Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Center during CMS and state inspections, most recent first.
Failure to Monitor Antibiotic Use and Report ASP Data in QAPI: The facility did not ensure its ASP policy included QAPI reporting, did not consistently use the IST/McGeer criteria for prescribed antibiotics, and did not maintain evidence of ongoing analysis of surveillance data with documented follow-up. The DON could only produce pharmacy printouts listing residents on antibiotics, and QAPI records showed multiple meetings without ASP, IST, or McGeer reports or analysis. The IPN stated she handled infection control and ASP tasks, but the facility was unable to locate the required ASP and surveillance documentation.
Dirty PTAC Filters Throughout Facility: Surveyors observed clogged and dirty PTAC filters throughout the facility during a tour, affecting 28 of 28 PTAC units. The MD and RPOD confirmed the findings, and a PTAC maintenance policy and procedure was requested but not provided at the LSC exit conference.
A resident with dementia and extensive care needs was found without a call bell within reach, and the roommate’s call bell cord was broken. Surveyors also observed peeling molding, chipped wood, cracked ceilings, stained ceiling tiles, dusty vents, cobwebs, ripped screening, and other damaged or dirty conditions in resident rooms, hallways, shower rooms, and the dining/activity area. Facility staff acknowledged several of the environmental issues and stated some should have been cleaned or repaired.
A resident with an indwelling catheter was observed with the drainage bag hung above bladder level and not placed in a privacy bag, and another resident’s catheter bag was also visible from the hallway without a privacy bag. Neither resident had EBP signage on the door, and the first resident’s care plan did not include EBP interventions. Staff interviews confirmed that catheter bags should be below the bladder, in a privacy bag, and that residents with indwelling catheters should have EBP signage.
Respiratory equipment was not handled according to infection control practices for two residents receiving O2 and neb treatments. Surveyors observed O2 tubing without dates or labels, neb masks and BiPAP masks left loose or not stored in bags, and one resident’s O2 setup lacked a cautionary sign on the door. Staff, including an LPN, RN, DON, and regional staff, acknowledged that tubing should be dated and masks stored in plastic bags, and facility policies required labeling and proper storage of respiratory equipment.
Surveyors found that staffing shortages led to delayed breakfast delivery, cold food, slow call bell response, and incomplete eMAR/eTAR documentation. Residents reported late trays and cold meals, and staff acknowledged that breakfast arrived late and that nurses and CNAs had to cover multiple duties, including meal distribution and feeding. A resident with severe cognitive impairment and significant medical needs also had multiple blank medication and treatment record entries, which the DON and unit manager said should not occur.
Missing Annual CNA Performance Evaluations: The facility failed to ensure annual performance evaluations were present for 5 of 5 CNA files reviewed. Surveyors repeatedly requested the records from the LNHA, DON, HR staff, and Regional Nurse, but the documentation was not provided. The LNHA acknowledged the missing file records, and the Regional Nurse stated they did not think the evaluations were available.
Infection Preventionist Not Properly Designated or Trained: The facility failed to ensure the designated IP worked at least part-time and completed required infection prevention training before taking on the role. Surveyors found that multiple IPs assumed duties without completed certification, no signed job descriptions were in the files, and there were periods when no designated IP was present. Records also showed the IP sometimes worked direct care RN shifts rather than serving consistently in the IP role.
Failure to Offer and Document Flu and Pneumonia Vaccinations: The facility did not document offering flu vaccines to two residents, and a third resident with Parkinson's disease, cognitive impairment, and dementia had no evidence of current flu or pneumonia vaccination status in the chart. Record review and staff interviews confirmed that the immunization records and unit charts did not show the vaccines were offered or up to date, and the LPN/UM stated the residents should have been offered the flu vaccine.
Missing CNA Training and Competency Documentation: The facility failed to maintain and provide required in-service education and annual competency/performance records for 5 of 5 CNA employee files reviewed. The surveyor made repeated requests to the LNHA, DON, HR staff, and Regional Nurse for the files, but the facility did not provide documentation showing completed staff training or competency records.
A resident with moderately impaired cognition reported that their bathroom toilet was flooded and unusable, requiring them to go by themself in a wheelchair to another bathroom after telling a caregiver. Surveyors repeatedly observed the bathroom toilet clogged or flooded with discolored water, feces, and tissues, with towels placed over the wet floor. The facility’s policy stated residents have the right to considerate care that safeguards personal dignity and that they are to be treated with respect and dignity.
A resident with Parkinson’s disease, dementia, psychosis, depression, and anxiety was restarted on Seroquel for target behaviors including agitation, pacing, combativeness, yelling, and psychosis. Record review and staff interview found no documentation that the RR was informed in advance of the risks, benefits, options, and alternatives when the antipsychotic was ordered again, despite the resident’s severely impaired cognition and the facility policy requiring patient and/or representative consent.
