Complete Care at Ridgewood LLC

Inspectors wroteBased on interview and record review, the facility did not complete a Preadmission Screening and Resident Review (PASARR) for individuals with a mental disorder and notify the state authority of a significant change in mental illness for 1 (R1) of 2 residents reviewed for PASARR screening.*R1 had a completed PASARR with an admission date of 10/15/25, with a 30-day exemption. R1 remained in the facility and a new PASARR was not completed despite changes in R1's psychiatric diagnoses and medication changes. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R8) of 13 residents received treatment and care in accordance with professional standards of practice. R8 was re-admitted back to the facility from the hospital on [DATE] with a [NAME] monitor (a wearable battery powered device that continuously records the heart's electrical activity) in place and instructions that it needed to be worn for 7 to 14 days. Facility staff did not enter an MD order for the [NAME] monitor use. Facility staff did not enter a care plan intervention for the [NAME] monitor. Facility staff did not provide documentation that R8's [NAME] monitor was functioning and in place every shift from readmission on [DATE] until R8 was discharged from the facility on 12/15/25.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R8 and R11) of 3 residents reviewed for pressure injuries. *R8 was admitted to the facility with an unstageable pressure injury. On 10/30/25, R8's pressure injury was assessed as a stage 3 pressure injury. On 11/6/25 and 12/11/25, R8 was readmitted to the facility after a hospital stay. Facility staff incorrectly staged R8's pressure injury as a stage 2 on these readmissions. In addition, R8's Wound MD changed R8's wound treatment on 11/20/25 and 12/4/25. Facility staff did not update R8's treatment order and R8 was treated with the incorrect treatment from 11/20 to 11/26/25 and 12/4 to 12/8/25. [...]

Inspectors wroteBased upon observation, interview and record review, the facility did not ensure 1 (R58) of 4 residents reviewed received medically related social services to address individual Resident needs in order to maintain the highest practicable physical, mental, and psychosocial well-being. R1 was admitted to the facility and started demonstrating sexually inappropriate behaviors. In December of 2025 R1 was diagnosed as having an Unspecified Mood Affective Disorder and was started on an antidepressant for anger and sexual inappropriateness. In February of 2026 R1 was diagnosed with an Adjustment Disorder with Depressed Mood. In March R1 started on Depakote Sprinkles along with Ativan as needed for behaviors. During this period of time staff and psychiatric practitioners documented on R1 sexual behavior. Individuals interacting with R1 expressed concern regarding his behaviors towards others; [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with special dietary needs received the appropriate food for 1 (R12) of 4 residents reviewed on a mechanically altered diet. R12 was on a mechanically soft diet and was observed to have tortilla chips, not a mechanically soft diet food.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to monitor fluids offered and consumed by a resident to ensure fluid intake was in accordance with a physician order for a 1500 milliliter (ml) fluid restriction for 1 (R4) of 2 sampled residents reviewed for dehydration.

Inspectors wroteBased on interview, observation, and record review the facility did not ensure 1 (R13) of 20 sampled residents care plans were revised accordingly. R13's care plan was not revised after R13 had a catheter re-inserted for urine retention.

Inspectors wroteBased on observation and interview the facility did not ensure facility stock medications were not expired in 1 of 2 medication storage rooms.- 1 bottle of Calcium with Vitamin D 600 mg/400 IU with an open date of 11/22 and expiration date of 7/2025.- 2 unopened bottles of Aspirin 325 mg with an expiration date of 6/2025.- 1 bottle of Iron 27 mg with an open date of 1/23/2025 and an expiration date of 4/2025 and 2 unopened bottles of Iron 27 mg with an expiration date of 4/2025.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R2) of 5 residents needing assistance with bathing received the necessary services for cares. R2 was admitted to the facility on [DATE] and discharged on 2/8/25. R2 went from 1/25/25 until 2/7/25 without receiving a shower/bath. R2 should have received a shower/bath on 1/31/25 according to the plan of care.

