Inspection Reports for
Ridgeway Nursing and Rehabilitation Facility
406 WYOMING ROAD, OWINGSVILLE, KY, 40360
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 8, 2025
Visit Reason
The inspection was conducted to investigate complaints related to resident abuse and misappropriation of resident property at Ridgeway Nursing & Rehabilitation Facility.
Complaint Details
The complaint investigation involved allegations of resident-to-resident physical abuse and misappropriation of controlled substances. The abuse was substantiated with witness statements and progress notes. The medication misappropriation was confirmed through medication error reports and discrepancies in controlled substance logs.
Findings
The facility failed to protect one resident from physical abuse by another resident and failed to ensure residents were free from misappropriation of property related to medication administration errors. Both incidents involved minimal harm with few residents affected.
Deficiencies (2)
F 0600: The facility failed to protect Resident 21 from physical abuse by Resident 72, who slapped her in the face over a teddy bear. The incident was witnessed and documented, and the facility had policies for abuse prevention and reporting.
F 0602: The facility failed to prevent misappropriation of medication for Resident 51 when an extra dose of oxycodone was administered by a nurse. Controlled substance logs and medication administration records did not match, and documentation was incomplete.
Report Facts
Brief Interview for Mental Status (BIMS) score: 3
Brief Interview for Mental Status (BIMS) score: 4
Brief Interview for Mental Status (BIMS) score: 12
Extra dose of oxycodone administered: 1
Scheduled oxycodone doses signed out: 4
Oxycodone doses administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN14 | Licensed Practical Nurse | Named in medication error involving extra dose of oxycodone administered to Resident 51. |
| LPN4 | Licensed Practical Nurse | Witnessed and reported resident abuse incident and provided statements about medication administration policies. |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Made medication adjustment recommendations for Resident 72 after abuse incident. |
| Administrator | Facility Administrator | Responsible for abuse coordination and expectations for reporting incidents. |
| Director of Nursing | Director of Nursing | Conducted investigation into medication misappropriation and provided staff reeducation. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: May 8, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements related to resident rights, care planning, medication administration, infection control, and other aspects of nursing home care.
Findings
The facility was found deficient in multiple areas including failure to document residents' advance directives, incomplete and untimely care plan development and revision, medication administration errors involving crushing extended-release tablets, and inadequate infection prevention and control practices including improper isolation precautions and catheter bag placement.
Deficiencies (5)
F 0578: The facility failed to provide documentation of residents' advance directive information for 2 of 12 sampled residents, R22 and R53.
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for Resident R47, including proper medication administration instructions.
F 0657: The facility failed to review and revise the care plan for Resident R43 to address his repeated placement of the catheter bag on the floor despite education.
F 0760: The facility failed to ensure Resident R47 was free from significant medication errors by crushing a potassium chloride extended-release tablet that should not be crushed.
F 0880: The facility failed to maintain an infection prevention and control program, including failure to place residents R36 and R390 on appropriate isolation precautions and allowing R43's catheter bag to be placed on the floor.
Report Facts
Residents sampled: 34
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Potassium chloride tablet dose: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KMA2 | Kentucky Medication Aide | Administered crushed potassium chloride ER tablet to Resident R47 |
| KMA14 | Kentucky Medication Aide | Administered medications to Resident R47, stated no ER potassium tablet given |
| Director of Nursing | Director of Nursing (DON) | Oversaw medication administration and infection control practices; interviewed regarding deficiencies |
| Administrator | Facility Administrator | Interviewed regarding facility expectations for advance directives, medication administration, and infection control |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection control program and isolation precautions |
| Wound Care Nurse | Wound Care Nurse | Interviewed regarding wound care and infection prevention for Resident R390 |
| RN2 | Registered Nurse | Interviewed regarding Enhanced Barrier Precautions (EBP) for residents |
| LPN2 | Licensed Practical Nurse | Interviewed regarding medication administration training and policies |
| LPN3 | Licensed Practical Nurse and Unit Manager | Interviewed regarding medication administration training and resources |
| SRNA8 | State Registered Nurse Aide | Interviewed regarding catheter bag placement for Resident R43 |
| Unit Manager 1 | Unit Manager | Interviewed regarding catheter bag placement for Resident R43 |
| LPN1 | Licensed Practical Nurse | Interviewed regarding catheter bag placement for Resident R43 |
| Assistant Director of Nursing 1 | Assistant Director of Nursing | Interviewed regarding catheter bag placement for Resident R43 |
| Assistant Director of Nursing 2 | Assistant Director of Nursing | Interviewed regarding catheter bag placement for Resident R43 |
| Medical Director | Medical Director | Interviewed regarding infection control expectations |
Inspection Report
Enforcement
Deficiencies: 10
Date: Mar 31, 2022
Visit Reason
The inspection was conducted due to multiple regulatory concerns including resident rights violations, abuse and neglect allegations, failure to provide adequate care plans, food safety issues, and administrative deficiencies.
