Ridge Crest at Meadow Ridge

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for two of three residents (Resident #2 and #3) reviewed for quality of care, the facility failed to maintain the confidentiality and privacy of Resident #2 and #3, when their medication blister packs containing resident-identifying information was improperly included with Resident #1's discharge medications.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for discharge process, the facility failed to ensure the resident was discharged with all prescribed narcotic medications as ordered.

Inspectors wroteBased on record review, facility documentation review, and staff interviews for one of three residents (Resident #1), reviewed for a change in condition, the facility left unlicensed staff with a resident who was identified with a significant change in condition, and failed to ensure a resident's active do not resuscitate (DNR) order was honored when he/she was identified to have no pulse, no respirations, and had fixed and dilated pupils, and failed to ensure Emergency Medical Services (EMS) was notified prior to a pronouncement of death.

Inspectors wroteBased on review of staff interviews, review of the clinical record and facility documentation for 1 of 1 sampled residents reviewed for hospice services (Resident #29) and for 1 of 2 sampled residents (Resident #46) reviewed for death, the facility failed to ensure the Resident Care Plan (RCP) was comprehensive to include hospice care.

Inspectors wroteBased on the facility policy, record review, and interviews for 1 of 3 sampled residents (Resident #36) reviewed for accidents, the facility failed to ensure the Resident Care Plan was reviewed and revised after a fall with a major injury. Resident #36 was admitted to the facility in January 2025 with diagnosis that included heart failure, hypotension, and falls. A Fall Risk assessment dated [DATE] identified Resident #36 was a fall risk, and a fall prevention care plan was initiated or updated. The admission Minimum Data Set assessment (MDS) dated [DATE] identified was cognitively intact and was independent for eating, and oral hygiene. The MDS also, identified Resident #36 required partially moderate assistance for transfers, dressing, and was dependent for showering. The MDS further identified Resident #36 required touch supervision when ambulating. [...]

Inspectors wroteBased on observations, interviews, review of the clinical record, and facility policy for 1 of 4 residents (Resident #45) reviewed for pressure ulcers, the facility failed to ensure physician orders related to an air mattress included type of setting and ensure the air mattress was set correctly.

Inspectors wroteBased on observations, review of facility policy/procedures and interviews regarding medication storage, the facility failed to ensure expired medication was disposed of and failed to ensure a medication cart was locked when not in use.

Inspectors wroteBased on observation, review of facility documentation, review of facility policy/procedures and interviews for medication storage and narcotic reconciliation, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled medication and failed to ensure that an account of all controlled drugs was maintained and periodically reconciled.

Inspectors wroteBased on record review, facility documentation, and staff interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure the medical record was complete and accurate to include a refusal of care.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for quality of care, the facility failed to notify the health care representative prior to the initiation of an antidepressant.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure staff notified the RN timely after a resident had an unwitnessed fall.

Inspectors wroteBased on a review of the facility Infection Control Program, review of facility documentation and staff interviews, the facility failed to ensure that licensed nursing staff completed the facility's annual education and competencies training for Intravenous Therapy IV.

Inspectors wroteBased on a review of the facility Infection Control Program, review of facility documentation, facility policy review, and staff interviews, the facility failed to ensure that unlicensed nursing staff completed the facility's annual education and competencies training for Intravenous Therapy IV.

Inspectors wroteBased on clinical record reviews, review of facility policy and interviews for 2 of 2 residents (Resident # 145 and #146) reviewed for grievances, the facility failed to act on the resident reported concern related to missing personal items in a timely manner and within accordance to facility policy.

Inspectors wroteBased on clinical record review, review of facility documentation, review of policy and staff interviews for 1 of 1 sampled resident (Resident # 346) reviewed for allegations of neglect, the facility failed to conduct a thorough investigation regarding an allegation of being left on the toilet for several hours.

Inspectors wroteBased on clinical record review, review of facility policy and staff interviews for 1 of 1 resident (Resident #3) reviewed for advance directive, the facility failed to transcribe the Do Not Resuscitate (DNR) and Registered Nurse may Pronounce (RNP) physician's orders according to professional standard and within accordance to facility practice.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and staff interviews for 1 resident (Resident # 145) reviewed for rehabilitation, the facility failed to implement specialized rehabilitative services related to the use of a motorized chair for mobility to attain the resident's highest level of physical, mental, functional, and psycho-social well-being in a timely manner.

Inspectors wroteBased on observations, clinical record review, facility policy and procedures, review of facility documentation and interviews for one of two units (Elm) reviewed for infection control for (Residents # 32 and #101), the facility failed to consistently implement standard precautions to prevent the spread of infection.