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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to organize and participate in resident/family groups in the
facility.

Based on interview and record review, the facility failed to respond to all concerns and
recommendations from (MONTH) (YEAR), (MONTH) 2019 and (MONTH) 2019 monthly Resident
Council meetings, and provide written documentation of responses and/or rationale related
to the concerns/recommendations. Three cognitively intact residents attended the group
meeting during the survey. The facility census was 84 residents.
Record review of the facility’s undated policy titled Resident and Family Council showed:
-The purpose of the Resident and/or Family Council was to provide a forum for:
–The residents to have input in the operation of the facility;
–Discussion of residents’ concerns;
–Consensus building and communication between residents and facility staff;
—Staff to disseminate information and gather feedback from interested residents and
family groups;
-Resident and/or Family Council meetings may be scheduled monthly, or more frequently, if
requested by the residents or Administrator;
-A Resident/Family Council response form is utilized to track issues and their resolution;
-If the Council raises an issue of concern, the Department responsible for the issue or
service is responsible for addressing the item(s) of concern promptly;
-The applicable Department should be able to demonstrate its response and rationale for
such responses;
-The facility will respond in writing to written request or concerns of the Family Council
in a prompt and timely manner;
-The facility will respond to issues discussed by the Resident Council using ACT-07-Form B
– Resident/Family Council Departmental Response Form.
1. Record review of the Resident Council meeting minutes, dated 12/14/18, showed the
following:
-Seven residents were in attendance;
-Residents had concerns/recommendations in the following areas:
–Residents wanted a new bus;
–Administration: Nothing gets done;
–Dietary: Residents requested Shepherd’s pie;
–Dietary: Food was still being served late;
–Dietary: The residents wanted a variety of potato chips;
–Dietary: The residents wanted more flavors of ice cream;
–Dietary: There were too many beans in the chili;
–Nursing: (Bad Habit) Certified Nurse Assistants (CNAs) were turning the call light off
and saying they would be back and would not come back;
–Maintenance: Channel 4 was missing on the television. The Chiefs games were not in the
Cable line up if the games were at night.
Record review of the Resident Council meeting minutes, dated 1/11/19, showed the
following:
-There were seven residents in attendance;
-Review of previously discussed business included:
–Call lights not being answered in a timely manner (1-2 hours);
–Request for a new bus;
–CNAs talking on their cell phones while giving care;
–Food not good;

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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
–The request for a variety of potato chips;
–More flavors of ice cream;
**Note: No resolutions, or the reason for the lack of resolutions, were stated in the
minutes;
-Resident had concerns/recommendations in the following areas:
–Administration: Residents wanted to have Channel 4 added to the television line up;
–Dietary: The food still didn’t taste good;
–Nursing: CNAs were still talking on their cell phones while providing care to the
residents;
–Nursing: It was still taking the CNAs on the night shift approximately 1-2 hours to
answer call lights;
–Beauty Shop: Residents wanted a new hair dresser, because the current hairdresser was
burning their hair and cutting it uneven.
Record review of the Resident Council meeting minutes, dated 2/15/19, showed the
following:
-There were six residents present;
-Review of previously discussed business showed:
–The call light situation was not corrected;
–Employees talking on their cell phones while providing cares was not corrected;
–The hairdresser situation was not handled;
–There was still the question of getting a new bus;
-Residents had concerns/recommendations in the following areas:
–Administration: The facility needed a new bus or a fairly new van;
–Nursing: Call lights were not being answered in a timely manner;
–Nursing: CNAs were still using their cell phones in residents’ rooms;
–Nursing: CNAs were rude on all shifts;
–Beauty Shop: Residents said they still had the same hairdresser, who had been cutting
their hair uneven and burning their hair.
Record review showed facility staff did not complete an ACT-07-Form B – Resident/Family
Council Departmental Response Form from for the (MONTH) (YEAR), (MONTH) 2019, or (MONTH)
2019 Resident Council meetings.
During Resident Meeting interviews on 2/21/19 at 2:08 P.M., the Resident Council President
said there is normally no response to recommendations and concerns discussed during the
meetings. He/She had not received written communications related to any of the concerns.
During an interview on 2/21/19 at 12:21 P.M., the Activities Director said:
-He/She was responsible for recording/documenting minutes at the Resident Council
meetings;
-A copy of the minutes was provided to the Administrator, Director of Nursing (DON) and
Social Services Director;
-He/She put the residents’ concerns from the Resident Council meetings in the department
mailboxes if there were concerns related to their department;
-He/She did not receive any written responses back;
-Each department should provide a written response on the departmental response form.
During an interview on 2/26/19 at 11:35 A.M., the Dietary Manager said he/she got a copy
of the dietary concerns from the meetings and tried to address them, but did not say
he/she provided written responses.
During an interview on 2/27/19 at 1:33 P.M., the Administrator said:
-He/She did receive copies of the minutes of the last couple of Resident Council Meeting
Minutes;
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
-If there was a concern in the minutes, he/she would normally follow up with the
departments having concerns noted, to make sure the concerns were addressed;
-The social worker would also normally assist with following up on concerns;
-He/She did not recall there being concerns in the last meetings.
During an interview on 2/27/19 at 2:40 P.M., the DON said:
-He/She got a copy of the resident council minutes and a written copy of the concerns for
nursing staff;
-He/She expected all departments to respond to the concerns of the Resident Council;
-He/She had addressed concerns with the nursing staff, but had not submitted any written
follow up or communication back to the Resident Council.

F 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on interview and record review, the facility failed to ensure incoming mail received
from the postal service for residents on Saturdays was delivered to the residents on the
same day or within 24 hours. The facility census was 84 residents.
Record review of facility’s undated policy titled Resident Rights – Mail showed:
-Mail was delivered to the resident within twenty-four (24) hours of delivery to the
premises or to the facility’s post office box (including Saturday deliveries).
1. During the Resident Council Interview on 2/21/19 at 2:00 P.M., cognitive residents in
attendance said mail was not delivered to the residents on Saturday.
During an interview on 2/21/19 at 2:43 P.M., the Resident Council President said:
-The mail was delivered to the facility and normally received by the receptionist;
-There was a receptionist on Saturday, but not the same one as during the week;
-Residents most often got Saturday’s mail on Monday or Tuesday.
During an interview on 2/22/19 at 10:22 A.M., the Activities Director said:
-The mail was sometimes delivered to the facility so late on Saturday, as late as 5:00
P.M. on some Saturdays;
-The staff person who worked with activities on Saturdays was already gone when the mail
arrived;
-There was no activity staff working on Sundays to deliver the mail received on Saturday
evening, so that mail was not delivered until Monday.
During an interview on 2/27/19 at 2:40 P.M., the Director of Nursing said:
-The mail was not an area that he/she had anything to do with;
-If the policy said Saturday’s mail should be delivered within 24 hours that should be
happening.
During an interview on 2/27/19 at 4:18 P.M., the Administrator said:
-There was a receptionist on Saturday;
-The residents should get their mail on Saturday;
-He/She would check into the matter.

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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure there was
a homelike environment provided for one (Resident #300) of 14 sampled residents, by
removing the resident’s bed from his/her room when he/she returned from an extended
hospital stay and replaced it with a sofa from the common area from the locked dementia
unit without the resident’s legal guardian’s input or permission. The facility census was
92.
1. Record review of Resident #300’s face sheet showed he/she was admitted to the facility
on [DATE] and had the following Diagnosis: [REDACTED].
-Dementia;
-[MEDICAL CONDITION].
Record review of the resident’s care plan dated 4/3/19, showed no mention of the resident
sleeping in other areas other than his/her bed.
Observation on 5/6/19 at 9:37 A.M., of resident’s room showed he/she sleeping on a sofa.
Record review of the facility’s Concern/Grievance Report dated 5/6/19, received via fax on
5/9/19 showed:
-The resident’s family member called on 5/6/19 to complain to the Minimum Data Set (MDS-a
federally mandated assessment instrument completed by facility staff for care planning)
Coordinator about the resident’s bed being replaced with a sofa;
-It was requested that the resident’s bed be put back in the resident’s room;
-The sofa was taken out of the resident’s room right after the conversation with the MDS
Coordinator.
During an interview on 5/6/19 at 9:54 A.M., Licensed practical Nurse A said:
-He/she was unsure why Resident #300 was sleeping on a sofa;
-When he/she arrived to his/her shift last Friday (5/3/19), housekeeping was in the
process of swapping out the resident’s bed for the sofa that had previously been out in
the common area;
-The resident would routinely sleep on the sofa, so that was maybe why it was moved into
his/her room;
-The resident routinely slept through the majority of the day in various different
locations.
During an interview on 5/7/19 at 10:11 A.M., the MDS Coordinator said:
-He/she was unaware of the resident’s bed being removed from his/her room;
-Something like that should be care planned and discussed with family;
-He/she would ensure that the information would be updated by the end of the day;
-He/she was aware that the resident had had previous altercations regarding others sitting
on the sofa in the common area and that was maybe the reason why the resident’s bed was
swapped out for the sofa;
-The resident routinely slept on the sofa and he/she would hope that the resident’s family
was involved in the decision to swap the bed for the sofa.
During an interview on 5/7/19 at 10:18 A.M., the Assistant Director of Nursing (ADON)
said:
-Resident #300 never slept in his/her bed;
-He/she had become very territorial over the sofa in the common area;
-He/she had multiple confrontations with other residents sitting on the sofa;
-He/she did not have a conversation with the resident’s family prior to the sofa being put
into the resident’s room;

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

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-He/she called the facility Administrator and Social Services and neither of them had a
conversation with the family regarding the resident’s bed being removed and replaced with
the sofa.
During an interview on 5/16/19 at 11:30 A.M., the resident’s family member said:
-The resident returned to the facility on [DATE];
-He/she brought the resident dinner and another family member went to the resident’s room
to get his/her blanket;
-It was discovered then, that the resident’s bed had been removed from his/her room;
-He/she immediately began asking staff why the resident’s bed had been replaced with the
sofa from the common area, and none knew why;
-About a week ago, he/she finally spoke to the facility Administrator and he/she was told
that the reason the resident’s bed was replaced with the sofa, was due to the resident
being territorial over the sofa;
-He/she explained that the resident would likely not sleep in his/her room like they
wanted;
-The resident will sleep in the common area in chairs and on the sofa where people
generally are;
-He/she would have never agreed to have the sofa placed in the resident’s room, because it
was from the common area. The sofa had been moved from the old unit to the current one;
-Other residents as well as his/her family member sat and occasionally slept on the sofa;
-His/her family member is incontinent as well as others, and he/she doesn’t feel it’s
sanitary;
-Now the sofa has been removed from the locked unit all together and he/she didn’t think
that was right;
-He/she felt the major issue was that there was just one sofa back on the unit and all the
resident’s enjoyed sitting on it, which lead to some trying to make room for themselves
when the sofa was already full.
MO 682

