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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to and the facility must promote and facilitate resident
self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
assistance to a resident for his/her chosen time to get out of bed in the morning by not
getting him/her up at 6:00 A.M. for one sampled resident (Resident #14) out of 23 sampled
residents. The facility census was 114 residents.
1. Record review of Resident #14’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by the facility staff for care planning) dated 9/17/18 showed:
-The resident was admitted to the facility on [DATE];
-The resident needs extensive mobility assistance;
-The ability to choose they go to bed or get out of bed is an important decision to the
resident; and
-The resident is able to make decisions on his/her own.
-The resident had the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (a disorder of the central nervous system that affects movement,
often including tremors) and
-[MEDICAL CONDITION] (a disorder in the brain which is disturbed).
During an interview on 9/18/18 at 2:00 P.M. the resident and his/her family member said:
-The resident needs assistance to get up out of bed in the morning;
-Needs assistance to change his/her briefs;
-The resident likes to get up at 6:00 A.M.;
-On the weekends there was not enough help making the resident stay in bed until 8:00
A.M.;
-This upsets the resident and he/she calls his/her family member and
-The family member talked to the Administrator concerning this problem a couple of weeks
ago.
Observation on 9/24/18 at 7:30 A.M. showed the staff assisted the resident out of bed.
During an interview on 9/27/18 at 8:10 A.M. Licensed Practical Nurse (LPN) E said:
-He/she works nights;
-In the last month the facility was short staffed 50% of the time;
-Ten times in the last month he/she was not able to get the residents up when they were
supposed to and
-The residents are left wet longer as there is not enough staff to change them.

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 record review and interview, the facility failed to timely provide a Skilled
Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS- ) and to timely provide a
Notice of Medicare Non-Coverage (NOMNC-form CMS- ) for one sampled resident (Resident
#169) who was discharged from Medicare part A services out of three sampled residents. The
facility census was 114 residents.
Record review of the undated Form Instructions for the NOMNC CMS- showed the NOMNC must be
delivered at least two calendar days before Medicare coverage services end.
Record review of the Centers for Medicare and Medicaid Services Survey and Certification

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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)
memo (S&C-09-20), dated 1/9/09, showed the following:
-The 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;
-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 Resident #169’s SNF ABN and NOMNC showed the resident was notified on
8/30/18 that coverage of services was ending 8/31/18.
During an interview on 9/21/18 at 2:19 P.M., the Social Services Director said he/she knew
the regulation required more advance notice of services ending.

F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to check the Nurse Aide (NA)
Registry for six out of eight sampled staff to ensure they did not have a Federal
Indicator (a marker given to a potential employee who has committed abuse, neglect, or
misappropriation of property against residents) prohibiting them to work in a certified
facility. The facility’s census was 114 residents.
1. Record review of the facility’s list of employees hired since the facility’s last
annual survey showed:
-Employee A, a Registered Nurse (RN) was hired on 6/25/18;
-Employee B, a housekeeper was hired on 6/25/18;
-Employee C, a Licensed Practical Nurse (LPN) was hired on 6/8/18;
-Employee F, a dietary worker was hired on 6/12/18;
-Employee G, a LPN was hired on 6/12/18 and
-Employee H, a RN was hired on 6/21/18.
Record review of the above employees’ employee files showed none of the employees were
checked against the NA Registry to ensure they did not have a Federal Indicator
prohibiting them to work in a certified facility.
During an interview on 9/24/18 at 10:20 A.M., the Staff Development Coordinator said:
-He/she did not know everyone needed to be checked against the NA Registry and
-He/she had been checking Certified Nursing Assistants against the NA Registry.

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 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 written notification
to the resident, and/or the resident’s representative(s) of transfers and/or discharges
and the reasons for the transfers and/or discharges for six sampled residents (Residents
#34, #109, #45, #30, #112, and # 74) out of 23 sampled residents. The facility census was
114 residents.
Record review of the facility’s transfer and discharge policy dated as revised 9/1/17
showed:
-The facility will provide written notification to the resident and the resident
representative prior to transfer and
-A copy of the transfer notice in an emergency transfer will be provided to the resident
and the resident representative as soon as practicable (able to be done).
1. Record review of Resident #34’s entry tracking records and discharge assessments showed
he/she:
-discharged from the facility on 9/7/18 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) of a transfer/discharge and the reason
for the transfer/discharge.
2. Record review of Resident #109’s entry tracking records and discharge assessments
showed he/she:
-Entered the facility on 12/16/17;
-discharged from the facility on 4/3/18;
-Returned to the facility on [DATE];
-discharged from the facility on 8/1/18;
-Returned to the facility on [DATE];
-discharged from the facility on 8/15/18; and
-Returned to the facility on [DATE].
Record review of the resident’s medical record showed there were no letters notifying the
resident and/or the resident’s representative(s) of transfers/discharges and the reasons
for the transfers/discharges.
3. Record review of Resident #45’s entry tracking records and discharge assessments showed
he/she:
-Entered the facility on 4/20/18;
-discharged from the facility on 5/6/18;
-Returned to the facility on [DATE];
-discharged from the facility on 8/9/18;
-Returned to the facility on [DATE];
-discharged from the facility on 9/17/18 and
-Returned to the facility on [DATE].
Record review of the resident’s medical record showed there were no letters notifying the
resident and/or the resident’s representative(s) of transfers/discharges and the reasons
for the transfers/discharges.
4. Record review of Resident # 30’s Nurses Notes dated 6/6/18 6:38 P.M., showed an order
for [REDACTED].>Record review of resident’s Nurses Notes dated 6/13/18 1:47 A.M.,

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

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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)
showed he/she was readmitted from the hospital.
Record review of the resident’s medical record showed there were no letters notifying the
resident and/or the resident’s representative(s) of transfers/discharges and the reasons
for the transfers/discharges.
Record review of resident’s Nurses Notes dated 8/7/18 at 7:51 P.M., showed he/she was sent
to hospital 6:10 P.M.
Record review of resident’s Nurses Notes dated 8/15/18 at 2:44 P.M., showed he/she
returned to the facility.
Record review of the resident’s medical record showed there were no letters notifying the
resident and/or the resident’s representative(s) of transfers/discharges and the reasons
for the transfers/discharges.
5. Record review of Resident # 112’s Nurses Notes dated 7/18/18 at 10:56 A.M., showed
he/she was sent to hospital at 9:45 A.M.
Record review of resident’s Nurses Notes dated 7/24/18 at 7:51 P.M., showed he/she
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) of transfers/discharges and the reasons
for the transfers/discharges.
6. Record review of Resident # 74’s Nurses Notes dated 9/12/18 at 6:41 P.M. showed he/she
was sent to hospital at 6:20 P.M.
Record review of the resident’s Admission Record showed he/she was readmitted on [DATE] at
6:00 A.M.
Record review of the resident’s medical record showed there were no letters notifying the
resident and/or the resident’s representative(s) of transfers/discharges and the reasons
for the transfers/discharges.
7. During an interview on 9/27/18 at 10:00 A.M., the Director of Nursing (DON) said they
are not doing transfer, discharge letters and they are not sent to the Ombudsman.
During an interview on 9/27/18 at 1:10 P.M., the Administrator said he/she does not do
transfer/discharge letters.

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 provide the resident and/or
their responsible party of the bed-hold policy at the time of the resident’s
transfer/discharge for six sampled residents (Residents #34, #109, #45, #30, #112, and
#74) out of 23 sampled residents. The facility census was 114 residents.
Record review of the facility’s transfer and discharge policy dated as revised 9/1/17
showed persons responsible for the transfer/discharge of the resident should adhere to the
bed hold policy. The bed hold policy was requested but the facility did not provide the
bed hold policy.
1. Record review of Resident #34’s entry tracking records and discharge assessments showed
he/she:
-discharged from the facility on 9/7/18 and
-Returned 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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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)
Record review of the resident’s medical record showed there was no letter notifying the
resident and/or the resident’s representative(s) of the bed hold policy upon
transferred/discharge from the facility.
2. Record review of Resident #109’s entry tracking records and discharge assessments
showed he/she:
-Entered the facility on 12/16/17;
-discharged from the facility on 4/3/18;
-Returned to the facility on [DATE];
-discharged from the facility on 8/1/18;
-Returned to the facility on [DATE];
-discharged from the facility on 8/15/18;
-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) of the bed hold policy upon
transferred/discharge from the facility.
3. Record review of Resident #45’s entry tracking records and discharge assessments showed
he/she:
-Entered the facility on 4/20/18;
-discharged from the facility on 5/6/18;
-Returned to the facility on [DATE];
-discharged from the facility on 8/9/18;
-Returned to the facility on [DATE];
-discharged from the facility on 9/17/18 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) of the bed hold policy upon
transferred/discharge from the facility.
4. Record review of Resident # 30’s Nurses Notes dated 6/6/18 6:38 P.M., showed an order
for [REDACTED].>Record review of resident’s Nurses Notes dated 6/13/18 1:47 A.M.,
showed he/she was readmitted from 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) of a bed hold policy.
Record review of resident’s Nurses Notes dated 8/7/18 at 7:51 P.M., showed he/she was sent
to hospital 6:10 P.M.
Record review of resident’s Nurses Notes dated 8/15/18 at 2:44 P.M., showed he/she
returned to facility.
Record review of the resident’s medical record showed there was no letter notifying the
resident and/or the resident’s representative(s) of a bed hold policy.
5. Record review of Resident # 112’s Nurses Notes dated 7/18/18 at 10:56 A.M., showed
he/she was sent to hospital at 9:45 A.M.
Record review of resident’s Nurses Notes dated 7/24/18 at 7:51 P.M., showed he/she
returned to facility.
Record review of the resident’s medical record showed there was no letter notifying the
resident and/or the resident’s representative(s) of a bed hold policy.
6. Record review of Resident # 74’s Nurses Notes dated 9/12/18 at 6:41 P.M. showed he/she
was sent to hospital at 6:20 P.M.
Record review of resident’s Admission Record showed he/she was readmitted on [DATE] at
6:00 A.M.
Record review of the resident’s medical record showed there was no letter notifying 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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 5)
resident and/or the resident’s representative(s) of a bed hold policy.
7. During an interview on 9/27/18 at 10:00 A.M., the Director of Nursing (DON) said they
are not doing bedhold letters.
During an interview on 9/27/18 at 1:10 P.M., the Administrator said he/she does not do
bedhold letters.

F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives an accurate assessment.

**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 assessments for two sampled residents (Residents #99 and #57) out of 23
sampled residents. The facility census was 114 residents.
1. Record review of Resident #99’s care plan dated 2/19/13 showed he/she was at risk for
wounds.
Record review of the resident’s non-pressure skin condition record dated 5/14/18 showed
the resident’s 2nd toe on his/her left foot was dry gangrene (tissue death caused by a
lack of blood supply) and it was first observed on 5/14/18.
Record review of the resident’s care plan showed an update on 5/14/18 that the resident
had a dry gangrene to his/her 2nd toe on his/her left foot.
Record review of the resident’s Physician’s Assistant’s note dated 6/6/18 showed the
resident’s gangrenous 2nd toe on his/her left foot was arterial (caused by poor
circulation).
Record review of the resident’s (MONTH) (YEAR) Treatment Administration Record (TAR)
showed he/she had a physician’s orders [REDACTED].
Record review of the resident’s non-pressure skin condition sheet dated 8/13/18 showed the
resident’s 2nd toe on his/her left foot was dry gangrene.
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 8/15/18 showed an
arterial wound was not indicated on the MDS.
Observation on 9/26/18 at 1:27 P.M. showed the resident’s 2nd toe on his/her left foot was
black.
During an interview on 9/28/18 at 10:18 A.M., the MDS Coordinator said an arterial wound
should have been documented on the quarterly MDS dated [DATE].
During an interview on 9/28/18 at 12:00 P.M., the Director of Nursing (DON) said he/she
expected the MDS to be accurate.
2. Record review of Resident #57’s MDS assessments showed:
-He/she weighed 191 pounds on his/her annual MDS dated [DATE] and
-He/she weighed 178 pounds on his/her quarterly MDS dated [DATE].
Record review of the resident’s care plan dated 7/22/18 showed:
-The resident had a history of [REDACTED].
-The resident had [MEDICAL CONDITION] (swelling) and weight loss could be due to the
resident taking medications to treat his/her [MEDICAL CONDITION].
Record review of the resident’s nurse’s note dated 7/23/18 showed the resident was found
on the floor.
Record review of the resident’s quarterly MDS dated [DATE] showed:
-He/she weighed 167 pounds;
-A significant weight loss was not identified (the resident lost 12.57% (191# to 167#)

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
over six months) and
-The resident had not fallen since his/her last MDS assessment (5/4/18).
Record review of the resident’s dietary notes from 2/1/18 through 9/25/18 at 9:41 AM
showed a dietary note dated 8/9/18 that the resident had lost weight but remained
overweight.
During an interview on 9/28/18 10:18 at A.M., the MDS Coordinator said:
-Their system didn’t automatically trigger weight loss;
-She uses the facility’s weight tracking form which shows dates, weights and calculates
weight loss and
-The resident’s quarterly MDS dated [DATE] should have indicated weight loss and a fall.
During an interview on 9/28/18 at 12:00 P.M., the DON said he/she expected the MDS to be
accurate.

