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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the resident’s code
status (the desire to be resuscitated or not if breathing stops) matches on all documents
for two sampled residents (Residents #7 and #48) out of 12 sampled residents. The facility
census was 47 residents.
1. Record review of Resident #7’s admission face sheet showed he/she was admitted on
[DATE] with the following Diagnoses: [REDACTED].
-PU unspecified site stage 4;
-PU unspecified heel stage 3;
-Unspecified open wound, left lower leg, initial encounter;
-PU right buttock un-stageable;
-Hypertension (high blood pressure);
-Morbid (of the nature of or indicative of disease) obesity (a disorder involving
excessive body fat that increases the risk of health problems);
-Congestive [MEDICAL CONDITION]/failure ([MEDICAL CONDITION]-disorder that impairs the
ability of the heart to fill with or pump a sufficient amount of blood throughout the
body) and
-[MEDICAL CONDITION] stage 4 (advanced kidney damage characterized by a loss of kidney
function over time).
Record review of the resident’s paper admission face sheet dated [DATE] showed No Code
status listed.
Record review of the resident’s Do Not Resuscitate (DNR the desire to not be resuscitated
if breathing stops) purple sheet showed:
-The resident had signed it on [DATE] and
-The physician had signed it on [DATE].
Record review of the resident’s Physicians Order Summary (POS) dated ,[DATE], ,[DATE],
,[DATE], and ,[DATE] all showed he/she was a Full Code (the desire to be resuscitated if
breathing stops).
Record review of the resident’s computerized face sheet dated [DATE] showed he/she was a
DNR.
Record review of the resident’s chart showed no red (DNR) or green (Full Code) dots on the
chart spine.
2. Record review of Resident #48’s admission face sheet showed he/she was admitted on
[DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION];
-Dependence on supplemental oxygen and
-High blood pressure.
Record review of the resident’s DNR purple sheet showed:
-The resident had signed it on [DATE] and
-The physician had signed it on [DATE].
Record review of the resident’s POS dated ,[DATE], ,[DATE], and ,[DATE] all showed that
the resident was a Full Code.
Record review of the resident’s computerized face sheet dated [DATE] showed he/she was
DNR.
Record review of the resident’s last paper admission face sheet dated [DATE] showed a No
Code status listed.

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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
Record review of the resident’s chart showed no red or green dots on the chart spine to
show desired code status.
3. During an interview on [DATE] at 1:00 P.M., Certified Medication Technician (CMT) A
said:
-He/she did not know what the red or green dots on a resident chart spine meant;
-He/she would check with someone and went and asked.
-He/she returned and said:
–The red dots on the spine of a chart represent DNR;
–The green dots represent do CPR (Cardiopulmonary Resuscitation) and
–No dots mean check the face sheet in the chart.
During an interview on [DATE] at 1:05 P.M., CMT B said that he/she did not know what the
dots on the resident charts meant.
During an interview on [DATE] at 9:22 A.M., Certified Nurse Assistant (CNA) B said to
check a resident’s code status that he/she would:
-Check the resident’s door for a red (DNR) or green (resuscitate) sticker if he/she or the
resident were in the room and
-Check the resident’s chart for a red or green sicker.
During an interview on [DATE] at 9:30 A.M., Registered Nurse (RN) A said:
-The resident’s code status is on the nurse daily shift report under the resident’s name;
-The resident’s chart and door should have a code status sticker, red for DNR and green
for full code and
-The resident’s POS would also show the resident’s code status.
During an interview on [DATE] at 2:15 P.M., the interim Director of Nurses (DON) said:
-All residents should have a code status documented and
-All documentation of a resident’s code status should match.

F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 a newly hired individual 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) prior to hiring, for one
out of three sampled employees. The facility hired 34 employees since the last annual
survey. The facility census was 47 residents.
Record review of the facility Human Resources Policies and Procedures – Background Checks
policy, revised January, 2007 showed:
-Offers of employment will be made contingent upon successful completion of background
investigation and pre-employment drug screen.
-A final offer of employment may not be made without completion of the background
investigation.
-We have established uniform standard criteria for completing background investigations on
employees and actions to take if a problem is detected.
1. Record review of Employee #1’s employee file showed:
-He/she was hired on 11/21/18 and
-There was no record of the CNA Register being checked to ensure he/she did not have a

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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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 – Few

(continued… from page 2)
federal indicator.
2. During an interview on 12/20/18 at 12:44 P.M., the Business Office Manager said he/she
could not find record of where the CNA Registry was checked prior to hiring the employee.
During an interview on 12/21/18 at 2:15 P.M., the Director of Nursing (DON) said:
-The CNA Registry should be checked for a federal indicator on all employees prior to hire
and
-The Business Office Manager does all the background/personnel checks.

