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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide dignity
to two sampled residents (Residents #21 and #32) by leaving hospital wristbands with care
information on them, and to trim or remove facial hair for one sampled resident (Resident
#21) out of 18 sampled residents. The facility census was 80 residents.
Record review of the facility’s considerate and respectful treatment policy revised 9/1/13
showed instructions to staff to:
-Care for residents in a manner that maintains or enhances each resident’s dignity and
-Not post signs that are able to be seen by other residents and/or visitors that include
clinical or personal information.
1. Observation during initial tour on 6/6/18 at 10:00 A.M. showed multiple residents were
wearing wristbands that had clinical information regarding the resident such as fall risk.
2. Record review of Resident #21’s care plan revised 10/3/17 showed:
-The resident was a high fall risk and
-The resident required extensive assistance with personal hygiene.
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool used by facility staff for care planning) dated 3/26/18 showed the
following staff assessment of the resident:
-Had clear speech;
-Had moderate hearing impairment;
-Had moderately impaired cognitive skills;
-Had disorganized thinking;
-Required extensive assistance with personal hygiene;
-One of his/her [DIAGNOSES REDACTED].
-Had not fallen since his/her last assessment (12/24/17).
Observation on 6/06/18 at 2:06 P.M. showed the resident had a fall risk wristband on, an
allergy wristband on and had a cluster of gray hairs that were about an inch long coming
out of a mole on his/her chin.
Observation on 6/11/18 at 5:25 A.M. showed the resident had a fall risk wristband on, an
allergy wristband on and had a cluster of gray hairs that were about an inch long coming
out of a mole on his/her chin.
Observation on 6/12/18 at 7:53 A.M. showed the resident had a fall risk wristband on, an
allergy wristband on and had a cluster of gray hairs that were about an inch long coming
out of a mole on his/her chin.
During an interview on 6/13/18 at 12:08 P.M., the Assistant Director of Nursing (ADON)
said:
-No one had tried to pull or trim the hairs coming out of the resident’s mole and
-He/she will ask the resident’s doctor if they can pull the hairs from the mole.
3. Record review of Resident #32’s admission MDS dated [DATE] showed the following staff
assessment of the resident:
-Had unclear speech;
-Sometimes understood others;
-Had short-term and long-term memory impairment;
-Received [MEDICAL TREATMENT] (a process of cleansing the blood by passing it through a
special machine when the kidneys are not able to filter the blood) and
-Required extensive assistance to being totally dependent upon staff for all cares.
Record review of the resident’s current care plan 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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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)
-Revised on 4/24/18: The resident required extensive assistance to being totally dependent
upon staff for all cares;
-Revised on 4/24/18: The resident had unclear to no speech and
-Revised on 5/4/18: The resident had multiple wounds.
Observation on 6/7/18 at 12:01 P.M. showed the resident had on a wristband that said limb
alert.
Observation on 6/11/18 at 6:04 A.M. showed the resident had on a wristband that said limb
alert.
Observation on 6/11/18 at 6:57 A.M. showed the resident had on a wristband that said limb
alert.
Observation on 6/13/18 at 7:15 A.M. showed the resident had on a wristband that said limb
alert.
4. During an interview on 6/12/18 at 11:39 A.M., the Director of Nursing (DON) said:
-They are not putting wristbands on the residents and
-The wristbands must be left over from the hospital or when out to a procedure and they
were not cut off.

F 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Keep residents’ personal and medical records private and confidential.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide privacy
by storing an employee’s personal belongings in a resident’s room for one sampled resident
(Resident #28) out of 18 sampled residents. The facility census was 80 residents.
Record review of the facility’s privacy rights policy revised 11/28/16 showed residents
have a right to personal privacy.
1. Record review of Resident #28’s care plan dated 1/3/18 showed he/she:
-Was resistive to cares related to dementia (a progressive mental disorder characterized
by memory problems, impaired reasoning and personality changes);
-Had the potential to be verbally aggressive related to dementia and
-Had impaired cognitive function and impaired thought processes related to dementia.
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by staff for care planning) dated 4/13/18 showed he/she:
-Was severely cognitively impaired and
-Had a [DIAGNOSES REDACTED].
Observation on 6/6/18 at 10:50 A.M. showed the Activity Assistant:
-Was in Resident #28’s room taking snacks out of an upper cupboard (The first half of the
room did not have a resident living in it. Resident #28 lived in the back half of the
room);
-No resident was present in the room;
-The Activity Assistant walked down the hallway stopped at the nurses’ station where
he/she gave a snack package to one of the Certified Nursing Assistants and
-He/she went into the dining room (where there was an activity in progress with the
residents), sat down and ate one of the snack packages.
During an interview on 6/6/18 at 2:00 P.M. the Director of Nursing (DON) said;
-He/she had talked to the Activity Assistant who told him/her those were his/her snacks
and

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

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
-He/she didn’t know why the Activity Assistant kept his/her snacks in a resident’s room.
During an interview on 6/12/18 at 10:00 A.M., the Activity Assistant said:
-He/she was keeping stuff he/she brought for the residents such as candy, hand gel, etc.
in the empty room (The room where Resident #28 resided);
-All the employee lockers were taken and
-The activity supplies are kept downstairs locked up.
During an interview on 6/14/18 at 11:15 A.M., the Regional Nurse said:
-Staff should not be storing items in a resident’s room or care area and
-They should be kept in the activity room, office or break room.
During an interview on 06/14/18 at 11:15 A.M., the DON said:
-They have a break room where staff should store their belongings and
-The Activity Assistant could store belongings in the activity office and not in a
resident area.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to provide notification to the
resident, and/or the resident’s representative(s) and the ombudsman (a resident advocate
who provides support and assistance with problems and/or complaints regarding the
facility) of the transfer or discharge and the reasons for the move in writing for three
sampled residents (Residents #48, #29, #57) out of 18 sampled residents and one closed
record resident (Resident #180). The facility census was 80 residents.
Record review of the facility’s Discharge and Transfer Policy effective dated of 6/1/96,
reviewed date of 10/10/’16 and revision date of 11/28/16 showed:
-All residents will receive a Notice of Transfer or Discharge whenever a voluntary or
involuntary transfer/discharge occurs;
-Residents and/or legal representatives will be provided proper notice in accordance with
state and federal regulations should a transfer or discharge be initiated;
-Social Services will ensure systems are implemented to provide written notification to
the resident/responsible party;
-For unplanned, acute transfers, residents, family, and legal guardian will be notified
verbally;
-Written notice will follow verbal notification per state requirements; and
-A copy of the written notice of transfer will be placed in the resident’s medical record.
1. Record review of Resident #48’s discharge return anticipated assessment dated [DATE]
showed he/she was transferred from the facility on 5/17/18.
Record review of the resident’s medical record showed there was no letter notifying the
resident and the resident’s representative(s) of a transfer and the reasons for the
transfer.
Record review of the resident’s entry tracking form dated 5/24/18 showed the resident
returned to the facility on [DATE].
2. Record review of Resident #29’s Nurses Note dated 5/23/18 at 9:25 A.M. showed he/she
was transferred to the hospital.
Record review of the resident’s medical record showed there was no letter notifying the

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

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
resident and/or the resident’s representative(s) or the Ombudsman of a transfer and the
reasons for the transfer.
Record review of the resident’s Nurses Note dated 6/6/2018 at 7:22 P.M., showed that the
resident was readmitted to the facility.
3. Record review of Resident #57’s Nurses Note dated 4/7/2018 at 10:50 P.M., late entry
showed he/she had been transferred to the hospital at 1:50 P.M.
Record review of the resident’s medical record showed there was no letter notifying the
resident and/or the resident’s representative(s) or the Ombudsman of a transfer and the
reasons for the transfer.
Record review of the resident’s Nurses Note dated 4/20/2018 at 5:56 P.M., showed that the
resident returned to the facility.
4. Record review of Resident #180’s Nurses Note dated 4/26/2018 at 4:00 P.M. showed he/she
was admitted to the hospital.
Record review of the resident’s medical record showed there was no letter notifying the
resident and/or the resident’s representative(s) or the Ombudsman of a transfer and the
reasons for the transfer.
Record review of the resident’s medical record showed no nurse’s note to indicate when or
if the resident was readmitted to the facility.
Record review of the resident’s Nurses Note dated 5/16/18 at 19:49 showed a Discharge
Summary Note that the Resident discharged into the care of family with the intent of
continuing hospice care in the home.
5. During an interview on 6/12/18 at 9:25 A.M., the Administrator said that the facility
does not send out letters of transfer to the hospital to the resident or responsible party
or to the Ombudsman.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and/or
the resident’s representative(s) of the facility’s bed-hold policy before transferring or
discharging the resident to the hospital for three sampled residents (Residents #48, #29,
and #57) out of 18 sampled residents and one closed record resident (Resident #180). The
facility census was 80 residents.
Record review of the facility’s Bed-Holds Policy effective date of 3/15/00 and revision
date of 11/28/16 showed:
-When a resident is transferred to a hospital the designee (e.g., Admissions, Social
Services, etc.) will provide the resident/resident representative with the written Bed
Hold Policy Notice & Authorization form and
-If the resident representative is not present at time of transfer to receive the written
notice a copy is delivered via e-mail or a hard copy by mail.
1. Record review of Resident #48’s discharge return anticipated assessment dated [DATE]
showed he/she was transferred from the facility on 5/17/18.
Record review of the resident’s medical record showed there was no letter notifying the
resident and the resident’s representative(s) of a transfer and the reasons for 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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
transfer.
Record review of the resident’s entry tracking form dated 5/24/18 showed he/she returned
to the facility on [DATE].
2. Record review of Resident # 29’s Nurses Note dated 5/23/18 at 9:25 A.M. showed he/she
was transferred to the hospital.
Record review of the resident’s medical record showed there was no letter notifying the
resident and/or the resident’s representative(s) of the facility’s bed-hold policy.
Record review of the resident’s Nurses Note dated 6/6/2018 at 7:22 P.M., showed that the
resident was readmitted to the facility.
3. Record review of Resident # 57’s Nurses Note dated 4/7/2018 at 10:50 P.M., late entry
showed he/she had been transferred to the hospital at 1:50 P.M.
Record review of the resident’s medical record showed there was no letter notifying the
resident and/or the resident’s representative(s) of the facility’s bed-hold policy.
Record review of the resident’s Nurses Note dated 4/20/2018 at 5:56 P.M., showed he/she
returned to the facility.
4. Record review of Resident # 180’s Nurses Note dated 4/26/2018 at 4:00 P.M. showed that
the resident was admitted to the hospital.
Record review of the resident’s medical record showed there was no letter notifying the
resident and/or the resident’s representative(s) of the facility’s bed-hold policy.
Record review of the resident’s medical record showed no nurse’s note to indicate when or
if the resident was readmitted to the facility.
Record review of the resident’s Nurses Note dated 5/16/2018 at 19:49 showed a Discharge
Summary Note that the Resident discharged into the care of family with the intent of
continuing Hospice (end of life) care in the home.
5. During an interview on 6/12/18 at 9:25 A.M., the Administrator said that the facility
does not send out the bed hold policy to the resident or responsible party when the
resident is being transferred or discharged .

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to provide a Preadmission
Screening and Resident Review (PASRR- a federally mandated preliminary assessment to
determine whether a resident may have a mental illness (MI) or an intellectual disorder
(ID), to determine the level of care needed. A level I is required for all residents and a
level II if the resident tests positive for any MI or ID) for three sampled residents
(Residents #48, #8 and #57) out of 18 sampled residents. The facility census was 80
residents.
Record review of the facility’s Pre-admission Screening for Mental Illness and
Intellectual/developmental disability Policy with an effective date of 6/1/01 and revision
date of 11/28/’16 showed:
-Social Services (SS) will coordinate and/or inform the appropriate agency to conduct the
evaluation and obtain results if:
–It is learned after admission that the PASRR was not completed or is incorrect, or
–There is a significant change in status that results in new evidence of possible MI, ID,
or a related condition;

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
-SS will review the PASRR to determine appropriate care needs;
-The PASRR will be placed in the admissions or legal section of the resident’s medical
record; and
-SS will be responsible for coordinating updates as needed and per state requirements.
1. Record review of Resident #8’s Admission Record showed he/she was admitted on [DATE]
and readmit on 4/14/17 with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (a [MEDICAL CONDITION] characterized by loss of contact with the
environment, by noticeable deterioration in the level of functioning in everyday life);
-[MEDICAL CONDITION] disorder (mood disorders characterized usually by alternating
episodes of depression and mania);
-Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety) and
-Unspecified intellectual disabilities (significant limitations in reasoning, learning,
problem solving and also adaptive behavior which covers a range of everyday social and
practical skills).
Record review of the resident’s medical record showed no PASRR.
2. Record review of Resident #57’s Admission Record showed he/she was admitted on [DATE]
and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Anxiety disorder and
-[MEDICAL CONDITION] disorder.
Record review of the resident’s medical record showed no PASRR.
3. Record review of Resident #48’s entry tracking form showed he/she was admitted to the
facility on [DATE].
Record review of the resident’s undated medical [DIAGNOSES REDACTED].
Record review of the resident’s medical records showed no documentation of a PASRR.
4. During an interview on 6/08/18 at 12:35 P.M., the Social Services Director said that
he/she did not have the DA124C/Level I PASRR assessments and would have to send off for
the Level II copies.
During an interview on 06/14/18 at 11:15 A.M., the Director of Nursing (DON) said that
he/she does not have anything to do with the PASRRs and would refer to Social Services.
During an interview on 06/14/18 at 11:15 A.M., the Regional Nurse said that PASRRs should
have been completed and on file.

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide the resident and
his/her representative with a summary of the resident’s baseline care plan for two sampled
residents (Resident #32 and #34) and one closed record (Resident #80B) out of 18 sampled
residents and three closed records. The facility census was 80 residents.
Record review of the facility’s Person-Centered Care Plan policy revised on 2/13/17 showed
instructions for staff to:
-Develop and implement a baseline person-centered care plan within 48 hours of admission
for each resident that includes the instructions needed to provide effective and
person-centered care and
-Provide the resident and his/her representative with a summary of the baseline care plan.

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
1. Record review of Resident #32’s admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 4/6/18 showed he/she
was admitted to the facility on [DATE].
Record review of the resident’s medical record showed no documentation that the resident’s
baseline care plan was given to the resident and/or resident’s representative.
2. Record review of Resident #34’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s admission MDS dated [DATE] showed the resident was
admitted to the facility on [DATE].
Record review of the resident’s medical record showed no documentation that the resident’s
baseline care plan was given to the resident and/or resident’s representative.
3. Record review of Resident #80B’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE].
Record review of the resident’s admission MDS dated [DATE] showed the resident was
admitted to the facility on [DATE].
Record review of the resident’s medical record showed no documentation that the resident’s
baseline care plan was given to the resident and/or resident’s representative.
4. During an interview on 6/13/18 at 10:00 A.M., the Director of Nursing (DON) said they
were not providing the residents and/or their representatives with a summary of the
resident’s baseline care plan and they did not have a plan for providing them within 48
hours.

