Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Living & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments experienced two falls from bed during care, resulting in head injuries requiring ER treatment. In both cases, staff failed to follow the care plan's required level of assistance for bed mobility—one aide used improper technique during a bed bath, and another provided incontinence care alone without checking the care plan or seeking help, despite the resident's need for two-person assistance.
The facility did not provide or document required COVID-19 vaccine education, offers, or outcomes for two residents with medical conditions, nor did it maintain documentation that any of its 156 staff received education or were offered the vaccine, despite facility policy and CDC guidance.
The facility did not ensure nurse aides received the federally required 12 hours of annual in-service training, including abuse prevention and dementia care education. Review of staff files and interviews with facility leadership confirmed that several nurse aides lacked documentation of completed training, and key staff were unaware of the training requirements.
A resident's MDS assessment was inaccurately coded to reflect both a fall with injury and a fall without injury, when only one fall with injury had occurred. The MDS nurse misread incident report dates, leading to the error, which was confirmed through staff interviews and record review.
A resident with chronic kidney disease and muscle weakness, who used bilateral grab bars for bed mobility, did not have side rail usage included in their care plan. Despite assessments and staff awareness of the resident's use of grab bars, the care plan was not updated to reflect this, resulting in a lack of individualized, person-centered planning.
A nurse failed to maintain sterile technique while providing tracheostomy care to a resident in a vegetative state, including not performing hand hygiene or donning sterile gloves before handling sterile equipment and placing clean dressings. Facility leadership confirmed that proper infection control protocols were not followed during the observed care.
Two residents were provided with bilateral grab bars without prior attempts at alternatives, proper assessment for entrapment risk, or documented review of risks and benefits. Staff did not obtain informed consent, and care plans and records lacked references to the use of grab bars. Facility staff, including the DON and Administrator, were unaware of the requirements for bed rail use and did not know the residents were using the devices.
A nurse failed to follow Enhanced Barrier Precautions (EBP) by not wearing a gown while providing tracheostomy care to a resident, despite facility policy and posted signage requiring both gloves and gowns for high-contact care. The nurse believed EBP was only needed for incontinence care and only recognized the requirement after reviewing the posted instructions. Facility leadership confirmed that the EBP policy was not followed during this incident.
A resident with COPD and a history of tobacco use was not provided education on the benefits and side effects of the pneumococcal vaccine, was not offered the vaccine, and had no documentation of consent, refusal, or administration in the medical record. Interviews with the resident, responsible party, and staff confirmed the vaccine was neither offered nor discussed, and the required documentation was missing.
A resident's controlled pain medication (oxycodone) was removed from their medication card and replaced with Buspirone tablets, which were not currently prescribed. The tampering was discovered by a nurse who noticed the pills did not match the expected appearance. The incident was confirmed through staff interviews, medication record review, and drug testing of staff with access to the medication cart, both of whom tested positive for oxycodone. The resident did not miss any prescribed doses and reported receiving pain medication when requested.
The facility did not maintain an effective pest control program in the laundry room, as brown crawling bugs were observed and standing water covered by cardboard was present. Staff reported frequent pest sightings, but pest control treatments were inconsistently documented and the laundry area was only treated monthly, not weekly as expected. There was no clear record of which areas were treated, contributing to ongoing pest issues.
A facility failed to control a German cockroach infestation affecting residents, with cockroaches observed in beds, on walls, and personal items. Despite weekly pest control services, the issue persisted, and staff did not effectively report or address the problem. A pest control contract for a cleanout was initiated but not fully implemented, leaving residents in distress.
The facility failed to accurately code the MDS for oxygen use for four residents, despite physician orders and MAR documentation confirming oxygen administration. The MDS coordinator misunderstood the coding criteria, leading to a deficiency in the assessment process. Administrative staff acknowledged the oversight.
A facility failed to conduct a quarterly interdisciplinary care plan meeting for a resident with multiple diagnoses, including hemiplegia and diabetes. The resident, assessed as cognitively intact, had her last care plan meeting several months prior, with no subsequent meeting held as required. Both the resident and a social worker confirmed the lapse, and the administrator acknowledged the requirement for quarterly meetings.
