Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Respond appropriately to all alleged violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed thoroughly investigate an
allegation of narcotic misappropriate for one sampled resident (Resident #36) when the
allegations were brought to the facility’s attention by two sources and to notify the
State Agency within 24 hours of the allegations of a suspicion of misappropriated narcotic
medications. Three residents were sampled for narcotic review (Residents #19, #22, and
#36) out of 13 sampled residents. The facility census was 46 residents.
Record review of the facility’s Abuse Prevention Program policy updated 8/2017 showed:
-If an incident occurs, or there is an allegation that an incident might have occurred, of
abuse, neglect, mistreatment, or misappropriation of resident property, the Administrator,
or designee, will investigate;
-The person doing the investigation will complete a Resident Abuse/Neglect Investigation
Report. It will not be necessary to complete an Incident Report;
-The Administrator will sign and maintain all completed Resident Abuse/Neglect
Investigation Reports and all investigations will remain confidential, except that the
findings and actions shall be reported according to state requirements;
-Any witnessed incidents, allegations of incidents, suspected incidents, including known
or reported misappropriation of resident property, are to be immediately reported to a
supervisor or the charge nurse who will report the incident to the Administrator, or
designee. Any person may also report directly to the Director of Nursing (DON) or
Administrator, or their designees;
-If an alleged or suspected incident of abuse, neglect, mistreatment, or misappropriation
of resident property occurs, the Administrator, or designee, will call he Missouri Elderly
Abuse and Neglect Hotline;
-While the investigation is being conducted, accused individuals, or those suspected of
being responsible for misappropriation of resident property, and who are employees of the
facility will be placed on suspension pending the results of the investigation;
-The Administrator shall keep the resident and his/her responsible party informed of the
progress and the results of the investigation;
-The Administrator will involve the Social Service Designee (SSD) in the investigative
process to provide the necessary medically-related social services appropriate for the
resident and
-If the events that cause the allegation do not involve abuse and do not result in serious
bodily injury, the report must be made to the State Agency within 24 hours of receiving
the allegation.
Record review of the facility’s Documentation of Medication Administration policy dated
4/2007 showed:
-A nurse or Certified Medication Technician (CMT) shall document all medications
administered to each resident on the resident’s Medication Administration Record (MAR).
-Administration of medication must be documented immediately after (never before) it is
given.
-Documentation must include, as a minimum:
–Name and strength of the drug.
–Dosage.
–Method of administration.
–Date and time of administration.
–Signature and title of the person administering the medication.
–Resident response to the medication, if applicable (such as PRN (as needed) and pain

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
medications).
Record review of the facility’s Controlled Substances policy dated 12/2012 showed:
-Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule
II (an opioid narcotic) controlled drugs maintained on premises;
-The DON will identify staff members who are authorized to handle controlled substances;
-An individual resident controlled substance record must be made for each resident who
will be receiving a controlled substance. Do not enter more than one prescription per
page. This record must contain: the name of the resident; the name and strength of the
medication; the quantity received; the number on hand; the name of the physician; the
prescription number; the name of the issuing pharmacy; the date and time received; the
time of administration; the method of administration; the signature of the person
receiving the medication; and the signature of the nurse administering the medication;
-All keys to controlled substance containers shall be on a single key ring that is
different from any other keys;
-The charge nurse on duty will maintain the keys to controlled substance containers. The
DON will maintain a set of back-up keys for all medication storage areas including keys to
controlled substance containers. and
-The DON shall investigate any discrepancies in narcotics reconciliation to determine the
cause and identify any responsible parties, and shall give the Administrator a written
report of such findings.
1. Record review of Resident #36’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Low back pain;
-Other chronic pain;
-[MEDICAL CONDITION] (never pain) and
-Dorsalgia (spinal pain).
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours prn for pain and
-Staff documented [MEDICATION NAME] 5/325 mg administered twice during the month.
Record review of the resident’s Controlled Substance Log showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours prn for pain;
-[MEDICATION NAME] 5/325 mg tablet was removed from the resident’s narcotic supply 18
times during the month;
–16 tablets of [MEDICATION NAME] 5/325 mg were unaccounted for and
–Nine tablets were signed out on the narcotic log and not documented on the resident’s
MAR as administered to the resident by CMT C.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg, one
tablet every four hours prn for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain and
-Staff documented [MEDICATION NAME] 5/325 mg administered seven times during the month.
Record review of the resident’s Controlled Substance Log showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain;
-[MEDICATION NAME] 5/325 mg tablet was removed from the resident’s narcotic supply 19
times during the month;
–12 tablets of [MEDICATION NAME] 5/325 mg were unaccounted for and
–Ten tablets were signed out on the narcotic log and not documented on the resident’s MAR
as administered to the resident by CMT C.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
Record review of the resident’s annual Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning) dated 4/6/18 showed
he/she:
-Was cognitively intact;
-Received scheduled pain medication;
-Received as needed pain medication and
-Received an opioid during the look-back period seven out of seven days.
Record review of the resident’s care plan dated 4/13/18 showed:
-He/She had discomfort/pain in he/her back and
-He/She is currently on scheduled pain medication and he/she requested as needed pain
medication.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg, one
tablet every four hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain;
-[MEDICATION NAME] 5/325 mg was crossed out on 5/27/18 with a handwritten note On Nurse
MAR and
-Staff documented [MEDICATION NAME] 5/325 mg administered 13 times during the month.
Record review of the resident’s Controlled Substance Log showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain;
-[MEDICATION NAME] 5/325 mg tablet was removed from the resident’s narcotic supply 49
times during the month;
–36 tablets of [MEDICATION NAME] 5/325 mg were unaccounted for;
–15 tablets were signed out of the narcotic log and not documented on the resident’s MAR
as administered to the resident between 5/1/18 – 5/27/18 when the MAR was crossed out on
5/27/18 with a handwritten On Nurse MAR by CMT C and
–Six tablets were signed out of the narcotic log and not documented on the resident’s MAR
as administered to the resident between 5/28/17-5/31/18 by CMT C.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg, one
tablet every four hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain was crossed
out on the CMT MAR with a handwritten note On Nurse MAR;
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain was
handwritten on the Nurse’s MAR and
-Staff documented [MEDICATION NAME] 5/325 mg administered twice during the month.
Record review of the resident’s Controlled Substance Log showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain;
-[MEDICATION NAME] 5/325 mg tablet was removed from the resident’s narcotic supply three
times between 6/1/18 – 6/6/18 and
–One tablet of [MEDICATION NAME] 5/325 mg was unaccounted for.
During an interview on 6/5/18 at 9:17 A.M., an anonymous resident said:
-He/She believed CMT C was taking Resident #36’s as needed narcotics;
-He/She reported this to the DON a week or two ago;
-The as needed narcotics were pulled from the CMT’s carts and given to the licensed
nursing staff to administer;
-The alleged perpetrator still worked at the facility and was still administering some as
needed narcotics;
-He/She felt the DON and Administrator did not investigate his/her complaint and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-Resident #36 had told the DON he/she was not getting his/her as needed narcotics.
During an interview on 6/5/18 at 9:55 A.M., the resident said:
-He/She did not usually take as needed pain medication since his/her pain is controlled
with a [MEDICATION NAME] (a narcotic);
-He/She had not requested an as needed pain medication for quite some time before the
previous night;
-Last week a staff member asked him/her if he had been taking two to three as needed
[MEDICATION NAME] 5/325 mg tablets a day and
-He/She told the staff member he had not taken any as needed [MEDICATION NAME] 5/325 mg
for a while and could not remember the last time he/she had requested to take one.
2. Record review of Resident #19’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED].
Record review of the resident’s care plan dated 10/13/17 showed:
-He/She had expressed pain in his/her knee and back at times;
-Had no scheduled pain medication at that time and
-Staff should administer pain medication as ordered.
Record review of the resident’s quarterly MDS dated [DATE] showed he/she:
-Was cognitively intact;
-Received as needed pain medication and
-Received an opioid seven out of seven days during the look-back period.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg; two
tablets every six hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain and
-[MEDICATION NAME] 5/325 mg was documented as administered to the resident 12 times during
the month for a total of 24 tablets.
Record review of the resident’s [MEDICATION NAME] 5/325 mg Controlled Substance Log
showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain;
-[MEDICATION NAME] 5/325 mg, two tables per dose, was removed from the resident’s narcotic
supply 55 times during the month for a total of 110 tablets;
-Forty-three doses, for a total of 86 [MEDICATION NAME] 5/325 mg were unaccounted for
during the month and
-Seventeen doses, for a total of 34 tablets were signed out of the narcotic log and not
documented on the resident’s MAR as administered to the resident by CMT C.
Record review of the resident’s quarterly MDS date 3/27/18, MAR and Controlled Substance
Log showed the resident:
-Had moderate cognitive impairment;
-Received as needed pain medication;
-Received an opioid three out of seven days during the look-back period;
–During the look-back period the resident’s MAR showed [MEDICATION NAME] 5/325 two
tablets every six hours as needed for pain was administered three out of the seven days
and
–During the look-back period the resident’s Controlled Substance Log showed [MEDICATION
NAME] 5/325 mg take two tablets every six hours as needed for pain was removed seven out
of seven days.
Record review of the resident’s (MONTH) (YEAR) POS showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain;
-Discontinue [MEDICATION NAME] 5/325 mg, two tablets every six hours as needed for pain on
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
4/19/18 and
-Start [MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain on
4/19/18.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain;
–Eleven doses were documented as administered between 4/1/18 – 4/19/18, for a total of 22
tablets;
–The rest of the month was crossed out with a handwritten notation the order was changed
on 4/19/18;
-Handwritten [MEDICATION NAME] 10/325 mg take one tablet every six hours as needed for
pain dated 4/19/18 and
–One dose was documented between 4/19/18 – 4/30/18.
Record review of the resident’s [MEDICATION NAME] 5/325 mg Control Substance Log showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain;
-A handwritten note on the second Control Substance Log received by the facility on
4/10/18 noting the order changed on 4/19/18 and nurse needs notified when this card runs
out on the Control Substance Log;
-[MEDICATION NAME] 5/325 mg, two tablets per dose, was removed from the resident’s
narcotic supply 52 times between 4/1/18 – 4/23/18 for a total of 101 tablets;
-Twenty doses for a total of 40 tablets were signed out on the resident’s narcotic log and
not documented as administered on the resident’s MAR by CMT C;
–The resident’s order for [MEDICATION NAME] 5/325 mg was discontinued on 4/19/18;
–Thirteen tablets were removed from the resident’s [MEDICATION NAME] 5/325 mg narcotic
supply after the resident’s order was discontinued;
-Forty-one doses, for a total of 82 [MEDICATION NAME] 5/325 mg were unaccounted for during
the month;
-[MEDICATION NAME] 10/325 mg, take one tablet every six hours for pain was removed from
the resident’s narcotic supply nine times between 4/24/18 – 4/29/18;
–Eight doses of [MEDICATION NAME] 10/325 mg for a total of eight tablets were unaccounted
for between 4/24/18 – 4/30/18 and
–Three tablets were signed out on the resident’s narcotic log and not documented as being
administered to the resident by CMT C.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 10/325 mg,
take one tablet every six hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain;
-Eight doses were documented as administered during the month for total of eight tablets;
-The order was crossed out with a hand-written note after 5/26/18 the medication was on
the nurse’s MAR;
-A handwritten [MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for
pain on the nurse’s MAR and
-No documented doses on the nurse’s MAR during the month.
Record review of the resident’s [MEDICATION NAME] 10/325 mg Control Substance Log showed:
-[MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain;
-[MEDICATION NAME] 10/325 mg, one tablet per dose, was removed from the resident’s
narcotic supply 44 times during the month for a total of 44 tablets;
-Thirty-six doses, for a total of 36 [MEDICATION NAME] 10/325 mg were unaccounted for
during the month;
-Twelve tablets were signed out on the resident’s narcotic log and not documented as
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
administered to the resident on the resident’s MAR by CMT C between 5/1/18 – 5/26/18 and
-Six tablets were signed out on the resident’s narcotic log and not documented as
administered to the resident on the resident’s MAR after the MAR was marked through on
5/27/18 with a handwritten note On Nurse MAR by CMT C.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 10/325 mg,
take one tablet every six hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain was
crossed out with a handwritten note On Nurses MAR;
-A handwritten [MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for
pain on the nurse’s MAR;
-Three doses were documented as administered between 6/1/18 – 6/6/18 for a total of three
tablets and
-No documented doses on the CMT MAR during the month.
Record review of the resident’s [MEDICATION NAME] 10/325 mg Control Substance Log showed:
-[MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain and
-[MEDICATION NAME] 10/325 mg, one tablet per dose, was removed from the resident’s
narcotic supply three times during the month for a total of three tablets.
During an interview on 6/7/18 at 2:53 P.M., the resident said:
-He/She takes his/her pain medication one time a day and
-He/She denied taking more than one pain medication a day.
3. Record review of Resident #22’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE].
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg one
tablet every six hours for pain dated 3/12/18.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg one tablet every six hours for pain and
-[MEDICATION NAME] 5/325 mg was documented as administered by the staff two times during
the month.
Record review of the resident’s medical record showed a Controlled Substance Log could not
be found for 3/12/18 – 3/31/18.
Record review of the resident’s significant change MDS dated [DATE] showed he/she:
-Was severely cognitively impaired;
-Did not receive as needed pain medication and
-Did not receive an opioid during the seven day look-back period.
Record review of the resident’s care plan dated 3/23/18 showed:
-The resident had the potential for pain related to a [MEDICAL CONDITION] and
-Coordinate with his/her physician to manage his/her pain medication for optimum control
of his/her pain.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg one
tablet every six hours for pain dated 3/12/18.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg one tablet every six hours for pain and
-[MEDICATION NAME] 5/325 mg was documented as administered by the staff two times during
the month.
Record review of the resident’s medical record showed no documentation of the resident’s
Controlled Substance Log from 4/1/18 – 4/30/18.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg one
tablet every six hours for pain dated 3/12/18 with a handwritten RN to the side of the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
order.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg one tablet every six hours for pain;
–The order was crossed out with a handwritten On Nurse MAR on 5/27/18 and
-[MEDICATION NAME] 5/325 mg was documented as administered by the staff two times during
the month.
Record review of the resident’s medical record showed no documentation of the resident’s
Controlled Substance Log between 5/1/18 – 5/26/18.
Record review of the resident’s Controlled Substance Log showed:
-[MEDICATION NAME] 5/325 mg, take one tablet four times a day as needed;
-Thirty tablets were delivered on 4/30/18;
-Eight tablets were removed from the resident’s narcotic supply between 5/27/18 – 5/29/18;
–Six [MEDICATION NAME] 5/325 mg were unaccounted for and
–Six tablets were signed out on the resident’s narcotic log and not documented on the
resident’s MAR as administered between 5/27/18-5/31/18 by CMT C. The resident’s MAR was
crossed out on 5/27/18 with a handwritten On Nurse MAR.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg one
tablet every six hours for pain dated 3/12/18 with a handwritten RN to the side of the
order.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg one tablet every six hours for pain;
–The order was crossed out with a handwritten On Nurse MAR on 5/27/18 and
-[MEDICATION NAME] 5/325 mg was documented as administered by the staff zero times during
the month.
Record review of the resident’s Controlled Substance Log showed:
-[MEDICATION NAME] 5/325 mg, take one tablet four times a day as needed;
-Thirty tablets were delivered on 4/30/18;
-One tablet was removed from the resident’s narcotic supply between 6/1/18 – 6/6/18 and
–One [MEDICATION NAME] 5/325 mg was unaccounted for.
Record review of the resident’s medical record showed no additional Controlled Substance
Logs for the resident’s [MEDICATION NAME] 5/325 mg were located by the facility staff
prior to 4/30/18.
During an interview on 6/15/18 at 2:30 P.M., the resident’s pharmacy said:
-On 3/14/18, 30 [MEDICATION NAME] 5/325 mg tablets were delivered to the facility;
-On 4/30/18, 30 [MEDICATION NAME] 5/325 mg tablets were delivered to the facility;
–Per the resident’s pharmacy interview, a total of 60 tablets were delivered to the
facility;
–Six tablets have been documented on the resident MAR as administered between 3/12/18 –
6/6/18;
–Nine tablets have been signed out on the resident’s Controlled Substance Log with 21
tablets remaining and
–A total of 54 [MEDICATION NAME] 5/325 mg tablets are unaccounted for.
4. During an interview on 6/7/18 at 2:56 P.M., the Administrator said:
-He/She recalled the DON calling him/her a week or so ago, he/she couldn’t remember the
exact date, regarding a concern about possible narcotic diversion by CMT C;
-The DON was supposed to call the Regional Nurse to help him/her with the investigation;
-The DON should have the results of the investigation and
-To his/her knowledge, the investigation was completed and unsubstantiated.
During an interview on 6/7/18 at 3:24 P.M., the DON said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
-He/She expected staff to document on the resident’s MAR each time an as needed medication
is administered;
-If staff remove a medication from the resident’s Controlled Substance Log, that
medication should be documented on the resident’s MAR as well;
-He/She does not compare the Controlled Substance Log with the MAR to ensure accuracy of
the medication count;
-He/She was made aware by a staff member and by a resident of a concern that Resident #36
was not receiving all of the narcotics that were being signed out as administered on
5/25/18 or 5/26/18;
-He/She did not compare the resident’s Controlled Substance Log to the resident’s MAR to
determine if there were any unaccounted for narcotics;
-He/She did not compare any other resident’s Controlled Substance Log to the resident’s
MAR to determine if any other residents had narcotics that were unaccounted for;
-He/She did not have record of his/her investigation;
-He/She did not think CMT C had diverted narcotics, thought it was a documentation issue;
-He/She had been aware there was an issue with medication documentation in the past;
-He/She had not been auditing medication administration documentation after being aware of
the documentation issue;
-He/She did not notify the State Agency regarding the alleged diversion;
-The alleged perpetrator was not suspended because he/she was not on the schedule to work
during the time he/she was investigating the diversion allegation;
-He/She removed the as needed narcotics for residents who were not alert and oriented from
the CMT’s cart and gave the narcotics to the licensed nurses on 5/27/18 due to this
allegation and the CMT’s lack of documentation;
-He/She did not have record of interviewing the resident who allegedly had missing
narcotics and
-He/She did not interview other staff regarding narcotic administration or documentation.
During an interview on 6/7/18 at 5:36 P.M., CMT C said:
-He/She had been in-serviced at some time about how to document administration of
narcotics;
-Staff should document on the resident’s narcotic Controlled Substance Log when a dose is
removed for administration;
-He/She would document on the front of the resident’s MAR when he/she administered a
medication, including an as needed narcotic;
-He/She would assess the resident’s pain prior to administering an as needed narcotic pain
medication and document it on the back of the resident’s MAR;
-The licensed nurse were to follow-up on the effectiveness of the resident’s as needed
narcotic pain medication;
-He/She could not explain why an as needed narcotic would be documented as removed from
the resident’s narcotic supply and not documented as administered on the resident’s MAR
and
-He/She denied diverting narcotic pain medication for his/her personal use.
Complaint #MO 471

