Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ridgewood Manor during CMS and state inspections, most recent first.
Two residents with multiple chronic conditions and cognitive impairment did not receive medications as ordered by their physicians. One newly admitted resident received no ordered medications on the first evening despite the drugs being available in the contingent supply, and an LPN later confirmed the nurse did not review and implement the admission medication orders as required. Another resident with epilepsy, hypothyroidism, GERD, chronic pain, and psychiatric diagnoses had numerous missed doses of antiepileptics, thyroid, GERD, cholesterol, pain, sleep, and anxiety medications over the course of a month, with no documentation of refusals. The resident reported that nurses were not waking her to administer medications, and the regional clinical leader verified that medications were not given as ordered and that this was not due to documented refusals, contrary to facility policy requiring administration per physician orders and time frames.
Two residents with multiple chronic conditions, including diabetes, heart failure, COPD, epilepsy, dementia, and anxiety disorders, did not receive medications as ordered by their physicians. For one newly admitted resident, no evening medications were given on the admission day despite active orders and the availability of several drugs in the contingent supply, and the resident reported not receiving needed anxiety medication. For another resident, MAR review showed numerous missed doses of seizure, thyroid, GERD, cholesterol, pain, and psychotropic medications over a month, with no documentation of refusals. The resident reported that nurses were not waking her for medications and that some nurses did not administer them, and leadership confirmed the lack of administration and refusal documentation, contrary to facility policy requiring medications to be given per physician orders and time frames.
The facility failed to honor resident choice for bathing and smoking. A cognitively intact resident who required assistance with bathing missed a scheduled shower and was observed with unwashed hair and the same clothes the next day. Two smokers were also denied access to cigarettes during posted smoke times because the lockbox keys and smoking supplies could not be found, and an LPN confirmed one smoke break was not given. The AD stated smoking supplies were normally stocked for off-hours use, but they were unavailable when needed.
Privacy Curtain Left Unusable During Personal Care and Treatment: Two roommates were observed with the privacy curtain tied in a knot and unable to be closed, leaving one resident’s wound vac care visible to the other while he ate lunch. A CNA confirmed the curtain could not be used, and the roommate stated he did not tie it and could not untie it. One resident was cognitively intact with diabetes, a recent toe amputation, and wound care needs; the other had anoxic brain damage, moderate cognitive impairment, and resistive-to-care behaviors.
Two residents with non-pressure wounds did not receive wound care according to physician orders due to failures in clarifying, documenting, and completing treatments. For one, wound care orders were not entered or followed, and treatments were not documented. For the other, wound care orders were not discontinued after healing, and dressings were applied without orders or not in accordance with orders. Staff confirmed these lapses, and policy required accurate order verification and documentation.
Staff did not properly store or label opened food and drink items in the nurse's station pantry, including undated packets, bowls, mugs, and bottles. The pantry floor was also found to be unsanitary, with trash and a sticky substance present, and was not cleaned between observations. These actions were confirmed by both a CNA and the Administrator, in violation of facility policy.
Staff left a pantry at the nurse's station unlocked, where two sharp kitchen knives were stored in a drawer accessible to residents, including several who were cognitively impaired and independently ambulatory. Facility policy required a safe environment, but the unlocked pantry allowed access to hazardous items.
A resident with type II diabetes and multiple comorbidities was admitted with physician orders for blood glucose monitoring three times daily. Despite these orders and a care plan intervention, staff did not perform or document any blood glucose checks or related insulin coverage until prompted by surveyors. Interviews with the resident, an LPN, and the DON confirmed the lack of monitoring and documentation since admission.
A resident with multiple chronic conditions requiring BiPAP therapy was observed with her BiPAP machine alarming for an extended period without staff awareness or response, as the alarm was not audible at the nurse's station. There were no physician orders or care plans for the resident's BiPAP or oxygen therapy at the time, and staff were unaware when the machine was not running. Facility policy and equipment instructions requiring prompt response and proper documentation were not followed.
Two residents did not receive their prescribed medications as ordered, with an LPN omitting a scheduled narcotic due to unavailability and administering other medications outside of the required timeframes. Multiple medications, including those for pain, anxiety, blood pressure, and eye conditions, were not given within the facility's policy of one hour from the scheduled time, resulting in a medication error rate of 36%.
Surveyors found that medications were not administered as ordered or within prescribed timeframes for three residents. An LPN omitted a scheduled narcotic due to unavailability and gave other medications late. Another resident received blood pressure, anti-hypertensive, and ophthalmic medications outside of scheduled times. A third resident missed multiple doses of prescribed eye medications over two months, with documentation showing the drugs were often unavailable or on order. Facility policy required timely administration within one hour of scheduled times, which was not met.
A resident with a stage four pressure ulcer did not receive wound care as per physician orders. Despite a new treatment plan being ordered, it was not entered into the electronic medical record or completed in a timely manner. The resident expressed dissatisfaction with the care, and an observation confirmed the wound was not treated as ordered. The facility's policy to verify and complete physician-ordered treatments was not followed.
A facility failed to implement physician orders for tracheostomy care for a resident with acute respiratory failure, resulting in a lack of documented care and necessary supplies at the bedside. Despite hospital discharge orders for tracheostomy care and suctioning, these were not reflected in the resident's admission orders or treatment records. Observations confirmed the absence of essential tracheostomy supplies, and interviews with staff verified the oversight.
The facility failed to maintain an effective QAPI program, resulting in repeated medication administration errors over four consecutive surveys. An LPN administered Novolog insulin to a resident without priming the pen, contrary to the package instructions, which is necessary to ensure proper dosing. This deficiency had the potential to affect all 44 residents.
The facility failed to conduct water temperature testing for Legionella prevention and did not ensure proper use of PPE during resident care. A CNA provided colostomy care to a resident on enhanced barrier precautions without wearing a gown, and an LPN administered insulin without cleansing the pen's rubber stopper. These deficiencies could impact all 44 residents.
The facility failed to maintain fully stocked and accessible emergency crash carts, with missing oxygen supplies and difficulties in accessing the carts. A resident was found with smoking materials in their possession despite facility policies, and another resident was transferred without the required mechanical lift and staff assistance, contrary to their care plan.
The facility failed to provide timely Medicare Part A discharge notifications to three residents, notifying them only 24 hours in advance instead of the required 48 hours. The Business Office Manager cited her responsibilities across two buildings as a reason for the delay.
