Ridgewood Center, Genesis HealthCare

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident received proper treatment to maintain hearing abilities for 1 of 1 residents reviewed for Communication-Sensory in a final survey sample of 22 residents. (Resident identifier is #11.)Findings include:Interview on 2/10/26 at approximately 9:00 a.m. with Resident #11 revealed that he/she had difficulty hearing and that his/her hearing aides were broken a long time ago. Further interview revealed that Resident #11 had been waiting a while to be seen for new hearing aids. Resident #11 stated the facility was aware and had given him/her a 'pocket talker,' but Resident #11 did not like using the pocket talker and would prefer hearing aids. Review on 2/11/26 of Resident #11's progress notes revealed a care plan meeting note, dated 12/16/25, . UM (Unit Manager) will see if [Resident name omitted] is on the list to be seen by [Name of Audiologist omitted] when they are in this week. Review on 2/11/26 of Resident #11's medical record revealed the last audiology consult…

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, interview, and policy review, it was determined that the facility failed to establish and maintain a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation for 2 of 2 residents reviewed for new admissions and 1 of 9 residents observed during medication administration. (Resident Identifiers are #26, #31, and #52.)Findings include:Resident #52 Observation on 2/10/26 at approximately 1:53 p.m. with Staff J (Licensed Practical Nurse) during medication administration revealed Staff J placing one-half tablet of Tramadol (opioid) 50 milligram (mg) into a medication cup. Staff J then documented on the controlled drug record that Resident #52 received one-half tablet of Tramadol 50 mg and documented that 18 half-tablets remained. Observation further revealed that Resident #52's Tramadol 50 mg bingo card indicated 17 half-tablets were present. Review on 2/10/26 at approximately 1:56 p.m. of Resident #52's controlled drug record for Tramadol 50 mg (half tablets) revealed a single entry on 2/10/26 at…

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, it was determined that the facility failed to ensure medications were appropriately labeled on 2 of 3 medication carts observed and 1 of 2 medication rooms observed and failed to ensure that expired medication was removed from the medication cart on 1 of 3 medication carts observed. (Resident identifiers are #71 and #66.)Findings include: 3rd Floor South Medication Cart Observation on [DATE] at approximately 8:30 a.m. with Staff A (Licensed Practical Nurse (LPN)) of the 3rd Floor South Medication Cart revealed: Lidocaine 1% multi-dose vial opened with no Resident identifier, no date of opening and no date of expirationResident #71 - 7 Depakote DR (Delayed Release) 125 mg (milligrams) expiration date 2/26 Interview on [DATE] at approximately 8:30 a.m. with Staff A confirmed the above findings. 2nd Floor North Medication Cart Observation on [DATE] at approximately 8:40 a.m. with Staff B (LPN) of the 2nd Floor North Medication Cart revealed:2 opened multi-dose…

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 laboratory services as ordered for 1 of 2 residents reviewed for respiratory infection. (Resident identifier is #87.)Findings include: Review on 2/11/26 of Resident #87's provider note, dated 1/31/26, revealed that Resident #87 had cough, nasal congestion, an upper respiratory infection and to test for flu, RSV, and COVID STAT (immediately or without delay). Review on 2/11/26 of Resident #87's active orders revealed a diagnostic test order for influenza (flu), respiratory syncytial virus (RSV), and COVID-19 with an order date of 1/31/26. Review on 2/11/26 of Resident #87's Respiratory Multiplex PCR (Polymerase Chain Reaction) laboratory report revealed a collection date of 2/3/26 (date when a specimen was collected, four days after the order date), a received date of 2/4/26 (date when specimen was received by the laboratory), and report date of 2/4/26 (when results were reported by laboratory). Further review revealed that Resident #87 was positive for RSV. Review on 2/11/26 of Resident #87's provider note, 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.

Based on observation, interview, and record review, the facility failed to policies and procedures for Enhanced Barrier Precautions (EBP) for 1 of 1 resident reviewed for pressure injuries and Transmission Based Precaution (TBP) and 4 of 7 residents reviewed for TBP. (Resident identifiers are #9, #37, #93, #100, and #102.)Findings include: Resident #9 Observation on 2/10/26 at approximately 11:23 a.m. in Resident #9's room revealed an EBP signage posted outside of Resident #9's room door. Further observation revealed that Staff L (Certified Occupational Therapy Assistant) was in Resident #9's room wearing mask and gloves. Staff L was not wearing a gown. Staff L was observed with a wet washcloth and talking to Resident #9. Interview on 2/10/26 at 11:28 a.m. with Staff L revealed that he/she was assisting Resident #9 in changing their clothes (shorts and socks). Staff L confirmed that he/she did not don a gown. Staff L also revealed that he/she did not see the EBP sign on Resident #9's door. Review on 2/10/26 of Resident #9's medical record revealed that Resident #9 was on EBP for 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.

