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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 and interview the facility failed to treat residents with dignity and
respect during meal times and while providing assistance with activities of daily living
(ADLs). This affected Resident #46, #13 and residents who required dining assistance. The
facility censes was 106.
1. Review of the facility’s undated, policy for Privacy and Dignity, showed:
– To ensure that care and services provided by the facility promote and/or enhance
privacy, dignity and overall quality of life;
– The facility promotes resident care in a manner and an environment that maintains or
enhances dignity and respect in full recognition of each resident’s individuality;
– Staff assist the resident in maintaining self-esteem and self-worth;
– Residents are groomed as they wish to be groomed;
– The facility promotes independence and dignity in dining;
– Staff treats residents with respect including respecting their social status, speaking
respectfully. listening carefully;
– Staff focus on residents as individuals when they speak to them and address residents as
individuals when when providing care and services.
2. Review of Resident #13’s Minimum Data Set, (MDS) a federally mandated assessment
completed by facility staff, dated 2/12/19, showed:
– Difficulty making decisions;
– Required assistance of staff with toilet use and personal hygiene;
– Occasionally incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan revised on 5/8/19 showed:
– Resident requires extensive assistance of staff with personal hygiene and toilet use.
Observation an interview on 5/8/19 at 7:06 A.M., showed the resident lay in bed, his/her
brief soiled with urine. The resident said he/she had held the urine for over an hour
waiting for staff to help him/her out of bed to go to the bathroom and couldn’t wait any
longer. He/she did not like to wet the bed because then you had to lay in it until staff
decided to help you and you smelled like pee all day. Certified Nurse Aide (CNA) A
provided peri care in the following way:
– Put on a pair of gloves and unfastened the resident’s brief;
– Grabbed a handful of wet wipes, balled them up in his/her hand and cleaned the front
side of the resident’s per area;
– CNA A did not speak to the resident, he/she flipped his/her wrist and pointed to the
wall;
– The resident pulled him/herself on to his/her side that faced the wall;
– CNA A completed peri care to the resident’s buttock’s tapped the resident’s hip and when
the resident looked at CNA A, he/she motioned with his/her hand to turn back over the
other way;
– After he/she completed peri care CNA A placed a brief pad on the resident, then placed
an incontinent pull up over the pad;
– When CNA A started to pull a pair of underpants over the pull up brief, the resident
told CNA A he/she did not know if the underwear would fit because it was not hers/his;
Observation showed the brief had another resident’s name written in large letters across
the top of the underpants;
– CNA A ignored the resident had spoken to him/her and continued to put another resident’s

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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)
underwear on the resident.
During an interview at 5/8/19 at 2:02 P.M., CNA A said:
– The resident just needed staff to wipe him/her after he/she went to the bathroom;
– Sometimes the resident was wet and sometimes not, the resident was happy if he/she was
not wet;
– The resident knew what he/she meant when he/she pointed to the wall and then pointed for
the resident to roll the other way. It was just the way he/she communicated, especially
early in the morning;
– He/she had not thought about how the resident felt when he/she put someone else’s
underpants on him/her That would be nasty, but at least he/she put a pad between the
resident and the underwear.
During an interview on 5/14/19 at 1:28 P.M., the resident said:
– He/she had started having to pee more in bed than he/she ever wanted to. If staff would
come and help him/her out of bed, he/she would be able to use the bathroom;
– It hurt him/her to try and hold the pee so long and after an hour or so, he/she just had
to let it go and pee on him/herself;
– I don’t like it, but they tell me I am not the only one on the hall they need to help.
– He/she did not like having someone else’s underwear on;
– CNA A doesn’t speak to me, he/she just gestures. The resident said when he/she points at
the wall, he/she was supposed to turn that way;
– It would nice to wake up and look forward to a smiling face and a kind word from who is
helping you;
He/she tried to be understanding that the CNAs had a lot of work to do.
3. Review of Resident #46’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 3/9/19, showed:
– Difficulty making daily decisions;
– Required assistance of staff for toilet use and personal hygiene;
– Indwelling catheter and frequently incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on 5/14/19 at 10:11 A.M., showed the resident lay in bed with a supra-pubic
catheter (a urinary catheter that is inserted into the abdominal wall and into the
bladder). The resident wore a shirt and jeans with suspenders. After CNA A finished
cleaning the resident’s catheter, he/she flicked his/her wrist and pointed to the wall.
The resident rolled over to the wall so CNA A could adjust the resident’s shirt, jeans and
suspenders.
During an interview on 5/14/19 at 4:00 P.M., the Director of Nurses said:
– Staff should talk with the resident’s while they provide care, it let the resident know
what they were doing;
– Unless a resident could only communicate with sign language, it was not acceptable for
staff to use sign language and not speak to them;
– Staff should use the resident’s own clothes to dress them.

4. Review of the undated facility policy titled Dining Service Standards showed:
– Policy- Patients/Residents are provided a positive meal experience;
– Assistance- adaptive devises are provided; foods, and beverages are set up to promote
independence; patients/ residents are properly positioned, encouraged, cured, and assisted
as needed.
5. Observation on 5/8/19 between 8:32 A.M. and 8:42 A.M. in the assisted dining room
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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)
– Four staff members sitting with residents assisting residents with eating, including
Resident #5, each at different tables;
– The four staff members were engaged in conversation amongst themselves regarding getting
their (the staff’s) hair done, as well as staff assignments;
– The staff were not talking with the residents.
6. During a group interview with 15 resident on 5/9/19 at 10:05 A.M. all of the resident
said they are not treated with dignity and respect from facility staff.
7. During an interview on 5/14/19 at 4:00 P.M. the Director of Nursing (DON) said:
– Staff assisting with feeding should not being about other things and should be talking
to the residents.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

Based on observation and interview, the facility failed to ensure they provided a safe,
clean, comfortable and homelike environment when they failed to maintain the facility’s
bathroom floors. This affected all residents who resided in the affected rooms. The
facility had a census of 106.
1. Observation and interview during Life Safety Code/environmental tour of the facility on
5/13/19, starting at 9:15 A.M., showed multiple dirty bathroom floors and baseboards on
the 300 hall and as well as dirty bathroom floors on the 400 and 500 halls. The
Maintenance Director said the floor technician was often pulled off floors to doing
cleaning. Staff have been stripping floors but have not gotten all of the bathroom floors
done.
During an interview on 5/14/19, at 4:05 P.M., Housekeeping Staff B said someone in the
past waxed over the dirt and stains on the 300 hall bathroom floors. Some of the 400 and
500 floors were also affected but they have most of the 400 and 500 halls bathroom floors
stripped. The un-stripped bathroom floors are impossible to clean.
During an interview on 5/14/19, at 4:12 P.M., the Housekeeping Supervisor said a
contractor about a year or so ago waxed over the dirt and stains on many of the facility’s
bathroom floors. She had asked administration to have the 300 hall bathroom floors re-done
but to date had not gotten permission to have them stripped. The bathroom floors look
really bad and are not cleanable.

F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on record review and interview the facility failed to ensure they provided the dates
for when the Nurse Aide (NA) Registry checks, (a check that will show any findings against
a Certified Nurse Aide (CNA) of abuse, neglect, or misappropriation of property), were
completed for three staff (Dietary Staff E, CNA A, and CNA C) the facility census was 106.
Review of the undated facility policy titled Staff Screening 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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
– Prior to employment or commencement of a contract, the facility will verify and document
or obtain a copy, if applicable, of the following information that may include, but no
limited to:
– A previous and/or current employer regarding work history, allegations of abuse against
resident, employee or others;
– Criminal Background Checks;
– National Sex Offender Public Website;
– Office of Inspector General Exclusion Screening;
– State exclusion screening, if applicable;
– Current Licenses and Certifications;
– References;
– Disclosure of information (i.e. self-disclosure of any criminal convictions or actions
that exclude them from any government healthcare program).
1. Review of Dietary Staff E’s employee file showed:
– Hire date 4/30/19;
– An NA registry check was found, with no findings, in the file but it did not have a date
when the check was completed.
2. Review of CNA A’s employee file showed:
– Hire date 4/5/19;
– An NA registry check was found, with no findings, in the file but it did not have a date
when the check was completed.
3. Review of CNA C’s employee file showed:
– Hire date 4/24/19;
– An NA registry check was found, with no findings, in the file but it did not have a date
when the check was completed.
4. During an interview on 5/14/19 at 10:39 A.M. the Administrator said:
– Human Resources (HR) was responsible for completing NA checks;
– They were supposed to be completed prior to employment;
– The previous HR person was responsible for the checks not having the dates on them.

F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on observation, interview and record review, the facility failed to complete
comprehensive and periodic assessments of the resident’s functional capabilities, to
include needs, strengths and physical functioning related to the use a a wheelchair
seatbelt for one our of 24 sampled residents (Resident #62). The facility census was 106.
1. Review of Resident #62’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/19/19, showed:
-Cognitively intact;
-Required total assistance by staff for transfers;
-Did not ambulate;
-Impaired bilateral lower extremity range of motion;
-Used a wheelchair for locomotion;
-No falls;

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-No restraints used.
Review of the resident’s care plan, last updated on 4/2/19, showed:
-Able to make his/her own choices;
-Required total assistance for transfers using a mechanical lift;
-Used an electric wheelchair for mobility;
-At risk for falls;
-Did not address the use of a wheelchair seatbelt.
Review of the resident’s assessments showed staff completed no assessment during the past
year for the use of a wheelchair seatbelt to determine if the seatbelt was safe or
appropriate for use for this resident.
Observation on 05/09/19 at 2:04 P.M. showed the resident in his/her electric wheelchair
with a seatbelt fastened at the waist.
Observation on 5/10/19 at 11:43 A.M. showed staff transferred the resident from bed to an
electric wheelchair and fastened the seatbelt. The resident said she needed the seatbelt
to prevent him/her from sliding, and it made him;her feel safer with it fastened. He/she
said it did not restrain him/her because he/she could unfasten it any time he/she wanted.
During an interview on 5/14/19 at 1:20 P.M., MDS staff A (MDSS A) said:
-He/she normally did the MDS assessments for the express rehabilitation unit (ERU) rather
than the long term side.
-He/she searched the resident’s records and found no wheelchair seatbelt assessment since
a date in (YEAR).
-He/she found no care plan entry related to use of a wheelchair seatbelt.
-The charge nurses completed assessments for use of devices with the potential to be a
restraint.
-MDS staff entered a prompt in the computer that showed up on the nurses’ computer screen
on the date the assessment was due, and the assessment was completed by the charge nurse
who worked that day.
During an interview on 5/14/19 at 1:32 P.M., the MDS coordinator (MDSC) said:
-Use of a wheelchair seatbelt should be assessed by nursing staff, and possible therapy,
as well.
-Approximately five to seven days prior to the MDS assessment review date, MDS staff
opened a trigger in the computer system that showed up on nursing staff’s dashboard
(computerized screen) that prompted them to complete the required assessments.
-He/she expected an assessment to be done quarterly and as needed related to the use of a
device that could potentially be a restraint.
-Use of a wheelchair seatbelt should be included in the care plan.
During an interview on 5/14/19 at 4:00 P.M., the director of nurses said:
-Staff should assess use of wheelchair seatbelts annually and with a significant change to
ensure it is not a restraint and the resident can still self-release it.
-Use of a wheelchair seatbelt should be included in the care plan.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
used residents’ comprehensive assessments to develop, implement and update each resident’s
comprehensive, person-centered care plan that included measurable objectives and time
frames to meet each resident’s medical, nursing, mental and psychosocial needs for four
out of 24 sampled residents (Residents #62,# 51, #5, #47. The facility census was 106.
1. Review of Resident #62’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/19/19, showed:
-Total dependence on staff for transfers;
-Used a wheelchair for mobility;
-No falls;
-Used no restraints.
Resident’s medical records from (MONTH) (YEAR) through (MONTH) 2019 showed no assessments
related to the use of a wheelchair seatbelt.
Review of the resident’s care plan, last revised on 4/2/19, showed:
-Required use of a mechanical lift for transfers;
-Used an electric wheelchair for mobility;
-Did not address the use of a wheelchair seatbelt.
Observation on 5/09/19 at 2:04 P.M., showed the resident in his/her electric wheelchair
with a seatbelt secured across his/her waist.
Observation on 5/10/19 at 11:43 A.M., showed staff transferred the resident from bed to
his/her electric wheelchair and the resident secured a seatbelt across his/her waist. The
resident stated that he/she needed the seatbelt as he/she tended to slide and it made
him/her feel safer with it fastened. The resident said he/she could unfasten it any time
he/she wanted.
During an interview on 5/14/19 at 1:20 P.M., MDS staff (MDSS) A said he/she found no
assessment for use of the resident’s wheelchair seatbelt since (YEAR), and found nothing
in the resident’s care plan related to use of a wheelchair seatbelt.
During an interview on 5/14/19, at 1:32 P.M., the MDS coordinator (MDSC) said he/she
expected quarterly assessments related to the use of a restraint or device that could
potentially be a restraint, and use of that device should be included in the resident’s
care plan.
2. Review of Resident # 51’s quarterly MDS dated [DATE] showed:
– IV Antibiotics for MDRO (multi-drug resistant organism)
– On [MEDICATION NAME] due to yeast infection
Review of the Resident’s current care plan on 5/14/19 for Urinary Catheter or UTI (urinary
track infection)., showed the resident received IV antibiotics and has a Urinary Tract
Infection due to (Escherichia coli (abbreviated as E. coli) are bacteria found in the
environment, foods, and intestines of people and animals and ESBL (Extended – Spectrum
Beta -Lactamase); a bacteria not resolved with common antibiotics and are spread via
direct and indirect contact with colonized/infected patients and contaminated
environmental surfaces. Contact Isolation started 2/27/2019 (no discontinued date).
Review of the resident’s current (MONTH) 2019 physician orders [REDACTED].
During an interview on 05/14/19 at 12:29 PM., MDS/Care Plan Coordinator B, said she was
the MDS/Care Plan Coordinator for the Long Term Care residents. She went to training a
couple of months ago and found out she needed to pull the 24 hour report daily so she
could keep the care plans up to date. She had started pulling the 24 hour reports about a
month ago but had not gotten the information carried over to the care plans. She was
behind updating the resident’s care plan as well as the care plan of other residents. The
resident’s care plan has not been updated. The resident has not received IV antibiotics or
been on isolation precautions for a couple of months. She was unsure with the [MEDICATION
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
NAME] order was discontinued.
3. Review of Centers of Disease Control and Prevention (CDC) Guideline for Isolation
Precautions showed:
– Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves
for all interactions that may involve contact with the patient or potentially contaminated
areas in the patient’s environment.
Review of Resident #5’s current care plan showed:
– The resident was on antibiotic therapy with regards to a urinary tract infection and on
contact isolation, precautions to prevent transmission of infectious agents, for Extended
Spectrum Beta-Lactamase (ESBL) in urine.
During an observation on 5/10/19 at 2:36 P.M. of wound care showed:
– LPN E provided wound care, wearing gloves but did not wear a gown.
Review of the resident’s (MONTH) 2019 physician order [REDACTED].>4. Review of Resident
#47’s comprehensive MDS dated [DATE] showed:
– Cognitively intact;
-Indwelling catheter.
Review of the resident’s care plan dated 5/3/19 showed the resident had a urinary
catheter. The intervention included staff to monitor and document intake and output (I/O)
as per facility policy.
During an interview on 5/08/19 at 1:27 P.M. the resident said it was hard to get ice water
at the facility. Observation at the same time showed no water was in the resident’s room,
the resident’s water cup was empty. The resident had fruit punch served with lunch but
said the facility staff knew he/she does not drink it.
Observation on 5/10/19 at 8:51 A.M. showed:
– The Resident yelled from his/her room that he/she needed some water, maintenance staff
walked by the resident’s door at the time he/she yelled it, did not say anything to the
resident.
– At 8:55 A.M. the resident yelled again, I need some ice water; An unknown staff member
in to the room asked if the resident had gotten his/her room tray, the resident said no
and that he/she wanted some ice water, staff took the resident’s cup got ice from the
storage closet and filled the resident’s cup at his/her sink.
During an interview on 5/14/19 at 1:23 P.M. Regional Cooperate staff said the facility did
not have I/O records for the resident and did not know why.
5. During an interview on 5/14/19 at 4:00 P.M. the Director of Nursing (DON) said:
– Staff should provide fresh water/ice as desired at least each shift;
– Care Plans should have been updated with regards to changes in the residents’
conditions, for example interventions, antibiotic therapy;
– Care plans should have been followed.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review, the facility failed to ensure staff
followed professional standards of care when staff failed to clean the port of the insulin
pen before use, did not complete accu checks, administer eye drops correctly, left