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 develop
comprehensive assessments for two sampled residents (Residents #32 and #26) out of 18
sampled residents. The facility census was 80 residents.
Record review of the facility’s Person-Centered Care Plan policy revised on 2/13/17 showed
a comprehensive, individualized care plan will be developed within seven days after
completion of the comprehensive assessment for each resident that includes measurable
objectives and timetables to meet the resident’s needs that are identified in the
comprehensive assessments.
1. Record review of Resident #32’s Admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 4/6/18 showed he/she
received [MEDICAL TREATMENT] (process of cleansing the blood by passing it through a
special machine when the kidneys are not able to filter the blood).
Record review of the resident’s (MONTH) (YEAR) Physician order [REDACTED].
Observation on 6/6/18 at 2:04 P.M. showed the resident was not in his/her room. Licensed
Practical Nurse (LPN) E said the resident was at [MEDICAL TREATMENT].
Record review of the resident’s current care plan showed the care plan did not include
[MEDICAL TREATMENT].
2. Record review of Resident #26’s dental note dated 5/16/16 showed the border on the
resident’s upper denture was broken and the resident’s upper denture was taken to the lab
to repair.

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
Record review of the resident’s dental note dated 5/26/16 showed the resident’s upper
dentures were returned to the resident.
Record review of the resident’s Electronic Health Record showed no dental notes.
Observation and interview on 6/11/18 at 5:59 A.M. showed the resident:
-Had upper dentures and his/her bottom teeth had black areas visible from the top of
his/her teeth and
-Said he/she needed to have the rest of his/her teeth pulled and then get lower dentures .
During an interview on 6/12/18 at 11:35 A.M., Social Services said:
-He/she has been working at the facility for two weeks;
-Nothing was left for him/her related to dental services;
-He/she interviewed all the residents and had a list of who wants to see the dentist;
-The dentist is coming tomorrow and
-The resident is on the list to be seen by the dentist.
Record review of the resident’s care plan showed no dental care plan.
During an interview on 6/14/18 at 11:15 A.M., the Director of Nursing (DON) said he/she
would expect a dental care plan to be in place for the resident.
3. During and interview on 06/14/18 at 11:15 A.M., the DON said they should develop a
comprehensive care plan.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed develop a comprehensive care
plan within seven days of the resident’s comprehensive assessment for one sampled resident
(Resident #34) out of 18 sampled residents. The facility census was 80 residents.
1. Record review of Resident #34’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Minimum Data Set (MDS – a federally mandated assessment
instrument completed by facility staff for care planning) dated 4/22/18 showed the
resident:
-Was severely cognitively impaired;
-Did not have any pressure ulcers (localized injury to the skin and/or underlying tissue
usually over a bony prominence, as a result of pressure, or pressure in combination with
shear and/or friction);
-Did not have any venous ulcers (venous stasis ulcer – open lesion caused by poor
circulation) or arterial ulcers (arterial stasis ulcer – open lesion caused by poor
circulation or blocked arteries);
-Did not have any foot wounds;
-Did not have any wounds or skin irregularities;
-Required total staff assistance for bathing, transfers, bed mobility, personal hygiene,
eating, dressing, toileting;
-Received tube feeding nutrition;
-Had a Foley catheter (a tube with retaining balloon passed through the urethra into the
bladder to drain urine);
-Was always incontinent of stool;

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
-Received antibiotics six out of seven days during the crookback period and
-Was not on isolation precautions.
Record review of the resident’s facility’s handwritten undated admission nursing report
showed he/she:
-Was on an antibiotic for Extended spectrum beta-lactamases (ESBL – a bacterial infection
resistant to many antibiotics) and had a Urinary Tract Infection [MEDICAL CONDITION];
-Had a Percutaneous Endoscopic Gastrostomy tube (PEG tube – a tube that is placed into a
patient’s stomach as a means of feeding them when they are unable to eat) and received
nutrition through his/her PEG tube;
-Had a scarred, healed wound to his/her right buttocks;
-Had a wound on his/her left calf with a dressing;
-Had a wound on his/her right foot with a dressing and
-Had a Foley catheter.
Record review of the resident’s Minimum Data Set (MDS a federally mandated assessment tool
completed by the facility staff for care planning) showed he/she:
-Was admitted to the facility on [DATE];
-Was severely cognitively impaired;
-Had open wounds on his/her right foot;
-Had wound dressings on his/her foot and/or feet;
-Had a Stage III wound (a full thickness tissue loss. Subcutaneous fat may be visible but
bone, tendon or muscle is not exposed. Slough may be present but does not obscure the
depth of tissue loss. (MONTH) include undermining or tunneling) or stage IV Stage IV (Full
thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present
on some parts of the wound bed. Often includes undermining and tunneling)pressure ulcer in
an area affected by incontinence;
-Was incontinent of urine and had a urinary catheter;
-Had an infection, was receiving antibiotic therapy, and was on contact isolation
precautions;
-Was totally dependant on staff for dressing, bathing, personal hygiene, bed mobility,
toileting, transferring, and ambulation;
-Had a [MEDICAL CONDITION] disorder;
-Was at risk for falls. The assessment directed staff to specify if the resident was a
high, moderate, or low risk for falls. The assessment did not specify the fall risk for
the resident.
-The resident received tube feeding nutrition and
-The assessment was documented as being completed on 5/22/18.
Record review of the resident’s care plan showed:
-On 5/22/18 a care plan was developed and initiated related to the resident required total
staff assistance for bathing, bed mobility, dressing, eating, personal hygiene, toileting,
transferring, oral care, and ambulation;
-On 5/22/18 a care plan was developed and initiated related to the resident’s fall risk.
The care plan directed staff to specify if the resident was a high, moderate, or low fall
risk ad to identify the reason for the resident’s fall risk potential. The care plan was
not personalized for the resident, did not specify the resident’s fall risk, and did not
identify the reason for the resident’s fall risk potential;
-On 5/22/18 a care plan was developed and initiated related to the resident’s tube feeding
nutrition;
-On 5/22/18 a care plan was developed and initiated related to the resident’s antibiotic
therapy;
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
–The care plan directed staff to identify the antibiotic and the reason for the
antibiotic use;
–The care plan did not identify the antibiotic or the reason for antibiotic therapy;
-The resident did not have a care plan to address his/her isolation precautions;
-On 5/22/18 a care plan was developed and initiated related to the resident’s nutritional
problem or potential for a nutritional problem;
–The care plan directed staff to identify a percentage the resident’s weight should be
maintained. This percentage was left blank;
–The care plan directed staff to identify the resident’s baseline weight. The resident’s
baseline weight was left blank;
–The care plan directed staff to the percentage of a specific number of meals the
resident should consume daily. The percentage and the number of meals were left blank;
—The resident was not able to consume meals by mouth and received his/her total
nutrition through tube feeding;
-On 5/22/18 a care plan related to the resident’s [MEDICAL CONDITION] disorder was
developed and initiated;
-On 5/4/18 a care plan related to the resident’s stage III pressure ulcer on his/her
buttocks was developed and initiated;
–Staff were directed to specify the type of pressure relieving devices and the frequency
to monitor the resident’s dressing. These were left blank;
-On 5/22/18 a care plan was developed and initiated related to the resident’s incontinence
of bladder and
-On 5/22/18 a care plan was developed and initiated related to the resident’s urinary
catheter.
During an interview on 6/14/18 at 11:41 A.M., the Director of Nursing (DON) said:
-A comprehensive care plan should have been developed within seven days of the resident’s
comprehensive assessment;
-A resident’s care plan should be individualized to the resident and
-A resident’s care plan should be updated as soon as a care area is identified.
During an interview on 6/14/18 at 2:54 P.M., Licensed Practical Nurse (LPN) B said:
-The resident should have had a care plan developed related to his/her wounds;
-The care plan should have been individualized to the resident to include the location of
the wounds at the time the wounds were discovered;
-The care plan should accurately reflect the resident’s condition and
-The resident was admitted with wounds and developed additional wounds while he/she was a
resident at the facility.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to document the
change in condition and death of one supplemental Resident (Resident #65) and the hospital
return and relevant health information regarding the resident’s hospital stay for one
sampled resident (Resident #48) out of 18 sampled residents. The facility census was 80
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
Record review of the facility’s nursing documentation policy with a review date of [DATE]
showed:
-Narrative charting should be used and
-Documentation may be completed by exception.
1. Record review of Resident #65’s admission summary dated [DATE] showed he/she was a full
code (all life-saving measures are taken in order to treat a patient after/during a
respiratory or [MEDICAL CONDITION]).
Record review of the resident’s care plan dated [DATE] showed he/she was a full code.
Record review of the resident’s telephone order dated [DATE] showed a physician’s orders
[REDACTED]. The order did not include a Do not resuscitate (DNR – an order from a doctor
that resuscitation should not be attempted if a person suffers cardiac or respiratory
arrest) order.
Record review of the resident’s OHDNR (Out of the hospital DNR) showed:
-It was signed by his/her responsible party on [DATE];
-It was signed by a physician;
-The physician left the date section blank;
-The physician left the name section under his/her signature blank;
-The physician’s license number was documented and
-The physician’s telephone number and address sections were left blank.
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
Observation on [DATE] at 8:05 A.M. showed staff talking about performing Cardiopulmonary
resuscitation (CPR-a lifesaving technique useful in many emergencies, including [MEDICAL
CONDITION] or near drowning, in which someone’s breathing or heartbeat has stopped).
Emergency Medical Services personnel arrived at the nurses’ station and asked where the
resident’s room was.
During an interview on [DATE] at 8:12 A.M., the Administrator said they did CPR on the
resident because the OHDNR was not dated and therefore, not valid.
Record review of the resident’s death in facility tracking form dated [DATE] showed he/she
died at the facility.
Record review of the resident’s interdisciplinary notes on [DATE]-[DATE] at 11:36 AM
showed there were no nurses’ notes since [DATE].
During an interview on [DATE] at 1:25 PM, the Assistant Director of Nursing (ADON) said
(regarding [DATE]):
-Residents were in the dining room and they had not started serving breakfast yet;
-Certified Nursing Assistant (CNA) A told him/her the resident was coughing;
-The resident had her hand over mouth and nose;
-When the resident moved his/her hand away from his/her mouth and nose, a lot of blood
came out;
-He/She removed the resident from the dining room and took the resident to the resident’s
room;
-He/She yelled down to the nurses’ station asking if the resident was a full code;
-Licensed Practical Nurse (LPN) A said the resident was a full code;
-He/she yelled for the crash cart;
-The resident was stiff by the time she got the resident back to the resident’s room;
-LPN B came into the resident’s room and they placed the resident on the floor;
-He/She looked, listened and felt to check if the resident was breathing;
-The resident had no pulse;
-He/She started compressions;
-LPN B got an ambu bag (a medical device used to provide assisted ventilation when someone
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
is either not breathing or are having trouble breathing);
-The Administrator came in the resident’s room;
-He/She and the administrator alternated doing compressions;
-The Administrator asked him/her to do a statement for the facility’s incident report;
-He/she has not entered a nurse’s note about the resident’s change of condition and the
provision of CPR and
-The Administrator will tell us when they are done with their investigation and he/she
would write a nurse’s note later.
During an interview on [DATE] at 11:15 AM, the Director of Nursing (DON) said:
-The staff that were involved with providing CPR should have documented what occurred and
what they did;
-He/She is not aware of any reason why no one documented a nurse’s note on the resident’s
change of condition and the cares that were provided and
-When they do an accident/incident report in the Electronic Heath Record (EHR), the
progress note inside the risk management system carries the note over to the
interdisciplinary notes in the EHR.
2. Record review of Resident #48’s interdisciplinary progress notes showed:
-On [DATE] at 3:01 PM, a nursing note documented that the resident was sent to the
hospital;
-On [DATE] at 3:42 PM, a nursing note documented that the resident’s family member was
called and informed the resident was sent to the hospital and
-On [DATE] 3:25 PM, a nursing note documented that a call was placed to the hospital
emergency room and the unit secretary stated that someone will call the facility nurse
back for report.
Record review of the resident’s discharge return anticipated assessment dated [DATE]
showed the resident was discharged on [DATE].
Record review of the resident’s entry tracking record dated [DATE] showed the resident
returned to the facility on [DATE].
Observation on [DATE] at 9:40 AM showed the resident was in his/her room.
Record review of the resident’s interdisciplinary progress notes on [DATE] showed there
were not any nurses’ notes after [DATE] documenting the resident’s return from the
hospital or anything regarding the resident’s emergency room visit or hospital stay.
During an interview on [DATE] at 11:15 AM, the DON said there should have been
documentation regarding the resident’s return from the hospital and his/her condition
related to his/her hospital stay.
MO 665

F 0660

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Plan the resident’s discharge to meet the resident’s goals and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop a discharge plan
according to the resident’s wishes for one sampled resident (Resident #80A) out of 18
sampled residents and three closed records. The facility census was 80 residents.
1. Record review of Resident #80A’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Admission Summary dated 2/23/18 showed he/she was admitted

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0660

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
to the facility for skilled nursing services and rehabilitation services.
Record review of the resident’s Nurse’s Note dated 2/24/18 showed the family requested the
resident transfer to a different facility after expressing concerns regarding the
resident’s medications.
Record review of the resident’s Care Plan dated 2/27/18 showed he/she wished to return to
the community once skilled services were completed.
Record review of the resident’s admission Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning) dated 3/2/18 showed
he/she:
-Was cognitively intact;
-The resident’s overall goal established during the assessment was left blank, including
if the resident expected to discharge to the community or if the resident expected to
discharge to another facility and
-The resident had no active discharge plan to return to the community.
Record review of the resident’s medical record showed:
-No documentation the facility involved the resident in developing a discharge plan that
reflected the resident’s goals, needs, and treatment preferences in conjunction with the
resident’s support system;
-No documentation the resident received information about possible discharge to the
community;
-No documentation the facility assisted the resident find alternate placement at another
long-term care facility and
-No documentation the facility assisted the resident find a home health provider.
Record review of the resident’s Nurse’s Notes dated 3/9/18 showed the resident was
discharged to home with home health services.
Record review of the resident’s Recapitulation of Stay dated 3/9/18 showed:
-No documentation of the resident’s attitude regarding discharge and
-No documentation of the resident’s discharge potential.
During an interview on 6/14/18 at 11:41 A.M., the Director of Nursing (DON) and the
Regional Nurse said:
-He/She would expect all of the areas of the recapitulation of stay to be completed by the
facility staff;
-He/She would have expected documentation by the facility staff regarding the resident
and/or the resident’s family’s request for the resident to transfer to another facility
and
-He/She would have expected documentation by the facility staff regarding assisting the
resident with a transfer to another facility and/or providing the resident information for
home health services.

F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure necessary information is communicated to the resident, and receiving health care
provider at the time of a planned discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete a comprehensive
discharge summary which included a recapitulation of stay for one sampled closed record
(Resident #80A) out of 18 sampled residents and three closed records. The facility census

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
was 80 residents.
1. Record review of Resident #80A’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s admission Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning) dated 3/2/18 showed
he/she:
-Was cognitively intact;
-The resident’s overall goal established during the assessment was left blank, including
if the resident expected to discharge to the community or if the resident expected to
discharge to another facility and
-The resident had no active discharge plan to return to the community.
Record review of the resident’s Nurse’s Notes dated 3/9/18 showed he/she was discharged to
home with home health services.
Record review of the resident’s Recapitulation of Stay dated 3/9/18 showed:
-Nursing documented the resident was discharged to home to continue care with home health
services;
-No documentation regarding the resident’s treatment that was provided during his/her stay
at the facility;
-No documentation regarding the resident’s progress, including any complications
experienced during his/her stay at the facility;
-No documentation related to the resident’s social services, activity services, or
rehabilitation services received during the resident’s stay at the facility and
-The recapitulation of stay was not signed by the resident’s physician.
During an interview on 6/14/18 at 11:41 A.M., the Director of Nursing (DON) and the
Regional Nurse said:
-He/She would expect all of the areas of the recapitulation of stay to be completed by the
facility staff;
-The DON opens the document for staff to complete each area of the resident’s
recapitulation of stay;
-The resident’s recapitulation of stay was incomplete and
-The recapitulation of stay should have included the medications and amount of each
medication the resident was sent home with.

