| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| 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** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| 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 | (continued… from page 1) Record review of the resident’s chart showed no red or green dots on the chart spine to show desired code status. 3. During an interview on [DATE] at 1:00 P.M., Certified Medication Technician (CMT) A said: -He/she did not know what the red or green dots on a resident chart spine meant; -He/she would check with someone and went and asked. -He/she returned and said: –The red dots on the spine of a chart represent DNR; –The green dots represent do CPR (Cardiopulmonary Resuscitation) and –No dots mean check the face sheet in the chart. During an interview on [DATE] at 1:05 P.M., CMT B said that he/she did not know what the dots on the resident charts meant. During an interview on [DATE] at 9:22 A.M., Certified Nurse Assistant (CNA) B said to check a resident’s code status that he/she would: -Check the resident’s door for a red (DNR) or green (resuscitate) sticker if he/she or the resident were in the room and -Check the resident’s chart for a red or green sicker. During an interview on [DATE] at 9:30 A.M., Registered Nurse (RN) A said: -The resident’s code status is on the nurse daily shift report under the resident’s name; -The resident’s chart and door should have a code status sticker, red for DNR and green for full code and -The resident’s POS would also show the resident’s code status. During an interview on [DATE] at 2:15 P.M., the interim Director of Nurses (DON) said: -All residents should have a code status documented and -All documentation of a resident’s code status should match. | |
| F 0606 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Based on interview and record review, the facility failed to check the State Certified |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| 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 0606 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) federal indicator. 2. During an interview on 12/20/18 at 12:44 P.M., the Business Office Manager said he/she could not find record of where the CNA Registry was checked prior to hiring the employee. During an interview on 12/21/18 at 2:15 P.M., the Director of Nursing (DON) said: -The CNA Registry should be checked for a federal indicator on all employees prior to hire and -The Business Office Manager does all the background/personnel checks. | |
| 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** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| 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) -On 9/21/18 no time noted, the resident returned to facility; -On 10/23/18 at 3:15 P.M. the resident was transferred to the hospital and -On 10/27/18 at 10:00 P.M. the resident returned to facility. Record review of the resident’s medical record showed there were no letters notifying the resident and/or the resident’s representative(s) or the Ombudsman of a transfer/discharge and the reasons for the transfer/discharge. 3. Record review of Resident #48’s Admission Face Sheet showed he/she was admitted on [DATE]. Record review of the resident’s Nurses Notes showed: -On 5/21/18 at 9:15 A.M. the resident was transferred to the hospital; -On 6/6/18 at 6:30 P.M. the resident returned to facility; -On 10/5/18 no time noted, the resident was transferred to the hospital; -On 10/13/18 at 9:00 P.M. the resident returned to facility; -On 11/3/18 at 3:15 A.M. the resident was transferred to the hospital and -On 11/9/18 no time noted, the resident returned to facility. Record review of the resident’s medical record showed there were no letters notifying the resident and/or the resident’s representative(s) or the Ombudsman of a transfer/discharge and the reasons for the transfer/discharge. 4. During an interview on 12/21/18 at 2:15 P.M., the Director of Nursing (DON) said: -The facility tries to call the family when a resident transfers to the hospital; -The facility does not send out a letter of the transfer to the family and -The facility just started notifying the Ombudsman of a resident’s transfers to hospital. | |
| 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** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) -Returned to the facility on [DATE]; -discharged from the facility on 9/14/18 and -Returned to the facility on [DATE]. Record review of the resident’s medical record showed there was no documentation of notification of the resident/responsible party of the bed hold policy when the resident was discharged /transferred. During an interview on 12/21/18 at 10:59 A.M., the Social Services Director said: -He/she calls family and asks if they want to do a bed hold when a resident is being transferred and -He/she does not have the family sign the bed hold agreement. 