Inspectors wrote2.) R7 was admitted to the facility on [DATE] with diagnoses of cerebral palsy, gastro-esophageal reflux disease with esophagitis with bleeding, protein-calorie malnutrition with a gastrostomy tube for all nutrition, anemia, and chronic embolism and thrombosis of deep veins. R7's admission Minimum Data Set (MDS) assessment dated [DATE] documented R7 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 and had impairment to both arms and legs requiring maximum to total assistance with all activities of daily living and bed mobility. The MDS documented R7 received all nutrition through the gastrostomy tube. The MDS documented R7 had a Deep Tissue Injury that was present upon admission and had a pressure reducing device for the chair and bed and received pressure ulcer care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 (R4 and R2) of 3 residents reviewed for falls. *R4 had unwitnessed falls on 1/17/2025, 1/19/2025, 2/4/2025, and 2/13/2025. The facility did not thoroughly investigate the falls to determine a root cause of each fall and develop personalized interventions to prevent future falls. *R2 had two unwitnessed falls on 1/17/2025 and 2/7/2025. The facility did not thoroughly investigate these falls. There is no evidence of a comprehensive assessment to determine when R2 was last observed, when R2 was provided toileting cares, staff statements, whether R2's call light was within reach at the time of the fall, and a thorough investigation to determine a root cause to determine necessary preventative interventions.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a sanitary environment was maintained to help prevent the development and transmission of infections during wound care for 1 (R7) of 1 residents observed during wound care. *R7 had a treatment to the right calf pressure injury and hand hygiene was not performed between dirty and clean aspects of the treatment.

Inspectors wroteBased on policy review, record review and interview, the facility failed to ensure the family member and Activated Responsible Party (FM1) of one Resident (R1) out of nine residents reviewed in the sample was provided with information required to make informed decisions about the residents health care. FM1 was not notified prior to rehabilitation services being discontinued for R1. This failure created the potential for the resident's rehabilitation services to be unnecessarily and/or prematurely discontinued.

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to ensure one of nine sample residents (Resident (R) 6) had her preferences honored.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure one comprehensive care plan for enhanced barrier precautions (EBP) was implemented for one of nine sample residents (Resident (R) 4) reviewed for care plans. This failure had the potential to put R4 and other residents at risk for infections.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy, the facility failed to follow enhanced barrier precautions (EBP) and infection control for one of nine sample residents (Resident (R) 4) reviewed for infection control precautions. The failure had the potential to put the residents at risk for the spread of an infection.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Medical equipment was not sanitized between resident use potentially affecting 3 (R36, R15, and R86) of 3 residents reviewed for monitoring of blood sugars and the handling of dirty laundry was not kept separate from the clean laundry potentially affecting all 92 residents in the facility. *An observation was made of Registered Nurse (RN)-K wiping off an EvenCare glucometer with an alcohol wipe. RN-K did not use a disinfectant wipe to clean the glucometer. RN-K had checked blood sugars on R36, R15, and R86 without disinfecting the glucometer between residents potentially exposing those residents to blood borne pathogens. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not treat residents with dignity when administering insulin for 2 (R33 and R55) of 2 residents observed receiving insulin. Licensed Practical Nurse (LPN)-G administered insulin to R33 in the hallway by the nurses' station with other residents present. LPN-G checked R55's blood sugar and then administered insulin to R55 in the TV room with another resident present. No privacy was provided to R33 or R55.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for assessing non-pressure wounds for 2 (R188 and R190) of 2 residents reviewed with non-pressure injuries. R188's non-pressure injuries were not comprehensively assessed on admission. R190's non-pressure injuries were not comprehensively assessed on admission.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents with pressure injuries received care consistent with professional standards of practice to promote healing for 4 (R188, R62, R14, and R12) of 5 residents reviewed with pressure injuries. *R188 was admitted to the facility with pressure injuries that were not comprehensively assessed on admission and the air mattress was observed to be not set according to R188's weight. *R62, R14, and R12 had pressure injuries and observations were made of their air mattresses not to be set according to their weight.

Inspectors wroteBased on observations, interview and record review, the facility did not ensure that 1 (R29) of 1 Residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. R29 has limitations in range of motion to R29's left upper extremity. The facility did not apply R29's left hand splint as per R29's Care Plan.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R75) of 6 residents reviewed for weight received the necessary services to assist with nutritional maintenance. * R75 had a significant weight loss of 23 pounds (LBS) or 10.7% in 8 days which was not addressed by the Dietician or notification given to R75's physician.

Inspectors wroteBased on interview and record review the facility did not ensure the accurate administration of all drugs and biologicals to meet the needs of each resident for 1 (R15) of 5 residents reviewed for medications. R15 has a Medical Doctor (MD) order for a daily Lantus injection (Lantus is a long-acting insulin used to control blood sugar). Registered Nurse (RN)-K did not follow the MD order on 4/10/24, 4/18/24 and 4/24/24 and the Lantus injection was not given by RN-K.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received care and services in accordance with professional standards of practice for 4 of 4 (R52, R82, R92, and R199) residents reviewed. R199 did not have a follow up assessment and monitoring of urinary symptoms following identified change in condition and physician orders were not followed. R199 was admitted to the hospital for a change in condition after orders were not followed to monitor R199 and push fluids. R52 did not have neurological assessments completed following falls according to facility policy. R82 did not have neurological assessments completed following falls according to facility policy. R92 did not have neurological assessments completed following falls according to facility policy.