F 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide basic life support, including CPR, prior to the arrival of emergency medical
personnel , subject to physician orders and the resident’s advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the Out
of the hospital Do Not Resuscitate (OHDNR-documents the instructions in an out-of-hospital
setting not to initiate resuscitation if a person suffers cardiac or respiratory arrest)
was fully complete for one supplemental Resident (Resident #65) out of 18 sampled
residents. The facility census was 80 residents.
Record review of the facility’s undated Cardiac and/or Respiratory Arrest policy showed:
-Every resident has the right to accept or decline cardiopulmonary resuscitation (CPR-a
lifesaving technique used when someone’s breathing or heartbeat has stopped) and
-CPR will be performed unless there is a written physician’s orders [REDACTED].

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

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
1. Record review of Resident #65’s admission summary dated [DATE] showed it was documented
that he/she was a full code (all life-saving measures are taken in order to treat a
patient after/during a respiratory or [MEDICAL CONDITION]).
Record review of the resident’s care plan dated [DATE] showed he/she was a full code.
Record review of the resident’s telephone order dated [DATE] showed a physician’s orders
[REDACTED]. The order did not include a DNR order.
Record review of the resident’s OHDNR showed:
-It was signed by his/her responsible party on [DATE];
-It was signed by a physician;
-The physician left the date section blank;
-The physician left the name section under his/her signature blank;
-The physician’s license number was documented and
-The physician’s telephone number and address sections were left blank.
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
Observation on [DATE] at 8:05 A.M. showed staff talking about performing CPR on the
resident. Emergency Medical Services personnel arrived at the nurses’ station and asked
where the resident’s room was.
During an interview on [DATE] at 8:12 A.M., the Administrator said they did CPR on the
resident because the resident’s OHDNR was not dated and therefore, not valid.
During an interview on [DATE] at 8:28 A.M., the Hospice nurse said:
-That’s our bad (referring to the Hospice company);
-We (Hospice) should have caught that (that the resident’s OHDNR wasn’t dated by the
physician) and
-If they (Hospice) get an OHDNR, they put one in the resident’s medical chart and one in
the Hospice chart.
During an interview on [DATE] at 8:40 A.M., the Assistant Director of Nursing (ADON) said:
-The nursing staff called Hospice and Hospice staff said the resident was a DNR but the
form was not dated and
-Emergency Medical Services (EMS) was called;
-The Hospice nurse takes the orders from the physician;
-The Hospice nurse notifies the ADON to put the orders into the computer as they (Hospice)
does not have computer privileges;
-He/she personally enters all Hospice orders into the computers and
-He/she said they have not had problems before and he/she doesn’t know why they did this
time.
During an interview on [DATE] at 9:15 A.M. the Regional Nurse said:
-They are doing an audit of all resident’s code status orders;
-Hospice doesn’t get all orders for residents receiving Hospice services and
-The new social worker probably hasn’t had time to audit code status orders.
During an interview on [DATE] 10:48 A.M., the Medical Director said:
-He/she doesn’t know if the resident’s OHDNR is legal, that’s a lawyer question.
-The OHDNR should have been dated by the physician;
-The staff did what they thought they needed to and
-It’s better to do CPR than not when there’s any doubt.
Record review of the resident’s death in facility tracking form dated [DATE] showed the
resident died at the facility.
Record review of the resident’s interdisciplinary notes on [DATE]-[DATE] at 11:36 A.M.
showed there were no nurses’ notes since [DATE].
During an interview on [DATE] at 1:25 P.M., the ADON said (regarding [DATE]):
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
-Residents were in the dining room and they had not started serving breakfast yet;
-Certified Nursing Assistant (CNA) A told him/her the resident was coughing;
-The resident had her hand over mouth and nose;
-When the resident moved his/her hand away from his/her mouth and nose, a lot of blood
came out;
-He/she removed the resident from the dining room and took the resident to the resident’s
room;
-He/she yelled down to the nurses’ station asking if the resident was a full code;
-Licensed Practical Nurse (LPN) A said the resident was a full code;
-He/she yelled for the crash cart;
-The resident was stiff by the time she got the resident back to the resident’s room;
-LPN B came into the resident’s room and they placed the resident on the floor;
-He/She looked, listened and felt to check if the resident was breathing;
-The resident had no pulse;
-He/She started compressions;
-LPN B got an ambu bag (a medical device used to provide assisted ventilation when someone
is either not breathing or are having trouble breathing);
-The Administrator came in the resident’s room;
-He/She and the administrator alternated doing compressions;
-The Administrator asked him/her to do a statement for the facility’s incident report;
-He/she has not entered a nurse’s note about the resident’s change of condition and the
provision of CPR and
-The Administrator will tell us when they are done with their investigation and he/she
would write a nurse’s note later.
During an interview on [DATE] at 11:15 A.M., the Director of Nursing (DON) said:
-Upon admission, the admitting nurse would obtain the OHDNR if there was one;
-Social services should review the OHDNRs for completion and place them in the front of
the chart;
-Social services should notify the DON and the ADON of a new OHDNR and they make sure the
code status order is correct in the orders section of the Electronic Health Record (EHR)
and include the OHDNR in the resident’s care plan;
-Hospice could obtain an OHDNR but Social Services should by monitoring and reviewing the
OHDNRs;
-He/she was not aware hospice staff were putting the OHDNR in the chart themselves;
-Social Services should be the one putting the OHDNR in the chart;
-The staff that were involved with providing CPR should have documented what occurred and
what they did;
-He/She is not aware of any reason why no one documented a nurse’s note on the resident’s
change of condition and the cares that were provided and
-When they do an accident/incident report in the EHR, the progress note inside the risk
management system carries the note over to the interdisciplinary notes in the EHR.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide activities to meet all resident’s needs.

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

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
assess and care plan the resident’s activity preferences and provide an ongoing,
individualized activity program for one sampled resident (Resident #32) out of 18 sampled
residents. The facility census was 80 residents.
Record review of the facility’s Recreation Assessment policy revised on 7/1/14 showed:
-Instructions for staff to complete a recreation assessment upon admission, annually and
with a significant change in condition;
-The purpose was to develop a plan of care that enables the resident to reach his/her
highest practicable level of physical, mental and psychosocial functioning;
-Recreation staff will conduct resident interviews and
-Recreation staff will obtain information from a variety of sources including family
members, significant others, medical records and caregivers.
1. Record review of Resident #32’s face sheet dated 3/30/18 showed his/her family member
was listed as his/her first contact person and a phone number was listed.
Record review of an activities assessment dated [DATE] showed:
-Another resident’s name was printed on the form next to the resident name section;
-The resident’s name was hand written at the top of the form on page one and
-The interview for daily preferences was marked not assessed.
Record review of the resident’s Admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 4/6/18 showed:
-The resident was admitted to the facility on [DATE];
-The instructions for Section F Preferences for Customary Routine and Activities showed
the following instructions: If resident is unable to complete, attempt to complete
interview with family member or significant other.
-The following staff assessment of the resident:
–Had long-term and short-term memory impairment;
–Had severely impaired cognitive skills for daily decision-making;
–Was totally dependent on staff for locomotion;
–Used a wheelchair;
–Had range of motion impairment on both sides of his/her lower extremities (hip, knee,
ankle, foot);
–Was receiving [MEDICAL TREATMENT] (process of cleansing the blood by passing it through
a special machine – necessary when the kidneys are not able to filter the blood);
–Was dependent upon staff for all cares;
–Activity preferences were not assessed and
-The family or significant other were not interviewed regarding the resident’s activity
preferences.
Record review of the resident’s (MONTH) (YEAR) activity participation showed:
-He/she attended an unknown activity five times (only dates were documented and not the
activity);
-He/she attended bingo twice;
-He/she attended music once;
-He/she attended Resident Council once and
-He/she did not participate in any activities 24 out of 31 days.
Record review of the resident’s (MONTH) (YEAR) activity participation (through 6/13/18)
showed:
-He/she attended Chronical, puzzle, trivia and chair yoga five times;
-He/she attended bingo once;
-He/she attended a movie once and
-He/she did not participate in any activities seven out of 13 days.
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
Observation during tour on 6/6/18 beginning at 10:00 A.M. showed the resident was not in
his/her room (The resident has [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays).
Observation on 6/6/18 at 2:04 P.M. showed the resident was not in his/her room. Licensed
Practical Nurse (LPN) E said the resident was at [MEDICAL TREATMENT].
Observation on 6/7/18 at 12:01 P.M., showed the resident was in bed and music was playing.
Observation on 6/11/18 at 6:04 A.M., showed the resident was in bed and his/her television
was on. The resident was not looking at the television.
Observation on 6/11/18 at 6:57 A.M., showed the resident was groaning and making coughing
sounds in his/her room.
Observation on 6/11/18 at 10:05 A.M., showed staff were providing cares for the resident.
Observation on 6/11/18 at 10:59 A.M. showed the resident was not in his/her room (The
resident has [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays).
Observation on 6/11/18 at 11:38 A.M. showed the resident was not in his/her room (The
resident has on Mondays, Wednesdays and Fridays).
Observation on 6/13/18 at 7:15 A.M., showed the resident was in bed with no stimulation
and no decorations in his/her room.
Observation on 6/13/18 at 2:45 P.M. showed the resident was not in his room (The resident
has on Mondays, Wednesdays and Fridays).
During an interview on 6/13/18 at 2:45 P.M., the Assistant Director of Nursing (ADON) said
the resident’s family member visits him/her.
Record review of the resident’s current care plan showed:
-The care plan did not include any activities for the resident and
-The resident had unclear to no speech.
During an interview on 6/14/18 at 10:00 A.M., the Activity Director said:
-He/she had worked at the facility for three weeks;
-He/she started as the Activity Assistant and now he/she was the Activity Director;
-The previous Activity Director was printing the Activity Assessment forms out and giving
them to him/her to complete and then the Activity Director entered the Activity
Assessments into the computer;
-Some of the Activity Assessments were not completed and/or entered into the computer;
-He/she has not talked to the resident’s parent;
-The resident attends activities (passive participation);
-He/she sometimes played a bingo card for the resident;
-He/she would do one-on-one activities with the resident and
-He/she helped the resident open a package that came in the mail. It was a sports shirt.
He/she asked the resident if he/she liked sports and the resident smiled real big.
Observation on 6/14/18 at 10:19 A.M. showed the resident was in bed. His/her television
was on the science channel. The resident was not looking at the television.
During an interview on 6/13/18 10:00 A.M., the Regional Nurse said:
-They should have tried to obtain information for the activity assessment and
-They need the assessment information to develop a plan of care.
During an interview on 06/14/18 at 12:43 P.M., the Administrator said:
-He/she would expect activities to have interviewed any available family member regarding
prior activity interests;
-He/she would have expected the activity assessment section of the MDS to be completed
with information from family member;
-He/she would have expected an activity care plan to be developed based on his/her prior
interests and
-The resident was a former truck driver.
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to document the
condition and size of the resident’s wounds and to update the resident’s care plan for one
sampled resident (Resident #32), to notify the physician of a change of condition for one
closed record resident (Resident #180), to obtain a valid [DIAGNOSES REDACTED]. in a
timely manner of a resident’s pressure and non-pressure wounds for one sampled resident
(Resident #34), and to accurately document and account for a resident’s narcotic
medications and to obtain a valid physician’s orders [REDACTED].#80A) out of 18 sampled
residents. The facility census was 80 residents.
Record review of the facility’s controlled substance medications policy dated 3/22/18
showed instructions that any discrepancy in controlled substance medication counts should
be reported to the Director of Nursing (DON) consultant pharmacist and Administrator.
1. Record review of Resident #32’s entry tracking form showed he/she was admitted to the
facility on [DATE].
Record review of the resident’s Resident Data Set (RDS) assessment dated [DATE] showed the
resident had a wound (the type of wound was not documented) on his/her right buttock, the
front of his/her left lower leg and his/her left heel.
Record review of the resident’s nurse’s note dated 3/19/18 showed he/she had the following
wounds:
-A left heel wound (which included measurements);
-Multiple abrasions on both legs;
-A buttock wound (which included measurements);
-A fluid filled blister to his/her abdomen;
-A right great toe had blister and
-A blister underneath the resident’s right foot.
Record review of the resident’s skin/wound note dated 3/20/18 showed:
-The resident:
–Was re-admitted on [DATE] and present on admission were:
—Several open blisters on his/her right shin.
—Open blisters on his/her right hip and thigh open blisters.
—Open diabetic wounds diabetic wound (a complication of diabetes (a condition in which
the pancreas no longer makes insulin and therefore blood glucose cannot enter the cells to
be used for energy, the pancreas does not make enough insulin or the body is unable to use
insulin correctly) on his/her right heel and right ankle.
-Descriptions of the wounds were included.
-Measurements were not included.
Record review of the resident’s medical record showed there were no weekly wound notes
between 3/20/18 and 5/6/18.
Record review of the resident’s discharge with his/her return anticipated assessment dated
[DATE] showed he/she was discharged from the facility.
Record review of the resident’s entry tracking form showed he/she was re-admitted to the
facility on [DATE].
Record review of the resident’s RDS assessment dated [DATE] showed he/she did not have any