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure
residents who required staff assistance with bathing were offered and/or received at least
two baths or showers per week for five sampled residents (Resident #19, #33, #96, #4, and
#17) out of 13 sampled residents. The Facility Assessment Tool showed the facility had 40
residents which required staff assistance for bathing. The facility census was 46
residents.
Record review of the facility’s Shower/Tub Bath policy dated 10/2010 showed:
-The following information should be recorded on the resident’s Activity of Daily Living
(ADL) record and/or in the resident’s medical record:
–The date and time the shower/tub bath was performed.
–The name and title of the individual(s) who assisted the resident with the shower/tub
bath.
–All assessment data, such as any reddened areas or sores on the resident’s skin,
obtained during the resident’s shower/tub bath.
–How the resident tolerated the shower/tub bath.
–If the resident refused the shower/tub bath, the reason(s) why, and the interventions
taken.
–The signature and title of the person recording the data.
-Notify the supervisor if the resident refused the shower/tub bath.
1. Record review of Resident #19’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE].
Record review of the resident’s Care Plan dated 10/13/17 showed the resident:
-Had been discharged to the hospital on [DATE] and returned on 5/8/18;
-He/She required staff assistance to complete ADL’s;
-Staff should provide assistance with bathing and
-He/She should be bathed per his/her schedule.
Record review of the resident’s quarterly Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning) dated 12/28/17 showed
he/she:
-Was cognitively intact and
-Required extensive staff assistance for bathing.
Record review of the resident’s quarterly MDS dated [DATE] showed he/she:
-Had moderate cognitive impairment and
-Required extensive staff assistance for bathing.
Record review of the resident’s Shower Log dated (MONTH) (YEAR) – (MONTH) (YEAR) showed:
-The resident received a shower on 5/3/18, 5/9/18, 5/14/18, 5/24/18 and 5/26/18;
-The resident was in the hospital on [DATE];
-The resident had no documented showers or baths from 6/1/18 – 6/7/18;
–No documentation by the facility staff the resident received at least two showers per
week and
–No documentation the resident received a shower between 5/26/18 – 6/7/18.
Record review of the resident’s Shower Sheet/Skin Assessment showed:
-The resident received a shower on 5/1/18, 5/14/18, and 5/24/18 and
-No documented showers after 5/24/18 – 6/7/18.
During an interview on 6/5/18 at 11:01 A.M. the resident said:
-He/She would like to have a bath or shower at least twice a week;
-Staff did not have time to give him/her a bath or shower twice a week and
-He/She was not sure how long it had been since he/she had a bath or shower.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
Observation on 6/6/18 at 6:00 A.M. showed the resident was sitting in his/her recliner
with his/her eyes closed. His/her hair was oily and slicked down to his/her scalp.
During an interview and observation on 6/6/18 at 7:19 A.M. showed the resident was in
his/her wheelchair propelling themselves down the hall. His/her hair was unclean, oily,
and slicked down to his/her scalp. The resident said it had been a while since he/she had
a bath.
During an interview and observation on 6/6/18 at 9:50 A.M. showed:
-The resident’s hair was oily and slicked down to his/her scalp;
-Certified Nursing Assistant (CNA) A and Registered Nurse (RN) A assisted the resident to
the toilet.
-CNA A said:
–RN A or Certified Medication Technician (CMT) A would be able to watch the resident’s on
the 300 and 400 hall if he/she had to stop answering call lights to give a resident a
shower;
–He/She could ask the charge nurse to watch call lights on the 300 and 400 hall, but
sometimes there is only one CMT for 100, 200, 300, and 400 halls, so the CMT may not be
available to help watch call lights;
–The facility had a shower book with a resident shower schedule, but he/she did not know
what happened to it;
–He/She did not know what days the residents were supposed to get baths;
–He/She will give a resident a shower if he/she thinks the resident needs one;
–He/She would document the resident’s shower in the shower book after it had been
completed and
-It was difficult to get showers done for the 300 and 400 hall when he/she is the only CNA
for 23 residents.
During an observation and interview on 6/7/18 at 8:55 A.M. the resident:
-Had oily hair slicked down to his/her scalp;
-Had a small, quarter-sized reddened area on his/her right chest, visible above the
neckline of his/her shirt;
-Was in his/her wheelchair in front of the nurse’s station with two unidentified staff in
the area.
-Said I hope I get a shower today and
-Reported he/she had not received a shower since before the survey started on 6/4/18 and
was not certain when his/her last shower was.
During an interview and observation on 6/7/18 at 7:00 P.M., the resident:
-Had oily hair slicked down to his/her scalp and
-Said he/she still had not received a shower.
During an interview on 6/7/18 at 9:39 A.M., CNA B said:
-Normally the facility has a dedicated shower aide, but does not currently have one;
-He/She tries to work resident showers in when he/she can and ask the charge nurse and CMT
to watch the unit and answer call lights while he/she give the residents showers;
-There is a shower book the staff are supposed to sign when a resident’s shower has been
completed;
-Staff is also supposed to complete a Shower Sheet that shows a skin assessment has been
completed with the resident’s shower;
-The Shower Sheet is turned in to the Director of Nursing (DON) for review and
-He/She has not been able to get resident showers done because there is not enough staff
to help watch the floor, toilet residents, and answer call lights while he/she is
assisting the resident’s in the shower.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
During an interview on 6/8/18 at 10:40 A.M., Licensed Practical Nurse (LPN) A said:
-All staff were responsible to ensure residents received baths;
-There is a bathing schedule for the staff to refer to know when a resident’s bath or
shower is due;
-He/She could not locate a resident bathing schedule in the Shower Book for the 300 and
400 halls;
-Staff should go through the Shower Book to see who has had an shower and to ask the
resident’s who have not had a shower that week if they want one;
-Staff should document in the Shower Book if a resident refused a shower;
-Staff should also complete a skin sheet when a resident’s bath is completed for the nurse
to review. This form is then turned into the DON to review;
-Nursing staff should also document in the resident’s Nurse’s Notes if the resident
refused a shower;
-Residents should be offered two showers a week;
-The charge nurse and the DON should follow up to ensure showers are at least offered
twice weekly and
-The last documented shower for Resident #19 was 5/26/18.
During an interview on 6/8/18 at 10:42 A.M., CMT A said:
-Residents should have at least two showers per week;
-Staff should write down on the Shower Log in the Shower Book if a resident refused
his/her shower, but sometimes staff forget to document when a resident refuses;
-Residents have assigned shower days, which should be located on the front of the Shower
Book and
-He/She could not locate the resident shower schedule for the 300 and 400 halls.
2. Record review of Resident #33’s Face Sheet showed he/she was admitted to the facility
on [DATE], and most recently readmitted on [DATE].
Record review of the resident’s Annual MDS, dated [DATE], showed he/she:
-Was cognitively intact;
-Had no behaviors and did not exhibit rejection of cares;
-Needed extensive assistance with bed mobility and toileting;
-Needed limited assistance with personal hygiene and dressing and
-Did not participate or have staff participation with bathing, walking or transfer during
the 7-day assessment look back period.
Record review of the resident’s Care Plan reviewed and updated 4/30/18, showed:
-The resident often refused cares and
-Staff should provide assistance with ADL’s.
Record review of the resident’s Shower Log for (MONTH) (YEAR) showed:
-The resident did not receive a shower or bed bath during the month of May;
-There was no documentation to show the resident was offered a shower or bath, or refusal
of a shower or bath and
-The shower log was blank.
Record review of the resident’s Shower Log for (MONTH) (YEAR) showed:
-The resident had not received a shower or bed bath and
-There was no documentation to show the resident refused a shower or bath.
-The shower log was blank.
3. Record review of Resident #96’s Face Sheet showed he/she was admitted to the facility
on [DATE], and most recently readmitted on [DATE].
Record review of the resident’s Annual MDS, dated [DATE], showed he/she:
-Was moderately cognitively impaired;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
-Had no behaviors and did not exhibit rejection of cares;
-Needed extensive assistance with transfers, walking, toileting, and bathing and
-Needed limited assistance with bed mobility, dressing, and personal hygiene.
Record review of the resident’s Care Plan reviewed and updated 4/30/18, showed staff
should provide assistance with ADL’s.
Record review of the resident’s Shower Log for (MONTH) (YEAR) showed he/she received four
showers during the month of (MONTH) (on 5/3, 5/7, 5/14, 5/26).
Record review of the resident’s Shower Log for (MONTH) (YEAR) showed the resident had a
shower on 6/7. (Note: The resident did not have a shower for 11 days prior to (MONTH) 7.)
Observation of the resident on 6/5/18 at 9:31 A.M. showed the resident in his/her
wheelchair outside his/her room. The resident had an odor.
Observation and interview of the resident on 6/5/18 at 10:00 A.M., during Resident
Council, showed the resident in his/her wheelchair. Another resident attending the meeting
would not sit by the resident because of the resident’s odor.
During an interview on 6/8/18 at 1:46 P.M., CNA A said:
-Residents should be getting showers every two or three days. It does happen sometimes;
-Showers should be documented in the shower book and
-There is a shower book at each nurses’ station.
During an interview on 6/8/18 at 2:13 P.M., the DON said
-Residents should be getting showers or baths twice weekly;
-We had a shower aide, but she has been working on the floor;
-He/she knew that some residents were not getting their baths;
-Showers should be documented on the shower sheet and the shower sheet should be given to
the charge nurse;
-The charge nurse should look at anything noted on the shower sheet and document anything
in reference to skin issues;
-The nurse should monitor shower sheets;
-Staff mentioned they did not have time to do baths/showers;
-The nurse should take initiative to help the CNAs by watching the floor while the CNAs
give showers;
-There have been audits and the audits show that more CNAs are needed;
-Even if a resident refuses their shower, it should be documented on the shower sheet and
-Showers should be offered and given to residents on halls 100 and 300 on Mondays and
Thursdays; and to residents on halls 200 and 400 on Tuesdays and Fridays.
4. Record review of Resident # 4’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following [DIAGNOSES REDACTED].
Record review of the resident’s quarterly MDS dated [DATE] showed he/she:
-Was cognitively intact and
-Required limited staff assistance for bathing.
Record Review of the resident’s Care Plan dated 9/7/17 showed:
-He/she required staff assistance to complete ADL’s and
-Staff should provide assistance with bathing.
Record review of the resident’s Shower Log dated (MONTH) (YEAR) and (MONTH) (YEAR) showed
the resident:
-Received a shower on 5/3/18, and 5/20/18;
-Had no documented showers or baths from 5/20/18 through 6/7/18 and
-Had no documentation, by facility staff, that showed the resident had received at least
two shower/baths per week.
Record review of the resident’s Shower Sheet/Skin Assessment for (MONTH) (YEAR) and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
(MONTH) (YEAR) showed he/she received a shower on 5/3/18.
Observation on 6/4/18 at 8:00 P.M. of the resident’s room showed:
-The room had a very strong odor;
-Flies flying around in room;
-Resident was sitting in his/her wheelchair watching TV and
-His/her hair slicked back.
Observation on 6/5/18 at 1:00 P.M. of the resident’s room showed:
The room had a very strong odor;
-Flies flying around in room;
-Resident was sitting in his/her wheelchair, TV on, and lunch tray in front of him/her and
-His/her hair slicked back.
During an interview on 6/5/18 at 1:00 P.M. the resident said:
-He/she would like to have a bath/shower more often;
-There wasn’t enough staff to give him/her a bath/shower;
-He/she was not sure how long it had been since he/she had a bath/shower and
-He/she don’t ask any more for a bath/shower because he/she won’t get one.
Observation on 6/6/18 at 7:00 A.M. showed of the resident’s room showed:
-The room had a very strong odor;
-Resident was sitting in his/her wheelchair with TV on and
-His/her hair slicked back.
Observation on 6/7/18 at 8:00 A.M. of the resident’s room showed:
-The room had a very strong odor;
-Resident was sitting in his/her wheelchair with TV on and
-His/her hair slicked back.
5. Record review of Resident # 17’s Face Sheet showed that he/she was admitted to the
facility on [DATE], readmitted on ,[DATE] and 3/17/18.
Record review of the resident’s Medical Record showed the following [DIAGNOSES REDACTED].
Record review of the resident’s quarterly MDS dated [DATE] showed he/she:
-Was severely cognitively impaired and
-Required total staff assistance for bathing.
Record Review of the resident’s Care Plan dated 2/20/18 showed:
-He/she was dependent on staff for daily hygiene/grooming;
-He/she to be showered/bathed per schedule and
-Staff should provide assistance with bathing.
Record review of the resident’s Shower Log dated (MONTH) (YEAR) and (MONTH) (YEAR) showed
the resident:
-Received a shower on 5/3/18;
-Had no documented showers or baths from 5/3/18 through 6/7/18 and
-Had no documentation, by facility staff, that showed the resident received at least two
shower/baths per week.
Record review of the resident’s Shower Sheet/Skin Assessment for (MONTH) (YEAR) and
(MONTH) (YEAR) showed he/she received a shower on 5/3/18.
Observation on 6/4/18 at 7:49 P.M., showed:
-The resident lying in bed on right side in fetal position and
– His/her hair looked oily and uncombed.
Observation on 6/5/18 at 12:48 P.M. showed:
-The resident sitting up in wheelchair and
-His/her hair looked oily and uncombed.
Observation on 6/6/18 at 6:20 A.M. showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
-The resident lying in bed on left side in fetal position and
-His/her hair looked oily and uncombed.
6. During an interview on 6/8/18 at 2:13 P.M., the DON said:
-Residents should be getting showers or baths twice weekly;
-We had a shower aide, but she has been working on the floor;
-He/she knew that some residents were not getting their baths;
-Showers should be documented on the shower sheet and the shower sheet should be given to
the charge nurse;
-The charge nurse should look at anything noted on the shower sheet and document anything
in reference to skin issues;
-The nurse should monitor shower sheets;
-Staff mentioned they did not have time to do baths/showers;
-The nurse should take initiative to help the CNAs by watching the floor while the CNAs
give showers;
-There have been audits and the audits show that more CNAs are needed;
-Even if a resident refuses their shower, it should be documented on the shower sheet and
-Showers should be offered and given to residents on halls 100 and 300 on Mondays and
Thursdays; and to residents on halls 200 and 400 on Tuesdays and Fridays.