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents with a
mental disorder and individuals with intellectual disability had a DA-124 C level I screen
(used to evaluate for the presence of psychiatric conditions to determine if a
preadmission screening/resident review (PASRR) level II screen is required) as required)
as required for two sampled residents (Residents #63 and #109) out of 23 sampled
residents. The facility census was 114 residents.
Record review of the Missouri Department of Health and Senior Services (DHSS) guide
titled, PASRR Desk Reference, dated 3/3/08, showed:
– The PASRR is a federally mandated screening process for any person for whom placement in
a Medicaid Title (XIX) certified bed is being sought. This is a Level I screening
(completion of the DA124C form). (In this facility, all beds are Medicaid certified) and
– A Level II assessment is completed on those persons identified at Level I who are known
or suspected to have a serious mental illness (such as [MEDICAL CONDITION] (a disorder
that affects a person’s ability to think, feel, and behave clearly.), dementia (a group of
thinking and social symptoms that interferes with daily functioning), [MEDICAL CONDITION]
(a mental health disorder characterized by persistently depressed mood or loss of interest
in activities), etc., Intellectual Delay, Developmental Delay or related condition to
determine the need for specialized service (completion of the DA124A/B form). The facility
responsible for completing the DA124A/B and/or DA124C forms is also responsible for
submitting completed form(s) to DHSS, Division of Regulation and Licensure, Section for
Long Term Care Regulation, Central Office Medical Review Unit (COMRU).
– PASRR screening is required:
–To assure appropriate placement of persons known or suspected of having a mental
impairment,
–To assure that the individual needs of mentally impaired persons can be and are being
met in the appropriate placement environment,
–To be compliant with the OBRA/PASRR federal requirements, see 42 CFR 483.Subpart C, and
–To assure Title XIX funds are expended appropriately and in accordance with Legislative
intent.
-To comply with PASRR requirements, the facility must maintain a legible copy on file of
the DA124C and Level II Screening Report for each resident until the resident is

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
transferred. If a legible copy is not maintained, the facility must complete and submit a
new set of DA124A/B and C forms to COMRU,
– If a resident is discharged to a new nursing home, the receiving facility is responsible
for assuring the DA124C and Level II screening results are included in the transfer
packet, and
– Should the DA124C not be included in the packet, admission should not be completed. The
DA124C and Level II screening results should be requested from the prior facility by the
receiving facility.
1. Record review of Resident #63’s annual Minimum Data Set (MDS-a federally mandated
assessment instrument completed by facility staff for care planning) dated 2/5/18 showed:
-The resident had [DIAGNOSES REDACTED]. severe loss of contact with reality) and
-The resident was not evaluated by a Level II PASRR and determined to have a serious
mental illness.
Record review of the resident’s medical record showed no DA124C.
2. Record review of Resident #109’s Admission MDS dated [DATE] showed:
-The resident was admitted to the facility on [DATE];
-The resident had [DIAGNOSES REDACTED].
-The resident was not evaluated by a Level II PASRR and determined to have a serious
mental illness.
Record review of the resident’s medical record showed no DA124C.
3. During an interview on 9/27/18 at 9:32 A.M., the Social Services Director said:
-Currently the Admission Coordinator is responsible for the PASRRs;
-The PASRRs should be in the chart;
-Social Services will be responsible for the PASRRs;
-They keep a copy in the front office and
-He/she was not able to locate a PASRR for Residents #63 or #109.

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 initiate a Baseline Care Plan
(initial written out plan for the care of the resident) for three sampled residents
(Resident #109, #45, and #269) out of 23 sampled residents. The facility census was 114
residents.
Record review of the Baseline Care Plan Policy dated 8/24/17 showed a baseline care plan:
-Directs the care team while a comprehensive care plan is developed;
-Provides an initial set of instructions needed to provide effective and person-centered
care of the resident that meet professional standards of care;
-Will be developed for every resident within 48 hours of admission and
-Is updated as needed to reflect current needs until the comprehensive care plan is
developed.
1. Record review of Resident #269’s Admission record showed he/she:
-Was admitted on [DATE];
-Was a Full Code status;
-Had no known drug allergies [REDACTED].>-Had a diet of pureed food and pudding thick
liquids 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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
-Had no diagnoses listed.
Record review of the resident’s Admission Minimum Data Set (MDS – a federally mandated
assessment tool completed by the facility staff for care planning) dated 9/25/18 showed
he/she had a cognitive loss/dementia (a general term for a decline in mental ability
resulting in memory loss, and other mental abilities severe enough to interfere with daily
functioning).
Record review of the resident’s undated Nutrition data Collection/Assessment record showed
he/she had the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] reflux disease (GERD – back up of stomach acid/heartburn);
-Hypertension (HTN- high blood pressure) and
-[MEDICAL CONDITION] Fibrillation (A-Fib – abnormal heart rhythm).
Record review of the resident’s medical record chart showed:
-A blank paper baseline care plan;
-A computer generated care plan dated 9/13/18 for risk for developing a Pressure Ulcer
(localized injury to the skin and/or underlying tissue usually over a bony prominence, as
a result of pressure, or pressure in combination with shear and/or friction) and
-No other type of care plan found.
Record review of the resident’s Nurses Notes dated 9/15/18 at 2:10 P.M., showed he/she:
-Had right sided weakness;
-Requires two-person assist with transfers and
-Receives Physical Therapy, Occupational Therapy, and Speech Therapy.
Record review of the resident’s Nurses Notes dated 9/16/18 at 7:33 A.M., showed he/she:
-Was [MEDICAL CONDITION] left sided weakness;
-Was a fall risk and
-Was unaware of safety needs.
Record review of the resident’s Nurses Notes dated 9/16/18 at 1:13 P.M., showed he/she:
-Was leaning to the left side and
-Had pillows for positioning, comfort and safety needs.
Record review of the resident’s Nurses Notes dated 9/17/18 at 4:38 P.M., showed he/she:
-Had left sided flaccidness and
-Had a bolster (a mattress cover with padded raised sections on both sides at the top and
bottom) added to his/her mattress for positioning.
Record review of the resident’s Nurses Notes dated 9/18/18 at 7:23 A.M., showed the
bolstered mattress did help the resident with positioning.
Record Review of the resident’s Nurses Notes dated 9/18/18 at 11:39 A.M., showed he/she:
-Received maximum assistance of two staff members to transfer to a wheelchair and
-Was propelled in the wheelchair by a staff member.
2. Record review of Resident #45’s entry tracking record showed he/she admitted to the
facility on [DATE].
Record review of the resident’s baseline care plan showed:
-It was not dated;
-It listed the resident’s allergies [REDACTED].>-The resident received [MEDICAL
TREATMENT];
-Everything else was left blank and
-No documentation that the baseline care plan was given to the resident and/or the
resident’s representative.
3. Record review of Resident #109’s entry tracking record showed he/she was admitted to
the facility on [DATE].
Record review of the resident’s medical record showed there was no baseline care plan.
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
4. During an interview on 9/28/18 at 11:59 A.M., the Director of Nursing DON) said a
baseline care plan should be completed as soon as the resident is admitted , possibly in
24 hours and by the Charge Nurse.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to update resident Care Plans
(written out plan for the care of the resident) for two sampled residents (Resident #30
and #110) out of 23 sampled residents. The facility census was 114 residents.
Record review of the facility’s Incident Management Policy dated revised 02/2007 showed
that the facility:
-Identifies residents at risk for incidents;
-Adequately plans care for the residents;
-Implements procedures designed to reduce incident risk;
-Minimizes the potential for occurrence;
-Residents receive adequate assistance and oversight as defined in an individualized plan
of care that reduces the risks for incidents;
-Develops and implements action plans in response to conclusions that reduce the potential
for recurrence.
-Following a resident incident:
–Reviews the resident’s care plan and
–Updates the care plan as necessary to reflect the resident’s current safety status and
interventions are designed to reduce the risk of recurrence.
Record review of the facility’s Fall Management Policy – Patient Fall Management Care
Planning dated 6-2016, 11-2016 showed:
-Development and implementation of the patients fall management plans is the ongoing
responsibility of the interdisciplinary team (IDT);
-During the admission and readmission process.
-With the event of a patient fall:
–A complete nursing assessment will be performed by the nurse;
–The patient’s fall management care plan will be revised as indicated and
-Upon the event of a patient fall, the patient will be reviewed by the IDT for any
indicated additional assessment and care plan revision.
1. Record review of Resident #30’s Admission Record showed he/she was admitted on [DATE]
and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Difficulty in walking.
Record review of the resident’s Care Plans dated 4/2/18 showed the following:
-Alteration in mobility and safety due to:
–History of falls;
–Poor safety awareness;
–Poor cognition and
–Weakness.
-No goal or target date listed.
-Interventions:
–Keep frequently used items within reach;

