Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to request, refuse, and/or discontinue treatment, to
participate in or refuse to participate in experimental research, and to formulate an
advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the resident’s current
code status (whether or not the resident wants to be resuscitated during respiratory or
[MEDICAL CONDITION]) was accurate on the resident’s physician’s orders [REDACTED].#19) out
of 18 sampled residents. The facility census was 77 residents.
Record review of the facility’s Advance Directive policy dated 11/9/13 showed the
resident’s code status should be documented on the resident’s POS.
1. Record review of Resident #19’s Admission POS dated 2/23/18 showed there was an x by
Full Code (all life-saving measures are taken in order to treat a patient after/during a
respiratory or [MEDICAL CONDITION]) that was scribbled out and an x was by Do Not
Resuscitate (DNR – an order from a doctor that resuscitation should not be attempted if a
person suffers cardiac or respiratory arrest).
Record review of the resident’s Out of the Hospital DNR (OHDNR – documents the
instructions in an out-of-hospital setting not to initiate resuscitation if a person
suffers cardiac or respiratory arrest) showed it was signed 2/24/18.
Record review of the resident’s lifestyle preference care plan dated 3/22/18 showed he/she
signed a DNR Order.
Record review of the resident’s POS’s for (MONTH) (YEAR)-August (YEAR) showed a Full Code
order.
During an interview on 8/29/18 at 7:33 A.M., Certified Medication Technician (CMT) A said:
-They look at the front of the chart to see if the resident has an OHDNR and
-If the resident doesn’t have an OHDNR, they are a full code.
During an interview on 8/31/18 at 1:30 P.M., CMT A said he/she thinks the night shift
nurse does the monthly change over of the POS’s.
During an interview on 8/31/18 at 5:00 P.M. the Director of Nursing (DON) said:
-The Resident Care Coordinator (RCC) does monthly change over;
-When a resident admits to the facility, Admissions, Social Services, the Care Plan
Coordinator, the RCC and the DON review the resident’s POS with code status and
-He/she would expect the staff to notice the change in Code Status during the monthly
changeover to the next month’s POS.

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on interview and record review, the facility failed to provide a Skilled Nursing
Facility Advanced Beneficiary Notice (SNFABN) (form CMS- ) when the resident was
discharged from Medicare A services (the federal health insurance program for people who
are 65 or older that covers some aspects of skilled nursing facility care) for one sampled
resident (Resident #1) out of three sampled residents (the other two sampled residents did
not require a SNFABN). The facility census was 77 residents.
1. Record review of Resident #1’s Notice of Medicare Non-Coverage letter showed the
resident’s responsible party was informed on 4/23/18 that the resident’s Medicare A

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
coverage would end on 4/26/18.
Record review of the SNFABN review form completed by facility staff showed the facility
did not complete an SNFABN when the resident’s Medicare A coverage ended.
During an interview on 8/31/18 at 9:30 A.M., the Administrator said they did not know the
resident needed a SNFABN form needed to be filled out.

F 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Keep residents’ personal and medical records private and confidential.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
personal privacy during cares for two sampled residents (Resident #270 and #21) out of 18
sampled residents. The facility census was 77 residents.
1. Record review of Resident #270’s Admission Record Profile Face Sheet showed the
resident was admitted on [DATE] and readmitted on [DATE] with the following Diagnoses:
[REDACTED].
-[MEDICAL CONDITION] Simplex (HSV- [MEDICAL CONDITION] causing contagious sores, most
often around the mouth or on the genitals);
-[MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the ability
of the lungs to perform ventilation); and
-Primary biliary [MEDICAL CONDITION] (an [DIAGNOSES REDACTED] disease that causes
progressive destruction of the bile ducts).
Record review of the resident’s Physicians Order Sheet (POS) dated (MONTH) (YEAR) showed
the following orders:
-Dated 8/10/18 [MEDICATION NAME] (an [MEDICAL CONDITION] drug that can treat [MEDICAL
CONDITION] virus infections, it does not cure [MEDICAL CONDITION] but may prevent [MEDICAL
CONDITION] sores or blisters) 200 milligrams (mg) five times a day times ten days for
genital [MEDICAL CONDITION];
-Dated 8/10/18 Foley catheter (a tube passed through the urethra into the bladder and left
to drain urine) until [MEDICAL CONDITION] healed;
-Dated 8/14/18 discontinue catheter;
-Dated 8/20/18 straight cath (a tube passed through the urethra into the bladder and
removed after draining urine) every six hours related to retention for 24 hours, call
doctor if output is over 300 milliliters (ml) and
-Dated 8/20/18 Discontinue the order to discontinue the Foley today. Continue Foley
catheter times two more weeks until 9/3/18.
Record review of the resident’s Quarterly Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning) dated 7/24/18 showed
that the resident’s cognition was intact.
Record review of the resident’s Care Plan (written out plan for the care of the resident)
dated 1/16/18 showed he/she had an alteration in bladder elimination as related to
incontinence.
Observation on 8/30/18 at 10:33 A.M. showed the Certified Nurse Assistant (CNA) D left the
resident’s lower private area uncovered and exposed while he/she removed his/her gloves
and washed his/her hands and donned new gloves to place a new incontinence brief under the
resident.
2. Record review of Resident #21’s Admission Record Profile Face Sheet showed he/she was

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
admitted on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (high levels of fat particles in the blood);
-On 3/11/14 with [MEDICAL CONDITION] and Hypertension (high blood pressure) and
-On 3/7/18 with Dementia without behaviors and psych (mental) disorder with delusions due
to known physical condition.
Record review of the resident’s Quarterly MDS dated [DATE] showed that the resident’s
cognition was severely impaired.
Record review of the resident’s Care Plan dated 7/9/14 showed the resident:
-Had cognitive loss/dementia;
-Required assistance with Activities of Daily Living (ADL’s) due to dementia and confusion
with memory loss and
-Was frequently incontinent of bladder.
Observation on 8/29/18 at 11:05 A.M. showed CNA’s A and B left the resident’s lower
private area uncovered and exposed while they removed their gloves and went to the sink
and washed their hands and donned new gloves.
During an interview on 8/31/18 at 2:02 P.M. CNA D said that a resident should be covered
when staff is not doing peri-cares.
During an interview on 8/31/18 at 4:42 P.M., the Director of Nursing (DON) said that a
resident should not be left uncovered when staff needs to step away from the resident
during care.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation, interview and record review, the facility failed to maintain the
residents’ ventilation ductwork (inside) and louvers (outside covers) free of dust located
in their toilet rooms. This deficient situation provides opportunities for contact and
airborne microorganisms to affect 77 residents who use their bathrooms and shower areas.
The facility’s census was 77 residents.
1. Observations on 8/28/18 between 9:25 A.M. and 1:11 P.M., during a segment of the
facility’s environmental/life safety tour with the Maintenance Director (MD), showed in
resident toilet rooms, ventilation ductwork (inside) and covers having heavy layers of
dust buildup and, white and green mold-like deposits covering the openings, specifically
in the following resident rooms: #101, #102, #104, #106, #202, #204, #205, #206, #207,
#208, #210, #212, #302, #306, #310, #314, #409, #501, #503, #504 and #511.
During an interview on 8/28/18 at 10:27 A.M., the MD said,
-It was the maintenance and housekeeping’s staff responsibilities to clean the vents in
the residents’ bathrooms areas; and
-Did not know whether or not the vents were on a cleaning schedule or when they were last
cleaned.
Record Review of the 2013 edition of the Food and Drug Administration (FDA) Food Code,
Chapter 6-501.12, showed, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary
to keep them clean.
Record review of the 2013 edition of the Missouri Food Code, Chapter 6-501.12, showed,
(A) Physical facilities shall be cleaned as often as necessary to keep them clean.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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 – Some

(continued… from page 3)
(B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall
be done during periods when the least amount of food is exposed such as after closing.
Record review of the 2013 edition of the Missouri Food Code, Chapter 6-501.14, showed,
(A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a
source of contamination by dust, dirt, and other materials.
(B) If vented to the outside, ventilation systems may not create a public health hazard or
nuisance or unlawful discharge.