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 – Some

(continued… from page 7)
medications at residents’ bedsides, failed to wrap the resident’s legs as ordered , which
affected of six 24 sampled residents (Resident #4, #34, #85, #17, #51, and #86). The
facility census was 106.
1. Review of the facility’s undated Blood Glucose Monitoring policy, showed:
– Clean the site (finger) with alcohol and allow to dry completely.
2. Review of Resident #4’s current (MONTH) 2019, physician order [REDACTED].
– [MEDICATION NAME]100 units/milliliters (ml) Inject 10 units before meals.
– The physician order [REDACTED].>Observation on 5/8/19 at 7:21 A.M.,showed Licensed
Practical Nurse (LPN) A wiped the resident’s finger with an alcohol pad, waved his/her
gloved hand over it a couple of times, pricked the finger with a lancet and used the the
first drop of blood to test the resident’s blood sugar.
Observation on 5/8/19 at 7:43 A.M., showed LPN A did not clean the port of the [MEDICATION
NAME] kwikpen before he/she applied a new needle, drew up the ordered amount of insulin
and without cleaning an area on the resident’s skin, administered it to the resident.
During an interview on 5/8/19 at 10:38 A.M., LPN A said:
– He/she should have cleaned the kwikpen port with alcohol before he/she put the new
needle on and should have cleaned an area on the resident’s skin, but did not have any
alcohol pads on his/her cart.
During an interview on 5/14/19 at 4:00 P.M., the Director of Nurses (DON) said:
– Staff should clean the port of the kwikpen with an alcohol pad before they applied a new
needle. Should also clean resident’s skin with alcohol pad before administering an
injection;
– Staff should let the alcohol on the finger air dry, wipe away the first drop of blood
and use the second drop for the blood sugar reading.
3. Review of the facility’s copy of the manufacturer’s guideline for Ilevro eye drops
showed to gently shake the eye drop before use. The facility did not have a manufacturer’s
guideline for Durazol eye drops.
Review of www.drugs.com showed Durazol [MEDICATION NAME] eye drops, hold gentle pressure
for one minute to prevent medication from entering the tear duct.
4. Review of Resident #34’s current May, 2019 physician order [REDACTED].
– [MEDICATION NAME] 0.005 % Instill one drop in left eye two times a day;
– Ilevro Suspension 0.3 % Instill one drop in left eye two times a day.
Observation on 5/8/19 at 8:12 A.M., showed Certified Medication Technician (CMT) C put on
gloves, did not shake or roll the eye drop bottle, did not make a pouch with the left
lower eye lid, instilled one drop of medication into the left eye, held pressure to the
inner canthus (inner corner of the eye) for 15 seconds while the resident blinked. A drop
of medication rolled down the side of the resident’s cheek.
Observation on 5/8/19 at 8:42 A.M., showed CMT C did not wash or sanitize hands, put on
gloves, did not shake or roll the eye drop bottle, instilled one drop in to the left eye
and held pressure on the inner canthus for 23 seconds.
During an interview on 5/919 at 9:43 A.M., CMT C said:
– He/she should shake all medicated eye drops as the solution in the drops could separate
and settle to the bottom;
– He/she thought staff should hold pressure to the inner canthus for 30 seconds to a
minute after they instilled the drop into the resident’s eye.
During an interview on 5/14/19 at 4:00 P.M., the DON said:
– Staff should shake or roll the eye drop medication before they administered the
medication
– Staff should apply gentle pressure to the inner canthus for 30 seconds to a minute after
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 – Some

(continued… from page 8)
they administered the medication.
5. Review of the website https://www.[MEDICATION
NAME].com/asthma/talking-to-you-doctor/how-to-use-the-inhaler.html showed to take
[MEDICATION NAME] exactly as prescribed by the physician. It is important not to miss a
dose or take more doses than prescribed.
6. Review of Resident #86’s (MONTH) 2019 physician order [REDACTED].>-[MEDICATION NAME]
inhaler 80/4.5 (used to decrease inflammation and dilate air pathways in the lungs) inhale
two times a day for breathing, ordered 4/15/19;
-[DIAGNOSES REDACTED].
Observation on 5/8/19 at 11:36 A.M. showed LPN B administered one inhalation of
[MEDICATION NAME], had the resident rinse his/her mouth with water and spit it out, then
returned at 11:50 A.M. and administered a second inhalation of [MEDICATION NAME].
During an interview on 5/8/19 at 12:08 P.M., LPN B said the order directed to give two
inhalations a day, so she administered two inhalations.
Review of the resident’s (MONTH) 2019 Medication Administration Record [REDACTED]
-[MEDICATION NAME] inhaler 80/4.5, inhale two times a day for breathing;
-Administer at 8:00 A.M. and 8:00 P.M.
-Staff documented that the resident received the inhaler twice a day 5/1/-5/8/19.
During an interview on 5/14/19 at 4:00 P.M., the director of nurses said that staff should
have clarified the [MEDICATION NAME] order with the physician.
7. Review of the facility’s undated medication administration policy showed that
medications must be given to the resident by a licensed nurse or licensed independent
practitioner, or as consistent with state law. Medications will not be left at the
bedside.
8. Review of Resident #85’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/27/19, showed:
-Moderate cognitive impairment;
-Required extensive staff assistance for transfers and toileting;
-Required supervision and set-up assistance for eating;
-Took medications that included antidepressants, blood thinners, diuretics and narcotic
pain medications.
Review of the resident’s (MONTH) 2019 physician order [REDACTED].
(for swelling.
Observation on 5/7/19 at 9:59 A.M., showed the resident sat in a wheelchair in his/her
room with a medication cup on the over-bed-table which contained seven pills, a second
medication cup which was 1/2 full of a white liquid, and a third medication cup full of a
golden colored liquid. The resident said staff left the medications while he/she was in
the bathroom.
During an interview on 5/14/19 at 4:00 P.M., the director of nurses (DON) said staff
should not leave medications in resident rooms.
9. Review of Resident 17’s ‘ quarterly MDS showed:
– BIM of 5 – impaired for decision making.
– One person physical assist with bed mobility.
– [DIAGNOSES REDACTED].
Observation and interview on 05/7/19 at 10:59 AM., showed Resident #17 asleep in bed.
Multiple medications (pills) in a small plastic cup sat beside a small glass of liquid
containing an unmixed powdery substance on the resident’s nightstand. The resident’s
room-mate said the nurse sometimes leaves medications on his/her room-mates bedside table.
His/her roommate is very confused.
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 – Some

(continued… from page 9)
Review of the resident’s physician orders [REDACTED].>- [MEDICATION NAME] Tablets 5 MG
one tablet each morning [MEDICAL CONDITION](high blood pressure).
– [MEDICATION NAME] Light Packets 4 GM by mouth one time a day for diarrhea mix with 8
ounces of liquid.
– [MEDICATION NAME] Capsules 1.5 MG give one capsule by mouth in the morning for dementia
GIVE WITH FOOD.
– Lactobacillus Tablet Give one tablet by mouth in the morning for supplement.
– Multiple Vitamin Tablet – Give one tablet by mouth in the morning for supplement-wound
healing.
– Xarelto Tablets 10 MG give one table by mouth in the morning for anticoagulant.
During an interview on 5/14/19 at 10:55 AM., the Assistance Director of Nursing (ADON)
said staff should not leave medications on the resident’s bedside table and should not
preset medications. Staff should go back a short time later and try to administer the
mediations.
10. Review of Resident # 51’s quarterly MDS dated [DATE] showed:
– BIMS score of 15 indicating resident has no impairment for decision making skills or
memory loss.
– Resident has occasional pain.
Observation and interview on 05/08/19 10:53 AM., showed Resident # 51., sat in a
wheelchair with loose wraps around both legs; a brown substance showed through one of the
leg wraps. The resident said staff do not change his/her legs dressings per the physician
orders. Some of the staff do not have a clue what they are doing and wrap them poorly and
they fall down. He/she was a retired nurse and knew a thing or two about how to wrap a leg
wound. Thank goodness he/she goes to the wound clinic or his/her legs would be in worse
shape than they are. The facility has had several wound nurses’s and he/she has no idea
who the wound nurse is at this time.
Record review of physician orders [REDACTED].
Wound #2 Left Lower Leg Care of Wound: * Remove Dressing, Cleanse with soap & water
or Wound Cleanser, Pat Dry – Apply Xeroform to weeping areas, cover with ABD Pad Wrap with
4 Layer compression (cotton, Kerlix, Ace, Coban) Change Dressings Mon/Wed/Fri one time a
day every Mon, Wed, Fri for Wound Care
Wound #1 Right Lower Leg Care of Wound: * Remove Dressing, Cleanse with soap & water
or Wound Cleanser, Pat Dry – Apply Xeroform to weeping areas cover with ABD Pad wrap with
4 Layer compression (cotton, Kerlix, Ace, Coban) Change Dressings Mon/Wed/Fri one time a
day every Mon, Wed, Fri for Wound Care
Other Active 5/1/2019 09:00 4/30/2019.
Review of the resident’s Treatment Administration Records (TAR) for (MONTH) showed the
following orders and treatments to the resident’s legs.
– Lower right Leg ( change dressing weekly on Wednesday and as needed): Dressing not
marked as done on (MONTH) 3rd and (MONTH) 24th.
– Lower left leg (change dressing weekly on Wednesday and as needed): Dressing not marked
as done on (MONTH) 3rd and 24th
Review of the Resident’s TAR for (MONTH) 2019 on 05/14/19 showed the following:
Wound 1: Right lower leg change dressing Monday, Wednesday and Friday. Staff did not mark
TAR to show dressing was changed on (MONTH) 3rd.
Wound Treatment BLE (Both lower extremities) wound: Document compression wraps intact
daily check every shift; Can be off for bath/shower care needs. Wrap with plastic
protection BLE compression wraps.
Staff did not mark that the wraps were in place on the day shift on (MONTH) 4th and the
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 – Some

(continued… from page 10)
evening shift on (MONTH) 9, 10th, and 12th.
During an interview on 5/14/19 at 4:00 P.M., the Director of Nurses said:
– All treatments and monitoring ordered by the physician should be completed and
documented.

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 observations, interviews and record review, the facility failed to ensure
dependent residents who were unable to carry out activities of daily living (ADL) received
the necessary services to maintain good personal hygiene when staff did not provide
complete perineal care, which affected three of 24 sampled residents (Residents #13, #22,
and #62). Staff also failed to ensure residents received baths/showers as scheduled and/or
preferred for five sampled residents (Residents #1, #49, #14, #75 and #66). The facility
census was 106.
1. Review of the facility’s undated policy for Perineal Care, showed:
– To maintain cleanliness of the genital area, to reduce odor and to prevent infection or
skin breakdown;
– Perineal care is provided as part of a resident’s hygienic program, a minimum of once
daily and per resident need;
– Wash the pubic area, separate and cleanse all perineal folds moving from front to back;
– Use a clean area of the wash cloth/cleansing wipe for each stroke;
– Rinse area moving front to back using a clean area of wash cloth or wipe for each
stroke;
– Wash, rinse and dry buttocks and peri-anal area without contaminating perineal area.
2. Review of Resident #13’s Minimum Data Set (MDS), a federally mandated assessment
completed by facility staff, dated 2/12/19, showed:
– Difficulty making decisions;
– Required assistance of staff with toilet use and personal hygiene;
– Occasionally incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan revised on 5/8/19, showed:
– Resident requires extensive assistance of staff with personal hygiene and toilet use.
Observation an interview on 5/8/19, at 7:06 A.M., showed the resident lay in bed, his/her
brief soiled with urine. The resident said he/she had held the urine for over an hour
waiting for staff to help him/her out of bed to go to the bathroom and couldn’t wait any
longer. Certified Nurse Aide (CNA) A provided peri-care in the following way:
– Put on a pair of gloves and unfastened the resident’s brief;
– Grabbed a handful of wet wipes and balled them up in his/her hand;
– He/she rubbed back and forth, up and down over the pubic and peri area without changing
the wipes or the position of the wipes;
– After the resident rolled over, he/she used the same wadded up wet wipes he/she used on
the front and wiped once from the resident’s coccyx to the rectal area.
– CNA A did not separate and clean all perineal folds, did not wash the resident’s inner
legs, hips or buttocks and cleaned the resident in the wrong direction.