Based on interview and record review, it was determined that the facility failed to develop and implement a comphrensive care plan for 1 of 4 residents reviewed for mood and behavior in a final sample of 23 residents. (Resident identifier is #92.) Findings include:Resident #92 Review on 1/7/25 of Resident #92's medical diagnosis list revealed that Resident #92 with a diagnosis of Post Traumatic Stress Disorder (PTSD). Review on 1/7/25 of Resident #92's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/1/24, revealed that it was documented in Section I6100, Diagnosis, that Resident #92 had PTSD. Review on 1/7/25 of Resident #92's comprehensive care plan revealed that there were no focus, triggers, or interventions for Resident #92's PTSD. Interview on 1/8/25 at 9:00 a.m. with Staff I (Unit Manager) confirmed that there were no focus, triggers, or interventions for PTSD in Resident #92's comprehensive care plan.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and policy review it was determined that the facility failed to follow the professional standards of care for 3 residents in a final sample to 23 residents. (Resident identifier is #273, #101, and #73.) Findings include:Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021. Chapter 31 Medication Administration Page 595, .Medications that are time critical most likely cause harm or have subtherapeutic effects if they are not administered in time (usually 30 minutes before and after the scheduled dose). Non-time-critical medications most likely do not cause harm if they are given within 1 hour to 2 hours before or after the schedule time. Thus, you need to administer time-critical medications at a precise time, within 30 minutes before and after a scheduled time. You administer non-time-critical medications within 1 to 2 hours of their scheduled times . Resident #73 Interview on 1/6/25 at approximately 10:45 a.m. with 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 interview and record review, it was determined that the facility failed to ensure that a resident who attends dialysis had interventions to care and monitor their access site and that they received physician ordered medications for 1 of 1 resident reviewed for dialysis in a final sample of 23 residents. (Resident identifier is #1.) Findings include: Interview on 1/7/25 at 1:35 p.m. with Resident #1 revealed that he/she attends dialysis 3 times a week on Monday, Wednesday, and Friday and is away from the facility from approximately 11:30 a.m. until 5:00 p.m. Review on 1/7/25 of Resident #1's January's 2025 Medication Administration Record (MAR) revealed that the medication Calcium Acetate (a phosphate binder) were documented as AW (away from center; meaning not administered) on 1/2, 1/4, and 1/6/25. Further review of Resident #1 MAR revealed that he/she has an order for Midodrine HCL (hydrochloride) Oral Tablet 5 MG (milligram) Give 2 tablets by mouth three times a day for low blood pressure 10 mg and 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 observation and interview, it was determined that the facility failed to ensure that food trays were stored dry and in sanitary condition in the main kitchen. Findings include: Standard: Review on 1/7/25 of the U.S. FDA (Food Drug and Administration) Food Code (2017), retrieved from: https://www.fda.gov/media/110822/download, [page 151-153] revealed the following: 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in 151 antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; and (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry. 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE…

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 interview, it was determined that the facility failed to maintain complete records for 1 of 1 record reviewed for death in a final sample of 23 (Resident identifier is #11.) Findings include: Review on 1/07/25 of Resident #11's nursing progress note ,dated 01/04/25 at 14:48, revealed .Resident time of death at 14:42 [2:42 p.m.], 2 RN [Registered Nurse] pronouncing death . No other information was present for this entry. Review on 1/07/25 at 3:15 p.m. of the facility's policy titled NSG104 Pronouncement of Patient Death, effective 5/01/23, revealed .Nurses will comply with all applicable laws and regulations regarding determination of death .1.5. A RN who has determined and pronounced death will document the clinical criteria for such determination and pronouncement in the patient's medical record. 1.5.1 Description of the discovery of the patient; 1.5.2 Any treatment of the patient undertaken; 1.5.3 Findings from assessment (presumptive and conclusive signs identified): 1.5.3.1 No carotid and peripheral pulse, 1.5.3.2 Pupils are fixed and nonreactive 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to provide sufficient staff to meet residents' needs (Resident Identifiers are #12, #13, #17, #31, #38, #39, #47, #74, #84, #156 and #250). Findings include: Resident #38 Observation on 10/29/23 at approximately 11:00 a.m. of Resident #38 appeared upset, tearful, and sitting in his/her fecal matter in bed. Interview on 10/29/23 at approximately 11:00 a.m. with Resident #38 revealed he/she had been sitting in his/her fecal matter for approximately an hour, after utilizing the call bell for assistance. Interview on 10/29/23 at approximately 11:05 a.m. with Staff H (Licensed Practical Nurse (LPN)) confirmed the above finding. Staff A (Administrator) stated that a Licensed Nursing Assistant (LNA) was on break leaving them short to answer call lights. Resident #156 Interview on 10/29/23 at approximately 11:10 a.m. with Resident #156 revealed after utilizing his/her call bell last week it took staff approximately a half hour…

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 interview, it was determined that the facility failed to ensure residents were offered, educated, and received the pneumococcal and/or influenza immunization 3 of 5 residents reviewed for immunizations (Resident Identifiers are #8, #55 and #67). Findings Include: Review on 10/31/23 of Summary: Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)-United States, 2023-24, found at https://www.cdc.gov/flu/professionals/acip/summary/summary-recommendations.htm, revealed the .Timing of vaccination - For most persons who need only one dose of influenza vaccine for the season, vaccination should ideally be offered during September or October. However, vaccination should continue throughout the season as long as influenza viruses are circulating . Resident #8 Review on 10/31/23 of Resident #8's medical record revealed the last documented influenza immunization was administered on 12/3/21. Review on 10/31/23 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, and record review, it was determined that the facility failed to ensure that a resident was assessed for restraints for 1 of 1 residents reviewed for restraints in a final sample of 22 residents. (Resident identifier is #12). Findings include: Observation on 10/29/23 at approximately 2:00 p.m. of Resident #12 revealed that he/she was in a wheelchair with a fastened seatbelt. Review on 10/30/23 of Resident #12's medical record revealed that there was no assessment of the seatbelt since 6/24/21 and no physician order for seatbelt usage. Further review of the medical record revealed a care plan dated 3/5/21 with an intervention to utilize and release restraint per the physician's order. Observation on 10/31/23 at approximately 9:10 a.m. of Resident #12 revealed that he/she was in a wheelchair with a seatbelt fastened. Interview on 10/31/23 at approximately 9:10 a.m. of Resident #12 revealed that he/she was able to remove the seatbelt on command. Interview on 10/31/23 at approximately 9:30 a.m. with Staff C (Third floor Unit Manager) confirmed that 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.