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 record review and interview, the facility failed to provide notification to the
resident, and/or the resident’s representative(s) and the ombudsman (a resident advocate
who provides support and assistance with problems and/or complaints regarding the
facility) of the transfer or discharge and the reasons for the transfer or discharge in
writing for three sampled residents (Resident #41, #15, and #48) out of 12 sampled
residents. The facility census was 47 residents.
Record review of the facility’s transfer and discharge policy showed it was a form letter
of notice of transfer/discharge.
1. Record review of Resident #41’s entry tracking records and discharge assessments showed
the resident:
-Entered the facility on 4/5/17;
-discharged from the facility on 4/27/18;
-Returned to the facility on [DATE];
-discharged from the facility on 7/3/18;
-Returned to the facility on [DATE];
-discharged from the facility on 9/14/18 and
-Returned to the facility on [DATE].
Record review of the resident’s medical record showed there was no letter notifying the
resident and/or the resident’s representative(s) or the Ombudsman of a transfer/discharge
and the reasons for the transfer/discharge.
During an interview on 12/21/18 at 10:59 A.M., the Social Services Director said:
-He/she only gives notice of transfer/discharge if it is a 30-day discharge notice or the
resident is transferring to another facility;
-He/she did not know he/she had to send a written transfer/discharge notice and
-He/she did not know about the ombudsman notification requirement.
2. Record review of Resident #15’s SBAR (Situation, Background, Appearance, Review and
notify) Transfer form and Physicians Telephone Orders dated 4/16/18 showed that the
resident transferred to the hospital.
Record review of the resident’s medical record showed there was no letter notifying the
resident and/or the resident’s representative(s) or the Ombudsman of a transfer/discharge
and the reasons for the transfer/discharge.
Record review of the resident’s Nurses Notes dated 4/21/18 at 1:30 P.M., showed that the
resident returned to facility.
Record review of the resident’s Nurses Notes showed:
-On 9/17/18 at 3:15 P.M. the resident was transferred to the 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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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 3)
-On 9/21/18 no time noted, the resident returned to facility;
-On 10/23/18 at 3:15 P.M. the resident was transferred to the hospital and
-On 10/27/18 at 10:00 P.M. the resident returned to facility.
Record review of the resident’s medical record showed there were no letters notifying the
resident and/or the resident’s representative(s) or the Ombudsman of a transfer/discharge
and the reasons for the transfer/discharge.
3. Record review of Resident #48’s Admission Face Sheet showed he/she was admitted on
[DATE].
Record review of the resident’s Nurses Notes showed:
-On 5/21/18 at 9:15 A.M. the resident was transferred to the hospital;
-On 6/6/18 at 6:30 P.M. the resident returned to facility;
-On 10/5/18 no time noted, the resident was transferred to the hospital;
-On 10/13/18 at 9:00 P.M. the resident returned to facility;
-On 11/3/18 at 3:15 A.M. the resident was transferred to the hospital and
-On 11/9/18 no time noted, the resident returned to facility.
Record review of the resident’s medical record showed there were no letters notifying the
resident and/or the resident’s representative(s) or the Ombudsman of a transfer/discharge
and the reasons for the transfer/discharge.
4. During an interview on 12/21/18 at 2:15 P.M., the Director of Nursing (DON) said:
-The facility tries to call the family when a resident transfers to the hospital;
-The facility does not send out a letter of the transfer to the family and
-The facility just started notifying the Ombudsman of a resident’s transfers to hospital.

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 record review and interview, the facility failed to notify the resident and/or
the resident’s representative(s) in writing of the facility’s bed hold policy before
transferring or discharging the resident for three sampled residents (Resident #41, #15,
and #48) out of 12 sampled residents. The facility census was 47 residents.
Record review of the facility’s bed hold policy and agreement form dated revised (MONTH)
2014 showed:
-The facility must notify the resident and/or their responsible party when the resident is
transferred to the hospital or on therapeutic leave of the bed hold policy;
-The facility is to obtain an acknowledgement stating whether or not the resident desires
a bed hold;
-The business office will notify the resident/responsible party to sign the bed hold
agreement and
-A telephone call may be documented as notification on the bed hold agreement.
1. Record review of Resident #41’s entry tracking records and discharge assessments showed
the resident:
-Entered the facility on 4/5/17;
-discharged from the facility on 4/27/18;
-Returned to the facility on [DATE];
-discharged from the facility on 7/3/18;

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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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 4)
-Returned to the facility on [DATE];
-discharged from the facility on 9/14/18 and
-Returned to the facility on [DATE].
Record review of the resident’s medical record showed there was no documentation of
notification of the resident/responsible party of the bed hold policy when the resident
was discharged /transferred.
During an interview on 12/21/18 at 10:59 A.M., the Social Services Director said:
-He/she calls family and asks if they want to do a bed hold when a resident is being
transferred and
-He/she does not have the family sign the bed hold agreement.
2. Record review of Resident #15’s SBAR (Situation, Background, Appearance, Review and
notify) Transfer form and Physicians Telephone Orders dated 4/16/18 showed he/she was
transferred to the hospital.
Record review of the resident’s medical record showed there was no documentation of
notification to the resident or responsible party of the bed hold policy when the resident
was discharged or transferred.
Record review of the resident’s Nurses Notes dated 4/21/18 at 1:30 P.M., showed
he/she returned to facility.
Record review of the resident’s Nurses Notes showed:
-On 9/17/18 at 3:15 P.M. the resident was transferred to the hospital;
-On 9/21/18 no time noted, the resident returned to facility;
-On 10/23/18 at 3:15 P.M. the resident was transferred to the hospital and
-On 10/27/18 at 10:00 P.M. the resident returned to facility.
Record review of the resident’s medical record showed there was no documentation of
notification to the resident or responsible party of the bed hold policy when the resident
was discharged or transferred.
3. Record review of Resident #48’s Admission Face Sheet showed he/she was admitted on
[DATE].
Record review of the resident’s Nurses Notes showed:
-On 5/21/18 at 9:15 A.M. the resident was transferred to the hospital;
-On 6/6/18 at 6:30 P.M. the resident returned to facility;
-On 10/5/18 no time noted, the resident was transferred to the hospital;
-On 10/13/18 at 9:00 P.M. the resident returned to facility;
-On 11/3/18 at 3:15 A.M. the resident was transferred to the hospital and
-On 11/9/18 no time noted, the resident returned to facility.
Record review of the resident’s medical record showed there was no documentation of
notification to the resident or responsible party of the bed hold policy when the resident
was discharged or transferred.
4. During an interview on 12/21/18 at 2:15 P.M., the Director of Nursing (DON) said the
Social Services Director notifies the family or resident representative and asks if they
want to have the bed held.

