Ridgecrest Manor Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Ridgecrest Manor Nursing & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Feb 22, 2024

  Based on observation and staff interview, the facility staff failed to prepare, distribute, and serve food in a manner that would prevent foodborne illnesses. The sanitizing cycle of the dishwashing machine was not working. The findings included: The sanitizing cycle of the dishwashing machine in the facility kitchen was not working. The test strips did not detect any sanitizing solution. On 02/20/24 at approximately 11:00 a.m., during the initial observation of the facility kitchen Dietary Employee #1 attempted to check the sanitizing solution of the dishwashing machine. Dietary Employee #1 used three different test strips to check the sanitizing solution. None of these test strips changed color. […]

• No harm, potential for more than minimal, isolatedF684Feb 22, 2024

  Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan and provider orders for 2 of 21 residents in the survey sample, Residents #34 and #56. The findings included: 1. For Resident #34, the facility staff failed to administer Hydroxychloroquine Sulfate (an oral medication prescribed to treat rheumatoid arthritis) as ordered by the provider on six (6) separate occasions. Resident #34's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 5, Rheumatoid Arthritis, Type 2 Diabetes Mellitus, and Essential Hypertension. […]

• No harm, potential for more than minimal, isolatedF689Feb 22, 2024

  Based on resident interview, staff interview, clinical record review and facility document review the facility staff failed to assess a resident's ability to safely smoke for 1 of 21 residents, Resident #64. Facility staff failed to complete a smoking assessment for Resident #64 when resident began smoking after admission. The findings included: For Resident #64 the facility staff failed to complete a safe smoking assessment once the resident began smoking. During entrance conference, surveyor was provided with a list of residents that smoke. Resident #64's name was on this list. Resident #64's face sheet listed diagnoses which included but not limited to bipolar disorder, severe, with psychotic features, chronic obstructive pulmonary disease, and generalized anxiety disorder. […]

• No harm, potential for more than minimal, isolatedF695Feb 22, 2024

  Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan and the provider orders for 1 of 21 residents in the survey sample, Resident #34. The findings included: For Resident #34, the facility staff failed to administer supplemental oxygen as ordered by the physician. Resident #34's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 5, Rheumatoid Arthritis, Type 2 Diabetes Mellitus, and Essential Hypertension. […]

• No harm, potential for more than minimal, isolatedF759Feb 22, 2024

  Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) medication errors in 29 opportunities for a medication error rate of 6.9%. These medication errors affected Resident #12 and/or Resident #57. The findings included: For Resident #12, the facility staff failed to administer Calcium-Vit D-Min Oral Tablet 600-400 mg-unit; this was documented on Resident #12 medication administration record (MAR) to be provided one time a day. On 2/21/24 at 8:18 a.m., Licensed Practical Nurse (LPN) #4 was observed to provide Calcium 500 mg-Vitamin D 5 mcg. On 2/21/24 at 9:58 a.m., LPN #4 confirmed they had provided Resident #12 the Calcium 500 mg tablet. […]