An altercation occurred between two residents in a shared room, where one resident verbally and physically attacked the other after being asked to move aside by an LPN. The incident was witnessed and documented, with the Director of Nursing confirming the abuse. Both residents were assessed with no injuries reported, but the facility failed to prevent the abuse.
A facility failed to administer a prescribed laxative to a hospice resident who was moderately cognitively impaired and had no documented bowel movements for eight days. Despite having an order for Glycolax powder as needed for constipation, the resident did not receive the medication. The DON confirmed the lapse, noting that routine orders ended with hospice care, and the Hospice RN was unaware of the issue, indicating a communication breakdown.
A resident with multiple health issues, including a stage two sacral pressure wound, did not receive timely and proper wound care as ordered. The facility failed to change the dressing on the resident's right dorsal foot as scheduled, and the sacral wound care was improperly performed, resulting in inadequate coverage. The Assistant Director of Nursing confirmed the missed dressing change, and the Wound Care Certified Nurse Practitioner noted the incorrect application of the wound care mixture.
A resident with type II diabetes did not receive their scheduled insulin glargine at the documented time. The LPN documented the administration at 7:54 A.M., but the insulin was not given until after the resident's breakfast, contrary to the facility's policy. This discrepancy was confirmed by the Corporate Risk Management Nurse.
A resident with type two diabetes mellitus did not receive insulin as ordered due to an LPN's failure to prime the Novolog insulin pen before administration. The LPN administered 12 units of insulin without priming, contrary to the manufacturer's instructions and facility policy, resulting in a significant medication error.
The facility failed to label insulin appropriately for two residents, leading to a deficiency. An LPN confirmed that a Basaglar insulin KwikPen and a Humalog insulin vial were open without documented opening dates, contrary to manufacturer instructions and facility policy. The residents had multiple diagnoses, including diabetes mellitus.
A facility failed to provide timely treatment for a symptomatic UTI in a resident with a suprapubic catheter, leading to hospitalization for sepsis. Despite a history of UTIs, the facility did not notify the physician of positive urinalysis results. Additionally, another resident did not receive documented catheter care for eight days post-admission, placing them at risk. Staff interviews revealed communication lapses and non-adherence to facility policies.
The facility's kitchen was found to be unsanitary, with broken floor tiles, dust buildup, and food debris in grease traps and on the floor. The Dietary Manager confirmed these issues, noting that deep cleaning occurred every six months and grease traps were cleaned weekly, contrary to the policy requiring daily cleaning of grease drip trays and regular mopping.
A facility failed to timely clarify and complete wound care orders for a resident with surgical wounds, leading to missed documentation of dressing changes. The issue was identified after a complaint was made, revealing that wound care orders were not in place initially and were only obtained after family concerns were raised.
The facility failed to supervise residents who required assistance with smoking, allowing them to keep cigarettes and lighters in their rooms against policy. This affected four residents, including one with cognitive impairment and another with upper extremity impairments. The Activity Director admitted to not securely storing smoking materials as required.
A resident with type II diabetes did not receive their prescribed Novolog insulin due to a blood sugar reading of 99. The LPN held the medication but failed to notify the physician, contrary to facility policy. The DON confirmed the lapse in communication.
A resident with muscle weakness and other health issues required assistance with personal hygiene, specifically toenail trimming, which was not provided by the LTC facility. Despite the resident's inability to trim their own toenails and a policy requiring staff assistance, the necessary care was not given, leading to overgrown toenails. Staff interviews confirmed the oversight in providing the required ADL support.
A resident with type II diabetes mellitus experienced medication administration errors, resulting in an 8.0% error rate. An LPN incorrectly withheld Novolog insulin despite the physician's order to notify the physician only if blood sugar was less than 70. Additionally, Gabapentin was administered outside the prescribed time frame. The facility's policy on medication administration was not adhered to, contributing to these errors.
A resident with type II diabetes did not receive their prescribed Novolog insulin before a meal due to an LPN's decision to hold the medication based on a blood sugar reading of 99, despite the physician's order to administer the insulin unless the blood sugar was below 70. The DON confirmed this was against the physician's order and facility policy.
The facility failed to obtain physician-ordered laboratory tests for three residents with various medical conditions, including diabetes and hypertension. Despite orders for regular blood tests, the facility did not complete the tests as required, and there was no documentation of resident refusals. The Director of Nursing confirmed the lapses, and the contracted laboratory did not maintain records of test refusals.
A resident's room was found to have significant cleanliness and maintenance issues, including damaged walls, a dirty privacy curtain, and a constantly running bathroom sink. The resident reported the sink issue had persisted for about two months, causing noise disturbances. Maintenance and floor staff confirmed these deficiencies, which were contrary to the facility's policy of providing a safe and homelike environment.
The facility failed to maintain its sprinkler systems and conduct proper fire watches, as revealed by a survey. The sprinkler system had leaks and was turned off, compromising fire safety. Additionally, the facility did not notify the Ohio Department of Health about being under a fire watch and had significant gaps in fire watch logs. Critical areas were not monitored due to staff not having access keys, violating the facility's fire watch policy.
The facility failed to maintain a safe environment after a water leak caused significant damage, including a collapsed ceiling in the north hall and a sagging, cracked ceiling in room 215. Staff interviews confirmed the extent of the damage, and the facility's assessment indicated non-compliance with maintaining a safe environment.
A facility failed to maintain an effective pest control program, affecting a resident and potentially all residents. Mice and insects were observed in various areas, including a resident's room, causing distress and sleep issues. Despite reports and recommendations for building repairs, the facility remained not rodent-proof, and scheduled exterminator visits were missed.