F 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Not transfer or discharge a resident without an adequate reason; and must provide
documentation and convey specific information when a resident is transferred or
discharged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to document the reason a
resident was discharged , to obtain a physician’s order to discharge the resident, and to
obtain a signature to indicate the resident’s belongings were returned to the resident for
one closed record resident (Resident #70) out of three closed records sampled. The
facility census was 77 residents.
Record review of the facility’s discharge planning policy dated 11/1/17 showed:
-A Post Discharge Plan of Care and a Discharge Care Plan shall be developed for each
resident anticipating discharge;
-Documentation of the discharge plan shall be recorded on the Post Discharge Plan of Care
and
-Upon discharges without anticipation of return, a discharge summary of care and services
shall be completed using the Interdisciplinary Discharge Summary.
Record review of the facility’s undated Transfer and Discharge policy showed a physician’s
discharge order shall be obtained in the resident’s medical record prior to the resident’s
discharge.
1. Record review of Resident #70’s current face sheet (undated) showed he/she was admitted
to the facility on [DATE].
Record review of the resident’s most recent Social Services note dated 4/3/18 showed no
documentation regarding his/her discharge planning.
Record review of the resident’s care plan conference date 4/14/18 showed he/she wanted to
live independently and the resident’s family wanted him/her to live in an assisted living
facility.
Record review of the resident’s discharge Minimum Data Set (MDS a federally mandated
assessment tool completed by facility staff for care planning) assessment dated [DATE]
showed the resident’s discharge was planned and the resident’s return was not anticipated.
Record review of the resident’s telephone orders and (MONTH) (YEAR) Physician’s Order
Sheet (POS) showed no orders to discharge the resident from the facility.
Record review of the resident’s medical record showed no physician’s order to discharge
the resident, no reason the resident was being discharged and no documentation regarding
the resident’s discharge.
Record review of the resident’s current inventory sheet showed it was not signed to
indicate the location of the resident’s belongings.
During an interview on 8/31/18 at 11:15 A.M., Licensed Practical Nurse (LPN) A said:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-They should have an order to discharge a resident;
-They should have discharge paperwork filled out and
-If the inventory sheet was not signed, they would not be able to say the resident’s
belongings went with the resident.
During an interview on 8/31/18 at 11:51 A.M., the Director of Nursing (DON) said they
should have a physician’s order for discharge, should have documentation regarding where
the resident went, if the resident had home health services and if his/her belongings went
with him/her.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide the resident and/or
their responsible party in writing of the reason for the transfer/discharge for six
residents (Residents #50, #373, #71, #44, #12 and #270) out of 18 sampled residents. The
facility census was 77 residents.
The facility did not have a policy regarding providing written notifications of transfers
and/or discharges.
1. Record review of Resident #50’s Minimum Data Sets (MDS-a federally mandated assessment
completed by facility staff for care planning) showed the resident:
-Was discharged on [DATE] and returned on 6/7/18;
-Was discharged on [DATE] and returned on 7/6/18 and
-Was discharged on [DATE] and returned on 8/13/18.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being notified of the resident’s discharges/transfers.
2. Record review of Resident #373’s MDS showed the resident:
-Was discharged on [DATE] and returned on 5/19/18;
-Was discharged on [DATE] and returned on 6/22/18;
-Was discharged on [DATE] and returned on 7/10/18;
-Was discharged on [DATE] and returned on 7/22/18 and
-Was discharged on [DATE] and had not returned by 8/31/18.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being notified of the resident’s discharges/transfers.
3. Record review of Resident #71’s MDS showed the resident was discharged on [DATE] and
did not return to the facility.
Record review of the resident’s medical record showed no documentation of resident or the
resident’s responsible party being notified of of the resident’s discharge.
4. Record review of Resident #44’s medical record showed:
-He/she was discharged to the hospital on [DATE];
-He/she stayed more than 48 hours and
-It did not include a transfer letter.
5. Record review of Resident #12’s Nurses Notes dated 5/10/18 at 11:18 A.M., showed the
resident left via ambulance to the hospital at 11:25 A.M.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being notified of the resident’s discharge/transfer.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
Record review of Resident’s Nurses Notes dated 5/15/18 at 11:00 P.M., showed that the
resident returned to the facility.
6. Record review of Resident #270’s hospital discharge record showed he/she was admitted
to the hospital on [DATE] at 4:37 P.M. and discharged on [DATE] at 3:24 P.M.
Record review of resident’s Nurses Notes 8/10/18 at 10:00 P.M., showed the resident
returned to the facility at 8:15 P.M., via ambulance transport.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being notified of the resident’s discharge/transfer.
7. During an interview on 8/30/18 at 1:40 P.M., the Administrator said they were not
informing the resident and/or their responsible party in writing when a resident was
discharged or transferred.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide the resident and/or
their responsible party of the bed-hold policy at the time of the resident’s
transfer/discharge for six residents (Residents #50, #373, #71, #44, #12 and #270) out of
18 sampled residents. The facility census was 77 residents.
The facility did not have a policy regarding providing the bed-hold policy at the time of
the resident’s transfer/discharge.
1. Record review of Resident #50’s Minimum Data Sets (MDS-a federally mandated assessment
completed by facility staff for care planning) showed the resident:
-Was discharged on [DATE] and returned on 6/7/18;
-Was discharged on [DATE] and returned on 7/6/18 and
-Was discharged on [DATE] and returned on 8/13/18.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being provided the bed-hold policy at the time of the
resident’s discharges/transfers.
2. Record review of Resident #373’s MDS showed the resident:
-Was discharged on [DATE] and returned on 5/19/18;
-Was discharged on [DATE] and returned on 6/22/18;
-Was discharged on [DATE] and returned on 7/10/18;
-Was discharged on [DATE] and returned on 7/22/18 and
-Was discharged on [DATE] and had not returned by 8/31/18.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being provided the bed-hold policy at the time of the
resident’s discharges/transfers.
3. Record review of Resident #71’s MDS showed the resident was discharged on [DATE] and
did not return to the facility.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being provided the bed-hold policy at the time of the
resident’s discharge/transfer.
4. Record review of Resident #44’s medical record showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-He/she was discharged to the hospital on [DATE];
-He/she stayed more than 48 hours and
-It did not include a bed-hold policy.
5. Record review of Resident #12’s Nurses Notes dated 5/10/18 at 11:18 A.M., showed the
resident left via ambulance to the hospital at 11:25 A.M.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being provided the bed-hold policy at the time of the
resident’s discharge/transfer.
6. Record review of Resident #270’s hospital discharge record showed that he/she was
admitted to the hospital on [DATE] at 4:37 P.M. and discharged on [DATE] at 3:24 P.M.
Record review of resident’s Nurses Notes 8/10/18 at 10:00 P.M., showed that the resident
returned to the facility at 8:15 P.M., via ambulance transport.
Record review of the resident’s medical record showed no documentation of the resident or
the resident’s responsible party being provided the bed-hold policy at the time of the
resident’s discharge/transfer.
7. During an interview on 8/29/18 at 1:20 P.M. the Director of Nursing (DON) said:
-The staff knows to send out a bed-hold policy and
-He/she knows the staff doesn’t always do it.
During an interview on 8/30/18 at 1:40 P.M., the Administrator said they were not
providing the bed-hold policy when a resident was discharged or transferred.

F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assess the resident when there is a significant change in condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to complete a
significant change assessment when the resident declined in multiple areas for one sampled
resident (Resident #17) out of 18 sampled residents. The facility census was 77 residents.

Record review of the Long-Term Care Facility RAI 3.0 User’s Manual, Version 1.15, (MONTH)
(YEAR) showed:
A significant change is a major decline or improvement in a resident’s status that:
1. Will not normally resolve itself without intervention by staff or by implementing
standard disease-related clinical interventions.
2. Impacts more than one area of the resident’s health status.
3. Requires interdisciplinary review and/or revision of the care plan.
1. Record review of Resident #17’s care plan dated 6/20/14 showed:
-The Activities of Daily Living (such as bathing, grooming, hygiene, etc.) ADL care plan
showed the resident required:
–Supervision to moderate assistance of one person with bed mobility;
–Minimal to moderate assistance of one person with dressing, hygiene and toileting.
-The psychosocial care plan showed:
–The resident had a behavior of not eating.
–An update on 6/5/18 that the resident had behaviors such as kicking, pushing, and
pinching staff during ADLs; verbally abusive to staff and residents and throwing and
smearing feces in the room.
-The mood care plan showed the resident displayed sad/depressed mood indicators of staying

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
in room and not eating.
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff used for care planning) dated 3/1/18 showed
the following staff assessment of the resident:
-Did not have any mood symptoms to indicate any depression;
-Did not display any behaviors and
-Required limited assistance with bed mobility, dressing, using the toilet and hygiene.
Record review of the resident’s quarterly MDS dated [DATE] showed the following staff
assessment of the resident:
-Displayed mood symptoms that indicated moderate depression;
-Displayed physical, verbal and other behaviors not directed toward others daily and
-The resident’s assistance required for bed mobility, dressing, toilet use and hygiene all
increased from limited assistance (on 3/1/18) to extensive assistance.
Observation on 8/24/18 at 2:51 P.M. showed:
-The resident was in bed and was yelling;
-His/her pillows and incontinence brief were across the room on the floor;
-The resident pushed his/her wheelchair away from the bed and it fell backwards onto the
floor and
-The resident cussed at Registered Nurse (RN) D who was trying to assist the resident.
During an interview on 8/31/18 at 2:01 P.M. the Administrator said they should have
completed a significant change MDS if two or more areas on the MDS had changed.
. During an interview on 8/31/18 at 4:43 P.M., the Administrator said:
-They did not have a specific policy on significant changes and
-They use the Resident Assessment Instrument (RAI-helps the facility staff to gather
definitive information on a resident’s strengths and needs, which must be addressed in an
individualized care plan) Manual for criteria for a significant change.

