Original Inspection report

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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation and interview staff failed to provide for resident dignity and
privacy when staff left four of 31 sampled resident’s (Residents #7, Resident #64, #68,
and #88) catheter bags exposed. The facility census was 96.
1. Observation and interview on 11/06/18 at 11:12 A.M., showed Resident #88 without a
dignity bag exposing his/her catheter bag. The resident said staff say he/she should have
something to cover the catheter bag, but then take me out in the common areas without it.
Observation on 11/7/18 at 3:00 P.M., showed Resident #7 in the main dining room with no
dignity bag covering his/her catheter bag. The resident said staff do not provide a cover
for the catheter bag.
Observations on 11/08/18 at 5:56 A.M., showed Resident #64 and Resident #88 with no
dignity bag covering their catheter bags.
Review of Resident #68’s care plan, dated 6/19/18 showed staff should always cover the
resident’s catheter drainage bag with a dignity bag.
Observation on 11/6/18 at 10:54 A.M. showed:
– The resident in his/her room in bed.
– The resident’s overfull catheter drainage bag on the floor outside the dignity bag.
2. During an interview on 11/08/18 at 2:29 P.M., Licensed Practical Nurse (LPN) B said
staff should assure residents have the catheter bags covered.
During an interview on 11/08/18 at 6:04 A.M., The Director of Nursing (DON) said staff
should provide dignity bags for residents with catheters.

F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Based on interview and record review, the facility failed to check the Nursing Assistant
(NA) Registry to ensure all newly-hired employees did not have a Federal Indicator (marker
given to individuals who have committed abuse/neglect). This affected seven out of 14
sampled employees hired since (MONTH) (YEAR). The facility census was 96.
Review of the facility’s undated policy related to employee hiring showed that abuse
registry verification will be completed and a copy of the registry will be placed in the
employee’s personnel file as required.
1. Review of personnel records for the following staff hired since (MONTH) (YEAR) showed:
-Director of nursing, hired on 5/14/18, no NA Registry check done;
-Administrator, hired on 5/7/18, no NA Registry check done;
-Licensed Practical Nurse (LPN) C, hired on 6/27/18, no NA Registry check done;
-Registered Nurse (RN) B, hired on 10/2/18, no NA Registry check done;
-LPN D, hired on 10/9/18, no NA Registry check done;
-LPN E, hired on 10/9/18, no NA Registry check done;
-RN C, hired on 7/17/18, no NA Registry check done.
During an interview on 11/9/18 at 8:45 A.M., the human resource manager (HRM) said he/she
was not aware of the need to check the NA Registry for all staff.

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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Based on interviews and record reviews, the facility failed to follow their policy to
check the employee disqualification list (EDL, a data base that indicates individuals who
are not allowed to work in long term care facilities due to evidence they have abused,
neglected or misappropriated funds or property of a resident) prior to employment for all
newly-hired employees. This affected nine out of 14 sampled employees who were hired in
the past year. The facility census was 96.
Review of the facility’s policy related to background and EDL checks, dated 10/01/00,
showed:
-Each center shall check the EDL prior to hiring an employee and to deny employment to any
person who is not qualified to work in or provide health care services.
-The administrator is responsible for ensuring that the EDL is checked prior to
employment.
1. Review of personnel records for the following staff hired since (MONTH) (YEAR) showed:
-Certified Medication Technician (CMT) A, hired on 4/25/18, EDL check done 11/7/18;
-Administrator, hired on 5/3/18, EDL check done 11/7/18;
-Certified Nurse Aide (CNA) D, hired on 10/11/18, EDL check done 11/9/18;
-License Practical Nurse (LPN) C, hired on 6/27/18, EDL check done 11/7/18;
-CNA I, hired 10/3/18, EDL check done 10/18/18;
-CNA B, hired on 8/23/18, EDL check done 9/11/18;
-Registered Nurse (RN) B, hired on 10/2/18, EDL check done 10/17/18;
-LPN D, hired on 10/9/18, EDL check done 10/17/18;
-LPN E, hired on 10/9/18, EDL check done 10/17/18.
During interviews on 11/9/18 done at 8:45 A.M., 9:15 A.M., 10:20 A.M. and 3:45 P.M., the
human resource manager (HRM) said:
-He/she had to check with the facility’s corporate office to obtain some of the employee
screening documentation as they might not be in the facility’s current possession.
-Employees generally are in orientation and job-follow for two to three days before they
start resident care.
-Employees should not have contact with residents until the EDL check is done.
-He/she did not have documentation to show when the employees started resident care.

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**
Based on interview and record review, facility staff failed to complete comprehensive
Minimum Data Set assessments (MDS-a federally mandated assessment tool), within the
required timeframes for three residents (Residents #14, #40, #16) of 31 sampled residents.
The facility census was 96.
1. Review on 11/9/18, of Resident #40’s Significant Change comprehensive MDS, dated [DATE]
had red alerts that stated MDS In Progress and Should Have Been completed on 10/31/18. The
Social Service Director had answered the questions in sections C, D, E and Q. Other
sections were not completed.
2. Review on 11/9/18, of Resident #16’s Quarterly MDS (due no later than 92 days following
the previous assessment) dated 10/17/18 had red alerts that stated MDS In Progress 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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 2)
Should Have Been completed on 10/31/18. The Social Service Director had answered the
questions in sections C, D, E and Q. Other sections were not completed.
3. Review on 11/8/18, of Resident #14’s quarterly MDS, dated , 10/24/18, had red alerts
which stated In Progress and Should Have Been completed on 1/24/18. The Social Services
Director had answered the questions in section C, D, E and Q. The other sections were not
completed.
During an interview on 11/9/18 at 3:32 P.M., the Director of Nurses, said:
– The facility currently did not have an MDS coordinator and utilized a part time MDS
Coordinator from a sister facility:
– The previous MDS Coordinator left sometime in September.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews, the facility failed to assure staff
used the comprehensive assessment to develop, implement and review a comprehensive
person-centered plan of care consistent with the resident rights that includes measurable
objectives and time frames to meet the resident’s medical, nursing, mental, and
psychosocial needs for three of 31 sampled residents (Resident #38, #52, and #14). The
facility census was 96.
1. Review of Resident #38’s Minimum Data Set, (MDS), a federally mandated assessment
instrument completed by facility staff, dated 8/13/18, showed:
– Some difficulty in making decisions;
– Dependent on staff for toilet use;
– Always incontinent of bowel and bladder; (indwelling catheter not coded)
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, last revised 11/7/18, showed:
– Resident on antibiotic therapy for a UTI;
– No care plan related to the resident’s indwelling catheter.
Observation on 11/8/18 at 8:00 A.M., showed staff lay in bed with a catheter drainage bag
attached to the bed.
2. Review of Resident 52’s care plan, initiated on 5/21/18 and revised on 6/5/18, showed:
– Resident has activity of daily living self care performance deficit:
– Goal:All of resident’s needs will be anticipated and met;
– Resident requires assistance with his/her bathing;
Review of the resident’s MDS, dated [DATE], showed:
– Dependent on staff for bathing;
– [DIAGNOSES REDACTED].
Observation on each day of the survey, 11/6, 11/7, 11/8 and 11/9/18, at various times
throughout the days, showed the resident had numerous white chin whiskers at least one
half inch long and neck whiskers up to at least an inch in length.
His/her hair looked dirty and had a matted knot that was almost two inches wide and four
inches long on the back side of his/her hair. The resident’s hair remained dirty and
uncombed throughout the survey. Observation on 11/7/18, 11/8/19 and 11/9/18 showed the
resident smelled of urine.
During an interview on 11/7/18 at 9:12 A.M., the resident said he/she did not like showers

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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 – Some

(continued… from page 3)
and had never had one prior to being at facility. He/She liked a tub bath.
Observation and interview on 11/8/18 at 3:20 P.M., showed the resident by the nurses
station with a bottle of body wash in his/her hands, He/she said he/she was looking for a
bath. Licensed Practical Nurse (LPN) B told the resident he/she would get staff to take
him/her to get a shower. The resident immediately refused to take a shower. LPN B said:
– Staff had a hard time getting the resident to take a shower;
– When the resident refused showers, hair care and incontinent care, he/she tried to
re-educate the resident to the benefits of being compliant with care.
During an interview on 11/8/18 at 3:50 P.M., Certified Nurse Aide (CNA) E said:
– Sometimes the resident refused cares, he/she told the charge nurse when that happened;
– He/she could not comb the resident’s hair, the resident just needed a good shower;
– The resident was afraid of the shower and often refused using it, he/she had only gotten
the resident to use the shower twice since the resident came to the facility.
During an interview on 11/9/18 at 3:32 P.M., the Director of Nurses, said:
– He expected the nursing staff to find a care plan for a resident with a catheter;
– If the goal for a problem had not been met and had not been updated, possibly the goal
should change and the approaches should be changed to try and get the residents table to
reach their goals;
– The facility currently did not have an MDS coordinator and utilized a part ime MDS
Coordinator from a sister facility.
3. Review of Resident #14’s admission MDS, dated , 7/24/18, showed:
– Cognitive skills intact;
– Had a Foley catheter (sterile tube inserted into the bladder to drain urine);
– Always continent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised, 7/27/18, showed:
– The resident had a potential for an ADL self care performance deficit related to
diabetes mellitus;
– The resident had a Foley catheter for bladder elimination.
– The care plan had not been updated to show the Foley catheter had been discontinued.
Review of the resident’s physician order [REDACTED].
– An order to discontinue the Foley catheter.
During an interview on 11/9/18, at 3:32 P.M., the DON said:
– The care plan should be updated to show the catheter had been discontinued.