Failure to Administer Medications per Physician Orders for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to administer medications according to physician orders for two residents. One resident was admitted with multiple diagnoses including hypertension, type 2 diabetes mellitus, osteoarthritis, heart failure, generalized anxiety disorder, and COPD, and had moderate cognitive impairment requiring substantial assistance with ADLs. Hospital discharge orders included several medications, some of which were paused pending further instruction, while others such as furosemide, gabapentin, guaifenesin, metformin, oxycodone, and zolpidem were ordered to be given. Facility physician orders dated the day after admission listed these medications and added lorazepam as needed for anxiety and tramadol as needed for pain. Despite the availability of these medications in the facility’s contingent supply, the medication administration record showed that no medications were administered on the day of admission. The resident later reported not receiving any evening medications on the admission date, including anxiety medication that he stated he really needed. The unit manager LPN confirmed that the floor nurse was responsible for reviewing and entering medication orders for new admissions and that the nurse should have addressed medication orders first. The unit manager verified that the resident did not receive medications per physician orders on the admission date and acknowledged that the nurse should have pulled available medications from the contingent supply. She also confirmed that the resident could have received lorazepam for anxiety if the paused orders had been clarified with the physician, and that the resident had voiced concerns about not receiving all medications. A second resident, admitted with schizoaffective disorder, dementia, chronic pain, anxiety, COPD, hypothyroidism, GERD, and epilepsy, had severe cognitive impairment and multiple standing medication orders, including lacosamide, levothyroxine, pantoprazole, trazodone, lamotrigine, buspirone, acetaminophen, and rosuvastatin. Review of the MAR for the month showed multiple missed doses of these medications on various dates, including antiepileptics, thyroid medication, GERD medication, cholesterol medication, pain medication, and anxiety medication. Nursing notes for the same period contained no documentation of medication refusals. The resident reported that nurses were not waking her up to give medications and that some nurses simply did not give her medications. The regional director of clinical services confirmed that the resident was not administered medications per physician orders, that there were no changes in condition since admission, and that there was no documentation of medication refusal. Facility policy required medications to be administered per physician orders, including required time frames.
Failure to Administer Ordered Medications and Prevent Significant Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, as required by physician orders and facility policy. For one resident with hypertension, type 2 diabetes, osteoarthritis, heart failure, generalized anxiety disorder, and COPD, hospital discharge orders included multiple scheduled and PRN medications, with some medications specifically paused pending further physician instruction. On admission, the physician orders at the facility included furosemide, gabapentin, guaifenesin, lorazepam PRN, metformin, oxycodone PRN, tramadol PRN, and senna plus. The facility’s contingent medication supply included several of these medications. However, review of the MAR showed that no medications were administered on the admission date despite active physician orders and the availability of several ordered drugs in the contingent supply. The resident later reported not receiving any evening medications on the admission date, including an anxiety medication that he stated he really needed. The Unit Manager LPN confirmed that the floor nurse was responsible for reviewing and entering medication orders for new admissions and that the nurse should have addressed medication orders first. The Unit Manager verified that the resident did not receive medications per physician orders on the admission date and acknowledged that the nurse should have pulled available medications from the contingent supply. She also stated that the resident could have received lorazepam for anxiety if the nurse had clarified the paused medication orders with the physician, and that the resident had voiced concerns about not receiving all medications. For a second resident with schizoaffective disorder, dementia, chronic pain, anxiety, COPD, hypothyroidism, GERD, and epilepsy, physician orders included lacosamide, levothyroxine, pantoprazole, trazodone, lamotrigine (in combination to equal 125 mg twice daily), buspirone, acetaminophen, and rosuvastatin. Review of the MAR for the month showed multiple dates on which these medications were not administered as ordered, including missed doses of seizure medications, thyroid medication, GERD medication, cholesterol medication, pain medication, and psychotropic/anxiolytic medications. Nursing notes for the same period contained no documentation that the resident had refused any medications. The resident reported that nurses were not waking her up to give medications and that some nurses simply did not give her medications. The Regional Director of Clinical Services confirmed that the resident was not administered medications per physician orders and that there was no documentation of medication refusal. Facility policy stated that medications would be administered per physician orders, including any required time frame.
Failure to Provide Scheduled Bathing and Smoking Access
Penalty
Summary
The facility failed to honor resident choice for bathing when Resident #19, who had diagnoses including traumatic brain injury, hypertension, and legal blindness, did not receive a scheduled shower as planned. Resident #19 was cognitively intact with a BIMS score of 15 and required set-up assistance with bathing and showering. Her care plan included support for impaired visual function, fall risk, and self-care deficit, including assistance with bathing/showering. Review of shower sheets showed her shower was documented as not applicable on 12/01/25, and observation that morning found her hair unwashed and uncombed. Resident #19 stated her shower days were Mondays and Thursdays on first shift and reported she had not gotten a shower yet, saying she would most likely not get one that day because it was already after 9:00 A.M. The next morning, she was observed wearing the same clothes as the previous day and her hair remained unwashed. She confirmed she had not received the shower as scheduled and said she wanted a shower but no one came to get her. A CNA later verified she had not been showered as scheduled and asked if she wanted a shower that day. The facility also failed to maintain resident choice for smoking for two residents. Resident #51, who was alert and oriented and admitted with acute versus chronic respiratory failure, COPD, and oxygen dependence, stated there were no cigarettes available for the 7:00 P.M., 9:00 P.M., or 6:00 A.M. smoke times, and she went to bed early because she could not smoke. An LPN confirmed the 7:00 P.M. smoke break was not given because the lockbox keys and cigarettes could not be found. Resident #29 also stated he was unable to smoke for the 7:00 P.M. and 9:00 P.M. smoke breaks because the smoking materials were locked and unavailable. The Activities Director stated smoking supplies were normally stocked for off-hours use, and the facility posted smoking times included 6:00 A.M., 10:00 A.M., 1:00 P.M., 4:00 P.M., 7:00 P.M., and 9:00 P.M.
Privacy Curtain Left Unusable During Personal Care and Treatment
Penalty
Summary
Resident privacy was not maintained during personal care and treatment for two residents who shared a room. Resident #35 was admitted with diagnoses including type I diabetes, traumatic amputation of a lesser toe, obesity, generalized anxiety disorder, major depressive disorder, cannabis use, and pancreatitis. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness, and the care plan included privacy preferences and interventions related to a recent toe amputation, wound care, and self-care needs. Resident #31 was admitted with diagnoses including anoxic brain damage, gait abnormalities, major depressive disorder, substance abuse, nicotine dependence, and cognitive communication deficit. The resident’s MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and the care plan addressed impaired cognition, resistive to care, and self-care deficit risk. During observation, the privacy curtain between the two beds was tied in a knot, positioned against the window, and could not be pulled closed for privacy. While Resident #35 was receiving wound vac care, Resident #31 was eating lunch on the side of his bed facing Resident #35, placing the treatment in his line of sight. A CNA verified that the curtain could not be closed and that the wound vac care was being provided in the roommate’s line of sight. Later observations on multiple days continued to show the curtain tied in a knot and unusable. Resident #31 stated he had not tied the curtain, could not untie it, and confirmed it could not be used for privacy for either resident. The facility policy stated that each resident had the right to personal privacy during accommodations, medical treatments, and personal care.
