Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Ridge Crest Nursing Center during CMS and state inspections, most recent first.
Infection Control and Legionella Program Deficiencies: The facility lacked a complete Legionella/water management program, with no facility-specific risk assessment, CDC toolkit assessment, completed CDC Legionella Environmental Assessment Form, or written water-flow diagram with risk-area analysis. In addition, an LPN performing wound care did not wash or sanitize hands after cleansing a resident’s wound before applying dressings, and a CNA used only one gloved hand during a transfer and urinal assist without hand hygiene between dirty and clean tasks.
Unsafe environment and inadequate supervision: Surveyors observed separated floor tiles, cracked ceilings, and damaged pavement in multiple areas, along with a resident being transferred in a sit-to-stand lift while staff provided toileting care before the transfer was completed. Surveyors also observed two residents with wandering and elopement behaviors repeatedly entering other residents’ rooms, approaching exits, and taking food from trays while staff relied on redirection, snacks, and intermittent monitoring.
A resident reported that dietary rarely served what was on the menu and said the food budget was too small. Review of the menu and substitution records showed multiple planned lunch items were replaced with different foods, including beef stroganoff, pork, turkey, broccoli, and different desserts, because items were too expensive, out of stock, or the DM said residents were tired of the same meats. The DM said the vendor created the menu, access to edit it had not been provided, and the Administrator said the DM sometimes forgot to order food.
Ice Machine Not Kept Clean: Surveyors observed a blackish and brownish substance growing inside the ice machine on the ceiling where ice comes out. The DM said maintenance was responsible for the machine and that it was cleaned every 3 to 6 months, while the MD said the company cleaned it every 3 to 4 months and the DM was responsible to call them. Staff could not identify a cleaning schedule, and the MD later stated there was no schedule known unless Dietary kept track of it.
A facility failed to document COVID-19 vaccine status, vaccine education, or refusal documentation for five sampled residents. Records for the residents showed no evidence that the vaccine was offered or that education on risks and benefits was provided since admission or readmission. The facility policy required consent, screening, administration, and documentation in the medical record, and staff interviews identified the Wound Nurse, charge nurse, ICP, and DON as responsible for tracking and documenting this information.
Failure to Provide Individualized Activity Programs: Two residents with dementia and significant care needs did not receive meaningful, preference-based activity programming or goal-directed activity care plans. One resident with wandering and exit-seeking behavior was offered group activities but rarely participated and was not provided one-to-one activities, while the other resident with severe cognitive and mobility impairment was often left in bed or at the nursing station without activity, despite documented preferences for music, going outside, pets, and social interaction. The AD stated one-to-one programming was not being routinely completed and there was no schedule for residents needing more assistance.
Incomplete IV Vancomycin Order Documentation: A resident admitted with C-Diff and a PICC line had IV Vancomycin ordered, but the physician order, MAR, and nursing notes did not include the infusion rate or how long the dose should run. During observation, the antibiotic was still infusing when an LPN disconnected it, and later the DON set the pump to 120 mL/hour for 75 minutes based on the pharmacy label.
A resident with a Foley catheter for neurogenic bladder had incomplete physician orders for ongoing monitoring and daily catheter care, and the record lacked documentation of licensed nursing assessment and catheter care. Staff observed the drainage bag placed on the bed during peri care, and interviews showed staff were unsure of the facility policy and expected documentation. The care plan did not specify how or when perineal and catheter care was to be provided, and the DON, administrator, ICP, and LPN acknowledged the order should have been comprehensive.
A resident with dementia, aphasia, and Hospice status was at nutritional risk and had orders for a regular diet, health shakes with meals, house supplements, weekly weights, and dronabinol for appetite stimulation. Surveyors observed that the breakfast health shake was not offered during the meal, and the resident required hands-on feeding and drank the shake only when it was placed to the resident’s mouth later. The MAR and notes showed the ordered dronabinol was not administered for several days because it had not yet been received from the pharmacy, and the family reported bringing in shakes and meals because the resident was no longer eating independently.