F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assess the resident completely in a timely manner when first admitted, and then
periodically, at least every 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to address dental issues in the

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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
Minimum Data Set (MDS – a federally mandated assessment tool completed by the facility
staff for care planning) for one sampled resident (Resident #9) out of 12 sampled
residents. The facility census was 47 residents.
1. Record review of Resident #9’s admission face sheet showed he/she was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Cognitive communication deficit and
-Mild cognitive impairment.
Record review of the resident’s admission MDS dated [DATE] showed he/she had no dental
issues.
Record review of the resident’s Clinical Notes Report for Dental Visit dated 3/12/18 at
10:34 A.M., showed he/she:
-Was uncooperative for the exam and
-Would not come to the exam room.
Record review of the resident’s significant change for behaviors MDS dated [DATE] under
the
Care Area Assessment (CAA- a problem-oriented framework for arranging MDS information and
additional clinically relevant information about an individual’s health problems or
functional status.) showed:
-No dental issues and
-Dental was care planned.
Record review of the resident’s Clinical Notes Report Dental Visit dated 6/8/18 at 9:13
A.M., showed:
-The resident was seen by a dentist;
-The resident had several teeth that were non-restorable root tips;
-The resident wished them to be extracted;
-It would be in the resident’s best interest for his/her primary care physician to refer
him/her to an oral surgeon where necessary extractions could be performed in a medically
controlled environment while under sedation;
-The resident inquired about receiving dentures;
-That the dentist explained to resident that he/she would be re-evaluated for dentures
after complete healing from his/her extractions and
-The resident verbalized understanding of waiting to get dentures.
Record review of the resident’s Quarterly MDS dated [DATE] showed no dental areas
addressed.
Record review of the resident’s provided dental progress note dated 8/1/18 showed:
-Resident refused to allow a gloved hand into his/her mouth;
-Resident appeared to have deterioration of some teeth;
-Dentist was uncertain of how much attention and treatment the resident would allow and
tolerate.
-Removal of fragmented teeth would definitely need to be under controlled setting for the
resident’s safety;
-Dentist was uncertain to what extent the resident would allow fabrication of a partial
denture or full denture and to what extent the resident would allow himself/herself to
adapt to dentures and
-Option to address symptomatic situations as they occur may be tolerable for a short-term
plan.
Record review of the resident’s Quarterly MDS dated [DATE] showed no dental areas
addressed.
During an interview on 12/21/18 at 2:15 P.M., the Director of Nursing (DON) said that if a
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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
resident had any dental issues it should show in the MDS.

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop a baseline care plan
for one sampled resident (Resident #41) out of 12 sampled residents. The facility census
was 47 residents.
Record review of the facility’s baseline care plan policy dated revised (MONTH) (YEAR)
showed:
-A baseline care plan would be developed within 48 hours of the resident’s admission to
assure the resident’s immediate care needs are met and maintained;
-The baseline care plan will be used until a comprehensive assessment was completed and a
comprehensive interdisciplinary person-centered care plan was developed and
-The resident and their representative will be provided a summary of the baseline care
plan.
1. Record review of Resident #41’s entry tracking records and discharge assessments showed
the resident:
-Entered the facility on 4/5/17;
-discharged from the facility with his/her return anticipated on 7/3/18 and
-Returned to the facility on [DATE].
Record review of the resident’s current medical record showed there was not a baseline
care plan for the resident when he/she returned to the facility on [DATE].
During an interview on 12/21/18 at 11:30 A.M., the Care Plan Coordinator said they did not
have to have a baseline care plan for the resident when he/she returned from being gone
from the facility over 30 days.
During an interview on 12/21/18 at 2:15 P.M., the Director of Nursing said the front line
nurse initiates a base line care plan within 24 hours of admission and gives a copy to the
resident and/or the resident’s responsible party.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to develop a care plan for two
sampled residents (Resident’s #9 and #11) out of 12 sampled residents. The facility census
was 47 residents.
1. Record review of Resident #9’s admission face sheet showed he/she was admitted on
[DATE] with the following Diagnoses: [REDACTED].
-Cognitive communication deficit and
-Mild cognitive impairment.
Record review of the resident’s significant change for behaviors Minimum Data Set (MDS – a
federally mandated assessment tool completed by the facility staff for care planning)
dated 3/28/18 under the Care Area Assessment (CAA- a problem-oriented framework for

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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
arranging MDS information and additional clinically relevant information about an
individual’s health problems or functional status) showed:
-No dental issues and
-Dental was care planned.
Record review of the resident’s Clinical Notes Report for Dental Visit dated 6/8/18 at
9:13 A.M., showed:
-The resident was seen by a dentist;
-The resident had several teeth that were non-restorable root tips;
-The resident wished them extracted;
-That it would be in the resident’s best interest for his/her primary care physician to
refer him/her to an oral surgeon where necessary extractions can be performed in a
medically controlled environment while under sedation;
-The resident inquired about receiving dentures;
-That the dentist explained to the resident that he/she would be re-evaluated for dentures
after complete healing from his/her extractions and
-The resident verbalized understanding of waiting to get dentures.
Record review of the resident’s Quarterly MDS dated [DATE] under the dental section
showed no dental areas addressed.
Record review of the resident’s dental progress note dated 8/1/18 showed:
-Resident refused to allow a gloved hand into his/her mouth;
-Resident appeared to have deterioration of some teeth;
-Dentist was uncertain of how much attention and treatment the resident would allow and
tolerate;
-Removal of fragmented teeth would definitely need to be under a controlled setting for
the resident’s safety;
-Dentist was uncertain to what extent the resident would allow fabrication of a partial
denture or full denture and to what extent the resident would allow himself/herself to
adapt to dentures and
-Option to address symptomatic situations as they occur may be tolerable for a short-term
plan.
Record review of the resident’s Care Plans (written out plan for the care of the resident)
dated 9/18/18 with the next review scheduled for 12/4/18 showed no care plan for the
resident:
-Wanting dental work and
-Refusing dental work.
During an interview on 12/21/18 the Director of Nursing (DON) said that there should be a
care plan showing a residents choice or refusal to have dental care done.
2. Record review of Resident #11’s admission face sheet showed he/she was admitted on
[DATE] with the following Diagnoses: [REDACTED].
-Anxiety and
-Personality disorder.
Record review of the resident’s physician’s orders [REDACTED].
-[MEDICATION NAME] (used to treat depression) 20 milligram (mg) by mouth (PO) daily at
noon for major [MEDICAL CONDITION] with a start date of 1/18/18;
-[MEDICATION NAME] NA DR ([MEDICATION NAME] an [MEDICAL CONDITION] medication also used to
treat [MEDICAL CONDITION] (a breakdown in the relation between thought, emotion, and
behavior, leading to faulty perception) 250 mg PO daily at 2:00 P.M. for [MEDICAL
CONDITION] disorder with a start date of 6/13/18.
–This dose was discontinued on 12/12/18;
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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
–A higher dose of [MEDICATION NAME] NA DR 500 mg PO at bedtime was started on 12/12/18
and
-[MEDICATION NAME] (used to treat anxiety) 0.25 mg PO daily for anxiety with a start date
of 8/21/18.
Record review of the resident’s care plans dated 9/28/18 showed no care plans for the
resident’s:
-[MEDICAL CONDITION];
-Anxiety;
-Personality disorder and
-[MEDICAL CONDITION] medication use.
During an interview on 12/21/18 at 2:15 P.M. the DON said he/she would expect the resident
to have care plans for [DIAGNOSES REDACTED].

