Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ridgewood Specialty Care during CMS and state inspections, most recent first.
Two residents on a mechanical soft diet were served regular corn instead of the prescribed pureed corn during lunch service. One staff member noticed the error before one resident ate, and another resident had already eaten the corn with a few kernels remaining on the plate. Meal tickets were used to direct diet texture orders, and an administrator from a sister facility confirmed the incorrect texture on the plate.
QAPI/QA Program Lacked Monitoring of Diet Texture Accuracy. The facility failed to document ongoing QAPI/QA activities related to staff serving the correct diet textures to residents after a prior F803 deficiency. Surveyors found concerns with incorrect diet textures being served, and the Administrator stated the QA binder contained no focused QA documentation for this issue. Additional records later provided included staff education and meal/diet consistency audits, but there was no recent evidence of monitoring, evaluation of performance improvement activities, or revision related to correct texture service.
An LPN failed to follow infection control practices while draining and flushing a resident’s JP drain for a right thigh abscess with a history of Pseudomonas bacteremia. The LPN placed supplies on an uncleaned bedside table, handled bloody drainage and drain tubing without changing gloves or performing hand hygiene, used a clear trash bag for contaminated items, and did not sanitize the bedside table or sink counter before leaving the room. Staff interviews also showed confusion about contact isolation supplies and disposal of contaminated materials.
A resident with dysphagia and a history of pneumonitis was given thin liquids instead of the prescribed nectar thickened liquids during medication administration, leading to excessive coughing. The CMA involved was aware of the thickened liquid order but failed to adhere to it due to a shortage of thickening supplement. The resident's care plan and physician orders required nectar thickened liquids, and the oversight was partly due to a lack of documentation of the resident's dietary preferences in the electronic MAR.
The facility failed to provide the correct texture for five residents on a mechanical soft diet, serving regular chicken and noodles instead of ground as required. The RD initially approved the regular texture but later corrected the error after reviewing the menu. The CDM admitted to incorrect information in the kitchen, and the facility lacked a specific policy for mechanically altered diets.
The facility failed to maintain safe food handling and kitchen sanitation, with issues such as improper sanitizer levels, lack of documentation, and unsanitary conditions observed. Staff did not adhere to hygiene practices, including wearing hair restraints and performing hand hygiene.
A resident with severe cognitive impairment was spoken to disrespectfully by a CNA, who became angry and told the resident that his behavior was unacceptable. The incident was confirmed by staff interviews, and both the ADON and Administrator emphasized the importance of respectful communication, as outlined in the facility's dignity policy.
The facility failed to ensure call lights were accessible for two residents, both with intact cognition and requiring assistance for toileting. Despite facility policy, call lights were out of reach, as observed during the survey.
A resident with Huntington's disease and muscle wasting, dependent on a wheelchair, was observed over three days with food debris on their wheelchair, indicating a failure in maintaining cleanliness. Staff interviews revealed inconsistencies in the cleaning schedule and responsibilities, with the DON acknowledging the schedule as a guideline. Despite this, the wheelchair was not cleaned as required, leading to the deficiency.
A facility failed to create a culturally competent care plan for a resident with severe cognitive impairment and a preference for Spanish. Despite noting the need for an interpreter, the resident was observed isolated and not participating in activities, displaying verbal aggressiveness due to the language barrier. Interviews revealed unmet needs and a lack of clarity in staff roles regarding care plan development.
A resident with Huntington's disease and mobility issues was not assisted in changing soiled clothing after meals, despite staff acknowledging the expectation to do so. Observations showed the resident remained in the same clothing with food spills after breakfast and lunch, contrary to the care plan requiring assistance for dressing.
A resident with dysphagia and severely impaired cognition was given medications with thin liquids instead of the prescribed nectar thick consistency, leading to significant coughing and distress. The staff's delayed response and lack of immediate comprehensive assessment highlighted a deficiency in following the facility's protocol for handling such incidents.
A resident with severely impaired cognition was observed being transported in a wheelchair without their feet on the pedals, contrary to their care plan. Staff members, including CMAs and a CNA, assisted the resident while their feet dragged on the floor. Interviews revealed staff knew feet should be on pedals, but misinformation from the previous DON led to unsafe practices.
The facility failed to revise a care plan to include supervised visits after a resident reported abuse by a family member. Although supervised visits were implemented and documented, the care plan was not updated to reflect this intervention.
A resident with multiple health conditions and an intact cognitive status did not receive necessary catheter care, grooming, or personal hygiene services. Despite being incontinent and having a Foley catheter, the resident was left in the same gown for days and did not receive regular peri care or catheter cleaning.
