Ridgeway Nursing & Rehabilitation Facility

The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases for 7 of 40 sampled residents (Resident (R) 16, R32, R40, R50, R78, R82, and R88). The findings include: Review of the facility's policy titled, Infection Prevention Manual for Long Term Care, undated, revealed gowns should be worn when there is potential for soiling clothing with blood/body fluids; the type of personal protective equipment [PPE] should be appropriate for the procedure being performed and the type of exposure anticipated. Review of the facility's policy titled, Medication Administration, dated 07/01/2024, revealed the facility will ensure medications are administered in accordance with manufacturers' specifications and good nursing principles and practices. Further review revealed gloves should be applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications; and hands are washed with…

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 interview and record review, the facility failed to provide documentation of residents' advance directive information for 2 of 12 sampled residents, Resident (R) 22 and R53. The findings include: Review of the facility's policy titled, Advance Directives, dated 08/08/2024, revealed the resident has the right to formulate an advance directive defined as a written instruction such as a living will, or durable power of attorney for healthcare recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Further review revealed during the admission process the facility will attempt to determine whether the resident has an advance directive and, if not, determine whether the resident wishes to formulate an advance directive. 1. Review of R22's Face Sheet revealed the facility admitted the resident on 10/10/2013 with diagnoses to include dementia, type 2 diabetes, and chronic kidney disease (CKD). Review of R22's annual Minimum Data Set (MDS), with an Assessment Reference…

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 interview, record review, and review of the facility's policy, the facility failed to protect 1 of 11 sampled residents from physical abuse involving a resident to resident altercation, Resident (R) 21. On 01/13/2024 at 1:20 PM, State Registered Nurse Aide (SRNA) 7 witnessed R72 smack R21 in the face for taking R72's teddy bear away from her. Per review of the progress notes, R21 stated she thought her nose had been broken after the incident. The findings include: Review of the facility's policy titled, Abuse, Neglect, Protection, Prevention, and Reporting Policy, dated 08/04/2024, revealed the facility will conduct screenings and trainings to prevent and identify instances of abuse. Further review of the policy revealed that all reports of abuse will be investigated, ensuring the protection of victims and the reporting of all instances of abuse. Review of the facility's policy titled, Resident Rights Policy, dated of 08/13/2024, revealed all residents have the right to be treated with respect, dignity, and in a manner and environment that promotes maintenance or…

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 interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation of resident property for 1 of 4 sampled residents, Resident (R) 51. The findings include: Review of the facility's policy titled, Medication Administration, dated 08/04/2024, revealed the person who prepares the dose for administration is the person who administers the dose and the individual who administers the medication dose records the administration on the resident's Medication Administration Record (MAR) which would show that the medication has been given. Review of the facility's policy titled, Preparation and General Guidelines; IIA7: Controlled Substances, dated 11/2021, revealed accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: date and time of administration; amount administered; remaining quantity; initials 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 observation, interview, record review, and review of the facility's policies, the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident's rights that included measurable objectives and timeframes to meet a the resident's medical and nursing needs for 1 of 1 sampled residents, Resident (R) 47. The findings include: Review of the facility's policy titled, Care Plan Policy, dated 08/04/2024, revealed the Comprehensive Care Plan (CCP) is based on a thorough assessment that includes but is not limited to, the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) Assessments; and is designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, and be revised as necessary with changes. Further review revealed the CCP will be person-centered for each resident. Review of the facility's policy titled, Medication Administration, dated 08/04/2024, revealed the facility will ensure medications are administered as prescribed in accordance with manufacturers'…

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 The facility failed to review and revise the Comprehensive Care Plan (CCP) for 1 of 34 sampled residents, Resident (R) 43. Review of R43's CCP revealed the facility failed to revise the care plan for placing his catheter bag on the floor, despite an interview with the resident stating that he liked to do so and observations of the catheter bag lying on the floor. The findings include: Review of the facility's policy titled, Care Plan Policy, dated 08/04/2024, revealed that the facility would develop and implement a person-centered care plan for each resident that is designed to incorporate identified problem areas, risk factors associated with the identified problems and should be revised as necessary with changes. Review of the facility's policy titled, Resident Rights Policy, dated 08/13/2024, revealed that residents have the right to see their care plan and to participate in decisions and care planning. Review of the facility's policy titled, Catheter Associated Urinary Tract Infection (CAUTI) Prevention, not…