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to update the care
plans to reflect the resident’s current status for four sampled residents (Residents #23,
#41, #1 and #13) out of 12 sampled residents. The facility census was 47 residents.
Record review of the facility’s care plan policy revised (MONTH) (YEAR) showed assessments
of residents are ongoing and care plans are revised as information about the residents and
the residents’ conditions change.
1. Record review of Resident 23’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool used for care planning) dated 10/26/18 showed the following staff
assessment of the resident:
-Required extensive assist of one for hygiene;
-Was totally dependent upon staff for bathing and
-Did not reject care.
Record reviewed of the resident’s care plan dated 12/4/18 showed:
-The resident required assistance with activities of daily living (such as showering,
bathing, etc.) and
-Instructions to staff to check the resident’s nail length and trim and clean them on bath
day and as necessary.
Observation on 12/19/18 at 6:59 A.M. showed the resident sitting in his/her wheelchair in
his/her room. The resident’s fingernails were long and dirty underneath on both hands.
Observation on 12/20/18 at 1:41 P.M., showed the resident sitting in his/her wheelchair
across from the nurses’ station. His/her fingernails were long and dirty underneath on
both hands.
During an interview on 12/21/18 at 8:20 A.M., Registered Nurse (RN) A said the resident
does not want his/her fingernails cut and he/she doesn’t like the staff messing with
his/her nails.
During an interview on 12/21/18 at 8:30 A.M., Certified Nursing Assistant (CNA) B said:
-He/she tries to wash the resident’s hands and clean his/her nails but the resident always
clutches the middle of the top of his/her shirt and
-He/she hasn’t been very successful at getting the resident to let her clean/fix his/her
nails

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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
During an interview on 12/21/18 at 9:21 A.M., Hospice (end of life care) aide A said:
-He/she tried doing the resident’s nails and the resident wouldn’t let him/her;
-He/she tries to clean the resident’s nails but the resident pulls back and says ow and
-He/she was able to get some of the resident’s nails done today.
During an interview on 12/21/18 at 2:15 P.M., the interim Director of Nursing (DON) said
he/she would care plan the resident’s right to refuse nail care.
2. Record review of Resident #41’s care plan with the admission date of [DATE] showed
he/she was incontinent of bladder and it did not include the use of a catheter (a tube
passed through the urethra into the bladder to drain urine).
Record review of the resident’s quarterly MDS dated [DATE] showed the following staff
assessment of the resident:
-Did not have a catheter and
-Was incontinent of bladder.
Observation on 12/18/18 at 10:25 A.M. and on 12/19/18 at 9:32 A.M. showed the resident had
a catheter.
During an interview on 12/21/18 at 2:15 P.M., the interim DON said the catheter should be
care planned.
3. Record review of Resident #1’s dental summary note dated 3/22/17 showed:
-The resident had upper and lower dentures;
-The resident’s dentures did not fit and the resident did not wear them;
-The dentist felt that a reline (a procedure that reshapes the underside of a denture to
make it more comfortable as it rests against one’s gums) would help make the upper denture
fit better and
-The plan was to reline the complete upper denture.
Record review of the resident’s dental summary note dated 4/26/17 showed:
-A soft reline was completed for the resident’s upper denture;
-The resident was satisfied and
-A follow-up in three months for a re-evaluation should be completed and another soft
reline could be completed if necessary or the resident’s denture could be sent in for a
hard reline if necessary.
Record review of the resident’s current medical record showed there were no further dental
notes after 4/26/17.
Record review of the resident’s most recent social services progress review dated 7/11/17
showed no documentation regarding dentures or dental appointments.
Record review of the resident’s current medical record showed no further documentation
regarding the resident’s dentures or dental appointments.
Record review of the resident’s annual MDS dated [DATE] showed the resident had no natural
teeth.
Record review of the resident’s care plan dated as initiated on 9/25/18 showed no
documentation regarding the resident’s dentures.
Record review of the resident’s quarterly MDS dated [DATE] showed the resident was
cognitively intact.
During an observation and interview on 12/18/18 at 1:30 P.M.:
-The resident said:
–His/her dentures give him/her sores in his/her mouth;
–He/she would wear his/her dentures if they fit and
-The resident was not wearing his/her dentures.
Observation on 12/20/18 at 11:20 A.M. showed a cup with dentures in it was on the
resident’s sink countertop.
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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
During an interview on 12/20/18 11:22 A.M., RN B said as far as he/she knew, the resident
wears his/her dentures but the resident may refuse to wear them.
During an interview on 12/21/18 at 8:20 A.M., RN A said:
-He/she’s not aware of any issues with the resident’s dentures and
-He/she thinks the resident usually wears his/her dentures.
During an interview on 12/21/18 at 10:05 A.M. CNA A said he/she’s never seen the
resident’s dentures out of the resident’s mouth.
During an interview on 12/21/18 at 2:15 P.M., the Interim DON said dentures and dental
issues should be care planned.
4. Record review of Resident #13’s (MONTH) (YEAR) physician’s orders [REDACTED].
Record review of the resident’s current care plan showed breathing treatments via a
nebulizer for wheezing was not on the care plan.
Observation on 12/18/18 at 11:30 A.M. showed a nebulizer with mask was in the resident’s
room.
During an interview on 12/21/18 at 2:15 P.M., the interim DON said if the resident had a
respiratory diagnosis, that should be care planned.