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 ensure staff
followed acceptable standards of practice when they failed to obtain an order for
[REDACTED].#196 and #93) and when staff left resident mediacations at the bedside which
affected one resident (Resident #196). The facility census was 96.
1. Review of the facility’s policy related to use of supplemental oxygen, dated 3/20/18,
showed:
-Oxygen is considered a medication and will be treated as such, including the need for a
physician order and placement on the Medication Administration Record [REDACTED]

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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 4)
-A nurse or respiratory therapist will verify the oxygen order for the route and liters
per minute (lpm) flow rate and deliver as prescribed.
2. Review of Resident #25’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 8/1/18, showed:
-A brief interview for mental status (BIMS) score of 15 out of 15;
-Received oxygen therapy.
Review of the resident’s care plan related to oxygen therapy, initiated on 9/21/18 and
last updated on 8/14/18, showed:
-On oxygen therapy due to [MEDICAL CONDITION] and [MEDICAL CONDITION] (chronically
obstructed airways causing decreased oxygen in the blood);
-Used oxygen through a nasal cannula at 4 liters continuously.
Review of the resident’s current physician orders showed no order for oxygen.
Observations on 11/6/18 through 11/8/18 at various times showed the resident received
oxygen per a nasal cannula.
3. Review of Resident #38’s MDS dated [DATE], showed:
– Some difficulty in making decisions;
– Dependent on staff for toilet use;
– Always incontinent of bowel and bladder; (indwelling catheter not coded)
Review of the resident’s care plan, last revised 11/7/18, showed:
– No care plan related to the resident’s indwelling catheter.
Review of the resident’s 11/18 physician order sheet (POS), showed there was no order for
the resident’s indwelling catheter.
Observation and interview on 11/8/18 at 8:00 A.M., showed staff lay in bed with a catheter
drainage bag attached to the bed. The resident said he/she returned to the hospital,
without an indwelling catheter, when hospital staff called about some blood work results
had come in, he/she returned to the facility with an indwelling catheter.
During an interview on 11/9/18 at 3:32 P.M., the Director of Nurses (DON) said:
– Staff should have clarified with the resident’s physician and gotten an order for
[REDACTED].>4. Review of Resident #16’s MDS, dated [DATE], showed:
– Able to make daily decisions:
– Used oxygen therapy;
[DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 10/19/18, showed:
– Give oxygen therapy as ordered by the physician;
– Uses oxygen continuously.
Review of the resident’s 11/18 physician order sheet, showed the physician ordered:
– Oxygen therapy at two liters per minute by nasal cannula continuously every shift for
shortness of air.
Observation and interview on 11/6/18 at 11:03 A.M., showed the resident used a portable
tank of oxygen and had a oxygen concentrator beside his/her bed. The resident sat on the
edge of his/her bed and said when he/she was up walking around the oxygen flow rate should
be on at least four liters per minute and when he/she was not up and about the flow rate
should be on two. He/she reached up and turned the knob on the portable oxygen tank from
four liters down to three liters.
Observation on 11/8/18 at 7:44 A.M., showed the resident lay in his/her bed with his/her
eyes closed his/her nasal cannula was in place and attached to the oxygen concentrator.
The flow rate on the oxygen concentrator was set on five liters per minute.
During an interview on 11/8/18 at 2:45 P.M., Licensed Practical Nurse (LPN) B said:
– Any staff CNA, CMT or Nurse could switch the residents oxygen from concentrator to
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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)
portable tank;
– Staff looked at the flow rate on the concentrator and then set the portable oxygen tank
flow rate to the same number as the concentrator;
– If staff ever questioned the flow rate a resident’s oxygen should be set on, they should
ask the charge nurse;
– Residents should not set their own flow rate.
During an interview on 11/8/18 at 2:50 P.M., CNA E said he/she looked on the oxygen
concentrator to check the flow rate. He/she set the portable tank’s flow rate to match the
concentrator,
5. Review of Resident #196’s care plan, revised on 4/9/18, showed:
– Oxygen therapy as ordered by the physician.
Review of the resident’s MDS, dated [DATE], showed:
– Able to make decisions;
– Oxygen therapy;
– [DIAGNOSES REDACTED].
Review of the resident’s 11/18 physician’s order did not show an order for
[REDACTED].>Observation on 11/6/18 at 10:31 A.M., showed the resident lay in bed using
an undated nasal cannula attached to an oxygen concentrator. The flow meter of the
concentrator was set on five liters per nasal cannula.
Observation on 11/7/18 at 9:46 A.M., showed the resident used his/her nasal cannula
attached to the oxygen concentrator that was set at five liters.
6. Review of Resident #13’s annual MDS, dated , 7/18/18, showed:
– Cognitive skills intact;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised 8/14/18, showed:
– The resident had oxygen therapy related to [MEDICAL CONDITION] and [MEDICAL CONDITIONS],
buildup of fluid in the lungs and surrounding body tissue;
– The resident had oxygen at 4 liters/nasal cannula continuously.
Observation on 11/7/18, at 8:36 A.M., showed:
– The resident laid in bed with oxygen on at 4 liters (L)/ per nasal cannula.
Review of the resident’s POS, dated 11/8/18, showed:
– The resident did not have an order for [REDACTED].>7. Review of Resident #93’s care
plan, revised, 8/24/18, showed:
– The care plan did not address the use of oxygen.
Review of the resident’s 14 day assessment MDS, dated , 10/24/18, showed:
– Cognitive skills intact;
– [DIAGNOSES REDACTED].
Review of the resident’s POS, dated, 11/8/18, showed:
– The resident did not have an order for [REDACTED].>8. During an interview on 11/9/18
at 3:32 P.M., the Director of Nurses said:
– Residents should not adjust the oxygen flow rate themselves;
– If a CNA was changing a resident from a concentrator to a portable tank, he/she should
verify with the charge nurse what the flow rate should be;
– A resident that used continuous oxygen should have a physician’s order for oxygen
9. Review of Resident #196’s care plan showed staff had not assessed the resident for self
administration of medications.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Totally dependent upon staff for transfers;
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 6)
– Required extensive staff assistance for toileting and hygiene;
– [DIAGNOSES REDACTED].
Observation on 11/7/18 at 9:45 A.M. showed the resident in bed with a cup containing 12
pills.
Observation on 11/7/18 at 11:33 A.M. showed:
– The resident with a Sprivia (used to treat lung disease) inhaler at his/her bedside.
– The resident taking one puff from his/her Sprivia inhaler.
During an interview on 11/7/18 at 2:14 P.M. LPN H said:
– He/she left the pills at the resident’s bedside because she had to leave to get
something for the resident.
– He/she should have not left the pills at the bedside.
– He/she should not leave the resident’s inhaler at the bedside.
During an interview on 11/9/18 3:00 P.M. the DON said:
– Staff should not leave a resident’s pills at the bedside.
– Staff should watch a resident take his/her pills.
– Staff should not leave a resident’s inhaler at the bedside.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 assure staff
performed proper and complete perineal care for dependent residents (Residents #40, #196,
#25, #56, and #396), did not remove facial hair or clean fingernails for Residents #52,
#88 and # 91. The facility census was 96.
1. Review of the facility’s policy for Male and Female Perineal Care, revised 9/6/17,
showed:
– Providing personal care services promotes a sense of well-being and meets hygiene
standards of care;
– Perineal care will be performed after incontinence of bowel and for incontinence of
bladder as needed;
– Perineal care includes cleansing of the area of perineum;
– This requires a two-step process beginning with the front genital area first and ending
with the coccyx area (cleanest to dirtiest);
– Thoroughly manipulate and cleanse all genital fold areas;
Removed fecal material and dispose of in the trash;
– Wipe from the rectum upward toward the resident’s waist;
– Wash each cheek of the buttocks from bottom to top then wipe upward through the crease
of the buttocks
Review of the facility’s policy for Nail and Hair Hygiene, revised 4/14/17, showed:
– Routine trimming, cleaning, and filing but not polishing of undamaged nails and on an
individual basis care for ingrown or damaged nails.
– Routine combing, brushing, shampooing, trimming and simple haircuts.
– To promote resident centered care by attending to the physical, emotional, social and
spiritual needs and honor resident lifestyle preferences;
– Facility will provide routine care for the resident for hygiene purposes and for the
psychosocial well-being of the resident including but not limited to hair hygiene that

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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 – Some

(continued… from page 7)
includes combing, brushing shampoo, trimming and simple haircuts. Routine care also
includes nail hygiene services including routine trimming and cleansing and filing;
– Can be completed in conjunction with bathing or performed separately;
– Routine nail care and hair care is provided as part of the bath or shower;
Hair shampooing will be completed on an as needed basis no less than weekly
Review of the facility policies for Bathing and Showers, revised 4/25/18. showed:
– It is the policy of this facility to provide resident centered care that meets the
psychosocial, physical and emotional needs and concerns of the residents.
– Residents have the right to choose their schedules, consistent with their interests,
assessments and care plans including choice for personal hygiene;
– This includes, but is not limited to , choices about the schedules and type of
activities for bathing that may include a shower, a bed-bath or a tub bath, or a
combination and on different days;
Bathing preferences should be care planned including type and schedule;
– In the event a resident refuses a bath because he/she prefers a shower or a different
bathing method, such as in bed bathing, prefers to bathe at a different time of day or on
a different day, does not feel well that day, is uneasy about the aide assigned to help or
is worried about falling, the resident’s preference must be accommodated,;
2. Review of Resident #40’s care plan, revised 8/14/18, showed:
– Check every two hours and as needed for incontinence;
– Wash, rinse and dry perineum;
– Change clothing as needed after incontinence episodes.
Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment
instrument, completed by facility staff, dated 8/15/18, showed:
– Unable to make daily decisions;
– Required extensive assistance of staff for toilet use and personal hygiene;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Observation on 11/8/19 at 2:00 P.M., showed staff transferred the resident to his/her bed
and provided incontinent care. Certified Nurse Aides (CNA) E and H provided perineal care.
CNA E removed the soiled incontinent brief and said it was wet. CNA E wiped one time down
the right groin with a pre-moistened wipe and one time down the left groin. CNA E rolled
the resident onto his/her right side. When CNA H started to wipe the resident’s left
buttock, the resident started to urinate in the bed.
CNA H wiped one hand width of the resident’s left buttock, rolled the resident to his/her
right side on the soiled incontinent pad and wiped one hand width on the left buttock and
up the center crease of the buttocks. Staff rolled the incontinent pad under the resident
and placed a brief under the resident. CNA H washed once down the left groin and one wipe
down the right groin then fastened the brief on the resident. Staff did not re-wash the
resident’s hips and buttocks after they rolled him/her on the wet incontinent pad. Staff
did nor thoroughly manipulate the perineal folds or wash the inner thighs.
3. Review of Resident 196’s care plan, reised 4/9/18, showed:
– Check throughout the day/night for incontinence;
– Wash, rinse and dry perineum;
– Change cthing as needed after incontinence episode;
– Provide consistency in care to promote comfort with activities of daily living;
– Maintain consistency in timing of activities of daily living, caregivers and routine, as
much as poossible.
Review of the resident’s MDS, dated 92218. showed:
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 – Some