2. Record review of Resident #15’s SBAR (Situation, Background, Appearance, Review and notify) Transfer form and Physicians Telephone Orders dated 4/16/18 showed he/she was transferred to the hospital. Record review of the resident’s medical record showed there was no documentation of notification to the resident or responsible party of the bed hold policy when the resident was discharged or transferred. Record review of the resident’s Nurses Notes dated 4/21/18 at 1:30 P.M., showed he/she returned to facility. Record review of the resident’s Nurses Notes showed: -On 9/17/18 at 3:15 P.M. the resident was transferred to the hospital; -On 9/21/18 no time noted, the resident returned to facility; -On 10/23/18 at 3:15 P.M. the resident was transferred to the hospital and -On 10/27/18 at 10:00 P.M. the resident returned to facility. Record review of the resident’s medical record showed there was no documentation of notification to the resident or responsible party of the bed hold policy when the resident was discharged or transferred. 3. Record review of Resident #48’s Admission Face Sheet showed he/she was admitted on [DATE]. Record review of the resident’s Nurses Notes showed: -On 5/21/18 at 9:15 A.M. the resident was transferred to the hospital; -On 6/6/18 at 6:30 P.M. the resident returned to facility; -On 10/5/18 no time noted, the resident was transferred to the hospital; -On 10/13/18 at 9:00 P.M. the resident returned to facility; -On 11/3/18 at 3:15 A.M. the resident was transferred to the hospital and -On 11/9/18 no time noted, the resident returned to facility. Record review of the resident’s medical record showed there was no documentation of notification to the resident or responsible party of the bed hold policy when the resident was discharged or transferred. 4. During an interview on 12/21/18 at 2:15 P.M., the Director of Nursing (DON) said the Social Services Director notifies the family or resident representative and asks if they want to have the bed held. | |
| F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) Minimum Data Set (MDS – a federally mandated assessment tool completed by the facility staff for care planning) for one sampled resident (Resident #9) out of 12 sampled residents. The facility census was 47 residents. 1. Record review of Resident #9’s admission face sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Cognitive communication deficit and -Mild cognitive impairment. Record review of the resident’s admission MDS dated [DATE] showed he/she had no dental issues. Record review of the resident’s Clinical Notes Report for Dental Visit dated 3/12/18 at 10:34 A.M., showed he/she: -Was uncooperative for the exam and -Would not come to the exam room. Record review of the resident’s significant change for behaviors MDS dated [DATE] under the Care Area Assessment (CAA- a problem-oriented framework for arranging MDS information and additional clinically relevant information about an individual’s health problems or functional status.) showed: -No dental issues and -Dental was care planned. Record review of the resident’s Clinical Notes Report Dental Visit dated 6/8/18 at 9:13 A.M., showed: -The resident was seen by a dentist; -The resident had several teeth that were non-restorable root tips; -The resident wished them to be extracted; -It would be in the resident’s best interest for his/her primary care physician to refer him/her to an oral surgeon where necessary extractions could be performed in a medically controlled environment while under sedation; -The resident inquired about receiving dentures; -That the dentist explained to resident that he/she would be re-evaluated for dentures after complete healing from his/her extractions and -The resident verbalized understanding of waiting to get dentures. Record review of the resident’s Quarterly MDS dated [DATE] showed no dental areas addressed. Record review of the resident’s provided dental progress note dated 8/1/18 showed: -Resident refused to allow a gloved hand into his/her mouth; -Resident appeared to have deterioration of some teeth; -Dentist was uncertain of how much attention and treatment the resident would allow and tolerate. -Removal of fragmented teeth would definitely need to be under controlled setting for the resident’s safety; -Dentist was uncertain to what extent the resident would allow fabrication of a partial denture or full denture and to what extent the resident would allow himself/herself to adapt to dentures and -Option to address symptomatic situations as they occur may be tolerable for a short-term plan. Record review of the resident’s Quarterly MDS dated [DATE] showed no dental areas addressed. During an interview on 12/21/18 at 2:15 P.M., the Director of Nursing (DON) said that if a |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) resident had any dental issues it should show in the MDS. | |
| F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | 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** | |