Incorrect Texture Served to Residents on Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure that 2 of 10 residents on a mechanical soft diet received the correct texture, as Residents #44 and #64 were both served regular corn instead of the prescribed pureed corn. The facility policy on Therapeutic Diets stated that therapeutic diets, including texture alterations, were to be prescribed in accordance with the resident's goals and preferences. The Diet Type Report listed both residents with a mechanical soft diet order, and the lunch menu spreadsheet for 12/17/25 indicated buttered corn for the mechanical soft diet as pureed corn. During the noon meal observation, Staff A served Resident #44 regular corn rather than the mechanical soft pureed corn, and Staff A noticed the error before the resident ate it. Staff A stated that kitchen prepared another tray for the resident. Later in the meal service, Resident #64 had a lunch plate in her room with a few kernels of regular corn remaining on the plate, and the resident stated she ate the corn without problems. Staff A stated she had a feeling she gave Resident #44 the wrong diet and asked Staff B, an administrator of a sister facility, to check the plate, and Staff B confirmed the plate contained regular corn.
QAPI/QA Program Lacked Monitoring of Diet Texture Accuracy
Penalty
Summary
The facility failed to carry out QA activities to prevent the reoccurrence of a deficient practice related to meal textures served to residents. Review of the facility’s QAPI policy showed that the governing body was responsible for ensuring the QAPI program was implemented and maintained to address identified priorities, and that the QSPI Committee was responsible for collecting and analyzing performance indicator data and establishing benchmarks and goals for performance improvement. The facility had a census of 55 residents. Review of the CMS Statement of Deficiencies dated 10/31/24 showed a deficiency for F803, Menus Meet Resident Needs/Prepared in Advance/Followed. During the current survey conducted 12/15/25 through 12/22/25, surveyors identified concerns related to staff serving incorrect textures to residents. On 12/22/25, the Administrator provided a binder of QA documentation since the last recertification, but it contained no QA activities focused on staff providing the correct diet textures to residents. The Administrator stated she had no additional QA documentation beyond the binder and acknowledged that asking for test trays of different textures would not evaluate whether staff provided the correct diet textures to residents. Additional documents later provided included certificates of completion for staff related to modified diets, meal observation audits, and diet and fluid consistency audits, but the facility lacked more recent documentation of ongoing QAPI/QA activities, monitoring, evaluation of corrective action or performance improvement activities, and revision as needed related to residents receiving the correct diet texture.
Failure to Follow Infection Control During JP Drain Care
Penalty
Summary
The facility failed to use infection control practices during the draining and flushing of a surgical JP drain for a resident with a right thigh abscess and a history of Pseudomonas bacteremia. The resident’s record showed intact cognition, a care plan for monitoring and flushing the JP drain, and treatment orders for flushing the drain with normal saline and cleaning the port with alcohol and a disinfecting cap. The resident was also placed on contact isolation precautions, with an isolation sign and cart outside the room. During observation, an LPN entered the resident’s room, performed hand hygiene, and donned gloves and a gown, but then placed a syringe and clean cup on the bedside table without wiping the table or using a barrier. The LPN emptied bloody drainage from the JP bulb into the cup, returned the cup to the bedside table, and then manipulated the drain tubing and stop-cock without changing gloves or performing hand hygiene. The LPN placed the contaminated cup and syringe on the bedside stand, later moved the cup to the sink counter, emptied the drainage into the toilet, and discarded the cup, gloves, and gown in a clear trash bag rather than a red contamination bag. The observation also showed the bedside table and sink counter were not sanitized before the LPN exited the room, and the resident was propelled out of the room without hand hygiene being completed. Staff interviews confirmed confusion about the resident’s isolation status and the use of red bags and isolation barrels. The ADON/Infection Preventionist stated the resident was to be on contact isolation and that isolation barrels and red bags were being placed in the room, while the DON stated nursing staff were expected to use barriers, hand hygiene before, after, and during care, and red biobags for bodily fluids and contaminated items.
