The Haven of Ridgeview

Inspectors wroteBased on interview and record review the facility failed to safely transfer 1 of 3 (R1) residents reviewed for accidents in a sample of 7. This failure resulted in R1 falling out of a whole-body lift machine onto the floor and sustaining a right hip fracture, a fracture of the distal right femur and a fracture of the right tibia. This past noncompliance occurred on 1/24/2026.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a working call light for one resident of three residents (R1) reviewed for call lights in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to provide an environment free of accident hazards for 1 (R1) of 3 residents reviewed for accidents in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to allow residents to smoke at the times they chose for 1 (R26) of 5 residents reviewed for smoking in a sample of 32.

Inspectors wroteBased on Interview and Record Review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN-CMS10055) for 1 of 3 residents (R5) reviewed for Beneficiary Protection Notification in the sample of 32. The Findings Included:R5's admission Record documented an admission date of 6/18/2025 with diagnoses including: osteomyelitis of vertebra, sacral and sacrococcygeal region, type 2 diabetes mellitus without complications, chronic kidney disease, and essential hypertension. R5's Skilled Nursing Facility Beneficiary Protection Notification Review form documents a discharge from Medicare Part A services prior to exhaustion of his benefit day allotment and a last covered day of Part A Services of 5/6/25. [...]

Inspectors wroteBased on interview and record review the facility to ensure residents were free from abuse for 2 of 2 (R3 and R47) resident reviewed for abuse in the sample of 32.

Inspectors wroteBased on interview and record review the facility failed to provide activities that meet the interest of the residents and ensure quarterly activities assessments were completed for 1 of 1 (R9) resident reviewed for activities in the sample of 32. Findings Include:R9's Transfer/Discharge Report with a print date of 8/14/25 documents R9 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia. R9's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 10, indicating R9 has a moderate cognitive deficit. R9's current Care Plan documents a Focus area of, Activity Interests/Preferences: visiting with family, being outside when the weather is nice Date Initiated: 01/01/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide restorative nursing services including assessments and care planning for 1 of 2 residents (R43) reviewed for restorative nursing services in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents had alternative meal options similar or equivalent nutritive value of the main meal selection for 3 of 3 residents (R25, R42, and R46) reviewed for nutrition in a sample of 32. The Findings Include:On 8/10/2025 at 12:29 PM, V7 (Cook) was observed serving residents their lunch meal that included herb roasted pork loin, herb stuffing, green beans and peach crisp from the steam table in the dining room. V7 was observed not serving the vegetable green beans or cream corn on R42, R46 and R25's trays. On 08/10/2025 12:40 PM, R42 was observed sitting in the dining room eating a regular mechanical soft diet that included ground herb roasted pork loin with gravy and soft herb stuffing with gravy and peach crisp. There were no vegetables observed on R42's lunch tray. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were equipped with a working call light for 1 of 1 residents (R27) reviewed for call lights in the sample of 32. Findings Include:R27's Transfer/Discharge Report with a print date of 8/12/25 documents R27 was admitted to the facility on [DATE] with diagnoses that include osteoporosis, chronic obstructive pulmonary disease, atrial fibrillation, contracture of left lower leg, major depressive disorder, and malignant neoplasm. R27's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 15, indicating R27 is cognitively intact. R27's current Care Plan documents a Focus area of (R27) has Self-Care Deficit as Evidenced by: Needs (extensive) assistance with ADL's (Activities of Daily Living) Related to impaired mobility, weakness. Date Initiated: 01/12/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to prevent the development of pressure ulcers for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 7. This failure resulted in R1 developing facility acquired moisture associated skin damage to the buttocks, a stage 2 pressure ulcer to the Left Ischium, a stage 3 pressure ulcer to the Right Ischium, and a stage 3 pressure ulcer to the Sacrum.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient direct care staff for meeting resident needs in a timely fashion. This has the ability to effect all 50 residents living at the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify a residents POA (Power of Attorney) of a change in condition for 1 of 3 residents (R1) reviewed for POA notification in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to provide incontinence care and timely toileting assistance for dependent residents for 2 of 7 residents (R1, R7) reviewed for ADL (Activities of Daily Living) care in the sample of seven.