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
–Keep bed in lowest position.
–Provide resident/family teaching to include:
—Safety measures to reduce fall risk;
—What to do if a fall occurs;
—Remind resident and reinforce safety awareness;
—Lock brakes on bed, chair, etc., before transferring;
—Appropriate foot wear;
—Transfer with assist;
—Keep bed at appropriate height for transfers and
-Risk for falls and possible related injury.
-Goals:
–Injury due to falls will be minimized related to fall interventions through next review
date 10/12/18.
-Interventions:
– Fall risk assessment per protocol or as warranted.
Record review of the resident’s Quarterly Minimum Data Set (MDS – a federally mandated
assessment tool completed by the facility staff for care planning) dated 7/10/18 showed:
-The resident’s cognition was severely impaired and
-History of falls in the last six months with one major injury fall.
Record review of the resident’s Incident/Accident Data Entry Questionnaire dated 4/21/18
at 6:15 A.M., showed:
-Unwitnessed fall.
-Incident follow-up and recommendation form showed:
–Therapy services.
–Floor mat.
–Google eye sign (for fall risk).
–Neurological checks (Neuro checks – neurological checkpoints to monitor level of
consciousness, ability to move extremities, eye responses and change in pupils and vital
signs).
-Care Plan updated.
-No documentation of a fall or updates noted on the resident’s Fall Care Plan for this
fall.
Record review of the resident’s Incident follow-up and recommendation form for an
unwitnessed fall on 4/26/18 showed:
-Therapy services;
-Floor mat;
-Google eye sign;
-Neuro checks;
-Care plan updated and
-No documentation of a fall or updates noted on the resident’s Fall Care Plan for this
fall.
Record review of the resident’s Nurses notes dated 6/1/18 at 9:12 P.M., showed he/she had
an unwitnessed fall.
Record review of the resident’s Fall Care Plan showed no documentation of a fall or any
updates for a fall on 6/1/18.
Record review of the resident’s Nurses notes dated 6/18/18 at 5:27 P.M., showed the
resident had a [DIAGNOSES REDACTED].
Record review of the resident’s Fall Care Plan showed no documentation of a fall or
updates showing a [MEDICAL CONDITION] for 6/18/18.
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
Record review of the resident’s Neurological Assessment Flow Sheet showed 72 hour charting
from 8/2/18 through 8/5/18 shifts.
Record review of the resident’s Nurses notes dated 8/3/18 at 3:53 P.M., showed fall
follow-up charting with Neuro checks.
Record review of the resident’s Fall Care Plan showed no documentation of a fall or
updates for a fall on 8/2/18.
Record review of the resident’s Incident/Accident Data Entry Questionnaire dated 8/7/18 at
3:30 A.M., showed an unwitnessed fall with no injury.
Record review of the resident’s Fall Care Plan showed no documentation of a fall or
updates for a fall on 8/7/18.
2. Record review of Resident #110’s Admission Record showed he/she was admitted on [DATE]
with the following Diagnoses: [REDACTED].
-Difficulty walking;
-[MEDICAL CONDITION] (a common, potentially serious bacterial infection of the skin and
the soft tissues underneath) of the left and right lower limbs;
-Chronic [MEDICAL CONDITION] (also known as [MEDICAL CONDITION] – [MEDICAL CONDITION] –
inadequate flow of blood to the extremities) and
-[MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the ability
of the lungs to perform ventilation).
Record review of the resident’s Care Plans dated 8/24/18 showed he/she had:
-A risk for falls.
–Goal: will have no serious injuries related to falls through next review 11/24/18.
–Interventions:
—Fall risk assessment per protocol or as warranted.
—Provide environmental adaptations as needed.
—Keep frequently used items close to resident.
—Report falls to physician and responsible party.
Record review of the Resident’s Admission MDS dated [DATE] showed that:
-That there was no cognition level recorded for the resident.
-The resident had a history of [REDACTED].
-The resident used [MEDICAL CONDITION] medications.
Record review of the resident’s Incident/Accident Data Entry Questionnaire dated 8/25/18
at 6:00 P.M., showed he/she had an unwitnessed fall in his/her room.
Record review of the resident’s Fall Care Plan showed no documentation of a fall or
updates for his/her fall on 8/25/18.
Record review of the resident’s Nurses Notes dated 9/3/18 at 3:54 A.M., showed evening
shift on 9/2/18 reported he/she had a fall around 8:15 P.M.
Record review of the resident’s Fall Care Plan showed no documentation of a fall or
updates for his/her fall on 9/2/18.
Record review of the resident’s Incident/Accident Data Entry Questionnaire dated 9/4/18 at
5:30 A.M., showed he/she had an unwitnessed fall in his/her room.
Record review of the resident’s Fall Care Plan showed no documentation of his/her fall or
updates for a fall on 9/4/18.
3. During an interview on 09/28/18 at 11:59 A.M., The Director of Nursing (DON) said:
-Each resident fall should be listed on his/her Care Plan and
-Each resident fall should have new interventions added to his/her Care Plan.

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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

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 document any
notes regarding the resident’s discharge when one sampled resident (Resident #45) was
discharged to the hospital; to document the date and time tube feeding bottles (used to
provide nutrition to patients who cannot obtain nutrition by swallowing) were hung and to
follow physician’s orders [REDACTED].#99) out of 23 sampled residents. The facility census
was 114 residents.
1. Record review of Resident #45’s the resident’s entry tracking forms and discharge
assessments showed he/she:
– Was discharged from the facility on 9/17/18 and
-Entered the facility on 9/22/18.
Record review of the resident’s nurses’ notes showed:
-It was documented on 1/17/18, that the resident was admitted to the facility on [DATE];
-On 9/15/18, the resident was found on the floor with his/her back next to the bed and
his/her head was up against the night stand;
-On 9/16/18, the resident remained on post-fall monitoring;
-On 9/17/18 at 12:09 A.M., the resident remained on post-fall monitoring;
-There were no nurses’ notes between 9/17/18 at 12:09 A.M. and 9/23/18 at 1:43 A.M. to
show when resident discharged to the hospital and
-On 9/23/18, the resident was readmitted to facility.
During an interview on 9/28/18 at 12:00 P.M., the Director of Nursing (DON) said there
should be documentation regarding why the resident went to the hospital when a resident
goes out to the hospital.
2a. Record review of Resident #99’s care plan dated 5/30/13 with a goal target date of
12/5/17 showed the resident received tube feedings.
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 8/15/18 showed he/she
received nutrition through a feeding tube.
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
Observation on 9/20/18 at 9:54 A.M. showed the resident’s tube feeding bottle was hung, it
was running and it was not labeled with the date or time it was hung.
Observation on 9/20/18 at 11:14 A.M. showed the resident’s tube feeding bottle was hung,
it was running and it was not labeled with the date or time it was hung.
Observation on 9/24/18 at 6:26 A.M. showed the resident’s tube feeding bottle was hung, it
was running and it was not labeled with the date or time it was hung.
During an interview on 9/28/18 at 9:55 A.M., Licensed Practical Nurse (LPN) D said they
should label the date and time of when the tube feeding bottle was hung.
During an interview on 9/28/18 at 12:00 P.M., the DON said tube feeding bottles should be
labeled with the date and time they were hung.
2b. Record review of the resident’s care plan dated 2/19/13 showed he/she was at risk for
wounds.
Record review of the resident’s non-pressure skin condition record dated 5/14/18 showed
the resident’s 2nd toe on his/her left foot was dry gangrene (tissue death caused by a
lack of blood supply) and it was first observed on 5/14/18.
Record review of the resident’s care plan showed an update on 5/14/18 that the resident
had a dry gangrene to his/her 2nd toe on his/her left foot.
Record review of the resident’s (MONTH) (YEAR) Treatment Administration Record (TAR)

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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)
showed [MEDICATION NAME] (an antiseptic-inhibits the growth and development of
microorganisms) to the resident’s 1st and 2nd toe of his/her left foot was not initialed
as completed seven out of 17 opportunities.
Record review of the resident’s (MONTH) (YEAR) TAR showed [MEDICATION NAME] to the
resident’s 1st and 2nd toe of his/her left foot was not initialed as completed seven out
of 11 out of 30 opportunities and one time it was documented that the resident refused.
Record review of the resident’s Physician’s Assistant’s note dated 6/6/18 showed the
resident’s gangrenous 2nd toe on his/her left foot was arterial in nature (caused by poor
circulation).
Record review of the resident’s (MONTH) (YEAR) TAR showed [MEDICATION NAME] to the
resident’s 1st and 2nd toe of his/her left foot was not initialed as completed three out
of 31 opportunities.
Record review of the resident’s (MONTH) (YEAR) TAR showed [MEDICATION NAME] to the
resident’s 1st and 2nd toe of his/her left foot was not completed at all that month. Two
lines were drawn through the order and healed was written on it.
Record review of the resident’s non-pressure skin condition sheet dated 8/13/18 showed the
resident’s 2nd toe on his/her left foot was dry gangrene.
Record review of the resident’s Minimum Data Set (MDS- a federally mandated assessment
tool completed by the facility staff for care planning) dated 8/15/18 showed an arterial
wound was not marked on the MDS.
Record review of the resident’s (MONTH) (YEAR) POS showed the resident had a physician’s
orders [REDACTED].
Record review of the resident’s (MONTH) (YEAR) TAR was initialed as only being completed
on 9/1/18. The rest of dates had two wavy lines drawn over them.
Observation and interview on 9/26/18 at 1:27 P.M. showed:
-The resident’s 2nd toe on his/her left foot was black.
-The wound nurse said:
–The resident came from the hospital with her toe like that and
–The resident is on Hospice (end of life care), the toe does not have any drainage, and
it does not have any open areas.
During an interview on 9/26/18 01:54 P.M., the wound nurse said [MEDICATION NAME] was
still an active order for the resident’s 2nd toe on his/her left foot and he/she did not
know why that order was not being followed.
During an interview on 9/28/18 at 10:18 A.M., the MDS Coordinator said an arterial wound
should have been documented on the quarterly MDS dated [DATE].
During an interview on 9/28/18 at 9:55 A.M., Licensed Practical Nurse (LPN) D said they
should document the completion of the treatment and if it was not done, they should
initial the TAR, circle their initials on the date and document the reason it was not
done.
During an interview on 9/28/18 at 12:00 P.M., the DON said they should follow physician’s
orders [REDACTED].

F 0685

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assist a resident in gaining access to vision and hearing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
resident had glasses in good working condition for one sampled resident (Resident #109)

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0685

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
out of 23 sampled residents. The facility census was 114 residents.
1. Record review of Resident #109’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 9/3/18 showed the
following staff assessment of the resident:
-Had vision that was adequate to complete the assessment without corrective lenses and
-It was marked that the staff should assess the resident’s mental status but then it was
left blank as to whether the resident had memory problems or not.
Record review of the resident’s 30 day MDS dated [DATE] showed he/she was moderately
cognitively impaired.
Record review of the resident’s medical record showed no documented vision exams.
Record review of the resident’s progress notes (social service, physicians’ and nurses’)
showed no documentation regarding the resident’s glasses from 12/1/17-9/27/18 at 12:49
P.M. other than on 4/6/18, the resident was going to be at the hospital for awhile so the
resident’s glasses were left at front desk for someone to pick up and take to the
resident.
Observation and interview on 9/18/18 2:07 P.M. showed:
-The resident said he/she liked to read and
-The resident’s glasses were broken with one ear piece missing.
Record review of the resident’s current care plan showed no care plan regarding glasses or
vision impairment.
During an interview on 9/27/18 at 9:32 A.M., the Social Services Director said he/she
doesn’t remember if he/she has ever seen the resident wear glasses.
During an interview on 9/28/18 at 9:42 A.M., Certified Nursing Assistant CNA) C said:
-The resident does wear glasses;
-He/she doesn’t think he/she’s seen the resident wear his/her glasses lately;
-The resident has asked him/her to get the resident’s glasses out of the drawer or
wherever they were and give them to the resident and
-He/she did not know the resident’s glasses were broken.
During an interview on 9/28/18 at 9:55 A.M., Licensed Practical Nurse (LPN) D said he/she
has not seen the resident wear glasses.
During an interview on 9/28/18 at 10:18 A.M., the MDS Coordinator said there should be a
care plan for glasses if the resident wears glasses.
During an interview on 9/28/18 at 12:00 P.M., the Director of Nursing (DON) said:
-He/she has not seen the resident wear glasses and
-He/she was not aware the resident’s glasses were broken.

