Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to manage his or her financial affairs.

Based on record review and interview, the facility failed to obtain authorization to
manage resident funds for four residents (Residents #33, #52, #50 and #85) out of five
residents sampled for the resident fund review process. The facility census was 106
residents.
1. Record review of the resident fund authorizations showed the following:
– One of five residents had a signed authorization form to allow the facility to manage
funds and
– Authorization forms could not be found for four residents (Residents #33, #52, #50 and
#85).
During an interview on 5/14/18 at 2:18 P.M., the Social Worker said the following:
– He/she was not able to find authorization paperwork for Residents #33, #52, #50 and #85,
– He/she contacted guardians to obtain verbal consents but he/she understood that regular
signed paperwork will be needed and
– He/she had only been employed at the facility for about one and half months.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain mattresses in three
resident rooms (308, 209, and 206) without rips which rendered the mattresses not easily
cleanable; failed to ensure the overbed lighting over one bed in resident rooms [ROOM
NUMBERS] worked; failed to maintain the floor in the shared restroom of resident rooms
328/327 in good repair; and failed to maintain the shower stall on the second floor shower
room with good lighting, and without rust stains and grime on the tiles. This practice
potentially affected at least 37 residents residing in or using those areas within the
facility. The facility census was 106 residents.
1. Observations with the Maintenance Supervisor and the Housekeeping Supervisor on
5/10/18, showed the following:
– At 9:10 A.M., there as a 60 inch (in.) long by 22 in. wide area of the mattress covering
that was peeling away from a mattress in resident room [ROOM NUMBER];
– At 10:04 A.M., one of the over bed lights in resident room [ROOM NUMBER] did not work
when the switch was turned on and the chain was pulled;
– At 10:32 A.M., a 33 in. long by 48 in. wide area of the floor in poor repair in the
shared restroom of resident rooms 328/327;
– At 11:04 A.M., one of the over bed lights in resident room [ROOM NUMBER] did not work
when the switch was turned on and the chain pulled;
– At 12:26 P.M., rust and grime was present in the shower stall of the second floor shower
room that covered an area of 54 in. wide by 48 in. deep form the back of the stall to the
front. Further observation showed that when the curtain was pulled in front of the shower
stall the lighting was very dim;
– At 12:43 P.M., 10 in. long rips were present in Bed C in resident room [ROOM NUMBER],
and
– At 12:50 P.M., there was a two in. hole in the mattress of bed B in resident room [ROOM
NUMBER].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
During an interview on 5/10/18 at 12:28 P.M., both the Maintenance Supervisor and the
Housekeeping Supervisor acknowledged that shower stall needed work and it was dark when
the curtain was pulled the Housekeeping Supervisor also said that when the grime and rust
could not be removed even when the housekeepers used housekeeping chemicals like bleach.
During interviews on 5/11/18 at 2:59 P.M., the Central Supply Coordinator said when the
mattresses were damaged, he/she should be informed about those so he/she could replace
those, and he/she did not know about the mattresses in resident rooms [ROOM NUMBER].
During interviews on 5/11/18 at 3:01 P.M., the Housekeeping Supervisor said the only time
the housekeeping staff was responsible for the mattresses, was on days that deep cleaning
of resident rooms were completed and he/she did let the maintenance department know about
the damage to the floor in resident rooms 328/327.

F 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Not transfer or discharge a resident without an adequate reason; and must provide
documentation and convey specific information when a resident is transferred or
discharged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure discharge/transfer
documentation was completed to include reasons for the discharge/transfer, discharge plan
and notification of the resident’s responsible party, for one sampled resident (Resident
#104), who was discharged to another facility, out of three sampled closed records and 30
sampled residents. The facility census was 106 residents.
1. Record review of Resident #104’s Facility Transfer Sheet dated 2/21/18, showed he/she
was transferred to the facility on [DATE] at the resident’s legal guardian’s requested.
Record review of the resident’s Nursing Notes showed the last nursing note dated 4/10/18
that the resident was having aggressive behaviors and was not re-directive using
non-medication interventions. It showed the nursing staff notified the resident’s
physician for a medication order to help calm the resident. There were no notes showing
the resident was ever discharged from the facility or that he/she was transferred to
another facility.
Record review of the resident’s Physician’s Order Sheet (POS) dated 3/15/18 to 4/14/18,
showed there were no physician’s orders documented showing the resident’s discharge
orders.
Record review of the resident’s Physician’s Telephone Orders (PTO) showed there were no
physician’s discharge orders for the resident.
Record review of the resident’s Medical Record showed there was no documentation in the
nursing notes showing when or why the resident was discharged . There was no documentation
showing the resident, resident’s responsible party/guardian or Ombudsman were made aware
of the resident’s transfer to another facility, any discharge letters and there was no
documentation of the resident’s discharge plan or aftercare.
During an interview on 5/16/18 at 9:35 A.M., the Administrator said:
-The resident transferred to the facility on [DATE] and was discharged to another facility
on 4/11/18; -Normally, when a resident is discharged from the facility, the nurse on duty
completes the transfer form, obtains the physician’s order for transfer, notifies the
responsible party or guardian, completes the disposition of medications and documents in
the nursing notes when the resident was to be discharged (the date and location), any
follow up care needs or orders, who the resident left with, the time the resident left and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
that the resident was discharged with all of their belongings;
-If Social Services was involved, there should be a social service note and especially if
the resident’s responsible party requested a transfer or discharge;
-The interdisciplinary team was supposed to document the recapitulation of the resident’s
stay on the Discharge Summary form. After looking in the resident’s electronic record,
he/she said he/she did not see a discharge summary for the resident and
-If the documentation was not in the resident’s medical record then it was not completed.

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to conduct a Level One Nursing
Facility Pre-Admission Service Screening for Mental Illness/Mental [MEDICAL CONDITION] or
Related Condition (PASRR) for one sampled resident (Resident #54) upon the resident’s
admission to the facility out of 30 sampled residents. The facility census was 106
residents.
Record review of the facility undated PASRR Assessment Policy showed showed the following:
-Purpose: The purpose of this policy is to utilize the PASRR Assessment to develop a plan
of care that shows continuity from previous history of behaviors and placement.
-Procedure: Upon the resident’s admission to the facility and upon the facility receiving
the PASRR, the Admissions Coordinator will make a copy of the PASRR with the clinical
history of previous behaviors and services provided. The Admissions Coordinator will give
a copy of the PASRR to the Director of Nursing, MDS/Care Plan Coordinator/Effective
Practices Community Supervision (EPICS) Case Manager and Social Services Director.
-The PASRR will be utilized as an instrument to assist the facility in maintaining as much
as possible, previous treatment modalities that were effective in the resident’s life
prior to placement at this facility.
1. Record review of Resident #54’s Face Sheet showed he/she was admitted to the facility
on [DATE] with a [DIAGNOSES REDACTED]. (A mental health disorder characterized by
persistently depressed mood or loss of interest in activities, causing significant
impairment in daily life).
Record review of the resident’s physician’s orders [REDACTED].
-The resident’s physician had approved the overall plan of care for the resident’s needs;
-To have a Psychiatrist and Psychologist consults as needed and
-To have a Behavioral Therapist consult as needed.
Record review of the resident’s Admission Minimum Data Set (MDS – a federally mandated
assessment tool to be completed by facility staff for care planning) dated 4/25/18 showed
he/she:
-Had a Brief Interview for Mental Status (BIMS) score of 13, which describes the resident
was cognitive alert and oriented and
-Had the ability to express ideas and wants to others in a consistent and reasonable
manner.
Record review of the resident’s Care Plan dated on 4/25/18, showed the following:
-Was to record and monitor for patterns of behaviors;
-Had to monitor for changes in condition that may warrant increased supervision/assistance
and notify the resident’s physician related to resident’s Major [MEDICAL CONDITION];
-Was at risk for side effects from antidepressant medication used;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
-Will have no injury related to medication usage and side effects;
-Administered medication as ordered by the resident’s physician;
-Was to observe the resident for adverse side effects, document and report to the
resident’s physician;
-Was to conduct a pharmacy consultant review for antidepressant medication use monthly and
-Was to monitor for signs of extrapyramidal symptoms (are drug induced movements disorders
that include tardive symptoms (repetitive, involuntary movements, such as grimacing and
eye blinking) and document.
During an interview on 5/11/18 at 1:45 P.M., the Social Services Director said he/she:
-Was to ensure all residents with PASRR had a comprehensive care plans related to mental
health and psychosocial functioning or needs;
-Was to receive a copy of each resident’s PASRR from the Admissions Coordinator;
-The PASRR is designed to holistically ( to look at the whole person) address the
resident’s needs and
-Was to assist in the resident reaching and maintaining their highest level mentally.
-Was to carry out their daily functional tasks.
During an interview on 5/14/18 at 1:30 P.M., the Assistant Director of Nursing (ADON)
said:
-All residents need initial screening assessment resident regarding their psycho-social
needs;
-PASRR Level I should be completed prior to the resident enters the nursing facility and
-He/she did not know that some residents may trigger the need to complete a PASRR II
screening or assessment.
During an interview on 5/14/18 at 3:00 P.M., the Social Services Director said he/she
needed to check with the Administrator to see if a PASRR was on file for Resident #54.
During an interview and record review on 5/15/18 at 10:30 A.M., the Social Services
Director said he/she did not have a PASRR on file in the Administrator Office for Resident
#54.
During an interview on 5/15/18 at 11:15 A.M., the Social Services Director said he/she:
-Residents who are admitted to the facility should have a PASRR completed prior to be
admitted to the facility;
-The residents coming from the hospital are expected to come with their PASRR screenings
or assessments paperwork;
-The benefit of the resident having a PASRR provides the staff with the resident’s history
and their [DIAGNOSES REDACTED].
-New staff are trained by Certified Nursing Assistants for one week of training on how to
read the resident’s care plans and how to deal the resident’s behaviors and
-The Psychological Services are provided to residents once a month by the psychiatric
team.
During an interview on 5/15/18 at 11:45 P.M., the Director of Nursing (DON) said he/she
expected PASRR’s to be completed on all residents prior to them be admitted to the
facility.
Record review on 5/16/18 at 12:05 P.M., of the facility’s Social Services/Admission job
description showed the following job duties or functions:
-Initial Psycho-social on all new admits;
-Admit notes on all new residents after filling out initial psycho-social and
-On new Medicaid patients, before accepting make sure that they have a PASRR Level II
screening, if needed, imitated by current hospital stay or get from previous facility and
get a copy of the PASRR from Cambodia Oxford Medical Research Unit (COMRU).
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 observation, interview and record review, the facility failed to ensure the care
plan was comprehensive and included a nutritional care plan for one sampled resident who
had a history of [REDACTED].#53) out of 30 sampled residents. The facility census was 106
residents.
1. Record review of Resident #53’s Face Sheet showed he/she was admitted to the facility
on
7/25/15, with [DIAGNOSES REDACTED]. strong enough to interfere with one’s daily activities
and diabetes.
Record review of the resident’s Weight Record showed the following monthly weights:
-Dec. (YEAR)-174 lbs.;
-Jan. (YEAR)-168 lbs.;
-Feb. (YEAR)-161 lbs.;
-Mar. (YEAR)-160 lbs.;
-April (YEAR)-162 lbs.; and (MONTH) (YEAR)-155 lbs. (showed a weight loss of 10.92 % in 6
months, 3.13% in 3 months, 4.32% in 30 days).
Record review of the resident’s annual Minimum Data set (MDS-a federally madated
assessment tool completed by facility staff used for care planning) dated 3/22/18, showed
he/she:
-Had a memory problem and was severely cognitively impaired;
-Was independent with ambulation, mobility, bathing, dressing and toileting and
-Did not have any weight loss.
Record review of the resident’s physician’s orders [REDACTED]. It also showed a
physician’s orders [REDACTED].
Record review of the resident’s Care Plan dated 7/25/17 and updated on 6/22/18 did not
show any nutritional problems, goals or interventions addressing the resident’s diet,
intake, weight loss, nutritional interventions or nutritional needs of the resident. It
did not show whether the resident needed assistance or encouragement to eat or or showed
the resident’s preferences.
Observation on 5/9/18 at 12:15 P.M., showed the resident was up in the dining room eating
a regular diet of ham, mashed potatoes, carrots and drinking a choice of beverages
(lemonade or fruit punch). The resident needed no assistive device and no assistance
needed to eat. He was eating without swallowing difficulty. The Resident ate 100% of his
meal. He did not receive a health shake. When he finished eating, he stood up and
ambulated from the table without assistance or assistive device. The resident was alert
and oriented, was clean and dressed for the weather.
During an interview on 5/15/18 at 3:11 P.M., the Director of Nursing said:
-They did not have anyone currently responsible for completing care plans and they were
behind;
-They were trying to hire someone to work on care plans on a permanent basis and
-Care plans should be comprehensive and reflect the current health status of the resident.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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

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
physician’s nutritional orders were followed which resulted in the resident receiving the
wrong diet for one sampled resident (Resident #42), to ensure the resident’s physician
orders where verified and followed for a narcotic medication, resulting in medication
given by facility nursing staff without a current physician orders for a schedule II
control substance medication and did not accurately document the resident’s narcotic
medication on the resident’s Medication Administration Record (MAR), Individual Patient
Narcotic Record for one sampled resident (Resident #72) out of 30 sampled residents. The
facility census was 106 residents.
Record review of the Facility Medication Administration Policy and Procedure revised
4/6/17 showed:
Medication are to be given per doctor orders. All medication are recorded on the
resident’s MAR and signed immediately after the resident has taken the medications.
-The Nurse or Certified Medication Technician (CMT) should initial a circle the time of
the medication in question not given and document on back of the resident’s MAR why
refused or not available. Notify the Director of Nursing (DON) or Registered Nurse (RN)
designee,
-Narcotics must be counted with the on-coming shift nurse. Remember to label the
medication card as you give the Narcotic, date and initial given. If the count is
incorrect the off-going nurse must stay until it is corrected and the Resident Care
Coordinator (RCC) and DON or designee must be notified.
-The Nurse or the CMT then will go to the progress note and note the documentation of the
medication discrepancy also noting physician notified,
-Each Resident’s drug regimen will be reviewed monthly by a licensed pharmacist,
-The facility will self-report any serious medication errors to the State department,
conduct an appropriate investigation,and issue disciplinary action up to and including
termination for the first offense based on the outcome of the investigation by the
facility and the findings of the state department’s investigation.
1. Record Review of Resident #42’s Face Sheet showed he/she was admitted on [DATE], with
[DIAGNOSES REDACTED]. chronic concurrent diseases and functional impairments).
Record review of the resident’s Minimum Data Set (MDS- a federally mandated assessment
tool to be completed by facility staff for care planning) dated 2/9/18, showed he/she:
-Was cognitively impaired;
-Was ambulatory without an assistive device and could eat independently with supervision;
-Did not have any swallowing problems, but received a therapeutic diet and
-had a history of [REDACTED].
Record review of the resident’s Physician’s Notes dated (MONTH) (YEAR), showed the
resident’s physician completed a physical exam of the resident and reviewed his/her
medications, labs and medical record. The resident’s physician documented the resident had
significant weight loss. The physician did not give any new nutritional orders, but the
physician noted he/she would continue to monitor the resident’s weight. He/she documented
a [DIAGNOSES REDACTED].
Record review of the resident’s Care Plan dated 2/21/18, showed the resident did not have
a care plan that showed his/her nutritional intake, diet, or food preferences. It did not
show if the resident needed any assistance with eating or had any chewing/swallowing
issues or issues with his/her weight. It showed the resident was diabetic and staff was to