Inspectors wroteBased on interview and record review the facility failed to notify the physician prior to a residents discharge for 1 of 3 residents (R1) reviewed for discharge planning in a sample of 5. Findings Include: Review of R1's admission Record documented R1's initial admission date to the facility as 08/02/2024 . The same document lists diagnoses for R1 as the following: other acute osteomyelitis, left foot and ankle, essential hypertension, alcohol use, and patient's other noncompliance with medication regimen. R1's Minimum Data Set (MDS) with an Assessment Reference Date of 08/09/2024 documented a Brief Interview for Mental Status Score of 15, indicating R1 is cognitively intact. A Progress Note dated 09/14/2024 with a time of 12:24 P.M. authored by V5 (Registered Nurse) documented R1 left the facility at 12:20 P.M., belongings, meds and narcotics sent with R1. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and manage pain for 1 (R198) of 2 residents reviewed for pain management in the sample of 34. This failure resulted in R198 experiencing severe pain and anxiety, resulting in a transfer to the ER (Emergency Room).

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient direct care staff to meet resident's needs. This has the potential to effect all 49 residents living at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were properly stored at appropriate temperatures. This failure has the potential to affect all 49 residents residing in the facility. Findings Include: On 10/04/24 01:23 P.M., the medication room was observed with V2 (Director of Nursing) present. V2 stated that the most recent temperature logs for the vaccine / medication fridge were in the binder on top of the fridge. V2 stated she is not sure why Septembers was not completed and had blanks where the temperature should have been recorded. V2 also stated she was unaware that there have not been any temperatures checked for the month of October 2024. V2 stated the facility has a medication storage policy but it is not specific to the checking of the refrigerator temperatures. On 10/09/2024 at 10:08 A.M. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide diets as ordered for residents with a nutritional risk for malnutrition for 4 of 4 (R13, R31, R33 and R38) residents reviewed for nutrition in a sample of 34. The Findings Include: 1. R13's admission Record documents and admission date of 9/5/24 and documents the following diagnoses: pressure ulcer of sacral region, Diabetes Mellitus Type 2, and Chronic Kidney Disease. R13's active Clinical Physician Orders with a print date of 10/9/24 documents a diet order of Consistent Carbohydrate Diet, Regular texture, thin liquids and double protein with all meals. On 10/3/24 at 12:30 PM, during lunch meal observation, R13 received one slice of meatloaf. On 10/4/24, at 12:35 PM, R13 received one slice of pizza. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper cooking time was reached when cooking meals for 4 of 4 (R18, R20, R23 and R27) residents reviewed for food preparation in a sample of 34. The Findings Include: R18's Order Summary Report for 10/2024 documents a diet order of: regular texture diet and thin/regular consistency. R20's Order Summary Report for 10/2024 documents a diet order of: No Added Salt diet, regular texture and thin liquid consistency. R23's Order Summary Report for 10/2024 documents a diet order of: No Added Salt, regular texture and thin liquid consistency. R27's Order Summary Report for 10/2024 documents a diet order of: Regular diet texture, thin liquid consistency. During the lunch meal observation on 10/2/24 at 11:45 AM, the meatloaf was being prepared to place on the serving table. [...]

