View Ridge Care Center

Inspectors wroteBased on interview and record review, the facility failed explain and ensure residents understood the arbitration agreement for 3 of 3 residents (Residents 74, 75, and 81) when reviewed for arbitration agreement. This failure placed residents at risk of forfeiting their right to a jury trial, inability to seek restitution for errors made by the facility, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 1 residents (Resident 81) reviewed for Transmission Based Precaution (TBP-are a set of infection control measures used in healthcare settings to prevent the spread of infectious diseases that are transmitted through contact with an infected patient, their bodily fluids, or contaminated surfaces or objects), 1 of 1 residents (Resident 3) observed during wound dressing change, 1 of 1 residents (Resident 78) observed for a Peripherally Inserted Central Catheter (PICC- a long, thin tube inserted into a small arm vein and threaded to a large vein near the heart) dressing changes and the develop a facility water management program to protect against the transmission of Legionella (serious type of pneumonia [...]

Inspectors wroteBased on interview and record review, the facility failed to follow-up on concerns of the resident council related to resident care for 4 of 5 resident council meeting minutes (June-August 2025 and October 2025) when reviewed for resident council. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were provided notices of their resident rights, both orally and written, annually for interviewed in the resident council for 4 of 10 who attended (Residents 6, 8, 29, 30). This had the potential to affect all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-an assessment tool) assessment accurately reflected the status for 3 of 14 sampled residents (Resident 8, 58, and 80) reviewed for accuracy of assessments. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 3 of 6 sampled staff (Staff R, S, and T) reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure 3 of 5 nurse aides (Staff S, T and W) had their required 12 hours of in-service training. The failure to ensure Nursing Assistants Certified (NACs) received 12 hours per year in-service training placed residents at risk of less than competent care and services from staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure that power of attorney (POA) legal documents were in the resident's medical record for 1 of 4 (Resident 5) residents reviewed for advance directives. This failure placed the resident at risk of having someone make medical decisions for the resident without proper legal authority, possible unmet care needs, or unwanted medical treatments.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely reporting of an allegation of neglect to the State Agency for 1 of 1 resident (Resident 78) reviewed for abuse/neglect reporting. This failure placed residents at risk for potential unidentified and ongoing abuse and lack of protection from abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop comprehensive care plans to reflect the resident's current medical status and/or to include all provided nursing services for 1 of 1 resident (Resident 19) reviewed for edema management, 1 of 1 residents (Resident 80) reviewed for stroke and impaired vision. These failures placed residents at risk of not receiving needed care, decline in condition, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that ensured a resident's abilities in activities of daily living (ADLs) did not diminish for 1 of 2 sampled residents (Resident 19) reviewed for activities of daily living. This failure put residents at risk for physical decline and decreased quality of life. Findings Included .Resident 19 admitted to the facility on [DATE] with diagnoses to include developmental disability and need for assistance with personal care. Review of Resident 19's Brief Interview for Mental Status (BIMS - an assessment tool used to screen for cognitive impairment) dated 10/23/2025 documented a score of 8 out of 15, indicating the resident had moderate impairment. Review of Resident 19's care plan, dated 10/29/2025, documented they required limited assistance by one staff with personal hygiene and oral care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the assistance with activities of daily living (ADL's) for 1 of 2 sampled dependent residents (Resident 58) reviewed for ADL's. The facility failed to provide one-to-one feeding assistance to Resident 58. This failure placed residents at risk for inadequate nutrition and unmet care needs and a diminished quality of life. Findings Included. Resident 58 was admitted to the facility on [DATE] with diagnoses to include transient cerebral ischemic attack (TIA- A short-term block in blood flow to the brain that causes symptoms similar to a stroke), dementia, muscle weakness and lack of coordination. Review of Resident 58's care plan, dated 09/23/2024 and revised on 08/27/2025, documented they required one-to-one assistance to eat their meals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 1 of 4 residents (Resident 58) consistent equipment and assistance to maintain their mobility. This failure placed residents at risk for decline in functional ability, frustration, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that dialysis communication documents were filled out before and after the resident had their dialysis appointments for 1 of 1 resident (Resident 8) reviewed for dialysis. This failure placed Resident 8 at risk of inadequate information given to the dialysis staff, a lack of assessment and documentation upon arrival back to the facility, undetected dialysis complications, and a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the medical records reflected the accurate weight for 1 of 4 residents (Resident 81) reviewed for weights and 1 of 2 residents (Resident 58) and for complete records to include hospice communication/documentation. These failures placed residents at risk for inaccurate medication dosage calculation, unmet care needs and possible medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in 1 of 1 facility kitchens, 1 of 2 dining rooms (1st floor) and 2 of 2 nourishment refrigerators (1st and 2nd floors). The facility failed to ensure the dishwashing machine maintained adequate hot water temperature, to ensure the kitchen and dining room ceilings were free of dust and lint, to ensure the nourishment refrigerators were clean and sanitary, to ensure food preparation equipment surfaces were sanitary, and to ensure overhead light fixtures were sanitary and in good repair. These failed practices placed residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 3 medication carts (Carts 3 and 4) and 1 of 1 medication rooms (first floor medication room) had unexpired medications and/or biologicals and medications were stored at the proper temperature. These failures placed residents at risk of receiving compromised medications and biologicals.