(continued… from page 8)
– Able to make daily decisions;
– Required extensive assistance of staff for toilet use ad personal hygiene;
– Frequently incontinent of bowel and bladder;
– Weight 437 pounds;
– [DIAGNOSES REDACTED].
Observation and interview on 11/7/18 at 9:45 A.M., showed the resident lay in bed
incontinent of urine. The resident said he/she night shift only changed him/her once the
night before, staff didn’t change him/her until 4:30 A.M., they always wanted to wake
him/her up then. He/she thought staff should check and change him/her through the night,
not just wake him/her at 4:30 in the moring to change him/her. The resident lay on an
incontinent brief with two additional liners on top of two paper chux(pads) that stretched
from mid way up the resident’s back to his/her knees. CNA G used one wipe per swipe and
cleaned one time under the resident’s large panis(skin fold), once down the left groin,
once down the right groin and once down the center. Staff assisted the resident to roll to
his/her side, the brief, liners and paper chux are stained brown with urine. The paper
chux were wet to up halfway up the resident’s back. CNA G used separate pre-moistened
wipes and wiped back and forth on the back side of each of the resident’s legs from
his/her knee to the gluteal fold and cleansed the buttocks. CNA G did not wash up the
resident’s back that lay on the urine soiled paper chux, did not wash the entire buttocks,
hip areas, the pubic area or inside each roll on the resident’s legs and did not
thoroughly manipulate and cleanse the front perineal folds.
Observation and on 11/8/18 at 2:20 P.M., CNA E and CNA H provided peri care for the
resident. The resident lay in bed incontinent of urine through his/her brief, two liners,
paper chux and the fitted sheet underneath the resident. The resident lay in urine up to
his/her shoulder blades. CNA H used pre-moistened wipes and wiped once under the abdominal
skin fold, twice down each groin and one down the front side middle, rolled the resident
over and wiped both inner legs from knee to gluteal fold and cleaned one hand width on
each buttock and from the rectum up towards the resident’s waste. CNA H did not manipulate
and cleanse the front perineal folds or wash the resident’s back that lay in urine.
4 Review of Resident #25’s annual MDS, dated [DATE], showed:
-Required extensive assistance of two staff for bed mobility and personal hygiene;
-Always incontinent of bowel and bladder;
-Had a stage II pressure ulcer (localized skin damage that may present as a blister or a
small crater in the dermis that does not extend into the fatty tissue).
Review of the resident’s care plan, last revised on 8/14/18, showed:
-Had functional bowel/bladder incontinence related to overactive bladder;
-Check every two hours and as needed for incontinence;
-Wash, rinse and dry perineum;
-Had moisture-associated abrasions of the right and left buttocks identified on 10/12/18;
-Not toileted, per resident’s choice, and refuses use of a bed pan.
Observation on 11/18/18, at 6:14 A.M., showed CNA’s A and B provided incontinent care for
the resident in the following manner:
-Both staff washed their hands and put on gloves;
-CNA A used two wet wipes to cleanse the resident’s lower abdomen and both groin areas,
folded each wipe multiple times, used the same two wipes on multiple areas, wiped in a
back and forth motion, and did not separate and cleanse between all genital skin folds;
-Fecal material remained on the last wipe used to cleanse the front genital areas;
-CNA changed his/her gloves but did not wash or sanitized his/her hands;
-Staff turned the resident onto his/her right side and cleansed the resident’s backside in
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 – Some

(continued… from page 9)
the same manner-wiped back and forth, and folded and wiped with the same wet wipes
multiple times;
-The resident had several superficial, long thin open areas on the buttocks;
-Staff turned the resident onto his/her back and cleansed his/her inner thighs with fecal
material still present on the last wipe used;
-Both staff replaced the soiled bed pad with a clean pad and continued the resident’s
care.
During an interview on 11/8/18 at 6:43 A.M., CNA A said:
-Should cleanse any place urine may have touched;
-Should not use the same wipe to cleanse different body areas;
-Should use one wipe per swipe;
-Should not wipe back and forth.
5. Review of Resident #56’s admission MDS, dated [DATE], showed:
-Required extensive assistance for personal hygiene and toileting;
-Occasionally incontinent of bladder and frequently incontinent of bowel.
Review of the resident’s care plan, dated 9/13/18, showed:
-Had bowel and bladder incontinence;
-Provide perineal care after each incontinent episode.
Observation on 11/6/18 at 11:48 A.M., showed CNA D provided care in the following manner:
-Washed his/her hands and put on gloves;
-Cleansed the front genital area;
-Turned the resident onto his/her side and cleansed the rectal area, but did not cleanse
the buttocks;
-Replaced the wet brief with a clean one;
-Removed his/her gloves and washed his/her hands.
. Review of Resident #396’s admission MDS, dated , 10/7/18, showed:
– Cognitive skills severely impaired;
– Dependent on the assistance of two staff for bed mobility, transfers, and toilet use;
– Frequently incontinent of bladder;
– Always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised, 11/7/18, showed:
– The resident was incontinent of bowel and bladder related to impaired mobility;
– Prefers disposable briefs;
– Change every two hours and as needed.
Observation on 11/8/18, at 5:59 A.M., showed:
– CNA A unfastened the resident’s wet incontinent brief;
– CNA A used the same wipe and wiped back and forth across the resident’s pubic area, then
down each side of the resident’s groin and did not separate and clean all the perineal
folds;
– CNA A pumped DermaKleen lotion soap (skin protectant) on the resident’s pubic area and
used the same wipe and wiped back and forth across the pubic area, and down the perineal
folds;
– CNA A did not separate and thoroughly cleanse all the perineal folds;
– CNA A turned the resident on his/her side and removed the wet incontinent brief;
– CNA B used a new wipe and used the same area and wiped from back to front with a smear
of fecal material multiple times;
– CNA B used a new wipe and with the same area of the wipe, wiped back to front three
times without any fecal material;
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 – Some

(continued… from page 10)
– CNA B wiped in the wrong direction and did not clean all areas of the skin where urine
had touched.
– CNA A and CNA B placed a clean incontinent brief on the resident.
During an interview on 11/8/18, at 6:39 A.M., CNA B said:
– He/she should have wiped from front to back;
– He/she should have cleaned all areas of the skin where urine had touched.
During an interview on 11/8/18, at 6:44 A.M., CNA A said:
– Should not use the same area of the wipe to clean different areas of the skin;
– It should be one wipe, one swipe, should not wipe back and forth;
– Should clean all areas of the skin where urine had touched.
During an interview on 11/8/18 at 1:17 P.M., CNA D said staff should clean everywhere the
brief touched.
6. During an interview on 11/8/18 at 2:40 P.M., CNA H, said:
– He/She used one swipe per wipe and should not clean more than one area with the same
wipe;
– He/She should always wipe front to back, start on the outer side and clean towards the
middle:
– He/She should wash all areas of skin that urine touched.
During an interview on 11/8/18 at 2:50 P.M. CNA E said:
– He/she used wipes to clean only one area at a time and only swiped once with each wipe;
– He/she should wipe front to back;
– He/She tried to clean one side and then the other, then tried to wipe down the center.
Sometimes the residents tightened their legs which made it difficult to get them clean,
but he/she did the best he/she could;
– He/she should have washed up the resident’s back where urine touched.
During an interview on 11/9/18 at 2:00 P.M., CNA G, said:
– After he/she removed an incontinent brief, he/she always wiped under the abdominal fold;
– He/she used one wipe per swipe;
– He/she used a clean wipe for each groin and used one more wipe to clean the center of
the perineal fold;
– After he/she rolled the resident to his/her side, he/she cleaned each buttock and then
up the center of the buttocks from the rectum up to the coccyx;
– He/she should also clean the resident’s thighs, inner thigh and anywhere urine or feces
touched the resident’s skin.
During an interview on 11/9/18 at 3:32 P.M., the Director of Nurses (DON) said:
– Staff use the disposable wipes, one wipe per swipe;
– Staff should not clean more that one area with each wipe;
– Staff should clean inner to outer on the resident’s peri area and wipe front to back;
– Staff should never wipe back and forth,
– Staff should thoroughly separate and clean all areas of the skin where urine or feces
had touched (hips back, abdomen etc).
7. Review of Resident 52’s care plan, revised 6/5/18, showed
– Resident requires with his/her bathing;
– Supervise the resident’s personal hygiene.
Review of the resident’s MDS, dated [DATE], showed:
– Unable to make daily decisions;
– Required assistance with personal hygiene and bathing;
– [DIAGNOSES REDACTED].
Observation on each day of the survey, 11/6, 11/7, 11/8 and 11/9/18, at various times
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 – Some

