Ridgeland Nursing Center Inc

Inspectors wroteBased on review of facility policy, record review, interview, and observation, the facility failed to ensure a safe environment and failed to provide adequate supervision to prevent elopement for 1 of 5 residents reviewed for elopement risk (Resident (R)1), a cognitively impaired resident with dementia and an inactive wander guard in place. This failure allowed R1 to exit the facility unsupervised through an unlocked front entrance on 05/22/26. On 06/02/26 at 6:05 PM, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the facility had failed to prevent Resident (R)1's elopement which occurred on 05/22/26, creating a reasonable expectation that serious injury, harm, impairment, or death could have occurred, constituting IJ. The IJ was related to 42 CFR 483.12 - Quality of Care. [...]

Inspectors wroteBased on review of facility policy, record review and interview, the facility failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies. Cross Reference F689Findings include: Review of the Summary Statement of Deficiencies, for a complaint survey on 05/13/26, indicated the facility was cited at Immediate Jeopardy-F689 when a resident eloped from the facility. Review of facility policy dated 08/01/23 and titled, Policies and Procedures. Subject: Quality Assurance Performance Improvement Program (QAPI), revealed, . Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee included active and meaningful participation by the Medical Director in the facility's Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all residents in the facility.

Inspectors wroteBased on review of facility policy, interview, observation, and record review, the facility neglected to provide a safe environment and adequate supervision to protect residents from elopement, when they failed to monitor a known elopement risk for Resident (R)1, failed to update the comprehensive care plan with targeted intervention;, failed to provide adequate supervision when the resident's Wander Guard system was inactive; failed to conduct monthly elopement drills per facility policy; failed to verify door locks per protocols; and failed to develop and implement a performance improvement plan following an actual elopement on 05/13/26. The facility's neglect to provide these services resulted in 1 of 5 sampled residents (R1), who exhibited known wandering behaviors, eloping from the facility unsupervised on 05/22/26.

Inspectors wroteBased on review of the facility policy, interview, observation, and record review, the facility failed to ensure Resident (R)5 was adequately supervised to prevent him from eloping on 05/10/26 between 8:45 AM- 9:15 AM, for 1 of 3 residents reviewed for elopement. On 05/10/26 between 8:45 AM- 9:15 AM, R5 had a successful, unwitnessed elopement from the facility. R5 was found by staff members on the sidewalk, off the facility's premises, next to an active highway. On 05/13/26, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. [...]

Inspectors wroteBased on review of the facility policy, observation, interview, and record review, the facility failed to ensure Resident (R)7 received appropriate care and services to prevent complications related to enteral feeding, for 1 of 2 residents reviewed. On 05/13/26, R7's Gastrostomy tube (G-Tube) site was observed with a dressing dated 05/03/26 stuck to the skin and a brown, crusted substance noted around the stoma. On 05/13/26, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 05/13/26 at 4:25 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 05/03/26. The IJ was related to 42 CFR 483.25 Quality of Care. [...]

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility and the pharmacy failed to provide pharmaceutical services to meet each resident's needs by not maintaining an effective system for ordering, receiving, and supplying medications, resulting in multiple missed medication doses. This failure had the potential to cause uncontrolled symptoms, worsening medical conditions, avoidable pain, and preventable decline. Findings Include:Review of the facility policy titled Ordering and Receiving Non-Controlled Medications, last revised August 2020, documented, Policy: Medications and related products are received from the pharmacy on a timely basis . Procedures . I. Ordering Medication from the Pharmacy: 1. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure all drugs and biologicals were safely and securely stored. Specifically, the B-wing medication room was observed unlocked, and the treatment carts were unlocked with the key hanging in the lock. Findings Include:Review of the facility policy titled Storage of Medications last revised August 2020, documented, Policy: Medications and biologicals are stored safely, securely, and properly . The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. I. General Guidance . 2. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. [...]

Inspectors wroteBased on review of the facility policy, observations, and interviews, the facility failed to ensure expired food items were removed from storage and food items were properly stored and labeled.

Inspectors wroteBased on review of the facility policy, observation and interview, the facility failed to ensure a successful elopement was reported timely to the State Agency (SA) within two (2) hours of its occurrence.

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident preferences were honored in relation to dietary meals. Specifically, the facility did not provide residents preferences or substitutes. This deficient practice had the potential to effect all residents obtaining food items from the kitchen.

