Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to promote dignity
with dining for two sampled residents (Residents #74 and #86) and to promote dignity for a
resident who had no clothes on from the waist down and could be viewed from the hallway
for one sampled resident (Resident #327) out of 26 sampled residents. The facility census
was 130 residents.
Record review of the facility’s undated Privacy and Dignity policy showed:
-The facility promotes resident care in a manner and in an environment that maintains or
enhances dignity and respect;
-Staff assist residents in maintaining self-esteem and self-worth;
-The facility promotes independence and dignity in dining; and
-As part of the Admission process residents are informed of their rights.
1. Record review of Resident #74’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].>-Dementia (a progressive organic
mental disorder characterized by chronic personality disintegration, confusion,
disorientation, stupor, deterioration of intellectual capacity and function, and
impairment of control of memory, judgment, and impulses) with behavioral disturbances; and
-Anxiety disorder (a feeling of worry, nervousness, or unease, typically about an imminent
event or something with an uncertain outcome).
Record review of the resident’s Care Plan revised on 10/18/18 showed he/she:
-Had an Activities of Daily Living (ADLs-dressing grooming, eating) self-care deficit
related to his/her [DIAGNOSES REDACTED].>-Needed one staff member for supervision,
cueing, and assistance with eating as needed.
Record review of the resident’s quarterly Minimum Data Set (a federally mandated
assessment tool required to be completed by the facility staff for care planning) dated
4/24/19 showed the resident:
-Was severely cognitively impaired;
-Needed supervision, oversight, and cueing with eating; and
-Needed one staff member’s physical assistance with eating.
Observation on the Secure Care Unit (SCU) dining room on 6/5/19 showed:
-At 12:23 P.M.:
–There was one staff member, Certified Nursing Assistant (CNA) D assisting the residents
with their lunch meals;
–The resident was in his/her wheelchair in the dining room;
–The resident had chicken, rice, green beans, bread, apple juice, water and a health
shake;
–The resident was eating his/her meal with his/her fingers;
–The resident stuck his/her fingers in the apple juice and would suck the juice off
his/her fingers repetitively;
-At 12:36 P.M.:
–CNA D stood over the resident and put his/her apple juice cup in the resident’s hand;
–CNA D stood over the resident and gave the resident a bite of food;
–CNA D pulled a chair up, then sat down and told the resident to use his/her fork and
spoon, then quickly got up to assist another resident to their room;
–The resident ate a few bites of food with his/her fork then started dipping the fork in
the apple juice and sucking it off the fork repetitively;
-At 12:42 P.M.:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
–CNA D stood over the resident and helped put green beans on his/her fork then left the
area and
–The resident started eating green beans with his/her fork.
2. Record review of Resident #86’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].
-Dementia with behavioral disturbances;
-[MEDICAL CONDITION] (a mental state involving loss of contact with reality and causing
deterioration of normal social functioning); and
-Anxiety disorder.
Record review of the resident’s Annual MDS dated [DATE] showed he/she:
-Was severely cognitively impaired;
-Needed supervision, oversight, and cueing with eating and
-Needed one staff member’s physical assistance with eating.
Record review of the resident’s Care Plan revised on 5/6/19 showed he/she:
-Had an ADL self-care deficit; and
-Needed supervision/setup and extensive assistance of staff with eating.
Observation on the SCU dining room on 6/5/19 showed:
-At 12:23 P.M.:
–The resident was in his/her wheelchair in the dining room;
–Had a divided plate with pureed chicken, rice, green beans and baked apples;
–Had a glass of honey thick red juice and honey thick water;
–The resident was not eating or drinking;
–At 12:32 P.M.:
–CNA D walked over and tried to give the resident a bite of food while standing over the
resident;
–The resident would not take a bite, the staff member did not speak to the resident then
walked away;
-At 12:35 P.M.:
–CNA D stood over the resident and assisted the resident with a drink of water and
–CNA D asked the resident if he/she wanted a drink of juice and the resident said no.
3. During an interview on 6/10/19 at 2:22 P.M., CNA D said:
-The residents who do not know what to do during a meal he/she would put the silverware
into their hands to prompt them;
-He/she was standing up to feed the residents;
-He/she could not sit down to feed the residents because he/she was the only one on the
unit to assist the residents;
-He/she had to go give the resident bites and drinks and rotate around them; and
-He/she did not have time to assist each resident.
During an interview on 6/11/19 at 10:24 A.M., Licensed Practical Nurse (LPN) B said:
-The CNA should sit next to the resident and feed the resident;
-The CNAs should only attend one to two residents at a time when assisting the residents
with their meals; and
-This was a dignity issue.
During an interview on 6/12/19 at 8:34 A.M., the Social Services Director (SSD) said:
-It was a dignity issue to be feeding residents while standing over them and giving bites
to them then walking away and
-The resident should have the undivided attention of the staff while being assisted it the
dining room.
During an interview on 6/12/19 at 11:12 A.M., the Director of Nursing (DON) said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
-The CNAs should be assisting with set up help for meals and if a resident needed to be
fed they should be sitting down with the resident and assisting them and
-CNA should not be giving bites, assisting others and standing over the resident;
-This was a dignity issue.
4. Record review of Resident #327’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had a [DIAGNOSES REDACTED].
Record review of the resident’s admission MDS dated [DATE] showed the resident:
-Was severely cognitively impaired; and
-Needed the extensive assistance of staff for personal hygiene and dressing.
Record review of the resident’s Care Plan revised on 5/24/19 showed the resident:
-Had a self-care performance deficit; and
-Was totally dependent on staff for dressing and personal hygiene.
Observation on 6/7/19 at 6:12 A.M. showed:
-The resident’s room door was open and the light was on;
-The resident was sitting on the side of the bed with two shirts and one hospital gown
layered on him/her;
-The resident was holding up a urine soiled brief;
-The resident stood up unsteadily and turned around;
-The resident bent over and exposed his/her unclothed lower body;
-A male resident walked to the resident’s door, looked at the exposed resident, then
continued down the hall; and
-There were no staff members in the room assisting the resident.
During an interview on 6/7/19 at 6:21 A.M., CNA H said:
-The resident should not be left unattended;
-The resident should not have been naked and exposed to others; and
-This was a dignity issue.
During an interview on 6/7/19 at 6:30 A.M., LPN D said:
-CNA H had been on another hall on the other SCU;
-The resident should not be left unattended; and
-This was a dignity issue with the resident being unclothed and another male resident
seeing the resident.
During an interview on 6/11/19 at 1:21 P.M., the Assistant Director of Nursing (ADON-also
Unit Manager) said:
-He/she expected a staff member monitoring all residents on both units at all times;
-One staff member should have been assisting the resident; and
-The resident being left unclothed and seen by others was a dignity issue.
During an interview on 6/12/19 at 11:12 A.M., the DON said:
-The residents should be assisted and not left unclothed and exposed; and
-This was a dignity issue.

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 promote
self-determination and choices with morning waking times for two sampled residents

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

(continued… from page 3)
(Resident #46 and #74) out of 26 sampled residents and the staff would waking up the
residents on the Secure Care Units (SCUs) at 4:00 A.M, and would start getting resident’s
out of bed at 5:00 A.M. The census on the 700 SCU was 15 residents, the census on the 800
SCU was 15 residents and the total census of the facility was 130 residents.
Record review of the facility’s undated Resident Rights policy showed:
-All residents have a right to a dignified existence and self-determination;
-Facility staff encourage residents to participate in planning their daily care routines;
-Facility staff will:
–Inform and regularly remind the resident and family members of the resident’s right to
self-determination;
–Gather information about personal preferences on initial assessment and periodically
thereafter, and document these preferences in the resident’s medical record;
–Include the resident’s preferences in the care planning process; and
-Each employee has a duty to read and be familiar with the resident’s rights.
1. Record review of Resident #46’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (a chronic mental illness that interferes with a person’s ability to
think clearly, to distinguish reality from fantasy, to manage emotions, make decisions,
and relate to others); and
-Hallucinations (an experience involving the apparent perception of something not
present).
Record review of the resident’s Care Plan revised on 12/31/18 showed he/she:
-Had an Activities of Daily Living (ADLs-dressing grooming, eating) self-care deficit
related to his/her [MEDICAL CONDITION]; and
-Needed extensive assistance of staff for bed mobility and dressing.
Record review of the resident’s quarterly Minimum Data Set (MDS a federally mandated
assessment tool required to be completed by facility staff for care planning) dated
3/29/19 showed the resident:
-Was severely cognitively impaired; and
-Needed the extensive assistance of staff with bed mobility, transfers, and dressing.
Observation on 6/7/19 on the 700 and 800 halls of the SCU showed:
-At 5:35 A.M., Certified Nursing Assistant (CNA) H and Licensed Practical Nurse (LPN) D
were on the unit;
-At 5:43 A.M. on the 700 hall of the SCU, one resident was up seated on the couch with a
small cup of water;
-At 5:48 A.M., on the 700 hall of the SCU, a female resident came out of his/her room and
walked down the hall. The resident was fully dressed including footwear, and the female
resident had repetitive non-sensical speech;
-At 5:59 A.M., on the 800 hall of the SCU Resident #46 was up in his/her wheelchair
dressed, at a table, with a small cup of water. There were no snacks or beverages (other
than water) being given to the residents;
-At 6:01 A.M., Resident #46 was asleep in his/her wheelchair seated at a table;
-At 6:10 A.M., Resident #46 was asleep in his/her wheelchair seated at a table;
-At 6:41 A.M., Resident #46 was asleep in his/her wheelchair seated at a table; and
-There was no music or television on.
2. Record review of Resident #74’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].>-Dementia (a progressive organic
mental disorder characterized by chronic personality disintegration, confusion,
disorientation, stupor, deterioration of intellectual capacity and function, and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

(continued… from page 4)
impairment of control of memory, judgment, and impulses) with behavioral disturbances; and
-Anxiety disorder.
Record review of the resident’s Care Plan revised on 10/18/18 showed he/she:
-Had an ADL self-care deficit related to his/her [DIAGNOSES REDACTED].>-Needed
extensive assistance of staff for bed mobility, transfers, dressing, and personal hygiene.
Record review of the resident’s quarterly MDS dated [DATE] showed he/she:
-Was severely cognitively impaired;
-Required extensive assistance of two staff members for transfers; and
-Required extensive assistance of one staff member for bed mobility, dressing, and
hygiene.
Observation on 6/7/19 on the 800 hall of the SCU showed:
-At 5:35 A.M., CNA H and LPN D were on the unit;
-At 5:59 A.M., the resident was up in his/her wheelchair rubbing his/her right hand
repetitively on his/her leg and wheelchair cushion. The resident did not have a beverage.
There was no music or television on.
-At 6:01 A.M., LPN D gave the resident a small cup of water; there were no other beverages
or snacks available to the residents; and
-At 6:08 A.M. the resident was up in his/her wheelchair rubbing his/her right hand
repetitively on his/her leg and wheelchair cushion.
During an interview on 6/7/19 at 6:21 A.M., CNA H said:
-He/she would do rounds at 4:00 A.M. on the halls;
-He/she woke the residents up at 4:00 A.M. and start dressing them;
-At 5:00 A.M., he/she would start getting the residents up;
-He/she did have snacks behind the desk but he/she did not give the residents any snacks;
and
-There were no beverages available on the unit to give to the residents.
During an interview on 6/7/19 at 6:30 A.M., LPN D said:
-The staff start getting residents up at 5:00 A.M. that were on the get up list;
-There was no official written get up list but the night nurse told him/her who to get up;
and
-The residents did not get up if they did not want to get up.
During an interview on 6/11/19 at 10:13 A.M., CNA F said:
-The night staff would get some of the residents up around 5:30 A.M. before he/she came in
at 6:30 A.M.; and
-The night staff got the residents up so they could eat breakfast at 8:00 A.M.
-During an interview on 6/11/19 at 10:24 A.M., LPN B said:
-At night, there was only one nurse and one aide for both the 700 and 800 hall of the SCU;
-The night staff get some of the residents up then the day shift would get the rest of the
residents up;
-He/she was not sure why the residents were gotten up so early;
-The staff should be giving snacks and beverages to the residents who were up; and
-The residents have dementia and should be left alone until they wake up on their own.
During an interview on 6/11/19 at 1:21 P.M., the Assistant Director of Nursing (ADON-also
Unit Manager) said:
-The night staff should not be waking residents up at 4:00 A.M., then getting residents
up;
-The residents should be waking up on their own; and
-The staff should be offering fluids to the residents who were up.
During an interview on 6/12/19 at 8:34 A.M., the Social Services Director (SSD) said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

(continued… from page 5)
-Resident #46 and Resident #74 were not aware enough to ask if they want to get up;
-The staff should let them wake up on their own;
-The staff should offer them fluids and snacks of fruits because breakfast was not until
8:00 A.M.; and
-The staff should have an activity with the residents who were up early, like morning
exercise and engage with the residents.
During an interview on 6/12/19 at 11:12 A.M., the Director of Nursing (DON) said:
-The staff should start getting residents up around 5:00 A.M. or 5:30 A.M.;
-The staff just start getting them up because the morning shift cannot get all the
residents up; and
-That was why the night shift started getting the residents up early in the morning.

F 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure residents have reasonable access to and privacy in their use of communication
methods.

Based on interview and record review, the facility failed to ensure personal mail such as
letters and cards delivered to the facility on Saturdays was dispersed to the residents on
the day of delivery. This has the potential to affect all the residents who receive mail
at the facility. The facility census was 130 residents.
Record review of the facility’s Resident Rights – Mail policy, undated, showed:
-Residents have access to mail delivery and
-Mail is delivered to the premises or to the facility’s post office box, including
Saturday deliveries.
1. During an interview on 6/6/19 at 1:36 P.M. with five residents who normally attend the
Resident Council Meetings, the group members said:
-During the week Activity Staff delivered mail to the residents Monday through Friday;
-Saturday mail was sorted by the Business Office on Monday and
-Nobody from Activities or any other department distributed mail to the residents on
Saturdays.
During an interview on 6/10/19 at 2:53 P.M. Business Office Staff A said:
-He/she separated facility and resident mail Monday through Friday;
-Mail was usually delivered to the facility by 1:00 P.M., although it can be delivered as
late as 3:00 P.M. and
-On Saturdays Activities Staff sorts and passes out mail to the residents.
During an interview on 6/11/19 at 11:35 A.M., Activity Assistant (AA) A and AA B said:
-The Business Office gets the mail and sorts out bills Monday through Friday, and gives
the Activity Staff the residents’ personal mail, such as letters and cards, around 12:00
P.M. to 2:00 P.M.;
-The Business Office sorted Saturday mail on Mondays;
-They (AAs) pass mail to residents around 1:30 P.M. Monday through Friday;
-Both AAs were scheduled to work on Saturdays;
-Neither AA had been given a key to get the mail themselves;
-Every once in a while there was a Front Office Staff working on Saturdays, but they do
not sort the mail and give personal mail to the Activity Staff to disperse or give the
mail to the Activity Staff to sort and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-Nobody distributed the mail to residents on Saturdays;
During an interview on 6/12/19 at 11:10 A.M. the Administrator said:
-Monday through Friday the Business Office sorted the mail and gave personal mail to
Activity Staff to distribute to residents;
-On Saturdays the Front Office Staff sorted the mail and gave Activity Staff mail to
distribute to the residents and
-On Monday mornings the Business Office gets any mail not distributed to the residents.

