Inspection Reports for
Ridge Crest Nursing Center
706 SOUTH MITCHELL, WARRENSBURG, MO, 64093-2828
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
113% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
38% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Census: 46
Capacity: 120
Deficiencies: 10
Date: Sep 8, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, infection control, medication administration, nutrition, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to provide meaningful activities tailored to resident preferences, incomplete physician orders for IV medication infusion rates, unsafe environmental conditions with tripping hazards, inadequate supervision of residents with wandering and exit-seeking behaviors, failure to properly monitor and document Foley catheter care, failure to follow nutritional orders including delayed administration of appetite stimulants and supplements, failure to maintain cleanliness of the ice machine, incomplete infection prevention and control program including Legionella risk assessment, failure to ensure proper hand hygiene during resident care, and failure to document resident education and consent for influenza, pneumococcal, and COVID-19 vaccinations.
Deficiencies (10)
Failed to provide activities based on resident preferences and meaningful activity care plans for residents unable to self-direct activities.
Failed to ensure physician orders included IV infusion rate for Vancomycin and proper documentation of administration.
Facility environment had floor tiles separating creating tripping hazards and cracked ceilings allowing possible contamination.
Failed to adequately monitor residents with wandering and exit-seeking behaviors and failed to ensure safe transfer practices.
Failed to obtain physician orders and document monitoring and daily care of Foley catheter for a resident at risk for urinary tract infections.
Failed to follow nutritional orders including timely provision of appetite stimulant and health shakes for a resident at risk for weight loss.
Failed to maintain cleanliness inside the ice machine with visible blackish and brownish substance buildup.
Failed to establish and maintain a comprehensive Legionella infection prevention and control program including risk assessments and environmental testing.
Failed to perform proper hand hygiene during wound care and resident transfer, risking cross contamination.
Failed to document resident education, offer, and obtain consent or refusal for influenza, pneumococcal, and COVID-19 vaccinations.
Report Facts
Residents affected: 46
Total licensed capacity: 120
Activities offered: 93
Activities participated: 3
Activities participated: 20
IV infusion rate: 120
IV infusion duration: 75
Foley catheter size: 16
Foley catheter balloon size: 30
House supplement: 60
Appetite stimulant dose: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Named in findings related to resident wandering and improper transfer using sit to stand lift |
| LPN A | Licensed Practical Nurse | Named in findings related to IV medication administration and vaccination documentation |
| Wound Care Nurse | Named in findings related to wound care hand hygiene and vaccination documentation | |
| Director of Nursing | DON | Named in findings related to IV medication orders, nutritional orders, infection control, and vaccination documentation |
| Dietary Manager | DM | Named in findings related to menu substitutions, nutritional supplement provision, and ice machine cleaning |
| Maintenance Director | MD | Named in findings related to ice machine cleaning and facility maintenance |
| Infection Control Preventionist | ICP | Named in findings related to infection control program and vaccination documentation |
Inspection Report
Routine
Census: 50
Deficiencies: 1
Date: Feb 10, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to bathing and showering assistance for residents who require staff help, following concerns about residents not receiving adequate bathing care.
Findings
The facility failed to ensure that residents requiring assistance with bathing received baths or showers as needed. Four of six sampled residents did not receive the expected frequency of baths/showers, with staff shortages and scheduling issues cited as contributing factors.
Deficiencies (1)
Failure to provide adequate bathing and showering assistance to residents requiring staff help, resulting in residents not receiving baths/showers as scheduled.
Report Facts
Residents affected: 4
Facility census: 50
Bath aide work schedule: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) A | Certified Nursing Assistant | Interviewed regarding bathing assistance and staffing issues |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding bathing policies and staffing shortages |
| Administrator | Administrator | Interviewed regarding bathing aide staffing and corrective actions |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Jan 24, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide adequate oversight and interventions to prevent falls, complete fall investigations including root-cause analysis, perform neurological checks after falls, and update care plans accordingly for sampled residents.
Complaint Details
The investigation was complaint-related, focusing on falls experienced by Residents #1, #6, and #7. The complaint included failure to complete fall investigations, neurological assessments, and care plan updates. The complaint was substantiated with findings of actual harm to residents.
Findings
The facility failed to provide appropriate fall prevention interventions and oversight for residents who experienced falls, did not complete required fall investigations or neurological assessments after falls, and failed to update care plans to reflect interventions post-fall. Several residents sustained injuries including head lacerations, and the facility's documentation and follow-up were inadequate.
Deficiencies (1)
Failed to provide oversight and appropriate interventions for residents who fell, including failure to complete fall investigations with root-cause analysis and neurological checks, and failure to update care plans after falls.