(continued… from page 11)
throughout the days, showed the resident had numerous white chin and neck whiskers, some
up to at least an inch in length.
During an interview on 117/18 at 9:12 A.M., the resident said he/she did not like when the
whiskers on his/her face got long like they are now. He/She used to take care of them
his/herself and did not know that staff at the facility would help him/her with the
whiskers. He/she had looked for a beauty shop but had not one found one and he/she thought
the facility needed one.
During an interview on 11/9/18 at 3:32 P.M., the DON said:
– Removal facial hair depended whether the resident did or did not want it. If not, then
staff should remove facial hair during the resident’s shower;
– Staff should remove the facial hair when needed.
8. Review of Resident #91’s facility records showed:
– A care plan revised 6/26/18, included the resident was dependent on staff assistance for
all ADL’s due to [DIAGNOSES REDACTED].
– The residents MDS, dated [DATE], included he/she had severely impaired cognitive skills
for daily decision making. He/she did not reject care. He/she required two-person physical
assistance with personal hygiene. He/she had limited upper-extremity range of motion.
Review of Resident #88’s facility records showed:
– A care plan revised 8/10/18, included the resident had ADL self-care performance deficit
due to spastic [MEDICAL CONDITION] (a neuromuscular condition of [DIAGNOSES REDACTED] that
results in the muscles on one side of the body being in a constant state of contraction),
poor balance and contracture of left hand requiring staff participation in personal
hygiene.
– The residents MDS, dated [DATE], included he/she was mentally-cognitively intact. Did
not reject care. Required one-person physical assistance with personal hygiene. He/she had
[DIAGNOSES REDACTED].
Observations on 11/7/18 at 3:00 P.M., showed Resident # 88 and Resident # 91’s fingernails
were long, uneven and dirty. Licensed Practical Nurse (LPN) F said both residents needed
their fingernails cleaned and trimmed.
In an interview on 11/8/18 at 12:02 P.M., CNA J said a week ago he/she noticed Residents
#88’s and Resident #91’s nails were too long and reported it to a charge nurse.
During an interview on 11/7/18 at 3:20 P.M., LPN F said both Resident #88 and Resident #91
nails were too long. Staff should have told nursing who could trim their nails. Two days
ago he/she noticed Resident #91’s finger nails needed trimming but did not trim them.
In an interview on 11/09/18 at 3:32 P.M., the DON said staff should trim resident
fingernails weekly.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure staff
transferred residents in a safe manner to prevent accidents or the potential for injury
during gait belt and mechanical lift transfers, which affected three out of 31 sampled
residents (Residents #56, #38, and #40). Additionally, staff did not follow facility
policy when residents kept cigarette lighters in their rooms. The facility census was 96.

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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
1. Review of the manufacturer’s undated guideline for mechanical lift use, showed:
– With the legs of the lift open use the steering handle to push the lift underneath the
bed;
– NOTE: Do not engage the rear locking casters when the patient is in the lift.
Review of the facility policy for Mechanical Lift and Transfer, revised 5/23/18, showed:
– Follow the manufacturer’s recommendations for specific mechanical lift equipment:
– When transporting a resident from one location to another using a total lift, the legs
of the lift must remain in the maximum open position for optimum stability and safety
while lifting and safety while the lift is moving;
– Transfer preparation, the rear casters are unlocked;
– Legs of the lift are in the optimum open position.
2. Review of Resident #40’s care plan, revised 8/14/18, showed:
-Resident requires total assistance of staff with transfers using the mechanical lift.
Review of the resident’s Minimum Data Set, a federally mandated assessment instrument,
completed by facility staff, dated 8/15/18, showed:
– Unable to make daily decisions;
– Dependent on staff for transfers;
– [DIAGNOSES REDACTED].
Observation on 11/8/18 at 2:00 P.M., showed the resident sat in a Broda type wheelchair.
Certified Nurse Aide (CNA)s E and H transferred the resident with a mechanical lift to
his/her bed.
– CNA H placed the closed lift legs through the wheels of the wheelchair and locked the
casters;
– After staff attached the sling to the lift, CNA H unlocked the caster, backed the lift,
turned the lift toward the bed and pushed the lift at least six feet to the resident’s bed
with the legs of the lift closed;
– CNA H left the legs of the lift closed as he/she lowered the resident to his/her bed.
3. Review of Resident #38’s Minimum Data Set, (MDS), a federally mandated assessment
instrument completed by facility staff, dated 8/13/18, showed:
– Some difficulty in making decisions;
– Dependent on staff for transfers;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, last revised 11/7/18, showed:
– Resident requires sliding board or mechanical lift for transfers, assist of two staff.
Observation on 11/8/18 at 8:00 A.M., showed the resident lay in his/her bed. CNA E and CNA
H placed a lift sling under the resident and transferred the resident with a mechanical
lift in the following way:
– CNA H placed the mechanical lift under the resident’s bed and left the legs in the
closed position;
– Attached the sling to the mechanical lift, lifted the resident from the bed and backed
the lift from under the bed, turned the lift towards the resident’s wheelchair and opened
the legs of the lift;
– Locked the castors of the mechanical lift and lowered the resident into his/her
wheelchair
4. During an interview on 11/8/18 at 2:40 P.M., CNA H said:
– He/she should open the legs of the lift while hooking up the sling to the lift and close
the legs of the lift when lifting, lowering and moving the resident;
– He/she locked the casters before he/she lowered the resident;
– The facility said he/she should follow manufacturer’s guidelines when he/she used 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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
mechanical lift.
During an interview on 11/9/18 at 3:32 P.M., the Director of Nurses said:
– Staff should follow the manufacturer’s guidelines when they use the mechanical lift;
– The legs of the lift should be in the open position when staff raise, lower or move the
resident;
– Staff should only lock the casters when raising or lowering the resident.
5. Review of Resident #56’s admission MDS, dated [DATE], showed:
-Severe cognitive impairment related to decision-making;
-Required extensive assistance of one staff for transfers.
Review of the resident’s care plan, dated 9/13/18, showed:
-At risk for falls related to decreased balance;
-Self care deficit related to generalized weakness compounded by dementia;
-Required extensive assistance for transfers.
Observation on 11/6/18 at 11:48 A.M., showed Certified Nurse Aide (CNA) D transferred the
resident from the bed to a wheelchair in the following manner:
-Provided incontinent care, washed his/her hands and put on gloves;
-Dressed the resident, then placed a gait belt around the resident’s waist;
-The resident stated, You’ve never used that before.
-CNA A stated that the resident must be used to staff grabbing his/her pants to transfer
him/her.
-CNA A placed the wheelchair near the bed and locked the wheels, grasped the back of the
resident’s gait belt and lifted the resident to a standing position;
-The gait belt slid up the resident’s back, pulling the resident’s clothing up his/her
back;
-CNA A held onto the gait belt with one hand and used his/her other hand to grasp the back
of the resident’s pants and pulled on the pants to moved the resident from the bed to the
wheelchair.
During an interview on 11/18/18 at 1:17 P.M., CNA D said:
-Place the gait belt around the area where the tummy starts;
-Grab the back of the gait belt and lift with the belt;
-Was taught that it was alright to lift the resident by holding onto their pants, but
he/she would rather lift with the gait belt.
_. During an interview on 11/9/18 at 3:00 P.M., the DON said:
-Place the gait belt tightly just above the resident’s hips.
-Grasp the gait belt to lift, not clothing.
-If the gait belt slides up, if possible, staff should lower the resident and adjust the
gait belt.
6. Review of the facility’s resident smoking policy, showed, in part:
– Smoking materials: smoking materials include but are not limited to cigarettes, cigars,
electronic cigarettes, lighters and matches;
– Independent smoker: a resident that is able to demonstrate safe smoking habits including
smoking materials management, lighting, controlling cigarette ash and extinguishing
smoking materials;
– IDT: an interdisciplinary team is composed of professionals from a variety of
disciplines (nursing, therapy, social services, dietary, pharmacy and other) working
together to solve or address an issue using a holistic perspective;
– It is the policy of this facility to promote resident centered care by providing a safe
smoking area for residents that request to smoke and are capable of safe smoking
behaviors;
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
– Smokers will be permitted to smoke only in designated smoking areas;
– Obtaining smoking materials is the responsibility of the resident/family/guardian;
– Facility staff will secure smoking materials in a locked area when not in use by the
resident for both independent and supervised smokers.
7. Review of Resident # 64’s quarterly MDS dated [DATE], showed:
– Makes self understood.
– Understand others.
– Moderately impaired cognitive status.
Review of the residents care plan dated 10/3/18, showed the resident was non-compliant
with the smoking policy as being a dependent smoker. The resident falls asleep when
smoking and required staff supervision. The resident burned him/herself several time since
admission. The Social Services Director (SSD) has educated the resident.
Review of the resident Smoking assessment dated [DATE], showed:
– The resident could not light his/her own cigarette.
– The resident falls asleep or drops cigarette. The resident has numerous burns.
Observation on 11/8/18 at 8:56 P.M., showed the resident in his/her room with smoke all
around and the odor of cigarette smoke in the air.
In an interview on 11/8/18 at 8:58 P.M., Certified Nurse Aide (CNA) L said another
resident smelled smoke, informed staff and the resident was found in his/her room smoking.

Review of Resident # 64’s care plan showed on 11/8/18, staff re-educated the resident of
no smoking allowed in the facility and policy not to have lighters on person for safety of
self and others.
In an interview on 11/9/18 at 1:32 P.M., the resident said last night he/she woke up from
a nap, forgot where he/she was and started smoking by using a lighter hid in his/her room.
He did not know what he/she was thinking. If he/she did not have a lighter he/she would
not have been able to light the cigarette. He/she worried that by smoking in his/her room
another resident could have been harmed. His/her neighbor is on oxygen.

