Inspection Reports for
Ridgecrest Health and Rehabilitation

The facility failed to administer medications within the recommended time frame for one resident (Resident #3) and failed to ensure that medications pulled by one nurse were administered by the same nurse. The deficiencies were determined to be of minimal harm with few residents affected.

The facility failed to ensure residents received proper assistance with activities of daily living, including nail care for diabetic residents, failed to provide all prescribed medications during administration resulting in medication errors, and failed to prepare meals according to the planned recipes and menus to meet residents' nutritional needs.

The facility was found deficient in multiple areas including failure to maintain resident dignity during care, incomplete and inaccurate Minimum Data Set (MDS) assessments, inadequate care planning and implementation for wounds and pressure ulcers, failure to provide timely and accurate medication administration, improper infection control practices including PPE use and contact isolation, inadequate foot and nail care for diabetic residents, failure to maintain food safety and proper meal preparation, and lack of effective Quality Assurance Performance Improvement (QAPI) documentation.

The facility was found deficient in multiple areas including failure to respect resident privacy by not knocking before entering rooms, inadequate maintenance of a safe and homelike environment, incomplete and outdated care plans and assessments for residents, failure to document and perform catheter and wound care properly, and poor infection control practices including failure to perform hand hygiene and glove changes appropriately.

The investigation was substantiated with findings that Resident #2 fell out of bed during peri-care, sustained a fracture, and the facility delayed appropriate response and communication. The APRN did not fully review x-rays until several days later, and the resident was only given Tylenol initially. The resident developed a DVT and was hospitalized.

The facility failed to ensure safe incontinent care, resulting in Resident #2 sliding out of bed and sustaining a comminuted and displaced femur fracture. The APRN delayed full review of x-ray results, and pain management was initially limited to Tylenol before escalation to stronger medication. The resident was not informed of x-ray results promptly, and family notification was delayed.

The facility failed to complete an admission assessment and initial body audit on the day of admission for one resident, resulting in delayed identification and treatment of a deep tissue injury (DTI) to the resident's right heel. Interviews with staff and review of policies confirmed the deficiencies in admission procedures and wound care.

The facility failed to ensure timely response to call lights for one resident and proper fingernail care for four residents, with observations of long, jagged, and unclean nails despite care plans addressing these issues.

The visit was complaint-related, triggered by multiple resident and family complaints about inadequate care, cleanliness, and staffing shortages. The complaints included missed showers, unclean rooms, medication issues, and insufficient staff coverage. The complaint was substantiated based on observations and interviews.

The facility failed to maintain resident rooms in a clean and homelike manner, did not provide adequate activities of daily living care including nail care for several residents, and lacked sufficient nursing staff to meet resident needs. Multiple residents and staff interviews confirmed ongoing issues with cleanliness, personal care, and staffing shortages.

The facility was found deficient in multiple areas including residents' access to personal funds after hours, cleanliness and maintenance of resident rooms, timely completion of quarterly assessments, provision of activities of daily living care, medication administration and storage, accident prevention, respiratory care, staffing adequacy, food temperature and handling, infection control practices, and quality assurance processes.

The complaint investigation found that Resident #1's feeding pump was disconnected for an extended period due to lack of a connector, and staff did not verify tube placement before feeding. Resident reported feeling hungry due to the feeding being off all night. The Nurse Consultant confirmed that continuous feeding should not be off for more than an hour to maintain proper nutrition.

The facility failed to follow the physician's order for continuous enteral feeding for Resident #1, who was observed multiple times with the feeding pump disconnected and tubing hung over the pole. Staff admitted to not checking tube placement prior to feeding and not having the proper connector, resulting in the feeding being off for an extended period.

The visit was complaint-related, investigating allegations of poor resident care, safety hazards, and sanitation issues. The facility was found to have multiple deficiencies affecting residents' dignity, safety, and health. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including use of worn and stained linens, failure to timely identify and investigate injuries of unknown origin, inadequate oral care for residents with NPO orders, failure to provide restorative services and proper use of positioning devices, lack of fall prevention interventions, improper storage of suction supplies, and poor food safety and sanitation practices in the kitchen.