Highland Rehabilitation & Health Care Center

F-F604 also indicated, Manual method means to hold or limit a resident's voluntary movement by using body contact as a method of physical restraint.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 12 265167 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265167 B. Wing 02/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Rehabilitation & Health Care Center 904 East 68th Street Kansas City, MO 64131

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 0604 1. An Admission Record revealed the facility admitted Resident #386 on 01/30/2025. According to the Admission Record, the resident had a medical history that included diagnoses of Huntington's disease (a Level of Harm - Minimal harm or progressive inherited neurodegenerative disorder that affects the brain, causing uncontrolled movements, potential for actual harm cognitive decline, and psychiatric symptoms), gastrostomy status, and anxiety disorder.

Residents Affected - Few An annual Minimum Data Set (MDS) with an Assessment Reference Date of 01/30/2025, indicated it was in progress.

A Nursing Admission/Readmission Data Collection tool, dated 01/30/2025, revealed Resident #386 had the ability to express ideas and wants, had the ability to understand verbal content, did not use a mobility device, and did not require assistance to transfer, walk in room, walk in corridor, or walk on the unit. According to the tool, the resident's current weight was 77.4 pounds and the resident's level of consciousness was alert and oriented to person, place and time. The tool indicated the resident did not use restraints, had adequate hearing and vision, and did not exhibit any verbal or physical behaviors in the last 14 days or have a history of harming self or others.

Resident #386's Care Plan included a focus area initiated 01/30/2025 that indicated the resident was a smoker. Interventions directed staff to keep smoking materials secured and to encourage smoking per facility protocol (initiated 01/30/2025).

An Initial Report dated 01/31/2025 indicated the facility admitted Resident #386 to the facility on [DATE REDACTED] and informed the resident about the smoking policy. The report indicated a skin assessment completed on 01/30/2025 noted bruises and scratches to the resident's arms, but that the resident reported to the Administrator that the bruises resulted from being manhandled by staff on 01/31/2025. The report indicated

the resident had displayed agitation when the resident went behind the nurse's station to get a cigarette and required staff redirection. The report indicated that the resident then went to the smoking patio and tried to take a lit cigarette from another resident, and a certified medication technician (CMT) wrapped their arms around the resident to keep the resident from harming another resident or harming self. The report revealed that the resident tried to get on the elevator but was redirected. The report indicated the CMT provided the facility with a written statement and was suspended pending the outcome of the investigation.

On 02/03/2025 at 12:06 PM, Resident #386 was observed ambulating independently on the second floor secure unit, with an unidentified staff member providing one-to-one monitoring. During an interview at this time, Resident #386 stated that at another facility (prior to admission to this facility), a staff member had manhandled them, causing bruises and scratches on both arms. During the interview, Resident #386 showed their arms to the surveyor, but no bruises were visible. Resident #386 then stated the incident occurred at the current facility over the weekend. The surveyor asked Resident #386 to clarify which weekend and what day of the weekend this occurred. Resident #386 stated, The weekend. The surveyor asked Resident #386 what time the incident occurred, and Resident #386 stated, In the morning. Resident #386 further stated that they were new to the facility, and staff on the third floor grabbed the resident's arms and threw the resident on the bed. Resident #386 stated they did not know the names of the staff. The resident stated this incident occurred on the third floor and after it occurred, the resident was moved to the second floor. The resident also stated that they reported the incident to the nurse on the second floor and then told the Administrator, who said the incident would be investigated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 12 265167 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265167 B. Wing 02/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Rehabilitation & Health Care Center 904 East 68th Street Kansas City, MO 64131

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 0604 During an interview on 02/04/2025 at 3:11 PM, Licensed Practical Nurse (LPN) #1 stated Resident #386 was moved to the second floor on 02/01/2025 around 10:30 AM, before lunch and before the 11:30 AM smoke Level of Harm - Minimal harm or break. LPN #1 stated that after the 11:30 AM smoke break, Resident #386 asked him/her to get a sandwich potential for actual harm the resident had left on the third floor, and when LPN #1 returned with the sandwich, the resident stuck their wrists out and told LPN #1 that staff on the third floor grabbed the resident and threw them on the bed. LPN Residents Affected - Few #1 stated that the resident's wrists were both red and had old bruising but did not have the color of fresh bruising. The resident reported to LPN #1 that they were aggressive with third floor staff and that third-floor staff were aggressive to them. LPN #1 stated he/she then called the Administrator to notify him/her of the resident's allegation. He/She stated the ADM instructed him/her to write a statement and place Resident #386 on one-to-one monitoring.