Failure to Clarify, Document, and Complete Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that physician orders for wound treatments were clarified, accurately documented, and completed as prescribed for two residents with non-pressure related wounds. For one resident with a history of hypertension, COPD, and peripheral vascular disease, a skin tear to the left shin was identified and treated initially, but no wound care treatment orders were entered into the medical record for several days, and there was no documentation that wound treatments were completed during that period. Observations confirmed that wound dressings were not applied as ordered, and staff verified that treatments had not been completed or documented as required. For another resident with cerebral infarction, spinal stenosis, and dementia, wound care orders were not updated or discontinued after wounds had healed. The treatment administration record indicated that wound care was documented as completed, but observations revealed that dressings were not applied according to orders, and some dressings were present without corresponding physician orders. Staff interviews confirmed that wound care orders were not discontinued when wounds healed and that wound care was not performed as documented. Policy review showed that the facility required verification of physician orders for wound care and accurate documentation of the care provided, including assessment data. The deficiency was identified through review of medical records, observations, and staff interviews, which revealed lapses in following physician orders, documentation, and communication regarding wound care treatments.
Failure to Properly Store and Label Food and Maintain Pantry Sanitation
Penalty
Summary
Staff failed to properly store and label food and drink items in the pantry located at the nurse's station. Observations revealed an opened and undated packet of thickened tea, two single-serve bowls of dried cereal without dates or labels, a plastic mug with condensation and no label or date, an opened and partially full water bottle with no date, an opened can of energy drink with no date, and an uncovered travel mug half-full of liquid with no date. These items were not stored in accordance with professional standards or the facility's own policy, which requires food not in its original container to be labeled and dated. Additionally, the pantry floor was not maintained in a sanitary manner. Behind the trash can, there was an empty single-serve cranberry juice container, two balled up paper towels, and a sticky dried red substance on the floor. These unsanitary conditions were confirmed by both a CNA and the Administrator during interviews. The facility's policy states that food storage areas should be clean, but observations showed the floor had not been cleaned between surveyor visits.
Unlocked Pantry with Sharp Knives Accessible to Cognitively Impaired Residents
Penalty
Summary
Staff failed to secure potential hazards in the facility by leaving the pantry at the nurse's station unlocked, where two sharp kitchen knives—one with a four-inch blade and another with an eight-inch blade—were found in a drawer. This area was accessible to residents, including six individuals identified as cognitively impaired and independently ambulatory. Observations confirmed the pantry was not locked, and staff interviews verified the presence of the knives and the unlocked status of the pantry. Facility policy required providing a safe environment for residents, but the unlocked pantry with accessible sharp objects did not comply with this expectation.
Failure to Monitor Blood Glucose as Ordered for New Admission
Penalty
Summary
A deficiency occurred when the facility failed to monitor and document blood glucose levels as ordered by the physician for a newly admitted resident with multiple diagnoses, including type II diabetes mellitus, acute kidney failure, chronic kidney disease stage five, myocardial infarction, hypertension, vitreous hemorrhage, glaucoma, and anemia. The resident was admitted with physician orders from the hospital discharge, specifically directing the use of a glucometer and glucose blood test strips to monitor blood sugar three times daily and as needed. The nursing plan of care also included interventions to monitor blood sugars as ordered by the physician. Despite these orders and the resident's history of daily blood sugar monitoring and insulin administration based on sliding scale, review of the medical record revealed no documented evidence that blood glucose monitoring had been performed since admission. Interviews with the resident, an LPN, and the DON confirmed that no daily blood glucose monitoring or related insulin coverage was documented or performed until the surveyor's inquiry, at which point a blood sugar reading was obtained. The DON verified that the physician's orders for daily blood sugar monitoring were present but had not been carried out since admission.
Failure to Initiate and Monitor BiPAP Therapy and Respond to Alarms
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident requiring BiPAP therapy. The resident, who had multiple diagnoses including diabetes, heart disease, leukemia, asthma, COPD, and obstructive sleep apnea, was observed on multiple occasions with her BiPAP machine alarming while she was resting in bed. Staff at the nurse's station were unaware of the ongoing alarms, as the alarms were not audible from their location, and could not confirm how long the alarms had been sounding. Additionally, there were no physician orders or care plans in place for the resident's BiPAP or oxygen therapy until after the deficiency was identified. Further observations revealed that the resident's BiPAP machine was not running at a later time, and the resident was unaware of why it was off. Nursing staff were also unaware that the machine was not operating and had not been informed of any issues or refusals regarding the therapy. Review of the BiPAP machine manual and facility policy indicated that alarms should be responded to promptly and that care should be provided per physician orders, which were not in place at the time of the observations.
Medication Administration Errors and Timing Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered by physicians and within the prescribed timeframes, resulting in a medication error rate of 36% (9 errors out of 25 administrations) during observation. For one resident, physician orders included multiple medications such as oxycodone for pain, Ativan for anxiety, Coreg for blood pressure and heart failure, gabapentin for nerve pain, and glargine insulin for diabetes. During medication administration, the LPN prepared and administered several of these medications but omitted the oxycodone due to unavailability and did not administer the remaining medications within the prescribed timeframes. The LPN confirmed these deviations from the physician's orders during an interview. Another resident had physician orders for Coreg, clonidine, erythromycin ophthalmic ointment, and prednisolone acetic ophthalmic suspension, all with specific administration times. Observation revealed that the LPN administered these medications outside of the prescribed timeframes, with some medications given significantly later than ordered. The LPN acknowledged that the medications were not administered according to the scheduled times. Facility policy requires medications to be administered safely, timely, and within one hour of the prescribed time unless otherwise specified, which was not followed in these instances.
