Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
76% occupied
Based on a March 2025 inspection.
Occupancy over time
Inspection Report
Routine
Deficiencies: 5
Date: Mar 24, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care plans, pressure ulcer care, medication management, and controlled substance reconciliation.
Findings
The facility failed to develop comprehensive care plans for residents receiving hospice services, failed to update care plans after a resident's fall with injury, failed to ensure proper pressure ulcer care including correct air mattress settings, and failed to maintain accurate and reconciled records of controlled substances. Additionally, expired medications were not properly disposed of and medication carts were sometimes left unlocked.
Deficiencies (5)
Failed to develop and implement a complete care plan that includes hospice services for residents #29 and #46.
Failed to review and revise the Resident Care Plan after a fall with major injury for Resident #36.
Failed to ensure physician orders for air mattress included type of setting and ensure the air mattress was set correctly for Resident #45 with pressure ulcers.
Failed to establish a system of records for receipt and disposition of all controlled drugs to enable accurate reconciliation and periodic audits.
Failed to ensure expired medication was disposed of and medication carts were locked when not in use.
Report Facts
Deficiencies cited: 5
Resident weight: 192
Dates of key events: Multiple dates including hospice admission 12/6/24, fall on 1/31/25, care plan revisions on 3/19/25, survey date 3/24/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | MDS Coordinator | Interviewed regarding failure to develop hospice care plan for Resident #29 |
| RN #4 | MDS Coordinator | Interviewed regarding failure to develop hospice care plan for Resident #29 and #46 |
| Director of Social Services | Interviewed regarding hospice referral notifications and care plan responsibilities | |
| DNS | Director of Nursing Services | Interviewed regarding hospice care plan development and fall care plan updates |
| Registered Nurse #1 | RN | Interviewed regarding air mattress pressure settings and physician orders |
| Assistant Director of Nursing Services | ADNS | Interviewed regarding air mattress settings |
| MD #1 | Physician | Provided wound consultation and treatment orders for Resident #45 |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication room stock rotation and expired items |
| LPN #3 | Licensed Practical Nurse | Observed leaving medication cart unlocked and interviewed about policy |
| Registered Nurse #2 | RN Nursing Supervisor | Interviewed regarding medication cart security and narcotic reconciliation |
| Occupational Therapist #1 | OT | Interviewed regarding Resident #45 therapy and bed rest |
| Direct Home Medical Provider of equipment Clinical [NAME] President | Interviewed regarding proper use of air mattress settings |
Inspection Report
Renewal
Census: 47
Capacity: 62
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
The inspection was conducted as a renewal licensing inspection with violations identified during the inspection.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as noted in an attached violation letter dated 4/3/25.
Report Facts
Inspection dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paul Brown | Administrator | Personnel contacted during inspection |
Inspection Report
Renewal
Census: 47
Capacity: 62
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
The inspection was conducted as a licensing inspection for renewal purposes.
Findings
The report indicates that this was a renewal licensing inspection. No violations or citations were marked as identified or issued in the provided document.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paul Brown | Administrator | Personnel contacted during the inspection. |
Inspection Report
Renewal
Deficiencies: 6
Date: Mar 24, 2025
Visit Reason
Unannounced visits were made to Ridge Crest At Meadow Ridge, concluding on March 24, 2025, by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a recertification survey.
Findings
The report details multiple violations of the Regulations of Connecticut State Agencies related to medical records, care plans, medication storage, and pressure ulcer management. Deficiencies include failure to complete significant change assessments, incomplete hospice care plans, inadequate fall risk care plans, improper medication reconciliation, and failure to ensure proper use and documentation of air mattresses for pressure ulcer prevention.
Deficiencies (6)
Failure to complete significant change assessment within 14 days after admission to hospice services for Resident #29.
Failure to ensure the Resident Care Plan was comprehensive to include hospice care for Residents #29 and #46.
Failure to review and revise the Resident Care Plan after a fall with major injury for Resident #36.