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 observation, interview and record review, the facility failed to provide the
resident and/or their representative with a summary of a baseline care plan that is
developed within the first 48 hours of admission for three sampled residents (Residents
#19, #373 and #61) out of 18 sampled residents. The facility census was 77 residents.
Record review of the facility’s Baseline Care Planning policy dated as revised on 11/1/17
showed the baseline care plan shall be completed with 48 hours of admission and a summary
of the baseline care plan shall be provided to the resident and/or the resident’s
representative.
1. Record review of Resident #19’s entry tracking record showed he/she was admitted to the
facility on [DATE].
Record review of the resident’s medical record showed no documentation that the resident’s
responsible party was provided with the resident’s baseline care plan.
Observation on 8/24/18 during the tour which began at 9:21 A.M. showed the resident was
sitting in a specialized wheelchair chair that was low to the ground and he/she was trying
to stand up out of the specialized wheelchair. Staff talked to the resident and asked the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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)
resident to sit down.
Observation on 8/29/18 at 5:21 A.M. showed the resident was self-propelling his/her
specialized wheelchair in the day area.
2. Record review of Resident #373’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’s
responsible party was provided with the resident’s baseline care plan.
Observation on 8/24/18 during tour which began at 8:55 A.M., showed the resident was
sitting in a wheelchair and had an oxygen concentrator in his/her room.
3. Record review of Resident #61’s entry tracking record showed the resident admitted to
the facility on [DATE].
Record review of the resident’s medical record showed no documentation that the resident’s
responsible party was provided with the resident’s baseline care plan.
Observation on 8/28/18 at 3:03 P.M. showed the resident was asleep in bed, he/she was
receiving continuous tube feeding and the head of his/her bed was elevated.
4. During an interview on 8/30/18 at 9:24 AM, the Director of Nursing (DON) said he/she
didn’t know if baseline care plans were being given to residents and/or responsible
parties.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop a
comprehensive care plan for one sampled resident (Resident #61) out of 18 sampled
residents. The facility census was 77 residents.
Record review of the Long-Term Care Facility RAI 3.0 User’s Manual, Version 1.15, (MONTH)
(YEAR) showed the comprehensive care plan must be completed within seven days of the
completion of the Admission Minimum Data Set (MDS-a federally mandated assessment tool
completed by staff and used for care planning) which must be completed by the 14th day.
1. Record review of Resident #61’s entry tracking form showed he/she was admitted to the
facility on [DATE].
Record review of the resident’s admission MDS dated [DATE] showed the following staff
assessment of the resident:
-Moderately cognitively impaired;
-Required limited assistance to total dependence on staff for Activities of Daily Living
(ADL such as hygiene, bathing, using the toilet, etc.);
-Was incontinent of bladder and sometimes was incontinent of bowel;
-Received tube feeding and
-Had a pressure ulcer (localized injury to the skin and/or underlying tissue usually over
a bony prominence, as a result of pressure, or pressure in combination with shear) that
was a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a
red/pink wound bed) that was present upon admission.
Record review of the facility’s care plan book showed there was no care plan for the
resident.
Observation on 8/28/18 at 12:17 P.M. showed the resident was in bed watching television,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
the head of his/her bed was elevated and he/she was receiving continuous tube feeding.
During an interview on 8/29/18 at 12:12 P.M., the Director of Nursing (DON) said the
resident’s care plan was not done and their corporate nurse was working on it.
During an interview on 8/30/18 at 8:22 A.M., the Administrator said the resident’s care
plan was in the computer, their system was down and she would print it off that day if she
could.
During an interview on 8/31/18 at 4:43 P.M., the Administrator said they follow the
Resident Assessment Instrument (RAI-helps the facility staff to gather definitive
information on a resident’s strengths and needs, which must be addressed in an
individualized care plan) Manual for developing care plans.
The resident’s care plan was not provided by 8/31/18 at 6:30 P.M.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow up on a
recommendation from the Registered Dietitian (RD) for one sampled resident (Resident #50),
and to provide a resident with pressure ulcers (localized injury to the skin and/or
underlying tissue usually over a bony prominence, as a result of pressure, or pressure in
combination with shear) necessary treatment and services, consistent with professional
standards of practice for one sampled resident (Resident #375) out of 18 sampled
residents. The facility census was 77 residents.
Record review of the facility’s Resident Weight Monitoring policy dated as revised (MONTH)
2008 showed:
-The food service manager and/or RD should notify nursing of any recommendations that have
been documented and
-Nursing should contact the physician to convey recommendations and obtain any new orders.
1. Record review of Resident #50’s monthly weights sheet for (YEAR) showed the resident
weighed:
-151 pounds in (MONTH) (YEAR);
-150.6 pounds in (MONTH) (YEAR);
-162.4 pounds in (MONTH) (YEAR);
-151.4 pounds in (MONTH) (YEAR);
-157.8 pounds in [NAME] (YEAR);
-145.0 pounds in (MONTH) (YEAR);
-157.0 pounds in (MONTH) (YEAR);
-145.2 pounds in (MONTH) (YEAR) and
-146.8 pounds upon readmission on 8/13/18.
Record review of the resident’s Minimum Data Sets (MDS-a federally mandated assessment
tool completed by staff used for care planning) and entry tracking forms showed:
-The resident discharged from the facility with return anticipated on 6/1/18 and
-The resident returned to the facility on [DATE].
Record review of the resident’s 6/20/17 nutrition care plan that was updated on 6/7/18
showed the resident was back from the hospital, refused fluids and a diet waiver for thin
liquids was signed by the resident’s responsible party. Snacks twice daily were not on the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
care plan.
Record review of the resident’s undated telephone order that was after 6/8/18 and before
6/13/18 showed physician’s orders [REDACTED].
Record review of the resident’s telephone order dated 6/19/18 showed a physician’s orders
[REDACTED].
Record review of the resident’s MDSs and entry tracking forms showed:
-The resident discharged from the facility with return anticipated on 7/2/18 and
-The resident returned to the facility on [DATE].
Record review of the resident’s return telephone orders dated 7/6/18 showed:
-A physician’s orders [REDACTED].
-No order for Med Pass as previously ordered.
Record review of the dietary note dated 7/18/18 showed:
-The resident was in the hospital 7/2/18-7/6/18;
-The resident had a mechanical soft (a diet specifically prepared to alter the consistency
of food in order to facilitate oral intake for residents who have trouble with chewing,
swallowing, etc.), thin liquids diet order;
-The resident did not want the supplements that were offered and
-A recommendation was made to offer snacks twice daily.
Record review of the resident’s telephone orders showed:
-There were no telephone orders dated 7/11/18 through 7/15/18 and
-There were no telephone orders about snacks 7/15/18 through 7/19/18.
Record review of the resident’s MDSs and entry tracking forms showed:
-On 7/13/18, the resident weighed 158 pounds and
-On 7/19/18, the resident weighed 158 pounds.
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
Record review of the resident’s MDSs and entry tracking forms showed:
-The resident weighed 145 pounds (an 8.23% loss from 7/19/18) on 8/8/18;
-The resident discharged from the facility with return anticipated on 8/8/18 and
-The resident returned to the facility on [DATE].
Record review of the resident’s physician’s most recent progress note dated 8/15/18 showed
no mention of weight loss.
Observation on 8/24/18 showed:
-At 12:16 P.M., the resident drank his/her tomato juice, was eating fruit, and had
chicken, rice, vegetables, water, and magic cup (a frozen dessert cup that provides
calories and protein) at his/her place at the table;
-At 12:47 P.M., the resident was drinking water and ate his/her magic cup;
-At 12:53 P.M., the resident was eating vegetables and
-At 12:56 P.M., the resident started to back away from the table. Staff asked if he/she
was done eating and the resident nodded yes.
Observation on 8/30/18 showed:
-At 12:21 P.M., staff served the resident noodles, mechanical soft meat, vegetables, a
roll and a brownie. The resident drank two small beverages and still had a cup of water.
The resident ate his/her brownie and
-At 12:37 P.M., the resident took a bite of noodles. The resident ate his/her roll. The
resident ate some more noodles and was drinking his/her water.
During an interview on 8/31/18 at 2:10 P.M., Certified Nursing Assistant (CNA) G said:
-The resident stopped eating about one month ago;
-He/she was told it was because of the taste of a medication or a supplement that left an
iron taste;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
-He/she was told the medication or supplement was discontinued and now the resident is
eating better;
-They give all the residents snacks. They give fudge rounds, oatmeal cream pies and magic
cups for residents with a mechanical soft diet;
-Recently the kitchen hasn’t been sending snacks and
-They keep running out of snacks.
During an interview on 8/31/18 at 5:00 P.M., the Director of Nursing (DON) said:
-The resident was in and out of the hospital;
-They have monthly weight meetings;
-The care plan coordinator was responsible for notifying the physician of weight loss;
-The snacks must have fallen off the POS and
-The Resident Care Coordinator does monthly change over to ensure accuracy of the POS.
2. Record review of Resident #375 medical record showed:
-The resident was admitted on [DATE] with the following Diagnoses: [REDACTED].
–[MEDICAL CONDITION] (an impairment of the lower extremities) and
-The resident was able to make daily choices, he/she had a Power of Attorney for Health
care and legal decisions.
During an interview on 8/27/18 at 9:47 A.M., Licensed Practical Nurse (LPN) A and LPN B
said:
-The resident has had two pressure ulcers for years;
-One pressure ulcer is on the resident’s right side and one is on the left side of the
resident’s gluteal folds (area between the buttock and the thigh);
-LPN A said the resident had frequent bowel movements and he/she was repositioned when
he/she was cleaned up;
-LPN B said the resident stayed in bed for breakfast then they help him/her get up into
his/her wheelchair after wound care was done and
-LPN B said he/she did not know how long the resident stayed up in the wheelchair as it
was after he/she goes home at 3:00 P.M.
During an interview on 8/28/18 at 2:12 P.M., the DON said:
-He/she has known this resident for several years;
-The resident had been in LTAC (long term acute care hospital) for several years with
pressure injuries;
-The resident has had many different treatments and
-The resident was being seen by the wound specialists.
Record review of the resident’s medical record showed the resident had been to the wound
clinic every month for evaluation and different treatments were tried.
During an interview on 8/28/18 at 2:30 P.M., Registered Nurse (RN) C said:
-The resident was turned frequently and
-It was charted in the Treatment Administration Record (TAR) by the CNA.
During an interview on 8/29/18 at 5:30 A.M., the resident said he/she was turned twice
during the night.
During an interview on 8/29/18 at 5:33 A.M., CNA C said:
-He/she worked there all night;
-He/she turned the resident twice during the night;
-He/she charts how many times the resident was turned in the TAR and
-He/she said his/her shift started on 8/28/18 and he/she worked the third shift (10:00
P.M. to 6:00 A.M.).
Record review on 8/29/18 at 5:35 A.M. of the resident’s TAR (turning and positioning
section) showed the resident had been turned three times on the third shift on 8/28/18.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
During an interview on 8/29/18 at 6:00 A.M., RN C was shown the TAR sheet and asked about
the discrepancy and he/she said:
-The CNAs are busy so they chart when they can and
-The CNA will probably reposition the resident one last time before he/she leaves.
Record review of the resident’s Care Plan dated 4/05/17 Pressure ulcers, with a goal date
of 9/14/18 showed:
-Staff was to assist the resident to turn and reposition every two hours and
-Reposition the resident as needed and to follow reposition schedule.
Record review of the resident’s TAR Turning and Positioning showed the staff charted the
following amount of repositions per shift for the month of (MONTH) (YEAR):
-August 1 – days – three, evenings – three, nights – three, for a total of nine times in a
24 hour period (24 divided by two should be 12);
-August 2 – days – three, evenings – blank, nights – three, for a total of six times;
-August 3 – days – three, evenings – blank, nights – three, for a total of six times;
-August 4 – days – blank, evenings – blank, nights – three, for a total of three times;
-August 5 – days – blank, evenings – blank, nights – three, for a total of three times;
-August 6 – days – three, evenings – blank, nights – three, for a total of six times;
-August 7 – days – three, then the resident went to the hospital over night and was
returned to the facility the next day;
-August 8 – nights – three;
-August 9 – days – three, evenings – blank, nights – three, for a total of six times;
-August 10 – days – three, evenings – blank, nights – three, for a total of six times;
-August 11 – days – three, evenings – blank, nights – three, for a total of six times;
-August 12 – days – three, evenings – blank, nights – three, for a total of six times;
-August 13 – days – three, evenings – blank, nights – three, for a total of six times;
-August 14 – days – three, evenings – blank, nights – three, for a total of six times;
-August 15 – days – three, evenings – blank, nights – three, for a total of six times;
-August 16 – days – three, evenings – blank, nights – three, for a total of six times;
-August 17 – days – three, evenings – three, nights – three, for a total of nine times;
-August 18 – days – three, evenings – three, nights – three, for a total of nine times;
-August 19 – days – three, evenings – three, nights – three, for a total of nine times;
-August 20 – days – three, evenings – blank, nights – three, for a total of six times;
-August 21 – days – three, evenings – three, nights – three, for a total of nine times;
-August 22 – days – three, evenings – blank, nights – three, for a total of six times;
-August 23 – days – three, evenings – three, nights – three, for a total of nine times;
-August 24 – days – three, evenings – three, nights – three, for a total of nine times;
-August 25 – days – three, evenings – three, nights – three, for a total of nine times;
-August 26 – days – three, evenings – three, nights – three, for a total of nine times;
-August 27 – days – three, evenings – three, nights – three, for a total of nine times;
-August 28 – days – three, evenings – three, nights – three, for a total of nine times;
-There were a total of 324 opportunities to be repositioned and
-There were a total of 189 documented times the resident was repositioned.
During an interview on 8/31/18 at 11:00 A.M., the DON said he/she would expect:
-The resident to be turned every two hours for a total of 12 times in a 24 hour period;
-Staff to reposition the resident every two hours if they are up in a wheelchair;
-Staff to chart how many times in a shift the resident was repositioned and
-Staff to document if the resident refused to be moved.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0660