Failure to Administer Medications as Ordered and Within Prescribed Timeframes
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians and within prescribed time frames, resulting in significant medication errors for three residents. For one resident, multiple medications including oxycodone, Ativan, Coreg, gabapentin, and glargine insulin were scheduled for specific times, but observation revealed that these medications were not administered within the required timeframes, and oxycodone was omitted due to unavailability. The LPN confirmed that the medications were not given as prescribed. Another resident had orders for Coreg, clonidine, erythromycin ophthalmic ointment, and prednisolone acetic ophthalmic suspension, all scheduled at specific times throughout the day. Observation showed that these medications were administered outside of the prescribed time frames, and the LPN verified the deviation from the physician's orders. A third resident, with a history of traumatic brain injury, glaucoma, and legal blindness, had orders for Rocklatan and ketorolac tromethamine ophthalmic solutions to be administered at specific times. Review of the medication administration records for two months revealed multiple missed doses and late administrations, with documentation indicating that the medications were often on order or unavailable. The RN confirmed the lack of documentation for administration on the specified dates. Facility policy required medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time, which was not followed in these cases.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure wound care treatments were completed per physician orders for a resident with a stage four pressure ulcer. The resident, who had diagnoses including paraplegia and chronic obstructive pulmonary disease, was admitted with a stage four pressure ulcer on the sacral region. Despite having intact cognition and being at moderate risk for skin breakdown, the resident's wound care was not managed according to the physician's orders. A nurse practitioner noted the absence of a primary dressing on the wound, and a new treatment plan was ordered but not implemented in a timely manner. The Treatment Administration Record indicated that the new treatment ordered on February 5th was not entered into the electronic medical record until February 9th and was not completed until February 10th. Interviews with the resident revealed dissatisfaction with the wound care, noting that the dressing was not applied correctly. An observation confirmed that the wound was covered with a foam dressing instead of the ordered bordered gauze, and there was no treatment or packing in the wound space. The facility's policy required verification and completion of physician-ordered wound care treatments, which was not adhered to in this case.
Failure to Implement Tracheostomy Care Orders
Penalty
Summary
The facility failed to clarify and implement physician orders for the care of a tracheostomy for Resident #19, who was admitted with diagnoses including acute respiratory failure and pneumonia. The hospital discharge orders specified tracheostomy care twice a day and suctioning as needed, but these were not reflected in the admission physician orders or the treatment administration record. Observations revealed the absence of essential tracheostomy supplies, such as a spare tracheostomy tube, Ambu bag, and inner cannula, at the resident's bedside. Interviews with nursing staff and the Director of Nursing confirmed the lack of these supplies and the absence of documented tracheostomy care or suctioning. The Director of Nursing acknowledged that the necessary physician orders for tracheostomy care were not entered into the electronic medical record until several days after the resident's admission. Despite the facility's policy requiring a replacement tracheostomy tube to be available at all times, this was not adhered to, and the resident's tracheostomy care was not documented as completed. The deficiency was identified during an investigation under Master Complaint Number OH00162375.
Repeated Medication Administration Errors in Facility
Penalty
Summary
The facility failed to maintain an effective quality assurance and performance improvement (QAPI) program, as evidenced by repeated deficiencies in medication administration identified during four consecutive comprehensive surveys. The CMS Provider History Profile document and CASPER system data revealed that the facility was cited for significant medication errors in August 2023, January 2024, and July 2024, with the same issue persisting in the current survey. This deficiency had the potential to affect all 44 residents in the facility. During the current survey, a specific incident involving a resident with multiple diagnoses, including epilepsy and type two diabetes mellitus, was observed. The resident was prescribed Novolog insulin to be administered subcutaneously before meals and per a sliding scale. An LPN was observed administering 12 units of Novolog insulin to the resident without priming the insulin pen, contrary to the instructions in the Novolog FlexPen package insert. The LPN confirmed the failure to prime the pen, which is necessary to avoid injecting air and ensure proper dosing. The facility's policy on administering medications, revised in 2012, mandates that medications be administered safely, timely, and as prescribed.
Deficiencies in Legionella Prevention and Infection Control Practices
Penalty
Summary
The facility failed to ensure water temperature testing was conducted as part of its Legionella prevention program. A review of the facility's water temperature logs revealed that testing was absent from October 1, 2024, through December 19, 2024. The Maintenance Supervisor, who was new to the facility, was unaware of the Legionella policy, and the Regional Director of Operations confirmed the lapse in testing. The facility's policy on Legionella surveillance, revised in September 2022, emphasizes the importance of preventing, detecting, and controlling water-borne contaminants, including Legionella. Additionally, the facility did not ensure proper use of personal protective equipment (PPE) during resident care. A CNA provided colostomy care to a resident on enhanced barrier precautions (EBP) without wearing a gown, as required by the facility's policy. Furthermore, an LPN administered insulin to another resident without cleansing the insulin pen's rubber stopper with an alcohol swab before attaching the needle, contrary to the instructions in the Novolog FlexPen package insert and the facility's medication administration policy. These deficiencies had the potential to affect all 44 residents in the facility.
Deficiencies in Emergency Preparedness, Smoking Material Storage, and Resident Transfer Procedures
Penalty
Summary
The facility failed to ensure that emergency crash carts were fully stocked and accessible, as required by their policy. During an observation, it was found that the crash cart at the North nurse's station lacked essential items such as oxygen tubing and an oxygen mask, and the oxygen tank was empty. Attempts by staff to determine if the tank contained oxygen were unsuccessful, and it was noted that the cart at the South nurse's station was missing an oxygen tank entirely. Additionally, staff had difficulty accessing the crash carts due to a jammed lock and a lack of familiarity with the cart's mechanisms. The Director of Nursing was unable to locate the crash cart checklist, which is supposed to be maintained and checked every 24 hours. The facility also failed to safely store smoking materials for a resident who was identified as a smoker. Despite being educated on the smoking policy and agreeing to store smoking materials at the nursing station, the resident was found with cigarettes and a lighter in his possession and in his room. Observations revealed cigarette burns on the resident's clothing, and further interviews confirmed that the resident had been keeping smoking materials in his room against facility policy. Additionally, the facility did not adhere to the care plan for a resident requiring a mechanical lift and two staff members for transfers. An observation showed a single CNA transferring the resident from a Broda chair to a bed without assistance or the use of a mechanical lift, contrary to the resident's care plan. This action was confirmed by the CNA and further verified by the MDS RN, who acknowledged the care plan's requirements for the resident.
