had done so, there may not have been a second incident and
-Had they put Resident on one to one monitoring after the first incident, there may not
have been a second incident.
During an interview on 6/15/18 at 1:40 P.M., the DON said:
-He/she expected nursing staff to know the facility protocol for resident to resident
altercations;
-Upon hire all staff are given training on abuse and neglect and resident to resident
abuse is covered in that training;
-They have mandatory training on abuse and neglect annually;
-With resident to resident altercations, he/she would expect nursing staff to separate the
residents, the nurse to complete a physical assessment of each resident, notify the
residents physicians and family and follow any physician’s orders [REDACTED].
-He/she would also expect the nursing staff to monitor the residents to ensure their
safety and well being and the safety and well being of other residents, whether through
one to one monitoring or otherwise and
-He/she expects the resident’s care plan interventions to be implemented to help manage
the resident’s behaviors.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to document and obtain
Physician’s order to send the resident to the hospital for evaluation and treatment for
[REDACTED]. to his/her Physician’s Order Sheet (POS) to discharge the resident from the
facility to a community facility for one sampled resident (Resident #201) out of 20
sampled residents. The facility census was 100 residents.
1. Record review of Resident #201’s Face Sheet showed the resident:
-Was admitted to the facility on [DATE] and discharged on [DATE].
-Had a [DIAGNOSES REDACTED].>–Dementia Disease (is a progressive disease that destroys
memory and other important mental functions);
–Anxiety (is a feeling of nervousness, fear, apprehension, and worrying);
-Restlessness and Agitation (causing a need to move around or pace, or become upset);
-impulse disorder (affected individuals typically report significant impairment in social
and occupational functioning and can’t resist the urge to do something harmful or
inappropriate behavior to themselves or others)
Record review of the resident’s discharge Minimum Data Set (MDS a federally mandated
assessment instrument completed by facility staff for care planning) dated 6/2/18 showed
he/she:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 – Few

(continued… from page 8)
-Had wandering behavior every day;
-Required supervision for transfer, mobility, toileting, personal cares and bathing;
-Was able make himself/herself under stood and usually can understand others;
-Was cognitively impaired and has a BIMS (Brief Interview for Mental Status) score of 00
and
-Had one injury fall during the look back time period.
Record review of the resident’s Care Plan reviewed on 5/23/18 date showed the resident:
-Was at risk for injury related to falls due to confusion, and [DIAGNOSES
REDACTED].>–Had a laceration (a deep cut or tear in skin or flesh) and raised area to
the back of his/her head. Cause unknown. Injury was being investigation and being assessed
as if fall occurred;
–The facility staff were to complete two hour rounds and assess the resident room and the
resident for any signs of an unwitnessed fall;
-The resident had a potential for skin breakdown;
–Had a raised area and a laceration to back of his/her head and required staples. The
resident was transferred to the hospital to rule out a closed head injury; Cause of injury
unknown was being investigated and treated as possible fall and
–Treatment to be done to the resident’s laceration, neuro checks to be done and to
monitor for any increase swelling, redness or drainage to the resident’s [MEDICAL
CONDITION]
Record review of the resident’s POS dated 5/23/18 to 6/3/18 showed the resident;
– Did not have documentation of verbal or written physician’s orders for the resident to
be sent to the hospital for evaluation and treatment for [REDACTED].
-Did not have documentation of written physician’s orders for the resident to be discharge
to another long term care facility on 6/2/18.
Record review of the resident’s Nurse’s Progress Notes dated 5/23/2018 at 4:28 A.M.,
showed:
-The resident was checked at 1:15 A.M., 5/23/18 and he/she was fully clothed and laying in
his/her bed, due to the resident’s behaviors of wandering and going into other people’s
rooms, the resident was not bothered during rounds. The staff had just checked to make
sure that the resident was in his/her room;
-During the second set of rounds at 3:00 A.M. in the morning. The resident was sitting in
the dining room in a chair when the aide had come and got the nurse, and said that the
resident had blood all down his/her right side. When the nurse had assessed the resident
and removed his/her wig, the resident had blood matted in his/her hair and was going down
the right side of her neck onto his/her back. The resident had blood all over his/her
clothes;
-When nursing staff began to clean the wound the resident tensed up because of the pain
and said the wound spray was cold;
-The resident was cleaned up and his/her room was checked by staff, found where he/she had
blood in both beds , in between both beds and in the middle of his/her dresser. Facility
staff did not find blood in the hallway or in any of the other resident’s rooms;
-The resident’s vitals were done at 3:08 A.M., blood pressure was 123/54, temperature was
97.8, the resident’s oxygen saturation was 93 percent, heart rate was 87, and respiration
was 18. The resident said he/she was not in pain;
-The resident’s primary care provider was notified at 3:35 A.M., his/her family member,
who was his/her Durable Power of Attorney (DPOA) was notified at 03:39 A.M. and the
Assistant Director of Nursing (ADON) was notified at 3:52 A.M.
-The ambulance arrived to transport the resident to the hospital at 4:08 A.M.,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 – Few

