West Ridge Specialty Care

Based on electronic record review, resident interviews, staff interviews, and policy review, the facility failed to provide restorative programs as care planned for 3 of 4 residents reviewed for restorative care (Residents #2, #7, and #8). The facility reported a census of 71. Findings include: 1. Resident #7's Minimum Data Set (MDS) Assessment completed on 10/2/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Diagnoses included a right femur (thigh bone) fracture, lack of coordination, history of falling, and cognitive communication deficit (difficulty speaking or understanding). The MDS documented limited range of motion on one side of the lower extremity including the hip, knee, ankle, and foot, and noted the use of a manual wheelchair for mobility. Resident #7 received Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) services in the seven days lookback period. On 4/21/26 at 12:42 PM Resident #7 reported he hadn't received his restorative programs recently for at least the past two weeks and he didn't know…

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 electronic record review, resident interviews, staff interviews, and policy review, the facility failed to provide resident showers as scheduled for 5 of 5 residents reviewed for activities of daily living (Residents #1, #2, #4, #5, and #7). The facility reported a census of 71. Findings include: 1. Resident #3's Minimum Data Set (MDS) Assessment completed on 3/18/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The DMS included diagnoses of arthritis (joint inflammation), low back pain, malnutrition (lack of proper nutrition), and osteoporosis (brittle bones). The MDS noted the use of a motorized wheelchair for mobility. Resident #3 required maximum staff assistance for bathing and transfers to and from the bed to the wheelchair. The Care Plan, revised 3/31/26, outlined Resident #3 required staff assistance for bathing. The Documentation Survey Report v2 outlined Resident #3 scheduled for bathing two times per week on Tuesdays and Fridays. Review of…

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 clinical record review, staff interview, policy review, and resident interviews, the facility failed to protect the resident's right to a dignified existence by failing to carry out perineal cares in a timely manner after incontinence episodes for 1 of 1 residents reviewed for incontinence care assistance (Resident #1) and for multiple, random residents affected, as reported by multiple staff members. The facility reported a census of 74 residents. Findings: 1. The Minimum Data Set(MDS) assessment tool, dated 10/24/25, listed diagnoses for Resident #1 which included hemiplegia(one-sided paralysis), anxiety, and depression. The MDS stated the resident was frequently incontinent with bowel and bladder and stated the resident was dependent on staff assistance for toileting hygiene. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. The facility policy Dignity, revised February 2021, stated the facility would care for residents in a manner that promoted and enhanced well-being, satisfaction with life, and…

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 clinical record review, staff and resident interview, and policy review, the facility failed to report suspected abuse to the proper state agency within two (2) hours. The facility reported a census of 72 residents. Findings include: A Facility Reported Incident (FRI) dated 7/29/24 indicated the facility reported to the State Agency (SA) on 7/24/24 at 10:58 am Resident #1 stated Staff A, Certified Nurse Aide (CNA) swore at her in the early morning of 7/24/24. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated completely intact cognition. It included diagnoses of anemia, Coronary Artery Disease (CAD), Heart Failure, renal failure, Diabetes Mellitus, thyroid disorder, and Chronic Obstructive Pulmonary Disease (COPD). It indicated the resident required set-up assistance with eating and oral hygiene and was dependent or required maximum assistance with all other areas of Activities of Daily…

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 clinical record review, policy review, and staff interview, the facility failed to notify the provider of a resident's low blood sugars for 1 of 3 residents reviewed for a change in condition (Resident#1). The facility reported a census of 74 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 8/15/23, listed diagnoses for Resident #1 which included diabetes, malnutrition, and anxiety disorder. The MDS stated the resident received insulin and listed the resident's Brief Interview for Mental Status(BIMS) score as 13 out of 15, indicating intact cognition. The facility policy Change in a Resident's Condition or Status, revised February 2021, stated the facility promptly notified the attending physician of changes in the resident's medial condition. The August 2023 Medication Administration Record(MAR) listed a 6/1/23 order to check blood sugars before meals and at bed time. The order directed staff to report to the primary care physician if below 60 milligrams per deciliter(mg/dl) or over 400 mg/dl. A 12/14/23 Care Plan entry stated the…

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 clinical record review, policy review, and staff interviews, the facility failed to carry out an intervention to prevent a fall, and failed to ensure Care Plan entries based on root cause analysis were carried out and documented on the Care Plan for 2 of 3 residents reviewed for falls(Residents #3 and #6). The facility reported a census of 74 residents. Findings include: 1. An 11/17/14 Care Plan entry documented that Resident #3 was at risk for falls. A 2/23/23 Care Plan entry stated the resident had bolsters on her mattress(additional cushions placed on a mattress which can prevent rolling). The Quarterly Minimum Data Set (MDS) assessment tool, dated 3/30/23, listed diagnoses for Resident #3 which included dementia, osteoarthritis of the knee(inflammation of the knee bone) and muscle wasting. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene, and depended completely on 1 staff for bathing. The MDS listed a…

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, clinical record review, policy review, resident and staff interviews the facility failed to accommodate medication administration time preference for 1 of 2 residents (Resident #27) in the sample. The facility reported a census of 75. Findings included: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 4/19/23, listed diagnosis for Resident #27 included: high blood pressure, depression, and hypothyroidism. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, which indicated intact cognition. A record review revealed a 3/20/23 physician order for Levothyroxine (a medication to treat hypothyroidism) 25 mcg (micrograms) 1 tablet by mouth one time a day. During an interview on 5/2/23 at 8:25 AM, Resident #27 stated that she has requested to receive levothyroxine before breakfast as the medication is to be taken before eating. The resident stated she receives the medication with all her morning medications, often after she has had her breakfast. During an observation on 5/3/23 at 9:41 AM, Resident #27 ate…