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 observation, interview and record review, the facility failed to ensure the
accuracy of the resident’s physician’s orders sheet (POS) for one sampled resident
(Resident #41); to obtain orders for a Foley catheter (a tube with retaining balloon
passed through the urethra into the bladder to drain urine) for two sampled residents
(Residents #36 and #41); to transcribe insulin (lowers the level of glucose (a type of
sugar) in the blood) orders correctly for one sampled resident (Resident#41) and to ensure
all physician’s orders had a [DIAGNOSES REDACTED].#36 and #41) out of 12 sampled
residents. The facility census was 47 residents.
Record review of the facility’s medication orders policy revised (MONTH) 2014 showed a
current list of orders must be maintained in the clinical record.
Record review of the facility’s medication and treatment orders policy revised (MONTH)
(YEAR) showed medication orders must include the clinical condition or symptoms for which
the medication is prescribed.
1. Record review of Resident #41’s care plan with an admission date of [DATE] showed:
-The resident had [MEDICAL CONDITION] to both legs;
-Some of the resident’s diagnoses included [MEDICAL CONDITION] ([MEDICAL CONDITION]-the
build-up of fatty material inside the blood vessels) and diabetes (a deficiency or
complete lack of insulin secretion in the pancreas or resistance to insulin);
-The resident was receiving an anticoagulant (used to slow down the blood clotting
process) medication;
-The resident had actual wounds including surgical below knee amputations to his/her right
and left lower extremities and a blister to his/her right knee;
-The resident was on isolation precautions related to a wound infection of his/her stump
and
-No care plan regarding a catheter.
Record review of the resident’s drug regimen review showed a recommendation dated 9/11/18

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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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 11)
that [MEDICATION NAME] (an anticoagulant) needed a stop date.
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 11/23/18 showed the
following staff assessment of the resident:
-Had surgical wounds;
-Received insulin injections seven days out of the last seven days;
-Did not have a catheter;
-Some of his/her diagnoses included [MEDICAL CONDITION], diabetes and high cholesterol and
-Was not receiving an anticoagulant medication.
Record review of the resident’s (MONTH) (YEAR) Physician’s Order Sheet (POS), (MONTH)
(YEAR) Treatment Administration Record (TAR) and (MONTH) (YEAR) through (MONTH) (YEAR)
telephone orders showed:
-The resident’s admitted was 9/28/18 on the POS;
-26 out of 30 physician’s orders did not include a diagnosis, clinical condition or
symptom on the POS;
-No physician’s orders for a catheter, for catheter care or when to change the catheter
were on the POS;
-No order for and no documentation that the catheter was changed on the TAR;
-Instructions dated 9/28/18 for catheter care every shift on the TAR;
-A telephone order dated 9/7/18 showed a physician’s order to change insulin sliding scale
from Humalog to [MEDICATION NAME] (two different types of insulin);
-A physician’s order dated 9/28/18 for Humalog 100 units/ml (per milliliter) vial, inject
per sliding scale subcutaneous (SQ-beneath the skin) before meals and at bedtime had
Humalog crossed out. [MEDICATION NAME] was written above Humalog. At bedtime was crossed
out and dated as changed on 12/1/18 on the MAR;
-An undated physician’s order for Humalog per sliding scale before meals and at bedtime
was on the POS;
-A physician’s order dated 9/28/18 for [MEDICATION NAME] ([MEDICATION NAME]) 40 milligrams
(mg)/0.4 ml, inject 0.4 ml (40 mg) SQ every 24 hours, clarify stop date was on the POS but
was not on the MAR.
-On the POS was a physician’s treatment order dated 10/4/18 to:
–Cleanse the resident’s knee (did not specify right or left) with facility choice
cleanser;
–Place strip [MEDICATION NAME] gauze (a wound dressing);
–Cover with kerlix (woven gauze that is non-adhesive used to wrap wounds) and secure with
ABD pad (a thick wound dressing);
–Change daily and as needed.
-On the TAR was a physician’s treatment order dated 11/15/18 to cleanse the resident’s
right knee with facility choice cleanser. Pat dry. Spray hypochlorous acid (used to fight
bacteria and inflammation in wounds) to the wound bed. Let dry. Apply skin prep (a topical
barrier between skin and adhesives) to open areas and leave open to air daily and as
needed was on the TAR;
-A physician’s treatment order dated 11/28/18 to cleanse the resident’s right, lower leg,
distal (away from center) with facility choice cleanser. Pat dry. Spray with hypochlorous
acid to wound bed. Let dry. Apply hydrogel (a dressing used for healing wounds) and Santyl
(an ointment used for the debridement of pressure ulcers). Cover with dry dressing and
change daily and as needed was on the TAR but not on the POS;
-A physician’s order dated 9/28/18 for Atorvastatin (treats high cholesterol) 40 mg, take
one tablet at bedtime on the MAR had a line drawn through it. It was written that it was
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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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 12)
discontinued on 10/9/18 and it had not been administered during (MONTH) (YEAR);
-A physician’s order dated 9/28/18 for Atorvastatin 40 mg, take one tablet at bedtime was
on the POS;
-A telephone order dated 10/9/18 showed a physician’s order to discontinue Atorvastatin 40
mg;
-A physician’s order dated 9/28/18 for [MEDICATION NAME] (an anti-depressant) 10 mg, take
one tablet at bed time that had a hand-written note that the medication was discontinued
on the MAR. It was administered 14 times through 12/17/18;
-A physician’s order dated 9/28/18 for [MEDICATION NAME] 10 mg, take one tablet at bed
time on the POS;
-A physician’s order dated 9/28/18 for [MEDICATION NAME] (an antipsychotic medication-used
to treat [MEDICAL CONDITION] and other mental and emotional conditions) 0.25 mg, take one
tablet at bedtime was on the POS and was not on the MAR and
-A telephone order dated 10/9/18 showed a physician’s order to discontinue [MEDICATION
NAME].
Observation on 12/18/18 at 9:50 A.M. showed:
-The resident had bilateral lower extremity amputations and a wound on one of his/her
knees and
-A catheter.
During an interview on 12/21/18 at 2:15 P.M., the Interim Director of Nursing (DON) said:
-There should be a physician’s order for the catheter that includes the diagnosis, the
catheter type and size, to clean the catheter and when to change the catheter, which is
typically once a month;
-The care plan should include the catheter;
-The orders should include the location of the wound;
-The Assistant DON (ADON) has been reviewing the POS, MAR and TARs monthly during the
changeover for accuracy;
-They shouldn’t have discontinued orders still on the POS;
-They should put the current wound treatment orders on the POS;
-They should have diagnoses or symptoms for all medication orders;
-They should draw a line through old orders and discontinue them and
-A new order should be written with the new start date when changing from one type of
insulin to another.
2. Record review of Resident #36’s face sheet showed he/she was admitted to the facility
on [DATE]. Observation of the resident during the initial tour on 12/4/18 and throughout
the survey showed he/she had a Foley catheter.
Record review of the resident’s Admission MDS dated [DATE], showed the resident:
-Was cognitively intact;
-Needed extensive assistance with bed mobility, dressing and personal hygiene;
-Was totally dependent on staff for transfers and toilet use;
-Was always incontinent of bowel, and
-Had an indwelling catheter.
Record review of the resident’s undated care plan showed the resident had a Foley Catheter
and the goal was that the resident show no signs and symptoms of urinary infection through
the next review date. The interventions/tasks included staff:
-Change catheter as needed;
-Monitor and document intake and output per the facility’s policy;
-Monitor and document pain/discomfort due to the catheter and
-Monitor and report to the doctor signs and symptoms of urinary tract infection,
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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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 13)
cloudiness, output, increased temperature, foul smell, fever, chills, changes in behavior
or eating patterns, or altered mental status.
Record review of the resident’s (MONTH) (YEAR) POS showed the following information:
–He/she was a [MEDICAL CONDITION] (paralysis of the legs and lower body),
–He/she had wounds,
–There was no order for or the care of his/her catheter, and
-There was no [DIAGNOSES REDACTED].
During an interview on 12/19/18 at 8:31 A.M., the ADON said the resident had the catheter
when he/she was admitted .
During an interview on 12/21/18 at 2:15 P.M., the Interim DON said there should have been
an order for [REDACTED].

