Ridgeview Skilled Nursing Facility

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure related to notification of the physician when one of three residents (Resident 1) who had a foley catheter (a thin flexible tube inserted through the urethra( the duct by which urine is conveyed out of the body) into the bladder to drain and collect urine) had episodes of low urine output on different shifts. This failure had the potential to affect Resident 1's health condition. Findings. A review of the facility's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included Nondisplaced Fracture of the Sacrum (a break in the base of the spine) and Neuromuscular Dysfunction of the Bladder (issues with bladder control and function). On 11/24/25 at 11:45 A.M., an interview and record review with Licensed Nurse (LN)1 was conducted. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the written care plan related to documenting intake and output for one of three residents (Resident 1) who had a foley catheter and passing low amount of urine. This failure had the potential to cause serious complications and could harm Resident 1's health. Findings. A review of the facility's admission Record indicated, Resident 1 was admitted on [DATE] with diagnosed which included Nondisplaced Fracture of the Sacrum (a break in the base of the spine) and Neuromuscular Dysfunction of the Bladder( issues with bladder control and function). On 11/24/25 at 11:45 A.M, an interview and record review with Licensed Nurse (LN) 1 was conducted. LN 1 stated a care plan for Resident 1's foley catheter use was in place. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor and identify episodes of low urine output and communicated to the physician for one of three residents (Resident 1). This failure had the potential to cause worsening symptoms for Resident 1. Findings. A review of the facility's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included nondisplaced fracture of the sacrum (a break in the base of the spine) and neuromuscular dysfunction of the bladder(issues with bladder control and function). On 11/24/25 at 11:45 A.M., an interview and record review with Licensed Nurse (LN)1 was conducted. LN 1 stated Resident 1 had a foley catheter (a flexible tube inserted through the urethra into the bladder to drain and collect urine) for Neurogenic Bladder. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions consistent with resident's needs to eliminate or reduce the risk of falling for one of four residents (Resident 1) reviewed for accidents when: Adequate assistance was not provided to Resident 1, who required total assistance with activities of daily living (ADL-bathing or showering, getting in and out of bed or a chair, turning, walking, toileting and eating). This failure resulted in Resident 1 falling off the bed.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician promptly when two of four residents (Resident 22 and Resident 31) had significant weight changes (weight loss or gain). As a result of this deficient practice, residents were placed at risk for delayed treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three residents (Resident 31) with a diagnosis of congestive heart failure (CHF, when the heart cannot pump blood effectively) was provided care and treatment according to acceptable standards of practice when: 1. Resident 31's weight was not taken daily as prescribed by the Medical Doctor (MD). 2. Resident 31 was not assessed for potential fluid overload (a condition where there was too much fluid in the body) after a 9.5 pound (lbs) weight gain. These failures had the potential to exacerbate the resident's congestive heart failure. Cross reference F580 and F726.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the intake of a nutrition intervention was measured for one of 19 sampled residents (Resident 20) with significant weight loss. The facility did not ensure a nutritional supplement for a resident who triggered for significant weight loss was accurately measured. This failure had the potential to cause more weight loss and further impair the resident's nutritional status.

Inspectors wroteBased on interview and record review the facility failed to ensure that two of four licensed nurses (LN 4 and RN 12) were competent to provide care for a resident (Resident 31) with a diagnosis of congestive heart failure (CHF, a condition where the heart does not pump blood as well as it should). This failure had the potential for Resident 31 and other residents with CHF to experience negative outcomes related to fluid overload (a condition where fluid builds up in the body). Cross reference F580 and F684.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medication as ordered by the prescriber for three weeks for one of five residents (Resident 20) reviewed for pharmacy services. This deficiency resulted in the facility's failure to provide a medication to meet the needs of the resident according to the prescribed orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff received appropriate training in food sanitation and food safety according to standards of practice and facility policy when: 1. One cook did not demonstrate the proper method of testing the sanitizer solution used for sanitization (the process of safely removing waste to prevent disease transmission and improve hygiene) on equipment and food prep surfaces to prevent cross contamination. 2. One cook did not demonstrate proper method on thickening for a puree soup for one resident. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The facility census was 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices in dietary services were maintained for food storage according to standards of practice when: 1. The facility did not ensure dry food storage room temperatures were monitored. 2. The facility did not ensure trash bins were stored next to clean dishware. These failures had the potential to cause widespread food borne illness among all 19 residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food items were labeled and dated/not expired. In addition, there were produce items with mold. These failures had the potential to cause food-borne illness for the residents.

Inspectors wroteBased on interview and record review, the facility failed to offer COVID-19 (a highly contagious virus) vaccine booster (an extra dose of the vaccine after an original is administer), to four out of five residents (Residents 4, 6, 114, and 116) reviewed for infection control. As a result, residents were at risk of contracting a potentially life-threatening infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a documented means of communication for coordination of care for one of one resident (Resident 4), reviewed for hospice (end of life), care was in place. This failure had the potential to disrupt continuity of care between the facility and the hospice agency.

Inspectors wroteBased on interview and record review, the facility failed to provide a nutritional supplemental feeding and apply a CPAP (continuous positive airway pressure - device to assist with breathing during sleep) machine as ordered by the physician for one of two sampled residents (1). This failure had the potential for Resident 1 to not meet his nutritional needs and have difficulty breathing.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a post fall assessment for one of one resident (Resident 5), after a fall. This failure had the potential for Resident 5 to have a repeat fall and at risk for further injury.

Inspectors wroteBased on observation, interview and record review the facility failed to complete an accurate documentation after a significant event for one resident (Resident 5) related to: 1. Resident 5 ' s fall incident and, 2. Post fall assessment. Failure to have an accurate documentation after a significant event had the potential for residents to not have proper assessment and interventions related to a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a staff member promoted dignity and respect by maintaining an eye to eye level during meal assistance for one of one resident (Resident 1) reviewed for dignity. As a result, this failure had the potential to negatively impact Resident 1's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and collaborate on unintended weight loss and the the decline in oral (by mouth) food intake for one of one resident (Resident 2) reviewed for care plan. This failure had a potential for Resident 2's weight loss to go unaddressed, leading to weakness, fatigue, and increasing dependency on others.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessments, non-pharmological interventions, and evaluation of medications use were conducted for one of three residents (Resident 5), reviewed for psychotropic use when: 1. Resident 5 had an assessment and evaluation for continued use of a PRN (as needed) psychoactive (alters the mind) hypnotic medication prescribed for sleeplessness. 2. Non- Pharmacological interventions (any intervention intended to improve the health or the well-being of individuals that does not involve the use of any drugs or medicine) were not attempted prior to medicating for sleeplessness. 3. Resident 5 had an assessment and evaluation for the use of a psychoactive antidepressant (for depression) medication that increased the effect of the hypnotic medication. [...]