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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)
monitor his/her nutritional intake and to educate the resident on appropriate nutrition in
order to maintain his/her blood sugar at an acceptable level. There were no additional
nutritional interventions documented.
Record review of the resident’s Dietician Notes dated 2/23/18 showed he/she was
hospitalized from [DATE] to 2/21/18. The Dietician documented the resident was on a
mechanical soft diet with nectar thickened liquids. He/she reviewed the resident’s labs
and documented the resident was currently under his/her normal weight range and had
significant weight loss. The Dietician recommendation was to continue giving the resident
health shakes twice daily. There are no dietician notes after 2/23/18.
Record review of the resident’s Medical Record did not show a speech therapy assessment
showing the resident was an aspiration risk or a re-assessment of his/her chewing and
swallowing capacity. There was no documentation showing the resident and/or his/her
responsible party were educated on the resident’s risk of aspiration if he/she declined
the physician ordered diet and that the decision was made to provide the resident with a
regular diet against physician’s orders.
Record Review of the resident’s Physician’s Order Sheet (POS) dated (MONTH) (YEAR), showed
physician’s orders for the resident to receive a mechanical soft diet (a diet consistency
of soft foods with ground meat) with nectar thickened liquids.
Record review of the resident’s MAR dated (MONTH) (YEAR), showed physician’s orders for a
mechanical soft diet with nectar thickened health shakes twice daily at lunch and dinner
due to weight loss (the physician’s order was dated 3/1/18).
Record review of the resident’s Physician’s Telephone Orders showed there were no
physician orders showing the resident’s diet order was changed or discontinued.
Record review of the resident’s Nursing Notes from 3/1/18 to 5/15/18, showed the nursing
staff did not document any notes showing the resident was non-compliant with his/her diet
and refused to eat a mechanical soft diet with nectar thickened beverages. There was no
documentation showing the nursing staff educated the resident on his/her diet orders or
failure to comply with them. There was no documentation showing that nursing staff
notified the resident’s responsible party or physician of the resident’s dietary
non-compliance.
Record review of the resident’s POS dated (MONTH) (YEAR), showed the resident was to
receive a mechanical soft diet with nectar thickened health shakes at lunch and dinner.
Observation on 5/9/18 at 12:15 P.M., showed the resident was ambulating in the dining room
and sat down to eat lunch. He/she was served a regular diet of ham (not ground), garlic
mashed potatoes, and cooked carrots. He/she received a glass of lemonade and did not
receive a health shake. Once the resident finished eating (he/she ate 100% of his/her
meal), he/she got up and ambulated to a chair in front of the television and sat down.
Observation and interview on 5/10/18 at 11:58 A.M., showed the resident was sitting in the
dining room waiting for lunch to be served. He/she was given a choice of beverage
(lemonade or fruit punch) and was served a small bowl of fruit crisp dessert. His/her
beverages were not thickened. The resident began eating and drinking independently without
any aspiration or choking. Staff then gave the resident a regular diet of meatballs with
broccoli. The resident ate all of his/her meal without any problems. He/she did not
receive a health shake with his/her meal. Licensed Practical Nurse (LPN) A said the
resident refused to eat the physician’s prescribed diet so they gave him/her a regular
diet and he/she eats it without any issues.
During an interview on 5/10/18 at 12:29 P.M., CMT A said:
-For those residents who receive health shakes, the health shakes came out on the beverage
carts and were served to the residents by the Certified Nursing Assistants (CNA) as their
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 7)
beverages were served;
-Health shakes were kept in the kitchen;
-If the resident was supposed to receive a health shake and did not receive it, the
nursing staff can go get it or request that dietary staff bring it to the dining room and
-Either the CMT’s or Charge Nurses were supposed to document that the resident received
their health shake in the resident’s medical record (on the resident’s MAR).
During an interview on 5/15/18 at 3:11 P.M., the DON said:
-He/she expected diet orders to be followed;
-Once the resident’s diet order is changed, the nurses on the unit are to communicate the
diet order change to the nursing staff;
-He/she would expect to see documentation showing why a diet order change was necessary;
-The nurse was also responsible for documenting the new diet order on the dietary
communication form and giving that to the dietary manager;
-If a resident did not wish to comply with the diet orders, the nurse should document this
and notify the resident’s physician and responsible party, and speak with the resident
about his/her non-compliance and
-If the resident chooses to be non-compliant with the recommended diet order, they should
have the resident or responsible party sign a waiver that is also documented in the
resident’s medical record, and notify his/her physician.
2. Record review of Resident #72’s Face Sheet showed he/she was admitted to the facility
on [DATE] and was readmitted on [DATE]. Had a [DIAGNOSES REDACTED].
Record review of the resident’s MDS dated [DATE] showed he/she:
-Was cognitively impaired and
-Was independent with his/her mobility and transfer with staff supervision at the time of
discharge.
Record review of resident’s POS dated from 1/15/18-3/14/18, showed physician’s orders for
-On 1/15/18-2/14/18, [MEDICATION NAME] APAP (a narcotic pain medication) 10/325 milligrams
(mg) one tablet by mouth three times a day ordered on [DATE] and
-On 2/15/18 to 3/14/18, [MEDICATION NAME]-APAP 10/325 mg one tablet by mouth three times a
day ordered on [DATE].
Record review of the resident’s POS dated from 3/15/18 to 5/14/18 showed physician’s
orders for:
-On 3/15/18 to 4/14/18 showed [MEDICATION NAME]-APAP 5/325 mg one tablet by mouth three
times a day and
-On 4/15/18 to 5/14/18 showed [MEDICATION NAME]-APAP 10/325 mg one tablet by mouth three
times a day
Record review of the resident’s Medical Record showed the resident had a medication record
review done by the pharmacy staff on 5/8/18 showed and no concerns was documented.
Record review of the resident’s MAR dated 3/15/18 to 4/15/18 showed a physician’s order
for [MEDICATION NAME]-APAP 5/325 one tablet by mouth three times a day for pain.
Record review of the resident’s nurse’s notes dated 4/9/18 at 5:15 P.M. showed:
-The Nurse had verified the resident’s [MEDICATION NAME]-APAP ([MEDICATION NAME]) order;
-Resident recently received [MEDICATION NAME]-APAP 10/325 mg;
-The pharmacy had sent [MEDICATION NAME]-APAP ([MEDICATION NAME]) 5/325 mg;
-Resident had been complaining of chronic pain, on a pain scale of 8 out of 10, the pain
was located in his/her legs and back;
-Nurse had verified and notified the resident’s physician for [MEDICATION NAME]-APAP
10/325 mg and faxed the physician’s order to the pharmacy and
-The staff had provided non pharmaceutical interventions for comfort measures by massage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 8)
and hot wash cloths.
Observation of the resident’s medication pass on 5/10/18 at 12:35 P.M., by LPN D showed:
-Had popped [MEDICATION NAME]-APAP 10/325 mg one tablet into a medication cup, and had
wrote the resident’s first name on bottom of the cup and said he/she had the medication
ready for when the resident came into the dining room;
– At 12: 56 P.M., The LPN D was going to give the resident the pre prepared medication;
-Had compared medication in medication cup with [MEDICATION NAME]-APAP 10/325 tab and
[MEDICATION NAME]-APAP 5/325 tab mg to make sure it was the right medication;
-The resident’s MAR and the Narcotic sign out sheet was reviewed prior to LPN D
administering the [MEDICATION NAME] and found that the [MEDICATION NAME] Medication card
count did not match the Narcotic sign out sheet and
-The Medication card showed the resident had 20 tabs left on his/her medication card and
the Narcotic sign out sheet for [MEDICATION NAME] showed the resident had 21 left which
showed LPN D had not sign out the [MEDICATION NAME].
Record review of the resident’s narcotic Medication card on 5/10/18 at 1:00 P.M., showed
the resident’s [MEDICATION NAME] Medication card had 21 tablets left and if one tab was
given then 20 tablets should be showing what was left;
-After further investigation was found that the resident also had a medication card for
[MEDICATION NAME]-APAP ([MEDICATION NAME]) 5/325 mg for one tab by mouth three times a day
for pain and
-The LPN D gave the resident the medication for pain and then gathered the MAR sheet and
the resident’s individual count sheet and took them to the DON for review.
Record review of the resident’s Medical Record with LPN D and the DON showed they were not
able to find a written telephone physician’s order from the resident’s physician to change
the [MEDICATION NAME]-APAP 5/325 mg one tab by mouth three times a day for pain to
[MEDICATION NAME]-APAP 10/325 one tab by mouth three times a day for pain or any current
physician’s orders to continue or discontinue the resident’s [MEDICATION NAME]-APAP 5/325
one tab by mouth three times a day.
Record review of the resident’s MAR and POS dated 4/15/18 to 5/14/18 showed:
-The resident did not have a current physician’s order for his/her [MEDICATION NAME]-APAP
([MEDICATION NAME]) 5/325 one tablet by mouth three times a day for pain and
-The resident’s MAR did not show any documentation that [MEDICATION NAME]-APAP 5/325 mg
had been given eight times on the resident’s MAR. and given without a current physician’s
order:
Record review of the resident’s faxed Physician’s order dated 5/10/18 sent to the pharmacy
showed:
-The original fax date on the physician order was 4/9/18 at 2:12 P.M.,
-Was for Continuance of the Schedule II Medication Therapy;
–[MEDICATION NAME]-APAP 10/325 mg one tablet by mouth three times a day;
–Had ordered 90 tablets and
-There was no physician’s order to stop or discontinue the resident’s [MEDICATION
NAME]-APAP 5/325 mg.
Review of the resident’s Individual Patient Narcotic Record on 5/10/18 showed he/she had a
start date of 4/9/18 for [MEDICATION NAME] 5/325 mg one tablet by mouth three times a day
and 45 tablets have been delivered. On 4/29/18 the narcotic record showed 21 tablets were
left.
Review of the resident’s Individual Patient Narcotic Record on 5/10/18 showed he/she had
90 tabs of [MEDICATION NAME] 10/325 one tab by mouth three times a day for pain was
received on 4/14/18 and the staff started administering on 4/15/18.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 9)
During an interview on 5/10/18 at 1:05 P.M., LPN D said:
-He/she and other nursing staff had been giving the resident medication from both
[MEDICATION NAME] 10/325 and [MEDICATION NAME] 5/325 medications cards, depending on how
the resident rated his/her pain;
-He/she had already written down the 12:30 P.M. dose of medication;
-He/she had placed it on the line where the nurse had marked through with a line as a
error, their name prior and added a later on the line below 5/10/18 at 8:00 A.M.;
– LPN D had placed his/her name in the 12:30 P.M. dose marked out space, to save space,
which he/she had pre-popped the medication and stored in the medication cup, prior to
administration and
-LPN said, so after the confusion of the count and which medication should been given
he/she had review of the medication count sheets and medications card and found it to be
correct, and which would have left 20 of the [MEDICATION NAME]-APAP 10 /325 mg on the
card.
During an interview on 5/10/18 at 2:10 P.M., LPN D said:
-He/she could not find the written telephone physician’s order for [MEDICATION NAME]-APAP
10/325 mg but was noted in the nurses note on 4/9/18;
-He/she should had clarified the [MEDICATION NAME]-APAP orders since it was confusing;
-Nursing staff should have discarded the [MEDICATION NAME]-APAP 5/325 mg after received
new medication from the pharmacy;
-Not able to find the resident current MAR for 4/16/18 to 5/14/18 with the documentation
of the [MEDICATION NAME]-APAP 5/325 mg that had been given and
-During each shift change, the nurses perform medication count for narcotic by counting
the cards then the number of pills left on each cards.
Record review of the resident Medical Record on 5/11/18 was able to find the missing
telephone physician’s order dated 4/9/18, which showed a clarification of the resident’s
[MEDICATION NAME]-APAP order was to be [MEDICATION NAME]-APAP ([MEDICATION NAME]) 10/325
mg one tablet three times a day.
During an interview on 05/15/18 02:37 P.M. DON said:
-Nursing staff was unable to find the MAR with the documentation for [MEDICATION
NAME]-APAP 5/325 from 4/14/18 to 5/14/18;
-Would except the nurses to verify a physician’s order for all of the resident’s
medication and to ensure to document medication and treatment given or provided in the
resident’s MAR and Treatment Administration Record (TAR);
-Would except the nursing staff to verify the resident’s physician orders for his/her
[MEDICATION NAME]-APAP 5/325 and [MEDICATION NAME]-APAP 10/325, this would have prevented
the resident from receiving [MEDICATION NAME]-APAP 5/325 without a physician’s order;
-Would have expected the nursing staff to document any medication given on the resident’s
MAR;
-The RCC and the DON were assigned to do a weekly checks on the facility medication carts
and medication card;
– He/she would expect the licensed nursing staff and CMT’s to review all medications prior
to administering the medication with the resident’s physician’s order, his/her MAR and
check for any discrepancies for the resident’s medications and
-He/she would expect licensed nursing staff and CMT’s to immediately report any
discrepancies found during narcotic administration and narcotic drug counts to the DON.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure necessary information is communicated to the resident, and receiving health care
provider at the time of a planned discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a discharge summary
and recapitulation was completed for one sampled resident (Resident #104) who was
discharged to another facility out of three sampled closed records and 30 sampled
residents. The facility census was 106 residents.
1. Record review of Resident #104’s Facility Transfer Sheet dated 2/21/18, showed he/she
was transferred to the facility on [DATE] at the resident’s legal guardian’s requested.
Record review of the resident’s Nursing Notes showed the last nursing note dated 4/10/18,
showed the resident was having aggressive behaviors and was not re-directive using
non-medication interventions. It showed the nursing staff notified the resident’s
physician for a medication order to help calm the resident. There were no notes showing
the resident was ever discharged from the facility or that he/she was transferred to
another facility.
Record review of the resident’s Physician’s Order Sheet (POS) dated 3/15/18 to 4/14/18
showed there were no physician’s orders documented showing the resident’s discharge
orders.
Record review of the resident’s Physician’s Telephone Orders (PTO) showed there were no
physician’s discharge orders for the resident.
Record review of the resident’s Medical Record showed there was no documentation in the
nursing notes showing when or why the resident was discharged . There was no documentation
showing a Discharge Summary was completed to recapitulate his/her stay at the facility,
where the resident was discharged to and any after care services ordered. There was no
documentation showing the disposition of the resident’s medications or belongings.
During an interview on 5/16/18 at 9:35 A.M., the Administrator said:
-The resident transferred to the facility on [DATE] and was discharged to another facility
on 4/11/18.;
-Normally, when a resident is discharged from the facility, the nurse on duty completes
the transfer form, obtains the physician’s order for transfer, notifies the responsible
party or guardian, completes the disposition of medications and documents in the nursing
notes when the resident was to be discharged (the date and location), any follow up care
needs or orders, who the resident left with, the time the resident left and that the
resident was discharged with all of their belongings;
-The nursing staff should also complete the resident’s inventory sheet to show the
resident left with all of their belongings;
-If Social Services was involved, there should be a social service note and especially if
the resident’s responsible party requested a transfer or discharge;
-The interdisciplinary team was supposed to document the recapitulation of the resident’s
stay on the Discharge summary form. After looking in the resident’s electronic record,
he/she said he/she did not see a discharge summary for the resident;
-There should have been a recapitulation of the resident’s stay documented on the
Discharge Summary form and the form should have been filled out to show that the resident
was transferring to another facility. The resident’s discharge should have included
completing the resident’s inventory sheet, physician’s orders to discharge the resident
and documentation of the disposition of the resident’s medications and
-If the documentation was not in the resident’s medical record then it was not completed.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
activities that met the resident’s individual needs and preferences were provided for
seven sampled residents (Resident #30, #53, #54, #68, #90, 92 and #203) who reside in the
locked units; to ensure an activity calendar was posted, provided and implemented to 31
resident’s residing on the men’s locked unit and 22 resident’s residing on the women’s
locked unit. This deficient practice potentially affected 106 residents in the facility.
The facility census was 106 residents.
Record review of the facility’s undated Activity policy and procedure showed the purpose
of the policy was to ensure that all residents in the facility are provided an ongoing
program of activities designed to meet, in accordance with comprehensive assessment, their
interests and their physical, mental and psychosocial well- being. The procedure showed:
-The Life Enhancement Director ensures that activities are designed to promote and enhance
the emotional health, self-esteem, pleasure, comfort, education, creativity, success and
independence for all residents, based on interview and assessing the resident’s likes and
dislikes.
-If the resident requires more intensive interventions for activities, one to one
programming that is relevant to the resident’s specific needs, interests, culture and
history/background, than a individualized activities plan of care will be developed to
enhance their psychosocial well-being.
-The activities calendar will be posted on each floor and will include activities that are
appropriate for the general therapeutic milieu population that meets the specific needs,
cognitive impairments, interests, and supports the quality of life while enhancing
self-esteem and dignity.
-Documentation will be completed on each resident’s activity within the facility.
Documentation will note participation in activities and specific resident-centered
individualized programming that will include, but not limited to, the emotional health,
physical, cognition, promotion of self-esteem, pleasure, comfort, education, creativity,
success and independence.
1. Record review of Resident #30’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s undated admission Activity Evaluation showed it was very
important to the resident to have choices, music (Bob Marley), news, things to do with
groups, favorite activities, going outside. It showed the resident liked spades (card
game), exercise, basketball, music, religious activities, trips/shopping, watching
TV/movies, gardening, talking, woodshop, hunting, helping others, parties, and community
outings.
Record review of the resident’s Activity Notes showed an admission note dated 5/25/17, and
a quarterly note dated 8/24/17, showed the resident was up daily and doing well. He/she
was able to arrive and leave activities at will. He/she enjoyed most social events,
snacks, outings such as shopping and going to the YMCA and smoking. Staff was to continue
to encourage his/her participation. There were no additional notes in the record and there
was no documentation showing how many activities the resident participated in weekly,
monthly or quarterly.
Record review of the resident’s Minimum Data Set (MDS-a federally mandated assessment tool
to be completed by facility staff for care planning) dated 5/26/18, showed he/she:
-Had memory loss;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-Was ambulatory without assistive devices and did not need assistance with bathing,
dressing, eating, or toileting;
-Noted choices were very important and
-Activities such as music, keeping up with the news, participating in favorite activities,
group activities, going outside and religion were very important.
Record review of the resident’s Care Plan updated on 5/18/18, showed the resident had
impaired thought processes, impaired memory and had a history of [REDACTED]. Care Plan
interventions showed:
-Social Services was to evaluate and visit the resident;
-Activity staff was to visit and provide diversional activities;
-Monitor and document the resident’s behaviors, identify causes of his/her behavior and
reduce factors that may provoke the resident;
-Discuss options for channeling anger, remove the resident from public areas when
behaviors are disruptive;
-Talk in a calm manner to the resident, administer behavior medications and assist him/her
in coping mechanisms;
-Encourage family/responsible party visits and
-There was no documentation showing the resident’s activity preferences and how the
facility would ensure individual preferences were met. The care plan did not show the
resident’s rate of participation in activities provided and there were no measurable
activity goals for the resident documented.
Observation on 5/9/18 at 10:28 A.M., showed the resident was standing in the hallway
outside of his/her doorway talking with staff and peers as they passed by. Upon entering
the resident’s room there was no observation of an activity calendar posted for the
resident or any of his/her roommates.
During an observation and interview on 5/9/18 at 2:30 P.M., there were no scheduled
activities on the unit. The resident was standing around in the hallway and talking with
peers passing by. He/she said:
-He/she smokes and does take advantage of the smoking breaks;
-They have supervised smoke breaks throughout the day and night outside on the smoking
patio;
-He/she liked to play basketball and sometimes they go to the YMCA;
-He/she was happy because his/her responsible party was going to visit him/her on Sunday
and his/her niece was going to visit him/her on Friday;
-They sometimes played games on the unit and watched television;
-They did not have a daily activity calendar and
-The activity person came onto the floor everyday throughout the day and talked to the
residents and completed banking (passing out resident funds requested).
During an interview on 5/10/18 at 9:30 A.M., the resident was laying down in his bed
resting. Certified Nursing Assistant (CNA) A said there were no planned activities, but
the residents had games they could play and activity staff sometimes came and played games
with the residents and the residents also go out to smoke. He/she said they did not have
an activity calendar on the unit.
Observation on 5/14/18 from 8:45 A.M. to 11:30 A.M., showed there were no scheduled
activities other than smoking at 9:30 A.M. At 9:15 A.M., the residents, to include
Resident #30, gathered at the nursing station to get ready to go out to smoke. CNA staff
took the residents to the smoking patio.
Observation and interview on 5/14/18 at 2:00 P.M., showed the resident was walking up and
down the hallway talking to peers and staff. He said that they did not have any activities
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
today besides smoking. He/she said he/she didn’t know if they were going to go to the YMCA
today but they do go sometimes.
2. Record review of Resident #53’s Face Sheet showed he/she was admitted to the facility
on
7/25/15, with [DIAGNOSES REDACTED].
Record review of the resident’s annual MDS dated [DATE], showed he/she:
-Had a memory problem and was severely cognitively impaired;
-Was independent with ambulation, mobility, bathing, dressing and toileting and
-Activities such as making choices, participating in music activities was important.
Record review of the resident’s Care Plan dated 7/6/17, showed the resident had no
interest in activities, but enjoyed music. The goal was that the resident will have daily
opportunities to participate in an activity of choice. It showed the resident preferred
spending time outside, activities that involved music and activities on an individual
basis.
Record review of the resident’s Medical Record showed there was no documentation showing
any one to one activities provided and there was no documentation showing the resident’s
activity participation record (to include activities that were offered and declined).
Observation on 5/9/18 at 10:20 A.M., showed the resident was in his/her room, laying on
top of his/her bed asleep. He/she was dressed for the weather without odors. His/her room
was clean but there was no evidence of an activity calendar posted.
Observation on 5/9/18 at 2:30 P.M., showed there were no scheduled activities occurring on
the unit. The resident was pacing back and forth down the hallway. He/she was not
interacting with anyone.
Observation and interview on 5/10/18 at 9:10 A.M., showed the resident ambulating up and
down the hallway. He/she went into the indoor smoking area and said that he/she liked
sports and was going to go to the YMCA today. There was no scheduled activity plan
documented and no activity calendar on the unit.
Observation on 5/14/18 from 8:45 A.M. to 11:30 A.M., showed there were no scheduled
activities occurring on the unit other than smoking at 9:30 A.M. At 9:15 A.M. the
residents gathered at the nursing station to get ready to go out to smoke (to include
Resident #53). CNA staff took the residents to the smoking patio.
3. Record review of Resident #203’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s admission MDS dated [DATE], showed he/she:
-Had memory loss with moderate cognitive impairment;
-Was independent with ambulation, mobility, dressing and needed assistance with toileting
and bathing and
-Was unable to answer activity preference questions. Staff reported that participating in
favorite activities and receiving snacks were somewhat important for the resident.
Record review of the resident’s Care Plan showed there was no care plan for activities in
the resident’s medical record.
Record review of the resident’s Medical record showed there was no documentation showing
the facility completed an activity assessment for the resident and there were no activity
notes documented to show the resident’s activity preferences, hobbies or interests.
Observation on 5/9/18 at 10:50 A.M., showed the resident was in his wheelchair in the
dining room watching TV. There was no structured activity occurring on the unit at this
time. There was no activity calendar on the unit. Observation of resident’s room showed
there was no activity calendar posted in his/her room.
Observation on 5/9/18 at 12:14 P.M., showed the resident eating lunch. When he/she was
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
finished, he/she got up from his/her wheelchair and ambulated across the room. Staff
redirected him/her to his/her wheelchair. He was compliant but continues to get up to
ambulate down the hallway and around in the dining area. There were no activities provided
to the resident to try to divert the resident. There were no activities observed on the
unit after the lunch period was over. From 2:00 P.M. to 3:00 P.M., the resident was
sitting in his wheelchair in front of the nursing station, quietly eating a snack and
began singing. There were three additional residents standing around in the hallway. There
were no scheduled activities occurring on the unit.
Observation on 5/10/18 at 9:02 A.M., showed the resident was ambulating up and down the
hallway, pacing and talking to himself/herself. Staff got his/her wheelchair and
encouraged him/her to sit down, and the resident was compliant, but kept getting up at
will to ambulate. There were no activities occurring on the unit and staff did not try to
provide an activity to the resident to try to divert his/her attention from getting up
from his/her wheelchair. At 9:30 A.M., nursing staff assisted the resident to lay down in
his/her bed.
During an interview on 5/15/18 at 11:00 A.M., the Administrator said he/he looked for the
resident’s activity notes and assessments and was not able to find any activity notes or
an activity assessment for the resident.
4. Record review of the facility’s Activity Lists showed:
-February (YEAR)-there was a list of activities that was not daily activities, but showed
an activity on specified dates throughout the month that gave instruction to unit staff on
what the activity on those days listed was supposed to be and how to implement the
activity;
-March (YEAR)-there was a list of activities (at least one activity on the dates
activities were documented) with instructions on how to implement each of those
activities;
-April (YEAR)- There was a list of special events scheduled for five dates during the
month with instructions on how to implement the activities and
-There was no activity list or special events listed for (MONTH) (YEAR).
Observation on 05/9/18 from 10:20 AM to 11:30 A.M., during a tour of the locked men’s unit
showed there was no activity calendar posted on the unit and there were no activity
calendars posted in any of the resident rooms. There were 31 residents residing on the
unit. Observation during this time showed there were no structured activities occurring on
the unit. There were two televisions in the dining/activity room and there were a few
games in the room that none of the residents were playing. Some of the residents were in
bed or in their rooms watching television, other residents were walking around on the
unit. At around 11:15 A.M., several residents on the unit began to gather at the nursing
station. Nursing staff said it was time for their smoke break and began to obtain smoking
supplies for the residents who smoked on the unit.
During an interview on 5/10/18 at 9:30 A.M., CNA A said there were no planned activities,
and he/she had not seen an activity calendar posted, but the residents had games they
could play on the unit, watch television and they had video games they also played at
times. He/she said activity staff came onto the unit every day to pass out resident funds,
but sometimes he/she also played games with the residents. He/she said the residents also
went outside to smoke at scheduled times throughout the day.
During an interview on 5/11/18 at 12:30 P.M., the Activity Assistant said:
-They did not currently have an Activity Director at the facility;
-He/she has been employed at the facility for one month;
-He/she had not been to activity training yet;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
-He/she received an activity calendar from the Activity personnel at the sister facility
by phone, but there was no daily activity calendar posted on the units or given to the
residents;
-The newly hired Activity Director was supposed to start on Monday of next week;
-When he/she came to work, he/she took care of resident complaints/concerns first, then
he/she started on completing resident banking on all three units. He/she said once he
finished that, he/she began addressing resident needs on each unit, and also went to the
store for residents and completed miscellaneous duties for administrative staff;
-He/she was unable to do activities at the same time on all of the units, and currently
he/she had no one else assisting him/her;
-He/she has brought in games and recently purchased supplies for activities, but has not
started to use those supplies and
-Nursing staff did not provide activities for the residents but on this unit they had
games available.
Observation on 5/14/18 from 8:45 A.M. to 11:30 A.M., showed there were no scheduled
activities other than smoking at 9:30 A.M. and at 9:15 A.M. the residents gathered at the
nursing station to get ready to go out to smoke.
During an interview on 5/14/18 at 3:04 P.M., Registered Nurse (RN) B said:
-They have activities on the unit such as bingo, play station, they go outside, and they
have a jukebox where they can play music;
-Since a lot of the residents are younger, they have games and cards, checkers that they
can also play and the activity personnel come to initiate the activity usually 3-4 times
weekly;
-They have recently started to take the residents shopping; it’s supposed to be twice
weekly to Walmart and Dollar General;
-They do not have a daily activity calendar yet, but they are supposed to get an activity
schedule; -The activity staff has also gone out to get food and run to the store for the
residents;
-He/she did not see any activities planned for today, outside of smoking;
-He/she thought that the Activity Assistant was trying to provide activities to the
residents, but he/she did not know that the activity assistant was aware that he/she was
supposed to make a monthly activity calendar and
-He/she did not think the Activity Assistant had much training because he/she was new to
the position.
During an interview on 5/15/18 at 3:11 P.M., the Director of Nursing (DON) said:
-He/she had only been employed at the facility for two months and since he/she had been at
the facility, he/she had not seen an activity calendar or any scheduled activities in the
facility;
-They have an Activity Assistant who has only been employed at the facility almost a
month;
-He/she did not know if the Activity Assistant had any training yet, but he/she was
responsible for resident banking and he/she also handled resident requests for obtaining
personal items, supplies, food (running errands) for the residents and
-He/she did not know how long it had been that the facility had not had an Activity
Director, but they had hired an Activity Director this week and so things should change
soon.
5. Record review of Resident #92’s Admission Face Sheet dated showed he/she as admitted on
[DATE], readmitted on [DATE] and 4/12/18 showed the resident had the following Diagnoses:
[REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
-Anxiety disorder (fear or worry);
-[MEDICAL CONDITION] disorder,( mental disorder have hallucinations or delusions );
-[MEDICAL CONDITION] disorder- (manic behavior);
-[MEDICAL CONDITION] (feeling sadness, worthiness);
-Board line intellectual function, (is a cognitive impairment, below normal -difficulty in
understanding in reasoning, problem solving, planning, and abstract thinking);
-Hepatic failure,(liver function);
-Convulsions ([MEDICAL CONDITION], body muscles contract and relax rapidly and repeatedly,
resulting in an uncontrolled shaking of the body) and
-Has a public administrator as his/her guardian.
Record review of the resident’s Care Plan dated 8/22/17 showed:
-The resident has a long history of attempted and actual self-harm.
-Intervention includes:
–Encourage participation in unit activities and
–Encourage him/her to bond with other resident with similar interest
Record review of the resident’s nurses notes form 4/12/18 to 5/12/18 showed any behavior
or mental health concerns express by the resident, the nursing staff recommended that the
resident to use his/her coping skills and to journal his/her thoughts and feelings.
Record review of the resident’s POS dated 4/15/18 to 5/14/18 showed:
-May have behavior therapist, psychiatrist and psychologist consults as needed and
-May participate in planned activities
Record review of the resident’s quarterly MDS dated [DATE], showed he/she:
–Re-entry from a psychiatric hospital on [DATE];
—The resident was not cognitively impaired and has a BIMS (brief interview for mental
status) score of 12 and but had disorganized thinking;
–Had received Anti-psychotic medication, anti-anxiety medication and anti-depressant and
–The resident did not have any psychological therapy (by any licensed mental health
professional during the look period of the last seven days)
Record review of the resident’s Medical Record showed the last Quarterly Activity progress
Note was dated 5/4/17.
Observation on 5/9/18 at 9:00 A.M., showed the resident:
-Had become upset very easily when other residents had been yelling out, crying or with
loud sounds;
-The resident would cover his/her ears and would rock in chair at times, had become
tearful at times;
– He/she would interacted with peers, and this seemed to help calm him/her;
-The resident was able to voice needs to staff;
-No observation of any type group activities on the unit; and
-Resident would walk back and forth from the resident rooms to front area, sit at the
table to visit with peers.
Observation of the Women’s 3rd floor locked units on 5/9/18 to 05/15/18 showed:
-The facility did not have a director for activities;
-The facility only has an assistant activities staff that recently started;
-Have not observed any Activity calendar posted, no posting of activity calendar in
resident rooms or hallway;
-No current documentation found from the activity staff;
-Observation on women’s 3rd south, the assistant activities staff was taking food orders
for the residents from local food establishment; and
-Also observation of banking day where staff were assisting in providing residents their
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
allowed amount of funds.
Observation and interview on 5/10/18 at 9:50 A.M., showed:
– The resident sitting in the front area /dining area;
-He/she would like the facility to have more activities and to include mental health or
behavioral health groups topics; and
-He/she would like to have relaxation groups.
During an interview on 5/15/18 at 12:45 P.M., Certified Nurse’s Assistant (CNA) E said:
-For the resident’s on the units, the CNA’s will provide activities such as nail care,
board games, hair and makeup, crossword puzzles and
-At this time there is no schedule activities with the activities staff.
During an interview on 5/15/18 at 2:37 P.M., the DON said:
-All resident should be on hourly face to face check for safety reasons;
-He/she was not aware of any structure or schedule activities provided for the resident on
the units;
-He/she has not seen any activities calendar posted in the facility and
-The SSW director would be responsible for arranging mental health or behavioral health
counseling services and groups.
6. Record review of Resident’s #54’s Face Sheet showed he/she was admitted to the facility
on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s POS showed on 4/11/18 the resident was to participate in
planned activities as tolerated.
Record review of the resident’s Care Plans showed on 4/25/18 the resident did not have
care plans related to activities as his/her doctor had ordered.
Observation and interview on 5/9/18 at 10:15 A.M., showed resident was seated in his/her
room in a wheelchair and said he had some pain in his/her lower back and the resident said
he/she would like to participate in some activities.
Observation on 5/10/18 at 9:30 A.M., showed resident was seated in his/her wheelchair in
the commons area at a table with no activities.
Observation on 5/11/18 at 2:00 P.M., showed the resident was seated in his/her wheelchair
after lunch at a large black table without a planned activity.
Observation on 5/14/18 at 11:00 A.M., showed the resident was in his room without
activities to participate in.
During an interview on 5/14/18 at 3:20 P.M., the resident indicated he/she would like to
participate in activities. He/She said the activities are boring and not interesting.
7. Record review of Resident’s #68’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Dysphagia- Difficulty starting a swallow and the sensation of food being stuck in the
neck or chest;
-Abnormalities of Gait and Mobility- A person’s manner of walking;
-Hypertension – High Blood Pressure and
-Bi Polar Disorder- A disorder associated with episodes of mood swings ranging from
depressive lows to manic highs.
Record review of the resident’s Admission MDS dated [DATE], showed he/she:
-Had a BIMS score of 8;
– Had Impaired thought processes;
-Had a problem of recalling events;
– He/she was able to find his room and knows staff and residents;
-He/she was able to express his needs and wants to staff;
-Had difficulty making self-understood at times and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
-His/her speech is clear but has difficulty finishing a sentence or finding the right
words.
Record review of the Resident’s Care Plan dated 6/22/17, showed the resident:
-Had required staff assistance with all Activities of Daily Living (ADL’s) bed mobility,
transfers, dressings, bathing and toileting);
-Displayed verbally aggressive behavior;
-Activities staff to visit and provide diversional activities and
-Social Services to evaluate and visit.
Record review of the resident’s POS dated 4/30/18, showed the resident:
-May participate in planned activities as tolerated up AD LIB with assistance;
-Ask about preferences throughout the day;
-Validate thoughts/feelings when confused or anxious and
-Give verbal cues/reminders when cannot remember
Observation on 5/9/18 at 2:00 P.M., showed the resident was not offered a structured
activity.
Observation on 5/10/18 at 10:30 A.M., showed the resident was not offered a structured
activity.
Observation on 5/11/18 at 1:30 P.M., showed the resident was not offered a structured
activity.
Observation on 5/14/18 at 9:30 A.M., showed the resident was not offered a structured
activity.
During an interview on 5/14/18 at 10:30 A.M., the resident said he/she would like to
participate in bingo and music activities. Had participated in activities in the past such
as going on the bus to Wal-Mart, the park and the YMCA Gym.
8. Record review of Resident’s 90’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Arthritis – Inflammation of a more joints, causing pain and stiffness than can worsen
with age;
-Paranoid [MEDICAL CONDITION] – Include auditory hallucinations and hearing voices;
-Type II Diabetes- A group of diseases that result in too much sugar in the blood.;
-Major [MEDICAL CONDITION] – A mental health disorder characterized by persistently
depressed mood or loss of interests in activities, causing significant impaired in daily
life and
– Hypertension – High Blood Pressure
Record review of the resident’s admission MDS dated [DATE], showed he/she:
-Had a BIMS score of 14;
-Required limited assistance of one staff member with all Activities of Daily Living
(ADL’s such bed mobility, transfers, dressing, bathing and toileting, range of motion
active and passive exercises;
-Was able to communicate his/her needs and wants to others and
-Was to provide the resident with assistive devices as needed.
Record review of the resident’s Care Plan dated 10/24/17 showed no care plan for
structured activities as indicated by his/her doctor’s orders.
Record review of the resident’s POS dated 04/15/18, showed the resident was to participate
in planned activities as tolerated with assistance of two staff members.
Observation on 5/9/18 at 10:30 A.M., showed the resident was lying in bed talking but was
not participating in activities.
Observation on 5/11/18 at 2:30 P.M., showed the resident was awake in bed but no one asked
or offered him/her an activity to participate in.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
During an interview on 5/14/18 at 1:30 P.M., the resident said he/she would like to
participate in activities at the facility and he/she liked arts and craft activities.
During an interview on 5/14/18 at 1:30 P.M., the Assistant Director of Nursing (ADON)
he/she said:
-The residents watched a lot of television at the facility;
-Had been working at the facility two weeks and no structured activities was offered to
the residents;
– He/she has a huge note book of facility incident reports to review and respond to
regarding the resident’s behaviors. If the residents were offered activities to
participate in, this would reduce the number of written resident’s incident reports to
review;
-No hands on learning activities are offered to the residents and
-The facility is in the process of hiring a new Activity Director.
Observation on 5/15/18 at 1:45 P.M., showed the resident was not offered a structured
activity.
During an interview on 5/15/18 at 11:00 A.M., the DON said;
– The facility had recently hired a new Activities Director on 5/14/18 to implement an
activity program for the residents;
– Had limited activities for the residents such as nail polishing for the female
residents;
– Had not seen any monthly structured activities or activity calendar posted in the
facility;
– Church groups comes on the weekends during mid mornings and after the lunch hour on
Saturdays and Sundays;
– Was not aware that resident’s activities should be recorded or charted for documentation
purposes;
– Was not aware that if residents refused to participate in activities that information
should be recorded or charted for documentation purposes and
– Was not sure if the MDS Coordinator had been completing the Resident’s Customary
Preferences Sheets related to resident’s activity interests.
During an interview on 5/15/18 at 2:30 P.M. the Social Services he/she said:
– During the (MONTH) (YEAR) Resident’s Council Meeting the residents requested an activity
program and
– The residents wanted fresh air and activities such as Crafts, Music and Exercise classes
so they would feel less confined.

