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:

265682

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

NAME OF PROVIDER OF SUPPLIER

INDEPENDENCE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1600 SOUTH KINGSHIGHWAY
INDEPENDENCE, MO 64055

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 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on interview and record review, the facility failed to fully complete the Skilled
Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS- ) for two sampled
residents (Resident #25 and #167) who were discharged from Medicare part A services and
remained in the facility out of three sampled residents. The facility census was 68
residents.
Record review of the Centers for Medicare and Medicaid Services Survey and Certification
memo (S&C-09-20), dated 1/9/09, showed the following:
-The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS- ) is issued when all
covered Medicare services end for coverage reasons;
-If the skilled nursing facility (SNF) believes on admission or during a resident’s stay
that Medicare will not pay for skilled nursing or specialized rehabilitative services and
the provider believes that an otherwise covered item or service may be denied as not
reasonable or necessary, the facility must inform the resident or his/her legal
representative in writing why these specific services may not be covered and the
beneficiary’s potential liability for payment for the non-covered services. The SNF’s
responsibility to provide notice to the resident can be fulfilled by the use of either the
SNFABN (form CMS- ) or one of the five uniform denial letters;
-The SNFABN provides an estimated cost of items or services in case the beneficiary had to
pay for them him/herself or through other insurance they may have and
-If the SNF provides the beneficiary with either the SNFABN or a denial letter at the
initiation, reduction, or termination of Medicare Part A benefits, the provider has met is
obligation to inform the beneficiary of his/her potential liability for payment and
related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys
notice to the beneficiary of his/her right to an expedited review of a service
termination.
1. Record review of the Beneficiary Notice-Resident discharged Within the Last Six Months
showed Resident #25 was discharged from Medicare Part A services on 5/22/18 and remained
in the facility.
Record review of the resident’s SNF/Beneficiary Protection Notification Review completed
by the facility staff showed:
-The resident’s Medicare part A skilled stay started on 4/28/18;
-The resident was discharged from Medicare Part A skilled services on 5/22/18 and
-The facility staff did not provide the resident the SNFABN form CMS- or an alternative
denial letter.
2. Record review of the Beneficiary Notice-Resident discharged Within the Last Six Months
showed Resident #167 was discharged from Medicare Part A services on 6/28/18 and stayed in
the facility.
Record review of the resident’s SNF/Beneficiary Protection Notification Review completed
by the facility staff showed:
-The resident’s Medicare part A skilled stay started on 5/30/18;
-The resident was discharged from Medicare Part A skilled services on 6/28/18 and
-The facility staff did not provide the resident the SNFABN form CMS- or an alternative
denial letter.
During an interview on 8/20/18 at 3:05 P.M., Social Services Designee (SSD) A said:
-He/she was responsible for delivering the Medicare Part A discharge notices;
-He/she was unaware the CMS- needed to be given to the resident upon discharge from

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:

265682

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

NAME OF PROVIDER OF SUPPLIER

INDEPENDENCE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1600 SOUTH KINGSHIGHWAY
INDEPENDENCE, MO 64055

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 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
Medicare Part A services and remained in the facility and
-He/she had been delivering the CMS- to residents who discharge from Medicare Part B only.

