Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Center, Genesis Healthcare during CMS and state inspections, most recent first.
Failure to ensure access to hearing services for a resident with broken hearing aids. The resident reported difficulty hearing, said the hearing aids had been broken for a long time, and stated a pocket talker was provided but not preferred. Record review showed the resident had not been seen by audiology since the last consult, which noted the resident could not be treated until the ears were cleaned by ENT, and staff confirmed audiology had not yet seen the resident.
Controlled drug records were not maintained in sufficient detail to allow accurate reconciliation. During med pass, an LPN documented a partial Tramadol dose on the controlled drug record, but the resident’s bingo card and EMAR did not match the count recorded. In addition, repeated discrepancies were found between MARs and narcotic inventory sheets for two other residents, and a regional nurse confirmed the counts did not match.
Medication Labeling and Expired Drug Storage Deficiencies: An LPN and other staff were observed with multiple medication storage issues, including an opened lidocaine multi-dose vial with no resident identifier or opening/expiration dates, expired Depakote on a cart, and opened fluphenazine decanoate vials lacking required dating. A Medication Nursing Assistant also showed an opened fluphenazine vial in a med room with only an opening date. The DON confirmed the findings, and facility policy and CDC guidance required dating multi-dose vials and removing outdated medications.
A resident with cough, nasal congestion, and an upper respiratory infection had a STAT order for flu, RSV, and COVID testing, but the specimen was not collected until several days later. The PCR result was positive for RSV, and there was no documentation explaining the delay or showing that the provider was notified before the specimen was finally collected. The DON confirmed the findings.
Failure to follow EBP and droplet precaution PPE requirements. A resident with an indwelling Foley catheter and pressure injuries had EBP posted, but a COTA assisted with clothing changes without a gown. Several staff entered rooms of residents on droplet precautions without the PPE required by posted signs and policy, including a LNA, Maintenance Director, RN, and Laundry Aide; one staff member also left a room without discarding a used mask.
A facility failed to include focus, triggers, or interventions for PTSD in a resident's care plan, despite the diagnosis being documented in the MDS. This oversight was confirmed by the Unit Manager during an interview.
The facility failed to adhere to professional standards in medication administration and wound care for three residents. A resident reported frequent late insulin administration, confirmed by records showing significant delays. Another resident's records revealed multiple instances of late medication administration. Additionally, undated dressings and unclear documentation were observed for two residents, indicating a lack of proper wound care management.
A facility failed to ensure a resident attending dialysis received necessary medications and care. The resident's MAR showed missed doses of Calcium Acetate and Midodrine HCL on dialysis days, with no orders to hold these medications. The care plan lacked details on the dialysis access site and necessary interventions. Staff confirmed these deficiencies.
The facility failed to store food trays in a dry and sanitary condition, as observed when a Dietary Aide dried wet trays with a dish towel. The Dietary Manager confirmed the trays were stored wet the previous night, violating FDA Food Code standards for air-drying equipment and utensils.
A facility failed to maintain complete medical records for a resident who passed away. The nursing progress note only recorded the time of death and that two RNs pronounced it, omitting required documentation such as clinical criteria for death determination. The facility's policy mandates detailed documentation, including assessment findings and notifications, which was confirmed by the DON.
A facility failed to prevent bloodborne pathogen exposure by using one insulin pen for two residents on multiple occasions. An LPN administered insulin from a pen designated for one resident to another, violating manufacturer instructions and facility policy. This practice was not initially recognized by another LPN, leading to repeated use of the pen for the original resident.
Failure to Ensure Access to Hearing Services
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain hearing abilities for one resident reviewed for communication-sensory concerns. The resident reported difficulty hearing and stated that hearing aids had been broken for a long time, with a long wait to be seen for new hearing aids. The resident also said the facility was aware of the issue and had provided a pocket talker, but the resident did not like using it and wanted hearing aids instead. Record review showed a care plan meeting note indicating the Unit Manager would check whether the resident was on the list to be seen by the audiologist, and the medical record showed the last audiology consult was on 10/18/24. That consult documented a recommendation for referral due to recent decreases in responsiveness, but a follow-up visit on 10/24/24 noted the resident was not to be treated because the ears had not been cleaned by ENT, and the resident could be added back to the audiology list once the ears were cleaned. Staff confirmed the resident had not been seen by audiology.