F 0790

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide routine and 24-hour emergency dental care for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide dental
services to one sampled resident (Resident #1) out of 12 sampled residents. The facility
census was 47 residents.
Record review of the facility’s dental services policy dated as revised (MONTH) (YEAR)
showed:
-Routine and emergency dental services should be provided to residents.
-Social services representatives will assist residents with appointments, transportation
arrangements and for reimbursement of dental services as eligible.
-All dental services provided are recorded in the resident’s medical record.
1. Record review of Resident #1’s dental summary note dated 3/22/17 showed:
-The resident had upper and lower dentures;
-The resident’s dentures did not fit and the resident did not wear them;
-The dentist felt that a reline (a procedure that reshapes the underside of a denture to
make it more comfortable as it rests against one’s gums) would help make the upper denture
fit better and
-The plan was to reline the complete upper denture.
Record review of the resident’s dental summary note dated 4/26/17 showed:
-A soft reline was completed for the resident’s upper denture;
-The resident was satisfied and
-A follow-up in three months for a re-evaluation should be completed and another soft
reline could be completed if necessary or the resident’s denture could be sent in for a
hard reline if necessary.
Record review of the resident’s current medical record showed there were no further dental
notes after 4/26/17.
Record review of the resident’s most recent social services progress review dated 7/11/17
showed no documentation regarding dentures or dental appointments.
Record review of the resident’s current medical record showed no further documentation
regarding the resident’s dentures or dental appointments.
Record review of the resident’s annual Minimum Data Set (MDS-a federally mandated
assessment instrument completed by facility staff for care planning) dated 3/16/18 showed
he/she had no natural teeth.
Record review of the resident’s care plan dated as initiated on 9/25/18 showed no

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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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 0790

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
documentation regarding the resident’s dentures.
Record review of the resident’s quarterly MDS dated [DATE] showed he/she was cognitively
intact.
Record review of the resident’s nursing data collection tool dated 11/30/18 showed he/she
could function with or without dentures.
During an observation and interview on 12/18/18 at 1:30 P.M.:
-The resident said:
–His/her dentures give him/her sores in his/her mouth;
–He/she would wear his/her dentures if they fit and
-The resident was not wearing his/her dentures.
During an interview on 12/20/18 at 9:39 A.M. the Social Services Director said:
-He/she started as the Social Services Director about one and a half months ago;
-The resident was seen in (YEAR) by a dentist who comes to the facility and
-He/she doesn’t have a list of residents who need to see the dentist.
During an observation and interview on 12/20/18 at 11:15 A.M.:
-The resident said:
–He/she has dentures;
–He/she doesn’t like to wear them because they hurt his/her mouth and cause sores and
-The resident was not wearing dentures.
Observation on 12/20/18 at 11:20 A.M. showed a cup with dentures in it was on the
resident’s sink countertop.
During an interview on 12/20/18 11:22 A.M., Registered Nurse (RN) B said as far as he/she
knew, the resident wears his/her dentures but the resident may refuse to wear them.
During an interview on 12/21/18 at 8:20 A.M., RN A said:
-He/she’s not aware of any issues with the resident’s dentures and
-He/she thinks the resident usually wears his/her dentures.
During an interview on 12/21/18 at 10:05 A.M. Certified Nursing Assistant (CNA) A said
he/she’s never seen the resident’s dentures out of the resident’s mouth.
During an observation and interview on 12/21/18 at 10:10 A.M.:
-The resident said he/she never wears his/her dentures anymore because they hurt and
-The resident was not wearing dentures.
During an interview on 12/21/18 at 2:15 P.M., the Interim Director of Nursing (DON) said:
-Dentures and dental issues should be care planned;
-Annual dental visits should be offered and
-There should be an order for [REDACTED].

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation and interview, the facility failed to date food items and separate a
damaged can in the dry storage area; to maintain sanitary and easily cleanable knives,
cutting boards, food preparation and serving utensils; to keep the kitchen floor clean; to
prevent an excessive buildup of grease above the stove; and to ensure food was kept away
from contamination sources. These deficient practices potentially affected all residents
who ate food from the kitchen. The facility census was 47 residents with a licensed
capacity for 60.