F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Respond appropriately to all alleged violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to complete a
timely thorough comprehensive investigation regarding an injury of unknown source for one
sampled resident (Resident #78) out of 14 sampled residents. The facility census was 92.
Record review of the undated facility policy, entitled Incident Investigation showed:
-The Licensed Practical Nurse fills out AP-31 C Form Incident Log to track and minimize
the number of incidents that take place in a facility.
-An incident includes falls, abuse, burns, usual occurrences, bruises, medication error,
missing person, property loss and respiratory arrest.
-The procedure is the Licensed Practical Nurse or the individual who first encounters or
witnesses an incident will complete the AP-31 Form A Incident/Accident report form and on
the AP-31 C documents the following: resident name, day and shift during which the
incident occurred, type of code, location code, severity code and medication treatment
error code.
-As appropriate, interviews with staff members and other witnesses will be documented 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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
AP-31 Form B Interview Record.
-The Director of Nursing (DON/DNS) and or designee will review the information incident
log every month and compile a total of each code.
-The DNS will submit the monthly incident log to the QA committee.
1. Record review of Resident #78’s undated face sheet showed he/she was admitted to the
facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED].
Record review of the resident’s care plan dated 1/26/19, showed:
-He/she has a potential/actual impairment to his/her skin integrity.
-The resident will maintain or develop clean and intact skin by the review date.
-Interventions were to avoid scratching and keep hands and body parts from excessive
moisture and keep fingernails short.
-Educate resident/family/caregivers of causative factors and measures to prevent skin
injury.
Record review of the resident’s Significant change Minimum Data Set (MDS-a federally
mandated assessment form to be completed by facility staff used for care planning) dated
4/9/19, showed he/she:
-Had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated the
resident was severely cognitively impaired.
-Usually understands.
-Usually understood.
-Had no behaviors.
-Utilized Hospice.
-Needed the assistance of two for transfers and dressing.
-Incontinent of bowel and bladder.
-Received antipsychotic, antianxiety, and anticoagulant medication.
Record review of the resident’s Skin Check form dated 4/22/19 at 5:29 P.M., showed he/she
had a new skin injury/wound identified. The skin injury was a bruise and the location
listed was the resident’s left side of his/her forehead and the rest of the form was left
blank.
Record review of the resident’s Skin Check form dated 4/24/19 at 5:29 P.M., showed skin
check preformed and the box none of the above was checked.
Record review of the resident’s facility investigation dated 4/30/19 at 6:01 A.M., showed:
-When this nurse went into the resident’s room, he/she noticed a black bruise no bigger
than a quarter on the resident’s left upper arm, a purple bruise a couple of inches away
from that bruise and on the resident’s right forearm there was a fresh black bruise.
-This nurse also noticed an old bruise on the resident’s left mid back and rib area
possibly from the most recent fall.
-The injury was listed as bruises in the left and right anticubitcal (region of the arm in
front of the elbow).
-The resident was confused, incontinent and had impaired mobility.
-During a transfer was checked for predisposing situation factors.
-No witnesses found. Responsible party, hospice and DON notified on 4/30/19.
Record review of the resident’s Situation Background Assessment Recommendation (SBAR)
dated 4/30/19 at 6:01 A.M., showed:
-Staff were to evaluate the resident, check vital signs and review an INTERACT care path
or Acute Change in Condition file card if indicated.
-Fresh bruising on the resident’s arm; two on the left arm and one on the right.
-Start date was 4/30/19.
-The resident had medication changes in the last week.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
-The resident has increased confusion, new or worsening behavioral symptoms, and a fall.
Record review of the resident’s facility investigation dated 4/30/19 at 6:01 A.M., and
revised on 5/6/19 at 1:35 P.M., showed;
-When this nurse went into the resident’s room, he/she noticed a black bruise no bigger
that a quarter on the resident’s left upper arm, a purple bruise a couple inches away from
that bruise, then on the resident’s right forearm there was a fresh black bruise.
-This nurse also notified an old bruise on the resident’s left mid back and rib area
possibly from the most recent fall.
-The bruise was listed as on the right and left anticubitcal.
-No witnesses found.
-Under the Notes section of the form, the facility added therapy to evaluate and geri
sleeves padding dated 5/1/19.
-The resident frequently is known to fight with hospice staff during showers, added on
5/1/19.
-Recent medication changes included an increase in [MEDICATION NAME] due to increased
behaviors of attempting to throw himself/herself out of his/her chair. Bruising is
consistent with hitting his/her arms on the wheelchair, added on 5/1/19.
-Under the Notes section of the form, the facility added a root cause analysis was
bruising on the resident’s bilateral arms was consistent with resident hitting his/her
arms on the table. Old bruising noted on the resident’s mid back and rib are consistent
with his/her previous fall, added 5/7/19.
-There was no follow up investigation with hospice staff concerning the resident fighting
with staff during showers.
Record review of the resident’s Skin Check form dated 4/30/19 at 7:01 A.M., showed he/she
had a previously noted skin injury/wound as a bruise and older bruises to bilateral
forearms.
Record review of the resident’s (MONTH) Physician order [REDACTED].M. and [MEDICATION
NAME] 25 mg at 12:00 P.M. and 100 mg at time of sleep.
Record review of the resident’s Skin Check form dated 5/2/19 at 7:01 A.M., showed skin
check preformed and the none of the above box was checked.
Record review of the resident’s Skin Check form dated 5/2/19 at 9:24 A.M., showed he/she
had a previously noted skin injury/wound, a bruise, previously noted bruising to bilateral
forearms and left upper arm. (Another skin check form from the same date at 7:01 A.M.,
said none of the above.)
Record review of the resident’s Skin Check form dated 5/4/19 at 10:25 A.M., showed he/she
had a previously noted skin injury/wound, bruise, previously noted bruising to bilateral
forearms and left upper arm.
Observation on 5/6/19 at 12:24 P.M., showed the resident was at the table near the nurse’s
desk. His/her head was resting on the handrail with his/her eyes closed. Staff were
providing one on one activities to another resident sitting by the resident. His/her arms
were not under the table or near the wheelchair and he/she was not wearing any protective
sleeves.
Record review of the resident’s Skin Check form dated 5/6/19 at 11:26 A.M., showed he/she
had a previously noted skin injury/wound, a bruise, previously noted bruising to bilateral
forearms and left upper arm.
Record review of the resident’s Skin Check form dated 5/7/19 at 6:00 P.M., showed he/she
had a previously noted skin injury/wound, bruise. Old bruising to bilateral forearms and
left upper arm in various stages of healing.
Record review of the resident’s care plan revised on 5/8/19, 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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
-He/she has a potential/actual impairment to skin integrity due to resident hitting arms
against tables and against his/her wheelchair arms, he/she has poor impulse control
regarding personal safety.
-The goal was the resident will maintain or develop clean and intact skin by the review
date.
-The interventions were to avoid scratching and keep hands and body parts from excessive
moisture.
-Keep fingernails short.
-Educate resident/family/caregivers of causative factors and measures to prevent skin
injury.
-Padded geri sleeves to bilateral arms was added on 5/1/19.
-Use a fiddle blanket in his/her lap to help redirect his/her from unsafe activities was
added on 5/8/19.
-Therapy to evaluate and treat as needed was added on 5/7/19.
-New order for labs was added on 5/8/19.
-This care plan update was faxed on 5/9/19 after the exit of 5/7/19.
During an interview on 5/7/19 at 1:00 P.M., the Assistant Director of Nursing (ADON) and
acting DON said the charge nurse fills out the form and gives it to the DON for review.
The DON signs off on the report and then it goes to the Administrator and Medical
Director. They have stand up meetings every Monday and they all have lap tops, so they can
update information if needed. The ADON said to investigate an injury of unknown source you
need to do an immediate investigation, root cause analysis, two hour window to self
report, SBAR and all notifications. The team did not feel this resident’s injury of
unknown source was abusive or neglectful, so they did not call the State. There should be
a comprehensive investigation in the record that supports that decision. He/she would look
to see if there was more information about the unknown injury.
Record review of the resident’s investigation faxed to the DHSS on 5/9/19, showed a
comprehensive investigation of the injury of unknown source completed on 5/8/19 to include
the resident’s diagnoses, medications, incident, contributing factors, immediate
interventions, long term interventions and additional interventions, skin checks and
conclusion. The conclusion was that the resident bangs his/her arms against the under side
of the table excessively. When removed from the table, he/she will bang his/her arms
against the wheelchair arms. Resident is unaware of his/her safety. Redirection is not
always effective. Resident has episodes of anxiety/restlessness and his/her as needed
[MEDICATION NAME] does provide some comfort. It has been determined that the bruising
assessed on his/her bilateral arms are consistent with the resident banging his/her arms
on the wheelchair and under side of the table.

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 baseline care
plan to the resident and/or their responsible party with a summary of the baseline care
plan for six sampled residents (Resident #14, #63, #68, #19, #56, and #60) out of 22
sampled residents. The facility census was 84 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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 8)
Record review of the facility’s undated Care Planning Policy showed:
-The Facility’s Interdisciplinary Team (IDT) will develop a baseline care plan for each
resident.
-The facility will develop a person-centered baseline care plan for each resident within
48 hours of admission.
-The facility must provide the resident and/or the resident’s representative with a
written summary of the baseline care plan.
-The baseline care plan summary must be provided to the resident and/or representative by
the time the comprehensive care plan is completed.
-The baseline care plan will be updated to reflect changes in the resident’s condition or
needs occurring prior to the development of the comprehensive care plan.
-The facility may choose to develop a comprehensive care plan in place of the baseline
care plan if it is completed within 48 hours of admission
-If the comprehensive care plan is completed within 48 hours of admission, then a written
summary must be provided to the resident and/or the resident’s representative.
-The medical record must contain evidence that the summary was given to the resident
and/or representative.
1. Record review of Resident #14’s entry tracking form showed the resident admitted to the
facility on [DATE].
Record review of the resident’s medical record showed no documentation that the resident
and/or their responsible party was provided with a summary of the baseline care plan.
2. Record review of Resident #63’s entry tracking form showed the resident admitted to the
facility on [DATE].
Record review of the resident’s medical record showed no documentation that the resident
and/or their responsible party was provided with a summary of the baseline care plan.
3. Record review of Resident #68’s entry tracking form showed the resident admitted to the
facility on [DATE].
Record review of the resident’s medical record showed no documentation that the resident
and/or their responsible party was provided with a summary of the baseline care plan.
4. Record review of Resident #19’s entry tracking form showed the resident admitted to the
facility on [DATE].
Record review of the resident’s medical record showed no documentation that the resident
and/or their responsible party was provided with a summary of the baseline care plan.
5. Record review of Resident #56’s Admission Record showed he/she was admitted on [DATE].
Record review of the resident’s medical record showed no documentation that the resident
and/or their responsible party was provided with a summary of the baseline care plan.
6. Record review of Resident #60’s Admission Record showed he/she was admitted on [DATE].
Record review of the resident’s medical record showed no documentation that the resident
and/or their responsible party was provided with a summary of the baseline care plan.
During an interview on 2/25/19 at 3:30 P.M., the Director of Nursing (DON) said:
-Baseline care plans are completed in the computer under the Resident Data Set (RDS-a
health screening and assessment tool).
-Are not printed out for the resident or his/her responsible party.
During an interview on 2/25/19 at 3:07 P.M., the Minimum Data Set (MDS-a federally
mandated assessment instrument completed by facility staff for care planning) Coordinator
said:
-He/She had been the MDS Coordinator for two months.
-The Resident Data Set is completed by the admitting charge nurse and it triggers care
plans.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 9)
-Facility staff are supposed to give a copy of the care plan to the resident and/or their
representative within two days.
-Facility staff have not been giving the baseline care plans to the resident and/or their
responsible party.
During an interview on 2/25/19 at 10:40 A.M., Licensed Practical Nurse A said:
-The nurses do the RDS on admission.
-He/She doesn’t know anything about giving the family a baseline care plan or the RDS.
During an interview on 2/27/19 at 2:40 P.M., the DON said:
He/She doesn’t know anything about giving the baseline care plan to the resident and/or
the resident’s responsible party.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the
resident/representative in writing of quarterly Care Plan (a written out plan for the care
of the resident) meetings for one sampled resident (Resident #25) out of 22 sampled
residents. The facility census was 84 residents.
Record review of the facility’s undated Care Planning Policy showed:
-The Facility’s Interdisciplinary Team (IDT) will develop a comprehensive care plan for
each resident.
-The resident has a right to be informed, in advance, of changes to the plan of care.
-The resident has the right to see the care plan, including the right to sign after
significant changes are made to the plan of care.
-The facility will invite the resident, if capable, and their family to care planning
meetings and use its best efforts to schedule care planning meetings at times convenient
for the resident and family.
-Care plan meetings may be conducted via teleconference.
-The medical record must contain evidence that the summary was given to the resident
and/or representative.
1. Record review of Resident #25’s admission record showed he/she was admitted to the
facility on [DATE].
Record review of the resident’s quarterly Minimum Data Set (MDS – a federally mandated
assessment tool completed by the facility staff for care planning) dated 12/3/18 showed:
-That the resident’s cognition was severely impaired with a Brief Interview for Mental
Status (BIM’s) score of two out of 15.
-That the resident’s son was his/her responsible representative/party.
During an interview on 2/21/19 at 9:56 A.M., the resident’s son said:
-He/She did not know about Care Plan meetings.
-He/She had never received a letter from the facility informing him/her of a Care Plan
meeting.
-He/She came to visit the resident every morning.
-His/Her wife came every afternoon.
Record review of the resident’s medical record showed no documentation of the
resident/representative being notified of the Care Plan meetings or of 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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
resident/representative attending or not attending the meetings.
During an interview on 2/26/19 at 9:29 A.M., MDS Coordinator said:
-He/She just started doing the Social Service Directors (SSD) duties since the SSD left at
the beginning of February.
-He/she would continue doing the SSD duties until the facility hired a new SSD.
-The facility sent out letters to the resident’s family/representatives of when the Care
Plan meeting would be every quarter.
-The facility did not document if the resident/representatives attended or not.
-He/She was unable to find any copy of or documentation of the resident’s
family/representative being notified of past Care Plan meetings.
During an interview on 2/27/19 at 2:40 P.M., the Director of Nursing said:
-He/She would expect that notifications letters of Care Plan meetings were sent to a
resident/representative by the SSD.
-He/She would expect the SSD to document that a resident/representative attended or did
not attend the Care Plan meeting in the Care Plan meeting notes.
-The MDS coordinator was doing the SSD duties until the facility hired a new SSD.

