Highland Rehabilitation & Health Care Center

Nurses Aides (CNA), or any staff member that saw the spills; however, the IDON said housekeeping

265167 02/08/2025

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

different place.

The Administrator stated that CMT #5 should have used better techniques to

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

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265167 02/08/2025

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

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.

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

According to the MDS, at the time of the assessment, the resident had active diagnoses that included psychotic disorder and depression. Resident #23's medical record revealed no documented evidence the facility completed a new PASRR after the resident was diagnosed with major depressive disorder or psychotic disorder.

During an interview on 02/07/2025 at 1:53 PM, the Administrator and Interim Director of Nursing (IDON) stated Resident #23's PASRR was not updated when Resident #23 received new major mental illness diagnoses.

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

During an interview on 02/06/2025 at 11:09 AM, the MDS Registered Nurse (RN) stated care plans were triggered by the admission assessments and baseline care plans completed. He/She stated they were set up to auto feed into a care plan based on triggers within the system. He/She stated he/she did not know Resident #73 well, but did know the resident had a diagnosis of PTSD.

The MDS RN acknowledged there was no care plan generated to address Resident #73's diagnosis of PTSD.

He/She stated he/she was responsible for the oversight of the care plans, and it was too much to keep up with. He/She stated he/she relied on what others put into the computer to be accurate, and there were a lot of things that might not be right or not have care plans that should be care planned.

During an interview on 02/07/2025 at 10:40 AM, the Interim Director of Nursing (IDON) stated residents with a diagnosis of PTSD needed to have their triggers listed on their care plan so that staff knew what they were. He/She stated staff should know how to approach the residents as to not create behaviors as well as how to de-escalate a situation when it should arise.

During an interview on 02/07/2025 at 10:42 AM, the Administrator stated his/her expectation was for staff to complete care plans per the facility policy.

The Administrator stated staff should know how to care for residents with a diagnosis of PTSD and how to approach them without triggering them.

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

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 if the resident was not back within an hour of the return time, management would start calling family and any other contacts they could find.

The IDON stated management would also call the police, detention centers, and hospitals.

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.

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

During an interview on 02/07/2025 at 3:04 PM, the IDON stated his/her expectation of CMTs was for

investigate and get the medication.

The IDON stated the nurse could call the pharmacy or could check for the medication in the emergency kit.

The IDON stated the nurse should call the doctor to let them know of the missed doses of medication.

The IDON stated the medications should go into the CMT's medication cart.

The IDON stated the nurses should have administered Resident #339's levothyroxine.

During an interview on 02/07/2025 at 3:20 PM, the Administrator stated that when the medication was in the facility, the physician orders should be followed to administer that medication.

During a concurrent observation of the walk-in refrigerator and an interview on 02/03/2025 at 9:15

wrap and a plastic container of diced pineapple were stored without a date to indicate when the items were prepared, opened, or when they should be discarded.

The DM and DA #32 stated that each food item should be labeled with the date of storage.

During a concurrent observation of the dry storage area and an interview on 02/03/2025 at 9:20 AM with the Dietary Manager (DM), an open package of peppered sausage gravy mix and five open bottles of honey were observed without a date to indicate when the items were opened or when they should be discarded.

The DM stated the items should have been labeled with the dates they were opened.

During an interview on 02/07/2025 at 9:12 AM, the Interim Director of Nursing (IDON) stated dietary staff were expected to date and label all foods with a label to record the date the food was made or opened prior to storing the food.

• A facility policy titled, Foods Brought by Family/Visitors, reviewed 01/2017, revealed, 5.

Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator.

Containers will be labeled with the resident's name and dated.

The policy also indicated, 6.

The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, foul odor, past due package expiration dates).

A concurrent interview and observation on 02/07/2025 at 8:29 AM of the fourth-floor dining room refrigerator revealed a pizza box not labeled with a name or date.

Staff who were present did not know who the pizza belonged to.

Certified Nursing Assistant (CNA) #17 said the pizza should have been labeled with the name of who it belonged to.

During an interview on 02/07/2025 at 9:25 AM, Resident #98 stated they ordered the pizza on the evening of 02/06/2025.

An observation of the refrigerator in the fourth-floor dining room on 02/07/2025 at 1:42 PM revealed a sandwich consisting of what appeared to be two pieces of bread and a jelly-like substance.

The sandwich was inside a plastic bag labeled with a date of 01/03/2025 but no name to indicate who it belonged to. A small plastic container with a white substance inside was also observed inside the refrigerator without a label identifying what it was, when it was prepared, opened, or placed in the refrigerator, or who it belonged to.

During an interview on 02/07/2025 at 1:48 PM, Assistant Director of Nursing (ADON) #42 stated that whoever placed items in the refrigerator was supposed to label the items with a name and date. ADON #42 stated he/she thought housekeeping was responsible for maintaining the items in the refrigerator but was not sure.

265167 02/08/2025

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

During an observation on 02/04/2025 at 2:05 PM, the Admissions Coordinator (AC) entered Resident #103's room without performing hand hygiene.

Without donning a gown or gloves, the AC assisted Resident #103 by placing the resident's leg back into the bed and repositioning the resident. In addition, the AC assisted the resident by rearranging the resident's pillows and repositioning a pillow under the resident's head.

The AC then left the room without performing hand hygiene.

During an interview on 02/04/2025 at 2:08 PM, the AC stated he/she should have performed hand hygiene before entering Resident #103's room and should have washed his/her hands after assisting the resident.

The AC further stated she guessed he/she should have also worn a gown while assisting Resident #103.

During an interview on 02/07/2025 at 2:17 PM, Assistant Director of Nursing (ADON) #41 stated that when a resident required EBP, staff should wash their hands before entering and when leaving the resident's room and should wear a gown and gloves when providing resident care.

During an interview with the Interim Director of Nursing (IDON) and the Administrator on 02/07/2025 at 3:22 PM, the IDON stated for a resident that required EBP, staff should perform hand hygiene prior to entering the room to provide care and when leaving the room.

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

According to the Admission Record, the resident had a medical history that included diagnoses of Huntington's disease (a progressive inherited neurodegenerative disorder that affects the brain, causing uncontrolled movements, cognitive decline, and psychiatric symptoms), gastrostomy status, and anxiety disorder.

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

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Form Approved OMB

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