| 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** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) arranging MDS information and additional clinically relevant information about an individual’s health problems or functional status) showed: -No dental issues and -Dental was care planned. Record review of the resident’s Clinical Notes Report for Dental Visit dated 6/8/18 at 9:13 A.M., showed: -The resident was seen by a dentist; -The resident had several teeth that were non-restorable root tips; -The resident wished them extracted; -That it would be in the resident’s best interest for his/her primary care physician to refer him/her to an oral surgeon where necessary extractions can be performed in a medically controlled environment while under sedation; -The resident inquired about receiving dentures; -That the dentist explained to the resident that he/she would be re-evaluated for dentures after complete healing from his/her extractions and -The resident verbalized understanding of waiting to get dentures. Record review of the resident’s Quarterly MDS dated [DATE] under the dental section showed no dental areas addressed. Record review of the resident’s dental progress note dated 8/1/18 showed: -Resident refused to allow a gloved hand into his/her mouth; -Resident appeared to have deterioration of some teeth; -Dentist was uncertain of how much attention and treatment the resident would allow and tolerate; -Removal of fragmented teeth would definitely need to be under a controlled setting for the resident’s safety; -Dentist was uncertain to what extent the resident would allow fabrication of a partial denture or full denture and to what extent the resident would allow himself/herself to adapt to dentures and -Option to address symptomatic situations as they occur may be tolerable for a short-term plan. Record review of the resident’s Care Plans (written out plan for the care of the resident) dated 9/18/18 with the next review scheduled for 12/4/18 showed no care plan for the resident: -Wanting dental work and -Refusing dental work. During an interview on 12/21/18 the Director of Nursing (DON) said that there should be a care plan showing a residents choice or refusal to have dental care done. 2. Record review of Resident #11’s admission face sheet showed he/she was admitted on [DATE] with the following Diagnoses: [REDACTED]. -Anxiety and -Personality disorder. Record review of the resident’s physician’s orders [REDACTED]. -[MEDICATION NAME] (used to treat depression) 20 milligram (mg) by mouth (PO) daily at noon for major [MEDICAL CONDITION] with a start date of 1/18/18; -[MEDICATION NAME] NA DR ([MEDICATION NAME] an [MEDICAL CONDITION] medication also used to treat [MEDICAL CONDITION] (a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception) 250 mg PO daily at 2:00 P.M. for [MEDICAL CONDITION] disorder with a start date of 6/13/18. –This dose was discontinued on 12/12/18; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| 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 8) –A higher dose of [MEDICATION NAME] NA DR 500 mg PO at bedtime was started on 12/12/18 and -[MEDICATION NAME] (used to treat anxiety) 0.25 mg PO daily for anxiety with a start date of 8/21/18. Record review of the resident’s care plans dated 9/28/18 showed no care plans for the resident’s: -[MEDICAL CONDITION]; -Anxiety; -Personality disorder and -[MEDICAL CONDITION] medication use. During an interview on 12/21/18 at 2:15 P.M. the DON said he/she would expect the resident to have care plans for [DIAGNOSES REDACTED]. | |
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 9) During an interview on 12/21/18 at 9:21 A.M., Hospice (end of life care) aide A said: -He/she tried doing the resident’s nails and the resident wouldn’t let him/her; -He/she tries to clean the resident’s nails but the resident pulls back and says ow and -He/she was able to get some of the resident’s nails done today. During an interview on 12/21/18 at 2:15 P.M., the interim Director of Nursing (DON) said he/she would care plan the resident’s right to refuse nail care. 2. Record review of Resident #41’s care plan with the admission date of [DATE] showed he/she was incontinent of bladder and it did not include the use of a catheter (a tube passed through the urethra into the bladder to drain urine). Record review of the resident’s quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Did not have a catheter and -Was incontinent of bladder. Observation on 12/18/18 at 10:25 A.M. and on 12/19/18 at 9:32 A.M. showed the resident had a catheter. During an interview on 12/21/18 at 2:15 P.M., the interim DON said the catheter should be care planned. 