Ridgewood Rehabilitation & Care Center

Licensure reference number 175 NAC 12.006.04(B)(ii)(1) Based on record reviews and interviews the facility failed to ensure staff had the required 12 hours of in-service training for 2 nursing assistants (2 out of 5 sampled) staff. This had the potential to affect all residents in the facility. The facility census was 57. Findings are: Record review of NA-D's Relias (a company that provides healthcare training/education) training hours revealed 8.59 hours of education for the last year (2024). Record review of NA-E's Relias training hours revealed 11.05 hours of education for the last year (2024). Record review of employee names with their hire date revealed NA-D's hire date was 7/11/13 and NA-E's hire date was 12/17/22. Record review of employee's education training for the past year, found NA-D and NA-E did not have the required 12 hours of education yearly. Interview with the IP/SD (Infection Preventionist/Staffing Development) on 1/21/25 at 2:32 PM revealed the facility's year for nurses' aides 12-hour education is from January 1st to December 31st. Interview with the IP/SD on…

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.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review, the facility failed to ensure the microwave, refrigerator, and freezer in the Life Enrichment (activities) kitchen were clean. The facility census was 57. Findings are: A record review of the facility's kitchens Deep Cleaning schedule revealed the microwave and refrigerator/freezer should have been cleaned daily. A record review of the facility's requested last 2 months of the Life Enrichment kitchen's Weekly Cleaning logs dated 11/21/2024 - 01/21/2025 did not reveal they had been completed. An observation on 01/15/2025 at 8:10 AM revealed the Life Enrichment kitchen's microwave had multi-colored food splatters and debris throughout and the residential refrigerator/freezer bottoms and drawers contained food drippings and debris. An observation on 01/15/2025 at 1:36 PM with the facility's Registered Dietician (RD) revealed the Life Enrichment kitchen's microwave had multi-colored food splatters and debris throughout and the residential refrigerator/freezer bottoms and drawers contained…

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.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on interviews and record reviews the facility failed to obtain a physician's order for the settings of the Continuous Positive Airway Pressure (CPAP, a treatment that uses mild air pressure to keep your breathing airways open) machine for 1 (Resident 11) of 4 sampled residents. The facility census was 57. Findings are: Record review of Resident 11's Clinical Census dated 1/16/25 revealed admission to facility was 12/16/24. Record review of Resident 11's Medical Diagnoses dated 1/15/25 revealed Obstructive Sleep Apnea. Record review of Resident 11's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 12/20/24 revealed: -Section C: BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 9 which indicates moderate cognitive impairment. -Section O Non-invasive Mechanical Ventilator. Record review of Resident 11's Physician's orders dated…

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 Licensure Reference Number 175 NAC 12-006.10 Based on observation, interview, and record review, the facility failed to provide rational and justification to extend 1 (Resident 30) of 5 sampled resident's as needed (PRN) Alprazolam (Xanax)(an anti-anxiety medication) beyond 14 days. The facility census was 57. Findings are: A record review of the facility's Psychoactive Medication and Medication Regimen Review Management Standard dated 09/2024 revealed that an indication for use was: the identified, documented clinical rational for administering a medication based upon an assessment of the resident's condition. An unnecessary drug was when a drug was ordered for an excessive duration, or without adequate indications for its use, or without adequate monitoring. A record review of Resident 30's Clinical Census dated 01/16/2025 revealed the resident was admitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. A record review of Resident 30's…

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.

Licensure Reference Number 175 NAC 12-006.10(D) Based on record review, observations and interviews, the facility failed to ensure 2 residents (Resident 5 and 36) out of 4 sampled residents were free of a significant medication error. The facility census was 57. Findings are: A. A record review of the facility's Oral Drug Administration policy dated 5/20/24 revealed: -Verify the order on the patient's medication administration record by checking it against the practitioners orders. -Check the expiration date on the medication. -Visually inspect the medication for particles, discoloration, or other loss of integrity -Verify that you're administering the medication at the proper time, in the prescribed dose, and by the correct route to reduce the risk of medication errors. An observation on 01/16/25 at 8:07 AM revealed the Registered Nurse (RN) opened the narcotic drawer from the medication cart and taking one Phenobarbital 32.4 mg pill out of the medication pack (A blister pack is a form of tamper-evident packaging where an individual pushes individually sealed tablets through 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.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review, the facility failed to ensure food in the Life Enrichment refrigerator and freezer were labeled with the resident's name and dated. The facility census was 57. Findings are: A record review of the facility's Visitor Food policy revealed that food stored for residents needed to be labeled, dated, and stored safely in designated area per facility policy following the food safety guidelines for personal food. An observation on 01/15/2025 at 8:10 AM revealed the Life Enrichment (activities) kitchen residential refrigerator/freezer contained: • 1 plastic container of grapes not labeled, dated, or sealed • 1 purple/pink/white cake light covered in plastic wrap not labeled, dated or sealed • 1 plastic wrapped white cheese that had a resident's name first name on it, no date • 1 sealed package of beef snack sticks that had a resident's first name on it, no date • 1 container Coffee Ice Cream with a resident's first name on it, no date • 1 container Rocky Road Ice cream had a resident's first…