Telephones and call devices were not readily accessible for multiple residents. A resident with intact cognition reported no phone in the new room after a room change, and surveyors observed two other residents with call devices out of reach, including one device under the bed and another on the floor with frayed wires and broken pieces. The RN and DON stated that room phones should be available, and the resident with the damaged call device said the facility had already been told about it and that it felt unsafe to use.
A resident’s SNF ABN listed that Medicare Part A coverage had ended and that the resident would be responsible for certain services if other insurance did not pay, but the form did not include any written dollar amount for the services. The CRC said she generated the notice and the BOM was responsible for delivery; the BOM confirmed the amount was omitted because she had notified the resident representative verbally. Record review showed the resident’s Part A stay had ended and the resident was later transferred for hospice care.
Missing Reference Checks in New Hire Files: The facility failed to ensure required reference checks were completed for newly hired employees. Review of 33 personnel files found 13 missing reference checks, despite the hiring policy requiring at least two professional references for external candidates and verification of required post-offer documents. The LNHA stated HR and Staffing handle the paperwork and submit it for Administrator approval, and the Regional Market Director described a plan to reeducate DON, UM, Staff/Payroll, and HR on the hiring process and use a checklist with sign-off before hire approval.
A resident had an unplanned hospital transfer after being found with labored respirations and worsening condition, with the NP notified and 911 used for transport. The facility did not document providing the resident or RR with the required written bed hold notice with reserve payment information, and it also did not send the emergency transfer notice to the LTCO as required by policy.
A resident receiving TF had a water flush bag that was not dated, and the resident’s diagnosis of C. auris was not entered in the medical record diagnosis section or active diagnoses despite hospital transfer documents showing colonization and contact precautions. In a separate review, another resident had conflicting PRN pain orders, duplicate sacral treatment orders, and no documented MRR identification of the irregularities; the CP stated the PRN orders should have been sequenced and separated and the duplicate orders should have been identified.
A resident with chronic respiratory failure and a stage 4 pressure ulcer had WCCP wound care orders for cleansing, packing, collagen powder, and a silicone bordered dressing, but the facility did not follow the ordered treatment. Staff stated that WCCP recommendations were typically followed unless the primary physician disagreed, and there was no documentation that the physician did not agree with the order.
Staffing Report Not Posted and Updated Each Shift: Surveyors found the NHRCSR was not posted over the weekend and was not updated with accurate census information. An HRS member said she did not realize the report needed weekend updates, and the LNHA said he thought the HRS member was posting it as required. A later review found the posted report listed an incorrect census, and the facility policy required the report to be completed daily at the beginning of each shift.
Improper Medication Storage and Labeling: A survey found medications and biologicals improperly stored and labeled in a med cart and med room. An opened inhalation solution pouch lacked a date of opening, and the med room contained an expired and used insulin pen with no resident label, an unlabeled inhalation vial, opened and expired glucose control solutions, and an expired insulin vial. The RN stated expired meds should have been discarded, and the facility policy required expired, discontinued, and contaminated meds to be removed from storage.
Improper Holding Temperatures During Breakfast Service: During breakfast meal service, a surveyor observed that trays for one wing were delayed while other residents had already been served. When the last tray was checked, hot items were at acceptable temperatures, but milk was 51 degrees Fahrenheit, above the expected cold holding temperature of less than 45 degrees Fahrenheit. The FSD and RFSD acknowledged the temperature concern, and the facility policy required cold foods to be held at 41 degrees Fahrenheit or below.
Surveyors found multiple infection control failures, including empty soap dispensers in shower/bath areas, dirty conditions in the laundry room, uncovered clean linens exposed to dust and airflow, an eyewash station with visible buildup and an outdated flushing log, and improper hand hygiene by an RN during med pass. A laundry staff member placed linen that touched the dusty floor back with clean linens, and facility leaders confirmed several of the observed conditions were not appropriate.