During a telephone interview on 02/05/2025 at 9:37 AM, CMT #5 stated he/she worked the 6:45 AM - 2:45 PM shift on 02/01/2025 and met Resident #386 for the first time that day. CMT #5 stated that during the shift, Resident #386 asked LPN #2 for a cigarette. The nurse gave the resident a cigarette, and the resident went to the smoking patio and smoked it. After the resident completed the cigarette, the resident tried to take Resident #64's cigarette. Resident #64 tried to keep the cigarette from Resident #386, but the resident stood over Resident #64 and continued to try and take it. CMT #5 stated when the resident would not stop trying to take Resident #64's cigarette, the only other option was to pick the resident up and bring the resident inside. CMT #5 stated he/she did not see any physical contact between the residents, but when Resident #386 would not stop trying to take Resident #64's cigarette, CMT #5 opened the patio door, grabbed Resident #386 by the waist from behind, picked the resident up, and put the resident back inside. CMT #5 stated Resident #386 was a small-framed resident and when he/she picked the resident up, he/she carried the resident inside about five feet and put the resident down on their feet. CMT #5 stated he/she blocked the patio door because the resident kept trying to go back outside. CMT #5 stated he/she received a phone call from the Administrator around 1:30 PM and was told to write a statement, clock out, and go home. The CMT denied that he/she threw the resident in bed or grabbed the resident by the wrists.

During a telephone interview on 02/05/2025 at 10:30 AM, Certified Nursing Assistant (CNA) #4 stated on 02/01/2025, an incident occurred around 9:30 AM when staff tried to get Resident #386 to calm down. CNA #4 stated he/she was at the nurse's desk charting when Resident #386 tried to go out to smoke and tried to take a cigarette from Resident #64. CNA #4 stated staff went outside, and CMT #5 grabbed Resident #386 around the waist, picked the resident up, and carried the resident back inside while the resident snatched, grabbed, punched, and swung their hands at staff. CNA #4 stated that once the resident was back inside,

they calmed down, then CMT #5 and CNA #4 walked with the resident to the resident's room, but on the way to the resident's room, the resident turned around to go back toward the door, so CMT #5 picked the resident up from behind by the waist again, carried the resident to the resident's room, and sat the resident on the bed. CMT #5 asked the resident to calm down and to come out of the room once they calmed down, and staff then left the room. CNA #4 stated staff were trained not to put their hands on residents. CNA #4 stated that when CMT #5 carried the resident inside from the smoking patio, the distance was a few feet, and the second time CMT #5 picked the resident up to take them to the room, the distance was the width of one resident's room. During a follow-up telephone interview on 02/07/2025 at 10:35 AM, CNA #4 stated that if a resident became combative, it would be best to walk away and go get the nurse but not to pick up the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 12 265167 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265167 B. Wing 02/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Rehabilitation & Health Care Center 904 East 68th Street Kansas City, MO 64131

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 0604 During an interview on 02/05/2025 at 3:46 PM, LPN #2 stated that on 02/01/2025 around 9:30 AM, Resident #386 came to the nurse's desk and asked for a cigarette. He/She gave the resident a cigarette, and the Level of Harm - Minimal harm or resident went to the third-floor smoking patio to smoke. LPN #2 stated that when the resident came back into potential for actual harm the third-floor dining room, the resident asked for cigarettes to smoke again. LPN #2 stated he/she told the resident to wait until the next smoke break, and Resident #386 came around the nurse's desk and took the Residents Affected - Few cigarette box. LPN #2 stated he/she was able to retrieve the cigarette box, but then Resident #386 went back to the smoking patio and physically tried to take a lit cigarette from Resident #64. LPN #2 stated that CMT #5 went onto the smoking patio and told the resident not to take the cigarette from Resident #64. LPN #2 stated he/she went onto the smoking patio to help, held the door open, and witnessed CMT #5 put his/her hands around Resident #386's waist from behind and walk the resident back inside.