Report Facts
Residents affected: 3
Facility census: 47
Falls for Resident #1: 3
Staples for Resident #1: 4
Fall follow-up monitoring duration: 48
Fall interventions check frequency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Involved in assessment and care of Resident #1 after falls; provided statements about fall interventions and neurological assessments |
| LPN B | Licensed Practical Nurse | Completed incident notes and transfer summaries for Resident #1; involved in post-fall care |
| CNA A | Certified Nursing Assistant | Provided information on fall reporting and interventions for residents |
| Director of Nursing | Director of Nursing | Responsible for fall investigations and oversight; provided statements on facility policies and deficiencies |
| Physician A | Physician | Involved in post-fall care and notifications; provided statements on expectations for neurological assessments and fall interventions |
Inspection Report
Routine
Census: 49
Deficiencies: 2
Date: Aug 9, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards, specifically focusing on residents' personal care including bathing and infection prevention practices.
Findings
The facility failed to ensure residents received adequate personal care, notably not offering showers or baths as scheduled to several residents due to staffing shortages. Additionally, the facility lacked a certified Infection Preventionist for over six months, impacting infection control oversight.
Deficiencies (2)
Failure to provide scheduled showers or baths to residents due to insufficient staffing.
Failure to employ a certified Infection Preventionist and lack of infection prevention policy.
Report Facts
Residents affected: 49
Showers given in August: 1
Months without Infection Preventionist: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) A | Certified Nursing Assistant | Interviewed regarding shower frequency and staffing shortages |
| Graduate Licensed Nurse (GLN) A | Graduate Licensed Nurse | Interviewed about shower schedules and staffing |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed about shower frequency and infection control education |
| Administrator | Facility Administrator | Interviewed about staffing, shower aide vacancy, and infection preventionist status |
| Director of Nursing (DON) | Director of Nursing | Interviewed about shower schedules, staffing shortages, and infection prevention responsibilities |
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 19
Date: Nov 17, 2023
Visit Reason
The inspection was conducted as part of the annual regulatory oversight of Ridge Crest Nursing Center to assess compliance with healthcare facility regulations, including resident care, safety, infection control, medication management, dietary services, and other regulatory requirements.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity, inadequate maintenance and cleanliness, incomplete criminal background checks for employees, failure to follow physician orders for pacemaker monitoring, inadequate hair care for a resident, incomplete wound care and documentation, incomplete fall investigations, improper catheter care, unsafe oxygen therapy practices, inaccurate narcotic medication documentation, unlocked medication carts, dietary deficiencies including lack of recipes and limited menu variety, cold food service, lack of antibiotic stewardship program, absence of a certified infection preventionist, and failure to ensure pneumococcal vaccinations were offered and documented.
Deficiencies (19)
Failure to ensure resident dignity by not placing catheter bag in a privacy bag and visible catheter bag contents.
Failure to maintain flooring, sprinkler heads, and fans in good repair and clean condition.
Failure to complete timely criminal background checks for five employees prior to employment.
Failure to ensure physician orders and monitoring for pacemaker for one resident.
Failure to maintain hair care for one resident who could not perform care independently.
Failure to follow and document physician ordered wound treatments and weekly skin assessments for sampled residents.
Failure to complete fall investigation and incident report for resident falls including one with hip fracture.
Failure to ensure sanitary catheter care including proper placement of catheter bags and inclusion of catheter care in care plans.
Failure to follow physician orders for oxygen therapy, maintain oxygen equipment, document oxygen administration, and store oxygen supplies properly.
Failure to ensure dialysis care per physician orders and to remove dialysis access bandages.
Failure to ensure nurse aides hired were certified within four months of hire.
Failure to post accurate nurse staffing information daily at the beginning of each shift.
Failure to ensure medication carts remained locked when unattended and medications stored in resident rooms were secured and properly ordered for bedside storage and self-administration.
Failure to ensure accurate narcotic medication documentation and reconciliation for sampled residents.
Failure to ensure dietary department had recipes for pureed foods and provide menu variety beyond chicken entrees.
Failure to maintain food at safe and appetizing temperatures during meal delivery and failure to provide palatable food.
Failure to implement an antibiotic stewardship program including monitoring antibiotic use and culture and sensitivity testing.
Failure to designate a qualified infection preventionist certified in infection prevention and control.
Failure to develop and implement policies and procedures for flu and pneumonia vaccinations including documentation of refusals.