Failure to Provide Timely Medicare Discharge Notifications
Penalty
Summary
The facility failed to provide timely notification to residents being discharged from Medicare Part A services, affecting three residents. Resident #25 was informed of the end of services via a telephone call only one day before the termination date. Similarly, Resident #49 and Resident #104 were notified just one day prior to the end of their services. The Business Office Manager confirmed that the Notice of Medicare Non-Coverage (NOMNC) documents were given 24 hours in advance instead of the required 48 hours. The manager attributed the delay to her responsibilities across two buildings, which hindered her ability to provide timely notifications.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by an altercation between two residents, Resident #7 and Resident #39. Resident #7, who was moderately cognitively impaired, and Resident #39, who was cognitively intact, were involved in a physical and verbal altercation in their shared bedroom. The incident occurred when Resident #39 was sitting in the doorway, preventing Resident #7 from exiting the room. An LPN witnessed the event and asked Resident #39 to move aside, which led to Resident #39 verbally abusing Resident #7 and subsequently physically attacking him by hitting and kicking him. The altercation was documented in a self-reported incident and a witness statement by the LPN, who intervened by verbally encouraging the residents to stop and assisting Resident #39 back into his wheelchair. Despite the intervention, Resident #39 continued to verbally attack Resident #7. The Director of Nursing confirmed the occurrence of resident-to-resident abuse. Both residents were assessed after the incident, with no injuries noted, and they denied pain or discomfort. However, the facility's failure to prevent this altercation indicates a deficiency in ensuring residents are free from abuse.
Failure to Implement Bowel Movement Interventions for Hospice Resident
Penalty
Summary
The facility failed to implement ordered interventions to aid in producing a bowel movement for a resident, affecting one resident reviewed for bowel and bladder care. The resident, who was moderately cognitively impaired and receiving hospice services, had a physician's order for the laxative Glycolax powder to be administered as needed for constipation. Despite this order, the resident did not receive any medication for constipation from December 6 to December 13, 2024, during which time no bowel movements were documented. Interviews with the Director of Nursing and the Hospice Registered Nurse revealed a lack of communication and follow-up regarding the resident's bowel movements. The Director of Nursing confirmed the eight-day period without a documented bowel movement and noted that routine orders ended when the resident began hospice services, leading to a lack of notification for intervention. The Hospice RN was unaware of the resident's condition and stated that the facility should have contacted the hospice provider for further orders. The facility's policy on bowel disorders indicated that staff and physicians should identify and address alterations in bowel movements, which was not followed in this case.
Deficiency in Timely and Proper Wound Care
Penalty
Summary
The facility failed to ensure timely and proper wound care for a resident, leading to a deficiency in care. The resident, who had chronic obstructive pulmonary disease, congestive heart failure, and malnutrition, was admitted to hospice care and had a stage two sacral pressure wound. The care plan required daily wound care for the resident's right dorsal foot and sacral area, but observations revealed that the dressing on the right dorsal foot was not changed as ordered, and the sacral wound care was not performed correctly. The Assistant Director of Nursing confirmed that the dressing change was missed, and the wound care procedure was not followed as per the physician's order. During the observation of the sacral wound care, the Assistant Director of Nursing mixed the collagen fibers and zinc ointment incorrectly, resulting in a sand-like consistency that did not adhere properly to the wound. This improper application left the wound inadequately covered, which was confirmed by the Wound Care Certified Nurse Practitioner. The facility's policy required staff to follow specific procedures for wound care, including marking the dressing with initials, time, and date, and ensuring there was a physician's order for the procedure. The failure to adhere to these procedures contributed to the deficiency in wound care for the resident.
Inaccurate Documentation of Insulin Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident with type II diabetes mellitus. The resident, who had intact cognition, was prescribed insulin glargine to be administered subcutaneously every morning and at bedtime. On the morning in question, the medication administration record (MAR) indicated that the insulin was administered at 7:54 A.M., but the resident had not yet received the medication. The resident requested the insulin after breakfast, and the CNA informed the LPN of this request. The LPN confirmed that she had documented the administration of the insulin at 7:54 A.M., despite not having administered it at that time. The LPN intended to give the insulin after the resident finished breakfast, which was contrary to the documentation. The facility's policy required that the individual administering the medication record the date and time of administration accurately in the resident's medical record. This discrepancy in documentation was confirmed by the Corporate Risk Management Nurse.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident received insulin as ordered, resulting in a significant medication error. The incident involved a resident with multiple diagnoses, including type two diabetes mellitus, who was cognitively intact. The resident was prescribed Novolog insulin to be administered subcutaneously before meals and per a sliding scale with meals and at bedtime. During a medication administration observation, an LPN obtained a blood glucose level of 224 mg/dL for the resident, which required four units of Novolog insulin according to the sliding scale order. The LPN stated she would administer a total of 12 units of Novolog insulin to the resident. The LPN was observed attaching an administration needle to the insulin pen, dialing the dose selector to 12 units, and administering the insulin without priming the pen. The Novolog FlexPen package insert specifies that the pen should be primed before each injection to avoid injecting air and ensure proper dosing. The facility's policy on administering medications, revised in 2012, states that medications should be administered safely, timely, and as prescribed. The LPN confirmed during an interview that she did not prime the pen needle prior to administration, which was a deviation from the manufacturer's instructions and the facility's policy.
Insulin Labeling Deficiency
Penalty
Summary
The facility failed to ensure that insulin was labeled appropriately for two residents, leading to a deficiency in medication management. For Resident #17, an observation revealed that a Basaglar insulin KwikPen was open and partially used without a documented date of when it was first opened. The resident, who was cognitively intact, had multiple diagnoses including type two diabetes mellitus and major depressive disorder. The manufacturer's package insert for Basaglar KwikPen specifies that it should be discarded 28 days after opening if stored at room temperature. An LPN confirmed the lack of labeling on the insulin pen. Similarly, for Resident #46, an open vial of Humalog insulin was found without a date indicating when it was opened. This resident, who was moderately cognitively impaired, had diagnoses including diabetes mellitus type II and hemiplegia following a cerebral infarction. The manufacturer's instructions for Humalog insulin also require it to be discarded after 28 days if stored at room temperature. The facility's policy mandates that the date of opening be recorded on multi-dose containers, which was not adhered to in these cases.
Failure to Provide Timely UTI Treatment and Catheter Care
Penalty
Summary
The facility failed to provide timely treatment for a symptomatic urinary tract infection (UTI) for Resident #17, who had an indwelling suprapubic catheter. Despite a history of UTIs and sepsis, and a physician's order for a urinalysis with culture and sensitivity, the facility did not notify the physician of the positive results indicating a UTI. Consequently, Resident #17 experienced severe symptoms, including abdominal pain and fever, leading to hospitalization for sepsis and treatment with intravenous antibiotics. Additionally, the facility did not provide indwelling urinary catheter care for Resident #52 for eight days following admission. There were no physician orders for catheter care, and no documentation was found to confirm that catheter care was performed during this period. The catheter was eventually removed without signs of infection, but the lack of documented care placed the resident at risk for potential harm. Interviews with staff, including the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #200, revealed communication lapses and a failure to follow up on laboratory results and resident complaints. The DON acknowledged that the physician was not notified of Resident #17's urinalysis results, and there was no documentation of the resident's reported abdominal pain. The facility's policies on change in condition and catheter care were not adhered to, contributing to the deficiencies identified in the report.
