Ridgeview Transitional Rehabilitation

Based on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of one resident (#20) to be free from abuse. The deficient practice could result in residents being at risk for abuse. The sample size was 4. The facility census was 41. Â

Based on clinical record review, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the regulatory timeframe of 14 days after admission for resident (#3). The deficient practice could result in delayed identification of potential risks and care needs.Â

Based on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of one resident (#20) to be free from abuse. The deficient practice could result in residents being at risk for abuse. The sample size was 4. The facility census was 41.

Based on clinical record review, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the regulatory timeframe of 14 days after admission for resident (#3). The deficient practice could result in delayed identification of potential risks and care needs.

Based on clinical record review, staff interviews, review of facility documentation and policies, the facility failed develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime for one resident (# 95) with an allegation of physical abuse. The sample size was one.

Based on clinical record review, staff interviews, review of facility documentation and policies, the facility failed develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime for one resident (# 95) with an allegation of physical abuse. The sample size was one.

Based on observation, the facility failed to provide a safe means of egress from the main hallway on the west side of patient rooms to the west exit. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency. NFPA 101, Life Safety Code, 2012 Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom or visibility thereof. Observations while on tour on January 29, 2025, revealed items being stored in the west side hallway. These items were not in use at the time and were obviously being stored. The hallway was 8 feet wide. The items were on one side, and they included ice chests, linen carts, scales, and Hoyer lifts. Management confirmed the finding and was present when the hallway was measured.

Based on observation and record review the facility failed to conduct properly testing to confirm the emergency light in the facility was tested to confirm the lights would operate in a loss of power to the facility. Failing to test the emergency lighting could result in failure when the power goes out which could result in injury to staff and patients NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests. , for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1. (2) The Test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.( 3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery-powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. (sic) Findings include: Findings during the document review on January 29, 2025, revealed the facility was not performing the 30 second monthly testing of the emergency lights in the facility. The facility staff was not able to provide documented proof the facility conducted monthly tests of the emergency lighting. Management confirmed they did not have documented proof they were conducting monthly testing of the emergency lights.

Based on observation, the facility failed to assure that all parts of the facility were provided with sprinkler system coverage. Failing to provide sprinkler coverage in all areas of the facility by blocking the sprinkler heads could result in the sprinkler not controlling the fire, which could harm the patients. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 18.3.5.1,"Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5." ." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition8.10.6.3 * Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard - Chapter 8 Installation Requirements. 8.10.6.3.2 Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as stairs and landings. Findings include: Observations while on tour on January 29, 2025, revealed that the sprinkler heads were missing from the first-floor elevator electrical room, which measured just over 6 feet long by 1 foot wide. The director of facilities confirmed during the exit interview conducted on January 29, 2025, that the room housing the elevator's electrical panels was not sprinklered.

Based on observation, it was determined that the rated corridor doors would not resist the passage of smoke. The service hall corridor door did not latch and close when tested three times. Failing to protect resident sleeping rooms from heat or smoke will cause harm to the residents and staff. NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction." Findings include: Observations made while on tour on January 29, 2025, reveal that the latching mechanism failed to engage for the fire door in the main lobby area. Three attempts were made to allow the door to latch. The Administrator and Director of Maintenance again acknowledged the above findings during the exit conference on January 29, 2025.

Based on the record review, the facility failed to conduct the required damper testing. Failure to conduct damper testing could result in the dampers failing, which would allow the firewalls to become inoperable, which could result in the death of patients or staff in the event of a fire. NFPA 101: Life Safety Code, 2012 Edition - Chapter 8 Features of Fire Protection 8,5,5,4,2 Smoke dampers and combination fire and smoke dampers required by this Code shall be inspected, tested, and maintained in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. NFPA 80: Standard for Fire Doors and Other Opening Protectives, 2010 Edition - Chapter 19 Installation, Testing, and Maintenance of Fire Dampers. 19.3.3 Inspection. Following completion of the test, a visual inspection shall be made of the assembly to ensure no obstructions have been introduced. 19.3.4 Documentation. All inspections and testing shall be documented, indicating the location of the fire damper, date(s) of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. 19.4 * Periodic Inspection and Testing. 19.4.1 Each damper shall be tested and inspected 1 year after installation. 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. Findings include: During a document review on January 29, 2025, revealed the facility did not have records showing that it had conducted the required damper testing in the last four years. Facility management confirmed during the exit interview the facility did not have the required records showing damper testing in the last 4 years.