Failure to document influenza and pneumococcal vaccine education and status: Two residents had no record of being educated on, offered, or able to decline flu and pneumococcal vaccines, despite facility policies requiring documentation of vaccine status, education on benefits and side effects, and refusals or administration details in the medical record. Staff interviews identified the Wound Nurse, charge nurse, ICP, and DON as responsible for tracking and documenting immunizations, but the facility could not locate the requested records.
Several residents dependent on staff for bathing did not consistently receive the required number of baths or showers, as confirmed by gaps in documentation, resident reports of missed showers, and observations of poor hygiene. Staff interviews revealed that insufficient staffing and inconsistent documentation practices led to missed baths, especially when the designated bath aide was unavailable.
The facility did not provide adequate oversight or implement appropriate interventions after multiple residents experienced falls, including repeated falls with injuries. Fall investigations and root-cause analyses were not completed, neurological assessments were missed after unwitnessed falls, and care plans were not updated to reflect new interventions. Staff interviews revealed confusion about responsibilities and a lack of documentation regarding fall prevention measures.
The facility failed to provide adequate grooming for residents due to insufficient staffing, resulting in residents not receiving scheduled showers. Four residents reported not receiving regular showers, leading to dissatisfaction and unkempt appearances. Staff interviews revealed a lack of a designated Shower Aide and insufficient CNAs to meet the facility's grooming standards.
The facility failed to employ a certified Infection Preventionist, leaving the Director of Nursing to perform these duties without proper certification. Staff interviews revealed a lack of awareness and training regarding infection control measures, including COVID-19 protocols. The facility has been without a designated Infection Preventionist for six months, and efforts to hire an Assistant Director of Nursing to fill this role are ongoing.
Infection Control and Legionella Program Deficiencies
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program for Legionella and other water-borne pathogens. During review of the facility’s water management materials, the binder and the Water Management Plan did not include a facility-specific risk assessment that considered ASHRAE standard #188, a CDC toolkit assessment with control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens, a completed CDC Legionella Environmental Assessment Form, or a schematic, flowchart, or diagram of the water system with a written explanation of water flow and identified risk areas. The Emergency Preparedness manual also contained a generic Legionella Water Management Program without those same required assessments and documentation. The facility’s physical plant included a municipal water main entering the building at the fire sprinkler riser room, wet and dry sprinkler systems, housekeeping closets with mop/service sinks, water heaters, water softeners, hot and cold water piping throughout resident hallways, at least 50 resident rooms with bathrooms and sinks, commercial clothes washers, four bathhouses, a beauty shop sink, and public restrooms. The Director of Maintenance stated that the water supply entered at the sprinkler riser room and that his responsibilities included weekly flushing of unused systems, checking pH and chloramine levels with test strips, and documenting water temperatures. The Administrator stated he was responsible for overseeing the Legionella program and that it had evolved over time. The facility also failed to ensure hand hygiene during resident care. A resident with heart failure, gait and mobility problems, cognitive communication deficit, and venous stasis ulcers had a wound care treatment performed by the Wound Care Nurse. After cleansing the wound, the nurse did not wash or sanitize hands before applying the new dressing materials and continued the treatment while wearing the same gloves. The nurse later acknowledged that hands should have been washed or sanitized after cleaning the wound to prevent cross contamination. A second resident with Parkinson’s disease, dementia, muscle contractures, and a history of falls required total assistance with transfers and used a wheelchair. During a transfer with a sit-to-stand lift, a CNA used only one gloved hand, assisted the resident with a urinal while the resident was semi-standing in the lift, and then lowered the resident into a recliner without washing or sanitizing hands between tasks. The CNA later removed the glove, washed hands, re-gloved, emptied the urinal, and then removed the lift from the room without again sanitizing or washing hands. The CNA stated he did not think there was concern with only gloving one hand and did not realize he needed to wash his hands again when re-entering the room.