F 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Immediately tell the resident, the resident’s doctor, and a family member of situations
(injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
notification of the resident’s physician when the resident’s blood sugars were greater
than 400 for one sampled resident (Resident #58) and to notify the residents responsible
party of the development of a wound to his/her leg for one sampled resident (Resident #79)
out of 26 sampled residents. The facility census was 130 residents.
Record review of the facility’s Change of Condition Notification policy, undated, showed:
-An Acute Change of Condition is defined as a sudden, clinically important deviation from
a resident’s baseline in physical, cognitive, behavioral or functional domains;
-The facility will promptly inform the resident, consult with the resident’s Attending
Physician and notify the resident’s legal representative when the resident endures a
significant change in condition including and
-The Licensed Nurse will notify the resident’s responsible party or the
family/decision-makers of any changes in the resident’s condition as soon as possible,
documenting the time the family/responsible person was contacted.
1. Record review of Resident #58’s face sheet showed he/she was admitted to the facility
on [DATE], and readmitted on [DATE], with the following Diagnoses: [REDACTED].
-Diabetes.
Record review of the resident’s physician’s orders [REDACTED]. sugar is less than 60 or
greater than 400 before meals and at bedtime for diabetes.
Record review of the resident’s Medication Administration Record [REDACTED]
-On 5/3/19 at 12:00 P.M. the resident’s blood sugar was 440; and
-On 5/6/19 at 12:00 P.M. the resident’s blood sugar was 415.
Record review on the resident’s Nurse’s Notes for (MONTH) showed the staff did not
document that they notified the resident’s physician on 5/3/19 or on 5/6/19 regarding the
resident’s elevated blood sugar over 400.
During an interview on 6/11/19 at 11:00 A.M. Licensed Practical Nurse (LPN) A said:
-Usually, blood sugar parameters were between 60-400, (anything below 60 and above 400 was
out of range);
-Out of range blood sugars were reported to the resident’s physician;
-The nurse who checked the blood sugar, notified the resident’s physician and documented
the physician’s response and/or order; and
-The blood sugar readings were documented on the resident’s MAR.
During an interview on 6/12/19 at 11:14 A.M., the Director of Nursing (DON) said he/she
expected:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
-Staff to follow the physician’s orders [REDACTED].>-The nurse who checked the blood
sugar:
–Would notify the resident’s physician based on the parameters set forth in the
physician’s orders [REDACTED].>–The Licensed Staff to document when they notified the
resident’s physician in the resident’s medical record; and
–Write any response/order the physician gave.
2. Record review of Resident #79’s Face sheet showed he/she was admitted to the facility
on [DATE] showed:
-The resident had the following Diagnoses: [REDACTED].
–Cognitive communication deficit and
-The resident had a family member as his/her Durable Power of Attorney (DPOA-a person
previously identified to make decisions for an individual in the event of inability to
make wishes known).
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool required to be completed by facility staff for care planning) dated
4/25/19 showed he/she:
-Was moderately cognitively impaired and
-Did not have wounds upon admission to the facility.
Record review of the resident’s Skin/Wound Note dated 5/28/19 showed:
-The resident’s scab to his/her left lower leg came off, having bloody drainage, and left
an area measuring 3.0 centimeters (cm) in length by 2.6 cm in width by 0.1 cm in depth;
-New physician’s orders [REDACTED].>-There was no staff documentation that showed the
resident’s DPOA was notified of this wound.
Record review of the resident’s (MONTH) 2019 POS showed the following physician’s orders
[REDACTED]. Alginate dressings maintain a physiologically moist microenvironment that
promotes healing and the formation of granulation tissue) and cover with a dry dressing to
be changed twice daily and in the evening if soiled.
During an interview on 6/6/19 at 1:29 P.M., the resident’s DPOA said:
-He/she would usually get a call about any of the resident’s changes or nursing concerns
and
-He/she had not been notified about the resident’s wound and felt the staff should have
notified him/her.
Observation on 6/6/19 at 1:49 P.M., showed:
-The resident had a left quarter sized wound on the front of his/her left leg and
-The DPOA was present in the room and viewed the wound.
During an interview on 6/11/19 at 10:24 A.M., LPN B said:
-If the resident had a wound, the nurse was responsible for notifying the physician and
the resident’s family/DPOA and
-Any change of condition, the nurse was responsible for notifying the resident’s physician
and family/DPOA.
During an interview on 6/11/19 at 1:21 P.M., the Assistant Director of Nursing (ADON-also
Unit Manager) said if a resident had a new wound, it was the nurses responsibility to
notify the resident’s DPOA.
During an interview on 6/12/19 at 11:12 A.M., the DON said if a resident had a change of
condition or a new wound, he/she expected the resident’s responsible party to be notified
by the nurse and documented in the resident’s medical record.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Respond appropriately to all alleged violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility staff failed to complete
an incident/accident report form per facility policy in a timely manner for a possible
injury of unknown origin to the knee for one sampled resident (Resident #327) out of 26
sampled residents. The facility census was 130 residents.
Record review of the facility’s Incident Investigation policy, undated, showed:
-An incident included, but was not limited to the following:
–Falls;
–Abuse;
–Burns;
–Unusual occurrences;
–Bruises;
–Medication error;
–Missing person;
–Property loss and
–Respiratory arrest;
-Injuries of unknown origin were not listed as an incident requiring investigation;
-In the event of an incident, a Licensed Nurse or the individual who first encounters or
witnesses an incident will complete the Incident/Accident Report Form and document the
following on the Incident Log:
–Resident name, day and shift the incident occurred;
–Indicate the Type, Injury, Location, Severity and Medication/Treatment Error Codes and
-Interviews with staff member and other witnesses will be documented on the Interview
Record;
-Incident information will be reviewed by the Director of Nursing (DON) and the Quality
Assessment and Assurance (QAA – a system to monitor and evaluate aspects of service and
care to ensue standards of quality are being met) Committee on a monthly basis.
1. Record review of Resident #327’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had a [DIAGNOSES REDACTED].
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff used for care planning) dated 5/16/19
showed he/she:
-Was severely cognitively impaired and
-Needed the limited assistance of staff for personal hygiene, dressing and transfers.
Record review of the resident’s Nurses Progress Notes dated 5/17/19 at 10:17 A.M. showed:
-The staff reported to the nurse that the resident screamed and yelled when they attempted
to get the resident dressed;
-The resident was assessed and the resident said his/her right upper hip and leg had pain
and
-The resident’s physician was notified and gave orders to obtain an x-ray of the
resident’s right hip and right leg.
Record review of the resident’s Nurses Progress Notes dated 5/17/19 at 4:57 P.M. showed:
-The resident told a Certified Nursing Assistant (CNA) My knee hurts so bad;
-The resident was assessed and had swelling and redness to his/her right knee;
-The resident’s right thigh and hip appear to be intact with no redness or swelling and
-The resident’s physician was notified and gave orders to x-ray the resident’s right knee
due to increased swelling and pain.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
Record review of the resident’s Nurses Progress Notes dated 5/17/19 at 7:55 P.M. showed
the resident’s responsible party stated the resident’s knee did swell at times due to the
bones rubbing together per the resident’s (previous) physician.
Record review of the resident’s Radiology Report dated 5/17/19 showed the resident’s right
hip and thigh had no fractures or dislocations and the right knee had no fractures or
dislocations.
Record review of the resident’s Care Plan revised on 5/24/19 showed he/she:
-Had a self-care performance deficit and
-Was totally dependent on staff for dressing, personal hygiene and transfers.
Record review of the resident’s medical record showed the staff did not complete an
incident/accident report form.
Observation on 6/05/19 at 9:29 A.M. showed the resident was in his/her wheelchair in the
common area asleep with a thick pressure relieving device in the resident’s wheelchair.
-During an interview on 6/11/19 at 10:24 A.M., Licensed Practical Nurse (LPN) B said:
-The nurses were responsible for completing an incident/accident report form for an injury
of unknown origin;
-The nurse should notify the resident’s physician, family, the Director of Nursing (DON)
and the Assistant Director of Nursing (ADON) and
-An incident/accident report form should be completed for any type of injury of unknown
origin.
During an interview on 6/11/19 at 1:21 P.M., the ADON (also the Unit Manager) said:
-The nurses were responsible for completing a risk management note (incident/accident
report form) for management to review and implement a solution;
-He/she would review the incident/accident report form and try to implement a solution;
-The nurse should have completed an incident/accident report form to try to figure out why
the resident’s knee was swollen and
-The resident was not interviewable to determine what happened to his/her knee.
During an interview on 6/12/19 at 11:12 A.M., the Director of Nursing (DON) said:
-The nurses were responsible for completing and incident/accident report form and
notifying the ADON and DON of the injury;
-An investigation was started by management to complete an investigation and complete a
conclusion on what happened to the resident and
-The investigation was done to try to determine if abuse occurred and if a self-report
needed to be called to the State Agency (SA).

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and the
resident’s representative(s) in writing of a transfer/discharge to the hospital, including
the reason for the transfer/discharge for one sampled resident (Resident #58) out of 26
sampled residents. The facility census was 130 residents.
Record review of the facility’s undated and unsigned policy titled Change of Condition
Policy, showed:
-The facility will promptly inform the resident, consult with the resident’s attending

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 – Few

(continued… from page 10)
physician, and notify the resident’s legal representative when the resident endures a
significant change in their condition resulting in a transfer or discharge of the resident
from the facility;
-The licensed nurse will assess the change of condition and document the observations and
symptoms;
-The licensed nurse will notify the resident, resident’s responsible party, or family
surrogate of any changes in the resident’s condition as soon as possible;
-The licensed nurse will document the following:
–Date, time and pertinent details of the incident and the subsequent assessment in the
nurse’s notes;
–The time the resident’s physician was notified;
–The time the resident’s family/responsible party was notified;
–Update the resident’s care plan to reflect the resident’s status; and
–Complete an inter-facility transfer form if the resident was sent to an acute care
hospital.
1. Record review of Resident #58’s face sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Major [MEDICAL CONDITION] (a state of intense sadness or despair that has advanced to the
point of being disruptive to an individual’s social functioning and/or activities of daily
living); and
-Encephalitis and encephalo[DIAGNOSES REDACTED] (swelling and loss of function in the
brain).
Record review of the resident’s admission Minimum Data Set (MDS-a required, federally
mandated assessment tool completed by facility staff for care planning) dated 4/11/19
showed he/she was cognitively intact.
Record review of the resident’s MDS tracking information showed the resident was
discharged from the facility on 5/30/19 and re-entered the facility on 6/5/19.
Record review of the resident’s nurse’s notes showed:
-On 5/30/19 at 5:05 P.M. the resident was discharged to the hospital; and
-On 6/5/19 at 2:24 P.M. the resident was readmitted to the facility.
Record review of the resident’s medical record showed no documentation the facility
notified the resident and the resident’s representative(s) in writing of the resident’s
transfer/discharge to the hospital on [DATE].
During an interview on 6/6/19 at 1:20 P.M., Licensed Practical Nurse (LPN) C said he/she:
-Never handed papers to the residents directly;
-Gave paperwork to the medics; and
-Called the Durable Power of Attorney (DPOA), guardian or family but did not send paper
work.
During an interview on 6/7/19 at 12:00 P.M. the Director of Nursing (DON) said the
resident had not received the transfer/discharge notification letter.
During an interview on 6/11/19 9:31 A.M. the Social Worker said, he/she was unsure if
transfer/discharge notification letters were given to the residents and sent to the
resident representatives.
During an interview on 6/11/19 at 11:00 A.M., LPN A said he/she:
-Had been back working at the facility for two weeks; and
-Was not sure if a letter, that explained the reason for transfer/discharge, was given to
the residents.
During an interview on 6/12/19 at 11:14 A.M. the DON said he/she expected:
-The notice of transfer/discharge letter would be given to the residents, if they were
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 – Few

(continued… from page 11)
their own responsible party;
-The notice of transfer/discharge letter is to be mailed to the resident’s representative,
if the resident was not their own responsible party; and
-Documentation in the medical record whenever the residents left and returned to the
facility.
During an interview on 6/12/19 at 11:14 A.M. the Administrator said he/she expected the
notice of transfer/discharge would be mailed to the resident’s representative.
During an interview on 6/12/19 at 11:14 A.M. the Corporate Nurse said:
-The nurses had the ability to give the notice of transfer/discharge to the resident;
-If the resident was not their own responsible party, the notice would be mailed to the
resident’s representative; and
-He/she expected documentation of family notification to be in the resident’s medical
record.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and the
resident’s representative of the facility’s bed-hold policy in writing before transferring
or discharging the resident to the hospital for two sampled residents (Resident #118 and
#58) out of 26 sampled residents. The facility census was 130 residents.
Record review of the facility’s Bed Hold policy dated 10/24/18 showed:
-The purpose of the policy was to ensure that the resident and/or their representative was
aware of the bed hold policy and
-Any time a resident was transferred to an acute care hospital for care the facility was
to notify the resident or his/her representative, in writing, of the bed hold policy.
1. Record review of Resident #118’s Durable Power of Attorney (DPOA) for Healthcare
Decisions showed the resident appointed a relative as his/her representative to make
healthcare decisions when he/she could not make or communicate decisions for
himself/herself on 11/22/17.
Record review of the resident’s Face Sheet showed:
-He/she was admitted to the facility on [DATE];
-He/she had [DIAGNOSES REDACTED].
-His/her DPOA’s name and telephone number was listed as his/her first emergency contact
person.
Record review of the resident’s admission Minimum Data Set (MDS a federally mandated
assessment tool to be completed by facility staff for care planning) dated 5/19/19 showed
he/she had moderate cognitive impairment (difficulty remembering, learning new things,
concentrating, or making decisions that affect everyday life).
Record review of the resident’s facility Hospital Transfer form dated 5/27/19 showed the
resident:
-Was transferred to the hospital due to the resident fell ;
-Had facial and shoulder pain;
-Was usually alert and disoriented but could follow simple instructions;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 – Few