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
skin conditions or treatments and did not have any foot problems, care or treatments.
Record review of the resident’s weekly skin check dated 4/6/18 showed he/she did not have
any current or previous skin injuries.
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 4/6/18 showed the
following staff assessment of the resident:
-He/she had diagnoses of diabetes and [MEDICAL CONDITION] (when the kidneys are not
functioning properly);
-He/she did not have any pressure ulcers (localized injury to the skin and/or underlying
tissue as a result of pressure)
-He/she did have a [MEDICAL CONDITION] and
-He/she had open [MEDICAL CONDITION] other than ulcers, rashes or cuts.
Record review of the resident’s diabetic ulcer care plan dated 4/24/18 showed he/she had
diabetic ulcers on his/her right heel and right ankle.
Record review of the resident’s multiple wounds upon admission care plan updated on 5/4/18
showed he/she had diabetic ulcers on his/her right heel, right ankle, left heel and left
ankle.
Record review of the resident’s skin/wound note dated 5/6/18 showed:
-The resident had wounds (type not documented) on his/her left and right heel and on
his/her left and right ankles;
-The wounds were described and
-Measurements were not included.
Record review of the resident’s wound care company progress note dated 5/8/18 showed the
resident had the following wounds:
-Other (other type of wound that is not pressure, not diabetic, etc.) /full thickness
(indicates that damage extends below all layers of the skin into the subcutaneous tissue
or beyond (into muscle, bone, tendons, etc.) to his/her left heel;
-Other/full thickness to his/her left great toe;
-Other/full thickness to his/her right heel and
-Other/full thickness to his/her left ankle.
Record review of the resident’s wound care company progress note dated 5/15/18 showed the
resident had the following wounds:
-Other/full thickness to his/her left heel;
-Other/full thickness to his/her left great toe;
-Other/full thickness to his/her right heel;
-Other/full thickness to his/her left ankle;
-Other/full thickness to his/her right ankle;
-Other/full thickness to his/her left buttock and
-Other/full thickness to his/her right buttock.
Record review of the resident’s wound care company progress note dated 5/22/18 showed the
resident had the following wounds:
-Other/full thickness to his/her left heel;
-Other/full thickness to his/her left medial (toward the middle) toe;
-Other/full thickness to his/her right heel;
-Other/full thickness to his/her left ankle;
-Other/full thickness to his/her right ankle;
-Other/full thickness to his/her left buttock;
-Other/full thickness to his/her right buttock and
-Other/full thickness to his/her right elbow.
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
Record review of the resident’s wound care company progress note dated 5/29/18 showed the
resident had the following wounds:
-Other/full thickness to his/her left heel;
-Other/full thickness to his/her left great toe;
-Other/full thickness to his/her right heel;
-Other/full thickness to his/her left ankle;
-Other/full thickness to his/her right ankle;
-Other/full thickness to his/her left buttock;
-Other/full thickness to his/her right buttock;
-Other/full thickness to his/her right elbow and
-Other/full thickness to his/her left foot.
Record review of the resident’s wound care company progress note dated 6/5/18 showed the
resident had the following wounds:
-Other/full thickness to his/her left heel;
-Other/full thickness to his/her left great toe;
-Other/full thickness to his/her right heel;
-Other/full thickness to his/her left ankle;
-Other/full thickness to his/her right ankle;
-Other/full thickness to his/her left foot and
-Other/full thickness to his/her coccyx (tail bone).
Record review of the resident’s wound care company progress note dated 6/12/18 showed the
resident had the following wounds:
-Diabetic wound of his/her left heel/Wagner 2 (grade 2 diabetic wounds extend into tendon,
bone, or capsule);
-Diabetic wound of his/her left great toe/Wagner 2;
-Diabetic wound of his/her left ankle/Wagner 2;
-Diabetic wound of his/her left foot/Wagner 2;
-Diabetic wound of his/her right heel/Wagner 2;
-Diabetic wound of his/her right ankle/Wagner 2 and
-Other/full thickness to his/her coccyx.
Record review of the resident’s current (MONTH) (YEAR) physician’s orders [REDACTED].
Record review of the resident’s current care plan (during the survey conducted
6/6/18-6/14/18) showed:
-It had not been updated since 5/4/18 and
-It did not include the resident’s left toe wound, left foot wound or left and right
buttocks wounds (which began to be documented as a coccyx wound as of 6/5/18.
Observation and interview on 6/13/18 at 8:13 A.M. showed the resident had a wound on
his/her coccyx, right ankle, right heel, and five wounds on his/her left, lower
foot/ankle, lateral ankle, medial great toe, medial distal left foot, left heel, lateral
distal left foot.
During an interview on 6/13/18 10:00 A.M., the DON said:
-There should be weekly wound documentation completed and
-The nurse that was responsible for the weekly wound documentation during (MONTH) (YEAR)
no longer worked at the facility.
During an interview on 6/14/18 at 3:50 P.M., the wound nurse/Licensed Practical Nurse
(LPN) B said:
-He/She was off the month of (MONTH) (YEAR) and
-Someone else was supposed to do the weekly wound assessments during the month of (MONTH)
(YEAR) but they did not do them.
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
During an interview on 6/14/18 at 4:07 P.M., DON said:
-They document the resident’s skin condition upon admission on the admission RDS;
-A summary of the skin assessment should be in a progress note;
-All wounds should be care planned
-They use a wound tool to document each resident’s wounds weekly;
-They measure, describe and document the wounds weekly when they round with the wound
doctor and
-Measurements should be documented every week.
2. Record review of Resident #180’s Face Sheet showed he/she was admitted on [DATE] and
readmitted on [DATE] with the following Diagnoses: [REDACTED].
– [MEDICAL CONDITION] (loss of ability to produce or comprehend language due to [MEDICAL
CONDITION]);
– [MEDICAL CONDITION] (below normal function of the [MEDICAL CONDITION] which regulates
metabolism) and
-[MEDICAL CONDITION].
Record review of the resident’s Nursing Note dated 4/15/2018 at 9:30 P.M. showed that
during this shift:
-The resident complained of mouth and jaw pain;
-The resident has several visible sores along the gum line;
-The resident’s physician was notified of;
–The resident’s sores;
–The resident not eating well for an extended period of time;
–The resident’s [MEDICATION NAME] swish (liquid pain medication) was not as effective;
-The nurse called and spoke to the Nurse Practioner (NP) and
-The NP ordered [MEDICATION NAME] (an antifungal medication) swish and swallow twice a day
for ten days and discontinued the [MEDICATION NAME] swish.
Record review of the resident;s Nursing Note dated 4/25/2018 at 7:29 P.M. showed:
-The resident continues to have complaints about his/her mouth/throat/gums;
-The resident was evaluated by a dentist;
-The dentist documented that the resident’s complaints are not of dental origin;
-The dentist suggested that the resident be evaluated by his/her physician;
-The NP examined the resident and ordered an antibiotic and a rapid strep test to be
performed and
-The nurse will anticipate the results and report to the physician if abnormal.
Record review of the resident’s Nursing Note dated 4/26/2018 at 4:00 P.M. showed:
-The resident’s Power of Attorney (POA) called and said the resident was admitted to the
hospital related to a growth on his/her neck and
-The hospital will be completing a biopsy.
Record review of the resident’s Nursing Notes/Progress Notes from 4/15/18-4/26/18 showed:
-No notes to indicate that the resident’s physician had been notified of a change in
condition or of an order to transfer to a hospital;
-No notes to indicate when the resident discharged to the hospital;
-No notes to indicate when he/she was readmitted to the facility and
-No hospital notes of a biopsy or results.
Record review of resident’s hospital discharge/ transfer to the facility dated printed
5/4/18 showed he/she:
-Was admitted to the hospital on [DATE] and
-Was discharged from the hospital to the facility on [DATE] with a [DIAGNOSES REDACTED].
Record review of resident’s POS showed orders dated 5/4/18 to:
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-Admit the resident to this facility with a [DIAGNOSES REDACTED].
-Diet: nothing by mouth (NPO) and
-Enteral (within or by way of the intestine) tube feedings.
Record review of the resident’s Nursing Note dated 5/7/18 at 3:30 P.M. showed that the
nurse informed the family that the resident would undo feeding tube and throw it in the
trash when he/she wants to go out to smoke. The family said that the physician said that
the resident can go outside to smoke.
Record review of the resident’s Nursing Notes/Progress Notes from 5/4/18-5/16/18 showed:
-No notes to indicate that the resident’s physician had been notified of a change in
condition and
-No indication that the resident was on Hospice (end of life) care.
Record review of the resident’s Discharge Summary dated 5/16/18 at 7:49 P.M. showed the
resident discharged into the care of his/her family at 5:00 P.M. with the intent of
continuing Hospice care in the home.
3. Record review of Resident #34’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Admission assessment dated [DATE] showed he/she:
-Was severely cognitively impaired;
-Had a Stage III or Stage IV pressure ulcer in an area affected by incontinence;
-Had a Foley catheter;
-Had an open lesion on his/her right foot;
-Required wound care;
-Required application of a dressing to his/her feet and
-Required application of a dressing to an area other than his/her feet.
Record review of the resident’s (MONTH) (YEAR) POS, Medication Administration Record
(MAR), and Treatment Administration Record (TAR) showed:
-The resident had a Foley catheter without a [DIAGNOSES REDACTED].
-No orders for wound care treatments.
Record review of the resident’s MDS dated [DATE] showed he/she:
-Was severely cognitively impaired and
-Did not have any pressure ulcers (localized injury to the skin and/or underlying tissue
usually over a bony prominence, as a result of pressure, or pressure in combination with
shear and/or friction).
Record review of the resident’s skin check sheet dated 4/23/18 showed the resident had
wounds described as other on his/her right foot and left shin.
Record review of the resident’s skin check sheet dated 4/30/18 showed he/she:
-Had skin injuries or wounds previously noted and described as other to his/her right foot
and left shin and
-Had a pressure ulcer to his/her coccyx.
Record review of the resident’s (MONTH) (YEAR) POS, MAR and TAR showed:
-The resident had a Foley catheter with no [DIAGNOSES REDACTED].>-an order for
[REDACTED].
-Cleanse left lateral leg with wound cleanser, pat dry, apply Santyl, cover with dry
dressing and tap daily and as needed for an open wound dated 5/4/18;
–No documentation by the staff notified the resident’s physician of the resident’s
documented wound on his/her left lateral leg or that the resident’s wound was being
treated from the time the resident was admitted on [DATE] until 5/3/18, or 17 days;
-Cleanse right lateral foot with wound cleanser, pat dry, apply Santyl, cover with calcium
alginate, dry dressing and tape. Change daily and as needed for an open wound start on
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
5/4/18;
–No documentation the staff notified the resident’s physician of the resident’s
documented wound upon admission on his/her right lateral foot or that the resident’s wound
was being treated from the time the resident was admitted on [DATE] until 5/4/18, for a
total of 17 days without treatment;
-Cleanse right buttock with wound cleanser, pat dry, apply Santyl, cover with calcium
alginate, dry dressing, and tape. Change daily and as needed for an open wound dated
5/4/18;
–No documentation staff notified the resident’s physician of the resident’s stage III
open buttocks wound documented as discovered on 4/30/18 until 5/4/18, for a total of five
days;
-Cleanse right lateral foot with wound cleanser, pat dry, apply Santyl, cover with calcium
alginate, dry dressing and tape. Change daily and as needed for an open wound dated 5/4/18
and
–No documentation staff notified the resident’s physician of the resident’s documented
open wound on his/her right foot that was present upon admission on 4/16/18 until 5/4/18,
for a total of 17 days without treatment.
Record review of the resident’s Wound Weekly Observation Tool dated 5/3/18 showed:
-The resident had a Stage III pressure ulcer to his/her right buttock that measured 5
centimeters (cm) in length by 4 cm in width by 0.1 cm in depth.
–NOTE: The resident’s buttocks pressure ulcer was documented as present during his/her
4/30/18 Skin Check.
-Had a diabetic ulcer to his/her front left lower leg that measured 3.5 cm length by 2 cm
width by 0.1 cm depth.
-Had a diabetic ulcer to his/her right foot that measured 3.5 cm length by 2.5 cm width by
0.1 cm depth.
-The resident’s physician and the resident’s representative was notified of the resident’s
wounds on 5/3/18 and
-Treatment orders were received from the resident’s physician.
–NOTE: The resident’s left lower leg wound and right foot wound were documented as
present upon admission on 4/30/18. No previous measurements or descriptions were
documented on the wounds from 4/16/18 – 5/3/18. No documentation the resident’s physician
was notified of the wounds upon admission.
During an interview on 6/14/18 at 2:54 P.M., LPN B said:
-The admitting nurse should have documented any skin irregularities upon the resident’s
admission to the facility;
-The nurse should have notified the resident’s physician of the resident’s right foot
wound and left lower leg wound when the resident was admitted to the facility for
treatment orders;
-The nurse should have notified the resident’s physician upon discovering the stage III
pressure ulcer on the resident’s buttocks on 4/30/18;
-He/She does not know why staff would have waited until 5/3/18 to notify the resident’s
physician of the resident’s wounds and
-The resident should have had a documented reason for his/her Foley catheter.
4. Record review of Resident #80A’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s admission POS and MAR dated 2/23/18 showed:
-[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 5 milligram (mg) – 325 mg
tablets, take one tablet by mouth every four hours as needed for pain;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
–Nine [MEDICATION NAME] 5/325 mg tablets administered between 2/23/18 – 2/28/18;
-[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 5-325 mg tablets, take one tablet
by mouth every six hours as needed for pain dated 2/26/18 and
–Two [MEDICATION NAME] 5/325 mg tablets administered between 2/26/18 – 2/28/18.
Record review of the resident’s [MEDICATION NAME] Controlled Drug
Receipt/Record/Disposition Form showed:
-[MEDICATION NAME] 5/325 mg tablets, give one tablet every four hours as needed for pain;
-On 2/24/18, 14 tablets of [MEDICATION NAME] 5/325 mg were received by the facility and
-Eight [MEDICATION NAME] 5/325 mg tablets were administered to the resident between
2/23/18 – 2/28/18.
Record review of the resident’s [MEDICATION NAME] Controlled Drug
Receipt/Record/Disposition Form showed:
-[MEDICATION NAME] 5/325 mg tablets, give one tablet every six hours as needed for pain;
-On 2/26/18, 30 tablets of [MEDICATION NAME] 5/325 mg were received by the facility;
-Six tablets were documented as removed from the narcotic count for administration to the
resident between 2/26/18 – 2/28/18 and
–Four [MEDICATION NAME] 5/325 mg tablets were unaccounted for.
Record review of the resident’s (MONTH) (YEAR) POS and MAR showed:
-[MEDICATION NAME] 5/325 mg tablets, take one tablet every four hours as needed for pain;
–Three tablets were documented as administered to the resident between 3/1/18 – 3/9/18;
-[MEDICATION NAME] 5/325 mg tablets, take one tablet every six hours as needed for pain;
–Eight tablets were documented as administered to the resident between 3/1/18 – 3/9/18;
-Discharge to home on 3/9/18 per the resident’s insurance with home health services for
skilled nursing and intravenous antibiotic therapy;
–The discharge order did not include an order to send the resident home with his/her
medications and
–The discharge order did not include an order to send the resident home with narcotic
medications.
Record review of the resident’s [MEDICATION NAME] Controlled Drug
Receipt/Record/Disposition Form showed:
-[MEDICATION NAME] 5/325 mg tablets, give one tablet every four hours as needed for pain;
-Five tablets were documented as removed from the narcotic count for administration to the
resident between 3/1/18 – 3/9/18;
-One tablet was sent home with the resident;
-The resident did not have a valid physician’s orders [REDACTED].
–Two tablets were unaccounted for.
Record review of the resident’s [MEDICATION NAME] Controlled Drug
Receipt/Record/Disposition Form showed:
-[MEDICATION NAME] 5/325 mg tablets, take one tablet every six hours as needed for pain;
-Eighteen tablets were documented as removed from the narcotic count for administration to
the resident between 3/1/18 – 3/9/18;
-Six tablets were set home with the resident;
-The resident did not have a valid physician’s orders [REDACTED].
–Ten tablets were unaccounted for.
Record review of the resident’s admission MDS dated [DATE] showed he/she:
-Was cognitively intact;
-Received scheduled and as needed pain medication and
-Received an opioid six out of seven days during the lookback period.
Record review of the resident’s Discharge Summary dated 3/9/18 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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
-The resident was discharged to home that morning with home health and
-His/her medications were sent home with the resident, including narcotic medications.
5. During an interview on 6/14/18 at 10:25 A.M., LPN F said:
-If a narcotic is signed out from the Controlled Drug Receipt/Record/Disposition log, the
medication should be documented as administered to the resident on the resident’s MAR and
-The resident should have an order to send narcotics home with the resident upon
discharge.
During an interview on 6/14/18 at 10:56 A.M., the DON said:
-He/She expected staff to document on the resident’s MAR each time a medication is
administered;
-If the staff signed out a narcotic from the resident’s Controlled Drug
Receipt/Record/Disposition log, he/she would expect the medication to be documented as
administered on the resident’s MAR;
-He/She would expect staff to obtain an order from the resident’s physician to send a
narcotic medication home with the resident;
-Narcotic sheets are audited weekly to check for scribbles and scratches;
-Narcotic sheets are not compared to the resident’s MAR for accuracy and
-A Foley catheter order should have the reason or [DIAGNOSES REDACTED].
During an interview on 6/14/18 at 4:14 P.M., the DON said:
-Staff should have notified the resident’s physician and responsible party as soon as a
pressure ulcer or non-pressure ulcer was found on the resident and
-He/She would expect a nurse’s note regarding physician notification for a pressure or a
non-pressure ulcer.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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
maintained proper positioning of a catheter (a flexible tube inserted through a narrow
opening into the bladder, drains into a collection bag, used for removing fluid from the
body) for two sampled resident (Resident #32, and #23) out of 18 sampled residents. The
facility census was 80 residents.
Record review of the facility’s Catheter Care policy revised date of 1/2/14 showed
instructions to keep the catheter drainage bag below the level of the resident’s bladder
and off of the floor.
1. Record review of Resident #32’s care plan dated 3/19/18 showed he/she had an indwelling
catheter and was totally dependent on two staff for transferring from one surface to
another with a mechanical lift.
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 4/6/18 showed the
following staff assessment of the resident:
-Rarely or never understood;
-Had an indwelling catheter and
-Totally dependent upon two or more staff for transferring from one surface to another.

