Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on interview and record review, the facility failed to ensure incoming mail received
from the postal service for residents on Saturdays was delivered to the residents on the
same day. The facility census was 108 residents.
Record review of facility’s policy titled Mail Distribution dated 10/4/2017, showed:
-The facility is to ensure each resident’s personal mail (incoming and outgoing) is
handled in a private and confidential manner;
-The facility will distribute all incoming mail to the addressed patient/resident unopened
and within the same day on which it was delivered to the Activity Department and
-Activity Staff or Designated Volunteer will deliver personal mail to the resident’s room
within 24 hours of receipt.
1. During the Resident Council/Group Interview (interview held as a part of the survey
process) on 12/4/18 at 9:15 A.M., residents attending the Group Interview said mail comes
to the facility on Saturday, but is not delivered to the residents until Monday.
During an interview on 12/7/18 at 12:47 P.M., the Administrator said:
-The mail should be delivered on the day it is received;
-The weekend receptionist receives the mail on Saturday, but is not expected to deliver
it;
-The Activities Department handles the mail;
-We have been short-staffed in the Activities Department and they may not have been
getting the mail delivered on Saturdays as they did when fully staffed and
-No one was assigned to deliver the mail on Saturdays since being short-staffed in the
Activities Department.

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 ensure the resident and/or the
resident’s representative and the ombudsman (a resident advocate who provides support and
assistance with problems and/or complaints regarding the facility) was notified in writing
of the discharge to the hospital for six sampled residents (Resident #29, #11, #210, #58,
#57, and #100) out of 22 sampled residents and to ensure the resident and/or the
resident’s representative was notified in writing of the discharge to the hospital for one
sampled closed record resident (Resident #112) out of two sampled closed record residents.
The facility census was 108 residents.
Record review of facility policy titled Discharge/Transfer dated 11/1/2017 showed the
following instructions to staff:
-Obtain a discharge/transfer order from the physician and
-Notify the resident, his/her legal representative, if any, or an interested family member
and document the discharge.
1. Record review of Resident #29’s entry tracking records and discharge assessments showed
he/she:
-Entered the facility on 1/8/18;
-discharged from the facility with return anticipated on 8/17/18;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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 1)
-Re-entered the facility on 8/30/18;
-discharged from the facility with return anticipated on 9/20/18;
-Re-entered the facility on 9/29/18;
-discharged from the facility with return anticipated on 10/8/18 and
-Re-entered the facility on 10/29/18.
Record review of the resident’s temporary bed hold forms showed the resident was
transferred from the facility for 8/17/18, 9/20/18 and 10/8/18, and the facility did not
provide the resident or the resident’s representative a discharge/transfer notice that
included the reason for the transfer/discharge.
Record review of the facility’s monthly lists of residents discharged that was sent to the
Ombudsman showed the Ombudsman was not notified of the resident’s transfer/discharge for
8/17/18, 9/20/18 or 10/8/18.
2. Record review of Resident #112’s undated face sheet showed he/she:
-admitted to the facility on

