The Ridge Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity for one of three sampled residents (Resident 1) when Resident 1 was called hardheaded or stubborn by a facility staff during ADL (Activities of daily living, are the fundamental self-care tasks individuals must perform daily to live independently and maintain their well-being) care. This failure had the potential for adverse effects on the psychosocial well-being and health of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were trained and competent in the use of Wander Management Transmitters (wander guard, a device placed on a resident's wrist, ankle, or wheelchair that alarms to notify the staff if a resident tries to leave the facility) used for two of two residents (Residents 7 and 35). This failure had the potential to result in transmitter equipment failure or system failure and resident elopement (to leave a health facility without notification or permission).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for four out of fifteen sampled residents (Residents 12, 5, 8 and 31): 1. For Resident 12, there was no comprehensive, person-centered care plan for his side rail or bed rail (bars attached to the side of the bed for safety and mobility aids);2. For Resident 5, she had no bed rail care plan; 3. For Resident 8, staff did not implement a care plan intervention of monitoring oxygen saturation (measurement of how much oxygen is in the blood) every shift. 4. For Resident 31, she had no activity care plan. These failures had the potential to result in the residents, not receiving the intervention and monitoring necessary to maintain their highest level of well-being.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure that the nurse staffing information was kept and maintained for at least eighteen months when their direct care service hours per patient day (DHPPD, a critical staffing metric for skilled nursing facilities requiring a minimum of 3.5 total hours of which 2.4 hours per patient day must be performed by certified nursing assistants or CNA) for 7/1/25 to 9/30/25, were not available and provided when requested. This failure had the potential to affect the quality of care that were provided to the forty-six residents residing in the facility that could also affect the residents' quality of life and well-being.

Inspectors wroteBased on interview and record review the facility failed to timely notify a representative of the Office of the State Long-Term Care Ombudsman (an entity that serves as an impartial advocate for individuals or groups who have concerns or complaints about a particular organization) regarding transfers for two of three sampled residents (Residents 3 and 7). This failure resulted in missed opportunities for an ombudsman to advocate if residents had concerns about their discharge.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure the residents assessments were reviewed and updated for effectiveness and accuracy for two of fifteen sampled residents, (Residents 12 and 40), when their activity assessments were not reviewed and revised quarterly. These failures had the potential to result in the residents not receiving the appropriate plan of care and interventions necessary to maintain their highest level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to follow the recommendations of the Preadmission Screening and Resident Review (PASARR, a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Individualized Determination Report for one of three residents (Resident 39). This failure had the potential to result in the resident not receiving appropriate care and services for a mental health condition.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure, the resident's medication was administered as per physician's orders by one of two nurses observed when the furosemide (a powerful loop diuretic, given to help treat fluid retention and swelling) 40 milligrams (mg, unit of mass or weight) tablet of Resident 53 was still given, without following the medication's parameter order (specific components of a prescription order that define how a medication should be safely administered). This failure had the potential to compromise the resident's health, safety and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented by one of two licensed vocational nurses observed during medication pass observation, when the licensed vocational nurse B (LVN B) did not remove dirty gloves, perform hand hygiene (the act of cleaning hands with soap and water or an alcohol-based hand sanitizer to remove germs and prevent the spread of infections) and don (put on) a new pair of gloves prior to medication administration of Resident 38 after she threw garbage and touched the garbage container attached to the side of the medication cart with the gloved hand. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure multiple resident rooms with two beds (Rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 115, 116, 117, 118, 120, and 121) measured at least 80 square feet per resident. Less than 80 square feet per resident in resident rooms could adversely affect resident health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, infection prevention and control practices were implemented when: 1. a laundry cart with clean linens was left in the passageway of the laundry room where the carts with dirty linens pass by; 2. laundry staff did not sanitize the laundry cart from outside before placing the clean linens in the cart; 3. a large bucket, full of soiled linens, was left open without cover; 4. there were missing logs in the laundry dryer cleaning inspection logs; 5. 2 out of 3 kitchen staffs did not know the sanitizer testing procedure; 6. cleaning chemicals were kept in the emergency food storage area and 7. a silverfish bug and a disposable spoon were found in the sink inside the medicine storage room. These failures had the potential to spread infection that could affect the 48 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program when two live cock roaches were observed in the social services office by health facilities evaluator nurses, during a recertification survey. This finding had the potential to put residents and staffs' health and safety at risk.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 12.12% when four medication errors occurred out of 33 opportunities for four residents (Resident 27, Resident 12, Resident 46, and Resident 154): 1. For Resident 27, the nursing staff did not confirm the exact dose as ordered by the physician for the medicine Lamotrigine (a medicine used for seizure). 2. For Resident 12, the nursing staff administered the medication Metformin (a medicine used to lower the blood sugar) without a meal. 3. For Resident 46, the nursing staff did not administer Lidocaine 5% Patch (used to alleviate pain). 