Ridgewood Manor

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, staff interview, coroner interview, and policy review, the facility failed to ensure resident supervision through purposeful rounding every two hours per the facility's standard of care. This affected one (#01) of three residents reviewed for death. The facility census was 67.

Inspectors wroteBased on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure resident medications were administered per physician orders. This affected two (#31, #19) of three residents reviewed for medications administration. The facility census was 55.

Inspectors wroteBased on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure residents were free of significant medication errors. This affected two (#31, #19) of three residents reviewed for medication administration. The facility census was 55.

Inspectors wroteBased on observation, resident and staff interview, medical record review, review of shower sheets, review of designated smoking times, and review of facility policies, the facility failed to maintain a resident's choice for bathing and smoking when the facility failed to ensure these activities were provided as scheduled. This affected one (#19) of two residents reviewed for activities of daily living and two (#29 and #51) of four residents reviewed for smoking. The facility census was 45.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure resident privacy was maintained during personal care and treatments. This affected two (#35 and #31) of 17 residents observed for privacy. The facility census was 45.

Inspectors wroteBased on review of the medical record, observation, staff and resident interview, and policy review, the facility failed to ensure physician orders for wound treatments were clarified, accurately documented and completed per physician orders. This affected two (#11, #37) of three residents reviewed for wound care. The facility identified six residents with non-pressure related wounds. The facility census was 38.

Inspectors wroteBased on observation, staff interview, and review of a facility policy, the facility failed to store and label food and drink items in a manner to prevent spoilage and failed to maintain the floor in the nursing unit pantry in a sanitary manner. This had the potential to affect all 39 residents who receive food from the facility. The facility census was 39.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to potential hazards were secured in a safe manner. This had the potential to affected six (#1, #6, #7, #19, #27, and #34) of six residents who the facility identified as cognitively impaired and independently ambulatory. The facility census was 39.

Inspectors wroteBased on medical record review, hospital discharge document review, resident interview, and staff interview, the facility failed to ensure resident blood glucose levels were monitored as ordered by the physician. This affected one (#141) of four residents reviewed as new admissions to the facility in a census of 39.

Inspectors wroteBased on observation, medical record review, staff interview, review of an equipment manual, and review of a facility policy, the facility failed to initiate orders and plans of care to ensure bilevel positive airway pressure (BiPAP) therapy was correctly utilized and staff responded timely to BiPAP machine alarms. This affected one (#14) of two residents reviewed for respiratory care. The facility census was 39.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure medications were provided as ordered by the physician and without error. This result in nine (9) medication errors out of 25 medications being administered for an error rate of 36 percent (%). This affected two (#24 and #141) of three residents observed for medication administration in a facility census of 39.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered as ordered by the physician, and within prescribed time frames, to prevent significant medication errors. This affected three (#16, #24, and #141) for four residents reviewed for the administration of medications in a facility census of 39.

Inspectors wroteBased on review of the medical record, staff interview, resident interview, and policy review, the facility failed to ensure wound care treatments were completed per physician orders. This affected one resident (#18) of three residents reviewed for wound care. The facility identified five residents with wounds. The facility census was 44.

Inspectors wroteBased on review of the medical record, observation, interview, and policy review, the facility failed to clarify and implement physician orders for the care of a tracheostomy and further failed to provide tracheostomy care. This affected one resident (#19) of two residents reviewed for respiratory care. The facility identified 19 residents receiving respiratory care. The facility census was 44.

Inspectors wroteBased on observation, staff interview, medical record review, and review of the Centers for Medicare and Medicaid Services (CMS) Provider History Profile document, the facility failed to have an effective quality assurance and performance improvement (QAPI) program to address repeated deficiencies identified during four consecutive comprehensive surveys. This had the potential to affected all 44 residents in the facility. The census was 44.

Inspectors wroteBased on observation, staff interview, medical record review, review of a medication package insert, and review of facility policies, the facility failed to ensure water temperature testing was completed as part of the facility Legionella prevention program. In addition, the facility failed to ensure staff wore proper personal protective equipment during resident care for a resident (#13) on enhanced barrier precautions and failed to cleanse a resident's (#24) insulin dispensing pen prior to affixing a needle for administration. This deficient practice had the potential to affect all 44 residents residing in the facility. The facility census was 44. Findings Include: 1. Review of the facility water temperature logs on 12/19/24 at 8:35 A.M. revealed water temperature testing was absent from 10/01/24 through 12/19/24. Interview with Maintenance Supervisor #631 on 12/19/24 at 8:40 A.M. [...]

Inspectors wroteBased on observation, resident and staff interview, review of medical records, review of a behavior contract, review of facility equipment logs, and review of facility policies, the facility failed to ensure emergency crash carts were completely stocked per facility policy. This had the potential to affect 33 (#1, #3, #4, #5, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #23, #24, #27, #28, #29, #30, #31, #32, #33, #35, #38, #39, #40, #41, #44, #45, #46, #48, and #50) residents identified by the facility as being full code (the resident wishes to receive resuscitation and all live saving measures in the event of a cardiac or respiratory arrest). [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents who were being discharged from Medicare Part A services received timely notification. This affected three (#25, #49, and #104) of three residents reviewed for beneficiary notices. The facility census was 44.

Inspectors wroteBased on medical record review, review of self-reported incidents (SRIs) and facility investigation, review of a witness statement, and staff interview, the facility failed to ensure residents were free from abuse. This affected two (#7 and #23) of three residents reviewed for abuse. The facility census was 44.