During an interview on 02/06/2025 at 8:46 AM, the Interim Director of Nursing (IDON) stated he/she looked through the facility's investigation on 02/03/2025, and he/she did not believe CMT #5's intention was to abuse or harm the resident but felt the CMT was trying to deescalate the situation. The IDON indicated the CMT could have stood between the residents, grabbed another staff member to help redirect, or offered food or medicine and try to get to the root cause of why the resident was so upset.

During an interview on 02/06/2025 at 10:03 AM, the Administrator stated during his/her investigation, he/she spoke with CMT #5, who stated that Resident #386 tried to take a cigarette from Resident #64 during a smoke break on the third-floor patio and would not stop when asked by Resident #64 and by staff to stop.

The Administrator stated that CMT #5 reported he/she then lifted the resident up by the waist and brought

the resident back inside but denied that he/ threw the resident on the bed. The Administrator stated CMT #5 said he/she just picked Resident #386 up by the waist and brought them back inside for redirection, to keep them from taking the cigarette from Resident #64, and to prevent anything from happening to Resident #64.

The Administrator stated that during his/her investigation, it was determined that CMT #5 did not intend to abuse or harm Resident #386, but that when he/she picked Resident #386 up, he/she violated the resident's right to move independently and the right not to be physically redirected to a different space. The ADM stated CMT #5's response to the resident was a poor method of redirection.

During a telephone interview on 02/07/2025 at 10:46 AM, CMT #6 stated that he/she worked the 7:00 AM to 3:00 PM shift on the third floor on 02/01/2025. He/She did not witness the incident involving Resident #386 and Resident #64 but stated he/she witnessed Resident #386 cursing and yelling when CMT #5 walked the resident to their room. CMT #6 stated that when CMT #5 walked Resident #386 to their room, CMT #5 held

the resident by the shoulders as they walked. CMT #6 denied witnessing CMT #5 pick the resident up. CMT #6 stated that if he/she witnessed a staff member pick up a resident, he/she would report this to the Director of Nursing, the Administrator, or the nurse. CMT #6 indicated that staff were not trained to pick up a resident or put hands on them. CMT #6 also stated, If they [residents] are able to walk and you pick them up, now

they can't walk. That's a restraint and we can't put them in a restraint, period. They would not be walking on their own.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 12 265167 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265167 B. Wing 02/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Rehabilitation & Health Care Center 904 East 68th Street Kansas City, MO 64131

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 0604 During a follow-up interview on 02/07/2025 at 11:39 AM, the IDON read the facility's Restraint Policy and stated he/she agreed with the definition of a restraint as recorded in the policy. The IDON stated that a Level of Harm - Minimal harm or restraint would be anything hindering a resident's ability to move about freely. He/She stated in an potential for actual harm emergency, the nurse would need to alert the DON, and the DON could give the authority for restraint use, and the attending physician would have to be notified and would need to sign orders within 48 hours of the Residents Affected - Few emergency. The IDON stated that in his/her opinion, when CMT #5 picked Resident #386 up, that was a poor choice but did not meet the definition of a restraint because the resident was let go and their arms and legs remained free. When asked if the IDON agreed that Resident #386 could ambulate independently prior to being picked up by staff but could not do so while being carried by CMT #5, he/she stated that the resident could not ambulate when they were picked up by staff, but that this was a poor choice, not a restraint. The IDON stated staff were expected to use other means to intervene like moving other residents away from an aggressive resident or attempting to corral the aggressive resident elsewhere, trying to talk to the aggressive resident to diffuse the situation, or trying to get the focus of the aggressive resident on staff rather than on everybody else. The IDON stated the expectation would be for staff to deescalate the situation by staying calm, making eye contact with the aggressive resident, and talking with the resident in a calm voice, while other staff moved other residents away from the situation to avoid any harm.

