Ridgeway Rehab Center

In the surveyor’s words

From the most serious findings on record at Ridgeway Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF578Feb 11, 2026

  Based on clinical record review and staff interviews, it was determined that the facility failed to: 1) ensure that a resident or their responsible party (RP) was offered the opportunity to develop an advanced directive, and 2) ensure two certificates of incapacity included a diagnosis or reason for the incapacity. These failures affected three residents (Resident #8, #10, and #15) out of a sample of three reviewed for advanced directives during the recertification/complaint survey. […]

• No harm, potential for more than minimal, patternF655Feb 11, 2026

  Based on clinical record review and staff interview it was determined that the facility staff failed to 1) ensure a resident had baseline care plan / care plans within the required timeframe and provided the resident and/or family with a copy of the care plans, and 2) provide evidence in the resident's medical record that this summary had been delivered. This was evident for Four (Resident #8, #9, #40, and #15) out of 18 residents reviewed during the investigation phase of the facility's recertification survey. The findings include: A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility. It must include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. […]

• No harm, potential for more than minimal, patternF657Feb 11, 2026

  Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that care plan meetings were held concurrently with quarterly care plan revisions, and resident and/or their representatives were invited to care plan meetings. This deficiency affected six residents (Resident #5, #7, #9, #17, #40, and #51) of 6 residents reviewed for care planning during the recertification/complaint survey. The findings include: Care plans serve as essential guides for the care residents receive within the facility. They must be developed within seven days of a resident's comprehensive admission Minimum Data Set (MDS) assessment and revised at least quarterly, or more frequently as necessitated by a change in condition. […]

• No harm, potential for more than minimal, patternF584Nov 6, 2024

  Based on observations and interviews with facility staff it was determined the facility failed to provide and maintain a safe, clean, and homelike environment for the residents. This was found to be evident when observations were made during tours of the building during the facility's survey. The findings include the following: An entrance tour was conducted on 10/27/24 at 9:15 AM and the following concerns were identified: Room # 200 was observed with marring noted on the wall Room # 201 was observed with marring noted on the wall behind each bed and near the door Room # 203 was observed with marring noted on the side of the walls Room # 204 was observed with marring noted on the walls, and the floor was dirty with a dark substance noted throughout the room Room # 205 was observed with… […]

• No harm, potential for more than minimal, patternF623Nov 6, 2024

  Based on record review and interviews with staff, it was determined that the facility failed to notify the resident or resident representative in writing of the reason for transfer to the hospital. This was found to be evident for 4 (Resident #55, # 37, # 41, #58) of 4 residents reviewed for hospitalization s during the investigative portion of the survey. The findings include: 1) On 10/30/24 at 07:30 AM, review of Resident #55's medical record revealed he/she was hospitalized on [DATE] and 9/24/24. On 10/30/24 at 11:25 AM, an interview with the [NAME] President of sister company (Staff #21) revealed they are unable to provide a copy of the written transfer form from the 9/21/24 hospitalization . […]