(continued… from page 12)
-The date of the resident’s hospital transfer was 5/27/19;
– A report was called to the hospital on [DATE] at 10:00 P.M.; and
-The staff did not document that a written notice was given to the resident and sent to
the resident’s representative regarding the facility bed hold policy.
Record review of the resident’s undated fall investigation summary regarding his/her fall
on 5/28/19, showed he/she:
-Was found on the floor in his/her room after supper;
-Had missing teeth and a laceration on his/her scalp, there was blood on the floor; and
-Was transferred to a hospital.
Review of the resident’s medical record on 6/11/19 showed:
-No documentation regarding a written notice being provided to the resident at the time of
or following his/her hospital transfer; and
-No documentation regarding written notice being provided to the resident’s representative
following his/her hospital transfer.
During an interview on 6/11/18 at 7:12 P.M. the resident’s representative said:
-He/she had received a telephone call from the facility the evening of the resident’s fall
and hospital transfer;
-Following the resident’s hospital transfer, the resident had not received written
information regarding the facility bed hold policy; and
-He/she also had not received written information regarding the facility bed hold policy
following the resident’s hospital transfer on 5/28/19.
During an interview on 6/12/19 at 11:20 A.M. the Director of Nursing (DON), Administrator
and Corporate Staff A said:
-The written bed hold policy was given to residents/resident’s representative as a part of
completing the admission paperwork;
-If the resident/resident’s representative was given written notification at the time
of/following hospital transfer a copy would be in the resident’s medical record;
-The resident’s medical record had no documentation or a copy of a written notification to
the resident/resident’s representative regarding the facility bed hold policy following
the resident’s 5/28/19 hospital transfer; and
-If there was a written notification of the facility bed hold policy being provided to the
resident/resident’s representative when the resident was transferred to the acute care
hospital that had not yet been scanned into the resident’s electronic medical record, it
would be given to the survey team.
As of 6/20/19, the survey team had not received documentation of written notification of
the facility bed hold policy being provided to the resident/resident’s representative
regarding his/her hospital transfer on 5/28/19.
2. Record review of Resident #58’s face sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Major [MEDICAL CONDITION] (a state of intense sadness or despair that has advanced to the
point of being disruptive to an individual’s social functioning and/or activities of daily
living); and
-Encephalitis and encephalo[DIAGNOSES REDACTED] (swelling and loss of function in the
brain).
Record review of the resident’s admission MDS dated [DATE] showed he/she was cognitively
intact.
Record review of the resident’s MDS tracking information showed he/she was discharged from
the facility on 5/30/19 and was readmitted to the facility on [DATE].
Record review of the resident’s nurse’s notes showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 – Few

(continued… from page 13)
-On 5/30/19 at 5:05 P.M., the resident was discharged to the hospital; and
-On 6/5/19 at 2:24 P.M., the resident was readmitted to the facility.
Record review of the resident’s medical record showed the staff did not document that they
notified the resident and the resident’s representative(s) in writing, of the bed hold
policy.
During an interview on 6/06/19 at 1:20 P.M., Licensed Practical Nurse (LPN) C said, he/she
never handed any papers to the residents directly upon transfer/discharge.
During an interview on 6/7/19 at 12:00 P.M. the DON said Resident #58 had not received a
copy of the bed hold policy at the time of transfer/discharge.
During an interview on 6/11/19 9:31 A.M., the Social Service Director (SSD) said;
-The residents receive a copy of the bed hold policy when they are transferred to the
hospital; and
-The residents have to sign the bed hold policy and return it.
During an interview on 6/11/19 at 11:00 A.M. LPN A said he/she:
-Has been employed at the facility for the last two weeks; and
-Was not sure if the residents received a copy of the bed hold policy.
During an interview on 6/12/19 at 11:14 A.M. the DON said he/she expected:
-The residents to received a copy of the bed hold policy at time of transfer/discharge;
-The bed hold policy was to be mailed to the resident representative, if the resident was
not their own responsible party; and
-Documentation in the resident’s medical record whenever the residents leave and returned
to the facility.
During an interview on 6/12/19 at 11:14 A.M. the Administrator said he/she expected the
bed hold policy would be mailed to the resident’s representative.
During an interview on 6/12/19 at 11:14 A.M. the Corporate Nurse said:
-The nurses had the ability to give the bed hold policy to the resident; and
-The resident signs the bed hold policy and returns it.

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 interview and record review, the facility failed to ensure activity care plans
contained the activity preferences and individualized activity plan for two sampled
residents (Resident #74 and #86) out of 26 sampled residents. The facility census was 130
residents.
1. Record review of Resident #74’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].>-Dementia (a progressive organic
mental disorder characterized by chronic personality disintegration, confusion,
disorientation, stupor, deterioration of intellectual capacity and function, and
impairment of control of memory, judgment, and impulses) with behavioral disturbances and
-Anxiety disorder.
Record review of the resident’s significant change Minimum Data Set ( MDS-a federally
mandated assessment tool required to be completed by facility staff used for care
planning) dated 10/22/18 showed he/she:
-Was severely cognitively impaired and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 14)
-Felt that it was very important to have books, newspapers, and magazines to read, to
listen to music, to be around pets, to keep up with the news, to do things with groups of
people, to do his/her favorite activities, and participate in religious services.
Record review of the resident’s Care Plan revised on 3/25/19 showed he/she:
-Was at risk of harm to self and others related to pushing, grabbing, abusive language,
pinching, scratching and spitting;
-Needed the staff to provide a program of activities that was of interest to the resident
and to accommodate his/her needs and
-The care plan was not updated to show the resident’s activity preferences or needs.
Record review of the resident’s Activities Quarterly Participation review dated 4/22/19
showed:
-The resident felt it was somewhat important to have books, newspapers, and magazines to
read, to listen to music, to keep up with the news, to do things with groups of people, to
do his/her favorite activities, participate in religious services and to go outside when
the weather was nice;
-The summary was the resident would participate three to four activities on the unit with
help and guidance from staff and
-The resident enjoyed readings from staff, group exercises and playing with stuffed
animals or baby dolls.
2. Record review of Resident #86’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].
-Dementia with behavioral disturbances;
-[MEDICAL CONDITION] (a mental state involving loss of contact with reality and causing
deterioration of normal social functioning) and
-Anxiety disorder.
Record review of the resident’s Activities Quarterly Participation review dated 4/23/19
showed:
-The resident felt it was very important to have books, newspapers, and magazines to read,
to listen to music, to keep up with the news, to do his/her favorite activities, and to go
outside when the weather was nice;
-The resident was felt it was somewhat important to do things with groups of people;
-The summary was the resident would observe one to two small group activities on the unit
and
-The resident enjoyed playing with baby dolls and receiving visits from his/her family.
Record review of the resident’s Annual MDS dated [DATE] showed he/she:
-Was severely cognitively impaired;
-Felt that it was very important to have books, newspapers, and magazines to read, to
listen to music, to keep up with the news, to do his/her favorite activities, and to go
outside when the weather was warm and
-Felt it was somewhat important to do things with groups of people.
Record review of the resident’s Care Plan revised on 5/6/19 showed he/she:
-Exhibited a decline in social enjoyment as evident by withdrawal from activities;
-Needed the staff to ensure that purposeful activities were offered every day;
-Needed the staff to inform, invite and encourage the resident to participate in
activities of choice and
-The care plan was not updated to show the resident’s activity preferences or needs.
During an interview on 6/11/19 at 12:56 P.M., the Activity Director said:
-The care plans should have the resident’s activity likes and dislikes and
-He/she had been working on updating the resident’s activity care plans.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 15)
During an interview on 6/12/19 at 9:29 A.M., MDS Coordinator C said:
-The Activity Director was responsible for completing the resident’s activity care plans
and
-The care plans should reflect the needs of the residents.
During an interview on 6/12/19 at 11:12 A.M., the Director of Nursing (DON) said the
activity staff should have a personal activity plan for the residents.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a Low Air
Loss (LAL) mattress (air holes in the mattress top surface continually blow out air
causing the patient to float) was maintained at the correct settings and to obtain
complete physician’s orders [REDACTED].#327) out of 26 sampled residents who was at risk
for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged
pressure on the skin). The facility census was 130 residents.
Record review of the facility’s Support Surface Guidelines policy, undated, showed:
-A Pressure Redistribution Support Surface is designed to prevent or promote healing of
pressure ulcers by distributing pressure over a larger surface area of the body and
reducing or eliminating tissue pressure in a concentrated area;
-The facility will identify residents at risk for pressure ulcers and provide care and
services to promote prevention of pressure ulcer development;
-Prevention of pressure ulcers includes support surfaces such as static surfaces (air,
foam, gel and water overlay mattresses) and dynamic surfaces requiring electricity to
operate;
-Dynamic surfaces include:
–Alternating air mattresses which have air cells that alternately inflate and deflate by
a pump, thus shifting supportive pressure from site to site;
–Low Air Loss mattresses which have very large air-filled pillows that continuously
inflate with air and
-Any individual at risk for developing pressure ulcers will be placed on a
pressure-reducing mattress.
1. Record review of Resident #327’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had a [DIAGNOSES REDACTED].
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff used for care planning) dated 5/16/19,
showed the resident:
-Was severely cognitively impaired and
-Was at risk of pressure ulcers and used a pressure reducing mattress.
Record review of the resident’s Braden Scale for Predicting Pressure Ulcer Risk dated
6/5/19 showed the resident was at high risk for developing pressure ulcers.
Record review of the resident’s physician’s orders [REDACTED]. (The staff did not document
they notified the resident’s physician to receive further specific physician’s orders
[REDACTED]. weight).
Record review of the resident’s weight dated 5/30/19 showed he/she weighed 97 pounds.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 16)
Observation on 6/05/19 at 9:14 A.M., showed the resident’s LAL mattress was set on a
weight of 350 pounds.
Observation on 6/05/19 at 9:29 A.M. showed the resident was in his/her wheelchair in the
common area asleep and had a pressure reducing cushion in his/her wheelchair.
Observation on 6/06/19 at 1:24 P.M. , 6/10/19 at 9:53 A.M. , and 6/11/19 at 10:11 A.M.
showed the resident’s LAL mattress was set on a weight of 350 pounds.
During an interview on 6/11/19 at 10:13 A.M., Certified Nursing assistant (CNA) F said:
-He/she did not change the residents’ LAL mattress settings and
-The nurses were responsible for the LAL mattress settings.
During an interview on 6/11/19 at 10:24 A.M., Licensed Practical Nurse (LPN) B said:
-If a resident had a LAL mattress and it displayed a weight setting, it should be set by
the resident’s weight and
-The nurses were responsible for obtaining the weight settings, setting the weights, and
clarifying the physician’s orders [REDACTED].
During an interview on 6/11/19 at 1:21 P.M., the Assistant Director of Nursing (ADON-also
Unit Manager) said:
-The nurses were responsible for obtaining the physician’s orders [REDACTED].
-The nurse was responsible for obtaining the physician’s orders [REDACTED].
-The LAL mattresses should be set by the resident’s weight.
During an interview on 6/12/19 at 11:12 A.M., the Director of Nursing (DON) said:
-LAL mattresses were set up upon arrival;
-The nurses were responsible for obtaining the physician’s orders [REDACTED].
-The nurses monitor the LAL mattresses and this was documented on the Treatment
Administration Record (TAR).

