Ridge Valley Center for Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Ridge Valley Center for Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF678Apr 27, 2023

  Based on record review and staff, Nurse Practitioner and Medical Director interviews the facility failed to have basic lifesaving equipment readily available for use to immediately begin cardiopulmonary resuscitation (CPR) when Resident #3 experienced sudden cardiac arrest on [DATE] and staff were unable to immediately begin CPR that included chest compressions and rescue breathing because the first crash cart (cart of emergency supplies) that was brought to the bed side did not have a ambu bag or manual resuscitator (device to administer rescue breathing) on it, staff began chest compressions and it took the staff approximately three minutes to get the second crash cart that did have a ambu bag to begin rescue breathing. […]

• Immediate jeopardy, patternF689Apr 27, 2023

  Based on record review, observation, and interviews with resident, Nurse Practitioner, and staff, the facility failed to implement measures to mitigate the risk of an accidental drug overdose for a resident who had a known history of substance abuse that included crushing and snorting pills/medications. On [DATE] Resident #3 was found unresponsive in his room as a result of sudden onset cardiac arrest and he was unable to be revived. Nursing Assistant (NA) #11, NA #12, and Housekeeper #1 had observed a white, powdery substance on the tray table in his room. […]

• Immediate jeopardy, patternF835Apr 27, 2023

  Based on record review, staff, Nurse Practitioner, and Medical Director interviews the facility's Administration failed to provide leadership and oversight to ensure the facility had supplies that were readily available and easily accessible to immediately start Cardiopulmonary Resuscitation (CPR) when 3 of 4 residents experienced sudden cardiac arrest (Resident #1, Resident #2, and Resident #3). This practice had the high likelihood of affecting other residents. Immediate Jeopardy began on [DATE] when Resident #3 experienced cardiac arrest and the facility did not have an ambu bag (used to deliver rescue breaths during CPR) readily available for use and it took the staff approximately three minute to locate the ambu bag and start rescue breathing. […]

• Immediate jeopardy, isolatedF760Jun 20, 2023

  Based on record review, resident, staff, and Medical Director interview the facility failed to prevent a significant medication error for 1 of 3 residents reviewed for medication errors (Resident #31). Nurse #1 administered 38 units of insulin glargine (a long-acting insulin that lasts for 24 hours and does not have a peak onset of action) in error to Resident #31, a resident who did not have a diagnosis of diabetes. Resident #31's blood sugar dropped throughout the night and the resident was sent to the hospital due to a blood sugar level of 50 (normal range 90-100) requiring an overnight hospitalization . […]

• Immediate jeopardy, isolatedF880Jun 20, 2023

  Based on observation, record review and staff interviews, the facility failed to follow the manufacturer's guidelines for cleaning and disinfection of a blood glucose meter which was stored in the medication cart after use for 2 of 2 residents observed (Resident #3 and Resident #105) during a medication pass on 06/06/23 at 9:05 AM. The blood glucose meter was stored in the medication cart and was not designated as an individual resident meter. The facility had three residents in the building with a diagnosis of a bloodborne pathogen (microorganisms that cause disease and are present in human blood) (Resident #104, Resident #64 and Resident #76). This deficient practice had a high likelihood for transmitting bloodborne pathogens within the facility. […]