(continued… from page 9)
-The nurse documented that report and statements were written and the proper procedures
were followed and
-No documentation was found that the nursing staff had received physician orders from the
resident’s physician to send the resident to the hospital for evaluation and treatment for
[REDACTED].
Record review of the resident’s nursing progress notes dated 6/2/18 at 2:45 P.M. showed
the nursing staff had documented a Discharge Summary Late Entry: showed:
-The resident was discharged on [DATE] at 1:45 A.M. to another long term care facility.
The resident was picked up by his/her family members. The resident exited the facility
with family and was transported to the other facility by way of personal vehicle;
-The resident primary care physician Nurse Practitioner was contacted and received phoned
and advised of intentions and instructions were received to discharge with medication,
face sheet, medication list and also the resident’s care plans. The facility will fax the
care plans to the new facility;
-The resident was in a pleasant mood and verbalized understanding that he/she was going to
a new facility.
-Discharge instructions were given to the resident’s family member as well as medications
and personal belongings of the resident and
-The mood of the resident was pleasant and no complaints were voiced before departure. The
resident denied any pain or discomfort.
Record review of the resident’s nursing progress notes dated 5/23/18 at 6:56 A.M. showed
the nursing staff had documented the hospital nursing staff had called to give report that
the resident had a 2 centimeter (cm) laceration and will be coming back with [MEDICATION
NAME] (antibiotic ointment) and his/her stitches needed to be removed in seven days per,
the Registered Nurse (RN) from the hospital.
Record review of the resident’s nursing progress notes dated 5/24/18 at 2:26 A.M., showed:
the resident was on fall follow-up and had a laceration on his/her left side of the back
of his/her head, The resident has staples (used to close gaping wound) in place, and was
dry and intact. The resident had no complaints of pain or discomfort. The resident’s neuro
checks was with in normal limits. He/she was in bed sleeping at this time, facility staff
are to monitor the resident every two hours during rounds, and to ensure to maintain the
resident call light was in reach.
During an interview on 06/15/18 at 10:51 A.M., Licensed Practical Nurse (LPN) A the 4th
floor charge nurse said:
-The resident wonders into other resident rooms, the facility staff provide music therapy,
movies and try to keep him/her around the nurse’s station for closer supervision;
-The facility staff would make rounds at least every two hours, but most of the time they
monitor every 45 minutes to one hour;
-He/she was made aware of the resident’s head injury on 5/23/18 in the morning nurses
report, but was not sure what happen;
-The resident had returned to the unit with new physician’s order from the hospital,
related to the care and treatment of [REDACTED].
-The nursing staff had started neuro checks and he/she had reassessed the resident and had
added additional monitoring for the resident;
-The resident did not have a roommate, because he/she would sleep in both beds and
-The resident should have physician’s orders to be sent to the hospital or to be discharge
to the community.
During an interview on 6/15/18 at 12:00 P.M. Director of Nursing (DON) said;
– They had initiated an investigation into the resident’s injury of unknown cause, and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 – Few

