Inspection Reports for
Crowley Ridge Care Center
1204 NORTH OUTER RD, DEXTER, MO, 63841-8684
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
10 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
82% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
56% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Jun 10, 2025
Visit Reason
The inspection was conducted due to a complaint alleging misappropriation of a resident's property by the Social Services Director (SSD). The investigation was initiated after notification of suspected theft from Resident #1's bank account.
Complaint Details
Complaint #MO2255231 regarding misappropriation of Resident #1's funds by SSD. The complaint was substantiated by investigation and police report. SSD admitted to the misuse but denied involvement during interview. Resident's family agreed not to press charges if funds were returned.
Findings
The facility failed to protect Resident #1 from misappropriation of property when the SSD used the resident's banking information for personal use, transferring funds to the SSD's Cash App account. The SSD admitted to the police department the misuse and was terminated. The facility took corrective actions including staff in-service and plans to refund the resident.
Deficiencies (1)
Failure to protect Resident #1 from misappropriation of property by SSD who used resident's banking information for personal use.
Report Facts
Census: 50
Amount misappropriated: 1035
Date of inspection: Jun 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Named in misappropriation of resident funds | |
| Administrator | Interviewed regarding facility policy and expectations |
Inspection Report
Plan of Correction
Census: 48
Deficiencies: 4
Date: Mar 20, 2025
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident care, including significant change assessments, trauma-informed care, and medication administration.
Findings
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days for a resident admitted to hospice, did not provide trauma-informed care for a resident with PTSD, and had a medication error rate exceeding 5%. The facility lacked policies regarding significant change MDS assessments, trauma-informed care, and insulin administration.
Deficiencies (4)
F637: The facility failed to complete a significant change MDS assessment within 14 days of admission to hospice for one resident. The facility census was 48.
F699: The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with PTSD. The facility did not have a policy regarding trauma-informed care.
F759: The facility failed to maintain a medication error rate below 5%, with an error rate of 7.89% affecting three residents. The facility did not have a policy for insulin administration.
A4055: The facility failed to maintain a safe and effective medication system as evidenced by deficiencies cited under F759.
Report Facts
Facility census: 48
Medication error opportunities: 38
Medication errors: 3
Medication error rate: 7.89
Residents affected by medication errors: 3
Residents sampled for medication error review: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication administration errors for not priming insulin pens |
| Director of Nursing | Interviewed regarding medication administration expectations | |
| Administrator | Interviewed regarding MDS and care plan expectations |
Inspection Report
Life Safety
Census: 48
Deficiencies: 4
Date: Mar 20, 2025
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations at Crowley Ridge Care Center.
Findings
The facility failed to meet the applicable provisions of the 2012 Life Safety Code related to sprinkler system installation and smoke barrier construction. Deficiencies included inconsistent sprinkler heads within smoke zones and unsealed holes in smoke walls.
Deficiencies (4)
K351 Sprinkler System installation did not ensure all sprinkler heads within a smoke zone were of the same type, potentially delaying fire response. The facility census was 48 at the time of observation.
K372 Smoke barriers were not maintained free of penetrations, including an 8 inch unsealed hole in the smoke wall on the 400 hall. This affected all residents and staff.
A2035 The facility did not install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition, as required for facilities licensed after August 28, 2007.
A2053 Each floor was not divided into the required smoke sections with dimensions not exceeding 150 feet, violating smoke section regulations.
Report Facts
Facility census: 48
Deficiencies cited: 4
Inspection Report
Routine
Census: 48
Deficiencies: 3
Date: Mar 20, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including completion of significant change Minimum Data Set (MDS) assessments, trauma informed care, and medication administration accuracy.
Findings
The facility failed to complete a significant change MDS assessment within 14 days of hospice admission for one resident, did not provide trauma informed care for a resident with PTSD, and had a medication error rate of 7.89% due to improper insulin administration techniques affecting three residents.
Deficiencies (3)
Failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of admission to hospice services for Resident #50.
Failed to identify, assess, and provide supportive interventions for Resident #47 with PTSD; care plan did not address personalized triggers or interventions.
Failed to maintain medication error rates below 5%; insulin pens were not primed before administration, resulting in a 7.89% error rate affecting Residents #37, #38, and #39.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Medication administration opportunities: 38
Medication errors: 3
Medication error rate: 7.89
Facility census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication administration errors for failing to prime insulin pens |
| MDS Coordinator | Interviewed regarding expectations for significant change MDS and care plan | |
| Administrator | Interviewed regarding expectations for MDS and care plan reflecting resident's current condition | |
| Director of Nursing (DON) | Interviewed regarding medication administration expectations |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Feb 10, 2025
Visit Reason
The inspection was conducted due to a complaint regarding misappropriation of narcotic medication involving four residents at Crowley Ridge Care Center.