8. Review of Resident #79’s care plan, revised, 6/8/18, showed:
– The resident wished to smoke and had been assessed as an independent smoker at risk for
/ potential [MEDICAL CONDITION] to strength: understands center’s smoking policy;
– Educate the resident regarding the center’s smoking policy, designated smoking areas and
storage of smoking materials.
Review of the resident’s smoking assessment, dated, 9/13/18, showed:
– The resident knew the location where smokeless tobacco was safely kept.
Review of Resident #79’s significant change in status MDS, dated , 9/20/18, showed:
– Cognitive skills intact;
– Supervision of one staff for bed mobility and transfers;
– Lower extremities impaired on both sides;
– The resident smoked cigarettes.
Observation and interview on 11/7/18, at 7:47 A.M., showed:
– The resident had two packs of cigarettes and two lighters on his/her over bed table;
– The resident said he/she was not supposed to have his/her cigarettes or lighters at
bedside but the staff let them.
Observation from 11/6/18 through 11/8/18 at various times, showed:
– The resident had his/her lighter and cigarettes on his bedside table or on his/her
person.
9. During an interview on 11/8/18, at 12:54 P.M., the Social Services Director said:

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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
– The residents are not allowed to have their cigarettes and lighters in their rooms;
– When staff see them, they should lock them up in captivities or in the cigarette box
which is kept in the east nurse’s station.
During an interview on 11/9/18, at 8:38 A.M., the Social Services Director said:
– It is against the facility’s policy for the resident’s to have their cigarettes or
lighters in their rooms;
– Staff should also notify him/her so he/she could document and re-educate the resident on
the smoking policy.
During an interview on 11/9/18, at 3:32 P.M., the DON said:
– The residents should not smoke in their rooms;
– The policy at Communicare is the residents cannot have a lighter on their person or in
their rooms
– Resident#64 was found smoking in his/her room and will be placed on one to one
monitoring.
– Residents were not allowed to have lighters.
– Staff was to report to administration when residents had lighters in their rooms.
– He was not aware that resident #79 stored lighters in his/her room.
– No residents were allowed to store lighters in their room.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure staff
provided proper catheter (a sterile tube inserted into the urinary bladder to drain urine)
care or supra pubic catheter care (a flexible tube inserted into the bladder through a cut
in the abdomen) in a manner to prevent a urinary tract infection [MEDICAL CONDITION] or
the possibility of a UTI which affected two of 31 sampled residents, (Resident #7 and
#68), and Resident #38. Additionally, staff held a urinary drainage bag above the level of
the bladder during care, did not clean a contaminated drain spout and allowed the catheter
drainage bag tubing to drag the floor, and did not use a leg strap to prevent pulling of
the tubing. The facility census was 96.
1. Review of the facility policy for Catheter Care, revised 4/20/17, showed:
– Catheter care is performed at least twice daily on residents that have indwelling
catheters;
– Perform peri care and catheter care with incontinence of bowel episodes;
– Obtain clean, wet washcloth with warm soap and water;
– Securely grasp the catheter tubing nearest the meatal opening to prevent movement or
accidental dislodgement;
– Wipe catheter from meatus downward approximately six inches;
– Repeat with clean side of cloth;
– Repeat until no visible soiling is observed on the catheter;
– Secure catheter to leg with a device or tape;
– Check that drainage bag is not on the floor and is draining properly and secured
allowing for no reflux of urine back to the bladder.
Review of the facility’s policy for Catheter Drainage Bag and Tubing maintenance, reviewed

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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
4/2017, showed:
– Tubing is maintained in a dependent position below the bladder, with the flow of urine
downward and preventing backflow;
– Drainage bags will be covered when the resident is out of the room for dignity and
infection prevention purposes;
– Drainage bags will not be placed on the floor;
– Drainage bags will be emptied each shift. Use alcohol or other antiseptic wipe for
disinfection of the port before and after draining urine.
2. Review of Resident #38’s Minimum Data Set, (MDS), a federally mandated assessment
instrument completed by facility staff, dated 8/13/18, showed:
– Some difficulty in making decisions;
– Dependent on staff for toilet use;
– Required extensive assistance with personal hygiene;
– Always incontinent of bowel and bladder; (indwelling catheter not coded)
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, last revised 11/7/18, showed:
– Resident on antibiotic therapy for a UTI;
– No care plan related to the resident’s indwelling catheter.
Observation on 11/8/18 at 8:00 A.M., showed staff lay in bed with a catheter drainage bag
attached to the bed. Certified Nurse Aides (CNA)s E and H provided peri care and catheter
care before getting the resident up for breakfast. Both staff put on gloves without
washing their hands.
– CNA E set a graduate (plastic measuring cup) on the floor without a barrier
on the floor;
– After CNA E drained urine from the drainage bag, he/she tapped the drainage port onto
the side of the graduate;
– CNA E did not clean the drainage spout with an alcohol pad but replaced the drainage
port into the holder on the drainage bag;
– CNA H returned to the resident’s room after he/she removed a soiled bag of linen from
the room and retrieved more pre-moistened wipes. He/she did not wash his/her hands, put on
gloves and without securely grasping the catheter tubing wiped down the tubing with three
clean pre-moistened wipes;
– CNA E held the catheter drainage bag above the bed as he/she threaded the bag through
the leg of the resident’s shorts;
– When staff transferred the resident to his/her wheelchair with a mechanical lift, CNA E
placed the urinary drainage bag into a dignity bag hooked under the resident’s wheelchair,
the tubing dragged the floor;
– Without adjusting the tubing, CNA H pushed the resident’s wheelchair down the hallway to
the dining room, the tubing dragged the floor up the hallway.
During an interview on 11/8/18 at 2:40 P.M., CNA H said:
– He/she should hold the catheter tubing by the entry site when wiping down the catheter
tubing, that would help support the tubing so it didn’t get pulled;
– The drainage tubing should never touch the floor.
During an interview on 11/6/18 at 2:50 P.M., CNA E said:
– He/she was suppose to have a clean field, towel or something, on the floor under the
graduate;
– He/she should have cleaned the drainage port with an alcohol wipe, but he/she did not
have any;
– The tubing and urinary drainage bag should always be kept below the level of the bladder
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
but not touch the floor.
3. Review of Resident #7’s annual MDS, dated , 10/12/18, showed:
– Cognitive skills moderately impaired;
– Required extensive assistance of one staff for bed mobility, transfers, and toilet use;
– Had a Foley catheter;
– Always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised, 11/6/18, showed:
– The resident had an indwelling catheter: suprapubic: [DIAGNOSES REDACTED].
– Catheter care every shift;
– Catheter strap in place at all times for securement of catheter;
– Position catheter bag and tubing below the level of the bladder and away from entrance
of the door;
– Change drainage bag and tubing every two weeks on Sunday and as needed;
– Monitor, record and report to physician for signs and symptoms of UTI.
Review of the resident’s active POS, showed:
– An order to change the drainage bag and tubing every night shift every 14 days;
– Change Foley catheter as needed for leakage;
– Foley catheter care as needed for hygiene;
– Foley catheter care every day and night shift for hygiene.
Observation on 11/8/18, at 6:27 A.M., showed:
– The resident propelled him/herself down the hallway and the dignity bag dragged on the
floor from the resident’s room to the dining room.
Observation on 11/9/18, at 9:49 A.M., showed:
– CNA C entered the resident’s room, did not wash his/her hands and applied gloves;
– CNA C placed a paper towel on the floor, placed the graduate on the paper towel and
placed the package of wipes directly on the floor;
– CNA C unclamped the drainage spout and emptied the urine into the graduate;
– CNA C used a wipe and and cleaned the drainage spout and replaced it in the sleeve.
During an interview on 11/8/18, at 10:00 A.M., CNA C said:
– He/she normally used a wipe to clean the drainage spout;
– He/she should not have placed the package of wipes directly on the floor.
Observation on 11/9/18, at 10:05 A.M., showed LPN A provided suprapubic catheter care in
the following manner:
– CNA C and CNA D transferred the resident from his/her wheelchair into his/her bed;
– LPN A did not wash his/her hands and applied gloves;
– LPN A used the same area of the wash cloth to clean the area around the insertion site;
– LPN A used a new wash cloth and wiped approximately an inch down the catheter tubing;
– LPN A applied a new dressing around the insertion site;
– LPN A placed the drainage bag directly on the resident’s floor and attempted to get the
urine out of the tubing.
During an interview on 11/9/18, at 10:21 A.M., LPN A said:
– He/she should not use the same area of the cloth to clean different areas of the skin;
– He/she should have wiped four inches down the catheter tubing;
– He/she should have anchored the tubing when he/she cleaned it.
– He/she should not have placed the drainage bag directly on the resident’s floor.
4. Review of Resident #68’s care plan, dated 6/8/18, showed:
– The resident had a suprapubic catheter.
– Staff must keep the drainage bad below the level of the bladder.
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
– Staff must provide catheter care every shift and as needed.
– Did not discuss the use of a leg strap.
Review of the resident’s quarterly MDS dated [DATE], showed:
– Cognitively intact;
– Total dependence upon staff for transfers;
– Required extensive staff assistance for dressing, toileting, and hygiene;
– Had a catheter;
– Frequently incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on 11/6/18 at 10:54 A.M. showed the resident’s bulging (overfilled) catheter
bag on the floor.
Observation on 11/7/18 at 10:55 A.M. of Licensed Practical Nurse (LPN) G providing
suprapubic care for the resident showed:
– He/she emptied the resident’s drainage bag of 3000 milliliters (ml) of cloudy urine.
– He/she then uncovered the resident and found the resident did not have a leg strap to
anchor his/her suprapubic catheter.
During an interview on 11/7/187 ay 10:55 A.M. LPN G said:
– The resident’s drainage bag was overflowing.
– Staff should empty it when ever the bag looks full.
– The resident should have a leg strap to anchor the suprapubic catheter.
During an interview on 11/7/18 at 11:55 A.M. the resident said:
– Staff infrequently emptied his/her drainage bag.
– Staff did not put on a leg strap.
During an interview on 11/9/18 at 8:00 A.M. the DON said:
– Staff should empty a resident’s drainage bag at the end of their shift and anytime the
bag looked full.
– Staff should anchor a resident’s suprapubic catheter with a leg strap.
– The resident refused a leg strap sometimes.
– Staff should care plan interventions if the resident refused a leg strap.
5. During an interview on 11/9/18 at 3:32 P.M., the Director of Nurses (DON), said:
– Staff should place the graduate on a clean barrier;
– If staff tapped the drainage spout on the graduate, it was contaminated and staff should
clean it with an alcohol pad before replacing it in the holder on the drainage bag;
– Staff should stabilize the catheter tubing before they wiped down the tubing;
– Staff should keep the drainage bag inside a dignity bag. The tubing, urinary drainage
bag and the dignity bag should never touch the floor unless there was a clear barrier;
– Staff should make sure the residents wore a leg strap;
– Staff should never place the drainage bag above the resident’s bladder.