A resident with diabetes mellitus did not receive a physician-ordered nutritional shake with breakfast, despite it being listed on the meal tray ticket. The Unit Manager delivered the tray without the shake, and the Nurse Aide failed to verify the tray contents or obtain a replacement. The nurse inaccurately documented the shake's consumption. Interviews revealed procedural lapses in ensuring meal accuracy and obtaining missing items.
A facility failed to properly clean and store a syringe used for enteral feeding for a resident in a persistent vegetative state. The syringe was observed with debris and liquid, stored improperly with the plunger inside. Nursing staff admitted to reusing the syringe for medication administration and checking residuals, contrary to facility protocol, which required separate drying of the syringe and plunger.
Two residents in an LTC facility were repeatedly served foods they disliked, despite these preferences being documented on their meal tickets. One resident, cognitively intact, was served green beans and carrots, while another, moderately cognitively impaired, received milk, eggs, and fish. The CDM confirmed that dislikes were recorded but could not explain the oversight. Interviews revealed communication lapses among dietary staff, leading to the deficiency.
The facility failed to accurately document the application of a splint and the intake of a nutritional supplement for two residents. A resident did not have a left-hand splint applied as ordered, yet it was documented as applied. Another resident did not receive a nutritional shake with breakfast, but the MAR inaccurately showed partial consumption. The inaccuracies were acknowledged by the staff involved.
A resident with a history of intracerebral hemorrhage and fall risk was found multiple times with her call light out of reach, despite her care plan requiring it to be accessible. Staff interviews confirmed the oversight, and the facility had longer call light cords available but did not use them.
A facility failed to assist a resident, who was cognitively intact and admitted with a stroke, in establishing advanced directives, as required by their policy. Staff interviews revealed no documentation or recollection of offering assistance, leading to a deficiency in care.
A resident with cognitive impairment and hemiplegia did not have a prescribed hand splint applied as ordered for contracture prevention. Despite the care plan and physician's orders, staff interviews and observations confirmed the splint was not consistently applied, with a nurse aide admitting to forgetting the task. The DON acknowledged the oversight.
A nursing assistant in an LTC facility failed to follow infection control protocols by placing soiled linens on the floor instead of in a plastic bag. This action was against the facility's policy, which aims to prevent cross-contamination. Staff interviews confirmed the breach in protocol, highlighting the risk of spreading germs throughout the building.
Failure to Provide Adequate Supervision and Safe Care During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and significant physical limitations experienced two separate incidents of falling from bed during care, resulting in injuries that required emergency room evaluation and treatment. In the first incident, a nurse aide was providing a bed bath and rolled the resident away from herself, contrary to safe technique, and then turned to grab a towel, during which time the resident rolled off the bed. The bed was elevated approximately two feet from the floor, and the resident sustained a scalp hematoma. The resident was dependent on staff for bed mobility and required total assistance, as documented in her care plan. In the second incident, the same resident, now with a care plan updated to require two-person assistance for bed mobility, was being provided incontinence care by a single nurse aide. The aide did not check the resident's care plan or Kardex prior to providing care and did not request assistance, despite other staff being available. While attempting to clean the resident after a large bowel movement, the aide pulled the resident closer using a draw sheet and then turned her, resulting in the resident rolling off the bed, which was elevated about three feet from the floor. The resident sustained a 15-centimeter scalp laceration requiring wound closure with sutures and staples. Both incidents involved a failure to follow the resident's assessed needs and care plan instructions regarding the required level of staff assistance for bed mobility and repositioning. Staff involved either did not use the correct technique or did not verify and adhere to the care plan, leading to preventable accidents and injuries during routine care activities.
