Ridgeway Nursing & Rehabilitation Facility

Inspectors wroteThe facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases for 7 of 40 sampled residents (Resident (R) 16, R32, R40, R50, R78, R82, and R88).

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of residents' advance directive information for 2 of 12 sampled residents, Resident (R) 22 and R53.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to protect 1 of 11 sampled residents from physical abuse involving a resident to resident altercation, Resident (R) 21. On 01/13/2024 at 1:20 PM, State Registered Nurse Aide (SRNA) 7 witnessed R72 smack R21 in the face for taking R72's teddy bear away from her. Per review of the progress notes, R21 stated she thought her nose had been broken after the incident.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation of resident property for 1 of 4 sampled residents, Resident (R) 51.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident's rights that included measurable objectives and timeframes to meet a the resident's medical and nursing needs for 1 of 1 sampled residents, Resident (R) 47.

Inspectors wroteThe facility failed to review and revise the Comprehensive Care Plan (CCP) for 1 of 34 sampled residents, Resident (R) 43. Review of R43's CCP revealed the facility failed to revise the care plan for placing his catheter bag on the floor, despite an interview with the resident stating that he liked to do so and observations of the catheter bag lying on the floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 5 sampled residents, Resident (R) 47.

Inspectors wroteBased on observations, interviews, record review, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 34 sampled residents, R36, R43 and R390. Observations revealed R390 and R36 did not have the proper signage or proper precautions in place. Observations revealed R43's catheter was observed on the floor on multiple observations.

Inspectors wroteBased on observation, interview, record review, review of food product package instructions, and review of the facility's policies, and the www.website it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety to prevent cross contamination of foods. The facility failed to ensure food was prepared and served at the proper temperature to prevent residents from receiving potentially hazardous food which could cause food-borne illness. This deficient practice had the potential to affect eighty-two (82) of eighty-four (84) current residents, as two (2) residents received tube feedings and not a meal tray. 1. [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's Administrator's Job Description, and review of the facility's policies, it was determined the Administrator failed to administer the facility in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The following deficiencies were identified: 1. The Administrator failed to ensure that food leaving the kitchen was stored, prepared, distributed and served in accordance with professional standards for food service safety; and that dietary staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents received written notice, including the reason for the room change/transfer, for eight (8) of fifty-three (53) sampled residents (Residents #6, #50, #72, #49, #3, #40, #60, and #82. The facility transferred Resident #6's personal belongings to another room, but when Resident #6 refused the transfer, the facility did not return the belongings for four (4) days. Resident #6 was upset and cried for four (4) days. The facility transferred Resident #50 out of a room the resident had shared with his/her spouse who had died in the room. The facility transferred Resident #72 several times who is a fall risk and has limited vision. The facility transferred Resident #49 who has Alzheimer's; the transfers caused confusion and behaviors. [...]

Inspectors wroteBased on interview, record review, and the facility's Social Services Director job description, it was determined the facility failed to provide medically-related social services related to the failure to advocate for residents and to assist them in the assertion of their rights. Residents were not assisted by the Social Services Director in voicing and obtaining resolution to grievances about treatment, living conditions, and accommodation of needs. Also, the Social Services Director did not provide services to meet the needs of residents who were coping with stressful events. This deficient practice affected eight (8) of fifty-three (53) sampled residents (Residents #3, #6, #40, #49, #50, #60, #72, and #82). [...]

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure one (1) of fifty-three (53) sampled residents (Resident #6) was treated with respect and dignity and failed to ensure the resident's right to retain and use personal possessions, including clothing. According to Resident #6, facility staff came into his/her room on 02/24/2022 and took all of his/her personal belongings to another room. Resident #6 stated he/she told staff to leave the belongings alone, and the resident refused the transfer. Resident #6 stated he/she cried and asked for his/her belongings from 02/24/2022 to 02/28/2022 until they were returned on 02/28/2022. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to protect residents from abuse and neglect for one (1) of fifty-three (53) sampled residents (Resident #6). The facility willfully deprived Resident #6 of his/her personal belongings, from 02/24/2022 to 02/28/2022. These belongings were necessary to attain or maintain his/her mental and psychosocial well-being necessary to avoid mental anguish or emotional distress. Resident #6 stated he/she felt this behavior was abuse, as well as staff, who described this behavior as abusive. Staff were aware Resident #6 was upset and cried during this time. However, the resident's belongings were not returned until 02/28/2022. [...]

Inspectors wroteBased on interview, record review, review of job descriptions, and review of the facility's policies, it was determined the facility failed to report allegations of abuse and neglect for one (1) of fifty-three (53) sampled residents (Resident #6), whose personal belongings were removed from his/her room for four (4) days causing him/her psychosocial harm. Resident #6 cried and was upset from Thursday to Monday. Staff wasn't able to provide the necessary care for the resident. The resident asked for his/her belongings to be given back. However, no one would give him/her his/her belongings. Although the resident felt this behavior was abusive and staff thought it was abuse, no one reported this as an allegation of abuse. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, to meet the resident's highest practicable quality of life, specifically nursing and psychosocial needs, that were identified in the comprehensive assessment for two (2) of fifty-three (53) sampled residents (Residents #6 and #50). The facility deprived Resident #6 and Resident #50 of goods or services that were necessary to attain or maintain his/her highest level of practicable physical, mental, and psychosocial well-being. Review of Resident #6's care plan, dated 11/23/2021, revealed a focus of psychosocial wellbeing risk related to a new environment. [...]

Inspectors wroteBased on observation, interview and record review, and the website it was determined the facility failed to ensure there was sufficient dietary staff with necessary skill sets to safely and adequately prepare and serve meals three (3) times a day. This lack of sufficient dietary staff had the potential to affect eighty-two (82) of eighty-four (84) current residents. Two (2) residents received tube feedings.

Inspectors wroteBased on observation, interview, review of the Dietary Manager's (DM) job description, and review of the facility's policy, it was determined the facility failed to distribute food that was palatable. Interviews with residents and staff revealed meals served on 03/09/2022 and 03/10/2022, were not palatable. On 03/09/2022, residents received overcooked and tough breaded pork tenderloin. On 03/10/2022, residents received steak fries that were white in color and did not appear to have been cooked. Interviews from numerous residents/family members and staff revealed, on 03/13/2022, at the dinner meal, residents were served cold, undercooked chicken nuggets and waffle fries, with the appearance of not being cooked. Eighty-two (82) of the eighty-four (84) current residents had the potential to be affected by the meals. Two (2) residents received tube feedings.

Inspectors wroteBased on observation, interview, and review of the facility's policy, it was determined the facility failed to routinely offer snacks for all residents, excluding those that received tube feedings and received no snacks. In addition, meal service was delayed on 03/08/2022, 03/11/2022, and 03/13/2022. These deficient practices affected eighty-two (82) of eighty-four (84) current residents.

Inspectors wroteBased on observations, interviews, and record review, it was determined the facility failed to ensure menus were posted and/or followed as posted. Review of the menus posted for 03/14/2022, lunch and dinner, and 03/17/2022, dinner only, did not match the foods observed to be served to the residents. This deficiency affected eighty-two (82) of eighty-four (84) current residents; two (2) residents were receiving tube feedings and did not receive meal trays.