Failure to Monitor Antibiotic Use and Report ASP Data in QAPI
Penalty
Summary
The facility failed to ensure that its Antibiotic Stewardship Program (ASP) policy and procedure, which was part of the Infection Prevention and Control Program (IPCP), included a procedure for reporting in QAPI. The facility also failed to consistently use the standardized infection assessment tool or management algorithm (IST) for prescribed antibiotics and failed to maintain evidence of ongoing analysis of surveillance data for organisms with documented follow-up in response to the collected data. The report states that these deficiencies could affect all residents in the facility, and the census at the time of the entrance conference was 74 residents. During interviews, the Infection Preventionist Nurse stated that her responsibilities included CDC weekly reporting, rounding the floor to ensure infection control was followed, providing education to staff, and other infection control tasks including ASP. She stated that if she was not at the facility, the DON and Unit Manager were responsible for her tasks. The DON stated that monthly audits were run and that antibiotics were supposed to follow McGeer criteria, but when asked to show the ASP monitoring and McGeer criteria since the last recertification survey, he could only produce a white binder containing printed pharmacy reports listing residents on antibiotics with start dates. He stated that the documents in the binder were the ASP, but the surveyor noted that the reports did not include information in accordance with the facility protocol and McGeer standards. The DON then looked in another room and other binders but was unable to find the ASP and McGeer criteria documentation. Review of the QAPI binder showed meeting dates across multiple months, but the entries did not contain ASP, IST, McGeer criteria reports, or ongoing analysis of collected data. The facility’s Antibiotic Stewardship Policy, revised 11/14/25, stated that the center would implement an ASP as part of the IPCP, that the IP was responsible for the IPCP including ASP, and that the program included antibiotic use protocols and a system to monitor antibiotic use. The policy also stated that the center uses CDC updated McGeer’s criteria or another surveillance tool to define infections and that data obtained from antibiotic stewardship monitoring activities is discussed in QAPI meetings. Despite these requirements, the survey team confirmed that there was no surveillance for ASP and only printed order listings were available.
Dirty PTAC Filters Throughout Facility
Penalty
Summary
The facility failed to maintain its Packaged Terminal Air Conditioner (PTAC) units in safe operating condition. During observations while touring the facility from 9:00 AM to 12:00 PM on 5/20/26 and 5/21/26, PTAC filters were found clogged and dirty throughout the facility. This condition was observed in 28 of 28 PTAC units. The Maintenance Director and the Regional Plant Operations Director were present and both confirmed the findings during interview. A policy and procedure for PTAC maintenance was requested but was not provided at the time of the Life Safety Code exit conference.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment in multiple areas, including both units, both shower rooms, and one dining room. During observation of a resident who had diagnoses including Alzheimer's disease, heart failure, atrial fibrillation, muscle weakness, gait abnormalities, and major depressive disorder, surveyors found no call bell within reach at the bedside. The resident's record showed severely impaired cognition with a BIMS score of 4 out of 15 and a care plan requiring extensive assistance with bed mobility, transfers, toileting, dressing, and personal hygiene, with interventions to arrange the environment for daily living and safety cueing. The assigned RN later identified that the resident's call bell was with the roommate and that the roommate's call bell cord was broken and cut off from the wall jack. Surveyors also observed environmental concerns in resident rooms and common areas. In one resident room, the entrance molding was peeled, with paint removed and wood exposed. In the nursing station area and main activity room, surveyors observed broken molding, scuffed and chipped wood on bookshelves and wall molding, peeling paint on an air vent, a ripped window screen with dust, residues, and cobwebs, a cracked hallway ceiling, ceiling tiles out of alignment with one heavily brown-stained tile, dust accumulation on a return air vent, and chipped wood on double fire doors. Facility staff, including maintenance personnel, acknowledged several of these conditions and stated some should have been cleaned, repaired, or spackled. Additional observations in the East shower room and the central bath showed an uncovered ceiling vent, floor tiles with greenish and brownish substances, grayish to blackish accumulation on a vent, an open ceiling vent with the cover placed on a nearby tile wall, and a lower pipe with greenish and bluish discoloration. In the main dining/activity room, surveyors observed grayish substances in ceiling tile vents, brownish substances around ceiling tiles, peeling wallpaper, chipped wood on tables, and an old television mantel with tears. The DR and maintenance staff stated several of these conditions should not have been present and should have been fixed or cleaned.
Catheter Bags Improperly Positioned and EBP Signage Missing
Penalty
Summary
The facility failed to provide appropriate catheter care for residents with indwelling urinary catheters and failed to implement enhanced barrier precautions for two residents. During observation, one resident with an indwelling catheter was seen seated up in bed with the collection bag hung on the head-of-bed rail and positioned above the level of the bladder; the bag was also not placed in a privacy bag, and there was no EBP signage on the door. The RN later confirmed the bag was above bladder level and moved it lower. That resident’s record showed diagnoses including malignant neoplasm of the right kidney and benign prostatic hyperplasia, intact cognition, and an order for daily and evening indwelling catheter care, but the care plan did not include a focus area or intervention related to EBP. A second resident with an indwelling catheter was observed lying in bed with the collection bag hung from the bed frame, visible from the hallway, and not placed in a privacy bag. There was also no EBP signage on the door. The resident’s record showed diagnoses including multiple sclerosis and atelectasis, intact cognition, and an order for indwelling catheter care every shift. Interviews with the IPN, LPN, CNA, LPN/UM, and DON reflected that staff understood that residents with indwelling catheters should have privacy bags, the bag should be below the bladder, and EBP signage should be present. The facility’s catheter policy did not address privacy bags or EBP use, and the EBP policy described when EBP should be used but did not include information regarding signage. The surveyor also cited the HICPAC guideline for catheter maintenance, including keeping the collecting bag below the level of the bladder at all times. The report documented that the concern was brought to the attention of facility leadership, and the regional nurse stated staff had been educated on the privacy bag and bladder-level expectations.