Sanitation Deficiency in Facility Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition, which had the potential to affect all 51 residents. Observations revealed several areas of broken floor tile trim leading into the dishwasher room, heavy dust buildup on the walls near the kitchen entrance, and a buildup of food debris in the three grease traps underneath the cook top stove. Additionally, there was debris on the floor on the side and behind the cook top stove. The Dietary Manager confirmed these observations and stated that the kitchen was deep cleaned every six months, and the grease traps were cleaned weekly. However, the facility's undated Kitchen Sanitation policy indicated that grease drip trays should be cleaned daily, and floors mopped after meals, with no guidelines for replacing broken tiles.
Failure to Timely Clarify and Complete Wound Care Orders
Penalty
Summary
The facility failed to ensure that new admission wound care orders were timely clarified and completed according to physician orders for a resident. The resident, who had intact cognition, was admitted with several medical conditions including malignant neoplasm of the bladder, chronic kidney disease, and diabetes mellitus type two. Upon admission, the resident had surgical wounds that required specific care. However, there were no wound care orders in place initially, and the necessary wound care was not documented as completed on two specific dates. The deficiency was identified when the facility's compliance hotline received a complaint regarding the resident's care, specifically that the resident had not received wound care for two to three days after admission. It was revealed that the Director of Nursing obtained wound care orders only after the resident's family raised concerns. Additionally, there was a lack of documentation for wound dressing changes on two occasions, with one nurse failing to document a dressing change and another agency nurse not documenting the wound treatment at all.
Failure to Supervise Smoking Residents
Penalty
Summary
The facility failed to ensure that residents who smoked did not have possession of smoking materials in their rooms and were properly supervised, affecting four residents who required supervision for smoking. Resident #6, who was cognitively intact but required supervision, was found to have cigarettes and a lighter in their room, contrary to the facility's smoking policy. The Activity Director admitted that the lock box for storing smoking materials was not locked due to having only one key, and Resident #6 confirmed they kept their own smoking materials in their room. Resident #17, who had impairments to bilateral upper extremities and required supervision and adaptive equipment for smoking, was also found to have cigarettes and a lighter in their room. Despite the smoking plan of care indicating that smoking materials should be stored in the activities office, Resident #17 stored them in their nightstand. The Activity Director confirmed that they did not store Resident #17's smoking materials as required. Similarly, Resident #42, who was moderately cognitively impaired and required supervision, was found to have smoking materials in their room. The Activity Director acknowledged that the lock box was not secure. Resident #158, who was dependent on staff for all ADLs and required supervision, also kept smoking materials in their room, despite the plan of care stating otherwise. The facility's policy required that smoking materials be retained by nursing staff and that residents be supervised during smoking times, which was not adhered to in these cases.
Failure to Notify Physician of Medication Administration Deviation
Penalty
Summary
The facility failed to notify the physician when a resident's medication was not administered as ordered. This deficiency was identified during a review of medication administration for a resident with type II diabetes mellitus, who was prescribed Novolog insulin to be injected before meals for blood sugar control. On a specific date, an LPN obtained the resident's blood sugar reading, which was 99, and subsequently did not administer the prescribed insulin. The LPN documented the medication as held due to the blood sugar level but did not notify the physician as required by the facility's policy. The facility's policy mandates that medications must be administered according to the physician's orders and that any concerns about medication administration should be communicated to the attending physician. Additionally, the facility's policy requires prompt notification of the physician and resident representative in case of significant changes in the resident's condition or treatment. The Director of Nursing confirmed that the physician was not notified when the insulin was held, which was a deviation from the established protocol.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required help with personal hygiene, specifically nail trimming. Resident #21, who was admitted with diagnoses including muscle weakness, morbid obesity, and hypertension, had intact cognition and required staff assistance for personal hygiene as per the Minimum Data Set (MDS) assessment. During an observation, it was noted that the resident's toenails were overgrown and curling, indicating a lack of proper hygiene care. The resident reported difficulty in trimming their own toenails and mentioned that although an aide had suggested a podiatrist visit, it had not occurred, nor had any staff offered to assist with the toenail trimming. Interviews with State tested Nurse Aides (STNAs) revealed that STNAs were responsible for checking and assisting with toenail trimming on scheduled shower days, except for residents requiring podiatrist care due to conditions like diabetes. However, it was confirmed by STNA #257 that Resident #21 was no longer able to trim their own toenails and required assistance, which had not been provided. The facility's policy on ADLs stated that residents unable to perform these activities independently should receive necessary services to maintain personal hygiene, which was not adhered to in this case.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and within prescribed time frames, resulting in a medication error rate of 8.0%, which exceeds the acceptable rate of 5%. This deficiency affected one resident who was reviewed for medication administration. The resident, diagnosed with type II diabetes mellitus, had a physician order for Novolog insulin to be administered before meals and Gabapentin to be given three times daily at specific times. However, the insulin was incorrectly withheld by an LPN when the resident's blood sugar was 99, despite the order specifying to notify the physician only if the blood sugar was less than 70. Additionally, the Gabapentin dose scheduled for 2:00 P.M. was administered outside the prescribed time frame. The facility's policy requires medications to be administered within one hour of their prescribed time unless otherwise specified. The LPN confirmed the error during an interview, and the DON acknowledged that the insulin should not have been held according to the physician's order. The facility's policy on administering medications, last revised in December 2012, was not followed, contributing to the medication errors observed.
Medication Administration Error for Diabetic Resident
Penalty
Summary
The facility failed to ensure that medications were administered without significant errors, affecting a resident with type II diabetes mellitus. The resident had a physician's order for Novolog insulin to be administered before meals for blood sugar control, with instructions to call the physician if the blood sugar was less than 70. On a specific day, an LPN checked the resident's blood sugar, which was 99, and decided to hold the insulin dose, contrary to the physician's order. The LPN documented the decision to hold the medication due to the blood sugar reading of 99 and provided the resident with applesauce instead. The Director of Nursing confirmed that the LPN should not have held the insulin as the physician's order did not permit holding the medication for a blood sugar level of 99. The facility's policy on administering medications requires that medications be given according to the orders and within the specified time frame. The policy also states that if a dosage is believed to be inappropriate, the person administering the medication should contact the attending physician or the facility's Medical Director. However, this protocol was not followed in this instance.
