Ridgeview Health Services, Inc

Inspectors wroteBased on interviews, record review, review of a facility policy titled, Negative Pressure Wound Therapy, review of Resident Identifier (RI) #150's hospital records and review of a complaint received by the State Agency, the facility failed to provide, in a timely manner, a wound vacuum (vac) as prescribed by RI #150's hospital physician. On 11/10/2022 RI #150 was admitted to the facility with hospital physician orders for a wet-to-dry packing and a wound vac was to be placed to RI #150's right abdominal surgical wound once RI #150 was admitted to the facility. According to facility staff the wound vac was not placed until 11/14/2022, four days after RI #150 was admitted to the facility. RI #150 was discharged from the facility back to the hospital on [DATE] due to an elevated Creatinine laboratory result. [...]

Inspectors wroteBased on interviews, record review, review of a Facility Reported Incident (FRI), review of the facility investigative file and a facility policy titled Abuse, Neglect and Exploitation the facility failed to protect Resident Identifier (RI) #152's right to be free from physical abuse perpetrated by another resident, RI #151. On 03/31/2023, Certified Nursing Assistant (CNA) #12 witnessed RI #151 physically abuse RI #152, a cognitively impaired resident, when RI #151 was found in RI #152's room placing a pillow over RI #152's head while RI #152 was in bed. The facility failed to provide adequate supervision and interventions for RI #151, a resident with a history of wandering and aggressive behaviors, to prevent other residents from being abused by RI #151. The witness, CNA #12 said, someone who had a pillow placed over their head may feel smothered or that someone was trying to harm them. [...]

Inspectors wroteBased on observations, record review, interviews and review of a facility policy titled, ACCIDENT/INCIDENT STAFF RESPONSIBILITY, the facility failed to ensure Resident Identifier (RI) #16's fall interventions to have mats on the floor on both sides of the bed; and for the bed to be lowered for safety was being implemented on three of four days of the survey. This affected RI #16, one of four residents sampled for accidents. Findings Include: Review of a facility policy titled, ACCIDENT/INCIDENT STAFF RESPONSIBILITY, with a revision date of 08/08/2022 revealed the following: . Accident refers to an unexpected or unintentional incident, which may result in injury or illness to a resident . RI #16 was admitted to the facility on [DATE] with diagnoses to include Dementia, Severity, with Agitation and Personal History of Transient Attack. [...]

Inspectors wroteBased on observations, interviews, resident record review, and review of a facility's policy titled Behavioral Health Services, the facility failed to ensure Resident Identifier (RI) #151, a resident with behaviors that were difficult to manage, had interventions and supervision to prevent abuse of other residents and to protect other residents and ensure safety and privacy from RI #151's aggressive wandering behaviors. This deficient practice affected RI #151 and RI #152 two of four residents sampled for behaviors. This deficiency was cited as a result of the investigation of complaint/report number AL00043781/459160.

Inspectors wroteBased on observation, interview, the facility's 2025 Spring/Summer Menu for Wednesday - Day 11, the facility's Portioning Utensils document, and the facility's policies for Menu Planning and Menu Substitution Lists, the facility failed to ensure the correct portions of pureed food were served at Dinner/Supper on 08/06/2025. This had the potential to affect three of eleven residents receiving a Pureed Diet. Findings Include: The facility's policy for Menu Planning, dated 2023, included the following: . Policy:Nutritional needs of individuals will be provided in accordance with the established national standards .Procedure:1. a. Regular and therapeutic menus will be written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances. [...]

Inspectors wroteBased on observations, interviews and a review of facility policies titled, Handwashing and Glove Use, Cleaning Dishes-Manual Dishwashing, Diet Spreadsheet, and Food Temperatures, The facility failed to ensure: 1. the PPM (parts per million) in the sanitizer bucket reached 200; 2. the temperature of a pan of rice and hot dog were taken at the tray line and; 3. staff did not turn off the handwashing sink faucet with bare hand. This had the potential to affect 60 of 103 residents who may have received rice, and one resident who may have received a hotdog from the kitchen. Findings Include: 1) A review of a facility policy titled, Cleaning Dishes-Manual Dishwashing, with no date, revealed: . Procedure .5. Check sanitation sink often using a test strip to assure the level of sanitizing solution is appropriate. [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policy titled Glucometer Cleaning, the facility failed to ensure that Employee Identifier (EI) #2 did not place the glucometer in her shirt pocket between use on multiple residents. This affected 1 of 2 licensed staff performing point-of-care glucometer testing and 2 of 2 residents who received blood sugar monitoring, Resident Identifier (RI) # 58 and #341. Findings Include: A facility policy titled GLUCOMETER CLEANING last revised on April 15, 2013. Policy . It is the policy of (name of facility) to clean the glucometer after each use. Procedure 1. After completing blood sugar testing, remove glucometer from resident's room. 2. Obtain germicidal sanitizing sheet from super Sani-cloth container (purple top), and wipe down glucometer. 3. Return glucometer to cart and allow to air dry for at least 2 minutes. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure eight cups were air dried prior to use. This had the potential to affect eight residents who received meals from the kitchen. Findings Include: On 08/14/18 at 11:37 AM, while observing the tray line, the surveyor observed eight cups that were washed, then dried with paper towels. On 08/16/18 at 2:27 PM, an interview was conducted with EI (Employee Identifier) #1, CDM (Certified Dietary Manager). EI #1 was asked how were cups to be properly dried prior to use. EI #1 said they should be air dried. EI #1 was asked what was the concern with staff drying cups with paper towels. EI #1 said it was an infection control and cross contamination issue.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure: 1) Resident Identifier (RI) #80 was supplied with a new feeding tube syringe after the syringe had been used for more than 24 hours; and 2) Certified Nursing Assistants (CNA's) did not transport linen up against their clothes on two of three days of the survey. These deficient practices affected RI #80, one of three residents observed with a feeding tube, and CNAs on one of four units at the facility. Findings Include: 1) RI #80 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses to include Encounter for Attention to Gastrostomy and Dysphagia. An Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/11/18, revealed RI #80 had a feeding tube during this assessment period. RI #80's August 2018 Physician Orders documented: [...]