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 Licensure reference number 175 NAC 12-006.17 Based on observations, record reviews, and interviews, the facility failed to ensure Resident 11's catheter drainage bag was off the floor, ensure staff wore gloves when touching Resident 4's catheter tube, use infection control technique when removing cleansing wipes, provide activities of daily living cares for Resident 4 without performing hand hygiene, and failed to clean Resident 2, 22, and 50's nebulizer kits to prevent potential cross contamination. The facility census was 57. Findings are: A. Record review of Resident 4's Clinical Census dated 1/16/25 revealed resident admitted to the facility on [DATE]. Observation of Resident 4 on 01/15/25 at 9:45 AM revealed slightly cloudy urine in catheter tubing. Record review of Resident 4's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 12/20/24 revealed: -Section C: BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's…

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 Licensure Reference Number 175 NAC 12.006.11E Based on observation, interview, and record review, the facility failed to ensure items stored in the facility's refrigerators and freezers were labeled and dated, ensure kitchen staff performed handwashing for at least 20 seconds, ensure floors in the dry storage and walk-in refrigerator and freezer were clean, and failed to test the sanitizing solution in the sanitizing bucket to prevent potential foodborne illness. This had the potential to affect 59 of the facility's 60 residents that consumed food from the kitchen. The total facility census was 60. Findings are: A. A record review of the facility's undated Labeling and Dating Foods (Date Marking) revealed in the dry storage, individual items would be marked with the date the item was received into the facility. Refrigerated and freezer storage items would be re-dated with a use by date once opened. Prepared food items should be discarded if it doesn't have a specific manufacturer date and has been refrigerated…

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 Licensure Reference Number 175 NAC 12.006.17B Based on observation, interview, and record review, the facility failed to ensure the oxygen concentrator's (a machine used to deliver purified oxygen) cabinet filters were present and clean for 4 residents (Residents 2, 4, 31, and 60) of 5 sampled residents, ensure 2 residents (Residents 2 and 60) of 2 sampled resident's positive airway pressure device (PAP) masks were cleaned daily, and ensure 1 resident (Resident 20) of 2 sampled resident's PAP filter was clean. The total facility census was 60. Findings are: A. A record review of the undated Platinum Series XL, 5, 10 Operators Manual revealed there were cabinet filters on both sides of the unit that should have been removed and cleaned at least once a week. https://www.invacare.com/product_files/1106664.pdf A record review of Resident 2's Order Summary Report dated 02/13/2024 revealed orders of: BiPAP (a machine used to treat sleep apnea) at night with oxygen at 2 liters per minute (l/m) and External Filter:…

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 Licensure Reference Number 175 NAC 12.006.05(21) Based on observation, interview, and record review, the facility failed to ensure secretions (a substance discharged from the body) were controlled to maintain the dignity of 1 (Resident 4) of 1 sampled resident. The facility census was 60. Findings are: A record review of Resident 4's admission Record dated 02/12/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 4's Medical Diagnosis dated 02/12/2024 revealed the resident had diagnoses of Cerebral Palsy, Unspecified (disorders that affect a person's ability to move and maintain balance and posture), Dysphagia, Oropharyngeal Phase (swallowing difficulties due to items get stuck in the back of the mouth), Neonatal Aspiration of Amniotic Fluid and Mucus with Respiratory Symptoms (inhaled fluids during birth), Acquired Deformity of the Chest and Ribs, Other Disorders of the Lung, and Muscle Wasting and Atrophy (loss of muscle tissue). A record review of Resident 4's…

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 LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview; the facility failed to follow standards of practice pertaining to notification of physician and treatment of blood sugars less than (<) 60 for Resident 17. The facility census was 56. Findings are: A. A review of Resident 17's face sheet revealed that Resident 17 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus without complications (a condition that affects the way the body processes blood sugar). A review of Resident 17's current orders, dated 1/5/23, revealed an order to: -Notify MD (Medical Doctor) for blood sugar greater than (>) 450 or <60. A review of Resident 17's blood sugars revealed that Resident 17's blood sugar was <60 on: -5/7/22 at 12:20 PM, blood sugar reading: 59 -7/24/22 at 8:31 AM. blood sugar reading: 57 -8/3/22 at 12:15 PM, blood sugar reading: 58 -12/16/22 at 7:42 AM, blood sugar reading: 59 A review of Resident 17's electronic medical record revealed no notification was…

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.