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 interview and record review, the facility staff failed to ensure neurological
assessment checks (neuro checks to monitor level of consciousness (L[NAME]), ability to
move extremities, eye responses and change in pupils and vital signs) were completed for
resident falls, as per facility policy for one sampled resident (Resident #72) out of 22
sampled residents. The facility census was 84 residents
Record review of the facility’s undated Fall Management Program showed:
-The facility will provide the highest quality care in the safest environment for the
residents.
Record review of the facility’s undated Neurological Assessment policy showed:
-Nursing staff will perform a neurological assessment in the following circumstances:
–Following an unwitnessed fall;
–Following a fall or other accident/injury involving a head trauma;
-Neurological checks will be performed as follows or otherwise ordered by the Attending
Physician;
–Four times every 15 minutes for one hour;
–Then, four times every 30 minutes for one hour;
–Then, four times every hour for two hours; and
–Then, four times every four hours for a combined total of 72 hours.
1. Record review of Resident #72’s Admission Record showed he/she was admitted on [DATE],
with the following Diagnoses: [REDACTED].
-Major [MEDICAL CONDITION] (mental health disorder characterized by persistently depressed
mood or loss of interest in activities, causing significant impairment in daily life);
-Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness,
tension, fast heart rate, and breathing difficulty not associated with an apparent
stimulus);

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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 – Few

(continued… from page 11)
-[MEDICAL CONDITION]’s Disease (is a fatal genetic disorder causing progressive breakdown
of nerve cells in the brain leads to physical and mental ability deterioration);
-Abnormal Posture;
-Repeated Falls.
Record review of the resident’s Nurses Notes, dated 10/16/18 at 12:41 A.M., showed:
-He/She was found lying on the floor when getting out of bed;
-He/She was assisted with Activities of Daily Living (ADLs) and helped back into bed;
-His/Her call light was in reach;
-Staff would continue to monitor.
Investigation with the neurological assessments for the fall on 10/16/18 was requested on
2/26/19. This information was not provided by the facility.
Record review of the resident’s Situation, Background, Assessment, and Request (SBAR)
communication form and progress note, dated 10/24/18 at 9:30 P.M., showed:
-He/She had a non-injury fall on 10/24/18, with no indication of the time of the fall;
-No indication if the fall was witnessed or un-witnessed;
-He/She had no changes in mental status;
-His/Her most recent vital signs were obtained on 10/24/18 at 8:30 P.M. and were:
–Blood Pressure 98/57 sitting, right arm;
–Pulse 72 and regular;
–Respirations 16;
–Temperature 96.6 axilla (under the arm);
–Oxygen saturation 98% on room air on 10/22/18 at 2:01 P.M.
Record review of the resident’s medical record showed no Neurological Assessment checks
were performed per the facility policy at the time of the fall or for the 72 hour period
following the fall.
Record review of the Resident’s SBAR communication form and progress note, dated 1/5/19 at
11:30 P.M., showed:
-The resident had a fall on 1/5/19, with no indication of the time of the fall;
-No indication if the fall was witnessed or un-witnessed;
-No indication if the resident sustained [REDACTED].>-The resident had no changes in
mental status;
-Monitor vital signs;
-The resident’s most recent vital signs were obtained on 1/6/19 at 2:30 A.M. and were:
–Blood Pressure 146/81 sitting, right arm;
–Pulse 84 and regular;
–Respirations 16;
–Oxygen saturation 98% on room air;
–Temperature 97.2 Tympanic (ear) on 1/6/19 at 2:30 A.M.
Record review of the resident’s Nurses Notes, dated 1/6/19 at 2:09 A.M., showed:
-The resident was found lying on his/her left side in front of his/her wheelchair;
-PROM was performed;
-The resident was put back into his/her wheelchair with the use of a gait belt (a belt,
usually made of heavy canvas with a sturdy buckle, used to help residents move) and three
employees;
-The resident was wheeled back to his/her room and assisted to bed.
Record review of the resident’s medical record showed no Neurological Assessment checks
were performed per the facility policy at the time of the fall or for the 72 hour period
following the fall.
Record review of the resident’s SBAR communication form and progress note dated 2/20/19 at
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 – Few

(continued… from page 12)
2:40 A.M., showed:
-The resident had a fall on 2/20/19, with no indication of the time of the fall;
-No indication if the fall was witnessed or un-witnessed;
-No indication if the resident sustained [REDACTED].>-The resident had no changes in
mental status;
-The resident had no changes in functional status;
-The resident’s most recent vital signs were obtained on 1/8/19 at 2:30 A.M.;
-Blood Pressure 146/81 sitting, right arm.;
-Pulse 84 and regular;
-Respirations 16;
-Oxygen saturation 98% on room air;
-Temperature 97.2 Tympanic on 1/5/19 at 2:30 A.M.;
-Monitor vital Signs.
Record review of the resident’s Nurses Notes, dated 2/20/19 at 3:01 A.M., showed:
-The resident was found lying on the floor;
-Had no bumps or bruises noted;
-The resident was able to move all extremities with ROM within his/her normal limits;
-The resident denied pain or discomfort;
-The resident’s hand grips were equal;
-The Nurse Practitioner, the ADON, and the resident’s responsible party were notified.
Record review of the resident’s Neurological Check List, dated 2/20/19 at 3:10 A.M.,
showed:
-The resident’s most recent vital signs were obtained on 2/20/19 at 3:10 A.M.,
–Temperature 97.8;
–Pulse 68 and regular;
–Respirations 21;
–Blood Pressure 128/69;
-The resident was assessed for L[NAME], pupil size and reaction, verbal responses, PROM,
and pain.
Record review of the resident’s medical record showed no Neurological Assessment checks
were performed per the facility policy at the time of the fall or for the 72 hour period
following the fall.
During an interview on 2/27/19 at 2:40 P.M., the DON said:
-Neurological Assessment should be done:
–For an unwitnessed fall;
–If the resident hit their head;
-He/She would have to check the policy as to how often and the length of time the
Neurological Assessment was to be done.

F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to ensure resident
safety while smoking by failing to monitor to ensure residents were smoking in designated
smoking areas; failed to ensure protective oversight by supervising the residents while

