Life Care Center Of Grandview

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview on 10/24/25 at 10:20 A.M. the facility's van driver said:-Resident #3 and Resident #11 were usually friendly teasing each other. -Sometimes Resident #11 was not up to it.-Resident #3 was normally really mellow. -Resident #3 did not have behaviors normally.Observation and interview on 10/24/25 at 11:25 A.M. Resident #11 showed:-His/her eyes were free from injury, and no redness was noted.-He/She thought

she remembered the incident, but when SA started questioning him/her about it he/she had not remembered. -He/She thought he/she normally got along well with Resident #3. -He/She could not confirm that they always were playing around with each other. -He/She was worried that Resident #3 had done it on purpose. During an interview on 10/24/25 at 11:42 A.M. the Social Services Designee said:-A staff member informed him/her that Resident #3 threw hot sauce in Resident #11's face. -He/She went with the Administrator to Resident #3's room. -They asked Resident #3 how he/she was doing. -Resident #3 responded poorly, he/she started pacing and saying that they wouldn't believe him/her anyway. -When asked when they could come back to chat and Resident #3 said, try two fucking days. -Then they went to check on Resident #11.During an interview on 10/24/25 at 12:55 P.M. LPN C said: -Resident #3 was very protective of Resident #11.-To his/her knowledge Resident #3 did not have any known triggers that would have caused the altercations.During an interview on 10/24/25 at 2:48 P.M. LPN D said:-Resident #3 and Resident #11 were sitting in the dining room.-He/She heard a noise and came over to the table that Resident #3 and Resident #11 were sitting at. -The table had juice and hot sauce all over it. -Resident #3 looked like he/she was going to hit Resident #11, but staff intervened in time and separated the residents. -When he/she looked at Resident #3, he/she had hot sauce all over his/her face and was afraid that it was

in his/her eyes.-Resident #11 and Resident #3 normally got along just fine, but he/she never noticed them playing around or teasing each other.During an interview on 10/27/25 at 10:47 A.M. the DON said:-He/She was not at the facility during the altercation. -It was playful teasing until it wasn't. -Resident #3 and Resident #11 were tablemates in the dining room and had no issues with each other prior to the incident.-He/She would consider the situation abuse because Resident #3 showed intent to harm Resident #11. -The altercation could not have been prevented. 2645298, 2640530, and 2551465

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Grandview

6301 East 125th St Grandview, MO 64030

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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for

a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure one sampled resident (Resident #3) was allowed back to the facility when the facility completed an Immediate Notice of Involuntary Discharge when they sent the resident to a local hospital on [DATE REDACTED] out of 13 sampled residents. The facility census was 106 residents.Review of the facility's policy titled Notices of Transfers and Discharges dated 8/5/25 showed no policy related to immediate notice of involuntary discharges.1. Review of Resident #3's admission Record showed that he/she was admitted to the facility with a diagnosis of Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).Review of the resident's Quarterly Minimum Data Set (MDS)(a federally mandated assessment instrument completed by facility staff) dated 8/7/25 showed:-The resident had moderately impaired cognition.-The resident had not exhibited any behaviors within the look back period.Review of the resident's Immediate Notice of Involuntary discharge date d 10/23/25 showed:-The resident would be forced to discharge from the facility.-The resident was being sent to a local hospital.-The safety of individuals in the facility was endangered.-The health of individuals in the facility would be otherwise endangered.-The resident was involved in a resident-to-resident altercation on 10/16/25.-The resident was involved in a resident-to-resident altercation

on 10/23/25.-The resident was threatening residents and staff.Review of an emergency room Note dated 10/23/25 showed the resident was being admitted to the hospital with a primary diagnosis of Social admission Secondary to Facility Refusal for Taking Patient Back.During an interview on 10/24/25 at 8:45 A.M. the resident said:-He/She didn't know what is going on. -No one has updated him/her on anything. -He/She felt that the Administrator just want him/her out of the facility. -He/She was really upset because he/she wanted to go back to the facility because that was his/her home.During an interview on 10/24/25 at 11:04 A.M. the Administrator said:-The resident would not be allowed back to the facility.-He/She did not feel the facility was adequately equipped to take care of the resident.During an interview of 10/24/25 at 11:42 A.M. the Social Services Designee (SSD) said:-He/She had sent multiple referrals to other facilities in

the area after the second resident-to-resident altercation that the resident was involved in. -The facility was not equipped to handle the resident's behaviors.-He/She had sent the Ombudsman (resident advocate) the Immediate Notice of Involuntary Discharge letter on 10/23/25.During an interview on 10/27/25 at 10:35 A.M. the Director of Nursing (DON) said:-The resident had to go. -He/She was sent to the hospital for increased behaviors and now couldn't come back to the facility. -He/She understood that the facility was not meeting regulation by not accepting the resident back, and by not providing a reevaluation after he/she received the necessary treatment. 2651315

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