Failure to Provide and Document COVID-19 Vaccine Education and Offerings
Penalty
Summary
The facility failed to provide required education regarding the benefits and possible side effects of the COVID-19 vaccine, did not offer the vaccine, and did not document either a refusal or administration of the vaccine in the medical records of two residents over the past 14 months. Both residents were cognitively intact and had medical conditions such as depression and chronic obstructive pulmonary disease (COPD). Their medical records lacked documentation of COVID-19 vaccine education, offer, or outcome, despite interviews indicating that the residents recalled being offered the vaccine or refusing it due to past experiences. Additionally, the facility did not maintain documentation that staff were provided education about the benefits and risks of the COVID-19 vaccine, nor did it document that staff were offered the vaccine or given information on how to obtain it within the past 14 months. Interviews with the Infection Preventionist, DON, and Administrator revealed uncertainty about current CDC recommendations and an absence of recent education or vaccine offers for staff. The facility had 156 regular and contract staff, none of whom had documentation of COVID-19 vaccine education or offer in the reviewed period. The facility's own policy required that all staff and residents receive education about the COVID-19 vaccine, including information consistent with CDC and FDA guidance, and that the vaccine be offered with documentation of acceptance or refusal. Despite having access to the vaccine through the pharmacy and previous rounds of vaccination, the facility did not ensure ongoing compliance with these requirements for both residents and staff.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of annual in-service training, including mandatory education on abuse prevention and dementia care. Record reviews for three nurse aides revealed missing documentation of completed in-service training within the previous 12 months, despite their employment during that period. Interviews with the Staff Development Coordinator and the Director of Nursing confirmed a lack of awareness regarding the federal requirement for annual in-service training, including abuse and dementia topics. The Administrator acknowledged the deficiency, attributing it to turnover in the staff development position, which resulted in lapses in tracking and providing the necessary training.
Inaccurate MDS Coding of Resident Fall Events
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of falls for one resident. The resident was admitted to the facility and subsequently experienced a fall from bed, resulting in a significant scalp laceration that required staples and sutures. The annual MDS assessment for this resident indicated both a fall with no injury and a fall with injury since the prior assessment. However, a review of the medical record revealed only one fall with injury during this period. During interviews, the MDS nurse acknowledged that the coding of an additional fall with no injury was an error, explaining that she misread the date on an incident report from the previous year. Both the Director of Nursing and the Administrator confirmed that MDS assessments are expected to be coded accurately.
Failure to Include Side Rail Use in Resident Care Plan
Penalty
Summary
The facility failed to develop an individualized, person-centered comprehensive care plan to address the use of side rails for a resident with chronic kidney disease stage 5 and generalized muscle weakness. The resident was admitted with significant mobility limitations, requiring partial to moderate assistance with bed mobility and substantial to maximal assistance with moving from lying to sitting. Despite being cognitively intact and using bilateral grab bars to assist with rolling over in bed, the resident's care plan did not reference the use of side rails. An assessment completed by a nurse indicated that the resident did not need or use side rails, and the most recent care plan review also omitted any mention of side rail usage. Observations confirmed that the resident was using bilateral grab bars, and the resident reported using them for assistance during care. Interviews with facility staff, including the MDS nurse, DON, and Administrator, revealed that the responsibility for updating the care plan with side rail usage information was understood but not executed. The omission was identified through observation, record review, and staff interviews, demonstrating a lack of comprehensive care planning for the resident's actual needs and equipment in use.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
Nurse #4 failed to maintain sterile technique during tracheostomy care for a resident in a persistive vegetative state with a tracheostomy. During the procedure, Nurse #4 performed hand hygiene and donned clean gloves, then removed the trach cap, soiled gauze, and inner cannula. Without performing hand hygiene or donning sterile gloves, she handled and inserted a new sterile inner cannula and placed clean split gauze. Additionally, when preparing to suction the resident, Nurse #4 donned sterile gloves over soiled gloves rather than removing the soiled gloves and performing hand hygiene first. Interviews with facility leadership, including the DON, Administrator, and Infection Preventionist, confirmed that Nurse #4 did not follow proper infection control protocols, specifically failing to perform hand hygiene and don sterile gloves before handling sterile items. The improper technique was observed during direct care and acknowledged by the nurse involved, as well as by facility leadership, who stated that these actions did not meet professional standards of practice for infection prevention.
Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to follow required procedures before installing and using bed rails (grab bars) for two residents. For both residents, staff did not attempt or document alternatives to bed rails prior to their use. Assessments completed by nursing staff indicated that bed rails or assist devices were not indicated for the residents at the time, yet bilateral grab bars were observed in use on both residents' beds. Staff interviews revealed a lack of awareness that grab bars are considered side rails and that alternatives should be tried and documented before use. Neither resident had a completed assessment for entrapment risk, nor was there evidence that the risks and benefits of bed rail use were reviewed with the residents or their representatives. Informed consent for the use of grab bars was not obtained or documented for either resident. The care plans and medical records did not reference the use of grab bars, and the required consent forms could not be located in the residents' charts. Staff, including the DON and Administrator, were unaware of the need for these steps and did not know that the residents were using bilateral grab bars. Both residents had significant medical conditions, including chronic kidney disease, diabetes, and generalized muscle weakness. One resident was cognitively intact and used the grab bars to assist with bed mobility, while the other was severely cognitively impaired and dependent on staff for mobility. Despite these conditions, the facility did not follow the necessary protocols for bed rail use, including assessment, documentation, and consent.
Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
Nurse #4 failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during high-contact care for a resident with a tracheostomy. The EBP policy, dated 4/24/24, requires staff to don gloves and gowns prior to performing high-contact resident care activities, such as tracheostomy care, to reduce the spread of multi-drug-resistant organisms (MDROs). During an observation, Nurse #4 performed hand hygiene and donned gloves but did not wear a gown while providing tracheostomy care and suctioning to the resident, despite clear signage and available personal protective equipment (PPE) at the resident's door indicating the requirement for both gloves and gowns. Upon interview, Nurse #4 stated she did not wear a gown because she believed EBP was only necessary for incontinence care, and only realized the requirement after reading the posted EBP sign. The Infection Preventionist, Director of Nursing, and Administrator all confirmed that Nurse #4 should have worn a gown in addition to gloves during the procedure, as per facility policy. The Medical Director noted that the respiratory tract is not a sterile space and did not believe the resident was put at risk, but acknowledged the policy was not followed.
Failure to Educate, Offer, and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to provide education regarding the benefits and possible side effects of a pneumococcal immunization, offer the immunization, and document either refusal or administration for one resident with a diagnosis of COPD who was a current tobacco user and moderately cognitively impaired. The resident's medical record did not contain any documentation of education about the pneumococcal vaccine, consent or refusal, or evidence that the vaccine had been administered. Interviews with the resident and her responsible party confirmed that neither recalled being offered the vaccine or receiving education about it, and both indicated willingness to accept the vaccine if it had been offered. The Infection Preventionist acknowledged awareness of residents not being up to date with pneumococcal vaccines and described an ongoing process to address the issue, starting with new admissions and proceeding chart by chart. However, the resident in question had not yet been included in this process. The Director of Nursing and the Administrator both confirmed the absence of required documentation for education, consent, refusal, or administration of the pneumococcal vaccine for this resident. The Medical Director also stated that the resident should have been offered the vaccine.
Misappropriation and Substitution of Controlled Medication
Penalty
Summary
A facility failed to protect a resident's right to be free from misappropriation of controlled medications when it was discovered that seven oxycodone tablets, prescribed as needed for pain, were removed from the resident's medication card and replaced with similar-looking Buspirone tablets. The tampering was first noticed by a nurse who, upon responding to the resident's request for pain medication, observed that the pills in the card did not match the expected appearance of oxycodone. Further inspection revealed that the back of the medication card had been incised and taped closed, and the substituted pills were identified as Buspirone, a medication previously discontinued for the resident. The medication administration record showed that the last documented administration of oxycodone was by a nurse who could not be reached for follow-up. The incident was reported internally after the discovery, and it was confirmed that the resident did not miss any prescribed doses of pain medication, as the medication was ordered on an as-needed basis and the resident rarely requested it. The investigation included interviews with multiple staff members, review of medication records, and confirmation that the resident's insurance was initially billed for the replacement oxycodone, which was later corrected to bill the facility instead. Interviews with staff and pharmacy personnel confirmed the misappropriation and substitution of the controlled medication. Drug tests were administered to staff who had access to the medication cart, and both tested positive for oxycodone. The resident reported that she received pain medication when requested and did not experience unaddressed pain. The facility's investigation did not substantiate abuse or neglect, but the misappropriation of controlled substances was clearly documented through observations, interviews, and record reviews.