Controlled Drug Records Did Not Match Medication Administration and Inventory Counts
Penalty
Summary
The facility failed to establish and maintain a system of records of receipt and disposition of controlled drugs in sufficient detail to allow accurate reconciliation for two residents reviewed for new admissions and one resident observed during medication administration. For one resident, during medication pass, an LPN placed one-half tablet of Tramadol 50 mg into a medication cup and documented on the controlled drug record that one-half tablet had been given with 18 half-tablets remaining, while the bingo card showed 17 half-tablets present. The resident’s controlled drug record contained only a single entry for that dose, and the EMAR showed Tramadol 25 mg had already been administered earlier that day. The LPN confirmed the controlled drug record was not documented correctly for the administered dose. For two other residents, review of the MARs and narcotic inventory sheets showed repeated discrepancies between the number of doses documented on the MAR and the counts recorded on the narcotic inventory sheets. For one resident, discrepancies were identified on multiple February dates, with counts differing between the two records on each reviewed date. For the other resident, similar discrepancies were identified across multiple January dates, with the MAR and narcotic inventory sheets showing different numbers of doses on each listed date. A regional nurse confirmed that the narcotic count sheets did not match the residents’ MARs. The facility policy stated that discrepancies noted at any step of the process are to be reported and that the nursing supervisor is to be notified and immediately initiate an investigation using the controlled drug discrepancy form.
Medication Labeling and Expired Drug Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications were appropriately labeled on 2 of 3 medication carts observed and 1 of 2 medication rooms observed, and failed to ensure expired medication was removed from a medication cart on 1 of 3 medication carts observed. During observation of the 3rd Floor South medication cart, an opened lidocaine 1% multi-dose vial had no resident identifier, no date of opening, and no date of expiration. The same cart also contained 7 Depakote DR 125 mg tablets for Resident #71 with an expiration date of 2/26. Staff A, an LPN, confirmed these findings during the observation. During observation of the 2nd Floor North medication cart, two opened multi-dose vials of Resident #66's fluphenazine decanoate injection had no date of opening and no date of expiration, and Staff B, an LPN, confirmed the findings. In the 2nd Floor medication room, one opened multi-dose vial of Resident #66's fluphenazine decanoate injection was labeled with a date of opening of 7/3, and Staff C, a Medication Nursing Assistant, confirmed the observation. Review of facility policy stated outdated medications are to be immediately removed from stock, and another policy stated nursing staff should document the date opened on multi-dose vials. The facility also provided CDC safe injection practices stating multi-dose vials should be dated when first opened and discarded within 28 days unless the manufacturer specifies otherwise. The DON confirmed the findings and stated the facility follows the CDC recommendations and that the pharmacy reviewed the manufacturer's instructions for multi-dose vials.
Delayed Respiratory Lab Testing and Notification
Penalty
Summary
The facility failed to provide laboratory services as ordered for a resident with cough, nasal congestion, and an upper respiratory infection. A provider note dated 1/31/26 ordered STAT testing for flu, RSV, and COVID, and the resident’s active orders reflected the diagnostic test order. However, the respiratory multiplex PCR specimen was not collected until 2/3/26, four days after the order date, and the laboratory received and reported the results on 2/4/26. The resident tested positive for RSV. Review of the resident’s progress notes found no documentation explaining why the specimen was not collected sooner, and there was no documentation that a provider was notified about the delay before 2/3/26. The DON confirmed these findings during interview.
Failure to Follow EBP and Droplet Precaution PPE Requirements
Penalty
Summary
The facility failed to follow its infection prevention and control policies for Enhanced Barrier Precautions and Transmission Based Precautions for residents with pressure injuries, an indwelling urinary catheter, and respiratory infections. Resident #9 had EBP posted outside the room for an indwelling Foley catheter and pressure injuries, but a COTA entered the room wearing only a mask and gloves while assisting the resident with changing clothes and did not don a gown. The COTA also stated they did not see the EBP sign on the door. For residents on droplet precautions, staff entered rooms without using the PPE required by the posted signs and facility policy. A LNA entered Resident #37’s room for breakfast setup without gown and gloves and left without discarding the mask. A Maintenance Director entered Resident #93’s room wearing only a surgical mask. An RN and an LNA exited Resident #100’s room without changing their surgical masks, and a Laundry Aide entered and exited Resident #102’s room wearing only a surgical mask. The facility policy for droplet precautions required a facemask for close contact and, when indicated, gloves, gown, and eye protection.
Failure to Address PTSD in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). During a review of the resident's medical records, it was noted that the diagnosis of PTSD was documented in the Admission Minimum Data Set (MDS). However, the resident's comprehensive care plan lacked any focus, triggers, or interventions related to PTSD. This deficiency was confirmed during an interview with the Unit Manager, who acknowledged the absence of these critical elements in the care plan.