3. Record review of Resident #1’s dental summary note dated 3/22/17 showed: -The resident had upper and lower dentures; -The resident’s dentures did not fit and the resident did not wear them; -The dentist felt that a reline (a procedure that reshapes the underside of a denture to make it more comfortable as it rests against one’s gums) would help make the upper denture fit better and -The plan was to reline the complete upper denture. Record review of the resident’s dental summary note dated 4/26/17 showed: -A soft reline was completed for the resident’s upper denture; -The resident was satisfied and -A follow-up in three months for a re-evaluation should be completed and another soft reline could be completed if necessary or the resident’s denture could be sent in for a hard reline if necessary. Record review of the resident’s current medical record showed there were no further dental notes after 4/26/17. Record review of the resident’s most recent social services progress review dated 7/11/17 showed no documentation regarding dentures or dental appointments. Record review of the resident’s current medical record showed no further documentation regarding the resident’s dentures or dental appointments. Record review of the resident’s annual MDS dated [DATE] showed the resident had no natural teeth. Record review of the resident’s care plan dated as initiated on 9/25/18 showed no documentation regarding the resident’s dentures. Record review of the resident’s quarterly MDS dated [DATE] showed the resident was cognitively intact. During an observation and interview on 12/18/18 at 1:30 P.M.: -The resident said: –His/her dentures give him/her sores in his/her mouth; –He/she would wear his/her dentures if they fit and -The resident was not wearing his/her dentures. Observation on 12/20/18 at 11:20 A.M. showed a cup with dentures in it was on the resident’s sink countertop. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) During an interview on 12/20/18 11:22 A.M., RN B said as far as he/she knew, the resident wears his/her dentures but the resident may refuse to wear them. During an interview on 12/21/18 at 8:20 A.M., RN A said: -He/she’s not aware of any issues with the resident’s dentures and -He/she thinks the resident usually wears his/her dentures. During an interview on 12/21/18 at 10:05 A.M. CNA A said he/she’s never seen the resident’s dentures out of the resident’s mouth. During an interview on 12/21/18 at 2:15 P.M., the Interim DON said dentures and dental issues should be care planned. 4. Record review of Resident #13’s (MONTH) (YEAR) physician’s orders [REDACTED]. Record review of the resident’s current care plan showed breathing treatments via a nebulizer for wheezing was not on the care plan. Observation on 12/18/18 at 11:30 A.M. showed a nebulizer with mask was in the resident’s room. During an interview on 12/21/18 at 2:15 P.M., the interim DON said if the resident had a respiratory diagnosis, that should be care planned. | |
| 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** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| 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) that [MEDICATION NAME] (an anticoagulant) needed a stop date. Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 11/23/18 showed the following staff assessment of the resident: -Had surgical wounds; -Received insulin injections seven days out of the last seven days; -Did not have a catheter; -Some of his/her diagnoses included [MEDICAL CONDITION], diabetes and high cholesterol and -Was not receiving an anticoagulant medication. Record review of the resident’s (MONTH) (YEAR) Physician’s Order Sheet (POS), (MONTH) (YEAR) Treatment Administration Record (TAR) and (MONTH) (YEAR) through (MONTH) (YEAR) telephone orders showed: -The resident’s admitted was 9/28/18 on the POS; -26 out of 30 physician’s orders did not include a diagnosis, clinical condition or symptom on the POS; -No physician’s orders for a catheter, for catheter care or when to change the catheter were on the POS; -No order for and no documentation that the catheter was changed on the TAR; -Instructions dated 9/28/18 for catheter care every shift on the TAR; -A telephone order dated 9/7/18 showed a physician’s order to change insulin sliding scale from Humalog to [MEDICATION NAME] (two different types of insulin); -A physician’s order dated 9/28/18 for Humalog 100 units/ml (per milliliter) vial, inject per sliding scale subcutaneous (SQ-beneath the skin) before meals and at bedtime had Humalog crossed out. [MEDICATION NAME] was written above Humalog. At bedtime was crossed out and dated as changed on 12/1/18 on the MAR; -An undated physician’s order for Humalog per sliding scale before meals and at bedtime was on the POS; -A physician’s order dated 9/28/18 for [MEDICATION NAME] ([MEDICATION NAME]) 40 milligrams (mg)/0.4 ml, inject 0.4 ml (40 mg) SQ every 24 hours, clarify stop date was on the POS but was not on the MAR. -On the POS was a physician’s treatment order dated 10/4/18 to: –Cleanse the resident’s knee (did not specify right or left) with facility choice cleanser; –Place strip [MEDICATION NAME] gauze (a wound dressing); –Cover with kerlix (woven gauze that is non-adhesive used to wrap wounds) and secure with ABD pad (a thick wound dressing); –Change daily and as needed. -On the TAR was a physician’s treatment order dated 11/15/18 to cleanse the resident’s right knee with facility choice cleanser. Pat dry. Spray hypochlorous acid (used to fight bacteria and inflammation in wounds) to the wound bed. Let dry. Apply skin prep (a