During a follow-up interview on 02/07/2025 at 12:33 PM, the Administrator read the definition of a restraint per the facility policy and stated that he/she agreed with the definition. The Administrator stated that if a resident could not remove a device applied by staff or anything that restricted the resident's physical ability to move, that would be considered a restraint and would require an assessment, documentation in the medical record, and a physician's order prior to its use. The Administrator stated CMT #5 used poor judgement and that he/she did not agree with the way CMT #5 handled the situation, as the resident had the right to move

on their own and not be redirected to a different place. The Administrator stated that CMT #5 should have used better techniques to deescalate the situation, like telling Resident #386 the goals and why the resident should calm down. The Administrator stated that he/she would expect CMT #5 to avoid putting his/her hands

on a resident and to redirect the resident with verbal cues and guide the resident in a safe direction.

MO00248912

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 12 265167 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265167 B. Wing 02/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Rehabilitation & Health Care Center 904 East 68th Street Kansas City, MO 64131

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or 28193 potential for actual harm Based on interview, record review, and facility document and policy review, the facility failed to thoroughly Residents Affected - Few investigate 1 of 3 entity self-reported incidents reviewed. Specifically, the facility failed to thoroughly investigate an incident involving a missing resident (Resident #96).

Findings included:

A facility policy titled, Abuse, Prevention and Prohibition Policy, revised 10/2022, revealed the section titled Investigation, included, The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. The policy further revealed, Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete a statement if indicated. The policy revealed the facility was to Complete the investigation summary of statements and summary of investigation within five business days.

1. Resident #96's Admission Record indicated the facility admitted the resident on 03/25/2024. According to

the Admission Record, the resident had a medical history that included diagnoses of orthopedic aftercare following surgical amputation, assistance with personal care, muscle weakness, abnormalities of gait and mobility, alcohol abuse, and psychoactive substance abuse.

A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/27/2024, revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS further indicated the resident used a manual wheelchair for locomotion independently. The MDS revealed the resident was independent with eating, oral hygiene, and toileting hygiene. The MDS revealed the resident required supervision or touching assistance with showering/bathing and personal hygiene and required setup or clean-up assistance with upper and lower body dressing.

Resident #96's care plan included a focus area initiated 01/12/2025, that indicated the resident had a current diagnosis of a substance use disorder related to alcoholism and had been leaving the facility, drinking, and returning inebriated. Interventions (initiated 01/12/2025) directed staff to allow one-on-one time to discuss behaviors and reasons for use of alcohol in a non-judgmental way; to ask the resident if they have ingested medications or drugs that were not prescribed to them; to assess and support respiratory and cardiovascular function; to assess mental status and determine if there was a change from the resident's baseline; and to assess the resident for the following symptoms and report as they present: stumbling, nodding off mid-conversation, incoherent speech, slurred speech, rambling, sleepy, erratic behavior, hyperactive, threatening, hostile, bloodshot eyes, pinpoint pupils, pale face sweaty unruly appearance, fumbling, nervous, jerky movements, and eating candy or sweets.

A sign-out sheet used by Resident #96 to leave the facility on 01/24/2025 revealed the resident placed their initials on the sheet and identified a date of 1-26. The sheet revealed the resident had marked the Time Out to be 10:40 AM. The sheet revealed that the resident did not fill out the Time Planned to Return and marked

the Visit Location to be the library.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 12 265167 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265167 B. Wing 02/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Rehabilitation & Health Care Center 904 East 68th Street Kansas City, MO 64131

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 0610 During an interview on 02/04/2025 at 12:40 PM, the Administrator stated Resident #96 had signed out at 10:40 AM on 01/24/2025 to go to the Downtown Library and had not returned. He/She stated the resident Level of Harm - Minimal harm or had dated the sign-out sheet for 01/26/2025; however, the date was 01/24/2025. potential for actual harm Resident #96's Progress Notes, revealed a Health Status Note, dated 01/25/2025 at 11:35 PM, that indicated Residents Affected - Few Resident #96 had left the facility the day before and still had not returned. The note revealed the Administrator and unit manager were notified and had asked staff to look for the resident throughout the facility. The note revealed that when Resident #96 was not found, the Administrator notified the police, who came to the facility to ask questions, obtained a Face Sheet, and called the local hospital. The note revealed

the police notified the Administrator the resident had been discharged from the hospital around 11:30 PM (the evening prior). The note revealed the police left an emergency number with instructions to call and have

the resident's name removed from the missing persons list if they arrived back at the facility. The note revealed Resident #96's Nurse Practitioner (NP) was notified and asked to be notified if the resident returned to the facility.