[DATE] and
-Had [DIAGNOSES REDACTED].
Record review of the resident’s nurse’s notes dated 10/24/18 showed he/she was sent to the
hospital and had not returned to the facility as of 12/5/18 for acute onset of dysphagia
(difficulty in swallowing food and liquids) and was unable to initiate swallowing and was
drooling.
Record review of the resident’s medical record showed the resident and/or the resident’s
representative was not notified in writing of the resident being discharged to the
hospital.
3. Record review of Resident #210’s face sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Nurses’ Notes dated 11/23/18 showed he/she was transferred
to the hospital on [DATE] when he/she complained of pain after a fall.
Record review of the resident’s Daily Skilled Nurse Notes dated 11/28/18, showed he/she
returned to the facility with [DIAGNOSES REDACTED].
Record review of the resident’s medical record showed the resident and/or the resident’s
representative was not notified in writing of the discharged to the hospital.
Record review of the facility’s transfer/discharge documents showed there was no
transfer/discharge notice related to the resident’s transfer to the hospital.
Record review of the facility’s (MONTH) (YEAR) monthly list of residents discharged that
was sent to the Ombudsman showed the Ombudsman was not notified of the resident’s transfer
to the hospital on [DATE].
4. Record review of Resident #58’s face sheet showed he/she was most recently readmitted
to the facility on [DATE] with the following Diagnoses: [REDACTED].
Urinary tract infection (an infection in any part of the urinary system);
-Acute [MEDICAL CONDITION] (a condition in which the kidneys suddenly can’t filter waste
from the blood);
-Acute pancreatitis (an inflammation of the pancreas) and
-Mantle cell [MEDICAL CONDITION] (a disease that develops when the body makes abnormal
white blood cells).
Record review of the resident’s nurses notes showed:
-The resident had passed out coming back from a physician’s appointment on 10/31/18;
-The resident’s daughter took the resident to the hospital;
-The resident returned to the facility on [DATE];
-On 11/15/18 the resident was sent to the hospital for confusion;
-The resident returned to the facility on [DATE] and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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 2)
-No transfer notices were documented as having been sent with the resident, or sent to the
resident’s Designated Power of Attorney (DPOA), and if they notified the Ombudsman of the
resident being transferred to the hospital.
During an interview on 12/05/18 at 10:45 A.M. Licensed Practical Nurse (LPN) B said:
-He/she calls the resident’s physician to get an order to transfer the resident to the
hospital;
-He/she send copies of the resident’s face sheet, Medication Administration Sheet (MAR),
DPOA paperwork and Advance Directives with the resident when a resident is being
transferred to the hospital;
-He/she calls the family or DPOA and
-Nothing else is done.
5. Record review of Resident #11’s Discharge Minimum Data Set (MDS – a federally mandated
assessment tool completed by the facility staff for care planning) showed he/she had
discharges from the facility on the following dates:
-On 7/12/18, the resident had an unplanned discharge and was anticipated to return to the
facility and
-On 9/12/18, the resident had a planned discharge and was anticipated to return to the
facility.
Record review of the resident’s medical record from 12/3/18-12/7/18 showed:
-The staff did not document they sent a transfer/discharge notice with the resident and/or
the resident’s representative(s) with the reason for the transfer and
-The staff did not document they notified the Ombudsman of the resident’s transfer and the
reasons for the transfer on 7/12/18 and 9/12/18.
Record review of Resident’s Reentry MDS’s showed that the resident returned to the
facility on [DATE] and on 9/21/18.
6. Record review of Resident #57’s Nurses Notes dated 9/22/18 at 2:15 P.M., showed:
-The resident was incontinent of his/her bowels that was watery and had blood in it;
-The resident’s physician was notified the resident’s bloody diarrhea stool and gave an
order to send the resident to the hospital for an evaluation and treatment and
-At 2:30 P.M. the resident was transferred to the hospital by ambulance.
Record review of the resident’s medical record from 12/3/18-12/7/18 showed:
-The staff did not document they sent a transfer/discharge notice with the resident and/or
the resident’s representative(s) with the reason for the transfer and
-They staff did not document they notified the Ombudsman of the resident’s transfer and
the reasons for the transfer on 9/22/18.
Record review of the resident’s Nurses Notes dated 9/26/18 and not timed showed, the
resident was readmitted to the facility at 2:15 P.M.
7. Record review of Resident #100’s Nurses Notes dated on 11/15/18 at 3:00 P.M. showed the
resident was transferred to the hospital due to the rattling sounds in his/her lungs and
the resident’s physician and family was notified.
Record review of the resident’s medical record from 12/3/18-12/7/18 showed:
-The staff did not document they sent a transfer/discharge notice with the resident and/or
the resident’s representative(s) with the reason for the transfer and
-They staff did not document they notified the Ombudsman of the resident’s transfer and
the reasons for the transfer on 11/15/18.
Record review of the resident’s Nurses Notes dated 11/24/18 at 5:00 P.M. showed that the
resident returned to the facility at 4:20 P.M.
8. During an interview on 12/06/18 at 11:30 P.M., the Administrator said:
-They did not know they were supposed to do discharge/transfer letter when they initiated
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
a transfer or discharge until earlier this year;
-They found out about the requirement around (MONTH) (YEAR);
-They did a performance improvement plan in (MONTH) (YEAR) on the transfer/discharge
notifications and
-They revised the discharge/transfer notice form.
During an interview on 12/6/18 at 2:05 P.M., the Administrator said Social Services sends
the ombudsman notification of resident discharges monthly.
During an interview on 12/6/18 at 2:10 P.M., the Social Services Designee (SSD) said:
-He/she started notifying the Ombudsman in (MONTH) (YEAR) when a resident is discharged
from the facility and
-He/she sends monthly a notification of residents discharges to the Ombudsman on the 5th
of the month.
During an interview on 12/07/18 at 1:15 P.M., the Administrator said:
-They switched software systems this year;
-The SSD sends the admission and discharge list to the Ombudsman and
-The SSD probably didn’t realize the residents who are transferred/discharged to the
hospital and then return to the facility did not show up on the list in the new system.
F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to ensure a bed hold notice was
given to the resident or the resident’s representative upon transfer to the hospital for
two sampled residents (Residents #58 and #210) out of 22 sampled residents. The facility
census was 108 residents.
Record review of the facility policy titled Bed-Hold Policy dated 3/2006 showed:
-The facility’s leadership will provide a written bed-hold notice at the time of transfer
of a patient/resident for hospitalization or therapeutic leave. The facility’s Leadership
will re-admit a patient/resident according to applicable state and federal guidelines if
his/her hospitalization or therapeutic leave exceeds the bed-hold policy.
-Two written notices are provided to a patient/resident/family or legal representative
regarding the bed-hold policy in the event of hospitalization or therapeutic leave.
-The first notice is given on admission and is re-issued in the event that the bed-hold
policy was to change.
-The second notice is provided at the time of transfer for hospitalization or therapeutic
leave, and specifies the duration of the bed-hold policy.
1. Record review of Resident #58’s nurses notes dated 10/31/18 showed:
-The resident had passed out coming back from a physician’s appointment on 10/31/18 and
-The resident’s daughter took the resident to the hospital.
Record review of the resident’s nurse’s notes dated 11/2/18 showed the resident returned
to the facility on [DATE].
Record review of the resident’s medical record from 12/3/18-12/7/18 showed no
documentation that the bed hold policy was given to the resident or the resident’s
representative at the time of discharge.
During an interview on 12/05/18 at 10:45 A.M., Licensed Practical Nurse (LPN) B said:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-He/she would call the resident’s physician to get an order to transfer the resident to
the hospital;
-He/she would send copies of the resident’s face sheet, Medication Administration Record[REDACTED] -He/she would call the resident’s family or DPOA and
-There is nothing else he/she would do.
2. Record review of Resident #210’s face sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Nurses’ Notes dated 11/23/18, showed the resident was
transferred to the hospital on [DATE] after a fall.
Record review of the resident’s medical record showed the resident and/or the resident’s
representative was not notified or given a copy of the facility bed-hold policy.
Record review of the resident’s Daily Skilled Nurse Notes dated 11/28/18, showed he/she
returned to the facility with [DIAGNOSES REDACTED].
Record review of the facility’s copies of the bed-hold documents provided to residents
and/or the residents’ representative(s) showed the resident and/or the resident’s
representative did not receive a copy of the facility’s bed-hold policy upon the
resident’s transfer to the hospital on [DATE].
During an interview on 12/06/18 at 11:30 PM, the Administrator said:
-They did not know they were supposed to do bed hold letters when they initiated a
transfer or discharge until earlier this year;
-They found out about the requirement around (MONTH) (YEAR);
-They did a performance improvement plan in (MONTH) (YEAR) on the bed hold notifications;
and
-They revised the bed hold notification form.
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 accurately
reflect the resident’s as needed (prn) pain medication administration and to consistently
document the location of the pain, the severity of the pain and the effectiveness of the
pain for one sampled resident (Resident #72) out of 22 sampled residents. The facility
census was 108 residents.
Record review of the undated facility policy titled Drug Administration General Guidelines
showed:
-The Medication Administration Record (MAR) is initialed by the person administering a
medication, in the space provided under the date, and on the line for the specific
medication dose administered and
-Documentation for as needed medications will include the date and time of administration,
dose, complaints or symptoms for which medication was given, results achieved from giving
the dose and the time results were noted.
1. Record review of Resident #72’s Admission Minimum Data Set (MDS-a federally mandated
assessment instrument completed by facility staff for care planning) showed the following
staff assessment of the resident:
-Cognitively intact and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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 5)
-Received scheduled and as needed pain medication.
Record review of the resident’s pain care plan dated 11/6/18 showed the resident
experienced generalized and frequent pain.
Record review of the resident’s (MONTH) (YEAR) MAR and Individual Patient Narcotic
(medication used to dull the senses, used for pain relief and is highly addictive) Records
dated 11/7/18 showed:
-A physician’s orders [REDACTED].
-[MEDICATION NAME] 5 mg IR, one tablet was documented as administered 50 times on the
Individual Patient Narcotic Record;
-[MEDICATION NAME] 5 mg IR, one tablet was documented on the front of the MAR as
administered 23 times (27 times less than on the narcotic record);
-The time [MEDICATION NAME] 5 mg was administered was not documented twice on the MAR;
-The reason [MEDICATION NAME] 5 mg was administered was not documented 18 times on the
MAR;
-The level of the pain was not documented 17 times on the MAR and
-The effectiveness was not documented eight times on the MAR.
Record review of the resident’s (MONTH) (YEAR) MAR and Individual Patient Narcotic Records
dated 11/7/18 and 12/1/18 showed:
-A physician’s orders [REDACTED].
-[MEDICATION NAME] 5 mg IR, one tablet was documented as administered 18 times on the
Individual Patient Narcotic Record;
-[MEDICATION NAME] 5 mg IR, one tablet was documented on the front of the MAR as
administered nine times (nine times less than on the narcotic record);
-The pain scale and effectiveness was not documented one time on the front of the MAR and
-[MEDICATION NAME] 5 mg IR, one tablet was documented on the back of the MAR as
administered six times (12 times less than on the narcotic record and three times less
than the front of the MAR).
During an observation and interview on 12/4/18 at 8:10 A.M., the resident was sitting in
his/her room in his/her wheelchair and said his/her right knee was bad.
During an interview on 12/07/18 at 9:30 AM, Licensed Practical Nurse (LPN) A said when
they administered as needed pain medication, they should document on the MAR what was
administered, when it was administered, the reason it was administered or the location of
the pain, how severe the pain was and they should follow-up and document the effectiveness
of the pain medication and the time the follow-up was noted
During an interview on 12/07/18 at 1:15 P.M., the Assistant Director of Nursing (ADON)
said:
-The MAR should reflect the same pain medication administration as the Individual Patient
Narcotic Record and
-The nurses should document on the MAR what was administered, when it was administered,
the reason it was administered, how severe the pain was and they should follow-up and
document the effectiveness of the pain medication.
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
requested drinks while in the dining room waiting for meals to arrive for one sampled
resident (Resident #17), out of 22 sampled residents. The facility census was 108.
Record review of the facility policy titled Self-Determination dated 10/31/2017, showed:
-The facility will promote and facilitate the residents’ right to self-determination by
exploring their daily routines and preferences when living in the community and continuing
such routines and preferences to the extent possible.
-During initial assessments, the Interdisciplinary Team (IDT) will review and document the
resident’s personal preferences such as:
–Food preferences and the time of day the resident prefers to eat his/her meals. The
facility will make reasonable effort to honor resident choices about aspects of his/her
life in the facility that is significant to the patient/resident;
–The facility will make reasonable effort to honor resident choices about aspects of
his/her life in the facility that is significant to the patient/resident and
–The facility will strive to honor the patients/residents known preferences and choice
whenever possible without compromising safety.
1. Record review of Resident #17’s face sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Significant Change Minimum Data Set (MDS – a federally
mandated assessment instrument completed by facility staff for care planning) dated
9/02/18, showed he/she:
-Was cognitively moderately impaired for daily decision making;
-Needed extensive assistance with bed mobility and transfers;
-Needed total assistance with dressing, toilet use and personal hygiene and
-Required setup of meals only and needed encouragement and cueing during meals.
Record review of the resident’s Care Plan showed:
-Interventions initiated 7/10/18 included encouraging fluids during the day to prevent UTI
(urinary tract infections – bacteria or viruses entering any part of the urinary system).
-Interventions initiated 9/10/18, showed the resident had the potential for fluid deficit
related to diuretic use; and interventions and staff tasks included:
-Encouraging the resident to drink fluids of choice and
-Providing required nectar thick liquids.
Record review of the resident’s Physician’s Order Sheet (POS) for (MONTH) (YEAR) showed
his/her diet orders were for pureed food and nectar thickened liquids.
Observation on 12/04/18 showed the following:
-At 11:16 A.M., the resident was brought to dining room in his/her Broda (specialized
wheelchair) chair by Certified Nurse Assistant (CNA) F;
-Residents already seated in the dining room had drinks, and other residents received
drinks after being seated in the dining room;
-The resident requested some chocolate milk four times;
-CNA G was standing in the dining room area and appeared to be ignoring the resident;
-The resident kept asking for chocolate milk.
-CNA G told the resident they were going to bring it down on his/her tray;
-At 11:23 A.M., the resident asked for chocolate milk again;
-CNA G told the resident it’s going to come on your tray Honey;
-Other residents had drinks, but the resident did not have one, and was not offered one;
-At 11:35 A.M. CNA G raised the resident’s Broda to the upright position;
-The resident’s tray was placed on the table in front of him/her;
-There was no chocolate milk on the tray;
-At 11:36 A.M. the resident asked for chocolate milk four more times;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
-He/she began eating his/her food and
-After eating a few bites of his/her pureed Swiss steak, he/she asked to leave the dining
room.
During an interview on 12/04/18 at 2:10 P.M. CNA G said:
-The resident was not allergic to chocolate milk and there was no restriction that would
keep the resident from having chocolate milk;
-Usually it comes down thickened. She gets it at breakfast on her tray;
-He/she didn’t know if they had any chocolate milk on the unit;
-The resident’s milk needed to be thickened and
-There should be some thickener here on the unit.
During an interview on 12/04/18 2:29 P.M. CNA F said:
-The resident did not get chocolate at lunch when he/she was asking for it because he/she
required thickened liquids;
-For the past week the resident had only been eating about 25% of his/her food and
-The resident drinks all of his/her drinks at breakfast, thickened coffee and chocolate
milk, but has declined eating his/her food.
During an interview on 12/04/18 at 2:39 P.M., Licensed Practical Nurse (LPN) D said:
-Usually the resident’s thickened drinks come from the kitchen already thickened;
-There was thickened coffee packets for the resident because he/she likes to drink coffee;