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to obtain a
physician’s orders for the monitoring and care of the resident’s [MEDICAL CONDITION]; to
follow physician’s orders for wound care and treatment to the resident’s abdominal wound,
to transcribe the resident’s abdominal wound treatment physician’s orders to the
resident’s Treatment Administration Record (TAR) and to document the assessment and the
description of the resident’s abdominal wound at least weekly for one sampled resident
(Resident #34) out of 30 sampled residents. The facility census was 106 residents.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
1. Record review of Resident #34’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE]. He/she had a [DIAGNOSES REDACTED]. from birth) and is
his/her own responsible party
Record review of the resident’s Minimum Data Set (MDS-a federally mandated assessment tool
to be completed by facility staff for care planning) dated 2/23/18 showed:
-The resident was not cognitively impaired and has a BIMS (Brief Interview for Mental
Status) score of 14;
-That the resident had frequent pain and took opioid (controlled substance medication)
pain medication for his/her pain;
-Bowel not rated has a ostomy (or stoma, is a surgically created opening between the
intestines and the abdominal wall);
-No indication of the resident having a wound and
-The resident does not require assistance from staff for care, and transfer.
Record review of the resident’s Assessment for bowel and bladder was done on 8/1/17 showed
the resident had a [MEDICAL CONDITION] and he/she was contient of their bladder.
Record review of the resident’s Medical Record showed no documentation found related
current assessment and care of the resident’s [MEDICAL CONDITION].
Record review of the resident’s Physician Order Sheet (POS) dated 4/15/18 to 5/14/18
showed the resident:
-had a history of [REDACTED].
-No physician’s order was found for the care for the resident’s [MEDICAL CONDITION] or for
the resident to provide his/her own care for his/her [MEDICAL CONDITION] and
-Had a physician’s order dated 5/5/18 for nursing staff to clean the resident’s abdominal
wound with Normal Saline then pat dry and apply Triple Antibiotic Ointment and cover with
a 4×4 gauze dressing (cotton dressing) or boarder foam dressing (super absorbent dressing)
and change the dressing every day until resolved.
Record review of the resident’s Treatment Administration Record (TAR) and Medication
Administration Record [REDACTED]
-Did not have a physician’s order for his/her [MEDICAL CONDITION] care, or for the
resident to provide his/her own care for his/her [MEDICAL CONDITION] and
-Had a physician’s order dated 5/5/18 showed to clean the resident’s abdominal wound with
Normal Saline, then pat dry, apply Triple Antibiotic Ointment, cover with a 4×4 gauze
dressing or boarder foam dressing and to change the dressing every day until resolved.
During an interview and observation on 05/9/18 at 9:50 A.M. the resident said:
-He/she has been providing his/her own [MEDICAL CONDITION] care since been in the
facility;
-The resident has a [MEDICAL CONDITION] and next to it has a dressing: the resident said
while he/she showering he/she scrubbed too hard and the area opened up around abdomen;
-The resident said the [MEDICAL CONDITION] stoma has been herniated, and the staff were
aware;
-The bandage on his/her stomach not been cared for at least three days and
-The stoma was red, [MEDICAL CONDITION] bag had loose greenish brown stool inside, no odor
was noted.
Record review of the resident’s Nurses Notes dated from 5/5/18 to 5/10/18 showed only two
nursing entries related to the resident’s abdominal wound:
-On 5/5/18 obtain new orders from the resident’s physician’s for wound care on the
resident’s abdomen abdomen. The resident said he/she scratched the area causing the area
to open up, orders were obtained; see the resident’s POS;
-On 5/9/18 showed the resident abdominal wound dressing was intact and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 21)
-No other wound documentation found to include the measurement of the wound and the
description of the resident’s wound.
Record review of the resident’s TAR on 5/09/18 at 10:00 A.M. ,showed the nurses staff had
their initial in the box with a circle around it one these dates 5/6/18, 5/7/18, and
5/10/18 indicating the wound treatment was not done, there was no documentation on the
back of the resident’s TAR or in the resident’s nurses notes to state why the treatment
was not completed.
During interview on 5/11/18 at 8:55 A.M., the Assistant Director of Nursing (ADON) and the
Regional Care Coordinator (RCC) said that nurse is no longer working at this facility,
there should have been documentation in the Nurses notes and on the TAR the why the
treatment to the resident’s abdomen was not done.
Observation on 05/11/18 at 8:55 A.M.,showed the resident had requested the LPN to look at
his/her wound on his/her abdomen. The Wound nurse/ADON) was not aware the resident had a
wound. The facility’s RCC was observed talking with the resident. The resident said he/she
was scrubbing the area during his/her shower and it had reopen the area up. The RCC said
to the ADON and to the LPN the were to obtain a physician’s order to treat the resident’s
wound and for the facility wound nurse to assess the resident’s wound and to provide any
wound care needed,
-The facility LPN nurse reviewed the resident’s TAR and found that the resident had a
physician’s order for treatment of [REDACTED].
During an interview and observation of resident wound care on 5/11/18 at 8:55 A.M., the
ADON said as the wound nurse:
-He/she was not aware the resident had a wound on his/her abdomen;
– The ADON/wound Nurse verified the resident’s wound orders and proceeded with the wound
care;
-The RCC requested to the ADON to measure the wound and the wound measurements were 2.5
centimeters (cm) wide by 3 cm long;
-The wound had slight amount of drainage, the wound outer edges were pink in color with
one area that was white inside, located by the old scar;
– The resident’s [MEDICAL CONDITION] stoma was very red and was protruding out more today;