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 11)
During an interview on 5/8/19, at 2:02 P.M., CNA A said:
– He/she wiped the front from top to bottom and wiped more times if the resident had pubic
hair;
– If there was no fecal material, it was okay to wipe back and forth in different
directions.
3. Review of Resident #22’s MDS, dated [DATE], showed:
– Unable to make daily decisions;
– Required assistance of facility staff for toilet use and personal hygiene;
– Frequently incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the nurse’s note, dated 3/10/19, showed the physician ordered [MEDICATION NAME]
(an antibiotic) 100 milligrams (mg) for a urinary tract infection.
Review of the resident’s care plan, dated 3/21/19, showed:
– Assist with toilet use and peri-care;
– Monitor and document signs and symptoms of urinary tract infection.
Observation and interview on 5/10/19, at 10:41 A.M., showed the resident in his/her wheel
chair trying to get into the bathroom. CNA E provided peri-care in the following way:
– He/she assisted the resident to remove his/her soiled brief and assisted him/her to the
toilet;
– While the resident sat on the toilet, CNA E reached between the resident’s legs and
provided partial peri-care;
– He/she assisted the resident to stand and wiped twice from the rectum to coccyx and one
hand width on each buttock;
– CNA E did not separate and thoroughly clean all perineal folds, inner legs or complete
buttocks;
– CNA E said the resident would not stand long enough to complete the peri-care. The
resident might fall.
4. Review of Resident #62’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Required extensive assistance for personal hygiene;
– Totally dependent on staff for toileting and bathing;
– Incontinent of bowel and bladder.
Review of the resident’s care plan, last revised on 4/2/19, showed:
– Incontinent of bowel and bladder;
– Clean peri-area with each incontinent episode;
– Had moisture-associated skin damage to the groin and buttocks;
– Required total assistance for toileting.
Observation on 5/14/19, at 10:24 A.M., showed CNAs A and D provided incontinent care in
the following manner as the resident lay in bed:
– Both washed their hands and put on gloves.
– CNA A unfastened the resident’s brief and wiped back and forth multiple times across the
area between the resident’s groin areas, using the same moist wipe and same area of moist
wipe.
– Staff did not cleanse the groin areas or between the front genital skin folds.
– CNA D turned the resident on his/her right side.
– CNA A pulled out several moist wipes, folded them together, and used the same wipes and
area of wipes to cleanse the buttocks and rectal areas as he/she wiped back and forth
across the buttocks.
– CNA D turned the resident on his/her back.
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 12)
– With the same gloves on, CNA A obtained several folded moist wipes and wiped between the
resident’s front genital folds several times, using the same wipes and area of wipes each
time.
– Staff then dressed the resident and transferred him/her to a wheelchair.
5. During an interview on 5/14/19, at 4:00 P.M., the Director of Nurses said:
– Staff should not use the same area of the wipe to clean different areas of the skin;
– Staff should wipe away from the urethra, should wipe front to back;
– Staff should clean every area that is touched by urine or fecal material;
– Staff should cleanse the inner legs, thighs front and back also.
6. Review of the facility’s undated policy related to showering residents showed:
– A shower/bath is given to residents to provide cleanliness, comfort and to prevent body
odors.
– Residents are offered a shower, at a minimum, once weekly, and provided per resident
request.
7. Review of Resident #1’s annual MDS, dated [DATE], showed that it was very important for
the resident to choose between a bath, shower or sponge bath.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Required extensive assistance for toileting, personal hygiene and bathing;
– Always incontinent of bladder and frequently incontinent of bowel.
Review of the resident’s bathing documentation for (MONTH) 2019 showed:
– Two different types of documentation forms (electronic documentation and paper skin
monitoring/shower review sheets);
– No documentation to show the resident’s preferred bathing choice;
– Paper shower sheets documented one shower not taken with no other explanation (2/1/19),
three received (2/13/19, 2/20/19 and 2/26/19), and two with was pulled or pulled to floor
written on them.
– Electronic documentation showed one bath/shower done on 2/12/19, and all other entries
showed and X, a blank, or Not Applicable.
Review of the resident’s bathing documentation for (MONTH) 2019 showed:
– Two paper shower sheets which documented pulled (3/1/19) and refused (3/5/19).
– Electronic documentation showed three refused baths/showers (3/5/19, 3/27/19 and
3/30/19) and the remaining dates showed an X, a blank, or Not Applicable.
Review of the resident’s bathing documentation for (MONTH) 2019 showed:
– No paper shower sheets;
– Electronic documentation showed two baths/showers completed 4/19/19 and 4/26/19 and the
remaining dates showed and X, a blank, or Not Applicable.
Review of the resident’s bathing documentation for (MONTH) 1 through (MONTH) 8, 2019
showed:
– No paper shower sheets;
– Electronic documentation showed Not Applicable for 5/1/19, 5/4/19 and 5/8/19, and an X
on all other dates.
Review of the resident’s urine culture and sensitivity (lab showing specific bacteria
identified and antibiotic specific to treating the bacteria), dated as collected on
5/1/19, showed the presence of E. coli (commonly found in the bowel) in sufficient amounts
to indicate the probability of a urinary tract infection.
Review of the resident’s care plan, last updated on 5/7/19, showed:
– Had a urinary catheter;
– Incontinent of bowel;
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 13)
– At risk for urinary tract infections;
– Required assistance with bathing/showering and hygiene;
– Did not indicate the resident’s bathing/showering preferences.
Observation and interview on 5/8/19, at 1:06 P.M., showed and the resident said:
– The resident had long hair that appeared greasy.
– He/she should receive two showers or baths a week.
– Staff offered him/her a shower yesterday, and the resident initially said he/she did not
feel like taking one. The nurse encouraged him/her, so he/she then consented to take it,
but it never happened.
– This Friday, it would be two weeks since he/she had a bath/shower.
– His/her hair was driving him/her crazy because it was so dirty and felt so bad.
– He/she had a large bowel movement and really needed a good shower.
– Staff tried to get him/her to take a bed bath, but he/she needed a good shower.
– Staff told him/her that he/she would get a shower today, but he/she was still waiting.
This occurred often.
– The facility previously had a shower aide, but currently did not have one.
8. Review of Resident #14’s admission MDS, dated [DATE], showed:
– Cognitively intact;
– Very important to choose between a bath, shower or bed bath.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Independent for transfers and ambulation;
– Continent of bowel and bladder.
The facility provided no bathing documentation for the resident for (MONTH) 2019.
Review of the resident’s (MONTH) 2019 bathing documentation showed:
– No paper shower sheets;
– Electronic documentation showed the resident received a bath/shower on 3/12/19, 3/19/19
and 3/30/19, and refused a bath/shower on 3/16/19.
Review of the resident’s (MONTH) 2019 bathing documentation showed:
– One paper shower sheet for 4/22/19;
– Electronic documentation showed the resident received a bath/shower on 4/6/19 and
4/17/19, refused a bath/shower on 4/27/19, and the remainder of dates showed a blank, and
X or Not Applicable.
Review of the resident’s bathing documentation for (MONTH) 1 through (MONTH) 8, 2019
showed:
– No paper shower sheets;
– Electronic documentation showed the resident received a bath/shower on 5/8/19 and the
remaining dates showed either and X or Not Applicable.
During an interview on 5/7/19, at 9:15 A.M., the resident said:
– Staff do not provide showers as scheduled.
– He/she sometimes received none, and other times received one a week.
– When he/she, or other residents spoke up, then staff would do a couple of showers, then
they stopped providing them again.
– He/she also had to sleep in the same pissy bed for five days.
Review of the resident’s care plan, last revised on 5/10/19, showed:
– Required set-up assistance with bathing/showering;
– Had moisture-associated skin damage under abdominal fold;
– Did not indicate the resident’s bathing/showering preferences.
9. Review of Resident #49’s (MONTH) 2019 bathing documentation 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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 14)
– Paper shower sheets showed the resident received baths/showers on 2/1/19, 2/5/19,
2/12/19, 2/15/19, 2/19/19, 2/22/19 and 2/26/19.
– Electronic documentation only documented the resident received baths/showers on 2/12/19,
2/19/19 and 2/26/19, and the remainder of the dates were either blank or showed Not
Applicable.
Review of the resident’s (MONTH) 2019 bathing documentation showed:
– One paper shower sheet, dated 3/1/19;
– Electronic documentation showed the resident received baths/showers on 3/5/19 and
3/27/19, and the remaining dates were either blank, showed an X or Not Applicable.
Review of Resident #49’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Limited range of motion of one side of the lower extremities;
– Required extensive assistance with toileting;
– Required physical help with part of bathing;
– Occasionally incontinent of bladder.
Review of the resident’s (MONTH) 2019 bathing documentation showed:
– No paper shower sheets;
– Electronic documentation showed the resident received baths/showers on 4/3/19, 4/10/19,
4/24/19 and 4/27/19 and the remaining dates were either blank, showed an X or Not
Applicable.
Review of the resident’s care plan, last revised on 4/25/19, showed:
– Occasionally incontinent of bladder;
– Required extensive assistance with bathing/showering;
– Did not indicate his/her bathing/showering preferences.
Review of the resident’s bathing documentation dated (MONTH) 1 through (MONTH) 8, 2019
showed:
– One paper shower sheet dated 5/7/19;
– Electronic documentation showed the resident received a bath/shower on 5/8/19 and the
remaining dates showed either an X or Not Applicable.
During an interview on 5/7/19, at 11:51 A.M., the resident said he/she did not receive two
showers a week and had to fight to get one a week. The facility did have a shower aide,
but he/she did not know if there was a shower aide any longer.
10. Review of Resident #66’s quarterly MDS dated [DATE], showed:
– Cognitively intact
– One person physical assistance with toilet use, dressing and showers.
– Uses Wheel-chair
– Has an indwelling catheter.
Review of the resident’s care plan, dated 4/29/19, showed the resident needs extensive
assist with bathing, No preferences related to bathing was noted.
Review of the resident’s (MONTH) 2019 bathing documentation showed:
– One paper shower sheet, dated 3/1/19;
– Electronic documentation showed the resident received baths/showers on 3/5/19 and
3/27/19, and the remaining dates were either blank, showed an X or marked Not Applicable.
Review of the resident’s shower sheets and electronic records for (MONTH) and (MONTH) on
5/8/19 showed staff documented only one shower as given to the resident in the last 30
days. Staff documented a shower as given on 4/25/19.
During an interview on 5/7/19, at 2:51 P.M., the resident said he/she needed a shower.
He/she had asked and asked for a shower. The facility did away with shower aides. It has
been at least two weeks since he/she received a shower. Staff mark baths as given or
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 15)
refused when they do not have time to give a shower. He/she was starting to smell; he/she
uses the sink and a wash cloth to wash his/her face and arms, but he/she is unable to wash
the bottom half of his/her body. He/she fell s dirty. He/she often has to take his/herself
to the bathroom or empty his/her catheter bag. He/she is unable to clean his/herself up
well after using the bathroom. Sometimes it take two hours for staff to respond to the
call light so he/she can either poop his/her pants or take his/herself. He/she just needs
a good shower so he/she does not stink.
11. Review of Resident #75’s admission (re-admission) MDS, dated [DATE], showed:
– Cognitively impaired;
– Has dementia and a mental health [DIAGNOSES REDACTED].>- Resident requires assistance
of one for dressing, hygiene and bathing;
– Resident uses a wheelchair or walker for mobility.
Review of the resident’s bathing follow-up report showed the resident received a
bath/shower on:
– 4/1/19, 4/15/19, 4/18/19, and 4/29/19;
– 5/2/19.
During an interview on 5/7/19, at 11:05 A.M., Guardian/Family Member A said:
– He/she had requested that the resident be bathed/showered daily for two weeks.
– He/she is in the facility daily and would know when and if the resident received a
shower.
– The resident last showers was over two weeks ago.
– The resident has an unpleasant body order.
– He/she thinks staff mark showers as given when they run out of time and do not get their
work done.
During an interview on 5/10/19, at 1:50 PM., CNA J said if he/she is the only CNA on unit,
he/she might get two showers done per day if he/she is lucky. He/she can only do them when
the certified medication technician (CMT) is on the floor. He/she tells the charge nurse
the showers were not done at the end of the shift but he/she does not document anything in
the computer or on paper.
During an interview on 5/14/19, at 8:40 A.M., CMT E said when showers are not given, staff
should mark the shower as not given so the shower will pop up for the next shift to give
the shower. Too many times, the CNAs mark not available when they (staff) are no available
to give the showers, then the showers do not show up for the next shift to give the
shower. Too many residents are not getting the showers they need. He/she often worked the
floor when they are short-handed instead of passing medications or doing his/her paper
work. There is just not enough staff to care for the residents. He/she cares and he/she is
working way too many hours but there is no one else to do it. When staff fail to come to
work and do not call in, it make it hard for the good employees; because they have to
works doubles and extra hard to cover for the staff that did not show up.
Observation and interview on 5/14/19, at 2:20 P.M., showed CNA G checking off tasks on the
computer. He/she said he/she had a long list of showers that were supposed to be given
today. He/she did not have time to do showers as he/she was busy helping with meals and
resident care. He/she marked the showers as not available. He/she did not know if the
shower marked not available would be triggered for someone to give the next shift or the
next day. There was just to must to do and not enough help. It is impossible to get
everything done.
12. During an interview on 5/10/19, at 7:35 A.M., the Administrator said:
– A lot of staff quit due to not being able to meet job performance expectations and a few
were dismissed.
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 16)
– She revamped the shower schedule in (MONTH) and put bathing in the electronic
documentation system as a task and the process is on-going.
– Corporate staff previously directed to quit using the paper shower sheets, but some
staff continued to use them on a hit-or-miss basis.
– The administrator directed to start using them again as of 5/1/19.
– She runs an audit weekly to monitor bathing and had done this three or four times.
– Residents should receive two baths/showers a week, although they have one resident who
was care planned for one a week and that resident usually refused it.
– The administrator looked at the electronic documentation for one resident but was unable
to decipher what the bathing documentation meant and said she would e-mail another staff
for an explanation.
– She could not explain why some bath sheets and electronic documentation did not match
and was not aware that some residents voiced that staff documented that they received or
refused baths/showers when they did not receive or refuse them.
– She stated that the current Director of Nurses (DON) had worked at the facility for
about three weeks and the previous DON had quit without notice.
During an interview on 5/14/19 at 4:00 P.M., the DON said:
– Staff should offer residents at least two baths/showers each week.
– Residents have a right to decline baths/showers and staff should care plan a resident’s
preference to bathe less than two times a week.
– Staff were to complete paper bath sheets and document bathing electronically.
– She did not know what Not Applicable meant related to electronic documentation of
bathing.
– Staff run bathing reports each morning, and if a bath is noted as not done, then the
resident should be offered one the next day.
– The facility currently had an evening staff scheduled to do bathing.
– They previously had a staff scheduled to do bathing on days, but not at this time.
– The CNAs should be assigned to do baths/showers if there is no bath aide.
– The nurse manager should follow-up if bathing is not documented, and if refused, staff
need to find out why the resident is refusing it.

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.

Based on observations, interview and record review, the facility failed to document and
investigate a fall for one additional sampled resident (Resident # 34). The facility
census was 106.
1. Review of Resident #34’s quarterly Minimum Data Set (MDS), a federally mandated
assessment completed by facility staff, dated 2/25/19 showed:
– Cognitively intact;
– Used a wheelchair;
– Required one person assist with transfers including to and from wheelchair and bed.
During an interview on 5/10/19 at 10:47 A.M. Resident #34 said:
– Five to seven weeks ago he/she was living on the 800 unit when CMT D assisted him/her
with transferring the resident to his/her 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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 17)
– When the resident stood up, CMT D pulled down his/her pants and briefs, but did not take
them off, just left them around his/her ankles;
– He/she was sitting on the side of the bed when CMT D turned his/her wheelchair on and
started backing it up when the wheels caught his/her pants and briefs;
-The resident told the staff to stop four times but was pulled off the bed and hit the
floor;
– Medical Records staff came in the next day and ask if he/she got hurt and he/she said
no. Medical Records staff told the resident that CMT D said the cause of the fall was due
him/her to being a fall risk;
-Medical Records staff helped the resident fill out a grievance form and she turned it in
to whomever handles the complaints, he/she saw her fill out grievance form;
– When a nurse came in the next shift (unknown staff) he/she also told him/her the story
of what happened;
– The resident said he/she has fallen two times since living at the facility.
Review of the Resident’s medical record did not show any documented falls.
During an interview on 5/10/19 at 10:19 A.M. Medical Records staff said:
– She thought the resident had a fall in the shower a couple months ago but did not recall
when it happened, and did not complete a grievance about it. She said the resident came in
and told her he had a fall but that was it.
During an interview on 5/10/19 at 11:00 A.M. the Administrator said there is was not any
reports of falls or incidents involving the resident.
During an interview on 5/10/19 at 11:16 A.M. Registered Nurse LPN B said;
– He/she knew the resident had fallen while living at the facility;
– There was an incident a month or two ago in the resident’s bathroom or bedroom area but
it was on the 500 Unit;
– He/she did not recall any falls on the 800 hall, he/she not fallen with her with her,
and was not sure if the falls were documented;
– He/she did not recall if the resident said anything about a fall being due to actions of
a staff member.
During an interview on 5/14/19 at 4:00 P.M. the Director of Nursing (DON) said falls
should be documented and investigated.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
provided complete catheter (a sterile tube inserted into the bladder to drain urine) care
in a manner to prevent infection or the possibility of infection which affected three of
24 sampled residents (Resident #46, #56, and #1). The facility census was 106.
1. Review of the facility’s undated policy for Care of Catheters, showed:
– To prevent catheter-associated urinary tract infections;
– A resident, with or without a catheter, receives the appropriate care and services to
prevent infections to the extent possible;
– Wash hands and don gloves prior to handling the catheter, drainage system or bag;

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
– Remove the leg strap and inspect the area for signs and symptoms of adhesive burns,
redness, tenderness, blisters or open skin areas;
– Cleanse the perineum from front to back and cleanse the outside of the catheter wiping
away from the meatus;
– Reattach the catheter to the leg strap. Ensure the catheter is properly anchored to
prevent tearing;
– Keep the urinary drainage bag will be kept below the level of the bladder;
– Empty the urinary drainage bag each shift or more often as indicated. Use a separate
container for each resident and avoid touching the spigot to the container.
2. Review of Resident #46’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 3/9/19, showed:
– Difficulty making daily decisions;
– Required assistance of staff for toilet use and personal hygiene;
– Indwelling catheter and frequently incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on all days (5/7, 5/8, 5/9, 5/10 and 5/14) at various times throughout the day
the resident was observed in his/her room, the hallways of the facility and in the dining
room areas with the catheter tubing dragging the floor. Observation and interview on
5/14/19 at 10:11 A.M., showed the resident lay in bed with a supra-pubic catheter (a
urinary catheter that is inserted into the abdominal wall and into the bladder) and no leg
strap to aide in preventing the catheter from being pulled or dislodged. The urinary
drainage bag hung under the resident’s wheel chair next to his/her bed and touched the
floor, the drain spout lay on the floor and was not placed in the sleeve attached to the
drainage catheter bag. Certified Nurse Aide (CNA) A said the insertion site looked
infected then he/she provided catheter care in the following way:
– Without washing his/her hands, he/she put on a pair of gloves;
– Did not fully manipulate and cleanse the perineal folds;
– Did not anchor the tubing close to the insertion cite of the catheter into the body;
– Took one wet wipe and wiped down the catheter, used a second wet wipe and cleansed
around the insertion site then proceeded to wipe down the catheter and also cleaned the
ports on the catheter with the second wet wipe;
– Retrieved a graduate (plastic measuring container) from the bathroom, set it down on the
floor without a clean field, opened the drain spout and drained the urine;
– Without cleaning the drain spout placed it in the sleeve on the urinary drainage bag.
3. Review of Resident # 56’s MDS, dated [DATE], showed:
– Difficulty making daily decisions;
– Required assist with toilet use and personal hygiene;
– Indwelling catheter and [MEDICAL CONDITION];
– [DIAGNOSES REDACTED].
Observation on 5/7/19 at 11:51 A.M., showed the resident lay in bed and the dignity bag
that contained the urinary drainage bag, dragged the floor. Observation on 5/14/19 at 9:11
A.M., showed CNA A retrieved the graduate from the bathroom. He/she sat the graduate on
the floor in the plastic bag it was stored in from the the bathroom, emptied the urine
from the urinary drainage spout and without cleaning the
spout replaced it in the sleeve.
During an interview on 5/14/19 at 3:59 P.M., CNA A said:
– He/she should have placed a mat or something on the floor to set the graduate on;
– He/she should have cleaned the port with hot water or some type of sanitary something;
– He/she didn’t think the facility had alcohol pads;
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
– He/she should anchor the tubing at the insertion site before cleaning the catheter;
– The residents should have a leg strap.
5. During an interview on 5/14/19 at 4:10 P.m., the Director of Nurses said:
– Staff should clean anything heavily soiled away from the area that might cause
infection;
– Staff should provide incontinent care prior to catheter care;
– Staff should use one swipe per wipe for any care;
– It is not acceptable to clean around an insertion site and with the same wipe clean the
catheter tubing;
– Staff should set the graduate on a clean surface before they drained urine into the
graduate;
– Staff should clean the drainage spout with either an alcohol wipe or a disinfectant wipe
of some type;
– Staff should use a leg strap to secure the tubing unless contraindicated and if so, it
should be care planned.
4. Review of Resident #1’s quarterly MDS, dated [DATE], showed:
-Incontinent of bladder;
-No UTI;
-Required extensive assistance for toileting and personal hygiene.
Review of the resident’s care plan, last revised on 5/7/19, showed:
-Had a catheter due to urine retention and neuromuscular dysfunction;
-Catheter care each shift;
-Started on antibiotic therapy on 5/6/19 for a UTI.
During interviews on 5/7/19 at 4:06 P.M. and 4:12 P.M., the resident said:
-He/she currently had a UTI and started receiving an intramuscular antibiotic injection.
-It was hard to get staff to empty his/her catheter bag and it got so full that it pulled
on his/her catheter tubing secured to his/her leg.
-He/she wondered if the urine backflushed when it got so full.
During an observation on 5/8/19 at 1:15 P.M., Licensed Practical Nurse (LPN) A provided
the following care:
-Set a container on the bare floor, emptied urine from the resident’s catheter bag and
returned the drain spout to the holder without cleansing the spout;
-Emptied the urine in the toilet;
-Removed his/her gloves and left the room without sanitizing or washing his/her hands.
-During an interview on 5/8/19 at 1:34 P.M., LPN A said he/she did not know staff should
place a barrier between the bare floor and container when they emptied a catheter, and did
not know staff should cleanse the drain spout before they returned it to the holder.