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews, the facility failed to assure staff
provided proper respiratory care when staff failed to properly clean oxygen concentrator
filters, and failed to date tubing/humidifiers when opened. Additionally, staff failed to
replace resident’s empty oxygen tank and allowed a resident to adjust their own flow rate.
This affected five of 31 sampled residents (Residents #13, #19, #16, #196, #93, 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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
facility census was 96.
1. Review of the undated facility policy on oxygen therapy showed:
– Staff should remove and clean oxygen concentrator filters once a week.
– Did not address person responsible for cleaning or when to clean the filter.
Review of the facility policy, dated 3/20/18, on supplemental oxygen using a nasal cannula
showed:
– Staff must label the cannula tubing when opened.
– Staff must change each resident’s nasal cannula weekly and as needed.
– Licensed nurse only to adjust the oxygen liter flow.
– Did not address the person responsible for changing the oxygen tubing and what day of
the week.
– Did not address changing the humidifier.
2. Review of Resident #19’s annual MDS, dated [DATE], showed:
– Mild cognitive impairment;
– Required supervision for dressing, toileting, and hygiene;
– Occasionally incontinent of bladder and bowel;
– [DIAGNOSES REDACTED].
– Did not indicate the resident received oxygen therapy.
Review of the resident’s treatment administration record (TAR) dated (MONTH) (YEAR)
showed:
– Staff must change and date oxygen tubing every Sunday.
– Did not discuss dating the oxygen humidifier.
– Staff to ensure the resident received oxygen at two liters (l) per nasal cannula
continuously.
Observation on 11/6/18 at 10:45 A.M. of the resident showed:
– The resident sitting in his/her wheelchair connected to a portable oxygen tank on the
back of the wheelchair.
– The portable oxygen tank was on empty.
– The resident’s oxygen tubing was not labeled when staff opened the tubing.
Observation on 11/7/18 at 9:21 A.M. showed:
– The resident’s oxygen tubing connected to an oxygen concentrator.
– The resident’s oxygen tubing not labeled when staff opened the tubing.
– The resident’s oxygen tubing connected to humidifier not labeled when staff opened the
tubing.
During an interview on 11/7/18 at 10:11 A.M. the Director of Nursing (DON) said:
– Staff should change each resident’s oxygen tubing once a week.
– Did not know which staff or which day of the week staff were supposed to change and
label the resident’s tubing and humidifiers.
– Staff should frequently check each resident’s oxygen tank and promptly change when
empty.
3. Review of the facility’s policy related to use of supplemental oxygen, dated 3/20/18,
showed:
-Oxygen is considered a medication and will be treated as such, including the need for a
physician order and placement on the Medication Administration Record [REDACTED]
-A nurse or respiratory therapist will verify the oxygen order for the route and liters
per minute (lpm) flow rate and deliver as prescribed.
4. Review of Resident #16’s MDS, dated [DATE], showed:
– Able to make daily decisions:
– Used oxygen therapy;
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 10/19/18, showed:
– Give oxygen therapy as ordered by the physician;
– Uses oxygen continuously.
Review of the resident’s 11/18 physician order sheet, showed:
– Oxygen therapy at two liters per minute by nasal cannula continuously every shift for
shortness of air;
– Change out oxygen tubing with date and initials once per week every night shift every
Sunday for infection control.
Observation and interview on 11/6/18 at 11:03 A.M., showed the resident used a portable
tank of oxygen and had a oxygen concentrator beside his/her bed. The oxygen concentrator
did not have a foam filter in place. Where the foam filter should have been was a space
covered with light gray dust that removed with a wipe of the finger. Neither nasal cannula
tubing on the concentrator nor the portable oxygen tank were dated. The resident sat on
the edge of his/her bed and said when he/she was up walking around the oxygen flow rate
should be on at least four liters per minute and when he/she was not up and about the flow
rate should be on two. He/she reached up and turned the knob on the portable oxygen tank
from four liters down to three liters.
Observation on 11/8/18 at 7:44 A.M., showed the resident lay in his/her bed with his/her
eyes closed and the undated nasal cannula attached to the oxygen concentrator beside
his/her bed. The flow rate on the oxygen concentrator was set on five liters per minute.
The tubing on the portable oxygen tank was also undated.
5. Review of Resident #196’s care plan, revised on 4/9/18, showed:
– Oxygen therapy as ordered by the physician.
Review of the resident’s MDS, dated [DATE], showed:
– Able to make decisions;
– Oxygen therapy;
– [DIAGNOSES REDACTED].
Review of the resident’s 11/18 physician’s order did not show an order for
[REDACTED].>Observation on 11/6/18 at 10:31 A.M., showed the resident lay in bed using
an undated nasal cannula attached to an oxygen concentrator. The top of the concentrator
was dirty with food crumbs and other debris, the foam filter of the concentrator was
covered with a whitish gray dust. The flow meter of the concentrator was set on five
liters per nasal cannula.
Observation on 11/7/18 at 9:46 A.M., showed the resident used an undated nasal cannula
attached to the oxygen concentrator that was set at five liters per nasal cannula.
During an interview on 11/8/18 at 2:45 P.M., Licensed Practical Nurse (LPN) B said:
– Any staff CNA, CMT or Nurse could switch the residents oxygen from concentrator to
portable tank;
– Staff looked at the flow rate on the concentrator and then set the portable oxygen tank
flow rate to the same number as the concentrator;
– If staff ever questioned the flow rate a resident’s oxygen should be set on, they should
ask the charge nurse;
– Sunday night charge nurses set up the oxygen tubing and supplies and the CNAs changed it
out:
– The CNAs should date the tubing when placed on the concentrators;
– He/she thought the night charge nurses were suppose to wash the filters;
– Residents should not set their own flow rate.
6. Review of Resident #13’s annual MDS, dated , 7/18/18, showed:
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 21)
– Cognitive skills intact;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised 8/14/18, showed:
– The resident had oxygen therapy related to [MEDICAL CONDITION] and [MEDICAL CONDITIONS],
buildup of fluid in the lungs and surrounding body tissue;
– The resident had oxygen at 4 liters/nasal cannula continuously.
Observation on 11/17/18, at 8:36 A.M., showed:
– The filter on the oxygen concentrator covered with gray dust;
– The oxygen tubing did not have a date when it was changed.
Review of the resident’s POS, dated 11/8/18, showed:
– The resident did not have an order for [REDACTED].>7. Review of Resident #93’s care
plan, revised, 8/24/18, showed:
– The care plan did not address the use of oxygen.
Review of the resident’s 14 day assessment MDS, dated , 10/24/18, showed:
– Cognitive skills intact;
– [DIAGNOSES REDACTED].
Observation on 11/6/18, at 10:08 A.M., showed:
– The oxygen tubing for the O2 concentrator did not have a date when it was changed;
– The portable oxygen tank tubing did not have a date when the oxygen tubing was changed.
Review of the resident’s POS, dated, 11/8/18, showed:
– The resident did not have an order for [REDACTED].>8. During an interview on 11/9/18
at 3:32 P.M., the Director of Nurses said:
– The orders for changing oxygen and nebulizer tubing is placed on the electronic
treatment sheets that the nurse and CMT signs off;
– Tubing should be changed and dated every Sunday night;
– The concentrator filters should be cleaned every Sunday night and who should clean the
filters depended on who changed the tubing;
– Residents should not adjust the oxygen flow rate themselves;
– If a CNA was changing a resident from a concentrator to a portable tank, he/she should
verify with the charge nurse what the flow rate should be;
– A resident that used continuous oxygen should have a physician’s order for oxygen

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on on observations, interviews, and record reviews the facility failed to ensure
staff properly stored medications and discarded expired medications. The facility census
was 96.
1. Observation on 11/8/18 at 5:52 A.M. of the medication cart on the west wing showed an
unchilled container of thickened lemon water dated 11/1/18.
Review of the label on the thickened lemon water showed:
– Staff should discard unchilled opened thickened lemon water eight hours after opening.
– Staff should discard chilled opened thickened lemon water seven days after opening.
During an interview on 11/8/18 at 5:52 A.M. the Director of Nursing (DON) said staff
should discard thickened lemon water according to the package directions.

