Resident 45 was admitted to the facility in late 2023 but had no documented physician visits or progress notes between November 28, 2023, and May 23, 2024. Federal regulations require physicians to see residents once every 30 days for the first 90 days after admission, then at least once every 60 days thereafter.
The Director of Nursing confirmed on July 26 that the resident's physician "did not visit the resident at the regulatory required frequency."
The same resident was prescribed Quetiapine, an antipsychotic medication, for mania and bipolar disorder since October 10, 2023. Inspectors found no evidence the facility had attempted to gradually reduce the dose of the powerful psychiatric drug, despite federal requirements to try dose reductions unless medically contraindicated.
"No attempts at gradually reducing the dose of the above psychoactive medication had been made," the Director of Nursing acknowledged during the inspection.
The medication oversight was one of multiple care failures inspectors documented at the 200 Pennsylvania Avenue facility. Residents complained repeatedly about running out of basic food items, with some buying their own snacks to ensure they had something to eat between meals.
Five cognitively intact residents told inspectors during a group interview that the facility "consistently fails to serve food as planned on the menus." Resident 1 said she was "frustrated because the facility continuously runs out of salad dressing, sugar packets, salt, and orange juice."
Resident 83, a vegetarian who orders salad every night for dinner, said the facility recently ran out of lettuce. "She was frustrated that the facility did not have her preferred meal items available," inspectors noted. The resident ordered pizza from outside the facility rather than accept the peanut butter and jelly sandwich staff offered instead.
The food service director confirmed the facility was out of orange juice through their supplier and was also out of ketchup. Bananas were no longer being ordered because they could only be purchased by the case and "there were only a few residents who requested bananas."
Multiple residents said they weren't consistently offered evening snacks despite facility policy requiring nutritious snacks between dinner and breakfast. The gap between dinner and breakfast exceeded 14 hours.
Resident 2 told inspectors that "about twice a week the facility runs out of snacks" and nursing staff tell her "snacks are not available." Resident 84 said he brings up the issue with nursing staff "but nothing seems to get done to resolve his concern."
During the group interview, Resident 89 described asking a nurse aide for an evening snack. "The nurse aide went to get her one but never returned," inspectors documented. Resident 26 said she "started buying her own snacks so that if the facility runs out or doesn't offer her something to eat, then she still has something nourishing between meals."
Food safety violations compounded the meal problems. Inspectors found the kitchen floor "patched with a concrete type substance and heavily soiled." Twenty-two thawed nutritional shakes in the walk-in cooler lacked required thaw dates, and an open container of food thickener had plastic scoops with handles in direct contact with the powder, violating manufacturer instructions.
The dishroom floor "under the dishwasher and along the wall extending to the two-compartment sink was heavily soiled with dirt and grime and in need of cleaning."
Care coordination failures affected terminally ill residents. Resident 58, admitted to hospice services in January for atherosclerotic heart disease, had a care plan that "failed to reflect coordination of services between the facility and the Hospice agency." The Director of Nursing confirmed the care plan "was not coordinated with hospice services."
Two serious incidents revealed the facility's inability to investigate problems and identify root causes. In March, four staff members were repositioning Resident 32 in bed when they banged his head against the headboard, causing immediate pain and a visible bump. The resident, who has diabetes and bilateral below-knee amputations, required emergency room evaluation.
Witness statements from the four employees contained conflicting accounts of what happened. But when inspectors interviewed the alert resident four months later, he contradicted the staff reports, saying only two nurse aides had helped reposition him, not four.
The Director of Nursing acknowledged "the witness statement completed by Employee 2 Licensed Practical Nurse (LPN), did not clearly state the employee's participation in the repositioning of the resident." She admitted "none of the witness statements obtained, nor the facility investigation had accurately represented the incident and the facility did not act on those discrepancies to identify the root cause of the incident."
A second incident in July involved Resident 148, who was receiving intravenous antibiotics through a tunneled catheter in his chest. On July 20, nursing staff were changing the catheter dressing when fluid leaked around the site, forcing them to stop the procedure immediately.
The resident told emergency room staff that facility employees "used scissors to help remove the dressing and they nicked the catheter causing it to leak." Emergency room documentation confirmed "a small linear laceration to the catheter causing the catheter to leak at that site."
Despite the resident's allegation that staff damaged his catheter and the emergency room findings, inspectors found no evidence the facility investigated the incident or attempted to determine what went wrong.
The Administrator could not provide "documented evidence that the facility initiated an investigation into the adverse event which resulted in the resident's transfer to the emergency room to determine the root cause of the laceration."
Both incidents highlighted the facility's failure to implement effective quality assurance programs. Despite having policies requiring systematic review of adverse events and root cause analysis, the facility repeatedly failed to follow through when residents were harmed.
The nursing home's own policy states that "systems failures and/or in-depth analysis of processes are addressed through development of a QAPI" that requires "systematic review of data, identification of the root cause(s) of the systems failure, and implementation of corrective actions."
But when a resident's head was injured during routine care and another resident's life-saving catheter was damaged, the facility collected conflicting information, failed to interview key witnesses, and took no meaningful steps to prevent similar incidents.
Resident 32 remains at the facility, still requiring assistance with positioning despite being care-planned for independent bed mobility using adaptive equipment. The facility never determined why he needed staff help or how to prevent future injuries during routine care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ridgeview Healthcare & Rehab Center from 2024-07-26 including all violations, facility responses, and corrective action plans.
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