F 0686

Level of harm – Actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to implement
interventions to prevent or attempt to prevent the development of pressure ulcers
(localized injury to the skin and/or underlying tissue usually over a bony prominence, as
a result of pressure, or pressure in combination with shear) and/or abrasions (a wound
consisting of superficial damage to the skin, such as a scrape that generally does not
scar or bleed) and/or blisters or other skin alterations caused by the residents’
brace/splint/cast for two sampled residents (Residents #34 and #28); failed to ensure that
skin remained intact for one sampled resident (Resident #34) by the resident developing

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 15)
four Stage 3 pressure ulcers (full thickness tissue loss; subcutaneous fat may be visible
but bone, tendon or muscle is not exposed) to his/her coccyx area, Deep Tissue Pressure
Injuries (DTPI-may be characterized by a purple or maroon localized area of discolored
intact skin or a blood-filled blister due to damage of underlying soft tissue from
pressure and/or shear) to his/her right upper thigh, caused by the ace wrap being wrapped
tightly around his/her thigh after he/she had destroyed the plaster cast/long leg splint
that was applied to his/her right leg; failed to ensure the resident’s [DEVICE] (machine
that applies negative pressure to an area to promote healing in acute or chronic wounds)
dressing was maintaining an airtight seal, and did not address the loud noise that the
[DEVICE] machine was making to ensure it was functioning properly for one sampled resident
(Resident #17); and failed to do pressure ulcer dressing changes and [DEVICE] dressing
changes for one sampled resident (Resident #115) out of 23 sampled residents. The facility
census was 114 residents.
Record review of the facility’s treatment of [REDACTED].
-Care of wounds involve the cleansing and application of dressings and possible adjuvant
therapies (i.e., electrical stimulation) as appropriate.
-Dressings are chosen based upon:
–The presentation of the wound.
–The desired dressing function.
–The patient’s medical condition.
–The cardinal rule is to keep the ulcer moist and the surrounding skin dry and intact.
-Adjuvant therapies may be considered when wounds have proven unresponsive to conventional
therapy and in keeping with patient goal and medical condition.
Record review of the facility’s Pressure Ulcer/Injury Prevention policy dated as revised
(MONTH) (YEAR) showed:
-A comprehensive skin assessment should be completed on admission and re-admission;
-A weekly skin assessment should be conducted;
-A plan should be developed to maintain and improve the resident’s skin integrity such as
skin inspections and encouraging food and fluid intake;
-Measures should be put in place to protect the resident’s skin integrity such as
repositioning at least every two to four hours, utilizing positioning devices, ensure
proper body alignment, maintain the head of the bed at the lowest degree of elevation,
pressure reduction mattresses and proper wheelchair positioning and
-Develop a change in the care plan when skin breakdown does occur.
Record review of the facility’s policy dated 12/29/14 Negative Pressure Wound Therapy
([DEVICE]), said:
-The wound must be surrounded by enough intact periwound skin (tissue surrounding a wound)
to ensure an airtight seal of the occulsive dressing;
-The nurse should check that the dressing is fully sealed at the beginning of each shift
and every four hours after;
-To be effective, the machine must be on at least 22 hours per day;
-The nurse must check and document that the clamps are open;
-The dressing is fully contracted at the beginning of each shift and every four hours
thereafter; and
-The policy does not instruct the staff to check the machine to see if it is working
correctly.
1. Record review of Resident #34’s care plan dated 4/21/16 showed:
-The resident was at risk for developing a pressure ulcer and
-The care plan was not updated for the resident’s tibia (shin bone) and fibula (calf bone)
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 16)
fracture on 9/7/18.
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 7/10/18 showed the
following staff assessment of the resident:
-Was severely cognitively impaired;
-Required extensive assistance with bed mobility, transferring from one surface to
another, locomotion on the unit, dressing and hygiene;
-Did not walk;
-Used a wheelchair;
-Had [DIAGNOSES REDACTED].
-Did not have any pressure ulcers.
Record review of the resident’s most recent bath sheet provided dated 8/21/18 showed the
resident had a brace on his/her leg and there were scratches on his/her right inner thigh.
Record review of the resident’s weekly skin integrity data collection sheet dated 9/6/18,
9/13/18 and 9/20/18 show the resident’s skin was intact.
Record review of the resident’s nurse’s note dated 9/7/18 at 11:12 P.M., showed:
-The resident’s family member reported to the nurse that the resident’s right knee looked
swollen and the resident was in pain;
-The nurse assessed the resident’s right knee and it was swollen and
-The resident was sent to the emergency room .
Record review of the resident’s nurse’s note dated 9/8/18 at 8:03 A.M., showed:
-The resident was sent out to the hospital by the evening shift the prior evening due to a
tibia and fibula fracture and
-The resident returned from the hospital at 6:00 A.M.
Record review of the resident’s nurse’s note dated 9/8/18 at 5:24 P.M., showed the
resident was in bed with his/her right leg elevated on a pillow and had a splint on
his/her right leg.
Record review of the resident’s nurse’s note dated 9/8/18 at 11:47 P.M. showed the
resident was in bed and had a splint on his/her right leg.
Record review of the resident’s nurse’s note dated 9/10/18 at 5:17 P.M. showed the
resident had a splint on his/her right leg.
Record review of the resident’s nurse’s note dated 9/11/18 showed a follow-up appointment
was scheduled with the resident’s orthopedic physician for 9/21/18.
Record review of the resident’s physician’s progress note dated 9/11/18 showed:
-The resident had a recent right leg fracture which is currently wrapped with ace wrap and
has a soft cast. The resident constantly pulls at the ace wrap and it gets very tangled
and pulled off;
-The resident has an appointment with an orthopedist this week to have the soft cast
removed and a hard cast placed and
-The plan was to re-wrap the resident’s right leg.
Record review of the resident’s nurse’s note dated 9/13/18 at 11:57 P.M. showed the
resident’s family member requested the resident be out of bed and up in his/her wheelchair
daily.
Record review of the resident’s nurse’s note dated 9/16/18 at 9:52 A.M., showed:
-The resident took apart his/her cast on his/her right leg;
-The resident took the soft fluffy material out of upper part of his/her cast, unwrapped
the ace bandage and snapped apart the plaster splinted areas and
-A family member reported that the resident says the cast itches and he/she wants it off.
Record review of the resident’s nurse’s note dated 9/17/18 at 8:00 P.M. showed 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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 17)
resident’s splint on his/her right leg was intact.
Observation on 9/18/18 at 10:00 A.M., showed the resident was asleep in bed.
Observation on 9/18/18 at 1:28 P.M., showed the resident was in his/her wheelchair in
his/her room. There was an ace wrap and a soft-cast on the resident’s right leg.
Observation on 9/20/18 at 11:45 A.M., showed the resident was in his/her room sitting in
his/her wheelchair. The resident’s position in the wheelchair was: the resident was
sitting at the very edge of the wheelchair seat. The resident’s left leg was bent with
his/her left heel resting against the footrest.
The resident’s right mid-calf was resting against the front part of the footrest.
Record review of the resident’s nurse’s note dated 9/21/18 at 3:12 P.M. showed:
-Staff reported to the nurse that the resident’s eyes appeared to rolled back and he/she
was not responding;
-The resident’s blood pressure was low at 85/44 and
-The nurse practitioner was at the facility and gave an order to send the resident to the
emergency room .
Record review of the resident’s hospital orthopedic consult dated 9/21/18 at 7:14 P.M.
showed:
-The resident’s right leg was in a long-leg splint.
-The lateral (away from the midline of the body) portion of the plaster was broken at the
level of the proximal (near the center) tibia and the ace bandages were tightly wrapped
around the right thigh. There were ecchymoses (discoloration of the skin that occurs when
blood leaks from a broken capillary into surrounding tissue under the skin) and blisters
about the right mid-thigh as well as the right lateral shin in the region where the
plaster was broken. There was exposed plaster over the medial (toward the middle) and
lateral aspects of the right knee, as the padding was removed at those sights. The right
knee was swollen as it was the only portion of the right leg that was not wrapped with ace
bandage.
Record review of the resident’s hospital wound notes dated 9/21/18 showed:
-The resident had a Stage 3 pressure ulcer on his/her sacrum (large, triangular bone at
the base of the spine and at the upper and back part of the pelvic cavity) that was
present upon admission;
-The resident had a DTPI on below his/her right, distal (away from the point of attachment
or origin) knee that was present upon admission and
-The resident had DTPI on both heels.
Record review of the hand-written report called from the hospital note dated 9/26/18
showed the following:
-The resident was returning to the facility with Hospice services (end of life care);
-Instructions to turn the resident right to left every two hours and do not lay the
resident on his/her back;
-The resident had a Stage 3 pressure ulcer on his/her sacrum;
-The resident had DTPIs from his/her cast and
-The resident had wounds on his/her right and left heels and right ankle.
Record review of the resident’s baseline care plan dated 9/26/18 showed:
-The resident had a break in skin integrity and
-Instructions for staff to reposition the resident every two hours.
Record review of the resident’s weekly skin integrity data collection dated 9/26/18 showed
the resident had boggy (spongy) heels, blisters on his/her right upper thigh, bruising on
his/her ankle and an open area on his/her sacrum (large, triangular bone at the base of
the spine and at the upper and back part of the pelvic cavity).
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 18)
Record review of the resident’s Braden Scale for predicting pressure ulcer risk dated
9/26/18 showed the resident was at high risk.
Record review of the resident’s physician’s orders [REDACTED].>-Lay down after lunch;
-Cleanse Stage 3 sacral wound with normal saline, cover with Allevyn (a wound healing
product that provides a moist wound environment) foam every three days until healed;
-Cover right ankle with Allevyn foam every three days until healed and
-Cover right upper thigh and right upper shin with Allevyn foam every three days until
healed and as needed.
Record review of the resident’s Pressure Ulcer Status Records dated 9/27/18 showed the
resident had the following pressure ulcers that were all first observed on 9/27/18:
-A Stage III pressure ulcer on his/her left distal sacrum.
–It measured 1.7 centimeters (cm) x 0.7 cm x 0.1 cm.
–It was 100% granulation.
-A Stage 3 pressure ulcer on his/her left, proximal sacrum.
–It measured 2.0 cm x 0.3 cm x 0.1 cm.
–It was 100% granulation.
-A Stage 3 pressure ulcer on his/her right distal sacrum.
–It measured 2.5 cm x 2.5 cm x 0.1 cm.
–It was 50% slough and 50% granulation.
-A Stage 3 pressure ulcer on his/her right proximal sacrum.
Record review of the resident’s non-pressure skin condition records dated 9/27/18 showed
the resident had had the following what the facility called blood blisters (a blister
containing blood or bloody serum usually caused by an injury) that were all first observed
on 9/27/18:
-Right thigh that measured 30.0 cm x 1.5 cm x unknown depth;
-Right thigh that measured 1.0 cm x 8.0 cm x unknown depth;
-Right thigh that measured 0.5 cm x 8.0 cm x unknown depth and
-Right shin that measured 4.0 cm x 6.0 cm x unknown depth.
Observation on 9/27/18 at 7:45 A.M. showed the resident:
-Was on his/her back with a wedge pillow under his/her right knee in bed;
-Had waffle boots (cushioned foot protector) on both feet and
-Had a regular mattress (not a low air-loss mattress).
During an interview on 9/27/18 at 8:15 A.M., Registered Nurse (RN) A said new admissions
and residents returning from the hospital have wounds measured by the wound nurse.
Continuous observation on 9/27/18 showed:
-At 8:20 A.M.:
–The resident was in bed and was on his/her back with a wedge pillow under his/her right
knee.
–The resident had waffle boots on both feet.
–The resident’s right leg was in a soft blue splint.
-At 8:43 A.M., the resident was on his/her back. A staff member elevated the resident’s
head to sitting up in bed.
-At 9:17 A.M., Certified Medication Technician (CMT) A removed the resident’s meal tray
and the resident remained on his/her back with his/her head elevated.
Observation on 9/27/18 at 9:45 A.M. showed:
-The resident had a linear blister across the top and around the resident’s upper right
thigh and had two additional blisters on his/her upper right thigh;
-The resident had two blisters on his/her right shin and
-The resident had multiple wounds on his/her coccyx.
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 19)
During an interview on 9/27/18 at 10:02 A.M., the wound nurse said he/she was not aware of
the resident having any wounds prior to going out to the hospital.
Observation on 9/27/18 at 9:45 A.M. showed the resident remained on his/her back with a
wedge cushion by the resident’s right side.
Observation on 9/28/18 showed:
-At 7:55 A.M., the resident was in bed, on a regular mattress, on his/her back with a
wedge cushion by the resident’s right side;
-At 9:10 A.M., the resident was lying on his/her back with the head of his/her bed
elevated;
-At 9:40 A.M., the resident remained positioned on his/her back with a wedge pillow on
his/her right side and the head of the bed elevated and
-At 10:05 A.M., the resident was positioned on his/her back.
During an interview on 9/28/18 at 8:00 A.M., CMT B said:
-If a resident was supposed to be turned from side to side, the resident should not be on
his/her back;
-If a resident had a pressure ulcer/injury on his/her bottom, the resident should be
positioned on his/her side with a pillow to support him/her on his/her side and
-A resident should not be positioned on his/her back if he/she had a wound on his/her
bottom.
During an interview on 9/28/18 at 9:25 A.M., Certified Nursing Assistant (CNA) D said:
-Residents are supposed to be turned and repositioned every two hours;
-Residents who have a wound on his/her bottom should be positioned on his/her side with a
pillow behind him/her to help hold them on his/her side;
-If a resident had specific instructions to keep off his/her back, the resident should not
be positioned on his/her back;
-No one told him/her to keep the resident off of his/her back;
-No one told him/her the resident had pressure ulcers on his/her bottom;
-If he/she had known the resident had pressure ulcers on his/her bottom, the resident
would not be positioned on his/her back but would be positioned on his/her side;
-The resident is not able to re-position himself/herself and
-Was not aware that the resident had pressure ulcers anywhere.
During an interview on 9/28/18 at 9:50 A.M., CNA E said:
-Residents are turned and repositioned every two hours;
-If a resident had a wound, the resident would be positioned so the wound was not getting
any pressure to it;
-The nurses will report to the CNAs if there is anything going on with the residents;
-Was informed of the cares of all the residents on the wing currently working.;
-Was not told the resident had any wounds;
-Had not performed any incontinent care to the resident since the beginning of his/her
shift (7:00 A.M.);
-Residents are to be changed every two hours;
-The resident is currently positioned on his/her back;
-The resident should have been turned side to side while in bed, but he/she had breakfast
so he/she was on his/ her back;
-The resident was positioned on his/her back at the beginning of his/her shift and
-The resident is not able to re-position himself/herself.
During an interview on 9/28/18 at 10:10 A.M. RN A said:
-Residents are repositioned every two hours;
-CNAs are present for morning shift 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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 20)
-CNAs can get information about the resident off the assignment sheet and the resident
list;
-The information shared with the CNA’s included any wounds residents’ had and how the
residents should be positioned;
-The resident should be repositioned at least every two hours;
-The resident should be positioned from side to side with a pillow to keep him/her on
his/her side;
-The resident is able to reposition himself/herself and favors his/her back;
-RN A does a walk through at the beginning of his/her shift between 6:45 A.M. and 7:00
A.M;
-The resident was positioned was on his/her right side during the walk through that
morning;
-The wedge pillow should be behind him/her by the wall;
-The resident had a popped blister where the adult brief was placed and it healed quickly;