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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
2. Observation on 11/8/18 at 8:26 A.M. of the west medication cart showed:
– A vial of Humalog insulin pen dated opened 10/8/18 (31 days after opening);
– An opened mixed vial of cefatriaxone (an antibiotic) labeled single use only and dated
10/8/18.
During an interview Registered Nurse (RN) D said:
– All insulins should be discarded 30 days after opening;
– Staff should discard single use only medications after use.
3. Observation of the East Medication Room and interview with Graduate Nurse (GN) A on
11/8/18 at 6:33 A.M., showed:
– A bottle of 82 [MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION]) 800 mg tablets,
that belonged to a resident who GN A said discharged from the facility on 10/30/18 to
another facility, in a drawer where other miscellaneous items were stored;
– Also in that drawer was an opened bottle of 58 [MEDICATION NAME] (sleep aid) 1 mg
tablets with an unreadable smeared date on it. GN A said the [MEDICATION NAME] was house
stock, he/she could not read the smeared date on the lid, did not know who had used
medication out of it and could not find an expiration date on the bottle;
– The upper cabinet held more house stock medication that included a bottle of [MEDICATION
NAME] (fiber supplement for digestive health) expired 10/18 and an opened jar of Vaseline
that the lid was not on correctly and that expired 6/18.
4. Observation and interview on 11/8/18, at 6:57 A.M., of the West medication room,
showed:
– One 1000 ml. bag of [MEDICATION NAME] HN ( used for individuals with increased calorie
needs and/or limited fluid tolerance), expired (MONTH) 6, (YEAR);
– One container of [MEDICATION NAME] 1.5 calorie, expired (MONTH) 8, (YEAR);
– One opened vial of Apisol ([MEDICATION NAME] Purified Protein Derivative) did not have a
date when it was opened;
– One can of 2 Cal HN, ( nutritionally complete high-calorie liquid food) 8 ounces,
expired (MONTH) 1, (YEAR);
– Five, 8 fluid ounce containers of nepro therapeutic nutrition, expired (MONTH) 1,
(YEAR);
– Registered Nurse (RN) A said all medications should have a date when they are opened.
Staff should not use medications if they are expired, the medications should be destroyed.
All charge nurses check for expired medications and make sure they have a date when they
were opened. If the medication does not have a date when it was opened, it should be
discarded.
During an interview on 11/9/18, at 3:32 P.M., the Director or Nursing (DON) said:
– The medications should be dated when opened;
– The Certified Medication Technicians (CMT’s) and the nurses check the medication rooms
for expired medications and central supply checks the medication room when he/she puts the
stock medications in it.

F 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure meals and snacks are served at times in accordance with resident’s needs,
preferences, and requests. Suitable and nourishing alternative meals and snacks must be
provided for residents who want to eat at non-traditional times or outside of scheduled
meal times.

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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
Based on observations and interviews, the facility failed to ensure staff offered each
resident a bedtime snack. This had the potential to affect all facility residents. The
facility census was 96.
1. During an interview on 11/6/18, at 10:08 A.M., Resident #72 said staff do not serve a
snack at bedtime.
During an interview on 11/6/18, at 10:19 A.M., Resident #18 said sometimes staff put
snacks out in the hall but not always. Staff do not pass the bedtime snacks.
During an interview on 11/6/18, at 10:54 A.M., Resident #68 said staff never bring him/her
a bedtime snack.
During an interview on 11/6/18, at 11:49 A.M., Resident #95 said:
– He/she does not get offered a snack at bedtime;
– He/she would take a snack at bedtime if it was offered.
During an interview on 11/7/18, at 8:27 A.M., Resident #34 said if you want a snack you
have to go and get it for yourself. Staff do not bring it to your room and offer it.
He/she would take a snack if it was brought to him/her and offered.
During the resident council meeting on 11/7/18, at 10:31 A.M., 10 residents said:
– Staff do not bring the snack carts to their rooms and offer them a snack;
– The residents said they would take a snack if it was offered to them;
– If they cannot get to the snack cart, they do not get a snack.
During an interview on 11/7/18, at 2:43 P.M., Resident #79 said:
– Staff do not come to his/her room at bedtime and offer him/her a snack;
– He/she would take a snack if it was offered at bedtime.
Observation on 11/8/18, of the 100 hall from 8:34 P.M. to 9:23 P.M., showed:
– At 8:45 P.M., dietary staff positioned a snack cart in front of the nurses’ station.
– A few residents went to the cart and obtained a snack.
– The cart remained in front of the nurses’ station. Staff did not pass bedtime snacks to
the residents.
During an interview on 11/8/18, at 9:08 P.M., Certified Nurse Aide (CNA) K said residents
who wanted a bedtime snack came and got one off of the bedtime snack cart. He/she did not
know that there was a time to serve snacks. If a resident request a snack, they are given
one.
During an interview on 11/8/18, at 9:15 P.M., CNA L said usually residents came to the
bedtime snack cart and got their own snack.
During an interview on 11/8/18, at 9:23 P.M. the Director of Nursing said staff served
snacks to residents with physician orders. The snack cart was available for any resident
who requested a snack.
During an interview on 11/9/18, at 10:19 A.M., Resident #70 said:
– Staff do not offer him/her a snack at bedtime;
– He/she would take a snack if it was offered at bedtime.
During an interview on 11/9/18, at 4:30 P.M., the Administrator said the facility did not
monitor to track if residents were offered snacks. Staff were trained to pass bedtime
snacks. She expected staff to offer bedtime snacks to each resident.

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.

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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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

Based on observations, interview and record review, the facility failed to properly store
foods and provide a sanitary environment in the kitchen. The facility census was 96.
Review of the facility’s policy which discussed the environment, revised (MONTH) (YEAR),
showed all food preparation areas will be maintained in a clean and sanitary condition.
1. Observation and interview on 11/6/18, at 10:15 A.M., showed:
– Rust on the shelves of the refrigerator near the food preparation areas;
– Three outdated 5-pound containers of yogurt;
– A container of applesauce split open and seeping out;
– Ricotta cheese uncovered and exposed;
– The Regional Dietary Director (RDD) said the rust in the refrigerator could cause cross
contamination. The Dietary manager was to monitor food to assure it did not pass
expiration dates. Food should be covered and sealed.
2. Observation on 11/6/18, at 11:57 A.M., showed the steam table in the main dining room
had food floating in the steam water when staff brought fresh food from the kitchen and
set it in the steam table.
Observation and interview on 11/8/18, at 8:17 A.M., showed the steam table water had
pieces of food in it as staff were putting fresh food trays in the table. The Cook and the
RDD said it was unsanitary. The RDD said staff were to clean the steam table every other
day but should clean it every shift.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
followed protocols to prevent the spread of infection which included staff failure to
change gloves and wash or sanitize their hands between dirty and clean tasks during peri
care and wound treatments, left a gait belt and bags of contaminated linens and trash on
the resident’s room floor and failed to disinfect a blood pressure cuff after use on a
resident on isolation precautions This affected seven out of 31 residents (Residents #40,
#38, #25, #68, #88, #70 and #396). The facility census was 96.
Review of the facility’s policy for Standard Procedures, reviewed 10/31/18, showed:
– Hand Hygiene: The cleaning of hands by using either handwashing (using soap and water),
antiseptic hand wash, antiseptic hand wash or antiseptic hand rub (alcohol-based sanitizer
including foams or gel).
– [MEDICATION NAME] hand hygiene is a simple but effective way to prevent the spread of
infections by breaking the chain of infection;
– Proper cleaning of hands can prevent the spread of germs, including those that are
resistant to antibiotics;
– The facility adheres to the Center for Disease Control (CDC) guidelines and
recommendations for hand hygiene unless otherwise explicitly stated;
– When hands are not visibly soiled, alcohol-based hand sanitizers are the preferred
method of cleaning hands;
– Use soap and water when hands are visibly soiled or dirty or known or suspected exposure
to [MEDICAL CONDITION] (C diff);
– Use an alcohol based product when hands are not visibly soiled or contaminated;
– Use soap and water when hands are visibly soiled, known or suspected C.diff outbreak or
occurrence (diarrhea);

