Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ridgewood Rehabilitation & Care Center during CMS and state inspections, most recent first.
A resident did not sign the SNF ABN or NOMNOC before Medicare coverage ended. The SSD told the POA that the last covered day was the same day, but both notices were not signed until two days later. The SSD confirmed the POA could not sign in person and had not given verbal permission during the phone call.
Hand hygiene and food storage practices were deficient when kitchen staff failed to clean hands before gloving, after touching raw shrimp, and after removing gloves during food prep. Surveyors also found multiple open, undated, unlabeled, and uncovered food items in the satellite kitchen and walkway refrigerator, and the Dietician stated there was no policy for food storage.
An infection control deficiency occurred during wound care for two residents when staff did not follow hand hygiene and glove-use standards. An IP performing sterile nephrostomy dressing changes used incorrect handwashing technique, turned off the faucet with bare hands, waved hands in the air to dry, and reused sterile gloves after touching the sterile field. An LPN changing a wound dressing did not change gloves after removing the soiled dressing before cleaning the wound, touched the resident curtain with soiled gloves, applied cream with a gloved finger, and did not date or initial the dressing.
The facility did not ensure that two nursing assistants completed the required 12 hours of in-service training for 2024. NA-D completed 8.59 hours and NA-E completed 11.05 hours of education through Relias. Interviews with the IP/SD confirmed the deficiency, which had the potential to affect all 57 residents.
The facility's Life Enrichment kitchen, serving 10-12 residents, was found to have unclean appliances, including a microwave with food splatters and a refrigerator/freezer with food drippings. Cleaning logs for the past two months were incomplete, despite a schedule requiring daily cleaning. The facility's RD and Administrator confirmed these findings.
A facility failed to obtain a physician's order for the settings of a CPAP machine for a resident with Obstructive Sleep Apnea. The resident had moderate cognitive impairment and was prescribed CPAP use at bedtime, but the specific settings were not documented. An interview with the ADON confirmed the absence of CPAP settings, and facility education materials lacked instructions on CPAP settings.
A facility failed to provide justification for extending PRN Alprazolam use beyond 14 days for a resident with anxiety disorder, dementia, and other conditions. The physician did not document the rationale for the extended prescription, and facility records lacked documentation of behaviors justifying the medication's use on several occasions. Observations showed the resident appeared calm, questioning the necessity of the PRN medication.
Two residents in a LTC facility experienced significant medication errors due to staff not following proper procedures. One resident received Phenobarbital from an LPN who did not verify the medication, while another resident with diabetes received insulin without the pen being primed, contrary to policy. These actions were against the facility's medication administration protocols.
The facility failed to label and date food stored in the Life Enrichment refrigerator and freezer as per policy. Observations revealed various food items, including grapes, cake, cheese, beef snack sticks, and ice cream, were not properly labeled or dated. The RD confirmed the non-compliance with the facility's Visitor Food policy, which requires food to be labeled, dated, and stored safely.
The facility failed to maintain proper infection control practices, as evidenced by improper catheter care for two residents and inadequate cleaning of nebulizer kits for three residents. A nursing assistant used contaminated gloves and failed to perform hand hygiene during catheter care, while nebulizer kits were left with residual medication and facial oils, indicating they were not cleaned after use. These deficiencies were confirmed by facility staff and highlight systemic issues in infection control.
The facility failed to properly label and date food items, ensure proper handwashing techniques by kitchen staff, maintain cleanliness in storage areas, and test the sanitizing solution. These deficiencies were confirmed by the cook and RD, affecting the safety and quality of food served to residents.
The facility failed to ensure the oxygen concentrator's cabinet filters were present and clean for four residents, and the PAP masks for two residents were cleaned daily. Additionally, the PAP filter for one resident was not clean. Observations and interviews confirmed that the required maintenance and cleaning were not performed consistently.
A resident with multiple medical conditions was frequently observed with thick oral secretions extending from their mouth to their lap. Despite having a suction machine in the room, it was not set up or used as per physician orders. Staff only suctioned the resident when they choked during oral care, leading to a deficiency in maintaining the resident's dignity and proper care.
Late Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure that Resident 33 signed the SNF ABN and NOMNOC before Medicare coverage ended. A progress note dated 03/11/2026 at 1729 showed that the SSD contacted the resident’s POA to inform them that 03/11/2026 would be the last covered day for Medicare SNF services. Record review showed that both the SNF ABN and the NOMNOC were not provided and signed until 03/13/2026, which was two days after the last covered day. During interview on 06/03/2026 at 11:30 AM, the SSD confirmed that the resident did not sign either notice until 03/13/2026 and that the POA could not sign in person and had not given verbal permission during the phone call about the last covered day.
