Ridgeview Post Acute

Inspectors wroteBased on record review and interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with state law for four of four allegations of abuse. Specifically, the facility failed to:-Report an allegation of physical abuse between Resident #1 and Resident #2 on 11/18/25 within two hours of the incident; .-Report an allegation of physical abuse between Resident #3 and Resident #4 on 1/19/26 within two hours of the incident;-Report an allegation of physical abuse between Resident #5 and Resident #6 on 2/8/26 within two hours of the incident; and,-Report an allegation of physical abuse between Resident #4 and Resident #11 on 3/22/26 within two hours of the incident.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#3) of four residents reviewed out of 16 sample residents was kept free from resident-to resident physical abuse. Specifically, the facility failed to protect Resident #3 from physical abuse by Resident #4.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public on one of four units. Specifically, the facility failed to provide the necessary housekeeping and maintenance services to maintain resident room [ROOM NUMBER], #307, #316, #318, #303, #302 and #311 in a sanitary and comfortable manner.

Inspectors wroteBased on record review, observations and interviews the facility failed to ensure two (#19 and #100) of three residents reviewed for out of 45 sample residents were free from involuntary seclusion. Specifically, the facility failed to ensure Resident #19 and Resident #100 who resided in the secured unit, had the required ongoing documentation of the review and revision to meet the criteria and if the interventions met the needs of the resident.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were provided services that meet professional standards. Specifically, the facility failed to ensure narcotic medications were documented on the narcotic log at the time of removal from the locked narcotic drawer on two of four medication carts.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in two of four medication carts and one of two medication storage rooms. Specifically, the facility failed to ensure: -Medications were labeled with the date it was opened; -Discontinued medications were removed from the medication cart in a timely manner; -Medications were properly disposed in a disposal receptacle; and, -Resident medication was stored in the proper location.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services for one (#54) of one resident reviewed for hospice care services out of 45 sample residents. Specifically, the facility failed to: -Establish a communication process, including how the communication would be documented between the facility and the hospice provider for Resident #54; and, -Ensure hospice agency staff notes were easily accessible to the facility staff and have consistent documentation of hospice care visits in Resident #54's record.

Inspectors wroteBased on interviews and record review, the facility failed to take steps to protect one (#19 and #256) of eight residents from physical abuse out of 45 sample residents reviewed for abuse. Specifically, the facility failed to prevent Resident #19 from physical abuse by Resident #256.

Inspectors wroteBased on observations, interviews, and record review, and facility policy the facility failed to ensure each resident received the care and supervision necessary to avoid accident hazards for three (#47, #85 and #92) of seven residents reviewed for accident hazards out of 52 sample residents. Specifically, The facility failed to: - Ensure Resident #47, who had severe cognitive impairment, received sufficient supervision to ensure safety while smoking on 2/13/23. Additionally, cigarette butts were not extinguished properly and placed in appropriate receptacles. A smoking blanket and smoking aprons were not readily available in the smoking area. Staff in the vicinity did not take action when a hot ash from the resident's cigarette fell into their lap after the resident burned themselves attempting to light one cigarette off of another; [...]

Inspectors wroteBased on interview, record review, and facility document review, the facility failed to ensure the employee performing the Registered Dietitian (RD) role and signing resident assessments as an RD was, in fact, registered as a dietitian with the Commission on Dietetic Registration (CDR). This had the potential to affect all 96 residents.

Inspectors wroteBased on observations and interviews, the facility failed to follow infection control measures to prevent potential cross-contamination and spread of SARS-CoV-2 COVID-19, during testing procedures on staff and residents. Specifically, the facility failed to: -Ensure COVID-19 testing of staff and residents was conducted properly to prevent the spread of an infectious disease, to include the utilization of proper personal protective equipment (PPE); -Maintain social distancing while performing the rapid (antigen) tests; and, -Properly disinfect the testing area between tests. On 1/12/22 at 9:28 a.m. outside agency staff were observed rapid testing Resident #80 for COVID-19 without wearing gloves and gown, with the resident's door open (see observation below). On 1/13/22 at 7:55 a.m. staff were observed self-testing for COVID-19. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure an unvaccinated resident (Resident #11) was socially distanced (six feet apart) from a confirmed COVID-19 positive resident (Resident #14) and Resident #2 (who was not COVID-19 positive) while consuming their lunch meal; -Ensure staff wore proper personal protective equipment (PPE) when entering Resident #65's and Resident #293's isolation rooms for COVID-19; and, -Ensure staff wore PPE (N95 mask) correctly to ensure secure fit. On 1/12/22 at 12:10 p.m. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to infection control and COVID-19 testing.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure services provided met professional standards of quality for one (#79) of eight out of 47 sample residents. Specifically, the facility failed to ensure Resident #79's blood pressure was within physician ordered parameters prior to administering hypertensive medication.