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, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 5 sampled residents, Resident (R) 47. The findings include: Review of the facility's policy titled, Medication Administration, dated 08/04/2024, revealed the facility will ensure medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices, and only by persons legally authorized to do so. Further review revealed long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. Observation on 05/06/2025 at 8:09 AM revealed Kentucky Medication Aide (KMA) 2 crushed all medications for R47 except for an esomeprazole (used to reduce stomach acid production) capsule. KMA2 placed the crushed medications in chocolate pudding, opened the capsule and emptied it into chocolate pudding, and administered all the medications to R47. Review of R47's admission Record revealed the facility admitted the resident on 06/02/2020…

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, interviews, record review, and review of the facility's policies, the facility failed to establish and 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 3 of 34 sampled residents, R36, R43 and R390. Observations revealed R390 and R36 did not have the proper signage or proper precautions in place. Observations revealed R43's catheter was observed on the floor on multiple observations. The findings include: Review of the facility's policy titled Infection Prevention Program Overview, no date given, revealed the goals of the program are to decrease risk of infection, implement appropriate control measures, and to identify and correct problems relating to infection prevention practices. Added review of goals revealed facility is to maintain compliance with state and federal regulations related to infection prevention. Continued…

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 observation, interview and record review, and the website it was determined the facility failed to ensure there was sufficient dietary staff with necessary skill sets to safely and adequately prepare and serve meals three (3) times a day. This lack of sufficient dietary staff had the potential to affect eighty-two (82) of eighty-four (84) current residents. Two (2) residents received tube feedings. The findings include: Interview and observations of [NAME] #1 taking food temperatures, on 03/17/2022 at 5:11 PM, during the supper meal service, revealed he was resting the thermometer on the bottom of the steam table pan. [NAME] #1 stated he did not know how to take food temperatures nor, did he know how to calibrate a thermometer. Observations of various meal preparation/service times, primarily evening shift, during 03/08/2022 through 03/20/2022, revealed staffing was a cook and a dietary aide (DA) to cook, plate, and deliver meal carts for eighty-two (82) residents. Review of the Dietary Work Schedules,…

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, interview, review of the Dietary Manager's (DM) job description, and review of the facility's policy, it was determined the facility failed to distribute food that was palatable. Interviews with residents and staff revealed meals served on 03/09/2022 and 03/10/2022, were not palatable. On 03/09/2022, residents received overcooked and tough breaded pork tenderloin. On 03/10/2022, residents received steak fries that were white in color and did not appear to have been cooked. Interviews from numerous residents/family members and staff revealed, on 03/13/2022, at the dinner meal, residents were served cold, undercooked chicken nuggets and waffle fries, with the appearance of not being cooked. Eighty-two (82) of the eighty-four (84) current residents had the potential to be affected by the meals. Two (2) residents received tube feedings. The findings include: Review of the facility's policy titled, Food Production and Food Safety 3-39, dated 02/2019, found in the Dietary Policy and Procedure Manual, Chapter 3, revealed the cook was responsible to taste all food…

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, interview, and review of the facility's policy, it was determined the facility failed to routinely offer snacks for all residents, excluding those that received tube feedings and received no snacks. In addition, meal service was delayed on 03/08/2022, 03/11/2022, and 03/13/2022. These deficient practices affected eighty-two (82) of eighty-four (84) current residents. The findings include: Review of the facility's policy titled, Process for Snacks in the Hydration Rooms, undated, revealed the Dietary Manager (DM) or designee checked the hydration rooms twice daily, Monday through Friday. This included checks for the number of snacks available, the dates on snacks and disposing of any that were out of date, and to restock, as needed. Also, the policy stated that on the Friday evening checks, the hydration rooms were stocked to provide snacks throughout the weekend. In addition, the policy stated the meal schedule was breakfast at 7:00 AM, lunch at 12:00 PM, and supper at 5:00 PM. State Survey Agency (SSA) Surveyor, on 03/10/2022 at 4:20 PM, requested a snack…

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, interviews, and record review, it was determined the facility failed to ensure menus were posted and/or followed as posted. Review of the menus posted for 03/14/2022, lunch and dinner, and 03/17/2022, dinner only, did not match the foods observed to be served to the residents. This deficiency affected eighty-two (82) of eighty-four (84) current residents; two (2) residents were receiving tube feedings and did not receive meal trays. The findings include: The facility did not provide a policy for following menus. Review of the Resident Council meeting minutes, dated 01/14/2022, revealed the Administrator's signature was not dated. Further review revealed residents voiced concerns related to mealtimes and menus not being posted. The resolution listed was to start posting mealtimes and menus. The minutes also stated the current menu would be changing from the Fall/Winter menu to the Spring/Summer Menu very soon. 1. Review of the lunch meal menu posted, for 03/14/2022, revealed the foods to be served included: pot roast, mashed potatoes, mixed vegetables, choice…

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.