Failure to Provide Correct Liquid Consistency Leads to Resident Coughing
Penalty
Summary
The facility failed to provide a resident with the correct diet ordered liquid consistency during medication administration, leading to excessive coughing and production of phlegm. The resident, who has diagnoses of dysphagia and a history of pneumonitis due to inhalation of food and vomiting, was given regular (thin) consistency water instead of the prescribed nectar thickened liquids. This incident occurred during a medication pass by a Certified Medication Assistant (CMA), who was aware of the resident's thickened liquid order but failed to adhere to it due to running low on the thickening supplement. The resident's medical history includes severe cognitive impairment, aphasia, cerebrovascular accident, and dysphagia, necessitating a mechanically altered diet with pureed food and thickened liquids. Despite these requirements, the CMA administered medications with thin liquids, which was contrary to the physician's orders and the resident's care plan. The resident's care plan and physician orders clearly indicated the need for nectar thickened liquids, and the Speech Therapy evaluation had highlighted the risk of aspiration if the resident did not receive the appropriate liquid consistency. Observations and interviews revealed that the staff involved were not fully aware of the resident's dietary preferences and requirements, leading to the administration of inappropriate liquid consistency. The Licensed Practical Nurse (LPN) involved noted that the resident's preference for pudding was not documented in the electronic Medication Administration Record (MAR), contributing to the oversight. The Registered Dietician and Certified Dietary Manager confirmed that the resident had consistently been on a nectar thick liquid order, emphasizing the importance of adhering to the prescribed diet to prevent aspiration risks.
Removal Plan
- The facility provided education with staff, including agency staff, to follow physician orders for fluid consistency.
- The facility provided education with nursing staff, including agency staff, on adequately assessing residents with changes in condition, to include vital signs and appropriate assessments. Physician is to be notified immediately and staff to remain with resident if change in condition.
- Resident #23 was assessed at bedside. The physician was notified. Physician orders were obtained for the following: Chest x-ray, referral to speech therapy, suction as needed (suction machine placed at bedside), crush medications as indicated, monitor lung sounds and pulse oximetry (blood oxygen) every shift.
- Completed an audit of all residents on an altered liquid consistency to ensure that it is reflected on their Medication Administration Record (MAR), resident care plan, and Kardex.
- Director of Nursing (DON) or designee will monitor and audit medication passes to ensure appropriate fluid consistency given as physician ordered. DON or designee will monitor and audit changes in condition to ensure appropriate assessments are completed and physician notifications are completed. Concerns are to be addressed with Quality Assurance Performance Improvement (QAPI).
Failure to Provide Correct Texture for Mechanical Soft Diets
Penalty
Summary
The facility failed to provide the correct texture for five residents who were on a mechanical soft diet. The menu for the Spring/Summer '24 Week 2 Tuesday Lunch specified that residents on a mechanical soft diet should receive ground chicken and noodles. However, during an observation, it was noted that the dietary staff prepared regular chicken and noodles for these residents. The Registered Dietician (RD) initially stated that the regular chicken and noodles would suffice but later, upon reviewing the menu, instructed the staff to grind the chicken as the pieces were too large, measuring up to 1.5 inches in length. Interviews revealed that the dietary staff were not following the therapeutic diet spreadsheets as expected. The Certified Dietary Manager (CDM) acknowledged that the kitchen had incorrect information regarding therapeutic diets but stated that the correct spreadsheets were now available. The facility's policy on dysphagia indicated that modified consistency diets should be ordered by a physician for residents with swallowing difficulties, but there was no separate policy for mechanically altered diets. The Administrator confirmed via email that the facility lacked a specific policy for mechanically altered diets.