Inspectors wroteBased on interview and record review the facility failed to identify a significant change and complete a timely Significant Change in Status Assessment (SCSA) within the required 14-day timeframe for 1 of 4 residents (Resident 7) reviewed for Hospice Services. Failure to complete the SCSA timely placed the resident at risk for unmet care needs, decreased quality of care and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for 1 of 4 residents (Resident 14) reviewed for Activities of daily living and 1 of 1 resident (Resident 6) reviewed for dental care. This failure placed residents at risk for inaccurate care planning and decreased quality of care.

Inspectors wroteBased on interview and record review the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 2 of 5 sampled residents (Resident 5 and 47) reviewed for unnecessary medications. Incomplete or inaccurate PASRR's placed residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnoses or disability.

Inspectors wroteBased on interview, observation and record review the facility failed to develop a comprehensive care plan for 1 of 2 sampled residents (Resident 6) reviewed for comprehensive care planning. Failure to ensure person centered care plans were developed and implemented placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident-centered care and treatment was provided in accordance with professional standards of practice when the facility failed to ensure consistent communication and collaboration of care occurred between the facility and hospice care for 1 of 2 resident's (Resident 29) reviewed for hospice services. The facility failed to ensure the management of a high-risk medication (anticoagulant used to regulate how much the blood clots), including when to test for appropriate dose of the medication were communicated appropriately between the facility provider and the hospice provider. The facility failed to ensure the comprehensive care plan was revised and updated consistent with the residents' goals and choices for end-of-life care. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 2 residents (Resident 29) reviewed for hospice services. The failure to ensure medications were acquired and administered as ordered, and follow facility processes for medications not available, placed residents at risk for adverse events related to missed medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 Residents (Resident 22) reviewed for unnecessary medications were free from unnecessary psychotropic medications. Facility staff failed to identify/monitor target behaviors for antipsychotic medication and attempt a Gradual Dose Reduction (GDR) for an Antipsychotic medication. These failures placed residents at risk to receive unnecessary psychotropic medications and experience adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with physical impairment and/or swallowing difficulty were fed by staff that were properly trained for 1 of 2 staff (Staff L) observed providing feeding assistance to residents in the second-floor assisted dining room. This failure placed residents at risk of choking and aspiration (inhalation of food or fluid into the lungs) and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed procedures to prevent the spread of disease for 2 of 3 rooms (room [ROOM NUMBER] and 216) reviewed for Transmission Based Precautions (TBP) and failure to store respiratory equipment in sanitary conditions for 1 of 2 residents (Resident 252) reviewed for respiratory care. Failure of staff to follow appropriate use of Personal Protective Equipment (PPE), perform hand hygiene consistently and properly store respiratory equipment, placed residents and staff at risk of transmitting a communicable disease and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare foods in accordance with professional standards in 1 of 1 kitchen reviewed. Failure to ensure foods stored in the refrigerator, freezer, and dry storage were labeled and dated after opening, failure of staff to wash their hands, and failure to wear a hair net in food preparation areas had the potential to spread food borne illness.

Inspectors wroteBased on observations, interviews, record review, the facility failed to ensure that 1 of 2 residents (Resident 7) reviewed for positioning and mobility was provided with a splint per Occupational Therapy's (OT) recommendations. Failure to provide a splint based on therapy recommendations had the potential for loss of Range of Motion (ROM) to affected joint and increased pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order was followed for the management of the humidifier on the oxygen concentrator for 1 of 2 residents (Resident 23) reviewed for oxygen administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an assessment and physician order was obtained for medications to be left at bedside for 1 of 1 resident (36) reviewed for self-medication program. Failure to assess if the resident had the cognitive and physical ability to keep medications at the bedside put residents at risk for using medication incorrectly and medications not being secure.