Findings
The facility was found to have Immediate Jeopardy related to failure to treat residents with dignity and respect, failure to protect residents from abuse and neglect, failure to provide written notice of room transfers, failure to implement comprehensive care plans, failure to provide medically-related social services, food safety violations including undercooked food and improper food storage, insufficient dietary staffing and training, and failure to administer the facility effectively. The Immediate Jeopardy was removed after corrective actions including reeducation, audits, and administrative changes.
Deficiencies (10)
F-557: The facility failed to treat Resident #6 with dignity and respect and failed to ensure the resident's right to retain and use personal belongings, causing emotional distress.
F-559: The facility failed to provide written notice of room changes to eight residents, causing confusion and distress.
F-600: The facility failed to protect Resident #6 from abuse and neglect by removing personal belongings without consent and failing to report the abuse.
F-609: The facility failed to timely report allegations of abuse and neglect related to Resident #6's personal belongings removal.
F-656: The facility failed to implement comprehensive person-centered care plans for Residents #6 and #50, neglecting psychosocial and physical needs.
F-745: The facility failed to provide medically-related social services to eight residents to address psychosocial needs and grievances related to room transfers.
F-812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including improper food storage, undercooked chicken nuggets, and inadequate dietary staff training.
F-802: The facility failed to provide sufficient dietary staff with necessary skills to safely and adequately prepare and serve meals to 82 residents.
F-809: The facility failed to serve meals and snacks at appropriate times and failed to provide suitable and nourishing snacks for residents.
F-835: The facility failed to administer the facility effectively to use resources to attain and maintain the highest practicable well-being of residents.
Report Facts
Residents sampled: 53
Current residents: 84
Residents affected: 82
Room transfers: 8
Room transfers for Resident #72: 9
Days Resident #6 was without belongings: 4
Training days for dietary aide #2: 3
Food handler cards: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in findings related to failure to report abuse, failure to ensure resident rights, and administrative oversight | |
| Director of Nursing (DON) | Named in findings related to reeducation, care plan oversight, and staff education | |
| Regional Director of Operations (RDO) | Named in findings related to administrative oversight and Immediate Jeopardy removal plan | |
| Licensed Mental Health Counselor | Performed PHQ-9 assessments and resident interviews post room transfers | |
| Dietary Manager (DM) | Named in findings related to dietary staff training, food safety, and meal preparation | |
| Corporate Certified Dietary Manager (CCDM) | Named in findings related to dietary staff training and food safety oversight | |
| State Registered Nurse Aides (SRNA) | Multiple SRNAs named in relation to abuse reporting fears and resident care | |
| Licensed Practical Nurses (LPN) | Named in relation to resident care and abuse reporting | |
| Housekeeping Supervisor | Named in relation to resident belongings removal and reporting concerns |
Inspection Report
Routine
Deficiencies: 5
Date: Aug 8, 2019
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality, medication administration, infection control, medication storage, and food safety in the nursing facility.
Findings
The facility failed to follow physician's orders for water flushes during medication administration via G-tube for Resident #4, improperly stored opened eye drop medication without an open date, failed to perform hand hygiene between glove changes during food distribution, and failed to follow infection control procedures during eye drop administration for Resident #66.
Deficiencies (5)
F 0658: The facility failed to ensure services met professional standards for Resident #4 by not following physician's orders to flush the G-tube with 30 milliliters of water before, after, and between medications during administration.
F 0693: The facility failed to provide appropriate care for Resident #4 receiving enteral feeding by not flushing the G-tube with the ordered amount of water between medications, risking dehydration and tube clogging.
F 0761: The facility failed to ensure proper storage of drugs by having an opened and undated bottle of Ketofine Furmate eye drops on the medication cart.
F 0812: The facility failed to distribute food in a sanitary manner when a staff member removed soiled gloves and did not perform hand hygiene before donning new gloves during the lunch tray line.
F 0880: The facility failed to provide an infection prevention program by not removing gloves, performing hand hygiene, and donning new gloves between administration of eye drops to each eye for Resident #66.
Report Facts
Medication flush volume: 30
Medication flush volume: 100
Medications administered: 4
Daily feeding volume: 500
Eye drop dosage frequency: 3
Eye drop dosage amount: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and infection control findings related to Residents #4 and #66 |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding medication storage policy for eye drops |
| Interim Director of Nursing | Regional Nurse Consultant | Provided expert opinion on medication administration and infection control policies |
| Assistant Director of Nursing | Infection Control Nurse | Interviewed regarding hand hygiene and infection control procedures |
| Interim Administrator | Provided expectations for staff compliance with physician orders and facility policies | |
| Director of Nursing | Interviewed regarding medication storage and infection control policies | |
| Dietary Manager | Interviewed regarding hand hygiene during food service | |
| Cook | Interviewed regarding hand hygiene during food service |
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