Deficiencies in Food Handling and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure safe food handling and kitchen sanitation during a survey observation. During a kitchen observation, a metal bowl of fruit was found sitting in the sink, and crumbs were present on the top of the dishwasher. A dietary aide ran a dishwashing cycle, and the Certified Dietary Manager (CDM) tested the sanitizer concentration, which initially showed 0 parts per million, indicating no sanitizer was present. The CDM adjusted the sanitizer tubing, and a follow-up test showed 100 ppm. The dish machine temperature log for October 2024 was blank, indicating a lack of documentation for several days. Additionally, a dietary aide did not wear a hair restraint to cover his mustache. Further observations revealed unsanitary conditions, including a red substance accumulating in the ice machine, significant hair hanging out from a dietary aide's hair net, and a dietary aide failing to perform hand hygiene after picking up a wrapper from the floor. A plate of half-eaten food was found in the microwave, and trash receptacles were overflowing. The facility's policies on sanitization and food preparation were not adhered to, as staff failed to maintain cleanliness, proper hygiene, and documentation as required.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that staff communicated with residents in a respectful and dignified manner, as evidenced by an incident involving a resident with severe cognitive impairment. The resident, diagnosed with bipolar disorder, schizophrenia, and obsessive-compulsive disorder, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. The care plan for this resident included specific communication strategies, such as making eye contact and returning if the resident became agitated. However, during an interaction, a Certified Nursing Assistant (CNA) became angry and spoke to the resident in a disrespectful manner, telling the resident that his behavior was unacceptable and that she would not tolerate disrespect. The incident was corroborated by interviews with staff members, who confirmed that the CNA's behavior was disrespectful and demeaning. The Assistant Director of Nursing (ADON) and the Administrator both stated that staff should speak to residents kindly and with respect, emphasizing the importance of maintaining a calm demeanor even when residents exhibit challenging behaviors. The facility's policy on dignity, revised in February 2021, directed staff to care for residents in a way that promotes their well-being and self-esteem, which was not adhered to in this instance.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident #18, who has diagnoses including dementia, diabetes, and a cognitive communication deficit, was observed with her call light out of reach while sitting in her recliner. Despite being dependent on staff for toileting and having intact cognition with a BIMS score of 13 out of 15, the call light was not accessible until a staff member retrieved it for her. Similarly, Resident #28, diagnosed with diabetes, a tibia fracture, and weakness, was also found with her call light out of reach while sitting in a chair. This resident, who requires substantial to maximal assistance with the bedpan and has a BIMS score of 14 out of 15, indicating intact cognition, was unable to access her call light. The facility's policy, revised in March 2021, directs staff to ensure call lights are within easy reach, yet this was not adhered to, as confirmed by the Assistant Director of Nursing.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to maintain a clean and well-maintained environment for Resident #14, who was dependent on a wheelchair for mobility due to Huntington's disease and muscle wasting. Over a period of three days, the resident's wheelchair was observed to have food debris on the frame, seat cushion, and lap belt, indicating a lack of proper cleaning and maintenance. The observations were made while the resident was both in the wheelchair and resting in bed, with the wheelchair positioned nearby. Interviews with staff members revealed inconsistencies in the cleaning schedule and responsibilities. Staff B, a Certified Medication Aid, mentioned that wheelchairs were cleaned according to a schedule during the night shift, while Staff F, a Certified Nursing Assistant, stated that it was everyone's responsibility to keep wheelchairs clean if needed immediately. The Director of Nursing acknowledged the existence of a cleaning schedule as a guideline but noted that Resident #14's wheelchair became dirty quickly due to the resident's eating habits. Despite the documented cleaning schedule, the observations indicated that the wheelchair was not cleaned as required, leading to the deficiency.
Failure to Develop Culturally Competent Care Plan
Penalty
Summary
The facility failed to develop a culturally competent care plan for a resident with severe cognitive impairment and a preferred language of Spanish. The resident, who has diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, and heart disease, was observed to be isolated and not participating in activities. The care plan noted the need for an interpreter and identified Spanish as the resident's preferred language, but the interventions were not effectively implemented. Observations showed the resident sitting alone, frowning, and not engaging in activities, as well as displaying verbal aggressiveness due to the language barrier. Interviews with staff and family members highlighted the resident's unmet needs due to the language barrier. A family member expressed concern about the resident's needs not being met and mentioned that the resident enjoyed Spanish music. A CNA noted that the resident's verbal aggressiveness was related to the language barrier and suggested that culturally directed activities could benefit the resident. The MDS Coordinator and Social Worker indicated a lack of clarity in roles regarding the development of culturally competent care plans, contributing to the deficiency.
Failure to Change Soiled Clothing After Meals
Penalty
Summary
The facility failed to assist a resident with changing their clothing after food was spilled on them during meals. This deficiency was observed in Resident #14, who has diagnoses of Huntington's disease, muscle wasting, and anxiety disorder, and is dependent on a wheelchair for mobility. The resident's care plan, initiated on 10/6/23, indicated that they require substantial assistance from one staff member for eating and are dependent on staff for upper and lower body dressing. On 10/22/24, observations revealed that after breakfast, Resident #14 was assisted to their room by a CNA, Staff S, with food spilled on their shirt and pants. Despite this, the resident remained in the same clothing after being assisted to bed. Later, after lunch, the resident was again observed in bed wearing the same soiled clothing with additional food spills from the noon meal. Interviews with staff, including a Certified Medication Aid and another CNA, confirmed that the expectation is to change a resident's clothes if they are dirty. The Director of Nursing also stated that staff should change residents' clothes if they are soiled.