Failure to Maintain Effective Pest Control in Laundry Room
Penalty
Summary
The facility failed to maintain an effective pest control program in the laundry room, as evidenced by the presence of brown crawling bugs observed on the walls and floor near the washing machines. Standing water was found on the floor, covered by a flattened cardboard box, which staff stated was used to prevent slipping but was also identified by the pest control representative as a potential harborage for pests. The Housekeeping and Laundry Director reported frequent pest sightings and stated these were reported to maintenance and entered into the electronic tracking system. However, the pest control logbook from June to August did not show any service requests for the laundry area. Interviews with facility staff and the pest control contractor revealed inconsistencies in the frequency and documentation of pest control treatments. The pest control representative treated the laundry area only monthly, while common areas were treated weekly, and there was no documentation specifying which areas were treated. The Assistant Maintenance Director confirmed that the laundry room itself had not been treated, only the laundry chute, and there were no records of specific areas treated during pest control visits. The Administrator expected weekly treatment of the laundry room, but this was not occurring, and the lack of documentation and targeted pest control contributed to the ongoing pest issue in the laundry area.
Cockroach Infestation in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant infestation of German cockroaches affecting four residents. Observations revealed cockroaches crawling on beds, walls, and personal items in residents' rooms. Housekeeping staff and residents reported frequent sightings of cockroaches, indicating a pervasive issue. Despite weekly pest control services, the infestation persisted, with cockroaches observed in multiple rooms and hallways. Interviews with staff and residents highlighted a lack of communication and reporting regarding the cockroach problem. Housekeeping staff admitted to seeing cockroaches regularly but did not report them, assuming management was already aware. Residents expressed distress over the presence of cockroaches, with some reporting that the insects crawled on them and their belongings. The Director of Housekeeping and other staff members acknowledged the infestation but seemed resigned to merely killing the cockroaches when seen, rather than implementing a comprehensive solution. The facility had initiated a pest control contract for a roach cleanout in some rooms, but the process was incomplete and not yet extended to all affected areas. The pest control company recommended a thorough cleanout process, which involved removing residents and personal items from rooms for treatment. However, the facility had not fully implemented this plan, and the infestation continued to affect residents' living conditions. The Medical Director was unaware of the cockroach issue and did not believe it posed a medical risk, despite the potential for exacerbating respiratory issues.
Failure to Accurately Code MDS for Oxygen Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for oxygen use for four residents, leading to a deficiency in the assessment process. Resident #3, who was admitted with chronic obstructive pulmonary disease, congestive heart failure, oxygen dependence, and hypoxemia, was not coded for oxygen use on her MDS assessment despite having a physician's order for continuous oxygen. Similarly, Resident #75, diagnosed with chronic obstructive pulmonary disease and diabetes, was not coded for oxygen use, although her physician's orders specified oxygen administration at bedtime and while napping. Both residents' Medication Administration Records (MAR) confirmed the administration of oxygen as per the orders. Resident #121, with a diagnosis of chronic obstructive pulmonary disease, and Resident #328, with a fracture of the right femur and asthma, were also not coded for oxygen use on their MDS assessments. Both residents had physician orders for continuous oxygen, which were documented in their MARs. Interviews with the MDS coordinator revealed a misunderstanding in coding criteria, as she only coded for oxygen use if the term 'hypoxia' was explicitly mentioned in the physician's order. The Director of Nursing and other administrative staff acknowledged that the residents should have been coded for oxygen use, indicating a lapse in the facility's assessment procedures.
Failure to Conduct Quarterly Care Plan Meeting
Penalty
Summary
The facility failed to conduct a quarterly interdisciplinary care plan meeting for one of the residents reviewed for care planning. Resident #8, who was admitted with diagnoses including hemiplegia, diabetes mellitus, unsteadiness on feet, cerebrovascular disease, muscle weakness, hyperlipidemia, and hypertension, was assessed as cognitively intact. Her last care plan meeting was documented on February 13, 2024. During interviews, both the resident and the social worker confirmed that no subsequent care plan meeting had occurred since that date, despite the requirement for quarterly meetings. The administrator also acknowledged that care plan meetings were supposed to be held quarterly for residents.