Unsafe Environment and Inadequate Supervision
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment by allowing multiple floor tiles to separate and create cracks, and by allowing ceiling damage in several areas. During the Life Safety Code walk-through, surveyors observed miscolored tiles that did not fit tightly at both entrances to the Main Dining Room, at the west end of 200 Hall by an electrical closet, and outside the north Clean Utility door. Surveyors also observed cracked or bulging ceilings in the Employee Training Room, a crack running the length of the Employee Breakroom ceiling, a cracked ceiling by a sprinkler head in a resident bathroom, and damaged ceiling patches in the Main Dining Room vaulted ceiling. The west resident enclosed smoking courtyard pavement also had multiple cracks and a broken cement patch with gravel-like pieces. The DOM stated the ceiling cracks and patches were from roof leaks that occurred about four years earlier, and the Administrator stated the facility should have no tripping hazards and be free of possible contamination of food or drinks. The facility also failed to ensure safe use of a sit-to-stand lift during resident care. Resident #40 had diagnoses including Parkinson’s disease, dementia, pain, muscle contracture, and a history of falling, and was dependent with all transfers and used a wheelchair. During observation, CNA B placed the resident in the lift, discovered it was not working, retrieved a battery, and then lifted the resident into a semi-standing position while the resident remained holding the lift handles. CNA B then used a gloved hand to pull the resident’s pants down, moved the brief aside, and used a urinal for the resident while the resident was still semi-standing in the lift before lowering the resident into the recliner. The DON and Administrator stated that no one should be hanging on to the sit-to-stand lift while staff are performing resident care and that the resident should have been transferred first and then provided the urinal. The facility further failed to adequately monitor residents with wandering and exit-seeking behaviors. Resident #33 had dementia and was identified in the care plan as an elopement risk with a history of attempts to leave unattended. Surveyors observed the resident sitting in the hallway unsure of where the room was, standing by an exit door, opening the door and triggering the alarm, and later attempting to leave again while staff redirected the resident with a wheelchair, snacks, and questions. Staff interviews confirmed the resident wandered, exit sought, and required more frequent monitoring and line-of-sight supervision when anxious or agitated. Resident #3 had severe cognitive impairment, wandering, and elopement risk, and the care plan called for line-of-sight monitoring while up in a wheelchair and redirection from inappropriate areas. Surveyors observed the resident entering other residents’ rooms, including Resident #20’s and Resident #32’s rooms, touching belongings, opening drawers, and remaining in those rooms without staff present. The resident also wandered into the dining room to eat food off another resident’s tray and repeatedly attempted to enter other areas, while staff described using snacks, activities, and redirection but acknowledged the resident needed continual monitoring.
Failure to Follow Planned Menus and Maintain Dietary Supplies
Penalty
Summary
The facility failed to follow pre-prepared menus to ensure meals met residents’ nutritional needs in accordance with established national guidelines, and it also failed to keep a basic ingredient in stock that was used in many recipes. Review of the 4-week menu schedule showed planned lunch meals for week 3 that included herb roast beef with brown gravy, roasted carrots, potatoes and onions, pudding parfait; ham steak with garlic potatoes, buttered carrots, and fruit crumble; and oven fried fish with cheesy rice, seasoned spinach, and lemon cookie bar. However, the menu substitution form showed multiple changes, including pot roast changed to beef stroganoff with brownie, ham changed to pork, and fish changed to turkey with broccoli and chocolate chip cake. These substitutions were documented as occurring because food items were too expensive, out of stock, or because residents were said to be tired of the same beef, pork, and chicken. During interview, a resident stated the food budget was too small, dietary never served what was on the menu, and the Dietary Manager said he or she could only feed what was available. The resident also reported the Administrator said the budget was the reason for the food options. The Dietary Manager stated the menus were on a 4-week seasonal schedule, that the vendor created the menu, and that the vendor had said access would be given so the DM could change the menu, but that had not happened yet. The Administrator stated corporate was responsible for the dietary budget, the vendor was responsible for the menu, substitutions were due to repetitiveness, and the DM sometimes forgot to order food. The Administrator also stated the only price-related change known was using medium eggs instead of large eggs.