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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 13)
smoking for residents who were known to sneak out of the facility to smoke at
non-scheduled smoke times; failed to monitor to ensure facility staff kept all resident
smoking materials when smoking was not occurring; failed to complete comprehensive
assessments that accurately addressed the resident’s potential risk for changes in smoking
behaviors; failed to ensure quarterly smoking assessments were completed to ensure
residents continued to meet safe smoking protocols; failed to communicate changes in
resident behavior and provide adequate supervision. One sampled resident who had a history
of [REDACTED].#83) and a second sampled resident (Resident #55) broke out a window on the
locked Behavioral Health Unit (BHU) and caught bed linens on fire out of 22 sampled
residents. The facility census was 84 residents.
1. Record review of the facility’s policy, dated (MONTH) 2019, titled smoking policy
showed:
-The facility was a non-smoking building;
-Smoking was ONLY permitted in designated smoking areas and supervised by staff during
designated times;
-The facility operated to balance the important need for fire safety with each resident’s
right for independence, highest practicable functioning and dignity;
-Residents would be assessed for their ability to smoke safely upon admission, quarterly,
annually and with a significant change in condition where such change might impact the
prior assessment;
-Residents MAY NOT keep lighter, matches, etc. in their possession at any time;
-Facility staff would keep fire/flame materials needed for smoking;
-Based upon the completed assessment, the interdisciplinary team would evaluate the
resident’s ability to safely smoke independently;
-A plan of care would be developed to indicate the resident’s ability, risk factors to
smoke safely and assistive devices deemed necessary to assist the resident to smoke
safely;
-Staff would supervise during smoke times in designated areas;
-The plan of care would be reviewed and updated as necessary and quarterly which could
impact the resident’s ability to smoke safely;
-Resident non-compliance with the facility’s smoking policy could result in up to and
including a 30 day involuntary discharge from the facility;
-Resident refusal to sign and abide by the facility policy could result in up to and
including 30 day involuntary discharge from the facility.
Record review of the facility’s policy Resident Supervised Smoking, effective 1/24/2019,
showed:
-Supervised smoking in designated smoking area only (outside the front entrance to the
right of the front door as you exit the building);
-Staff member will stay with residents for up to 15 minutes each time;
-Any staff may supervise from any department;
-Must be ongoing seven days a week;
-(The following is a list of which department is responsible for smoke breaks):
-7:15 A.M. Nursing;
-8:30 A.M. Housekeeping/Laundry/Floor Technician (Tech);
-12:15 P.M. Housekeeping/Laundry/Floor Tech;
-1:30 P.M. Housekeeping/Laundry/Floor Tech;
-5:15 P.M. Evening housekeeper;
-6:30 P.M. Nursing;
-8:30 P.M. Nursing.
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 14)
Record review of the facility’s (blank) admission packet with a revision date of 4/16/18
showed:
-The staff were directed to fill out the smoking safety evaluation;
-All residents must be supervised when they smoke;
-Smoking is not allowed anywhere on the premises of the facility by residents;
-Cigarette butts must be disposed of in provided receptacles.
Record review of the National Fire Prevention Agency’s policy Elimination of Sources of
Ignition, section 11.5.1.1 dated 1999, showed smoking materials (e.g., matches,
cigarettes, lighters, lighter fluid, tobacco in any form) shall be removed from patients
receiving respiratory therapy.
Record review of the 1/25/19 In-service titled Incident/Accident Prevention and Safety,
which included the new smoking policy showed Registered Nurse (RN) A had attended the 7:00
A.M. educational meeting.
Record review of Resident #83’s face sheet showed he/she admitted to the facility on
[DATE] and was re-admitted on [DATE].
Record review of the resident’s medical record on, 2/22/19 at 7:00 A.M., showed:
-He/She had signed the smoking policy on 1/30/19;
-No smoking assessment was found in the electronic chart for the 1/30/19 admission and the
2/21/19 re-admission;
-No smoking assessment was found in the paper chart for the 1/30/19 admission and the
2/21/19 re-admission.
During an interview on 2/22/19 at 7:20 A.M., Assistant Director of Nusing (ADON) B said:
-The admitting nurse usually does the smoking assessment;
-If it is at the end of a shift it might be done by the next shifts charge nurse.
Record review of Resident #83’s Minimum Data Set (MDS a federally mandated assessment tool
completed by the facility staff for care planning), dated 2/6/19, showed:
-The resident was admitted on [DATE];
-The resident had adequate hearing and did not require a hearing aide;
-The resident had unclear speech (slurred or mumbled);
-The resident could respond to simple direct communications only;
-The resident needed supervision for locomotion on or off of the unit (oversight,
encouragement, or cueing);
-The resident smoked;
-The resident had the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION];
-The resident was able to make decisions for himself/herself.
Record review of the resident’s care plans showed no care plan for smoking prior to
2/22/19.
Record review of the resident’s physician’s orders [REDACTED].
-The resident was to have oxygen as needed (PRN) from three to eight liters for hypoxemia
(the absence of enough oxygen in the tissues to sustain bodily functions);
-Keep oxygen level above 88 percent (%).
Observation and interview of the resident on 2/22/19 at 5:20 A.M., showed:
-He/She came outside the facility’s front door by himself/herself unsupervised by staff;
-He/She was sitting in a wheelchair;
-He/She lit a cigarette and sat by himself/herself smoking unsupervised;
-He/She had an oxygen tank attached to the back of his/her wheelchair, and oxygen tubing
in his/her nose;
-The oxygen was on (a slight hissing noise was heard coming from the tubing, indicating 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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 15)
was on);
-When asked if he/she was smoking while he/she had oxygen on, the resident said no then
took the oxygen tubing out of his/her nose and moved the tubing to the top of his/her
head;
-He/She smoked the cigarette down to the butt and then threw the cigarette butt onto the
pavement;
-He/She reapplied the oxygen tubing into his/her nose and went back into the building;
-The oxygen tank was on and set at three liters;
-There was no designated smoking area sign at the location where the resident was smoking;
-There was no smoking receptacle located where the resident was smoking;
-The smoking receptacle was located in front of the building 16 feet down the sidewalk
from where the resident was smoking.
During an interview on 2/22/19 at 5:30 A.M., RN A said:
-He/She was coming to see if the resident was smoking;
-The resident had told him/her that he/she was going outside for fresh air;
-He/she had told the resident not to smoke;
-The resident kept his/her own cigarettes and lighter in his/her possession.
During an interview on 2/22/19 at 6:01 A.M., the resident said:
-He/She only goes out to smoke once in a while (staff said he/she went out for every smoke
break);
-He/She did not know if there were regular smoking times or not (he/she had signed the
smoking agreement on 1/30/19);
-He/She told staff he/she was going out for air;
-He/She knew the door code to get out of the front door.
Record review of the Nurse’s Progress Notes, written on 2/22/19 at 8:33 A.M., showed:
-RN A had observed the resident going toward the front door of facility with his/her
oxygen on;
-The nurse followed the resident to the front door and warned him/her that he/she could
not go outside to smoke with his/her oxygen on;
-RN A was aware of the resident’s previous non-compliance of smoking with oxygen on during
his/her previous admission;
-The resident stated he/she just wanted the cold air;
-The nurse went to check on another resident taking five to seven minutes;
-The nurse then stepped outside to check on the resident to make sure he/she wasn’t
smoking;
-The resident was found to be smoking with his/her oxygen on;
-The nurse then asked the resident to put the cigarette out;
-The nurse asked the resident to come inside;
-The resident complied.
During an interview on 2/22/19 at 6:38 A.M., Certified Nursing Assistant (CNA) A said:
-He/She worked the night shift last night on the same hallway as the resident;
-He/She had worked with the resident before;
-The resident goes out to smoke;
-The resident was to be supervised when he/she goes out to smoke;
-He/She did not know if the resident kept his/her cigarettes or lighter;
-CNA A had been with the resident previously when he/she had smoked;
-The resident did not go out to smoke last night;
-The resident might have gone out this morning while he/she was getting other people up;
-CNA A had provided care to him/her at 4:45 A.M. this morning;
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 16)
-The resident did not say he/she wanted to go out to smoke;
-CNA A always punched the door code for the resident;
-CNA A did not know if the resident knew the door code;
-CNA A had seen the resident trying to sneak outside to smoke;
-CNA A had caught him/her trying to use the door code, but did not get outside;
-The residents should not smoke with oxygen on;
-The staff should put the resident’s oxygen on a stand;
-The oxygen (tubing and tank) doesn’t go outside with the residents.
During an interview on 2/22/19 at 6:49 A.M., the Administrator said:
-He/She went in to talk to the resident;
-He/She had the resident turn in his/her lighter;
-He/She had searched and there was no other lighter or matches in the resident’s room;
-The resident was allowed to keep his/her cigarettes with him/her;
-The resident said he/she knew there were smoking times;
-The resident had the paper with the smoking schedule on it.
Record review of the Social Service Designee’s (SSD) Progress Notes, written on 2/22/2019
at 6:57 A.M., showed:
-The SSD had talked with RN C about the resident smoking outside with oxygen on;
-RN C had searched the resident’s coat pockets;
-RN C had removed one black lighter with the resident’s permission;
-The ADON and the Administrator had searched his/her room with his/her permission;
-No other lighters, matches, or etc. were found;
-RN C reported back to the charge nurse that the resident’s lighter was now in the
possession of the
Administrator.
Record review of the SSD’s Progress Notes written, on 2/22/2019 at 7:07 A.M., showed:
-The resident was noted outside smoking with his/her oxygen on;
-The SSD spoke with the resident;
-The resident said he/she woke up that morning and really needed a cigarette;
-The resident said he/she used the key pad in the front to go outside;
-The SSD asked him/her about him/her still wearing his/her oxygen while smoking;
-The resident said he/she forgot to take it off, but at home sometimes he/she wore it and
smoked;
-The resident said, It’s only two liters;
-Education was provided by the SSD on the facility’s policy to smoke with supervision;
-Education was provided by the SSD on the facility’s scheduled smoking times;
-The resident voiced his/her understanding of that policy;
-The resident said when he/she wants to smoke he/she will smoke;
-Education was provided to him/her about the risks and benefits of him/her smoking with
his/her oxygen on.
During an interview on 2/22/19 at 7:26 A.M. RN A said:
-He/She had talked to the resident last night;
-The resident was alert and oriented;
-The resident was his/her own person;
-The resident had smoked previously on each smoke break;
-He/She did not not know how the resident got out of the building;
-The nurse when admitting a resident should have done a smoking evaluation;
-He/She was the admitting nurse;
-He/She did not do the smoking evaluation;
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 17)
-RN A watched the resident go out this morning;
-He/She told the resident he/she could not go out to smoke;
-The resident replied he/she just wanted cold air;
-The resident had the code to the door;
-The resident was his/her own person;
-The resident couldn’t have been out more than five minutes as all he/she had was the butt
left;
-He/She said the facility smoking policy said if residents were their own person they
could go out on their own to smoke when they want (this was not in the facility policy);
-No smoking assessment had been done.
During an interview on 2/22/19 at 8:00 A.M., RN B said:
-He/She had worked with the resident before, mostly on the weekends;
-Residents should not go out to smoke without supervision to make sure their oxygen is not
on;
-He/She believed the facility’s policy said that the residents can only go out on
supervised smoke breaks;
-The smoking assessment was not done on 1/30/19 on admission;
-The smoking assessment was not done on 2/21/19 on re-admission;
-He/She saw the resident outside smoking about two weeks ago without supervision;
-The oxygen tank was on the back of his/her wheelchair;
-The resident was re-educated about not smoking with oxygen on;
-The resident was re-educated about only going out during smoke break times with
supervision;
-He/She did not chart any of this.
During an interview 2/22/19 at 9:15 A.M., the Administrator said:
-He/She had met with the residents that smoked on 1/24/19;
-He/She met with the residents to determine smoking times;
-He/She said there would be no more independent smoking;
-Smoking must be supervised;
-The residents were not allowed to keep their lighters on them;
-He/She had spoken with the resident upon admission regarding the new policy of supervised
smoking only at scheduled times;
-The resident said he/she smoked with oxygen on at home;
-The resident said he/she forgot to take it off;
-The new policy was posted at the nurses station.
During an interview on 2/22/19 at 9:50 A.M., the Medical Director said:
-The resident had signed a contract when he/she came in;
-The medical director has seen it (the survey team had not been provided with a copy at
the time of exit);
-The resident was cognitively intact;
-The resident was smoking when he/she wasn’t supposed to;
-The resident was smoking with oxygen on;
-The resident had a lighter when he/she wasn’t supposed to.
During an interview on 2/22/19 at 10:05 A.M., ADON A said:
-He/She knew they had a new smoking policy;
-The residents had to be supervised while smoking;
-He/She found out about the policy about a month ago;
-The Administrator told him/her and the other ADON about the policy at the same time;
-The Administrator sent out an email regarding the new policy.
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 18)
During an interview on 2/22/19 at 10:10 A.M., the Administrator said:
-He/She verbally told staff about the new smoking policy;
-He/She gave in-services about the new smoking policy. It was done but not listed on the
agenda;
-He/She posted the policy at the main nurse’s station (closest to front door);
-They have done some cleaning up of the nurse’s station and may have taken it down;
-The new smoking policy is posted in the copy room.
Observation on 2/22/19 at 10:12 A.M., showed the new smoking policy, dated 1/25/19, was on
the bulletin board in the copy room by the time clock.
During an interview on 2/22/19 at 10:50 A.M., the Dietary Manager said:
-The residents have scheduled times to smoke;
-The residents were to smoke in the front of the facility by door;
-If the resident wore oxygen, it needed to come off of the wheelchair (they can’t wear it
to go out to smoke);
-Over the last three months, he/she had seen three or four residents sneak out to smoke
(he/she was unable to remember who the residents were);
-If staff saw any residents sneak out to smoke the staff were to go out with them;
-The staff should supervise them while they smoked.
During an interview on 2/26/19 at 2:40 P.M., the Administrator said:
-The resident was transferred to the secured care unit;
-When the resident goes out to smoke, he/she would have to have someone let him/her
outside;
-The staff would go outside with him/her to smoke;
-The staff would keep his/her cigarettes.
During an interview on 2/27/19 at 3:29 P.M., the Director of Nursing (DON) said:
-He/She expected the staff to stay with a resident when they go out to smoke;
-If the resident had oxygen the oxygen tank should be taken off of the wheelchair;
-The oxygen tank should not go outside with the resident.