Medication and Wound Care Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of care in the administration of medications for three residents. Resident #73 reported frequent late administration of insulin, with records confirming multiple instances where insulin was administered significantly later than the scheduled time. This included delays of over three hours on several occasions, which were confirmed by the Director of Nursing. Resident #101 also expressed concerns about the timeliness of medication administration. A review of their medication records revealed numerous instances where insulin and other medications were administered well beyond the acceptable time frame. This included insulin being given several hours late and other medications being administered hours after the scheduled time, which was again confirmed by the Director of Nursing. Additionally, the facility failed to properly document and manage wound care for Resident #273 and Resident #101. Observations revealed undated dressings on Resident #273's knee and multiple undated dressings on Resident #101's leg. There was also a lack of clear documentation regarding the dressing orders for Resident #101, as confirmed by a registered nurse. These deficiencies indicate a failure to maintain professional standards in medication administration and wound care management.
Failure to Provide Appropriate Dialysis Care and Medication Administration
Penalty
Summary
The facility failed to provide appropriate dialysis care and medication administration for a resident who attends dialysis three times a week. The resident was not administered physician-ordered medications, Calcium Acetate and Midodrine HCL, on specific dates when they were away for dialysis, as indicated by the Medication Administration Record (MAR) entries marked as 'AW' (away from center). There were no documented orders to hold these medications on dialysis days. Additionally, the resident's care plan did not specify the type of dialysis access site or include interventions to care for and monitor the access site. Interviews with staff confirmed the absence of necessary orders and care plan details, leading to the deficiency in care for the resident requiring dialysis services.
Improper Storage of Food Trays in Kitchen
Penalty
Summary
The facility failed to ensure that food trays were stored in a dry and sanitary condition in the main kitchen, as required by the U.S. FDA Food Code. During an observation, it was noted that Staff J, a Dietary Aide, picked up trays that were stored wet in a large stack and proceeded to dry each tray with a dish towel. This action was contrary to the FDA Food Code, which mandates that equipment and utensils must be air-dried or adequately drained before coming into contact with food and should not be cloth dried unless they have been air-dried first. An interview with Staff L, the Dietary Manager, confirmed the findings and revealed that the trays had been stored wet the previous night. The FDA Food Code specifies that cleaned equipment and utensils should be stored in a clean, dry location, not exposed to splash, dust, or other contamination, and should be stored in a self-draining position that allows air drying. The facility's failure to adhere to these standards resulted in the deficiency noted by the surveyors.
Incomplete Documentation of Resident Death
Penalty
Summary
The facility failed to maintain complete medical records for a resident who passed away, as evidenced by the review of the nursing progress note. The note, dated January 4, 2025, indicated the time of death and that two RNs pronounced the death, but lacked further required documentation. According to the facility's policy on pronouncement of patient death, effective May 1, 2023, the RN is required to document specific clinical criteria for determining and pronouncing death. This includes a description of the discovery of the patient, any treatment undertaken, findings from assessment such as absence of pulse and respirations, fixed pupils, and lack of response to stimuli, as well as the date and time of death, individuals notified, and results of any communications. An interview with the Director of Nursing confirmed the expectation that all clinical signs of death should be documented in the medical record.
Improper Use of Insulin Pen for Multiple Residents
Penalty
Summary
The facility failed to ensure residents were free from exposure to bloodborne pathogen transmission when staff used one insulin pen to administer insulin to two residents on multiple days. Specifically, a Licensed Practical Nurse (LPN) used a Lantus insulin pen designated for one resident to administer insulin to another resident on two consecutive days. This pen was then returned to the medication cart and subsequently used again for the original resident without the knowledge of another LPN, who was unaware of the pen's prior use for a different resident. The facility's records confirmed that both residents had active physician's orders for Lantus insulin, which was administered according to the schedule. However, the use of a single insulin pen for multiple residents contravened the manufacturer's instructions, the facility's pharmacy policy, and the Centers for Disease Control and Prevention (CDC) guidelines, all of which emphasize that insulin pens are for single-patient use only to prevent the risk of bloodborne pathogen transmission.
Removal Plan
- QA meeting was conducted
- The provider evaluated Resident #1 and Resident #2 and ordered Hepatitis panel and HIV blood tests and a retest for the hepatitis panel and HIV blood test was ordered
- Facility-wide audit of all residents insulin availability was conducted
- Education and competencies of facility's medication availability protocol, facility's insulin pen policy, and CDC's injection safety were conducted
- Insulin inventory sheet was created and initiated
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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 Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bedford Hills Center | 0.3 mi | ★★★★★ | 2 | 0 |
| Bedford Nursing & Rehabilitation Center | 1.2 mi | ★★★★★ | 7 | 1 |
| Maple Leaf Health Care Center | 2.8 mi | ★★★★★ | 2 | 0 |
| Mount Carmel Rehabilitation And Nursing Center | 3 mi | ★★★★★ | 0 | 0 |
| Hanover Hill Health Care Center | 3.1 mi | ★★★★★ | 2 | 0 |
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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.