topical barrier between skin and adhesives) to open areas and leave open to air daily and as needed was on the TAR; -A physician’s treatment order dated 11/28/18 to cleanse the resident’s right, lower leg, distal (away from center) with facility choice cleanser. Pat dry. Spray with hypochlorous acid to wound bed. Let dry. Apply hydrogel (a dressing used for healing wounds) and Santyl (an ointment used for the debridement of pressure ulcers). Cover with dry dressing and change daily and as needed was on the TAR but not on the POS; -A physician’s order dated 9/28/18 for Atorvastatin (treats high cholesterol) 40 mg, take one tablet at bedtime on the MAR had a line drawn through it. It was written that it was |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| 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) discontinued on 10/9/18 and it had not been administered during (MONTH) (YEAR); -A physician’s order dated 9/28/18 for Atorvastatin 40 mg, take one tablet at bedtime was on the POS; -A telephone order dated 10/9/18 showed a physician’s order to discontinue Atorvastatin 40 mg; -A physician’s order dated 9/28/18 for [MEDICATION NAME] (an anti-depressant) 10 mg, take one tablet at bed time that had a hand-written note that the medication was discontinued on the MAR. It was administered 14 times through 12/17/18; -A physician’s order dated 9/28/18 for [MEDICATION NAME] 10 mg, take one tablet at bed time on the POS; -A physician’s order dated 9/28/18 for [MEDICATION NAME] (an antipsychotic medication-used to treat [MEDICAL CONDITION] and other mental and emotional conditions) 0.25 mg, take one tablet at bedtime was on the POS and was not on the MAR and -A telephone order dated 10/9/18 showed a physician’s order to discontinue [MEDICATION NAME]. Observation on 12/18/18 at 9:50 A.M. showed: -The resident had bilateral lower extremity amputations and a wound on one of his/her knees and -A catheter. During an interview on 12/21/18 at 2:15 P.M., the Interim Director of Nursing (DON) said: -There should be a physician’s order for the catheter that includes the diagnosis, the catheter type and size, to clean the catheter and when to change the catheter, which is typically once a month; -The care plan should include the catheter; -The orders should include the location of the wound; -The Assistant DON (ADON) has been reviewing the POS, MAR and TARs monthly during the changeover for accuracy; -They shouldn’t have discontinued orders still on the POS; -They should put the current wound treatment orders on the POS; -They should have diagnoses or symptoms for all medication orders; -They should draw a line through old orders and discontinue them and -A new order should be written with the new start date when changing from one type of insulin to another. 2. Record review of Resident #36’s face sheet showed he/she was admitted to the facility on [DATE]. Observation of the resident during the initial tour on 12/4/18 and throughout the survey showed he/she had a Foley catheter. Record review of the resident’s Admission MDS dated [DATE], showed the resident: -Was cognitively intact; -Needed extensive assistance with bed mobility, dressing and personal hygiene; -Was totally dependent on staff for transfers and toilet use; -Was always incontinent of bowel, and -Had an indwelling catheter. Record review of the resident’s undated care plan showed the resident had a Foley Catheter and the goal was that the resident show no signs and symptoms of urinary infection through the next review date. The interventions/tasks included staff: -Change catheter as needed; -Monitor and document intake and output per the facility’s policy; -Monitor and document pain/discomfort due to the catheter and -Monitor and report to the doctor signs and symptoms of urinary tract infection, |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| 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 13) cloudiness, output, increased temperature, foul smell, fever, chills, changes in behavior or eating patterns, or altered mental status. Record review of the resident’s (MONTH) (YEAR) POS showed the following information: –He/she was a [MEDICAL CONDITION] (paralysis of the legs and lower body), –He/she had wounds, –There was no order for or the care of his/her catheter, and -There was no [DIAGNOSES REDACTED]. During an interview on 12/19/18 at 8:31 A.M., the ADON said the resident had the catheter when he/she was admitted . During an interview on 12/21/18 at 2:15 P.M., the Interim DON said there should have been an order for [REDACTED]. | |