-The resident had no other wounds;
-RN A expected the CNA to report any skin abnormalities to him/her immediately and
-RN A did not notice if the resident had any wounds and no one had reported the resident
had any wounds.
During an interview on 9/28/18 at 12:00 P.M. the Director of Nursing (DON) said:
-He/she expected staff to turn and reposition residents every two hours at least every
couple hours;
-He/she expected staff to document assessments of resident’s skin condition;
-They document residents’ skin conditions on the bath sheets;
-If a resident had wounds to his/her bottom, they should get a low air loss mattress, turn
and re-position the resident, check on the resident every couple of hours and as needed;
-The charge nurse should be looking at wounds and documenting what the residents’ wounds
look like;
-He/she expected the resident’s skin to be assessed upon return on his/her hospital return
on 9/8/18 and the assessment documented;
-The resident was not able to reposition himself/herself;
-The resident sometimes slid down in the bed but he/she does not consider that as
repositioning and
-He/she would expect the charge nurse to give a report to the CNAs.
During an interview on 9/28/18 at 12:10 P.M. the resident’s physician’s nurse practitioner
said:
-Staff should have done an assessment of the resident’s right lower extremity after he/she
returned to the facility with the fracture.
-The ace wrap was wadded up around the resident’s thigh.
-The wound care nurse at the facility should report wounds in the facility to him/her.
MO 871
2. Record review of Resident #28’s annual MDS dated [DATE] showed he/she:
-Was moderately impaired cognitively;
-Had two pressure ulcers;
-Had a healed pressure ulcer;
-Had no other skin alterations;
-Was totally dependent on staff for bathing, bed mobility, personal hygiene and dressing;
-Did not walk;
-Used a wheelchair 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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 21)
-Had [DIAGNOSES REDACTED].
Record review of the resident’s care plan dated 7/15/16 for pressure ulcers showed he/she
had a pressure ulcer on his/her buttocks and left ankle. No other skin alterations were on
the care plan. There were no care plan updates since 7/15/16.
Record review of the resident’s nurse’s note dated 8/26/18 showed he/she returned to
facility (from the hospital) with a knee splint on his/her right leg.
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
-There were treatment orders for the resident’s left and right ischium (forms the lower
and back part of the hip bone).treatment orders;
-9/19/18: Right inner ankle: Clean with normal saline, apply [MEDICATION NAME] AG (a
dressing that is indicated for moderate to high exuding wounds which are infected or at
risk of infection), secure with bordered foam and change daily and as needed if soiled and
-9/19/18: Right shin: Clean with normal saline, apply [MEDICATION NAME] AG, secure with
bordered foam and change daily and as needed if soiled.
Observation on 9/18/18 at 1:52 P.M. showed the resident had visible bandages on his/her
left ankle and left shin. The resident said he/she did not know how he/she got them
Record review of the resident’s non-pressure skin condition record completed by the
facility wound nurse dated 9/20/18 showed:
-Site A:
–Was an abrasion on the resident’s left shin;
–Was first observed on 9/19/18 (bandages were observed in place on 9/18/18);
–The abrasion was 1.5 cm x 0.5 cm x 0.1 cm;
–The tissue was 50% granulation (new connective tissue and tiny blood vessels that form
on the surfaces of a wound during the healing process) and 50% slough (dead tissue that is
in the process of separating from the viable portions of the body);
–Did not have any drainage and
-The documentation did not specify why the wound was documented to be an abrasion and not
a pressure ulcer.
Record review of the resident’s facility’s wound nurse’s note dated 9/19/18 showed:
-The resident had two new wounds on his/her left leg;
-The wounds corresponded with the metal on the leg brace the resident wore on his/her
right leg for his/her fractured kneecap and
-Treatment orders were written for wound care for the two new wounds.
Record review of the resident’s nurses’ notes dated 9/19/18 through 9/28/18 at 9:33 A.M.
showed no further documentation regarding the resident’s brace or new wounds.
Record review of the resident’s consulting wound company’s physician’s assistant’s wound
note dated 9/20/18 at 11:20 A.M. showed:
-The resident had a pressure ulcer on his/her left ischium.
-The resident had a wound caused by pressure from a brace on his/her left, medial ankle
that:
–Was a Stage 3 pressure ulcer;
–Measured 1.0 cm x 1.0 cm x 0.2 cm;
–Had no drainage; and
–Was 100% granulation.
-There was no documentation regarding the resident’s shin wound.
During an interview and observation on 9/24/18 at 10:28 A.M.:
-The wound nurse said:
–The resident has two areas, one on his/her left shin and one on his/her left ankle that
were caused by the resident’s brace on his/her right leg;
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 22)
–The joints of the brace rub on the rsident’s left leg;
–The resident had a brace on his/her right leg due to a fractured kneecap;
–The resident had recurring wound areas on his/her ischium;
–The resident had [DIAGNOSES REDACTED] (a birth defect that occurs when the spine and
spinal cord do not form properly);
-The resident’s legs were together with the left side of the brace on the resident’s right
leg being directly up against the right side of the resident’s left leg;
-The wound nurse had to pull the resident’s legs apart to separate them;
-The wound nurse removed the bandages on the resident’s left leg and there were red open
areas on the resident’s left shin and left ankle;
-When the wound nurse was asked if therapy had looked at the resident’s brace, he/she said
the brace was for the resident’s fractured patella (kneecap);
-When the wound nurse was asked if they tried to put something between the resident’s legs
to prevent the brace from rubbing on his/her left leg, he/she said no, that the resident
was up most of the time during the day and
-The resident had a dressing on his/her left ischium.
Observation on 9/25/18 at 2:50 P.M. showed the resident was sitting in his/her wheelchair
in his/her room. His/her right foot was on the floor. His/her left foot was partially on
the foot rest. The resident’s left ankle was touching the brace on the resident’s right
leg.
During an interview on 9/26/18 at 8:30 A.M., the DON said:
-They tried pillows to keep his/her legs apart and
-They did not refer the resident to therapy because he/she was not able to stand on
his/her right leg.
During an interview on 9/28/18 at 9:42 A.M., CNA C said:
-The resident’s wounds on his/her left leg were from his/her brace rubbing against his/her
skin and
-The resident has had the same brace since he/she first broke his/her kneecap.
During an interview on 9/28/18 at 9:55 A.M., Licensed Practical Nurse (LPN) D said:
-The resident’s wounds on his/her left leg were from the brace rubbing on it and
-They tried using towels and pillow cases to position the resident’s legs in the past but
not specifically since he/she started wearing the brace.
During an interview on 9/28/18 at 11:04 A.M., the facility’s wound nurse said:
-The wound on the resident’s left shin was healed and
-They received a physician’s orders [REDACTED].
During an interview on 9/28/18 at 12:00 P.M., the DON said:
-The staff should document any preventative measures they put in place for the resident’s
brace rubbing on his/her skin and
-They did not refer the resident to therapy to evaluate the positioning of the brace.
During an interview on 9/28/18 at 12:10 P.M., the resident’s physician’s nurse
practitioner said:
-The resident is constantly moving himself/herself;
-The resident is in his/her wheelchair a lot;
-A pillow probably would not stayed between the resident’s legs and
-If the resident had been referred to therapy, therapy could have looked at the resident
to make sure the brace fit well, to make sure the brace was on properly and for
positioning of the brace.
3. Record review of the facility’s inservice sign in sheet on 6/26/18 showed LPN D had
attended an inservice on the Wound Vac (vacuum).
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 23)
Record review of Resident 17’s admission MDS dated [DATE] said the resident had the
following Diagnoses: [REDACTED].
-Pressure ulcer.
Record review of the resident’s medical record showed he/she was admitted to the facility
on [DATE] from a hospital with a Stage 4 ulcer (wound that exposes bone, muscle, or
tissue).
The resident was unable to make decisions for his/her self.
During an observation on initial tour on 9/18/18 at 10:00 A.M. the resident was observed
to have:
-A [DEVICE] attached to his/her lower back;
-The collection canister was half full with a yellow colored drainage;
-The [DEVICE] machine was making a very loud noise indicating a malfunction; and
-The seal on the dressing covering the wound and [DEVICE] was stuck to itself not flat to
the skin.
During an observation and interview on 9/18/18 at 10:33 A.M. with LPN D said:
-The resident had a bridge in the [DEVICE] system (an extension to the system);
-The nurse was able to stick his/her fingers in the dressing and said that was ok;
-The noise was ok; and
-According to the facility’s policy it said the wound vac should be sealed to create a
vacuum.
During an observation on 9/18/18 at 12:44 P.M., showed:
-The resident’s dressing covering the wound and [DEVICE] was stuck to itself not flat to
the skin; and
-The [DEVICE] machine was still making a loud noise indicating it was not working
properly.
During an observation and interview on 09/18/18 at 02:32 P.M. with the DON and LPN D:
-Turned the resident so his/her lower back wound site could be more observable;
-The seal on the low back [DEVICE] dressing was stuck to itself not flat to the skin; and
-LPN D said the dressing and noise from the machine were ok.
During an interview on 09/18/18 at 2:45 P.M. with the DON said:
-The [DEVICE] noise and the dressing was not attached correctly; and
-He/she would make sure it was fixed.
Record review on 09/25/18 at 2:32 P.M., showed the resident’s POS dated 09/04/18 directed
the staff to monitor the function of the [DEVICE] every shift.
4. Record review of Resident #115’s Admission Record showed he/she was admitted on [DATE]
and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-PU of the left hip, unspecified stage.
-Unspecified open wound of the resident’s left foot, sequela (a condition that is the
consequence of a previous disease or injury).
-Unspecified injury at T11-T12 level of [MEDICATION NAME] spinal cord, sequela.
-[MEDICAL CONDITION].
-Diabetes II with diabetic peripheral angiopathy (generic term for a disease of the blood
vessels, a common complication of chronic diabetes) without gangrene (dead tissue caused
by an infection or lack of blood flow).
Record review of Resident’s POS dated 8/2/18 showed physician’s orders
[REDACTED].>-Change the resident’s Wound Vac dressing on Monday, Wednesday, and Friday
on the 7:00 A.M.-3:00 P.M. shift.
-Monitor Wound Vac function every shift and as needed.
Record review of the Resident’s Treatment Administration Record (TAR) dated (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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 24)
showed that the PU and wound vac dressings were not changed on the following dates:
-Wednesday 8/8/18.
-Monday 8/13/18.
-Wednesday 8/15/18.
-Wednesday 8/22/18.
-Monday 8/27/18.
-Friday 8/31/18.
Record review of Resident’s POS dated (MONTH) (YEAR) showed:
-No order for a Wound Vac machine to wounds.
Record review of the Resident’s TAR dated (MONTH) (YEAR) showed that the PU dressings were
not changed on Monday 9/3/18.
Record review of the Resident’s medical record showed only one entry for a missed dressing
change on 9/3/18 as follows:
-Dressing changes not done this shift.
-Nurse told resident several times that he/she was ready to change the dressings.
-The resident was either in another resident’s room or outside each time the nurse went to
do the dressing changes.
-The on-coming nurse was informed.
Record review of Resident’s Care Plan (written out plan for the care of the resident)
dated 9/7/18 showed:
-Risk for developing a pressure ulcer, currently has PU.
-Goal: will have intact skin by next review of 12/31/18.
-Interventions:
–Reposition/shift weight to relieve pressure.
–Minimize pressure over bony prominences.
–Provide pressure relieving or reduction device:
—Low air loss mattress.
—Chair cushion.
—Pressure reduction device in wheelchair.
—Reposition.
Record review of Resident’s medical record showed no Care Plan for the care of the
Resident’s wounds or the use of a Wound Vac.
Record review of the Resident’s Wound Rounds charting dated 8/28/18 at 1:38 P.M. showed:
-Physician here for rounds.
-Resident non-compliant with wound care/dressing changes.
-While changing his/her dressing he/she would not roll to the right side to allow access
to the wound on the left great trochanter (a part of the thigh bone).
-While taping the bridge (connects two or more dressings to a wound vac) down he/she
continued to state the tape was tight and to remove it.
-Resident continu