Failure to ensure physician orders related to air mattress settings were followed for Resident #45 with pressure ulcers.
Failure to establish a system of records for receipt and disposition of controlled drugs and failure to ensure account of all controlled drugs was maintained and periodically reconciled.
Failure to ensure expired medication was disposed of and medication storage areas were locked when not in use.
Report Facts
Residents reviewed for hospice services: 1
Residents reviewed for death: 1
Residents reviewed for accidents: 1
Residents reviewed for pressure ulcers: 1
Residents reviewed for medication storage and narcotic reconciliation: 1
Residents reviewed for medication storage and expired medication: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judith Birtwistle | Supervising Nurse Consultant | Signed the notice letter regarding the plan of correction submission. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 26, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to the facility's failure to ensure complete and accurate medical record documentation, specifically regarding a resident's refusal of care.
Complaint Details
The complaint investigation found that Resident #2 refused incontinent care on 8/28/2023, which was reported by nursing assistant NA #2 to RN #2, but the refusal was not documented in the medical record or communicated to the on-coming shift. The deficiency was substantiated.
Findings
The facility failed to document Resident #2's refusal of incontinent care on 8/28/2023, despite staff reports of the refusal. The investigation confirmed the resident required two staff for care and was incontinent, but the refusal was not recorded in the medical record as required by facility policy.
Deficiencies (1)
Failure to ensure the medical record was complete and accurate to include a refusal of care for Resident #2.
Report Facts
Date of refusal incident: Aug 28, 2023
Date of investigation summary: Aug 30, 2023
BIMS score: 3
Date of Resident Care Plan: Aug 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #2 | Nursing Assistant | Reported Resident #2's refusal of care to RN #2 |
| RN #2 | Registered Nurse | Did not document refusal of care or notify on-coming shift |
| DNS | Director of Nursing Services | Interviewed and confirmed lack of documentation of refusal of care |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 16, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify a resident's responsible party prior to initiation of an antidepressant medication and failure to ensure staff timely notified the nurse after a resident had an unwitnessed fall.
Complaint Details
The complaint investigation focused on two issues: failure to notify the responsible party before starting an antidepressant for Resident #2, and failure to timely notify the nurse after Resident #1's unwitnessed fall. The facility was unable to provide signed consent for the medication initiation and lacked a notification policy. Staff failed to report the fall promptly, leading to employment termination and education.
Findings
The facility failed to notify the responsible party prior to starting Mirtazapine for Resident #2 and lacked a policy for such notification. Additionally, the facility failed to ensure timely nurse notification after Resident #1's unwitnessed fall, resulting in termination of one nursing assistant and education for another.
Deficiencies (2)
Failure to notify the resident's responsible party prior to initiation of an antidepressant medication.
Failure to ensure staff notified the nurse timely after a resident had an unwitnessed fall.
Report Facts
Medication dosage: 7.5
Medication administration duration: 14
BIMS score: 99
BIMS score: 4
Incident date: Sep 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nursing Assistant | Failed to report Resident #1's fall to nurse; employment terminated |
| NA #2 | Nursing Assistant | Assisted after Resident #1's fall; did not report incident; received education |
| APRN #1 | Advanced Practice Registered Nurse | Recommended Mirtazapine for Resident #2 |
| DON | Director of Nursing | Interviewed regarding medication notification policy and fall incident |
| Person #1 | Resident #2's Power of Attorney | Responsible party not notified prior to medication initiation |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 27, 2022
Visit Reason
The inspection was conducted based on complaints regarding failure to act on resident grievances about missing personal items, allegations of neglect related to leaving a resident on the toilet for several hours, failure to transcribe physician orders for DNR and RNP, and concerns about staff training and competency in IV therapy.
Complaint Details
The complaint investigation included grievances from residents about missing personal items (Residents #145 and #146), an allegation of neglect for leaving Resident #346 on the toilet for several hours, failure to transcribe DNR and RNP orders for Resident #3, and concerns about IV therapy training for licensed and unlicensed staff.