-He/she thought there was some thickener on the unit;
-Thickened chocolate milk could have been ordered from the kitchen and
-When a resident makes a special request staff can call the kitchen to ask for what the
resident wants.
Observation on 12/05/18 at 7:42 A.M. showed:
-The resident asked LPN D for a drink (he/she had finished his/her glass of milk);
-LPN D told the resident his/her drink was coming down on his/her tray and
-LPN D was serving other residents juice.
Observation on 12/5/18 beginning at 11:08 A.M. showed:
-Residents coming to dining area for lunch being given drinks (red punch) after they were
seated;
-At 11:55 A.M. residents in the dining room continued receiving red punch prior to lunch
arriving on the unit;
-The resident began asking for strawberry pop, repeating over and over I want pop .I want
strawberry popand
-No staff one responded.
During an interview with CNA C on 12/5/18 at 11:56 A.M. when asked why the resident wasn’t
getting a drink, CNA C said:
-The resident was not receiving a drink because his/her liquids had to be thickened and
-He/she did not know if there was thickener on the unit.
During an interview on 12/7/18 at 1:15 P.M., the Director of Nursing (DON) said:
-Drinks should have been thickened and served to the resident and
-There should have been thickener on the unit.

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
Based on observation, interview and record review, the facility failed to complete
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) treatments as
ordered for one sampled resident (Resident #29) out of 22 sampled residents. The facility
census was 108 residents.
Record review of facility’s Wound Care Principles for Managing and Treating pressure
ulcers revised 6/1/2015 showed:
-Once a resident experiences a pressure ulcer, an evaluation should take place immediately
that determines the severity of injury and the treatment interventions necessary. Once the
evaluation has been completed, the primary care provider is notified of the pressure area
and provides a treatment order and
-Wound treatments are provided per physician orders and documented as complete. Daily
documentation includes description of wound bed, drainage, odor, color, and if signs or
symptoms of pain were present during the treatment.
1. Record review of Resident #29’s pressure ulcer risk evaluation/prevention intervention
protocol dated 9/11/18 showed he/she was at high risk for the development of pressure
ulcers.
Record review of the resident’s significant change Minimum Data Set (MDS- a federally
mandated assessment instrument completed by facility staff for care planning) dated
9/12/18 showed the following staff assessment of the resident:
-Required extensive assistance of one person for bed mobility;
-Required extensive assistance of two people for transfers;
-Did not walk;
-Had a [DIAGNOSES REDACTED].>-Had no skin impairment.
Record review of the resident’s pressure ulcer risk care plan dated 9/19/18 showed:
-The resident was at risk for pressure ulcers related to [MEDICAL CONDITION] (cancer that
has spread from where it originated to different parts of the body), [MEDICAL CONDITION] (treatment that uses drugs to stop the growth [MEDICAL CONDITION] cells), incontinence and
impaired mobility and
-Interventions included weekly skin inspections, a pressure relief mattress, keep the
resident clean and dry as possible, obtain labs as ordered, provide diet as ordered and
use absorbent briefs.
Record review of the resident’s discharge assessment dated [DATE] showed he/she
transferred/discharged from the facility and it was expected the resident would return to
the facility.
Record review of the resident’s entry tracking form dated 10/29/18 showed he/she returned
to the facility.
Record review of the resident’s Clinical Health Status form dated 10/29/18 showed:
-The resident had a pressure ulcer on his/her buttock (the side of a person’s bottom) and
two pressure ulcers on his/her coccyx (tailbone) and
-The form included a Braden Scale (a pressure ulcer risk assessment instrument) that
showed the resident was not at risk for the development of pressure ulcers.
Record review of the resident’s nurse’s note dated 10/29/18 showed:
-The resident readmitted to the facility with two small pressure ulcers on his/her
buttocks and one small pressure ulcer on his/her coccyx and
-A dressing was observed on the area.
Record review of the resident’s Licensed Nurse skin assessment dated [DATE] showed:
-Open area was check marked and
-Under other, coccyx and buttock were hand-written.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
Record review of the resident’s telephone order dated 11/8/18 showed a physician’s order
for zinc oxide ointment (a skin protectant) mixed with triple antibiotic ointment
(TAO-used to prevent infection and encourage healing); apply to open areas on buttocks
three times a day and as needed.
Record review of the resident’s Treatment Administration Record (TAR) dated 11/8/18
showed:
-Physician’s orders for zinc oxide ointment mixed with TAO, apply to open areas on
buttocks three times a day and as needed and
-The treatment was initialed as completed 11/8/18-11/30/18.
Record review of the resident’s skin assessment dated [DATE] showed old open area was
check marked.
Record review of the resident’s nurses’ notes showed there were no nurses’ notes between
11/15/18 at 3:00 P.M. and when the resident’s medical record was reviewed on 12/06/18 at
9:55 A.M.
Record review of the resident’s skin assessment dated [DATE] showed old open area was
check marked.
Record review of the resident’s (MONTH) (YEAR) Physician’s Order Sheet (POS) showed
physician’s orders dated 11/8/18 for zinc oxide ointment mixed with TAO, apply to open
areas on buttocks three times a day as needed (The order as written on the (MONTH) (YEAR)
POS was three times daily as needed. The order in (MONTH) (YEAR) was three times daily and
as needed and there was no physician’s order to change the order to as needed only).
Record review of the resident’s telephone order dated 12/3/18 showed:
-Physician’s orders to clean with normal saline/wound cleanser and pat dry. Apply Santyl
(an ointment used for pressure ulcers that helps remove dead tissue), Vaseline gauze and
bordered dressing and secure daily and as needed on the day (7:00 A.M.-3:00 P.M.) shift
and
-The locations of the pressure ulcers were not included in the treatment order.
Record review of the resident’s (MONTH) (YEAR) TAR showed physician’s orders for Zinc
mixed with TAO to open areas on buttocks three times daily as needed (should have been
three times daily and as needed) were not completed at all in (MONTH) (YEAR)
(12/1/18-through 12/7/18).
Observation on 12/3/18 at 9:22 A.M. and 10:45 A.M. showed the resident was asleep in bed.
Observation and interview on 12/4/18 at 8:20 A.M. showed:
-The resident was in bed.
-The resident said:
–He/she slept all day yesterday;
–He/she received [MEDICAL CONDITION] weekly on Thursdays and
–He/she had a doctor’s appointment today out of the facility.
Observation on 12/4/18 at 1:48 P.M. showed the resident was not in the building. The
Assistant Director of Nursing (ADON) said the resident was still out at his/her
appointment.
Record review on 12/4/18 at 2:02 P.M. showed the Santyl treatment order was not
transferred onto the resident’s (MONTH) (YEAR) TAR.
Record review on 12/4/18 at 2:20 P.M. showed the resident’s care plan did not include
his/her pressure ulcers.
During an interview on 12/5/18 at 7:07 A.M., Licensed Practical Nurse (LPN) A (the charge
nurse for the area where the resident resided) said he/she did not have any residents in
his/her area that required wound treatments that day.
During an interview on 12/5/18 at 7:08 A.M., the Administrator said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
-The nurses do all wound treatments and
-They don’t have a designated nurse who does wound treatments.
Observation on 12/05/18 at 10:13 A.M. and 11:54 A.M. showed the resident was in bed on
his/her back asleep.
During an interview on 12/6/18 at 9:07 A.M., the ADON said:
-The nurse should document information regarding any new pressure ulcers in the nurses’
notes;
-They have a wound team physician that comes weekly on Thursdays;
-The resident had excoriation (scratches or abrasions of the skin);
-The areas opened this week and
-They are planning on the resident being seen by the wound team today.
Observation on 12/6/18 at 9:30 A.M., 1:00 P.M. and 3:25 P.M. showed the resident was not
in the building (the resident was at [MEDICAL CONDITION]).
Record review of the resident’s nurse’s note dated 12/6/18 showed:
-The wound team was unable to see the resident on 12/6/18 because the resident was out of
