Ridgeway Manor Healthcare Center

Inspectors wroteBased on observation, record review, staff interview, facility policy review, and Ecolab email, the facility failed to ensure the low-temperature dishwasher maintained the required final rinse temperature of at least 120 degrees Fahrenheit to ensure proper sanitization of dishware and utensils and reduce the potential for foodborne illness transmission. This deficient practice was identified in 1 of 1 main kitchens. Findings Include: Facility Policy: Dishwasher Temperature, Policy: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. Policy Explanation and Compliance Guidelines: 4. For low temperature dishwashers (chemical sanitization):a. The wash temperature shall be 120 degrees Fahrenheit.b. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that one Certified Nursing Assistant (CNA) received a performance evaluation in 2025, for 1 of 5 direct-care staff records reviewed.

Inspectors wroteBased on review of the facility policy, observations, and interviews, the facility failed to ensure an excessive amount of lint was removed from lint screens for 2 of 2 commercial clothes dryers in the main laundry room.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that one Certified Nursing Assistant (CNA) received 12 hours of annual in-service training, for one of 5 direct-care staff records reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to use its resources effectively and efficiently related to suspension of food service delivery, suspension of oxygen supply, and suspension of linen orders, and an incomplete facility assessment. This inaction in administering the facility had the potential to affect all residents living in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide evidence of having a governing body, ensuring a facility assessment was complete to assess the overall management and operation of the facility, a failure to develop and implement bylaws and operational policies for the facility which resulted in a failure to ensure facility's Ethics and Compliance Program was implemented. These failures resulted in vendors not getting paid and a disruption in delivery of food and supplies to residents and had the potential to affect all residents living in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the facility assessment was complete and to identify all necessary resources to attain and maintain resident needs, and failed to ensure active involvement of required participants. This inaction in administering the facility had the potential to affect all residents living in the facility. Review of the Facility assessment dated [DATE] revealed it was not signed and was reviewed with the QAA Committee on 04/10/25. Several sections were blank or incomplete, and many had no supporting documentation. There was no signature page or other documentation to identify the participating members included in the development of the assessment. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a sufficient amount of bath and bed linens, in good condition, in 2 of 2 linen closets reviewed out of a total of 2 linen closets in The Home building. This had the potential to affect 58 of 58 residents residing in The Home building in a total facility census of 92.

Inspectors wroteBased on observation, interview, and record review, the facility failed to completely and accurately document the suspected cause of a fracture for 1 (Resident (R)3) of 3 residents reviewed for accidents.

Inspectors wroteBased on review of facility policies, observations, and interviews, the facility failed to ensure that all mechanical, electrical, and patient-care equipment was maintained in safe operating condition. Specifically, on 12/08/25, the facility's Heating, Ventilation, and Air Conditioning (HVAC) systems serving the 200 and 300 halls and the lobby were inoperable and/or unable to provide adequate heat, resulting in an inability to maintain required ambient temperatures for residents. This failure placed residents at risk for cold-related discomfort and adverse health outcomes.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to monitor, protect, and prevent misappropriation of narcotic medication for 1 of 3 residents (Resident (R)8) reviewed for misappropriation out of a total sample of 21 residents. This failure had the potential to place all residents receiving narcotic pain medication at risk of serious harm of uncontrolled pain due to drug diversion. Cross-Reference: F755 Pharmacy Services. The facility's failure to ensure prevention of misappropriation of property related to narcotic drug diversion had the potential to cause serious harm. Immediate Jeopardy was identified on 03/03/25 and was determined to exist on 02/26/25 in the area of §483.12 Misappropriation F602 at a scope and severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on 03/03/25 at 8:35 PM. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide and maintain pharmaceutical services for the receipt, disposition, reconciliation, and control of narcotic medication for 1 of 3 residents (Resident (R)8) reviewed for medications out of a total sample of 21 residents. This failure had the potential to place all residents receiving narcotic pain medication at risk of serious harm of uncontrolled pain due to drug diversion. Cross Reference: F602 Misappropriation. The facility's failure to ensure pharmaceutical services were provided to meet the needs of each resident had the potential to cause serious harm. Immediate Jeopardy was identified on 03/03/25 and was determined to exist on 02/26/25, in the area of §483.45 Pharmacy Services F755 at a scope and severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on 03/03/25 at 8: [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to implement a Quality Assurance and Performance Improvement (QAPI) program when they did not adequately identify, analyze, and address issues impacting resident care through proper data collection, monitoring, and improvement initiatives related to pharmaceutical services. This had the potential to affect 85 of 85 residents who resided at the facility. The facility's failure to adequately identify, analyze, and address issues impacting resident care through proper data collection, monitoring, and improvement initiatives related to pharmaceutical services had the potential to cause serious harm to residents. Immediate Jeopardy was identified on 03/03/25 and was determined to exist on 02/26/25, in the area of §483.75 Quality Assurance and Performance Improvement at a scope and severity (S/S) of J. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure food stored in the main kitchen was labeled and dated. The failures had the potential to increase the prevalence and spread of foodborne illness and infection for 79 residents who receive food from the kitchen. 6 residents receive tube feedings with no food/fluids provided by the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure Registered Nurse coverage was provided eight hours a day seven days a week for a total of seven days in July, August, and September 2024. The failure created the potential for the clinical needs of all residents not to be met.