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 offer sufficient
nutrition and hydration services to maintain proper nutritional status and hydration for
two of 24 sampled residents (Residents #47, and #70) and one additionally sampled resident
(Resident #26) according to the care plan for Resident #47, failed to provide the
physician-ordered ice cream and yogurt for Resident #70 and staff failed to ensure the

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 20)
resident was able to swallow when they fed him/her. Staff also failed to ensure residents
of the memory care (dementia) unit who did not have a way to obtain fluids anytime day or
night received sufficient hydration. The facility census was 106.
1. Review of Resident #70’s Minimum Data Set (MDS) a federally mandated assessment
completed by facility staff, dated 3/29/19, showed:
– Resident severely impaired for decisions making (never or rarely made decisions);
– Swallowing issues;
– History of coughing or chocking during meals and medication pass.
– Mechanically altered diet;
– One person assist with feeding.
Review of the resident’s care plan created on 3/8/18, and last revised on 4/10/19, showed:
– Serve puree texture food, regular thin liquids as ordered;
– Serve ice cream at every meal;
– Must have mechanical soft snacks with supervision;
– Divided plates at all meals in order to increase self-feeding tasks;
– House supplement three times daily.
Review of the resident’s physician order [REDACTED].
– Ice cream at evening meal for weight management; start date 3/2/19;
– Yogurt with breakfast for weight management; start date 3/2/19;
– House supplement three times daily for weight management (8:00 A.M., 12:00 P.M, and 4:00
P.M.).
Review of the resident’s current dietary card showed:
– Ice cream with every meal;
– No information about yogurt with his/her breakfast;
– Double portion;
– Divided plate.
Observation on 5/7/19, at 12:15 P.M., showed the resident sat in a wheelchair with his/her
head tilted backwards. Certified Medication Technician (CMT) B held the resident’s head
forward and feed him/her gritty pureed chicken and gravy; mashed potatoes, pureed carrots.
Staff did not fed the resident the regular textured cubed pineapple that was on the
resident’s tray. The tray did not contain ice cream and no health/supplement shake was
provided to the resident nor was there an empty supplement cup at the table like in the
main dining room.
Observation on 5/8/19, at 12:41 P.M., showed dietary staff sent a food tray containing
pureed food, regular pineapple chunks and no ice cream. The resident sat at the dining
room table with his/her head projected backwards. Certified Nurse Aide (CNA) I tried to
hold the resident’s head up and give him/her bites of food except for the pineapple chunks
which the resident should not have been served. CNA I told CMT B that the resident was not
swallowing and he/she was going to get the nurse and a magic cup (a frozen ice cream like
fortified food used as a dietaty supplement). CMT B picked up the resident’s spoon, held
his/her head forward and started to feed the resident. The CMT said he/she could get the
resident to swallow, so it was no big deal and continued feeding the resident pureed
chicken and gravy, mashed potatoes and pureed carrots.
Observation on 5/9/19, at 9:08 A.M., showed dietary staff prepared the resident’s tray and
sent it to the unit. The tray contained pureed eggs, pureed sausage and cream of wheat; no
ice cream or yogurt was on the tray. No supplement cup sat at the resident’s table or was
on the tray.
During an interview on 5/9/19, at 10:45 A.M., CMT E said they are supposed to pass dietary
supplements to residents who have orders for the supplement during medication pass.
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 21)
However, the supplement is not always available.
During an interview on 5/10/19, at 8:20 A.M., CNA B said hospice staff informed the unit
staff that they had placed the resident on comfort care and he/she was not to be fed as
he/she was not swallowing.
Review of the resident’s dietary intake sheet showed staff recorded the resident received
yogurt each morning at breakfast, even the morning of 5/10/19 when he/she was not to be
fed. Nursing staff documented he/she received supplements three times a day and ice cream
daily from 5/1/19 to the afternoon of 5/10/19.
During an interview on 5/14/19, at 8:34 A.M., CMT B said there is suppose to be a nurse at
every meal in each dining room to make sure residents do not choke. The nurse comes back
to the unit to do the accu-checks (fingerstick blood sugar readings), but then they are
busy and leave the unit before the food is served. There is no nurse on the unit during
meals and some of the residents are at risk for chocking; just like Resident #70 had been.

During an interview on 5/10/19, at 2:15 P.M., Cook B said the resident was supposed to
have ice cream with every meal according to his/her meal ticket. The person filling the
tray should pull the ice cream out of the freezer and place it on the resident’s tray. The
person handling the resident’s tray should make sure the tray contains the correct food at
the correct texture before it is given to the resident. The resident should not have been
served pineapple tiblets. Nursing should pass out the supplements to the residents. He/she
had never received a written order to send the resident yogurt on his/her breakfast tray
nor was he/she aware they were to only send ice cream with the supper tray. She had never
sent yogurt to the resident. She serves what is on the dietary carts to the best of
his/her ability.
During an interview on 5/10/19, at 2:20 P.M., Dietary Staff D said nursing should send
down a completed dietary communication form when there was a change in a resident’s diet
order. There was no dietary change form in the dietary manager’s desk drawer containing
other diet change forms.
2 . Observation on 5/7/19, at 11:05 AM., showed Resident #26 in his/her room trying to
lean across the sink to obtain water in a small plastic glass. The water ran onto the sink
and onto the resident’s sleeve. The resident said all he/she wanted was a good drink. The
resident had only a few sips of water in his/her glass.
Observation on all days of the survey showed multiple rooms on the Memory Care Unit
without water, ice or a cup.
During an interview on 5/8/19, at 1:30 P.M., CMT B, CNA B and CNA I, said they were not
allowed to provide mugs of ice water for the residents to have in their rooms like in
other parts of the building because many of the residents are confused and poured the
water on the floor or spilled it . They used to have a two gallon container of ice water
with a spout in the dining room/activity area so they could give resident’s drinks during
the day. It was removed and not replaced. They try to keep the left over milk and juice in
the refrigerator to give the residents to drink during the day but they seldom have more
than a few cups of leftover fluids. All three agreed they needed a hydration cart for the
unit residents. Some of the residents drink out of their room faucets but some of the
residents are not able to do so. CMT B said they used to have supplements in the
refrigerator to pass to the residents who are supposed to receive the supplements or
residents who were hungry. Anymore the supplement are not in the refrigerator and unless
there is help on the unit they cannot go to the kitchen after the supplement to use for
medication pass or at meal time.
During an interview on 5/13/19, at 12:55 P.M., Registered Dietitian (RD) said there should

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 22)
be juices, milk, meal supplement and finger foods as well as other easy to fix ingredients
in the unit refrigerator to allow for staff to offer a variety of drinks and snacks to the
residents several times daily (day or night). Residents with dementia are at high risk for
weight loss and dehydration.
Observation of the unit refrigerator of 5/14/19, at 3:10 P.M., showed three or four
glasses of chocolate milk in a 1/2 gallon size container; three or four cups of orange
drink and a small carton of yogurt was in the refrigerator. The refrigerator contained no
cartons of supplements for staff to serve the residents with physician ordered house
supplement(s).
3. Review of the undated facility policy titled Intake and Output Recording showed:
– Intake and output (I&O) is documented when indicated by an attending physician order
[REDACTED].
– I&O may be instituted per an attending physician’s orders [REDACTED].
– I&O is required for residents with indwelling catheters.
– For such residents: A resident will be placed on I&O for 30 days, or as required by
state law, until the resident’s output has been deemed stable by a licensed nurse; After
30 days, or as required by state law, the resident must be reevaluated by the licensed
nurse to determine further need for the recording of I&O;
– Nursing staff will be responsible for completing the I and O record at the end of each
shift;
– Information obtained from the I and O will be totaled daily and reviewed to ensure that
resident’s intake and output are sufficient to meet the resident’s needs;
– The licensed nurse conducts and documents a review of the I&O record at least weekly
or as specified by state law, to assess the resident’s fluid status and determine if
intake and output recording is still required;
– I&O recording may be discontinued if either of the criteria below is met: After the
licensed nurse’s assessment that indicated that resident is taking adequate intake and has
adequate output, if I&O was instituted by nursing department; The attending physician
discontinues the monitoring of I&O.
Review of Resident #47’s MDS, dated [DATE], showed:
– Cognitively intact;
– Indwelling catheter;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 5/3/19, showed the resident had a urinary
catheter. The intervention included staff to monitor and document I&O as per facility
policy.
Review of the resident’s medical record showed staff did not complete I&O records for
the resident.
Observation and interview on 5/8/19, at 1:27 P.M., the resident said it was hard to get
ice water at the facility. The resident had no water in his/her room and the resident’s
water cup was empty. The resident had fruit punch served with lunch but said the facility
staff knew he/she does not drink it.
Observation on 5/10/19, at 8:51 A.M., showed:
– The resident yelled from his/her room that he/she needed some water; maintenance staff
walked by the resident’s door at the time he/she yelled it and did not say anything to the
resident;
– At 8:55 A.M., the resident yelled again, I need some ice water! An unknown staff member
came in to the room and asked if the resident had gotten his/her room tray. The resident
said no and that he/she wanted some ice water. Staff took the resident’s cup, got ice from
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 23)
the storage closet and filled the resident’s cup at his/her sink.
During an interview on 5/14/19, at 1:23 P.M., Regional Cooperate staff said the facility
did not have any I&O records for the resident and did not know why.
2. Review of the Resident #47’s (MONTH) 2019 Physician order [REDACTED].
– Controlled Carbohydrate diet, regular texture, regular/thin consistency, no added salt.
Review of the resident’s care plan, dated 5/3/19, showed the resident:
– Has a nutritional problem or potential nutritional problem; diet restrictions;
– Is on a controlled carbohydrate, no added salt, regular texture, thin liquid diet.
– Interventions included provide, serve diet as ordered, monitor intake and record with
meal.
Observation and interview on 5/8/19, at 1:19 P.M., showed staff served the resident
his/her lunch in his/her room. The resident said he did not get any breakfast that
morning.
Observation and interview on 5/14/19, at 8:53 A.M., showed:
– The resident was sitting in bed;
– He/she said he wanted to get up to go down to the kitchen this morning to have breakfast
and had been trying to get up since 5:30 A.M. this morning and staff had not assisted him
yet.
– The resident said he/she wanted over easy eggs but they deliver scrambled to his room.
– CNA F came in and offered breakfast that included milk, juice, scrambled egg and bacon,
– The resident said he did not want it because the eggs were scrambled;
– Staff walked out with the food without offering any other food.
During an interview on 5/14/19, at 8:55 A.M., CNA F said:
– He/she was not sure what the facility had as an alternative;
– He/she was from a staffing agency;
– A staff had been in earlier and the resident also refused the food they offered.
Review of the resident’s (MONTH) 2019 meal intake record showed staff only recorded two
meals for the resident, on 5/4/19 (no supper), 5/5/19 (no supper), and 5/11/19 (no lunch).
No meals were recorded on 5/10/19 or 5/12/19.
3. During an interview on 5/14/19, at 4:00 P.M., the Director of Nursing (DON) said:
– Staff should provide fresh water/ice as desired at least each shift.
– Care plans should have been followed.

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
received proper respiratory care when staff failed to clean oxygen concentrator filters,
failed to ensure concentrators that should have filters had them, and failed to change
and/or date oxygen and nebulizer tubing. This affected six out of 24 sampled residents
(Residents #1, #4, #22, #28, #38 and #64) and additional (Residents #43 and #57). The
facility census was 106.
Review of the facility’s undated policy related to oxygen administration showed:
– All oxygen tubing, humidifiers, masks and cannulas used to deliver oxygen will be
changed weekly and when visibly soiled, or as indicated by state regulation.
– Oxygen items will be stored in a plastic bag at the resident’s bedside to protect the

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 24)
equipment from dust and dirt when not in use.
– Administer oxygen at the prescribed rate.
– Ensure the oxygen is flowing through the cannula tubing.
1. Review of Resident #28’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/28/19, showed;
– Totally dependent on staff for all care;
– [DIAGNOSES REDACTED].
– Received oxygen therapy, suctioning and had a [MEDICAL CONDITION] (external opening in
the skin to the trachea for breathing) care.
Review of the resident’s (MONTH) 2019 physicians’ order sheet (POS) showed;
– Order dated 2/21/19, oxygen at two liters per nasal cannula continuously, or to keep
oxygen saturation above 90%;
– Change oxygen tubing and label each component with date and initials every Wednesday;
– Clean oxygen concentrator (machine that delivers oxygen) filter weekly every Wednesday;
– [DIAGNOSES REDACTED].
Review of the resident’s (MONTH) 2019 treatment administration record (TAR) showed:
– Staff initialed that they cleaned the oxygen concentrator filter on 5/1/19 and 5/8/19.
– Staff initialed that they changed and dated the oxygen tubing and each component on
5/2/19 and 5/9/19.
Observations on 5/10/19 and 5/14/19, showed:
– 5/10/19, at 8:35 A.M.: filters on the oxygen concentrator were covered with fluffy gray
lint, the humidifier was dated 5/4/19, and the oxygen tubing had no date on it;
– 5/10/19, at 10:45 A.M.: resident in his/her room with oxygen on at 3 liters per nasal
cannula;
– 5/14/19, at 9:00 A.M.: filters on the oxygen concentrator remained covered in fluffy
gray lint, the humidifier was dated 5/4/19, and the oxygen tubing had no date on it.
2. Review of Resident #4’s quarterly MDS, dated [DATE], showed:
– [DIAGNOSES REDACTED].
– Received oxygen therapy.
Review of the resident’s (MONTH) 2019 TAR showed:
– Administer oxygen at 2 liters per nasal cannula continuously for [MEDICAL CONDITION];
– Administer breathing treatments every four hours as needed for shortness of breath;
– Change the oxygen tubing weekly every Wednesday and label each component with the date;
– Change the [MEDICAL CONDITION]/[MEDICAL CONDITION] (Devices used to treat sleep apnea)
tubing every Wednesday;
– Clean the oxygen concentrator filter every Wednesday.
Observation on 5/7/19, at 3:57 P.M., showed:
– The resident’s oxygen concentrator had no filters on either side and was generally
dirty, with a brown substance dried on near the handle on top of the machine.
– There was no date on the oxygen tubing and the nebulizer cup for his/her breathing
treatments was dated 4/18/19.
Observation on 5/14/19, at 9:38 A.M., showed there were still no filters on either side of
the oxygen concentrator, no date on the oxygen tubing and the nebulizer cup was still
dated 4/18/19.
3. Review of Resident #1’s quarterly MDS, dated [DATE], showed the resident received
oxygen therapy.
Review of the resident’s (MONTH) 2019 TAR showed:
– Administer oxygen at three liters per nasal cannula continuously or as needed to
maintain oxygen saturation levels greater than 90%.
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 25)
– Administer breathing treatments four times a day while awake, for [MEDICAL CONDITION].
– Change oxygen tubing every Wednesday and label each component with the date.
– Change the resident’s [MEDICAL CONDITION]/[MEDICAL CONDITION] tubing every Wednesday.
During an interview and observation on 5/7/19, at 4:13 P.M., the resident said and
observation showed:
– The resident said he/she used a [MEDICAL CONDITION] at night.
– Staff tried to change oxygen-related tubing every week and the date on the nebulizer
tubing was probably when they last changed the oxygen tubing as well.
– The oxygen tubing had no date on it and the nebulizer cup had a date of 4/18/19, written
on it.
Observation on 5/14/19, at 9:36 A.M., showed:
– The resident’s nebulizer cup was still dated 4/18/19, and was placed in a zip-lock bag
dated 5/10/19.
– The oxygen tubing had no date on it.
4. Review of Resident #22’s MDS, dated [DATE], showed:
– Unable to make daily decisions;
– Used oxygen therapy;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 3/21/19, showed the plan did not address the
resident’s oxygen use.
Review of the resident’s current, (MONTH) 2019, POS showed- An order of oxygen at 2
liters;
– (MONTH) titrate to keep oxygen saturation at 88 %;
– Do not titrate oxygen above 4 liters.
– Every shift for titrate oxygen.
Review of the resident’s current medication and treatment records showed they did not
include the order to titrate oxygen saturation levels.
Observations showed the resident wore a nasal cannula connected to a portable oxygen tank
which showed empty on the following dates and times:
– 5/8/19, at 7:08 A.M., and 11:15 A.M.;
– 5/9/19, at 11:34 A.M.;
– 510/19, at 9:46 A.M.; at 10:41 A.M., Certified Nurse Aide (CNA) E retrieved the portable
tank and filled it with liquid oxygen;
– 5/14/19, at 10:32 A.M.
5. Review of Resident #57’s MDS, dated [DATE], showed:
– Used oxygen therapy.
Observation on 5/7/19, at 11:01 A.M., showed the resident had an oxygen concentrator and a
portable oxygen tank hooked on his/her wheelchair. The tubings were undated, the plastic
bag attached on the concentrator that held the tubing was dated 3/7/19. The concentrator
filter was covered with a gray lint. The housekeeping staff had just mopped the floor and
the portable tank tubing cannula lay on the wet floor.
6. Review of Resident #38’s MDS, dated [DATE], showed:
– Used oxygen therapy.
Review of the resident’s current May, 2019 POS showed no order for oxygen use.
Review of the resident’s current care plan showed no care plan for oxygen use.
Observation on 5/7/19, at 11:32 A.M., showed the resident’s oxygen tubing was undated and
the filter on the concentrator was covered in rollable gray lint.
Observation on 5/8/19, at 6:10 A.M., showed the resident asleep in bed. His/her oxygen
concentrator was running and the nasal cannula lay across the top of the concentrator. The
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 26)
oxygen tubing was undated and the filter remained covered in gray lint.
7. Review of Resident #43’s MDS, dated [DATE], showed:
– Used oxygen therapy.
Review of the resident’s current May, 2019 POS showed no order for oxygen use.
Review of the resident’s current care plan showed no care plan for oxygen use.
Observation on 5/7/19, at 11:45 A.M., showed the resident asleep in bed with an oxygen
cannula in his/her nose. The oxygen tubing was not dated and the filter was covered with
gray lint.
8. Review of Resident #64’s MDS showed:
– Received oxygen therapy;
– [DIAGNOSES REDACTED].
Review of the resident’s (MONTH) 2019 POS showed the following order:
– Oxygen tubing: change weekly, label each component with date and initials every night
shift every Sunday.
Review of the resident’s care plan, dated 5/3/19, showed:
– The resident has altered respiratory status/difficulty breathing;
– Oxygen via nasal cannula per physician order. Humidified.
Observation on 5/7/19, at 9:48 A.M., showed:
– The resident’s oxygen tubing was not dated and the oxygen concentrator filter was caked
with dust.
9. During an interview on 5/14/19, at 4:00 P.M., the Director of Nurses said:
– It is documented on the nurse’s treatment administration record to change out and date
all oxygen and nebulizer tubings weekly:
– Plastic bags attached to the concentrators to hold the tubing should also be changed out
and dated weekly;
– Staff should also clean the oxygen filters weekly.