the facility at an appointment;
-The resident’s wounds were assessed when he/she returned from his/her appointment;
-The resident had two open wounds.
-The following was the description of the pressure ulcer on the resident’s right buttock:
–It measured 2.4 centimeters (cm) x 3.2 cm x 0.1 cm.
–The wound bed had black, necrotic (dead) tissue.
–It was unstageable.
–It had no drainage.
-The following was the description of the pressure ulcer on the resident’s coccyx:
–It measured 1.6 cm x 1.9 cm x 0.2 cm.
–The wound bed was pink with some yellow slough (nonviable yellow, tan, gray, green or
brown tissue; usually moist, can be soft, stringy and mucinous in texture);
–It had no drainage;
–It was a Stage 3 pressure ulcer (Full-thickness loss of skin, fat is visible,
granulation tissue is often present, slough and/or eschar may be present but they do not
obscure the extent of tissue loss).
-The resident denied any pain or discomfort;
-The areas around the wounds were reddened and blanchable (when redness fades when the
skin is touched and released);
-The resident [MEDICAL CONDITION] and has been receiving [MEDICAL CONDITION];
-The resident goes out of facility frequently to appointments and sits in his/her
wheelchair for long periods of time and
-The resident prefers to stay in bed most of the time when he/she is at the facility and
prefers to lie on his/her back.
Record review of the resident’s (MONTH) (YEAR) TAR showed:
-The Santyl treatment order was undated and left blank as not completed 12/3/18-12/5/18
(three days) with no documented reason for why the treatment was not completed as ordered;
-The Santyl treatment was initialed and circled on 12/6/18 as not being completed during
the day shift on 12/6/18 because the resident was out to an appointment and
-The Santyl treatment was not completed on 12/6/18 on the evening or night shift.
During an interview on 12/07/18 at 8:35 A.M., the ADON said:
-They had not been doing the resident’s new wound treatment (from 12/3/18) this week;
-The Santyl telephone treatment order should have been transferred to the (MONTH) (YEAR)
TAR;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
-They usually go over the telephone orders at their daily morning meetings and
-They did not have their meetings this week, so they did not notice that it was not placed
on the TAR.
Observation on 12/7/18 at 9:17 A.M. showed the resident was asleep in bed.
Record review of the resident’s care plan on 12/7/18 showed:
-The pressure ulcer care plan developed on 9/19/18 was updated (no date documented);
-The resident had an unstageable pressure ulcer on his/her right buttock and a Stage 3
pressure ulcer on his/her coccyx.
-Interventions included:
–Treatment as per order;
–Monitor for increased pain;
–Monitor for signs and symptoms of infection;
–Would not benefit from low air mattress as it would increase the resident’s fall risk
and
–Wound team to follow.
During an interview on 12/7/18 at 9:30 A.M., LPN A said:
-He/she did not know the resident had a new (12/3/18) wound treatment order (until
12/6/18);
-When the telephone treatment order was taken, the new order should have been written on
the TAR;
-The resident prefers to lie on his/her back;
-He/she wasn’t able to do the resident’s treatment yesterday because the resident was
still gone to an appointment at the end of his/her shift and
-The evening shift was going to do the resident’s treatment on 12/6/18.
Observation on 12/7/18 at 10:09 A.M. showed the resident was asleep in bed.
During an interview on 12/7/18 at 10:10 A.M., LPN A said:
-He/she did the resident’s treatment this morning around 7:00 A.M;
-The resident had to have a transfusion yesterday;
-The resident did not look well this morning and
-He/she would keep checking on the resident to see if the resident wakes up.
During an interview on 12/7/18 at 1:15 P.M., the ADON said:
-He/she thought the Zinc mixed with TAO was as needed only but that was incorrect.
Therefore, the (MONTH) TAR was inaccurate;
-The Zinc mixed with TAO order did not change from (MONTH) (YEAR) to (MONTH) (YEAR) and
-The Zinc mixed with TAO should have been done three times daily and as needed in (MONTH)
(YEAR).
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete an ongoing
assessment of the resident’s condition and monitor for complications before and after[MEDICAL TREATMENT] treatments received at a certified [MEDICAL TREATMENT] facility for
one sampled resident (Resident #89) out of 22 sampled residents. The facility census was
108 residents.
Record review of facility policy titled Shunt Care-Arteriovenous dated 11/1/2016 showed:
-Care will be directed by qualified licensed nursing staff in order to maintain the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
patency of the Arteriovenous shunt, prevent complications, i.e., infection, bleeding and
trauma, and identify specific measures to follow, if complications occur.
-Routine shunt care:
–Shunt care is provided with a physician’s orders [REDACTED].
–Inspect shunt sites every shift for color, warmth, redness, [MEDICAL CONDITION] and
drainage.
–Inspect and auscultate the shunt for bruit and thrill ( a pulsation felt of blood
flowing through the Arteriovenous anastomosis.
–Check for bruit upon return from [MEDICAL TREATMENT] and then once per shift. If the
bruit changes in regularity and depth or a thrill is not palpable, Notify the physician
immediately.
-Post [MEDICAL TREATMENT] Care:
–Take vital signs upon return from [MEDICAL TREATMENT]. If blood pressure variance
occurs, or the patient/resident status warrants, take vital signs as needed and/or as
ordered by the physician.
–Inspect the shunt site for color, warmth, redness, and [MEDICAL CONDITION].
–Leave the dressing in place for twenty-four (24) hours after [MEDICAL TREATMENT] unless
contraindicated or as ordered by the physician. Inspect the dressing for evidence of
drainage.
-Dressing changes:
–Document date, time, shunt site condition, and patency post [MEDICAL TREATMENT] and
shunt care in the medical record.
1. Record review of Resident #89’s face sheet showed he/she was admitted on [DATE] with
the following Diagnoses: [REDACTED].
-Muscle weakness;
-Cognitive communication deficit (problems with communication with an underlying cause)
and
-[MEDICAL TREATMENT] (the process of removing excess water, solutes, and toxins from the
blood in people whose kidneys can no longer perform these functions naturally).
Record review of the resident’s care plan showed:
-The resident has [MEDICAL TREATMENT] treatment on Tuesday, Thursday, and Saturdays
related to end stage [MEDICAL CONDITION];
-The resident was to be assessed for signs/symptoms of infection at the access site prn
(as needed);
-The care plan was dated 11/01/18 and
-The physician approved of the care plan.
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
-Nursing staff should check the right arm shunt for bruit (sound generated by the flow of
blood) and the thrill (feel for the vibration) each shift (7-3), (3-11), and (11-7) and
-The physician signed the order on 11/14/18.
Record review of the resident’s nurse’s notes starting on 11/14/18 showed:
-The resident’s skin had been checked once on 11/18/18 on the night shift and
-36 opportunities had been missed (all three shifts for 12 days).
Record review of the resident’s (MONTH) (YEAR) POS and Medication Administration Record
(MAR) showed:
-The resident had been admitted to the facility on [DATE];
-The physician did not write an order to check the shunt until 11/14/18 and
-Nursing staff did not document checking the shunt on the MAR as ordered by the physician
until 12/01/18.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
During an interview on 12/5/18 at 10:00 A.M., Licensed Practical Nurse (LPN) C said:
-The resident had a shunt in his/her right arm;
-He/she checked it every shift;
-The assessment should be charted in MAR (medication administration record);
-The resident came in with the [MEDICAL TREATMENT] shunt;
-LPN C was not able to find documentation in the (MONTH) MAR assessing the shunt and
-The nurse could not find any daily skilled nurse’s notes after 11/18/18 where the
skin/[MEDICAL TREATMENT] shunt was assessed.
During an interview on 12/06/18 at 2:02 P.M., LPN A said:
-The [MEDICAL TREATMENT] shunt assessment should be documented on the (MONTH) (YEAR) MAR;
-The nurse could not find any documentation on the (MONTH) (YEAR) MAR and
-It probably did not get transferred over from the month before.
During an interview on 12/12/18 at 2:30 P.M. with the Assistant Director of Nursing (ADON)
said:
-The resident’s [MEDICAL TREATMENT] shunt should be assessed by a nurse every shift and
-The assessment should be documented on the MAR.
F 0791