Resident #96's Progress Notes revealed a Health Status Note dated 01/28/2025 at 7:53 PM, that indicated Resident #96 had returned to the facility with another person. The note revealed the person that accompanied Resident #96 back to the facility stated they found the resident wandering around 39th and Main [street] and Resident #96 asked for a ride back to the facility. The note revealed this person pushed Resident #96 in the wheelchair from 39th street to the facility. The note revealed Resident #96 was alert, not

in distress, and had no complaints of pain or discomfort. The note revealed the resident's clothes were visibly soiled, so staff assisted to get the resident toileted, changed, and offered them snacks and fluids. The note revealed the resident had no recollection of being gone for four days. The note revealed Resident #96's physician and NP were notified of the resident's safe return.

During an interview on 02/05/2025 at 1:30 PM regarding investigative efforts into the event involving Resident #96, the Administrator stated, There are no other interviews written anywhere, or additional information. He/She stated, Every incident that is called into the State [Survey Agency] has an initial investigation and then we have to send in our final five-day investigation for each one as well. He/She stated, All the information for that incident is in the folder I gave to you.

A folder containing a copy of the investigation completed for Resident #96 included an initial report submitted to the State Survey Agency (SSA); the sign-out sheet filled out by Resident #96 prior to the leave of absence; timelines to show the dates and times phone calls were placed to the police, local hospitals, detention centers, and jails; and the in-service sign-in sheets for the education provided on the sign-out process for residents given to the staff following Resident #96's departure from the facility. No interviews from staff or residents were present in the folder presented as the investigation, and a follow-up five-day final report was not completed or submitted to the SSA for this incident.

During an interview on 02/07/2025 at 10:17 AM, the Administrator stated, In hindsight, I should have interviewed everyone. We are learning, and no one has ever said anything about that [interviewing everyone] before. He/She also stated, Any incidents that we send into the State [Survey Agency] should have an initial investigation and a final five-day investigation sent in for each.

MO00248567

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 12 265167 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265167 B. Wing 02/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Rehabilitation & Health Care Center 904 East 68th Street Kansas City, MO 64131

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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28193

Residents Affected - Few Based on interview, record review, and facility document and policy review, the facility failed to provide adequate supervision for 1 (Resident #96) of 6 residents reviewed for accidents.

Findings included:

A facility policy titled, Signing Residents Out, reviewed by the facility 10/2022, indicated, 1. Each resident leaving the premises (excluding transfers/discharges) must sign out or be signed out. 2. A sign-out log is located in designated areas within the facility. Logs will include the following: - Resident Name - Person Name accompanying resident if resident is not taking self out - Date and Time leaving - Date and Time of anticipated return - If anticipated return date and time is not documented on the log, the facility will initiate the steps after 4 hours of the residents signing out - Where the resident is going - Date and Time of Return - Signature of responsible party or resident 3. Resident or person accompanying the resident will sign resident back into the community upon return and notify the nurse [sic] 4. In the event there is inclement weather (rain, snow, extreme temperatures)facility [sic] staff will educate the resident on the risks of exposure and encourage them to wait until the weather is favorable. 5. If the resident does not return within an hour of anticipated return time, the community will initiate the following process until resident is contacted. - Notify Administrator and DON [Director of Nursing] - Contact the resident or person accompanying resident if have known phone number - Contact the location the resident was going - Contact the resident representative - Notify Provider - Contact Local Emergency Department - Notify Local Police Department. The policy revealed, 6. Staff observing a resident leaving the premises, [sic] and having doubts about the resident being properly signed out, should notify their supervisor at once.