F 0692

Level of harm – Actual harm

Residents Affected – Few

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure one
resident was provided sufficient nutrition, fluids and monitoring while on a diuretic
(medication used to treat heart-related conditions by helping the body get rid of unneeded
water and salt through increased urination which helps lower blood pressure and helps make

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0692

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 25)
it easier for the heart to pump), high blood pressure medications and was sent to the
hospital emergency room for a very low pulse and blood pressure and for critical lab
results which resulted in the resident to have poor kidney function and was placed on
hospice (end of life care); and to assist the resident with his/her meals after being
readmitted to the facility after a hospital stay with a significant change in condition
for one sampled resident (Resident #34) out of 23 sampled residents. The facility census
was 114 residents.
Record review of the facility’s hydration policy dated as revised 3/1/13 showed:
-Instructions for staff to staff to watch for risk factors for dehydration such as
insufficient fluids, loss of appetite, the use of diuretics refusal of fluids and Dementia
(a progressive mental disorder characterized by memory problems, impaired reasoning and
personality changes) and
-Clinical symptoms of a deficit of fluids include decreased blood pressure.
1. Record review of Resident #34’s care plan dated 4/21/16 showed instructions to staff to
encourage the resident to eat and drink.
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 7/10/18 showed the
following staff assessment of the resident:
-Was severely cognitively impaired;
-Required supervision, encouragement or cueing with eating and
-Had [DIAGNOSES REDACTED].
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
-A diet order of mechanical soft and discontinued on 9/21/18;
-A physician’s orders [REDACTED].
– A physician order [REDACTED].>-A physician orders [REDACTED]. Notify MD if any BP
meds are held) and discontinued on 9/21/18;
-Please encourage po fluids at all meals dated 2/28/17 and discontinued on 9/21/18;
-Monitor BP and pulse weekly. Notify MD is SBP is less than 90 or above 200 or if pulse is
less than 50 every day dated 7/18/17 and discontinued on 9/21/18 and
-[MEDICATION NAME] 30 mg daily dated 7/3/18 (hold if SBP is below 100. Notify MD if any BP
meds are held) and discontinued 9/21/18.
Record review of the resident’s nurse’s note dated 9/8/18 at 5:24 P.M. showed he/she
consumed 75% of breakfast and 50% of lunch.
Record review of the resident’s Nurse’s Note dated 9/8/18 at 11:47 P.M. showed he/she was
fed dinner by a Certified Nursing Assistant (CNA).
Record review of the resident’s Nurse’s Note dated 9/10/18 at 5:17 P.M. showed:
-The resident was fed breakfast by staff;
-The resident’s family member fed the resident lunch and
-The resident’s family member reported that the resident ate 100% of the food they brought
from home.
Record review of the resident’s physician’s progress note dated 9/11/18 showed:
-The resident’s heart rate was low at 47 beats per minute (normal is 60-100);
-The resident was seen urgently for low heart rate and low blood pressure;
-The resident has a very dry mouth;
-Nursing stated the resident refuses to drink regular water and likes sweets and
-The resident’s family brought the resident in [MEDICATION NAME] flavored water to drink.
Record review of the resident’s Nurse’s Note dated 9/17/18 at 12:50 P.M. showed the
resident’s blood pressure was low at 115/46 ( normal range is 120/80) and the resident’s
pulse was low 47.
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0692

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 26)
Observation on 9/18/18 at 10:00 A.M. showed the resident was asleep in bed.
Observation on 9/18/18 at 1:28 P.M. showed the resident was in his/her wheelchair in
his/her room.
Record review of the resident’s Nurse’s Note dated 9/18/18 at 4:54 P.M. showed the
resident’s blood pressure medication was held due to a low blood pressure of 84/44.
Record review of the resident’s Nurses’ Notes showed there were no nurses’ notes dated
9/19/18-9/20/18.
Observation on 9/20/18 at 11:45 A.M. showed the resident was in his/her room in his/her
wheelchair.
Record review of the resident’s Nurse’s Note dated 9/21/18 at 12:55 A.M. showed the
resident’s blood pressure medication was held due to a low blood pressure of 97/37. The
physician was informed. The physician ordered a Basic Metabolic Panel (a blood test that
measures sugar levels, electrolytes, fluid balance, and kidney function), Urinary Analysis
and a Complete Blood Count (a test that gives information about blood cells) in the
morning.
Record review of the resident’s lab results dated 9/21/18 at 11:38 A.M. showed:
-The resident’s white blood cell count was elevated at 11.0 (normal range 4.5-10.5) which
can indicate an infection;
-The resident’s red blood cell count was low at 3.45 (normal range 3.9-5.2) which can
indicate [MEDICAL CONDITION] (when one doesn’t have enough healthy red blood cells to
carry adequate oxygen to the body’s tissues), kidney disease and other conditions;
-The resident’s potassium level was elevated at 5.4 (normal range 3.5-5.1) which can
indicate kidney disease;
-The resident’s blood urea nitrogen (BUN-A measurement of the amount of nitrogen in the
blood. A high BUN may indicate heart failure or dehydration) was elevated at 71 (normal
range 7-25);
-The resident’s Creatinine (blood test is used to assess kidney function) was elevated at
3.7 (normal range 0.6-1.3) which can indicate dehydration and/or impaired kidney function;
-The resident’s hemoglobin level (the protein molecule in red blood cells) was low at 8.4
(normal range is 12.0-16.0) which can indicate [MEDICAL CONDITION];
-The resident’s Hematocrit (a blood test that measures the percentage of red blood cells
found in whole blood) was low at 27.8 (normal range is 36.0-48.0) which can indicate
conditions such as [MEDICAL CONDITION] or blood loss and
-The lab was dated, initialed and it was hand-written on the lab results that the resident
was sent to the emergency room .
Record review of the resident’s Nurse’s Note dated 9/21/18 at 3:12 P.M. showed:
-Staff reported to the nurse that the resident’s eyes appeared to roll back and he/she was
not responding;
-The resident’s blood pressure was 85/44 and
-The Nurse Practitioner was at the facility and gave an order to send the resident to the
emergency room .
Record review of the resident’s hospital notes dated 9/21/18-9/26/18 showed the resident
had [DIAGNOSES REDACTED]. Hypovolemia occurs with dehydration or bleeding).
Record review of the hand-written report called from the hospital note dated 9/26/18
showed the following:
-The resident was returning to the facility with hospice services and
-A diet order of puree food with thin liquids.
Record review of the resident’s POS dated 9/26/18 showed physician orders:
-[MEDICATION NAME] CD 240 mg daily dated 9/26/18 (hold if SBP is less than 90 or pulse is
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0692

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 27)
less than 50. Notify MD if any BP meds are held);
-Please encourage po fluids at all meals dated 9/26/18;
-Monitor BP and pulse weekly and notify MD if SBP is less than 90 or above 200 or pulse is
less than 50 every day dated 9/26/18;
-[MEDICATION NAME] 12.5 mg twice a day dated 9/26/18 and
-[MEDICATION NAME] 25 mg three times a day, date 9/26/18.
Record review of the resident’s baseline care plan dated 9/26/18 showed:
-The resident required some or total assistance to eat/drink and he/she had a chewing,
swallowing or choking problem and
-Instructions for staff to assist the resident with eating.
Record review of the resident’s initial data collection tool/nursing service dated 9/26/18
showed the resident:
-Eats poorly;
-Has trouble swallowing;
-Has choking problems;
-Accepts fluids when offered and
-Had a [DIAGNOSES REDACTED].
Observation on 9/26/18 at 2:40 P.M. showed:
-There were five bottles of flavored water in the resident’s room. One of the bottles had
been opened and about 1/4 of it was gone and
-There was an insulated mug that had water in it by his/her television.
During an interview on 9/26/18 at 2:45 P.M., CNA G said:
-The resident’s family brings bottled water;
-They put the flavored water in her pitcher in the resident’s room;
-They give the resident flavored water at meals and
-The resident’s family member comes every day at lunch and gives the resident flavored
water when he/she’s here.
Record review of the resident’s POS upon return from the hospital on [DATE] showed diet
orders for puree food (food that is ground and altered into a consistency of a soft,
smooth, thick paste (similar to a thick pudding) that requires very little or no chewing)
and to encourage beverages with all meals.
Observation on 9/27/18 at 7:45 A.M. showed the resident(‘s):
-Tongue was coated with a white substance that was cracked in appearance;
-Water pitcher was on his/her bedside table;
-Flavored water bottle was half full and
– A sucker was on the open wrapper on the bedside table.
Continuous observation on 9/27/18 showed:
-At 8:20 A.M.:
–The resident was in bed.
–The resident’s water pitcher was on his/her bedside table.
–The resident’s flavored water bottle was half full.
–The resident’s sucker was on the open wrapper on the bedside table.
-At 8:24 A.M., housekeeping was cleaning the resident’s room.
-At 8:41 A.M., the housekeeper left the resident’s room.
-At 8:43 A.M., the resident was served a breakfast tray in his/her room that consisted of
eggs, oatmeal, bread, 1/2 a glass of orange juice, [MEDICATION NAME] water, unopened
butter and jelly. Certified Medication Technician (CMT) A elevated the resident’s head to
sitting up in bed. Staff did not assist the resident with his/her breakfast. The resident
was not able to feed himself/herself.
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0692