Inspectors wroteBased on observation and interview the facility did not ensure safe, clean, comfortable, and homelike environment. This deficient practice was noted for 7 (R61, R52, R18, R26, R90, R32, and R199) of 22 Resident rooms reviewed for cleanliness.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 4 of 7 (R34, R61, R8, and R90) residents reviewed for pressure injuries. *R34 developed a blister on their right heel that was identified on 12/8/2022. There was not a comprehensive assessment completed on R34's right heel pressure injury until 12/20/22. *R61 was identified to be at high risk for developing pressure injuries. R61 was observed without a cushion in their wheelchair during survey. *R8 was observed without their heels floated during survey per their plan of care. R8's air mattress was not being checked for function per shift. [...]

Inspectors wroteBased on observation, facility policy and procedure review, and interview, the facility did not ensure a safe smoking environment for residents and visitors. This had the potential to effect all 7 (R150, R55, R300, R42, R29, R17 and R54) of 7 assessed resident smokers. This also had the potential to effect anyone that utilized the designated smoking area for the facility. The facility designated smoking area did not include a fire extinguisher, nor did the facility lobby area. There were observations of individuals smoking in the designated area and in front of the facility entrance.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure medications requiring refrigeration were stored at the appropriate temperature for 2 of 3 medication room refrigerators reviewed. This has the potential to affect 9 (R74, R17, R15, R85, R82, R11, R67, R8, and R39) of 9 residents observed to have medications stored in medication room refrigerators. *Observation of the second-floor east medication room refrigerator temperature log documented the facility was not monitoring the medication room refrigerator temperature daily to ensure proper storage of medications that require refrigeration. Monitoring was not completed for 5 days in the month of January. Surveyor also observed 8 cans of alcoholic beverages being stored in the medication room refrigerator with medications labeled for resident use. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure residents were treated with dignity and care that promotes their quality of life. This was observed with 2 (R26 and R151) of 22 residents reviewed. * R26 was observed with their Foley drainage bag uncovered. * R151 was observed with their Foley drainage bag uncovered and did not have their personal clothes to wear for days.

Inspectors wroteBased on observation, record review and interview, the facility did not promote or facilitate the residents choice for sleep schedules and health care. This was observed with 2 (R39 and R85) of 22 residents reviewed. * R39 gained weight in the facility and was not offered any alternate dietary diet to assist with weight control and/or loss. * R85 sleep preferences were not implemented by staff.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R62) of 4 Residents reviewed for weight loss received the necessary care and services to assist with nutritional maintenance. *R62 was admitted on [DATE] and the first weight obtained on R62 was 10/2/22. Further, R62 has a physician's order as of 11/11/22 to obtain daily weights and this was not completed by the facility. Findings Include: Surveyor reviewed the facility weight monitoring policy and procedure dated 10/2022 and noted the following: .Policy: Based on the Resident's comprehensive assessment, the facility will ensure that all Residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the Resident's clinical condition demonstrates that this is not possible or Resident preferences indicate otherwise. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure a resident with a gastrostomy tube received the appropriate care and services for a resident with a gastrostomy tube. This was observed with 1 (R90) of 2 residents with a gastrostomy tube. R90 has a gastrostomy tube that was not flushed or care planned after feeding was discontinued.

Inspectors wroteBased on interview and record review the facility did not have evidence of ongoing communication and collaboration between the facility and the dialysis center for the care and services of 1 of 1 Residents (R62) reviewed who was receiving dialysis. *R62 did not always have evidence of assessment of R62's condition and monitoring for complications before and after dialysis, specifically obtaining R62's pre-weight by the facility staff and did not have ongoing communication and collaboration with the dialysis center. The form contains documentation from the dialysis center and serves as a communication tool between the facility and the dialysis center.

Inspectors wroteBased on record review and interviews, the facility did not ensure residents receiving psychotropic medications had indications for use, adequately monitored administration and comprehensively assessed need for the medication. This was discovered with 3 (R39, R58 and R32) of 5 resident medication reviews. -R39's psychotropic medication did not indicate the individualized use with non-pharmacological interventions. -R58's psychotropic medication was not comprehensively assessed to identify their individual use and non-pharmacological interventions. -R32's psychotropic medication did not have a definitive stop date and was not discontinued when ordered by the physician.

Inspectors wroteBased on observation, record review and interview, the facility did not implement isolation measures with a resident with potential symptoms of an infection. This was observed with 1 (R39) of 1 residents observed with loose stools that were to be assessed for potential (clostridium difficile) C-Diff. R39 had noted to be experiencing recurring loose stools/diarrhea. The physician was called and ordered testing for C-Diff with an antibiotic based upon test results. R39 was not placed in contact isolation when C-Diff was suspected.