Settlers Ridge Care Center

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 5 of 5 residents (Resident #33, #57, #10, #65, and #16) reviewed for comprehensive care plans. The facility failed to ensure Resident #33, #57, #10, #65 and #16's comprehensive care plan addressed their goals, needs, strengths, medical, nursing, mental, and psychosocial needs. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on observations, interviews, 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 1 kitchen reviewed for kitchen safety. The facility failed to ensure food in the facility's dry storage, and refrigerator areas were labeled and dated according to guidelines. The facility failed to seal lids securely on containers in the refrigerator area and dry storage pantry. These deficient practices could affect residents who received meals or snacks from the kitchen and place them at risk for cross contamination and other food-borne illnesses. Findings Included: 3/31/2026 Dry Pantry area revealed 12 plastic round maroon bowls had plastic lids that were unsealed, exposed to the air, not labeled and not dated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain essential equipment in operating condition by failing to maintain walk-in refrigerator and walk-in freezer coolant fans for 1 of 1 kitchens reviewed for equipment in operating condition. The facility failed to maintain the coolant fans in the walk-in freezer and in the walk-in refrigerator for operating condition. The facility's failure to maintain coolant fans in operating condition had the potential to place all residents at risk for cross-contamination and increased risk of foodborne illness. Findings Included:Walk-in refrigerator revealed dripping liquid from the coolant fan within the refrigerator. Walk-in freezer revealed ice build up on the coolant fan within the freezer. Observations of the kitchen during the brief initial tour of the kitchen on 03/31/26 at 9:12am revealed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a therapeutic diet that take into account the resident's clinical condition for one (Resident #86) of six residents reviewed for diet status and maintenance. The facility failed to offer Resident #86 the right diet as indicated in the residents' physician orders. These failures could increase the resident's risk for aspiration and choking. Record Review of Resident #86's admission MDS dated [DATE] reflected Resident #86's admission date of 03/18/26. She was [AGE] year-old female with active diagnoses included: acute respiratory failure with hypoxia, pneumonia, and pleural effusion (buildup of excess fluid between the layers of the pleura outside your lungs), malnutrition (imbalance between the nutrients your body needs to function and the nutrients it gets) and dysphagia (difficult swallowing). [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 Residents reviewed for medication administration (Resident #26). The facility failed to ensure Resident #26 swallowed his medication before the staff member left the resident's room. This failure could place Residents at risk for missed doses, ineffective treatment, and potential decline in condition. Findings Included:Record review of Resident #26's Quarterly MDS Assessment, dated 03/23/26, reflected the Resident was a [AGE] year-old male with a BIMs score of 11 indicating he was moderately cognitively impaired. His diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store drugs and biologicals in locked compartments based on the needs of one of five residents (Resident #16) reviewed for medication storage. The facility failed to ensure Resident #16 did not have unsecured Glipizide 10 MG tablet (an oral medication used to treat Type 2 Diabetes) in his room. This failure could place residents at risk for compromised medication efficacy, unsafe administration, and increased harm to residents. Findings Included:Record review of Resident #16's MDS assessment dated [DATE], reflected a [AGE] year-old male, admitted to the facility on [DATE]. The Resident's BIMS score was 8 which indicated moderate cognitive impairment. The Resident had diagnoses that included: [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents in 2 (Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]) of 5 shower rooms reviewed for environment. 1. The facility failed to properly clean and sanitize the floor, toilet and sink of Shower room [ROOM NUMBER] and failed to empty the trash and soiled linen bins. 2. The facility failed to properly clean and sanitize the floor of one of the showers in Shower room [ROOM NUMBER]. This failure could affect all residents that were showered in the shower rooms by exposing them to bacteria and organisms that could impact their health and diminish their quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately inform the resident, consult with the resident's physician, notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 resident (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's physician when an injury of unknown origin was discovered on 5/06/2025. This deficient practice could place residents at risk of not having their physician informed when there was a change in condition resulting in a delay in medical intervention and decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 4 of 10 residents (Resident #23, Resident #22, Resident #72, and Resident #64) observed for infection control. 