Inspectors wroteBased on interview and record review, the facility failed to promote resident dignity by providing timely incontinence care for 3 (R1, R198, R21) of 6 residents reviewed for resident rights in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident or resident representative in writing of hospital transfers for 1 (R19) of 4 resident reviewed for hospitalizations in the sample of 34. Findings Include: R19's admission Record documented an initial admission date to the facility of 01/12/2023. R19's Nursing Note documented on 08/02/2024 at 10:45 A.M., R19 was transported and admitted for observation for D-Dimer elevation, and redness to bilateral lower extremities. R19's Nursing Note dated 08/03/2024 at 1:20 P.M., documented R19 was transported to facility per daughter in a private vehicle. On 10/04/2024 at 10:30 A.M. V3 (Business Office Manager) stated she is the person responsible for sending out the notice of transfer to the resident and / or the resident representative. V3 initially stated that the resident was not out of the building for 24 hours. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident or resident representative in writing of the bed hold policy during resident transfers for 1 (R19) of 4 residents reviewed for hospitalization in the sample of 34. Findings Include: R19's admission Record documented an initial admission date to the facility of 01/12/2023. R19's Nursing Note documented on 08/02/2024 with a time of 10:45 A.M., R19 was transported and admitted for observation for D-Dimer elevation, and redness to bilateral lower extremities. R19's Nursing Note dated 08/03/2024 with a time od 1:20 P.M., documented R19 was transported to facility per daughter in a private vehicle. On 10/04/2024 at 10:30 A.M. V3 (Business Office Manager) stated she is the person responsible for sending out the bed hold and the notice of transfer to the resident and / or the resident representative. [...]

Inspectors wroteBased on interview and record review, the facility failed to acquire medications timely from the pharmacy for administration for 1 (R2) of 3 residents reviewed for pharmacy services in the sample of 34.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from unnecessary medications for 1 of 5 resident (R20) reviewed for unnecessary medications in the sample of 34. The Findings Include: R20's admission Record documents an initial admission to the facility on [DATE]. The diagnoses listed on the admission Record include the following: unspecified dementia as of 06/06/2023, anxiety disorder as of 09/20/2022, bipolar disorder as of 08/26/2022, major depressive disorder as of 10/17/2019, and insomnia as of 10/25/2023. R20's Order Summary Report with Active Orders As Of 10/09/2024 documented the following medications: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide routine dental services for 1 of 1 (R31) residents reviewed for dental services in a sample of 34. The Findings Include: R31's admission Record documents an admit date of 8/2/23. This same document includes the following diagnoses: Diabetes Mellitus, Hypertension, Polycystic Kidney Disease, and Gout. R31's July 29, 2024 quarterly Minimum Data Set (MDS) Section C, Cognitive Patterns, documents a BIMS Brief Interview of Mental Status (BIMS) score of 12, indicating R31 is cognitively intact. Section L, Oral/Dental Status, of this same MDS does not have an item checked for 1. Broken, loosely fitting full or partial dentures or 2. Mouth or facial pain, discomfort, or difficulty with chewing. R31's Care Plan does not include any dental concerns listed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to clean the glucometer in between resident use for 3 (R7, R28, and R199) of 5 residents reviewed for glucose testing in the sample of 34. Findings Include: On 10/02/2024 at 11:26 A.M. V4 (Registered Nurse) obtained R7's blood glucose sample. V4 then placed the glucometer on the med cart on top of a towelette. V4 then draped the top part of the towelette over the glucometer. On 10/02/2024 at 11:34 A.M. V4 took the glucometer off the top of the med cart and obtained R28's blood glucose test. After getting the result and removing the test strip, V4 then placed the glucometer back on top of the med cart on the same towelette. V4 then draped part of the towelette over the glucometer. On 10/02/2024 at 11:39 A.M. V4 took the glucometer off the top of the med cart and obtained R199's blood glucose test. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a sufficient amount of staff to ensure residents care needs were being met. This failure has the potential to effect all 43 residents living at this facility.

Inspectors wroteBased on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner for 4 residents of 10 residents (R2, R5, R6, R8, R9) reviewed for call lights in a sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered per current standards of practice for 1 (R1) of 3 residents reviewed for medication administration in the sample of 3. Findings Include: On 4/12/24 at 8:50 AM, V2 (Director of Nursing) stated she cannot recall the specific date, but does believe it was in the early afternoon, she was notified by V4 (Certified Nurse Assistant, CNA) that she had found a cup of medications in R1's room. V2 stated she spoke with V3 (Registered Nurse, RN) who was R1's nurse that day and educated her that medications could not be left at the resident's bedside, unless that resident had been assessed for self-administration of medication. V2 stated there were no ill outcomes or incidents as a result of the medications being left that required the State Agency notification. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician in a timely manner for 1 (R2) of 3 residents reviewed for physician notification. This failure resulted in the hospitalization of R2 for 2 days with a diagnosis of cellulitis of the right abdominal pannus and left lower extremity cellulitis, and insertion of a Peripherally Inserted Central Catheter (PICC) line for intravenous (IV) antibiotic therapy.