Resident #96's Admission Record indicated the facility admitted the resident on 03/25/2024. According to the Admission Record, the resident had a medical history that included diagnoses of orthopedic aftercare following surgical amputation, assistance with personal care, muscle weakness, abnormalities of gait and mobility, alcohol abuse, and psychoactive substance abuse.

A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/27/2024, revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS further indicated the resident used a manual wheelchair for locomotion independently. The MDS revealed the resident was independent with eating, oral hygiene, and toileting hygiene. The MDS revealed the resident required supervision or touching assistance with showering/bathing and personal hygiene and required setup or clean-up assistance with upper and lower body dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 265167 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265167 B. Wing 02/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Rehabilitation & Health Care Center 904 East 68th Street Kansas City, MO 64131

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 1. Resident #96's care plan included a focus area initiated 01/12/2025, that indicated the resident had a current diagnosis of a substance use disorder related to alcoholism and had been leaving the facility, Level of Harm - Minimal harm or drinking, and returning inebriated. Interventions (initiated 01/12/2025) directed staff to allow one-on-one time potential for actual harm to discuss behaviors and reasons for use of alcohol in a non-judgmental way; to ask the resident if they have ingested medications or drugs that were not prescribed to them; to assess and support respiratory and Residents Affected - Few cardiovascular function; to assess mental status and determine if there was a change from the resident's baseline; and to assess the resident for the following symptoms and report as they present: stumbling, nodding off mid-conversation, incoherent speech, slurred speech, rambling, sleepy, erratic behavior, hyperactive, threatening, hostile, bloodshot eyes, pinpoint pupils, pale face sweaty unruly appearance, fumbling, nervous, jerky movements, and eating candy or sweets. The care plan revealed a focus area initiated on 03/26/2024, that indicated Resident #96 had an activity of daily living self-care performance deficit. Interventions (revised 12/30/2024) directed staff that the resident was able to reposition themselves, allow sufficient time for dressing and undressing with assistance for lower body dressing at times, the resident could feed themselves, brush their teeth, wash their hand, wipe self and adjust clothing independently, take themselves to the bathroom, transfer independently, and self-propel in the wheelchair.

Resident #96's Order Summary Report, with active orders as of 02/07/2025, revealed an order dated 01/09/2025 for May go LOA [leave of absence] independently without meds [medications].

Resident #96's Progress Notes, revealed a Health Status Note dated 01/25/2025 at 11:35 PM, that indicated Resident #96 had left the facility the day before and still had not returned. The note revealed the Administrator and unit manager were notified and had asked staff to look for the resident everywhere in the facility. The note revealed that when Resident #96 was not found, the Administrator notified the police, who came to the facility to ask questions, obtained a Face Sheet, and called the local hospital. The note revealed

the police notified the Administrator the resident had been discharged from the hospital around 11:30 PM (the evening prior). The note revealed the police left an emergency number with instructions to call and have

the resident's name removed from the missing persons list if they arrived back at the facility. The note revealed Resident #96's Nurse Practitioner (NP) was notified and asked to be notified if the resident returned to the facility.

A sign-out sheet used by Resident #96 to leave the facility on 01/24/2025 revealed the resident placed their initials on the sheet and identified a date of 1-26. The sheet revealed the resident had marked the Time Out to be 10:40 AM. The sheet revealed that the resident did not fill out the Time Planned to Return and marked

the Visit Location to be the library.

On 02/05/2025 at 2:45 PM, the Administrator provided the name of the library Resident #96 went to frequently. The library website revealed they closed at 6:00 PM on Fridays.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 265167 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265167 B. Wing 02/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Rehabilitation & Health Care Center 904 East 68th Street Kansas City, MO 64131