-The ADON cleaned the wound with normal saline, then pat dried the area, then applied
Triple Antibiotic Ointment and covered the wound with a boarder foam dressing and
-The RCC had contacted the contracted wound specialist company for further orders.
Record review of the resident’s POS and TAR dated 5/11/18, showed; new Telephone
Physician’s Order dated 5/11/18, to change the wound treatment to the resident’s abdomen
for the staff to cleanse the resident’s left abdominal wound with normal saline, then
apply calcium Alginate with silver, cover the wound with a border foam dressing, and to
change the dressing daily and as needed if soiled.
During an interview and record review on 05/14/18 at 9:49 A.M., LPN E, said;
-There should have been a physician’s order for the resident’s [MEDICAL CONDITION] for
care and assessment;
-The resident’s does prefer to provide their own care and he/she thought the resident had
a verbal agreement with the physician for own care;
-He/she thought there should have had a physician’s order for wound care on resident’s TAR
or on the skin assessment book;
-Review of the resident’s TAR/MAR showed no physician’s orders were found for the
resident’s [MEDICAL CONDITION] care or assessment;
-Review of resident’s medical record was unable to find documentation for the nursing

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
assessment of the resident’s [MEDICAL CONDITION] or physician’s orders and
-LPN E said he/she will contact the resident’s physician’s to obtain a physician’s order
for the care and assessment of the resident’s [MEDICAL CONDITION].
During an interview on 05/15/18 at 2:37 P.M., DON said;
-He/she expected the licensed nurses to verify and write a physician order for
[REDACTED].>-Would except the nurse to document the reason why wound treatment was not
completed on the back of the resident TAR and in the resident’s nurses notes;
-The wound nurse is responsible for all wound care, during time of 5/5/18 the nursing
staff would have been responsible for ensure wound care was provided and to document the
wound assessment and description of the resident’s wound in the resident’s nursing notes
and
-Would except the nurse to ensure to obtain physician’s order for the resident’s [MEDICAL
CONDITION] care and treatment and to document the assessments and description in the
resident nurses notes.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 ensure the
locked and alarmed doors were secured and in proper working order at all times to prevent
one sampled resident (Resident #53) out of 30 sampled residents, who was at risk for
elopement, from leaving the facility and to update the resident’s care plan to show he/she
was at risk for elopement and initiate interventions to prevent further elopements. The
facility census was 106 residents.
Record review of the facility’s Elopement policy and procedure dated 4/6/17, showed an
elopement will be defined as any time a resident is missing from the facility or there is
a possibility that a resident has left the facility without appropriate supervision and
their whereabouts are unknown. It showed:
-The first person aware of the elopement will call a code white to the area of the
believed elopement, if known;
-If the resident is believed to be still inside of the facility, the first person to be
aware of the missing resident is to page for all units to search room to room for the
resident;
-As soon as the pages have been made, the Administrator is to be called immediately;
-If the resident has in fact left the facility, notify the resident’s family or guardian;
-The charge nurse on duty will initiate the facility grounds search;
-The charge nurse will call the police to report the elopement when the resident is not
found in the building or on grounds;
-The Administrator will initiate the emergency call list and coordinate the search and
-After the resident is located and returned to the facility, facility staff will notify
the family or guardian, notify all persons involved in the search, perform a full body
assessment, obtain vital signs (pulse, temperature, blood pressure and respirations),
notify the physician, initiate the monitoring protocol document all findings and notify
the state agency at the discretion of the Administrator.
1. Record review of Resident #53’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED]. enough to interfere with one’s daily activities) and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 – Few

(continued… from page 23)
diabetes.
Record review of the resident’s annual Minimum Data Set (MDS- a federally mandated
assessment instrument completed by facility staff for care planning) dated 7/5/17, showed
he/she:
-Had a memory problem and was severely cognitively impaired;
-Was independent with ambulation, mobility, bathing, dressing and toileting and
-Had no history of elopement.
Record review of the resident’s Care Plan dated 7/6/17, showed the resident:
-had a history of [REDACTED].
-The resident’s care pan did not show that the resident resided on a locked unit and was a
high risk for elopement per facility assessment.
Record review of the resident’s Elopement and Wandering assessment dated [DATE], showed
he/she:
-Had no current wandering behavior;
-Was physically able to leave;
-Was disoriented to place and
-Was at high risk for elopement bases on nursing judgement.
Record review of the resident’s Nursing Notes from 1/1/18 to 4/25/18, showed the nursing
staff did not document the resident had any attempts to leave the facility or had any exit
seeking behaviors.
Record review of the resident’s Psychiatric Notes dated 4/16/18, showed:
-The resident was seen for a follow up visit, medication review and management;
-The Psychiatry Nurse Practitioner reviewed the resident’s medical record, labs,
medications and assessed the resident’s current status;
-The Nurse Practitioner noted the resident had a restricted affect with disorganized
thought processes, poor judgement and memory, low functionality and was delusional at
times and
-The report showed the resident ha a severely complex mental health condition, but his/her
medications were helping the resident.
Record review of the Facility Intensive Monitoring Checks dated 5/6/18, showed:
-From 7:30 A.M. to 6:30 A.M., staff was to place a check in the box every hour, showing
that the resident was seen face to face.;
-If the resident was not on the unit, staff was to place a number in the box to show where
the resident was and
-For the resident, the monitoring showed the resident was visualized every hour until 8:30
P.M. and 9:30 P.M. (there was a number in the two boxes showing other which was not
defined).
Record review of the resident’s Nursing Notes dated 5/6/18, showed:
-The resident eloped off of the unit at around 8:30 P.M., and returned to the unit by
10:30 P.M;
-The nurse documented the Administrator, Director of Nursing (DON) and the resident’s
guardian were notified of the resident’s elopement;
-The nurse completed a skin assessment and no issues were noted and
-Nursing staff took the resident’s vital signs (blood pressure, temperature, pulse and
oxygen level) and they were within normal range.
Record review of the resident’s Investigation dated 5/6/18, showed:
-On 5/6/18 at 8:35 P.M., the resident exited the facility through the side door. The alarm
sounded and staff were alerted;
-Staff completed a head count and concluded the resident was no longer on the unit;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 – Few

(continued… from page 24)
-An internal and external facility search was completed and the resident was not located
on facility property;
-Facility staff located the resident and returned him/her to the facility at 10:23 P.M;
-Facility staff notified the resident’s guardian on 5/6/18 at the time of the resident’s
elopement and when the resident was returned to the facility;
-Upon return to the facility the resident was placed on one to one monitoring for
protective oversight;
-Staff asked the resident how he/she got out of the facility and the resident said he/she
went out of the side door by the dining room on the men’s unit (a locked unit) and
-The facility provided staff education of the abuse/neglect procedure and immediately
changed the entry and exit codes on the facility doors.
Observation on 5/9/18 at 10:51 A.M., showed:
-The resident resided on a locked unit on the second floor;
-The unit was accessible by stairs, an elevator and a door in the dining area that lead to
an outside patio;
-There was also a set of doors that lead to the kitchen. All of the doors required a
keypad entry to open them;
-There was also a key pad at the elevator and at the stairs that required entry of a code
in order to release the doors to open;
-At this time, the resident was laying down in his/her bed asleep with the covers pulled
up. He/she was fully dressed;
-At 12:15 P.M., the resident was in the lunch room eating lunch and
-When the resident finished eating, he/she stood up and ambulated from the dining area
without using an assistive device.
During an interview on 5/9/18 at 12:30 P.M., Certified Nursing Assistant (CNA) A said:
-He/she was not working on the day the resident eloped from the facility, but he/she
happened to be at the gas station when the resident came down the aisle, tapped him/her on
the shoulder and asked if he/she had a cigarette;
-He/she did not see any staff with the resident and asked the resident how he/she got to
the gas station;
-The resident told him/her that he/she went out of the side door by the dining room and
ran once he/she got outside, then walked to the gas station;
-He/she told the resident he/she was going to take the resident back to the facility and
at first the resident would not get in his/her car, but then he/she did and he/she brought
the resident back to the facility;
-When CNA A arrived back at the facility with the resident, he/she saw the staff standing
outside looking for the resident;
-Normally, the doors were all locked and alarmed. If someone tried to open the door
without entering the code, the alarm will sound but the door will not open and
-He/she thought that the resident may have somehow gotten the code to the door in order to
get out.
During an interview on 5/9/18 at 3:10 P.M., the Assistant Director of Nursing (ADON) said:
-He/she was not at work on 5/6/18, when the incident occurred, but he/she received the
report the following morning that the resident had eloped from the exit door by the dining
room on the men’s unit;
-He/she thought that all of the doors were alarmed and locked at the time of the
resident’s elopement so he/she did not know how the resident managed to get out, unless
the door alarm was turned off, or the resident obtained the code to get out of the door;
-The door would have not alarmed if the resident had entered the code to deactivate the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 – Few