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 – Few

(continued… from page 26)
Record review of the resident’s lab results on 5/20/18 showed the resident’s urine culture
was positive for E. Coli (bacteria commonly found in the bowel) in his/her urine and the
resident’s physician ordered an antibiotic to be administered for ten days.
Observation on 6/12/18 at 12:50 P.M. showed that while Certified Nursing Assistant (CNA) A
and CNA D transferred the resident from his/her chair to his/her bed using a mechanical
lift, the resident’s catheter bag was hanging on the bar of the lift (about shoulder
height).
2. Record review of Resident # 23’s Admission Record showed he/she was admitted on [DATE]
with the following Diagnoses: [REDACTED].
-Neuromuscular Dysfunction of bladder (a disorder of urinary bladder control due to damage
to the spinal cord or to the nerves supplying the bladder).
Record review of the resident’s care plan dated 4/4/18 showed that he/she had:
-Activities of Daily Living (ADL’s) self-care performance deficit related to paralysis and
dependent on 1-2 staff;
-Limited physical mobility and
-Indwelling catheter.
Observation on 6/8/18 at 9:23 A.M. showed during a mechanical lift transfer from the
resident’s bed to his/her chair showed:
-CNA B placed the resident’s catheter bag on his/her knees above the level of the bladder;

-The catheter bag leaked urine and
-The resident was lowered to the bed to be changed and cleaned.
Observation on 6/8/18 at 10:17 A.M. showed during a mechanical lift transfer from the
resident’s bed to his/her and CNA A placed the resident’s catheter bag on his/her legs
above the level of the bladder.
During an interview on 06/14/18 at 11:15 A.M., the Director of Nursing (DON) said:
-The resident’s catheter should be kept below the bladder when the resident is transferred
and
-The catheter bag is not allowed on the lift even if it is below the resident’s bladder.

F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe, appropriate pain management for a resident who requires such services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to manage and treat
pain to the extent possible when pain medication was not administered according to the
physician’s orders [REDACTED].#16 and #23) and facility staff did not offer or attempt
non-pharmacological interventions prior to administering a narcotic as needed pain
medication for one sampled resident (Resident #80A) out of 18 sampled residents. The
facility census was 80 residents.
Record review of the facility’s Pain Management Policy with revision date of 11/26/16
showed:
-Patients will be evaluated as part of the nursing assessment process for the presence of
pain upon admission/re-admission, quarterly, with change in condition or change in pain
status;
-At a minimum of daily, patients will be evaluated for the presence of pain by making an
inquiry of the patient or by observing for signs of pain;

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

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
-If PRN (as needed) medications are given, document on the back of the Medication
Administration Record (MAR) or on the PRN Pain Management Flow Sheet and
-Patients receiving interventions for pain will be monitored for the effectiveness and
side effects in providing pain relief.
Record review of the facility’s Medication: Administration: General Policy with revision
date of 5/15/17 showed:
-A licensed nurse, medication technician, or medication aide, per state regulations, will
administer medications to patients.
-If discrepancies, including medication not available, notify physician and/or pharmacy as
indicated;
-If medication is refused by the patient, discard the medication and attempt to administer
again at a later time;
-Document administration of medication on the MAR;
-Document medication refused by patient on the back of the MAR, or for electronic order
management by entering the refusal code on the MAR and
-Document the effectiveness of PRN medication.
Record review of the facility’s Controlled Substance (drugs that are regulated by laws
that aim to control the danger of addiction, abuse, harm, etc.) Medications Policy dated
3/12/18 showed:
-Only authorized nursing and pharmacy personnel have access to controlled substances;
-The Director of Nursing (DON) is responsible for the control of these medications at the
facility;
-Controlled substances will be dispensed by the pharmacy with an individual Charting
Record;
-The Charting Record will be maintained by the nursing staff at the time of each
administration of the medication as follows:
–Record each dose at the time of administration;
–confirm the amount of controlled drug remaining is correct prior to assembling required
dose for administration;
-When the prescription is no longer an active order the remaining quantity of the
medication will be destroyed by two licensed personnel in accordance with state law;
-At each shift change, a physical inventory is conducted by two licensed nurses and is
documented on an audit record;
-Any discrepancy in controlled substance medication counts is reported to the DON
immediately;
-The DON or designee investigates and makes every reasonable effort to reconcile all
reported discrepancies;
-Irreconcilable discrepancies are documented by the DON and reported to the Consultant
Pharmacist and Administrator; and
-The Administrator, Pharmacist, and the DON will make a determination concerning of any
action that may need to be taken.
1. Record review of Resident # 16’s Admission Record showed he/she was admitted on [DATE]
and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (loss of movement of both legs and generally the lower trunk);
-Contracture (a condition of shortening and hardening of muscles, tendons, or other
tissue, often leading to deformity and rigidity of joints) of the right and left knees;
and
-Pressure Ulcer (localized injury to the skin and/or underlying tissue usually over a bony
prominence, as a result of pressure, or pressure in combination with shear and/or
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 28)
friction) of the sacral region (area at base of spinal column and top of pelvic bones).
Record review of the resident’s Significant Change in status Minimum Data Set (MDS – a
federally mandated assessment tool completed by the facility staff for care planning)
dated 3/16/18 showed he/she:
-Had moderately impaired cognition and problems with long and short term memory;
-Used opioid (a class of drugs that include prescription drugs such as [MEDICATION NAME],
and many others) pain medications;
-Had pressure ulcers;
-Was incontinent of bowel;
-Had a urinary drainage catheter;
-Had mobility issues related to [DIAGNOSES REDACTED].>-Used [MEDICAL CONDITION] drugs
(drugs which affect psychic function, behavior, or experience).
Record review of the resident’s Care Plan (written out plan for the care of the resident)
dated 3/21/18 showed that the resident had:
-Chronic pain;
-A supra pubic catheter (a hollow flexible tube that is used to drain urine from the
bladder and inserted through the abdominal wall into the bladder);
-Skin breakdown related to pressure on Left buttock;
-Used [MEDICAL CONDITION] drugs;
-Had a Do Not Resuscitate (DNR – an order from a doctor that resuscitation should not be
attempted if a person suffers cardiac or respiratory arrest) order; and
-Had hospice services (A special healthcare option for patients and families who are faced
with a terminal illness. A multi-disciplinary team of physicians, nurses, hospice aides,
social workers, bereavement counselors and volunteers work together to address the
physical, social, emotional and spiritual needs of each patient and family) start date of
3/2/18.
Record review of the resident’s MAR dated (MONTH) (YEAR) showed orders for:
-[MEDICATION NAME]-[MEDICATION NAME] (APAP) tablet 5-325 milligrams (mg);
–One tablet by mouth in the morning before treatment for [REDACTED].>–Start date
3/6/18 at 8:00 A.M. and stop date 3/8/18 at 6:04 P.M.;
–Administered on 3/6/18, 3/7/18, and 3/8/18 and
–The dates before 3/6/18 and after 3/8/18 X out as not to administer;
Record review of the resident’s Controlled Drug Receipt/Record/Disposition Form showed
receipt of the following medication on 3/6/18:
– [MEDICATION NAME]/APAP 5-325 mg tablets, 30 tablets, directions take one tablet by mouth
every morning prior to treatment;
-Administered at the wrong time three times in (MONTH) ’18 at the following times:
–4/26/18 at 6:00 P.M.;
–4/27/18 at 9:00 P.M.;
–4/30/18 at 7:30 P.M.;
-Administered at the wrong time 21 times in (MONTH) ’18 at the following times:
–5/1/18 at 7:00 P.M.;
–5/2/18 at 6:30 P.M.;
–5/3/18 at 6:00 P.M.;
–5/4/18 at 6:30 P.M.;
–5/6/18 at 6:30 P.M.;
–5/10/18 at 6:30 P.M.;
–5/11/18 at 6:30 P.M.;
–5/13/18 at 6:30 P.M.;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
–5/14/18 at 6:30 P.M.;
–5/17/18 at 6:30 P.M.;
–5/18/18 at 1:20 P.M.;
–5/18/18 at 6:30 P.M.;
–5/19/18 at 6:45 P.M.;
–5/20/18 at 6:30 P.M.;
–5/21/18 at 6:30 P.M.;
–5/23/18 at 6:30 P.M.;
–5/25/18 at 6:00 P.M.;
–5/26/18 at 6:15 P.M.;
–5/26/18 at 5:00 P.M.;
–5/29/18 at 6:30 P.M. and
–5/30/18 at 4:00 P.M.
Record review of the resident’s Controlled Medication Utilization Record for [MEDICATION
NAME] ER (Extended Release) 15 mg tablet take one tablet by mouth every 12 hours received
on 5/29/18 showed administered:
-On 5/30/18 at 4:00 P.M. and
-On 5/30/18 at 8:00 P.M.
Record review of the resident’s MAR dated (MONTH) (YEAR) showed that:
-The scheduled doses of the evening shift [MEDICATION NAME] sulfate 30 mg ER were not
administered four times on the following dates: 5/15/18; 5/20/18; 5/21/18; and 5/31/18 and
-No charting found showing the reasons the doses were not administered as scheduled.
Record review of the resident’s MAR dated (MONTH) (YEAR) showed that:
-The scheduled doses of the morning [MEDICATION NAME] sulfate 30 mg ER were not
administered twice on the following dates: 5/13/18; and 5/31/18 and
-No charting found showing the reasons the doses were not administered as scheduled.
Record review of the resident’s Physician order [REDACTED].
-[MEDICATION NAME] Tablet 650 mg by mouth every six hours as needed for mild to moderate
pain of 0-5 on a 0-10 pain scale/or fever not to exceed three grams (GM) in a 24 hour
period dated 2/20/18;
-[MEDICATION NAME] (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 1 hour as
needed for severe pain may give 0.25-1 ml every hour date 3/22/18;
-[MEDICATION NAME]-[MEDICATION NAME] Cream 2.5-2.5 % (a pain medication) Apply two
milliliters (ml) to wound topically (on the skin) every 15 to 20 minutes prior to dressing
changes as needed for pain, dated 4/20/18;
-[MEDICATION NAME] ER Tablet 30 mg by mouth every evening shift for Pain, start date
4/27/18 and
-[MEDICATION NAME] ER Tablet 30 mg by mouth every morning for Pain, start date 4/27/18.
During an interview on 6/6/18 at 2:00 P.M., the resident said:
-He/she gets scheduled pain medication;
-Believes it is [MEDICATION NAME];
-Does not think he/she has missed or not been given a scheduled dose of medication and
-Gets pain medication before dressing changes or does not let the nurse do it until has
had it.
During an interview on 6/7/18 at 2:20 P.M., the resident’s family member said:
-The facility Administrator had called about a possible issue with medications;
-Was made aware of an investigation of possible missing medications;
-Was informed that none of the resident’s pain medication was involved with the issue and
-That the State had been informed of a possible issue of missing medications.
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 30)
During an interview on 6/14/18 at 3:11 P.M., wound care nurse Licensed Practical Nurse
(LPN) B said that he/she checks with the resident to see if the resident has had or needs
ordered pain medication before doing wound care.
2. Record review of Resident # 23’s Admission Record showed he/she was admitted on [DATE]
with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] and
-Neuromuscular Dysfunction of bladder (a disorder of urinary bladder control due to damage
to the spinal cord or to the nerves supplying the bladder)
Record review of the resident’s care plan dated 4/4/18 showed that he/she had:
-Activities of Daily Living (ADL’s) self-care performance deficit related to paralysis and
dependent on 1-2 staff;
-Limited physical mobility;
-Risk for impaired comfort related to chronic pain;
-Used [MEDICATION NAME] for chronic pain;
-Impairment to skin integrity of the right gluteal fold (the lowest part of the buttocks)
related to impaired mobility and
-Indwelling catheter.
Record review of the resident’s Admission MDS dated [DATE] showed his/her:
-Cognition was intact;
-Was totally dependent on 2-3 staff members for his/her ADL’s;
-Used an electric wheel chair for mobility;
-Altered urinary function with indwelling catheter;
-Had frequent pain and
-Used scheduled pain medications.
Record review of the resident’s MAR dated (MONTH) (YEAR) showed:
-8:00 P.M. dose of [MEDICATION NAME] 30 mg, give one tablet by mouth three times a day was
not administered on the following days: 4/10/18, 4/11/18, 4/16/18, and 4/27/18; and
-No charting found showing the reasons the doses were not administered as scheduled.
Record review of the resident’s MAR dated (MONTH) (YEAR) showed that the [MEDICATION NAME]
30 mg, give one tablet by mouth three times a day was not administered for the following
times and days:
-8:00 A.M. dose on 5/13/18 at;
-4:00 P/M. dose on 5/21/18 and 5/31/18;
-8:00 P.M. dose on 5/2/18, 5/20/18, and 5/21/18 and
– No charting found showing the reasons the doses were not administered as scheduled.
Record review of the resident’s Controlled Medication Utilization Record received on date
of 5/29/18 for [MEDICATION NAME] ER 30 mg tablet take one tablet by mouth three times a
day showed administered:
-On 5/30/18 at 4:00 P.M.;
-On 5/30/18 at 6:40 P.M.;
-On 5/30/18 at 8:00 P.M. and
-On 5/30/18 entered as PRN (as needed) in the time spot.
Record review of the resident’s Controlled Medication Utilization Record received on date
of 5/25/18 for [MEDICATION NAME] IR (Immediate Release) 15 mg tablet take one tablet by
mouth every four hours as needed for pain showed administered:
-On 5/28/18 as PRN two tablets at 12:30 P.M.;
-On 5/29/18 as two tablets at 4:00 P.M.;
-On 5/29/18 as two tablets at 8:00 P.M.;
-On 5/29/18 as PRN one tablet at 6:45 P.M., no comment as a late entry and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
-On 5/30/18 as two tablets at 4:00 P.M.
Record review of the resident’s POS dated (MONTH) (YEAR) showed:
-[MEDICATION NAME] 30 mg, give one tablet by mouth three times a day for pain, start date
4/4/18;
-[MEDICATION NAME] 15 mg, give one tablet by mouth every four hours as needed for pain,
start date 4/4/18;
-[MEDICATION NAME] Tablet 200 mg, give one tablet by mouth every 8 hours as needed for
pain, start date 4/4/18 and
-[MEDICATION NAME] Tablet, give 500 mg by mouth every 6 hours as needed for pain, start
date 5/21/18.
During an interview on 6/6/18 at 2:30 P.M., the resident said:
-Has pain medication scheduled [MEDICATION NAME] 30 mg three times a day at 8:00 A.M.,
4:00 P.M., and 10: P.M.;
-Sometimes has not received it on the evening shift;
-The nurse would come in about 9:00 P.M. or 10:00 P.M. get him/her distracted with
something and then leave without giving the pain pill;
-He/she is not sure what dates the missed doses were;
-When he/she does not receive and requests it after the evening shift the night shift
nurse informs him/her that the MAR shows he/she had received it;
-He/she believes the nurse not administering the pain medication no longer works here and
-He/she has been receiving the evening dose of pain medication for the last week.
During an interview on 6/14/18 at 11:15 A.M. the DON and the Regional Nurse said:
-When a resident says has not received pain medication and is cognitive, and the MAR shows
it was administered he/she would expect the nurse to notify administration about it;
-The narcotic medication control sheets should be audited every week;
-The ADON and the DON look at the narcotic sheets for scribbles, dropped pill notations,
and not comparing narcotic sheet to the MAR for potential discrepancies at the risk
meetings;
-A completed narcotic count sheet is filed in the resident’s medical record;
-If there is a suspicion of a medication diversion the ADON and the DON would look for a
trend with any nurse and
-The facility is now using a new form to track and compare medications on.
3. Record review of Resident #80A’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Care Plan dated 2/23/18 showed:
-The resident has (specify acute or chronic) pain related to:
–Staff did not specify the type of pain the resident experienced and did not identify
what the pain was related to and
-The interventions did not include what or how to use non-pharmacological interventions
for the resident.
Record review of the resident’s admission POS and MAR dated 2/23/18 showed:
-[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 5 milligram (mg) – 325 mg
tablets, take one tablet by mouth every four hours as needed for pain;
–Nine [MEDICATION NAME] 5/325 mg tablets administered between 2/23/18 – 2/28/18;
-[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 5-325 mg tablets, take one tablet
by mouth every six hours as needed for pain dated 2/26/18;
–Two [MEDICATION NAME] 5/325 mg tablets administered between 2/26/18 – 2/28/18 and
-No documentation the facility staff attempted non-pharmacological interventions prior to
administering a narcotic as needed pain 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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
Record review of the resident’s [MEDICATION NAME] Controlled Drug
Receipt/Record/Disposition Form showed:
-[MEDICATION NAME] 5/325 mg tablets, give one tablet every four hours as needed for pain;
-On 2/24/18, 14 tablets of [MEDICATION NAME] 5/325 mg were received by the facility and
-Eight [MEDICATION NAME] 5/325 mg tablets were administered to the resident between
2/23/18 – 2/28/18.
Record review of the resident’s [MEDICATION NAME] Controlled Drug
Receipt/Record/Disposition Form showed:
-[MEDICATION NAME] 5/325 mg tablets, give one tablet every six hours as needed for pain;
-On 2/26/18, 30 tablets of [MEDICATION NAME] 5/325 mg were received by the facility;
-Six tablets were documented as removed from the narcotic count for administration to the
resident between 2/26/18 – 2/28/18 and
–Four [MEDICATION NAME] 5/325 mg tablets were unaccounted for.
Record review of the resident’s (MONTH) (YEAR) POS and MAR showed:
-[MEDICATION NAME] 5/325 mg tablets, take one tablet every four hours as needed for pain;
–Three tablets were documented as administered to the resident between 3/1/18 – 3/9/18;
-[MEDICATION NAME] 5/325 mg tablets, take one tablet every six hours as needed for pain;
–Eight tablets were documented as administered to the resident between 3/1/18 – 3/9/18
and
-No documentation the facility staff attempted non-pharmacological interventions prior to
administering a narcotic as needed pain medication.
Record review of the resident’s [MEDICATION NAME] Controlled Drug
Receipt/Record/Disposition Form showed:
-[MEDICATION NAME] 5/325 mg tablets, give one tablet every four hours as needed for pain;
-Five tablets were documented as removed from the narcotic count for administration to the
resident between 3/1/18 – 3/9/18;
-One tablet was sent home with the resident;
-The resident did not have a valid physician’s orders [REDACTED].
–Two tablets were unaccounted for.
Record review of the resident’s [MEDICATION NAME] Controlled Drug
Receipt/Record/Disposition Form showed:
-[MEDICATION NAME] 5/325 mg tablets, take one tablet every six hours as needed for pain;
-Eighteen tablets were documented as removed from the narcotic count for administration to
the resident between 3/1/18 – 3/9/18;
-Six tablets were set home with the resident;
-The resident did not have a valid physician’s orders [REDACTED].
–Ten tablets were unaccounted for.
Record review of the resident’s admission MDS dated [DATE] showed he/she:
-Was cognitively intact;
-Received scheduled and as needed pain medication and
-Received an opioid six out of seven days during the lookback period.
Record review of the resident’s Discharge Summary dated 3/9/18 showed:
-The resident was discharged to home that morning with home health and
-His/her medications were sent home with the resident, including narcotic medications.
4. During an interview on 6/14/18 at 10:25 A.M., LPN F said:
-If a narcotic is signed out from the Controlled Drug Receipt/Record/Disposition log, the
medication should be documented as administered to the resident on the resident’s MAR;
-The resident should have an order to send narcotics home with the resident upon discharge
and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 33)
-Non-pharmacological interventions should be documented on the resident’s MAR if attempted
prior to administering a narcotic as needed pain medication.
During an interview on 6/14/18 at 10:56 A.M., the DON said:
-He/She expected staff to document on the resident’s MAR each time a medication is
administered;
-If the staff signed out a narcotic from the resident’s Controlled Drug
Receipt/Record/Disposition log, he/she would expect the medication to be documented as
administered on the resident’s MAR;
-He/She would expect staff to attempt non-pharmacological interventions prior to
administering a narcotic as needed pain medication;
-He/She would expect staff to obtain an order from the resident’s physician to send a
narcotic medication home with the resident;
-Narcotic sheets are audited weekly to check for scribbles and scratches and
-Narcotic sheets are not compared to the resident’s MAR for accuracy.
MO 166