Respiratory Equipment Not Labeled or Stored Properly
Penalty
Summary
The facility failed to ensure that respiratory equipment was handled and stored according to infection control measures for residents receiving O2 and nebulizer treatments. For one resident with chronic respiratory failure with hypercapnia, COPD, interstitial pulmonary disease, obstructive sleep apnea, morbid obesity with alveolar hypoventilation, and chronic diastolic CHF, surveyors observed O2 via nasal cannula at 2 LPM, but the O2 tubing had no date or label. The resident’s neb tubing and neb mask were lying loose on the bedside table without a date or label and were not stored in a bag. The resident’s BiPAP mask was also lying loose on the bedside table and was not stored in a bag. The resident’s record showed orders for continuous O2, weekly tubing changes with labeling of each component, and BiPAP use at night if the resident agreed. For a second resident with diagnoses including multiple sclerosis and atelectasis, surveyors observed an O2 concentrator with nasal cannula tubing connected and lying on the floor. The tubing was not dated and was not stored in a plastic bag. The resident stated that O2 had not been used for two weeks. Surveyors also observed the resident’s nebulizer mask lying on top of a plastic bag on the dresser rather than stored in a bag, and there was no cautionary sign on the door indicating O2 use. The resident’s May 2026 medication record included an order for O2 at 2 LPM via nasal cannula for shortness of breath or O2 saturation below 92%, and a short course of ipratropium-albuterol inhalation treatment that had been discontinued. Staff interviews confirmed the expected practice for respiratory equipment storage and labeling. An LPN/UM, RN, DON, and other nursing staff stated that O2 tubing should be labeled with the date changed and that neb and BiPAP masks should generally be stored in a plastic bag. The DON also stated that O2 tubing should have a label indicating when it was changed. The facility’s respiratory equipment policies stated that O2 delivery devices and tubing were to be changed every 7 days or as needed, that O2 tubing was to be labeled with the date changed, and that respiratory equipment was to be stored appropriately to prevent contamination. The nebulizer policy stated that the treatment bag was to be labeled with the patient name and date.
Insufficient staffing affected meal service, call bell response, and medication documentation
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs, and surveyors observed delayed meal delivery, delayed response to call bells, and incomplete medication/treatment documentation. During observations on the East and [NAME] units, call bells were heard ringing while nurses and CNAs were occupied with other tasks, including medication pass and meal distribution. Staff told surveyors that the breakfast truck arrived late, there were only two CNAs on the unit at one point, and nurses had to help with tray delivery and feeding. Surveyors also observed a resident’s call bell continue ringing for an extended period while staff remained at the nursing station or in the hallway. Meal service concerns were documented for multiple residents. One resident stated breakfast had not yet been received during the morning tour, and the tray was later delivered at 10:30 AM. Another resident reported that breakfast was late and that this happened because of staffing shortages. Surveyors observed a resident with a breakfast tray still untouched in the room, and another resident’s tray remained in the room while the resident had not been fed breakfast. A resident council meeting also reflected complaints that meals were late, food was cold, and trays were not being delivered promptly because of short staffing. The facility’s food service leadership stated that breakfast should be served within the posted meal service time frame and not at 10:30 AM. Medication record review for one resident with chronic respiratory failure, a stage 4 pressure ulcer, and severely impaired cognition showed multiple blank entries on the eMAR and eTAR for medications and treatments on more than one date. An LPN stated she was likely the only nurse on the unit on one of those dates and had 36 residents, and that she did not get to sign all the orders. The unit manager and DON stated that the eMAR and eTAR should not have blanks and should be signed or explained if not administered. The facility’s policies stated that staffing levels should meet resident needs, call lights should be answered promptly, meals should be delivered timely and at the proper temperature, and medication administration documentation should be completed appropriately.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure Certified Nurse Aides (CNAs) had annual performance evaluations for 5 of 5 CNA employee files reviewed. During record review on 5/19/26 and 5/20/26, the surveyor repeatedly requested the five CNA files containing documentation of annual performance evaluations from the LNHA, DON, Human Resources staff, and the Regional Nurse. On 5/21/26, the LNHA acknowledged the missing employee file documentation and stated that the files with missing records could be used as an official way moving forward to make sure everything is correct in the future. Later that morning, the Regional Nurse stated, "I do not think they have them, but we will try to get what we have and provide that to you." The surveyor did not receive documentation of the five CNAs' annual performance evaluations, and at the exit conference the LNHA provided no additional information.