Inspectors wroteBased on review of the facility policy, record review and interviews, the facility failed to report an allegation of misappropriation of narcotic medication to the state survey agency within two hours for 1 of 3 residents (Resident (R)8) reviewed for abuse out of a total sample of 21 residents. This had the potential to allow continued misappropriation.

Inspectors wroteBased on interviews, and facility policy review, the facility failed to use nursing rights of medication administration while administrating a medication for 1 of 21 residents (Resident (R)8), reviewed for professional standards. This failure had the potential for residents being subject to adverse effects leading to worsening symptoms, long-term effects, and death.

Inspectors wroteBased on review of the facility policy, record reviews, and interviews, the facility failed to update Resident (R)1 and R2's care plan to reflect a person-centered change in status, related to potential desire/preference. 2 of 7 reviewed for Care Plans.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a clean and safe environment on 2 (Unit 100 and Unit 200) of 3 resident care units in 1 of 2 buildings.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to follow the menu for 52 of 52 residents served mechanical soft or regular diets in the in 1 unit.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident (R) 4) of 41 sampled residents had the right to choose health care providers consistent with her wishes.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to release Resident (R)3's restraint during meals as ordered by the physician for 1 of 3 sampled residents reviewed for restraints.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to conduct a thorough investigation of an allegation of abuse for 1 (Resident (R)4) of 41 sampled residents.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure 3 of 3 residents and their representatives (Resident (R)68, R96, and R98) reviewed for facility initiated emergent hospital transfer were provided with written transfer/discharge notice that contained all required information. This failure has the potential to affect the resident and their Resident Representative (RR) 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, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure 1 (Resident (R)85) of 41 sampled residents had an accurate Minimum Data Set (MDS) assessment.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to ensure that a care plan related to smoking was developed for 1 (Resident (R)85) of 41 sampled residents. This failure had the potential to cause the resident to not have adequate supervision while smoking.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure staff implemented interventions identified to aid in the prevention of harm with a fall for 1 (Resident (R)38) of 3 sampled residents reviewed for falls. This had the potential for R38 to sustain injuries from a fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure the appropriate coordination of hospice care by specifically failing to maintain hospice care plans, nurses' notes, certified nurse aide (CNA) notes, and/or hospice election forms and physician certification and recertification of the terminal illness specific to each resident for 2 (Residents (R)76 and R199) of 41 sampled residents. This failure had the potential to result in the interruption of the residents' coordination of care.

Inspectors wroteBased on interview, record review, and review of manufacturer's instructions, the facility failed to ensure bed frames and rails, if present, were inspected and serviced per the Manufacturer's Instructions for Use (MIFU) to minimize the risks of bed malfunction or resident injury. This failure had the potential to affect 98 of 98 residents who resided at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure 1 (Resident (R)199) of 41 sampled residents had a functioning call light system. This had the potential to affect the resident's ability to call for assistance.