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 have sufficient
staff meet the needs of the residents. The facility had a census of 106
1. Review of Resident #66’s (MONTH) 2019 bathing documentation showed:
-One paper shower sheet, dated 3/1/19;
-Electronic documentation showed the resident received baths/showers on 3/5 and 3/27, and
the remaining dates were either blank, showed an X or marked Not Applicable.
Review of the resident’s shower sheets and electronic records for (MONTH) and (MONTH)
showed staff documented only one shower as given to the resident in the last 30 days.
Staff documented a shower given on 4/25/19.
Review of the resident’s quarterly MDS dated [DATE], showed:
– Cognitively intact.
– One person physical assistance with toilet use, dressing and showers.
– Uses Wheel-chair.
– Has an indwelling catheter.
During an interview on 05/07/19 at 02:51 PM, the resident said he/she needed a shower.

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 27)
He/she had asked and asked for a shower. The facility did away with shower aides. It has
been at least two weeks since he/she received a shower. Staff mark baths as given or
refused when they do not have time to give us a shower. I am starting to smell, he/she
uses the sink and a wash cloth to wash his/her face and arms but he/she is unable to wash
the bottom half of his/her body. He/she fell s dirty. He/she often has to take his/her
self to the bathroom or empty his/her catheter bag. He/she is unable to clean self up well
after using the bathroom. Sometimes it take two hours for staff to respond to the call
light so he/she can either poop his/her pants or take his/herself. He/she just needs a
good shower so he/she does not stink.
2. Review of Resident #75’s admission (re-admission) MDS, dated [DATE], showed:
– Cognitively impaired
– Has dementia and a mental health [DIAGNOSES REDACTED].
– Resident requires assistance of one for dressing, hygiene and bathing
-Resident uses a wheelchair or walker for mobility.
Review of the resident’s bathing follow-up report showed the resident received a
bath/shower on:
– (MONTH) 1, 15 18, 29.
– (MONTH) 2nd.
During an interview on 5/7/19 at 11:05 AM., the Guardian/Family Member A said:
– He/she had requested that the resident be bathed/showered daily for two weeks.
– He/she is in the facility daily and would know when and if the resident received a
shower.
– The Resident last showers was over two weeks ago.
– The resident has an unpleasant body order.
– He/she thinks staff mark showers as given when they run out of time and do not get their
work done.
During an interview on 5/10/19 at 1:50 PM., CNA J said if he/she is the only CNA on unit
he/she might get two showers done per day if lucky. He/she can only do them when the CMT
is on the floor. He/she tells the charge nurse the showers were not done at the end of the
shift but he/she does not document anything in the computer or on paper.
During an interview on 05/14/19 at 08:40 AM., CMT E said., when showers are not given
staff should mark the shower as not given so the shower will pop up for the next shift to
give the shower. Too many times the CNAs mark not available when they (staff) are no
available to give the showers and then the showers do not show up for the next shift to
give the shower. Too many residents are not getting the showers they need. He/she often
worked the floor when they are short handed instead of passing medications or doing
his/her paper work. When staff fail (no show) to come to work it make it hard for the good
employees; because they have to works doubles and extra hard to cover for the staff that
no showed.
Observation and interview on 5/14/19 at 2:20 PM., showed CNA G checking off tasks on the
computer. He/she said he/she had a long list of showers that were supposed to be given
today. He/she did not have time to do shower as he/she was busy helping with meals and
resident care. He/she marked the showers as not available. He/she did not know if the
shower marked not available would be triggered for someone to give the next shift or the
next day. It is impossible to get everything done.
During an interview on 5/14/19 at 4:00 P.M., the DON said:
-Staff should offer residents at least two baths/showers each week.
-Residents have a right to decline baths/showers and staff should care plan a resident’s
preference to bathe less than two times a week.
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 28)
-Staff were to complete paper bath sheets and document bathing electronically.
-She did not know what Not Applicable meant related to electronic documentation of
bathing.
-Staff run bathing reports each morning, and if a bath is noted as not done, then the
resident should be offered one the next day.
-The facility currently had an evening staff scheduled to do bathing.
-They previously had a staff scheduled to do bathing on days, but not at this time.
-The CNA’s should be assigned to do baths/showers if there is no bath aide.
-The nurse manager should follow-up if bathing is not documented, and if refused, staff
need to find out why the resident is refusing it.-
3. During an interview on 05/08/19 at 5:15 AM., the Administrator said they had been at
the facility all night. Only one Certified Nurse Aide show up to work the night shift so
she and some of the department heads worked all night.
During a group interview with 15 resident on 5/9/19 at 10:05 A.M., the residents said:
– The facility makes one meal and if you do not like what they serve then you do not get
anything else.
– Meals are often late – more than two hours.
– There is not enough staff to serve meals timely.
– Staff seldom pass ice water.
– Bed time snacks are not passed to the residents; they are at the nurses’ station and
residents has to help there self and there is not enough to go around.
– If you are unable to get your own bed time snack you are out of luck.
Observation and interview on 05/14/19 at 08:40 AM., showed the Staffing Coordinator
helping care for resident’s on the unit. He/she said he/she is often pulled to work the
floor or pass medications when they were short staffed which is almost always. He/she
often makes the staffing schedules at night because that is the only time she has to do
them. There a lots of no shows and those that are good workers have to stay when no one
comes to take their place. At times they just leave without their being staff to cover
since it happens so often.
During an interview on 05/14/19 at 09:15 AM., CMT E said dietary runs out of food all the
time sometimes even run out of cheese for the grilled cheese; it has been so bad that they
have even run out of peanut butter so a jelly sandwich was what was served on the hall
trays. Residents do not get shower, are not gotten up timely and meals are always late.
Often resident’s have accidents because there is not sufficient staff to answer the call
lights
During an interview on 5/13/19 at 1:18 PM., the Registered Dietitian said:
– Staff should always fix enough food for the resident’s to eat a complete meal.
– A sandwich is not a complete meal, fruits and vegetables should also be served.
– It should never take 3 hours to get resident’s their breakfast after meal service has
started.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure a licensed pharmacist perform a monthly drug regimen review, including the
medical chart, following irregularity reporting guidelines in developed policies and
procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 – Some

(continued… from page 29)
Based on interview and record review, the facility failed to ensure the physician provided
a rationale when the physician did not agree with the pharmacist’s recommendations for
gradual dose reductions (GDR)’s-tapering of medication dose in an effort to discontinue or
determine the lowest, most effective dose) for two of 24 sampled residents (Residents #4,
and #7) who received [MEDICAL CONDITION] (any drug that affects brain activities
associated with mental processes and behavior) medications. The facility census was 106.
1. Review of the undated facility policy titled Psychotherapeutic Drug Management showed:
Purpose
– To implement the most desirable and effective interventions to change, modify, decrease,
or eliminate behaviors that are distressing to the resident and/or are decreasing or
negatively impacting the resident’s quality of life;
– To help promote or maintain the resident’s highest practicable mental, physical, and
psychosocial well-being, promote resident safety and security and to enhance the
resident’s ability to interact positively with his/her environment;
– To ensure the resident receives only those medications, in dosed and for the duration
clinically indicated to treat the resident’s assessed condition (s);
– To ensure non-pharmacological interventions are considered and utilized when indicated,
instead of or in addition to medication;
– To ensure clinically significant adverse consequences are minimized;
– To ensure that any potential contribution the medication regimen has to an unanticipated
decline or newly emerging or worsening symptoms is recognized and evaluated, and the
regimen is modified when appropriate.
2. Guidelines for GDR
– During the first year if receiving an antipsychotic or other psychopharmacologic
medication, at least one attempt at GDR is attempted;
– A second attempt, in a subsequent quarter the same 12 month period unless the first
attempt demonstrated that GDR was clinically contraindicated. The first attempts should be
at least a month apart;
– After the first year, GDR should be attempted annually;
– GDR may be considered clinically contraindicated if the resident’s targeted symptoms
worsened or returned during the reduction. IF this occurs the physician must document the
clinical rationale why further GDR attempts should not be done;
– All GDR’s will be initiated per pharmacist recommendations as received for all
classifications of [MEDICAL CONDITION] medications.
3. Review of Resident #4’s pharmacy progress note, dated 6/12/18 at 1:38 P.M., showed:
-Please assess if there is potential for a gradual dose reduction for the resident’s
[MEDICATION NAME].
-Resident currently takes 75 milligrams (mg) daily. Consider a trial reduction to 75 mg
every other day for four to six weeks, and if no adverse effects/increase in symptoms
during this time, then discontinue (if clinically appropriate).
-If no reduction is made, please provide a brief rationale as to why and supply this to
the facility to aid them in remaining in compliance with state regulations.
Review of the resident’s records showed no response to the pharmacy request.
Review of the resident’s pharmacy progress note dated 12/19/18, at 11:02 A.M., showed:
-Please assess if there is a potential for a gradual dose reduction for the resident’s
[MEDICATION NAME].
-He/she currently takes 75 mg daily. Consider a trial reduction to 37.5 mg daily, if
clinically appropriate.
Review of the resident’s records showed no response to the pharmacy request.
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 – Some

(continued… from page 30)
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 5/2/19, showed:
-[DIAGNOSES REDACTED].
-Received medication for anxiety and depression.
Review of the resident’s (MONTH) 2019 physician order [REDACTED].
-4/27/19, [MEDICATION NAME] 75 mg daily.
4. Review of Resident #7’s Minimum Data Set (MDS), a federally mandated assessment
completed by facility staff, dated 1/30/19 showed:
– Included the following Diagnoses: [REDACTED].
– Used [MEDICAL CONDITION] medications.
Review of the resident’s (MONTH) 2019 Physician order [REDACTED].
– [MEDICATION NAME] HCL (used to treat anxiety) 5 milligrams (mg), give two tablets by
mouth three times a day for anxiety, order date 9/11/18;
– [MEDICATION NAME] (used to treat [MEDICAL CONDITION] disease) delayed release 250 mg,
give one tablet by mouth two times a day for depression and behavior, order date 11/9/18;
– [MEDICATION NAME] (used to treat anxiety) 0.5mg, give one tablet two times a day for
anxiety, order date 9/11/18;
– Trazadone (used to treat depression and [MEDICAL CONDITION]) HCL Tablet, give 25 mg by
mouth at bedtime for [MEDICAL CONDITION], order date 11/6/18;
– [MEDICATION NAME] (used to treat depression) 150 mg, give one tablet by mouth one time a
day for depression
Review of the pharmacy recommendations dated 1/23/19 showed the following:
– Please assess if there is a potential for gradual done reduction for the resident’s
[MEDICATION NAME] ([MEDICATION NAME]). He/she currently takes 250 mg twice a day, consider
trial reduction to 125 mg twice a day if clinically appropriate;
– A form signed by the physician, dated 2/1/19, indicated that he/she disagreed with the
recommendations but did not provide any rationale as to why.
5. During an interview on 5/14/19 at 1:50 P.M., Regional Staff A said the administrator
told him/her the previous director of nurses employed from (MONTH) 2019 through (MONTH)
2019 was throwing pharmacist’s monthly review recommendations away and the facility could
not produce any type of physician rationale for any recommendations.
During an interview on 5/14/19 at 4:00 P.M. the Director of Nursing said:
– The pharmacist completes the Drug Regimen Reviews (DRR) then sends a report to staff
with recommendations. Staff give the report to the DON or Assistant DON, then they give it
to the physician for review. The physician usually responds to the recommendations within
the same day. If the physician disagrees with the recommendations, there should be a
rationale documented and that documentation should be kept in the DON’s office.
– If a resident is started on a [MEDICAL CONDITION] medication PRN, it should be
re-evaluated within 14 days to determine if it should continue.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
administered medications with a medication error rate of less than 5%. Facility staff made
two medication errors out of 28 opportunities for error, resulting in a medication error

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
rate of 7.1 %. This affected two of 15 sampled residents (Resident #4 and #86). The
facility census was 106.
1. Review of the facility’s Specific Medication dministration procedures, dated 3/18
showed:
– A meal tray should be at the resident’s table in dining room or at bedside prior to the
licensed nurse administerng rapid acting insulin.
2. Review of Resident #4’s current (MONTH) 2019, physician order [REDACTED].
– [MEDICATION NAME]100 units/milliliters (ml) Inject 10 units before meals.
Observation on 5/8/19 at 7:43 A.M., showed Licensed Practical Nurse (LPN) A administered
10 units of [MEDICATION NAME] to the resident. The resident waited in his/her room for
breakfast. At 8:44 A.M., the resident had still not been served his/her breakfast.
During an interview on 5/8/19 at 10:37 A.M., the resident said staff did not bring his/her
breakfast until about 9:25 A.M., just a piece of toast, a piece of bacon and Rice
Krispies.
During an interview on 5/8/19 at 10:38 A.M., LPN A said:
– [MEDICATION NAME] was a rapid acting insulin;
– Staff should make sure the resident had a meal within 15 to 20 minutes of the insulin
injection;
– He/she gave insulin to residents who received hall trays last so they should get their
meal on time.
3. Review of the website https://www.[MEDICATION
NAME].com/asthma/talking-to-you-doctor/how-to-use-the-inhaler.html showed to take
[MEDICATION NAME] exactly as prescribed by the physician. It is important not to miss a
dose or take more doses than prescribed.
4. Review of Resident #86’s (MONTH) 2019 physician order [REDACTED].>-[MEDICATION NAME]
inhaler 80/4.5 (used to decrease inflammation and dilate air pathways in the lungs) inhale
two times a day for breathing, ordered 4/15/19;
-[DIAGNOSES REDACTED].
Observation on 5/8/19 at 11:36 A.M. showed LPN B administered one inhalation of
[MEDICATION NAME], had the resident rinse his/her mouth with water and spit it out, then
returned at 11:50 A.M. and administered a second inhalation of [MEDICATION NAME].
During an interview on 5/8/19 at 12:08 P.M., LPN B said the order directed to give two
inhalations a day, so she administered two inhalations.
Review of the resident’s (MONTH) 2019 Medication Administration Record [REDACTED]
-[MEDICATION NAME] inhaler 80/4.5, inhale two times a day for breathing;
-Administer at 8:00 A.M. and 8:00 P.M.
-Staff documented that the resident received the inhaler twice a day 5/1/-5/8/19.
During an interview on 5/14/19 at 4:00 P.M., the director of nurses said that staff should
have clarified the [MEDICATION NAME] order with the physician.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to ensure staff

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
properly dated and discarded resident medications. The facility census was 106.
1. Review of the facility’s Specific Medication Administration Procedures, dated 3/18, did
not address dating medications when opened. The procedure guide stated if a label of an
insulin pen is illegible or missing, the pen should be discarded and a new pen received
from the pharmacy.
Observation on 5/14/19 at 9:56 A.M., of the 500 hall nurse’s cart showed:
– A container of opened [MEDICATION NAME] powder that had no resident name or date it was
opened;
– Resident #11’s [MEDICATION NAME] Insulin Pen dated as opened 4/12/19;
– Resident #69’s [MEDICATION NAME] Insulin Pen dated as opened 4/9/19 and a [MEDICATION
NAME] Pen opened but undated;
– Resident #4’s one [MEDICATION NAME] undated when opened and one dated as opened 4/15/19;
– Resident #9’s [MEDICATION NAME] opened 4/2/19;
– A used [MEDICATION NAME] opened but with no label or date opened.
During an interview on 5/14/19 at 9:56 A.M., LPN C said:
– Staff should date the insulin when they first opened it for use;
– He/she thought insulin could be kept out of the refrigerator for 30 days after it was
opened.
Observation on 5/14/19 of the 500 hall Medication Cart showed:
– Resident’s #11, #4 and #97 had [MEDICATION NAME] Discus inhalers that were all undated
when opened;
– Resident #38’s [MEDICATION NAME] inhaler undated when opened;
– Four resident’s [MEDICATION NAME] nasal spray undated when opened;
– Resident #41’s [MEDICATION NAME] eye drops were undated when opened.
– Resident #43’s [MEDICATION NAME] and [MEDICATION NAME] B Sulfates eye drops were undated
when opened.
During an interview on 5/14/19 at 11:00 A.M., Assistant Director of Nursing (ADON) A said:
– Staff should date the inhalers, nasal spray and eye drops when opened, otherwise there
was no way to prove when it was opened and when it should be discarded.
– Staff should discard insulin 28 to 30 days from the date of opening depending on the
type of insulin.
During an interview on 5/14/19 at 4:00 P.M., the Director of Nurses (DON) said:
– Staff should date insulins, inhalers, nasal sprays and eye drops when opened for use.
– Opened insulin should be discarded after 28 days.
Observation on 5/14/19 at 9:16 A.M. showed Certified Medication Technician (CMT) F
administered medications from a 500 hall medication cart and there were no open or discard
dates on stock medication containers of acidophilus, iron 325 mg tabs and vitamin D3 1000
mg.
During an interview on 5/14/19 at 9:29 A.M., CMT F said he/she tried to look at medication
containers this morning to ensure they all had open dates, but may have missed some.
During an interview on 5/14/19 at 4:00 P.M., the DON said that staff should date
medication containers when they are opened.

