Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crowley Ridge Care Center during CMS and state inspections, most recent first.
A Social Services Director used a resident's debit card information, obtained during an office visit, to make unauthorized transfers from the resident's bank account into the SSD's own Cash App account. The resident, who was severely cognitively impaired and had multiple chronic conditions, did not authorize these transactions. The misappropriation was discovered when the resident's family noticed missing funds, and a bank investigation confirmed the SSD's involvement.
The facility failed to complete a significant change MDS assessment within 14 days for a resident admitted to hospice services. The resident's medical record showed no significant change MDS dated after the hospice admission. Interviews with the MDS Coordinator and Administrator confirmed the expectation for such an assessment, but the facility lacked a policy on completing significant change MDS assessments.
A facility failed to provide trauma-informed care for a resident with PTSD, as their care plan did not identify PTSD or address personalized triggers. Despite the resident's expressed anxiety due to loud noises, the care plan lacked interventions for this condition. Staff interviews indicated an expectation for the care plan to reflect the resident's current condition, but the absence of a trauma-informed care policy contributed to this deficiency.
The facility failed to maintain a medication error rate below five percent, resulting in a 7.89% error rate. An LPN did not prime insulin pens before administering doses to three residents, contrary to manufacturer guidelines. The DON and Administrator expected adherence to these guidelines.
A CMT failed to follow proper procedures for administering and documenting narcotic medications, resulting in the misappropriation of pain medications prescribed to four residents with severe cognitive impairment. The issue was discovered after another CMT reported concerns about improper destruction of narcotics and discrepancies in medication counts, leading to an audit that confirmed missing tablets and a subsequent admission by the responsible staff member.
Deficiencies were identified in the storage and distribution of food under sanitary conditions, posing a risk of cross-contamination and food-borne illness. Observations revealed unlabeled containers of dry cereals, salt, and sugar, dented cans of various food items, a medication cup with a white cream substance, and a sweatshirt on a food storage shelf. The Dietary Manager acknowledged the need for proper labeling, segregation of dented cans, and prohibition of personal items in the food storage area. The facility's policy from April 2011 outlined guidelines for orderly storage, labeling, and segregation of damaged cans, but adherence to these policies was lacking.
The facility failed to ensure that two residents, who required a Level II PASARR, received the necessary evaluations. Both residents were transferred from other facilities without the required Level II PASARR completed upon admission. The Administrator acknowledged that such screenings should have been completed.
The facility failed to follow infection control protocols, as a CMT stored a personal cup in the medication cart and an LPN stored multiple residents' insulin pens together, risking cross-contamination.
The facility failed to provide the required annual competencies of Abuse Prevention and Dementia Care for two nurse aides. Review of in-service records showed that both CNAs did not attend the necessary annual competency in-services. The Administrator confirmed that these trainings should be included in annual nurse aide training.
Misappropriation of Resident Funds by Social Services Director
Penalty
Summary
A Social Services Director (SSD) misappropriated a resident's property by using the resident's banking information for personal use. The SSD obtained the resident's debit card information when the resident visited the SSD's office for assistance with insurance cards. The SSD wrote down the debit card numbers without authorization and later used this information to transfer funds from the resident's account into the SSD's own Cash App account. Bank records showed multiple unauthorized transfers, including two separate $500 transactions and earlier transfers of $10 and $25 to the SSD's account. The resident, who had a history of chronic medical conditions and was assessed as severely cognitively impaired, did not give permission for the SSD to use the bank card or transfer funds. The misappropriation was discovered when the resident's family attempted to withdraw funds and found the money missing. A bank investigation confirmed the transfers to the SSD's account. During interviews, the SSD initially denied taking the funds and claimed the Cash App account had been hacked, but later admitted to law enforcement that the resident's information had been added to the SSD's Cash App. The SSD had previously received in-service training on abuse and neglect, including the facility's abuse prevention policy, which prohibits the misappropriation of resident property.
Failure to Complete Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days for a resident who was admitted to hospice services. The resident was admitted to hospice on February 26, 2025, but there was no significant change MDS dated on or after this date. During interviews, both the MDS Coordinator and the Administrator acknowledged that they would expect a significant change MDS to be completed to reflect the resident's current condition. However, the facility did not provide a policy regarding the completion of significant change MDS assessments.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with post-traumatic stress disorder (PTSD) among other mental health conditions. The resident's medical record indicated diagnoses of PTSD, major depressive disorder, panic disorder, generalized anxiety disorder, unspecified dementia, and delusional disorder. Despite these diagnoses, the resident's care plan did not identify PTSD as a problem, nor did it address personalized triggers or interventions related to the resident's condition. The resident expressed that loud noises agitated them and made them anxious, yet this was not reflected in their care plan. Interviews with facility staff, including the Minimum Data Set (MDS) Coordinator and the Administrator, revealed an expectation that the care plan should include a diagnosis of PTSD with identified triggers and reflect the resident's current condition. However, the facility did not provide a policy regarding trauma-informed care, which contributed to the oversight in the resident's care plan. The lack of a comprehensive care plan addressing the resident's PTSD and associated triggers represents a deficiency in providing trauma-informed and culturally competent care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration, resulting in an error rate of 7.89%. This deficiency affected three residents out of seven sampled, with a facility census of 48. The errors were related to the administration of insulin without following the manufacturer's guidelines for priming the insulin pens before each injection. Specifically, the Licensed Practical Nurse (LPN) did not prime the insulin pens for Residents #37, #38, and #39 before administering their prescribed doses. Resident #37 was prescribed insulin lispro per sliding scale, and the LPN administered two units without priming the pen. Resident #38 had orders for Novolog FlexPen, and the LPN administered nine units without priming. Similarly, Resident #39 was prescribed insulin aspart, and the LPN administered 11 units without priming the pen. During interviews, the LPN stated that they only primed the pens when first opened, contrary to the manufacturer's guidelines. The Director of Nursing and the Administrator acknowledged that they expected staff to follow the manufacturer's guidelines for medication administration.