| F 0790 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide routine and 24-hour emergency dental care for each resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| 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 0790 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 14) documentation regarding the resident’s dentures. Record review of the resident’s quarterly MDS dated [DATE] showed he/she was cognitively intact. Record review of the resident’s nursing data collection tool dated 11/30/18 showed he/she could function with or without dentures. During an observation and interview on 12/18/18 at 1:30 P.M.: -The resident said: –His/her dentures give him/her sores in his/her mouth; –He/she would wear his/her dentures if they fit and -The resident was not wearing his/her dentures. During an interview on 12/20/18 at 9:39 A.M. the Social Services Director said: -He/she started as the Social Services Director about one and a half months ago; -The resident was seen in (YEAR) by a dentist who comes to the facility and -He/she doesn’t have a list of residents who need to see the dentist. During an observation and interview on 12/20/18 at 11:15 A.M.: -The resident said: –He/she has dentures; –He/she doesn’t like to wear them because they hurt his/her mouth and cause sores and -The resident was not wearing dentures. Observation on 12/20/18 at 11:20 A.M. showed a cup with dentures in it was on the resident’s sink countertop. During an interview on 12/20/18 11:22 A.M., Registered Nurse (RN) B said as far as he/she knew, the resident wears his/her dentures but the resident may refuse to wear them. During an interview on 12/21/18 at 8:20 A.M., RN A said: -He/she’s not aware of any issues with the resident’s dentures and -He/she thinks the resident usually wears his/her dentures. During an interview on 12/21/18 at 10:05 A.M. Certified Nursing Assistant (CNA) A said he/she’s never seen the resident’s dentures out of the resident’s mouth. During an observation and interview on 12/21/18 at 10:10 A.M.: -The resident said he/she never wears his/her dentures anymore because they hurt and -The resident was not wearing dentures. During an interview on 12/21/18 at 2:15 P.M., the Interim Director of Nursing (DON) said: -Dentures and dental issues should be care planned; -Annual dental visits should be offered and -There should be an order for [REDACTED]. | |
| 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 date food items and separate a |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 15) 1. Observations during the kitchen inspection on 12/14/18 between 8:39 A.M. and 12:51 P.M., showed the following: – Four unopened eight count packages of hamburger buns and one opened package with 6 remaining were undated in the dry storage room; – One 104 ounce (oz.) can of sliced beets in a large can rack was dented on the top rim in the dry storage room; – One case containing 12 oz. cans of chunk light tuna in the dry storage room with 21 cans remaining was neither dated on the box, nor on the individual cans; – Seven packages of tortilla shells on a bread rack in the dry storage room were undated; – A ladle, a green handled scoop, and several plate warmer lids had food residue on them; – There was a large buildup of dust under the food preparation table next to the assisted dining room door; – The red, yellow, and green cutting boards were chipped to the point of small bits of plastic hanging loosely on them; – Two large knives and a metal spatula had streaks of an unknown substance on their blades; – The excessive buildup of grease on the baffles (metal filters that capture grease droplets from rising hot air and condenses them to drain into a filter tray, which drastically reduces the risk of spreading flames should a fire occur on the cooking surface) above the stove was to the point of creating visible drip lines, and – During lunch preparation, a large cooking sheet of chicken strips and a smaller sheet of hamburgers were placed on top of the range hood, which was very greasy to the touch and visibly dirty, for at least 25 minutes before being placed in the oven. During an interview on 12/20/18 at 9:31 A.M., the Dietary Manager said: – The dry storage food was checked in by the various kitchen staff as a team and reconciled against their purchase order, dated, and labeled; – He/she would expect every single item to be dated when checked in; – If dented cans aren’t caught when received they are separated onto a different rack and the food company representative called for credit or disposal; – All kitchen staff are responsible for cleaning the floors after each shift; – The kitchen staff try to clean the range hood baffles at least once a week or more; – He/she would expect food to be kept away from contamination sources and – He/she would expect that food preparation and serving utensils are kept sanitary and in an easily cleanable condition. | |