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide or obtain dental services for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure routine
dental service was provided for one sampled resident (Resident #77) out of 22 sampled
residents. The facility census was 108 residents.
1. Record review of Resident #77’s face sheet showed he/she was admitted to the facility
on [DATE].
Observation and interview of the resident during the initial tour of the facility on
12/3/18 at 9:39 A.M. showed the resident was missing top and bottom teeth. The resident
said:
-It would be better if he/she had some teeth in the middle to bite sandwiches and
-He/she likes eating just about anything and teeth in the middle would make it easier to
eat.
Record review of the resident’s Significant Change Minimum Data Set (MDS-a federally
mandated assessment tool completed by the facility staff for care planning) dated
10/25/18, showed he/she:
-Was cognitively impaired for making decisions;
-Needed eating encouragement and cueing and
-Had a check mark in the box stating none of the listed oral/dental concerns were present,
which included difficulty with chewing.
Record review of the resident’s medical record showed no documentation of dental
cleanings, no dentist progress notes and no documentation showing dental visits were
attempted.
During record review and interview with Licensed Practical Nurse (LPN) D on 12/7/18 at
11:22 A.M., he/she said:
-He/she could not find any record of dental service for the resident;
-When the dentist comes to the facility we take the residents upstairs to see the dentist
and
-He/she did not remember ever taking the resident to see the dentist.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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 0791