1. The facility failed to ensure MA C administered Resident 23's medication without cross contaminating her medications on 02/18/25. 2. The facility failed to ensure MA B prepared Resident 72's medication without cross contaminating her medications on 02/18/25. 3. The facility failed to ensure MA B sanitized the blood pressure cuff between use on Resident #22 and Resident #72 on 02/18/25. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #205) reviewed for intravenous fluids. RN A failed to change Resident #205's Central Venous Catheter line dressing using sterile technique. This failure could affect residents by placing them at risk for infections and cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 Residents (Resident #64) reviewed for respiratory care. 1. The facility failed to obtain an order for Resident #64's use of supplemental O2 with stated liter amount to be delivered. 2. The facility failed to include rationale for the use of O2 for Resident #64 from 02/16/25 through 02/18/25. These failures could place residents who received oxygen therapy at risk of receiving an incorrect amount of oxygen and the risk of oxygen toxicity. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident#1) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #1 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #2) of one resident reviewed for catheter care. The facility failed to ensure LVN B maintained Resident #2's indwelling urinary catheter drainage bag below the bladder level during wound care on 11/19/24. This failure placed residents at risk for not receiving care appropriate to address their incontinence and risk for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (600 hall nurses' medication cart and 400 hall nurses' medication cart) of 4 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1- The 600 Hall medication cart had 2 insulin pens for Resident #18 without an opened date. 2- The 400 Hall medication cart had 1 insulin pen for Resident #54 without an opened date. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food with appetizing temperature for one (01/24/24 breakfast) of one meal reviewed for appetizing temperature. The facility failed to serve eggs and oatmeal that had a palatable texture during the breakfast meal on 01/24/24. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one (Resident #5) of eight residents reviewed for ADLs. The facility failed to ensure Resident #5 had her fingernails cleaned and trimmed. This failure could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #5) of three residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #5's contracture to her right and left hands after discharge from occupational therapy on 11/13/23. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for two (Resident #17, Resident #72) of eight Residents reviewed for accidents/hazards/supervision/ devices. The facility failed to properly maintain wheelchairs for Residents #17 and Resident# 72. This failures could affect the resident by placing the residents at risk for discomfort, pain, and injuries. Resident #17 Record review of Resident #17's quarterly MDS assessment dated [DATE] revealed resident was a [AGE] year-old female with an admission date of 03/10/2023. Resident #17 had a BIMS score of 9 indicating moderate cognitive impairment. Resident #17 required 2-person assistance with transfers, and she used a manual wheelchair for mobility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (Resident #7) of four residents reviewed for behavioral health services. The Social Worker failed to follow up to ensure Resident #7 received a psychiatric service after a referral was made on 11/02/23. This failure could place residents at risk for not receiving behavioral health services and a decline in Quality of life. Findings Included: Record review of Resident #7 quarterly MDS assessment dated [DATE] reflected an [AGE] year-old female with an admission date of 10/31/23. Resident #7 had a BIMS of 9 which indicated she was moderately cognitively impaired. There were no behaviors, signs of delusions or rejection of care noted on the assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a condition as diagnosed and documented in the clinical record, and the resident received behavioral interventions unless clinically contraindicated in an effort to discontinue these drugs for 1 (Resident #86) of 5 residents reviewed for unnecessary medications. The facility failed to attempt gradual dose reduction for Resident #86's Divalproex (antipsychotic) and Seroquel (antipsychotic) medications. The facility failed to have specific side effect monitoring for Resident #86s Divalproex and Seroquel medications. These failures could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life.

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure Dietary Aide O had an effective hair restraint during breakfast meal serving on 01/23/24. This failure could place residents at risk for food-borne illness and food contamination.