Infection Preventionist Not Properly Designated or Trained
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) worked at least part-time at the facility and completed specialized infection prevention and control training before assuming the IP role. Surveyors reviewed facility records and interviewed the LNHA, DON, Regional Clinical Lead, Regional Nurse, and the IPs, and found that IPN #1 accepted the position of Infection Preventionist Nurse/Nurse Educator on 5/9/25 but did not complete the CDC Nursing Home Infection Preventionist Training Course until 5/25/25. IPN #1 also stated that she did not sign a job description and that the facility did not provide one. The survey team also reviewed the timeline and time sheets for multiple IPs and found gaps in coverage and periods when no designated IP was present at the facility. The records showed that IPN #2 served as IP from 2/7/25 through 5/6/25, with no hours documented for March and April 2025. IPN #1 was listed as IP from 5/11/25 through 1/1/26, but the time sheets showed she worked direct care RN hours before and after assuming the IP role, and she had not completed the IP certificate when she began the role. IPN #3 was listed as IP from 1/5/26 through 2/7/26, but no work hours were documented for January 2026. IPN #4 was listed as IP from 4/20/26 through 5/15/26, but there were no work hours for the week of 5/10 to 5/15/26. Facility staff confirmed that there were times when no IP was at the facility, and the provided timeline and time sheets showed no designated IP in April 2025, June 2025, July 2025, August 2025, October 2025, November 2025, December 2025, January 2026, and March 2026. The facility's Infection Prevention and Control Program Description policy stated that the IP must work at least part-time and is responsible for developing, implementing, monitoring, and maintaining the IPCP. Despite this policy, the surveyors found no signed job descriptions for the IPs reviewed and documented that multiple IPs assumed responsibilities without completing the required certification.
Failure to Offer and Document Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to offer influenza vaccinations to Resident #8 and Resident #9, and there was no documentation in either the electronic medical record or the paper chart showing that the flu vaccine had been offered for the 2025-2026 flu season. During record review, the surveyor confirmed that the immunization tabs and unit records for both residents did not contain evidence of an offer, and the LPN/Unit Manager stated that after checking the records, there was no documentation that either resident had been offered the flu vaccine. The LPN/UM also stated that the residents should have been offered the flu vaccine. The facility also failed to offer or document current influenza and pneumococcal vaccination status for Resident #10, who had Parkinson's disease, cognitive impairment, unspecified dementia, and was rarely understood on the MDS. Review of the resident's MDS showed flu was not offered and the pneumonia vaccine was not up to date, and the immunization record showed only a historical Pneumovax dose from 11/4/20. The IPN stated that she, the DON, and the Unit Manager were responsible for vaccinations when she was not in the facility, and that admission review should include what vaccines residents had received and signed forms if vaccines were needed. The LPN/UM reviewed the records and confirmed there was nothing indicating the vaccines were up to date and that flu and pneumonia vaccines were not offered last year.
Missing CNA Training and Competency Documentation
Penalty
Summary
The facility failed to maintain and provide documentation of required staff in-service education and annual competency/performance records for 5 of 5 CNA employee files reviewed for staff training requirements. During the survey, the surveyor made multiple requests to the LNHA, DON, Human Resources staff, and Regional Nurse for five CNA employee files containing documentation of staff in-service education and annual competency/performance records. The LNHA acknowledged the concern related to missing employee file documentation, and the Regional Nurse stated that they did not think the records were available but would try to obtain what they had and provide it. The surveyor did not receive documentation showing completed staff in-service education records or annual competency/performance documentation for the five CNA employee files requested for review.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with respect and dignity. Resident #9 was observed in bed and stated that the bathroom toilet was flooded and could not be used, requiring the resident to go by themself in a wheelchair to another bathroom. The resident said they told a caregiver, who responded that they would call somebody. At the same time, the surveyor observed the resident’s bathroom toilet flooded with discolored water and filled with feces and tissues, with towels placed over the wet floor outside the bathroom. The bathroom condition was observed again the next day and later that same day, and each time the toilet remained clogged and dirty, filled with feces and tissues, or flooded with discolored water and feces and tissues. Resident #9’s quarterly MDS showed a BIMS score of 11 out of 15, indicating moderately impaired cognition. The facility’s Resident Right Under Federal Law policy stated that residents have the fundamental right to considerate care that safeguards personal dignity and that residents are to be treated with respect and dignity.