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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 15)
1. Observations during the kitchen inspection on 12/14/18 between 8:39 A.M. and 12:51
P.M., showed the following:
– Four unopened eight count packages of hamburger buns and one opened package with 6
remaining were undated in the dry storage room;
– One 104 ounce (oz.) can of sliced beets in a large can rack was dented on the top rim in
the dry storage room;
– One case containing 12 oz. cans of chunk light tuna in the dry storage room with 21 cans
remaining was neither dated on the box, nor on the individual cans;
– Seven packages of tortilla shells on a bread rack in the dry storage room were undated;
– A ladle, a green handled scoop, and several plate warmer lids had food residue on them;
– There was a large buildup of dust under the food preparation table next to the assisted
dining room door;
– The red, yellow, and green cutting boards were chipped to the point of small bits of
plastic hanging loosely on them;
– Two large knives and a metal spatula had streaks of an unknown substance on their
blades;
– The excessive buildup of grease on the baffles (metal filters that capture grease
droplets from rising hot air and condenses them to drain into a filter tray, which
drastically reduces the risk of spreading flames should a fire occur on the cooking
surface) above the stove was to the point of creating visible drip lines, and
– During lunch preparation, a large cooking sheet of chicken strips and a smaller sheet of
hamburgers were placed on top of the range hood, which was very greasy to the touch and
visibly dirty, for at least 25 minutes before being placed in the oven.
During an interview on 12/20/18 at 9:31 A.M., the Dietary Manager said:
– The dry storage food was checked in by the various kitchen staff as a team and
reconciled against their purchase order, dated, and labeled;
– He/she would expect every single item to be dated when checked in;
– If dented cans aren’t caught when received they are separated onto a different rack and
the food company representative called for credit or disposal;
– All kitchen staff are responsible for cleaning the floors after each shift;
– The kitchen staff try to clean the range hood baffles at least once a week or more;
– He/she would expect food to be kept away from contamination sources and
– He/she would expect that food preparation and serving utensils are kept sanitary and in
an easily cleanable condition.

F 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have a policy regarding use and storage of foods brought to residents by family and
other visitors.

Based on interview and record review, the facility failed to educate all staff as to the
existence, whereabouts, and content of a written, on-site policy regarding the acceptance,
usage, and storage of foods brought into the facility for residents by family and other
visitors, to ensure the food’s safe and sanitary handling and consumption. This deficient
practice had the potential to affect all residents who ate food brought in by visitors.
The facility census was 47 residents with a licensed capacity of 60 residents.
1. Record review of the policy titled Foods Brought by Family/Visitors, provided earlier
by the Administrator, 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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
– It was a generic document obtained from an online datatbase,
– There was no facility specific information added, and
– There were 14 separate points for safe implementation of the policy.
During an interview on 12/14/18 at 9:36 A.M., the Dietary Manager said he/she thought
there was a copy of an outside food policy somewhere, but the previous dietary manager may
have mislaid it.
During an interview at the nurse’s station on 12/14/18 at 1:48 P.M., Registered Nurse (RN)
A said the following:
– What we do with outside food brought in depends on what it is;
– It can be kept in a refrigerator in the nurse station store room if marked with the
resident’s name and dated;
– Foods left after two to three days would be disposed of;
– The procedures may be written down somewhere but it’s just something they all know, and
– There is also a refrigerator in the activities area that can be used, but most residents
don’t use it because everyone has access to it.
During an interview on 12/19/18 at 1:12 P.M., the Administrator said that staff were
taught about the outside food policy by the Human Resources Director at orientation and
then signed off on a sheet saying they received the education, however, multiple
subsequent requests to the Administrator and the Director of Nursing failed to result in
copies of the sign off sheets.
During an interview at the nurse’s station on 12/20/18 at 10:07 A.M., Licensed Practical
Nurse (LPN) B did not answer when asked about their outside food policy and looked at CMT
A who said the following:
– They make sure outside food is labeled and dated when it comes in;
– It’s either put in the nurse’s station refrigerator or the one in the activities area if
the resident is ambulatory;
– He/she didn’t know if the procedure was written down anywhere, it was merely common
knowledge and
– Some residents have their own refrigerators in their rooms to use as well.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain the
resident’s catheter (a tube passed through the urethra into the bladder to drain urine)
collection bag below his/her bladder during a transfer, failed to have orders for catheter
care and when to change a catheter for one sampled resident (Resident #41); to complete an
annual screening for [MEDICAL CONDITION] (Tb-a communicable disease that affects
especially the lungs, that is characterized by fever, cough, difficulty in breathing,
abnormal lung tissue and function) for three sampled residents (Resident #1, #7, and #48);
to document the person administering the vaccinations, the lot number and the expiration
date for the influenza and pneumonia vaccinations administered to one sampled resident
(Resident #1) and to ensure proper storage of a nebulizer mask (a device used to
administer medication to people in the form of a mist inhaled into the lungs) for one
sampled resident (Resident #13) out of 12 sampled residents. The facility census was 47
residents.
Record review of the facility’s urinary catheters policy dated revised (MONTH) (YEAR)

