Inspection Reports for
Ridge Crest Nursing Center

The facility was found deficient in multiple areas including failure to provide meaningful activities tailored to resident preferences, incomplete physician orders for IV medication infusion rates, unsafe environmental conditions with tripping hazards, inadequate supervision of residents with wandering and exit-seeking behaviors, failure to properly monitor and document Foley catheter care, failure to follow nutritional orders including delayed administration of appetite stimulants and supplements, failure to maintain cleanliness of the ice machine, incomplete infection prevention and control program including Legionella risk assessment, failure to ensure proper hand hygiene during resident care, and failure to document resident education and consent for influenza, pneumococcal, and COVID-19 vaccinations.

The facility failed to ensure that residents requiring assistance with bathing received baths or showers as needed. Four of six sampled residents did not receive the expected frequency of baths/showers, with staff shortages and scheduling issues cited as contributing factors.

The facility failed to ensure residents who required assistance with bathing received adequate baths or showers. Several residents had not received showers as frequently as their care plans required, resulting in body odor and unkempt appearance.

The investigation was complaint-related, focusing on falls experienced by Residents #1, #6, and #7. The complaint included failure to complete fall investigations, neurological assessments, and care plan updates. The complaint was substantiated with findings of actual harm to residents.

The facility failed to provide appropriate fall prevention interventions and oversight for residents who experienced falls, did not complete required fall investigations or neurological assessments after falls, and failed to update care plans to reflect interventions post-fall. Several residents sustained injuries including head lacerations, and the facility's documentation and follow-up were inadequate.

The facility failed to provide adequate supervision and interventions to prevent resident falls, failed to complete neurological checks after falls, and did not update care plans accordingly. Multiple residents experienced falls with injuries, and root cause analyses and follow-up interventions were incomplete or missing.

The facility failed to ensure residents received adequate personal care, notably not offering showers or baths as scheduled to several residents due to staffing shortages. Additionally, the facility lacked a certified Infection Preventionist for over six months, impacting infection control oversight.

The facility failed to ensure residents received adequate personal hygiene care, specifically showers, and lacked a certified Infection Preventionist. Multiple residents did not receive the required showers, and the facility did not have a policy or trained staff for infection prevention.

The facility had multiple deficiencies including failure to maintain resident dignity, inadequate maintenance and cleanliness, incomplete criminal background checks for employees, failure to follow physician orders for pacemaker monitoring, inadequate hair care for a resident, incomplete wound care and documentation, incomplete fall investigations, improper catheter care, unsafe oxygen therapy practices, inaccurate narcotic medication documentation, unlocked medication carts, dietary deficiencies including lack of recipes and limited menu variety, cold food service, lack of antibiotic stewardship program, absence of a certified infection preventionist, and failure to ensure pneumococcal vaccinations were offered and documented.

The facility was found not to be in compliance with emergency preparedness requirements and life safety codes, including failure to properly account for hazards in the Hazard Vulnerability Plan, lack of emergency power plans for certain residents, inadequate subsistence needs policies, and multiple fire safety deficiencies such as sprinkler system impairment and door fire resistance issues.

The investigation was complaint-related, focusing on Resident #18's hair care. The resident refused care from certain staff and preferred external hair care services. The facility did not document refusals consistently, and the care plan lacked specific hair care instructions or refusal documentation.

The facility failed to ensure proper hair care maintenance for Resident #18, who had matted hair and a knot on the back of the head. The resident refused care from certain staff and preferred to have hair care done outside the facility due to lack of supplies and staff qualifications. Documentation of care refusals and hair care preferences were lacking in the care plan and resident's chart.

The investigation was triggered by a complaint about missing narcotic medication for Resident #1. The complaint was substantiated as the facility confirmed 30 tablets of Hydrocodone-Acetaminophen were missing. An extensive search and interviews were conducted, and a report was filed with local police.

The facility failed to keep one card of Hydrocodone-Acetaminophen 5/325 mg double locked at all times, resulting in 30 tablets missing for one sampled resident. The medication carts did not lock properly, and the narcotic drawer was vulnerable to being unlocked, leading to a loss of medication.

The visit was complaint-related due to the missing card of Hydrocodone-Acetaminophen 5-325 mg tablets for Resident #1. The complaint was substantiated as the medication was confirmed missing after an investigation, interviews, and a search. The local police were involved, and drug testing of staff was conducted.

The facility failed to secure controlled substances properly, leading to the loss of a narcotic medication card for Resident #1. The medication cart locks were faulty, and nursing staff did not consistently follow narcotic counting and storage policies. An extensive search and interviews were conducted, and the local police were notified. The medication remained missing at the time of the report.

The facility was found to have multiple deficiencies including failure to maintain authorization forms for resident funds, inadequate notification of residents regarding personal funds, failure to check Nurse Aide Registry for new hires, lack of bathing policy and documentation, improper foot care, food safety violations, and infection control issues related to Legionella. The facility census was 47 residents with a licensed capacity of 120 beds.

The facility was found deficient in multiple areas including resident financial record keeping, notification of resident fund balances, employee registry checks, bed-hold policy notices, bathing assistance, diabetic shoe provision, safe resident transfers, food temperature maintenance, food storage labeling, dumpster maintenance, hospice documentation, and infection prevention water management.

The visit was complaint-related due to concerns about nursing staff competency and scope of practice during the COVID-19 pandemic. The complaint was substantiated as the CNA performed unauthorized medical tasks.

The facility failed to ensure that a Certified Nursing Assistant (CNA) provided care within their scope of practice, including performing blood sugar checks and breathing treatments. Documentation and nursing staff training deficiencies were noted related to medication administration and treatment procedures.

Complaint investigation was substantiated with findings of multiple deficiencies related to injury notification, pressure ulcer care, fall prevention, and quality of care.

The facility failed to ensure timely notification of injuries and changes in resident condition, failed to prevent and properly treat pressure ulcers, and failed to implement appropriate fall prevention interventions. Multiple residents experienced injuries and adverse events that were not properly managed or documented.

The facility was found not to be in compliance with emergency preparedness requirements and life safety code provisions including deficiencies in the Emergency Operational Preparedness program, fire alarm system testing and maintenance, fire drills, maintenance and inspection of fire doors, and oxygen storage room safety.

The facility failed to provide a physician-prescribed mechanical soft diet for one sampled resident, resulting in improper food texture and potential risk. Multiple staff interviews revealed inconsistent understanding and documentation of what constitutes a mechanical soft diet.

The facility failed to meet several emergency preparedness and life safety code requirements, including deficiencies in emergency water supply location communication, delayed egress door signage, exit signage placement, range hood inspections, fire extinguisher accessibility, door latching, fire drills, and electrical system maintenance.

The complaint involved allegations of narcotic misappropriation and inadequate care for residents, including failure to provide assistance with bathing and pain management. The investigation found these allegations substantiated with multiple deficiencies.

The facility was found to have deficiencies related to narcotic medication management, insufficient assistance with resident bathing and hygiene, inadequate pain management documentation, and food safety violations. Several residents did not receive scheduled showers or baths, and medication administration records showed discrepancies.