2. Record review of Resident #55’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Altered mental status;
-Muscle weakness;
-Unsteadiness on feet;
-Abnormal gait and mobility;
-Cognitive communication deficit;
-Dementia (a progressive organic mental disorder characterized by chronic personality
disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity
and function, and impairment of control of memory, judgment, and impulses) without
behavioral disturbance;
-Tobacco use.
Record review of the resident’s Care Plan, dated 11/13/18, showed:
– No documentation the facility staff developed a care plan for the resident’s smoking
and/or tobacco use.
Record review of the resident’s admission History and Physical, dated 11/15/18, showed the
resident was a current tobacco smoker.
Record review of the resident’s admission MDS, dated [DATE], showed the resident:
-Did not use tobacco products.
Record review of the resident’s medical records showed no documentation by the facility

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

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 19)
staff the resident was assessed for safe smoking from the time of the resident’s admission
on 11/12/18 until the resident was discharged from the facility on 12/1/18.
Record review of the resident’s admission MDS, dated [DATE], showed he/she:
-Was a current tobacco user;
Record review of the resident’s revised care plan, dated 1/15/19, showed the resident:
-Used anti-anxiety medications and to monitor and record the following targeted behavioral
symptoms: pacing; wandering; disrobing; inappropriate responses to verbal communication;
violence/aggression toward staff dated 1/23/19;
-Was a smoker and was able to light his/her cigarettes without assistance, but required
staff to keep his/her lighter related to poor safety awareness dated 1/24/19;
-Instruct the resident about the facility smoking policy, locations, times, and safety
concerns dated 1/24/19;
-Notify the charge nurse immediately if it is suspected the resident had violated the
facility smoking policy dated 1/24/19;
-He/She required supervision while smoking dated 2/14/19;
–NOTE: No documentation the facility staff assessed the resident for safe smoking from
his/her readmission on 1/11/19 until 2/22/19.
Record review of the resident’s Social Service note, dated 2/19/19, from the Administrator
showed:
-Talked with the resident today and re-educated him/her on the facility’s smoking policy;
-He/She tends to go out to smoke between scheduled smoke times and without supervision;
-The facility staff had attempted to contact the resident’s family to inform the family
member the resident could not have his/her own matches, lighters, etc.;
-The call went straight to the family member’s voicemail and the voicemail box was full.
Record review of the resident’s Smoking Assessment, dated 2/22/19, showed the resident:
-Was safe to smoke without supervision;
-Had cognitive loss;
-Had dexterity problems;
-Smoked 5-10 cigarettes a day;
-Can light his/her own cigarette;
-The facility needed to store the resident’s lighter and cigarettes;
-Had a plan of care to ensure the resident was safe while smoking;
-Notes from the Interdisciplinary Team showed the resident was able to light his/her own
cigarettes without attendance, but the facility policy was for staff to keep his/her
lighter;
-The team decision was the resident could smoke without supervision with a condition the
resident required staff to provide a lighter.
Record review of the resident’s medical record showed the resident signed a facility
smoking policy, dated 2/22/19.
During an interview on 3/12/19 at 9:11 A.M., Receptionist A said:
-He/She was sitting at the front desk on 3/10/19 when the resident came up to the desk in
his/wheelchair;
-The resident left and came back ambulating with his/her cane;
-The resident seemed agitated at that time;
-The resident walked behind the front desk and tried to open a utility closet saying
he/she wanted to get out;
-The resident then pushed open the front doors and got outside;
-Nursing staff checked on the resident and left the resident outside;
-He/She tried to keep an eye on the resident while he/she was outside, but since 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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 20)
resident was walking up and down the parking lot, he/she was not able to visualize the
resident the entire time;
-He/She thinks the resident may have gone outside to the parking lot unattended twice that
day;
-When the resident came back inside the second time, he/she started pacing up and down the
halls and fiddling with signs on the staff doors;
-He/She then heard what sounded like a door being shut, so he/she got up from the
reception desk and checked the administrator’s door again to verify it was locked;
-Because the administrator’s door was locked, he/she was not aware the resident was in the
administrator’s office;
-LPN B then came down the hall and unlocked the administrator’s door and removed the
resident from behind the administrator’s desk;
-The administrator did have lighters in his/her desk;
-He/She did not see staff confiscate anything from the resident when they removed him/her
from the administrator’s office.
During an interview on 3/12/19 at 9:19 A.M., LPN B said:
-The resident seemed to be okay earlier in the shift;
-Around 1:00 P.M. on 3/10/19, he/she was told by a visitor the resident was outside in the
parking lot smoking;
-He/She went outside, found the resident in the parking lot, but did not see the resident
smoking;
-He/She asked the resident if he/she had been smoking and the resident denied smoking;
-He/She reminded the resident of the facility smoking policy and had the resident come
back into the facility to watch television;
-About few minutes later, he/she saw the resident outside in the parking lot talking to an
unidentified person in a car;
-He/She saw the person in the car hand the resident a cigarette and the resident started
smoking;
-He/She assumed the person in the car was the resident’s family, so he/she did not go out
to intervene at that time;
-He/She looked outside sometime later and noticed the resident was still outside, but the
window to the car was rolled up and no one was in the car;
-It was at that time, he/she realized the person in the car earlier was not a visitor or
family of the resident, so he/she brought the resident back into the facility and
confiscated a lighter from the resident;
-The resident had gone to the nurse’s station several times after being brought back into
the facility, asking staff for a cigarette;
-A little while later, he/she found the resident in the administrator’s office going
through the administrator’s desk drawers;
-He/She removed the resident from the administrator’s office and called the DON;
-The DON told him/her to take the resident to the (Behavioral Health Unit) BHU for the
night for day care services and to notify the resident’s physician and family;
-He/She took the resident to the BHU around 1:30 P.M.;
-He/She did not check the resident for lighters after the resident was removed from the
administrator’s office;
During an interview on 3/12/19 at 8:32 A.M. and 12:46 P.M., LPN G said:
-LPN B was responsible for the Resident #55’s care on 3/10/19 and took the resident to the
BHU;
-LPN B told him/her the resident was being transferred to the BHU for the night on 3/10/19
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 21)
and would be re-evaluated for placement the following morning (3/11/19);
-He/She was not responsible for the resident’s care before or after the resident was
transferred to the BHU on 3/10/19.
-He/She was the charge nurse on the 100/300 halls on 3/10/19;
-LPN B was in charge of the resident when he/she was transferred back to the 600 hall;
-He/She was the charge nurse for the other resident’s on the 600 and 700 halls, which was
located at the opposite side of the building from the main 100/300 halls;
Record review of the resident’s Smoking Assessment, dated 3/10/19 at 1:45 P.M., showed the
resident:
-Was safe to smoke with supervision;
-Had cognitive loss;
-Did not have dexterity problems;
-Smoked 5-10 cigarettes a day;
-Can light his/her own cigarette;
-Required staff supervision for safety;
-The facility needed to store the resident’s lighter and cigarettes;
-Had a plan of care to ensure the resident was safe while smoking;
-Notes from the Interdisciplinary Team showed the resident had continually gone outside to
attempt to smoke outside of scheduled smoking times;
-The team decision was the resident could smoke with supervision with a condition the
resident was to be transferred to the locked unit.
During an interview on 3/14/19 at 3:03 P.M., CNA E said:
-When the resident was transferred to the BHU for day care services, meaning he/she was
not officially transferred to the BHU but was on the locked unit for monitoring and
supervision, he/she was told the resident had tried to elope and was found in the
administrator’s office;
-He/She was not told the resident had been seen outside of the facility smoking unattended
outside of the designated smoking times;
-He/She did not search the resident for lighters upon transfer to the BHU;
-He/She confiscated a pack of cigarettes from the resident, but did not confiscate a
lighter when the resident was transferred to the BHU;
-LPN B told him/her the resident had a lighter when he/she transferred the resident to the
BHU on 3/10/19 at 4:30 P.M.;
-He/She gave report on the evening of 3/10/19 to LPN H;
-The resident opened the dining room window about six inches and tried to climb out the
window, but it would not lift any higher so he/she could not get out;
-When he/she attempted to get the resident away from the window, he/she hit him/her with
his/her cane;
During an interview on 3/12/19 at 9:19 A.M., LPN B said:
-Around 7:00 P.M., the fire alarm went off on the BHU;
-He/She went to the fire alarm and found the resident in his/her room standing by a window
with the room full of smoke;
-He/She removed the resident from the room and had a CNA put the resident in a wheelchair
and transfer him/her to the 700 hall;
-The 600 unit had started to fill up with smoke, so the night charge nurse and CNA started
evacuating the residents from the 600 hall to the 700 hall;
-He/She saw the fire was outside the resident’s window, the resident’s window was broken
and the window was lifted up about six inches;
-He/She went outside to extinguish the fire;
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 22)
-When he/she came back inside from extinguishing the fire, he/she was told the resident
broke a window out in the 700 unit;
-He/She did not know how the resident broke out his/her window;
-He/She was told the resident’s cane was confiscated about an hour after he/she was
transferred to the BHU;
-The resident was transferred to the BHU around 2:30 P.M.;
-He/She did not know how or where the resident got the lighter;
-After the resident was evacuated to the 700 hall, staff found a lighter on the resident.
During an interview on 3/12/19 at 12:20 P.M., LPN B said:
-The resident was taken back to the 600 hall around 4:00 P.M. – 5:00 P.M. and not 1:30
P.M. as he/she previously reported;
-He/She was not the charge nurse for the 600 and 700 hall that day;
-He/She did not give report to the night shift nurse for the 600 and 700 halls that day;
-He/She was not aware the resident tried to open a window in the dining room to try to
climb out of the window;
-He/She was not aware the resident had tried to hit staff and residents with his/her cane
before the fire;
–NOTE: LPN B documented in his/her nursing notes on 3/10/19 at 2:35 P.M., the resident
had been observed outside smoking twice during the shift and was observed in the
administrator’s office going through his/her desk drawers and was transferred to the BHU
until further notice.
During an interview on 3/12/19 at 9:33 P.M., CNA H said:
-He/She was the only CNA working the 600 and 700 halls with the night charge nurse (LPN H)
on 3/10/19;
-He/She had been on the 700 hall and went to the 600 hall to check on residents, when
he/she smelled smoke from the nurse’s station at the front of the 600 hall coming from the
direction of the resident’s room at the end of the 600 hall;
-LPN H activated the alarm and they began evacuating the resident’s from the 600 hall to
the 700 hall;
-He/She did not see the resident when he/she found the fire;
-He/She found out the resident then broke a window on the 700 hall from another resident,
however he/she did not hear the window break;
-He/She did not hear a window break on the 600 hall prior to the fire;
-He/She would not have been able to hear a window break while he/she was on the 700 hall
or if he/she was in the shared nurse’s station;
-He/She did not know how the resident got the lighter to start the fire.
During an interview on 3/12/19 at 9:39 A.M., LPN H said:
-He/She came on duty at 6:30 P.M.;
-The report he/she received was the resident was transferred to the BHU from the main unit
for not following the facility’s smoking policy;
-While he/she was receiving report from the previous shift CNA, the resident was at the
nursing station asking staff how to get out;
-He/She told the resident he/she could not go out at that time;
-The resident tried to hit LPN H with his/her cane, so he/she took the resident’s cane;
-The resident then ambulated with a wheelchair;
-Around 7:00 P.M., he/she was on the 700 unit and heard the smoke alarm activated for the
600 hall;
-He/She smelled smoke from the nurse’s station and saw smoke coming down the hall from the
resident’s room at the end of the 600 hall to the front of the unit;
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 23)
-He/She went to the resident’s room and found the resident in the doorway;
-He/She saw the fire was outside the resident’s window;
-The resident’s window had been broken and the window on the right was raised about six
inches;
-He/She called for the Code Red (fire alarm) and started moving the residents from the 600
unit to the 700 unit with the assistance of CNA H;
-A resident reported the resident had broken the 700 unit window with his/her hands;
-He/She did not know where the resident obtained the lighter;
-Per the facility policy, residents are not allowed to have lighters or matches;
During an interview on 3/12/19 at 10:18 P.M., CNA E said:
-The resident was transferred to the 600 hall around 4:30 P.M. from the 200 hall;
-The resident had tried to open the window in the dining room to climb out, but the window
would only open around six inches, so he/she could not get out;
-The resident hi