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
Activity of Daily Living (ADL-eating, dressing, bathing) assistance for two sampled
residents (Resident #74 and #86) with dining; and to assist one supplemental resident
(Resident #40) with opening a snack out of 26 sampled residents. The facility census was
130 residents.
Record review of the facility’s undated Dining Service Standards policy showed:
-The residents are provided a positive meal experience;
-Services provided are based on the needs of the resident population; and
-Adaptive devices are provided, food and beverages are set up to promote independence and
residents are properly positioned, encouraged, cued and assisted as needed.
1. Record review of Resident #74’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].>-Dementia (a progressive organic
mental disorder characterized by chronic personality disintegration, confusion,
disorientation, stupor, deterioration of intellectual capacity and function, and
impairment of control of memory, judgment, and impulses) with behavioral disturbances and
-Anxiety disorder.
Record review of the resident’s Care Plan revised on 10/18/18 showed he/she:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
-Had an Activities of Daily Living (ADLs-dressing grooming, eating) self-care deficit
related to his/her [DIAGNOSES REDACTED].>-Needed one staff member for supervision,
cueing, and assistance with eating as needed.
Record review of the resident’s quarterly Minimum Data Set (MDS a federally mandated
assessment tool required to be completed by facility staff for care planning) dated
4/24/19, showed he/she:
-Was severely cognitively impaired;
-Needed supervision, oversight, and cueing with eating and
-Needed one staff members physical assistance with eating.
Observation on the Secure Care Unit (SCU) dining room on 6/5/19 showed:
-At 12:23 P.M., there was one staff member, Certified Nursing Assistant (CNA) D assisting
the residents with their lunch meals;
–The resident was in his/her wheelchair in the dining room;
–He/she had chicken, rice, green beans, bread, apple juice, water and a health shake;
–The resident was eating his/her meal with his/her fingers;
–The resident stuck his/her fingers in the apple juice and would suck the juice off
his/her fingers repetitively;
-At 12:36 P.M., CNA D stood over the resident and put his/her apple juice cup in the
resident’s hand;
–CNA D stood over the resident and gave the resident a bite of food;
–CNA D pulled a chair up then sat down, told the resident to use his/her fork and spoon,
then quickly got up to assist another resident to their room;
–The resident ate a few bites of food with his/her fork then started dipping fork in
apple juice and sucking it off fork repetitively;
-At 12:42 P.M., CNA D stood over the resident and helped put green beans on his/her fork
then left the area;
–The resident started eating green beans with his/her fork;
–The resident ate less than 25% of his/her meal and
-The staff did not assist the resident with the meal.
Observation on 6/6/19 of the SCU dining room showed:
-At 8:00 A.M., the resident was in the dining room in his/her wheelchair;
–The resident was served mechanical soft sausage, oatmeal, toast, eggs, red juice, milk,
and a health shake;
–The resident used his/her spoon to drink the red juice repetitively;
-From 8:09 A.M. to 8:39 A.M., the resident used his/her spoon to continue to drink the red
juice. The resident had not eaten any food;
-At 8:40 A.M., CNA D sat down and prompted the resident to eat and handed him/her a fork;
–CNA D got up and continued to clear other resident’s breakfast trays off the tables;
-From 8:41 A.M. to 8:55 A.M., the resident took a couple of bites of the eggs then used
his/her butter knife to try to drink fluids out of an empty cup;
-At 8:57 A.M., CNA D took the resident’s breakfast meal away and
-The staff did not assist the resident with dining.
2. Record review of Resident #86’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].
-Dementia with behavioral disturbances;
-[MEDICAL CONDITION] (a mental state involving loss of contact with reality and causing
deterioration of normal social functioning) and
-Anxiety disorder.
Record review of the resident’s Annual MDS dated [DATE] showed he/she:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
-Was severely cognitively impaired;
-Needed supervision, oversight, and cueing with eating and
-Needed one staff members physical assistance with eating.
Record review of the resident’s Care Plan revised on 5/6/19 showed he/she:
-Had an ADL self-care deficit and
-Needed supervision/setup and extensive assistance of staff with eating.
Observation on the SCU dining room on 6/5/19 showed:
-At 12:23 P.M., resident was in his/her wheelchair in the dining room;
–Had a divided plate with pureed chicken, rice, green beans and baked apples;
–Had a glass of honey thick red juice and honey thick water;
–The resident was not eating or drinking;
-At 12:32 P.M., CNA D walked over and tried to give the resident a bite of food while
standing over the resident;
–The resident would not take a bite, the staff member did not speak to the resident then
walked away;
-At 12:35 P.M., CNA D stood over the Resident and assisted the resident with a drink of
water;
–CNA D asked the resident if he/she wanted a drink of juice and Resident #86 said no;
–CNA D took the resident’s meal tray away and
-The staff did not assist the resident with dining.
Observation on 6/06/19 in the SCU dining room showed:
-At 8:00 A.M., the resident was in his/her wheelchair in the dining room;
-He/she was served pureed eggs, sausage, oatmeal, and honey thick water, milk and apple
juice;
-At 8:01 A.M. through 8:10 A.M. the resident ate using a fork and he/she was dipping
his/her fork into the milk and trying to drink it;
-The resident was using his/her fork and continually dipped it in his/her milk trying to
drink it;
-From 8:11 A.M. to 8:16 A.M., the resident dumped his/her apple juice cup over trying to
drink the apple juice with a fork;
-The resident was eating very fast and trying to get more food on his/her fork but had
eaten most of his/her food;
-The resident could not get more food on the fork and kept taking empty bites
repetitively;
-The residents thickened water cup and milk cup had pureed food in it from the resident
trying to drink with the fork;
-The resident had an empty water cup and there was food in it at the bottom;
-The resident was trying to dig the food out of the empty water cup with the fork;
-The resident then tried to drink the food that was left in the bottom of the empty water
cup;
-At 8:17 A.M., the residents cups, plate, and bowl, were empty;
-From 8:18 A.M. to 8:28 A.M., the resident continued repetitively taking empty bites off a
fork off his/her empty plate and bowl and there was no food or fluids left for the
resident to eat or drink;
-At 8:29 A.M., CNA D took the resident’s meal tray away and did not offer any more food or
fluids to the resident and
-No staff members assisted the resident with dining.
3. Record review of Resident #40’s Face Sheet showed he/she was admitted to the facility
on [DATE] with a [DIAGNOSES REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
Record review of the resident’s Care Plan revised 7/12/18 showed he/she:
-Had an ADL self-care performance deficit and
-Needed the assistance of staff for set up help and supervision with eating.
Record review of the resident’s quarterly MDS dated [DATE] showed he/she:
-Was severely cognitively impaired and
-Needed set up help with eating, supervision and cueing.
Observation on 6/7/19 showed:
-At 10:12 A.M., the resident was in his/her wheelchair in the common area by the window;
–A staff member gave the resident an unopened package of peanut butter crackers;
-From 10:13 A.M. to 10:34 A.M. the resident kept trying to open the crackers;
–The resident never was able to open the package of crackers;
–He/she placed the crackers on the table;
-At 10:35 A.M., a staff member asked the resident if he/she was going to eat the crackers
and the resident said no and
-At 10:41 A.M., the resident picked the crackers up, looked at the crackers, and put the
crackers back down on the table.
4. During an interview on 6/10/19 at 2:22 P.M., CNA D said:
-The residents who did not know what to do with their food, he/she would put the
silverware into their hand to prompt them to eat;
-He/she could not sit down to feed the residents because he/she was the only staff member
assisting so he/she had to go give the resident’s bites and drinks and rotate around them;
-He/she did not have time to assist each resident;
-Three residents need total assistance with meals and some other residents needed set-up
help with their meals;
-Some days, some of the residents need more help at different meals and
-There were 15 residents to assist in the dining room.
During an interview on 6/11/19 at 10:24 A.M., Licensed Practical Nurse (LPN) B said:
-The CNA should sit next to the resident and assist the resident with dining;
-The CNA should only assist one to two residents at a time with dining;
-The staff should have obtained more food and fluids for Resident #86 when he/she
continued to try to eat and drink;
-There were 15 residents on the SCU and three required full assistance with meals;
-Many of the other residents can feed themselves but need assistance with beverages and
assistance during the meal with set up and
-There were not enough staff to assist the residents.
During an interview on 6/11/19 at 1:21 P.M., the Assistant Director of Nursing (ADON-also
Unit Manager) said:
-The CNAs should coax the residents to eat and remind them to get a drink;
-The CNAs should give total attention to the residents who needed assistance with dining;
-The CNAs should be sitting down while assisting the resident with dining and
-Other staff on the unit should be helping the residents with dining assistance.
During an interview on 6/12/19 at 11:12 A.M., the Director of Nursing (DON) said:
-The CNAs should be assisting the residents with set up help for dining and if they need
to be fed, the CNA should be sitting down with the resident assisting them; and
-He/she expected other staff on the unit to help with dining.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
meaningful activities to meet the interests of and support the physical, mental, and
psychosocial well-being of two sampled residents (Resident #74 and #86) out of 26 sampled
residents; and to provide activities for the 700 and 800 Secure Care Units (SCU). The
facility census was 130 residents.
Record review of the facility’s activity schedules for the 700 and 800 SCUs for 3/2019,
4/2019, 5/2019, and 6/2019 showed there were seven to eight activities scheduled daily
Monday through Saturday including: readings, church, puzzles, trivia, board games, movies
and snacks, nail care, hand massages, card games, exercises, cooking groups, Wii games
(video games), balloon volleyball, arts and crafts, sing-a-longs and sensory stimulations.

