Ridgewood Manor Health And Rehabilitation

Based on observations, staff interviews, record review, and review of the facility policies titled, Food and Nutrition Services Staff Policy, and Preventing Food Borne Illness-Food Handling, the facility failed to ensure food was stored, prepared, and labeled in a safe and sanitary manner, including maintaining the cleanliness of kitchen equipment. This deficient practice affected 79 residents who consume food from the kitchen with the potential to cause cross-contamination and/or food borne illness. Findings Include: On 05/04/2026 at 9:43 AM, an observation of the kitchen area revealed several food items with no label or date of opening. The food items included: observation of cooler revealed two bags of lettuce, one of which was discolored; two cartons of strawberries, one of which had a gray fluffy substance on the strawberry inside of the carton; three pitchers of orange juice, and seven pitchers of apple juice with no opened on dates. In addition, observation of a kitchen storage room revealed a popcorn machine used as a part of resident activities which was unclean and had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan that included trauma-informed care related to the resident's experiences in order to eliminate or mitigate triggers that may cause re-traumatization related to the resident's diagnosis of Post Traumatic Stress Disorder (PTSD) for one of one resident (Resident (R)46) reviewed for person-centered care plans for PTSD out of 21 sampled residents. This failure placed the residents at an increased risk for re-traumatization of emotional distress. Findings include: Review of R46's admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R46's annual Minimum Data Set (MDS) located in the resident's EMR, under the MDS tab, with an Assessment Reference Date (ARD) of 12/16/24, revealed R46 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and facility policy review, the facility failed to ensure three (Residents (R) 5, R15, and R59) reviewed out of 12 residents receiving hospice services out of a total sample of 21 residents had visit notes from the hospice agency. These failures could lead to the risk that the needs of these residents are not addressed. Findings include: Review of the facility policy titled, Hospice Services dated 11/01/19 revealed, Supervision/Coordination of Care Each party is responsible for documenting such communication in its respective clinical records to ensure the needs of hospice patients are addressed and met 24 hours a day. 1. Review of R59's admission Record located in the Profile tab of the electronic medical record (EMR) revealed R59 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, cerebral infarction (stroke), and paraplegia. Review of R59's Orders tab of the EMR revealed an order dated 11/24/23 to admit to hospice services related to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility's policy titled, Preventing Foodborne Illness-Food Handling, the facility failed to store stacked pans free from wet nesting to prevent bacterial growth and to discard leftover food items by the use by date in the walk-in refrigerator. The facility census was 77 and the deficient practices affected all 77 residents who received an oral diet. Findings include: 1. Review of the facility's policy titled, Preventing Foodborne Illness-Food Handling revealed that all food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. Observation on 6/2/2023 at 9:05 a.m. of the pot and pan storage rack revealed a stack of ten medium sized rectangle steam table pans. The top three pans were turned over and all three pans had water/moisture inside. Interview on 6/2/2023 at 9:05 a.m. with the Certified Dietary Manager (CDM) confirmed that all three steam table pans were stacked, and the inside of the pans were wet. The CDM stated that staff should let pans dry completely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to maintain the walk-in freezer in a manner to prevent ice build-up from forming on the air condenser piping, this failure had the potential to contaminate food items located under the ice. The facility census was 77 and 76 residents consumed an oral diet. Findings include: Observation on 6/2/2023 at 8:55 a.m. of the walk-in freezer revealed a large ice build-up on the piping to the air condenser. The ice build-up was six inches in height and five inches wide on the piping. Interview on 6/2/2023 at 8:55 a.m. with the Certified Dietary Manager (CDM) revealed that she has never seen that ice build-up before. Observation on 6/4/2023 at 8:45 a.m. of the walk-in freezer revealed the ice build-up remained on the piping to the air condenser. The ice build-up was smaller than previous observation due to an attempt at removal. Ice remained at the top of the pipe by the air condenser housing and was the size of a golf ball. Another area on the pipe towards the bottom near the metal food rack also had ice build-up about the size…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policies titled, Resident Self-Administration of Medications and Medication Administration-General, the facility failed to clinically assess one of 26 sampled residents (R) (R#45) for the ability to self-administer medications prior to leaving medications at the bedside. The deficient practice had the potential to adversely affect the safety of R#45 and other residents in the facility. Findings include: Review of the facility's policy titled, Resident Self-Administration of Medications dated 10/1/2019 and revised 3/13/2023 revealed the purpose was each resident who