(continued… from page 25)
door and open it and
-They changed the codes on all of the doors in the facility after the resident was brought
back to the facility.
Observation and interview on 5/10/18 at 9:10 A.M., the resident was up ambulating in the
hallway and went into the indoor smoking area. He/she said:
-On the day that he/she left the facility (he/she could not remember the date), he/she was
going to visit his/her grandparents;
-He/she initially left out of the exit door in the dining room because the door was
cracked and he/she pushed it open.;
-He/she then said he/she entered the door code on the key pad, opened the door and left
but when asked how he/she obtained the code, he/she said that he/she did not see anyone
put the code in the key pad and no one gave him/her the door code;
-The resident said that he/she walked to his/her grandparents house, then he/she walked
back to the facility;
-It was noted that the resident had some delusional statements as we were talking and
could not provide any detail as to what occurred while he/she was away from the facility
and
-He/she denied that staff brought him/her back to the facility, and did not remember that
he/she had gone into the grocery mart where he/she saw one of the nursing home staff.
During an interview on 5/16/18 at 9:50 A.M., the Administrator said:
-All of the doors and the elevator can only be accessed with a code in order to release
the doors and open the elevator door because they have several residents who are at a high
risk for elopement;
-There is a panel on each unit that shows all of the doors on the unit and whether they
are alarmed and any given time (the lights will be red showing the doors are locked and
green if they are not);
-If there are two doors that are unlocked at the same time, it will deactivate all of the
doors and the alarm will still sound when the door is open, but the doors will open;
-Nursing staff was supposed to monitor the residents to ensure they know where all
residents are, especially if any of the doors have been deactivated (to take out trash
from the kitchen or accept deliveries etc.);
-Nursing staff notified him/her that the resident was not in the facility as soon as the
elopement was confirmed by staff;
-Nursing staff conducted and internal and external search for the resident on the property
and within a smaller radius of the facility and were unable to locate him/her, then all of
the department heads were called in to begin an off grounds search for the resident;
-Staff found the resident and brought the resident back to the facility and they put the
resident on one to one monitoring and changed the codes on all of the doors;
-The resident did not try to leave the facility and has not made any further attempts to
leave since then;
-Upon further investigation of how the resident got out of the building, the Administrator
found that facility staff had disarmed two of the doors in order to take out trash so the
door by the dining room was alarmed, but it was not locked. The resident took the
opportunity and went out of the door and the alarm sounded;
-The panel showed that two doors were green and had not been reactivated;
-The charge nurse should have been notified when the doors had been deactivated so they
could have alerted everyone and ensured all of the residents were away from the doors
until they were reactivated and
-Once the task was completed, they should have immediately reactivated the doors so they
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 – Few

(continued… from page 26)
would have been locked.
MO 260

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 ensure that the
urinary catheter bag for one sampled resident (Resident #90) out of 30 sampled residents
was kept at a level below his/her bladder; and did not prevent the catheter tubing from
touching the floor. The facility census was 106 residents.
Record review of the facility’s urinary catheter policy dated 4/6/17, showed:
-The facility will ensure any resident with a urinary catheter (a tube inserted into the
bladder to drain the urine) will be maintained to prevent infection.
-Catheter care procedures as follows:
–Keep the urinary drainage bag below the level of the bladder to prevent back flow of the
urine and
–Make sure that the urinary bag does not touch the floor.
1. Record review of the Resident’s #90’s Face Sheet showed he/she was admitted to the
facility on [DATE], with the following Diagnoses: [REDACTED].
-Kidney Failure – A condition in which the kidneys lose the ability to remove waste and
balance fluids;
-Arthritics- Inflammation of joints, causing pain and stiffness than can worsen with age;
-[MEDICAL CONDITION] – A high concentration sodium in the blood and
-Paranoid [MEDICAL CONDITION] – Include auditory hallucinations hearing voices.
Record review of the resident’s Annual Minimum Data Set ( MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 6/29/18, showed
he/she:
-Had a Brief Interview for Mental Status (BIMS) score of 14, which describes the resident
was cognitively alert and oriented;
-Had ability to express idea and wants to others in a consistent and reasonable manner and
-Total dependence with two person assist with Activities for Daily Living (ADL’s)
assistance for eating, bathing, dressing, transferring and mobility.
Record review of resident’s Treatment Administration Record (TAR) dated 1/19/18, showed
treatment orders for Foley Catheter for Wound Healing at 7:00 A.M. and 7:00 P.M.
Record review of the resident’s physician’s orders [REDACTED].
-To change the resident’s catheter every month with a #22 French catheter with 30
mililiters (ml) balloon and to change the urinary drainage bag every month;
-Weekly skin assessments to be completed on Wednesdays (7:00 A.M. and 7:00 P.M.) and
-Had Foley Catheter for Wound Healing.
Record review of the resident’s Care Plan dated 6/29/18, showed he/she:
-Had impaired urinary incontinence and occasionally incontinent of bowel;
-Was at risk for urinary infection;
-Had an indwelling catheter;
-Had on-going assessment of color;
-Had on going assessment for symptoms of urinary tract infection [MEDICAL CONDITION];

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 – Few

(continued… from page 27)
-Was to observe for acute behavioral changes that may indicate UTI;
-Secure tubing to the resident’s thigh to prevent pulling of the catheter and
-Monitor the resident’s catheter tubing for kinks or twists in tubing.
Observation of the resident being transferred on 5/9/18 at 3:00 P.M., showed:
-The resident was transferred by two Certified Nursing Assistant’s (CNA’s) from his/her
wheelchair to his/her bed and
-During the mechanical lift transfer the resident’s urinary catheter bag was caught
between the resident’s lower legs.
Observation on 5/10/18 at 10:35 A.M., showed the resident’s urinary catheter bag was
touching the floor.
During an interview on 5/14/18 at 1:35 P.M., the Assistant Director of Nursing (ADON) said
he/she:
-Catheter bag should not touched the floor bag should be ½ to one inch from the ground,
proper placement of catheter bag for caring for resident;
-Catheter bag should be placed below the resident’s bladder;
-Catheter bag should be enclosed in a privacy bag;
-Positioning of the Catheter bag was important to prevent UTI’s and
-Poor positioning of Catheter bag caused bladder irritations and leakage for the resident.
During an interview on 5/15/18 at 10:00 A.M., the Certified Nursing Assistant CNA (D) said
he/she:
-Had to clean and ensure the catheter bag was in a privacy bag;
-Make sure catheter bag was placed in proper positioning for resident;
-His/her first week of employment he/she had training on catheter bag proper usage and
Corporate Nurse approved all completed training on nursing competency areas;
-Educated residents regarding the risks and benefits of catheter bag usage;
-Catheter tubing should not be on the floor and
-Catheter bag should be position below the resident’s bladder area.
During an interview on 5/15/18 at 11:00 A.M., the Licensed Practical Nurse (LPN) A said:
-The staff are oriented and the Corporate Nurse provided in-services on catheter care
during their orientation period;
-Catheter care is on-going training for staff;
-Catheter bag must be placed in privacy bag;
-Staff are to wear gloves during catheter care;
-Staff are to wipe down and wipe the resident in the wrong direction during the peri wash
care;
-Catheter bag should not be over the resident’s leg and
-The resident’s catheter bag not to be placed on the resident’s floor area.
During interview on 5/15/18 at 12:00 P.M.,the Director of Nursing (DON) said he/she:
-Expected staff to keep catheter bag below the resident’s bladder level and
-Expected staff to keep resident’s catheter tubing off the floor at all times.

F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure adequate
monitoring of the nutritional status by not following physician’s orders [REDACTED].
status and weight loss for one sampled resident (Resident #53) who had a history of

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 28)
[REDACTED]. The facility census was 106 residents.
1. Record review of Resident #53’s Face Sheet showed he/she was admitted to the facility
on
7/25/15, with [DIAGNOSES REDACTED]. enough to interfere with one’s daily activities) and
diabetes.
Record review of the resident’s Care Plan dated 7/25/17, did not show any nutritional
problems, goals or interventions addressing the resident’s diet, intake, weight loss,
nutritional interventions or nutritional needs of the resident. It did not show whether
the resident needed assistance or encouragement to eat or show the resident’s food
preferences.
Record review of the resident’s Weight Record showed the following monthly weights:
-Dec. (YEAR)-174 pounds (lbs.);
– Jan. (YEAR)-168 lbs.;
-Feb. (YEAR)-161 lbs.;
-Mar. (YEAR)-160 lbs.;
-April (YEAR)-162 lbs. and
May (YEAR)-155 lbs. (showed a weight loss of 10.92 % in 6 months, 3.13% in 3 months, 4.32%
in 30 days).
Record review of the resident’s annual Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff used for care planning) dated 3/22/18,
showed he/she:
-Had a memory problem and was severely cognitively impaired;
-Was independent with ambulation, mobility and eating;
-Did not have significant weight loss during the look back period and
-Had no chewing or swallowing problems.
Record review of the resident’s Physician’s Telephone Orders dated 3/30/18, showed a
physician’s orders [REDACTED]. Labs were also ordered.
Record review of the resident’s Dietician Notes dated 4/30/18, showed the resident
remained on his/her regular diet and was now receiving health shakes three times daily. It
showed the resident’s current weight was 162 lbs. and had increased his/her weight by 2
lbs. over one month. The Dietician documented the resident was within his/her normal
weight range and no recommendations were made at this time (record review of the
resident’s electronic chart did not show any additional notes made by the Dietician after
4/30/18).
Record review of the resident’s Medication Administration Record [REDACTED]. The MARs
showed nursing staff administered the med pass as ordered throughout the month.
Record review of the resident’s physician’s orders [REDACTED]. It also showed a
physician’s orders [REDACTED].
Record review of the resident’s Nutritional assessment dated [DATE], showed:
-The resident’s diet order was for a regular consistency diet with thin liquids;
-His/her admission weight was 182 lbs and ideal body weight was 184 lbs;
-The resident was able to feed himself/herself and had his/her own teeth;
-He/she had good intake between 60-100% and
-The report did not show the resident’s supplements ordered or any recommendations.
Record review of the resident’s Medical Record did not show documentation that staff were
recording the resident’s intake at each meal.
Observation on 5/9/18 at 12:15 P.M., showed the resident was up in the dining room
independently eating a regular diet of ham, mashed potatoes, carrots and drinking a choice
of beverages (lemonade or fruit punch). The resident needed no assistive utensils to eat
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
with and no staff assistance or encouragement was needed to eat. He/she was eating without
any swallowing difficulty, choking or aspiration. The Resident ate 100% of his/her meal.
He/she did not receive a health shake. When he/she finished eating, he/she stood up and
ambulated from the table without assistance or assistive device.
Observation on 5/10/18 at 11:58 A.M., showed the resident was sitting in the dining room
waiting for lunch to be served. He/she was given a beverage (fruit punch) and a bowl of
fruit crisp dessert. The resident independently ate all of his/her dessert and drank
his/her fruit punch. At 12:15 P.M., the resident was served a regular diet of meatballs
with cooked broccoli. He/she did not receive a health shake. Staff gave the resident more
fruit punch and he/she began eating his/her meal without any difficulty. The resident ate
100% of his/her meal and when he/she was finished, he/she got up from the dining table and
left the dining area.
During an interview on 5/10/18 at 12:29 P.M., Certified Medication Technician (CMT), A
said:
-For those residents who receive health shakes, the health shakes came out on the beverage
carts and were served to the residents by the Certified Nursing Assistants as their
beverages were served.
-Health shakes were kept in the kitchen;
-If the resident was supposed to receive a health shake and did not receive it, the
nursing staff can go get it or request that dietary staff bring it to the dining room;
-Either the CMT’s or the Charge Nurses were supposed to document that the resident
received their health shake in the resident’s medical record (on the resident’s Medication
Administration Record);
-He/she was unaware that the resident did not receive his/her health shake today and
-After looking on the beverage cart, he/she went to the kitchen and obtained a health
shake, then went to give it to the resident.
During an interview on 5/15/18 at 3:11 P.M., the Director of Nursing (DON) said:
-He/she expected diet orders to be followed;
-Once the resident’s diet order is changed, the nurses on the unit are to communicate the
diet order change to the nursing staff;
-He/she would expect to see documentation showing why a diet order change was necessary;
-The nurse was also responsible for documenting the new diet order on the dietary
communication form and giving that to the dietary manager;
-If a resident did not wish to comply with the diet orders, the nurse should document this
and notify the resident’s physician and responsible party, and speak with the resident
about his/her non-compliance and
-If the resident chooses to be non-compliant with the recommended diet order, they should
have the resident or responsible party sign a waiver that is also documented in the
resident’s medical record, and notify his/her physician.

F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Ensure that nurses and nurse aides have the appropriate competencies to care for every
resident in a way that maximizes each resident’s well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure that nursing staff had
the appropriate competencies and skills sets to provide nursing and related services to
ensure: resident safety, residents attained or maintained the highest practicable

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 30)
physical, mental, and psychosocial well-being of each resident as determined by resident
assessments; and considering the number, acuity, and [DIAGNOSES REDACTED]. The facility
census was 106 residents.
1. Record review of the facility’s Facility Assessment Tool dated 5/9/18 showed:
-The facility was licensed for 116 beds;
-The average number of occupied beds during the previous quarter was 104;
-The facility had resident rooms on two floors;
-The facility had two special care behavioral health units;
-The facility had one resident requiring suctioning and tracheotomy (surgical opening into
the wind pipe into which a tube is inserted to allow passage of air and removal of
secretions) care, three residents with ostomy (artificial or surgical opening) care, and
no residents with intravenous medications.
-Facility resources needed to provide competent support and care for the resident
population every day and during emergencies included:
–Identify the type of staff members that are needed to provide support and care for
residents;
—Nursing services: one Director of Nursing (DON), one Assistant Director of Nursing
(ADON), one Registered Nurse (RN), seven Licensed Practical Nurses (LPN), seven Certified
Medication Technicians (CMT), and 14 Certified Nursing Assistants (CNA). The total of
direct care staff should be 29 per day.
-The facility’s Average Daily Facility Staffing Plan showed:
–One DON, one ADON, one RN, 13 LPNs, 10 CNAs, two Quality Lead Aids (QLAs – A mentor CNA)
and one Restorative Aide (RA). The total of direct care staff should be 27 per day.
-Staff training, education, and competencies will include competency check-offs from
orientation;
-The training time required for newly hired CNAs was 8.25 hours;
-The training time required for newly hired RN and LPNs were 11.5 hours and
-CNAs were required to complete 12 hours of training annually.
Record review of the facility’s Daily Staffing Sheet dated 5/9/18 – 5/15/18 showed:
-On 5/9/18 the facility had one RN, five LPNs, four CMTs, 14 CNAs, one RA (Rehabilitation
Assistant), and one QLA. One of the four CMTs was in orientation. The total direct care
staff scheduled, not including the staff in orientation, was 25;
-On 5/11/18 the facility had one RN, five LPNs, five CMTs, 13 CNAs, one RA, and two QLAs.
One of the five CMTs was in orientation, and one of the five LPNs was in orientation. The
total direct care staff scheduled, not including staff in orientation, was 25;
-On 5/12/18 the facility had one RN, five LPNs, five CMTs, 16 CNAs, two QLAs, and no RA.
Three of the 16 CNAs were in orientation. The total direct care staff scheduled, not
including staff in orientation, was 26;
-On 5/13/18 the facility had one RN, five LPNs, five CMTs, 15 CNAs, two QLAs, and no RA.
Two of the 15 CNAs were in orientation and one LPN was in orientation. The total direct
care staff scheduled, not including staff in orientation, was 25;
-On 5/14/18 the facility had one RN, five LPNs, five CMTs, 17 CNAs, one RA, and one QLA.
Five of the 17 CNAs were in orientation, one of the five CMTs was in orientation, and one
of the five LPNs was in orientation. The total direct care staff scheduled, not including
staff in orientation, was 23 and
-On 5/15/18 the facility had one RN, five LPNs, five CMTs, 18 CNAs, one RA, and one QLA.
One of the 18 CNAs was in orientation, and one of the five LPNs was in orientation. The
total direct care staff scheduled, not including staff in orientation, was 29.
Record review of the the facility’s Competency and In-service book showed no competencies
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 31)
were found for any of the staff during the previous 12 months.
During an interview on 5/15/18 at 8:14 A.M., the DON said:
-He/She could not locate staff competencies in the Competency and In-service book;
-He/She would look elsewhere for the staff competencies during the last 12 months and
-He/She would check if licensed nursing staff were given competency check offs for
percutaneous endoscopic gastrostomy tube (PEG tube – a tube that is placed into a
patient’s stomach as a means of feeding them when they are unable to eat) care, [MEDICAL
CONDITION] care, Peripherally Inserted Central Catheter (PICC – an intravenous (IV)
catheter placed inserted into a large vein) line care, and wound care.
During an interview on 5/15/18 at 9:36 A.M., the DON said:
-He/She could not locate any competencies for the staff over the past 12 months;
-He/She could not locate competencies for licensed nursing staff related to PEG tube care,
[MEDICAL CONDITION] care, PICC line care, ostomy care, or wound care;
-He/She would check if CMTs were given competency check offs for blood glucose monitoring
and
-He/She provided the surveyor with a packet of blank staff orientation check lists.
During an interview on 5/15/18 at 12:30 P.M., the Administrator said he/she could not
locate any staff competencies during the last 12 months.