Inspectors wroteBased on observation and interviews, the facility failed to label and date all food stored in the walk-in cooler and ensure food was cooked at the proper temperature prior to service with the potential to affect 79 of 83 residents who consumed food prepared from the facility's kitchen. This failure had the potential to lead to food borne illnesses.

Inspectors wroteBased on record review, observations and interviews, the facility failed to allow family visitation for one of one resident (Resident (R) 38). This failure violated R38's right as a resident of the facility and had the potential to violate the rights of 83 residents that lived in the facility.

Inspectors wroteBased on review of the facility policy, observations and interviews, the facility failed to ensure residents' equipment was kept clean and blinds were in good working order for two of two residents (Residents (R) 47, and R72) reviewed for the environment of 21 sample residents. Specifically, R47's bedside fall mats were observed with a dry brown substance, and R72's window blinds were in disrepair. This failure had the potential to not support the residents' right to a safe, clean, comfortable, and homelike environment. Findings Include: [...]

Inspectors wroteBased on review of the facility policy, record reviews and interviews, the facility failed to report an allegation of resident-to-resident abuse for two of three residents (Resident (R) 28 and R35) reviewed for abuse out of 21 sampled residents. This had the potential to affect all residents who received care.

Inspectors wroteBased on review of the facility policy, record reviews and interviews, the facility failed to investigate an allegation of resident-to-resident abuse for two of three residents (Resident (R) 28 and R35) reviewed for abuse out of 21 sampled residents. This had the potential to affect all residents who received care.

Inspectors wroteBased on record review and interview, the facility failed to ensure a written transfer notice that contained all required information was provided for two of five residents and/or their representatives (Resident (R) 11 and R39) reviewed for hospital transfer out of 21 sample residents. This failure had the potential to affect the residents and their Resident Representative (RP) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review, observation and interviews, the facility failed to ensure there was an active physician ' s order for oxygen administration for one of one residents reviewed, (Resident (R) 12) reviewed for oxygen administration of 21 sample residents. This failure had the potential for residents to receive increased oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen).

Inspectors wroteBased on record review, observation and interviews, the facility failed to ensure residents received alternative measures prior to the installation of side rails and that assessments were completed for the risk of entrapment for one of two residents (Resident (R) 12) reviewed for side rails out of 21 sample residents. The lack of alternate side rail measures and proper assessment could lead to potential restraint or side rail entrapment.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure that residents were offered and received the pneumonia vaccinations for two of five residents (Resident (R) 45 and R57) reviewed for immunization of 21 sample residents. This places residents at an increased risk of complications related to pneumonia. Findings Include: Review of the facility's policy titled, Immunizations-Pneumococcal Vaccination (PPV), dated 06/19, revealed the facility will follow current recommended practice guidelines for the pneumococcal vaccination. Residents will be offered the pneumococcal vaccination as appropriate. 1. [...]

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to develop and implement a comprehensive person-centered Care Plan for Resident (R)1, for 1 of 3 residents.

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that 1 resident (Resident (R)79) out of 23 sampled residents had an accurate Minimum Data Set (MDS) assessment.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to assess a resident for the use of side rails on the bed, including a review of risks and potential entrapment; or obtained informed consent for the use of side rails from the resident and/or the resident representative to ensure the appropriate use of side rails for 1 resident (Resident (R)47) out of 23 sampled residents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to obtain statements from all parties involved for 1 of 3 sampled residents reviewed for abuse.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to label and date food items in one of two refrigerators in the kitchen. This had the potential to affect 60 of the 62 resident of the facility who consume food from the kitchen. The facility identified two residents who were ordered to received nothing by mouth (NPO).

Inspectors wroteBased on observations, interviews and review of facility policy, the facility failed to ensure staff wore all the required personal protective equipment (PPE), specifically eye protection when entering occupied (COVID positive) residents' rooms in order to potentially prevent the spread of COVID in the facility. The deficient practice had potential to affect 40 of the 62 residents of the facility who were negative for COVID.

Inspectors wroteBased on interviews, record reviews and review of facility policy, the facility failed to ensure care plans were revised and updated related to COVID in order to provide person-centered care for two residents ((R)10 and R 55) of 16 reviewed for care plans.

Inspectors wroteBased on observation, interview and review of the facility policy, the facility failed to ensure maintenance services were provided in order to maintain a sanitary kitchen. Tours of the facility throughout the survey dates from 01/17/22 to 01/19/22 revealed concerns with cleanliness of the vent hood filters in the kitchen and the floors/baseboards in the kitchen.