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to accurately
document the administration of pain medication, to administer pain medication as ordered;
to ensure medication administration records were consistent for controlled medications
(drugs that are regulated by laws that aim to control the danger of addiction, abuse,
harm, etc.) for four sampled residents (Resident #7, #48, #16 and #23) and to ensure a
resident’s narcotic medications were accurately documented as administered and accounted
for on the resident’s Controlled Substance log for one sampled resident (Resident #80A)
out of 18 sampled residents. The facility census was 80 residents.
Record review of the facility’s Medication: Administration: General Policy with revision
date of 5/15/17 showed:
-If discrepancies, including medication not available, notify physician and/or pharmacy as
indicated;
-If medication is refused by the patient, discard the medication and attempt to administer
again at a later time;
-Document administration of medication on the Medication Administration Record (MAR) and
-Document medication refused by patient on the back of the MAR, or for electronic order
management by entering the refusal code on the MAR.
Record review of the facility’s Controlled Substance (drugs that are regulated by laws
that aim to control the danger of addiction, abuse, harm, etc.) Medications Policy dated
3/12/18 showed:
-The Director of Nursing (DON) is responsible for the control of these medications at the
facility;
-Controlled substances will be dispensed by the pharmacy with an individual Charting
Record;
-The Charting Record will be maintained by the nursing staff at the time of each
administration of the medication as follows:

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
–Record each dose at the time of administration;
–confirm the amount of controlled drug remaining is correct prior to assembling required
dose for administration;
-When the prescription is no longer an active order the remaining quantity of the
medication will be destroyed by two licensed personnel in accordance with state law;
-At each shift change, a physical inventory is conducted by two licensed nurses and is
documented on an audit record;
-Any discrepancy in controlled substance medication counts is reported to the DON
immediately;
-The DON or designee investigates and makes every reasonable effort to reconcile all
reported discrepancies;
-Irreconcilable discrepancies are documented by the DON and reported to the Consultant
Pharmacist and Administrator; and
-The Administrator, Pharmacist, and the DON will make a determination concerning of any
action that may need to be taken.
1. Record review of Resident #7’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool used by facility staff for care planning) dated 2/28/18 showed the
following staff assessment of the resident:
-Was cognitively intact;
-Received scheduled and as needed pain medication; and
-Reported having frequent pain with seven out of ten (ten being the worst pain) being the
highest level of pain he/she was experiencing.
Record review of the resident’s undated care plan showed he/she had chronic pain.
Record review of the resident’s (MONTH) (YEAR) nurses’ notes showed no documentation
regarding the administration of [MEDICATION NAME] (an opioid (narcotic) pain medication
used to treat moderate to severe pain) 10 milligrams (mg).
Record review of the resident’s Controlled Medication Utilization Record dated 6/1/18
through 6/13/18 at 8:00 AM and the resident’s (MONTH) (YEAR) (through 6/13/18 at 8:00 AM)
MAR for [MEDICATION NAME] 10 mg, one tablet every four hours as needed showed it was
signed out on the Controlled Medication Utilization Record as being administered 19 more
times than it was on the (MONTH) (YEAR) MAR.
2. Record review of Resident #48’s pain care plan updated on 11/27/17 showed he/she had
chronic pain.
Record review of the resident’s quarterly MDS dated [DATE] showed the following staff
assessment of the resident:
-Was cognitively intact;
-Received scheduled pain medication and
-Reported having frequent pain with six out of ten (ten being the worst pain) being the
highest level of pain he/she was experiencing.
Record review of the resident’s (MONTH) (YEAR) nurses’ notes and administration notes
showed:
-On 6/6/18 at 12:15 A.M., [MEDICATION NAME] Hcl Extended Release (ER) ([MEDICATION NAME])
40 mg was held because the resident was sleeping (this corresponded with the (MONTH)
(YEAR) MAR);
-On 6/6/18 at 7:25 A.M., [MEDICATION NAME] Hcl ER 40 mg was unavailable (this corresponded
with the (MONTH) (YEAR) MAR);
-On 6/6/18 at 2:16 P.M., [MEDICATION NAME] Hcl ER 40 mg was unavailable (this did not
corresponded with the (MONTH) (YEAR) MAR) and
-On 6/6/18 at 7:12 P.M., the resident was out of [MEDICATION NAME] Hcl ER 40 mg and had
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 35)
missed three doses.
Record review of the resident’s interdisciplinary progress notes showed on 6/8/18 at 3:01
P.M., a nursing note documented that the resident was sent to the hospital.
Record review of the resident’s discharge return anticipated assessment dated [DATE]
showed the resident was discharged on [DATE].
Record review of the resident’s entry tracking record dated 6/12/18 showed the resident
returned to the facility on [DATE].
Observation on 6/13/18 at 9:40 A.M. showed the resident was in his/her room talking to
staff about his/her pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-A physician’s orders [REDACTED].
–[MEDICATION NAME] Hcl ER 2 hour 40 mg was not documented as being administered on 6/4/18
at 10:00 P.M., 6/5/18 at 10:00 P.M., 6/6/18 at 6:00 A.M. and 6/8/18 at 2:00 P.M;
-A physician’s orders [REDACTED].
–[MEDICATION NAME] 20 mg, one tablet every four hours was documented as being
administered on 6/8/18 at 4:00 P.M., on 6/8/18 at 8:00 P.M., on 6/9/18 at 12:00 A.M. and
on 6/9/18 at 4:00 A.M. while the resident was in the hospital.
Record review of the resident’s (MONTH) (YEAR) Controlled Medication Utilization Records
showed:
-There were no controlled records for 6/1/18-6/6/18 (before 8:00 P.M.) for the resident’s
[MEDICATION NAME] HCL ER 40 mg and 6/1/18-6/5/18 for the resident’s [MEDICATION NAME] 20
mg;
-[MEDICATION NAME] 20 mg, one tablet every four hours was not documented as being
administered after 8:00 A.M. on 6/8/18;
-[MEDICATION NAME] 20 mg, one tablet every four hours was documented as being administered
on 6/8/18 at 8:00 A.M. twice and
-[MEDICATION NAME] ER 12 hour 40 mg was not documented as being administered on 6/8/18 at
10:00 P.M. and on 6/9/18.
During an interview on 6/13/18 at 9:55 A.M., the Assistant Director of Nursing (ADON) said
the administration of pain medication should be documented on the Controlled Record and
the MAR and that they both should match.
During an interview on 6/13/18 at 3:30 P.M., the Regional Nurse said he/she could not find
the controlled sheets for 6/1/18-6/6/18 for the resident’s [MEDICATION NAME] HCL ER 40 mg
or 6/1/18-6/5/18 for the resident’s [MEDICATION NAME] 20 mg.
During an interview on 06/14/18 at 11:15 A.M., the DON said:
-The medication administration documented on the Controlled Medication Utilization Records
and MAR should match;
-Nursing staff should not be documenting they are administering medications after a
resident has been discharged to the hospital and
-The Controlled Medication Utilization Records are supposed to be filed into the
residents’ medical records.
3. Record review of Resident #80A’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s admission Physician order [REDACTED].
-[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 5 mg – 325 mg tablets, take one
tablet by mouth every four hours as needed for pain;
–Nine [MEDICATION NAME] 5/325 mg tablets administered between 2/23/18 – 2/28/18;
-[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 5-325 mg tablets, take one tablet
by mouth every six hours as needed for pain dated 2/26/18 and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 36)
–Two [MEDICATION NAME] 5/325 mg tablets administered between 2/26/18 – 2/28/18.
Record review of the resident’s [MEDICATION NAME] Controlled Drug
Receipt/Record/Disposition Form showed:
-[MEDICATION NAME] 5/325 mg tablets, give one tablet every four hours as needed for pain;
-On 2/24/18, 14 tablets of [MEDICATION NAME] 5/325 mg were received by the facility and
-Eight [MEDICATION NAME] 5/325 mg tablets were administered to the resident between
2/23/18 – 2/28/18.
Record review of the resident’s [MEDICATION NAME] Controlled Drug
Receipt/Record/Disposition Form showed:
-[MEDICATION NAME] 5/325 mg tablets, give one tablet every six hours as needed for pain;
-On 2/26/18, 30 tablets of [MEDICATION NAME] 5/325 mg were received by the facility;
-Six tablets were documented as removed from the narcotic count for administration to the
resident between 2/26/18 – 2/28/18 and
–Four [MEDICATION NAME] 5/325 mg tablets were unaccounted for.
Record review of the resident’s (MONTH) (YEAR) POS and MAR showed:
-[MEDICATION NAME] 5/325 mg tablets, take one tablet every four hours as needed for pain;
–Three tablets were documented as administered to the resident between 3/1/18 – 3/9/18;
-[MEDICATION NAME] 5/325 mg tablets, take one tablet every six hours as needed for pain;
–Eight tablets were documented as administered to the resident between 3/1/18 – 3/9/18;
-Discharge to home on 3/9/18 per the resident’s insurance with home health services for
skilled nursing and intravenous antibiotic therapy;
–The discharge order did not include an order to send the resident home with his/her
medications and
–The discharge order did not include an order to send the resident home with narcotic
medications.
Record review of the resident’s [MEDICATION NAME] Controlled Drug
Receipt/Record/Disposition Form showed:
-[MEDICATION NAME] 5/325 mg tablets, give one tablet every four hours as needed for pain;
-Five tablets were documented as removed from the narcotic count for administration to the
resident between 3/1/18 – 3/9/18;
-One tablet was sent home with the resident;
-The resident did not have a valid physician’s orders [REDACTED].
–Two tablets were unaccounted for.
Record review of the resident’s [MEDICATION NAME] Controlled Drug
Receipt/Record/Disposition Form showed:
-[MEDICATION NAME] 5/325 mg tablets, take one tablet every six hours as needed for pain;
-Eighteen tablets were documented as removed from the narcotic count for administration to
the resident between 3/1/18 – 3/9/18;
-Six tablets were set home with the resident;
-The resident did not have a valid physician’s orders [REDACTED].
–Ten tablets were unaccounted for.
Record review of the resident’s admission MDS dated [DATE] showed he/she:
-Was cognitively intact;
-Received scheduled and as needed pain medication and
-Received an opioid six out of seven days during the lookback period.
Record review of the resident’s Discharge Summary dated 3/9/18 showed:
-The resident was discharged to home that morning with home health and
-His/her medications were sent home with the resident, including narcotic medications.
4. During an interview on 6/14/18 at 10:25 A.M., LPN F said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 37)
-If a narcotic is signed out from the Controlled Drug Receipt/Record/Disposition log, the
medication should be documented as administered to the resident on the resident’s MAR and
-The resident should have an order to send narcotics home with the resident upon
discharge.
During an interview on 6/14/18 at 10:56 A.M., the DON said:
-He/She expected staff to document on the resident’s MAR each time a medication is
administered;
-If the staff signed out a narcotic from the resident’s Controlled Drug
Receipt/Record/Disposition log, he/she would expect the medication to be documented as
administered on the resident’s MAR;
-He/She would expect staff to obtain an order from the resident’s physician to send a
narcotic medication home with the resident;
-Narcotic sheets are audited weekly to check for scribbles and scratches and
-Narcotic sheets are not compared to the resident’s MAR for accuracy.
5. Record review of Resident # 16’s Admission Record showed he/she was admitted on [DATE]
and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (loss of movement of both legs and generally the lower trunk);
-Contracture (a condition of shortening and hardening of muscles, tendons, or other
tissue, often leading to deformity and rigidity of joints) of the right and left knees and
-Pressure Ulcer (localized injury to the skin and/or underlying tissue usually over a bony
prominence, as a result of pressure, or pressure in combination with shear and/or
friction) of the sacral region (area at base of spinal column and top of pelvic bones).
Record review of the resident’s Significant Change MDS dated [DATE] showed the resident:
-Had moderately impaired cognition and problems with long and short term memory;
-Used opioid (a class of drugs that include prescription drugs such as [MEDICATION NAME],
and many others) pain medications;
-Had pressure ulcers;
-Had mobility issues related to [DIAGNOSES REDACTED].>-Used [MEDICAL CONDITION] drugs
(drugs which affect psychic function, behavior, or experience).
Record review of the resident’s Care Plan dated 3/21/18 showed he/she:
-Had chronic pain;
-Had skin breakdown related to pressure on his/her left buttock and
-Used [MEDICAL CONDITION] drugs.
Record review of the resident’s MAR dated (MONTH) (YEAR) showed orders for:
-[MEDICATION NAME]-[MEDICATION NAME] (APAP) tablet 5-325 mg)
–One tablet by mouth in the morning before treatment for [REDACTED].>–Start date
3/6/18 at 8:00 A.M. and stop date 3/8/18 at 6:04 P.M.;
–Administered on 3/6/18, 3/7/18, and 3/8/18 and
–The dates before 3/6/18 and after 3/8/18 X out as not to administer;
Record review of the resident’s Controlled Drug Receipt/Record/Disposition Form received
on 3/6/18 for [MEDICATION NAME]/APAP 5-325 mg tablets, 30 tablets, directions take one
tablet by mouth every morning prior to treatment showed:
-Administered at the wrong time three times in (MONTH) (YEAR) at the following times:
–4/26/18 at 6:00 P.M.;
–4/27/18 at 9:00 P.M.;
–4/30/18 at 7:30 P.M.;
-Administered at the wrong time 21 times in (MONTH) (YEAR) at the following times:
–5/1/18 at 7:00 P.M.;
–5/2/18 at 6:30 P.M.;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 38)
–5/3/18 at 6:00 P.M.;
–5/4/18 at 6:30 P.M.;
–5/6/18 at 6:30 P.M.;
–5/10/18 at 6:30 P.M.;
–5/11/18 at 6:30 P.M.;
–5/13/18 at 6:30 P.M.;
–5/14/18 at 6:30 P.M.;
–5/17/18 at 6:30 P.M.;
–5/18/18 at 1:20 P.M.;
–5/18/18 at 6:30 P.M.;
–5/19/18 at 6:45 P.M.;
–5/20/18 at 6:30 P.M.;
–5/21/18 at 6:30 P.M.;
–5/23/18 at 6:30 P.M.;
–5/25/18 at 6:00 P.M.;
–5/26/18 at 6:15 P.M.;
–5/26/18 at 5:00 P.M.;
–5/29/18 at 6:30 P.M. and
–5/30/18 at 4:00 P.M.
Record review of the resident’s Controlled Medication Utilization Record for [MEDICATION
NAME] ER (Extended Release) 15 mg tablet take one tablet by mouth every 12 hours received
on 5/29/18 showed administered:
-On 5/30/18 at 4:00 P.M. and
-On 5/30/18 at 8:00 P.M.
Record review of the resident’s MAR dated (MONTH) (YEAR) showed:
-The scheduled doses of the evening shift [MEDICATION NAME] sulfate 30 mg ER were not
administered four times on the following dates: 5/15/18; 5/20/18; 5/21/18; and 5/31/18 and
-No charting found showing the reasons the doses were not administered as scheduled.
Record review of the resident’s MAR dated (MONTH) (YEAR) showed that:
-The scheduled doses of the morning [MEDICATION NAME] sulfate 30 mg ER were not
administered twice on the following dates: 5/13/18; and 5/31/18 and
-No charting found showing the reasons the doses were not administered as scheduled.
Record review of the resident’s POS dated (MONTH) (YEAR) showed orders for:
-[MEDICATION NAME] Tablet 650 mg by mouth every six hours as needed for mild to moderate
pain of 0-5 on a 0-10 pain scale/or fever, start date 2/20/18;
-[MEDICATION NAME] (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 1 hour as
needed for severe pain may give 0.25-1 ml every hour, start date 3/22/18;
-[MEDICATION NAME]-[MEDICATION NAME] Cream 2.5-2.5 % (a pain medication) Apply two
milliliters (ml) to wound topically (on the skin) every 15 to 20 minutes prior to dressing
changes as needed for pain, dated 4/20/18;
-[MEDICATION NAME] ER Tablet 30 mg by mouth every evening shift for pain, start date
4/27/18 and
-[MEDICATION NAME] ER Tablet 30 mg by mouth every morning for pain, start date 4/27/18.
During an interview on 6/6/18 at 2:00 P.M., the resident said:
-He/she gets scheduled pain medication;
-Believes it is [MEDICATION NAME];
-Does not think he/she has missed or not been given a scheduled dose of medication and
-Gets pain medication before dressing changes or does not let the nurse do it until has
had it;
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 39)
During an interview on 6/7/18 at 2:20 P.M., the resident’s family member said:
-The facility Administrator had called about a possible issue with medications;
-Was made aware of an investigation of possible missing medications;
-Was informed that none of the resident’s pain medication was involved with the issue and
-That the State had been informed of a possible issue of missing medications.
During an interview on 6/14/18 at 3:11 P.M., wound care nurse Licensed Practical Nurse
(LPN) B said that he/she checks with the resident to see if the resident has had or needs
ordered pain medication before doing wound care.
6. Record review of Resident # 23’s Admission Record showed he/she was admitted on [DATE]
with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] and
-Neuromuscular Dysfunction of bladder (a disorder of urinary bladder control due to damage
to the spinal cord or to the nerves supplying the bladder).
Record review of the resident’s care plan dated 4/4/18 showed:
-Activities of Daily Living (ADL’s) self-care performance deficit related to paralysis and
dependent on 1-2 staff;
-Limited physical mobility;
-Risk for impaired comfort related to chronic pain;
-Used [MEDICATION NAME] for chronic pain; and
-Impairment to skin integrity of the right gluteal fold (the lowest part of the buttocks)
related to impaired mobility and
-Indwelling catheter.
Record review of the resident’s Admission MDS dated [DATE] showed the resident:
-Cognition was intact;
-Was totally dependent on 2-3 staff members for his/her ADL’s;
-Used an electric wheel chair for mobility;
-Altered urinary function with indwelling catheter;
-Had frequent pain and
-Used scheduled pain medications.
Record review of the resident’s MAR dated (MONTH) (YEAR) showed:
-8:00 P.M. dose of [MEDICATION NAME] 30 mg, give one tablet by mouth three times a day was
not administered on the following days: 4/10/18, 4/11/18, 4/16/18, and 4/27/18 and
-No charting found showing the reasons the doses were not administered as scheduled.
Record review of the resident’s MAR dated (MONTH) (YEAR) showed that the [MEDICATION NAME]
30 mg, give one tablet by mouth three times a day was not administered for the following
times and days:
-8:00 A.M. dose on 5/13/18 at;
-4:00 P/M. dose on 5/21/18 and 5/31/18;
-8:00 P.M. dose on 5/2/18, 5/20/18, and 5/21/18 and
– No charting found showing the reasons the doses were not administered as scheduled.
Record review of the resident’s Controlled Medication Utilization Record received on
5/29/18 for [MEDICATION NAME] ER 30 mg tablet take one tablet by mouth three times a day
showed administered:
-On 5/30/18 at 4:00 P.M.;
-On 5/30/18 at 6:40 P.M.;
-On 5/30/18 at 8:00 P.M.; and
-On 5/30/18 entered as PRN (as needed) in the time spot.
Record review of the resident’s Controlled Medication Utilization Record received on date
of 5/25/18 for [MEDICATION NAME] IR (Immediate Release) 15 mg tablet take one tablet by
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 40)
mouth every four hours as needed for pain showed administered:
-On 5/28/18 as PRN two tablets at 12:30 P.M.;
-On 5/29/18 as two tablets at 4:00 P.M.;
-On 5/29/18 as two tablets at 8:00 P.M.;
-On 5/29/18 as PRN one tablet at 6:45 P.M., no comment as a late entry and
-On 5/30/18 as two tablets at 4:00 P.M.
Record review of the resident’s POS dated (MONTH) (YEAR) showed:
-[MEDICATION NAME] 30 mg, give one tablet by mouth three times a day for pain, start date
4/4/18;
-[MEDICATION NAME] 15 mg, give one tablet by mouth every four hours as needed for pain,
start date 4/4/18;
-[MEDICATION NAME] Tablet 200 mg, give one tablet by mouth every 8 hours as needed for
pain, start date 4/4/18; and
-[MEDICATION NAME] Tablet, give 500 mg by mouth every 6 hours as needed for pain, start
date 5/21/18.
During an interview on 6/6/18 at 2:30 P.M., the resident said:
-Has pain medication scheduled [MEDICATION NAME] 30 mg three times a day at 8:00 A.M.,
4:00 P.M., and 10: P.M.;
-Sometimes has not received it on the evening shift;
-The nurse would come in about 9:00 or 10:00 P.M. get him/her distracted with something
and then leave without giving the pain pill;
-He/she is not sure what dates the missed does were;
-When does not receive and requests it after the evening shift the night shift nurse
informs him/her that the MAR shows he/she had received it;
-He/she believes the nurse not administering the pain medication no longer works here; and
-He/she has been receiving the evening dose of pain medication for the last week.
During an interview on 6/14/18 at 11:15 A.M the DON and the Regional Nurse said:
-When a resident says has not received pain medication and is cognitive, and the MAR shows
it was administered he/she would expect the nurse to notify administration about it;
-The narcotic medication control sheets should be audited every week;
-The ADON and the DON look at the narcotic sheets for scribbles, dropped pill notations,
and not comparing narcotic sheet to the MAR for potential discrepancies at the risk
meetings;
-A completed narcotic count sheet is filed in the resident’s medical record;
-If there is a suspicion of a medication diversion the ADON and the DON would look for a
trend with any nurse; and
-The facility is now using a new form to track and compare medications on.
MO 166

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure that as needed (PRN)
orders for [MEDICAL CONDITION] drugs (any drug capable of affecting the mind, emotions,

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 41)
and behavior including stimulants, antidepressants, antipsychotics, mood stabilizers, and
antianxiety agents) were limited to 14 days per Centers for Medicare and Medicaid Services
(CMS) regulations and reviewed by physician if needed for a longer time period for one
sampled resident (Resident #16) out of 18 sampled residents. The facility census was 80
residents.
Record review of the facility’s Psychotherapeutic Medication Use Policy revised on 5/15/14
showed that:
-The physician and the consultant pharmacist work together in selecting for the resident;
–The most effective drug;
–With the fewest potential side effects;
–The lowest risk of adverse drug reactions; and
–The lowest effective dose for the resident.
-Physician considers a gradual dose reduction (GRD);
–For the purpose of finding the lowest effective dose and
–Or of discontinuing the drug.
1. Record review of Resident #16’s Admission Record showed he/she was admitted on [DATE]
and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (loss of movement of both legs and generally the lower trunk) and
-Contracture (a condition of shortening and hardening of muscles, tendons, or other
tissue, often leading to deformity and rigidity of joints) of the right and left knees.
Record review of the resident’s Significant Change in status Minimum Data Set (MDS – a
federally mandated assessment tool completed by the facility staff for care planning)
dated 3/16/18 showed he/she:
-Had moderately impaired cognition and problems with long and short term memory;
-Used opioid (a class of drugs that include prescription drugs such as [MEDICATION NAME],
and many others) pain medications and
-Used [MEDICAL CONDITION] drugs.
Record review of the resident’s Care Plan (written out plan for the care of the resident)
dated 3/21/18 showed the resident:
-Had chronic pain;
-Used [MEDICAL CONDITION] medications related to depression and anxiety;
-Used antidepressant medications;
-Used antianxiety medications;
-Used opioid medications;
-Had a behavior problem with being non-compliant and
-Had Hospice (end of life care) services start date of 3/2/18.
Record review of the resident’s Medication Regime Review dated 3/15/18 showed:
-New CMS regulations require PRN [MEDICAL CONDITION] medications to be reviewed every 14
days, (Hospice residents are not exempt);
-The resident had PRN [MEDICATION NAME] that was used only one time in the last 30 days;
-Must be given a 14 day stop date;
-PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless
the attending physician or prescribing practitioner evaluates the resident for the
appropriateness of that medication;
-Or may be written for a longer specific duration if the attending physician or
prescribing practitioner believes that it is appropriate for the PRN order to be extended
beyond 14 days and
-He/she should document their rationale in the resident’s medical record and indicate the
duration for the PRN order;
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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 42)
Record review of the resident’s Medication Regime Review dated 4/16/18 showed the
recommend stop date (at which time appropriateness of use will be assessed) to the order
for PRN [MEDICATION NAME] for the resident.
Record review of the resident’s physician’s orders [REDACTED].
-[MEDICATION NAME] ([MEDICATION NAME]) one milligram (mg). Give one capsule by mouth every
6 hours as needed for anxiety and
-No 14 day stop order for the PRN [MEDICATION NAME] order.
No record found in the resident’s charting of a physician’s note for why PRN [MEDICATION
NAME] was ordered longer than the 14 day recommendation.