F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow orders to
provide finger foods for one sampled resident (Resident #7) out of 22 sampled residents.
The facility census was 84 residents.
Record review of the facility’s policy titled Dietary-Therapeutic Diets dated 8/1/04,
showed:
-Therapeutic diets were prepared and served as prescribed by the attending physician.
-A therapeutic diet was defined as any deviation from the regular diet.
-The nursing department was responsible for having diet orders submitted to the dietary
department in writing. These orders must correspond to the resident’s medical record.
Record review of the unlabeled and undated document, provided with the policies requested,
titled Finger Food Diet showed:
-The Finger Food Diet includes those menu items that can be eaten with minimal use of
feeding utensils. The diet may be utilized to promote food intake in residents with
[MEDICAL CONDITION] and/or arthritis and allows them to maintain an active role in daily
meal consumption. Quality of life is enhanced as residents participate in food consumption
to maintain or improve their nutritional status.
-Regular entrees may be made into sandwiches by slicing or grinding meat portions and
placing between two slices of bread. (MONTH) also serve cut-up versions of regular entrees
if appropriate. Scrambled eggs may also be served.
-Gravies and sauces can be served on the side for dipping.
-Fresh fruits are allowed if the resident is allowed to tolerate the texture. Canned
fruits should be well drained.
-Whole foods may be cut up and served as strips, wedges or chunks.
1. Record review of the resident’s Care Plan, revised on 1/24/19, showed:
-The resident had severe cognitive loss and very seldom verbalized any words, and staff
should cue, reorient and supervise as needed;
-Due to memory loss related to [MEDICAL CONDITION], the resident was unable to communicate
his/her needs, therefore behaviors may indicate needs/discomfort; and staff should:
–Distract him/her from wandering by offering pleasant diversions, structured food,

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

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 24)
conversation, television, or a book. Resident prefers: (Note: The preference was not
completed on the care plan);
–Monitor for fatigue and weight loss.
Record review of the resident’s quarterly MDS, dated [DATE], showed the resident:
-Was severely cognitively impaired;
-Had behaviors;
-Needed supervision or cueing with transfers, bed mobility and eating;
-Was independent with walking and locomotion on the unit and was not observed off the
unit;
-Needed extensive physical assistance of one person with dressing, bathing, toilet use and
personal hygiene;
-Was not steady, but was able to stabilize without staff assistance;
-Had weight loss of 10% or more in the last six months;
-Used Antidepressant and Antianxiety medications.
Record review of the resident’s Administration Note, dated 1/7/19, showed an order for
[REDACTED].
Record review of the resident’s Nutrition/Dietary Progress Note, dated 2/13/19, showed:
-The resident had a history of [REDACTED].
-His/Her current weight was down by six pounds (#) (4.1%) since the last Registered
Dietician’s assessment on 11/8/18, when the resident’s weight was 147#, with a loss of 21#
(13%) loss since 2/1/18, from a weight of 162#;
-His/Her intake continued to be variable between 0-100% of regular diet with large
portions, ice cream with lunch and dinner, House Shake supplement three times daily with
meals, and snacks;
-The certified dietary manager suggested the resident may benefit from finger foods at
meals, as he/she has trouble sitting still;
-The medication [MEDICATION NAME] (an antidepressant also used for the side effect of
increased appetite) remained in place in further attempts to stimulate the resident’s
appetite and/or increase his/her oral nutritional intake;
-Consider discontinuing the resident’s large meal portions with his/her variable oral
intake, and providing finger foods at meals with 120 milliliter (ml) Med Pass 2.0
supplement three times daily between meals;
-Encourage intake by mouth greater than 50% at all meals, especially of high protein foods
and supplements to provide adequate nutrition to maintain resident’s nutritional status.
Record review of the resident’s current Order Summary Report on 2/25/19, showed the
following dietary order:
-Regular diet/Regular texture;
-Liquids: Regular/Thin consistency;
-Finger foods as much as possible;
-The order date was 2/14/19.
Observations of the resident showed:
-On 2/19/19 at 9:26 A.M., the resident wandering into other residents’ rooms;
-On 2/19/19 between 12:58 P.M. and 1:20 P.M., the resident was wandering around the common
area and in and out of the dining rooms, putting his/her hands in the food of other
residents, and trying to get to food being served. There was not a prepared plate or tray
specific to the resident with finger foods. Certified Nurse Assistant (CNA) B tried to
assist the dietary staff with selecting something that would be finger food for the
resident;
–The resident grabbed cake from the cart and began eating 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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 25)
–The resident touched another piece of cake and was also given that cake;
–The resident received chunks of meat with barbeque sauce on it between 2 slices of
bread;
–The resident was seated with the sandwich in front of him/her. When the resident picked
up the sandwich, the meat fell out of the bread. The resident left the plate and went to
another resident plate and took the bread from his/her sandwich;
-On 2/19/19 at 1:28 P.M., the resident grabbed a thickened liquid drink from the drink
cart and drank from it when staff was not watching. The drink was for another resident.
Observations of the resident showed:
-On 2/21/19 at 12:57 P.M., the dietary staff arrived on the Memory Care Unit with the food
cart. There was not a prepared plate or finger food prepared for the resident. The
resident was wandering in and out of the east and west dining rooms and in the common area
reaching for food. The resident was redirected;
-On 2/21/19 at 1:04 P.M., Licensed Practical Nurse (LPN) F asked dietary staff about
finger foods for the resident. Dietary staff said they could make him/her a sandwich with
the beef and some bread.
During an interview on 2/21/19 at 1:05 P.M., LPN F said:
-The resident had an order for [REDACTED].>-He/She does not like to stay seated;
-He/She eats on the go.
Observation on 2/21/19 at 1:13 P.M., showed the resident seated in the common area by the
nurses’ station with his/her eyes closed:
-CNA B directed the resident to a table in the common area;
-The resident was served a BBQ beef sandwich, BBQ potato chips, cookies, lemonade, and
water. The meat fell from the sandwich.
Observation on 2/21/19 1:18 P.M., the resident was up from his/her seat wandering down the
hall with the sandwich (mostly bread) in his/her hand.
Observation on 2/25/19 at 3:39 P.M., showed:
-CNA D directed the resident to be seated in a chair near the nurses’ station;
-CNA D gave the resident a ham and cheese sandwich from the refrigerated snacks and a
nutrition shake;
-The resident was able to handle the sandwich well and ate 100%.
Observation on 2/26/19 at 10:00 A.M., showed the resident got up after breakfast had been
served, but his/her breakfast was kept warm on the unit:
-The resident was given breakfast sausage, bacon, an extra-large portion of scrambled eggs
and toast with jelly;
-The resident began to wander around after sitting for a short period;
-He/She ate the toast with jelly and a bite of sausage, went back to the plate several
time, but did not eat any more of the food from the plate.
During an interview on 2/26/19 at 10:45 A.M., CNA C said:
-The kitchen staff does not send the resident a plate with finger foods already prepared;
-CNA B has been talking to kitchen staff about sending the resident finger foods;
-This morning the only thing that was finger food was the bacon and sausage;
-He/She felt that the dietary staff could have made the resident a breakfast sandwich.
During an interview on 2/26/19 at 10:51 A.M. LPN F said:
-Dietary had been given the order for finger foods for the resident;
-It had been a constant daily battle trying to get what is requested from dietary;
-Dietary doesn’t send nutrition shakes down with meals;
-Staff have to leave the unit to go get items;
-It is difficult to get the resident to sit down to eat;
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 26)
-The resident is constantly up.
During an interview on 2/26/19 at 11:35 A.M. the Dietary Manager said:
-He/She did have an order for [REDACTED].>-He/She said that on his/her program
scrambled eggs were listed as finger food;
-He/She had requested to schedule to meet with the Assistant Director of Nursing (ADON)
because the Director of Nursing (DON) was out sick last week;
-He/She needed to get clarity on the resident’s diet orders and finger foods that would
work for the resident.
During an interview on 2/27/19 at 2:40 P.M., the Director of Nursing said:
-He/She would try and get a policy related to the special diet;
-The order would be reviewed;
-He/She did not consider scrambled eggs to be a finger food.
-He/She expected dietary to send finger foods to a resident that had an order for
[REDACTED].>-He/She expected dietary to follow the facility policy for finger foods.