Failure to Administer Correct Liquid Consistency Leads to Resident Distress
Penalty
Summary
The facility failed to provide continued assessment for a resident after an episode of excessive coughing caused by taking medications with a thin liquid, contrary to the physician's order for nectar consistency liquid. The resident, who had severely impaired cognition and a history of dysphagia, was observed receiving medications with regular water by a Certified Medication Assistant (CMA). This led to significant coughing and drainage from the resident's mouth and nose. The Licensed Practical Nurse (LPN) acknowledged the resident's need for thickened liquids and noted that the resident usually received medications with pudding, a preference not communicated to the CMA. Following the coughing episode, the resident continued to show signs of distress, including a bright red face and large amounts of secretions. Despite the resident indicating discomfort and feeling like something was stuck in his throat, the initial response from the staff was inadequate. The Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS) were informed and involved, but the resident's condition was not immediately reassessed comprehensively. The resident's vital signs were eventually taken, and the physician was notified, but the delay in response highlighted a lapse in the facility's protocol for handling such incidents. Interviews with staff, including the Registered Dietician and the Certified Dietary Manager, confirmed that the resident had a long-standing order for nectar thick liquids due to the risk of aspiration. The facility's policy required a comprehensive assessment and physician notification in the event of a significant change in a resident's condition, which was not promptly executed. The Speech Therapist also emphasized the resident's high risk for aspiration, underscoring the importance of adhering to the prescribed diet consistency.
Failure to Ensure Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure safe wheelchair transport for a resident with severely impaired cognition, as indicated by a score of 00 out of 15 on a Brief Interview for Mental Status (BIMS) exam. The resident, who utilized a wheelchair for mobility, was observed multiple times with their feet not on the wheelchair pedals while being assisted by staff. This was contrary to the care plan intervention, which specified that the resident's wheelchair pedals should be off due to their preference to self-propel. Observations on the specified date revealed that staff members, including Certified Medication Aides (CMAs) and a Certified Nursing Assistant (CNA), assisted the resident while their feet were dragging on the floor, posing a risk of accident. Interviews with staff members confirmed that they were aware that the resident's feet should be on the pedals when being assisted in a wheelchair. However, the Director of Nursing (DON) explained that there was misinformation from the previous DON, suggesting that staff could assist residents who could self-propel without using foot pedals. This misunderstanding contributed to the failure to provide adequate supervision and ensure the resident's safety during wheelchair transport.
Failure to Revise Care Plan for Supervised Visits
Penalty
Summary
The facility failed to revise a care plan to address the need for supervised visits following an allegation of abuse by a family member. Resident #1, who had an intact cognitive status and required dependent assistance with various activities, reported that her spouse caused bruising on her right arm. The Director of Nursing (DON) was informed of the allegation and took immediate steps to notify the police, the Department of Health and Human Services (DHS), and made a self-report to the Department of Inspections, Appeals and Licensing (DIAL). The DON also initiated supervised visits between Resident #1 and her spouse, which were documented in the Nursing Assignment sheets but not added to the care plan or Kardex. Despite the intervention of supervised visits being implemented, the care plan for Resident #1 did not reflect this change. The DON confirmed that line-of-sight supervision was provided throughout the remainder of Resident #1's stay, but the necessary updates to the care plan were not made. This oversight led to a deficiency in the facility's compliance with care plan revisions, as the care plan did not address the need for supervised visitations following the abuse allegation.
Failure to Provide Catheter Care and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary catheter care, grooming, and personal hygiene services for a resident who required dependent assistance with these activities. The resident, who had an intact cognitive status and diagnoses including congestive heart failure, atrial fibrillation, renal insufficiency, arthritis, and morbid obesity, was observed on multiple occasions throughout the day without receiving the required care. Despite being incontinent of urine and bowel and having a Foley catheter, the resident reported not receiving peri care, catheter care, or basic grooming services such as a bed bath, oral care, or a change of clothes. Observations and interviews revealed that the resident was left in the same gown for several days and was not provided with a fresh brief or cleaned catheter tubing. The resident expressed feeling ignored and stated that therapy staff were the only ones who could transfer her. The Director of Nursing confirmed that staff are expected to provide these cares each morning and as needed throughout their shift, but this was not done for the resident in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ottumwa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Ottumwa | 0.3 mi | ★★★★★ | 13 | 0 |
| Accura Healthcare Of Ottumwa | 2.2 mi | ★★★★★ | 2 | 0 |
| Bloomfield Care Center | 17.4 mi | ★★★★★ | 5 | 0 |
| Oakwood Specialty Care | 18.1 mi | ★★★★★ | 2 | 0 |
| Davis Center | 20.9 mi | — | 0 | 0 |
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