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 observation, interview, and record review, the facility failed to ensure
medications were stored, labeled and dated correctly in two sampled medication carts out
of four medication carts and one sampled medication room out of two medication rooms. The
facility census was 80 residents.
Record review of the facility’s policy revision date [DATE] Storage and Expiration Dating
of Drugs, Biologicals, Syringes, and Needles said:
-Drugs, biologicals, syringes, and needles are stored under proper conditions with regard
to sanitation, temperature, light, moisture, ventilation, segregation, safety, security,
and expiration date as directed by state and federal regulations and manufacturer/supplier
guidelines;
-Food is not stored in the refrigerator, freezer, or general storage areas where drugs and
biologicals are stored;
-Drugs and biologicals that have an expired date on the label or are after
manufacturer/supplier guidelines/recommendations, or if contaminated or deteriorated, are
stored separately, away from use, until destroyed or returned to the provider; and
-Storage location of the interim/stat/emergency boxes is known to all personnel handling
medications and located in an area readily available to licensed staff.
1. Observation on [DATE] at 5:15 A.M. with Licensed Practical Nurse (LPN) C of the North
Medication Cart showed the following medications were found to be opened without an open
date marked on them or were expired:
-[MEDICATION NAME] (medication to treat heartburn) 16 fluid ounces opened without an
opened date marked on the bottle;
-Dicto Liquid ([MEDICATION NAME] Sodium)(medication to treat constipation) 16 fluid ounces
opened without an opened date marked on the bottle;
-Melox .09% Lamotr 2.6% Lidocane spray (medication that numbs an area) which had expired
on ,[DATE];
-[MEDICATION NAME] (medication used to treat depression) 240 milliliters (ml) bottle
opened without an opened date marked on the bottle and
-Medications, batteries, a flashlight, and cigarettes were observed in the same drawer.
During an interview on [DATE] at 5:15 A.M. LPN C, said:
-Medications should have an opened date on them if they have been opened; and

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

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 43)
-Medications should not be in the medication cart if they were expired.
2. Observation on [DATE] at 5:40 A.M. with Registered Nurse (RN) A of the South Medication
Cart showed the following medications were found to be opened without an opened date:
-[MEDICATION NAME] Insulin (a hormone used to treat diabetes) 10 ml vial;
-[MEDICATION NAME] liquid (vitamin) an eight ounce bottle; and
-[MEDICATION NAME] (pain medication) 473 ml bottle.
3. Observation on [DATE] at 6:00 A.M. RN A of the South Medication Room showed:
-The nurse was unable to produce the key to unlock the cabinet labeled Emergency Meds;
-The nurse was unable to produce a medication sheet that listed the medications which
included narcotics that was to go back to the pharmacy;
-The nurse’s lunch bag was in the locked medication room;
-Food was observed in the medication sink drain;
-Two apples were found in the file cabinet with the medical supplies;
-Standing water was observed in a plastic tub under the medication sink from a leaky pipe;
-Ice in the freezer section of the medication refrigerator was built up and dripping below
into the refrigerator compartment onto the resident’s medications making them wet; and
-The refrigerator’s temperature was not checked daily, the following days had 40 degrees
written on the temperature check sheet without a signature:
-[DATE] P.M. the signature was absent;
-[DATE] A.M. and P.M. the signatures were absent;
-[DATE] P.M. the signature was absent and
-[DATE] A.M. and P.M. the signatures were absent.
During an interview on [DATE] at 6:00 A.M. RN A, he/she said:
-Medications should have an opened date on them if they have been opened;
-He/she said he/she did not know what happened to the key for the Emergency Medication
cabinet;
-He/she did not know why there was food in the medication sink drain;
-He/she said there was a leak in the sink and that is why there is a tub full of water
underneath it;
-He/she said the temperature on the medication refrigerator is to be checked every shift;
-He/she said he/she did not know who put the apples in the cabinet;
-He/she said the backpack in the medication room was his/hers;
-He/she said that two nurses have to count the narcotics and sign for them on every shift;
and
-The pharmacy they used to use had a sheet that showed which medications that were to go
back to the pharmacy but they don’t have one now and he/she doesn’t know why they no
longer have one.
During an interview on [DATE] at 11:15 A.M., the Director of Nursing (DON) said:
-Medications should have an opened date on them;
-Food items should not be in the medication room;
-He/she does not know who cleans the medication room;
-Food should not be found in the medication sink;
-Food items should not be stored in the cabinets with the medical supplies;
-Maintenance worker A said there was a leak under the sink, he/she repaired it, and he/she
put a bucket under it to see if it was still leaking;
-The refrigerator temperatures should be checked daily in early morning hours around 6
A.M. and then documented on the log daily, the Assistant Director of Nursing (ADON) is
responsible for monitoring this;
-Whoever records the temperatures should report any ice build up or drips to 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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 44)
maintenance department;
-The narcotic sheets are kept on the medication cart;
-There is a pharmacy sheet the nurse would fill out when the medications are supposed to
go back to the pharmacy;
-The disposal record was not filled out yet;
-They (the staff) do it every shift and
-They (the staff) may not have done it yet.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observations and interviews the facility failed to prevent food and trash debris
on the floor of the walk-in refrigerator and the kitchen perimeter; to monitor produce
freshness; to refrigerate food properly; to maintain a clean can opener blade; to separate
dented cans from undented ones in the dry storage; to cover individual food bowls for
transport; and to ensure the cleanliness of an ice cooler. These practices potentially
affected all residents who ate food from the kitchen. The facility census was 80 residents
with a licensed capacity for 100.
1. Observations in the kitchen and kitchenette on 6/6/18 between 9:09 A.M. and 12:48 P.M.,
showed the following:
– The walk-in refrigerator had various debris, i.e, fruit, grapes, and butter packages,
under storage racks,
– Two separate undated produce boxes of wilted lettuce and shriveled peppers in the dry
storage,
– The double sink food preparation area had eggshells and trash underneath,
– A one gallon opened jug of soy sauce on the shelf under the double sink area read
refrigerate after opening for quality on the label,
– The kitchen perimeter floor had numerous small trash, food debris, and cups,
– Three six pound ( lb.) dented cans of pineapple chunks were not properly separated from
undented cans on a rack in the dry storage,
– A cart with individual bowls of chunk pineapple were being transported to the main
dining room uncovered, and
– An unsecured lid on an ice cooler in the kitchenette next to the main dining room fell
on the floor and a staff member picked it up, placed it back on the base, and proceeded to
fill it with ice from the ice machine for one of the units.
During separate interviews on 6/6/18 at 10:29 A.M. and 1:51 P.M., the Director of
Nutrition Services (DNS) said the following:
– When dented cans are found they usually just throw them away; they must have just got a
bad case,
– It is the day dishwasher’s responsibility to sweep the refrigerator daily and the night
dishwasher is to mop the whole kitchen at that shift’s end,
– If an item’s label suggested refrigeration after opening it should absolutely be done,
– It is expected that individually prepared dessert bowls be covered during transport,
– The can opener blade should be cleaned after each use, and
– If a piece of equipment that comes in to contact with food or beverages fell on 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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 – Some

(continued… from page 45)
floor it should be cleaned before further use.

F 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on record reviews and interviews the facility failed to readily produce an on-site
policy, in the kitchen or at either nurse’s desk, regarding the acceptance, usage, and
storage of foods brought into the facility for residents by family and other visitors, to
ensure the food’s safe and sanitary handling and consumption, and failed to have fully
educated all staff as to its existence, whereabouts, and content. This deficient practice
had the potential to affect all residents who ate food brought in by visitors. The
facility census was 80 with a licensed capacity of 100.
1. Observation during Entrance Conference on 6/6/18 at 9:07 A.M., showed the Administrator
was given a list of required documents with a subheading entitled Information Needed from
the Facility Within One Hour of Entrance, which included the policy for food brought in
from visitors.
Request for and subsequent record review of kitchen documents on 6/6/18 at 9:09 A.M., in
the Dietary Office failed to show a policy for outside food brought in for residents.
During an interview on 6/6/18 at 9:13 A.M., the Director of Nutrition Services (DNS) said
the following:
– There was a policy for outside food brought in for residents, but he/she did not know
where the policy was currently located,
– That copies of the policy should be at each nurse’s desk, and
– That a copy would be provided later for review.
During an interview on 6/6/18 at 11:24 A.M., the DNS said he had spoken with the
Administrator and he/she would provide a copy of the outside food policy.
During an interview on 6/7/18 at 1:45 P.M., at the south nurse’s desk, Licensed Practical
Nurse (LPN) E said the following:
– He/she thought they had read somewhere that staff was to make sure anyone who brought
food in for a resident knew their particular diet and texture needs,
– The food would have to be dated with the resident’s name on it and stored in the unit
refrigerator, and
– He/she did not know where an actual written policy may be located.
During an interview on 6/7/18 at 1:53 P.M., the Director of Human Resources said:
– He/she thought the policy was mentioned to all staff during the last in-service; and
– Record review of the last in-service dated 5/25/18 showed the subject of an outside food
policy was not listed as a covered topic.
During an interview on 6/7/18 at 2:37 P.M., at the north nurse’s desk, LPN F said he/she
was unaware of any outside food policy, but there was a refrigerator for such items if
they ensure there is a name and date on them.
During an exit interview on 6/8/18 at 12:07 P.M., the Administrator provided the
following:
– A corporate policy titled Foods Brought by Family/Visitors that was not facility
specific and included procedures that staff interviews failed to disclose,
– A staff in-service topic sheet dated 6/8/18 with Foods Brought in by Family Members

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 46)
policy listed as a subject to be covered, and
– A previous all staff in-service sign-in sheet dated 4/10/18 with Food by Family listed
as a topic to be covered.

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 interview, and record review, the facility failed to establish and maintain an
infection prevention and control program designed to provide a safe, sanitary and
comfortable environment by not maintaining an infection control program, and to ensure the
Infection Control program policies were reviewed at least annually. This could potentially
affect all of the residents in the facility. The facility census was 80 residents.
Record review of the facility Infection Control Surveillance and Reporting policy dated
9/1/04 and revised on 11/28/16 showed:
-The Infection Preventionist will conduct regular outcome surveillance which consists of
collecting and documenting data on individual cases and comparing the collective data to
standard, written definitions of infection;
-The Infection Preventionist will conduct regular process surveillance to review which
practices directly related to patient care. Examples of this type of surveillance include
monitoring of compliance with Transmission Based Precautions, proper hand washing, the use
and disposal of gloves, and observation of the environment and
–The policy of the previous ownership was adopted by the current facility on 4/25/18.
Record review of the facility’s Procedure: Infection Control Outcome Surveillance and
Reporting policy dated 9/1/04 and revised on 11/28/16 showed:
-Community acquired infections are those infections incubating at the time of admission or
that develop in less than two calendar days from admission;
-Healthcare acquired infections (HAI) are those in which there is no evidence of an
incubating infection at the time of admission to the facility (on the basis of clinical
documentation of appropriate signs and symptoms and not solely on screening microbiologic
data), and onset of clinical manifestation occurs more than two days after admission and
–The policy of the previous ownership was adopted by the current facility on 4/25/18.
1. Record review on 6/13/18 at 1:58 P.M. of the facility’s computer generated Infection
Control Log Tracking and Trending report showed:
-The facility had two infections in (MONTH) (YEAR);
-The next entry was dated on 11/2/17.
-Staff were directed to document the following information:
–The order date;
–The resident’s room number;
–The resident’s name;
–Was the infection community acquired or facility acquired;
–The resident’s admitted ;
–Any cultures or X-rays that were done;
–Any signs or symptoms that had been documented;
–Which type of infection (Urinary Tract Infection, upper respiratory infection, lower
respiratory infection, skin or soft tissue, gastrointestinal, other);
–Was the resident on isolation;

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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)
–Which type of antibiotic was the resident prescribed;
–Was the care plan initiated or updated; and
–Did the resident have Intravenous (IV) access.
Record review of the facility’s handwritten Infection Control Log dated (MONTH) (YEAR) and
(MONTH) (YEAR) showed staff were directed to document:
-The resident’s name;
-The name of the resident’s physician;
-The resident’s room number;
-The date the resident was admitted ;
-The onset date of the infection;
-Was the infection hospital or community acquired;
-The symptoms that the resident had;
-Did the infection meet McGeer’s criteria (Infection surveillance definitions for long
term care facilities);
-Was a culture or X-ray obtained;
-What antibiotic was prescribed;
-Were any isolation precautions initiated; and
-The infection resolved date.
During an interview on 6/14/18 at 8:12 A.M., the Assistant Director of Nursing (ADON)
said:
-He/She inherited the Infection Control tracking program recently;
-The computer logs were from the previous staff person in charge of the program and the
handwritten logs were from him/her;
-He/She thought community acquired infections were infections the resident developed
within the facility;
-He/She thought healthcare acquired infections were infections the resident developed
prior to his/her admission to the facility;
-He/She did not track all infections in the facility, only the infections that were
treated with an antibiotic;
-He/She did not track lab results to determine if there were any trends with the type of
bacteria or infectious organism in the facility;
-He/She did not track if the infections were resolved;
-He/She did not have a copy of the McGeer’s criteria in the Infection Control log book to
determine if an infection met the McGeer’s criteria;
-He/She did not have information on the types of infections that needed to be reported to
the local and/or state health departments;
-If a resident was suspected to have [MEDICAL CONDITION] (C. diff – an infection which
typically occurs after use of antibiotic medications that can cause symptoms ranging from
diarrhea to life-threatening inflammation of the colon) the staff would collect a stool
sample and if the sample was positive for [DIAGNOSES REDACTED], the resident would be
placed on contact isolation precautions;
-The resident did not require to be placed on isolation precautions unless and until the
stool specimen results were received;
-He/She was working on a color-coded map of infections in the facility for (MONTH) (YEAR)
and (MONTH) (YEAR) and
-He/She had not found any infectious trends for (MONTH) – (MONTH) (YEAR) at this time.

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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

F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement a program that monitors antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish a facility-wide
infection prevention and control program that included an antibiotic stewardship program
that included antibiotic use protocols and a system to monitor antibiotic usage. The
facility census was 80 residents.
Record review of the facility Infection Control Surveillance and Reporting policy dated
9/1/04 and revised on 11/28/16 showed:
-The Infection Preventionist will conduct regular outcome surveillance which consists of
collecting and documenting data on individual cases and comparing the collective data to
standard, written definitions of infection;
-The Infection Preventionist will conduct regular process surveillance to review which
practices directly related to patient care. Examples of this type of surveillance include
monitoring of compliance with Transmission Based Precautions, proper hand washing, the use
and disposal of gloves, and observation of the environment and
–The policy did not address antibiotic use protocols.
Record review of the facility’s Procedure: Infection Control Outcome Surveillance and
Reporting policy dated 9/1/04 and revised on 11/28/16 showed:
-Community acquired infections are those infections incubating at the time of admission or
that develop in less than two calendar days from admission and
-Healthcare acquired infections (HAI) are those in which there is no evidence of an
incubating infection at the time of admission to the facility (on the basis of clinical
documentation of appropriate signs and symptoms and not solely on screening microbiologic
data), and onset of clinical manifestation occurs more than two days after admission.
1. During an interview and record review on 6/13/18 at 1:58 P.M., the Assistant Director
of Nursing (ADON) said:
-He/She completes the facility Infection Control Log.
-He/She documents the following information each month: The resident’s name; physician;
room number; the resident’s date of admission; the date of onset of symptoms; if the
infection was HAI or community acquired, the type of symptoms; did the infection meet
McGeer’s criteria (infection surveillance definitions for long term care facilities); was
a culture or X-ray completed; what antibiotic was used; if any isolation precautions were
used; and the date the infection was resolved.
-He/She tracks the infections with an antibiotic in the facility each month;
-He/She does not keep track of infections not being treated with an antibiotic;
-He/She does not keep track of any labs to determine what bacteria is being treated and
-He/She does not keep track does not track the date the infections were resolved.
During an interview on 6/14/18 at 8:12 A.M., the ADON said:
-He/She thought community acquired infections were the infections that developed after the
resident was admitted to the facility;
-He/She thought healthcare acquired infections were infections the resident had prior to
being admitted to the facility;
-He/She did not have any way to determine if the antibiotics prescribed were appropriate
for the resident’s infectious organism;
-He/She thought the McGeer’s criteria definitions were in the Infection Control folder;
–McGeer’s criteria definitions were not located in the Infection Control folder and
-For antibiotic stewardship, he/she looks at the Infection Control logs to see if too many
antibiotics were being used in the facility, and if so, he/she would ask for an alternate

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:

265758

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF KANSAS CITY SOUTH

STREET ADDRESS, CITY, STATE, ZIP

8033 HOLMES
KANSAS CITY, MO 64131

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 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 49)
treatment such as cranberry juice or a [MEDICATION NAME].