(continued… from page 10)
they are unsure if it was from the resident falling and hitting his/her head on dresser in
his/her room or other causes;
-He/she would excepted the nursing staff to obtain written physician’s orders from the
resident’s physician’s, to be sent to the hospital for him/her to be evaluation and
treatment for [REDACTED].
-He/she would excepted nursing staff to obtain written physician’s orders from the
resident physician’s to be discharge the resident from the facility to the community,
During an Interview on 06/15/18 at 1:40 P.M., the Assistant Director of Nursing (ADON)
said it is the exception that resident’s discharge to the community or to the hospital
should have a physician’s order.
Complaint # MO 869

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, record review and interview, the facility staff failed to ensure to
obtain and document the resident physician’s orders for [MEDICAL TREATMENT] services prior
coordination of services for a resident with End Stage [MEDICAL CONDITIONS] and to ensure
to have physician’s orders prior to providing care and treatment to the resident’s newly
inserted [MEDICAL TREATMENT] port for one sampled resident (Resident # 49), out of 20
sampled residents. The facility census was 100 residents.
1. Record review of Resident #49’s Face Sheet showed, he/she was admitted to the facility
on [DATE] and readmitted [DATE]. Had a [DIAGNOSES REDACTED].
Record review of the resident’s Care Plan updated on 4/4/18 showed:
-The resident needs [MEDICAL TREATMENT] related to his/her [MEDICAL CONDITION];
–He/she will have [MEDICAL TREATMENT] on Tuesday, Thursday, Saturday at the [MEDICAL
TREATMENT] clinic;
–The resident will be transported by the facility on Tuesday, Thursday and by Secure
medical transport on Saturdays;
–He/she was to be transferred into a wheel chair/ using a Hoyer lift (is a hydraulic lift
that lifts a resident who can not stand in a sling from the bed to the chair and back
again) and sling to go with him/her to the [MEDICAL TREATMENT] clinic;
–The resident’s chair time at [MEDICAL TREATMENT] is 11:30 A.M. and the resident will be
picked up time at approximately 10:30 A.M.,
–Check dressing daily at access site and document;
–[MEDICAL TREATMENT] is located at the right internal jugular (neck and upper chest area)
and was initiated at the hospital;
–Monitor/document for [MEDICAL CONDITION] (swelling in legs and arms);
-Monitor/document/report to the resident’s physician’s as needed (PRN) for any signs and
symptoms of infection to the [MEDICAL TREATMENT]: redness, swelling, warmth or drainage;
-Monitor/document/report to the resident’s physician as needed for signs and symptoms of
[MEDICAL CONDITION]: changes in level of consciousness, changes in skin turgor, oral
mucous, changes in heart and lung sounds.
-Notify nephrology or [MEDICAL TREATMENT] center immediately in case of:
— Pus draining from catheter, fistula, or graft
— Redness or swelling at catheter site
— Enlarging hematoma or pain