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 interview and record review, the facility failed to notify a resident’s physician
when the resident’s blood sugar was below defined parameters and to follow the facility’s
[DIAGNOSES REDACTED] (low blood sugar) policy for one sampled resident (Resident #36) out
of 13 sampled residents. The facility was 46 residents.
Record review of the facility’s Nursing Care of the Resident with Diabetes Mellitus
(Diabetes – a complex disorder of carbohydrate, fat, and protein metabolism that is
primarily a result of a deficiency or complete lack of insulin secretion in the pancreas
or resistance to insulin) dated 12/2015 showed:
-The management of individuals with diabetes should follow relevant protocols and
guidelines.
-For asymptomatic (no symptoms) and responsive residents with [DIAGNOSES REDACTED] less
than the physician ordered parameter, give the resident an oral form of rapidly absorbed
glucose (4 ounces (oz.) juice or 5-6 oz. of soda) then recheck the resident’s blood sugar
in 15 minutes.
-For symptomatic but responsive residents with [DIAGNOSES REDACTED] less than the
physician ordered parameter who are able to swallow, immediately give the resident an oral
form of rapidly absorbed glucose then recheck the resident’s blood sugar in 15 minutes.
-For symptomatic but responsive residents with [DIAGNOSES REDACTED] less than the
physician ordered parameter who are not able to swallow, immediately administer oral
glucose paste to the [MEDICATION NAME] mucosa (the inner lining of the cheek and gum area)
then recheck the resident’s blood sugar in 15 minutes.
1. Record review of Resident #36’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 14)
Record review of the resident’s annual Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning) dated 4/6/18 showed
he/she was cognitively intact.
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED]. Notify the
resident’s physician for blood sugar results below 60 or above 400.
Record review of the resident’s (MONTH) (YEAR) Medication Administration Record [REDACTED]
-Accuchecks three times daily before meals. Notify the resident’s physician for blood
sugar results below 60 or above 400.
-5/3/18 evening blood sugar was 57;
-5/4/18 morning blood sugar was 53;
-5/9/18 morning blood sugar was 48;
-5/19/18 morning blood sugar was 50;
-5/25/18 evening blood sugar was 56;
-5/26/18 morning blood sugar was 49 and
-No documentation on the back of the MAR indicated [REDACTED].
Record review of the resident’s Accucheck Record showed:
-On 5/10/18 the facility faxed the resident’s blood sugar results from 5/3/18 – 5/9/18 to
the resident’s physician;
-On 5/17 the facility faxed the resident’s blood sugar results from 5/10/18 – 5/16/18 to
the resident’s physician;
-On 5/24/18 the facility faxed the resident’s blood sugar results from 5/17/18 – 5/23/18
to the resident’s physician and
-On 5/31/18 the facility faxed the resident’s blood sugar results from 5/24/18 – 5/30/18
to the resident’s physician.
Record review of the resident’s Nurse’s Notes from 5/1/18 – 5/31/18 showed no
documentation the resident’s physician was notified of the resident’s low blood sugar
results, any interventions done by the staff, or any repeat blood sugar testing results
when the resident’s blood sugar was below 60.
Record review of the resident’s (MONTH) (YEAR) POS showed Accuchecks (blood sugar
monitoring) three times daily before meals. Notify the resident’s physician for blood
sugar results below 60 or above 400.
Record review of the resident’s (MONTH) (YEAR) MAR indicated [REDACTED]
-Accuchecks three times daily before meals. Notify the resident’s physician for blood
sugar results below 60 or above 400;
-6/2/18 morning blood sugar was 51 and
-No documentation on the back of the MAR indicated [REDACTED].
Record review of the resident’s Nurse’s Notes from 6/1/18 – 6/6/18 showed no documentation
the resident’s physician was notified of the resident’s low blood sugar results, any
interventions done by the staff, or any repeat blood sugar testing results when the
resident’s blood sugar was below 60.
During an interview on 6/5/18 at 10:45 A.M. the resident said:
-He/She has had a few times when his/her blood sugar was low and
-He/She thinks the fall he/she had last month may have been due to low blood sugar.
During an interview on 6/8/18 at 10:42 A.M., Certified Medication Technician (CMT) A said:
-He/She performs the resident’s blood glucose monitoring and
-He/She would report to the charge nurse if the resident’s blood sugar level was less than
the physician’s parameters or greater than the physician’s parameters.
During an interview on 6/8/18 at 10:45 A.M., Licensed Practical Nurse (LPN) A said:
-The CMT’s performs the resident’s blood glucose monitoring;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 15)
-He/She would expect the CMT to report to him/her when a resident’s blood sugar level was
less than or greater than the physician’s parameters;
-The nurse should document on the back of the resident’s MAR indicated [REDACTED]
-The nurse should document on the back of the resident’s MAR indicated [REDACTED]
-The nurse should document in the resident’s Nurse’s Note the date and time of the
resident’s physician’s notification;
-If the resident’s order was to notify the resident’s physician for a blood sugar less
than 60, the nurse should have called the resident’s physician and documented it in the
resident’s medical record and
-Notifying the resident’s physician several days later by fax with the resident’s weekly
blood sugar notification would not be appropriate notification.
During an interview on 6/8/18 at 2:03 P.M., the Director of Nursing (DON) said:
-He/She expected the staff to follow the resident’s physician’s orders [REDACTED].>-If
a resident has an order to notify the resident’s physician for blood sugar levels less
than 60, he/she expected the staff to notify the resident’s physician and to document the
notification in the resident’s Nurse’s Notes and/or on the back of the resident’s MAR;
-The CMT’s usually obtain the resident’s blood sugars;
-The CMT should notify the charge nurse if a resident’s blood sugar level is out of the
physician ordered parameters and
-The resident’s physician should be notified before the weekly fax reporting the
resident’s blood sugar levels.

F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide safe, appropriate pain management for a resident who requires such services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a resident’s pain was
assessed by a licensed nurse prior to the administration of an as needed narcotic pain
medication, to ensure a resident’s pain was assessed for the effectiveness of an as needed
narcotic pain medication, to accurately document the administration of an as needed
narcotic pain medication, and to provide non-pharmacological interventions for four
sampled residents (Residents #19, #22, #33 and #36) out of 13 sampled residents. The
facility census was 46 residents.
Record review of the facility’s Documentation of Medication Administration policy dated
4/2007 showed:
-A nurse or Certified Medication Technician (CMT) shall document all medications
administered to each resident on the resident’s Medication Administration Record (MAR);
-Administration of medication must be documented immediately after (never before) it is
given.
-Documentation must include, as a minimum:
–Name and strength of the drug.
–Dosage.
–Method of administration.
–Date and time of administration.
–Signature and title of the person administering the medication.
–Resident response to the medication, if applicable (such as PRN (as needed) and pain
medications).