Failure to Inform Representative Before Restarting Antipsychotic Medication
Penalty
Summary
The facility failed to inform the resident’s representative in advance of the risks, benefits, options, and alternatives related to treatment with a psychoactive medication. Resident #10 was observed sitting on the bed eating breakfast and was unable to answer questions. Record review showed diagnoses including Parkinson’s disease, unspecified dementia, cognitive impairment, major depressive disorder, anxiety disorder, unspecified psychosis, and sleep disorder. The resident’s MDS indicated the resident was rarely understood, had memory problems, and had severely impaired decision-making, and also showed use of antipsychotic, antianxiety, and antidepressant medications, with the antipsychotic given daily. The record also showed a physician order for Quetiapine Fumarate (Seroquel) 25 mg at bedtime for anxiety disorder with target behaviors of agitation, pacing, combativeness, yelling, and psychosis. A psychiatry consult later documented psychosis and dementia and stated to continue Seroquel for psychosis, with target symptoms of hallucinations and behavioral dysregulation, and noted that indication, risks, benefits, treatment alternatives were discussed with the RR. However, staff review found no psychiatry consultation in February 2026 showing the RR was informed when the antipsychotic was restarted, and the LPN/UM confirmed there was no documentation that the RR was informed at that time. The facility policy also stated that patient and/or representative consent should be obtained.
Telephones and Call Devices Not Readily Accessible
Penalty
Summary
The facility failed to ensure that residents' telephones and call devices were readily accessible for 3 of 18 residents reviewed for reasonable accommodations of needs and preferences. Resident #7, who had diagnoses including T11-T12 wedge compression fracture, PTSD, anxiety, depression, osteoporosis, and gait/mobility abnormalities, stated after being moved to a new room that there was no telephone in the room even though one had been in the prior room. Survey staff observed that neither Resident #7 nor the roommate had a telephone available, and the assigned RN stated that every room should have a phone for residents to use. The LNHA later acknowledged that residents were expected to have access to telephones in their rooms and requested that a telephone be placed in Resident #7's room, also stating that the roommate did not have access to a telephone either. The resident's MDS showed a BIMS score of 15 out of 15, indicating intact cognition, and the care plan included maintaining communication that was consistent, open, respectful, and compassionate. Survey staff also observed Resident #57 lying in bed with the call device underneath the bed and out of reach, and the CNA confirmed it was not within reach before leaning the bed forward to retrieve it. Resident #57's diagnoses included generalized muscle weakness, other abnormalities of gait and mobility, and history of falling. In a separate observation, Resident #73 was found in bed with the call device on the floor on the other side of the curtain and out of reach; the device had frayed and exposed wires and broken pieces. Resident #73 stated the call device had been in that condition for a while, that the facility had been told about it, and that the resident did not feel comfortable using it because it was unsafe. Resident #73's diagnoses included other lack of coordination, history of falling, and other abnormalities of gait and mobility, and the MDS showed a BIMS score of 13 out of 15, indicating intact cognition.
Missing Written Cost Information on Beneficiary Notice
Penalty
Summary
The facility failed to notify a resident in writing of the items and services covered by the beneficiary notice and the associated costs for services not covered. For Resident #80, the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage showed that the resident’s last covered Medicare Part A day was 2/8/26 and that beginning 2/9/26 the resident would have to pay out of pocket if other insurance did not cover physical therapy, daily skilled nursing care, and occupational therapy. However, the form did not include any written amount per service, even though it stated that the services would cost the resident a per-day or per-item amount. The Clinical Reimbursement Coordinator stated she generated beneficiary notice forms and the Business Office Manager was responsible for delivering them to the resident or resident representative. The Business Office Manager confirmed, in the presence of the Regional Clinical Lead, that no amount was included on the signed SNF ABN because she had notified them verbally. Review of the record showed the resident’s end of Part A stay MDS with an ARD of 2/8/26 indicated Medicare Part A services had ended, and a progress note effective 2/11/26 stated the resident was transferred to another facility for hospice care.
Missing Reference Checks in New Hire Files
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to ensure reference checks were completed for newly hired employees in accordance with its hiring policy. During review of 33 newly hired employee personnel files, the surveyor identified that 13 files lacked completed reference checks, including Employee #4, #5, #6, #8, #10, #21, #23, #24, #26, #28, #29, and #31. The facility’s Hiring Policy, revised 7/1/22, required that external candidates have at least two professional references checked and that post-offer requirements include verification of credentials, licenses, certificates, and other required documents for the position. During interview, the LNHA stated that Staffing and HR complete the paperwork and submit it to the Administrator for approval, and the Regional Market Director stated that regional HR would be onsite to reeducate DON, UM, Staff/Payroll, and HR on the hiring process and implement a checklist for hiring and sign-off before hiring and uploading into the system.
Failure to Provide Bed Hold and Ombudsman Notifications After Hospital Transfer
Penalty
Summary
The facility failed to provide Resident #77 and the resident representative with a written bed hold policy notice that included reserve payment information after the resident had an unplanned discharge to the hospital. The medical record showed that the resident was transferred to the hospital by 911 after being observed in bed with labored respirations and oxygen via non-rebreather mask, with the nurse practitioner notified and the resident noted to be getting worse. Review of the record found no documented evidence that the bed hold policy notice was provided for the acute transfer. The facility also failed to send a copy of the emergency transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. When asked about acute transfer notifications for 2026, the Regional Nurse stated they did not have it, and the surveyor’s review of the binder confirmed the resident did not have a bed hold policy notice for the transfer. The facility’s discharge and transfer policy stated that for unplanned, acute transfers, the resident and resident representative are to be notified verbally and then in writing, and that copies of emergency transfer notices must also be sent to the Ombudsman when practicable.