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 11)
–Staff to attended [MEDICAL TREATMENT] session when family not attending.
Record review of the resident’s Physician’s Order Sheet (POS) showed the resident:
-Had a newly [DIAGNOSES REDACTED].
-Does not have a physician’s order for [MEDICAL TREATMENT] service or for monitoring of
his/her [MEDICAL TREATMENT] port.
Record review of the resident’s medical record showed:
-On 5/1/18, nursing staff had documented in the resident’s skilled nursing that he/she had
a [MEDICAL TREATMENT] port located in his/her right chest and had a [DIAGNOSES REDACTED].
-On 6/7/2018 at 5:00 P.M., Nursing progress Health Status Note said the resident had
returned from [MEDICAL TREATMENT] at 5:15 P.M., the resident weight upon return was 116
pounds, vital signs; blood pressure was 102/70, temperature was 98.0, respiration was 16,
was pulse 88, oxygen saturation was 98% room air. The resident’s [MEDICAL TREATMENT] port
in his/her right chest was clean/ and intact, no bleeding was noted. the resident had no
problems or concerns upon return from [MEDICAL TREATMENT]. The facility staff will
continue to monitor.
Record review of the resident’s Treatment Administration Record (TAR) showed the resident:
-Does not have a physician’s order for [MEDICAL TREATMENT] services or for monitoring of
his/her [MEDICAL TREATMENT] port at the right chest area and
-No documentation was found on the resident’s TAR for monitoring the resident’s [MEDICAL
TREATMENT] port.
During an observation of the resident’s [MEDICAL TREATMENT] port and interview on 6/15/18
at 10:50 A.M., showed:
-The resident’s port on right chest had no redness, the dressing was dry and clean;
-Licensed Practical Nurse (LPN) A said, the nursing staff is to document in the resident’s
progress notes and on the [MEDICAL TREATMENT] communication form when the resident returns
from his/her [MEDICAL TREATMENT] appointments which include vital signs weights, and to
check the port dressing;
-Review of the resident’s POS and TAR with LPN A, he/she was unable to find a physician’s
order for monitoring of the resident’s [MEDICAL TREATMENT] port or for the resident to
receive [MEDICAL TREATMENT] services and
-He/she said should have a physician’s order for [MEDICAL TREATMENT] services and the
monitoring and care of the resident’s [MEDICAL TREATMENT] port.

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
medications were stored, labeled and dated correctly in one of the three sampled
medication carts and one of the two sampled medications rooms which affecting four out of
the 20 sampled residents (Resident #8, #10, #19, and #63, and three additional residents (
Resident #151, #13 and #1000). The facility census was 100 residents.
1. During observation and interview of the medication room on fourth floor on 6/14/18 at
9:35 A.M., with Registered Nurse (RN) B showed:
-Observation of the medication refrigerators showed:
–For Resident #10 had a open bottle of [MEDICATION NAME] (used to treat anxiety- feelings

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 12)
of worry or overwhelmed) two milligram (mg)/milliliter (ml) , the bottle was not labeled
with the resident’s name and did not have a date when the medication had been opened on
the bottle or the box. The medication box had the pharmacy label that had the resident’s
name, dosage and was filled on 5/11/18;
–An open bottle of [MEDICATION NAME] (is a sterile extract purified protein derivative
PPD) 5 tu/o.1ml, did not have a date when it had been open on the bottle or the box;
-Review of the over the counter medication showed: Vitamin D 400 IU that expired on 4/18 –
and Antifungal Cream (skin care barrier cream) that expired on 5/18;
-Review of the over the facility stock dressing supplies showed; Tega Derma AG Mesh
(Provides fast-acting, long-[MEDICATION NAME] microbial barrier control for up to seven
days) two boxes expired on 9/17: and three Dressing change Tray ( is a professional
solution to provide basic care for PICC lines or other surgical or wounds kits) expired on
1/16, 12/15 and 4/16;
-Review of the over the facility stock intravenous (IV supply caps) showed: Had 14
multifunction blue caps expired on 7/15 , had nine multifunction red caps expired on 12/15
and 5 replacement caps 5/14 and
-Registered Nurse (RN) B said; this was not his/her normal floor, would expect the
medication rooms to be monitored for expired medication and medical supplies.
2. During an observation of the Nurse’s Medication Cart on the second floor on 6/14/18 at
10:20 A.M., with RN A showed:
-[MEDICATION NAME] HFA6.75 inhaler (puffer or pump, is a medical device used for
delivering medication into the body via the lungs); was in box but the inhalers was not
labeled with the residents name or dated first used or opened for Resident #8;
-Pro Air 90 mcg inhaler; was in box but the inhalers was not labeled with the residents
name or dated first used or opened for two residents: Resident #19 and Resident #13;
-[MEDICATION NAME] HFA inhaler; was in box but the inhalers was not labeled with the
residents name or dated first used or opened for three residents: Resident #151, Resident
#63 and for Resident #1000;
-RN A during review of the cart corrected the undated and unlabeled inhalers with the
resident name and dated opened during reviewing of the medication cart and
-RN A said he/she checks the medication cart daily for expired medication and cleanliness
and he/she was not aware that the inhalers should have been labeled with the resident’s
name, an the date it was opened, but understood.
3. During an interview on 06/15/18 10:05 A.M., Certified Medication Technician (CMT) A
said: he/she check the medication cart every 30 days for expired medications, the
medication room and the refrigerator are monitored by the licensed nurses.
During an interview on 6/15/18 at 12:50 P.M., Director of Nursing (DON) said:
-He/she expected the nursing staff and the CMTs to ensure that the medications are labeled
with the resident’s name and the date they had been opened on the box and on the
medication bottle;
-The pharmacy audits the medication rooms and carts every month and the nursing staff are
responsible for weekly and daily checks and
-He/she expected the nursing staff to check the medication room for any expired dressing
supplies and medications at least weekly.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 – Few