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
1. Record review of Resident #36’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Low back pain;
-Other chronic pain;
-[MEDICAL CONDITION] (never pain) and
-Dorsalgia (spinal pain).
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain;
-Staff documented [MEDICATION NAME] 5/325 mg was administered twice during the month;
-No documentation on the back of the resident’s MAR the resident’s pain was assessed prior
to or after the administration of [MEDICATION NAME] 5/325 mg and
-No documentation the staff attempted non-pharmacological interventions prior to
administering an as needed narcotic pain medication.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg, one
tablet every four hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain;
-Staff documented [MEDICATION NAME] 5/325 mg administered seven times during the month;
-The CMT assessed the resident’s pain prior to administering an as needed [MEDICATION
NAME] 5/325 mg tablet five times. Three of the five assessments did not include a pain
scale rating;
-The licensed nurse assessed the resident’s pain prior to administering an as needed
[MEDICATION NAME] 5/325 mg tablet one time;
-The licensed nurse assessed the effectiveness of the resident’s as needed pain medication
my documenting a down arrow pain without a pain scale rating six times and
-No documentation staff attempted non-pharmacological interventions prior to administering
as needed narcotic pain medication.
Record review of the resident’s annual Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning) dated 4/6/18 showed
he/she:
-Was cognitively intact;
-Received scheduled pain medication;
-Received as needed pain medication and
-Received an opioid during the look-back period seven out of seven days.
Record review of the resident’s care plan dated 4/13/18 showed:
-He/She had discomfort/pain in his/her back and
-He/She is currently on scheduled pain medication and has requested as needed pain
medication.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg, one
tablet every four hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain;
-[MEDICATION NAME] 5/325 mg was crossed out on 5/27/18 with a handwritten note On Nurse
MAR;
–Staff documented [MEDICATION NAME] 5/325 mg administered 13 times during the month;
–The CMT documented the resident’s pain assessment prior to the administration of an as
needed [MEDICATION NAME] 5/325 mg five times;
–The licensed nurse reassess the resident’s pain after the administration of an as needed
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
[MEDICATION NAME] 5/325 mg four times. Three of the four times did not include a pain
scale rating;
-Non-pharmacological interventions every shift;
–Staff documented nothing for non-pharmacological interventions 92 out of 93 shifts and
–No documentation of a non-pharmacological intervention prior to each documented as
needed [MEDICATION NAME] administration.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg, one
tablet every four hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain was crossed
out on the CMT MAR with a handwritten note On Nurse MAR;
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain was
handwritten on the Nurse’s MAR;
–Staff documented [MEDICATION NAME] 5/325 mg administered twice during the month;
-Non-pharmacological intervention prior to giving pain medications and chart result every
shift and
–Staff documented nothing for non-pharmacological interventions 16 out of 16 shifts.
2. Record review of Resident #19’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED].
Record review of the resident’s care plan dated 10/13/17 showed:
-He/She had expressed pain in his/her knee and back at times;
-Had no scheduled pain medication at that time and
-Staff should administer pain medication as ordered.
Record review of the resident’s quarterly MDS dated [DATE] showed he/she:
-Was cognitively intact;
-Received as needed pain medication and
-Received an opioid seven out of seven days during the look-back period.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg; two
tablets every six hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain;
-[MEDICATION NAME] 5/325 mg was documented as administered to the resident 12 times during
the month for a total of 24 tablets;
–Staff documented the resident’s pain assessment prior to and after the administration of
as needed [MEDICATION NAME] three times;
–Two of the three times the resident’s pain was assessed prior to the administration of
an as needed [MEDICATION NAME] was completed by the CMT and
-No documentation the staff attempted non-pharmacological interventions prior to
administering an as needed narcotic pain medication.
Record review of the resident’s quarterly MDS dated [DATE], MAR and Controlled Substance
Log showed he/she:
-Had moderate cognitive impairment;
-Received as needed pain medication and
-Received an opioid three out of seven days during the look-back period.
–During the look-back period the resident’s MAR showed [MEDICATION NAME] 5/325 two
tablets every six hours as needed for pain was administered three out of the seven days
and
–During the look-back period the resident’s Controlled Substance Log showed [MEDICATION
NAME] 5/325 mg take two tablets every six hours as needed for pain was removed seven out
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
of seven days.
Record review of the resident’s (MONTH) (YEAR) POS showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain;
-Discontinue [MEDICATION NAME] 5/325 mg, two tablets every six hours as needed for pain on
4/19/18 and
-Start [MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain on
4/19/18.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain;
–Eleven doses were documented as administered between 4/1/18 – 4/19/18, for a total of 22
tablets;
–The rest of the month was crossed out with a handwritten notation the order was changed
on 4/19/18;
–The CMT documented the resident’s pain assessment prior to the administration of an as
needed [MEDICATION NAME] 5/325 mg 9 times;
-Handwritten [MEDICATION NAME] 10/325 mg take one tablet every six hours as needed for
pain dated 4/19/18;
–One dose was documented between 4/19/18 – 4/30/18;
–The CMT documented the resident’s pain assessment prior to the administration of an as
needed [MEDICATION NAME] 10/325 mg one time and
-No non-pharmacological interventions were documented as attempted prior to the
intervention of an as needed narcotic pain medication.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 10/325 mg,
take one tablet every six hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain;
-Eight doses were documented as administered during the month for total of eight tablets;
-The order was crossed out with a hand-written note after 5/26/18 the medication was on
the nurse’s MAR;
-A handwritten [MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for
pain on the nurse’s MAR;
-No documented doses on the nurse’s MAR during the month;
-The resident’s pain was assessed prior to the administration of as needed [MEDICATION
NAME] 10/325 mg seven times. The CMT assessed the resident’s pain prior to administering
as needed [MEDICATION NAME] 10/325 mg four times;
-The effectiveness of the as needed [MEDICATION NAME] was assessed four out of seven times
the medication documented as assessed prior to administration and
-Non-pharmacological interventions prior to giving pain medications every shift.
–Staff documented nothing as the non-pharmacological intervention 50 out of 85 shifts;
–Staff documented relaxation as the non-pharmacological intervention 26 out of 85 shifts
and
–Staff documented music as the non-pharmacological intervention eight out of 85 shifts.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 10/325 mg,
take one tablet every six hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain was
crossed out with a handwritten note On Nurses MAR;
-A handwritten [MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for
pain on the nurse’s MAR;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
-Three doses were documented as administered between 6/1/18 – 6/6/18 for a total of three
tablets and
-No documented doses on the CMT MAR during the month.
3. Record review of Resident #22’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE].
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg one
tablet every six hours for pain dated 3/12/18.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg one tablet every six hours for pain;
-[MEDICATION NAME] 5/325 mg was documented as administered by the staff two times during
the month;
-No documentation the staff assessed the resident’s pain prior to or after the
administration of an as needed [MEDICATION NAME] 5/325 mg tablet and
-No documentation the staff utilized non-pharmacological interventions prior to
administering an as needed [MEDICATION NAME] 5/325 mg tablet.
Record review of the resident’s significant change MDS dated [DATE] showed he/she:
-Was severely cognitively impaired;
-Did not receive as needed pain medication and
-Did not receive an opioid during the seven day look-back period.
Record review of the resident’s care plan dated 3/23/18 showed:
-The resident had the potential for pain related to a [MEDICAL CONDITION] and
-Coordinate with his/her physician to manage his/her pain medication for optimum control
of his/her pain.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg one
tablet every six hours for pain dated 3/12/18.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg one tablet every six hours for pain;
-[MEDICATION NAME] 5/325 mg was documented as administered by the staff two times during
the month;
-The CMT assessed the resident’s pain prior to administering an as needed [MEDICATION
NAME] 5/325 mg two times;
-The resident’s pain was not reassessed after the administration of an as needed
[MEDICATION NAME] 5/325 mg two out of two times and
-No documentation by the facility staff a non-pharmacological intervention was attempted
prior to administering an as needed [MEDICATION NAME] 5/325 mg tablet.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg one
tablet every six hours for pain dated 3/12/18 with a handwritten RN to the side of the
order.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg one tablet every six hours for pain;
–The order was crossed out with a handwritten On Nurse MAR on 5/27/18;
-[MEDICATION NAME] 5/325 mg was documented as administered by the staff two times during
the month;
-The CMT assessed the resident’s pain prior to administering an as needed [MEDICATION
NAME] 5/325 mg tablet two times;
-The CMT assessed the resident’s effectiveness of the resident’s pain medication and
documented the assessment with a down arrow pain one time;
-The resident’s pain was not reassessed after an as needed [MEDICATION NAME] 5/325 mg
tablet one out of two times and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-Non-pharmacological interventions prior to giving pain medications per shift.
-Staff documented nothing as the non-pharmacological intervention 93 out of 93 shifts.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg one
tablet every six hours for pain dated 3/12/18 with a handwritten RN to the side of the
order.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg one tablet every six hours for pain;
–The order was crossed out with a handwritten On Nurse MAR on 5/27/18;
-[MEDICATION NAME] 5/325 mg was documented as administered by the staff zero times during
the month;
-Non-pharmacological interventions prior to giving pain medications and chart each shift
and
-Staff documented nothing as the non-pharmacological intervention 20 out of 20 shifts.
4. During an interview on 6/7/18 at 3:24 P.M., the Director of Nursing (DON) said:
-He/She expected staff to document on the resident’s MAR each time an as needed medication
is administered;.
During an interview on 6/7/18 at 5:36 P.M., CMT C said:
-He/She had been in-serviced at some time about how to document administration of
narcotics;
-He/She would document on the front of the resident’s MAR when he/she administered a
medication, including an as needed narcotic;
-He/She would assess the resident’s pain prior to administering an as needed narcotic pain
medication and document it on the back of the resident’s MAR and
-The licensed nurse was responsible to follow-up on the effectiveness of the resident’s as
needed narcotic pain medication.
During an interview on 6/8/18 at 10:44 A.M., Licensed Practical Nurse (LPN) A said:
-The CMT and the nurse can administer an as needed narcotic to a resident;
-The licensed nurse should assess the resident’s pain with a pain scale prior to the
resident being administered an as needed pain medication;
-Staff should document as needed medication administration on the front of the resident’s
MAR;
-The back of the resident’s MAR should have the resident’s pain assessment before and
after an as needed medication is administered;
-If the CMT gives him/her the resident’s MAR to show an as needed medication was
administered, he/she will reassess the resident and document the reassessment on the back
of the resident’s MAR;
-If the CMT does not give him/her the resident’s MAR, he/she would not know an as needed
narcotic was administered to the resident;
-Non-pharmacological interventions should be attempted before an as needed pain
medications is administered unless the resident refused the non-pharmacological
intervention and
-If the resident refused a non-pharmacological intervention, it should be documented on
the resident’s MAR.
During an interview on 6/8/18 at 10:50 A.M., CMT A said:
-He/She would assess a resident’s pain and report to the charge nurse what the resident’s
pain was and where it was;
-It depends on who the charge nurse is if he/she would report the resident’s pain report
before giving the as needed pain medication and depending on the resident;
-Staff should document as needed medication administration on the front of the resident’s
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
MAR;
-The back of the resident’s MAR should have the resident’s pain assessment before and
after an as needed medication is administered.
5. Record review of Resident #33’s Face Sheet showed he/she was admitted to the facility
on [DATE], and most recently readmitted on [DATE].
Record review of the resident’s annual MDS, dated [DATE], showed he/she:
-Was cognitively intact;
-Had no behaviors;
-Needed extensive assistance with bed mobility and toileting;
-Needed limited assistance with personal hygiene and dressing;
-Experienced frequent pain;
-Had pain that made it hard to sleep and
-Received Opioid pain medication 7 out of 7 days during the assessment period.
Record review of the resident’s Care Plan reviewed and updated 4/30/18, showed:
-The resident verbalized discomfort/pain freely and talked to his/her Primary Care
Physician (PCP) about his/her pain on visits.
-Interventions included:
–Provide comfort measures as needed.
–Comfort measures included back rubs, lotion to the resident’s body, sponge baths, and
repositioning.
–Pain medication was to be administered as needed.
Record review of the resident’s current POS showed a physician’s orders [REDACTED].
-Two tablets were to be administered by mouth every four hours PRN for pain;
-The order was originally dated 8/25/17 and
-The order was renewed 5/26/18.
Record review of the resident’s MAR showed the resident received [MEDICATION NAME] 50 mg
tablets on the following dates:
-On 5/1/18 at 11:45 A.M. for general pain all over;
–No non-pharmacological interventions were documented;
-On 5/1/18 at 9:30 P.M. for general pain at 9, on a scale of 1 to 10;
–No non-pharmacological interventions were documented;
–The effectiveness of the medication was not evaluated;
-On 5/2/18 at 7:00 P.M. for general pain at 6 on a scale of 1 to 10;
–No non-pharmacological interventions were documented;
-On 5/3/18 at 10:00 A.M. for general pain at 6 on a scale of 1 to 10;
–No non-pharmacological interventions were documented;
–The effectiveness of the medication was not evaluated;
-On 5/4/18 at 4:45 A.M. for general pain at 9 on a scale of 1 to 10;
–No non-pharmacological interventions were documented;
-On 5/4/18 at 10:00 A.M. for general pain at 8 on a scale of 1 to 10;
–No non-pharmacological interventions were documented;
–The effectiveness of the medication was not evaluated;
-On 5/5/18 at 10:00 A.M. for general pain all over;
–No non-pharmacological interventions were documented;
–The effectiveness of the medication was not evaluated;
-On 5/6/18 at 10:00 A.M. for general pain all over;
–No non-pharmacological interventions were documented;
-On 5/6/18 at 9:00 P.M. for general pain at 9 on a scale of 1 to 10;
–No non-pharmacological interventions were documented;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
–The effectiveness of the medication was not evaluated;
-On 5/7/18 at 9:30 P.M. for general pain all over;
–No non-pharmacological interventions were documented;
-On 5/10/18 at 10:00 P.M. for general pain all over at 9 on a scale of 1 to 10;
–No non-pharmacological interventions were documented;
-On 5/10/18 at 5:00 P.M. for general pain at 7 on a scale of 1 to 10;
–No non-pharmacological interventions were documented;
–The effectiveness of the medication was not evaluated;
-On 5/12/18 at 1:45 A.M. for general pain all over;
–No non-pharmacological interventions were documented;
-On 5/12/18 at 1:40 P.M. for general pain all over.
–No non-pharmacological interventions were documented.
-On 5/12/18 at 5:40 P.M. for general pain all over;
–No non-pharmacological interventions were documented;
-On 5/13/18 at 4:00 P.M. for general pain;
–No non-pharmacological interventions were documented;
–The effectiveness of the medication was not evaluated;
-On 5/13/18 at 8:00 P.M. for general pain;
–No non-pharmacological interventions were documented;
–The effectiveness of the medication was not evaluated;
-On 5/14/18 at 11:30 A.M. for general pain all over;
–No non-pharmacological interventions were documented;
–The effectiveness of the medication was not evaluated;
-On 5/15/18 at 11:30 A.M. for general pain at 8 on a scale of 1 to 10;
–No non-pharmacological interventions were documented;
-On 5/16/18 at 11:00 A.M. for general pain at 9 on a scale of 1 to 10;
–No non-pharmacological interventions were documented;
-On 5/27/18 at 5:00 P.M. for general pain at 7 on a scale of 1 to 10.
–No non-pharmacological interventions were documented.
-On 5/28/18 at 5:30 A.M. for general pain at 6 on a scale of 1 to 10;
–No non-pharmacological interventions were documented;
-On 5/30/18 at 11:40 A.M. for general pain at 8 on a scale of 1 to 10;
–No non-pharmacological interventions were documented;
-On 5/30/18 at 11:30 A.M. for general pain at 8 on a scale of 1 to 10 and
–No non-pharmacological interventions were documented.
During observation and interview of the resident on 6/6/18 at 6:09 A.M., showed:
-The resident was in bed watching television;
-He/she was lying on his/her back with his/her upper body leaning toward the right side of
the bed and
-He/she said the pain had been terrible before going into the hospital (the resident was
hospitalized ,[DATE] – 5/26), but has gotten better.
During an interview on 6/8/18 at 1:18 P.M., Registered Nurse (RN) B said:
-Non-pharmacological interventions should be tried before administering pain medication;
-Non-pharmacological interventions such as back rubs and music could be attempted and
-Nurses should assess the resident prior to and after administering pain medication.
During an interview on 6/8/18 at 2:13 P.M., the DON said he/she would expect:
-Nurses to assess the resident and attempt non-pharmacological interventions prior to
administering medication;
-Non-pharmacological interventions and the reason for giving medication should be
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
documented and
-Nurses should also assess and document the results after a resident receives the
medication.
#MO 471

F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide enough nursing staff every day to meet the needs of every resident; and have a
licensed nurse in charge on each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure bathing
was completed at least weekly for two sampled residents (Resident #4 and #17) who were
dependent on staff for completing all Activities of Daily Living (ADL-bathing, dressing
and grooming) that there was adequate nursing staff in place to meet the needs of all
residents, out of 13 sampled residents. The facility census was 46 residents.
1 Record review of Resident # 4’s Face Sheet showed that he/she was admitted to the
facility on [DATE].
Record review of the resident’s Medical Record showed the following [DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS a federally mandated
assessment tool completed by facility staff for care planning) dated 2/27/18 showed the
resident:
-Was cognitively intact and
-Required limited staff assistance for bathing.
Record Review of the resident’s Care Plan dated 9/7/17 showed:
-He/she required staff assistance to complete ADL’s and
-Staff should provide assistance with bathing.
Record review of the resident’s Shower Log dated (MONTH) (YEAR) and (MONTH) (YEAR) showed
the resident:
-Received a shower on 5/3/18, and 5/20/18;
-Had no documented showers or baths from 5/20/18 through 6/7/18 and
-Had no documentation, by facility staff, that showed the resident had received at least
two shower/baths per week.
Record review of the resident’s Shower Sheet/Skin Assessment for (MONTH) (YEAR) and
(MONTH) (YEAR) showed the resident received a shower on 5/3/18.
Observation on 6/4/18 at 8:00 P.M. of the resident showed:
– The room had a very strong odor;
-Flies flying around in room;
– The resident was sitting in his/her wheelchair watching TV and
-His/her hair slicked back.
Observation on 6/5/18 at 1:00 P.M. of the resident showed:
-the room had a very strong odor;
-Flies flying around in room;
– The resident was sitting in his/her wheelchair, TV on, and lunch tray in front of
him/her; and
-His/her hair slicked back.
Observation on 6/6/18 at 7:00 A.M. of the resident showed:
-Room had a very strong odor;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
-Resident was sitting in his/her wheelchair with TV on; and
-His/her hair slicked back.
Observation on 6/7/18 at 8:00 A.M. of the resident showed:
-Room had a very strong odor;
-Resident was sitting in his/her wheelchair with TV on and
-His/her hair slicked back.
During an interview on 6/5/18 at 1:00 P.M. the resident said:
-He/she would like to have a bath/shower more often;
-There wasn’t enough staff to give him/her a bath/shower;
-He/she was not sure how long it had been since he/she had a bath/shower; and
– He/she don’t ask any more for a bath/shower because he/she won’t get one.
2. Record review of Resident # 17’s Face Sheet showed he/she was admitted to the facility
on [DATE], readmitted on ,[DATE] and 3/17/18 with the following [DIAGNOSES REDACTED].
Record review of the resident’s quarterly MDS dated [DATE] showed he/she:
-Was severely cognitively impaired and
-Required total staff assistance for bathing.
Record Review of the resident’s Care Plan dated 2/20/18 showed:
-He/she was dependent on staff for daily hygiene/grooming;
-He/she to be showered/bathed per schedule and
-Staff should provide assistance with bathing.
Record review of the resident’s Shower Log dated (MONTH) (YEAR) and (MONTH) (YEAR) showed
the resident:
-Received a shower on 5/3/18;
-Had no documented showers or baths from 5/3/1 through 6/7/18 and
-Had no documentation, by facility staff, that showed the resident received at least two
shower/baths per week.
Record review of the resident’s Shower Sheet/Skin Assessment for (MONTH) (YEAR) and
(MONTH) (YEAR) showed, he /she received a shower on 5/3/18.
Observation on 6/4/18 at 7:49 P.M. of the resident showed:
– The resident lying in bed on right side in fetal position and
-His/her hair was oily and uncombed.
Observation on 6/5/18 at 12:48 P.M. of the resident showed:
-The resident sitting up in wheelchair; and
-His/her hair was oily and uncombed.
Observation on 6/6/18 at 6:20 A.M. of the resident showed:
-The resident sitting up in wheelchair and
-His/her hair was oily and uncombed.
During an interview on 6/6/18 at 6:22 A.M., Certified Nursing Assistant (CNA) C said:
-It is impossible for one aide to be on a hall and they’re are multiple lights going off
and
-It is hard to meet to everyone’s needs without him/her being too late to get to them.
During an interview on 6/6/18 at 9:50 A.M. CNA A said:
-He/She could ask the charge nurse to watch call lights on the 300 and 400 hall, but
sometimes there is only one Certified Medication Technician (CMT) for 100, 200, 300, and
400 halls, so the CMT may not be available to help watch call lights; and
-It was difficult to get showers done for the 300 and 400 hall when he/she is the only CNA
for 23 residents.
During an interview on 6/7/18 at 9:39 A.M., CNA B said:
-Normally the facility has a dedicated shower aide, but does not currently have one and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
-He/She has not been able to get resident showers done because there is not enough staff
to help watch the floor, toilet residents, and answer call lights while he/she is
assisting the resident’s in the shower.
During an interview on 6/8/18 at 10:40 A.M., Licensed Practical Nurse (LPN) A said all
staff were responsible to ensure residents received baths.
During an interview on 6/8/18 at 2:03 P.M., the Director of Nursing (DON) said:
-Residents should get showers or baths at least twice weekly;
-The facility used to have a dedicated shower aide, but that staff member is working the
floor now;
-The facility does not have a dedicated shower aide at this time;
-The facility bath schedule is the 100 and 300 halls receive baths on Monday and Thursday
and residents on the 200 and 400 halls receive baths on Tuesday and Friday;
-He/She does not think there is not enough staff to do resident baths but that it is a
time management issue;
-Staff have not mentioned to him/her they have not had time to give resident baths;
-The facility is currently working on getting more staff hired and
-It was not acceptable for residents to go 12 days without a bath.