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to obtain an accurate discharge
order for one sampled resident (Resident #71) out of 18 sampled residents, and to provide
discharge planning for one closed record resident (Resident #70) out of three closed
records sampled. The facility census was 77 residents.
Record review of the facility’s discharge planning policy dated 11/1/17 showed:
-A Post Discharge Plan of Care and a Discharge Care Plan shall be developed for each
resident anticipating discharge and
-Documentation of the discharge plan shall be recorded on the Post Discharge Plan of Care.
1. Record review of Resident #70’s current face sheet (undated) showed he/she was admitted
to the facility on [DATE].
Record review of the resident’s most recent Social Services note dated 4/3/18 showed no
documentation regarding discharge planning.
Record review of the resident’s care plan conference date 4/14/18 showed the resident
wanted to live independently and the resident’s family wanted him/her to live in an
assisted living facility.
Record review of the resident’s discharge Minimum Data Set (MDS a federally mandated
assessment tool completed by facility staff for care planning) assessment dated [DATE]
showed the resident’s discharge was planned and the resident’s return was not anticipated.
Record review of the resident’s medical record showed no documentation of any discharge
plan.
During an interview on 8/31/18 at 11:15 A.M., Licensed Practical Nurse (LPN) A said
discharge paperwork should have been filled out.
During an interview on 8/31/18 at 11:51 A.M., the Director of Nursing (DON) said there
should have been documentation regarding where the resident was discharging to and what
services the resident would need if he/she went home.
2. Record review of Resident #71’s entry tracking record showed he/she was admitted to the
facility on [DATE].
Record review of the resident’s Social Services Note dated 6/26/18 showed the resident
reported to him/her that he/she would have another surgery the next week.
Record review of the resident’s nurse’s note dated 7/2/18 showed documentation that the
resident was going to the hospital the next day for surgery.
Record review of the telephone orders dated 7/3/18 showed there was a physician’s orders
[REDACTED].
During an interview on 8/31/18 at 9:56 A.M., the DON said the resident went to the
hospital.
During an interview on 8/31/18 at 10:04 A.M., the Social Services Director said:
-He/she did not have any documentation regarding the resident’s surgery;
-The resident told him/her about the surgery;
-The resident went to have surgery at a local hospital and told him/her he/she was going
to another long-term care facility for rehabilitation after the surgery;
-The other long-term care facility did not know anything about him/her going there for
rehabilitation after his/her surgery and
-He/she has a transportation note for the resident to go to the hospital.
During an interview on 8/31/18 at 11:07 A.M. LPN A said:
-The resident went to the hospital to have surgery on a wound and then was going to

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0660

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
another long-term care facility;
-They should have completed discharge paperwork and
-Social Services handles all the resident’s appointments.
During an interview on 8/31/18 at 3:27 P.M., the Administrator and DON said:
-The nurse must have written the discharge order to a long-term care facility in error and
-There should have been a nurse’s note documenting where the resident was discharged to.

F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to document a summary of the
resident’s stay for one closed record resident (Resident #70) out of three closed records
sampled. The facility census was 77 residents.
Record review of the facility’s discharge planning policy dated 11/1/17 showed upon
discharges without anticipation of return, a discharge summary of care and services shall
be completed using the interdisciplinary discharge summary.
1. Record review of Resident #70’s current face sheet (undated) showed the resident was
admitted to the facility on [DATE].
Record review of the resident’s most recent Social Services note dated 4/3/18 showed no
documentation regarding discharge planning.
Record review of the resident’s care plan conference date 4/14/18 showed the resident
wanted to live independently and the resident’s family wanted him/her to live in an
assisted living facility.
Record review of the resident’s discharge Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) assessment dated [DATE]
showed the resident’s discharge was planned and the resident’s return was not anticipated.
Record review of the resident’s medical record showed no discharge summary was completed.
During an interview on 8/31/18 at 11:15 A.M., Licensed Practical Nurse (LPN) A said
discharge paperwork should have been filled out.
During an interview on 8/31/18 at 11:51 A.M., the Director of Nursing (DON) said there
should have been documentation regarding the resident’s stay and discharge.