| F 0813 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Based on interview and record review, the facility failed to educate all staff as to the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0813 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 16) – It was a generic document obtained from an online datatbase, – There was no facility specific information added, and – There were 14 separate points for safe implementation of the policy. During an interview on 12/14/18 at 9:36 A.M., the Dietary Manager said he/she thought there was a copy of an outside food policy somewhere, but the previous dietary manager may have mislaid it. During an interview at the nurse’s station on 12/14/18 at 1:48 P.M., Registered Nurse (RN) A said the following: – What we do with outside food brought in depends on what it is; – It can be kept in a refrigerator in the nurse station store room if marked with the resident’s name and dated; – Foods left after two to three days would be disposed of; – The procedures may be written down somewhere but it’s just something they all know, and – There is also a refrigerator in the activities area that can be used, but most residents don’t use it because everyone has access to it. During an interview on 12/19/18 at 1:12 P.M., the Administrator said that staff were taught about the outside food policy by the Human Resources Director at orientation and then signed off on a sheet saying they received the education, however, multiple subsequent requests to the Administrator and the Director of Nursing failed to result in copies of the sign off sheets. During an interview at the nurse’s station on 12/20/18 at 10:07 A.M., Licensed Practical Nurse (LPN) B did not answer when asked about their outside food policy and looked at CMT A who said the following: – They make sure outside food is labeled and dated when it comes in; – It’s either put in the nurse’s station refrigerator or the one in the activities area if the resident is ambulatory; – He/she didn’t know if the procedure was written down anywhere, it was merely common knowledge and – Some residents have their own refrigerators in their rooms to use as well. | |
| 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** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| 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 17) showed instructions to staff to keep the catheter collection bag below the level of the resident’s bladder to maintain unobstructed urine flow. Record review of the facility’s Tb screening: Administration and Interpretation of [MEDICATION NAME] Skin Test (TST-used to screen for Tb) policy revised (MONTH) 2013 showed it did not address when Tb screening was required. Record review of the facility’s influenza vaccine and pneumococcal vaccine policies revised (MONTH) (YEAR) showed when a resident received the vaccines, the date of vaccination, lot number, expiration date, person administering, and the site of the vaccination would be documented in the resident’s medical record. A nebulizer policy was not provided by the facility. 1. Record review of Resident #41’s care plan with the admission date of [DATE] showed no care plan regarding his/her catheter. Record review of the resident’s current medical record showed the (MONTH) (YEAR) Treatment Administration Record (TAR) was not on the chart and was not provided by the end of the survey. Record review of the resident’s (MONTH) (YEAR) Physician’s Order Sheet (POS) showed: -The resident’s admitted was 8/18/18 and -No physician’s orders for a catheter, for catheter care or when to change the catheter. Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 11/23/18 showed the following staff assessment of the resident: -Totally dependent upon staff for transferring from one surface to another; -Always incontinent of bladder and -Did not have a catheter. Record review of the resident’s (MONTH) (YEAR) POS showed: -The resident’s admitted was 9/28/18 and -No physician’s orders for a catheter, for catheter care or when to change the catheter. Record review of the resident’s (MONTH) (YEAR) TAR showed: -No order for and no documentation that the catheter was changed and -Instructions dated 9/28/18 for catheter care every shift. Observation on 12/18/18 at 10:25 A.M. showed: -Two staff members transferred the resident from one surface to another using a full body mechanical lift and -One of the staff members placed the resident’s catheter collection bag on his/her abdomen above his/her bladder during the transfer. During an interview on 12/21/18 at 8:20 A.M., Registered Nurse (RN) A said: -He/she didn’t know if the catheter bags they have are anti-reflux (minimize urine back flow into the drainage tube); -The catheter should be changed monthly and that should be on the TAR; -The catheter care is on the (MONTH) (YEAR) TAR and -The monthly changing of the catheter is not on the (MONTH) (YEAR) TAR. During an interview on 12/21/18 at 2:15 P.M., the interim Director of Nursing (DON) said: -The catheters they use are not the anti-reflux type; -The catheter should be kept below the resident’s bladder and -There should be orders for the resident’s catheter, catheter care and changing of the catheter. 