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide pharmaceutical services to meet the needs of each resident and employ or obtain
the services of a licensed pharmacist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to accurately reconcile the
disposition of as needed (PRN) narcotics for three sampled residents (Residents #19, #22,
and #36) out of 13 sampled residents. The facility census was 46 residents.
Record review of the facility’s Documentation of Medication Administration policy dated
4/2007 showed:
-A nurse or Certified Medication Technician (CMT) shall document all medications
administered to each resident on the resident’s Medication Administration Record (MAR);
-Administration of medication must be documented immediately after (never before) it is
given.
-Documentation must include, as a minimum:
–Name and strength of the drug.
–Dosage.
–Method of administration.
–Date and time of administration.
–Signature and title of the person administering the medication.
–Resident response to the medication, if applicable (such as PRN and pain medications).
Record review of the facility’s Controlled Substances policy dated 12/2012 showed:
-Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule
II (an opioid narcotic) controlled drugs maintained on premises;
-The Director of Nursing (DON) will identify staff members who are authorized to handle
controlled substances;
-An individual resident controlled substance record must be made for each resident who
will be receiving a controlled substance. Do not enter more than one prescription per
page. This record must contain: the name of the resident; the name and strength of the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
medication; the quantity received; the number on hand; the name of the physician; the
prescription number; the name of the issuing pharmacy; the date and time received; the
time of administration; the method of administration; the signature of the person
receiving the medication; and the signature of the nurse administering the medication;
-All keys to controlled substance containers shall be on a single key ring that is
different from any other keys;
-The charge nurse on duty will maintain the keys to controlled substance containers. The
DON will maintain a set of back-up keys for all medication storage areas including keys to
controlled substance containers and
-The DON shall investigate any discrepancies in narcotics reconciliation to determine the
cause and identify any responsible parties, and shall give the Administrator a written
report of such findings.
1. Record review of Resident #36’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Low back pain;
-Other chronic pain;
-[MEDICAL CONDITION] (never pain) and
-Dorsalgia (spinal pain).
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 milligram (mg), one tablet every four hours as needed for pain
and
-Staff documented [MEDICATION NAME] 5/325 mg administered twice during the month.
Record review of the resident’s Controlled Substance Log showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain;
-[MEDICATION NAME] 5/325 mg tablet was removed from the resident’s narcotic supply 18
times during the month and
–16 tablets of [MEDICATION NAME] 5/325 mg were unaccounted for.
Record review of the resident’s Pharmacy Consulting Services record dated 3/6/18 showed no
documentation by the pharmacy consultant of any discrepancies between the Controlled
Substance Log and the resident’s MAR.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg, one
tablet every four hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain and
-Staff documented [MEDICATION NAME] 5/325 mg administered seven times during the month.
Record review of the resident’s Controlled Substance Log showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain;
-[MEDICATION NAME] 5/325 mg tablet was removed from the resident’s narcotic supply 19
times during the month and
–12 tablets of [MEDICATION NAME] 5/325 mg were unaccounted for.
Record review of the resident’s Pharmacy Consulting Services record dated 4/4/18 showed no
documentation by the pharmacy consultant of any discrepancies between the Controlled
Substance Log and the resident’s MAR.
Record review of the resident’s annual Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning) dated 4/6/18 showed
he/she:
-Was cognitively intact;
-Received scheduled pain medication;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
-Received as needed pain medication and
-Received an opioid during the look-back period seven out of seven days.
Record review of the resident’s care plan dated 4/13/18 showed:
-He/She had discomfort/pain in he/her back and
-He/She is currently on scheduled pain medication and he/she requested as needed pain
medication.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg, one
tablet every four hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain;
-[MEDICATION NAME] 5/325 mg was crossed out on 5/27/18 with a handwritten note On Nurse
MAR and
-Staff documented [MEDICATION NAME] 5/325 mg administered 13 times during the month.
Record review of the resident’s Controlled Substance Log showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain;
-[MEDICATION NAME] 5/325 mg tablet was removed from the resident’s narcotic supply 49
times during the month and
–36 tablets of [MEDICATION NAME] 5/325 mg were unaccounted for.
Record review of the resident’s Pharmacy Consulting Services record dated 5/1/18 showed no
documentation by the pharmacy consultant of any discrepancies between the Controlled
Substance Log and the resident’s MAR.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg, one
tablet every four hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain was crossed
out on the CMT MAR with a handwritten note On Nurse MAR;
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain was
handwritten on the Nurse’s MAR and
-Staff documented [MEDICATION NAME] 5/325 mg administered twice during the month.
Record review of the resident’s Controlled Substance Log showed:
-[MEDICATION NAME] 5/325 mg, one tablet every four hours as needed for pain;
-[MEDICATION NAME] 5/325 mg tablet was removed from the resident’s narcotic supply three
times between 6/1/18 – 6/6/18 and
–One tablet of [MEDICATION NAME] 5/325 mg was unaccounted for.
Record review of the resident’s Pharmacy Consulting Services record dated 6/5/18 showed no
documentation by the pharmacy consultant of any discrepancies between the Controlled
Substance Log and the resident’s MAR.
2. Record review of Resident #19’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED].
Record review of the resident’s care plan dated 10/13/17 showed:
-He/She had expressed pain in his/her knee and back at times;
-Had no scheduled pain medication at that time and
-Staff should administer pain medication as ordered.
Record review of the resident’s quarterly MDS dated [DATE] showed he/she:
-Was cognitively intact;
-Received as needed pain medication and
-Received an opioid seven out of seven days during the look-back period.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg; two
tablets every six hours as needed for pain.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain and
-[MEDICATION NAME] 5/325 mg was documented as administered to the resident 12 times during
the month for a total of 24 tablets.
Record review of the resident’s [MEDICATION NAME] 5/325 mg Controlled Substance Log
showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain;
-[MEDICATION NAME] 5/325 mg, two tables per dose, was removed from the resident’s narcotic
supply 55 times during the month for a total of 110 tablets and
-Forty-three doses, for a total of 86 [MEDICATION NAME] 5/325 mg were unaccounted for
during the month.
Record review of the resident’s Pharmacy Consulting Services record dated 3/6/18 showed no
documentation by the pharmacy consultant of any discrepancies between the Controlled
Substance Log and the resident’s MAR.
Record review of the resident’s quarterly MDS dated [DATE], MAR and Controlled Substance
Log showed he/she:
-Had moderate cognitive impairment;
-Received as needed pain medication;
-Received an opioid three out of seven days during the look-back period.
–During the look-back period the resident’s MAR showed [MEDICATION NAME] 5/325 two
tablets every six hours as needed for pain was administered three out of the seven days.
–During the look-back period the resident’s Controlled Substance Log showed [MEDICATION
NAME] 5/325 mg take two tablets every six hours as needed for pain was removed seven out
of seven days.
Record review of the resident’s (MONTH) (YEAR) POS showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain;
-Discontinue [MEDICATION NAME] 5/325 mg, two tablets every six hours as needed for pain on
4/19/18 and
-Start [MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain on
4/19/18.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain;
–Eleven doses were documented as administered between 4/1/18 – 4/19/18, for a total of 22
tablets;
–The rest of the month was crossed out with a handwritten notation the order was changed
on 4/19/18;
-Handwritten [MEDICATION NAME] 10/325 mg take one tablet every six hours as needed for
pain dated 4/19/18 and
–One dose was documented between 4/19/18 – 4/30/18.
Record review of the resident’s [MEDICATION NAME] 5/325 mg Control Substance Log showed:
-[MEDICATION NAME] 5/325 mg, take two tablets every six hours as needed for pain;
-A handwritten note on the second Control Substance Log received by the facility on
4/10/18 noting the order changed on 4/19/18 and nurse needs notified when this card runs
out on the Control Substance Log;
-[MEDICATION NAME] 5/325 mg, two tablets per dose, was removed from the resident’s
narcotic supply 52 times between 4/1/18 – 4/23/18 for a total of 101 tablets;
–The resident’s order for [MEDICATION NAME] 5/325 mg was discontinued on 4/19/18;
–Thirteen tablets were removed from the resident’s [MEDICATION NAME] 5/325 mg narcotic
supply after the resident’s order was discontinued;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
-Forty-one doses, for a total of 82 [MEDICATION NAME] 5/325 mg were unaccounted for during
the month;
-[MEDICATION NAME] 10/325 mg, take one tablet every six hours for pain was removed from
the resident’s narcotic supply nine times between 4/24/18 – 4/29/18 and
–Eight doses of [MEDICATION NAME] 10/325 mg for a total of eight tablets were unaccounted
for between 4/24/18 – 4/30/18.
Record review of the resident’s Pharmacy Consulting Services record dated 4/4/18 showed no
documentation by the pharmacy consultant of any discrepancies between the Controlled
Substance Log and the resident’s MAR.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 10/325 mg,
take one tablet every six hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain;
-Eight doses were documented as administered during the month for total of eight tablets;
-The order was crossed out with a hand-written note after 5/26/18 the medication was on
the nurse’s MAR;
-A handwritten [MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for
pain on the nurse’s MAR and
-No documented doses on the nurse’s MAR during the month.
Record review of the resident’s [MEDICATION NAME] 10/325 mg Control Substance Log showed:
-[MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain;
-[MEDICATION NAME] 10/325 mg, one tablet per dose, was removed from the resident’s
narcotic supply 44 times during the month for a total of 44 tablets and
-Thirty six doses, for a total of 36 [MEDICATION NAME] 10/325 mg were unaccounted for
during the month.
Record review of the resident’s Pharmacy Consulting Services record dated 5/1/18 showed no
documentation by the pharmacy consultant of any discrepancies between the Controlled
Substance Log and the resident’s MAR.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 10/325 mg,
take one tablet every six hours as needed for pain.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain was
crossed out with a handwritten note On Nurses MAR;
-A handwritten [MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for
pain on the nurse’s MAR;
-Three doses were documented as administered between 6/1/18 – 6/6/18 for a total of three
tablets and
-No documented doses on the CMT MAR during the month.
Record review of the resident’s [MEDICATION NAME] 10/325 mg Control Substance Log showed:
-[MEDICATION NAME] 10/325 mg, take one tablet every six hours as needed for pain and
-[MEDICATION NAME] 10/325 mg, one tablet per dose, was removed from the resident’s
narcotic supply three times during the month for a total of three tablets.
Record review of the resident’s Pharmacy Consulting Services record dated 6/5/18 showed no
documentation by the pharmacy consultant of any discrepancies between the Controlled
Substance Log and the resident’s MAR.
3. Record review of Resident #22’s Face Sheet showed he/she was admitted to the facility
on [DATE] and readmitted on [DATE].
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg one
tablet every six hours for pain dated 3/12/18.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg one tablet every six hours for pain and
-[MEDICATION NAME] 5/325 mg was documented as administered by the staff two times during
the month.
Record review of the resident’s significant change MDS dated [DATE] showed
he/she:
-Was severely cognitively impaired;
-Did not receive as needed pain medication and
-Did not receive an opioid during the seven day look-back period.
Record review of the resident’s care plan dated 3/23/18 showed:
-The resident had the potential for pain related to a [MEDICAL CONDITION] and
-Coordinate with his/her physician to manage his/her pain medication for optimum control
of his/her pain.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg one
tablet every six ours for pain dated 3/12/18.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg one tablet every six hours for pain and
-[MEDICATION NAME] 5/325 mg was documented as administered by the staff two times during
the month.
Record review of the resident’s Pharmacy Consulting Services record dated 4/4/18 showed no
documentation by the pharmacy consultant of any discrepancies between the Controlled
Substance Log and the resident’s MAR.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg one
tablet every six hours for pain dated 3/12/18 with a handwritten RN to the side of the
order.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg one tablet every six hours for pain and
–The order was crossed out with a handwritten On Nurse MAR on 5/27/18.
-[MEDICATION NAME] 5/325 mg was documented as administered by the staff two times during
the month.
Record review of the resident’s Controlled Substance Log showed:
-[MEDICATION NAME] 5/325 mg, take one tablet four times a day as needed;
-Thirty tablets were delivered on 4/30/18;
-Eight tablets were removed from the resident’s narcotic supply between 5/27/18 – 5/29/18
and
–Six [MEDICATION NAME] 5/325 mg were unaccounted for.
Record review of the resident’s Pharmacy Consulting Services record dated 5/1/18 showed no
documentation by the pharmacy consultant of any discrepancies between the Controlled
Substance Log and the resident’s MAR.
Record review of the resident’s (MONTH) (YEAR) POS showed [MEDICATION NAME] 5/325 mg one
tablet every six hours for pain dated 3/12/18 with a handwritten RN to the side of the
order.
Record review of the resident’s (MONTH) (YEAR) MAR showed:
-[MEDICATION NAME] 5/325 mg one tablet every six hours for pain;
–The order was crossed out with a handwritten On Nurse MAR on 5/27/18 and
-[MEDICATION NAME] 5/325 mg was documented as administered by the staff zero times during
the month.
Record review of the resident’s Controlled Substance Log showed:
-[MEDICATION NAME] 5/325 mg, take one tablet four times a day as needed;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
-Thirty tablets were delivered on 4/30/18;
-One tablet was removed from the resident’s narcotic supply between 6/1/18 – 6/6/18 and
–One [MEDICATION NAME] 5/325 mg were unaccounted for.
Record review of the resident’s Pharmacy Consulting Services record dated 6/5/18 showed no
documentation by the pharmacy consultant of any discrepancies between the Controlled
Substance Log and the resident’s MAR.
Record review of the resident’s medical record showed no additional Controlled Substance
Logs for the resident’s [MEDICATION NAME] 5/325 mg were located by the facility staff
prior to 4/30/18.
During an interview on 6/15/18 at 2:30 P.M., the resident’s pharmacy said:
-On 3/14/18, 30 [MEDICATION NAME] 5/325 mg tablets were delivered to the facility;
-On 4/30/18, 30 [MEDICATION NAME] 5/325 mg tablets were delivered to the facility;
–Per the resident’s pharmacy interview, a total of 60 tablets were delivered to the
facility;
–Six tablets have been documented on the resident MAR as administered between 3/12/18 –
6/6/18;
–Nine tablets have been signed out on the resident’s Controlled Substance Log with 21
tablets remaining and
–A total of 54 [MEDICATION NAME] 5/325 mg tablets are unaccounted for.
4. During an interview on 6/7/18 at 3:24 P.M., the DON said:
-He/She expected staff to document on the resident’s MAR each time an as needed medication
is administered;
-If staff remove a medication from the resident’s Controlled Substance Log, that
medication should be documented on the resident’s MAR as well;
-He/She does not compare the Controlled Substance Log with the MAR to ensure accuracy of
the medication count;
-He/She thought the Pharmacy Consultant would compare the Controlled Substance Log with
the resident’s MAR during the monthly Drug Regimen Reviews;
-He/She was made aware by a staff member and by a resident of a concern that Resident #36
was not receiving all of the narcotics that were being signed out as administered on
5/25/18 or 5/26/18;
-He/She did not compare the resident’s Controlled Substance Log to the resident’s MAR to
determine if there were any unaccounted for narcotics and
-He/She did not compare any other resident’s Controlled Substance Log to the resident’s
MAR to determine if any other residents had narcotics that were unaccounted for.
During an interview on 6/11/18 at 10:40 A.M., the Pharmacy Consultant said:
-He/She reviews the resident’s MAR to determine how many as needed pain medications the
resident received per month;
-He/She does not compare the resident’s MAR with the resident’s narcotic Controlled
Substance Log to determine if there are any discrepancies in the narcotic counts and
-He/She will listen to the staff while they are doing the end of shift narcotic count for
any discrepancies during the shift count, but does not review the narcotic logs.
Complaint #MO 471