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, clinical record review, staff interview and facility policy review the facility failed to maintain appropriate care for 2 out of 2 resident's catheters (Resident #26 and #52). The facility reported a census of 75 residents. Findings included: 1. The Quarterly Minimum Data Set Assessment (MDS) for Resident # 52 dated 4/19/23, listed diagnoses of dementia, obstructive uropathy and benign prostate hyperplasia (BPH). The MDS included the Brief Interview for Mental Status score of 7 (sever cognitive impairments). The MDS listed Resident # 52 required extensive assist of 1 staff for transfers, toileting, and personal hygiene. The Care Plan for Resident # 52 dated 04/28/2023, revealed a urinary tract infection (UTI), treated with an antibiotic from 4/28/23 through 5/3/23. The Physician's note dated 4/21/23, reflected the Chief Complaint/Nature of Presenting Problem: New onset dysuria (painful or difficult urination) and urgency with indwelling catheter present. The progress note revealed Resident…

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, policy review, resident and staff interviews the facility failed to administer pain medication in a timely manner for 1 of 1 residents (Resident #176) in the sample. The facility reported a census of 75 residents. Findings include: 1. Theadmission Minimum Data Set (MDS) assessment tool, dated 4/11/22, listed diagnoses for Resident #176 which included: Cellulitis (skin infection) of right and left lower legs, peripheral venous insufficiency (veins not working effectively, making blood return difficult), and anxiety disorder. The MDS listed the Brief Interview for Mental Status) BIMS score as 3 out of 15, whcih indicated severely impaired cognition. During an interview on 5/1/23 at 2:06 PM, Resident #176 stated there have been times when she had to wait too long for pain medication. A record review revealed a 4/5/23 physician's order for hydrocodone-acetaminophen (tylenol) 7.5-325 mg (milligrams) 1 tablet every six hours as needed for pain (PRN). During an interview on 5/3/23 at 10:48 AM,…

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, clinical record review, and staff interviews the facility failed to support the behavior health needs in an effort to prevent self harm for 1 of 1 residents (Resident #27) in the sample. The facility reported a census of 75. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 4/19/23, listed diagnoses for Resident #27 included: Alzheimer's disease, depression, and hypothyroidism. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, which indicated intact cognition. The MDS Behavior Section documented no hallucinations or delusions during the review period. The assessment documented a 0, indicating behaviors such as scratching or picking self not exhibited. During an observation on 5/2/23 at 8:22 AM, Resident #27 noted to have a nickel size wound on her nose. The resident explained she had something on her nose and had to pick it off. A Skin & Wound note, dated 4/27/23 documented the wound as an abrasion, and acquired in house 12/13/22 with location documented as face. A review of the…

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 employee training list, facility policy and staff interviews the facility failed to provide behavior management training to staff to meet the behavioral health needs 1 of 1 residents (Resident #27) in the sample The facility reported a census of 75 residents. Findings Include 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 4/19/23, listed diagnosis for Resident #27 included: Alzheimer's disease, depression, and hypothyroidism. The MDS listed the resident ' s Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A review of progress notes in the Electronic Health Record (EHR) revealed the resident acquired the following wounds from picking her skin: a. On 12/13/23 an abrasion on her face (nose) b On 2/11/23 a skin tear on her right forearm c. On 2/20/20 two abrasions on her abdomen d. On 4/29/23 an abrasion on her right, and left thighs A review of the residents care plan revealed a lack of focus and interventions for the behavior of picking skin.…

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 clinical record review, staff interview, and policy review, the facility failed to report an injury of unknown origin for 1 of 1 sampled (Resident #117) to the Department. The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set assessment dated [DATE] documented Resident #117 had diagnoses of diabetes, arthritis, and dementia. The MDS stated the resident required the limited assistance of 2 staff for walking and personal hygiene, extensive assistance of 2 staff for bed mobility, transfers, and toilet use, and depended completely on 2 staff for bathing. Resident #117 had a Brief Interview for Mental Status score of 8, indicating moderately impaired cognition. An Incident Report dated 7/11/21 documented Resident #117 had a bruise on the left medial thigh measuring 9.72 centimeters (cm) by 6.15 cm of unknown origin. The facility lacked documentation they reported the injury to the State Agency. The Dependent Adult Abuse policy dated November 2019 directed staff to report…

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 clinical record review, resident interview, staff interview, and policy review, the facility failed to carry out Physician's orders for 2 of 20 (Residents #10 and #118) sampled for orders. The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #10 had diagnoses of dry eye syndrome, muscle wasting, and kidney disease. Resident #10 had a Brief Interview for Mental Status score of 14, indicating no cognitive impairments. During an interview on 7/19/21 at 11:01 a.m., Resident #10 stated she was supposed to have eye surgery today but the facility forgot to order her eye drops so they had to cancel the surgery. An undated Clinic Notes stated Resident #10 had surgery scheduled on July 19, 2021 and instructed to administer one drop of Besivance (antibiotic) eye drop and Prolensa (anti-inflammatory) eye drop in the right eye 2 times per day for 14 days starting on 7/18/21 (one day before the surgery). An undated Clinic Note…

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.