Complaint Details
Complaint #MO 248707 was investigated and substantiated. The facility was found to have failed in preventing misappropriation of narcotic medications by a staff member.
Findings
The facility failed to prevent the misappropriation of narcotic medications for four residents. An investigation revealed missing narcotic tablets and improper medication record keeping by a Certified Medication Technician, leading to disciplinary action and termination.
Deficiencies (1)
F 602: The facility failed to prevent misappropriation of narcotic medication for four residents, violating residents' rights to be free from abuse and exploitation. Medication records showed missing tablets and lack of proper administration documentation.
Report Facts
Facility census: 46
Number of residents involved: 4
Quantity of Hydrocodone/APAP tablets: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in findings related to narcotic medication misappropriation and record discrepancies |
| CMT B | Certified Medication Technician | Reported concerns about CMT A's narcotic record keeping and destruction of narcotics |
| DON | Director of Nursing | Involved in investigation and audit of medication records |
| ADON | Assistant Director of Nursing | Assisted in audit of medication cart and investigation |
Inspection Report
Routine
Census: 43
Deficiencies: 4
Date: Apr 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to PASARR screening, food storage and safety, infection prevention and control, and nurse aide training at Crowley Ridge Care Center.
Findings
The facility failed to ensure two residents received required Level II PASARR screenings, improperly stored food increasing risk of contamination, did not follow infection control protocols including medication handling, and failed to provide required annual nurse aide training on Abuse Prevention and Dementia Care.
Deficiencies (4)
Failed to ensure two residents received required Level II PASARR screening after positive Level I screening.
Failed to store and distribute food under sanitary conditions, including unlabeled containers, dented cans stored with food, and personal items in food storage.
Failed to follow standard precautions to prevent infection spread, including medication cart contamination and improper insulin pen storage.
Failed to provide required annual competencies on Abuse Prevention and Dementia Care for two nurse aides.
Report Facts
Facility census: 43
In-service hours for CNA C: 16.5
In-service hours for CNA D: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Named in infection control deficiency related to medication cart contamination |
| Licensed Practical Nurse B | Licensed Practical Nurse | Named in infection control deficiency related to insulin pen storage |
| Certified Nursing Assistant C | Certified Nursing Assistant | Named in nurse aide training deficiency for missing annual competencies |
| Certified Nursing Assistant D | Certified Nursing Assistant | Named in nurse aide training deficiency for missing annual competencies |
| Social Services Director | Social Services Director | Interviewed regarding missing Level II PASARR screenings for residents #8 and #16 |
| Administrator | Administrator | Interviewed regarding expectations for PASARR screening, food storage, infection control, and nurse aide training |
Inspection Report
Plan of Correction
Census: 43
Deficiencies: 8
Date: Apr 5, 2024
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding PASARR screening, food safety, infection control, and nurse aide training at Crowley Ridge Care Center.
Findings
The facility failed to ensure proper Level II PASARR screening for residents with mental disorders, maintain food safety standards including proper labeling and storage, establish an effective infection prevention and control program, and provide required annual in-service training for nurse aides.
Deficiencies (8)
F645 PASARR Screening for MD & ID was not properly completed for residents #8 and #16, lacking required Level II screening documentation upon admission.
F812 Food Procurement, Storage, Preparation, and Sanitation requirements were not met due to unlabeled and undated food items and improper storage conditions, risking cross-contamination.
F880 Infection Prevention & Control program was deficient; the facility failed to follow standard precautions and maintain an effective infection control program, risking disease transmission.
F947 Required in-service training for nurse aides was not provided; the facility failed to ensure annual competencies in abuse prevention and dementia care for sampled nurse aides.
A4022 Employee Orientation/Continuing Education requirements were not met; the facility lacked an adequate in-service orientation and continuing education program for staff.
A4086 Infection Control/Communicable Disease regulations were not met; the facility failed to use acceptable infection control procedures and timely report communicable diseases.
A4106 DMH Referral, Treatment/Habilitation Plan requirements were not met; residents admitted on referral lacked individualized treatment or habilitation plans updated annually.
A7019 Food Stored in Identifying Containers was not met; bulk food items were not stored in containers labeled with the common name of the food.
Report Facts
Facility census: 43
Deficiencies cited: 8
Inspection Report
Life Safety
Census: 43
Deficiencies: 2
Date: Apr 5, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain all exit discharges free of obstructions and did not have code numbers posted on exit doors. Gates leading to exit doors were locked without posted codes, and staff were unaware of gate codes for emergency egress.
Deficiencies (2)
K211 Means of Egress - General: The facility failed to maintain all exit discharges free of obstructions and did not post code numbers on exit doors. Gates leading to exits were locked with different locks and no posted codes, impeding emergency egress.
