Deficiency Records for Ridgeview Healthcare and Rehab Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Ridgeview Healthcare and Rehab Center. 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? |
|---|---|---|---|---|
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-01-31 | 2024-03-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-31 | 2024-03-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-31 | 2024-03-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-31 | 2024-03-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-26 | 2024-03-07 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-26 | 2024-03-07 | 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 | 2024-01-26 | 2024-03-07 | N |
| Provide activities to meet all resident's needs. | Health | 2024-01-26 | 2024-03-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-26 | 2024-03-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-26 | 2024-03-07 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-01-26 | 2024-03-07 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-01-26 | 2024-03-07 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2024-01-26 | 2024-03-07 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-01-26 | 2024-03-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-26 | 2024-03-07 | 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 | 2024-01-26 | 2024-03-07 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-01-26 | 2024-03-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-01-26 | 2024-03-07 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-01-26 | 2024-03-07 | 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 | 2024-01-26 | 2024-03-07 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-01-26 | 2024-03-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-26 | 2024-02-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-26 | 2024-02-27 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-01-26 | 2024-02-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-26 | 2024-02-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-26 | 2024-02-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-31 | 2023-11-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-31 | 2023-11-29 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-31 | 2023-11-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-28 | 2023-10-31 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-28 | 2023-10-31 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-06-09 | 2023-10-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-09 | 2023-10-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-09 | 2023-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-09 | 2023-10-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-09 | 2023-10-31 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-09 | 2023-10-31 | N |
| Use approved construction type or materials. | Fire Safety | 2023-06-20 | 2023-08-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-06-20 | 2023-08-18 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-06-20 | 2023-08-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-20 | 2023-08-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-20 | 2023-08-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-09 | 2023-08-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-09 | 2023-08-17 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-06-09 | 2023-08-17 | N |
| Provide activities to meet all resident's needs. | Health | 2023-06-09 | 2023-08-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-09 | 2023-08-17 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-06-09 | 2023-08-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-06-09 | 2023-08-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-09 | 2023-08-17 | N |
| Dispose of garbage and refuse properly. | Health | 2023-06-09 | 2023-08-17 | 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 | 2023-06-09 | 2023-08-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-09 | 2023-08-17 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-09 | 2023-08-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-09 | 2023-08-17 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-09 | 2023-08-17 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-06-09 | 2023-08-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-28 | 2023-04-25 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-28 | 2023-04-25 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-28 | 2023-04-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-28 | 2023-04-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-28 | 2023-04-25 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-28 | 2023-04-25 | Y |
| Keep all essential equipment working safely. | Health | 2023-03-28 | 2023-04-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-22 | 2023-04-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-03 | 2023-01-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-03 | 2023-01-24 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-11-15 | 2023-01-06 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-11-15 | 2023-01-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-15 | 2023-01-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-15 | 2023-01-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-15 | 2023-01-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-11-15 | 2023-01-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-04 | 2022-12-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-11-04 | 2022-12-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-04 | 2022-12-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-04 | 2022-12-21 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-11-04 | 2022-12-21 | N |
| Provide appropriate foot care. | Health | 2022-11-04 | 2022-12-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-04 | 2022-12-21 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-11-04 | 2022-12-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-04 | 2022-12-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-04 | 2022-12-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-04 | 2022-12-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-04 | 2022-12-21 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-07-28 | 2022-11-04 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-07-28 | 2022-09-28 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-28 | 2022-09-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-28 | 2022-09-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-28 | 2022-09-28 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-04-20 | 2022-06-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-20 | 2022-06-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-20 | 2022-06-02 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-02-03 | 2022-03-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-03 | 2022-03-09 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-03 | 2022-03-09 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-03 | 2022-03-09 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-12-10 | 2022-03-09 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-12-10 | 2022-03-09 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-12-17 | 2022-02-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-17 | 2022-02-03 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-12-10 | 2022-02-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-26 | 2022-02-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-26 | 2021-12-10 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-10-26 | 2021-12-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-26 | 2021-12-10 | Y |
| Report COVID19 data to residents and families. | Health | 2021-10-26 | 2021-12-10 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-26 | 2021-12-10 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-10-26 | 2021-12-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-04 | 2021-06-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-28 | Not Fixed | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-17 | Not Fixed | Y |