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 28)
-At 8:54 A.M., the resident was crying out.
-At 8:56 A.M., the charge nurse walked by the resident’s room.
-At 9:01 A.M., the resident was crying out. The resident cried out my leg.
-At 9:05 A.M., the resident’s breakfast tray remained untouched on a bedside tray.
-At 9:15 A.M., the resident’s breakfast tray remained untouched on a bedside tray. No
staff entered the resident’s room since his/her breakfast tray was delivered. The
resident’s food and drink remained untouched.
-At 9:17 A.M., staff were picking up room trays. CMT A offered the resident a sip of
orange juice. The resident shook his/her head no. The resident was offered flavored water.
The resident took a sip of flavored water. CMT A removed the resident’s meal tray. The
resident was not offered any food. The resident’s glass of orange juice and flavored water
were left for the resident.
During an interview on 9/27/18 at 10:10 A.M., the resident’s family member said:
-The resident’s appetite declined around the same time he/she complained of knee pain on
9/7/18;
-The resident began pocketing food in his/her cheeks and not eating and
-He/she noticed the resident was more lethargic recently.
Record review of the resident’s Nurse’s Note dated 9/27/18 at 3:23 P.M. showed Registered
Nurse (RN) A documented:
-The resident ate a few bites for breakfast;
-The resident’s family member brought the resident lunch and
-The resident’s family member reported to RN A that the resident ate two bites and refused
to eat or drink.
Record review of the resident’s Nurse’s Note dated 9/27/18 at 6:56 P.M. showed RN A
documented:
-CNA F reported to RN A that he/she served the resident dinner and
-CNA F reported to RN A that the resident’s family member asked CNA F to take away the
resident’s dinner as the family member was bringing the resident soup.
Continuous observation on 9/28/18 showed:
-At 9:10 A.M.:
–The resident was in bed.
–A breakfast tray was in the resident’s room uncovered. It included pureed eggs, oatmeal,
bread, water and orange juice. The resident was not feeding himself/herself and staff were
not in the room assisting the resident. None of the food and/or drinks were consumed.
-At 9:15 A.M., a housekeeper began cleaning the resident’s room.
-At 9:20 A.M.:
–The resident had not eaten any food.
–A CNA removed the resident’s breakfast tray without offering the resident any food or
drink.
During an interview on 9/28/18 at 8:00 A.M., CMT B said:
-The resident drinks flavored water when taking his/her medications;
-The resident will drink orange juice when he/she is in the dining room;
-The resident will eat cereal for breakfast and
-The resident will feed himself/herself.
During an interview on 9/28/18 at 9:25 A.M., CNA D said:
-The resident was able to feed himself/herself and
-He/she would encourage the resident to eat and then inform the charge nurse.
During an interview on 9/28/18 at 9:50 A.M., CNA E said:
-The nurses will report to the CNAs if there is anything going on with the residents;
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0692

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 29)
-He/she was informed of the cares of all the residents on the wing currently working;
-The resident was able to feed himself/herself but required a lot of cueing and
-The meal tray should be covered until the staff are sitting next to him/her and
assisting/cueing him/her to eat or feeding him/her.
During an interview on 9/28/18 at 10:10 A.M. RN A said:
-CNAs are present for morning shift report;
-CNAs can get information about the resident off the assignment sheet and the resident
list;
-The resident was able to feed himself/herself with verbal cueing;
-The resident would eat what he/she wants to eat and if he/she doesn’t want to eat it,
he/she won’t;
-Family have been coming in and bringing food for the resident;
-The resident does not drink regular water but will drink flavored water his/her family
brings in;
-He/she attempted to feed the resident but he/she would not eat anything;
-The resident had always been a picky eater but it has been decreasing recently and
-He/she would expect staff to assist the resident with meals.
During an interview on 9/28/18 at 12:00 P.M. the Director of Nursing (DON) said:
-He/she expected staff to assist residents with meals as needed;
-He/she expected staff to feed residents when needed;
-He/she did not expect staff to place a room tray in the room, uncover the meal and leave
the room if the resident was unable to feed himself/herself;
-The resident was able to feed himself/herself when he/she wants to eat;
-The resident does need assistance with meals;
-The resident would eat the dessert first;
-The resident doesn’t have the appetite so he/she is not eating as much as he/she was
before;
-The resident will only drink flavored water and will not drink orange juice and
-The resident’s family said the resident will eat sweets.
During an interview on 9/28/18 at 12:10 P.M. the resident’s physician’s Nurse Practitioner
said:
-He/she would expect the staff to feed the resident if he/she was unable to feed
himself/herself and
-He/she would expect staff to notify him/her of a resident refusing to eat if the resident
was refusing to eat on a regular basis.
MO 871

F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide enough nursing staff every day to meet the needs of every resident; and have a
licensed nurse in charge on each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to provide
sufficient staff to provide appropriate treatment and services for eight sampled residents
(Resident’s #2, #14, #15, #16,#37, #39, #48, and #106) out of 23 sampled residents. The
facility census was 114 residents.
1. Record review of the following resident’s Minimum Data Sets (MDS-a federally mandated
assessment tool completed by facility staff for care planning) 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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 30)
-Resident #106’s quarterly MDS dated [DATE] showed the resident was cognitively intact;
-Resident #37’s quarterly MDS dated [DATE] showed the resident was cognitively intact;
-Resident #48’s quarterly MDS dated [DATE] showed the resident was cognitively intact;
-Resident #2’s quarterly MDS dated [DATE] showed the resident was cognitively intact;
-Resident #14’s annual MDS dated [DATE] showed the resident was cognitively intact;
-Resident #39’s quarterly MDS dated [DATE] showed the resident was cognitively intact and
-Resident #15’s quarterly MDS dated [DATE] showed the resident was cognitively intact.
During the resident group meeting on 9/18/18 at 10:22 A.M.:
-Resident #15 said staff tell the residents they are short-staffed and that they are
tired;
-Resident #37 said he/she doesn’t get his/her medication timely;
-Resident #14 said he/she has to bang on the walls in the morning to get someone to come
get him/her out of bed;
-Resident #6 arrived to the meeting at 10:25 A.M. and said they were just getting his/her
spouse up out of bed;
-Resident #15 and #48 said staff often tell them that they can get up after breakfast, so
they have to eat breakfast in their rooms because staff don’t get them up before
breakfast;
-Residents #14, #15, #48 and #106 said it frequently takes an hour for staff to answer
their call lights;
-Residents #2, #14, #15, #37, #39, #48 and #106 said:
–The facility is short-staffed and because of the facility being short-staffed, they are
not gotten out of bed timely, not put to bed timely, they get medications late, the call
light response time is very long and their beds don’t get made.
2. Record review of the facility staffing sheets from 9/10/18 through 9/27/18 showed that
the facility was below the facility staffing ratios for the nursing staff on these days
for he entire building:
– On 9/10/18 the facility was short three licensed nurses and three CNA’s;
-On 9/11/18, the facility was short two licensed nurses and four CNA’s;
-On 9/12/18, the facility was short two licensed nurses and two CNA’s;
-On9/13/18, the facility was short two licensed nurses and three CNA’s;
-On 9/14/18, the facility was short six CNA’s;
-On 9/15/18, the facility was short eight CNA’s;
-On 9/16/18, the facility was short nine CNA’s;
-On 9/17/18, the facility was short one licensed nurses and three CNA’s;
-On 9/18/18, the facility was short seven CNA’s;
-On 9/19/18, the facility was short four CNA’s;
-On 9/20/18, the facility was short five CNA’s;
-On 9/21/18, the facility was short seven CNA’s;
-On 9/22/18, the facility was short seven CNA’s;
-On 9/23/18, the facility was short seven CNA’s;
-On 9/24/18, the facility was short six CNA’s;
-On 9/25/18, the facility was short three CNA’s;
-On 9/26/18, the facility was short five CNA’s and
-On 9/27/18, the facility was short two CNA’s.
3. Record review of Resident #16’s medical record showed he/she was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Nocturia (frequent urination at night);
-High blood pressure 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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 31)
-The resident is not able to make decisions about his/her cares.
During an observation and family interview on 09/17/18 at 2:00 P.M. the spouse said:
-They live together in the same room;
-The spouse has written a blue sheet (grievance) almost every month since he/she has lived
here and would like both of them to move to a different facility;
-He/she said the staff will put his/her spouse to bed at 8:30 P.M.;
-The staff will not check on him/her all night;
-The resident is not able to toilet himself/herself;
-The spouse has talked to the Administrator about getting more help especially on the
evening and night shifts and
-The resident was not able to use the call light or answer a question with more than a one
word answer.
During an observation on 09/22/18 at 11:15 P.M. the evening charge nurse had called two of
the night shift CNAs (Certified Nurse Assistant) who had been scheduled for the night
shift and were more than 30 minutes late;
-One CNA said he/she was not scheduled for that shift;
-The charge nurse was not able to contact the other CNA and
-The night shift worked without two of the CNAs that had been scheduled.
During an interview on 09/27/18 at 11:00 A.M. the Director of Nursing (DON) said:
-The facility has open positions for five full time CNA’s and five full time nurses;
-The facility is currently working with a local college to try to hire more help.
-The CNA’s that work here have several issues:
-They have limited resources such as transportation and daycare;
-They have little family support and
-They are frequently late or don’t show up;
-He/she has had to come in and work on the floor as a CNA and
-He/she has given himself/herself 18 months to try to resolve this issue.
During an interview on 09/28/18 at 07:00 A.M. Licensed Practical Nurse (LPN) E said:
-In the last 30 days the night shift is short staffed 50% of the time;
-He/she frequently has to work extra shifts;
-The night shift is short five full time positions;
-As a result of not having enough staff the residents are left wet longer and
-The residents do not get turned every two hours like they should be.
During an interview on 09/28/18 at 11:00 A.M. with the Administrator he/she said:
-The parent company of the facility has a good staffing budget and
-The facility is currently working with an online employee recruiting tool.
4. During an observation on 9/18/18 the following employees were observed to be on their
personal cell phones:
-Two on the 100 hallway;
-Three on the 300 hallway and
-Two on the 400 hallway were looking at pictures.
During an interview on 9/23/18 at 10:00 A.M., the Administrator said:
-He/she knows there’s a problem with staff being on their cell phones during work hours;
-It’s hard to get the employees to stop using their cell phones and
-When the new Director of Nursing (DON) was hired he/she has been slowly working on this
problem.
During an interview on 9/27/18 at 8:23 A.M. LPN E said:
-He/she works the night shift;
-He/she is in charge of the 600 hallway and locked unit with 13 and 30 residents
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 32)
respectively;
-The facility should have one nurse and one Certified Nurse Assistant (CNA) to work on
each hallway;
-In the past month he/she said they were short staffed 50% of the time;
-At times there is a Certified Medication Technician (CMT) in charge of the locked unit
with a CNA with the nurse being the only staff on the other hallway;
-That has happened twice this last month;
-Over the last 30 days there were 10 times that people could not get up when they wanted
to because there was not enough staff and
-It takes longer to get to each resident if there is only one staff so they are wet
longer.
During an observation on 9/27/18 at 12:37 P.M. the following employees were observed to be
talking on their personal cell phones:
-One on the 100 hallway;
-One on the 200 hallway and
-One on the 400 hallway.
During an observation on 9/27/18 at 1:15 P.M. one employee on the 200 hallway was observed
on his/her personal cell phone looking at pictures.
5. During an interview on 9/28/18 at 9:00 A.M. LPN C said:
-He/she works his/her regular shift plus two extra most weeks because of shortages or call
ins and
-Record review of the staffing sheet showed in the last 17 days he/she has worked 20
shifts.
During an interview on 9/28/18 at 9:15 A.M. Registered Nurse (RN) A said:
-He/she works here full time and an extra two to three shifts a week;
-If he/she doesn’t work extra when there is a call in he/she will get complaints the next
day from the residents about cares not having been done and
-Record review of the staffing sheet showed he/she had worked 24 shifts in the last 17
days.
MO 055, MO 371, MO 094 and MO 416

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on interview and record review, the facility failed to provide the annual 12 hours
of inservice training for the nursing staff. The facility census was 114 residents.
1. Record review of the facility’s training classes showed the following were full time
employees and had been employed for longer than 12 consecutive months in this facility:
-The training provided did not include Dementia care;
-The training did not equal 12 hours;
-The average amount of training for a Certified Nurses Aide (CNA) was four hours;
-Registered Nurse (RN) A had seven hours of annual training which included abuse and
neglect;
-Licensed Practical Nurse (LPN) C had seven hours of annual training which included abuse
and neglect and
-CNA A had four hours of training which included abuse and neglect.
During an interview on 9/28/18 at 8:45 A.M. with the Director of Nursing (DON) said:

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 33)
-The staff should have 12 hours of training; and
-Training should be annually.
During an interview on 9/28/18 at 9:00 A.M. LPN C said:
-He/she takes the facility training whenever it is offered;
-He/she does not do any outside training or classes; and
-He/she does not think the amount of training the facility provided equaled 12 hours.
During an interview on 9/28/18 at 9:15 A.M. RN A said:
-He/she does not do any training outside of the facility; and
-He/she did not think the amount of training would equal 12 hours.
During an interview on 9/28/18 at 11:59 A.M., the Director of Nursing (DON) said:
-Staff education is done throughout the year;
-Monthly inservices cover different categories;
-Staff receive a minimum of 12 hours a year; and
-He/she believes that dementia (a general term for a decline in mental ability resulting
in memory loss, and other mental abilities severe enough to interfere with daily
functioning) care is covered yearly.