Ice Machine Not Kept Clean
Penalty
Summary
The facility failed to maintain the cleanliness inside the ice machine. During the initial walk-through on 9/2/25 at 9:46 A.M., surveyors observed a blackish and brownish substance growing inside the ice machine on the ceiling where the ice comes out. The facility policy titled Ice Handling and Cleaning, dated 2016, stated the ice machine would be wiped down daily with sanitizer, emptied quarterly and thoroughly cleaned with an approved sanitizer, and that ice storage bins shall be drained through an air gap. During interviews, the Dietary Manager stated maintenance was responsible for the ice machine and that it was cleaned every 3 to 6 months. The Maintenance Director stated the ice machine company cleaned it every 3 to 4 months and that the Dietary Manager was responsible to call the company. Later, the Dietary Manager said the Maintenance Director may have a schedule but did not have it, while the Maintenance Assistant said he/she did not know of any cleaning schedule and that the ice machine was a rental that either kitchen or maintenance would call the company to clean periodically. The Maintenance Director later stated there was no schedule known unless Dietary kept track of it.
Missing COVID-19 Vaccine Documentation and Education
Penalty
Summary
The facility failed to ensure that five sampled residents had documentation of their COVID-19 vaccination status, education about the risks and benefits of the vaccine, or documentation of refusal of vaccine education. Review of the medical records for Residents #4, #5, #7, #22, and #48 showed no documentation that they were offered the COVID-19 vaccine or that they received education about the vaccine since admission or readmission to the facility. The facility census was 46 residents, and the review focused on immunization documentation for the sampled residents. The facility’s Coronavirus (COVID-19) Vaccine policy dated 11/7/23 stated that each resident would have the opportunity to affirm or deny consent to receive COVID-19 vaccine doses, that consent would be obtained from each resident or representative, and that screening and administration of the vaccine would be documented in the resident’s medical record. During interviews, an LPN stated that immunizations should be documented in the electronic record under the immunization tab and that the Wound Nurse and charge nurse were responsible for ensuring COVID-19 vaccine status or education was documented upon admission and annually. The ICP/Administrator and DON stated that the Wound Nurse and ICP were responsible for tracking and documenting vaccine status, offers, refusals, and education, but the facility was not able to locate the requested documentation for the sampled residents.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide activities that were based on resident preferences and meaningful to two residents who were not able to self-direct activities, and it failed to develop goal-directed activity care plans and interventions for those residents. The activity policy stated that activities should be meaningful and individualized to meet the needs of all residents, and that activity staff should work with nursing to coordinate resident care and needs with scheduled activities. The Activity Director was responsible for completing the activities section of the MDS and assisting with the activity care plan. One resident had dementia and a stroke with left-sided paralysis, was alert with some confusion, and had preferences that included reading books, magazines, news, animals/pets, going outside, group activities, music, and favorite activities. The resident’s care plan addressed impaired cognition, wandering, elopement risk, and unsafe attempts to leave the facility, with interventions to distract the resident using structured activities, food, conversation, television, and books. However, there was no goal-directed activity plan or documented activity interventions in the care plan. The activity participation record showed the resident was offered three activities daily in August 2025, but participated only three times out of 93 opportunities, and there was no documentation of one-to-one activities. During observations, the resident was found in the hallway unable to identify where he or she was, was not directed to an ongoing activity, and on another occasion opened an exit door and triggered the alarm before being returned to the room without an activity being provided. The second resident had dementia, lack of coordination, cognitive communication deficit, and muscle weakness, was alert with significant confusion, required total care, did not ambulate, and used a wheelchair. The resident’s preferences included going outside, religious services, snacks, animals/pets, group activities, and music. The care plan addressed impaired cognition, communication, and mobility, but did not include an activity goal or activity interventions. The activity participation record showed the resident was offered at least three activities daily and participated in 20 out of 97 opportunities, with no documentation of one-to-one activity such as nails. Observations showed the resident often remained in bed or sat in front of the nursing station without any activity, and there were no books, music, television, or activity calendar in the room. The Activity Director stated he or she had not really been completing one-to-one activities, did not have a list or schedule for residents needing more assistance or one-to-one plans, and acknowledged not doing as much as should have been done for the first resident and that more individualized activities were needed for residents who could not come to group activities.