Hand Hygiene and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure kitchen staff performed hand hygiene during food preparation and failed to properly store opened food in the satellite kitchen. Record review of the Nebraska Food Code and the facility hand hygiene competency showed that food employees should clean their hands before food preparation, during preparation as needed to prevent cross contamination, when switching between raw and ready-to-eat food, before donning gloves, and after activities that contaminate the hands. The facility also had no policy for food storage, according to the Dietician. During observation of the satellite walkway refrigerator, surveyors found an open half gallon of chocolate milk with no open date, a pitcher of light-colored brown liquid with no date or label, an open water bottle with no date, and two uncovered glasses filled with orange liquid. In the satellite kitchen refrigerator, surveyors observed two bottles of unlabeled and undated dressings and an opened, unsealed, undated bag of hashbrowns. During food preparation, Culinary Assistant-A did not perform hand hygiene before putting on gloves, touched shrimp, removed gloves without hand hygiene, used utensils to stir the shrimp, cleaned spices from the counter, and wiped the counter with a reusable towel draped and damp over the sink. The assistant later completed hand hygiene, but did not don gloves before transferring cooked shrimp to a separate container, and during preparation of an alternate no garlic plate, handled raw shrimp without gloves, did not perform hand hygiene, and then touched the refrigerator and cleaned the counter with the same reusable towel. Culinary Assistant-B confirmed the open, undated, and unlabeled items in the satellite kitchen, and Culinary Assistant-A confirmed not completing hand hygiene after touching shrimp and after removing gloves on two occasions.
Infection Control Failures During Wound Care
Penalty
Summary
The facility failed to follow infection control standards of practice during wound care, including hand hygiene and glove use, during dressing changes for two residents. The report cites the facility’s hand hygiene competency and wound dressing application procedures, which required hand hygiene before and after gloving, after touching a resident or contaminated items, and proper handwashing technique with soap and water or hand sanitizer. The facility census was 62, and the deficiency affected 2 of 3 residents observed for wound care. Resident 13 was admitted with diagnoses including renal tubule-interstitial disease and bladder cancer, and had nephrostomy tubes present on admission. The resident had an order for weekly sterile dressing changes to the nephrostomy tube dressings. During observation of the Infection Preventionist performing bilateral nephrostomy dressing changes, hand hygiene was not performed according to the facility’s competency: soap-and-water handwashing lasted only five seconds at one point and seven seconds at another, the faucet was turned off with bare hands instead of a paper towel, and hands were waved in the air to dry. The Infection Preventionist also used hand sanitizer and waved hands in the air rather than rubbing until dry, and reused the same pair of sterile gloves after touching and repositioning them on the sterile field. Resident 6 was observed during wound care performed by an LPN. The LPN entered the room with gown and gloves, removed the old dressing, and did not change gloves before cleaning the wound. The wound was cleaned multiple times with gauze, the resident curtain was moved with soiled gloves, and hand hygiene was performed after glove removal but without paper towels available. The LPN later re-entered the room with new gown and gloves, applied cream to the wound with a gloved finger, applied dressings, and did not date or initial the dressing. The LPN confirmed that gloves were not changed after removal of the dirty dressing and before cleaning the wound, and the Administrator confirmed the expected sequence was to remove gloves, perform hand hygiene, and apply new gloves after removing the soiled dressing.
Deficiency in Required In-Service Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that two nursing assistants, NA-D and NA-E, completed the required 12 hours of in-service training for the year 2024, as mandated by licensure reference number 175 NAC 12.006.04(B)(ii)(1). Record reviews revealed that NA-D completed only 8.59 hours and NA-E completed 11.05 hours of education through Relias, a healthcare training provider. NA-D was hired on July 11, 2013, and NA-E on December 17, 2022. Interviews with the Infection Preventionist/Staffing Development (IP/SD) confirmed that the facility's training year runs from January 1st to December 31st, and both nursing assistants did not meet the required training hours for 2024. This deficiency had the potential to affect all 57 residents in the facility.
Unclean Kitchen Appliances in Life Enrichment Kitchen
Penalty
Summary
The facility failed to maintain cleanliness in the Life Enrichment kitchen, which serves food to 10-12 residents. Observations revealed that the microwave had multi-colored food splatters and debris, while the refrigerator/freezer contained food drippings and debris. A review of the facility's Deep Cleaning schedule indicated that these appliances should have been cleaned daily. However, the Weekly Cleaning logs for the past two months did not show completion of these tasks. Both the facility's Registered Dietician and Administrator confirmed the unclean state of the kitchen appliances.