F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide each resident with a nourishing, palatable, well-balanced diet that meets his
or her daily nutritional and special dietary 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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 33)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews and record reviews the facility failed to provide
residents with a nourishing, palatable, well-balanced diet, taking into consideration the
preferences of each resident. This had the potential to affect any resident who received
food from the facility’s main kitchen. The facility had a census of 106.
1. During interview on 5/7/19 at 10:27 AM., Resident #300 said the food is cold and not
pleasant to taste. He/she does not eat pork. He/she told staff he/she did not eat pork
upon admission but he/she received bacon for breakfast again this morning.
During interview on 5/7/19 at 10:29 AM., Resident #299 said food is cold and not good, has
no flavor and is poor quality. lf you do not like the food served, you can have a ham
sandwich, cheese sandwich or canned soup. The substitute menu is always the same.
During an interview on 5/7/19 at 10:42 AM., Resident #46 said the food is cold. He/she
said staff did not help him/her up for. He/she ahd placed his/her call light over 2 hours
before they helped him/her up for breakfast. He/she like to go to the dining room for a
hot meal but since staff helped him/her late all he/she got this morning was a bowl of
cold cereal.
During interview on 5/7/19 at 10:55 AM., Resident #89 said the food is of poor quality,
not very good but the worst part is they are always running out. If you are lucky, you
will get a grilled cheese or peanut butter and jelly sandwich and nothing else with it
besides a cup of punch or tea.
During interview on 5/7/19 at 10:57 AM., Resident #51 said food is a major problem. They
run out of food and if you are lucky get grilled cheese or peanut butter and jelly
sandwich. Cold grilled cheese is not pleasant to eat.
During interview on 5/7/19 at 10:29 AM., Resident #66 said said you do not have enough
days to listen to the food problems. The kitchen runs out of food almost daily. The food
purchased is very poor quality. They do not get not enough to eat, have no fresh fruits
and vegetables, and no alternate menu for the whole mea. If you do not go to the main
dining room, there are poor choices if you unable to go to the main dining room then you
are out of luck getting the main meal at lunch because they run out of food for hall
trays. We either get a grilled cheese sandwich and once in a while a ham and cheese
sandwich, but mostly they serve a peanut butter and jelly sandwich with a drink on the
hall trays. Nothing else comes with the sandwich. They are always running out of food.
He/she did not know why they fill out a menu sheet; they do not serve what is asked for.
It is limited to only the choice of the main meal or a sandwich. Dietary never supplies
condiments; we buy them and share them among ourselves. Ketchup, mayo, mustard are never
served with the meal.
During interview on 5/7/19 at 12:27 AM., Resident #73 said food is a thumbs down.
Sometimes no one will eat the food served. No alternate foods are offered. You just do
without.
During interview on 5/7/19 at 2:29 AM., Resident #8 said he/she does not eat pork so the
kitchen no longer sent it on his/her tray but he/she does not get anything in its place to
eat. He/she get hungry often.
Observation and interviews on 5/7/19, starting at 11:55 A.M., showed residents on the
Special Care Unit unit received fish, orzo (seed shaped pasta), dilled carrots and
pineapple cubes. No condiments were served. Observation of the meal showed most of the
residents tasted the fish, but at least half of the residents did not eat the fish. The
residents told staff the seeds (Orzo pasta) were tasteless, the carrots tasted funny. It
was observed that most of the reidents left their carrots uneatten on their plates at the
end of the meal service. Most of the residents ate their pineapple. Several 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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
asked for tarter sauce, ketchup and bread. Thirty minutes later the residents had not
received slices of bread nor the condiments of tarter sauce and ketchup that they
requested and by then most of the residents had left the dining area.
Observation and interview on 5/7/19 at 12:36 P.M., showed residents in the main dining
starting to receive their meal. Baked fish, sead like pasta, dilled carrots pneapple
tibblets were on the trays. Family Member C said his/her loved one does not like and will
not eat fish; he/she requested a deli sandwich and strawberry ice cream for the resident’s
lunch. He/she asked for mayo but that will probably not happen. The resident does not like
the noodles but they serve them anyway or he/she gets nothing. The chicken they fixed the
other day was so dry his/her loved one could not chew it. On two different occassions they
served pork chops that residents could not chew and looked like thye had been boiled.
Yesterday he/she asked for iced tea; dietary had not had time to make it. They often run
out of chocolate milk. The resident did not eat breakfast today. They did not get him/her
up until late so they gave him/her a bowl of dry rice crispies without milk. It was still
in the resident’s room when he/she arrived an hour ago. Dietary staff do not fix enough
food for the residents to eat.
Observation and interview on 5/7/19, at 1:15 P.M., showed Dietary Staff F serving out
lunch trays. He/she said they had 25 more trays to fill. He/she had no clean silverware
and not enough prepared food. There was only seven pieces of baked fish left. A couple of
the residents had requested chief salads but the morning cook did not make any chief
salads. He/she had requests for grilled ham and cheese sandwiches but what they have are
grilled cheese that were setting on the counter when he/she arrived at noon. He/she came
to work at noon to serve out. We constantly run out of food and all they have time to fix
is grilled cheese or peanut butter and jelly sandwiches. They run out of food daily.
He/she does not know why the morning cook cannot prepare enough food for all of the
residents. He/she was very frustrated.
During an interview on 5/8/19, at 12:26 P.M., Resident #59 said the food is always cold.
If you do not like the menu, the only alternates are a cheese sandwich or peanut butter
and jelly sandwich. Meals are always late. He/she gets served his/her meal two hours after
mealtime.
During an interview on 5/10/19, at 10:35 A.M., Dietary Staff B said:
– He/she was not aware he/she did not prepare enough food for all of the residents.
– He/she never fixed the alternate menu on the menu sheets.
– They have alternate foods of grilled cheese sandwich, ham and cheese sandwich, deli
sandwich, chef salad or peanut butter and jelly sandwich.
– They added the deli sandwich and chief salad to the alternate this week.
– He/she had never prepared alternate food for vegetables, fruits, starchy foods, etc.
– He/she did not know dietary staff needed to offer like nutritional foods for foods
residents do not eat or like.
During an interview on 5/10/19, at 10:39 A.M., Dietary D said :
– He/she was not aware of the facility ever preparing the alternate menu written on the
dietary spread sheets.
– The menus have a lot of fish one week and lot of chicken next week.
– The residents do not like fish.
During an interview on 5/10/19, at 1:00 P.M., Family Member B said his/her loved one was
served undercooked fish today. His/her loved one could not eat the fish but was hungry.
He/she went to the kitchen to see if there was something else for his/her loved one to eat
but was told they only had peanut butter and jelly sandwiches which his/her loved one
cannot eat. They have talked to administration about the poor quality and lack of food
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 35)
served the residents but it continues to happen day after day.
During an interview on 5/10/19, at 1:23 P.M., CNA B said the residents on the unit did not
eat the fish served. More than half of the residents left their trays uneaten except for
the unfrosted cake which most of the residents ate. No alternate foods were offered. The
unit residents never have a choice of foods. They just get what is sent. She asked dietary
staff for alternate and substitute foods but it does not happen. CNA J said if the
residents do not like or eat the food served, nothing else is offered.
During an interview on 5/13/19, at 1:18 P.M., the Registered Dietitian (RD) said:
– The facility policy is not to prepare the alternate meal listed on the spread sheets.
– She was not aware they were running out of food. Staff should be able to prepare
sufficient amount of food.
– Their always available list was fixed last week; they added deli sandwich and chief
salad to go along with the grilled cheese sandwich, ham and cheese sandwich and peanut
butter and jelly sandwich.
– An alternate food of like nutritional value should be offered to residents who do not
eat the food served.
During an interview on 5/13/19, at 1:34 P.M., the Administrator said she had intervened a
couple of times when she found out the kitchen said they were out of food. She was unaware
that they ran out of food daily and some residents only received a grilled cheese or
peanut butter and jelly sandwich for their meal. They always have food they can prepare
for the residents. There is enough food purchased; dietary staff just need to prepare
sufficient amounts of food. She cannot fix things if she is not made aware of the
problems. She had been trying to fix dietary issues for some time. The facility hired a
new dietary manager who started today. She brought two staff with her today and two more
will join her in about a week.
Observation and interview on 5/13/19, at 3:34 P.M., of the memory care unit’s refrigerator
showed the refrigerator contained no snacks or foods to make a sandwich if residents were
hungry. Unit refrigerator contained less than 1/4 gallon of chocolate milk and about three
cups of fruit punch and one small container of yogurt. An unidentified staff member said
he/she used the yogurt in the refrigerator for medication pass. There is not sufficient
staff for a staff member to leave the unit to obtain the supplement or additional foods we
know the residents would like to have. Unit residents have no choice of the foods they
receive. If they do not eat what is serve they do without and that is just not right.
Residents deserve to have foods they like to eat and to feel full after a meal.
2. Review of Resident #1’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/31/18, showed:
– Cognitively intact;
– Very important to receive snacks between meals;
– [DIAGNOSES REDACTED].
Observation of the posted meal times in the kitchen said breakfast 7:00 AM.
During an interview on 5/7/19, at 4:09 P.M., the resident said he/she did not receive
breakfast yesterday until 10:00 A.M., and received breakfast today at 9:30 A.M. Staff did
not serve his/her lunch today until 1:50 P.M., and that was after it set in the hall for
15-30 minutes before staff starting passing the trays.
3. Review of Resident #14’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Somewhat important to receive snacks between meals.
During interviews on 5/7/19, at 2:00 P.M. and 3:35 P.M., the resident said he/she:
– Did not receive the soup he/she ordered for lunch today; dietary staff do not follow the
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 36)
menu;
– Received two grilled cheese sandwiches for lunch, but no vegetables, fruit or dessert;
– Did not receive breakfast on 5/6/19; they sometimes forget to give trays to residents
and he/she has to remind staff or go get his/her own meal;
– Dietary staff do not follow the menu;
– Used his/her monthly $50.00 to buy snacks and other food to store in his/her room since
the kitchen does not have enough food for everyone.
4. Review of Resident #49’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Very important to receive snacks between meals;
– [DIAGNOSES REDACTED].
During an interview on 5/7/19, at 11:51 P.M., the resident said dietary:
– Often ran out of chocolate milk and other food items;
– Often ran out of items on the menu or serve something different than what is on the
menu;
– Did not provide condiments like pickles or parmesan cheese any more;
– Does not serve what residents request, if residents even get a menu to choose from.
5. Review of Resident #62’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Very important to receive snacks between meals.
During an interview on 5/9/19, at 2:54 P.M., the resident said that meals usually run
late. Dietary often ran out of food, and some residents did no receive menus to fill out.
6. Review of Resident #47’s comprehensive MDS, dated [DATE], showed:
– Coginitively intact;
– [DIAGNOSES REDACTED].
Review of the resident’s (MONTH) 2019 physician order [REDACTED].
– Controlled carbohydrate diet, regular texture, regular/thin consistency, no added salt.
Review of the resident’s care plan dated 5/3/19, showed the resident:
– Has nutritional problem or potential nutritional problem. Diet restrictions;
– Is on a controlled carbohydrate, no added salt, regular texture, thin liquid diet.
Interventions included provide, serve diet as ordered, monitor intake and record with
meal.
Observation and interview on 5/14/19, at 8:53 A.M., showed:
– The resident was sitting in bed;
– He/she said he wanted to get up to go down to the kitchen this morning to have breakfast
and had been trying to get up since 5:30 A.M. this morning and staff had not assisted him
yet.
– The resident said he/she wanted over easy eggs but they deliver scrambled to his room.
– CNA F came in and offered breakfast that included milk, juice, scrambled egg and bacon;
– The resident said he/she did not want it because the eggs were scrambled;
– CNA F walked out with the food without offering any other food.
During an interview on 5/14/19, at 8:55 A.M., CNA F said:
– He/she was not sure what the facility have as an alternative;
– He/she was from a staffing agency;
– A staff had been in earlier and the resident also refused the food they offered.
7. During a group interview with 15 residents on 5/9/19, at 10:05 A.M., residents said the
facility makes one meal and if you do not like what they serve then you do not get
anything else.

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives and the facility provides food prepared in a form
designed to meet individual needs.

Based on observation , record review and interview, the facility failed to prepare pureed
food to be smooth and palatable and failed to follow the approved menu. This had the
potential to affect four residents the facility identified with a physician ordered puree
diet including one of 24 sampled residents (Resident #70). The facility identified as
having a physician ordered puree diet. The facility had a census of 106.
1. Review of the spread sheet for 5/7/19’s noon meal showed staff should serve residents
who received a pureed diet:
– Pureed white fish with a cream sauce;
– Pureed Orzo ( a seed shaped pasta);
– Pureed dill carrots;
– Pureed hot roll with margarine;
– Pureed peaches;
– And a cup of an orange colored drink.
Observation of the noon meal on 5/7/19, at 12:35 P.M., showed staff served Resident #70 a
meal tray containing a dark pureed fish with gravy, mashed potatoes, pureed carrots and
regular pineapple tiblets. The pureed fish contained pieces of a brown substance and was
not smooth; the mashed potatoes had streaks of a powdery substance; the pureed carrots
were not smooth and contained small pieces of carrots.
During an interview on 5/7/19, at 12:40 P.M., Certified Medication Technician (CMT) B,
said the resident cannot have regular pineapple.
2. Review of the dietary spread sheet for the the 5/8/19 breakfast showed staff should
prepare:
– Cranberry Juice;
– Pureed oatmeal;
– Pureed sausage;
– Pureed pancakes with margarine and syrup;
– Coffee/tea/milk;
– Sugar/salt/pepper/non dairy creamer.
Observation and interview on 5/8/19, at 5:15 A.M., showed the cream of wheat and oatmeal
already prepared and on the steam table. Dietary Staff (DS) B said he/she started at 4:00
A.M., preparing the day’s breakfast.
Observation on 5/8/19, at 6:06 A.M., showed DS B placed 15 sausage links into the Robo
coupe, and ran the sausage for a minute or so. He/she rubbed the sausage between his/her
fingers then went into the dry storage room after obtaining a Styrofoam cup from coffee
maker area and dipped the cup into the open box of food thickner. DS B added the
unmeasured food thickener to the Robo Coupe containing the sausage. He/she checked the
texture again with his/her fingers and went over to the coffee service areaobtained about
1/3 cup of hot water and added the hot water to sausage. He/she ran the Robo Coupe a
couple of minutes longer then placed the pureed sausage into a small steam table pan using
his/her hands to scoop the mixture out of Robo Coupe into steam pan. The pureed sausage
was not smooth and contained small pieces of the ground sausage.
Observation on 5/8/19, at 8:38 A.M., showed Resident #70 received large portions of cream
of wheat, double portion of oatmeal (prepared more than 3 1/2 hours before served), double

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 38)
portion of scrambled eggs and a large portion of sausage (2 1/2 hour after being
prepared). The cream of wheat and oatmeal was very dry and sticky. The scrambled eggs were
not pureed and the sausage contained small pieces of the sausage.
Observation of the test tray at 5/8/19, at 8:41 A.M., showed the pureed sausage had a
strong spicy taste and contained pieces of the sausage that would not smooth out in the
mouth; the scrambled eggs had no flavor but could be swallowed without chewing. The bland
oatmeal was thick and gummy, would not smooth out in the mouth and was hard to swallow.
Theoatmeal was unpleasant to taste. A spoon stood upright when placed in the middle of the
oatmeal. No cream of wheat was on the test tray. The orange drink did not taste like
orange juice but like a powdered drink that was thin and unsweetened.
During an interview on 5/8/19, at 9:15 A.M., DS B said they did not have enough staff to
prepare pancakes along with sausage and oatmeal. Eggs were easier to prepare for this many
residents. It would take one staff all morning to make enough pancakes. That is just not
possible with only one person to prepare breakfast. He/she did not know he/she had to have
approval to change menus.
During an interview on 5/10/19, at 10:35 A.M., DS B and DS D said:
– DS B said pureed foods should be smooth but it is hard to get it to the correct texture.

– DS D said the Robo Coupe’s blade may be dull preventing the Robo Coupe from grind the
food into a smooth consistency. Nursing staff should always check the trays and make sure
the correct food is on the resident’s tray.
During a interview on 5/13/19 at 1:18 P.M., the Registered Dietitian (RD) said:
– Pureed foods should be smooth with no pieces of the food product visible.
– Pureed foods should be prepared just prior to meal service.
– Foods should not be on the steam table for hours before they are served. Three or four
hours on the steam table is not acceptable.
– She should have been notified of a menu change to ensure the nutritional values were
adequate since they were without a dietary manager for the last month or so.