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to attempt non-pharmacological
interventions before administering PRN (as needed) antianxiety medication, and assess and
document the results after administering the medication, for one (Resident #33) out of 13
sampled residents. The facility census was 46 residents.
1. Record review of Resident #33’s Face Sheet showed he/she was admitted to the facility
on [DATE], and most recently readmitted on [DATE].
Record review of the resident’s Annual (MDS-a federally mandated assessment tool completed
by facility staff for care planning) dated 4/27/18, showed he/she:
-Was cognitively intact;
-Had no behaviors;
-Needed extensive assistance with bed mobility and toileting;
-Needed limited assistance with personal hygiene and dressing and
-Received anti-depression, hypnotic and antianxiety medication all seven days of the
assessment lookback period.
Record review of the resident’s Care Plan reviewed and updated 4/30/18, showed:
-The resident was at risk for adverse reactions related to use of [MEDICAL CONDITION]
medications and
-Medication was to be administered as ordered.
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].>-One
tablet was to be administered by mouth every four hours PRN for anxiety;
-The order was originally dated 8/25/17 and
-The order was renewed 5/26/18.
Record review of the resident’s (MONTH) (YEAR) Medication Administration Record [REDACTED]
-On 5/1/18 at 9:30 P.M.
–No non-pharmacological interventions were documented.
–Results were not assessed and documented after administering the medication.
-On 5/3/18 at 10:00 A.M.
–No non-pharmacological interventions were documented.
–Results were not assessed and documented after administering the medication.
-On 5/4/18 at 10:00 A.M.
–No non-pharmacological interventions were documented.
–Results were not assessed and documented after administering the medication.
-On 5/6/18 at 5:00 P.M.
–No non-pharmacological interventions were documented.
–Results were not assessed and documented after administering the medication.
-On 5/6/18 at 9:00 P.M.
–No non-pharmacological interventions were documented.
–Results were not assessed and documented after administering the medication.
-On 5/7/18 at 9:30 P.M.
–No non-pharmacological interventions were documented.
-On 5/10/18 at 5:00 P.M.
–No non-pharmacological interventions were documented.
–Results were not assessed and documented after administering the medication.
-On 5/16/18 at 11:00 A.M.
–No non-pharmacological interventions were documented.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 33)
-On 5/26/18 at 5:40 P.M.
–No non-pharmacological interventions were documented.
–Results were not assessed and documented after administering the medication.
-On 5/27/18 at 5:00 P.M.
–No non-pharmacological interventions were documented.
-On 5/30/18 at 8:45 P.M.
–No non-pharmacological interventions were documented.
During an interview on 6/8/18 at 1:18 P.M., Registered Nurse (RN) B said:
-Nonpharmacological interventions should be attempted prior to administering PRN
antianxiety medications and
-The nurse administering the medication should go back about 45 minutes after
administering the PRN medication to the resident to check for results.
During an interview on 6/8/18 at 2:13 P.M., the Director of Nursing (DON) said he/she
would expect:
-Nurses to assess the resident and attempt non-pharmacological interventions prior to
administering PRN medication;
-Non-pharmacological interventions and the reason for giving medication should be
documented and
-Nurses should also assess and document the results after a resident receives the PRN
medication.

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 ensure a medication
error rate of less than five percent (%) for two sampled residents and one randomly
observed resident, out of 13 sampled residents. Out of 30 opportunities observed, 12
errors occurred, resulting in a medication error rate of 40%. The facility census was 46
residents.
Record review of the facility’s policy titled Administering Medications dated (MONTH) 2012
showed medications administered safely and timely by:
– Medication must be administered in accordance with the orders and within required time
frame;
– Medication must be administered within one hour of their prescribed time, unless
otherwise specified and
-If a dosage is believed to be inappropriate for the resident, the person preparing or
administering the medication shall contact the resident’s Attending Physician or the
facility’s Medical Director to discuss the concerns.
Record review of Administration Recommendations in front of the Medication Administration
Record [REDACTED]
-[MEDICATION NAME] ([MEDICATION NAME]) (medications to treat low [MEDICAL CONDITION]
hormone);
–Should be taken on an empty stomach on half hour to one hour before breakfast and
–Should be administered apart from medications that interfere with absorption.
1. Record review of Resident #17’s Face Sheet showed he/she was admitted to the facility
on [DATE], readmitted on [DATE] and on 3/17/18 with the following Diagnoses: [REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 34)
-[MEDICAL CONDITION] (Is a condition in which your [MEDICAL CONDITION] doesn’t produce
enough of certain important hormones.)
Record review of the resident’s Quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 3/23/18 showed
he/she:
-Was severely cognitively impaired;
-Had a [DIAGNOSES REDACTED].>–[MEDICAL CONDITION];
–Dysphasia (difficulty swallowing food and liquids) with Gastrostomy Tube ([DEVICE]-a
tube surgically placed through the skin into the stomach that delivers food, liquids and
medications) and
–[MEDICAL CONDITION] Reflux Disease (GERD).
Record review of the resident’s [MEDICAL CONDITION] Stimulating Hormone (TSH-a test that
measures the amount of stimulating hormone in your blood) lab results showed:
-12/8/17 the TSH was 4,820 IU (International Units)/milliliters (ml);
-3/19/18 the TSH was 33,520 IU/ml and
–Normal value range was 0.270 to 4,200 IU/ml
Record review of the resident’s physician’s orders [REDACTED].
-[MEDICATION NAME] Sodium 125 micrograms (mcg) one tablet per [DEVICE] at 6:00 A.M. for
[MEDICAL CONDITION] and
-[MEDICATION NAME] (a medication to treat GERD) 20 milligrams (mg) every 12 hours.
Observation on 6/6/18 at 6:25 A.M. showed Licensed Practical Nurse (LPN) B removed,
crushed and
administered through his/her [DEVICE], in the following order:
-[MEDICATION NAME] 125 mcg, put it in 15 ml of Sterile Normal Saline (NS);
-30 ml of water;
-[MEDICATION NAME] 20 mg, put it in 15 ml of NS and
-100 ml of water by gravity;
During an interview on 6/6/18 at 6:45, LPN B said:
-The Physician ordered both medications to be given at 6 A.M.; and
-The Director of Nursing (DON) approved it this way.

2. Record review of Resident #3’s Face Sheet and Quarterly MDS dated [DATE] showed he/she
was admitted to the facility on [DATE], readmitted on [DATE] with the following Diagnoses:
[REDACTED].
-[MEDICAL CONDITION] (a group of eye conditions that can cause [MEDICAL CONDITION]);
-[MEDICAL CONDITION] and
-Diabetes.
Record Review of the POS [REDACTED]
-Dorzolamide/[MEDICATION NAME] (Dorzol/Timol-a medicine to treat [MEDICAL CONDITION])
2.23/0.68, one drop to each eye two times a day:
–Hold pressure at the inner corner of eye for one minute and
–Wait five minutes between different medications.
-[MEDICATION NAME] 0.2% (a medicine to treat [MEDICAL CONDITION]) one drop in each eye two
times a day:
–Wait five minutes between different medications.
-[MEDICATION NAME] 50 micrograms (mcg) on an empty stomach, ordered to be given at 6:00
A.M.;
-[MEDICATION NAME] (medicine to treat high blood pressure) 5 milligrams (mg), hold if
systolic blood pressure is less (<) than 100, diastolic blood pressure is < 50, or

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 35)
heart rate is < 50;
-[MEDICATION NAME] (medicine to treat nerve pain) 300 mg two times a day;
-[MEDICATION NAME] (medicine to treat GERD) 10 mg to be given at 6:00 A.M.;
-[MEDICATION NAME] (medicine to treat diabetes) 500 mg after meals or with snack;
-[MEDICATION NAME] (medicine to treat high blood pressure) 100 mg daily;
-[MEDICATION NAME] (medicine to treat depression and anxiety) 60 mg daily;
-[MEDICATION NAME] acid (ASA-aspirin) 81 mg daily;
-[MEDICATION NAME] (medicine to treat excessive gas/bloating in the stomach) 80 mg daily;
-Multi vitamin one tablet two times a day and
Record review of lab results showed:
-Record review of the residents TSH levels showed:
–On 2/3/16 the TSH was 1,740 IU/ml;
–On 2/1/17 the TSH was 1950 IU/ml and
–On 3/28/18 the TSH was 2090 IU/ml.
Observation on 6/6/18 at 7:29 A.M. showed Certified Medication Technician (CMT) B:
-Removed the following medications placed them into a medicine cup:
— [MEDICATION NAME];
— [MEDICATION NAME];
— [MEDICATION NAME];
— [MEDICATION NAME];
— [MEDICATION NAME];
— [MEDICATION NAME];
— [MEDICATION NAME];
— ASA;
— [MEDICATION NAME]
— Multi vitamin and
-Gave the medication cup to the resident to take.
Observation on 6/6/18 at 7:54 A.M. showed CMT B administered:
-Dorzol/Timol in the resident’s left eye at 7:54 A.M.;
-Dorzol/Timol in the resident’s right eye at 7:55 A.M.;
-[MEDICATION NAME] in the resident’s left eye at 7:56 A.M.; and
-[MEDICATION NAME] in the resident’s right eye at 7:57 A.M.
During an interview on 6/6/18 at 8:00 A.M. CMT B said:
-He/she has to wait one minute between medications for the eye drops and
-The resident prefers to take his/her medicines all at one time.
During an interview on 6/7/18 at 12:00 P.M. Registered Nurse (RN) B, said:
-[MEDICATION NAME] should be given about one hour before the resident eats or drinks and
-It should not be given with any other medications.
During an interview on 6/8/18 at 2:30 P.M. the DON said:
-[MEDICATION NAME] should be given by itself;
-He/she has told the nurses that;
-He/she will have to tell them again and
-The nurses should look at the lab values and notify the resident’s physician.

F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide each resident with a nourishing, palatable, well-balanced diet that meets his
or her daily nutritional and special dietary needs.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Based on observation, interview and record review, the facility failed to ensure the
vegetable soup was cooled down to 70 degrees Fahrenheit (ºF) within two hours of being
removed from the steam table. The facility also failed to ensure the temperature of the
pureed (a paste or thick liquid suspension usually made from cooked food that was ground
finely) sausage was reheated to 165 ºF, before placing on the steam table This practice
potentially affected 45 residents who ate food from the kitchen. The facility census was
46 residents.
1. Observation on 6/4/18 at 6:29 P.M., showed the temperature of the vegetable soup that
was about to be placed in the walk-in refrigerator to be cooled off, was 154 ºF.
During an interview on 6/4/18 at 6:30 P.M. Dietary Cook (DC) A said the food in the
container was indeed vegetable soup and that he/she was about to place that food into the
walk-in to be cooled off.
Observation with the Dietary Manager and the Administrator on 6/4/18 at 8:32 P.M., showed
the temperature of vegetable soup was 103 ºF through 106 ºF.
During interviews at the time of the observation, both acknowledged that the temperature
had not cooled to 70 ºF. The DM said he/she came across information like this in his/her
dietary manager courses.
2. Observation on 6/6/18 from 7:23 A.M. through 7:28 A.M., showed the following:
– Dietary Cook (DC) B added cold whole milk to the pureed sausage mixture, with no recipe
book open;
– DC B did not warm the milk before adding it;
– DC B placed the pureed sausage in a metal pan and placed the pan on the steam table
without checking the temperature;
-The temperature of the pureed sausage was 83 ºF; and
-At 8:28 A.M., DC B said he/she forgot to take the temperature of the pureed sausage that
morning.
Record review of 2009 Food and Drug Administration (FDA) Code Chapter 3-501.14 showed:
Cooling.
(A) Cooked potentially hazardous food (time/temperature control for safety food) shall be
cooled: 1) Within 2 hours from 135ºF to 70°F; P and
Chapter 3-501.15 Cooling Methods, showed the following:
A) Cooling shall be accomplished in accordance with the time and temperature criteria
specified under 3-501.14 by using one or more of the following methods based on the type
of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into
smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a
container placed in an ice water bath; (5) Using containers that facilitate heat transfer;
(6) Adding ice as an ingredient; or (7) Other effective methods.
Record review of 2009 FDA Code Chapter 3-403.11, showed:
A) Except as specified under paragraphs (B) and (C) and E of this section, potentially
hazardous food (time/temperature control for safety food) that is cooked, cooled, and
reheated for hot holding shall be reheated so that all parts of the food reach a
temperature of at least 165 ºF for 15 seconds.