F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
sufficient staffing in the Behavioral Health Unit (BHU) (600 and 700 halls) to adequately
monitor resident safety for one resident (Resident #55) out of 22 sampled residents. The
facility census was 84 residents.
1. Record review of the facility staffing schedule for the BHU from 2/23/19 – 2/27/19
showed the following:
-On 2/23/19, one Licensed Practical Nurse (LPN) and one Certified Nursing Assistant (CNA)
for day shift; one Registered Nurse (RN) and one CNA for night shift.
-On 2/24/19, one LPN and one CNA for day shift; one RN and one CNA for night shift.
-On 2/25/19, one LPN and one CNA for day shift; one LPN and one Certified Medication
Technician (CMT) for night shift.
-On 2/26/19, one LPN and one CNA for day shift; one RN and one CNA for night shift.
-On 2/27/19, one RN and one CNA for day shift; one LPN and one CNA for night shift.
-On 2/28/19, one LPN and one CNA for day shift; one RN and one CNA for night shift.
-On 3/1/19, one LPN for day shift; two CNAs for night shift.
-On 3/2/19, one LPN and one CNA for day shift; one CMT and one CNA for night shift.
-On 3/3/19, the Director of Nursing (DON) and one CNA for day shift; one RN and one CNA
for night shift.
-On 3/4/19, one LPN and one CNA for day shift; one CMT and one CNA for night shift.
-On 3/5/19, one CMT and one CNA for day shift; one RN and one CNA for night shift.
-On 3/6/19, one LPN and one CNA for day shift; one LPN and one CNA for night shift.
-On 3/7/19, one LPN and one CNA for day shift; two CNAs for night shift.
-On 3/8/19, one CMT and one CNA for day shift; two CNAs for night shift.
-On 3/9/19, one LPN and one CNA for day shift; two CNAs for night shift.
-On 3/10/19, two CNAs for day shift; one RN and one CNA for night shift.
During an interview on 3/12/19 at 10:03 A.M., CMT C said:
-He/She had been in charge of the 800 hall Memory Care unit, which was on the opposite

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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
side of the building from the 600 and 700 halls on 3/10/19.
-From 6:30 A.M. – 2:30 P.M., he/she was also in charge of the 600 and 700 halls and was
responsible for passing medications on all three units during that time.
-The only day shift staff on the 600 hall and 700 hall were two CNAs.
Record review of Resident #55’s Face Sheet showed he/she was admitted to the facility on
[DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Altered mental status.
-Muscle weakness.
-Unsteadiness on feet.
-Abnormal gait and mobility.
-Cognitive communication deficit.
-Dementia (a progressive organic mental disorder characterized by chronic personality
disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity
and function, and impairment of control of memory, judgment, and impulses) without
behavioral disturbance.
-Tobacco use.
Record review of the resident’s admission Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning), dated 1/11/19,
showed he/she:
-Was severely cognitively impaired.
-Was a current tobacco user.
-Was on hospice services.
Record review of the resident’s care plan, 1/15/19, showed the resident:
-Had an alteration in neurological status due to his/her [DIAGNOSES REDACTED].
-Was on hospice services dated 1/15/19.
-Used anti-anxiety medications and to monitor and record the following targeted behavioral
symptoms: pacing; wandering; disrobing; inappropriate responses to verbal communication;
violence/aggression toward staff dated 1/23/19.
During an interview on 3/12/19 at 10:18 P.M., CNA E said:
-He/She was working on the BHU on 3/10/19 day shift with another CNA.
-The Resident #55 had been transferred to the 600 hall from the 200 hall around 4:30 P.M.
-The resident had tried to open the window in the dining room to climb out, but the window
would only open around six inches, so he/she could not get out.
-The resident hit him/her with his/her cane and had been walking down the hall trying to
hit others with his/her cane.
-The resident had said he/she wanted to get out and continued to ask how he/she could get
out.
-He/She gave report on the evening of 3/10/19 to LPN H.
-If staff are on the 700 hall providing cares for a resident, they are unable to see or
hear what is happening on the 600 hall.
-If staff are on the 600 hall providing cares for a resident, they are unable to see or
hear what is happening on the 700 hall.
-If staff are at the nurse’s station, they would only be able to see one side of the unit,
either the 600 hall or the 700 hall.
During an interview on 3/12/19 at 9:39 A.M., LPN H said:
-The only staff working on the 600 and 700 hall on the night of 3/10/19 working with
him/her was CNA H.
-Around 7:00 P.M., he/she was on the 700 unit and heard the smoke alarm activated for the
600 hall.
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 28)
-He/She and CNA H began evacuating residents from the 600 hall to the 700 hall.
-He/She did not know if anyone was monitoring the residents on the 700 hall while they
were moving the residents from the 600 hall.
-He/She found out from another resident that Resident #55 had broken another window out on
the 700 hall.
-He/She did not hear the resident break the window on the 600 hall and did not hear the
resident break the window on the 700 hall.
During an interview on 3/12/19 at 1:48 P.M., LPN H said:
-CNA E had given him/her report at shift change.
During an interview on 3/12/19 at 9:33 P.M., CNA H said:
-He/She was the only CNA working the 600 and 700 halls with the night charge nurse (LPN H)
on 3/10/19.
-He/She had been on the 700 hall and went to the 600 hall to check on residents when
he/she smelled smoke from the nurse’s station at the front of the 600 hall.
-He/She was assisting moving residents from the 600 hall to the 700 hall.
-He/She did not know if anyone was monitoring the residents on the 700 hall while the
residents on the 600 hall were being moved to the 700 hall.
-He/She found out the resident broke a window on the 700 hall from another resident,
however, he/she did not hear the window break.
-He/She did not hear a window break on the 600 hall prior to the fire.
-He/She would not have been able to hear a window break while he/she was on the 700 hall
or if he/she was in the shared nurse’s station.
During an interview on 3/12/19 at 11:30 P.M., the Administrator and Director of Nursing
(DON) said:
-It was discovered CMT C, from the 800 hall (on the opposite side of the building) was
covering the 600 and 700 halls until 2:30 P.M. on 3/10/19.
-They did not know where the staff were when the resident broke out the window and started
the fire on the 600 hall.
-They expected staff to stay on the 700 hall with the residents while the residents on the
600 hall were being evacuated.
-The facility’s goal is to have a nurse or CMT on the 600 and 700 halls during all shifts.
-If the facility does not have a nurse or CMT on the 600 and 700 halls, then the nurse in
charge of the 100 and 300 halls at the front of the building (on the opposite side of the
600 and 700 halls) would be in charge of overseeing the residents in an emergency
situation.
-The facility staff know to call up front or one of the ADONs for assistance when another
staff person is needed to monitor.
During an interview on 3/12/19 at 12:24 P.M., Assistant Director of Nursing (ADON) B said:
-The CMT (CMT C) that was in charge of the 800 hall on the opposite side of the building,
was also in charge of the 700 and 600 halls until 2:30 P.M.
-The CMT that was working on the 100, 200, 300, and 400 halls on the opposite side of the
building was responsible for passing the medications on the 600 and 700 halls from 2:30
P.M. – 6:30 P.M. when the night shift arrived.
-LPN B, who was in charge of the 200 and 400 halls on the opposite side of the building,
was responsible for the resident while he/she still resided on the 200 hall.
-Once the resident was transferred back to the 600 hall, the nurse in charge of the 100
and 300 halls, LPN G, became responsible for the resident.
-He/She did not know where staff were when the fire was started in the resident’s room.
-It was his/her understanding LPN H and CNA H were moving residents from the 600 hall 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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
the 700 hall.
-He/She was not sure if anyone was on the 700 hall to monitor the residents while LPN H
and CNA H were evacuating residents from the 600 hall.
During an interview on 3/12/19 at 12:46 P.M., LPN G said:
-LPN B was in charge of the resident when he/she was transferred back to the 600 hall.
-He/She was the charge nurse for the other resident’s on the 600 and 700 halls.
-He/She did not give report to the on-coming night shift.
During an interview on 3/12/19 at 12:20 P.M., LPN B said:
-He/She was not the charge nurse for the 600 and 700 hall on 3/10/19.
During an interview on 3/14/19 at 3:45 P.M., ADON A, ADON B, and the Interim DON said:
-They were not at the facility on 3/10/19.
-If the BHU only has two staff working on a shift and a resident needs assistance, staff
are expected to call the main nurse’s station for assistance and someone from the main
halls should go back to assist them immediately.
-If staff from the main hall were not available, the BHU staff could call one of them to
help and they would go back.
Observation on 3/11/19 at 5:15 P.M., showed no staff on the 600 hall with four residents
sitting at dining tables eating.
Observation on 3/11/19 at 5:20 P.M., showed two staff were seen passing meal trays on the
700 unit.
During an interview on 3/11/19 at 5:23 P.M., CNA F said:
-He/She was the CNA assigned to the 600 hall that evening.
-He/She was assisting the CNA on the 700 hall pass out meal trays for dinner.
-He/She is supposed to check on each resident on the BHU at least every 15 minutes.
-If he/she is at the nurse’s station closer to the 700 hall, he/she could not see
residents or resident rooms on the 600 hall.
-If the staff working on the 600 hall or 700 hall required assistance with a resident and
there were only two staff on the unit, then no one would be monitoring the residents on
the other unit.
During an interview on 3/11/19 at 5:31 P.M., CNA G said:
-He/She was the CNA assigned to the 700 hall the evening of 3/11/19.
-If he/she was at the shared nurse’s station for the 600 hall and 700 hall, he/she would
not be able to hear any activity coming from the end of the 600 hall.
Record review of the facility staffing schedule for the BHU on 3/12/19 showed:
-One LPN and one CNA on the day shift.
-One RN and one CNA on the night shift.
Record review of the facility staffing schedule for the BHU showed the following:
-On 3/13/19, two CNAs for day shift.
-On 3/13/19, one CMT and one CNA on night shift.
-On 3/14/19, one CMT and one CNA on day shift.
-On 3/14/19, one RN and one CNA on night shift.
During an interview on 3/14/19 at 3:03 P.M., CNA E said:
-The BHU regularly only has two staff scheduled to provide cares for the 600 and 700
halls.
-The BHU has a total of 16 residents on the 600 and 700 halls currently.
-Of the 16 residents, at least four require extensive staff assistance for cares,
including one to two person transfers, and one to two person assistance for toileting.
-All of the residents on the BHU have behaviors requiring staff monitoring.
-He/She is not always able to complete all cares timely or thoroughly.
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 30)
-If he/she calls the front main nursing station, staff do not always answer the phone, are
not available to assist when the staff and residents need assistance on the BHU, or do not
come to assist at all.
-When staff from the main unit do not come back to assist, that means the two staff that
are on the unit have to provide the care, leaving the rest of the residents unattended.
During an interview on 3/14/19 at 3:28 P.M., CNA E said:
-The BHU units are supposed to have two CNAs and one nurse or one CMT during the day, for
a total of three staff during the day.
-If the facility has a call-in, sometimes staff are shuffled to and from other units, but
the BHU does not always get additional coverage and may just have two CNAs on the unit to
provide care for the residents on both halls.
-There is one resident on the 700 hall who requires total assistance for transfers and
toileting, which would require two staff members to provide the care.
-There are about five or six residents on the 600 hall and 700 hall who require at least
one staff assistance for cares and transfers.
-The 700 hall had more behaviors that required staff monitoring and intervention.
-If there are only two staff members on the BHU and a resident required assistance, the
rest of the residents are left unattended for staff to provide the care.
-Staff have tried to call the main hall nursing station (100, 200, 300, and 400 halls) for
assistance, but either the calls go unanswered, staff are not available, or they are not
available in a timely manner to assist the resident on the BHU.
-When additional staff are not available to assist from the main hall nursing station, the
staff on the BHU have to assist the resident in a rushed manner since the other residents
are left unattended.
-He/She is not always able to provide cares in a timely manner or get all of the resident
cares completed during his/her shift when there is not enough staff to provide assistance
or support on the BHU.
MO 715

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 three of six sampled medication
carts and one of four sampled medication rooms. The facility census was 84 residents.
Record review of the facility’s policy, titled Medication Storage in the Facility, dated
(MONTH) (YEAR), showed:
-Medications and biological’s were to be stored safely, securely, and properly, following
manufacturer’s recommendations or those of the supplier;
-Outdated, contaminated, or deteriorated medications and those in containers that are
cracked, soiled, or without secure closures were to be immediately removed from stock,
disposed of according to procedures for medication disposal;
-Medication storage areas were to be kept clean, well-lit, and free of clutter and extreme
temperatures.