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
During an interview on 12/7/18 at 1:15 P.M., with the Director of Nursing (DON) and
Assistant Director of Nursing (ADON), the ADON said:
-Some of the residents don’t have dental coverage;
-Residents usually don’t see the dentist if they don’t have a problem with their teeth
when the dentist comes in and
-Residents do not get routine annual oral exams.
During an interview on 12/7/18 at 2:14 P.M. the Social Services Designee (SSD) said:
-He/she did not see any record showing the resident visited with the dentist that comes to
the facility and
-The resident evidentially had not had an oral exam since admission to the facility over a
year ago.
F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation, interview, and record review, the facility failed to ensure that
foods are maintained at a safe and appetizing temperature on the steam table according to
current Food and Drug Administration (FDA) standards (at or less than 41 degrees
Fahrenheit for cold foods and at or above 135 degrees for hot). This practice potentially
affected all residents who ate food from the kitchen. The facility census was 108
residents.
1. Observations on 12/3/18 between 10:01 A.M. and 12:35 P.M., showed the Day Cook (DC)
placing foods on the steam table and subsequently serving the lunch meal without
temperatures being taken to confirm they were maintained correctly.
During an interview on 12/3/18 at 1:03 P.M., the DC said:
– Food temperatures were not taken at the steam table on this occasion;
– The temperature log was introduced a couple months ago when the new Dietary Manager came
and
– The temperature log did have a column for steam table temps.
Record review of the food temperature log book provided by the DC on 12/3/18 at 1:05 P.M.,
showed that food temperatures had yet to ever be recorded after being placed on the steam
table.
During an interview on 12/4/18 at 1:30 P.M., the Dietary Manager said that food
temperatures should be taken again at the steam table after initial meal preparation.
Review of the FDA 2013 Code showed at Section 3-501.16 Time/Temperature Control for Safety
Food, Hot and Cold Holding, that:
(A) Except during preparation, cooking, or cooling, or when time is used as the public
health control as specified under Section 3-501.19, and except as specified under
paragraph (B) and in paragraph (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY
FOOD shall be maintained:
(1) At 57 degrees Celsius (C) (135 degrees Fahrenheit (F)) or above (for hot foods),
except that roasts cooked to a temperature and for a time specified in paragraph
3-401.11(B) or reheated as specified in paragraph 3-403.11(E) may be held at a temperature
of 54 degrees C (130 degrees F) or above; or (2) At 5 degrees C (41 degrees F) or less
(for cold foods).

