Ridge Crest Nursing Center

In the surveyor’s words

From the most serious findings on record at Ridge Crest Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jul 22, 2026

  Based on interview and record review, the facility failed to ensure appropriate identification and timely treatment of a resident's broken femur and severe pain for one sampled resident (Resident #1) out of four sampled residents. On 05/30/26 at 11:12 P.M., the resident fell and had severe pain. The facility failed to perform pain assessments, did not provide any non-pharmacological pain relief, and the resident's pharmacological pain relief treatment was delayed until 05/31/26 around 7:00 A.M. X-Ray was not completed until 05/31/26 around 11:14 A.M. Facility staff did not notify the physician the resident's ordered pain medication was not sufficient for the resident's pain and the x-ray was delayed. The resident was transferred to the hospital on [DATE] at 12:34 P.M. […]

• Actual harm, isolatedF689Jan 24, 2025

  Based on interview, and record review, the facility failed to provide oversight and put appropriate interventions in place for one sampled resident (Resident #1) who fell twice on 12/27/24 and sustained head lacerations and then fell again on 1/3/25; failed to ensure fall investigations were completed to include root-cause analysis (RCA-a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems) and interventions that were put in place for three sampled residents (Resident #1, Resident #6, and Resident #7); failed to complete neurological checks for one sampled resident (Resident #6) after an un-witnessed fall, and failed to update the care plans for three sampled residents (Resident #1, Resident #6, and Resident #7) to include the… […]

• No harm, potential for more than minimal, widespreadF880Sep 8, 2025

  Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. […]

• No harm, potential for more than minimal, widespreadF732Nov 17, 2023

  Based on observation and interview, the facility failed to ensure staffing was posted daily and accurately at the beginning of each shift including the total number and actual hours worked by licensed care staff which could have the potential to affect some residents and visitors in the facility. The facility census was 41 residents. 1. Review of the facility's policy titled Posting Direct Care Daily Staffing Numbers dated August 2022 showed: -The facility would post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. […]

• No harm, potential for more than minimal, widespreadF803Nov 17, 2023

  Based on observation, interview and record review, the dietary department failed to have recipes available to process the following foods into a pureed (to make food into a paste or thick liquid suspension usually made from cooked food that was ground finely) form (peach crisp, chicken [NAME] pasta, and Italian Blend vegetables) potentially affecting three residents with pureed diets; and to provide a menu with a wider variety of choices for entrees, other than chicken, for the week 1 menu. This practice potentially affected all residents. The facility census was 41 residents. 1. Observation on 11/13/23 from 9:45 A.M. […]