Inspectors wroteBased on interview, observation, record review, the facility failed to follow fall interventions for 1 (R1) of 3 residents reviewed for falls. This failure resulted in R1 experiencing a fall and receiving a broken rib.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) entries accurately reflected a resident's status for 3 (R26, R40, R2) of 12 reviewed for MDS accuracy in the sample of 25. Findings Include: 1. At periods throughout this survey, R26 was observed smoking in designated smoking area of the facility with no concerns observed. Review of R26's most recent MDS dated [DATE] documents in section J1300 No to the question of current tobacco use. On 11/2/23 at 2:15 PM, V1 (Administrator) stated she acknowledges the error in MDS coding in which R26 is marked as not being a current tobacco user in the 9/21/23 MDS. V1 stated the error will be corrected. 2. Review of R40's Diagnosis List documents a diagnosis of bipolar disorder dated 8/19/23. [...]

Inspectors wroteBased on interview and record review the facility failed to refer a resident for a Level I Preadmission Screening and Resident Review (PASARR) for 2 (R21 and R27) of 2 residents reviewed for PASARR's in the sample of 25. Findings Include: 1. R21's admission record, as provided by the facility, dated 11/7/23 documents an admission date of 10/17/19. R21's diagnoses included on this document include a major depressive disorder as of 10/17/19, unspecified dementia with behaviors on 6/6/23, anxiety on 9/30/22, and bipolar disorder on 8/26/22. R21's PASARR Level I and Level II two provided by V1 (Administrator) have a completion date of May 1, 2023. 2. R27's admission record, as provided by the facility, dated 11/7/23 documents an admission date of 7/20/21. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a plan of care regarding smoking for 1 (R26) of 1 resident reviewed for smoking in the sample of 25. Findings Include: At periods throughout this survey, R26 was observed smoking in designated smoking area of the facility with no concerns observed. R26's current plan of care documented a focus area of long standing smoking history with a date initiated as 11/2/23. Review of the facility policy number C11.82, with a subject of Care Plan and revision date of 1/11/23 documented, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. On 11/2/23 at 2:15 PM, V1 (Administrator) stated she acknowledges that R26 did not have a current plan of care in place for smoking. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide urinary catheter care per current standards of practice for 1 (R24) of 1 resident reviewed for urinary catheters in the sample of 25. Findings Include: Review of R24's current plan of care documents a focus area of (Name) R24 has High Risk for Urinary Tract Infection due to Indwelling catheter use, r/t (related to) wound healing. This focus area has a date initiated as 10/20/23. Review of R24's Physician Orders documents an order date and start date of 10/27/23 for Bactrim DS (Double Strength) Oral Tablet 800-160 MG (milligrams) (Sulfamethoxazole-Trimethoprim). Give 1 tablet by mouth two times a day for UTI (Urinary Tract Infection) until 11/07/2023. On 11/2/23 at 1:15 PM, urinary catheter care was observed being performed by V4 (Certified Nurse Assistant, CNA) with V2 (Director of Nursing) present. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin to the Administrator, the State Agency, the Office of Ombudsman, and local law enforcement for 1 of 7 residents (R1) reviewed for injuries of unknown origin in the sample of 13.

Inspectors wroteBased on interview and record review, the facility failed to initiate an investigation into an injury of unknown origin for 1 of 7 residents (R1) reviewed for injuries of unknown origin in the sample of 13.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents are free of greater than five percent medication errors for 3 (R2, R10, R13) of 13 residents reviewed for medication administration in the sample of 13.