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation and interview, the facility failed to thoroughly clean floors in the
kitchen and walk-in refrigerator; to maintain a sanitary and easily cleanable large can
opener, scoop, and spatula; to remove and isolate dented cans; to have a thermometer
inside a reach-in refrigerator; to store items labeled Keep Frozen in the freezer; and to
employ proper hand hygiene for the prevention of foodborne illnesses. These deficient
practices potentially affected all residents who ate food from the kitchen. The census was
108 residents.
1. Observations during the kitchen inspection on 12/3/18 between 9:15 A.M. and 12:35 P.M.,
showed the following:
– Two butter pods were on the floor under a rack in the walk-in refrigerator;
– There was a dessert bowl under the dishwashing area with some food still in it;
– The large manual can opener had food and paper residue on the blade;
– In the dry storage there were three dented cans on the rack and shelves; a 105 ounce
(oz.) can of fruit cocktail, a 104 oz. can of sliced apples, and a four pound (lb.) can of
chunk light tuna;
– There was an unopened box with six five lb. cartons of pasteurized liquid frozen egg
product in the walk-in refrigerator labeled Keep Frozen;
– A small blue scoop had food residue on the outer bowl and a smaller spatula’s edge was
very chipped and not easily cleanable;
– There was no thermometer in the reach-in refrigerator;
– The Day Cook and morning Dietary Aide did not wash hands or put new gloves on between
food preparation tasks and
– Open boxes of gloves were available.
Observations on 12/04/18 at 11:25 A.M., showed the same residue still on the large can
opener blade.
During an interview on 12/4/18 at 1:30 P.M., the Dietary Manager said:
– The walk-in floors were to be cleaned by whoever stocks them and detailed every
Wednesday and Friday;
– The large can opener should be cleaned after each use by whomever uses it;
– Dented cans are to be put aside for credit or disposal;
– If something is labeled Keep Frozen it should be in the freezer unless currently being
used;
– It is expected that food preparation and serving utensils are free from food residue and
easily cleanable;
– All refrigerators and freezers should have thermometers inside and
– The staff had been educated on hand hygiene by the Assistant Director of Nursing (ADON).