Failure to Obtain CPAP Settings for Resident
Penalty
Summary
The facility failed to obtain a physician's order for the settings of a CPAP machine for a resident diagnosed with Obstructive Sleep Apnea. The resident, who was admitted to the facility with moderate cognitive impairment, had a physician's order for CPAP use at bedtime and discontinuation in the morning. However, the specific settings for the CPAP machine were not documented in the physician's orders, care plan, or treatment administration record. An interview with the Assistant Director of Nursing confirmed the absence of CPAP settings for the resident. Additionally, the facility's educational materials on CPAP/Bi-Level units did not include instructions regarding the CPAP settings.
Failure to Justify Extended PRN Use of Alprazolam
Penalty
Summary
The facility failed to provide a valid rationale and justification for extending the use of PRN Alprazolam (Xanax) for a resident beyond the 14-day limit. The resident, who had a history of anxiety disorder, pain, dementia, COPD, and pneumonia, was prescribed Alprazolam to be taken twice daily and as needed every eight hours for anxiety. However, the physician did not document the rationale for the PRN prescription exceeding 14 days, as required by regulations. The facility's records, including the Physician Visit/Communication Form, did not include any justification for the extended use of the medication. Additionally, the facility's documentation did not support the administration of PRN Xanax on several occasions, as there were no documented behaviors or clinical indications justifying its use on those dates. Observations of the resident showed that they appeared calm and in no distress, further questioning the necessity of the PRN medication. The facility's administrator confirmed the lack of documented rationale and behaviors to justify the use of Xanax on specific dates, indicating a failure in adhering to the required medication management protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For Resident 5, a Registered Nurse (RN) improperly removed a Phenobarbital pill from the narcotic drawer and handed it to a Licensed Practical Nurse (LPN-A) for administration, which is against the facility's policy. The LPN-A then administered the medication to Resident 5 via a peg tube without verifying the medication against the medication record, which was confirmed as the normal practice for this resident. Interviews with the RN and LPN-A confirmed the improper handling and administration of the medication. For Resident 36, who has a history of Type 2 Diabetes Mellitus and moderate cognitive impairment, a medication error occurred during insulin administration. The LPN-B administered 21 units of Novolog insulin without priming the needle, contrary to the facility's Pre-filled Insulin Pen Competency Policy. The policy requires priming the pen before each administration to ensure the correct dose is delivered. The LPN-B was under the impression that priming was only necessary the first time the pen was used, which was incorrect according to the Interim Director of Nursing (DON). These incidents highlight a failure in following established medication administration protocols, leading to significant medication errors for both residents. The facility's policies clearly outline the correct procedures for medication handling and administration, which were not adhered to in these cases, resulting in deficiencies noted by the surveyors.
Improper Labeling and Dating of Resident Food
Penalty
Summary
The facility failed to ensure that food stored in the Life Enrichment refrigerator and freezer was properly labeled and dated according to the facility's Visitor Food policy. During observations on multiple occasions, it was noted that various food items, including grapes, cake, cheese, beef snack sticks, and ice cream, were not labeled with the resident's full name or dated. The facility's policy requires that food brought in by visitors for residents be labeled, dated, and stored safely in a designated area following food safety guidelines. The Registered Dietician (RD) confirmed the observations, acknowledging that the items in the refrigerator and freezer should have been sealed, labeled with the resident's name, and dated with the date they were placed in storage. Despite the facility's policy, the food items were found to be non-compliant, lacking proper labeling and dating, which is essential for maintaining food safety and ensuring that residents receive safe and appropriate food storage.
Infection Control Deficiencies in Catheter and Nebulizer Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several observations and interviews. Resident 4's catheter care was compromised when a nursing assistant (NA-C) used contaminated gloves to handle cleansing wipes and failed to perform hand hygiene after removing gloves. The NA-C also touched the resident's catheter tubing without gloves and engaged in other activities of daily living without washing hands. These actions were confirmed by both the interim Director of Nursing (DON) and the NA-C, who acknowledged the lapses in infection control procedures. Resident 11's catheter care was similarly deficient. The NA-C placed the catheter drainage bag on the floor and used contaminated gloves to handle cleansing wipes. The NA-C did not perform hand hygiene or change gloves during the procedure, which was confirmed by both the interim DON and the NA-C. Additionally, the facility lacked a specific catheter care policy, which contributed to the improper handling of the catheter drainage bag and the failure to maintain proper hygiene. The facility also failed to properly clean nebulizer kits for Residents 2, 22, and 50. Observations revealed that the nebulizer kits were left with residual medication and facial oils, indicating they were not cleaned after use. The Assistant Director of Nursing (ADON) confirmed that the nebulizer kits should have been cleaned and dried after each treatment, as per the facility's policy. These deficiencies in infection control practices were observed across multiple residents, highlighting a systemic issue within the facility.