Record review of the facility’s Daily Census report dated 6/5/19 showed:
-There were 15 residents residing on the 700 hall SCU and
-There were 15 residents residing on the 800 hall SCU.
1. Record review of Resident #74’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].>-Dementia (a progressive organic
mental disorder characterized by chronic personality disintegration, confusion,
disorientation, stupor, deterioration of intellectual capacity and function, and
impairment of control of memory, judgment, and impulses) with behavioral disturbances and
-Anxiety disorder.
Record review of the resident’s significant change Minimum Data Set (MDS-a federally
mandated assessment tool required to be completed by facility staff used for care
planning) dated, 10/22/18 showed he/she:
-Was severely cognitively impaired and
-Felt that it was very important to have books, newspapers, and magazines to read, to
listen to music, to be around pets, to keep up with the news, to do things with groups of
people, to do his/her favorite activities, and participate in religious services.
Record review of the resident’s Daily Activity Attendance dated 2/2019 showed the
resident:
-Watched television 28 out of 28 days;
-Went to a music/entertainment activity two times that month;
-Went to an educational/reading activity two times that month;
-Did not have any one on one activities and
-There were no other activities attended by the resident.
Record review of the resident’s Daily Activity Attendance dated 3/2019 showed the
resident:
-Watched television 31 out of 31 days;
-Went to a music/entertainment activity four times that month;
-Went to an educational/reading activity three times that month;
-Had sensory stimulation group five times that month;
-Did not have any one on one activities and
-There were no other activities attended by the resident.
Record review of the resident’s Care Plan revised on 3/25/19 showed he/she:
-Was at risk of harm to self and others related to pushing, grabbing, abusive language,
pinching, scratching and spitting and
-Needed the staff to provide a program of activities that was of interest to the resident
and accommodated his/her needs.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
Record review of the resident’s Daily Activity Attendance dated 4/2019 showed the
resident:
-Watched television 30 out of 30 days;
-Went to a music/entertainment activity four times that month;
-Went to an educational/reading activity four times that month;
-Had sensory stimulation group two times that month;
-Did not have any one on one activities and
-There were no other activities attended by the resident.
Record review of the resident’s Activities Quarterly Participation review dated 4/22/19
showed:
-The resident felt it was somewhat important to have books, newspapers, and magazines to
read, to listen to music, to keep up with the news, to do things with groups of people, to
do his/her favorite activities, participate in religious services and to go outside when
the weather was nice;
-The summary was the resident would participate three to four activities on the unit with
help and guidance from the staff and
-The resident enjoyed readings from staff, group exercises and playing with stuffed
animals or baby dolls.
Record review of the resident’s Daily Activity Attendance dated 5/2019 showed the
resident:
-Watched television 31 out of 31 days;
-Went to a music/entertainment activity seven times that month;
-Went to an educational/reading activity three times that month;
-Had sensory stimulation group eight times that month;
-Did not have any one on one activities and
-There were no other activities attended by the resident.
Record review of the activity schedule for 6/5/19 for the 700 and 800 SCUs showed:
-At 9:30 A.M. sing and dance to jazz;
-At 10:00 A.M. nail care;
-At 11:00 A.M. coloring pages;
-At 2:30 P.M. ice cream social;
-At 4:00 P.M. room visits;
-At 5:00 P.M hand massages and
-At 6:00 P.M television.
Observation on 6/05/19 at 10:16 A.M. showed:
-The Activity Assistant was painting a few residents’ nails on the 800 SCU and engaging
with a few of the residents and
-The resident did not participate in the activity.
Observation on 6/05/19 at 10:20 A.M. on the 800 hall SCU showed:
-The resident was in his/her wheelchair by the television and
-The resident had repetitive hand movements.
Observations on 06/05/19 at 2:35 P.M., 2:45 P.M. and 2:52 P.M. showed there were no
activities on the 700 SCU and 800 SCU.
Record review of the activity schedule for 6/6/19 for the 700 and 800 SCUs showed:
-At 9:30 A.M. sit and get fit;
-At 10:00 A.M. sing-a-long;
-At 11:00 A.M. short story time;
-At 1:30 P.M. room visits;
-At 2:00 P.M. movie and popcorn;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-At 4:00 P.M. quiet moments-Motown music and
-At 6:00 P.M television.
Observation on 6/06/19 at 8:49 A.M. showed:
-The resident was in his/her wheelchair by the television and
-The resident had repetitive hand movements.
Observation on 6/6/19 at 9:45 A.M. on the 800 hall SCU showed:
-The resident was in his/her wheelchair and a staff member brought him/her to the dining
room table;
-The staff member had fingernail polish and nail supplies;
-The staff member sat down in a chair by the resident;
-The resident was not having repetitive hand movements;
-The resident’s expressions showed he/she was engaged with the staff member;
-CNA D came into the area and told the staff member the resident could not have his/her
nails done because of his/her repetitive hand movements;
-The staff member got up and went to another resident and started nail care;
-The resident was left at the table with his/her back to everyone;
-The resident had no interactions from any other staff members and
-The resident started repetitive hand movements while sitting at the table alone.
Observation on 6/07/19 on the 800 hall SCU showed:
-At 9:45 A.M. through 10:11 A.M., the resident was in his/her wheelchair by the television
and had repetitive hand movements with his/her head down and
-At 10:12 A.M. through 10:37 A.M., the resident was offered an oatmeal cream pie and a cup
of water. The resident slowly ate the oatmeal cream pie and drank his/her water.
Record review of the activity schedule for 6/10/19 for the 700 and 800 SCUs showed:
-At 9:00 A.M. current events;
-At 9:30 A.M. yoga man (on the 700 unit);
-At 10:30 A.M. art pages;
-At 11:15 P.M. basketball;
-At 1:30 P.M. room visits and mail delivery;
-At 2:30 P.M. Wii games and
-At 5:00 P.M Scrabble game.
Observation on 6/10/19 at 10:12 A.M. through 10:52 A.M. showed:
-The resident was in his/her wheelchair asleep by the television with his/her back to the
dining room;
-There were two residents seated at a table in the dining area coloring pictures and jazz
music was playing and
-The resident was not included in the activity or engaged by any staff members.
Observation on 6/10/19 at 2:15 P.M., showed the resident was in his/her wheelchair in the
television area.
2. Record review of Resident #86’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].
-Dementia with behavioral disturbances;
-[MEDICAL CONDITION] (a mental state involving loss of contact with reality and causing
deterioration of normal social functioning) and
-Anxiety disorder.
Record review of the resident’s Daily Activity Attendance dated 2/2019 showed the
resident:
-Watched television 28 out of 28 days;
-Went to a music/entertainment activity one times that month;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
-Went to an educational/reading activity one times that month;
-Did not have any one on one activities and
-There were no other activities attended by the resident.
Record review of the resident’s Daily Activity Attendance dated 3/2019 showed the
resident:
-Watched television 31 out of 31 days;
-Went to a music/entertainment activity three times that month;
-Went to an educational/reading activity two times that month;
-Did not have any one on one activities and
-There were no other activities attended by the resident.
Record review of the resident’s Daily Activity Attendance dated 4/2019 showed the
resident:
-Watched television 30 out of 30 days;
-Went to a music/entertainment activity two times that month;
-Went to an educational/reading activity three times that month;
-Did not have any one on one activities and
-There were no other activities attended by the resident.
Record review of the resident’s Activities Quarterly Participation review dated 4/23/19
showed:
-The resident felt it was very important to have books, newspapers, and magazines to read,
to listen to music, to keep up with the news, to do his/her favorite activities, and to go
outside when the weather was nice;
-The resident was felt it was somewhat important to do things with groups of people;
-The summary was the resident would observe one to two small group activities on the unit
and
-The resident enjoyed playing with baby dolls and receiving visits from his/her family.
Record review of the resident’s Annual MDS dated [DATE] showed the resident:
-Was severely cognitively impaired;
-Felt that it was very important to have books, newspapers, and magazines to read, to
listen to music, to keep up with the news, to do his/her favorite activities, and to go
outside when the weather was warm and
-Felt it was somewhat important to do things with groups of people.
Record review of the resident’s Daily Activity Attendance dated 5/2019 showed the
resident:
-Watched television 31 out of 31 days;
-Went to a music/entertainment activity four times that month;
-Went to an educational/reading activity one times that month;
-Did not have any one on one activities and
-There were no other activities attended by the resident.
Record review of the resident’s Care Plan revised on 5/6/19 showed he/she:
-Exhibited a decline in social enjoyment as evident by withdrawal from activities;
-Needed the staff to ensure that purposeful activities were offered every day and
-Needed the staff to inform, invite and encourage the resident to participate in
activities of choice.
During a telephone interview on 6/5/19 at 11:28 A.M., the resident’s family member said:
-He/she saw the resident almost every day;
-He/she never saw the staff engaging the residents with activities;
-He/she would bring a portable music player with him/her to the unit and play music from
the resident’s era;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
-There were no one on one individualized activities for the resident and
-When the resident was agitated, music would calm him/her down.
Observation on 6/7/19 on the 800 hall SCU showed:
-At 9:45 A.M. through 10:11 A.M., the resident was in his/her wheelchair asleep in the
television area;
-At 10:12 A.M. through 10:14 A.M., the resident was in his/her wheelchair in the
television area, exhibiting repetitive hand movements and
-At 10:15 A.M. through 10:37 A.M., the resident was slumped over, asleep, in his/her
wheelchair in the television area.
Observation on 6/10/19 at 10:12 A.M. through 10:52 A.M. on the 800 hall SCU showed:
-The resident was in his/her wheelchair asleep by the television with his/her back to the
dining room;
-There were two residents seated at a table in the dining area coloring pictures and jazz
music was playing and
-The resident was not included in the activity or engaged by any staff members.
Observation on 6/10/19 at 2:15 P.M. showed the resident in his/her wheelchair in the
television area with no activities or stimulation.
3. During an interview on 6/7/19 at 10:44 A.M., Certified Nursing Assistant (CNA) F said:
-Sometimes, the activity staff would come to the 800 hall SCU and read a daily sheet;
-The activity staff did try to make it back to the unit for activities;
-Many of the scheduled activities did not happen for the residents and
-He/she did not see activities being done with the residents.
During an interview on 6/10/19 at 2:22 P.M., CNA D said:
-Usually activities happen two times on the unit and
-Resident #74 and #86 were not active in activities because they cannot focus during
activities.
During an interview on 6/11/19 at 10:24 A.M., Licensed Practical Nurse (LPN) B said:
-The activity staff come back once per day and do an activity and
-If the resident cannot participate in activities he/she should be getting one on one
activities.
-During an interview on 6/11/19 at 11:51 A.M., Activity Assistant A said:
-He/she mainly worked on the 700-800 SCUs;
-He/she tried to do at least two to three activities per unit in the morning between the
units (700-800);
-He/she tried to fit in two activities one on each of the SCUs in the afternoon;
-There were scheduled Wii games for the 700-800 SCUs but had to do a balloon toss instead
because there was no Wii gaming system on the unit;
-He/she did one on ones doing reading and singing;
-He/she tried to chat with the residents for one on one activities;
-He/she did not engage #74 or #86 during the coloring and music activity yesterday;
-He/she should be engaging them during the activity;
-Resident #86 liked 40’s music including Dean Martin and Frank Sinatra
-He/she has seen Resident #86 tap his/her foot when music was played that he/she liked;
-Resident #74 did engage in the balloon volleyball activity;
-Resident #74 would sing to music, old hymns he/she liked;
-He/she tried to switch back and forth to each unit to do things with the residents;
-The Activity Director completed the activity assessments;
-He/she would document the one on one and activity participation on Activity Participation
Record and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
-He/she did not review the activity assessment or care plan to see what the residents’
activity preferences were because he/she did not have access to the computers.
During an interview on 6/11/19 at 12:56 P.M., the Activity Director said:
-The activity calendars were developed to do more therapeutic activities for dementia
residents;
-There should be a total of six activities on the 700 and 800 SCU units;
-Each SCU should have three activities in the morning and three activities in the
afternoon;
-The activity aide should be on one hall for 30 minutes then rotate to the next hall;
-All of the residents should participate in all of the activities;
-He/she did not have a specialized program for the lower functioning residents but was
working on a program for dogs to visit, trying to get volunteers, and had just got someone
to come in to do yoga on the 700 SCU;
-He/she had been working to get more volunteers to assist;
-He/she expected one on one activities to be completed by the staff at least twice a week
per resident;
-Activity participation was documented on the resident’s activity participation sheet;
-The Wii was moved up front and should have been changed to a bean bag toss activity;
-He/she had two activity staff and one hospitality aide but the hospitality aide did more
nursing and not activities;
-The activity assessments should be detailed to the residents’ activity preferences;
-The two activity aides did the activities and he/she tried to help with the activities
but was responsible for all the assessments and paperwork for the residents;
-There was not enough time to do all the activities and for one activity person to go back
and forth to each of the SCUs;
-The activity aide tried but could not get to all activities for both units and
-He/she would be changing the activity calendar to reflect more activities for residents
with dementia.
During an interview on 6/11/19 at 1:21 P.M., the Assistant Director of Nursing (ADON-also
Unit Manager) said the activity staff should be doing activities with all residents and
engaging Resident #74 and #86 during an activity.
During an interview on 6/12/19 at 8:34 A.M., the Social Services Director (SSD) said:
-The activity staff should be engaging all the residents in activities and with brain
stimulation;
-This helped the residents with their memory and functional abilities;
-Individuals engage better with someone doing an activity with them and engaging them;
-The cognitively impaired residents see familiar faces and this helps their overall
function and
-The staff need to assist the severely cognitively impaired residents and bring them to
the activity for stimulation and engagement.
During an interview on 6/12/19 at 11:12 A.M., the Director of Nursing (DON) said:
-He/she expected the staff to follow the activity schedule;
-All of the residents should be engaged in any activity that goes on;
-The residents should have activities daily and
-The resident’s should have an individualized activity plan.
A policy was requested but not received from the facility.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident was transferred in a safe manner using a gait belt and to transfer the resident
according to the most recent Minimum Data Set (MDS-a federally mandated assessment
instrument completed by facility staff for care planning) for one sampled resident
(Resident #86) out of 26 sampled residents. The facility census was 130 residents.
Record review of the facility’s Transfer policy, undated, showed:
-A transfer is a safe movement of a resident from one surface to another;
-Safe and efficient transfers are a combination of the resident’s physical abilities and
perceptional capacity, proper equipment, appropriate techniques and good planning;
-Transfers may be independent or assisted by one or more caregivers;
-Transfers may involve a mechanical lift or one of several assistive devices;
-General guidelines include monitoring the resident’s tolerance of the procedure and
knowing the resident’s abilities and limitations;
-During gait belt (a device placed around the waist of a resident with mobility issues to
aid the caregiver in safely moving a resident) transfers staff were to:
–Apply the gait belt around the resident’s waist and place the resident’s wheelchair (if
applicable) at a slight angle, locking the brakes;
–Hold the gait belt and instruct the resident to bend forward, placing the stronger foot
slightly behind the weaker foot and directing the resident to push off on the count of
three;
–Provide necessary assistance to help the resident stand and pivot;
–Instruct the resident to reach back with one or both hands and to feel the edge of the
seat against the back of the legs before sitting and
–Remove the gait belt once the resident is safely seated.
1. Record review of Resident #86’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].
-Dementia (a progressive organic mental disorder characterized by chronic personality
disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity
and function, and impairment of control of memory, judgment, and impulses) with behavioral
disturbances;
-[MEDICAL CONDITION] (a mental state involving loss of contact with reality and causing
deterioration of normal social functioning) and
-Anxiety disorder.
Record review of the resident’s Annual MDS dated [DATE] showed he/she:
-Was severely cognitively impaired and
-Needed the extensive assistance of two staff members for transferring.
Record review of the resident’s Care Plan revised on 5/6/19 showed he/she:
-Had an Activities of Daily Living (ADL – dressing, grooming, bathing, eating, and
toileting) self-care deficit and
-Needed the extensive assistance of staff with transfers.
Record review of the resident’s Physical Therapy Evaluation dated 4/29/19 showed:
-The resident was evaluated for transfers;
-The resident was unable to stand and
-Was totally dependent on the staff with transfers.
Observation on 6/05/19 at 12:49 P.M. showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
-Certified Nursing Assistant (CNA) D was transferring the resident from his/her wheelchair
to his/her bed;
-CNA D placed a gait belt (a belt, usually made of heavy canvas with a sturdy buckle, used
to help residents move) around the resident’s waist;
-CNA D stood in front of the resident, held onto the gait belt, and pulled up on the
resident;
-The resident’s legs were crossed and the resident did not put any weight on his/her feet
during the transfer and
-The resident landed onto his/her bed.
During an interview on 6/5/19 at 12:51 P.M., CNA D said:
-He/she had worked with the resident for a long time;
-This was how the resident usually transfers and
-He/she did not notify the nurse that the resident was not putting weight on his/her feet
during transfers.
During an interview on 6/11/19 at 12:11 P.M., Certified Occupational Therapy Assistant
(COTA) A and Physical Therapist (PT) A said:
-The resident was totally dependent on the staff with transfers;
-The resident could be very combative during transfers;
-PT A completed the transfer evaluation and recommended the resident be transferred by
gait belt and two staff members;
-PT A did not recommend a mechanical lift due to the resident’s cognition and behaviors
for the resident’s safety;
-At the time of the evaluation, the resident was transferring with two staff members and
was able to pivot on his/her feet and
-The CNA should have notified the nurse if the resident had a decline in his/her ability
to transfer.
-During an interview on 6/11/19 at 10:24 A.M., Licensed Practical Nurse (LPN) B said:
-The resident should put weight on his/her feet with a one person gait belt transfer and
-The CNA was responsible for notifying the nurse if the resident was not putting weight on
his/her feet during a transfer.
During an interview on 6/12/19 at 11:12 A.M., the Director of Nursing (DON) said:
-During a transfer with one staff member and a gait belt, the resident should be able to
put weight on his/her feet and assist with the transfer and
-He/she expected the CNA to notify the charge nurse if the resident did not bear weight on
his/her feet during a transfer.

F 0692

Level of harm – Minimal harm or potential for 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 assist the
resident at meals with his/her beverages to ensure the resident drank his/her allotted
fluids and to offer snacks and beverages for one cognitively impaired sampled resident who
was on pureed foods and thickened liquids (Resident #86) out of 26 sampled residents. The
facility census was 130 residents.
1. Record review of Resident #86’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnoses: [REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 28)
-Dementia (a progressive organic mental disorder characterized by chronic personality
disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity
and function, and impairment of control of memory, judgment, and impulses) with behavioral
disturbances;
-[MEDICAL CONDITION] (a mental state involving loss of contact with reality and causing
deterioration of normal social functioning) and
-Anxiety disorder.
Record review of the resident’s Annual Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning) dated 4/27/19 showed
he/she:
-Was severely cognitively impaired;
-Needed supervision, oversight, and cueing with eating and
-Needed one staff members physical assistance with eating.
Record review of the resident’s Care Plan revised on 5/6/19 showed he/she:
-Had an ADL self-care deficit and
-Needed supervision/setup and extensive assistance of staff with eating.
Record review of the resident’s physician’s orders [REDACTED].
Observation on 6/06/19 in the SCU dining room showed:
At 8:00 A.M., the resident was in his/her wheelchair in the dining room;
-He/she was served pureed eggs, sausage, oatmeal, and honey thick water, milk and apple
juice;
-At 8:01 A.m. through 8:10 A.M. the resident ate using a fork and he/she was continuously
dipping his/her fork into the milk and trying to drink it;
-At 8:11 A.M. through 8:16 A.M., the resident dumped his/her apple juice cup over trying
to drink the apple juice with a fork;
-The resident’s thickened water cup and milk cup had pureed food in it from the resident
trying to eat with the fork;
-The resident had an empty water cup and there was food in it at the bottom;
-The resident was trying to dig the food out of the empty water cup with the fork;
-The resident then tried to drink the food that was left in the bottom of the empty water
cup;
-At 8:17 A.M., the resident’s cups were empty;
-At 8:29 A.M., CNA D took the residents meal tray away and did not offer any more fluids
to the resident and
-No staff members offered the resident more fluids or food.
Observation on 6/7/19 on the 800 hall SCU showed:
-At 9:45 A.M. through 10:11 A.M., the resident was in his/her wheelchair asleep in the
television area;
-At 10:12 A.M. through 10:14 A.M., the resident was in his/her wheelchair in the
television area, exhibiting repetitive hand movements;
-At 10:12 A.M., Certified Nursing Assistant (CNA) F offered eight other residents in the
common area an oatmeal cream pie and then passed out water cups to the residents; No snack
or fluids were offered to the resident and
-At 10:15 A.M. through 10:37 A.M., the resident was slumped over, asleep, in his/her
wheelchair in the television area.
During an interview on 6/7/19 at 10:44 A.M., CNA F said:
-There were no thickened liquids on the unit;
-There was no pureed food kept on the unit to give to the resident as a snack and
-There were never snacks or thickened fluids on the unit to give to the resident.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
Observation on 6/10/19 at 10:27 A.M. through 10:51 A.M., showed:
-The resident was in the television area in his/her wheelchair;
-CNA D had a small cup of honey thick water;
-He/she gave the resident a drink from the cup, then sat the cup on the television stand
and
-No more water was offered to the resident.
During an interview on 6/10/19 at 2:22 P.M., CNA D said:
-He/she would try to give the resident thickened fluids and
-He/she was trying to do his/her best to assist the residents.
During an interview on 6/11/19 at 10:24 A.M., Licensed Practical Nurse (LPN) B said:
-The residents should be getting fluids with meals then mid-morning, then mid-afternoon,
and about two hours before bed;
-The staff should have been passing fluids to the residents;
-The resident can have a mashed banana as a snack;
-The staff can get thickened liquids from the kitchen and
-The staff should have gotten the resident more food and fluids when he/she was done with
his/her meal and the plate and cups were empty.
During an interview on 6/11/19 at 1:21 P.M., the Assistant Director of Nursing (ADON-also
Unit Manager) said:
-The CNA should be offering fluids every two hours to the residents on the units and
-The CNA should be offering the resident honey thicken fluids every two hours.
During an interview on 6/12/19 at 11:12 A.M., the Director of Nursing (DON) said:
-He/she expected the staff to be passing fluids throughout the day;
-The staff have access to thickened liquids in the medication room and
-There should be snacks for the residents on a pureed diet on the secure care unit.