F 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure meals and snacks are served at times in accordance with resident’s needs,
preferences, and requests. Suitable and nourishing alternative meals and snacks must be
provided for residents who want to eat at non-traditional times or outside of scheduled
meal times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the faciity failed to provide meals no more than 14
hours apart when dietay staff were consistently late with breakfast; failed to ensure they
offered every resident a bedtime snack; and failed to provide nurshing foods for residents
who would like to eat at alternate times of day when the are awake hungry. This had the
potential to affect any resident unable to go to the nurses’ station for an evening snack,
residents who received their meals late and residents on the unit who wandered at night
and slept through meal times. The facility had a census of 106.
1. Review of the facility’s undated dietary policy #DS-00 showed the dietary department is
to prepare and provide for the nutritionally adequate, attractive, well-balanced meals
that are consistent with physician orders [REDACTED].
Observation and interview on 5/7/19, at 9:15 A.M., showed the posted meal times in the

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 39)
kitchen as breakfast 7:00 A.M., lunch 12:30 P.M., dinner at 5:00 P.M. Dietary Staff C said
snacks were served after they get all the residents served dinner and get the kitchen
cleaned up sometime between 8:00 P.M. and 8:30 P.M.
Observation and interview on 5/7/19 at 10:05 A.M. showed dietary staff delivered a bowl of
dry cereal to Resident #46 for his/her breakfast. The resident said he/she is unable to
get out of bed and staff did not get him/her out of bed in time to go to the main dining
room for breakfast. Too often, there is no one to answer his/her call light and get
him/her up. He/she had his/her call light on for over two hours this morning before staff
came and helped him/her out of bed. He/she was hungry and dry cereal is not breakfast.
Supper was a long time ago. He/she did not get an evening snack. Too often by the time
he/she gets to the nurses’ station the snacks are all gone. It is to long and he/she gets
hungry when he/she had supper about 5:30 P.M. and does not get breakfast till 10:00 A.M.
During an interview on 5/8/19, at 10:15 A.M., Dietary Staff (DS) B said they prepare the
breakfast menu between 4:00 A.M. and 7:00 A.M., They start serving breakfast at 7:00 A.M.
If nursing is late getting the residents up and the hot food is gone, they will send the
resident a bowl of dry cereal. They have trouble getting breakfast served timely to the
residents because the residents are late getting their menu request to the kitchen. When
the hot food is gone, we serve cold cereal as the alternate. Too often they are still
serving breakfast tray out mid-morning when they need to be preparing lunch. He/she does
not have time to prepare more eggs for residents who get up late when he/she is trying to
prepare lunch. We need more staff so one group can fix the next meal while the other meal
is still be served out.
Observation on 5/8/19, at 10:20 A.M., showed staff continued to pass out breakfast hall
trays.
2. Observation on 5/8/19, at 8:10 A.M., showed Resident #8 received a breakfast hall tray
containing one piece of toast and a bowl of oatmeal for his/her breakfast. The other
residents received hot cereal, toast and sausage. The resident said he/she could not eat
pork so he/she got nothing in place of the sausage. It would have been nice to have eggs
for breakfast.
During the group interview on 5/9/19, at 11:07 A.M., the residents said:
– The facility runs out of food daily and there are times they do not get anything to eat.
– Usually they get a peanut butter and jelly sandwiches or a grilled cheese sandwich with
nothing else.
– Meals are always late and sometimes it is mid-morning before they get their breakfast.
– There is a small tray of snacks at the nurses’ station but one resident can wipe that
out.
– Most of the residents do not consistantly get a bedtime snacks since the snack tray will
be empty.
– Sometimes they sit in the dining room for hours waiting on their meals.
– Dietaty substitutes foods without asking what they would like to eat.
– We fill out a menu sheet but it is not honored.
– Some of the residents said they had missed meals, both supper and breakfas,t because
they were alseep and needed staff assistance to obtain their meal or the kitchen ran out
of food.
– If you miss a meal, you are just out of luck until the next meal and hope they do not
run out of food.
– Residents were often hungry.
– We look forward to a nice warm meal but that does not happen at this facility.
During an interview on 5/8/19, at 2:45 P.M., DS B said the afternoon staff prepare the
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 40)
snacks. They send trays of snacks to the nurses’ station. We have packages of graham
crackers, cookies and chips. After they leave the kitchen, we do not know who gets the
snacks.
During an interview on 5/10/19, at 3:10 P.M., Resident #66 said if he/she is fast enough
to the nurses’ station, he/she gets an evening snack. However, often they are all gone by
the time he/she gets to the nurses’ station. He/she thinks staff should pass out the
snacks with the evening medication. That way it is fair and everyone could have a snack
before going to bed. It is a long time between supper and breakfast especially if you have
a room tray. You do not receive your breakfast tray until between 9:30 A.M. and 10:30 A.M.
He/she would prefer to go to the dining room for meals, but he/she cannot get his/herself
out of bed and it takes hours for staff to answer the call lights and have time to help
him/her out of bed in the morning. He/she feels sorry for the certified nurses’ aides
(CNA), too often they work alone when the other aides just do not show up to work.
During an interview on 5/14/19, at 9:57 A.M., Resident #51 said snacks are brought down to
the nurses’ station on a couple of trays for all the residents on 300, 500 and the short
part of 400 halls. They bring cookies like Oreo packages, chips, graham crackers, and
sometimes peanut butter and jelly sandwich halves You have to go get your own snack. If
you are unable to get your own snack, you are just out of luck. No one has ever come door
to door and asked if he/she would like a snack. Snack trays come down and people help
themselves. The biggest problem is a few residents take most of the snacks if they get
there first and the rest of us are out of luck. People are hungry so they grab what they
can. There are never enough snacks to go around.
During an interview on 5/14/19, 1:14 P.M., Liciensed Practicial Nurse (LPN) D said dietary
staff bring snack trays to the nurses’ station each evening. Residents help themselves to
the snacks. He/she is not sure what happends to residents who cannot come get their
snacks. He/she guessed they could ask their CNA for a snack. Nursing does not monitor who
gets snacks; there is no way since they help themselves.
During an interview on 5/8/19, at 1:30 P.M., CNA I said dietary sends small packages of
cookies, graham crackers, cups of applesauce or yogurt and once in a while a banana on the
snack tray to the unit. They only send enough for each resident; no extra. They also send
a pitcher of juice or a flavored drink. We have asked and asked for small sandwiches,
cheese and crackers or other finger foods since some of the residents wander up and down
the hallway and do not sit down to eat. We have asked for food to be put in the
refrigerator to give to residents who wander at night. We need to be able to feed the
residents when they are hungry day or night, but we are not given any extra food to give
the residents between meals or at nights. Too often, the residents do not like and will
not eat the meal served but we have nothing else to fed them. He/she has asked that the
kitchen send a few grilled cheese sandwiches down with the meal trays but it has never
happened. The unit residents always receive the regular meal from the kitchen. If a
resident is allergic to or cannot eat a food, like pork, it is just omitted from their
plate but nothering else is added. No one is listening to staff on the unit when we tell
dietary and nursing what the residents need on the memory care unit. We have residents who
sleep past meal time; we have no way of heating up a meal tray even if we would keep their
meal tray in the refrigerator. Often if a resident sleeps a lot in the day time they just
miss out on their meal.
During an interview on 5/13/19, at 12:45 P.M., the Registered Dietitian said:
– The facility should provide everyone who wants an evening snack at snack of their
liking.
– Dietary needs to provide finger foods and ingredients for sandwiches on the memory care
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 41)
unit for residents who sleep in the day time and wander at night.
– Even residents off the unit should be able to have foods at alternate times if that is
what they need to obtain their nutritional needs.
– It should never take three hours to serve everyone breakfast.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation. record review and interview, the facility failed to prepare, store
and serve food in accordance with professional standards for food service safety when
staff did not wash their hands and put on clean gloves as needed, touched food with dirty
gloves, served food at unsafe temperatures, failed to ensure the dishwasher and sanitizing
solution worked properly, failed to sanitize food preperation areas and served residents
soft unpasturized eggs. These practices had the potential to affect all of the facility’s
residents who consumed food from the facility kitchen. The facility had a census of 106.
1. Observation on 5/8/19, starting at 5:16 A.M., showed the following:
– Dietary Staff (DS) B mopping the kitchen floor;
– Area on the floor where electrical plug went into steam table was coated in grease and
dirt; the pipes next to the electrical unit coated in dirt and grease; grease dripped off
the bottom of the main steam table;
– The can opener still contained dirty paper and food on the blade as noted the day
before;
– The top of trashcan contained splatters of food;
– DS B stopped mopping, came over to the stove/food preparation area and put on gloves
without washing his/her hands; put oven mitts on over the plastic gloves and checked the
bacon and sausage in the oven; then went back to mopping the floor wearing his/her plastic
gloves;
– Still wearing the same gloves and without washing his/her hands, DS B sat the mop in
the doorway by the coffee maker, came back into the kitchen preparation area, put on the
oven mitts and checked the sausage in the oven, spilling grease from the pan
– DS B picked up a damp white cloth from red roller cart, wiped up the spilled grease on
the counter from sausage pan and tossed the white cloth back on the red cart;
– DS D entered the kitchen and said he/she came over to help out; he/she was the assistant
dietary manager from a sister facility; the acting dietary manager not able to be present
during the survey;
– At 5:32 A.M., DS B pulled the bacon out of the oven;
– A whip, coated with a yellowish, dried substance, lay on the side of the stove by a
skillet; DS B picked up a second white cloth, wiped more spilled grease from the counter
then tossed the cloth onto the counter by the stove, landing on the dirty whip;
– DS B wore the oven mitt over his/her same gloved hands and removed pans of sausage out
of oven;
– He/she checked the sausage temperature and placed the sausage into steam pan. The
sausage was unevenly cooked one side of pan contained light-colored sausage and the other
side contained dark brown sausage and the middle of the pan looked light brown;
– DS B rinsed the thermometer under running water and placed the thermometer back into its

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 42)
holder;
– DS B picked up the white cloth from the red roller cart and placed the damp greasy white
cloth on the counter;
– He/she placed a grease laden sheet pan from the cooked sausage across the red cart and
wheeled the cart and pan over to the dirty dish area;
– He/she returned from the dirty dish area and tried to open a box, still wearing the same
greasy gloves;
– He/she removed his/her gloves to tear open the box of plastic wrap;
– He/she put on clean gloves without washing hands;
– DS B went to the oven, touched the sticky, greasy door handle; checked the sausage in
the oven, went into the walk-in cooler and came back with cartons of cholesterol free/fat
free egg product; (contained egg whites on carton) placed about 1/4 cup of margarine in
the skillet with his/her gloved hands and added the liquid egg mixture into skillet, all
while still wearing the same soiled gloves;
– Without washing his/her hands, changing gloves or sanitizing the dirty cloth, he/she
picked up the white cloth that laid on the whip, wiped off the counter and tossed it back
on the end of the counter then picked up the dirty whip and took it to the dishwashing
areas;
– He/she removed sausage from the steam pan with his/her gloved hands and placed the
sausage into the food processor across the room. He/she processed the sausage for about a
minute, removed the lid and placed his/her gloved hands into the food processor then using
his/her gloved hand, scooped the ground sausage out of Robo Coupe into a steam pan;
– DS B went back to work area, covered the pan of ground sausage with plastic wrap and
placed the pan into the small steam table; grease from his/her gloved hands stained the
plastic wrap package;
– He/she returned to the oven/range and stirred the scrambled eggs with a spatula; after
finding them cooked, poured the scrambled eggs into a small steam table pan and checked
the temperature (172 F);
– At 6:07 A.M., DS G entered the kitchen and started pouring milk, juice etc. into small
glasses;
– At 6:11 A.M., a red substance was noted splattered on the wall and doorway near the
small steam table and behind the large floor-standing mixer; the splattered area covered
several feet of the wall and doorway;
– DS B left the kitchen preparation area and went over to the passed through window, where
a resident was requesting a cup of coffee. DS B got a coffee cup and poured coffee into
the cup, opened the kitchen door going into the dinning room and gave the resident the cup
of coffee, touching the sticky kitchen door with his/her gloved hands;
– DS B added more butter, using his/her gloved fingers, into the previously used skillet
and added another carton of the egg mixture into the dirty skillet;
– DS B, wearing the same gloved hands, picked up 15 sausage links out of a pan of sausage
and placed the sausage in the Robo Coupe. He/she ran the Robo Coupe for a minute or so and
turned off the Robo Coupe, removed the lid and placed his/her gloved hand into the ground
sausageand rubbed the ground sausage between his/her gloved fingers;
– He/she left the Robo Coupe area, went to the coffee area at the front side of the
kitchen and obtained a Styrofoam cup then went into the dry storage room and dipped the
Styrofoam cup into an open box of food thickener, filling the cup about 1/3 full and
returned to the Robo Coupe. He/she then added the thickener and processed the mixture for
another minute;
– DS B placed his/her same gloved hands back into the sausage mixture, rubbing the mixture
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 43)
with his/her fingers and said the sausage mixture was too thick. He/she went back to the
coffee area, obtained a cup of hot water and poured about 1/3 of a cup of hot water into
the Robo Coupe with the sausage. He/she ground the sausage mixture a little longer then
scooped the mixture out of the Robo Coupe with his/her hands and placed the sausage
mixture into small steam table pan. DS B did not change his/her gloves or wash his/her
hands during this time.
– At 6:11 A.M., without washing his/her hands and changing gloves, DS B placed the
sausage mixture on the steam table.
– DS B returned to the oven, wearing the same gloves, then went to the stove to stir the
scrambled eggs and placed the scrambled egg mixture into steam table pan. The side of the
steam table pan shinned from DS B’s greasy gloves;
– He/she went into walk-in freezer, touching handles and several boxes, then returned with
an unopened box of sausage patties; he/she said he/she did not have enough sausage cooked
because he/she used more sausage than he/she thought preparing the pureed and ground
sausage;
– Still wearing the same soiled gloves, he/she got a sheet pan, placed parchment paper
from a box splattered with food and grease and placed the parchment on the pan; went over
to the stove area, obtained a bottle of cooking spray and sprayed the parchment then laid
sausage patties, touching each patty with his/her same greasy soiled gloved hands. He/she
placed the pan of sausage into the oven, leaving grease from his/her gloved hands on the
oven handle.
– At 6:25 A.M., the filled milk glasses remained sitting on counter. DS G placed small
pieces of plastic over the top of each glass.
– DS B went back to the walk-in refrigerator, placed the box of sausage into the
refrigerator then went back across the room to the roller toaster. He/she used the same
gloved hands to pull the slices of bread out of the loaf of bread and placed the bread
into the toaster;
– He/she went back across the room to get a resident a cup of coffee, again touching the
kitchen door with his/her gloved hands.
– He/she returned to the skillet, added more butter using his/her fingers and poured egg
mixture into the used skillet.
– He/she went back to toaster and found it not working; he/she handled multiple parts of
the toaster and the outlet and found the toaster was unplugged. He/she plugged the toaster
cord into the outlet, and with the same gloved hands, picked up slices of bread and placed
the bread into the roller part of toaster, returned to the oven/range to stir the eggs and
returned, moving back and forth from the stove to the toaster several times, stopping in
between to get residents coffee.
– Staff placed a tray of silverware from the dishwasher to counter for dietary staff to
roll napkins around the silverwear for meal service. Multiple pieces of food were mixed in
with the supposedly cleaned silverware. Pineapple chunks and a small rice like pasta was
on the silverware and in the tray. An unknown staff wrapped the silverware for breakfast
tray use.
– At 6:35 A.M., DS G added a thin layer of ice in a plastic container and sat the glasses
of milk on the ice. The ice was about an inch high on the glasses of milk and juice.
– DS B checked the temperature of the scrambled eggs in the skilled and said they were 159
degrees F which was close enough to the required 160 degree F.
– At 6:38 A.M., DS B removed his/her gloves, took the dirty egg skillet to the dishwashing
room; sprayer the skillet with hot water and wiped the skillet dry with the a white cloth.
He/she used the same white cloth to clean off the stove and tossed the cloth onto the red
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 44)
cart. DS B used no soap nor did he/she sanitize the skillet.
– Without washing his/her hands, DS B put on new gloves and took sausage out of the oven;
placed the cooked sausage into the pan of previously cooked sausage on steam table and
returned the dirty pan to dish room.
– He/she removed plastic wrap from the food on the steam table and adding serving spoons.
– At 6:44 A.M., showed DS D making more toast with his/her greasy gloved hands.
– DS B remove his/her gloves and started going through the menu sheet for the day’s
breakfast. He/she took the menu sheets to the dining room for residents to fill out.
– At 7:08 A.M., DS D brought unpasteurized eggs out of the walk in cooler to the stove.
DS D put on gloves without washing his/her hands.
– DS B returned to the kitchen and without washing his/her hands or changing gloves,
he/she placed his/her hand into the steam table pans and pulled out two links of sausage
placed on plate; went into the dry storage room after containers of dry cereal and
returned to the tray line;
– DS B continued to fill trays touching sausage, toast etc with his/her gloved hands;
– DS D told DS B to use tongs when serving food but DS B continued to use his/her gloved
hands touching the food.
– DS B took the stack of paper menu tickets down off the shelf and placed the paper menus
in middle of a plate to find the one he/she wanted; he/she placed the menu sheets back on
the shelf; filled the same plate he/she had touched with all of the residents’ menu sheets
and served the food to a resident.
– DS B removed a piece of sausage off of a resident’s plate that had been prepared,
tossed the sausage back into the steam pan and added eggs in place of the sausage to the
same plate. Greasy shined on the resident’s plate from DS B’s gloved hand.
During an interview on 5/13/19, at 1:18 P.M., the Registered Dietitian said:
– Staff should wash their hands and put on clean gloves between tasks.
– Staff should not be mopping the floor and cooking at the same time.
– Staff should not touch food with gloved hands during meal preparation and service.
– Staff are to use tongs during meal service.
– Staff should wash their hands and put on clean gloves between tasks and any time their
gloves came in contact with a dirty surface.
– Doors and boxes are considered unclean surfaces.
– Damp used clothes should not be on the counter, carts or work areas and should not be
used to clean food preparation surfaces.
– Staff should always store their cleaning cloths in a sanitizing solution and sanitize
the counter when items were spilled or after food preparation.
– Staff should not rinse pans or skillets, dry with a cloth and re-sure. Pan and skillets
must be washed, rinsed and sanitized properly or washed in the dishwasher.
– Staff are to air dry dishes and pans.
– Staff should clean all parts of the kitchen including the elecrical cords, outlets and
the walls.
During an interview on 5/14/19, at 10:20 A.M., the Administrator said she was aware the
dietary department had issues. They hired a new dietary manager who started today and
brought trained staff with her.
2. Observation on 5/8/19, at 7:18 A.M., showed DS D fried unpasteurized eggs hard. DS B
said he/she needed over easy eggs. DS D said their facility does not serve soft eggs. DS B
said he/she was aware some buildings do not serve soft eggs but they do. DS D said the
health department said no soft eggs. DS B said he/she knew this, but the residents liked
soft eggs and they made and serve easy over eggs. DS D prepared the soft over easy eggs
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 45)
for DS B to put on the residents’ plates.
During an interview on 5/8/19, at 9:50 A,M., the Administrator said:
– The facility does not serve unpasteurized soft eggs.
– They only use pasteurized eggs.
– She called the former dietary manager who still did the ordering for the facility at
9:52 A.M., and found out he/she had never ordered pasteurized eggs.
– The Administrator said she would stop the serving of over easy eggs until she can order
and the pasteurized eggs were delivered.
– She believed they used pasteurized eggs.
During an interview on 5/8/19, at 10:10 A.M., the Registered Dietitian said:
– The facility does not serve soft eggs.
– She told the former dietary manager that he/she could not serve soft eggs unless they
were pasteurized.
– She instructed the dietary manager to order pasteurized eggs.
– She had never been in the facility when a soft unpastured egg was served.
During an interview on 5/9/19, at 11:15 A.M., the Administrator said he/she checked the
food orders and did not find where staff had ordered pasturized eggs.
During an interview on 5/8/19, at 2:59 P.M., Resident #25 said he/she always orders
his/her eggs over medium and wanted the yolk runny. He/she received a good runny egg this
morning. He/she liked to dip his/her toast in the runny egg yolk.
During an interview on 5/9/19, at 9:20 A.M., Resident #66 said he/she was upset because
the dietary staff would not prepare easy over eggs this morning. He/she always ate easy
over eggs.
During an interview on 5/9/19, at 11:21 A.M., DS B said he/she did not know anything about
pasteurized eggs. He/she was not to serve any more soft eggs until told otherwise.
During an interview on 5/10/19, 10:35 A.M, DS B said he/she cooked about 35 soft easy over
eggs daily. He/she was not aware until this week that she could not serve easy over
unpasteurized eggs.
3. Observation on 5/8/19, at 8:41 A.M., showed the test tray temperatures’s out of range
included a sausage link 117.3 F; milk 55.9 F and orange juice 55.2 F.
During an interview on 5/10/19, at 10:15 A.M., DS B said no one monitors the food
temperatures once the food leaves the kitchen. He/she was unaware that residents had
complained of cold food and lukewarm milk. It take a long time to get all of the residents
feed.
During an interview on 5/10/19, at 10:35 A.M., DS D said hot food should be at least 135
degrees F when served to the residents and the cold food should be below 42 degrees F.
They should have placed the glasses of milk and juice encased in ice, just not sat the
glasses of milk on top of a layer of ice.
4. Observation on 5/8/19, at 6:40 A.M., showed a tray of silverware just out of the
dishwasher. The silverware contained pieces of pineapple and orzo pasta which stuck onto
the silverware. Staff used the silverware during the breakfast meal.
Observation and interview on 5/9/19, at 2:15 P.M., showed:
– DS D checked the sanitizing solution in the dishwasher more than twice.
– He/she said he/she could not get the test strips to register any sanitizing solution.
– He/she fiddled with the containers and tubing, trying to make sure the sanitizing
solution was going into the machine.
– He/she could not get the sanitizing solution to test.
– DS B said he/she was unaware how often anyone checked the sanitizing solution in the
dishwasher. Staff only record the dishwasher’s temperature daily.
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 46)
– DS B said the dishwasher was old and sometimes did not clean the the best.
During an interview on 5/13/19, at 1:18 P,M., the Registered Dietitian said:
– Staff should check and record the sanitizing solution of the dishwasher before or during
every meal
– Staff should make sure the dishwasher is work correctly.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews the facility failed to ensure staff
used acceptable infection control procedures when staff did not wash their hands and
change gloves during catheter care and peri care. This affected four of 24 sampled
residents (Resident #13, #1, #62 and #46). Staff also did not wash hands during blood
sugar checks and medication administration, which affected Residents #86, #98 and #200.
Staff also did not wash their hands when entering or exiting a room with a resident
(Resident #47) with [MEDICAL CONDITIONS], bacterium that causes diarrhea and an
inflammation of the colon. The facility census was 106.
1. Review of the facility’s undated, Hand Hygiene policy, showed:
– The facility considers hand hygiene the primary means to prevent the spread of
infection;
– Staff are trained and regularly in-serviced on the importance of hand hygiene in
preventing the transmission of healthcare-associated infections;
– Wash hands with soap and water when soiled with visible dirt or debris
– After contact with intact and non-intact skin, clothing and environmental surfaces of
residents with active diarrhea even if gloves are worn;
– In between glove changes;
– Alcohol based hand hygiene products can and should be used to decontaminate hands
immediately upon entering a resident occupied area and immediately upon exiting a resident
occupied area before exiting into a common area such as a corridor.
-The use of gloves does not replace use of hand hygiene procedures.
– Hand hygiene is always the final step after removing and disposing personal protective
equipment.
2. Review of Resident #13’s Minimum Data Set, (MDS) a federally mandated assessment
completed by facility staff, dated 2/12/19, showed:
– Difficulty making decisions;
– Required assistance of staff with toilet use and personal hygiene;
– Occasionally incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan revised on 5/8/19 showed:
– Resident requires extensive assistance of staff with personal hygiene and toilet use.
Observation an interview on 5/8/19 at 7:06 A.M., showed the resident lay in bed, his/her
brief soiled with urine. Certified Nurse Aide (CNA) A provided peri care in the following
way:
– Did not wash his/her hands before he/she put on a pair of gloves and unfastened the
resident’s brief;
– Completed peri care and without changing gloves or washing hands, he/she put on a clean