Failure to Provide Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to provide a nutritional supplement as ordered by the physician for a resident diagnosed with diabetes mellitus. The resident was admitted with a care plan indicating a risk for nutritional problems due to poor oral intake, with a goal to maintain stable weight. Despite a physician's order for a nutritional shake three times a day to prevent weight loss, the resident did not receive the shake with his breakfast on the observed date. The resident's meal tray ticket listed the shake, but it was missing from the tray delivered by the Unit Manager, and the oversight was not corrected by the Nurse Aide responsible for checking the meal ticket against the tray contents. The Nurse Aide mistakenly believed the nutritional shakes had been discontinued due to the resident's previous refusals, and the nurse inaccurately documented that the resident consumed 50% of the shake without verifying its presence. Interviews with the Unit Manager, Dietary Manager, and Director of Nursing revealed a lack of adherence to procedures for ensuring meal tray accuracy and obtaining missing items. The Administrator confirmed that the kitchen should ensure the presence of nutritional shakes on trays, and staff should contact the kitchen for replacements if items are missing.
Improper Cleaning and Storage of Enteral Feeding Syringe
Penalty
Summary
The facility failed to properly clean and store a syringe used for enteral feeding for a resident in a persistent vegetative state with a feeding tube. The resident, who was admitted with diagnoses including muscle weakness, persistent vegetative state, and anoxic brain damage, received more than half of their total calories and fluid intake through tube feeding. Observations revealed that the syringe was stored with the plunger inside, in a plastic bag beside the resident's bed, with visible debris and liquid at the base of the plunger. This was noted on two separate occasions. Interviews with nursing staff indicated that the syringe was reused for medication administration and checking residuals. The nurses admitted to rinsing the syringe and plunger but then storing them together in a bag to dry, contrary to the facility's protocol. The Director of Nursing confirmed that the correct procedure was to clean the syringe and plunger with soap and water, dry them with a paper towel, and store them separately to dry. The failure to adhere to these procedures resulted in the observed deficiency.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, leading to a deficiency in meeting their nutritional needs. Resident #27, who was cognitively intact, expressed her dislike for green beans and carrots, which were repeatedly served to her despite being listed as disliked foods on her meal ticket. She had not been contacted by the dietary department since her readmission, as her dislikes were already recorded from a prior admission. Observations confirmed that her meal trays contained the disliked vegetables, contrary to her stated preferences. Resident #117, who was moderately cognitively impaired, also experienced a similar issue. She disliked milk, eggs, and fish, yet these items were served to her on multiple occasions. Her meal ticket clearly listed these dislikes, but observations showed that scrambled eggs and milk were still included in her meals. The Certified Dietary Manager (CDM) confirmed that residents' dislikes were recorded and should have been honored, but could not explain why these residents received foods they disliked. Interviews with dietary staff revealed a breakdown in communication and procedure. The dietary aide was responsible for reading meal tickets and informing the cook of any dislikes, but failed to do so in some instances. The evening aide relied on the dietary aide to communicate dislikes and did not independently verify the meal tickets. The Director of Nursing and the Administrator acknowledged that the residents should not have received foods they disliked, indicating a lapse in the facility's adherence to dietary protocols.