2. Record review of Resident #1’s care plan with the admission date of [DATE] showed he/she was admitted to the facility on [DATE]. Record review of the resident’s Immunization Record dated (YEAR) showed the last two-step |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| 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 18) TST was: -Administered on 10/24/16, results read on 10/27/16 and the results were negative and -Administered on 11/7/16, results read on 11/10/16 and the results were negative. Record review of the resident’s current medical record showed no further TSTs or annual signs and symptoms screening. During an interview on 12/21/18 at 7:51 A.M., the interim DON: -Acknowledged the resident’s most recent documented TST was from (YEAR) and -Acknowledged a Tb screening should have been completed annually and it was not. Record review of the resident’s Immunization Report showed: -The resident received the influenza vaccination on 11/28/18; -The resident received the pneumonia vaccination on 12/18/18 and -The person administering the vaccination and the lot number and expiration dates were not documented for either vaccination. During an interview on 12/21/18 at 2:15 P.M., the interim DON said the facility nursing staff should have documented the lot number and the expiration date when administering the vaccinations. 3. Record review of Resident #13’s (MONTH) (YEAR) POS showed the resident had physician’s order for the use of [REDACTED]. Record review of the resident’s current care plan showed the care plan did not include the use of a nebulizer. Observation on 12/18/18 at 11:30 A.M. and on 12/19/18 at 9:30 A.M., showed the resident’s nebulizer mask was on his/her dresser with no barrier, a bag was not present for the nebulizer to be placed in and the tubing was not dated. During an interview on 12/21/18 at 2:14 P.M., Certified Nursing Assistant (CNA) A said: -The bags for the nebulizer masks were kept in the room behind the nurses’ station and -The Certified Medication Technicians (CMT)s were responsible for placing bags in the residents’ rooms for the nebulizer mask to be placed in. During an interview on 12/21/18 at 2:15 P.M., the interim DON said: -The nebulizer masks should be stored in a clean bag; -The bags were stored in the back medical supply room and some in the nurse utility room; -The CMTs were responsible for ensuring the bags for the nebulizer masks were in the residents’ rooms and -If a resident had a respiratory diagnosis, the care plan should include treatments as ordered. 4. Record review on 12/18/18 of Resident #36’s face sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident’s Immunization Record form showed: -His/her first step of the two-step TB test was administered 9/17/18 and -The TB test was not read. Record review on 12/19/18 of the resident’s MAR indicated [REDACTED]. During an interview on 12/19/18 at 8:31 A.M., the Assistant Director of Nursing (ADON) said: -He/she thought this was the resident’s first time being admitted to a Long Term Care facility; -The resident was admitted to the facility from the hospital; -He/she saw in the resident’s chart where the TB test was administered, but could not find where the TB test was read; -The day the TB test results were supposed to be read the resident went out for an angiogram (a x-ray of the blood vessels), but did come back the same day and |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/31/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265512 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER LEE’S SUMMIT POINTE HEALTH & REHABILITATION | STREET ADDRESS, CITY, STATE, ZIP 1501 SW 3RD STREET | |||||||||
| 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 19) -He/she could not find a record of the second step being administered. During an interview on 12/21/18 at 2:15 P.M., the interim Director of Nursing said: -A two-step TB test should be completed on all residents new to long term care and -The first step of the resident’s TB test should have been read within 48-72 hours, and a second step administered within seven to twenty-one days after the first step was read. 5. Record review of Resident #7’s admission face sheet showed he/she admitted to the facility on [DATE]. Record review of the resident’s Immunization Record dated (YEAR) showed: -The first step of a two-step Mantoux TST was administered on 9/12/18; -The results were negative on 9/14/18 and -There was no documentation that the second TST had been administered. 6. Record review of Resident #48’s admission face sheet showed he/she admitted to the facility on [DATE] and last re-admission was on 11/9/18. Record review of the resident’s medical record showed: -That the Influenza vaccine was given on 11/20/18; -That the resident refused the Pneumococcal Vaccine and -That there was no documentation that the TST had been administered. The resident’s Immunization Record was requested from the facility on 12/20/18 at 10:13 A.M. and on 12/21/18 at 9:15 A.M. During an interview on 12/21/18 at 1:15 P.M. the interim DON said the facility did not have a copy of it or when the resident would have received the TST for this year. During an interview on 12/21/18 at 2:15 P.M., the interim DON said: -The TST should be a two-step process and -The facility uses a signs and symptoms (characterized by fever, cough, difficulty breathing, and abnormal lung function) screening for each resident for the annual TB testing. | |