F 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure that properly trained
personnel certified in cardiopulmonary resuscitation (CPR-a lifesaving technique useful in
many emergencies, in which someone’s breathing or heartbeat has stopped) were certified to
provide basic life support to residents requiring emergency care prior to the arrival of
emergency medical personnel, and subject to accepted professional guidelines, by allowing
the staff to certify/recertify for CPR online. The facility census was 77 residents.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
The facility’s CPR certification policy was not available as the facility’s computer
Internet was not working for it to be printed.
Record review of the Centers for Medicare and Medicaid (CMS) policy revision date [DATE]
CPR in Nursing Homes, showed:
-Staff must maintain current CPR certification for healthcare providers through a CPR
provider whose training includes hands-on practice;
-Staff CPR certification required in-person skills assessment and
-Online CPR certification was not acceptable.
1. Record review on [DATE] showed the following staff did their CPR certification on-line:
-The Administrator through the American Academy of CPR & First Aid, Inc. an on-line
program and his/her card had expired on [DATE];
-The Activities Director through the American Academy of CPR & First Aid, Inc. an
on-line program;
-The criminal background check/employee disqualification list personnel contact through
the American Academy of CPR & First Aid, Inc. an on-line program and his/her card had
expired on [DATE];
-The Medical Records Supervisor through the American Academy of CPR & First Aid, Inc.
(the card stated it was an on-line program);
-The Maintenance Supervisor through the American Academy of CPR & First Aid, Inc. (the
card stated it was an on-line program);
-Maintenance worker A through the American Academy of CPR & First Aid, Inc. an on-line
program;
-The Housekeeping Supervisor through the American Academy of CPR & First Aid, Inc. an
on-line program;
-Housekeeper A through the American Academy of CPR & First Aid, Inc., an on-line
program;
-Housekeeper B through the American Academy of CPR & First Aid, Inc., an on-line
program;
-Housekeeper C through the American Academy of CPR & First Aid, Inc., an on-line
program;
-Housekeeper D through the American Academy of CPR & First Aid, Inc., an on-line
program;
-Housekeeper E through the American Academy of CPR & First Aid, Inc., an on-line
program;
-Housekeeper F through the American Academy of CPR & First Aid, Inc., an on-line
program;
-Housekeeper G through the American Academy of CPR & First Aid, Inc., an on-line
program;
-Housekeeper H through the American Academy of CPR & First Aid, Inc., an on-line
program;
-The Dietary Manager through the American Academy of CPR & First Aid, Inc., an on-line
program;
-Dietary Aide A through the American Automated External defibrillator/CPR Association, an
on-line program;
-Dietary Aide B through the National CPR Foundation, an on-line program;
-Dietary Aide C through the American Academy of CPR & First Aid, Inc., an on-line
program;
-Dietary Aide D through the American Academy of CPR & First Aid, Inc., an on-line
program;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
-Dietary Aide E through the American Health Care Academy, an on-line program;
-Dietary Aide F through the National CPR Foundation, an on-line program;
-Dietary Aide G through the American Academy of CPR & First Aid, Inc., an on-line
program and
-Dietary Aide H through the American Academy of CPR & First Aid, Inc., (the card
clearly stated it was an on-line program).
During an interview on [DATE] at 1:15 P.M., the Director of Nursing (DON) said:
-All of his/her nursing staff was certified with an accepted CPR program and
-He/she was not responsible for the other staff.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide an
activity program based on the residents’ comprehensive assessments, care plans and
activity preferences to meet the residents’ interests and needs for six sampled residents
(Residents #8, #17, #19, #37, #50 and #56) that resided on the secure care unit out of 18
sampled residents. The facility census was 77 residents.
Record review of the facility’s Activity Policy last reviewed in (MONTH) (YEAR) showed:
-The facility would provide an ongoing program of activities designed to meet, in
accordance with the comprehensive assessment, the interests and the physical, mental and
psychosocial well-being of each resident;
-The Activity Director shall have a specific planned program of group and individual
activities based upon the residents’ needs and interests and
-The facility will obtain sufficient, detailed information to determine what activities
each resident prefers and what adaptations may be needed.
1. Record review of Resident #8’s activities care plan dated 11/10/16 showed instructions
for staff to:
-Provide the monthly activity calendar;
-Invite, remind and escort the resident to and from activities;
-Provide one-on-ones if necessary;
-Encourage the use of radio and of television;
-Provide the resident with independent leisure materials as requested;
-Develop a program that accommodates the resident’s limitations and
-Provide positive feedback about the resident’s independent activities.
Record review of the resident’s annual Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff used for care planning) dated 11/13/17 showed
the resident liked reading, music, pets, keeping up with the news, doing activities with
groups of people, doing his/her favorite activities, being outside and religious
activities were all very important to him/her.
Record review of the resident’s quarterly MDS dated [DATE] showed the following staff
assessment of the resident:
-Was severely cognitively impaired;
-Wandered one to three days of the seven-day observation period;
-Some of his/her [DIAGNOSES REDACTED].
-Walked with supervision/oversight.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
Record review of the resident’s (MONTH) (YEAR) Activities Attendance Record showed:
-The resident actively participated in socials five times, one-on-ones three times, ball
toss once, reminiscing twice, a movie three times and coloring twice and
-There were 20 days without any documented activities for the resident in (MONTH) (YEAR).
Record review of the resident’s Activity assessment dated [DATE] showed the resident’s
preferred activities included Catholic services, magazines (did not indicate any specific
kinds), books (did not indicate any specific kinds), a variety of music, dogs, cats,
socials, visiting with others, one-on-ones, reading and television.
Record review of the resident’s quarterly Activity Note dated 8/15/18 showed the resident
was social during the afternoon and wanders to keep busy.
Record review of the resident’s (MONTH) (YEAR) Activities Attendance Record showed:
-The resident actively participated in socials four times, one-on-ones three times, snacks
once, entertainment once, hand massage twice, reminiscing once and nails once and
-There were 19 days without any documented activities for the resident in (MONTH) (YEAR).
Observation on 8/24/18 on the initial tour which began at 9:21 A.M. showed the resident
was awake in bed with no activity.
Observation on 8/24/18 at 1:17 P.M. showed the resident was walking back and forth from
the dining room to the 400 and 500 halls.
Observation on 8/27/18 showed:
-At 5:23 A.M., the resident was walking from his/her room to the dining room and
-At 9:33 A.M., the resident was asleep in bed.
Observation on 8/29/18 showed:
-At 7:31 A.M., the resident was walking in the hall toward the nurses’ station. The
resident asked Department of Health and Senior Services (DHSS) staff if they needed any
help and the resident said he/she likes to help people;
-At 9:05 A.M., the resident was in bed and his/her eyes were closed and
-At 9:30 A.M., the resident was asleep in bed.
Observation on 8/30/18 showed:
-At 9:30 A.M., the resident was asleep in bed;
-At 11:00 A.M., the resident was in bed awake with no activity;
-At 11:26 A.M., the resident was walking down the hall, following staff, trying to ask
questions of the staff walking in front of him/her and
-At 2:10 P.M. the resident was sitting at the dining room table with no activity.
During an interview on 8/31/18 at 12:16 P.M., the Activities Director said the resident
liked to get his/her nails done and watched a movie occasionally.
Observation on 8/31/18 showed:
-At 11:10 A.M., the resident was walking down the hall, fidgeting with the multiple shirts
he/she was wearing;
-At 2:20 P.M., the resident was in bed with his/her eyes closed. There was nothing on the
resident’s wall other than the activity calendar. There was one artificial flower
arrangement on his/her bedside dresser, a few knick knacks on another dresser and one baby
doll on his/her recliner and
-At 2:51 P.M., the resident was walking up the hall. The resident asked the staff if it
was time to eat. The resident stood by the nurses’ station with no activity. The resident
walked into the dining room and wandered around in the dining room.
2. Record review of Resident #17’s activities care plan dated 6/20/14 showed:
-Instructions for staff to:
–Provide the monthly activity calendar;
–Invite, remind and escort the resident to and from activities and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
-The resident enjoyed reading the paper, watching television, getting his/her nails done,
going outside, dogs and family visits.
Record review of the resident’s Annual MDS dated [DATE] showed the following staff
assessment of the resident:
-Was severely cognitively impaired;
-Had mood indicators that indicated mild depression;
-Had verbal, physical and other behaviors daily;
-Music and his/her favorite activities were very important to him/her and
-Some of his/her [DIAGNOSES REDACTED].
Record review of the resident’s Activity assessment dated [DATE] showed the resident’s
activity interests included music and movies.
Record review of the resident’s most recent activity progress note dated 6/12/18 showed
the resident:
-Was provided with one-on-ones;
-Had good and bad days and
-Sometimes came out of his/her room and would dance in his/her chair and other times
he/she didn’t want to even talk.
Record review of the resident’s (MONTH) (YEAR) Activity Participation One-on-One sheet
showed:
-The resident had five one-on one activities during the month of (MONTH) (YEAR) which
included:
–Snacks and talking on 7/3/18;
–A puzzle on 7/11/18;
–Ice cream in his/her room on 7/17/18;
–Reminiscing on 7/26/18 and
–A birthday party in the hallway on 7/31/18.
-There were 26 days without any documented activities for the resident in (MONTH) (YEAR).
The resident’s (MONTH) (YEAR) Activity Participation One-on-One sheet was requested but
was not received.
Observation on 8/24/18 during the initial tour which began at 9:21 A.M. showed the
resident was asleep in bed.
Observation on 8/24/18 at 2:51 P.M. showed the resident was in bed, yelling and cursing.
Observation on 8/27/18 at 10:28 A.M. showed the resident was asleep in bed.
Observation on 8/29/18 showed:
-At 5:32 A.M., the resident was in bed awake with no activity;
-At 9:05 A.M., the resident was sitting at a dining room table alone with no activity;
-At 9:30 A.M., the resident was asleep in bed and
-At 9:50 A.M., the resident was sitting at a dining room table alone with no activity.
Observation on 8/30/18 showed:
-At 9:42 A.M., the resident was asleep in bed and
-At 11:00 A.M., the resident was asleep in bed.
During an interview on 8/31/18 at 12:16 P.M., the Activities Director said the resident
sometimes participated in activities while other times, the resident didn’t even want
anyone to talk to him/her.
Observation of the resident’s room on 8/31/18 at 2:20 P.M. showed there was nothing on the
resident’s walls and nothing to personalize the room.
3. Record review of Resident #19’s Admission MDS dated [DATE] showed the resident said
that reading, music, pets, keeping up with the news, participating in group activities,
participating in his/her favorite activities, being outside and religious activities were
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
all very important to him/her.
Record review of the resident’s care plan dated 3/22/18 showed there was no activity plan.
Record review of the resident’s quarterly MDS dated [DATE] showed the following staff
assessment of the resident:
-Was severely cognitively impaired;
-Had mood indicators that indicated mild depression;
-Did not have any behaviors;
-Did not wander;
-Did not walk;
-Was totally dependent upon staff for locomotion;
-Used a wheelchair;
-Had a [DIAGNOSES REDACTED].>-Received Hospice (end of life) care.
Record review of the resident’s most recent Activity progress note dated 6/5/18 showed the
resident roams around the living room area, plays some games, socializes and attends
socials and music.
Record review of the resident’s (MONTH) (YEAR) Activities Attendance Record showed:
-The resident actively participated in exercise once, reminiscing once, a hand massage
once, noodle ball once, four socials and television or music nine times and
-There were 15 days without any documented activities for the resident in (MONTH) (YEAR).
Record review of the resident’s (MONTH) (YEAR) Activities Attendance Record showed:
-The resident actively participated in reminiscing twice, a movie once, entertainment
twice, a game once, a one-on-one once and participated some in one social and
-There were 24 days without any documented activities for the resident in (MONTH) (YEAR).
Observation on 8/24/18 showed:
-At 10:49 A.M., the resident was trying to stand up from his/her wheelchair. Staff talked
to the resident and asked the resident to sit down. Staff pushed the resident over to a