F 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that an
enteral feeding (the delivery of a nutritionally complete feed, containing protein,
carbohydrate, fat, water, vitamins, and minerals directly into the stomach) was
administered as ordered and to ensure the intermittent water flush/intake was administered
as ordered for one sampled resident (Resident #126) out of 26 sampled residents. The
facility census was 130 residents.
Record review of the facility’s Tube Feeding (a procedure used for placing food, fluids
and medications directly into the stomach through a tube inserted through the abdomen)
policy, unsigned and undated, showed:
-The facility will meet the guidelines and resident’s nutritional requirements according
to physician orders;
-A physician order [REDACTED].
-The physician’s orders [REDACTED].
-Upon receipt of the Diet Order and Communication Form the Dietary Manager should contact
the Dietician to review the nutritional order; and
-The physician order [REDACTED].>–The type of formula;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 30)
–The amount of formula and
–Frequency and amount of feeding.
1. Record review of Resident #126’s face sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Gastrostomy tube ([DEVICE] – a surgical creation of a permanent opening into the stomach
through the skin for the introduction of nourishment and fluids through a tube).
Record review of the resident’s Physician order [REDACTED].
-Tube feeding water flush 175 milliliters (ml-a unit of measure) every four hours, start
5/27/19;
-Nepro Liquid (nutritional supplement), give 45ml/hour (hr) via [DEVICE], start 5/28/19,
until 5/29/19;
-Nepro Liquid, give 50ml/hr via [DEVICE], start 5/29/19, until 5/30/19;
-Nepro Liquid, give 55ml/hr via [DEVICE], start 5/30/19, until 5/31/19 and
-Nepro Liquid, give 60ml/hr via [DEVICE], start 5/31/19.
Record review of the resident’s POS for (MONTH) 2019 showed the following orders:
-Written on 5/27/19:
–Tube feeding water flush 175 ml every four hours;
–Nepro Liquid, give 65 ml/hr via [DEVICE], start 6/1/19, until 6/2/19 and
–Nepro Liquid, give 70 ml/hr via [DEVICE], start 6/2/19.
-Written on 6/9/19:
–FYI: Ensure Nepro Tube feed is running at 70 ml/hr via [DEVICE], start 6/9/19.
Observation on 6/5/19 at 9:30 A.M., showed the resident’s tube feeding infusing at 60
ml/hr and a water flush set for 120 ml every four hours.
Observation on 6/6/19 at 8:00 A.M., showed the resident’s tube feeding infusing at 60
ml/hr and a water flush set for 120 ml every four hours.
Observation on 6/7/19 at 9:49 A.M., showed the resident’s tube feeding infusing at 60
ml/hr and a water flush set for 120 ml every four hours.
During an interview on 6/7/19 at 10:06 A.M., Licensed Practical Nurse (LPN) C said:
-Tube feeding and water flushes should infuse per the physician’s orders
[REDACTED].>-All nurses checked the orders;
-The nursing manager checked all orders;
-The Assistant Director of Nursing (ADON) or Director of Nursing (DON) also checked
orders;
-If a discrepancy was found:
–The order was double checked and corrected;
–Findings were reported to the resident’s physician, charge nurse, ADON and DON and
–A medication error form was filled out if necessary.
During an interview on 6/7/19 at 10:10 A.M., the ADON said:
-Tube feeding and water flushes should infuse per the physician’s orders
[REDACTED].>-Every nurse on every shift, was to check orders, this included the ADON
and DON;
-He/she would research immediately if there was a discrepancy was found and
-The ADON said he/she to the resident’s room and found the resident’s tube feeding was
infusing as ordered and he/she fixed it and now it is infusing as ordered.
During an interview on 6/11/19 at 11:00 A.M. LPN A said:
-Tube feeding and water flush rates were checked every shift;
-Tube feeding and water flushes should infuse per physician’s orders [REDACTED].>-The
Medication Administration Record [REDACTED]
-If a discrepancy was found;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
–The order was double checked and corrected and
–Findings were reported to the resident’s physician, the charge nurse, the ADON and DON.
During an interview on 6/12/19 at 11:14 A.M., the DON said he/she expected:
-Tube feeding and water flush rates to be checked every shift;
-Tube feeding and water flushes would infuse by the physician’s orders [REDACTED].>-The
MAR indicated [REDACTED]
-If a discrepancy was found;
–The physician’s orders [REDACTED].
–Discrepancies were to be reported to the resident’s physician, the charge nurse, the
ADON and the DON.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure communication between
the facility and [MEDICAL TREATMENT] (process of cleansing the blood by passing it through
a special machine – necessary when the kidneys are not able to filter the blood) center,
for every [MEDICAL TREATMENT] treatment, for one sampled resident (Resident #126) out of
26 sampled residents. The facility census was 130 residents.
Record review of the facility’s [MEDICAL TREATMENT] Care Policy, not signed and not dated
showed:
-The Facility will be responsible for the overall care delivered to the resident,
monitoring of the resident prior to and after the completion of each [MEDICAL TREATMENT]
treatment, and providing for all non-[MEDICAL TREATMENT] needs of the resident including
during the time period when the resident is receiving [MEDICAL TREATMENT];
-The Facility maintains a contract with a [MEDICAL TREATMENT] service provider which
addresses communications between the Facility and Provider;
-Nursing staff will communicate pertinent information in writing to the [MEDICAL
TREATMENT] Staff which may include:
–Any medication changes;
–Any recent changes in condition;
–The resident’s tolerance of [MEDICAL TREATMENT] procedures.
-The [MEDICAL TREATMENT] Provider will communicate in writing to the facility:
–The resident’s current vital signs;
–Pre and post [MEDICAL TREATMENT] weights; and
–Any problems encountered while the resident was at the [MEDICAL TREATMENT] provider.
-Nursing staff may use the Nurse [MEDICAL TREATMENT] Communication Record to convey
information to the [MEDICAL TREATMENT] Provider;
-All documentation concerning [MEDICAL TREATMENT] services and care of the [MEDICAL
TREATMENT] resident will be maintained in the resident’s medical record; and
-Documentation may include the:
–Nurse [MEDICAL TREATMENT] Communication Record;
–[MEDICAL TREATMENT] Flow Sheet-Return Assessment and
–[MEDICAL TREATMENT] Medical Intake Sheet.
1. Record review of Resident #126’s face sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
-Dependence on [MEDICAL TREATMENT].
Record review of the resident’s Physician order [REDACTED].
Record review of the resident’s medical record showed the following [MEDICAL TREATMENT]
Communication Records:
-From 5/18/19 through 6/6/19 there were eight opportunities for [MEDICAL TREATMENT] and
-Only three [MEDICAL TREATMENT] Communication Records were available in the resident’s
medical record on these dates 6/1/19, 6/4/19 and 6/6/19.
During an interview on 6/7/19 at 10:06 A.M. the Assistant Director of Nursing (ADON) said
he/she expected a [MEDICAL TREATMENT] Communication Record for every day a resident went
to [MEDICAL TREATMENT].
During an interview on 6/12/19 at 11:14 A.M., the Director of Nursing (DON) said:
-He/she expected a [MEDICAL TREATMENT] Communication Record for every day a resident went
to [MEDICAL TREATMENT];
-It was difficult to get [MEDICAL TREATMENT] to fill out the form and return it;
-Follow up calls to the [MEDICAL TREATMENT] center were made regarding forms and stressed
the importance of returning of the forms to the facility; and
-He/she expected documentation in the medical record if the form was not returned.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Try different approaches before using a bed rail. If a bed rail is needed, the
facility must (1) assess a resident for safety risk; (2) review these risks and benefits
with the resident/representative; (3) get informed consent; and (4) Correctly install and
maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to assess
appropriateness of side rail use for residents on a quarterly basis to include showing
alternates attempted that failed to meet resident needs prior to the use of side rails for
one sampled resident (Residents #327) out of 26 sampled residents. The facility census was
130 residents.
1. Record review of Resident #327’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had a [DIAGNOSES REDACTED].
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff used for care planning) dated 5/16/19,
showed he/she:
-Was severely cognitively impaired and
-Needed the limited assistance of staff for bed mobility and transfers.
Record review of the resident’s Care Plan revised on 5/24/19 showed he/she:
-Had a self-care performance deficit and
-Was totally dependent on staff for dressing, personal hygiene and transfers.
Record review of the resident’s physician’s orders [REDACTED].¼ side rails on the bed.
Observation on 6/5/19 at 9:15 A.M., showed the resident’s bed with ¼ side rails up on both
sides of the upper part of the bed.
Observation on 6/5/19 at 1:45 P.M., showed the resident’s bed with ¼ side rails up on both
sides of the upper part of the bed.
Observation on 6/6/19 at 1:25 P.M., showed the resident’s bed with ¼ side rails up on both
sides of the upper part of the bed.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 33)
Record review of the resident’s medical record on 6/6/19 showed there was no side rail
assessment.
During an interview on 6/11/19 at 10:24 A.M., Licensed Practical Nurse (LPN) B said:
-When side rails were placed on a resident’s bed, the nurses were responsible for doing
the side rail assessments and
-The facility did not try any alternate piece of equipment prior to the use of side rails.
During an interview on 6/11/19 at 1:21 P.M., the Assistant Director of Nursing (ADON-also
Unit Manager) said:
The nurses were responsible for completing the assessment for the side rails;
-Not doing anything else prior to side rails; no other enablers and
-The facility did not try any alternate piece of equipment, like enabler bars, prior to
the use of side rails.
During an interview on 6/12/19 at 11:12 A.M., the Director of Nursing (DON) said:
-The facility did not use side rails but if the nurse did get a physician’s orders
[REDACTED].
-In the past, therapy would look at the residents for positioning and
-The facility did not try prior alternatives prior to placing side rails.
A policy was requested but not received from the facility.

F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 ensure
sufficient nursing staffing for the 700 Secure Care Unit and the 800 SCU to meet the
safety and attain or maintain the highest practicable physical, mental, and psychosocial
well-being of each resident. There were a total of 30 residents that reside on the 700 and
800 SCUs. The facility census was 130 residents.
Record review of the facility’s Nursing Department – Staffing, Scheduling and Postings
policy, undated, showed:
-The facility will employ sufficient nursing staff as determined by resident assessments
and individual plans of care, taking into account the number, acuity (cognitive levels),
and [DIAGNOSES REDACTED].
-Scheduling will be done as needed to meet resident needs and will account for the number,
acuity and [DIAGNOSES REDACTED].
1. Record review of the facility’s staffing sheets for the night shift (from 10:30 P.M.
through 6:30 A.M.) dated 4/1/19 through 5/31/19 showed:
-There was one Licensed Practical Nurse (LPN) or one Certified Medication Technician (CMT)
on the night shift for both the 700 and 800 SCUs;
-There was one Certified Nursing Assistant (CNA) on the night shift for both the 700 and
800 SCUs and
-This was a total of two staff members to care for 30 cognitively impaired residents.
Observation on 6/7/19 of the 700 and 800 SCUs showed:
-At 5:35 A.M. LPN D and CNA H were on the 800 SCU. There were two residents up in
wheelchairs on the 800 SCU. There were no staff members on the 700 SCU;
-At 5:39 A.M., LPN D went into the nurses’ station that connected the 700 SCU and 800 SCU.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 – Some

(continued… from page 34)
There were no staff members on the 700 SCU;
-At 5:44 A.M., LPN D sat at the nurses’ station area with visibility to only the 800 SCU.
There were no staff members on the 700 SCU;
-At 5:48 A.M., on the 700 hall, an ambulatory resident came out of his/her room, walked
down the hall, was speaking in non-sensical words, turned around and walked back to
his/her room. LPN D stood up, viewed the 700 SCU, sat back down at the nurses station with
visibility to only the 800 SCU. There were no staff members on the 700 SCU;
-At 5:56 A.M., CNA H and LPN D went to the 700 hall. There were no staff members on the
800 SCU.
-At 5:59 A.M., through 6:10 A.M., there were two residents up in wheelchairs on the 800
hall SCU. A resident in room [ROOM NUMBER] was sitting on the edge of his/her bed stating
everyone needed to be quiet and not wake up his/her children. There were no staff members
on the 800 SCU.
At 6:11 A.M., there were no staff members on the 700 SCU and
-At 6:12 A.M., a female resident’s room door was open and the light was on. The resident
was sitting on the side of the bed with two shirts and one hospital gown layered on
him/her. The resident was holding up a urine soiled brief. The resident stood up
unsteadily and turned around. The resident bent over and exposed his/her unclothed lower
body. A male resident walked to the resident’s door, looked at the exposed resident, then
continued down the hall. There were no staff members in the room assisting the resident.
There were no staff members on the 700 SCU.
During an interview on 6/7/19 at 6:21 A.M., CNA H said he/she tries to monitor both SCUs
by staying at the nurses’ station.
During an interview on 6/7/19 at 6:30 A.M., LPN D said:
-He/she was new to the facility;
-Both of the SCUs should be monitored at all times;
-This put vulnerable residents at risk of something happening to them by being left
unattended and
-The residents had been left unattended for periods of time.
During an interview on 6/11/19 at 10:24 A.M., LPN B said:
-Each unit should have staff members on the units to monitor the residents;
-At night there was only one nurse and one CNA for both SCUs and
-The residents were cognitively impaired and were at risk when being left alone.
During an interview on 6/12/19 at 11:12 A.M., the Director of Nursing (DON) said:
-Both units should have staff members on them and the staff should have been monitoring
the residents;
-At night there was one CNA for both sides and one nurse and
-These (cognitively impaired) residents were at risk and needed to be monitored.