(continued… from page 13)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
handwashing was completed to prevent cross contamination prior to performing resident
catheter (a flexible tube inserted through a narrow opening into a body cavity,
particularly the bladder, for removing fluid) care for one sampled resident (Resident #8)
and to ensure the correct placement of the resident’s catheter bag and tubing for one
sampled resident (Resident #11 ) out of 20 sampled residents. The facility census was 100
residents.
1. Record review of Resident #8’s Face Sheet showed he/she was admitted to the facility
with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 6/8/18, showed
he/she:
-Had little cognitive impairment;
-Needed limited assistance with personal cares and
-Had a catheter and was incontinent of bowel.
Record review of the resident’s physician’s orders [REDACTED].
Observation on 6/11/18 at 11:59 A.M., showed the resident was sitting on his/her bed in
his/her room and he/she was alert and oriented, groomed and dressed for the weather.
His/her catheter was covered (under his/her pants leg).
Observation on 6/12/18 at 1:11 P.M., Certified Nursing Assistant (CNA) A:
-Entered the resident’s room with gloves on. He/she did not take her gloves off or wash
his/her hands.
-CNA A went to the resident, who was sitting on his/her bed and asked him/her if it was
okay to drain his/her catheter bag, and the resident said it was okay;
-CNA A ensured the resident’s privacy curtain was pulled so that neither of his/her
roommates could see the resident and pulled up his/her pant leg revealing the catheter;
-CNA A un-capped the catheter drainage bag tubing and, using an alcohol wipe, cleaned the
tip of the drainage bag tubing. CNA A then drained the urine into a urinal, using another
alcohol wipe, cleaned the tip again then re-capped the tubing and
-CNA A then took his/her gloves off, put a new pair of gloves on, emptied the urinal then
took his/her gloves off and washed his/her hands before leaving the resident’s room.
During an interview on 6/12/18 at 1:20 P.M., CNA A said:
-He/she should always wash his/her hands upon entering the resident’s room and before
leaving.;
-He/she had washed his/her hands and put on gloves, then left the resident’s room but when
he/she re-entered, he/she did not re-wash his/ her hands because he/she had not touched
anything and
He/she did not need to wash or sanitize her hands during the care provided to the
resident.
During an interview on 6/12/18 at 1:42 P.M., Licensed Practical Nurse (LPN) B said:
-When nursing staff enter the resident’s room, they are to knock on the door first, wash
their hands before gloving, after removing any dirty tubing;
-If the aide is just draining the catheter bag, he/she would expect the aide to wash and
glove upon entering the resident’s room, clean the spout of the catheter then drain the
catheter bag and empty the contents of the bag into the toilet, then remove their gloves
and wash their hands then re-glove and finish any additional care and
-The CNA should have taken their gloves off and washed their hands and put on clean gloves
before providing resident care.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 – Few