Multiple Deficiencies in Food Storage, Handwashing, and Sanitizing Procedures
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items stored in refrigerators and freezers. Observations revealed multiple opened containers and bags of food items, such as chicken base, mozzarella cheese, and various vegetables, that were not labeled or dated. The facility's cook and Registered Dietician (RD) confirmed these items should have been labeled and dated after being opened. Additionally, food stored for residents in the side-by-side refrigerator/freezer in the North dining room was also found to be improperly labeled and dated, with items such as a bowl covered with plastic wrap and a green cup without proper labeling or dating. The facility also failed to ensure proper handwashing techniques were followed by kitchen staff. Observations showed the cook performing handwashing for only 12 seconds and changing gloves multiple times without washing hands in between tasks. The RD confirmed that the cook should have washed hands for at least 20 seconds and performed handwashing before and after glove changes. Furthermore, the floors in the walk-in refrigerator, walk-in freezer, and locked dry storage room were found to be dirty, with gray fuzzy substances and scattered food items observed. The cook and RD confirmed that these areas should have been clean. Lastly, the facility did not test the sanitizing solution in the sanitizing bucket to ensure its effectiveness. The cook was observed wiping the prep table with a rag from the sanitizing bucket without testing the solution's dilution. A review of the kitchen's logbooks revealed no records of testing the sanitizing bucket. The cook confirmed that the sanitizing bucket had not been tested since being re-hired and should have been tested twice a day to ensure the sanitizer was effective. The RD also confirmed that the sanitizing bucket should have been tested regularly.
Failure to Maintain Oxygen Concentrator Filters and Clean PAP Masks
Penalty
Summary
The facility failed to ensure the oxygen concentrator's cabinet filters were present and clean for four residents (Residents 2, 4, 31, and 60) out of five sampled residents. Observations revealed that the oxygen concentrators in the rooms of these residents were missing cabinet filters, which should have been cleaned and replaced weekly. Interviews with staff confirmed that the filters were not maintained as required, leading to the presence of gray fuzzy substances on the internal filters of the concentrators. The Assistant Director of Nursing (ADON) confirmed that the external cabinet filters should have been cleaned and replaced every week, but this was not done consistently. Additionally, the facility failed to ensure that the positive airway pressure (PAP) masks for two residents (Residents 2 and 60) were cleaned daily. Observations showed that the PAP masks had an oily film on the mask seals, indicating they were not wiped daily as required by the facility's policy. Interviews with the residents and staff confirmed that the masks were only cleaned weekly, not daily. The ADON acknowledged that the staff did not follow the policy for daily cleaning of the PAP masks. Furthermore, the facility did not ensure that the PAP filter for one resident (Resident 20) was clean. Observations revealed that the PAP filter had a gray fuzzy substance on it, indicating it had not been cleaned or replaced as required. Interviews with the resident and staff confirmed that the filter maintenance was not performed as per the manufacturer's recommendations. The ADON confirmed that the PAP filter should have been cleaned and changed but was not, leading to the deficiency.
Failure to Manage Resident's Oral Secretions
Penalty
Summary
The facility failed to ensure the dignity of a resident by not properly managing their oral secretions. Resident 4, who has multiple medical diagnoses including Cerebral Palsy and Dysphagia, was observed multiple times with thick strands of secretions extending from their mouth to their lap. Despite having a suction machine in the room, it was not set up or used as per the physician's orders, which stated that the resident should be suctioned orally as needed every hour for secretions. Staff confirmed that they only suctioned the resident when they choked during oral care, and not as a routine measure to manage the secretions. Observations over several days revealed that the resident was frequently seen with thick secretions and a towel covering their chest and abdomen, which was held by clips around the neck. The suction machine in the resident's room was consistently found without the necessary canister or tubing set up, rendering it unusable. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the presence of thick secretions was considered normal for the resident, and the staff did not routinely suction the resident unless they were choking. The Administrator acknowledged that the excessive secretions could be a dignity issue and admitted that the staff had not attempted to suction the resident throughout the day to see if it would reduce the secretions. The facility did not know how the resident felt about the excessive secretions and the use of a towel to protect their clothing. This lack of action and failure to follow physician orders led to the deficiency in maintaining the resident's dignity and proper care.
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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 Seward
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Milford Meadows Care Center | 11.1 mi | ★★★★★ | 1 | 0 |
| Eventide Crete | 22.2 mi | ★★★★★ | 0 | 0 |
| Emerald Nursing & Rehab Lancaster Llc | 22.5 mi | — | 17 | 0 |
| Brookestone Of David City | 22.5 mi | ★★★★★ | 8 | 0 |
| Sumner Place | 23.1 mi | ★★★★★ | 0 | 0 |
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