Report Facts
Facility census: 41
Resident census: 41
Weight: 465
Weight: 464
Weight: 476
Weight: 477.5
Weight: 469
Weight: 470
Temperature: 112
Temperature: 105.2
Narcotic tablets: 46
Narcotic tablets: 63
Narcotic tablets: 24
Narcotic tablets: 9
Narcotic tablets: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Hired 4/20/23, enrolled in CNA classes but not certified within 4 months |
| NA B | Nurse Aide | Hired 12/14/22, not certified within 4 months |
| NA D | Nurse Aide | Hired 5/29/23, not certified within 4 months |
| Certified Nursing Assistant A | CNA | Interviewed about catheter care and oxygen supply storage |
| Certified Nursing Assistant J | CNA | Interviewed about catheter care and oxygen supply storage |
| Licensed Practical Nurse B | LPN | Interviewed about catheter care, wound care, oxygen therapy, narcotic documentation |
| Registered Nurse A | RN | Interviewed about wound care, narcotic documentation, medication cart security |
| Director of Nursing | DON | Interviewed about catheter care, wound care, oxygen therapy, narcotic documentation, infection prevention |
| Administrator | Administrator | Interviewed about staffing, infection prevention, dietary, vaccination refusals |
| Dietary Manager | DM | Interviewed about dietary menus, recipes, food temperature, kitchen sanitation |
| Regional Registered Nurse | RN | Infection Control Preventionist role, antibiotic stewardship |
| Certified Medication Technician C | CMT | Interviewed about oxygen therapy and dialysis care |
| Licensed Practical Nurse LPN B | LPN | Interviewed about dialysis care and catheter care |
| Dialysis Clinic Registered Nurse | RN | Interviewed about dialysis access care |
| Consultant Registered Dietitian | RD | Interviewed about dietary menus and resident preferences |
| Former Director of Nursing A | Former DON | Interviewed about resident weight management |
| Former Director of Nursing B | Former DON | Interviewed about resident weight management |
| Physician A | Physician | Interviewed about resident weight management and fall investigations |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Nov 17, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide adequate hair care for a resident (Resident #18) who was unable to perform hair care independently.
Complaint Details
The investigation was complaint-related, focusing on Resident #18's hair care. The resident refused care from certain staff and preferred external hair care services. The facility did not document refusals consistently, and the care plan lacked specific hair care instructions or refusal documentation.
Findings
The facility failed to ensure proper hair care maintenance for Resident #18, who had matted hair and a knot on the back of the head. The resident refused care from certain staff and preferred to have hair care done outside the facility due to lack of supplies and staff qualifications. Documentation of care refusals and hair care preferences were lacking in the care plan and resident's chart.
Deficiencies (1)
Failure to provide adequate hair care for Resident #18 who could not perform hair care independently, resulting in matted hair and a knot.
Report Facts
Residents affected: 1
Sampled residents: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant B | Certified Nursing Assistant | Interviewed regarding Resident #18's hair care and refusals |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed about Resident #18's hair care and documentation of refusals |
| Social Services Designee | Social Services Designee | Interviewed about Resident #18's hair care and potential community assistance |
| Director of Nursing | Director of Nursing | Interviewed about facility responsibilities and documentation related to Resident #18's hair care |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Apr 6, 2023
Visit Reason
The inspection was conducted due to a complaint or concern regarding the facility's failure to keep a card of Hydrocodone-Acetaminophen 5/325 mg double locked at all times, resulting in 30 tablets missing for one sampled resident.
Complaint Details
The visit was complaint-related due to the missing card of Hydrocodone-Acetaminophen 5-325 mg tablets for Resident #1. The complaint was substantiated as the medication was confirmed missing after an investigation, interviews, and a search. The local police were involved, and drug testing of staff was conducted.
Findings
The facility failed to secure controlled substances properly, leading to the loss of a narcotic medication card for Resident #1. The medication cart locks were faulty, and nursing staff did not consistently follow narcotic counting and storage policies. An extensive search and interviews were conducted, and the local police were notified. The medication remained missing at the time of the report.
Deficiencies (1)
Failure to keep controlled substances double locked at all times, resulting in missing narcotic medication.
Report Facts
Residents census: 44
Missing medication count: 30
Number of sampled residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse and Assistant Director of Nursing (ADON) | Signed for medication delivery, involved in narcotic counts, and provided statements regarding the missing medication. |
| LPN A | Licensed Practical Nurse | Reported missing medication to Director of Nursing, involved in narcotic counts, and provided statements. |
| RN B | Registered Nurse | Involved in narcotic counts and provided statements about the missing medication. |
| RN C | Registered Nurse | Involved in narcotic counts, discovered missing medication, and provided statements. |
| Director of Nursing | Director of Nursing (DON) | Notified of missing medication, conducted investigation, provided statements, and reported on medication cart issues. |
| Administrator | Facility Administrator | Provided statements regarding corrective actions and expectations for narcotic storage and counting. |
Report
Apr 28, 2022
Viewing
Loading inspection reports...
