A list of the most recent deficiencies for Peace Healthcare at Ridgeway Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-26 | 2021-05-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-26 | 2021-05-09 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-26 | 2021-05-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-26 | 2021-05-09 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-03-26 | 2021-05-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-26 | 2021-05-09 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-03-26 | 2021-05-09 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-03-26 | 2021-05-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-26 | 2021-05-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-26 | 2021-05-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-26 | 2021-05-09 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-26 | 2021-04-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-26 | 2021-04-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-03-26 | 2021-04-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-19 | 2019-01-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-11-19 | 2019-01-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-19 | 2019-01-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-11-19 | 2019-01-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-11-19 | 2019-01-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-19 | 2019-01-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-11-19 | 2019-01-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-19 | 2019-01-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-11-19 | 2019-01-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-19 | 2019-01-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-19 | 2019-01-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-11-19 | 2019-01-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-11-19 | 2019-01-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-11-19 | 2019-01-14 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-11-19 | 2019-01-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-11-19 | 2019-01-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-19 | 2019-01-14 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-11-19 | 2019-01-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-19 | 2019-01-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-11-19 | 2019-01-14 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-11-19 | 2019-01-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-12-14 | 2019-01-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-14 | 2018-12-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-14 | 2018-12-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-08-28 | 2017-10-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-08-28 | 2017-10-27 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-08-28 | 2017-10-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-08-28 | 2017-10-27 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-07-28 | 2017-10-20 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-07-28 | 2017-10-20 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-07-28 | 2017-10-20 | N |
| Provide housekeeping and maintenance services. | Health | 2017-07-28 | 2017-10-20 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-07-28 | 2017-10-20 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-07-28 | 2017-10-20 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-07-28 | 2017-10-20 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-07-28 | 2017-10-20 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-07-28 | 2017-10-20 | N |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2017-07-28 | 2017-10-20 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-07-28 | 2017-10-20 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-07-28 | 2017-10-20 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-07-28 | 2017-10-20 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-07-28 | 2017-10-20 | N |