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Observe each nurse aide’s job performance and give regular training.

Based on interview and record review, the facility failed to have a system in place to
ensure Certified Nurse Assistant (CNA’s) received the required 12 hours in-service
education and based on performance reviews annually. The facility census was 106
residents.
1. Record review of the facility’s Facility Assessment Tool dated 5/9/18 showed:
-The facility was licensed for 116 beds;
-The average number of occupied beds during the previous quarter was 104;
-Staff training, education, and competencies will include competency check-offs from
orientation;
-The training time required for newly hired CNAs was 8.25 hours and
-CNAs were required to complete 12 hours of training annually.
Record review of the the facility’s Competency and In-service book showed:
-No competencies were found for the any of the CNAs during the previous 12 months;
-Less than 12 hours of CNA in-service hours were performed during the last 12 months;
-4.25 hours of CNA in-service hours between 7/16/17 – 3/12/18 and
-Six monthly in-service topics list with no documented in-service training hours.
During an interview on 5/15/18 at 8:14 A.M., the Direct of Nursing (DON) said:
-He/She could not locate staff competencies in the Competency and In-service book;
-He/She would look elsewhere for the staff competencies during the last 12 months and
-The Competency and In-service book should include all CNA in-service hours.
During an interview on 5/15/18 at 12:30 P.M., the Administrator said:
-He/She could not locate any staff competencies during the last 12 months and
-The Competency and In-service book should include all the CNA in-service hours.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

F 0742

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide the appropriate treatment and services to a resident who displays or is
diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history
of trauma and/or post-traumatic stress disorder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
necessary mental and behavioral health treatment and services, consistent with
professional standards of practice, to promote mental health wellness by not providing
social services assessment and providing mental health counseling and therapy services for
one sampled resident ( Resident #92), who had a history of [REDACTED]. The facility census
was 106 residents.
Record review of the resident’s Admission Face Sheet dated 5/18/16, readmitted last on
4/12/18 showed the resident had a public administrator as his/her guardian, and the
following Diagnoses: [REDACTED].
-Anxiety disorder (fear or worry),
-[MEDICAL CONDITION] disorder (mental disorder have hallucinations or delusions),
-[MEDICAL CONDITION] disorder (manic behavior),
-[MEDICAL CONDITION] (feeling sadness, worthiness),
-Board line intellectual function (is a cognitive impairment, below normal -difficulty in
understanding in reasoning, problem solving, planning, and abstract thinking),
-Hepatic failure (liver function), and
-Convulsions ([MEDICAL CONDITION], body muscles contract and relax rapidly and repeatedly,
resulting in an uncontrolled shaking of the body).
Record review of the resident’s Care Plan dated 8/22/17 showed:
-The resident had a long history of attempted and actual self harm;
-He/she has multiple scars on his/her arms where he/she had bitten himself/herself;
-He/she talked of drinking shampoo and soap,
-Hand written notes of the residents attempted or actual self harm showed 11 total
attempts on the following dates 3/3/18, 3/15/18, 3/25/18, 3/27/18 and 4/13/18,
-Interventions include:
–Facility staff were to redirect the resident immediately when behavior of self harm
starts,
–They were to attempt to determine what might trigger this behavior and educate staff,
–Medication and treatment as order, wrap arms, place on 1:1 staffing,
–Notify physician if behavior begins to discus options and ensure that he/she does not
have access to items that can cause him/her harm,
–Psychiatrist consult as needed,
–Encourage participation in activities,
–Encourage him/her to bond with other resident with similar interest
Record review of the resident’s Long term Psych Management Encounter Note dated 12/13/17,
showed:
-The resident was seen by a Psychiatric Nurse Practitioner on 12/13/17,
-The visit was a follow-up visit, for medication review and management,
-Patient was to be encouraged to pursue more positive behaviors such as talking to staff,
-Complexity of his/her mental condition was noted to be severe,
-Psycho-education and support was provide,
-Staff were to monitor mood, behavior and medications for side effects, and
-Gradual dose reductions were not recommended.
Record review of the resident’s Quarterly Minimum Data Set (MDS-a federally mandated

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0742

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 33)
assessment tool completed by facility staff for care planning) dated 2/21/18 showed the
resident did not have any psychological therapy.
Record review of the resident’s Discharge MDS dated [DATE] showed the resident did not
have any psychological therapy.
Record review of the resident medical record showed:
-On 3/22/18 the resident was discharged for m the hospitals behavioral unit with discharge
instruction;
-Notes showed he/she was admitted for an attempted suicide; and
-The resident needed follow-up behavioral care.
Record review of the resident’s Discharge MDS dated [DATE] showed the resident did not
have any psychological therapy.
Record review of the resident’s nurse notes dated 4/12/18 and 4/13/18 showed:
-On 4/12/18 the resident had just been readmitted to the facility placed on one on one
staffing,
-On 4/13/18 at 4:00 P.M., the resident was discontinued from one on one staffing, he/she
denied any suicidal, homicidal and elopement ideation’s;
-On 4/13/18 at 5:30 P.M., the resident was laying in bed with a self inflicted abrasion to
his/her left arm;
-The resident’s room was searched, and possible harmful items removed;
-The resident’s guardian, physician, the facility Director of Nursing (DON), and the
Administrator were notified; and
-The resident was placed back on one on one staffing care.
Record review of the resident’s Physician order [REDACTED].
-[MEDICATION NAME] Carb 300 miligrams (mg) one tab by mouth twice a day with food (for
[MEDICAL CONDITION] disorder),
-[MEDICATION NAME] 0.5 mg one tab by mouth twice a day (anxiety),
-[MEDICATION NAME] 50 mg one tab by mouth twice daily (for [MEDICAL CONDITION] disorder),
-[MEDICATION NAME] ER 500 mg take three tabs (1500 mg by mouth at bedtime (for [MEDICAL
CONDITION] disorder),
-Quetiapine Fum ([MEDICATION NAME]) 300 mg one tab by mouth at bedtime (for [MEDICAL
CONDITION] disorder), and
-May have behavior therapist, psychiatrist and psychologist consults as needed.
Record review of the resident’s Quarterly MDS dated [DATE] showed;
-Re-entry from a psychiatric hospital on [DATE],
-The resident was not cognitively impaired and has a BIMS (brief interview for mental
status) score of 12 and but had disorganized thinking,
-Had received Anti-psychotic, anti-anxiety and anti-depressant medication,
-The resident did not have any psychological therapy (by any licensed mental health
professional during the look period of the last seven days).
During an observation on 5/9/18 of the resident while on the closed unit showed the
resident:
-Had become upset very easily when other residents had been yelling out, crying or with
loud sounds,
-The resident would cover his/her ears and would rock in chair at times, had became
tearful at times,
– He/she would interaction with peers, and seemed to help calm him/her,
-The resident was able to voice needs to staff,
-No observation of any type group activities on the unit, and
-Resident would walk back and fourth from the resident rooms to front area, sit at the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0742

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 34)
table to visit with peers.
During interview on 05/10/18 at 9:50 A.M., the resident said he/she:
-Had been hospitalized for [REDACTED].
-Colored pencils were removed from him/her along with other potential items that he/she
could use to cut himself/herself,
-Had also had used bottle caps in the past,
-Had been calmer since returned to the facility, not hearing the voices in his/her head,
-Had not seen a counselor or any mental health therapist since return to the facility, a
counselor may come by see him/her today.
-Would like the facility to have more activities and to include mental health or
behavioral health groups topics,
-Would like to have a calming place to go to, and to have relaxation groups,
-Will not be able to move back in with his/her parent,
-Does not feel comfortable talking to staff about any of his/her suicidal thought and
ideation, thoughts of cutting himself/herself, or if have more paranoia affecting
-Does his/her own search of his/her room for any items that may tempt him/her to use to
cut on self such as the colored pencils and bottle caps;
-Has history of [MEDICAL CONDITION] also, think they are more from stress, and
-Is working on be more happy and not to bottle up feelings and to manage his/her feelings.

Record review of the resident’s medical record found no ongoing mental health or
behavioral health counseling services had been provided for the resident since the last
suicidal attempt. No documentation found related to a pending appointments.
Record review of the resident’s nurses notes form 4/12/18 to 5/12/18 showed no behavior or
mental health concerns expressed by the resident, the nursing staff recommended that the
resident to use his/her coping skills and to journal his/her thought and feeling,
During a follow up interview on 5/14/18 at 1:57 P.M., the resident said he/she would like
to have individual counseling and group counseling related to mental health concerns.
During an interview on 5/15/18 at 12:45 P.M., Licensed Practical Nurse (LPN) C said:
-At this time the facility does not provide any one on one counseling or group counseling
services for the residents, and
-He/she was not aware of any of the residents attending outpatient counseling services.
During an interview on 5/15/18 at 12:45 P.M., Certified Nurses Assistant (CNA) E said:
-He/she was not aware of any counseling serves offered for the resident’s at the
facilities, and
-The only specialized training they receive is for Crisis Alleviation Lessons and Methods
(CALM-a progressive series of de-escalation/crisis intervention techniques) class.
During an interview on 5/15/18 at 2:37 P.M., the Director of Nursing (DON) said:
-For resident with suicidal risk they would placed on one on one staffing, then every four
hours monitoring,
-All resident should be on hourly face to face check for safety reasons,
-He/she would expect staffing to monitor the resident’s room for any sharp objects,
-At this time the facility does not provide one on one counseling or group counseling for
the residents, and
-The SSW director would be responsible for arranging mental heal or behavioral health
counseling services.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure the
medication pass error rate was less than five percent. The facility had three medication
errors out of 41 opportunities for a 7.3% medication error rate. The facility census was
106 residents.
1. Record review of Resident #18’s Face Sheet showed he/she was admitted to the facility
on [DATE].
Record review of the resident’s Telephone Order Sheet (TOS) dated 4/23/18 showed:
-Decrease [MEDICATION NAME] to 250 milligrams (mg) daily for seven days then discontinue;
-Discontinue [MEDICATION NAME] 325 mg and
–There was no physician’s order to discontinue the Multivitamin or the Aspirin 81 mg
daily.
Record review of the resident’s 4/15/18 – 5/14/18 Physician’s Order Sheet (POS) showed:
-Multivitamin, take one tablet daily for supplement dated 6/16/12;
-Aspirin 81 mg, take one tablet daily for [MEDICAL CONDITION] (CAD -narrowing of the
coronary arteries) dated 8/14/12;
-[MEDICATION NAME] 325 mg, take one tablet daily with no [DIAGNOSES REDACTED].
-[MEDICATION NAME] 250 mg by mouth daily in the morning for [MEDICAL CONDITION] dated
4/21/14 and
-[MEDICATION NAME] 500 mg by mouth at bedtime for [MEDICAL CONDITION] dated 6/22/16.
Record review of the resident’s Medication Administration Record [REDACTED]
-[MEDICATION NAME] 500 mg at bedtime for [MEDICAL CONDITION] dated 6/22/16 with a
handwritten notation to discontinue (dc) dated 4/23/18 and
-Multivitamin, Aspirin 81 mg, and [MEDICATION NAME] 325 mg were not on the resident’s MAR.
–The resident did not receive Multivitamin one tablet or Aspirin 81 mg.
Observation on 5/14/18 at 9:01 A.M., showed Certified Medication Technician (CMT) C did
not administer Aspirin 81 mg or Multivitamin one tablet to the resident during the
medication pass.
During an interview on 5/14/18 at 11:48 A.M., CMT C said:
-He/She administered all of the resident’s morning medications during the medication pass
observation;
-Aspirin 81 mg was not listed on the resident’s MAR indicated [REDACTED]
-Multivitamin one tablet was not listed on the resident’s MAR indicated [REDACTED]
-He/She thinks they were discontinued at the same time the resident’s [MEDICATION NAME]
was discontinued on 4/23/18.
2. Record review of Resident #50’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s POS and MAR indicated [REDACTED]
-[MEDICATION NAME] (a corticosteriod used to reduce irritation and swelling in the airways
to improve breathing) 0.5 mg/2 milliliters (ml) suspension, use one vial via nebulizer (a
device used to administer medication to people in the form of a mist inhaled into the
lungs) once daily at 9:00 A.M. dated 1/17/18 for pneumonia and
-Ipratroprium-[MEDICATION NAME] (a [MEDICATION NAME][MEDICATION NAME] that relaxes the
muscles around the airway so they open up and make breathing easier) 0.5 mg/3 ml one vial
via nebulizer every four hours as needed for pneumonia dated 1/17/18.
Observation on 5/15/18 at 8:01 A.M. showed Licensed Practical Nurse (LPN) E:
-Removed Ipratroprium-[MEDICATION NAME] 0.5 mg/3 ml from the medication cart and entered
the resident’s room;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 36)
-He/She could not find the resident’s [MEDICATION NAME] in the medication cart and
-He/She did not administer either medication due to the resident did not have a mask or
tubing for his/her nebulizer in his/her room.
During an interview on 5/15/18 at 8:10 A.M., LPN E said:
-[MEDICATION NAME] is the same as Ipratroprium [MEDICATION NAME];
-After looking at the box for the Ipratroprium [MEDICATION NAME], he/she noted the dose
was not the same as the [MEDICATION NAME] and
-He/She will administer Ipratroprium-[MEDICATION NAME] any way, since the resident has an
order for [REDACTED].>During an interview on 5/15/18 1:36 PM, LPN E said:
-He/She did not know what happened to the resident’s nebulizer mask and tubing and
-He/She would have to get the resident a new nebulizer mask and tubing before he/she could
administer a nebulizer treatment.
3. During an interview on 5/15/18 at 2:51 P.M., the Director of Nursing (DON) said:
-He/She expected the nursing staff to check the POS and MAR for accuracy;
-If a medication is on the POS but not on the MAR, he/she expected staff to notify the
resident’s physician for a clarification order;
-He/She expected staff to verify each medication with the resident’s MAR before entering
the resident’s room to administer the medication to ensure the medication was correct;
-It was not appropriate for staff to pre-pop a medication and
-He/She expected staff to ensure the resident had a current order for a medication prior
to administering the medication.

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 observation, interview, and record review, the facility staff failed to ensure
the safe storage and accountability of the resident’s narcotic medication card resulting
in missing of 60 tabs of Tramodol (pain medication) and failed to have detail written
documentation related to the discrepancy of the missing medication on the 12 hour
Controlled Drug-Count Record Sheet and the resident’s Individual Patient Narcotic Record,
to include what correction had been taken, to have written documentation of the facility’s
findings from the internal audit of the all facility’s narcotic count sheets and auditing
of the all narcotic on the medication carts related to the facility Register Nurse (RN)
Investigation into the missing narcotic medication, for one sampled resident (Resident
#34); to maintain cleanliness of the medication cart, to ensure unidentified medications
were not stored in the medication cart, failed to ensure opened eye drops were labeled
with the date the medication was opened in one Certified Medication Technician’s (CMT)
medication cart on the 3 North (N) unit. The facility further failed to ensure the
medication refrigerator temperatures were maintained within acceptable parameters, failed
to remove expired medications from the medication refrigerator, and to label opened with
the date the medication was opened in the 3 North medication room. The facility also
failed to ensure insulin stored in the 3 North licensed nursing medication cart was
labeled with the date the insulin was opened. The facility has 3 medication rooms and 6
medication carts. The facility census was 106 residents.
Record review of the Facility Medication Administration Policy and Procedure revised