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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 47)
brief and assisted the resident to dress;
– Assisted the resident to stand from his/her bed;
– He/she touched the handles of the resident’s wheelchair and assisted the resident to sit
in the wheelchair;
– He/she removed his/her gloves , did not wash his/her hands, gathered trash and soiled
clothing in bags and without washing his/her hands, opened the resident’s door, left the
resident’s room and walked down the hall to the soiled utility room.
3 Review of Resident #46’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 3/9/19, showed:
– Difficulty making daily decisions;
– Required assistance of staff for toilet use and personal hygiene;
– Indwelling catheter and frequently incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation and interview on 5/14/19 at 10:11 A.M., showed the resident lay in bed with a
supra-pubic catheter (a urinary catheter that is inserted into the abdominal wall and into
the bladder). Certified Nurse Aide (CNA) A entered the resident’ room and without washing
his/her hands, he/she put on a pair of gloves. CNA A said the insertion site looked
infected then he/she provided catheter care in the following way:
– Provided catheter care for the resident. changed gloves and washed his/her hands;
– Retrieved a graduate (plastic measuring container) from the bathroom, drained urine into
the graduate and handled the drain spout,
– Without changing gloves or washing hands, CNA A adjusted the resident’s clothing,
gathered trash and after removing gloves, without washing hands left the resident’s room.
4. Review of Resident #62’s quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Total dependence for toileting;
-Extensive assistance required for personal hygiene;
-Incontinent of bowel and bladder;
-Had moisture-associated skin damage.
Review of the resident’s care plan, last revised on 4/2/19, showed:
-Required extensive assist with personal hygiene;
-Total dependence for toileting;
-At risk for skin breakdown;
-Peri care after each incontinent episode.
Observation on 5/14/19 at 10:24 A.M., showed CNA’s A and D provided care in the following
manner as the resident lay in bed:
-Both staff washed hands and put on gloves;
-CNA A unfastened the resident’s wet brief and cleansed part of the resident’s front
genital area, wiping back and forth with the same bunch of moist wipes;
-CNA D turned the resident to the resident’s right side;
-CNA A cleansed the resident’s backside, wiping back and forth with the same bunch of
moist wipes;
-CNA D turned the resident onto his/her back;
-With the same soiled gloves on, CNA A cleansed the remainder of the front genital skin
folds, picked up the resident’s pants, put a stocking on the resident’s left foot, helped
CNA D put pants on the resident, picked up the moist wipes container and laid it on the
resident’s over-the-bed table, picked up a lift sling and laid it on the bed, helped CNA D
place the sling under the resident, adjusted the resident’s top and pants, touched the
handle bar of the resident’s electric wheelchair, removed his/her gloves and left the
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 48)
room, but did not wash his/her hands first.
5. Review of Resident #1’s quarterly MDS, dated [DATE], showed:
-Required extensive assistance with toileting and personal hygiene;
-Incontinent of urine.
Review of the resident’s care plan, last revised on 5/7/19, showed:
-Had a urinary catheter (sterile tube inserted into the bladder to drain urine);
-At risk for urinary tract infection [MEDICAL CONDITION] due to a history of UTI’s;
-Started on an antibiotic for a UTI on 5/6/19.
Observation on 5/8/19 at 1:15 P.M. showed Licensed Practical Nurse (LPN) A provided care
in the following manner:
-Washed his/her hands and put on gloves;
-Emptied urine from the resident’s catheter drainage bag and emptied it in the toilet;
-Removed his/her gloves, but did not wash or sanitize his/her hands;
-Left the resident’s room, took keys from his/her uniform pocket, unlocked the medication
cart and removed items from it, then sanitized his/her hands.
During an interview on 5/8/19 at 1:34 P.M., LPN A said staff should wash or sanitize their
hands after they emptied a catheter drainage bag. He/she did not realize he/she touched
multiple items and surfaces before he/she sanitized his/her hands.
During an interview on 5/14/19 at 2:40 P.M., CNA A said:
– He/she should wash his/her ands when he/she entered a room and before he/she finished
resident care;
– He/she should wash his her hands after care before putting on clean stuff.
6. Review of Resident #47’s Minimum Data Set (MDS), a federally mandated assessment
completed by facility staff, dated 3/18/19 showed:
-Cognitively intact.
Review of the resident’s Care Plan dated 5/7/19 showed:
– The resident was on antibiotic therapy due to [MEDICAL CONDITION];
– Administer antibiotic as per MD orders;
– Maintain universal precautions when providing resident care.
Review of the (MONTH) 2019 Physician order [REDACTED].>- [MEDICATION NAME] MCL
(antibiotic) 125 milligrams (mg), give one capsule by mouth every 6 hours for infection
until 5/15/19, start date 5/9/19.
During an interview on 5/08/19 at 1:12 P.M. the resident said he/she:
– Had [MEDICAL CONDITION];
– Took an antibiotic to treat it 3 times per day;
– Had 3 bowel episodes of diarrhea that day, and had been having diarrhea for about week;
– Had been hospitalized the last week of April, three days after he/she returned to the
facility, the diarrhea returned;
– tested positive for [MEDICAL CONDITION] and was kept in bed for three days.
Observation at the same time showed there was no signage posted that the resident was on
any kind of infection control precautions.
Observation on 5/08/19 01:55 P.M. beginning at 1:55 P.M. showed:
Regional Human Resources staff entered the resident’s room, spoke briefly with the
resident then left.
– CNA I entered the resident’s room then left;
– CNA H entered the resident’s room, retrieved at room tray, spoke with the resident, then
left. The staff then returned to the room then left again
– None of the staff washed their hands or took any other precautions after entering or
before exiting the room
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 49)
Observation on 5/10/19 9:09 A.M. showed Housekeeping C (Lisa Carlock) walked in to
resident’s room, got a bowl with partially eaten hard boiled egg, walked out of room with
it and put it on a food cart. He/she did not his/her wash hands or take any other
precautions.
During an observation on 5/10/19 at 8:55 A.M. showed an unknown staff member walked in to
the room asked if the resident had gotten his/her room tray, the resident said no and the
he/she wanted some ice water, staff took the resident’s cup, with ungloved hands, and got
ice from the storage closet, walked back in to the resident’s room, filled resident’s
water at the sink, and said he/she would be right back, then walked out of the resident’s
room and walked in to another resident’s room, spoke with a resident, then walked out,
then walked in to another resident’s room, walked out and walked down the hallway. The
staff did not wash his/her hands or take any other precautions.
During an interview on 5/10/19 at 7:51 A.M. the Administrator said the resident had
chronic, colonized [MEDICAL CONDITION].
During an interview on 5/14/19 at 4:00 P.M. the Director of Nursing (DON) said:
– Staff should wash their hands before leaving a room of a resident with an infection,
such as [MEDICAL CONDITION].
7. Review of the facility’s undated policy related to blood glucose monitoring showed, in
part:
-Assemble needed equipment;
-Wash hands and put on gloves;
-Perform the blood sugar check;
-Remove gloves and wash hands;
-Put on gloves and clean glucometer (machine used to check blood sugar levels) per
manufacturer’s directions;
-Remove gloves and wash hands.
Review of the facility’s undated medication administration policy showed to wash hands
before and after medication administration.
8. Review of Resident #200’s (MONTH) 2019 physician order [REDACTED].
Observation on 5/8/19 at 7:45 A.M., showed LPN B checked blood sugar levels and
administered insulin to the resident in the following manner:
-Gathered supplies and set them on an aluminum foil barrier at the resident’s bedside;
-Washed hands and put on gloves;
-Checked the resident’s blood sugar;
-Removed gloves, but did not wash or sanitize hands;
-Put on new gloves and drew insulin into a syringe;
-Removed gloves, did not wash or sanitize hands, and put on new gloves;
-Administered the insulin in the resident’s left upper arm;
-Removed gloves, but did not wash or sanitize hands;
-Touched the computer mouse, touched an ink pen and paper notebook, took keys from his/her
uniform pocket and touched the medication cart lock and drawer handle, went to the ERU
(express rehabilitation unit) dining room and touched Resident #98’s wheelchair handles,
then returned to the medication cart and opened a drawer, removed a piece of aluminum foil
and put on gloves, but did not wash or sanitize his/her hands;
-Sanitized the glucometer with a sanitizing wipe and set it on the foil to dry, then
gathered supplies from the medication cart drawer for Resident #98’s blood sugar check and
set them on a piece of aluminum foil on the cart and removed his/her gloves, but did not
wash or sanitize his/her hands.
9. Review of Resident #98’s (MONTH) 2019 POS showed he/she received blood sugar level
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 50)
checks before meals and at bedtime, and received insulin for diabetes.
Observation on 5/8/19 at 7:55 A.M., showed LPN B checked the resident’s blood sugar level
and administered insulin in the following manner:
-Took supplies to the resident’s room and set them on a piece of aluminum foil;
-Put on gloves, but did not wash or sanitize his/her hands first;
-Checked the resident’s blood sugar level and set the glucometer on a piece of foil on the
medication cart;
-Removed his/her gloves, but did not wash or sanitize his/her hands;
-Opened the medication cart, touched multiple medication containers, then removed the
resident’s insulin bottle from the drawer;
-Put on new gloves, but did not wash or sanitize his/her hands;
-Drew insulin into a syringe;
-Removed his/her gloves, did not wash or sanitize his/her hands, and put on new gloves;
-Went to the resident’s room and administered the insulin in the resident’s abdomen;
-Removed his/her gloves, but did not wash or sanitize his/her hands.
During an interview at 8:03 A.M., LPN B said:
-He/she did not know staff should wash or sanitize their hands after each glove removal.
-He/she thought it was ok to wash or sanitize hands after every second resident as long as
he/she wore gloves.
10. Review of Resident #86’s (MONTH) 2019 POS showed orders for:
-[MEDICATION NAME] (water pill) 80 milligrams (mg) daily;
-[MEDICATION NAME] (to lower cholesterol) 40 mg daily;
-Magnesium Oxide (supplement) 400 mg twice a day;
-[MEDICATION NAME] (stimulates gastric movement) 10 mg before meals and at bedtime;
-[MEDICATION NAME] (renal supplement) once a day;
-[MEDICATION NAME] (for heart arrhythmia) 200 mg daily;
-[MEDICATION NAME] (for gastric reflux) 40 mg daily;
-[MEDICATION NAME] 8.6 mg daily for constipation;
-[MEDICATION NAME] inhaler two times a day for breathing;
-[MEDICATION NAME] 0.25 mg twice a day for anxiety;
-[MEDICATION NAME]-[MEDICATION NAME] solution 0.5-2.5 mg/3 milliliters per nebulizer
(device that disperses medication into a fine mist for inhalation) four times a day for
shortness of air.
Observation on 5/8/19, between 11:36 A.M. and 11:50 A.M., showed LPN B administered the
resident’s medications in the following manner:
-Sanitized hands and put on gloves;
-Administered one inhalation of [MEDICATION NAME];
-Removed his/her gloves, but did not wash or sanitize his/her hands;
-Touched the computer mouse, then opened the medication cart and obtained the resident’s
medications from medication cards and stock medication containers and put them in a
medication cup;
-Put gloves on, but did not wash or sanitize his/her hands;
-Returned to the resident’s room and administered a second inhalation of [MEDICATION
NAME];
-Removed his/her gloves, did not wash or sanitize his/her hands;
-Administered the resident’s oral medications;
-Put on new gloves, did not wash or sanitize his/her hands;
-Checked the resident’s oxygen saturation level, listened to his/her lung sounds, removed
his/her gloves, but did not wash or sanitize his/her hands;
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:

265693

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF INDEPENDENCE

STREET ADDRESS, CITY, STATE, ZIP

1800 S SWOPE DRIVE
INDEPENDENCE, MO 64057

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 51)
-Left the room to obtain a new nebulizer face mask;
-Returned to the resident’s room, did not wash or sanitize his/her hands;
-Administered the resident’s [MEDICATION NAME]-[MEDICATION NAME] nebulizer treatment,
removed his/her gloves and sanitized his/her hands.
During an interview on 5/8/19 at 12:08 P.M., LPN B said he/she should have washed or
sanitized his/her hands before he/she obtained the resident’s medications, after he/she
administered the inhaler, after he/she administered the nebulizer treatment and with each
glove change.
11. During an interview on 5/14/19 at 4:00 P.M.,the Director of Nurses said:
– Staff should wash their hands before and after patient care;
– Staff could use hand sanitizer, but should use soap and water if visibly soiled;
– Staff should wash their hands between glove changes;
– Staff should wash their hands between care provided after the front side of the resident
and the back side;
– Staff should was their hands after peri care before they touch anything else;
– Staff should wash their hands before they left the resident’s room.