F 0741

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that the facility has sufficient staff members who possess the competencies and
skills to meet the behavioral health needs of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide 12 hours of inservice
training for the nursing staff for Dementia training. The facility census was 114
residents.
1. Record review of the facility’s training classes showed the following were full time
employees and had been employed for longer than 12 consecutive months in this facility:
-The training provided did not include Dementia care; and
-The facility had residents with a [DIAGNOSES REDACTED].
During an interview on 9/28/18 at 8:45 A.M. with the Director of Nursing (DON) he/she
said:
-The education should be annual.
During an interview on 9/28/18 at 9:00 A.M. Licensed Practical Nurse (LPN) C said:
-He/she takes the facility training whenever it is offered;
-He/she has not had any Dementia training; and
-He/she does not do any outside training or classes.
During an interview on 9/28/18 at 9:15 A.M. with Registered Nurse (RN) A he/she said:
-He/she has not had any Dementia training and does not know why they have not because
there are several residents with that disease;
-He/she does not do any training outside of the facility.

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
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.

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 34)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to document
indications, symptoms, reason or [DIAGNOSES REDACTED].#80) out of 23 sampled residents.
The facility census was 114 residents.
1. Record review of Resident #80’s nurses’ notes dated (MONTH) (YEAR)-September (YEAR)
showed no documentation regarding symptoms or indications for the use of [MEDICATION NAME]
(an antidepressant that has a sedating effect).
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].>-Dated
7/31/18 for [MEDICATION NAME] (an antidepressant) 20 milligrams (mg) for Depression (a
mental disorder in which the individual has intense sadness or despair that affects their
daily life) and
-Dated 8/3/18 for [MEDICATION NAME] 25 mg at bedtime and there was not a [DIAGNOSES
REDACTED].
Record review of the resident’s care plan dated 9/18/17 with a goal date of 6/13/18
showed:
-The resident made negative statements about himself/herself;
-The resident made negative statements about life;
-The goals were that the resident would allow basic cares and not harm himself/herself or
others;
-The resident was at risk of mood and/or behavior changes related to depression and
-The care plan did not include the use of [MEDICAL CONDITION] medication.
Record review of the resident’s annual Minimum Data Set ( MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 9/10/18 showed the
following staff assessment of the resident:
-Was cognitively intact;
-The resident’s self-reported mood symptoms indicated mild depression;
-Had no behaviors and
-Had a [DIAGNOSES REDACTED].
Observation during an initial tour conducted on 9/17/18 at 10:39 A.M. showed the resident
was lying in bed watching television.
Observation on 9/24/18 at 6:21 A.M. showed the resident was asleep in bed.
During an interview on 9/28/18 at 9:42 A.M., Certified Nursing Assistant C said the
resident had not said anything about having trouble sleeping.
During an interview on 9/28/18 at 12:00 P.M., the Director of Nursing (DON) said:
-There should be a [DIAGNOSES REDACTED].
-There should be documentation of symptoms indicating the need for [MEDICATION NAME].

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 help prevent
the potential for development and transmission of communicable diseases and infections by
not writing the date initiated on the tube feeding (a device inserted into your stomach to
supply nutrition when you have trouble eating) tubing, on the intravenous (IV) tubing nor
by ensuring the occlusive (clear) dressing on the peripherally inserted central catheter
(PICC) line tubing or [DEVICE] (machine that uses negative air flow to aid in healing a
wound) were correctly sealed for two sampled residents (Resident’s #17 and #46); to keep

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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 35)
oxygen tubing off the floor for one sampled resident (Resident #269) and to keep oxygen
tubing bagged when not in use for two sampled residents (Resident’s #269 and #110) out 23
sampled residents. The facility census was 114 residents.
Respiratory Therapy Policy and Procedure Manual; Chapter 1 Oxygen Therapy; Infection
control dated 3/28/16 showed:
-Change oxygen supplies weekly and when visibly soiled.
-Humidifier/Aerosol bottles should be dated and replaced every seven days regardless of
water level;
-Store oxygen and respiratory supplies in bag labeled with resident’s name when not in use
and
-Licensed healthcare providers are responsible for seeing that oxygen equipment/supplies
are setup and cared for and for the removal of the equipment from rooms when the oxygen is
discontinued.
Record review of the facility’s policy dated 05/01/2015 Central Vascular Access Device
said:
-Central vascular access devices includes peripherally inserted central catheter (PICC)
lines;
-Nurses caring for patients receiving infusion therapies are expected to follow infection
control and safety compliance procedures;
-The catheter insertion site (where the tubing enters the skin) is a potential entry site
for bacteria that may cause a catheter-related infection;
-A transparent dressing is the preferred dressing;
-Dressing change is performed if the integrity of the dressing has been compromised (wet,
loose, or soiled);
-The staff is directed to apply the transparent dressing, according to the manufacturers’s
instructions, smoothing around the catheter starting at the insertion site and moving to
the periphery (outer edge); and
-The staff is directed to observe the site with intermittent therapy or when not in use.
Record review of the facility’s policy dated 12/29/2014 Negative Pressure Wound Therapy (a
[DEVICE] is a machine that helps to heal a wound with negative pressure), said:
-The wound must be surrounded by enough intact periwound skin (tissue surrounding a wound)
to ensure an airtight seal (of the occlusive seal); and
-The nurse should check that the dressing is fully sealed at the beginning of each shift
and every four hours after.
1. Record review of the Resident #269’s Admission record showed he/she:
-Was admitted on [DATE];
-Was a Full Code status;
-Had no known drug allergies [REDACTED].>-Had a diet of pureed food and pudding thick
liquids and
-Had no diagnoses listed.
Record review of the resident’s undated Nutrition data Collection/Assessment record showed
the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] reflux disease (GERD – back up of stomach acid/heartburn);
-Hypertension (HTN- high blood pressure) and
-[MEDICAL CONDITION] Fibrillation (A-Fib – abnormal heart rhythm).
Record review of the resident’s Admission Minimum Data Set (MDS – a federally mandated
assessment tool completed by the facility staff for care planning) dated 9/25/18 showed
he/she has cognitive loss/dementia (a general term for a decline in mental ability
resulting in memory loss, and other mental abilities severe enough to interfere with daily
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 36)
functioning).
Observation on 9/17/18 10:35 A.M., showed the resident’s oxygen tubing lying on floor
behind the concentrator not bagged.
Observation on 9/25/18 03:00 P.M., showed the resident’s oxygen tubing laying on floor
behind concentrator not bagged and a family member was in room and said he/she had used it
once since being admitted to the facility.
Record review of the resident’s Physicians Order Sheet (POS) dated (MONTH) (YEAR) showed:
-No physician’s order for oxygen and
-No order for C-Pap (a ventilation device that blows a gentle stream of air into the nose
during sleep to keep the airway open).
2. Record review of Resident #110’s Admission record showed he/she was admitted on [DATE]
with [MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the
ability of the lungs to perform ventilation).
Record Review of the Resident’s POS dated (MONTH) (YEAR) showed:
– Oxygen at 3 Liters (L) per Nasal Cannula continuously each shift;
-No orders for the C-Pap machine.
Record review of the resident’s Care Plan (written out plan for the care of the resident)
dated 8/24/28 showed no care plan for oxygen usage.
Record review of the resident’s 14-Day MDS dated [DATE] showed he/she had [MEDICAL
CONDITION] and [MEDICAL CONDITION].
Observation on 9/18/17/18 10:40 A.M., showed:
-The resident not wearing oxygen;
-Oxygen concentrator settings were 3.5 lpm (liters/per minute);
-Oxygen tubing not bagged lying on the concentrator and
-C-pap mask lying on nightstand not bagged.
3. During an interview on 9/28/18 11:59 A.M., the Director of Nursing (DON) said:
-Oxygen tubing should be bagged if the resident is not using it and
-C-Pap mask should be bagged when not being used by a resident.
4. Record review of Resident’s #17 MDS dated [DATE] showed the resident had the following
Diagnoses: [REDACTED].
-Pressure ulcer (wound that is an opening in the skin) and
-The resident was not able to make decisions about his/her cares.
Record review of the resident’s medical record showed:
-He/she was admitted to the facility on [DATE] from a hospital with a Stage 4 ulcer (wound
that exposes bone, muscle, or tissue);
-The resident was on an antibiotic (Memperim) intermittently to be given through his/her
PICC line;
-The resident was to receive [MEDICATION NAME] (a liquid food substitute) through a
feeding tube as well as pureed food and
-He/she had a [DEVICE] dressing to his/her lower back.
Observation on initial tour on 9/18/18 at 10:00 A.M. showed the resident:
– Had a [DEVICE] attached to his/her lower back;
-The seal on the dressing covering the wound and [DEVICE] was stuck to itself not sealed
flat to the skin;
-The occlusive dressing covering the PICC line was loose not covering the insertion site;
-The antibiotic with tubing was not dated with the date it was hung and
-The [MEDICATION NAME] bottle and tubing were not dated with the date it was hung.
During an observation and interview on 9/18/18 at 10:33 A.M. with Licensed Practical Nurse
(LPN) D he/she said:
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:

265355

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF GRANDVIEW

STREET ADDRESS, CITY, STATE, ZIP

6301 EAST 125TH ST
GRANDVIEW, MO 64030

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 37)
-The nurse was able to stick his/her fingers in the dressing but that was ok;
-The occlusive dressing covering the PICC line was loose and not covering the insertion
site;
-The antibiotic with tubing was not dated;
-The [MEDICATION NAME] bottle and tubing were not dated.
-LPN D said he/she thought the antibiotic may have been discontinued but the resident may
need a lab sample before he/she could take out the PICC line.
Observation on 9/18/18 at 12:44 P.M. showed the resident:
-The [DEVICE] dressing was still stuck to itself and not flat to the skin;
-The occlusive dressing covering the PICC line was loose not covering the insertion site;
-The antibiotic with tubing was not dated and
-The [MEDICATION NAME] bottle and tubing were not dated.
During an observation and interview on 09/18/18 at 02:32 P.M. the DON said:
-The [DEVICE] dressing was still stuck to itself not sealed flat to the skin;
-The occlusive dressing covering the PICC line was loose and not covering the insertion
site;
-The antibiotic with tubing was not dated and
-The [MEDICATION NAME] bottle and tubing were not dated.
During an interview on 09/18/18 at 2:45 P.M. the DON said:
-The [DEVICE] dressing, and the PICC line dressing were not correct;
-The antibiotic bottle and tubing were not dated when opened;
-The [MEDICATION NAME] bottle and tubing were not dated when opened; and
-He/she would make sure it was fixed.
Observation on 9/22/18 at 10:30 A.M. showed the resident:
-The [MEDICATION NAME] bottle was not dated and
-The feeding tube tubing was not dated.
5. Record review of Resident #46’s face sheet showed he/she was admitted on [DATE] with
the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (impaired lung function that leads to a decreased oxygen uptake).
Record review of the resident’s medical record showed he/she was not able to make his/her
needs known.
Record review of the resident’s (MONTH) (YEAR) POS showed he/she had an order for
[REDACTED].>During an observation and interview on 9/20/18 at 09:30 A.M. with
Registered Nurse (RN A):
-A [MEDICATION NAME] tube feeding was infusing the bottle nor the tubing were dated;
-RN A said the [MEDICATION NAME] container and the tubing should be dated and
-The tubing and the bottle should be dated showing when it was opened.