Findings
The facility failed to timely and adequately address resident grievances regarding missing personal items, did not conduct a thorough investigation of neglect allegations, failed to transcribe critical physician orders timely, and did not provide evidence of required annual IV therapy training and competency for licensed and unlicensed nursing staff. Additionally, the facility failed to implement specialized rehabilitative services related to motorized wheelchair use in a timely manner.
Deficiencies (6)
Failed to act on resident reported concern related to missing personal items in a timely manner and within accordance to facility policy.
Failed to conduct a thorough investigation regarding an allegation of being left on the toilet for several hours.
Failed to transcribe the Do Not Resuscitate (DNR) and Registered Nurse may Pronounce (RNP) physician's orders according to professional standard and facility practice.
Failed to ensure licensed nursing staff completed the facility's annual education and competencies training for Intravenous Therapy IV.
Failed to implement specialized rehabilitative services related to the use of a motorized chair for mobility to attain the resident's highest level of physical, mental, functional, and psycho-social well-being in a timely manner.
Failed to ensure unlicensed nursing staff completed the facility's annual education and competencies training for Intravenous Therapy IV.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Deficiency count: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rehabilitation Director #1 | Identified assessment and safety evaluation of motorized wheelchair use for Resident #145 | |
| Rehabilitation Director #2 | Inquired about acquisition of one-armed wheelchair for Resident #145 | |
| Admissions Person #1 | Informed Resident #145 about motorized wheelchair policy and alternate wheelchair provision | |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Responsible for follow-up on transcription of Resident #3's physician orders |
| Licensed Practical Nurse (LPN #4) | Licensed Practical Nurse | Responsible for transcribing physician's orders for Resident #3 |
| Dietary Director | Interviewed regarding missing tweezers reported by Resident #145 | |
| Occupational Therapist (OT #1) | Assessed Resident #145's use of motorized chair | |
| Occupational Therapist (OT #2) | Received report of missing shoes from Resident #146 | |
| Social Worker (SW #1) | Follow-up on missing items grievance for Resident #146 | |
| Director of Nursing Services (DNS) | Director of Nursing Services | Interviewed regarding IV therapy training and miscommunication about wheelchair services |
| Registered Nurse (RN #2) | Registered Nurse | Interviewed regarding IV therapy training and competency documentation |
Inspection Report
Renewal
Census: 41
Capacity: 56
Deficiencies: 0
Date: Oct 21, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. The certification file was reviewed.
Report Facts
Licensed Bed/Bassinet Capacity: 56
Census: 41
Inspection Dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Feia Roseno | DNS | Personnel contacted during inspection |
| Claudia Dunford | ADON | Personnel contacted during inspection |
Inspection Report
Monitoring
Census: 44
Capacity: 62
Deficiencies: 0
Date: Jan 27, 2021
Visit Reason
COVID-19 monitoring visit to the facility.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yvette Dobruck | Administrator | Personnel contacted during the inspection. |
Inspection Report
Abbreviated Survey
Census: 46
Capacity: 62
Deficiencies: 0
Date: Jul 1, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey conducted on July 1, 2020.
Inspection Report
Abbreviated Survey
Census: 49
Capacity: 62
Deficiencies: 0
Date: Jun 19, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Abbreviated Survey
Census: 36
Capacity: 62
Deficiencies: 0
Date: May 27, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey focused on infection prevention and control practices related to COVID-19 compliance at the facility.
Inspection Report
Routine
Deficiencies: 0
Date: Apr 24, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found the facility compliant with no deficiencies cited related to infection prevention and control practices for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 13, 2020
Visit Reason
The visit was conducted to assess the facility's infection prevention and control program, specifically reviewing compliance with standard precautions to prevent the spread of infection on the Elm unit.