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, interview and record review, the facility failed to ensure one
sampled resident’s (Resident #8) room out of 18 sampled residents,was free of strong urine
odor; and to ensure that all residents had a clean environment by maintaining the ceiling
fan blades in the dining room of the locked unit and a ceiling vent in the laundry area
free from a heavy build-up of dust; this practice potentially affected 20 residents who
reside in the locked unit and may use that dining room for meals and/or activities. The
facility census was 68 residents with a licensed capacity for 99.
1. Record review of Resident #8’s Face Sheet showed he/she was admitted to the facility on
[DATE] with the [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (a slowly progressive
disease of the brain that is characterized by impairment of memory and eventually by
disturbances in reasoning, planning, language, and perception);
-Generalized muscle weakness and
-Need for assistance with personal care.
Record review of the resident’s Potential for Skin Breakdown Care Plan, dated 7/27/17,
showed:
-The resident used a pressure-relieving mattress and chair cushion and
-The staff were to clean the resident following urination and bowel movements.
Record review of the resident’s Incontinence Care Plan, dated 8/10/17 showed:
-The staff were to change the resident’s soiled clothing after each incontinent episode
and
-The resident may wear briefs in bed according to family request.
Record review of the resident’s Activities of Daily Living (ADL’s – dressing, grooming,
bathing, eating, and toileting) Care Plan, dated 12/1/17, showed he/she required
one-person assistance with all ADL’s, with the exception of transfers in which he/she
required two-person assistance.
Record review of the resident’s Urinary Incontinence Evaluation, dated 5/11/17 showed:
-The resident was always incontinent of urine;
-The resident was in later stages of Dementia (a progressive organic mental disorder
characterized by chronic personality disintegration, confusion, disorientation, stupor,
deterioration of intellectual capacity and function, and impairment of control of memory,
judgment, and impulses);
-The resident was dependent upon staff for bed mobility, transfers, toileting and personal
hygiene;
-The resident was unable to change his/her own incontinence pad and sometimes soaked
his/her pad and
-The resident’s incontinence was due to cognitive (mental) and/or physical functioning.
Record review of the resident’s Annual Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning), dated 8/6/18, showed
he/she:
-Was severely cognitively impaired;

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:

265682

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

NAME OF PROVIDER OF SUPPLIER

INDEPENDENCE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1600 SOUTH KINGSHIGHWAY
INDEPENDENCE, MO 64055

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)
-Required extensive one-person assistance with bed mobility and extensive assistance with
toileting tasks such as cleansing self following elimination, changing an incontinence pad
and adjusting clothing;
-Was not on a urinary or bowel toileting program and
-Was always incontinent of urine and bowel.
Observations on 8/13/18 in the resident’s room on the Center Hall showed:
-At 9:08 A.M. the resident was in bed with a cloth incontinence pad under his/her hip
area. There was a strong urine odor in the resident’s room;
-At 9:50 A.M. the resident was still in bed and there was a strong urine odor in the
resident’s room and
-At 11:50 A.M. the resident was out of his/her room. A strong urine odor remained in the
resident’s room.
Observations on 8/14/18 of the resident’s room showed:
-At 10:19 A.M. the resident was in bed with eyes closed. There was a urine smell from the
resident’s side of the room;
-At 11:09 A.M. the resident was not in his/her room. The room had a strong urine smell.
The bedspread had a very strong urine smell and the bedspread had been pulled up over the
bed and pillow as if the bed had been made for the day. There were no visual signs of
wetness on the bedspread and
-At 1:21 P.M. the resident was not in his/her room. The resident’s side of the room
continued to smell strongly of urine.
Observations on 8/17/18 of the resident’s room showed:
-At 6:43 A.M. the resident was lying in bed. A strong smell of old urine was in the
resident’s room. The odor could be smelled outside the resident’s doorway;
-At 7:42 A.M. the resident was in bed and his/her room had a strong urine odor;
-At 12:57 P.M. Certified Nurses Aide (CNA) A and CNA B brought the resident into his/her
room in order to transfer the resident into his/her bed. CNA A said he/she could smell an
odor on the resident’s bedspread, removed the bedspread and fitted sheet from the
resident’s mattress and exited the room with the linens;
-CNA B said Housekeeping had a disinfectant spray they used to clean mattress tops and
left the room to inform the housekeeper of the soiled mattress top;
-At 1:02 P.M. Housekeeper A entered the room carrying a spray bottle labeled Neutral
Disinfectant Cleaner. Housekeeper A said every bed was stripped weekly and mattress tops
were supposed to be washed. The urine odor remained on the mattress top after the cover
was disinfected. CNA A removed the mattress cover and said he/she could smell the urine
odor in the mattress;
-One of the two CNAs left the room to inform Management of the mattress odor;
-At 1:10 P.M. the Administrator entered the room and noted the mattress was an Immersion
I-Heal pressure-reducing model. The Administrator said he/she would check an empty room to
see if there was a similar mattress available and
-Another Immersion I-Heal mattress was brought into the resident’s room. The mattress
cover was removed and the mattress revealed an approximately one and a half to two foot
yellow circled stain in the center of the mattress.
Observation on 8/21/18 at 10:46 A.M. in the resident’s room showed a urine odor was noted
from the resident’s side of the room near the resident’s bed. The resident was not in
his/her room. The bedspread was dry and covered the bed.
During an interview on 8/21/18 at 10:50 A.M. CNA C said:
-CNAs don’t check mattresses on a routine basis, but if a CNA is aware there is a problem,
staff are to alert maintenance by putting in a Maintenance Request Form or verbally
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:

265682

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

NAME OF PROVIDER OF SUPPLIER

INDEPENDENCE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1600 SOUTH KINGSHIGHWAY
INDEPENDENCE, MO 64055

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)
letting Maintenance know and
-Disinfectant wipes were located at the Nurses’ station and could be used on the mattress
tops.
During an interview on 8/21/18 at 11:00 A.M. Licensed Practical Nurse (LPN) A said:
-He/she expected CNAs to report to him/her if a mattress was odorous or unsanitary and of
any strong urine odor that lingered after soiled linens were removed and
-He/she would report an odorous mattress to the Director of Nursing (DON).
During an interview on 8/21/18 at 11:50 A.M. the DON said:
-He/she expected bed linens to be clean and the mattress cover sterilized if soiled;
-If there was still an odor in the resident’s room he/she would expect staff to
investigate the smell further and notify the Charge Nurse of the offensive odor and
-Staff should report soiled mattresses to the Charge Nurse and the Charge Nurse should let
the Assistant Director Of Nurses (ADON) or the DON know so the problem could be addressed.
2. Observations in the locked unit’s dining area on 8/13/18 at 10:11 A.M. showed both
ceiling fan’s blades had a heavy build-up of dust on their tops and leading edge that was
easily visible from at least 12 feet away.
During an interview on 8/13/18 at 10:11 A.M., the Maintenance Assistant acknowledged the
observations at the same distance and said that the housekeeping department was
responsible for cleaning the ceiling fans at least once a month.
Observations in the laundry area on 8/13/18 at 2:17 P.M. showed a ceiling vent in the
washer/dryer room had a heavy build-up of dust on it.
Observations in the locked unit’s dining area on 8/14/18 at 9:31 A.M. showed both ceiling
fan’s blades had a heavy build-up of dust on their tops and leading edge.

F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Based on interview and record review, the facility failed to check the State Certified
Nurse Aide (CNA) Registry to determine if newly hired individuals had a Federal Indicator
(shows abuse, neglect or misappropriation of property occurred while the individual was
employed as a CNA in a Medicaid and/or Medicare federally certified facility, which
prohibits the individual from working in a certified facility), Criminal Background Check
(CBC) and the Employee Disqualification List (EDL), a search to see if an applicant is not
eligible for hire, prior to hiring the staff member; and to ensure the facility policy
reflected the current guidelines for screening staff prior to hire for ten out of ten
sampled employees. The facility census was 68 residents.
Record review of the facility’s Abuse Prevention Policy updated 11/2017 showed:
-No later than two working dates of the date an applicant for a position to have contact
with residents is hired, a CBC will be completed,
–The policy did not outline the current required background checks that were required and
–The policy did not state the background checks were to be completed prior to hire.
1. Record review of Employee A’s personnel file showed:
-He/she was hired as a CNA on 1/17/18 and
-His/her CBC, EDL, and CNA registry check was completed on 7/19/18.
Record review of Employee B’s personnel file showed:
-He/she was hired as a CNA on 9/27/17;
-His/her CBC and EDL were completed on 1/11/18 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:

265682

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

NAME OF PROVIDER OF SUPPLIER

INDEPENDENCE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1600 SOUTH KINGSHIGHWAY
INDEPENDENCE, MO 64055

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 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
-His/her CNA registry check was completed on 9/28/17.
Record review of Employee C’s personnel file showed:
-He/she was hired as a laundry assistant on 8/6/18;
-His/her CBC and EDL were completed on 8/13/18 and
-His/her CNA registry check was completed but not dated.
Record review of Employee D’s personnel file showed:
-He/she was hired as a dietary aide on 6/27/18;
-His/her CBC was completed on 6/28/18;
-There was no record of an EDL check and
-His/her CNA registry check was completed but not dated.
Record review of Employee E’s personnel file showed:
-He/she was hired as a CNA on 5/10/18;
-His/her CBC and EDL were completed on 5/11/18 and
-His/her CNA registry check was completed but not dated.
Record review of Employee F’s personnel file showed:
-He/she was hired as a Certified Medication Technician (CMT) on 4/30/18;
-His/her CBC and EDL were completed on 5/1/18 and
-His/her CNA registry check was completed but not dated.
Record review of Employee G’s personnel file showed:
-He/she was hired as a Housekeeper on 4/25/18 and
-His/her CBC, EDL and CNA registry check were completed on 4/27/18.
Record review of Employee H’s personnel file showed:
-He/she was hired as an Activity Aide on 4/4/18 and
-His/her CBC, EDL, and CNA registry check were completed on 4/5/18.
Record review of Employee I’s personnel file showed:
-He/she was hired as a Licensed Practical Nurse (LPN) on 3/21/18;
-His/her CBC and EDL were completed on 6/21/18 and
-His/her CNA registry check was completed on 3/21/18.
Record review of Employee J’s personnel file showed:
-He/she was hired as a CMT on 3/20/18;
-His/her CBC and EDL were completed on 8/13/18 and
-His/her CNA registry check was completed on 2/15/18.
During an interview on 8/20/18 at 2:30 P.M., the Staffing Coordinator said:
-He/she completed all background checks including CBC, EDL and CNA registry check upon
hire,
-He/she did not complete background checks prior to hire,
-He/she was unaware background checks had to be completed prior to hire,
-He/she thought background checks did not have to be completed until after orientation and

-He/she was responsible for ensuring all background checks were completed.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and the
resident’s representative(s) in writing of a transfer or discharge to a hospital,

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:

265682

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

NAME OF PROVIDER OF SUPPLIER

INDEPENDENCE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1600 SOUTH KINGSHIGHWAY
INDEPENDENCE, MO 64055

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
including the reasons for the transfer for three sampled residents (Resident #51, Resident
#11 and Resident #50 ) out of 18 sampled residents. The facility census was 68 residents.
1. Record review of Resident #51’s face sheet showed he/she was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].>-[DIAGNOSES REDACTED] (small sac like pouches that
protrude through the tube like intestinal wall) of the small intestine without perforation
or bleeding and
-Intestinal obstruction (a mechanical or functional obstruction of the intestines which
prevents the normal movement of the products of digestion).
Record review of the resident’s significant change Minimum Data Set (MDS- a federally
mandated assessment instrument to be completed by facility staff for care planning) dated
6/21/18 showed the resident was cognitively intact.
Record review of the resident’s nurses notes dated 5/22/18 at 9:49 A.M. showed physician’s
orders [REDACTED].
Record review of the resident’s nurses notes dated 6/1/18 at 4:17 P.M. show the resident
was readmitted to the facility.
Record review of the resident’s medical records on 8/20/18 showed no written notice of
transfer had been provided to the resident or the resident’s representatives.
During an interview on 1/20/18 at 3:00 P.M., the Director of Nursing (DON) said:
-He /she is going to incorporate sending a discharge policy letter with the resident when
the residents transfers out of the facility and
-He/she will ensure that a copy of the discharge policy letter is sent to the resident’s
representative(s).
2. Record review of Resident #11’s Face Sheet showed he/she was originally admitted to the
facility on [DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s nursing notes dated 7/14/18, showed the resident’s
physician was notified and orders were obtained to transfer the resident to the emergency
room (ER) due to laboratory results showing critical sodium levels. The resident’s Durable
Power of Attorney (DPOA – A type of advance medical directive in which legal documents
provide the power of attorney to another person in the case of an incapacitating medical
condition) were notified of the transfer by telephone.
Record review of the resident’s medical record showed no documentation that the resident’s
legal representative had been notified of the transfer in writing.
Record review of the resident’s Nursing notes, dated 7/16/18 showed:
-The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED].
-The resident arrived back at the facility on 7/16/18 at 1:30 P.M.
During an interview on 8/17/18 at 9:06 A.M. the Social Services Designee said:
-The facility’s procedure for transfer or discharge notification was as follows:
–The charge nurse on duty at the time of the resident’s transfer notifies the
guardians/families over the phone about the transfer. The Ombudsman is notified of the
transfer/discharge in writing and
–The resident and his/her legal representative is not notified in writing of the transfer
or discharge.
During an interview on 8/21/18 at 11:50 A.M. the DON said:
-He/she was unaware the transfer and discharge notifications to the residents and their
legal guardians had to be in writing and
-The facility had been notifying residents verbally and the legal representatives verbally
over the phone.
3. Record review of Resident #50’s Face Sheet showed he/she:
-Was admitted to the facility on [DATE];
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:

265682

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

NAME OF PROVIDER OF SUPPLIER

INDEPENDENCE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1600 SOUTH KINGSHIGHWAY
INDEPENDENCE, MO 64055

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-Had [DIAGNOSES REDACTED].
-Had a Durable Power of Attorney.
Record review of the resident’s Nurse’s Notes dated 4/1/18 and untimed showed he/she had
he/she was transferred to a hospital emergency room and was admitted to the hospital.
During an interview on 8/21/18 at 11:16 A.M. the Social Service Designee (SSD) said:
-The resident was transferred to an emergency room and then admitted to the hospital on
[DATE];
-No transfer/discharge letter was given to the resident; or the resident’s DPOA and
-He/she had thought the nursing discharge sheet (a document given to ambulance drivers to
give to hospital staff that contains resident information) which went to the hospital with
the resident was what needed to be done by facility staff.
During an interview on 8/21/18 at 11:50 A.M. the DON said:
-He/she was now aware of the new requirements that transfer/discharge letters need to go
out with the resident and be sent to the resident’s representative at the time of the
resident’s transfer/discharge and
-The transfer/discharge letters need to give the reason for the transfer/discharge.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Notify the resident or the resident’s representative in writing how long the nursing
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and the
resident’s representative(s) in writing of the facility bed hold policy for three sampled
residents (Resident #51, Resident #11 and Resident #50) out of 18 sampled residents. The
facility census was 68 residents.
Record review of an undated copy of the facility Bed Hold Policy showed when a resident
was hospitalized the facility would contact the resident’s responsible party(s) to ask if
he/she wishes to hold the room.
1. Record review of Resident #51’s face she showed he/she was admitted to the facility on
[DATE] with [DIAGNOSES REDACTED].>-[DIAGNOSES REDACTED] (small sac like pouches that
protrude through the tube like intestinal wall) of the small intestine without perforation
or bleeding and
-Intestinal obstruction (a mechanical or functional obstruction of the intestines which
prevents the normal movement of the products of digestion).
Record review of the resident’s significant change Minimum Data Set (MDS- a federally
mandated assessment instrument to be completed by the facility staff for care planning)
dated 6/21/18 showed the resident was cognitively intact.
Record review of the resident’s Nurse Notes dated 5/22/18 at 9:49 A.M. showed physician’s
orders [REDACTED].
Record review of the resident’s Nurse Notes dated 6/1/18 at 4:17 P.M. showed the resident
was readmitted to the facility.
Record review of the resident’s medical records on 8/20/18 showed no written notice of the
facility bed hold policy had been provided to the resident or the resident’s
representatives.
During an interview on 08/20/18 at 10:15 A.M. the Social Services Designee (SSD) said:
-The resident and the resident’s representative(s) were given a copy of the facility bed

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:

265682

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

NAME OF PROVIDER OF SUPPLIER

INDEPENDENCE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1600 SOUTH KINGSHIGHWAY
INDEPENDENCE, MO 64055

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
hold policy in the admissions packet.
During an interview on 08/20/18 at 3:00 P.M., the Director of Nursing (DON) said:
-He/she expected the resident to be provided with a copy of the bed hold policy when they
transfer from the facility and
-He/she expected the resident’s representative to be provided with a copy of the bed hold
policy.
2. Record review of Resident #11’s Face Sheet showed he/she was originally admitted to the
facility on [DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s Nurses’ notes, dated 7/14/18, showed the resident’s
physician was notified and orders were obtained to transfer the resident to the emergency
room (ER) due to laboratory results showing critical sodium levels.
Record review of the resident’s Nurses’ notes, dated 7/16/18 showed the resident arrived
back at the facility on 7/16/18 at 1:30 P.M.
Record review of the resident’s Medical record showed there was no documentation that the
resident’s legal guardian received a copy of the facility’s bed hold policy at the time of
the transfer.
During an interview on 8/17/18 at 9:06 A.M. the SSD said the facility hadn’t been
notifying the residents and their legal representative in writing of the facility’s bed
hold policy at the time of transfer.
During an interview on 8/21/18 at 11:50 A.M. the DON said the facility had not been
notifying residents and legal representatives in writing of the facility’s bed hold policy
at the time of transfer to a hospital or other location.
3. Record review of Resident #50’s Face Sheet showed he/she:
-Was admitted to the facility on [DATE];
-Had [DIAGNOSES REDACTED].
-Had a Durable Power of Attorney (DPOA – A type of advance medical directive in which
legal documents provide the power of attorney to another person in the case of an
incapacitating medical condition).
Record review of the resident’s Nurse’s Notes dated 4/1/18 and untimed showed:
-He/she had he/she was transferred to a hospital emergency room and
-He/she was admitted to the hospital.
During an interview on 8/21/18 at 11:16 A.M. the SSD said:
-The resident was transferred to an emergency room and then admitted to the hospital on
[DATE];
-No transfer/discharge letter was given to the resident; or the resident’s DPOA and
-He/she had thought the nursing discharge sheet (a document given to ambulance drivers to
give to hospital staff that contains resident information) which went to the hospital with
the resident was what needed to be done by facility staff.
During an interview on 8/21/18 at 11:50 A.M. the DON said:
-He/she was now aware of the new requirements that notice of the facility bed hold policy
needed to go out with the resident and be sent to the resident’s representative at the
time of the resident’s transfer/discharge;
-Nursing staff would begin giving the residents the bed hold policy at the time of the
resident’s transfer/discharge and
-The SSD would provide the resident’s responsible party the bed hold policy.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
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:

265682

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

NAME OF PROVIDER OF SUPPLIER

INDEPENDENCE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1600 SOUTH KINGSHIGHWAY
INDEPENDENCE, MO 64055

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure one sampled resident
(Resident #11) taking Pro Re Nata (PRN – as needed) anti-anxiety medications had orders
limited to 14 days or to indicate a specific duration for the medication; and to
re-evaluate the continued need for a PRN medication after 14 days for one sampled resident
(Resident #35) out of 18 sampled residents. The facility census was 68 residents.
1. Record review of Resident #11’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnosis: [REDACTED].
-Restlessness and Agitation;
-[MEDICAL CONDITION] (a [MEDICAL CONDITION] characterized by loss of contact with the
environment, by noticeable deterioration in the level of functioning in everyday life) and
-Major [MEDICAL CONDITION] (a state of intense sadness or despair that has advanced to the
point of being disruptive to an individual’s social functioning and/or activities of daily
living).
Record review of the resident’s Physician order [REDACTED]. Give 0.25 ml every two hours
PRN for anxiety.
Record review of the resident’s nurses notes dated 7/14/18 through 7/16/18 showed:
-The resident was transferred to a local hospital on [DATE] and
-The resident returned to the facility on [DATE].
Record review of the resident’s POS, dated 8/2018 showed a physician’s orders [REDACTED].
Give 0.25 ml every two hours PRN for anxiety.
Record review of the resident’s Pharmacy Recommendation (date not indicated on form)
showed:
-Limit [MEDICAL CONDITION] medication to 14 days;
-The prescribing practitioner must document clinical rational and specify the duration of
use;
-There were no exceptions for Hospice (end of life care) residents and
-Add 14 day stop date to PRN [MEDICATION NAME] and re-evaluate for continuation at that
time.
Record review of the resident’s physician’s response to the Pharmacy’s recommendation,
signed 8/14/18, showed the following notes:
-No stop date;
-Continued behavior problems and
-Yells and aggressive.
During an interview on 8/21/18 at 10:30 A.M. the Director of Nursing (DON) said:
-The resident was the only facility resident receiving a PRN for anxiety and
-The resident’s physician had not limited the resident’s PRN antianxiety medication to 14
days or indicated a stop date of a different duration.
2. Record review of Resident #35’s admission face sheet shows he/she as admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Convulsions (an uncontrolled shaking of the body) and
-Anxiety disorder (a mental illness defined by feelings of uneasiness, worry and fear).
Record review of the residents quarterly Minimum Data Set (MDS-a federally mandated
assessment instrument to be completed by facility staff for care planning) dated 6/6/18
showed:

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:

265682

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

NAME OF PROVIDER OF SUPPLIER

INDEPENDENCE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1600 SOUTH KINGSHIGHWAY
INDEPENDENCE, MO 64055

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
-The resident to have severe cognition impairment and
-He/she required extensive assistance in Activities of Daily Living (ADL’s).
Record review of the resident’s physician’s telephone order (TO) sheet dated 4/4/18 at
12:13 P.M. showed a physician’s orders [REDACTED]. Give one capsule orally every six hours
PRN for restlessness and or agitation for 14 days then re- evaluate.
Record review of the resident’s POS dated from (MONTH) (YEAR) through (MONTH) (YEAR),
showed [MEDICATION NAME] 125 mg, give one capsule orally every 6 hours PRN for
restlessness and or agitation for 14 days then re-evaluate.
During an interview on 8/20/18 at 1:50 P.M., the Assistant Director of Nursing (ADON)
said:
-A physicians order should have been obtained to discontinue the [MEDICATION NAME] order
that was PRN after 14 days and
-He/she was going to obtain a physician’s orders [REDACTED].
During an interview on 8/20/18 at 3:00 P.M., the Director of Nursing (DON) said:
-He/she expected all prescribed medications will have an indication for the prescription,
with the name of the prescriber;
-He/she expected that any PRN medication should be evaluated as prescribed;
-He/she expected that any PRN medication that has not been used in 60 days will be
discontinued and
-He/she expected that nursing staff should have put a nurses note into the resident’s
medical record about the need for the PRN medication.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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.

Based on observation, record review and interview, the facility failed to store
medications at a safe temperatures for effective administration at the front nurse’s
station medication room. This could affect all the residents who are on insulin who have
their insulin stored in the front nurse’s station medication room. The facility census was
68 residents.
Record review of the facility’s storage of medications policy dated (MONTH) 2007 states
medication requiring refrigeration must be stored in a refrigerator located in the drug
room at the Nurses station or other secured location. Medications must be stored
separately from food and must be labeled accordingly.
Record review of a Health and Human Services, Federal Drug Administration document on
Insulin (a hormone that helps lower the amount of sugar in the blood) storage states all
three U.S. pharmaceutical companies that manufacture insulin recommend that insulin be
stored in temperatures of 36 degrees to 46 degrees Fahrenheit. That insulin should not be
frozen, and that frozen insulin should not be used but should be discarded.
1. Observation on 8/17/18 at 9:04 A.M. with the Director of Nursing (DON) at front nurse’s
station medication storage refrigerator showed:
-The freezer compartment was heavily crusted with frozen condensate;
-The insulin injector pens (a device with a prefilled cylinder of insulin shaped like a
pen) were stored in a labeled plastic bags in a small plastic container beneath the
freezer compartment;

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:

265682

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

NAME OF PROVIDER OF SUPPLIER

INDEPENDENCE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1600 SOUTH KINGSHIGHWAY
INDEPENDENCE, MO 64055

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 – Few

(continued… from page 10)
-One insulin injector pen was in a plastic bag was partially frozen into the condensate
beneath the freezer compartment and
-The insulin in the cylinder of the insulin injector pen cylinder was frozen.
During an interview on 8/17/18 at 9:20 A.M., the DON said:
-The insulin in the injector pen was frozen;
-The air bubble in the insulin cylinder would not move and
-He/she was going to order a new insulin injector pen for the resident.
During an interview on 8/20/18 at 3:00 P.M., the DON said:
-He/she expected the nursing staff to store the insulin injector pens correctly;
-Insulin injector pens should not have been stored beneath the freezer compartment and
-The refrigerator should have been checked for frozen condensate around the freezer
compartment with it having been removed.