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 37)
4/6/17 showed:
Medication are to be given per doctor orders. All medications are recorded on the
Medication Administration Record (MAR) and signed immediately after the resident has taken
the medications,
-The Nurse or Certified Medication Technician (CMT) should initial and circle the time of
the medication in question not given and document on back of the MAR why refused or not
available. Notified the Director of Nursing (DON) or RN designee,
-Narcotics must be counted with on-coming shift nurse. Remember to label the medication
card as you give the Narcotic, date and initial given. If the count is incorrect the
off-going nurses must stay until it is corrected and the Regional Care Coordinator (RCC)
and the DON or designee must be notified.
-The Nurse or the CMT then will go to the progress note and note the documentation of the
medication discrepancy also noting physician notified,
-Each Resident’s drug regimen will be reviewed monthly by a licensed pharmacist,
-The facility will self-report any serious medication errors to the State of department,
conduct an appropriate investigation,and issue disciplinary action up to and including
termination for the first offense based on the outcome of the investigation by the
facility and the findings of the state department investigation
1. Record review of Resident #34’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE]. He/she had a [DIAGNOSES REDACTED]. from birth) and was
his/her own responsible party
Record review of the resident’s Minimum Data Set (MDS- a federally mandated assessment
tool completed by facility staff for care planning) dated 2/23/18 showed:
-The resident was not cognitively impaired and has a BIMs (Brief
Interview for Mental Status) score of 14;
-That the resident had frequent pain and took opioid (controlled substance medication)
pain medication for his/her pain;
-Bowel was not rated has a ostomy (or stoma, is a surgically created opening between the
intestines and the abdominal wall);
-There was no indication of the resident having a wound and
-The resident’s does not require assistance from staff for care, and transfer.
Record review of the resident’s Physician order [REDACTED].
-On 4/16/18, had new physician’s orders [REDACTED].
-On 4/21/18, the resident had new physician’s orders [REDACTED].
During review of the facility Register Nurse (RN) Investigation Report dated 4/27/18
showed:
-The date of the incident was 4/27/18, had obtained employee witness statements, had
notified the resident and his/her physician;
-The incident report was completed by the RCC/charge nurse and was marked that the
resident’s guardian, physician, RCC, Director of Nursing (DON), the Administrator were
notified;
-Disciplinary Action Required marked yes: Final written warning for Certified Medication
Technician (CMT).
Investigative Narrative Note;
–On 4/27/18 at approximately 6:30 P.M., CMT C had reported at 4:00 P.M. he/she was
counting his/her narcotics and noted 60 tab card of [MEDICATION NAME] for the resident was
missing,
–An immediate search of the medication cart was done,
–The discrepancy verified. Search of the medication carts was conducted and interviews
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 38)
were conducted for all personnel involved in the use of the cart on the given day,
–Note that narcotic count completed the previous shift on 4/26/18 was correct, and all
controlled substances were accounted for,
–Immediate contact was made to the Administrator, this writer and the regional Specialist
regarding the incident,
–An immediate RN investigation was initiated referencing the Abuse, Neglect and Grievance
Policy and Procedure, CMT C and the Administrator was unable to reconcile the missing
medication,
-Summary of Findings;
–At approximately 6:45 P.M. the Administrator, Regional Specialist and the DON spoke with
CMT C, regarding missing medication,
–CMT C said that he/she did not count his/her cart with off going Licensed Practical
Nurse (LPN) B at the beginning of his/her shift,
–The medication count was correct at shift change on 4/26/18,
–CMT C said that no one had been on the CMT medication cart during the shift and he/she
had maintained control of the medication cart keys at all time,
–LPN C said that he/she did not at any time utilize the CMT cart during the shift,
–LPN B was interviewed by phone and said; she did not count as policy and procedure and
he/she had left the keys on the medication cart,
-Plan of action and Education Needs:
— An immediate RN Investigation with an complete internal investigation by referencing
the facility’s Medication Administration Policy and Procedure in addition to the Abuse ,
Neglect and Grievance Policy and Procedure,
–Contact was made with the Administrator, this writer, and the resident’s Primary Care
Physician,
–An immediate re-education on Safe Medication Practices was provided,
–Re-education of the Abuse, Neglect and Grievance Policy and Procedure,
–Provided re-education to all LPNs/CMT’s/RNs regarding narcotic administration and
immediately reporting any discrepancies.
-Criteria for self-reporting showed steps that have been taken to prevent further
occurrence of the issue was;
— An immediate re-education on Safe Medication Practices
–Re-education of the Abuse, Neglect and Grievance Policy and Procedure
-Other recommendation from management Team;
–Continue re-education on Safe Medication Practices, the Abuse, Neglect and Grievance
Policy and Procedure
–Review the Drug Diversion Power point at Pay day in-services
–Included in the Investigation report sent and received was copy of the witness
statements, training sign in sheet dated 4/27/18, the resident face sheet, two employee
discipline notice and pharmacy contact sheet for refill of missing medication,
–No interruption of the mediation availability for this resident, as the medication was
available by an existing card.
–The pharmacy was contacted by the Director of nursing regarding current identified
occurrence,
–Self-report to the Division of Health and Senior Services (DHSS) Long Term Care,
-No other documentation was provided or found related to the missing medication and the
documentation of the internal audit of all medication carts,
-RN Investigation Report did not have copies of the resident’s Medication Administration
Record, 12 hour Controlled Drug-Count Record Sheet or the Individual Patient Narcotic
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 39)
Record.
Record review of the CMT 3rd floor North 12 hour Controlled Drug-Count Record Sheet (is
the process to obtain the signatures of CMT and licensed nursing staff for accountability
for the number of controlled drugs on hand at time of shift change and found that the
quantity of each medication count is in agreement with the quantity stated on the
controlled Drug Administration Record) dated (MONTH) (YEAR), showed;
-The Unit book was for the Narcotic Book North,
-On 4/26/18 and 4/27/18, had missing signature for the 2nd shift nurse coming on duty for
the 4/26/18 and missing signature for a nurse coming off duty on 1st shift 4/27/18,
-For 4/26/18, documented in comment section had numbers showed; had a minus 1, 25 + 1 then
26 and did not show any documentation of any missing medication or adjustment.
– For 4/27/18, documented in the comment section the count number was 26 and did not show
any documentation of any missing medication or an adjustment had been done, nor did it
show that an audit had been done during the time of the missing [MEDICATION NAME] card.
Record review of the resident’s [MEDICATION NAME] 50 mg dated 4/20/18 medication had
written number one on the card. There was no nurses or CMT initial or dates by any
medication given.
Record review of the resident’s [MEDICATION NAME]- Individual Patient Narcotic Record date
start of 4/20/18 showed,
-The resident had received 240 tablets of [MEDICATION NAME] 50 mg on 4/20/18 was ordered
for the resident to take two tabs by mouth four times a day, someone had hand written as
needed (PRN) on the sheet,
-The resident had three Individual Patient Narcotic Record for his/her of [MEDICATION
NAME] 50 mg that was received on 4/20/18 and showed 240 tablets were received. The
resident’s fourth Individual Patient Narcotic Record sheet and the 60 tablet medication
card that was delivered on 4/20/18 was missing, which would had equal the 240 tab count.
-The first day the resident had given [MEDICATION NAME] medication from the 240 count was
on 4/21/18,and showed on the Individual Patient Narcotic Record had 60 on hand and was
given two tabs, which left 58 tabs remaining,
-Each of the resident’s [MEDICATION NAME] Individual Patient Narcotic record from 4/20/18
had 60 under the amount on hand and does not indicate was for which [MEDICATION NAME] 60
count card, one, two, three or four,
-On 4/27/18, the resident had 36 tablets left on this medication card and was given two
tabs at 3:30 P.M. by CMT C showed had 34 left on the card.
-5/1/18 the facility had order a replacement card for the missing 60 tabs of [MEDICATION
NAME] which arrived on 5/1/18,
-The resident now had a total of four Individual Patient Narcotic Record sheet,
-The fourth sheet shows, sub for [MEDICATION NAME] 50 mg. tab 60 tabs and on 5/1/18 the
resident had 60 tablets on hand,
-Did not have any documentation or adjustment had been made or that the resident had any
medication missing noted on the first page of his/her Individual Patient Narcotic Record.
Record review of the pharmacy consolidated delivery Sheet dated 4/20/18 showed:
-On 4/20/18 the facility had received 240 tablets of [MEDICATION NAME] 50 mg tab,
-Had no signature on the sheet of any facility staff had verified the delivery of the 240
tabs of [MEDICATION NAME].
Record review of the pharmacy medication order sheet was faxed on 5/1/18 to the pharmacy
showed an order for [REDACTED]. On 5/1/18, the facility had replaced the resident’s
[MEDICATION NAME] medication at their expense with total cost of 60 missing tablets was
$503.00.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 40)
During an interview on 5/9/18 at 10:25 A.M., the resident said he/she was aware of the
missing medication and the facility had replaced the missing medication.
During an observation of shift change CMT medication cart count on 5/10/18 at 6:35 A.M.
showed:
-CMT C coming on shift for day time and LPN B leaving for night time,
-LPN read off the information that was on the Narcotic count book while the CMT check the
medication in the locked medication cart,
-The CMT counts the number controlled medication cards or controlled medication in the
cart first report that number,
-Then by each resident and name of the medication goes through each Individual Patient
Narcotic Record to ensure the number of pills left on the cards matches the documentation
on the sheet,
-No concern found during shift change, keys was then handed over both staff signed off on
Narcotic count sheet.
During an interview on 5/10/18 at 6:40 A.M., LPN B said;
-During the shift change count, if notice discrepancy, you would double check the numbers
again, check the resident’s MAR to see if someone forgot to sign the medication out,
– After LPN and CMT have looked and doubled checked to verify the count, and still have
discrepancy in count, the staff coming on duty would not accept the medication cart keys
from the staff person leaving the shift
– He/she would call his/her supervisor and the Director of Nursing immediately,
-No staff could leave until the count is corrected or approved by the supervisor to leave,
-The DON would initiate an investigation,
-On 4/27/18, he/she said had received a phone call asking question about the CMT
medication cart,
-He/she was not sure what happened to the medication, LPN B did not take any medications
out of the CMT medication cart the evening or night shift of 4/26/18 or 4/27/18,
-On 4/26/18 between 9:00 P.M. and 10:00 P.M., that was the evening CMT was leaving for the
night and was passing the CMT medication cart and keys to LPN B,
-LPN B said he/she did count the number of tablets on the card or counted the number of
cards with the CMT on the night of /26/18.
-During the night shift the CMT cart is left in the medication room at night and the keys
are with the night nurse,
-LPN B said, he/she should have counted the number of cards first, then go over each sheet
and count the number of pills left on every card,
-The resident’s missing medication was not found, the facility did replace the medication,
-The resident had been on schedule [MEDICATION NAME] then received new orders to change to
prn,
-The label instruction on the medication cards may not match the resident’s physician
order, the nursing staff and the CMT’s need to double check the resident’s physician’s
orders [REDACTED].
During an interview on 5/10/18 at 2:10 P.M., LPN D said;
-During each shift change, the nurses perform medication count for narcotic by counting
the cards then the number of pills left in each card.
During an interview on 5/16/18 at 8:30 A.M., LPN C said:
-On 4/27/18 the CMT C informed the LPN about the missing medication and they checked the
CMT medication cart and other cart in the area, did not find the medication so they
notified the Director of Nursing,
-He/she had completed the witness statement,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 41)
-He/she had been off for few days
-They facility did not call or investigate back any further than 4/26/18 and 4/27/18,
-The only audit system in place is when the pharmacy comes to the facility for monitoring,
and at CMT/Nursing shift change during drug count,
-The licensed nursing staff do not normally audit or count with the CMT’s during shift
change, except when there are no CMT’s working during that shift,
-The CMT and the Administrator had looked in all the medication carts during the
investigation did not find the missing [MEDICATION NAME].
During an interview on 05/15/18 02:37 P.M. DON said;
-He/she expected the nurse to verify the physician’s orders [REDACTED].
[REDACTED].>-The RCC and the DON are assigned to do a weekly checks on the facility
medication carts and the medication cards,
-Education was provided to all staff on the Abuse and Neglect policy and the safe
medication administration and counting the medication cart
-During shift change it takes two staff members either or both a CMT or a licensed nurse
to count the medications carts and the medication cards,
– He/she would expect the licensed nursing staff and the CMT’s to check all medication
carts for missing medications or discrepancies, for possible miss placement of the
resident’s medication,
-He/she would expect licensed nursing staff and the CMT’s to immediately report any
discrepancies found during a narcotic administration and narcotic drug counts to the DON,
-The CMT medication cart is kept in the medication room or up at the front nurses station
during night shift,
-RN Investigation Report is the incident report the facility uses for any incident with
medication.
During an interview on 05/16/18 11:00 A.M., the DON and the Administrator said;
-The Pharmacy provide the auditing all resident’s medication including the safe storage of
medications in the medication rooms, medication carts,
-The investigation on 4/27/18 included the statements from all party’s involved,
-He/she would expect the licensed nursing staff and the CMT’s to count the number of
Narcotic medication cards in the medication cart, then count and compare number of tablets
or pills left in the cards with the narcotic count sheets,
-If the resident has multiple cards of the same medication, the cards and the sheets
should be numbered to match,
-On 4/27/18, the resident had three medication cards for his/her [MEDICATION NAME] left in
the CMT Medication Cart narcotic box, there should have been four medication cards, the
resident’s [MEDICATION NAME] Individual Patient Narcotic record was also missing,
-The missing [MEDICATION NAME] medication card was reported in the evening,
-He/she called the pharmacy to verify that they had delivered four medication cards of
[MEDICATION NAME], each card had 60 tablets for a total of 240 tablets.
-The facility had replaced the resident medication the replacement [MEDICATION NAME] was
received on 4/20/18,
-During the RN investigation of the resident’s missing [MEDICATION NAME], he/she said the
facility did not document the audit findings of all medication carts and did not signed
off or initial by the DON or administrator on the each Individual Patient Narcotic record
for each 12 hour Controlled Drug-Count Record Sheets,
-He/she said the facility did not monitor the resident MAR for current physician orders
[REDACTED].>-He/she felt the outcome and action plan from the RN Investigation from
4/27/18 was met with the following actions;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 42)
–Completed full RN Investigation including auditing of all the medication carts, witness
statements and interviews and self-reported to DHSS,
–The CMT and LPN did not follow the facilities policy and procedure and both staff
members had received discipline final action warnings for their action,
–The DON had provided re-education to all staff involved in the incident on safe
medication administration and Abuse and Neglect,
-He/she said for future preventive measure, the facility administration does not have any
process or action plan at this time to provide an ongoing documentation of medication
monitoring and auditing system to ensure safe storage and accountability of the resident’s
narcotic medications and other physician’s orders [REDACTED].
Complaint MO 989
Record review of Drugs.com retrieved on 5/15/18 showed:
-[MEDICATION NAME] (influenza vaccine) should be stored between 36 degrees Fahrenheit (F)
and 46 degrees F. Do not freeze.
-[MEDICATION NAME] ([MEDICATION NAME] screening) should be stored between 36 – 46 degrees
F. Do not freeze.
-[MEDICATION NAME] (insulin) should be stored between 36 – 46 degrees F if unopened. Do
not freeze.
-Opened [MEDICATION NAME] vials and pens should be discarded after 28 days.
-[MEDICATION NAME] (insulin) should be stored between 36 – 46 degrees F if unopened. Do
not freeze.
-Opened [MEDICATION NAME] vials and pens should be discarded after 28 days.
-Humalog should be stored between 36 – 46 degrees F if unopened. Do not freeze.
-Opened Humalog (insulin) vials and pens should be discarded after 28 days.
-[MEDICATION NAME][MEDICATION NAME](an antipsychotic medication) should be stored between
36 – 46 degrees F.
-[MEDICAL CONDITION] vaccine should be stored between 36-46 degrees F. Do not freeze.
-[MEDICATION NAME] 23 vaccine should be stored between 36-46 degrees F.
-[MEDICATION NAME] (an antipsychotic medication) store at room temperature 59 – 86 degrees
F. Do not freeze.
-[MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) should be stored at
36-46 degrees F. Do not freeze.
-[MEDICATION NAME] (insulin) should be discarded 42 days after opening.
2. Observation on 5/14/18 at 9:13 A.M. of the 3 N CMT medication cart showed:
-One round, green pill and one round orange pill loose in the top drawer with debris in
the drawer;
-A wrapped chocolate candy heart;
-One uncovered medication cup without a resident name or the name of the medication with
red liquid in the top drawer;
-One uncovered medication cup without a resident name or the name of the medication with
clear liquid in the top drawer;
-Two opened, undated, [MEDICATION NAME] prescription eye drop vials;
-One opened, undated, Latanoprost prescription eye drop vial;
-One opened, undated Dorzolamide-[MEDICATION NAME] prescription eye drop vial;
-Two opened, undated [MEDICATION NAME] prescription eye drop vial and
-One opened, undated Dorzolamide prescription eye drop vial.
During an interview on 5/14/18 at 9:15 A.M., CMT C said:
-The medication cups with the red liquid and the clear liquid was supposed to be
administered to a resident, but the resident had complained of pain, so he/she put the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 43)
medication cups in the drawer to administer to the resident later;
-Staff should clean out any debris from the medication cart drawers as needed;
-Unidentified, loose pills should not be in the medication carts;
-Eye drop vials should be dated on the vial when they are opened and
-Food items should not be stored in the medication carts.
3. Record review of the 3 N medication refrigerator temperature logs showed:
-Refrigerator temperatures should be regulated between 32 degrees (F) to 40 degrees F;
-Staff were directed to document the refrigerator temperatures and to check that all items
were dated;
-The documented refrigerator temperatures for (MONTH) (YEAR) showed the temperatures were
below 36 degrees F 14 out of 14 days and
-The facility was unable to locate or provide medication refrigerator temperature logs for
the 3 N medication refrigerator prior to (MONTH) (YEAR).
4. Observation of the 3 N medication room on 5/14/18 at 9:30 A.M. showed:
-Two opened, undated [MEDICATION NAME] vials;
-One opened, undated [MEDICATION NAME] vial;
-Six [MEDICATION NAME] flex pens;
-Three [MEDICATION NAME][MEDICATION NAME] mg pens;
-Two [MEDICATION NAME][MEDICATION NAME] mg pen;
-Six [MEDICAL CONDITION] vaccine syringes;
-One [MEDICATION NAME][MEDICATION NAME] mg pen;
-One [MEDICATION NAME][MEDICATION NAME] mg pen;
-Two [MEDICATION NAME] vials;
-Three [MEDICATION NAME] 10,000 units (u) per milliliter (ml) vials;
-Three [MEDICATION NAME]vials;
-One Humalog insulin vial;
-Two [MEDICATION NAME] pens;
-One Latanoprost 0.005% eye drop;
-One [MEDICATION NAME] 5 milligram (mg)/ml vial;
-28 [MEDICATION NAME] 23 (pneumonia vaccine) vials;
-Two 470 ml bottles [MEDICATION NAME] liquid 50 mg/ml;
-An insulin box containing one [MEDICATION NAME] vial, one [MEDICATION NAME] vial, one
[MEDICATION NAME] vial, and one [MEDICATION NAME] 70/30 vial;
-A locked narcotic box containing 59 dronabinol 5 mg capsules, 38 [MEDICATION NAME] 2
mg/ml vials. One of the 38 [MEDICATION NAME] 2 mg/ml vials expired on 11/17;
-Nine Tetanus vaccine vials expired on 3/15/18;
-The medication refrigerator temperature log showed the staff should maintain the
temperatures between 32 degrees F to 40 degrees F and
-The temperature documented on 5/14/18 was 32 degrees F.
5. Observation of the 3 N licensed nurse medication cart on 5/14/18 at 10:45 A.M. showed:
-Two opened [MEDICATION NAME] dated 4/9/18;
-One opened [MEDICATION NAME] dated 4/4/18;
-One opened [MEDICATION NAME] dated 4/10/18;
-Two opened, undated [MEDICATION NAME] insulin;
-Four opened, undated Humalog insulin;
-One opened, undated [MEDICATION NAME] Insulin;
-Two opened [MEDICATION NAME] Flex Pen dated 3/25/18;
-One opened Humalog insulin with no date on the vial, date on the outside bottle was
5/10/18;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 44)
-Two opened, undated [MEDICATION NAME] pens;
-Two opened, undated [MEDICATION NAME]pens;
-One opened, undated [MEDICATION NAME]pen. The date on the outside bottle was 3/27/18;
-One opened, undated bottle of Vitamin C;
-One opened, undated bottle of Vitamin B 12;
-Two opened, undated bottle of Senna;
-One opened, undated bottle of Vitamin B 6;
-One opened, undated bottle of Aspirin 81 mg and
-Two opened, undated [MEDICATION NAME] 1% 10 ml vials.
6. During an interview on 5/15/18 at 1:11 P.M., Licensed Practical Nurse (LPN) C said:
-The night shift is responsible for checking the medication refrigerator temperatures;
-Pharmacy is responsible for checking the medication refrigerator and medication carts for
expired medications;
-Pharmacy is also responsible for ensuring there is no loose, unidentified medications in
the medication carts;
-CMT and LPN staff are responsible for checking the medication carts monthly to ensure
opened medications are dated;
-Insulin should have an open date on the vial;
-Eye drops should have an open date on the bottle and
-All opened medications should have an opened date on the bottle or vial.
During an interview on 5/15/18 at 2:54 P.M., the Director of Nursing (DON) said:
-He/She expects the medication carts to be checked by nursing staff daily for loose pills
and cleanliness;
-Food items and debris should not be in the medication carts;
-All opened medications should have the opened date on the vial or bottle;
-He/She expected nursing staff to check for expired medications daily and remove any
expired medications from the medication carts and/or medication refrigerators;
-The medication rooms should be checked by the nursing staff for expired medications;
-The narcotic box in the medication refrigerator should also be checked by nursing staff
for expired medications;
-He/She expected staff to ensure the medication refrigerator is checked daily for
temperatures and to document the medication refrigerator daily;
-He/She expected the medication refrigerator temperatures to be maintained within the
recommended range for the medications stored in the refrigerator and
-It was not appropriate for staff to store uncovered, unlabeled medications in the
medication cart. If the resident declined the medication after it has been dispensed into
a medication cup, the medication should be discarded at that time.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation and interview, the facility failed to keep scoops out of sugar and
flour bins; to properly date food cans in the dry storage room; to refrigerate open
condiment jugs; to monitor two inner refrigerator thermometers; to keep a kitchen garbage
can lidded when not in use; to prevent grease build-up on range hood baffles; and to
maintain a sanitary manual can opener blade. These practices potentially affected all