Inaccurate Documentation of Treatment and Nutrition
Penalty
Summary
The facility failed to accurately document the application of a left-hand splint for a resident, which was ordered for contracture prevention. The order specified that the splint should be applied after breakfast and removed after supper. However, on the morning of June 10, 2024, the resident reported that the splint had not been applied, and observations confirmed this. Despite this, the nurse documented in the Treatment Administration Record (TAR) that the splint was applied at 8 AM. The nurse admitted to not checking if the splint was actually applied and acknowledged that she documented it based on routine practice rather than verification. Additionally, the facility failed to accurately document the intake of a nutritional supplement for another resident. A physician's order required the resident to receive a nutritional shake three times a day with meals. On June 11, 2024, the resident did not receive the shake with breakfast, yet the Medication Administration Record (MAR) inaccurately reflected that the resident consumed 50% of it. The nurse responsible for the documentation initially claimed to have verified the intake with a nurse aide, but later realized there was a miscommunication and that the shake was not provided. The Director of Nursing and the Administrator both emphasized the importance of accurate documentation in residents' records.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of Resident #54 by not ensuring her call light was within reach, as required by her care plan. Resident #54, who was admitted with a diagnosis of intracerebral hemorrhage and was at risk for falls, was observed multiple times with her call light out of reach. Despite being moderately cognitively impaired and having functional limitations in her upper extremities, the resident was unable to reach her call light, which was hanging from the headboard on the opposite side of her bed. This situation left her unable to call for assistance, causing frustration as she had to wait for staff to enter her room. Interviews with staff, including Nurse Aide #6 and the Director of Nursing, confirmed that the call light was not within reach and that it should have been. NA #6 admitted to not ensuring the call light was accessible after leaving the resident's room, and the Director of Nursing emphasized the importance of keeping call lights within reach. The facility had longer call light cords available, but they were not utilized in this instance, leading to the deficiency in accommodating the resident's needs.
Failure to Assist Resident with Advanced Directives
Penalty
Summary
The facility failed to provide the opportunity for a resident to establish advanced directives and document this in the medical record. The facility's policy required staff to offer assistance in establishing advanced directives if a resident or their representative had not already done so, and to document the offer and the resident's decision in the medical record. However, for one resident who was cognitively intact and admitted with a diagnosis of stroke, there was no documentation indicating that the resident was offered assistance with advanced directives or that she refused such assistance. Interviews with various staff members, including the social worker, admissions director, and nursing staff, revealed that there was no recollection or documentation of conversations with the resident about establishing advanced directives. The admissions director confirmed that while she inquired about existing advanced directives upon admission, she did not offer assistance in establishing them if they were not already in place. This lack of documentation and failure to offer assistance led to the deficiency identified in the report.
Failure to Apply Hand Splint as Ordered
Penalty
Summary
The facility failed to apply a hand splint to a resident as ordered, which was necessary for maintaining and preventing further decline in the resident's range of motion. The resident, who was moderately cognitively impaired and had a history of muscle weakness, cerebral infarction, and flaccid hemiplegia affecting the left side, was supposed to have a left-hand splint applied daily after breakfast and removed after supper. Despite this order, observations and interviews revealed that the splint was not applied on multiple occasions, as confirmed by the resident and staff members. On several occasions, the resident reported that the splint was not applied, and observations confirmed the absence of the splint. Interviews with staff, including a nurse and a nurse aide, revealed that the splint was not applied as required, with the nurse aide admitting to forgetting to place it. The Director of Nursing acknowledged that the splint should have been applied as ordered, indicating a lapse in following the care plan and physician's orders for the resident's contracture prevention.
Improper Handling of Soiled Linen
Penalty
Summary
The facility failed to handle soiled linen in a manner that prevents the spread of infection for a resident reviewed for infection control and prevention. During an observation of incontinence care, a nursing assistant placed soiled bath cloths and towels directly on the floor instead of in a plastic bag as per facility protocol. After removing her soiled gloves and washing her hands, she left the room to retrieve plastic bags, returned, and then placed the soiled items into the bags. This action was contrary to the facility's policy, which requires contaminated laundry to be placed in a bag or container at the location where it is used. Interviews with staff, including the nursing assistant involved, a nurse, the Staff Development Coordinator/Infection Control Nurse, and the Director of Nursing, confirmed that the soiled linens should not have been placed on the floor. The staff acknowledged that placing soiled linens on the floor could lead to cross-contamination, as germs could be transferred to the floor and spread throughout the building. The facility's protocol was to place soiled linens directly into a plastic bag to prevent such risks, and staff had been educated on proper infection control practices.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 39 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Trace Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 12 | 2 |
| The Carrolton Of Williamston | 13.2 mi | ★★★★★ | 4 | 0 |
| Cypress Glen Retirement Community | 18.6 mi | ★★★★★ | 0 | 0 |
| Greenville Health And Rehabilitation Center | 22.3 mi | ★★★★★ | 0 | 0 |
| East Carolina Health And Rehabilitation Center | 22.4 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ridgewood Living & Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.