Misappropriation of Narcotic Medications by Staff
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medications belonging to four residents, all of whom had severe cognitive impairment and were prescribed controlled substances for pain management. On a specific date, it was discovered that one tablet of narcotic medication was missing from each of the four residents' medication supplies. Documentation showed that the medications had been received and logged, but the actual count of tablets in the medication cards did not match the records, with one tablet unaccounted for in each case. The discrepancy was identified when a Certified Medication Technician (CMT) reported concerns about another CMT's record keeping and destruction of narcotics to the Director of Nursing (DON). The reporting CMT noted that the other CMT had documented dropping and destroying pills without a witness, which is against facility policy. The reporting CMT also mentioned being aware of the other CMT's history with drug addiction, prompting the report to the DON. An audit of the medication cart assigned to the implicated CMT revealed the missing narcotic tablets. During the investigation, the CMT in question was unable to account for the missing pills and later admitted to taking them, though did not specify whether the pills were ingested or where they were at the time. The facility's records and interviews confirmed that the required procedures for medication administration and destruction were not followed, resulting in the misappropriation of resident medications.
Deficiencies in Sanitary Food Storage and Distribution Practices
Penalty
Summary
The facility was found to have deficiencies in storing and distributing food under sanitary conditions, posing a risk of cross-contamination and food-borne illness for all residents. Observations on 04/03/24 revealed several issues in the dry food storage room, including unlabeled containers of dry cereals, salt, and sugar, dented cans of sliced apples, sauerkraut, and great northern beans, a medication cup with a white cream substance, and a sweatshirt on a food storage shelf. The Dietary Manager acknowledged that dented cans should be separated or returned to the distributor, containers should be labeled with item and date, and personal items should not be stored in the food storage room. During an interview on 04/04/24, the Administrator emphasized the expectation for staff to separate and return dented food cans, label containers properly, and avoid storing personal items in the food storage room. The facility's policy on Storage of Dry Food and Supplies from April 2011 outlined guidelines for storing dry food and supplies in an orderly manner, labeling containers, and segregating damaged cans. However, the observations and interviews indicated a lack of adherence to these policies, leading to the identified deficiencies in food storage and distribution practices.
Failure to Complete Level II PASARR for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, who required a Level II Preadmission Screening and Resident Review (PASARR), received the necessary evaluations. Resident #8, who was admitted with diagnoses including neurogenic bladder, cerebral vascular accident, paraplegia, anxiety disorder, depression, and schizophrenia, had a Level I PASARR completed on 11/05/12, indicating the need for a Level II PASARR. However, there was no documentation of a Level II PASARR being completed. The Social Services Director (SSD) confirmed that Resident #8 was transferred from another facility without a Level II PASARR completed upon admission to this facility. Similarly, Resident #16, who was admitted with diagnoses including Huntington's disease, major depressive disorder, bipolar disorder with psychotic features, and anxiety disorder, had a Level I PASARR completed on 10/20/12, indicating the need for a Level II PASARR. There was no documentation of a Level II PASARR being completed for this resident either. The SSD confirmed that Resident #16 was also transferred from another facility without a Level II PASARR completed upon admission. The Administrator acknowledged that residents who trigger a Level II PASARR should have that screening completed.
Infection Control Breach in Medication Storage and Handling
Penalty
Summary
The facility failed to follow standard precautions to prevent the spread of infection, as observed during a survey. A Certified Medication Technician (CMT) was seen with a personal travel cup containing a cream-colored liquid stored in the medication cart drawer alongside stock medications. The CMT admitted to forgetting to place the cup in the breakroom. Additionally, the CMT was observed pulling medication from the same drawer to administer to a resident, indicating a breach in infection control protocols. Further observations revealed that a Licensed Practical Nurse (LPN) stored multiple residents' insulin pens in the same basket within the medication cart. The LPN confirmed that opened insulin pens were kept together, which contradicts the facility's policy requiring separation to prevent cross-contamination. The facility administrator acknowledged that insulin pens should be separated by resident to avoid cross-contamination, highlighting a lapse in adherence to infection prevention guidelines.
Failure to Provide Required Annual Competencies for Nurse Aides
Penalty
Summary
The facility failed to provide the required annual competencies of Abuse Prevention and Dementia Care for two out of two nurse aides sampled. Review of the facility's in-service records from April 2023 through March 2024 showed that CNA C, hired on 04/26/14, attended a total of 16.5 hours of in-services but did not attend annual competency in-services on Abuse Prevention and Dementia Care. Similarly, CNA D, hired on 01/20/22, attended a total of 12 hours of in-services but also did not attend annual competency in-services on Abuse Prevention and Dementia Care. During an interview, the Administrator confirmed that annual nurse aide training should include these competencies. The facility census was 43, and no policy regarding Abuse Prevention and Dementia Care training was provided.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dexter
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cypress Point-skilled Nursing By Americare | 1.2 mi | ★★★★★ | 7 | 0 |
| Memory Lane Of Dexter | 1.6 mi | ★★★★★ | 0 | 0 |
| Prairie View Skilled Nursing | 5.3 mi | ★★★★★ | 0 | 0 |
| Winchester Nursing Center, Inc | 10 mi | ★★★★★ | 0 | 0 |
| Puxico Nursing And Rehabilitation Center | 14.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.