Incomplete documentation of tube feeding, diagnosis, and medication orders
Penalty
Summary
The facility failed to ensure that a resident’s tube feeding supplies were labeled or dated and failed to include Candida auris in the resident’s medical diagnosis section of the medical record. During observation, the resident was seen lying in bed receiving Jevity tube feeding at 70 ml/hr, and the water flush bag connected to the tube feeding was not dated. The resident’s record showed severe cognitive impairment, a tube feeding, chronic respiratory failure, and a stage 4 pressure ulcer of the right hip. Hospital transfer documents identified the resident as colonized with Candida auris and on contact precautions, but the diagnosis was not listed in the electronic medical record diagnosis section or in the active diagnoses on the admission MDS. The DON stated that the resident had C. auris but that it was not an active infection, and that the resident had been placed on contact precautions when transferred from the hospital. The LPN confirmed that the water flush bag was not dated and stated that all equipment should be dated. The LPN/UM also stated that the tube feeding and water flush bag should be dated and that diagnoses were expected to be listed in the medical record. The DON further stated that the tube feeding and water flush bag should both be dated and that diagnoses should be placed in the medical record within a certain time frame. The facility also failed to ensure that PRN and routine orders were not duplicative or clinically appropriate and were clarified for another resident. The resident’s active orders included acetaminophen tablets every 6 hours PRN for pain, acetaminophen suppositories every 6 hours PRN for mild pain or fever over 101, and morphine solution every 2 hours PRN for pain. Review showed conflicting PRN pain orders, two acetaminophen suppository orders that were not separated, and no indication of when morphine and acetaminophen should be administered in sequence. The resident also had duplicate sacral-area treatment orders for zinc oxide every shift and Medihoney wound care every day shift. The medication regimen review binder did not document these irregularities, and the consultant pharmacist stated the PRN pain medications should have been sequenced and separated and that the duplicate orders should have been identified in the review.
Failure to Follow WCCP Wound Care Orders
Penalty
Summary
The facility failed to follow the Wound Care Consultant Physician’s recommendations for a resident admitted with chronic respiratory failure and a stage 4 pressure ulcer of the right hip that was present on admission. The resident’s quarterly MDS showed severe cognitive impairment with a BIMS score of 5 out of 15. The WCCP’s 2/17/26 order directed staff to clean the right iliac crest wound with Vashe, pack it with calcium alginate, apply collagen powder to the wound base, and cover it with a silicone bordered dressing daily and as needed. Weekly WCCP visits from 3/3/26 through 5/12/26 continued to direct the same wound care, except the dressing frequency was changed to three times a week and as needed. The facility did not follow the WCCP order, and there was no documented evidence that the primary physician disagreed with the recommendation. Staff interviews reflected that wound recommendations were routed to managers, that the WCCP came weekly and the facility followed the orders unless the primary physician objected, and that any disagreement should be documented in the medical record. The DON also stated that the facility followed WCCP recommendations unless the primary physician did not want them followed and that such disagreement would be documented.
Staffing Report Not Posted and Updated Each Shift
Penalty
Summary
The facility failed to ensure the Nursing Home Resident Care Staffing Report was posted and maintained with accurate and current staffing and census information for each shift. On 5/17/26 at 9:00 AM, surveyors observed the staffing report at the receptionist desk and found it was dated 5/15/26 for the day shift, with no staffing report available at the receptionist desk for any day or shift over the weekend. On 5/18/26 at 11:00 AM, the Human Resources Staff member stated she was responsible for posting the staffing report and did not realize it needed to be updated on weekends. On 5/19/26 at 8:10 AM, surveyors obtained a staffing report from the receptionist desk that was dated for the day shift and listed the facility census as 74 residents. At 8:23 AM, the Human Resources Staff member provided a corrected staffing report for the day shift showing the current census as 73 residents and stated the original report had an incorrect census. The Licensed Nursing Home Administrator stated he thought the Human Resources Staff member was posting the staffing report as required. The facility's Posting Staffing Policy required the posting to include the current date, patient census at the beginning of each shift, staffing by category, and to be completed daily at the beginning of each shift.