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 – Some

(continued… from page 45)
residents who ate food from the kitchen. The facility census was 106 residents.
1. Observations on 5/9/18 at 9:39 A.M., in the dry storage room showed the following:
– Scoops in the brown sugar bin and the flour bin;
– A one gallon jug of soy sauce approximately 1/2 full that read refrigerate after opening
for quality on the label, and
– Numerous large cans of various foods on racks not dated with expiration date, best used
by date, or date of receipt by the facility.
2. Observations on 5/9/18 at 9:48 A.M., showed the Unit #4 and Unit #7 refrigerators had
no inner thermometers.
3. Observations on 5/9/18 at 10:41 A.M., showed the following:
– The kitchen garbage pail was unlidded;
– The range hood baffle filters had a heavy film of grease to the point of showing drips;
– The range hood had no dated sticker of the last professional cleaning and
– The can opener blade had a build-up of food and debris.
Observation on 5/9/18 at 11:56 A.M., showed the garbage can unlidded and the lid not
within sight.
Observation on 5/9/18 at 2:36 P.M., showed the garbage can still unlidded.
4. During an interview on 5/9/18 at 9:45 A.M., the Dishwasher who was stocking the dry
storage room said the large cans on the racks are usually dated but the facility had been
short staffed for a while.
During an interview on 5/9/18 at 9:51 A.M., the Certified Dietary Manager (CDM) said there
was a thermometer in Unit #4, but it was just hidden behind some boxes. Upon immediate
investigation to confirm, it read 70 degrees Fahrenheit.
During interviews on 5/9/18 at 10:45 A.M. and 11:13 A.M., the CDM acknowledged some cans
in the dry storage room were undated and said the range hood was professionally cleaned
every six months.
During interviews on 5/9/18 at 12:31 P.M. and 1:01 P.M., the Maintenance Director said the
baffle filter cleaning frequency was unknown and upon phone inquiry to the facility’s
professional hood cleaning company a verbal last date of hood cleaning in (MONTH) of
(YEAR) (one year ago) was provided.
During an interview on 5/9/18 at 2:37 P.M., the CDM said the following:
– The baffle filters were cleaned by maintenance, but the frequency was unknown, and
– The garbage can lid is kept in the back and it is covered after meals are done for the
day and everyone is gone.

F 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Have a policy regarding use and storage of foods brought to residents by family and
other visitors.

Based on record review and interviews, the facility failed to produce an on-site policy
regarding the acceptance, usage, and storage of foods brought into the facility for
residents, by family and other visitors, to ensure the food’s safe and sanitary handling
and consumption. This deficient practice had the potential to affect all residents who ate
food brought in by visitors. The facility census was 106 residents.
1. Record review of available facility kitchen documents, forms, and logs on 5/9/18
between 9:28 A.M. and 10:45 A.M., failed to show the presence of a policy regarding foods
brought in for residents by family and other visitors.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 46)
During interviews on 5/09/18 at 11:13 A.M., with Administrator and the Certified Dietary
Manager (CDM) the following was said:
– The CDM said there was no such policy in the kitchen and
– The Administrator said they didn’t think there was one either, and could not find any
located on the computer, but that he/she could contact corporate owners and probably get
one.

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 interview and record review, the facility failed to ensure facility-wide
infection control logs were maintained for a twelve month period to track infections
within the facility, monitor and/or identify infection trends, and to ensure appropriate
interventions related to facility-wide infection trends were identified and implemented.
The facility census was 106 residents.
Record review of the facility Infection Control Program policy dated 11/28/16 showed:
-The facility will identify, monitor, and track infections in the facility utilizing the
Quality Assurance Process.
-The facility will report incidents of communicable diseases or infections according to
state and federal regulations.
1. During an interview with the Director of Nursing (DON) and record review of the
facility’s Infection Control Tracking showed:
-On 5/14/18 at 8:11 A.M. twelve months of tracking was requested from DON;
-On 5/14/18 at 9:00 A.M. the DON provided an Infection Control Tracking book with
information from (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR);
-The DON said he/she was still working on the infection control logs from (MONTH) (YEAR)
and (MONTH) (YEAR). He/She would look for the remaining 12 months of tracking and the
information provided to the surveyor was complete for (MONTH) (YEAR), (MONTH) (YEAR), and
(MONTH) (YEAR).
-An Antibiotic Report was printed for the entire facility for the month in (MONTH) (YEAR)
– (MONTH) (YEAR).
-An Infection Control Line Listing for each unit each month directed staff to document the
following:
–The residents name, room number, infection site, date the specimen was collected and the
pathogen identified in the specimen, date the symptoms started, any predisposing factors,
date the treatment started, if the antibiotic was appropriate to the organism, and if the
infection was resolved;
—Staff did not document any specimen collection, identified pathogens, or if the
infection was resolved;
—Staff did not consistently document if the antibiotic was appropriate to treat the
organism.
-An Antibiotic Usage Report for each unit each month directed staff to document the
following:
–The resident’s name, room number, the antibiotic prescribed, the prescribed dosage, the
start and stop dates of the medication, the date the culture was collected, if the
organism identified in the specimen was sensitive to the prescribed antibiotic, if the
resident had clinical signs of an infection, was the infection resolved, the resident’s

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 47)
physician, and any additional comments;
–Staff did not document antibiotic stop dates of prescribed antibiotics;
–Staff did not consistently document if a specimen was collected, if the resident had any
clinical signs of an infection, or if the infection had resolved and
–Staff documented the antibiotic used was appropriate to the organism being treated.
-No lab specimen records were included in the documentation for the Infection Control Log.
Record review on 5/15/18 at 9:36 A.M. showed the DON provided an Infection Control Log
from (MONTH) (YEAR) – (MONTH) (YEAR). The Infection Control Log book included the
following information:
-Printed Infection Log each month with the name of the resident, the resident’s room
number, if the infection was facility acquired or community acquired, the date of
infection symptom onset, infection site category, if a specimen was obtained and what
pathogen was identified, any related diagnosis, and if an antibiotic was prescribed;
–The Infection Log reports from (MONTH) (YEAR) – (MONTH) (YEAR) showed no antibiotic use
in the facility, no specimens were collected, and no pathogens were identified.
–Infection Report – Basic for each resident listed on the Infection Log each month. The
report included the infection site category, Signs/Symptoms/Conditions section, the notes
included if any medications were prescribed, and under Interventions if the resident was
prescribed an antibiotic.
—August (YEAR) the facility had 10 infections with no antibiotics used listed on the
facility Infection Log. The facility Infection Report – Basic reports for the 10 resident
infections showed in the notes section nine of the ten infections had an antibiotic
prescribed, but no antibiotics were documented in the interventions section.
–A handwritten Antibiotic Usage Report for each unit each month directed staff to
document the resident’s name, room number, antibiotic prescribed and dosage, the
medication start and stop dates, date a specimen culture was obtained, if the organism was
sensitive to the prescribed antibiotic, the clinical signs of infection present, was the
infection resolved, the resident’s physician, and any additional comments.
—Staff did not consistently document the antibiotic stop dates, and did not document if
a specimen was obtained, the results of the specimen, if the resident had clinical signs
of an infection, and if the infection was resolved.
–A handwritten Infection Control Line Listing for each unit each month directed staff to
document the resident’s name, room number, the infection site, the date a specimen was
collected and the identified pathogen, the date infection symptoms started, any
predisposing factors, the date of the treatment, if the antibiotic was appropriate for the
organism, and if the infection was resolved.
—The staff did not document the dates any specimens were collected and if there was any
identified pathogens, the date they infection symptoms started, any predisposing factors,
and if the infection was resolved.
—Staff documented the antibiotic used was appropriate to the specimen being treated.
-October (YEAR) had an Antibiotic Log and no other tracking information.
-November (YEAR) and (MONTH) (YEAR) included a laboratory report listing all of the
specimens collected during the month but did not have any other information related to the
resident’s infections and/or antibiotic use.
2. During an interview on 5/15/18 at 2:37 P.M., the DON said:
-Infection Control Tracking was a new process for him/her;
-He/She reviews the infections with antibiotics in the facility, what the antibiotic is
being used to treat, and log the information in the book;
-With that information, he/she will try to identify a trend;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 48)
-He/She will go through all of the physician orders [REDACTED].
-He/She determines if an antibiotic was appropriate or not by the symptoms the resident
had related to the infection;
-At this time, the facility does not track pathogens to determine if there is a trend or
pattern of infections;
-He/She determines an infection trend if there is the same type of infection, such as a
wound infection or Urinary Tract Infection [MEDICAL CONDITION] on the same unit or a
repeat of the same infection in the same resident;
-He/She would let the physician and the Administrator know if he/she identified any trends
and would in-service the staff;
-He/She has not had to do any staff in-services related to infections;
-He/She did not have anything to refer to know what infections to report and to what
agency the infection needed to be reported to. If there was an outbreak or a communicable
disease in the facility, he/she would report it to the Administrator.
-He/She is not certain if any staff competencies have completed with the nursing staff
related to infection control practices and
-He/She has not incorporated antibiotic stewardship in the facility Infection Control
Program at this time.

F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Implement a program that monitors antibiotic use.

Based on interview and record review, the facility failed to establish a facility-wide
infection prevention and control program that included an antibiotic stewardship program
that included antibiotic use protocols and a system to monitor antibiotic usage. The
facility census was 106 residents.
Record review of the facility Infection Control Program policy dated 11/28/16 showed:
-The facility will identify, monitor, and track infections in the facility utilizing the
Quality Assurance Process;
-The facility will report incidents of communicable diseases or infections according to
state and federal regulations and
–The policy did not address antibiotic use protocols.
1. During an interview with the Director of Nursing (DON) and record review of the
facility’s Infection Control Tracking showed:
-On 5/14/18 at 9:00 A.M. the DON provided an Infection Control Tracking book with
information from (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR);
-The DON said he/she was still working on the infection control logs from (MONTH) (YEAR)
and (MONTH) (YEAR). The information provided to the surveyor was complete for (MONTH)
(YEAR), (MONTH) (YEAR), and (MONTH) (YEAR);
-An Antibiotic Report was printed for the entire facility for the month in (MONTH) (YEAR)
– (MONTH) (YEAR).
-An Antibiotic Usage Report for each unit each month directed staff to document the
following:
–The resident’s name, room number, the antibiotic prescribed, the prescribed dosage, the
start and stop dates of the medication, the date the culture was collected, if the
organism identified in the specimen was sensitive to the prescribed antibiotic, if the
resident had clinical signs of an infection, was the infection resolved, the resident’s

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265721

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

05/16/2018

NAME OF PROVIDER OF SUPPLIER

GREGORY RIDGE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

7001 CLEVELAND AVENUE
KANSAS CITY, MO 64132

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 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 49)
physician, and any additional comments.
–Staff did not document antibiotic stop dates of prescribed antibiotics.
–Staff did not consistently document if a specimen was collected, if the resident had any
clinical signs of an infection, or if the infection had resolved.
–Staff documented the antibiotic used was appropriate to the organism being treated.
-No lab specimen records were included in the documentation for the Infection Control Log.
2. During an interview on 5/15/18 at 2:37 P.M., the DON said:
-He/She reviews the infections with antibiotics in the facility, what the antibiotic is
being used to treat, and log the information in the book;
-He/She determines if an antibiotic was appropriate or not by the symptoms the resident
had related to the infection and
-He/She has not incorporated antibiotic stewardship in the facility Infection Control
Program at this time.

F 0924

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Put firmly secured handrails on each side of hallways.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain hand rails in the
following areas in good repair or firmly affixed to the wall: the corridor outside 322,
the bathing room next to resident room [ROOM NUMBER], the shower room next to the third
floor south nurse’s station, and the second floor south shower room. This practice
potentially affected at least 50 residents who reside in or use those areas in the
facility. The facility census was 106 residents.
1. Observations with the Maintenance Supervisor and the Housekeeping Supervisor on
5/10/18, showed the following:
– At 10:26 A.M., the handrail outside resident room [ROOM NUMBER] had missing plastic
covering which exposed the metal parts underneath, of which some were potentially sharp
enough to damage skin;
– At 10:33 A.M., the handrail in the bathing room next to resident room [ROOM NUMBER],
moved back and forth when it was grabbed;
– At 10:41 A.M., the handrail in the third floor south shower room next to the nurse’s
station, moved back and forth when it was grabbed and
– At 12:24 P.M., the handrails in the second floor south shower room moved back and forth
when they were grabbed.
During an interview on 5/10/18 at 10:26 A.M., the Maintenance Supervisor acknowledged that
handrail outside of room [ROOM NUMBER] needed to be repaired.
During an interview on 5/10/18 at 12:25 P.M., the Maintenance Supervisor acknowledged that
the handrail in the second floor shower room was not only loose from the wall but also
loose from brackets which held the hand rail in place.