Incomplete IV Vancomycin Order Documentation
Penalty
Summary
The facility failed to ensure physician orders were accurately transcribed to include the IV infusion rate for IV Vancomycin for one resident admitted with C-Diff and a PICC line for IV therapy. The resident was cognitively intact and able to understand others and make needs known. The admission note documented that the resident returned from the hospital with a single lumen PICC line in the upper left arm and an order for IV vancomycin, but there was no documentation of the infusion flow rate in the admission note. The physician order sheet and licensed MAR listed Vancomycin HCl 750 mg/150 mL IV daily for 14 days, but neither document included the IV infusion rate or how long the medication was to run. Nursing progress notes also did not document the infusion flow rate. During observation, the resident’s IV antibiotic was still running with one-quarter of the bag left when an LPN disconnected the therapy and flushed the PICC line. On a later observation, the DON set the IV pump to infuse at 120 mL/hour for 75 minutes, and the pharmacy label on the bag indicated administration over 75 minutes. Staff interviews confirmed they expected the physician order to include the infusion rate, and the DON stated nursing staff were responsible for ensuring complete physician orders were documented.
Incomplete Foley Catheter Orders and Missing Documentation
Penalty
Summary
The facility failed to obtain a comprehensive physician order for the ongoing monitoring and daily care of an indwelling Foley catheter for one resident with a flaccid neuropathic bladder and neurogenic bladder. The resident’s quarterly MDS showed moderate cognitive impairment and that the resident required an indwelling Foley catheter. The physician order sheet listed the catheter type and directed that the Foley catheter be changed as needed for clinical indications such as infection, obstruction, or when the system was compromised, but it did not include detailed instructions for ongoing monitoring or daily catheter care. The resident’s care plan stated that licensed nurses and CNAs were to monitor the Foley catheter and document per facility policy, but it did not include how and when perineal and catheter care was to be provided. The treatment administration record also did not contain a detailed physician order for ongoing monitoring and daily care, and the record review did not find documentation that licensed nursing staff provided daily monitoring, assessment, or catheter care. CNA task documentation also did not include a catheter care task for the resident. During observation, the resident’s catheter drainage bag was seen hung on the side bed rail in a privacy bag, and later during catheter care it was observed lying on top of the bed by the resident’s feet while care was being provided. The CNAs did not keep the bag below the bladder during care. Staff interviews showed uncertainty about the facility policy for catheter care and bag placement, and the resident stated the bag had been placed on the bed during peri care because of pulling and sensitivity at the catheter site. The DON, administrator, ICP, and LPN acknowledged that the order should have been comprehensive and that nursing documentation of catheter care and assessment was expected.
Failure to Follow Nutritional Orders and Timely Appetite Stimulant Administration
Penalty
Summary
The facility failed to follow one resident’s nutritional plan for maintaining weight by not obtaining and providing a physician-ordered appetite stimulant in a timely manner and by not consistently providing a supplemental health shake at breakfast. The resident had diagnoses including dementia, aphasia, cognitive communication deficit, high blood pressure, and insomnia, and was identified as being at nutritional risk with weight loss concerns. The resident was also on Hospice services for senile degeneration of the brain and required substantial assistance to eat and drink. The resident’s physician orders included a regular diet, a health shake with meals, a house supplement 60 ml twice daily, dronabinol 2.5 mg three times daily for appetite stimulation, and weekly weights. The RD recommended weekly weights, house supplement twice daily, a health shake with meals, and assistance with meals as needed. The care plan identified the resident as at nutritional risk, but the record did not show updates documenting interventions implemented to maintain nutritional status. The MAR showed the house supplement was given as ordered, but there was no documentation that health shakes were given with meals. Survey observations showed the resident sitting in a recliner with a breakfast tray that included a health shake, but the resident was not eating and the CNA did not offer the shake during breakfast. Later, the resident drank an entire health shake when it was placed to the resident’s mouth with a straw during lunch. The resident’s family reported bringing in protein shakes and meals and feeding the resident because the resident had stopped eating on his/her own and needed substantial assistance. The MAR and nursing notes showed the ordered dronabinol was not available and was not administered for several days after the order start date, with notes indicating the medication had not yet arrived from the pharmacy.