bench by the nurses’ station and talked to resident and
-At 12:51 P.M., showed the resident was trying to stand up, staff assisted the resident in
sitting down and started pushing the resident in his/her wheelchair out of the dining room
and said he/she was going to help the resident clean his/her hands.
Observation on 8/27/18 showed:
-At 9:00 A.M., the resident was sitting in his/her wheelchair in the living room area.
Relaxation music was on the television. The resident’s eyes were closed and
-At 9:24 A.M., the resident was in his/her wheelchair in living room area. Relaxation
music was on the television. The resident’s eyes were closed.
Observation on 8/29/18 showed:
-At 5:21 A.M., the resident was self-propelling himself/herself in his/her wheelchair in
the living room area;
-At 9:05 A.M., the resident was in bed with his/her eyes closed;
-At 9:30 A.M., the resident was sitting at table in the dining room where other residents
were playing bingo. The resident was not participating and
-At 10:59 A.M., the resident was asleep in a semi-circle of residents in the living room
area where residents were playing with a beach ball.
Observation on 8/30/18 showed:
-At 9:16 A.M., the resident was in his/her wheelchair, self-propelling himself/herself
toward the nurses’ station and was not engaged in any activity;
-At 9:41 A.M., the resident was sitting at a dining room table where bingo was being
played. The resident was not participating;
-At 10:24 A.M., the resident was in the living room area. His/her eyes were closed and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
he/she was not engaged in any activity;
-At 11:00 A.M., the resident was wandering around the living room area in his/her
wheelchair and
-At 2:10 P.M., the resident was wandering around the living room area in his/her
wheelchair.
During an interview on 8/31/18 at 12:16 P.M., the Activities Director said the resident
just wandered around the unit and did some social things.
Observation of the resident’s room on 8/31/18 at 2:20 P.M. showed there was nothing on the
resident’s walls and nothing to personalize his/her room.
4. Record review of Resident #37’s Admission MDS dated [DATE] showed the resident liked:
-Reading, music, pets and his/her favorite activities were very important to him/her and
-Going outside, keeping up with the news and participating in group activities were
somewhat important to him/her.
Record review of the resident’s quarterly MDS dated [DATE] showed the following staff
assessment of the resident:
-Had long-term and short-term memory impairment;
-Had moderately impaired decision-making skills;
-Required extensive assistance with locomotion;
-Used a wheelchair and
-Had [DIAGNOSES REDACTED].
Record review of the resident’s quarterly activity note dated 7/3/18 showed the resident
liked his/her baby doll, stuffed dog and getting his/her nails done with his/her family.
Record review of the resident’s (MONTH) (YEAR) activity attendance record showed the
resident:
-Actively participated in movies three times, television or music four times, exercise
once and socials five times;
-Had some participation in exercise once and a hand massage once and
-There were 18 days without any documented activities for the resident in (MONTH) (YEAR).
Record review of the resident’s (MONTH) (YEAR) activity attendance record showed the
resident:
-Actively participated in a hand massage once, a one-on-one once and socials twice;
-Had some participation in entertainment twice, reminiscing once and a social once and
-There were 23 days without any documented activities for the resident in (MONTH) (YEAR).
Observation on 8/24/18 during the initial tour which began at 9:21 A.M. showed the
resident was asleep in bed.
Observation on 8/24/18 at 2:02 P.M. showed the resident was asleep in bed.
Observation on 8/29/18 showed:
-At 9:05 A.M., the resident was in bed asleep and
-At 9:30 A.M., the resident was asleep in bed, there were photos on his/her dresser and
one stuffed animal on his/her chair.
Observation on 8/30/18 showed:
-At 9:42 A.M., the resident was asleep in bed and
-At 11:00 A.M., the resident was in bed and staff were assisting the resident.
During an interview on 8/31/18 at 12:16 P.M., the Activities Director said the resident
sleeps until 11:30 A.M., will attend afternoon social activities, loves puppy dogs and
loves baby dolls.
5. Record review of Resident #50’s activity care plan dated 6/20/17 showed:
-Instructions to staff to provide the resident with a monthly activity calendar and
-The resident liked to look nice, football, baseball, going to the beauty shop, getting
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
his/her nails done, to go out with activities, dogs, cats, bingo, stuffed animals,
jewelry, socials, parties, music programs and westerns on television.
Record review of the resident’s Annual MDS dated [DATE] showed the resident said:
-Reading, music, doing his/her favorite activities and going outside were very important
to him/her and
-Pets and doing activities with groups of people were somewhat important to him/her.
Record review of the resident’s most recent activity progress note dated 2/6/18 showed the
resident’s favorite thing to do was to go shopping and get dressed up.
Record review of the resident’s quarterly MDS dated [DATE] showed the following staff
assessment of the resident:
-Was severely cognitively impaired;
-Required supervision/oversight with locomotion;
-Did not walk;
-Used a wheelchair and
-Had a [DIAGNOSES REDACTED].
Record review of the resident’s (MONTH) (YEAR) activity attendance record showed:
-The resident actively participated in coloring four times, exercise twice, and socials
four times and
-There were 22 days without any documented activities for the resident in (MONTH) (YEAR).
Record review of the resident’s (MONTH) (YEAR) activity attendance record showed:
-The resident actively participated in exercise twice, one-on-one twice, socials twice,
puzzles once, entertainment once and going outside once;
-The resident participated some in a snack once and
-There were 23 days without any documented activities for the resident in (MONTH) (YEAR).
Observation on 8/24/18 showed:
-At 10:49 A.M., the resident was at the dining room table and was not engaged in any
activity;
-Licensed Practical Nurse (LPN) C took the resident to the nurse’s station, took the
resident’s blood glucose level and returned the resident to the dining room table where
he/she was not engaged in any activity and
-At 2:48 P.M., the resident was in bed.
Observation on 8/27/18 showed:
-At 9:27 A.M., the resident had a beverage while sitting in front of the television which
was playing relaxation music and
-At 9:43 A.M., the resident was holding a baby doll. The resident dropped the baby doll on
the floor. Another resident picked it up and gave it back to him/her. Staff gathered
residents in a semi-circle, passed out pool noodles, started playing noodle ball and the
resident actively participated.
Observation on 8/29/18 showed:
-At 5:30 A.M., the resident was asleep in bed;
-At 9:30 A.M., the resident was playing bingo and
-At 10:53 A.M., the resident was sitting by a bench by the nurses’ station. LPN C asked
the resident if he/she was ready to go to his/her appointment.
Observation on 8/30/18 showed:
-At 9:39 A.M., the resident was playing bingo;
-At 10:23 A.M., the resident was at the dining room table and was not engaged in any
activity;
-At 11:00 A.M., the resident was in the living room area and was not engaged in any
activity and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-At 2:10 P.M., the resident was in bed.
Observation on 8/31/18 at 11:10 A.M., the resident was in the living room area. His/her
head was leaning forward and his/her eyes were closed. There was a movie on the
television.
During an interview on 8/31/18 at 12:16 P.M., the Activities Director said the resident
liked to get his/her nails done, played exercise games, did puzzles and colored.
6. Record review of Resident #56’s care plan dated 1/17/18 showed:
-Instructions to staff to:
–Continue to evaluate for activity participation interests;
–Provide the monthly activity calendar;
–Invite, remind and escort the resident to and from activities of choice and praise
evolvement;
–Assess for changes in activity pursuits;
–Provide leisure activity materials as requested by the resident;
–Provide a radio or television outside the resident’s room for added stimulation and
–Encourage the resident to help other residents.
Record review of the resident’s most recent activity progress note dated 7/6/18 showed the
resident was very talkative, liked visiting with other residents, staff and family, liked
to watch birds, read books and attended some socials.
Record review of the resident’s Activity assessment dated [DATE] showed:
-The resident’s religion was listed;
-The activities that were very important to the resident included reading westerns, music
(type not specified), dogs, news, talking with friends and going outside;
-The activities that were somewhat important to the resident included doing things with
groups of people and participating in religious services and
-The residents interests included reading (type not specified), music (type not
specified), wild life/nature, television (type not specified) and movies (type not
specified).
Record review of the resident’s Annual MDS dated [DATE] showed:
-The following staff assessment of the resident:
–Had moderately impaired cognitive skills;
–Did not walk;
–Used a wheelchair;
–Required supervision/oversight for locomotion;
–Had [DIAGNOSES REDACTED].
-The resident said reading, music, pets, news, group activities, doing his/her favorite
activities, going outside and religious activities were all very important to him/her.
Record review of the resident’s (MONTH) (YEAR) Activity Attendance Record showed:
-The resident actively participated in nails four times, reminiscing four times and
socials three times and
-There were 21 days without any documented activities for the resident in (MONTH) (YEAR).
Observation and interview on 8/24/18 during the initial tour which began at 9:21 A.M.
showed the resident was sitting in his/her wheelchair in his/her room and was not engaged
in any activity. The resident said they have nothing to do. He/she would like to play some
games. He/she would like to go out somewhere.
Observation on 8/24/18 at 12:36 P.M. showed the resident was self-propelling
himself/herself from the dining room toward the nurses’ station.
Observation on 8/29/18 at 9:30 A.M. showed the resident was getting his/her nails done.
Observation and interview on 8/30/18 showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
-At 9:28 A.M. the resident was sitting in his/her wheelchair by a bench toward the back of
the living room area. Some residents were playing bingo in the dining room. The resident
asked DHSS staff why they wasn’t playing bingo. The resident said he/she wasn’t playing
bingo because it’s boring;
-At 11:00 A.M., the resident was yelling at the nurses’ station saying he/she wanted to
get out and
-At 2:10 P.M., the resident was sitting in the hallway near the day room door and was not
engaged in any activity.
Observation on 8/31/18 at 11:10 A.M. showed the resident was asleep in bed.
During an interview on 8/31/18 at 12:16 P.M., the Activities Director said:
-Resident #50 liked to get his/her nails done, played exercise games, did puzzles and
colored;
-Resident #19 just wandered around the unit and did some social things;
-Resident #8 liked to get his/her nails done and watched a movie occasionally;
-Resident #56 liked to talk, sit in the dining room and drinks coffee, goes outside with
the Activities Director to spread out bird seed and listens to live music entertainers and
-Resident #37 sleeps until 11:30 A.M., will attend afternoon social activities, loves
puppy dogs and loves baby dolls.
-Observation on 8/31/18 at 2:20 P.M. showed the resident’s room had one plant, a clock on
the wall and birdseed hanging outside the window.
7. During an interview on 8/31/18 at 12:16 P.M., the Activities Director said:
-He/she worked at the facility for three years;
-He/she had been the activity director for one year;
-He/she worked full-time;
-He/she did not have an activities assistant;
-They have the Certified Nursing Assistants (CNAs) doing the activities for the residents
on the special care unit;
-The corporation said that when the facility’s census got to 75 residents, they could have
an activities assistant and
-The CNAs use the activity supplies that are in the day area.
During an interview on 8/31/18 at 1:30 P.M., Certified Medication Technician (CMT) A said:
-He/she had worked at the facility for one month;
-The nursing staff on the secure care unit do the resident activities;
-They usually all pitch in and do some sort of exercise in the A.M. like tossing the beach
ball, balloon ball, or noodle ball;
-They try to follow what activities are scheduled on the activities calendar;
-Some days the nursing staff have time to do the activities and some days they don’t and
-Some residents like to color or do puzzles so they put those residents at a table while
doing exercise with the other residents.
During an interview on 8/31/18 at 2:10 P.M., CNA G said:
-They try to do activities with the residents between meals, assisting residents with
using the toilet and giving showers;
-It’s hard to do the activities and all of the other cares they have to provide;
-Sometimes they have enough time sometimes, they don’t and
-They will put on a movie or turn on baseball or football game but they can’t really do a
large, organized group activity that involves a lot of their time.
During an interview on 8/31/18 at 4:24 P.M. the Administrator said the Activities Director
did not meet the qualifications of a qualified activity director.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0680