F 0802

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide sufficient support personnel to safely and effectively carry out the functions
of the food and nutrition service.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0802

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Based on observation, interview and record review, the facility failed to adequately staff
the kitchen with enough dietary staff to ensure the proper amount of cleaning was
completed and room tray food temperatures were checked on a regular basis. This practice
potentially affected 45 residents who ate food from the kitchen. The facility census was
46 residents.
1. Observation during the initial kitchen tour on 6/4/18 from 6:27 P.M. through 7:32 P.M.,
showed the following:
– A cracked food delivery cart;
– A dusty fan;
– Grime on the fan vent cover in the walk in fridge;
– A yellow stain on the door sill of the walk in fridge;
– A buildup of dust and grime under the shelves in dry storage room;
– Dust and grime behind ice machine, and
– A soy sauce bottle and debris behind six burner stove.
During an interview on 6/4/18 at 7:07 P.M., the Dietary Manager (DM) said they attempted
to pull out the stove every two weeks but since there are usually only two people working
in the kitchen during a shift, they did not get a chance to do the cleaning they desired
to do.
Observation of the room trays on 6/6/18, showed the following:
– At 7:58 A.M., the temperature of the regular sausage that was going to be served to
Resident #35, was 107 ºF, with Certified Nurse’s Aide (CNA) A, observing;
– At 8:02 A.M., the temperature of the bacon and toast that was going to be served to
Resident #14, was 80-82 ºF, with Registered Nurse (RN) A observing;
– At 8:06 A.M., the temperature of the eggs that was going to be served to Resident #28,
was 115.5 ºF, with Registered Nurse (RN) A observing and
– At 8:10 A.M., the temperature of the pureed sausage that was going to be served to
Resident #19 was 97.1 ºF, with CNA D observing.
During an interview on 6/6/18 at 8:33 A.M., the DM said the following:
-They did not check temperatures, because they did not have the time;
-If they had an extra person they could do more;
– Just having a manager and 2 people made tasks difficult. 8:34 AM., and
-Usually it was just the manager and another worker.
Record review of the dietary staff payroll detail from 5/20/18 through 5/31/18 showed the
following:
– On 5/20/18, two people worked the morning shift and two people worked the
afternoon/evening shift;
– On 5/21/18, 3 dietary staff worked the morning shift, and two people worked the evening
shift;
– On 5/22/18, one person worked the morning shift and two people worked the afternoon
shift;
– On 5/23/18, three people worked the morning shift and two people worked the
afternoon/evening shift;
– On 5/24/18, three people worked the morning shift and one person worked the
afternoon/evening shift;
– On 5/25/18, three people worked the morning shift and two people worked the
afternoon/evening shift, but one of those people only worked for 2 hours and 45 minutes;
– On 5/26/18, two people worked the morning shift, and two people worked the
afternoon/evening shift;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0802

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 38)
– On 5/27/18, two people worked the morning shift, and two people worked the
afternoon/evening shift;
– On 5/28/18, four people worked the morning shift, and two people worked the
afternoon/evening shift;
– On 5/29/18, one person worked the morning shift and two people worked the
afternoon/evening shift;
– On 5/30/18, two people worked the morning shift, and two people worked the
afternoon/evening shift and
– On 5/31/18, two people worked the morning shift, and two people worked the
afternoon/evening shift.
In summary, two people worked the morning shift on 5 days and one person worked on two
days and two people worked the afternoon/evening shift for all 10 days listed. Only on
four of ten days did three or more dietary staff work the morning shift.
During an interview on 6/6/18 at 8:56 A.M., Dietary Cook (DC) B said the following:
– A dishwasher, a Dietary Cook, a Dietary Aide and the DM was needed and
– They cannot always get clean the way they need to because they have to be off the clock
a certain time usually at 2:00 P.M., if he/she started his/her shift at 5:30 a.m.,
To get the cleaning done that was needed, he/she would have to work over time.
During an interview on 6/6/18 at 9:02 A.M., the DM said the following:
– There used to be two people that came in with the DM but in the present there was only
one person;
-That got changed about 7-8 months ago;
– If there was an extra person, someone from the dietary staff would be able to take
temperatures and
– When he/she had meetings such as leadership meetings or care planning meetings, DC B
got stuck with all the dietary tasks.
During an interview on 6/6/18 at 9:23 A.M., the Administrator said if there was not enough
dietary staff, the DM did not let him know there was not enough staff.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure food and drink is palatable, attractive, and at a safe and appetizing
temperature.

Based on observation and interview, the facility failed to ensure breakfast foods were at
or around 120 ºF (degrees Fahrenheit) at the time of service for Residents #35,#14, #28,
and #19. This practice potentially affected at least 20 residents who resided on the south
side of the facility. The facility census was 46 residents.
1. During the group interview on 6/5/18, the following was said:
– At 10:28 A.M., Resident #36 said the carts come from the kitchen and sit at the nurses
station for 1/2 hour before being served and he/she used his/her microwave to warm food.
They (the facility) removed the microwave and now he/she had no way of warming his/her
food and
– At 10:07 A.M., Residents #1 and #40 said they have complained about the quality of food
for two years.
2. Observation on 6/6/18 from 7:23 A.M. through 7:28 A.M., showed the following:
– Dietary Cook (DC) B added cold whole milk to the pureed sausage mixture, with no recipe

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 39)
book open;
– DC B did not warm the milk before adding it;
– DC B placed the pureed sausage in a metal pan and placed the pan on the steam table
without checking the temperature and
– The temperature of the pureed sausage after it was placed in the steam table was 83 ºF.
3. Observation of the room trays on 6/6/18, showed the following:
– At 7:58 A.M., the temperature of the regular sausage that was going to be served to
Resident #35, was 107 ºF, with Certified Nurse’s Aide (CNA) A, observing;
– At 8:02 A.M., the temperature of the bacon and toast that was going to be served to
Resident #14, was 80-82 ºF, with Registered Nurse (RN) A observing;
– At 8:06 A.M., the temperature of the eggs that was going to be served to Resident #28,
was 115.5 ºF, with (RN) A observing and
– At 8:10 A.M., the temperature of the pureed sausage that was going to be served to
Resident #19 was 97.1 ºF, with Certified Medication Technician (CMT) A observing.
4. During an interview on 6/6/18 at 8:14 A.M., CNA A said he/she served breakfast on that
side of the facility regularly and has not seen anyone from dietary check temperatures of
room trays.
5. During an interview on 6/6/18 at 8:34 A.M., the DM said they do not check temperatures
of room trays, because they do not have the time. Just having a manager and 2 people makes
things difficult, and he/she did not know the temperature that hot foods should be, when
it was delivered to the residents.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation, interview and record review, the facility failed to do the
following: prevent the buildup of grime behind the ice machine; ensure the hair of two
employees, (Dietary Cook (DC) A and Dietary Aide (DA) C was completely covered; prevent
the buildup of grime on the walk-in refrigerator fan vent cover; maintain the floor of the
dry goods storage room free of dust and grime; maintain the floor of the walk-in
refrigerator free of a yellow stain; maintain the stand-up fan free of dust; maintain the
floor behind the six-burner stove free of debris; maintain the red cutting board in an
easily cleanable condition; maintain the utensil storage bins free of debris; calibrate
(to determine, check, or rectify the graduation of any instrument); their thermometers;
check inside the food processor blade; and ensure the sanitizing strength of the
sanitizing water was strong enough. This practice potentially affected 45 residents who
ate food from the kitchen. The facility census was 46 residents.
1. Observation and interview during the initial kitchen tour on 6/4/18 from 6:27 P.M.
through 7:32 P.M., showed the following:
– A cracked food delivery cart;
– A dusty fan;
– Grime on the fan vent cover in the walk in fridge;
– A yellow stain on the door sill of the walk in fridge;
– A buildup of dust and grime under the shelves in dry storage room;
– Dust and grime behind ice machine;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 – Many

(continued… from page 40)
– At 6:55 P.M., the Dietary Manager (DM) said he/she was not sure how long the fan has
been like that, but it may have been like that for a month or so,
– The hairnet for DC A, did not completely covered his/her hair;
– At 6:57 P.M., the DM said he/she has not found a hair net big enough for the hair of DC
A
– DA C’s hair was not completely covered;
– At 6:58 PM DC A said that he/she usually has to place two hair nets on but realized
there was hair hanging out from between the hairnets;
– At 7:00 P.M., the DM said it is hard to get behind the ice machine because it cannot be
pulled out, and hard to get behind the pipes on the floor because he/she did not want to
break anything, he/she could speak with the maintenance guy about getting something to go
behind the ice machine;
– A soy sauce bottle and debris behind six burner stove;
– At 7:07 P.M., the DM said he/she tried to pull out the stove every two weeks but because
there are only two people they do not get a chance to do the cleaning they want to do;
-Two bins with cups and lids with debris inside of those bins;
– At 7:23 P.M., the DM said he/she and the dietary staff did not check the bins too often;
– A red cutting board with numerous indentations making it not easily cleanable;
– A delivery cart with a 7 inch (in.) crack;
– At 7:31 P.M., the DM said he/she was only employed as the DM for 4 months and
– At 7:32 P.M., the DM said the maintenance man was usually the one that handles the fan
vent cover in the walk-in refrigerator.
2. Observation during the breakfast meal preparation on 6/6/18 from 6:15 A.M., through
8:20 A.M., showed the following:
– Four mittens that were torn and not in an easily cleanable condition;
– At 6:15 A.M., DC B said the mittens have been torn up for about six months;
– At 6:31 A.M., DC B used the facility’s thermometer to measure the temperature of hot
cereal and the temperature was between 140 to 145 ºF (degrees Fahrenheit); the surveyor’s
thermometer measured the temperature of the hot cereal between 183-188 ºF;
– At 6:32 A.M., DC B said he/she did not know the last time she calibrated that
thermometer;
– The presence of debris inside the inner part of the food processor blade just before she
pureed sausage;
-At 7:09 A.M., DC B said he/she was rushed that day and did not check the inner part of
the food processor blade and
– The sanitizing solution was too weak for 3 compartment sink, when measured with a test
strip, Further observation showed the pump was not pulling the sanitizing solution all the
way through to the sink marked sanitization
Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and
Missouri Food Codes, showed:
– In Chapter 2-402.11 (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall
wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing
that covers body hair, that are designed and worn to effectively keep their hair from
contacting exposed FOOD.
– In Chapter 3-305.14, During preparation, unPACKAGED FOOD shall be protected from
environmental sources of contamination.
– In Chapter 4-202.11, regarding Food-Contact Surfaces; Multi-use FOOD-CONTACT SURFACES
shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and
similar imperfections; (3) Free of sharp internal angles, corners, and crevices; and 4)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 – Many

(continued… from page 41)
Finished to have SMOOTH welds and joints;
-In 4-203.11 B) Temperature Measuring Devices, Food.
Food temperature measuring devices that are scaled only in Fahrenheit shall be accurate
to ±2 °F in the intended range of use.
– In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to
scratching and scoring shall be resurfaced if they can no longer be effectively cleaned
and SANITIZED, or discarded if they are not capable of being resurfaced. Surfaces such as
cutting blocks and boards that are subject to scratching and scoring shall be resurfaced
if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not
capable of being resurfaced.
– In Chapter 4-601.11, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to
sight and touch.
– In Chapter 4-602.13, nonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a
frequency necessary to preclude accumulation of soil residues;
– In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as
necessary to keep them clean.

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 observation, interview, and record review, the facility failed to ensure
infection control practices were maintained during blood sugar monitoring to prevent
cross-contamination between residents for three supplemental residents (Resident #25, #28,
and #31); to ensure urine graduates (used to obtain or collect urine from a catheter bag)
were changed weekly for two sampled residents (Resident #17, and #5); to ensure isolation
was initiated for resident with a confirmed Escherichia coli (E Coli-a bacteria commonly
found in the intestines of humans frequently causing Urinary Tract Infections,
UTI-infection of the urinary); Extended Spectrum Beta-Lactamase Producer bacteria/germ
(ESBL-is an enzyme that makes the germ harder to treat with antibiotics like the
[MEDICATION NAME], cephalosporins and monobactam aztreonam) in his/her urine for one
sampled resident (Resident #17) and to ensure staff’s compliance with hand washing
technique and glove use during peri care and catheter care for one sampled resident
(Resident #5) out of 13 sampled residents. The facility census was 46 residents.
Record review of the facility’s undated Cleaning and Disinfecting policy showed:
-Blood glucose meters need to be cleaned and disinfected after each use;
-Cleaning can be accomplished by wiping the blood glucose meter (glucometer) with soap and
water or [MEDICATION NAME] alcohol, but it will not disinfect a meter;
-Disinfecting can be accomplished with a disinfectant detergent or germicide that is
approved for healthcare settings or a solution of 1:10 concentration of bleach and
-Blood glucose meters are at high risk of becoming contaminated with bloodborne pathogens
such as [MEDICAL CONDITION] Virus, [MEDICAL CONDITION] Virus, and Human Immunodeficiency
Virus. Transmission of [MEDICAL CONDITION] from resident to resident has been documented
due to contaminated blood glucose devices. According to the Centers for Disease Control
and Prevention (CDC), cleaning and disinfecting of meters between resident use can prevent
the transmission of [MEDICAL CONDITION] through indirect contact.
Record review of the 2007 Guidelines for Isolation Precautions: Preventing Transmission of

