SHANGRI LA REHAB & LIVING CENTER

Nursing Home Inspector

930 NE DUNCAN ROAD
BLUE SPRINGS, MO 64014
Jackson County
Phone: 816-229-6677
Provider Number: 265595
Last Inspection: 07/24/2017

About the Nursing Home

Number of Beds: 120
Number of Residents: 69
Beds Available: 51
Percent Occupancy: 57%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

38

Facility
35

County
21

MO
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

38

2017
55

2016
87

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

7/24/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 8/31/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 8/31/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 8/31/2017
 
Failed To: Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. Isolated : Minimal 3 8/31/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 8/31/2017
 
Failed To: Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. Isolated : Minimal 3 8/31/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 8/31/2017
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 8/31/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 8/31/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 8/31/2017
 
Failed To: Keep all essential equipment working safely. Isolated : Minimal 3 8/31/2017
 

7/27/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Honor a residents' rights as a residents of the nursing home, free of coercion and reprisal, and as citizens or residents of the United States. Pattern : Minimal 4 9/1/2016
 
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Isolated : Minimal 3 9/1/2016
 
Failed To: Upon the death of a resident, convey the resident’s personal funds and an accounting of those funds to the appropriate party. Pattern : Potential 3 9/1/2016
 
Failed To: Provide housekeeping and maintenance services. Widespread : Potential 4 9/26/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 9/1/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 9/1/2016
 
Failed To: Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. Isolated : Minimal 3 9/1/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 9/1/2016
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 9/1/2016
 
Failed To: Keep all essential equipment working safely. Isolated : Minimal 3 9/1/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 9/1/2016
 
Failed To: Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Widespread : Minimal 5 9/26/2016
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread : Minimal 5 9/1/2016
 
Failed To: Provide timely notification to the resident before transfer or discharge. Isolated : Minimal 3 9/1/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 9/1/2016
 

9/11/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Pattern : Minimal 4 10/23/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 10/25/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 10/23/2015
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 10/20/2015
 
Failed To: Hire sufficient dietary support personnel. Widespread : Minimal 5 10/25/2015
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 10/20/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/16/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 11/27/2015
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 10/21/2015
 
Failed To: Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Widespread : Minimal 5 10/21/2015
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread : Minimal 5 10/25/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 10/24/2015
 
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 10/25/2015
 
Failed To: Try to resolve each resident's complaints quickly. Pattern : Minimal 4 10/25/2015
 
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Minimal 3 10/25/2015
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 10/14/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 11/27/2015
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 10/25/2015
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Pattern : Minimal 4 10/22/2015
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 10/26/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 10/23/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 10/23/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 10/23/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 11/27/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

3/14/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 4/25/2016
 

4/15/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 5/30/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MO State Avg
Number of Residents 69 90.72 74.26
Registered Nurses 0.51 0.71 0.60
Licensed Practical / Vocational Nurses 0.85 0.77 0.72
Certified Nursing Assistants 2.39 2.40 2.43
Total Staff Hours 3.74 3.88 3.75

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MO State Avg%
of high risk long-stay residents with pressure ulcers 1 5 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 91 89 88
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 91 91 93
of long-stay residents experiencing one or more falls with major injury 5 3 4
of long-stay residents who have depressive symptoms 22 3 3
of long-stay residents who lose too much weight 2 6 7
of long-stay residents who received an antianxiety or hypnotic medication 22 22 26
of long-stay residents who received an antipsychotic medication 23 18 18
of long-stay residents who self-report moderate to severe pain 2 7 7
of long-stay residents who were physically restrained 1 0 0
of long-stay residents whose ability to move independently worsened 7 16 15
of long-stay residents whose need for help with daily activities has increased 8 14 14
of long-stay residents with a catheter inserted and left in their bladder 3 2 2
of long-stay residents with a urinary tract infection 4 3 4
of low risk long-stay residents who lose control of their bowels or bladder 18 31 32
of short-stay residents assessed and appropriately given the pneumococcal vaccine 82 75 74
of short-stay residents who had an outpatient emergency department visit 22 11 12
of short-stay residents who newly received an antipsychotic medication 2 67 68
of short-stay residents who self-report moderate to severe pain 5 2 2
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 66 16 16
of short-stay residents who were rehospitalized after a nursing home admission 38 75 73
of short-stay residents with pressure ulcers that are new or worsened 0 25 22