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure the activities program is directed by a qualified professional.

Based on interview and record review, the facility failed to ensure their activities
program was directed by a qualified activities professional. The facility census was 77
residents.
Record review of the facility’s Policy for Activity Director reviewed (MONTH) (YEAR)
showed the activities program was directed by a qualified professional.
1. During an interview on 8/31/18 at 12:16 P.M., the Activities Director said:
-He/she had been the activity director at the facility for one year and
-He/she was going to take an on-line Activity Director class.
During an interview on 8/31/18 at 4:24 P.M., the Administrator said:
-The Activity Director did not meet the qualifications of a qualified activity director;
-He/she placed multiple ads for a qualified activity director and he/she had not found
anyone;
-The current Activity Director was going to take an Activity Director class and
-He/she did not have any proof that the Activity Director had registered for the Activity
Director class.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to identify the
resident’s pants were too long and too big and caused a fall hazard for one sampled
resident (Resident #8) out of 18 sampled residents. The facility census was 77 residents.
1. Record review of Resident #8’s care plan initiated 11/10/16 showed the resident:
-Had impaired cognition related to dementia (a progressive mental disorder characterized
by memory problems, impaired reasoning and personality changes)
-Was a fall risk and
-Had the potential for weight loss.
Record review of the resident’s Minimum Data Set (MDS-a federally mandated assessment tool
completed by facility staff for care planning) showed the resident was 5 feet and 2 inches
tall and weighed:
-156 pounds on 11/19/16;
-155 pounds on 2/16/17;
-157 pounds on 5/15/17;
-159 pounds on 8/5/17;
-160 pounds on 11/17/17 and
-157 pounds on 2/12/18.
Record review of the resident’s quarterly MDS dated [DATE] showed the following staff
assessment of the resident:
-Had one non-injury fall since his/her last assessment (2/12/18);
-Was severely cognitively impaired;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 25)
-Walked in the halls with supervision;
-Wandered one to three days of the seven days of observation;
-Had a [DIAGNOSES REDACTED].>-Weighed 146 pounds.
Record review of the resident’s Situation, Background, Assessment, Recommendation (SBAR)
dated 5/28/18 showed the resident was found on floor where he/she had stepped in feces.
Record review of the resident’s SBAR dated 6/1/18 showed the resident was found sitting on
the floor on his/her bottom in front of a chair with his/her legs extended in front of
him/her with a plastic bag wrapped around his/her right shoe and tied to his/her leg.
Record review of the resident’s monthly weight and vitals sheet for (YEAR) showed the
resident weighed:
-142.2 pounds in (MONTH) (YEAR) and
-144.8 pounds in (MONTH) (YEAR).
Observation on 8/24/18 showed:
-At 1:17 P.M.:
–The resident stood up and his/her pants were so long that they came down to the floor
and about to the middle of his/her feet;
–The resident was wearing socks and no shoes;
–The resident walked on the bottom of the pants from the dining room to the 400 hall,
back into the dining room, back to 400 hall and back into the dining room and then he/she
sat down and
-At 1:24 P.M., the resident got up and walked down the 500 hall with his/her pants so long
that he/she was walking on them.
Observation on 8/29/18 at 5:23 A.M. showed the resident was walking from his/her room to
the dining room with his/her pants to long that he/she was walking on them and he/she was
not wearing shoes.
Observation on 8/29/18 at 7:31 AM showed the resident was walking in the hall toward the
nurses’ station with his/her pants so long that he/she was walking on them and he/she was
not wearing shoes.
Record review of the Social Services progress notes dated 5/28/17, 8/15/17, 11/13/17,
5/15/18 and 8/12/18 did not address any clothing issues.
Observation on 8/30/18 at 12:32 P.M. showed the resident stood up, grabbed his/her pants
around the waist that were too big around the waist. The resident was holding his/her
pants up on both sides while walking to the bathroom. Certified Nursing Assistant (CNA) G
went in the bathroom carrying several pairs of pants. The resident exited out of the
bathroom in a different pair of pants.
During an interview on 8/31/18 at 1:30 P.M., Certified Medication Technician (CMT) A said
he/she had heard some of the other staff talking the day before about the resident’s pants
being big around his/her waist and they said that maybe the resident had lost some weight.
During an interview on 8/31/18 at 2:10 P.M., CNA G said:
-The resident used to be taller than CNA G;
-The resident was now shorter than CNA G;
-He/she noticed the resident had gotten shorter and had lost some weight and
-He/she noticed some of the resident’s pants were big.
During an interview and record review on 8/31/18 at 6:03 P.M., the Social Services
Director said he/she had not heard about the resident’s pants being too big until he/she
received a note dated 8/30/18 that the resident needed some new pants.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide needed
oxygen via a portable oxygen tank for one sampled resident (Resident #47) out of 18
sampled residents. The facility census was 77 residents.
1. Record review of Resident #47’s entry tracking record showed that the resident admitted
to the facility on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the ability
of the lungs to perform ventilation);
-Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness,
tension, fast heart rate, and breathing difficulty not associated with an apparent
stimulus) and
-Oxygen therapy.
Record review of the resident’s Care Plan (written out plan for the care of the resident)
dated 7/17/18 showed the resident:
-Used oxygen at 2 Litters (L) per Nasal Cannula (NC-tubing with prongs that insert into a
resident’s nose to deliver oxygen) and
-Had a cognitive (thought process) loss.
Record review of the resident’s Minimum Data Set (MDS – a federally mandated assessment
tool completed by the facility staff for care planning) dated 7/17/18 showed that the
resident’s cognition was moderately impaired.
Observation on 8/24/18 at 9:41 A.M., showed the resident in his/her room wearing oxygen
per NC at 2 L from an oxygen concentrator (a machine that provides oxygen).
Observation on 8/27/18 at 9:22 A.M., showed: the resident:
-The resident had oxygen tubing with the NC in his/her nares;
-The resident had a portable oxygen tank on the back of his/her wheelchair and
-The portable oxygen tank level indicator was on empty.
Observation on 8/27/18 at 11:58 A.M., showed the resident’s portable oxygen tank level
indicator was still on empty.
During an interview on 8/30/18 at 11:45 A.M., the resident’s family member said that
sometimes when he/she visits that he/she finds the portable oxygen tank empty and has to
tell the staff to change it.
During an interview on 8/30/18 at 1:30 P.M., Certified Nurse Assistant (CNA) A said:
-CNA’s can check the level of oxygen on the portable oxygen tanks;
-If a tank is close to being empty or empty they can get a new tank;
-CNA’s can’t switch the tanks and
-The nurse has to switch the tanks because it is considered a medication.
During an interview on 08/31/18 at 4:42 P.M. the Director of Nursing (DON) said:
-Oxygen tanks should be checked each shift by the CNA or the Nurse and
-The Nurse is the one to change the tank since oxygen is a medication order.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to respond timely
to the pharmacist’s recommendation for one sampled resident (Resident #8) out of 18
sampled residents. The facility census was 77 residents.
During an interview on 8/31/18 at 4:43 P.M., the Administrator said they did not have a
policy specific to Drug Regimen Reviews (DRR) and responses to them.
1. Record review of Resident #8’s care plan dated 11/10/16 showed he/she received [MEDICAL
CONDITION] medications (medications used to alter brain chemistry in order to modify a
person’s emotional or cognitive (thinking) functions).
Record review of the resident’s quarterly Minimum Data Set (MDS- a federally mandated
assessment tool completed by facility staff used for care planning) dated 5/15/18 showed
the following staff assessment of the resident:
-Was severely cognitively impaired and
-Received antidepressant medication daily.
Record review of the resident’s DRR dated 6/27/18 showed a pharmacist’s recommendation to
decrease [MEDICATION NAME] (an antidepressant) from 10 milligrams (mg) to 5 mg.
Record review of the resident’s most recent physician’s progress note dated 7/20/18 showed
it did not address the pharmacist’s recommendation.
Record review of the resident’s DRR dated 6/27/18 showed the resident’s primary care
physician agreed to the pharmacist’s recommendation and wrote new orders on 8/22/18 to
discontinue [MEDICATION NAME] 10 mg, start [MEDICATION NAME] 5 mg for seven days and then
discontinue the [MEDICATION NAME].
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].>-A
physician’s orders [REDACTED].
-physician’s orders [REDACTED].
Observation on 8/24/18 during the initial tour which began at 9:21 A.M., the resident was
asleep in bed and his/her lights were off.
Observation on 8/27/18 at 9:33 A.M. showed the resident was asleep in bed.
During an interview on 8/27/18 at 1:00 P.M. the Social Services Director said:
-Their psychiatrist was the one who handled all the antipsychotic (class of medicines used
to treat [MEDICAL CONDITION] and other mental and emotional conditions) and [MEDICAL
CONDITION] medications (medications used to alter brain chemistry in order to modify a
person ‘ s emotional or cognitive (thinking) functions);
-Their psychiatrist had not been to the facility since (MONTH) (YEAR);
-They called their psychiatrist multiple times because he/she did not come back after
his/her last visit in (MONTH) (YEAR);
-Their psychiatrist kept saying he/she would come to the facility and he/she never showed
up and
-Finally, on 8/15/18, the psychiatrist sent them information indicating that he/she would
now require a stipend. They have contacted several other psychiatrists and are in the
process of selecting a psychiatrist to replace their previous psychiatrist.
During an interview on 8/27/18 at 1:08 P.M., the Administrator said they did not have a
contract with their previous psychiatrist.
During an interview on 8/29/18 12:01 P.M., the Director of Nursing (DON) said:
-The pharmacist emails his/her recommendations to him/her;
-He/she prints out the recommendations;
-He/she holds recommendations for psych medications to give to the psychiatrist and
-Their psychiatrist kept telling them he/she would come next week repeatedly and then sent
paperwork saying he/she needed a stipend before he/she would come back, so the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 28)
recommendations on the psych medications he/she had held had to be given to the primary
care physicians.

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 one sampled medication room of two
sampled medication rooms and two sampled medication carts of three sampled medication
carts for opened medications that had been prescribed by the physician. The facility
census was 77 residents.
Record review of the facility’s Procurement and Storage of Medications policy dated
(MONTH) 2006 showed all medication containers should be labeled with the date opened by
the person breaking the container seal.
1. Observation on 8/27/18 at 3:00 P.M. with the Director of Nursing (DON) of the
medication room between 100 and 200 hallways showed the following medications in the
refrigerator were opened without an opened date written on them:
-[MEDICATION NAME] (medication used to treat infections caused by bacteria) a 250
milligram (mg) bottle and
-[MEDICATION NAME] (medicine used to treat anxiety) a 2mg/milliliter (ml) bottle.
The 200 hallway medication cart showed the following medications were opened without an
open date written on them:
-Robofen DM (cough medication) syrup a 479 ml bottle and
-Senna (medication used to treat constipation) syrup a 237 ml bottle.
The 300 hallway medication cart showed the following medications were opened without an
open date written on them:
-[MEDICATION NAME]/APAP (pain medication) 7.5/325 mg a 120 ml bottle;
-[MEDICATION NAME] (pain medication) 100/5 ml a 30 ml bottle with a used oral syringe in
the box and
-Cough Syrup 100/5 ml a 473 ml bottle.
During an interview on 8/27/18 at 3:00 P.M., the DON said:
-He/she did not know why all the opened medications were not dated and
-The nursing staff had dated some of the medications and knew they were supposed to be
labeled when opened.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation, interview and record review, the facility failed to prevent a
combination of a buildup of grease, dust and dirt on the kitchen lights and vents located