4. For Resident 154, the nursing staff did not administer an inhalation solution in accordance with the facility procedure. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the recipe (a set of instructions on how to prepare or make a particular food) for making vegetable puree (smooth, crushed, or blended food that has the consistency of a creamy paste or liquid) was being followed when the lead cook did not follow the recipe for making carrot puree. This failure had the potential to result in decreased palatability that could lead to decrease in food intake for the 6 residents with puree consistency diet order out of the skilled nursing facility census of 48.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care was provided in accordance with professional standards of quality for one (Resident 13) out of three sampled residents when Resident 13 had an unnecessary and improper blood sugar check done. This failure resulted in a potentially inaccurate blood sugar result and an additional finger prick which can be painful.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that appropriate care and services were provided to one out of twelve sampled residents, (Resident 8), when the restorative nursing assistant (RNA) totally assisted Resident 8 in feeding instead of set-up help only. This failure had the potential, for the resident, not to maintain or achieve the highest level of self-care or independence in feeding.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure equipment is in safe operating condition for four (Residents 8, 23, 26 and 38) out of eight sampled residents when a commode with noticeable rust was found in their shared toilet. This failure had the potential to put residents at risk for harm during their usage of the rest room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure multiple resident rooms with two beds (Rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 115, 116, 117, 118, 120, and 121) measured at least 80 square feet per resident. Less than 80 square feet per resident in resident rooms could adversely affect resident health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for two of three sampled residents (Residents 2 and 1) when: 1. Licensed nurses did not start to monitor Resident 2's whereabouts after the incident with Resident 3 on 1/15/2023; 2. Licensed nurses did not monitor Resident 2's whereabouts until the 6/15/2023's incident with Resident 1 and had some missing documentations on Resident 2's implementation of Elopement Risk/Wanderer care plan dated 6/15/2023; 3. Licensed nurses did not complete Resident 1's admission Assessment in a timely manner, who was admitted on [DATE]; the admission Assessment was only completed on 6/16/23; and 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate social services (SS) support for two of three residents (Residents 2 and 3) when: 1) There was no SS support following Resident 2 and Resident 3's altercation (a heated or angry dispute) on 1/15/23; and 2) There was no SS support following an abuse allegation against Resident 2 and no documentation on SS follow up to address Resident 2's psychosocial needs and behaviors. These failures resulted in a lack of timely social services interventions for Resident 2 and Resident 3. These failures had potential not to address Resident 2, Resident 3 and other residents' mental distress.

Inspectors wroteBased on interview and record review, the facility failed to report an abuse allegation incident for one of one sampled resident (Resident 1, female) when the facility staffs found Resident 2 (male) on Resident 1 ' s bed. This failure had left the public agencies with jurisdiction over the facilities unaware of the event.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of 16 sampled residents (91, 29, 93, 94, and 30 ) were provided care in a manner that maintained the resident's dignity and respect when : 1. Resident 91's urine collection bag for the indwelling catheter (sterile tube inserted into the bladder to drain urine), was not covered; 2. Resident 29's incontinent pad was exposed to public view while walking in the hallway; 3. Staff did not greet, communicate with Resident 93,and spoke in his native language (non-English language); and 4. Staff spoke in their native language (non-English language ) during resident care, around other residents, in the hallways within resident's hearing distance, for Residents 94, 91, 30 . These failures had the potential to negatively affect the residents' emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activity program that meet the residents' needs, interests and preferences for four of 16 sampled residents (Residents 30, 23, 37 and 3), when: 1. Resident 30's activity care plan was not updated and followed; 2. Staff provided activities to Resident 23 without having an activity initial assessment and a care plan was not developed timely; 3. Staff provided activities to Resident 37 without having an activity initial assessment and care plan; and 4. Resident 3's activity was not provided. These failures had the potential to affect the residents' physical, mental, psychosocial well-being and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for 8 of 16 sampled residents (Resident 32, 5, 95, 2, 23, 3, 15, and 19) when: 1. A licensed nurse did not implement the facility's policy for Resident 32 with a gastrostomy tube (G-tube, inserted through the wall of the abdomen directly into the stomach and can be used to give drugs and liquids, including liquid food) during medication administration 2. A licensed nurse did not follow the manufacturer's recommendation in taking blood pressure for Residents 32 and 5 3. A licensed nurse did not properly give instructions during eye drop administration for Resident 95. 4. A liciensed nurse did not follow a physician order for administration of inhalers for Resident 2 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to employ a full-time registered dietitian (RD) or designate a kitchen supervisor or certified dietary manager to carry out the functions of the food and nutrition service based on resident assessments and individual plans of care. This failure had the potential to compromise the nutritional status of the 46 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, monitored and served in accordance with professional standards for food safety when: 1. foods in the dry food storage room and freezer in the kitchen, had no received and use by dates, 2. missing temperature logs for the dry food storage room, refrigerator and freezer in the kitchen, and 3. certified nursing assistant M (CNA M), did not perform hand hygiene prior to Resident 30's lunch meal set-up. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were implemented when: 1. An unlabeled urinal (a plastic container used to collect urine) and unlabeled specimen collection hat (SCH- a wide brimmed hat shape basin placed inside a toilet used to collect urine samples) were on top of the commode; 2. Resident 192's feeding pump (a medical device, pumps the feeding formula from container to feeding tube [FT - a tube that is inserted into the stomach to give medication and liquid food]) had some dry brown stains; 3. Resident 19's room air oxygen concentrator (RAOC-an electronic medical device that provides oxygen to the patients by concentrating room air into pure oxygen) had whitish, grayish buildup substance; 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 98 ) discharged from Medicare Part A services received a Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying that Part A coverage is being terminated and providing information on how to file an appeal of that decision) letter in a timely manner. This failure had the potential to prevent the resident from filing a timely appeal of the decision to discharge from Medicare Part A services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered care plans for two of 16 sampled residents (Resident 3 and 33) when care plans for: 1.the use of ankle foot orthosis (AFO, is used for people with cerebral palsy [a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth] for positioning, deformity management, or to improve standing or walking.) boot was not developed for Resident 3; 2. Resident 3's activity care plan was not implemented; and 3. the use of eyeglasses was not developed for Resident 33. The failure to develope and to follow care plans had the potential to not meet the care needs of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received foot care and treatment in accordance with professional standards of practice for one out of three Residents (Resident 19). This failure had the potential for podiatric complications for Resident 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents (Resident 32) was accurately assessed, and received services to prevent further decrease in range of motion (ROM- how far a person can move or stretch a part of the body, such as a joint or a muscle) of Resident 32's left upper extremity (LUE - left upper arm) and left lower extremity (LLE - left lower leg). This failure had the potential for further decline of ROM and contractures of Resident 32's LUE and LLE.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to implement interventions for free of accident hazards and to prevent avoidable accidents for three of 16 sampled residents (Resident 19, 93, and 3) when: 1. Resident 19's bed was not in the lowest position as ordered; 2. Resident 93's television cord was dangling through the sink unsecured; and 3. the Oxygen in use sign was not placed at the room entrance of Resident 3. These failures had the potential to result in accidents and injury to Resident 19, Resident 93, and Resident 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure intravenous (IV,within a vein ) solution from emergency kits (e-kits) was replaced in a timely manner. This failure had the potential to result in medications not being available during emergency situations.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of 7 residents (Resident 192) was free from unnecessary drugs when Resident 192 was not monitored for specific target behaviors for use of mirtazapine (a medication to treat symptoms of depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]). This failure had the potential to affect Resident 192's medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 11.54 % when three medication errors occurred out of 26 opportunities during the medication administration for three residents (Residents 32,19, and 5). The failure resulted in medication not given as scheduled and according to physician orders or/the manufacturer's specifications, and had the potential for the residents not receiving the full therapeutic effects of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in a safe manner when when eye drops were expired and insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood ) bottles were not properly labeled in the medication carts. These failures had the potential for the medications to be used beyond the date they were safe and effective for use.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the food preferences for two of 16 sampled residents (Residents 24 and 37) when: 1. Resident 24's choice of food was not followed; and 2. Resident 37's food preference was not provided. This deficient practice could affect the food intake and nutritional status of these residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide palatable and appetizing foods and also to ensure, the palatability of cooked foods were maintained when: 1. for Resident 24, he stated that his food lack in taste, 2. the regular and pureed vegetable samples in the test tray were not palatable, and 3. the recipe for making pureed foods were not followed. These failures had the potential to result in decreased food consumption leading to decreased nutrient intake for the 45 of 46 residents, getting their meals from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to follow their written policy and procedure (P&P) for influenza (flu- a common viral infection affects lungs, nose, and throat), and pneumococcal (PNA- a serious infection of one or both of the lungs caused by bacteria, viruses, fungi, or chemical irritant) vaccines (a preparation that is used to stimulate the body's immune response against diseases) for three out of five sampled residents (Resident 19, Resident 29, and Resident 192) when: 1. Facility failed to provide risks versus benefits education to resident or resident's responsible party (RP) when flu vaccine was refused; 2. Facility failed to provide risks versus benefits education to resident or resident's RP when PNA vaccine was refused. These failures exposed Residents 19, 29, and 192 to the risk of contracting flu, and PNA along with their associated complications.

Inspectors wroteBased on interview, and record review, the facility failed to follow its policy and procedure (P&P) for staff Covid-19 (a contagious respiratory disease caused by SARS [severe acute respiratory syndrome]-COV-2 [coronavirus disease] virus) vaccination, and medical exemption requirements for one of one sampled staff. This failure could expose the residents and staff in the facility to the risk of exposure and transmission of Covid-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident rooms (Rooms 101-107, 109, 110, 114-118, 120, and 121) measured at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive in the facility.