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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 25)
– Perform hand hygiene before feeding or assisting in the dining room for tray pass,
before and after direct contact with a resident’s intact skin, after contact with blood,
body fluids or excretions, mucous membranes non intact skin or wound dressings, after
contact with inanimate medical equipment;
– Perform hand hygiene when hands move from a contaminated body site to a clean body site
during patient care, care between residents and after glove removal.
Review of the facility’s policy for Standard Precautions and Transmission Based
Precautions, reviewed 10/31/18, showed:
– Change gloves between clean and dirty tasks and procedures on the same resident after
contact with material that may contain a high concentration of microorganisms;
– Remove gloves promptly after use, before touching non-contaminated items and
environmental surfaces.
1. Review of Resident #25’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 8/1/18, showed:
– Extensive assistance of two staff for personal hygiene;
– Always incontinent of bowel and bladder.
Review of the resident’s care plan, last revised on 8/14/18, showed:
– Had functional bowel and bladder incontinence;
– Check and provide incontinence care every two hours and as needed.
Observation on 11/8/18, at 6:14 A.M., showed Certified Nurse Aides (CNAs) A and B provided
care for the resident in the following manner:
– Both staff washed their hands and put on gloves.
– CNA A used only two wet wipes, wiped back and forth, and folded and re-used the same
wipe multiple times in more than one area as he/she cleansed the resident’s front genital
area.
– Fecal material was present on the wipes.
– CNA A changed gloves, but did not wash or sanitize his/her hands between glove changes.
– Staff turned the resident to his/her right side.
– CNA A wiped back and forth and folded and re-used the same wet wipe multiple times as
he/she cleansed the resident’s buttocks and rectal areas.
– Staff turned the resident onto his/her back and CNA A cleansed fecal material from the
resident’s inner thighs.
– Without removing his/her gloves and washing his/her hands, CNA A removed the soiled bed
pad and placed a clean one beneath the resident.
– CNA A, with the same soiled gloves on, gathered the bagged soiled items, placed the bags
on an empty bed, obtained a pillow and placed it behind the resident’s back, removed
his/her gloves, but did not wash or sanitize his/her hands before he/she left the room.
– CNA B gave the resident his/her call light, positioned the resident’s neck pillow and
positioned the over bed table within the resident’s reach, removed his/her gloves and
washed hands before he/she left the room.
During an interview on 11/8/18, at 6:35 A.M., CNA A said:
– Staff should wash their hands when they enter a room, each time they remove their
gloves, if the gloves become soiled with fecal material, and before they leave a resident
room.
– Staff should remove their gloves after they complete peri care, before they touch other
items in the room.
During an interview on 11/9/18, at 3:00 P.M., the Director of Nurses (DON) said:
– Staff should wash their hands before and after resident care, when hands are visibly
soiled, after glove removal and before they leave a resident room.
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 26)
– Staff should not touch other items or surfaces with soiled gloves.
2. Review of Resident #40’s care plan, revised 8/14/18, showed:
– Check every two hours and as needed for incontinence;
– Wash, rinse and dry perineum;
– Change clothing as needed after incontinence episodes.
Review of the resident’s MDS, dated [DATE], showed:
– Unable to make daily decisions;
– Required extensive assistance of staff for toilet use and personal hygiene;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Observation on 11/8/19, at 2:00 P.M., showed CNA E and H provided perineal care. Neither
staff washed their hands before they put on gloves. CNA E removed the soiled incontinent
brief and said it was wet. When CNA H started to wipe the resident’s left buttock, the
resident started to urinate in the bed. CNA H wiped one hand width of the resident’s left
buttock, rolled the resident to his/her right side on the soiled incontinent pad and wiped
one hand width on the right buttock and up the center crease of the buttocks. CNA H washed
once down the left groin and one wipe down the right groin then fastened the brief on the
resident. CNA H changed his/her gloves but did not wash or sanitize hands. CNA H assisted
to cover the resident, touched the remote control to lower the bed, pulled the string to
turn down the light and moved the resident’s Broda type wheelchair.
3. Review of Resident #38’s MDS, dated [DATE], showed:
– Some difficulty in making decisions;
– Required staff assistance for bed mobility, transfers, dressing, toilet use, personal
hygiene and bathing;
– Limited range of motion on one side;
– Two unstageable pressure ulcers;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, last revised 11/7/18, showed:
– Resident has an amputation below the left knee;
– Resident has skin breakdown to the right heel and a surgical wound to let leg;
– Administer treatments as ordered and monitor for effectiveness.
Review of the resident’s November, (YEAR), physician order [REDACTED]. Apply Santyl
(debridement agent) to be nickel thick, apply calcium alginate (absorbent dressing) and
cover with border gauze and wrap with [MEDICATION NAME] (four inch gauze strip) and secure
with tape.
Observation and interview on 11/9/18, at 8:59 A.M., showed the resident lay in bed with a
border gauze covering his/her right heel. Registered Nurse (RN) B washed his/her hands and
gloved before and after he/she removed the old dressing on the right heel. RN B used wound
cleanser and gauze pads to clean the wound. RN B said the wound had no depth and was 3.4
centimeters (cm) by 4.7 cm. The wound bed was 50 % yellow slough (mass of dead skin), 20 %
eschar (black scab, falling away of dead tissue) and 30 % granulation (healthy skin), the
wound had a small amount of drainage. After cleaning the wound, without changing gloves or
washing his/her hands, RN B placed santyl on the wound with a Q-tip, picked up calcium
alginate with his/her soiled glove and place it on the wound, then covered the alginate
with a border gauze dressing. After he/she picked up the trash from his/her clean field
and threw it away, he/she washed his/her hands and changed gloves. RN B said he/she washed
his/her hands after he/she removed the soiled dressing. He/she should have washed hands
and changed gloves after he/she cleaned the wound.
During an interview on 11/9/18, at 3:21 P.M., the Director of Nurses (DON) said:
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 27)
– The nurse should have washed his/her hands and changed gloves after he/she cleaned the
wound.
4. Review of Resident #70’s admission MDS, dated [DATE], showed:
– Cognitive skills intact;
– Required extensive assistance of one staff for bed mobility, transfers and dressing;
– Lower extremity impaired on one side;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised 10/4/18, showed:
– The resident had an actual impairment to skin integrity related to fragile skin and
diabetes;
– Provide treatment as ordered.
Observation on 11/8/18, at 1:59 P.M., showed RN A did the following:
– Sanitized his/her hands;
– Placed the wound supplies in a plastic basin and placed it on the resident’s over the
bed table;
– Did not wash his/her hands and applied gloves;
– Used his/her gloved hands and picked the trash can up and placed it within his/her reach
by the table;
– Removed his/her gloves, did not wash his/her hands and applied gloves;
– Removed the resident’s incontinent brief, removed his/her gloves, washed his/her hands
and applied gloves;
– The resident’s spouse assisted in putting a clean incontinent brief on him/her;
– Measured the resident’s wound on his/her left buttock;
– Removed gloves, ran water over his/her hands and applied new gloves;
– Completed the wound treatment, removed one glove and dated the dressing, did not wash
his/her hand and applied a new glove;
– Pulled the resident’s incontinent brief and pants up;
– Removed his/her gloves, ran water over his/her hands and took supplies out of the
resident’s room.
During an interview on 11/8/18, at 2:15 P.M., RN A said:
– He/she should wash his/her hands between clean and dirty surfaces and between glove
changes.
5. Review of Resident #396’s admission MDS, dated [DATE], showed:
– Cognitive skills severely impaired;
– Dependent on the assistance of two staff for bed mobility, transfers, and toilet use;
– Frequently incontinent of bladder;
– Always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised 11/7/18, showed:
– The resident was incontinent of bowel and bladder related to impaired mobility;
– Prefers disposable briefs;
– Change every two hours and as needed.
Observation on 11/8/18, at 5:59 A.M., showed:
– CNA A and CNA B entered the resident’s room, did not wash their hands and applied
gloves;
– CNA A provided incontinent care to the front perineal folds;
– CNA B provided incontinent care to the rectal area with a smear of fecal material noted;
– Without removing their gloves or washing their hands, they placed a clean incontinent
brief on the resident;
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 28)
– CNA B removed his/her gloves, did not wash his/her hands and left the room to get a
clean gown;
– CNA A removed his/her gloves and washed his/her hands and applied new gloves;
– CNA B entered the room and CNA A and CNA B placed a clean gown on the resident;
– CNA A and CNA B washed their hands before they left the room.
During an interview on 11/8/18, at 6:39 A.M., CNA B said:
– He/she should wash his/her hands when he/she enters the room, between glove changes and
before leaving the room.
6. Review of Resident #68’s care plan, dated 6/19/18, showed:
– He/she had wounds requiring wound care;
– Staff must provide wound treatments as ordered.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Total dependence upon staff for transfers;
– Required extensive staff assistance for dressing, toileting, and hygiene;
– [DIAGNOSES REDACTED].
– Had one or more Stage II pressure ulcers (partial thickness loss of skin).
Observation on 11/8/18, at 2:31 P.M., of RN A providing wound care for the resident
showed:
– He/she took scissors from his/her pants pocket.
– Without disinfecting the scissors, he/she used the scissors to cut a wound treatment.
– With gloved hands, he/she cleaned the resident’s rectal area which was soiled with fecal
material.
– Without washing his/her hands and changing gloves, he/she cleaned all three open areas
on the resident’s rectal area.
– Without washing his/her hands and changing gloves, he/she applied a large dressing over
a draining wound and a non-draining wound.
– Without washing his/her hands and changing gloves, he/she dressed the resident’s other
wound.
During an interview on 11/8/18, at 2:31 P.M., RN A said:
– He/she should have disinfected the scissors with a bleach wipe and allowed the scissors
to dry before using them.
– He/she should have washed his/her hands and changed gloves after cleaning the resident’s
rectal area.
– He/she should have cleaned each wound separately and washed his/her hands in between
cleaning each wound.
– He/she should have placed a separate dressing over each wound.
During an interview on 11/9/18, at 8:00 A.M., the DON said:
– Staff must disinfect scissors with a bleach wipe and allow them to dry before using the
scissors for wound care.
– Staff must wash their hands and change gloves after cleaning a resident’s rectal area.
– Staff must clean each wound seperately and wash their hands and change gloves.
– Staff must dress each wound seperately.
7. Review of Resident #88’s care plan, dated 10/2/18, showed:
– Staff must isolation precautions due to an infection with [MEDICAL CONDITION] (an
infection causing diarrhea).
– Staff must wear gowns and masks when changing contaminated linens.
– Staff must place soiled linens and trash in bags marked biohazard.
– Staff must disinfest all equipment before removing the equipment from the room.
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:

265366

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

NAME OF PROVIDER OF SUPPLIER

MAPLE WOOD HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

724 NORTHEAST 79TH TERRACE
KANSAS CITY, MO 64118

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 29)
Review of the resident’s significant change in condition MDS, dated [DATE], showed:
– Mild cognitive impairment;
– Required extensive staff assistance for transfers, dressing, toileting and hygiene;
– Frequently incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on 11/8/18, at 1:57 P.M., of CNA F providing care for the resident showed:
– On the resident’s bathroom floor, an open overflowing red biohazard full of trash and
another full of linens;
– CNA F put on a gown and gloves;
– CNA F removed his/her gait belt from under his/her gown and applied the gait belt around
the resident’s waist.
– After transferring the resident, CNA F started to put the gait belt back around his/her
waist, touching his/her clothes, but stopped and placed the gait belt in the laundry;
– CNA F went into the resident’s bathroom, removed his/her gloves and gown.
– CNA F’s pants brushed the linen in the open bag while he/she washed his/her hands.
During an interview on 11/8/18, at 1:57 P.M., CNA F said:
– The resident’s trash and soiled linens should be in bins and not on the floor.
– Staff should disinfest all equipment after using it in an isolation room.
Observation on 11/9/18, at 1:02 P.M., of Certified Medication Technician (CMT) B
administering medications to the resident showed:
– He/she removed a blood pressure (BP) cuff from the medication cart.
– Without wearing a gown and gloves, he/she entered the resident’s room, checked the
resident’s BP and administered the resident’s BP medication.
– After washing his/her hands, he/she placed the used BP cuff back in the medication cart.
During an interview on 11/9/18, at 1:02 P.M., CMT B said he/she did not realize that
he/she should have disinfected the used BP cuff before returning the BP cuff to the
medication cart.
During an interview on 11/9/18, at 3:00 P.M., the DON said:
– Staff should not put any linen or trash on the floor.
– Trash and linens from an isolation room should be placed in a bag holder.
– Staff should provide dedicated equipment to be kept and used only in an isolation room.
– If staff must remove any equipment from an isolation room, staff must disinfect the
equipment.