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
above the kitchen stove and food preparation tables. This deficient situation of greasy
dirt on the lights and vents hanging over the food preparation areas and the stove
provides opportunities for dirty and greasy droppings, particulates and non-food, contact
contaminants to be added to the prepared food and meals which would affect all of the
residents and staff who eat from the kitchen. The facility census was 77 residents.
1. Observations on 8/29/18 between 5:01 A.M. and 7:55 A.M., during the facility’s kitchen
inspection, showed greasy dirt on the lights and vents hanging over the food preparation
areas and the stove.
During an interview on 8/29/18 at 6:02 A.M., the Dietary Manager said:
-He was unaware of the unsanitary conditions of the vents and lights;
-He did not know when they were cleaned last;
-They were not on a cleaning list in the kitchen; and
-It was the maintenance staffs responsibility to clean the lights and vents.
Record Review of the 2013 edition of the Food and Drug Administration (FDA) Food Code,
Chapter 6-202.12, showed, Heating, ventilating, and air conditioning systems shall be
designed and installed so that make-up air intake and exhaust vents do not cause
contamination of FOOD, FOOD-CONTACT SURFACES, EQUIPMENT, or UTENSILS.
Record review of the 2013 edition of the Missouri Food Code, Chapter 6-202.12, showed,
Heating, ventilating, and air conditioning systems shall be designed and installed so that
make-up air intake and exhaust vents do not cause contamination of food, food-contact
surfaces, equipment, or utensils.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure
appropriate infection control practices when staff failed to properly change their gloves
and wash their hands during incontinence care for four sampled residents (Resident #12,
#22, #270, and #375); to provide a clean surface for cleaning supplies for one sampled
resident (Resident #375); to keep a nephrostomy (a passage way maintained by a thin tube
placed through the back into the kidney to temporarily drain urine that is blocked) bag
below a resident’s bladder and off of the floor for one sampled resident (Resident #375)
and to properly change gloves and clean hands during a medication pass out of 18 sampled
residents . The facility census was 77 residents.
Record review of the facility’s Hand Washing policy dated revised 10/09 showed hand
washing was to be done:
-Before putting on gloves and
-After removal of gloves.
Record review of the facility’s Perineal cleansing policy dated revised 9/21/10 showed:
-After cleaning area remove gloves and wash hands with soap and water, cleansing gel or
Theraworx (a brand name of cleansing product that the facility uses);
-Note in bold type at end of policy:
–The basic infection control concept for peri-care is to wash from the cleanest to the
dirtiest area and
–Remember to change or remove gloves and wash hands when going from working with
contaminated items to clean items.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
1. Record review of Resident #12’s Admission Record Profile Face sheet showed he/she was
admitted on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] ([MEDICAL CONDITION], stroke, cerebral artery occlusion with infarct
(a blockage in the one or more of the arteries supplying blood to the brain resulting in a
stroke)) with residual effects of [MEDICAL CONDITION] (total or [DIAGNOSES REDACTED] of
one side of the body that results from disease of or injury to the motor centers of the
brain).
Record review of the resident’s Care Plan (written out plan for the care of the resident)
dated 5/14/18 showed:
-Impaired physical mobility related to a history [MEDICAL CONDITION] residual effects of
[MEDICAL CONDITION], max assist with Activities of Daily Living (ADL’s) and
-Alteration in bladder elimination with indwelling catheter (tubing inserted into the
bladder to drain urine) related to urine retention.
Observation of care on 8/31/18 at 1:43 P.M., showed:
-Certified Nursing Assistant (CNA) D with gloved hands closed privacy curtain and
-CNA D did not change his/her gloves, wash his/her hands or put on new gloves before
he/she cleaned the resident’s peri area and catheter tubing.
2. Record review of Resident #22’s Admission Record Profile Face sheet showed he/she was
admitted on [DATE] with the following Diagnoses: [REDACTED].
-Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension,
fast heart rate, and breathing difficulty not associated with an apparent stimulus);
-[MEDICAL CONDITION] (weakness, numbness, and pain from nerve damage, usually in the hands
and feet) and
-Metabolic [MEDICAL CONDITION] (abnormalities that adversely affect brain function).
Record review of the resident’s undated Care Plan with a next review date of 9/13/18
showed that the resident:
-Was dependent for ADL assistance and required moderate to maximum assistance with ADL’s
and transfers and
-Had an alteration in bladder elimination related to incontinence.
Observation of care on 8/29/18 at 6:29 A.M., showed CNA F:
-With gloved hands used the bed controller to raise the resident’s bed;
-Uncovered the resident and removed his/her dirty brief and
-Did not change his/her gloves, wash his/her hands, or put on new gloves before he/she
cleaned the resident’s lower private area.
3. Record review of Resident #270’s Admission Record Profile Face sheet showed that the
resident was admitted on [DATE] and readmitted on [DATE] with the following Diagnoses:
[REDACTED].
-Primary biliary [MEDICAL CONDITION], (an [DIAGNOSES REDACTED] disease that causes
progressive destruction of the bile ducts);
-Dated 8/10/18 [MEDICAL CONDITION] Simplex ([MEDICAL CONDITION] causing contagious sores,
most often around the mouth or on the genitals) and
-Dated 8/10/18 Vaginitis (an inflammation of the vagina that can result in discharge,
itching, and pain).
Record review of the resident’s Care Plan dated 1/16/18 showed that the resident had an
alteration in bladder elimination related to incontinence.
Observation of care on 8/30/18 at 10:33 A.M., showed CNA D:
-With gloved hands opened the resident’s drawer and removed a package of wipes;
-Unfastened and removed the resident’s brief and
-Did not change his/her gloves, wash his/her hands, or put on new gloves before cleaning
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
the resident’s lower private area and catheter tubing.
4. Record review of Resident #375’s Annual Minimum Data Set (MDS – a federally mandated
assessment tool completed by the facility staff for care planning) dated 6/12/18 showed
the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (loss of movement of both legs and generally the lower trunk).
Observation on 8/27/18 at 9:53 A.M., showed:
-The resident has two Nephrostomy (a passage way maintained by a thin tube placed through
the back into the kidney to temporarily drain urine that is blocked) bags;
-The resident’s right Nephrostomy bag was on the floor;
-Licensed Practical Nurse (LPN) B moved the resident’s breakfast tray off of the bedside
table;
-LPN B did not clean the bedside table and did not put a barrier down before putting the
nephrostomy supplies on the bedside table;
-LPN B did not change his/her gloves after cleaning the resident’s wound and applying the
clean dressing;
-The resident had a large bowel movement;
-LPN B did not change his/her gloves after cleaning up the bowel movement and before
cleaning the lower private area;
-LPN B pulled the resident’s pants up with the soiled gloves still on;
-LPN B gave the resident his/her TV remote control with the soiled gloves on;
-LPN B put the scissors (that were used to cut dressings off the resident) in his/her
pocket without cleaning them and
-While repositioning the resident the left nephrostomy bag was laid on the resident’s
stomach (higher than his/her bladder) which could cause the urine to flow back into the
resident’s kidneys.
During an interview on 8/31/18 at 11:00 A.M., the Director of Nursing (DON) said:
-The staff had been educated on hand hygiene;
-He/she would expect the staff to lay down a clean barrier for the supplies;
-He/she would expect the staff to change gloves and cleanse their hands between cleaning
soiled areas;
-He/she would expect the staff to clean their scissors after use;
-To treat a nephrostomy bag like a catheter bag and keep it below a resident’s bladder at
all times and
-To keep nephrostomy and catheter bags off of the floor and in a dignity bag.
During an interview on 8/31/18 at 2:02 PM CNA D said that when providing care he/she
would:
-Set supplies up;
-Close privacy curtains;
-Wash his/her hands and put on gloves;
-Wash from top to bottom of peri areas and sides of peri area;
-If the resident has a catheter he/she would take a hold of base of tubing and clean down
about 4 inches to clean it;
-Change gloves, wash hands and put on clean gloves;
-Roll the resident and clean buttocks from top to bottom;
-Change gloves, wash hands and put on clean gloves and apply any ordered barrier creams;
-Cover the resident and
-Change gloves, wash hands, and pit on clean gloves and put a new brief on the resident.
During an interview on 8/31/18 at 4:38 P.M., CNA E said:
-He/she would wash his/her hands between glove changing and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265595

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

NAME OF PROVIDER OF SUPPLIER

SHANGRI LA REHAB & LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
-Would not touch other items in and around the room while doing peri cares without
changing gloves, washing his/her hands and putting on clean gloves.
During an interview on 8/31/18 at 4:42 P.M., the DON said he/she would expect staff:
-To not to touch other items in room when doing peri cares without changing gloves,
washing hands and putting clean gloves on;
-To change gloves, wash hands and put clean gloves on when cleaning from one area of peri
care to another area;
-To always wash hands between each glove change;
-To wash hands after removing gloves when cares are finished and
-To clean scissors after use.
5. During an observation on 08/29/18 at 7:20 A.M. of the medication pass with Registered
Nurse (RN) B:
-Administered eye drops to a resident and changed gloves but did not cleanse his/her
hands;
-Checked a resident’s blood sugar with contaminated gloves;
-Cleaned the glucometer (machine used to check blood sugar) with contaminated gloves;
-Took off his/her gloves but did not cleanse his/her hands;
-Gave three oral medications to a resident with contaminated gloves;
-Gave a resident a shot of insulin with contaminated gloves;
-Put on a new pair of gloves then administered a nasal spray to a resident;
-Did not change gloves or cleanse his/her hands;
-Administered eye drops to a resident with contaminated gloves;
-Did not change gloves or cleanse his/her hands;
-Checked placement of a resident’s feeding tube and flushed it with water with
contaminated gloves;
-Crushed medications and opened capsules with contaminated gloves;
-Put medications into individual medication cups and administered medications into a
resident’s feeding tube with contaminated gloves;
-Flushed the feeding tube with water with contaminated gloves and
-Took off his/her gloves but did not cleanse his/her hands.
During an interview on 8/31/18 at 4:42 P.M. the DON said:
-The staff had been educated on hand hygiene and
-He/she expected staff to always wash their hands between each glove change.