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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 31)
1. During observation and interview of the 400 medication cart on 2/25/19 at 12:42 P.M.,
with Assistant Director of Nursing (ADON) A showed:
-[MEDICATION NAME] concentrate (medication used to treat certain types of mental
disorders) 2 milligram (mg)/milliliter (ml) bottle was opened without an opened date
written on it;
-ADON A said medications should be dated if they are opened;
-Comparison of the controlled substance count book and the actual medication card showed:
–The controlled substance count book indicated there should be four [MEDICATION NAME] (a
sedative) pills available;
–The actual medication card of [MEDICATION NAME] only had three pills available;
-ADON A asked Certified Medication Technician (CMT) A about the discrepancy;
-CMT A said he/she had forgotten to sign the [MEDICATION NAME] out that morning;
-CMT A then signed the controlled substance count book;
-ADON A said the controlled substances are counted every shift by two nurses and the count
should never be off
-One un-identified loose white pill in the bottom of the medication cart drawer;
-Two pieces of un-identified broken white pills in the bottom of the medication cart
drawer;
-One un-identified light pink pill loose in the bottom of the medication cart drawer;
-ADON A did not know how the pills got there;
-ADON A said the licensed nurse’s and the CMT’s were responsible for keeping the
medication carts and medication rooms clean and making sure all opened items had dates as
to when they were opened.
2. During observation and interview on 2/25/19 at 1:09 P.M., with ADON A of the Behavioral
Health Unit’s medication cart showed:
-[MEDICATION NAME] (a medicine to relieve pain and numb the skin) solution 2 percent (%) a
100 ml tube was opened without an opened date on it;
-ADON A said it should have a date on it if it was opened.
3. During observation and interview on 2/25/29 at 1:15 P.M., with ADON A of the Memory
Care Unit’s medication cart showed:
-One un-identified loose pink pill found at the bottom of the medication cart drawer;
-One un-identified gray capsule was loose in the bottom of the medication cart drawer;
-ADON A said there should not be any loose pills or capsules in the medication cart
drawers;
-One used 4.6 mg Execelon (used to treat Dementia) patch loose on bottom of drawer dated
2/19;
-ADON A said there should not be any used medication patches in the medication cart
drawers;
-An open container of Cucumber body mist spray was in a drawer with the resident’s
medications;
-ADON A did not know who the body mist spray belonged to, but it should not be in the
medication cart;
-An opened 32 ounce carton of thickened dairy drink (used in medication pass for residents
who have a hard time swallowing) was in the medication drawer without a opened date
written on it and included the following directions for use:
–Refrigerate before opening;
–Serve chilled;
-ADON A said the thickened liquid should have been dated, refrigerated, and not stored in
the medication cart.
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
During an interview on 2/27/19 at 3:15 P.M., the Director of Nursing said:
-He/She would not expect to find loose pills or used medication patches in the medication
carts;
-The narcotic count should be accurate;
-There should not be body spray in the medication cart.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation and interview, the facility failed to keep the kitchen, walk-in
refrigerator, and walk-in freezer floors clean; failed to preserve sanitary knife and can
opener blades; failed to wipe off the outside of a condiment jug; failed to maintain
cutting boards in an easily cleanable condition to prevent plastic contamination; and
failed to follow basic sanitation procedures. These deficient practices potentially
affected all residents who ate food from the kitchen. The facility census was 84 residents
with a licensed capacity for 142.
1. Observations during the kitchen inspection on 2/19/19 between 8:51 A.M. and 12:37 P.M.,
showed the following:
– The walk-in refrigerator and freezer by the service area had food and trash debris under
the racks;
– One green and one red cutting board were heavily scratched to the point of having bits
of plastic hanging freely;
– There was a buildup of black food and paper residue on the manual can opener blade;
– The kitchen floor under the food preparation table was dirty;
– One knife in the knife rack had plastic on the blade;
– A 1-gallon jug of syrup on a bottom rack by the steamer was heavily covered with streaks
of syrup;
– In the dry storage area there was an opened package of 16 hot dog buns with 12 left
inside with no date of opening written on it;
– The walk-in refrigerator and freezer by the dry storage area had food and trash debris
under the racks;
– A garbage can was left without a lid on the entire time during food preparation.
Observations during the kitchen inspection on 2/21/19 between 8:11 A.M. and 8:53 A.M.,
showed the following:
– There was still a buildup of black residue on the manual can opener blade that was able
to be scratched;
– Debris under the racks in the walk-in refrigerator and freezer by the dry storage
remained;
– The 1-gallon jug of syrup was still covered with streaks and very sticky to the touch.
During an interview on 2/25/19 at 9:31 A.M., the Dietary Manager (DM) said:
– The dietary aides are to sweep and mop the kitchen at the end of the day;
– Cleaning the walk-in refrigerators and freezers is assigned by the DM as needed;
– The cutting boards are monitored by the DM and are replaced as needed;
– No one is specifically responsible for cleaning the can opener;
– The cooks are to clean the knives after each use.

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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

F 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Arrange for the provision of hospice services or assist the resident in transferring to
a facility that will arrange for the provision of hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to obtain and/or maintain
communication with a resident’s hospice provider for one sampled resident (Resident #55)
out of 22 sampled resident’s. The facility census was 84 residents.
1. Record review of Resident #55’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Altered mental status.
-Muscle weakness.
-Unsteadiness on feet.
-Abnormal gait and mobility.
-Cognitive communication deficit.
-Dementia (a progressive organic mental disorder characterized by chronic personality
disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity
and function, and impairment of control of memory, judgment, and impulses) without
behavioral disturbance.
-Tobacco use.
Record review of the resident’s admission Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning), dated 1/11/19,
showed he/she:
-Was severely cognitively impaired.
-Was on hospice services.
Record review of the resident’s care plan, dated 1/15/19, showed the resident:
-Had an alteration in neurological status due to his/her [DIAGNOSES REDACTED].
-Was on hospice services dated 1/15/19.
During an interview on 3/12/19 at 11:30 A.M., the Administrator and Director of Nursing
(DON) said:
-Staff were directed to contact the resident’s hospice provider when the resident was
being transferred to the Behavioral Health Unit (BHU) on 3/10/19 at 4:30 P.M.
-It was their understanding staff had communicated with the resident’s hospice provider of
the resident’s non-compliance to the facility smoking policy by going outside unattended
to smoke and going into the Administrator’s office before the resident was transferred to
the BHU.
Record review on 3/14/19 at 3:40 P.M., showed the resident’s hospice record only contained
vital signs with no other communication between the hospice provider and the facility.
During an interview on 3/14/19 at 3:45 P.M., Assistant Director of Nursing (ADON) A, ADON
B, and the Interim Director of Nursing (DON) said:
-They could not locate any communication between the resident’s hospice provider and the
facility.
-The previous DON was responsible for maintaining communication between the facility
hospice providers and the facility.
-They did not know where the previous DON would have stored the resident’s hospice
communication if it was not in the resident’s hospice binder.
-They would have no way of knowing if the resident’s hospice provider had made

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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 34)
recommendations about the resident’s medications or cares, if those recommendations were
communicated with the resident’s physician, or if those recommendations were followed.
During an interview on 3/19/19 at 9:54 A.M., the resident’s hospice Registered Nurse (RN)
said:
-The facility had not notified the hospice provider of the resident’s behaviors on 3/10/19
or that the resident was transferred to the Behavioral Health Unit (BHU) until after the
resident had started a fire.
-The DON of the facility had access to online hospice documentation and should have
printed the documentation for the resident’s hospice chart.
MO 715

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide and implement an infection prevention and control program.

Based on interview and record review, the facility failed to establish and maintain a
comprehensive infection prevention and control program designed to help prevent the
development and transmission of water borne pathogens (a bacterium, virus, or other
microorganism that can cause disease), and failed to provide a documented, facility
specific risk assessment for such an outbreak in accordance with the Centers for Medicare
and Medicaid Services (CMS) standards. This deficient practice had the potential to affect
all residents, visitors, and staff who reside in, visit, use, or work in the facility. The
facility census was 84 with a licensed capacity for 142.
Record review on 2/22/19 at 2:29 P.M., of the facility’s emergency preparedness plan
entitled Emergency Preparedness Manual provided by the Administrator showed a generic 13
page printed section with the heading 3.8 Legionella Management Policy, that had the name
Redwood repeatedly added in handwriting, did not contain any of the following items that
are required by CMS:
– A facility risk assessment or water management program that considers the ASHRAE
(American Society of Heating, Refrigeration, and Air-Conditioning Engineers) industry
standard;
– The CDC (Centers for Disease Control) toolkit including control measures such as
physical controls, temperature management, disinfectant level control, and visual
inspections;
– A schematic or diagram of the facility’s water system and environmental assessment of
the water system.
During an interview on 2/25/19 at 10:42 A.M., the Administrator said he/she acknowledged
there were missing items and they were unaware of all the current CMS water-borne pathogen
prevention assessments and requirements for skilled nursing facilities.

F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop and implement policies and procedures for flu and pneumonia vaccinations.

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

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 35)
pneumococcal immunizations, provide documentation the resident had refused, or provide a
medical reason the immunizations could not be given for one sampled resident (Resident
#83) out of five sampled residents for immunizations, out of 22 total sampled residents.
The facility census was 84 residents.
Record review of the facility’s policy titled Influenza (Flu) Immunization Program with a
revision date of 9/01/15 showed:
-The facility will provide the opportunity for residents to receive the appropriate
(standard dose, high dose, or egg-free) influenza vaccine;
-With the attending physicians order and the resident’s or the resident’s representative’s
consent, a licensed nurse will provide the appropriate influenza immunizations to the
residents;
-If the immunization is refused, document the resident’s or resident’s representative’s
refusal of the immunization and education and counseling given regarding the benefit of
immunization.
Record review of the facility’s policy titled Pneumococcal Vaccination with a revision
date of 9/28/15 showed:
-The facility will provide the opportunity for all resident’s to receive the pneumococcal
vaccine;
-With the attending physicians order and the resident’s or the resident’s representative’s
consent, a licensed nurse will provide the pneumococcal immunization to the resident;
-Obtain the pneumococcal vaccination history of all patients;
-Based on resident’s history offer the appropriate vaccination;
-If the immunization is refused document the resident’s or the resident’s representative
reason for refusal and education and counseling given regarding the benefit of
immunization.
1. Record review of resident #83’s admission sheet showed the resident:
-Was admitted to the facility on [DATE] and readmitted on [DATE];
-Had no known allergies [REDACTED].>-Was his/her own person.
Record review of the resident’s physician’s orders [REDACTED].
-The physician had given a verbal order to Assistant Director of Nursing (ADON) A to
administer the flu vaccine;
-The physician had given a verbal order to ADON A to administer the pneumonia vaccine;
-The order was electronically signed by the Medical Director/resident’s physician on
1/31/19.
Record review of the resident’s, (MONTH) 2019 and (MONTH) 2019, Electronic Medication
Administration Record [REDACTED]
-The flu vaccine was not given;
-The pneumococcal vaccine was not given.
During an interview on 2/26/19 at 10:00 A.M., ADON A said:
-He/She was not able to find documentation that the immunizations were given;
-He/She was not able to find documentation that the resident had refused the
immunizations;
-No one was assigned to do the vaccines;
-The immunizations were to be given in the first day or two after a resident was admitted
;
-These were not done.
During an interview on 02/27/19 at 12:38 P.M., the Director of Nursing said:
-ADON B is in charge of tracking the vaccinations;
-ADON B is out sick.
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:

265476

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

NAME OF PROVIDER OF SUPPLIER

REDWOOD OF RAYMORE

STREET ADDRESS, CITY, STATE, ZIP

600 E SUNRISE DRIVE
RAYMORE, MO 64083

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 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few