Findings
The facility failed to consistently implement standard precautions to prevent infection spread, as evidenced by a housekeeper wearing protective equipment outside residents' rooms and improper handling of protective gear and cleaning items.
Deficiencies (1)
Failure to consistently implement standard precautions to prevent the spread of infection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HK #1 | Housekeeper | Observed failing to properly remove and dispose of protective equipment and improperly handling cleaning items during infection control surveillance. |
| DNS | Interviewed regarding observations of HK #1's improper use of protective equipment. |
Inspection Report
Renewal
Census: 48
Capacity: 56
Deficiencies: 0
Date: Feb 10, 2020
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility Ridge Crest at Meadow Ridge.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as noted in an attached violation letter.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Weld | DPS | Personnel contacted during the inspection |
| Yvette DuBose | Personnel contacted during the inspection | |
| Admini | Personnel contacted during the inspection |
Inspection Report
Annual Inspection
Census: 51
Capacity: 56
Deficiencies: 5
Date: Dec 17, 2018
Visit Reason
Unannounced visits were made on December 17, 18, and 19, 2018 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a certification inspection.
Findings
Violations of the Connecticut General Statutes and/or regulations were identified during the inspection, including issues related to physical restraints, infection control, medication administration, and pressure ulcer care. The facility failed to ensure residents were free from physical restraints and did not consistently implement infection control precautions. Plans of correction were submitted addressing these deficiencies.
Deficiencies (5)
Failure to ensure residents were free from physical restraints, including improper bed placement against the wall and chairs placed around beds.
Failure to consistently implement standard infection control precautions, including improper use of personal protective equipment by housekeeping staff.
Failure to accurately code resident's utilization of antipsychotic medication on the Minimum Data Set (MDS) assessment.
Failure to treat or implement intervention to treat a resident's change in skin condition related to pressure ulcers.
Failure to ensure a safe environment for residents, including issues related to falls and environmental hazards.
Report Facts
Licensed Bed Capacity: 56
Census: 51
Inspection Dates: 3
Fall Risk Score: 90
Fall Risk Score: 55
Pressure Ulcer Measurement: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ellen Belanger | Administrator | Named in relation to the inspection and findings. |
| Yvette Dobruck | Administrator | Named in plan of correction responses and correspondence. |
| Connie Greene | Supervising Nurse Consultant | Signed inspection and correspondence documents. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Dec 17, 2018
Visit Reason
Unannounced visits were made to Meadow Ridge on December 17, 18 and 19, 2018 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a certification inspection.
Findings
The report details violations related to resident care, including improper use of physical restraints and failure to ensure a safe environment for residents at risk of falls. Specific findings include issues with bed placement against walls and use of chairs as restraints, as well as failure to accurately code medication utilization and inconsistent infection control practices.
Deficiencies (3)
Failure to ensure residents were free from physical restraints, including bed placement against the wall without waiver and use of chairs as restraints.
Failure to accurately code resident's utilization of antipsychotic medication on the Minimum Data Set (MDS) assessment.
Failure to consistently implement standard precautions to prevent the spread of infection, including improper use of personal protective equipment by housekeeping staff.
Report Facts
Fall risk assessment score: 90
Fall risk assessment score: 55
Compliance date: Mar 26, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Greene | Supervising Nurse Consultant | Signed letter and involved in investigation |
| Yvette Dobruck | Administrator | Signed Plan of Correction letter |
Inspection Report
Renewal
Census: 47
Capacity: 56
Deficiencies: 0
Date: Jan 12, 2018
Visit Reason
The inspection was conducted as a licensing renewal inspection and included a complaint investigation (Complaint # CT #22285).
Complaint Details
Complaint investigation # CT #22285 was conducted as part of this inspection.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection, resulting in a citation (Citation # 18-05).
Report Facts
Citation number: 18.05
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ellen Belanger | Administrator | Personnel contacted during the inspection. |
| Kimberly Held | Nurse | Personnel contacted during the inspection. |
Viewing
Loading inspection reports...