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 use appropriate
infection control measures to prevent the potential for development and transmission of

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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 – Few

(continued… from page 16)
communicable diseases by not using clean techniques during resident care for one sampled
resident (Resident #17), and by failure to perform proper hand washing between glove
changes for two sampled residents (Resident #6 and #36), out of 22 sampled residents. The
facility census was 108 residents.
Record Review of the facility policy titled Hand Hygiene/Hand Washing dated 11/27/2017
showed:
-Hand Hygiene/Hand washing is the most important component for preventing the spread of
infection;
-Maintaining clean hands is important for patients/residents/visitors as well as staff.
-Hand hygiene/hand washing is done:
–Before patient/resident contact;
–Before taking part in a medical or surgical procedure;
–After contact with soiled or contaminated articles, such as articles that are
contaminated with body fluids;
–After patient/resident contact;
–After contact with a contaminated object or source where there is a concentration of
microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds and
–After removal of medical/surgical or utility gloves.
1. Record review of Resident #17’s face sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Significant Change Minimum Data Set (MDS – a federally
mandated assessment instrument completed by facility staff for care planning) dated
9/2/18, showed the rsident:
-Was cognitively moderately impaired for daily decision making;
-Needed extensive assistance with bed mobility and transfers;
-Needed total assistance with dressing, toilet use and personal hygiene and
-Was incontinent of bowel and bladder.
Record review of the resident’s Care Plan initiated 7/10/18, showed the resident’s
incontinence was related to dementia (symptoms associated with a decline thinking skills
that is great enough to affect a person’s daily functioning) and impaired mobility.
Interventions and staff tasks included:
-Assessing the resident for various signs and symptoms;
-Using briefs to maintain hygiene and dignity;
-Checking the resident periodically for incontinence;
-Washing, rinsing and drying the resident after incontinence episodes, and changing
his/her clothing as needed and
-Encouraging fluids during the day to prevent a UTI (urinary tract infection – bacteria or
viruses entering any part of the urinary system).
Observation on 12/5/18 at 9:10 A.M. Certified Nurse Assistant (CNA) C and CNA E providing
peri-care showed the following:
-The resident was cleaned from back to front and
-CNA C took off his/her gloves and pushed the trash down into the wastebasket with his/her
bare hands and took the trash from the room.
During an interview on 12/7/18 at 1:15 P.M., with the Director of Nursing (DON) and the
Assistant Director of Nursing (ADON), the ADON said he/she would have expected the staff
to use proper peri-care protocol and appropriate hand-washing.
2. Record review of Resident #6’s Admission MDS dated [DATE] showed he/she:
-Was admitted on [DATE] and
-Was incontinent of bowel and bladder.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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 – Few

(continued… from page 17)
Observation of perineal care on 12/5/18 at 9:14 A.M., showed CNA A:
-Uncovered the resident and unfastened the resident’s brief;
-Removed his/her gloves;
-Did not wash or sanitize his/her hands;
-Donned new gloves;
-Completed the resident’s peri care;
-Removed soiled brief;
-Did not change gloves or wash or sanitize his/her hands;
-Placed clean brief under the resident and
-Removed his/her gloves and washed his/her hands.
3. Record review of Resident #36’s Admission Face Sheet showed he/she was admitted on[DATE] with a stage four sacral region (area at base of spinal column and top of pelvic
bones) Pressure Ulcer (localized injury to the skin and/or underlying tissue usually over
a bony prominence, as a result of pressure, or pressure in combination with shear and/or
friction).
Observation of wound care on 12/4/18 at 8:22 A.M., showed Licensed Practical Nurse (LPN)
B:
-Washed hands, donned gloves and set up supplies needed on a clean barrier surface,
including:
–Silver (an antimicrobial incorporated into wound dressings to prevent bacterial
contamination) alginate (turns into a gel that maintains a moist wound environment and
helps in the debridement of sloughing (dead tissue) wounds);
–Bordered gauze dressing;
-Cleaned wound per orders;
-Removed his/her gloves, sanitized hands, and donned gloves;
-Opened the silver alginate and the dressing packages;
-Took an ink pen out of his/her pocket and dated the dressing;
-Did not change his/her gloves or wash or sanitize his/her hands;
-Placed the silver alginate strips into the wound bed and
-Placed the bordered gauze dressing over the wound.
Observation of peri care on 12/5/18 at 9:52 A.M., showed CNA A:
-Washed his/her hands and put on gloves;
-Completed peri care;
-Removed his/her gloves;
-Did not wash or sanitize his/her hands;
-Donned gloves;
-Cleaned Foley catheter (a tube with retaining balloon passed through the urethra into the
bladder to drain urine) tubing;
-Removed his/her gloves;
-Did not wash or sanitize his/her hands;
-Donned gloves;
-Lowered the bed;
-With the same gloves on pushed an unused wet wipe that was partially out of the container
back into the container contaminating it;
-Put the resident’s fall mat next to the bed and
-Picked up the trash and exited the resident’s room.
During an interview on 12/7/18 at 10:34 A.M., CNA C said staff should always wash or
sanitize their hands before putting on their gloves, between glove changes and after
removing their gloves.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265339

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

12/07/2018

NAME OF PROVIDER OF SUPPLIER

AUTUMN TERRACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

6124 RAYTOWN ROAD
RAYTOWN, MO 64133

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 – Few

(continued… from page 18)
During an interview on 12/7/18 at 10:43 A.M., CNA D said during resident cares he/she
washes or sanitizes his/her hands when entering a resident’s room, before putting on
his/her gloves, between glove changes, after removing his/her gloves and before leaving
the resident’s room.
During an interview on 12/7/18 at 10:50 A.M., LPN B said that during resident cares he/she
would would wash or sanitize his/her hands when entering a resident’s room, before putting
on gloves. He/she would change his/her gloves and wash and sanitize his/her hands after
touching dirty items. He/she would wash or sanitize his/her hands, put on gloves then
remove the soiled items and throw them away in the dirty utility room , then he/she would
remove his/her gloves and wash his/her hands.
During an interview on 12/7/18 at 11:17 A.M., the Director of Nursing (DON) who is also
the infection control designee said:
-Yearly education is done for infection control areas;
-When there is a large trend of something like urine infection they do an additional
in-service to educate staff;
-In (MONTH) the facility had two residents in same room with an urinary tract infection[MEDICAL CONDITION];
-He/she did 1 on 1 education with staff on that hall and
-He/she is planning another in-service on hand washing and gloving.
[/fusion_text][/fusion_builder_column][/fusion_builder_row][/fusion_builder_container]