Failure to Document Influenza and Pneumococcal Vaccine Education and Status
Penalty
Summary
The facility failed to ensure that two sampled residents were educated on, offered, and/or given the opportunity to decline influenza vaccination, and failed to document education, offering, and/or the opportunity to decline pneumococcal vaccination for the same two residents. Review of the facility’s influenza and pneumococcal vaccine policies showed that residents were to be offered these vaccines, provided education on benefits and potential side effects, and that refusals or administrations were to be documented in the medical record. However, the medical records for Resident #4, who was readmitted to the facility on [DATE], contained no documentation of influenza or pneumococcal vaccine status or education regarding the risks or benefits of the vaccines since admission and annually. Resident #22, who was admitted to the facility on [DATE], also had no documentation in the medical record of influenza or pneumococcal vaccine status or education regarding the risks or benefits of the vaccines since admission and annually. During interviews, an LPN stated that immunization should be documented in the electronic record under the immunization tab and that the Wound Nurse and charge nurse were responsible for ensuring vaccine status and education were documented. The ICP/Administrator and DON stated that the Wound Nurse and ICP were responsible for tracking and documenting vaccine status, refusals, and education, and the facility stated it was not able to locate the requested documentation for the sampled residents.
Failure to Provide Required Bathing Assistance Due to Staffing and Documentation Issues
Penalty
Summary
The facility failed to ensure that residents who required staff assistance with bathing received baths or showers according to their needs. Four residents who were dependent on staff for bathing did not consistently receive the minimum standard of two baths or showers per week, as evidenced by gaps in documentation and resident interviews. For example, one resident with legal blindness and glaucoma reported receiving only one shower since admission and expressed dissatisfaction, noting staff cited being short-handed as the reason for not providing showers. Observations confirmed the resident had body odor and greasy, uncombed hair. Another resident with hemiplegia and legal blindness required substantial staff assistance for bathing but reported going about a month without a shower before finally receiving one. Documentation for this and other residents showed inconsistent or missing records of baths/showers, with some residents receiving only one or two baths in a month. Observations of these residents revealed signs of poor hygiene, such as greasy hair and body odor, and in some cases, residents were unable to communicate their needs due to cognitive impairment. Interviews with staff, including CNAs and an LPN, confirmed that baths and showers were not provided on days when the designated bath aide was off, due to insufficient staffing. The bath aide was sometimes reassigned to other duties, and CNAs reported not having enough help to provide showers as scheduled. Documentation practices were inconsistent, with some staff using electronic records and others using paper sheets, further contributing to the lack of reliable records for resident bathing.