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 During an interview on 02/04/2025 at 12:40 PM, the Administrator stated Resident #96 had signed out at 10:40 AM on 01/24/2025 to go to the Downtown Library and had not returned. He/She stated the resident Level of Harm - Minimal harm or had dated the sign-out sheet for 01/26/2025; however, the date was 01/24/2025. The Administrator stated an potential for actual harm Assistant Director of Nursing (ADON) was made aware by the evening shift nurse that Friday night (01/24/2025) Resident #96 had not returned from the library, but he/she was unsure of the exact time and Residents Affected - Few would have an ADON answer to that. The Administrator stated Licensed Practical Nurse (LPN) #7 notified him/her on 01/25/2025 at 9:07 AM that Resident #96 had not returned to the facility. The Administrator called

the Regional Director of Operations (RDO), and phone calls to the police department, local hospitals, detention centers, and jails were started. The Administrator stated that just prior to lunch, the police notified him/her that Resident #96 had been to the ER (emergency room ), got violent with the nurses, and left AMA (against medical advice). The Administrator stated when he/she called the hospital to get a full report, he/she was told the resident was verbally aggressive and left the ER to get a cab and go to a hotel. The Administrator stated during the afternoon on 01/25/2025, he/she went to the facility and started education on what should be written in the sign-out books going forward and when to respond or act and stated the facility did have a policy regarding residents signing in and out of the facility. The Administrator stated the decision to report the incident to the State Agency was made because he/she was told it was the facility's policy to report a resident who left and choose to not return, and he/she was guided by her RDO to report to the State Agency. He/She stated they reported the incident not as an elopement, but as a person that did not return. He/She stated that per their regional office, their guidance was to report a person that did not return to the facility, even after signing themselves out. The Administrator stated an interim Director of Nursing (IDON) from the corporate office was covering the building; however, there was no on-site DON during the time of

this incident. The Administrator stated that he/she made the IDON aware Resident #96 had not returned to

the facility right after he/she was notified on Saturday morning (01/25/2025).

During an interview on 02/06/2025 at 3:01 PM, Certified Medical Technician (CMT) #8 stated it was supper time (on Friday 01/24/2025) and Resident #96 was not at the table ready to eat. He/She stated that he/she went to the resident's room, checked the bathroom, and looked all over the third floor in places the resident would normally go. He/She stated that when he/she could not find Resident #96, she/he told the floor nurse, who was an agency nurse and was unsure exactly what to do. CMT #8 stated he/she then called the Staffing Coordinator, who was the manager on call for the weekend. CMT #8 stated he/she saw the resident had signed out to go to the library that morning and relayed that to the Staffing Coordinator. He/She stated that while the Staffing Coordinator was on the phone with an ADON, letting him/her know, he/she called the Administrator and told him/her Resident #96 had not returned from the library. CMT #8 stated the Administrator told him/her to go check the sign-out books as well, and no further instructions were given to him/her that evening. CMT #8 stated Resident #96 did not return to the facility during the remainder of the shift.

During a telephone interview on 02/05/2025 at 11:08 AM, the Staffing Coordinator stated he/she received a phone call from CMT #8 between 6:30 PM and 7:00 PM on Friday (01/24/2025). The Staffing Coordinator stated CMT #8 said they had not seen Resident #96, so he/she had him/her check the sign-out books to see where the resident had gone. He/She stated that he/she then told CMT #8 that he/she would call an ADON and let him/her know. The Staffing Coordinator stated when he/she spoke to an ADON, the ADON gave the same instructions to check the sign-out book to see where Resident #96 had gone. The Staffing Coordinator stated the ADON did not give any other instructions or ask him/her to notify anyone else and stated he/she did not hear anything more about the situation again after that.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 265167 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265167 B. Wing 02/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Rehabilitation & Health Care Center 904 East 68th Street Kansas City, MO 64131

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 During an interview on 02/04/2025 at 12:53 PM, ADON #41 stated he/she received a call from the Staffing Coordinator at 7:00 PM on 01/24/2025 and was told CMT #8 had called and stated Resident #96 was not at Level of Harm - Minimal harm or the facility. ADON #41 stated he/she instructed the Staffing Coordinator to check both sign-out books and to potential for actual harm call the Administrator and to keep him/her updated. He/She stated he/she did not hear from anyone else that night about Resident #96. Residents Affected - Few