Improper Medication Storage and Labeling
Penalty
Summary
Drugs and biologicals were not properly stored and labeled in one medication cart and one medication room. On the [NAME] Low Unit medication cart, the surveyor found Unsampled Resident #1's Ipratropium Bromide 0.5 mg and Albuterol Sulfate 3 mg inhalation solution box with an opened foil pouch containing unit-dose vials, but the pouch had no date of opening written on it. The pouch instructions stated that unit-dose vials should remain in the protective foil pouch at all times and, once removed, the individual vials should be used within one week. The RN stated the pouch should have been labeled with the date it was opened. UR #1 was not in the facility's electronic medical record, and the DON stated the resident was never admitted to the facility. In the [NAME] Low Unit medication room, the surveyor found an expired and used Insulin Lispro KwikPen with a date of 3/28 written on it and no resident label, an Ipratropium Bromide and Albuterol Sulfate inhalation solution vial with no resident label or date, a box of Glucose Control Solutions with two opened and expired bottles and a date of opening of 2/16/26, and Resident #60's Insulin Lispro multiple-dose vial that had expired with an expiration date of 5/19 written on it. The RN stated the expired medications should have been discarded, and the RCL stated the Glucose Control Solution was good for 90 days and should have been thrown out because it was expired. The facility's Medication Storage Policy stated that expired, discontinued, and/or contaminated medications would be removed from medication storage areas and disposed of in accordance with facility policy.
Improper Holding Temperatures During Breakfast Service
Penalty
Summary
The facility failed to ensure potentially hazardous food items were maintained at safe temperatures during breakfast meal service on the West unit. At 8:00 AM, the surveyor notified the Food Service Director that a breakfast test tray was needed for temperature checks and was told that room R47 would be the last room to receive breakfast on the morning meal pass. The surveyor observed that the breakfast tray cart for the Wing rooms 28-47 had not yet left the kitchen at 8:20 AM, and staff on the Wing rooms 1-27 stated at 8:25 AM that breakfast had already been served there while the remaining residents in rooms 28-47 were still waiting. Staff on the East Wing stated at 8:26 AM that all residents there had already received breakfast trays. At 8:30 AM, the last breakfast tray was delivered to R47 and the surveyor checked the tray temperatures in the presence of the FSD and RFSD. The tray included oatmeal at 182 degrees Fahrenheit, sausage at 173.3 degrees Fahrenheit, pancakes at 176.9 degrees Fahrenheit, coffee at 155 degrees Fahrenheit, orange juice at 44 degrees Fahrenheit, and milk at 51 degrees Fahrenheit. The RFSD stated that milk should be held at less than 45 degrees Fahrenheit, and the FSD and RFSD acknowledged concern that the milk exceeded the expected cold holding temperature. The facility policy stated that cold foods are to be held at 41 degrees Fahrenheit or below.
Infection Control Failures in Laundry, Eyewash, Soap Supply, and Hand Hygiene
Penalty
Summary
The facility failed to maintain infection prevention and control practices in multiple areas, including laundry handling, laundry room cleanliness, eyewash station maintenance, soap availability, and hand hygiene during medication administration. Surveyors observed empty soap dispensers in the east shower room and the west central bath, and facility staff confirmed the dispensers were empty and should have been replaced. The facility’s hand hygiene policy required hand washing with soap and water when hands are visibly soiled and required liquid soap reservoirs to be discarded when empty and replaced as needed. During a laundry room observation, surveyors found the clean linen area uncovered while fans and an air conditioning unit were blowing air, with dust accumulation on the floor and on top of the air conditioning unit. A gallon of half-filled water was sitting on one of the clean folding tables next to folded white linens, towels, and blankets. In the dirty area, surveyors observed dust accumulation on the floor, an open chute area with a large uncovered bin, and two used gloves. The laundry staff member was observed folding linen that touched the dusty floor and then placing that folded linen back onto the clean table with other clean linens. The DON confirmed that linen touching the floor should not be mixed with clean supplies. Surveyors also observed the eyewash station with whitish substance covering the holes where water comes out and whitish and grayish substances around the sink area. The posted sign indicated the eyewash station should be flushed weekly, but the laminated flushing log had last been signed in 2025. Facility leaders stated the eyewash station should have been cleaned and maintained, and that there was no log to ensure the laundry room was being cleaned. In addition, during medication pass observation, an RN washed hands for 11 seconds before handling medications for a resident and used the same paper towel to turn off the faucet that was used to dry hands. The RN stated that hand washing should have lasted 20 seconds and that a clean, unused paper towel should have been used to turn off the faucet.
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 1,451 citations issued within 25 miles in the last 12 months — including the 15 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 Ridgewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bergen New Bridge Medical Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Family Of Caring Healthcare At Ridgewood | 1.7 mi | ★★★★★ | 0 | 0 |
| New Jersey Veterans Memorial Home At Paramus | 3.1 mi | ★★★★★ | 2 | 0 |
| Dellridge Health & Rehabilitation Center | 3.6 mi | ★★★★★ | 22 | 0 |
| Careone At Ridgewood Avenue | 3.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.