(continued… from page 14)
During an interview on 6/15/18 at 1:40 P.M., the Director of Nursing (DON) said the
nursing staff should never enter the resident’s room and prepare to provide care without
removing the gloves and then washing their hands and re-gloving before assisting with or
completing any resident care. He/she said nursing staff should wash their hands any time
they remove their gloves and whenever they finish performing a dirty task, before
performing a clean one. He/she said nursing staff should wash their hands again before
leaving the resident’s room.
2. Record review of Resident #11’s Face Sheet showed he/she was admitted to the facility
with [DIAGNOSES REDACTED]. noncancerous increase in size of the prostate gland- which it
can impede the flow of urine can cause symptoms of urinary hesitancy, blockage of urine
and weak stream)
Record review of the resident’s quarterly MDS dated [DATE], showed he/she:
-Was severely cognitively impairment;
-Needed extensive assistance with personal cares,bathing, toileting and
-Had a catheter and was incontinent of bowel.
Record review of the resident’s POS dated (MONTH) (YEAR) showed the resident had a Foley
catheter 20 french (size of tip of catheter) with 10 ml balloon (amount liquid used to
inflate the balloon that used to hold catheter in place) for [DIAGNOSES REDACTED].
Observation on 6/11/18 at 10:31 A.M., showed the resident was sitting on his/her
wheelchair in dining room. He/she was alert to self and was well groomed. His/her catheter
was covered in a privacy bag under his/her wheelchair.
Observation on 6/11/18 at 12:43 P.M., showed the resident was sitting on his/her
wheelchair in the dining room. He/she had received meal of purred food, able to feed self.
His/her catheter was covered in a privacy bag under his/her wheelchair, the catheter
tubing was laying on the flooring during the time the resident was in the dining room for
meals.
Observation on 6/13/18 at 7:40 A.M. A.M., showed the resident was wheeled to the shower
room by CNA C and Restorative Aide (RA):
-The resident’s Foley catheter bag had been placed beside the resident while he/she was in
his/her wheelchair;
-The resident’s catheter bag remained at bladder level while preparing his/her whirlpool
and removing his/her old dressing;
-RA had kept the resident’s catheter bag outside of the whirlpool tub and below the
bladder, during his/her time in the whirlpool tub and
-CNA C and RA said the resident likes to hold to the catheter bag when transporting
him/her, and the resident does transfer himself/herself to and from bed a times and place
the catheter bag in his/her wheel chair.
During an interview on 6/15/18 at 10:50 A.M., CNA B said;
-The resident’s catheter tubing should not be touching the floor;
-He/she would take cloth like a bleach wipe or alcohol wipe and clean the tube and
-When transferring the resident, the catheter bag should be below the resident’s bladder
During an interview on 6/15/18 at 10:50 A.M., LPN A said;
-The resident’s catheter tubing should not be touching the floor;
-The catheter tubing should be attached under the resident’s wheel chair in a privacy bag
and
– The facility staff continues to reeducate the resident about not keeping this/her
catheter bag in the chair, due to his/her dementia having to redirect the resident related
to the placement of his/her catheter bag.
During an Infection Control Interview on 6/15/18 at 10:09 A.M., DON and (Assistant
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265167

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

NAME OF PROVIDER OF SUPPLIER

HIGHLAND REHABILITATION & HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

904 EAST 68TH STREET
KANSAS CITY, MO 64131

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 – Few

(continued… from page 15)
Director of Nursing ADON) said their expectations for infection control were;
-The resident’s catheter drainage bag should be in a dignity bag when out of the room and
-The resident catheter drainage bag should be lower than the bladder during transfers,
while in wheel chair and in bed.
During an interview on 6/15/18 at 12:50 A.M., DON said he/she would expect the direct care
staff and the nursing staff to ensure the resident’s catheter tubing should not be
touching the floor while sitting in his/her wheelchair, and should be kept below the
resident’s bladder during transfer.