desires to self-administer medications(s) is permitted to do so if the interdisciplinary team has determined that the practice would be safe for the residents and other residents of the facility. The policy stated residents are provided the opportunity to express their desire to self-administer medications. If the resident indicates they would like to self-administer,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one of 26 sampled residents (R) (R#54) related to transfers. Findings include: Review of the 3/13/2023 Significant Change MDS revealed, in section G - Functional Status, the resident is an extensive 2+ person assist for transfers. Review of the care plan dated 3/3/2023 for R#54 revealed he required assistance with Activities of Daily Living (ADL) related to cognitive deficits, had functional limitations, and tires easily. R#54 had diagnoses of Parkinson's disease, dementia with behavioral disturbance, and Chronic Obstructive Pulmonary Disease (COPD). Interventions include: 3/3/2023 Use Maxi-Move (lift device) with extra-large sling for all transfers. Review of the HLTC Safe Patient Handling Evaluation dated 7/21/2023 revealed that the Arjo's passive and active series of lifts are designed for safe usage with one caregiver. There are circumstances, such as combativeness, obesity,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to follow the person-centered comprehensive care plan for one of 26 sampled resident (R) R#54 related to utilizing the correct lift for transfers. Findings include: Review of the 3/13/2023 Significant Change Minimum Data Set (MDS) revealed, in section G - Functional Status, the resident was an extensive 2+ person assist for transfers Review of the care plan dated 3/3/2023 for R#54 revealed he requires assistance with Activities of Daily Living (ADL) related to cognitive deficits, has functional limitations, and tires easily. R#54 has diagnoses of Parkinson's disease, dementia with behavioral disturbance, and Chronic Obstructive Pulmonary Disease (COPD). Interventions include: 3/3/2023 Use Maxi-Move (lift device) with extra-large sling for all transfers. Review of the nurse's note dated 5/16/2023 at 1:17 p.m. by Licensed Practical Nurse (LPN) CC revealed, in part, at approximately 2000 [8:00 p.m.], Certified Nursing Assistant (CNA) came to this nurse to report R#54 fell while she was transferring R#54 to bed. Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility's policy titled, HLTC Safe Patient Handling, the facility failed to ensure the safety of one of 26 sampled residents (R) (R#54) by use of an incorrect lift resulting in a fall without injury. Findings include: Review of the facility's policy titled, HLTC Safe Patient Handling dated September 2022 revealed the facility will provide a safe work environment by implementing and maintaining a Safe Patient Handling Program that integrates evidence-based practices and technology designed to minimize the risk of injury to residents and staff caused by resident lifting and movement. Review of the HLTC Safe Patient Handling Evaluation dated 3/3/2023. The evaluation revealed that the resident is, as of 3/3/2023, a total lift (Maxi Move) one-person physical assist. Review of the HLTC Safe Patient Handling Evaluation dated 7/21/2023. The evaluation revealed that the resident was, as of 7/21/2023, a sit-to-stand lift ([NAME] Flex) one-person physical assist.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interviews, and review of the facility's policy titled, Psychotropic Medication Management, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for two of five residents (R) (R#28 and R#64) reviewed for unnecessary medications. This failure had the potential for medication interaction, adverse reactions, respiratory depression, falls, constipation, and increased anxiety. Findings include: Review of the facility's policy titled, Psychotropic Medication Management, revised 5/3/2022, revealed as needed (PRN) orders for psychotropic medications are limited to 14 days, except if the attending physician believed it was appropriate for the PRN orders to be extended beyond 14 days. The attending physician would document their rationale in the resident's clinical record and indicate the duration and appropriateness of the PRN order. 1. Review of the Medical Doctor (MD) orders for R#28, dated 1/19/2023, revealed the MD ordered Ativan 0.5 milligram (mg), one tablet by mouth (PO) every 24 hours, PRN for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and review of the facility's policy titled, HLTC Non-Controlled and Controlled Medication Ordering, Receiving and Storage, the facility failed to ensure one open and punctured insulin vial was discarded on the discard date on one of four medication carts. The deficient practice resulted in resident (R) (R#17) receiving doses from an insulin vial that was past the discard date. Findings include: Review of the facility's policy titled, HLTC Non-Controlled and Controlled Medication Ordering, Receiving, and Storage dated 10/1/2019 with a revision date of 1/7/2022 revealed the purpose was for the facility to comply with all laws, regulations, and other requirements related to medication ordering, receiving, and storing processes for non-controlled and controlled medications. The policy section revealed: 1. Resident medications will be ordered, received, and stored in accordance with all state and federal requirements. Review of the document titled, Insulin In-Use Expiration Dates, located on the medication cart revealed Novolog insulin vials had an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.