Failure to Obtain Ordered Laboratory Tests for Residents
Penalty
Summary
The facility failed to ensure laboratory blood testing was obtained as ordered by the physician for three residents. Resident #19, who had diagnoses including hyperlipidemia, type II diabetes mellitus, and hypertension, had physician orders for weekly blood tests starting on 05/29/24. However, out of eight opportunities, the tests were only conducted four times, with no documentation of refusal by the resident for the missed tests. The Director of Nursing confirmed the lapses in obtaining the required laboratory tests. Resident #25, with conditions such as depression, type II diabetes mellitus, and chronic kidney disease, had orders for various blood tests starting on 06/06/24, but there was no evidence that these tests were completed by 07/17/24. Similarly, Resident #42, who had diagnoses including hypertension and chronic obstructive pulmonary disease, had orders for blood tests from 02/01/24, but none were completed by 07/17/24. The Director of Nursing verified the lack of completed tests for both residents, and the contracted laboratory did not keep records of test refusals, indicating that the tests were not obtained as ordered.
Failure to Maintain a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by the conditions observed in the room of Resident #21. The resident's room had significant damage and cleanliness issues, including large gouges in the wall behind the bed, dirty walls with dark marks and a dried red substance, and a privacy curtain with numerous black marks and a dried brown substance. Additionally, the bathroom door and the wall next to it were scraped. The resident reported that the sink in their bathroom had been running constantly for about two months, despite requests for it to be fixed, and the noise was bothersome. Interviews and observations with the Maintenance Director and Floor Technician confirmed the issues reported by Resident #21. The Maintenance Director verified that the sink could not be turned off without replacing the entire faucet, and acknowledged the damage to the wall behind the bed. The Floor Technician confirmed the presence of the dirty curtain, dirty wall, and scraped wall and door. The facility's policy on providing a safe and homelike environment was reviewed, which stated the facility's commitment to maintaining a clean and comfortable environment, yet these standards were not met in this instance.
Failure to Maintain Fire Safety Systems and Conduct Proper Fire Watches
Penalty
Summary
The facility failed to maintain its sprinkler systems in operational status for fire safety, as observed during a survey. The State Fire Marshal's Fire Safety Inspection Report revealed that the fire protection system had not been inspected, tested, or maintained as required, resulting in several leaks in the dry sprinkler system. The system was turned off due to pinhole leaks after an employee shut off the compressor. Additionally, there were multiple instances of improperly sealed penetrations in the facility's ceilings, including missing sections of drywall and water-damaged areas, which compromised the fire/smoke barriers. The facility also failed to notify the Ohio Department of Health (ODH) about being under a fire watch and did not conduct fire watches correctly. There was no evidence of notification to ODH, and the Director of Operations could not provide proof of such notification. Furthermore, there were significant gaps in the fire watch logs, with missing checks and discrepancies in documentation. The fire watches were not comprehensive, as they only included patient care areas, and other critical areas like the kitchen, dietary, laundry rooms, and mechanical and electric rooms were not monitored due to staff not having access keys. The facility's fire watch policy required a periodic walking tour of the entire facility with direct observation of all rooms for signs of fire, which was not adhered to. The policy also stated that the fire department should be notified if the fire protection system is not working completely, and the Department of Health should be informed if the system is inoperable for more than four hours in a 24-hour period. The facility assessment emphasized maintaining the physical environment to protect residents' health and safety, which was not achieved in this instance.
Facility Fails to Maintain Safe Environment After Water Leak
Penalty
Summary
The facility failed to maintain a safe and clean environment following a water leak that caused significant damage. Observations during a facility tour revealed a missing section of the ceiling in the north hall, with plastic loosely stapled to exposed wood trusses. In the south hall, a section of drywall was loosely screwed to a patched ceiling, and in room 215, several bath towels with brownish-yellow dried discoloration were found on the floor below a sagging ceiling with deep cracks. These conditions were observed to potentially affect all residents in the facility, which had a census of 52. Interviews with facility staff confirmed the extent of the damage. The Assistant Director of Nursing reported that the ceiling in room 215 began to leak after the sprinkler system was shut down, necessitating the relocation of residents. The Director of Maintenance verified that the north hall central ceiling had collapsed on May 19, 2024. The facility's assessment, dated May 3, 2024, stated that the physical environment would be maintained to protect and promote the health and safety of residents, yet the observed conditions indicated non-compliance with this standard.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, which directly affected one resident and had the potential to affect all residents. During a facility tour, a mouse trap was observed in the office of the MDS Nurse, who confirmed sightings of mice in the building over the weekend. The Occupational Therapist also reported mice sightings in the therapy room, where traps were set nightly. In Resident #51's room, dead insects were found, and the resident reported seeing a mouse and experiencing issues with gnats, earwigs, and centipedes for several weeks. The resident expressed distress over the inability to sleep due to the bugs and had provided a collection of bugs to the Director of Maintenance, who promised an exterminator visit that did not occur as scheduled. Further observations revealed ants in the conference room, and the Director of Maintenance acknowledged the pest issues and the missed exterminator appointment. Review of exterminator invoices from previous months indicated ongoing pest issues, including fruit flies, ants, and mice, with recommendations for building repairs to prevent rodent entry. However, these recommendations were not fully implemented, and the facility remained not rodent-proof. The facility's housekeeping reports also noted ant clean-up in the dining room, and the Facility Assessment claimed the environment was maintained to protect residents' health and safety, which was contradicted by the observed pest issues.
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 593 citations issued within 25 miles in the last 12 months — including the 4 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 Maumee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Addison Heights Health And Rehabilitation Center | 1 mi | ★★★★★ | 44 | 0 |
| Lutheran Village At Wolfcreek | 1.5 mi | ★★★★★ | 17 | 0 |
| Lakes Of Monclova Health Campus The | 1.6 mi | ★★★★★ | 14 | 0 |
| Elizabeth Scott Community | 2 mi | ★★★★★ | 0 | 0 |
| Heatherdowns Rehab & Residential Care Center | 2.5 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ridgewood Manor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.