Failure to Investigate and Address Resident Falls and Update Care Plans
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident experienced two falls in a single day, resulting in head lacerations that required emergency care, and then suffered another fall a week later. Despite these incidents, the facility did not complete thorough fall investigations, including root-cause analysis (RCA), nor did they document or implement new interventions after each fall. The care plan for this resident was not updated to reflect new interventions or changes in condition following the falls, and there was a lack of documentation regarding the use of fall prevention measures beyond fall mats and a helmet, which was not consistently recorded in the care plan. For two additional residents, the facility also failed to conduct proper fall investigations and did not update care plans to include interventions implemented after falls. One resident had an unwitnessed fall, but neurological assessments were not completed as required by facility policy, and the care plan was not revised to address the actual fall or any new interventions. Another resident experienced both witnessed and unwitnessed falls, but the facility did not document any new fall interventions or complete a root-cause analysis for these incidents. In all cases, the lack of comprehensive documentation and follow-up after falls was evident. Interviews with staff, including the DON, LPNs, and CNAs, revealed confusion and inconsistency regarding responsibilities for fall investigations, neurological assessments, and care plan updates. Staff were often unaware of the facility's policies or the specific interventions in place for residents who had fallen. The DON confirmed that fall investigations and RCAs were not consistently completed and that interventions such as frequent checks were not always documented. The physician interviewed was not informed of all interventions and was unaware that thorough fall investigations and care plan updates were not being performed. These failures resulted in a lack of oversight and appropriate response to resident falls, as required by facility policy.
Inadequate Grooming Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure that residents were adequately groomed by not offering showers or baths to four sampled residents out of seven. The facility's policy required that residents be offered two showers a week, and any refusals should be revisited. However, the records showed that residents did not receive showers as scheduled, and there was a lack of documentation indicating that showers were offered or refused. This deficiency was observed in the cases of four residents who were not provided with the necessary assistance for personal hygiene, leading to them feeling unkempt and expressing dissatisfaction with their care. Resident #1, who was cognitively intact and required substantial assistance for bathing, did not receive showers as per the schedule from August 1 to August 6, 2024. The resident appeared unkempt with oily hair during an observation. Similarly, Resident #2, who was moderately cognitively impaired and needed moderate assistance, reported not receiving regular showers and having to clean themselves at the sink. Resident #3, who required partial assistance, also expressed dissatisfaction with the lack of regular showers, stating that they did not feel as clean with sponge baths. Resident #4, who needed substantial help, reported not receiving the scheduled showers and having to wash up at the sink. Interviews with staff, including CNAs, a GLN, an LPN, the Administrator, and the DON, revealed that there was insufficient staffing to provide the required showers. The facility did not have a designated Shower Aide, and CNAs were expected to provide showers to residents on their assigned hallways. However, due to staffing shortages, residents were not receiving even one shower a week. The staff acknowledged the lack of documentation on shower sheets and the failure to offer showers at different times if initially refused. The DON and Administrator were aware of the issue but cited staffing challenges as the reason for not meeting the facility's grooming standards.
Lack of Certified Infection Preventionist in Facility
Penalty
Summary
The facility failed to employ a certified Infection Preventionist, which is a requirement for managing the infection prevention and control program. The facility, with a census of 49 residents, did not have a policy for an Infection Preventionist, and the Administrator had only completed the first module of the Infection Prevention and Control Program training. Interviews revealed that the Graduate Practical Nurse (GPN) was unaware of the location of Personal Protective Equipment (PPE) and had not received education about COVID-19 or the facility's infection prevention expectations. The Director of Nursing (DON) was performing the Infection Preventionist's duties without having completed the necessary certification. The facility had been without a designated Infection Preventionist for six months, following the resignation of the previous individual in that role. Efforts to hire an Assistant Director of Nursing (ADON) to assume the Infection Preventionist responsibilities were ongoing, but no one had been employed in that capacity. Interviews with staff, including a Licensed Practical Nurse (LPN), confirmed the lack of a designated Infection Preventionist and indicated that some education on COVID-19 protocols had been provided, but it was insufficient. The Administrator acknowledged the absence of a certified Infection Preventionist and noted that both he and the DON were enrolled in an online course to address this gap.
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Illustrative
What surveyors actually found near you
We read the 72 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Warrensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warrensburg Manor Care Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Country Club Rehab And Healthcare Center | 1 mi | ★★★★★ | 0 | 0 |
| Johnson County Care Center | 1 mi | ★★★★★ | 17 | 0 |
| Holden Manor Health & Rehabilitation | 14.9 mi | ★★★★★ | 1 | 0 |
| Lutheran Nursing Home | 18.3 mi | ★★★★★ | 4 | 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.