A2046 Corridor Requirements: Corridors were not maintained free of obstruction, equipment, or supplies not in use, and doors to resident rooms swung into the corridor, violating corridor requirements.
Report Facts
Facility census: 43
Inspection Report
Plan of Correction
Census: 41
Deficiencies: 3
Date: Nov 4, 2022
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding respiratory care, infection prevention, and nursing care at Crowley Ridge Care Center.
Findings
The facility failed to obtain a physician's order for oxygen use for one resident and did not ensure that the infection preventionist had completed specialized training. Nursing care regulations were also not met as referenced by a related deficiency.
Deficiencies (3)
F695 Respiratory care, including tracheostomy care and suctioning, was not provided according to professional standards as the facility failed to obtain a physician's order for oxygen use for one resident.
F882 The facility failed to ensure the infection preventionist had completed specialized training in infection prevention and control, impacting all residents.
A4075 Nursing care per resident condition was not met as evidenced by failure to meet F695 requirements.
Report Facts
Facility census: 41
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding oxygen orders and infection prevention training | |
| Licensed Practical Nurse | Interviewed regarding physician's orders for oxygen | |
| Administrator | Interviewed regarding oxygen orders and infection prevention training | |
| Registered Nurse | Shared responsibility for infection prevention program |
Inspection Report
Census: 41
Deficiencies: 2
Date: Nov 4, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including respiratory care and infection prevention and control.
Findings
The facility failed to obtain a physician's order for oxygen use for one resident out of 12 sampled, and failed to ensure that at least one person had completed specialized training for the Infection Preventionist position. Both deficiencies were cited with minimal harm or potential for actual harm.
Deficiencies (2)
Failed to obtain a physician's order for oxygen use for one resident (Resident #138) out of 12 sampled residents.
Failed to ensure at least one person had completed specialized training in infection prevention and control for the Infection Preventionist position.
Report Facts
Residents affected: 1
Residents affected: Many residents affected by infection preventionist training deficiency
Facility census: 41
Sampled residents: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen order and infection preventionist training |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding missing oxygen order for Resident #138 |
| Administrator | Administrator | Interviewed regarding expectation of oxygen order and infection preventionist training |
| Registered Nurse D | Registered Nurse | Shared responsibility for Infection Preventionist role |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 2
Date: Mar 10, 2022
Visit Reason
The inspection was conducted based on a complaint investigation regarding the facility's failure to provide adequate care and services for activities of daily living, specifically bathing, for several residents.
Complaint Details
The complaint investigation found substantiated deficiencies related to inadequate bathing and hygiene care for residents. Interviews with family members and staff confirmed residents were not bathed as scheduled due to short staffing.
Findings
The facility failed to provide appropriate care and services for activities of daily living, including bathing, for three sampled residents. The facility census was 41, and staff interviews and record reviews confirmed residents were not bathed as scheduled due to staffing shortages.
Deficiencies (2)
F676: The facility failed to provide care and services for activities of daily living, including bathing, dressing, grooming, mobility, elimination, dining, and communication, for three sampled residents. The facility did not have an Activities of Daily Living policy and residents were not bathed as scheduled.
A4076: Each resident shall be clean, dry, and free of body and mouth odor that is offensive to others. This regulation was not met as evidenced by the F676 deficiency.
Report Facts
Facility census: 41
Plan of correction completion date: Completion date for corrective actions is 2022-04-23
Inspection Report
Routine
Deficiencies: 0
Date: Dec 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 11
Date: Dec 6, 2019
Visit Reason
Annual inspection survey conducted on 12/06/2019 to assess compliance with federal regulations for Crowley Ridge Care Center.
Findings
The facility was found deficient in multiple areas including abuse/neglect policies, resident assessment transmissions, accuracy of assessments, baseline and comprehensive care plans, infection control, medication labeling, and immunization procedures. Several residents' records and care practices did not meet regulatory requirements.
Deficiencies (11)
F607 Develop/Implement Abuse/Neglect Policies. The facility failed to follow policy to check the CNA Registry for all new hires to ensure no Federal Indicator for abuse/neglect.
F640 Encoding/Transmitting Resident Assessments. The facility failed to electronically transmit quarterly Minimum Data Sets (MDS) in a timely manner for multiple residents.
F641 Accuracy of Assessments. The facility failed to accurately code the Minimum Data Set (MDS) for three residents.
F655 Baseline Care Plan. The facility did not provide a policy and failed to address the resident's diagnosis of Alzheimer's disease and ensure a written summary of the baseline care plan.
F656 Develop/Implement Comprehensive Care Plan. The facility failed to implement an individualized comprehensive care plan meeting residents' highest practicable well-being.
