Ridgewood at the Woodlands

Inspectors wroteBased on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care services for one of two residents (Resident #1) reviewed for PASARR. The facility failed to submit a request through the simple LTC portal for a customized manual wheelchair for Resident #1 within the time frame set by PASARR. This failure could place residents at risk of not having their PASARR specialized service needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #17) reviewed for accidents and supervision. The facility failed to ensure the locking mechanism on Resident #17's bed was operating properly, which caused her to fall and hit her head and resulted in a head injury, laceration over her right eye, and need for emergency medical attention. An IJ was identified on 6/12/2025. The IJ template was provided to the facility on 6/12/2025 at 2:33 pm. While the IJ was removed on 6/13/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility ' s need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents had the right to self-administer medication, if the interdisciplinary team, has determined this practice as clinically appropriate for 1 out of 8 residents (Resident #45) reviewed for self-administration of medication. The failed to assess Resident #45, who suffered from tremors associated with a diagnosis of Parkinson's Disease, for the ability to self-administer lubricant eye drops in that Resident #45 self-administered eye drops to herself from admission [DATE]) to 05/21/25. This failure could place residents at risk of inappropriate medication doses, medication errors, drug interactions, and side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administrating of all drugs and biologicals, to meet the needs of each resident for 1 of 8 residents (Resident #45) and 1 of 4 med carts ( 200 Hall Med Aide Cart) reviewed for pharmacy services. - The facility failed to administer Resident #45's Carbidopa/Levodopa (a medication used to treat tremors associated with Parkinson's Disease) on time, resulting in the resident experiencing increased tremors. - The facility failed to ensure that the 200 Hall Med Aide Cart did not contain expired OTC Aspirin 325 mg (about the weight of ten grains of rice). These failures could place residents at risk for adverse drugs reactions, side effects and uncontrolled health conditions. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (200 Hall Med Aide Cart) and 1 of 8 residents (Resident #45) reviewed for medication storage . The facility failed to ensure Resident #45 did not have unauthorized and unsecured OTC eyedrops at her bedside. The facility failed to ensure that the 200 Hall Med Aide Cart did not contain: loose pills and inappropriately labeled oral and liquid protein supplements. These failures could place residents at risk for adverse drugs reactions, side effects and uncontrolled health conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare puree and regular food by methods that conserve nutritive value, flavor, texture and appearance for 3 out of 5 residents reviewed for food and nutrition dietary services (Residents #2, #40, #73). The facility failed to ensure that puree diet and regular diet was prepared by methods that conserve nutritive value, flavor, and appearance. This failure could place residents on regular diet and puree diet at risk of receiving inadequate diet that could affect their health.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 12 residents (Resident #43) reviewed for rights and dignity. - The facility failed to ensure that nursing staff used privacy curtain between the hallway door and the resident, removing resident from public view and prevent exposure of body parts while providing peri care to Resident #43. - The facility failed to ensure that the nursing staff used the privacy curtain between Resident #43 and Resident #45 while providing incontinence care to Resident #43, to prevent exposure of body parts. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the resident and the resident's representative of a transfer and the reasons for the transfer, effective date, location and statement of resident's appeal rights, and duration of the bed-hold policy in writing for 1 of 4 residents (CR #332) reviewed for transfers. The facility failed to ensure CR #332's representative received a written notice of transfer when she was transferred to a local psychiatric hospital on 2/21/25 and 2/26/25. These failures could place residents at risk of an insufficient preparation or orientation during transfer, inability to use their right to appeal, and lack of information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 8 residents (Resident #45 and Resident #49) reviewed for accuracy of assessments. The facility failed to identify Resident #45's diagnosis of Parkinson's Disease in her Quarterly MDS and list of medical diagnosis. The facility failed to identify Resident #49's use of oxygen in her MDS. This failure could place residents at risk of a compromised plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 Residents (Resident #49) reviewed for care plans. - The facility failed to identify Resident #49's use of oxygen in her care plan. This failure could place residents at risk of not having their needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 5 residents (Resident #22) reviewed for pain management. The facility failed to ensure Resident #22's pain control was maintained at a level acceptable to the resident. This failure could place the resident at risk of a decrease in quality of life due to pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 dining room reviewed for essential equipment. The facility failed to keep the ice machine and water machine free of leaks. This failure could place the residents at risk of slipping on spilled water on the floor and consuming water and ice from equipment which may be contaminated due to malfunction.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse for 3 of 4 residents (Resident #1, Resident #22 and Resident #43) reviewed for abuse. The facility failed to ensure Resident #1 was free from verbal abuse when CNA S yelled at her using a cuss word and asking what was wrong with her. The facility failed to ensure Resident #22 was free from verbal abuse when Medication Aide B used a racial slur towards her. The faciity failed to ensure Resident #43 was free from physical abuse when CNA A assisted with changing Resident #43's adult brief. These failures could place residents at risk of feelings of indignity, irritability, and sadness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practices, the comprehensive care plan, and the residents' choices and based on the comprehensive assessment of a resident for 1 of 12 residents (Resident #43) reviewed for quality of care. - CNA-E failed to transfer Resident #43 using a gait belt as an assistance device to prevent accidents. CNA-E hooked her arm under Resident #43's arm, pulling upward to transfer resident from the bed to the wheelchair. This failure could place residents at risk of pain, injury, or hospitalization. Record review of Resident #43's face sheet dated 06/11/25 revealed a [AGE] year-old admitted to the facility on [DATE] and originally admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review 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 infection for 1 of 4 residents (Resident #1) reviewed for infection. -The facility failed to ensure LVN A (Head Charge Nurse) performed hand hygiene during wound care on Resident #1. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for 1 of 3 residents (Resident #1) who needed respiratory care was provided care consistent with professional standards of practice reviewed for respiratory care, in that: - Resident #1 was observed to be administered oxygen PRN, but nurses did not document the times PRN oxygen was given . - LVN D reported Resident #1's oxygen dipping low at times but did not document change of conditions and times in which PRN oxygen was needed. This failure placed Resident #1 at risk of not receiving adequate respiratory care.

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 6 resident (Resident #1) reviewed for accidents. The facility did not provide supervision to prevent Resident #1 from having a witnessed fall, when CNA A failed to ensure the resident was secured and placed appropriately in her bed prior to plugging in her bed. As a result the resident sustained a fracture. This failure could place residents at risk for inadequate supervision resulting in injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 3 residents (Resident #1) reviewed for food preferences. This failure had the potential to affect all facility residents who consumed food from the facility's kitchen. The facility failed to ensure Residents #1 was provided a lunch when she went to dialysis during lunch time on her dialysis day. The facility failed to have an effective system in place to ensure sufficient and routine replenishment of food for Resident #1. The facility failed to provide approved and adequate meal equivalate substitutions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received, and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community for 1 of 3 residents (Resident #1) reviewed for timely meals, in that: 1. Resident #1 was sent to dialysis without a lunch during lunch time and returned hungry. 2. Resident #1 sometimes did not get breakfast before she left for dialysis. 3. Resident #1 felt hungry when she did not get an adequate meal when returning from dialysis. The failures placed residents at risk of unplanned weight loss, altered nutritional status, decreased feelings of self-worth. Resident #1 had a diminished quality of life; not getting a lunch on her dialysis day, feeling hungry and not feeling cared for.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 3 (Resident #1) room reviewed for food service safety. 1. The facility failed to ensure Resident #1 and Resident #2's dinner trays were property stored until residents arrived from dialysis. 2. The facility failed to have a system in place when storing dialysis resident's meals. These failures could place residents at risk of food borne illness.