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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
showed instructions to staff to keep the catheter collection bag below the level of the
resident’s bladder to maintain unobstructed urine flow.
Record review of the facility’s Tb screening: Administration and Interpretation of
[MEDICATION NAME] Skin Test (TST-used to screen for Tb) policy revised (MONTH) 2013 showed
it did not address when Tb screening was required.
Record review of the facility’s influenza vaccine and pneumococcal vaccine policies
revised (MONTH) (YEAR) showed when a resident received the vaccines, the date of
vaccination, lot number, expiration date, person administering, and the site of the
vaccination would be documented in the resident’s medical record.
A nebulizer policy was not provided by the facility.
1. Record review of Resident #41’s care plan with the admission date of [DATE] showed no
care plan regarding his/her catheter.
Record review of the resident’s current medical record showed the (MONTH) (YEAR) Treatment
Administration Record (TAR) was not on the chart and was not provided by the end of the
survey.
Record review of the resident’s (MONTH) (YEAR) Physician’s Order Sheet (POS) showed:
-The resident’s admitted was 8/18/18 and
-No physician’s orders for a catheter, for catheter care or when to change the catheter.
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 11/23/18 showed the
following staff assessment of the resident:
-Totally dependent upon staff for transferring from one surface to another;
-Always incontinent of bladder and
-Did not have a catheter.
Record review of the resident’s (MONTH) (YEAR) POS showed:
-The resident’s admitted was 9/28/18 and
-No physician’s orders for a catheter, for catheter care or when to change the catheter.
Record review of the resident’s (MONTH) (YEAR) TAR showed:
-No order for and no documentation that the catheter was changed and
-Instructions dated 9/28/18 for catheter care every shift.
Observation on 12/18/18 at 10:25 A.M. showed:
-Two staff members transferred the resident from one surface to another using a full body
mechanical lift and
-One of the staff members placed the resident’s catheter collection bag on his/her abdomen
above his/her bladder during the transfer.
During an interview on 12/21/18 at 8:20 A.M., Registered Nurse (RN) A said:
-He/she didn’t know if the catheter bags they have are anti-reflux (minimize urine back
flow into the drainage tube);
-The catheter should be changed monthly and that should be on the TAR;
-The catheter care is on the (MONTH) (YEAR) TAR and
-The monthly changing of the catheter is not on the (MONTH) (YEAR) TAR.
During an interview on 12/21/18 at 2:15 P.M., the interim Director of Nursing (DON) said:
-The catheters they use are not the anti-reflux type;
-The catheter should be kept below the resident’s bladder and
-There should be orders for the resident’s catheter, catheter care and changing of the
catheter.
2. Record review of Resident #1’s care plan with the admission date of [DATE] showed
he/she was admitted to the facility on [DATE].
Record review of the resident’s Immunization Record dated (YEAR) showed the last two-step
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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
TST was:
-Administered on 10/24/16, results read on 10/27/16 and the results were negative and
-Administered on 11/7/16, results read on 11/10/16 and the results were negative.
Record review of the resident’s current medical record showed no further TSTs or annual
signs and symptoms screening.
During an interview on 12/21/18 at 7:51 A.M., the interim DON:
-Acknowledged the resident’s most recent documented TST was from (YEAR) and
-Acknowledged a Tb screening should have been completed annually and it was not.
Record review of the resident’s Immunization Report showed:
-The resident received the influenza vaccination on 11/28/18;
-The resident received the pneumonia vaccination on 12/18/18 and
-The person administering the vaccination and the lot number and expiration dates were not
documented for either vaccination.
During an interview on 12/21/18 at 2:15 P.M., the interim DON said the facility nursing
staff should have documented the lot number and the expiration date when administering the
vaccinations.
3. Record review of Resident #13’s (MONTH) (YEAR) POS showed the resident had physician’s
order for the use of [REDACTED].
Record review of the resident’s current care plan showed the care plan did not include the
use of a nebulizer.
Observation on 12/18/18 at 11:30 A.M. and on 12/19/18 at 9:30 A.M., showed the resident’s
nebulizer mask was on his/her dresser with no barrier, a bag was not present for the
nebulizer to be placed in and the tubing was not dated.
During an interview on 12/21/18 at 2:14 P.M., Certified Nursing Assistant (CNA) A said:
-The bags for the nebulizer masks were kept in the room behind the nurses’ station and
-The Certified Medication Technicians (CMT)s were responsible for placing bags in the
residents’ rooms for the nebulizer mask to be placed in.
During an interview on 12/21/18 at 2:15 P.M., the interim DON said:
-The nebulizer masks should be stored in a clean bag;
-The bags were stored in the back medical supply room and some in the nurse utility room;
-The CMTs were responsible for ensuring the bags for the nebulizer masks were in the
residents’ rooms and
-If a resident had a respiratory diagnosis, the care plan should include treatments as
ordered.
4. Record review on 12/18/18 of Resident #36’s face sheet showed he/she was admitted to
the facility on [DATE].
Record review of the resident’s Immunization Record form showed:
-His/her first step of the two-step TB test was administered 9/17/18 and
-The TB test was not read.
Record review on 12/19/18 of the resident’s MAR indicated [REDACTED].
During an interview on 12/19/18 at 8:31 A.M., the Assistant Director of Nursing (ADON)
said:
-He/she thought this was the resident’s first time being admitted to a Long Term Care
facility;
-The resident was admitted to the facility from the hospital;
-He/she saw in the resident’s chart where the TB test was administered, but could not find
where the TB test was read;
-The day the TB test results were supposed to be read the resident went out for an
angiogram (a x-ray of the blood vessels), but did come back the same day 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:

265512

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

NAME OF PROVIDER OF SUPPLIER

LEE’S SUMMIT POINTE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1501 SW 3RD STREET
LEES SUMMIT, MO 64081

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
-He/she could not find a record of the second step being administered.
During an interview on 12/21/18 at 2:15 P.M., the interim Director of Nursing said:
-A two-step TB test should be completed on all residents new to long term care and
-The first step of the resident’s TB test should have been read within 48-72 hours, and a
second step administered within seven to twenty-one days after the first step was read.
5. Record review of Resident #7’s admission face sheet showed he/she admitted to the
facility on [DATE].
Record review of the resident’s Immunization Record dated (YEAR) showed:
-The first step of a two-step Mantoux TST was administered on 9/12/18;
-The results were negative on 9/14/18 and
-There was no documentation that the second TST had been administered.
6. Record review of Resident #48’s admission face sheet showed he/she admitted to the
facility on [DATE] and last re-admission was on 11/9/18.
Record review of the resident’s medical record showed:
-That the Influenza vaccine was given on 11/20/18;
-That the resident refused the Pneumococcal Vaccine and
-That there was no documentation that the TST had been administered.
The resident’s Immunization Record was requested from the facility on 12/20/18 at 10:13
A.M. and on 12/21/18 at 9:15 A.M.
During an interview on 12/21/18 at 1:15 P.M. the interim DON said the facility did not
have a copy of it or when the resident would have received the TST for this year.
During an interview on 12/21/18 at 2:15 P.M., the interim DON said:
-The TST should be a two-step process and
-The facility uses a signs and symptoms (characterized by fever, cough, difficulty
breathing, and abnormal lung function) screening for each resident for the annual TB
testing.