F658 Services Provided Meet Professional Standards. The facility failed to provide professional standards of care for one resident by crushing delayed release medication.
F677 ADL Care Provided for Dependent Residents. The facility failed to provide showers and appropriate incontinence care for sampled residents.
F744 Treatment/Service for Dementia. The facility failed to ensure residents diagnosed with dementia had a personalized care plan to promote highest level of functioning and psychosocial needs.
F761 Label/Store Drugs and Biologicals. The facility failed to label and store drugs and biologicals properly in a locked storage area and ensure medication pass safety.
F880 Infection Prevention & Control. The facility failed to establish and maintain an infection prevention and control program, including proper screening for tuberculosis and infection control practices.
F883 Influenza and Pneumococcal Immunizations. The facility failed to ensure residents received pneumococcal vaccine upon admission and proper immunization education and documentation.
Report Facts
Facility census: 61
Sampled residents: 15
Deficiencies cited: 11
Inspection Report
Life Safety
Census: 61
Deficiencies: 6
Date: Dec 6, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain portable fire extinguishers, functioning smoke barrier doors, restrict use of temporary wiring including power strips and extension cords, and maintain required outlet testing. The facility also failed to have an annual fire department consultation.
Deficiencies (6)
K355 Portable fire extinguishers were not maintained properly, potentially affecting all residents and staff. The facility census was 61.
K374 The facility failed to maintain functioning smoke barrier doors, which did not close properly during fire alarm testing. This potentially affected all residents and staff. The facility census was 61.
K920 The facility failed to restrict use of temporary wiring including power strips and extension cords, potentially affecting all residents and staff. The facility census was 61.
K921 The facility failed to maintain required electrical outlet testing and had not performed outlet inspections for the last 12 months. This potentially affected all residents and staff. The facility census was 61.
A2058 The facility failed to have an annual fire department consultation, potentially affecting staff readiness in an emergency. The facility had a census of 61.
A3037 Extension cords were not used according to regulations, with multiple appliances connected improperly and cords placed where subject to physical damage. See K920.
Report Facts
Facility census: 61
Deficiencies cited: 6
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 4
Date: Oct 12, 2018
Visit Reason
The inspection was conducted to evaluate compliance with bed hold policy and ADL care requirements following identified deficiencies.
Findings
The facility failed to inform residents and their representatives in writing about the bed hold policy at the time of transfer for three residents. The facility also failed to provide thorough cleansing after incontinent episodes for three residents, as evidenced by observations and record reviews.
Deficiencies (4)
F625 Notice of bed hold policy and return: The facility failed to inform three residents and their representatives in writing of the bed hold policy at the time of transfer to hospital or therapeutic leave.
F677 ADL care for dependent residents: The facility failed to provide thorough cleansing after incontinent episodes for three residents, as observed and documented in medical records.
A4074 Nursing care per resident condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as referenced in F677.
A4075 Clean, dry, odor free: Each resident shall be clean, dry, and free of offensive body and mouth odor. This regulation was not met as referenced in F677.
Report Facts
Facility census: 67
Residents sampled: 6
Residents affected: 3
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lynne Christian | Administrator | Signed the report and plan of correction |
Inspection Report
Life Safety
Census: 67
Deficiencies: 5
Date: Oct 10, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain clear and unobstructed means of egress, proper exit illumination, and smoke barrier walls free from penetrations. These deficiencies potentially affected all residents and staff.
Deficiencies (5)
K271 Discharge from Exits: The facility failed to maintain clear and unobstructed means of egress, including locked gates with combination locks and no posted code. This affected all residents and staff.
K281 Illumination of Means of Egress: The facility failed to have exit illumination from two exit doors leading to the public way, affecting all residents and staff.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barrier walls free from penetrations, including unsealed holes and pipes, affecting all residents and staff.
A2049 Exit Sign-Maintain/Illuminate: The facility failed to maintain all exit and directional signs to be clearly legible and electrically illuminated at all times by acceptable means.
A2050 Emergency Lighting: The facility failed to maintain emergency lighting of sufficient intensity for safety of residents and others using any exit, stairway, and corridor, including required testing and documentation.
Report Facts
Facility census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lynn Christian | Administrator | Signed the inspection report and plan of correction |
| Certified Nurse Aide (CNA) | Interviewed regarding lock codes | |
| Environmental Director | Interviewed regarding removal of locks and installation of lighting | |
| Environmental Supervisor | Interviewed regarding sealing of holes in smoke barrier walls |
Document
Deficiencies: 0
Visit Reason
The document content is unavailable, so the purpose cannot be determined.
Findings
No findings or content are available due to lack of readable text.
Viewing
Loading inspection reports...