Based on record review and interviews with staff, the facility failed to properly conduct, maintain, and document electrical receptacle testing in all patient care areas annually. Failing to test and document the receptacle testing of all patient care areas annually could lead to an ignition hazard in a patient care area, potentially causing a fire and/or injury to the patients. NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction." NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 6.3.4.1.3 "Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months." 6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). Findings include: During the document review on January 29, 2025, it was revealed that the retention force of the grounding blade was not tested. The director of maintenance stated that they performed all the other required tests but were not aware of this requirement. Facility management confirmed during the exit conference that there was no documentation to review for receptacle retention force testing in patient care areas.

Based on observation, the facility failed to provide a record of electrical equipment tests, repairs, and modifications being maintained for some time to demonstrate compliance following NFPA 99 2012 Edition Chapter 10 Record Keeping Patient Care Appliances. Failing to conduct maintenance on patient care appliances could cause harm to the patient if the appliance malfunctions. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 10, Section 10.5.6 Record Keeping-Patient Appliances Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 Findings include: During the document review on January 29, 2025, revealed that none of the electrical equipment had PCREE testing performed. The facility maintenance director stated that they did perform visual inspections of the equipment but not calibration or electrical safety testing. Facility management confirmed that during the exit interview, none of the electrical equipment had PCREE testing performed.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#50) was free from preventable pressure related injuries. Findings include: -Resident #50 was admitted to the facility on August 1, 2024, with diagnoses that include osteoarthritis, weakness, depression, rheumatoid arthritis, and a left knee replacement. A care plan initiated on August 11, 2024 revealed the resident was at risk of altered skin integrity as evidenced by decreased mobility with a goal of the resident having no new alterations in skin integrity, with noted interventions of notifying the doctor for any changes. Review of the Admission Minimum Data Set (MDS) assessment dated August 7, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had no cognitive impairment. A review of the clinical record progress notes for resident #50 dated August 7, 2024 at 10:32 a.m. revealed resident #50 is "having pain to left lateral side of leg. Upon arrival resident had ted hose on pulled down to calf area, stated ted hose had rolled down to knee area and have caused discomfort, noted popped blister to area. " Another skin care plan added August 7, 2024 revealed the resident has an open blister to left lateral leg, with a goal of being free from infection through the review date and noted interventions of monitor and document size and treatment, as well as report abnormalities, failure to heal, and signs and symptoms of infection. A second progress note dated August 12, 2024 at 2:07 p.m. revealed that resident #50 "continues with open blister to left lateral leg, provider updated regarding scant slough noted to lateral leg. Received ok to place mepilex ag and foam and continue to monitor." A third progress note dated August 13, 2024 at 10:50 a.m. revealed that the resident #50 acquired a pressure sore that was noted to left knee. The note stated resident #50 was seen by her ortho doctor. The note stated to "Continue to ED for I&D (Incision & Drainage) of stage 3 pressure sore." An interview was conducted with a Nurse Practitioner (NP/staff #15) on August 26, 2024 at 2:40 p.m. The NP stated that resident #50 was sent to the skilled nursing facility on August 1, 2024, and seen for a follow up outpatient on August 13, 2024. The NP stated that when resident #50 was seen for the follow up that she was re-admitted and taken into surgery same day because of how bad resident #50's pressure injury was on examination. The NP also stated the wound was also infected and required antibiotic treatment. The NP further concluded that the resident is presently following up with infectious disease and required a wound vac for proper healing. The NP concluded that when the injury was reported to their office, the skilled nursing staff reported it was just a blister. The NP stated it was clearly not a blister as it required multiple treatments and surgical intervention. An