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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to conduct federally required
annual training regarding care for residents with dementia (dementia is the name of a
group of symptoms caused by disorders that affect the brain – people with dementia may not
be able to think well enough to do normal activities, such as getting dressed or eating,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 35)
they may lose their ability to solve problems or control their emotions; their
personalities may change; they may become agitated or see things that are not there) and
for cognitively impaired (general term for conditions that cause loss of memory severe
enough that they may impact a person’s ability to carry out daily activities) residents.
This had the potential to affect all residents at the facility. The facility census was
130 residents.
1. Record review of the Facility assessment dated [DATE] showed:
-Common characteristics of facility residents included residents with dementia;
-The facility had two secured (locked) dementia care units;
-Staff training needed for the dementia units included effective communication and
dementia management;
-Staff competencies for the secured care units included specialized care for residents
with dementia and
-The resident population assessment identified that 71 residents had dementia.
Record review of the facility Resident Condition and Census form dated 6/5/19 showed:
-The facility census was 130 residents and
-60 residents had a [DIAGNOSES REDACTED].
During an interview on 6/12/19 the Administrator said:
-The facility had started looking at Certified Nursing Assistant (CNA) performance reviews
and what training CNAs needed in April, 2019;
-The facility had not conducted staff training regarding care for residents with dementia
over the past calendar year and
-The facility had not conducted staff training regarding care for residents with cognitive
impairment over the past calendar year.

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide pharmaceutical services to meet the needs of each resident and employ or obtain
the services of a licensed pharmacist.

Based on observation, interview and record review, the facility failed to ensure the
controlled medications (narcotics – medications with a potential for abusive use and
dependence upon the medication) were counted and documented at the beginning of each shift
and at the end of each shift for the 700-800 hall and the 300-400 halls to ensure the
accuracy of the distribution and use of the controlled medications. This had the potential
to affect all residents who used controlled medications on the 700, 800, 300 and 400
halls. The facility census was 130 residents.
Record review of the facility Clinical Competency Validation Management of Controlled
Medication, undated, showed:
-The controlled medication inventory is verified between each shift in the process of
handing off the keys to the oncoming nurse from the off-going nurse;
-The off-going nurse and the oncoming nurse together validate that inventory counts of
controlled medications are correct and
-Once all controlled medication counts are verified, the off-going nurse and the oncoming
nurse sign the shift to shift controlled medication reconciliation sheet for the date and
shift of the count.
1. Observation of the 700-800 Licensed Nurse Medication Cart on 6/10/19 at 10:39 A.M.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 36)
showed:
-Controlled (narcotic) substances were double locked and
-Eight Hour Verification of Controlled Substances Count sheets were kept with the
medication cart.
During an interview on 6/10/19 at 10:39 A.M. Licensed Practical Nurse (LPN) E said:
-The Controlled Substance Count sheets should be signed by two licensed nurses at every
shift change;
-The purpose for licensed nurses counting controlled medications at shift change was to
reconcile (count all narcotics and compare the count against the narcotic records);
-All three shifts were expected to count narcotics and sign the narcotic count sheet and
-It was required that two licensed nurses count narcotics and sign the narcotic count
sheet at shift change.
Record review of the Controlled Substance Count sheets for the 700-800 halls dated 4/26/19
3:00 P.M. to 11:00 P.M. through 6/10/19 7:00 A.M. to 3:00 P.M. showed:
-270 opportunities for licensed nurses to sign the Controlled Substance Count sheets at
shift change;
-69 missed licensed nurse signatures; and
-The Controlled Substance Count sheets were not signed by a licensed nurse for 25.55% of
the opportunities.
2. Observation of the 300-400 Licensed Nurse Medication Cart on 6/11/19 at 11:33 A.M.
showed:
-Controlled (narcotic) substances were double locked and
-Controlled Medication Count sheets were kept with the medication cart.
During an interview on 6/11/19 at 11:33 A.M. Registered Nurse (RN) B said:
-The Controlled Substance Count sheets should be signed by two licensed nurses for all
counts and
-To reconcile all controlled substances the sheets must be signed by two licensed nurses
at each shift change.
Record review of the Controlled Substance Count sheets for the 300-400 halls dated
5/24/19 7:00 A.M. to 3:00 P.M. through 6/11/19 7:00 A.M. to 3:00 P.M. showed:
-68 opportunities for licensed nurses to sign the Controlled Substance Count sheets at
shift change;
-15 missed licensed nurse signatures and
-The Controlled Substance Count sheets were not signed by a licensed nurse for 22.05% of
the opportunities.
3. During an interview on 6/12/19 at 11:12 A.M., the Director of Nursing (DON) said:
-Two licensed nurses were responsible for completing narcotic counts at each shift change;
-The two licensed nurses should be documenting that they both counted the narcotics at
shift change;
-Both licensed nurses should be signing for the controlled substances count; and
-The purpose of counting controlled medications at shift change is to ensure the accuracy
of the count of controlled medications.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure a licensed pharmacist perform a monthly drug regimen review, including the
medical chart, following irregularity reporting guidelines in developed policies and
procedures.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the resident’s monthly
pharmacy Drug Regimen Review (DRR) recommendations were reviewed and acted upon by the
physician, for two sampled residents (Resident #18 and #28), out of 26 sampled residents.
The facility census was 130 residents.
Record review of the facility’s Drug Regimen Review policy, undated, showed:
-The Pharmacist will review each resident’s medication regimen at least once a month to
identify irregularities and to identify clinically significant risks and/or actual or
potential adverse consequences which may result from or be associated with medications;
-An irregularity is defined as medication that is inconsistent with acceptable standards
of practice and/or interferes with achieving the intended outcomes of pharmaceutical
services. An irregularity includes, but is not limited to:
–Use of medications without adequate indication;
–Without adequate monitoring;
–In excessive doses;
–In the presence of adverse consequences; and
–Identification of conditions that may warrant initiation of medication therapy.
-The Pharmacist will report any irregularities to the Attending Physician and the
facility’s Medical Director and Director of Nursing (DON), and these reports must be acted
upon;
-The Attending Physician will respond to any irregularities reported by the Pharmacist by
reviewing the irregularities and documenting in the resident’s medical record that the
irregularity has been review and what, if any, action has been taken to address it;
-If no action has been taken the Attending Physician must document his/her rationale;
-Documentation by the Attending Physician must occur within 30 days of issuance of the
Pharmacist’s report, unless the irregularity is an emergent issue requiring immediate
action; and
-The Medical Director and DON will also review the Pharmacist’s report and if any
irregularities are identified the DON is responsible for following up with the Physician
as indicated.
1. Record review of Resident #28’s face sheet showed, he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (a mental state involving loss of contact with reality and causing
deterioration of normal social functioning and may experience hallucinations or
delusions).
Record review of the resident’s DRR showed:
-On 8/21/18, the resident was prescribed the antipsychotic [MEDICATION NAME]/[MEDICATION
NAME] for [MEDICAL CONDITION]:
–Please schedule a quarterly Abnormal Involuntary Movement Scale (AIMS);
–Be sure to monitor and chart daily for behaviors, side effects including restlessness,
tremor or stiffness;
–Appropriate documentation from the physician and/or psychiatrist to justify the use of
this medication for this diagnosis.
-On 9/13/18, Please schedule a quarterly AIMS assessment for this resident, he/she is
prescribed the antipsychotic [MEDICATION NAME]/[MEDICATION NAME].
-On 10/16/18, Please schedule a quarterly AIMS assessment for this resident, he/she is
prescribed the antipsychotic [MEDICATION NAME]/[MEDICATION NAME].
Record review of the resident’s medical record showed, a completed the AIMS assessment
once out of three opportunities, on 3/13/19.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 38)
Record review of the resident’s physician’s orders [REDACTED].
2. Record review of Resident #18’s face sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Pseudobulbar Affect (a type of emotional disturbance characterized by uncontrollable
episodes of crying and/or laughing, or other emotional displays; typically occurs in
people with neurological conditions like: stroke, [MEDICAL CONDITION] (TBI), Alzheimer’s,
[MEDICAL CONDITIONS] (MS) and Amyotrophic lateral [MEDICAL CONDITION] (ALS))
Record review of Resident #18’s DRR showed:
-On 6/22/18, if necessary please forward to the resident’s hospice (end of life care) so
they can take care of this:
–Please write the resident’s [MEDICATION NAME] orders for a specific duration (i.e. 14
days, 60 days, 6 months, etc.);
–Cannot be indefinite due to new Centers for Medicare and Medicaid (CMS) regulations;
–This new regulation does apply to hospice residents in skilled facilities per CMS
surveyors;
–As needed (PRN) orders for [MEDICAL CONDITION] drugs are limited to 14 days; and
–Except if the physician believes that it is appropriate for the PRN order to be extended
beyond 14 days, he/she should document their rationale in the resident’s medical record
and indicate the duration of the PRN order.
-On 7/26/18, if necessary please forward to the resident’s hospice so they can take care
of this:
–Please write the resident’s [MEDICATION NAME] orders for a specific duration (i.e. 14
days, 60 days, 6 months, etc.);
–Cannot be indefinite due to new Centers for Medicare and Medicaid (CMS) regulations;
–This new regulation does apply to hospice residents in skilled facilities per CMS
surveyors;
–As needed (PRN) orders for [MEDICAL CONDITION] drugs are limited to 14 days; and
–Except if the physician believes that it is appropriate for the PRN order to be extended
beyond 14 days, he/she should document their rationale in the resident’s medical record
and indicate the duration of the PRN order.
-On 2/7/19, if necessary please forward to the resident’s hospice so they can take care of
this:
–Please write the resident’s [MEDICATION NAME] orders for a specific duration (i.e. 14
days, 60 days, 6 months, etc.);
–Cannot be indefinite due to new Centers for Medicare and Medicaid (CMS) regulations;
–This new regulation does apply to hospice residents in skilled facilities per CMS
surveyors;
–As needed (PRN) orders for [MEDICAL CONDITION] drugs are limited to 14 days; and
–Except if the physician believes that it is appropriate for the PRN order to be extended
beyond 14 days, he/she should document their rationale in the resident’s medical record
and indicate the duration of the PRN order.
-On 3/19/19, if necessary please forward to the resident’s hospice so they can take care
of this:
–Please write the resident’s [MEDICATION NAME] orders for a specific duration (i.e. 14
days, 60 days, 6 months, etc.);
–Cannot be indefinite due to new Centers for Medicare and Medicaid (CMS) regulations;
–This new regulation does apply to hospice residents in skilled facilities per CMS
surveyors
–As needed (PRN) orders for [MEDICAL CONDITION] drugs are limited to 14 days and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 39)
–Except if the physician believes that it is appropriate for the PRN order to be extended
beyond 14 days, he/she should document their rationale in the resident’s medical record
and indicate the duration of the PRN order.
Record review of the resident’s POS and Physicians Progress Notes showed no response to
the Pharmacist’s recommendations until 3/2019.
During an interview on 6/6/19 at 2:04 P.M. the Assistant Director of Nursing (ADON) said:
-Evidently the physician didn’t respond to the Pharmacist’s recommendations;
-If the physician agreed with the recommendation, an order was written in the resident’s
medical record and
-If the physician disagreed with the recommendation, a note was written in the resident’s
medical record.
During an interview on 6/11/19 at 11:00 A.M. Licensed Practical Nurse (LPN) A said:
-The nurses reviewed the pharmacy’s recommendation of the DRR;
-The unit manager also reviewed the DRR;
-He/she would let the Physician know what the pharmacy recommended;
-He/she obtained orders based upon what pharmacy had recommended and
-Every resident on anti-[MEDICAL CONDITION] medication had the AIMS assessments completed.
During an interview on 6/12/19 at 11:14 A.M., the DON said:
-The physician should promptly respond to DRR recommendations,
-Management staff completed the AIMS quarterly and
-Management staff were to reach out to the physicians to obtain responses to the DRR
monthly.

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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure Pro Re
Nata (PRN – prescribed as needed) [MEDICAL CONDITION] medications (drugs that affect brain
activities associated with mental processes and behavior) were limited to a duration of 14
days and that the resident’s physician indicated the duration of extended PRN anxiolytic
(anti-anxiety – drugs used to inhibit anxiety) medications for two sampled residents
(Resident #18 and Resident #109) out of 26 sampled residents. The facility census was 130
residents.
Record review of the facility’s Psychotherapeutic Drug Management policy, undated and
unsigned showed:
-[MEDICAL CONDITION] medications are drugs that affect brain activities associated with
mental processes and behavior;
-Residents should not receive [MEDICAL CONDITION] drugs pursuant to a PRN order unless
that medication is necessary to treat a diagnosed specific condition that is documented in
the clinical record;
-PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days;
-Except in the case of anti-psychotic drugs (medications used to treat severe mental
disorders that cause abnormal thinking and beliefs and/or perceptions which are not in