Inspectors wroteBased on medical record review, resident interview, staff interview, and facility policy review, the facility failed implement ordered interventions to aid in producing a bowel movement. This affected one (#15) of one residents reviewed for bowel and bladder. The facility census was 44.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure wound care was completed timely and as ordered. This affected one (#9) of two residents reviewed for wound care. The facility census was 44.

Inspectors wroteBased on observation, staff interview, medical record review, review of a medication manufacturer package insert, the facility failed to ensure residents received insulin as ordered which resulted in a significant medication error. This affected one (#13) of three residents observed during medication administration. The facility identified 10 residents with orders for insulin in a facility census of 44. Findings Include: Review of Resident #13's medical record revealed an admission date of 10/26/18. Diagnoses included epilepsy, iron deficiency anemia, heart failure, primary osteoarthritis, insomnia, hyperlipidemia, hypertension, atrial fibrillation, type two diabetes mellitus, post-traumatic stress disorder, and major depressive disorder. Review of Resident #13's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. [...]

Inspectors wroteBased on observation, staff interview, medical record review, review of medication manufacturer package inserts, and review of facility policy, the facility failed to ensure that insulin was labeled appropriately. This affected two (#17 and #46) of 10 residents with orders for insulin. The facility census was 44. Findings Include: 1. Review of Resident #17's medical record revealed an admission date of 05/27/24. Diagnoses included nonrheumatic aortic stenosis, hyperlipidemia, type two diabetes mellitus, hypertension, mild protein-calorie malnutrition, obstructive sleep apnea, major depressive disorder, anxiety disorder, insomnia, and bilateral primary osteoarthritis. Review of Resident #17's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] the resident was cognitively intact. Observation on 12/16/24 at 9:11 A.M. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure medication administration was accurately documented. This affected one (#24) of four residents reviewed for medication administration. The facility census was 44.

Inspectors wroteBased on medical record review, review of hospital documentation, staff and resident interviews and policy review, the facility failed to ensure Resident #17, who had an indwelling suprapubic catheter, received timely treatment for a symptomatic urinary tract infection (UTI). This resulted in Actual Harm on 10/05/24 when Resident #17's symptomatic UTI was not treated at the facility and the resident was subsequently transported to the hospital and admitted . Resident #17 required intravenous (IV) antibiotic at the hospital to treat the UTI and sepsis. Additionally, the facility failed to provide indwelling urinary catheter care for Resident #52 for a period of eight days, from admission on [DATE] to 09/24/24, placing the resident at risk for the potential for more than minimal harm, at which time the urinary catheter was removed. [...]

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure the kitchen was kept in a sanitary manner. This had the potential to affect all 51 residents residing in the facility. The facility census was 51.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, staff interviews and policy review, the facility failed to ensure new admission wound care orders were timely clarified and completed per physician orders. This affected one (#52) of three residents reviewed for wound care. The facility census was 51.

Inspectors wroteBased on observation, staff interview, review of the State Fire Marshal Report, review of facility assessment, and review of the policy, the facility failed to maintain the sprinkler systems in operational status for fire safety, failed to ensure fire/smoke barriers were maintained, failed to notify the Ohio Department of Health (ODH) of the facility being under a fire watch, and further failed to ensure fire watches were being conducted correctly. This has the potential to affect all residents in the facility. The facility census was 52.

Inspectors wroteBased on observation, staff interview, and review of facility assessment, the facility failed to maintain a safe and clean environment after the facility had a water leak causing damage. This has the potential to affect all residents in the facility. The facility census was 52.

Inspectors wroteBased on observation, resident interview, staff interview, review of facility assessment, review of the housekeeping daily cleaning reports, and review of the exterminator inspection report, the facility failed to maintain an effective pest control program. This directly affected one resident (#51) with the potential to affect all residents of the facility. The facility census was 52.

Inspectors wroteBased on record review, interview, medication admin audit report, and policy, the facility failed to administer medications in the time frame ordered by the physician. This affected twelve residents (#3, #8, #9, #10, #11, #16, #17, #18, #20, #23, #24, and #26) who resided on the north front hallway. The facility census was 64.

Inspectors wroteBased on record review and interview, the facility failed to fill out a discharge notice completely. This affected one (Resident #65) of two residents reviewed for facility initiated discharges. The facility census was 64.

Inspectors wroteBased on record review and interview the facility failed to ensure a safe an orderly discharge. This affected one (Resident #65) of two residents reviewed for facility initiated discharges. The facility census was 64.

Inspectors wroteBased on observation, record review, and policy review, the facility failed to ensure a medication error rate less than five percent with 13 medication errors out of 33 opportunities resulting in a medication error rate of 39.39%. This affected one (Resident #8) of four observed for medication pass. The facility census was 64.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and facility policy, the facility failed to ensure residents who smoked had safe interventions in place. This affected one (Resident #51) of three residents reviewed for smoking. The facility census was 73.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure residents were offered pneumococcal vaccinations. This affected two (Residents #52, #11) of five reviewed for immunizations. The facility census was 58.

Inspectors wroteBased on review of the medical record, staff interviews, policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure residents were offered the updated COVID-19 vaccination. This affected three (Residents #52, #11, #16) of five reviewed for vaccinations. The facility census was 58.