During a telephone interview on 02/05/2025 at 11:15 AM, LPN #7 stated he/she had worked on Thursday (01/23/2025), and Resident #96 was at the facility. He/She stated he/she had Friday (01/24/2025) off and returned to work on Saturday (01/25/2025) for the dayshift. He/She stated when he/she arrived at work, he/she printed out the shower list for the day, and Resident #96 was on the list. LPN #7 stated the certified nursing assistant (CNA) working with him/her stated the resident was not there. LPN #7 stated an agency nurse had worked on Friday night (01/24/2025) and probably did not know the residents, so they did not know Resident #96 was not in the building. LPN #7 stated he/she sent the CNAs to look around the building for the resident room to room and all the places the resident liked to go when in the facility. He/She stated he/she saw the resident had signed out at 10:40 AM, but the date was written wrong. He/She stated he/she called the Administrator early on 01/25/2025 and told him/her the staff had looked around the building, and

the resident had signed out the day before to go to the library. LPN #7 stated the police came to the building to ask questions and notified them Resident #96 went to the hospital and was discharged at 11:20 PM on Friday (01/24/2025) night but did not return to the facility. LPN #7 stated the police took a copy of Resident #96's Face Sheet and were going to do a street search and place the resident on the missing persons list. LPN #7 stated the police officer gave the facility an emergency phone number to call if the resident came back. He/She stated he/she was the nurse on duty when Resident #96 returned to the facility on [DATE REDACTED], and called the phone number to let the police department know the resident had come back.

Resident #96's Progress Notes revealed a Health Status Note dated 01/28/2025 at 7:53 PM, that indicated Resident #96 had returned to the facility with another person. The note revealed the person that accompanied Resident #96 back to the facility stated they found the resident wandering around 39th and Main [street] and Resident #96 asked for a ride back to the facility. The note revealed this person pushed Resident #96 in the wheelchair from 39th street to the facility. The note revealed Resident #96 was alert, not

in distress, and had no complaints of pain or discomfort. The note revealed the resident's clothes were visibly soiled, so staff assisted to get the resident toileted, changed, and offered them snacks and fluids. The note revealed the resident had no recollection of being gone for four days. The note revealed Resident #96's physician and NP were notified of the resident's safe return.

A Progress Note dated 01/28/2025 at 11:00 PM revealed a visit from Resident #96's NP. The note revealed

the Chief Complaint was a visit after returning from leave. The note revealed Resident #96 went out to the library after signing out on 01/24/2025 via self-check-out and came back on 01/28/2025. The note revealed Resident #96 was intoxicated, sent to the ER, and then discharged to the street. The note revealed the resident was known to drink alcohol, refused treatment for alcoholic addiction, and was reported to be under

the influence when they arrived back at the facility the day before; but that day was A&Ox3 [alert and oriented times three; person, place, and time], got out of bed, and was propelling their wheelchair. The note revealed It appears difficult to control the patient's alcoholism. The note revealed Resident #96 was Entitled to self-check-out. Refused AA [Alcoholics Anonymous] or other medical treatment for history of alcoholism.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 265167 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265167 B. Wing 02/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Highland Rehabilitation & Health Care Center 904 East 68th Street Kansas City, MO 64131

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 During an interview on 02/07/2025 at 10:25 AM, the Interim Director of Nursing (IDON) stated his/her expectation was if they had a missing person, the staff would check to see if the resident had signed out, and Level of Harm - Minimal harm or if the resident was not back within an hour of the return time, management would start calling family and any potential for actual harm other contacts they could find. The IDON stated management would also call the police, detention centers, and hospitals. Residents Affected - Few

During an interview on 02/07/2025 at 10:17 AM, the Administrator stated his/her expectation, if a resident was missing, was for the staff to look at the sign-out log. The Administrator stated an hour after the time the resident said they were going to return, the staff were to contact her and the phone tree would begin with calling the location they said they were going to, calling the doctor and power of attorney, and start going place by place where the resident would go. He/She stated they should have acted sooner with Resident #96 and that was why he/she came in and provided more education to the staff after this incident on following the one-hour rule and ensuring the residents were filling out the sign out book completely.

MO00248567

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 265167