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 40)
touch with reality), if the prescribing practitioner believes that it is appropriate for
the PRN order to be extended beyond the initial 14 day order, he/she should document their
rationale in the resident’s medical record and indicate the duration of the PRN order and
-PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless
the prescribing practitioner evaluates the resident in person for the appropriateness of
the medication.
Record review of the facility’s Behavior-Management Policy, undated and unsigned showed:
-Upon observing the adverse behavior symptoms, staff will do the following as indicated:
–Document notification of the attending physician; and
–Document notification of the resident’s family/responsible party about the change in
behaviors and the physician’s response.
-In the evaluation of outcome, licensed nursing staff will document observations,
interventions and outcome.
-If the physician determines that the resident requires psychotherapeutic medications:
[REDACTED]
–Nursing staff will document the resident’s response to medication, including behaviors
and side effects on the Medication Administration Record [REDACTED]
Record review of the facility’s Guidelines for Psychotherapeutic Medication Policy,
undated and unsigned showed, appropriate non-drug interventions shall be attempted prior
to prescribing antipsychotic medications.
1. Record review of Resident #18’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Pseudobulbar Affect (PBA-a type of emotional disturbance characterized by uncontrollable
episodes of crying and/or laughing, or other emotional displays; typically occurs in
people with neurological conditions like: stroke, [MEDICAL CONDITION] (TBI), Alzheimer’s,
[MEDICAL CONDITIONS] (MS) and Amyotrophic lateral [MEDICAL CONDITION] (ALS).
Record review of the resident’s Electronic Medical Record (EMR) Nurse’s Notes showed staff
did not document anything in the resident’s nursing notes regarding the resident’s
behaviors of yelling, screaming and agitation The staff did not document they notified the
resident’s physician of these behaviors, did not document any non-pharmaceutical
interventions tried before medications were given and did not document any side effects of
the antipsychotic medications that were given from 4/21/19 through 5/2/19.
Record review of the resident’s physician’s orders [REDACTED].
-Monitor behaviors every shift related to PBA such as uncontrollable crying and/or
laughing starting on 5/26/17 and
-[MEDICATION NAME]/[MEDICATION NAME] Intersol Concentrate (a concentrated oral medication
solution used to reduce anxiety) two milligram (mg)/milliliter (ml), give sublingually
every four hours for anxiety/agitation/yelling, start 3/28/19.
Record review of the resident’s POS dated (MONTH) 2019 showed the following:
– Monitor behaviors every shift related to PBA, start 5/26/17;
-[MEDICATION NAME] solution two mg/ml ([MEDICATION NAME]) inject one ml intramuscularly
(IM) every 24 hours as needed (PRN) for anxiety until 5/15/19 (14 days) and reassess,
started 5/2/19 and
-[MEDICATION NAME]/[MEDICATION NAME] Intersol two mg/ml, give sublingually every four
hours for anxiety/agitation/yelling with a start date of 3/28/19.
Record review of the resident’s Medication Administration Record [REDACTED]
-[MEDICATION NAME] ([MEDICATION NAME]) Solution two mg/ml, inject one ml intramuscularly
(IM) every 24 hours PRN for anxiety, until 5/15/19 (14 days) and reassess with a start
date of 5/02/19 and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 41)
-The staff did not document the behaviors that warranted the staff to administer the IM
[MEDICATION NAME] and the staff did not document if the IM [MEDICATION NAME] was effective
and if his/her behaviors subsided or not.
Record review of the resident’s POS dated (MONTH) 2019 showed the following:
-Antianxiety: [MEDICATION NAME] behaviors: worrying, crying, refusing car, monitor for
side effects to include dry mouth, constipation, blurry vision every shift for anxiety
with a start date of 6/4/19;
-Monitor behaviors every shift related to PBA, start 5/26/17 and
-[MEDICATION NAME]/[MEDICATION NAME] Intersol two mg/ml, give sublingually every four
hours for anxiety/agitation/yelling with a start dated of 3/28/19.
Record review of the resident’s MAR indicated [REDACTED]
–Antianxiety: [MEDICATION NAME] behaviors: worrying, crying, refusing care, monitor for
side effects to include dry mouth, constipation, blurry vision every shift for anxiety
with a start date of 6/4/19;
— Monitor behaviors every shift related to PBA with a starte date of 5/26/17 and
–[MEDICATION NAME]/[MEDICATION NAME] Intersol two mg/ml, give sublingually every four
hours for anxiety/agitation/yelling ,with a start date of 3/28/19.
During an interview on 6/11/19 at 11:00 A.M., Licensed Practical Nurse (LPN) A said:
-The MAR/Treatment Administration Record (TAR)’s, in the EMR contained the documented
behaviors;
-Nurse’s notes should contain:
–Behaviors exhibited;
–Physician notification;
–Orders received and
–Effectiveness of the medication.
During an interview on 6/12/19 at 11:14 A.M., the Director of Nursing (DON) said he/she
expected:
-Certified Nursing Assistants (CNA)’s charted and notified the nurse of resident’s
behaviors and
-The licensed nurses to document the resident’s behaviors, the notification of the
resident’s behaviors, if any orders were received, administration of the medication and if
the medication was effective or not and if any interventions were used and effectiveness
of the interventions.
At the time of exit on 6/12/19 the facility failed to present a copy of the resident’s
(MONTH) MAR for review.
2. Record review of Resident #109’s Face Sheet showed he/she:
-Was admitted to the facility on [DATE] and
-Had [DIAGNOSES REDACTED].
Record review of the resident’s significant change Minimum Data Set (MDS a federally
mandated assessment tool required to be completed by facility staff for care planning)
dated 5/14/19 showed he/she:
-Was cognitively intact and
-Received hospice (end of life care) services.
Record review of the resident’s POS dated 6/1/19 through 6/30/19 showed physician’s orders
[REDACTED].>-Hospice services dated 5/14/19 and
-[MEDICATION NAME] (concentrated solution) 2 mg/mL, give 0.5 ml every one hour as needed
for anxiety until 6/5/19, give 0.25 ml, if anxiety persists, increase to 0.5 mL in 30
minutes for 14 days and reassess, dated 5/23/19 and
-[MEDICATION NAME] 2 mg/ml give 0.5 mL by mouth every one hour as needed for anxiety if
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 42)
0.25 ml does not help, increase to this dose, dated 5/23/19.
Record review of the resident’s MAR indicated [REDACTED]
-[MEDICATION NAME] (concentrate solution) 2 mg/mL, give 0.25 ml every one hour as needed
for anxiety until 6/5/19, give 0.25 ml, if anxiety persists, increase to 0.5 mL in 30
minutes for 14 days and reassess, without the stop date indicated in the administration
date column and
-[MEDICATION NAME] 2 mg/ml give 0.5 mL by mouth every one hour as needed for anxiety if
0.25 ml does not help, increase to this dose, without the stop date indicated in the
administration date column.
Observation of the resident 6/05/19 10:33 A.M. showed:
-He/she was seated in his/her tilt in space chair; and
-He/she was alert, calm and answered questions.
Observation of the resident on 6/6/19 at 10:40 A.M. showed:
-He/she was seated in his/her tilt in space chair and
-He/she was alert and calm.
Observation of the resident on 6/6/19 at 1:35 P.M. showed:
-He/she was seated in his/her tilt in space chair and
-He/she was alert and calm.
Observation of the resident on 6/7/19 at 5:51 A.M. showed:
-He/she was seated in his/her tilt in space chair in his/her room;
-He/she was alert, calm and watching TV and
-He/she said it was OK with him/her to be up and that he/she was comfortable.
Observation of the resident on 6/7/19 at 10:29 A.M. showed:
-He/she was seated in his/her tilt in space chair in his/her room and
-He/she was alert, calm and watching TV.
Observation on 6/7/19 at 5:51 A.M. showed:
-He/she was laying in his/her bed and
-He/she was alert, calm and watching TV.
During an interview on 06/11/19 10:35 A.M. Hospice LPN (A) said he/she has not seen the
resident anxious.
During an interview on 6/11/19 at 10:24 A.M. the DON looked in the resident’s electronic
medical record and said:
-The resident’s original orders for [MEDICATION NAME] were dated 5/23/19 until 6/5/19;
-He/she did not see a new order written for [MEDICATION NAME] on or after 6/5/19;
-The resident’s MAR indicated [REDACTED]
-The resident should have been reassessed by his/her physician before any new orders for
PRN [MEDICATION NAME] after 6/5/19;
-The Federal requirement is that for a PRN psychoactive medication to be ordered after the
initial two week duration order, the physician needs to reassess the resident and a new
order would need to be written,
-He/she did not see where the resident’s physician reassessed him/her and
-The Federal requirements for PRN psychoactive medications were the same for hospice
residents as for other residents.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 43)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure urinary
catheter (a tube passed through the urethra into the bladder to drain urine) tubing was
kept off the floor for one sampled resident (Resident #88), and to ensure urine graduates
(a container used to measure urine) were changed weekly and labeled with the resident’s
name, date, room and bed number for one sampled resident (Resident #105), to ensure use of
a disposable under pad in a manner to prevent cross contamination (unintentional transfer
of bacteria or other contaminant from one surface to another) for one sampled resident
(Resident # 77) out of 26 sampled residents, and the facility failed to maintain 12
consecutive months of infection control records. The facility census was 130 residents.
1. Record review of Resident #88’s Face Sheet showed he/she was admitted to the facility
on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s Quarterly Minimum Data Set (MDS-a federally mandated
assessment to be completed by facility staff used for care planning) dated 5/13/19, showed
he/she:
-Was severely cognitively impaired and
-Required extensive assist of one to two people for transfers, ambulation, toileting, and
personal hygiene.
Observations were made of the following:
-On 6/05/19 at 9:00 A.M. the resident’s catheter tubing was dragging on the floor;
-On 6/05/19 at 10:56 A.M. the resident’s catheter tubing was on the floor;
-On 6/06/19 at 1:18 P.M. the resident’s catheter tubing clip was on the floor and
-On 6/07/19 at 5:57 A.M. the resident’s catheter bag was on floor.
During an interview on 6/05/19 at 10:41 A.M. the resident said he/she has had frequent
urinary tract infections [MEDICAL CONDITION] since he/she got the catheter, about a year
ago.
During an interview on 6/11/19 at 10:14 A.M. Certified Nursing Assistant (CNA) A said:
-Care staff was responsible to observe if catheter tubing/bag was on the floor and to
correct it;
-The catheter tubing/bag could not be on the floor;
-He/she would clean the catheter tubing/bag if found on the floor;
-He/she would educate the resident regarding why the tubing/bag needed to stay off the
floor and
-If the resident was ambulatory, a leg bag (a urinary bag which straps to the leg) should
be used.
During an interview on 6/11/19 at 10:26 A.M., CNA B said:
-The tubing/bag needed wiped off, cleaned and put into the dignity bag;
-The resident needed to be educated to try to keep tubing/bag off the floor and
-The resident needed to be reminded to turn on his/her call light if he/she needed help.
During an interview on 6/11/19 at 10:35 A.M., Certified Medicine Technician (CMT) A said:
-He/she would explain to the resident why the tubing/bag needed to stay off the floor and
-He/she would clean the tubing/bag and put it into the dignity bag.
During an interview on 6/11/19 at 11:00 A.M. Licensed Practical Nurse (LPN) A said:
-Everyone was responsible to check for the catheter tubing being off the floor;
-If the residents were independent they should use a leg bag during the day;
-If a resident’s catheter tubing was found on the floor it needed to be cleaned or changed
and
-The resident would be educated regarding why the tubing needed to stay off the floor.
During an interview on 6/12/19 at 11:14 A.M., the Director of Nursing (DON) said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 44)
-It was an infection control issue whenever the catheter tubing/bag was on the floor;
-Education of the resident was expected and
-He/she always expected catheter tubing/bag to be maintained off the floor.
2. Record review of Resident #105’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (a condition where the flow of urine is blocked which can injure the
kidneys) and
-[MEDICAL CONDITION] (a [MEDICAL CONDITION] characterized by loss of contact with the
environment, by noticeable deterioration in the level of functioning in everyday life).
Observations were made of the following:
-On 6/5/19 at 8:41 A.M. the urine graduate had dried urine in the bottom, was not covered,
was not dated or labeled with the resident’s room and bed number;
-On 6/6/19 at 1:17 P.M. the urine graduate had dried urine in the bottom, was not covered,
was not dated, or labeled with the resident’s room and bed number;
-On 6/7/19 at 5:56 A.M. the urine graduate had dried urine in the bottom, was not covered,
was not dated, or labeled with the resident’s room and bed number and
-On 6/10/19 at 10:17 A.M. the urine graduate had dried urine in the bottom, was not
covered, was not dated, or labeled with the resident’s room and bed number.
During an interview on 6/11/19 at 10:14 A.M. CNA A said:
-The unit manager changed the graduates every week;
-The urine graduates should be labeled with date, resident’s name, room and bed number and
-After use, the graduate needed to be rinsed out and placed into a plastic bag.
During an interview on 6/11/19 at 10:26 A.M. CNA B said:
-The CNA’s changed the urine graduates every week;
-The urine graduates should be labeled with date, resident’s name, room and bed number and

-When not in use the urine graduate should be in a bag or covered.
During an interview on 6/11/19 at 10:35 A.M., CMT A said he/she thought urine graduates
were:
-Changed every one to two days by the CNA’s, especially if dirty;
-Kept in a bag or covered in the resident’s bathroom and
-Labeled with resident’s name, room and bed number and date.
During an interview on 6/11/19 at 11:00 A.M. LPN A said:
– CNA’s, CMT’s or nurses change the urine graduates weekly;
-The graduates were to be labeled with the date, resident’s name, room and bed number and
-The graduate was stored in a bag or with a cover over the top.
During an interview on 6/12/19 11:14 A.M., the DON said he/she expected urine graduates
were:
-Changed weekly;
-Labeled with resident’s name, room and bed number and date and
-Covered or in a bag.
3. Record review of the facility’s Resident Census and Condition of Residents dated 6/5/19
showed there were six residents who received antibiotics.
Record review for the 12 consecutive months of Infection Prevention and Control Program
records (June (YEAR) through (MONTH) 2019) showed:
-Three months of records were missing:
–July (YEAR);
–August (YEAR) and
–May 2019.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265597

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF BLUE RIVER

STREET ADDRESS, CITY, STATE, ZIP

10425 CHESTNUT DR
KANSAS CITY, MO 64137

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 45)
During an interview on 6/12/19 11:14 A.M., the DON said:
-He/she had been there for two weeks;
-The Administrator had been there for two months and
-He/she and the Administrator had looked for the missing records and were unable to locate
them.
4. Record review of Resident #77’s Face Sheet showed he/she:
-Was admitted to the facility on [DATE] and
-Had [DIAGNOSES REDACTED].
Record review of the resident’s annual MDS dated [DATE] showed:
-He/she was moderately cognitively impaired;
-He/she needed total assistance from two or more staff for transferring from one surface
to another surface and
-He/she did not walk.
Record review of the resident’s care plan dated 5/2/19 showed two staff persons were to
assist him/her with transfers with use of a mechanical lift.
Observation on 6/10/19 at 9:04 A.M. showed:
-The resident was seated in his/her wheelchair;
-The resident’s roommate’s wheelchair had an unfolded disposable under pad on the seat
cushion and was near the resident’s side of the room, near the resident’s sink;
-CNA I removed the disposable under pad from the resident’s roommates wheelchair seat and
placed it on the resident’s bed and
-Using a mechanical sling lift CNA I and CNA J transferred the resident to his/her bed and
positioned him/her on the disposable under pad CNA I had taken from the resident’s
roommate’s wheelchair.
During an interview on 6/10/19 at 9:12 A.M. CNA I said:
-He/she had placed the disposable under pad in the resident’s roommate’s wheelchair just
before the observation on 6/10/9 at 9:04 A.M.;
-After he/she put the disposable under pad in the resident’s roommate’s wheelchair, it was
considered contaminated and he/she should not have placed it on the resident’s bed and
-Using the disposable under pad from the resident’s roommate’s wheelchair could cause the
resident to get and infection.
During an interview on 6/12/19 at 11:19 A.M. the DON said:
-He/she would not expect the CNAs to use a disposable under pad that had been in the
resident’s roommate’s wheelchair and place it in the resident’s bed;
-Once a disposable under pad was placed in the roommate’s wheelchair, it was no longer
suitable for the resident and
-This was an infection control cross contamination issue.