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 42)
Infectious Agents in Healthcare Settings provided by the Centers for Disease Control and
Prevention (CDC) showed: -Transmission-Based Precautions were for patients who were known
or suspected to be infected or colonized (organism present without signs or symptoms of
infection) with infectious agents, including certain epidemiologically (branch of medicine
that deals with the incidence of disease and epidemics of infections) important pathogens,
which require additional control measures to effectively prevent transmission. One of the
three categories of Transmission-Based Precautions included Contact Precautions (methods
used to prevent the spread of infectious organisms by direct or indirect contact with the
patient or his/her environment):
-Contact Precautions also applied where the presence of excessive wound drainage, fecal
incontinence, urine or other discharges from the body suggested an increased potential for
extensive environmental contamination and risk of transmission;
-Healthcare personnel caring for patients on Contact Precautions were to wear a gown and
gloves for all interactions that may involve contact with the patient or potentially
contaminated areas in the patient’s environment;
-Donning personal protective equipment (PPE) upon room entry and discarding before exiting
the patient room was done to contain pathogens, especially those that have been implicated
in transmission through environmental contamination.
Record review of National Library of Medicine, a branch of the National Institute of
Health showed:
-Most Extended Spectrum Beta-Lactamasw (ESBL-an infectious bacteria) infections are spread
by direct contact with an infected person’s bodily fluids (blood, drainage from a wound,
urine, stool, or sputum); and
-ESBL infections are spread by contact with equipment or surfaces that have been
contaminated with the germ.
Record review of the facility’s [MEDICAL CONDITION] (MDRO) Policy dated (MONTH) (YEAR),
showed:
-Appropriate precautions will be taken when caring for individuals known or suspected to
have infection with a MDRO. (Note: Infection means that the organism is present and is
causing illness. Colonization means that the organism is present in or on the body but is
not causing illness.);
-MDRO are bacteria and other microorganisms that have developed resistance to one or more
classes of antimicrobial drugs, common examples of MDRO in long-term care facilities
include aram-negative bacilli (like E Coli ESBL producing) have been identified as
emerging MDRO threats in long-term care.
-The staff and practitioner will evaluate each individual known or suspected to have
infection with a MDRO for room placement and initiation of Contact Precautions on a
case-by-case basis, Standard Precautions will be adequate for some;
-The infection prevention and control committee or medical director may implement of
consider the following to determine the need for Contact Precautions and/or room
placement.
Record review of the facility’s Handwashing/Hand Hygiene Policy, dated (MONTH) (YEAR)
showed:
-This facility considers hand hygiene the primary means to prevent the spread of
infections;
-All personnel shall follow the Handwashing/Hand Hygiene procedures to help prevent the
spread of infections to other personnel, residents, and visitors;
-Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following
situations:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 43)
–When hands are visibly soiled; and
-Use an alcohol-base hand rub containing at least 62% alcohol; or, alternatively, soap
(antimicrobial or non-antimicrobial) and water for the following situations:
–Before and after direct with residents;
–Before and after handling an invasive device (e.g. urinary catheters);
–After contact with a resident’s intact skin;
–After contact with bloody or bodily fluids;
-After contact with objects in the immediate vicinity of the resident;
–After removing gloves;
–Before and after entering isolation precaution settings.
Record review of the facility’s Catheter (a tube inserted in the bladder to drain urine)
Care, Urinary Policy, dated (MONTH) 2014 showed:
-The purpose of this procedure is to prevent catheter-associated urinary infections:
-Use standard precautions when handling or manipulating the drainage system;
-Maintain clean technique when handling or manipulating the catheter, tubing, or drainage
bag;
–Do not clean the per urethral area with antiseptics to prevent catheter-associated
urinary catheter infection (UTI’s) while the catheter is in place;
–Empty the drainage bag regularly using a separate, clean collection container for each
resident. Avoid splashing, and prevent contact of the drainage spigot with the non-sterile
container;
-Wash the resident’s genitalia and perineum thoroughly with soap and water. Rinse the area
well and towel dry;
-Place soiled linen into designated container;
-Put on clean gloves;
-Remove gloves and discard into the designated container. Wash and dry your hands
thoroughly;
-Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from
insertion site to approximately four inches outward.
1. Record review of Resident #25’s Face Sheet showed he/she was admitted to the facility
on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
2. Record review of Resident #28’s Face Sheet showed he/she was admitted to the facility
on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s (MONTH) (YEAR) POS and MAR indicated [REDACTED].
3. Observation and interview on 6/6/18 at 7:45 A.M., Certified Medication Technician (CMT)
A showed:
-He/She was waiting to get aluminum foil for a barrier;
-He/She could probably use paper towels for a barrier, but thinks the policy is for the
staff to use aluminum foil, so he/she will wait for the foil;
-He/She put two pieces of aluminum foil on top of his/her medication cart and said one
piece was for clean barrier and one piece was for dirty barrier;
-He/She said each resident had their own glucometer to use for blood sugar monitoring;
-He/She placed an alcohol wipe, lancet, and meter strip on the clean barrier;
-He/She removed a glucometer for Resident #25 from the medication cart drawer and cleaned
the strip insertion port with an alcohol wipe and placed the contaminated glucometer on
the clean barrier;
–He/She did not sanitize the glucometer after removing the meter from the medication cart
drawer;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 44)
-He/She entered Resident #25’s room and discovered the resident’s glucometer battery was
dead causing the meter to not turn on;
-He/She exited the resident’s room, sanitized his/her hands, and removed the glucometer
for Resident #28 out of the medication cart drawer;
-He/She cleaned the strip insertion port of Resident #28’s meter with an alcohol wipe, and
without sanitizing the meter, placed the contaminated glucometer on a clear barrier and
entered Resident #25’s room;
-He/She performed the resident’s accucheck with the contaminated glucometer belonging to
Resident #28;
-He/She then placed the contaminated meter on the resident’s bedside table without a
barrier, removed his/her gloves and washed his/her hands;
-Without gloved hands, he/she removed the contaminated meter, placed it on top of the
medication cart without a barrier and
-Without sanitizing the contaminated meter, he/she placed the contaminated meter in the
medication cart drawer with the other residents’ glucometers.
4. Record review of Resident #31’s Face Sheet showed he/she was admitted to the facility
on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s (MONTH) (YEAR) POS and MAR indicated [REDACTED]
Observation on 6/6/18 at 7:57 A.M. showed CMT A:
-Removed the contaminated glucometer for Resident #31 from the medication cart drawer and
placed the contaminated meter on top of the contaminated medication cart without a
barrier;
-He/She cleaned the meter strip insertion port with an alcohol wipe and placed the
contaminated meter with the lancet, alcohol wipe, and sample strip on a clean barrier;
-He/She placed the contaminated meter with supplies on the clean barrier and a separate
dirty barrier on the resident’s table in his/her room and obtained the resident’s blood
sample;
-CMT A placed the contaminated meter on the resident’s table where the resident was eating
breakfast without a barrier, removed his/her gloves, and removed the contaminated barrier
from the resident’s room and
-CMT A placed the contaminated meter on top of the contaminated medication cart, and
without sanitizing the contaminated meter, placed the contaminated meter in the medication
drawer with the other residents’ meters.
5. During an interview on 6/6/18 at 8:22 A.M., CMT A said:
-He/She cleaned the glucometer port with alcohol wipes;
-He/She thought alcohol wipes to clean the glucometer ports were according to the facility
policy;
-He/She thought he/she only needed to clean the glucometer ports with alcohol since that
was closest to where the blood sample was obtained;
-He/She should have used the dirty barrier to place the contaminated meters and did not
realize he/she did not use the dirty barriers he/she brought into the resident room when
performing Accuchecks;
-He/She should have had gloves on when handling the contaminated meter and
-It was not appropriate to place the contaminated meter on the resident’s table, bedside
table, or on top of the medication cart without a barrier.
During an interview on 6/8/18 at 11:08 A.M., Licensed Practical Nurse (LPN) A said:
-Staff should use a dirty barrier for contaminated meters;
-Staff should wear gloves when handling contaminated meters;
-Staff should sanitize meters with bleach wipes before and after each resident use;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 45)
-Each resident has a dedicated meter just for that resident.
-Staff should not use another resident’s meter to perform an blood sugar test for a
different resident and
-If a resident’s meter had a dead battery, staff should get a new battery for the meter to
use for the resident.
During an interview on 6/8/18 at 2:03 P.M., the Director of Nursing (DON) said:
-He/She expected staff to sanitize meters with bleach wipes before and after resident use;
-It was not appropriate to clean the meter with only an alcohol wipe before resident use;
-He/She expected staff to place contaminated meters on a barrier;
-It was not appropriate to place contaminated meters on a resident table, bedside table,
or on top of the medication cart without a barrier;
-He/She expected staff to sanitize a contaminated meter with a bleach wipe before placing
the meter back into the medication drawer with other residents’ meters;
-Staff should wear gloves when handling contaminated meters;
-He/She expected staff to replace the batteries in a meter if the batteries were dead
before using the meter on a resident;
-Each resident had a dedicated meter to be used only for that resident and
-It was not appropriate to use one resident’s meter for another resident’s blood sugar
testing.
6. Record review of Resident # 5’s face sheet showed that he/she was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Foley catheter was placed to aid in the healing of coccyx wounds.
Observation on 6/4/18 at 7:40 A.M. showed a urine graduate was in the bathroom setting on
top of the toilet tank. It as not placed in a plastic bag. The date on the urine graduate
was 4/20/18 and it did not have a resident’s name on it.
Observation on 6/6/18 at 9:53 A.M. of the resident’s peri care performed by CNA C and CNA
D showed:
-CNA D washed hands, donned gloves and assisted to hold the resident on his/her side;
-CNA C washed hands, donned gloves then removed a wet coccyx (tail bone) dressing;
-With contaminated gloves, CNA C removed wipes out of the container with his/her right
hand and wiped around the resident’s coccyx wounds;
-CNA C removed his/her gloves an immediately donned on clean gloves;
-CNA D removed his/her gloves and donned clean gloves;
-CNA C with contaminated gloves applied A&D Ointment (a skin protectant) to the
resident’s buttocks;
-CNA C removed is/her gloves and immediately donned on clean gloves;
-CNA C & CNA D repositioned the resident with pillow support, and pulled up the cover
over the resident;
-CNA C & CNA D removed their gloves and
-CNA C with contaminated hands, put the oxygen on the resident.
Observation on 6/07/18 at 10:42 A.M., CNA C and CNA D performed catheter care on the
resident:
-CNA C and CNA D wash their hands, donned gloves;
-CNA D removed the resident’s oxygen, and pulled back the resident’s covers, removed the
resident’s mechanical lift sling by rolling the resident side to side and pulled the
resident’s pants down to to the ankles;
-CNA C removed wipes from the container with his/her contaminated right hand, wiped the
resident’s bottom from bottom up with his/her right hand and grabbed the trash can with
his/he right hand;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 46)
-CNA C removed his/her gloves and donned on clean gloves;
-CNA D used both hands to remove the dirty/contaminated linens;
-CNA D with contaminated hands grabbed wipes from the container and wiped the resident’s
bottom;
-CNA D rolled the soiled linens handed them to CNA C;
-CNA D removed his/her gloves and donned on new gloves;
-CNA D with contaminated hands grabbed the wipes out of the container;
-CNA C using both hands to grab the wipes, wiped oozing feces from the resident’s bottom;
-CNA C removed gloves, washed hands with sanitizing gel, donned on clean gloves and
removed the resident’s pants;
-CNA D washed his/her hands with sanitizing gel, donned on clean gloves with wipes and
wiped the resident’s both groins from top to bottom and
-CNA D with contaminated hands cleaned the resident’s catheter with the contaminated wipes
and applied clean briefs.
During an interview on 6/6/18 at 10:15 A.M. CNA D said he/she should have washed hands
between each glove change
During an interview on 6/6/18 at 10:18 A.M. CNA C said, the resident’s coccyx wound was
his/her only concern during the peri care.
7. Record review of Resident #17’s Face Sheet showed he/she was admitted to the facility
on [DATE], readmitted on ,[DATE] and 3/17/18 with the following Diagnoses:
[REDACTED].>-Stroke with [MEDICAL CONDITION] (muscle weakness or [DIAGNOSES REDACTED]
on one side of the body);
-Pneumonia/Pneumonitis and
-All three times he/she also had an urinary tract infection [MEDICAL CONDITION].
Record review of the resident’s quarterly MDS dated [DATE] showed he/she:
-Was severely cognitively impaired and
-Required total staff assistance for bathing.
Record Review of the resident’s Care Plan dated 2/20/18 showed:
-He/she was dependent on staff for daily hygiene/grooming;
-He/she to be showered/bathed per schedule and
-Staff should provide assistance with bathing
Observation on 6/4/18 at 7:49 A.M. showed a urine graduate was in the bathroom sitting on
the toilet tank, was not bagged, the date written on the graduate was 3/18/18.
Record review on 6/6/18 11:08 A.M. of the resident’s urine analysis (UA) results showed on
5/23/18 it was confirmed the resident has ESBL in his/her urine and was placed on an
antibiotic.
During an interview on 6/7/18 at 2:00 P.M. Registered Nurse (RN) B said:
-I’ve asked a doctor, he/she said it was just harder to get rid of;
-I don’t really know much about it and
-The resident has a Foley catheter so he/she doesn’t think he/she needs to be in isolation
or have any other precautions.
During an interview on 6/8/18 at 2:03 P.M. the DON said:
-Urine graduates should be changed monthly;
-It will be changed to weekly;
-The resident had a Foley catheter so the urine was contained;
-Since the urine was contained isolation was not necessary;
-Didn’t think of emptying the Foley and the potential contamination;
-Contaminated gloves should be changed; and
-He/she did not expect staff to pull wipes out of the container with contaminated gloved
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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)
hands.

F 0925

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Make sure there is a pest control program to prevent/deal with mice, insects, or other
pests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain the
dining room free of flies during the meal service; to maintain the kitchen free of flies;
to maintain resident room [ROOM NUMBER] free of live roaches; and to maintain 306 and the
circuit breaker room free of an accumulation of dead insects. This practice potentially
affected an unknown number of residents who resided in or used different areas of the
facility. The facility census was 46 residents.
1. During the group interview on 6/5/18 at 10:50 A.M., Resident #14 said the following:
– He/she saw a roach crawling on his/her bed;
– There were roaches in the bathroom;
– Roaches were seen in the halls, at the nurse’s station, the middle hall shower room, in
resident rooms 402, 211, 212, 302, 311,103, window sills in the dining room and
– He/she told the Administrator and the Administrator said the facility was going to be
exterminated.
2. Observations during the lunch meal on 6/5/18 at 12:32 P.M., showed a fly which flew
around table and some residents (Residents #45, #19, #39, #23) shooed the fly away while
they ate.
3. Observations with the Maintenance Supervisor on 6/5/18, showed the following:
– At 2:33 P.M., dead roaches behind the refrigerator in resident room [ROOM NUMBER];
– At 2:35 P.M., at least 3 live roaches were observed crawling around a cabinet in
resident room [ROOM NUMBER];
– At 2:35 P.M., the Maintenance Supervisor said the resident had food all over the chair
and the food were not in sealed containers; and
– At 4:57 P.M., numerous dead insects were present on the floor of the breaker room.
4. Observation on 6/6/18 at 7: 08 A.M., and 7:41 A.M., showed several flies flying around
the kitchen.
During an interview on 6/8/18 at 1:47 P.M., the Housekeeping Account Manager said the
facility was currently just using fly swatters, they do not like to use chemicals and the
maintenance department would handle pests.
During an interview on 6/8/18 at 1:52 P.M., the Maintenance Assistant said the following:
– Exterminators come every two weeks;
– They focus on areas that are written in maintenance log particularly areas where staff
and residents have seen roaches/pests and
– There are bug lights in the dining room.
Record review of the 2009 Food and Drug Administration Food Code, showed the following:
Chapter 6-501.111 Controlling Pests.
The premises shall be maintained free of insects, rodents, and other pests. The presence
of insects, rodents, and other pests shall be controlled to eliminate their presence on
the premises by:
A) Routinely inspecting incoming shipments of food and supplies;
B) Routinely inspecting the premises for evidence of pests;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265797

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

NAME OF PROVIDER OF SUPPLIER

RIDGE CREST NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

706 SOUTH MITCHELL
WARRENSBURG, MO 64093

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 0925

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 48)
C) Using methods, if pests are found, such as trapping devices or other means of pest
control as specified under; and
D) Eliminating harborage conditions.
6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests.
Dead or trapped birds, insects, rodents, and other pests shall be removed from control
devices and the premises at a frequency that prevents their accumulation, decomposition,
or the attraction of pests.