Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ridgecrest Post Acute during CMS and state inspections, most recent first.
Surveyors found multiple failures in food storage, labeling, and hot holding practices, including dented canned goods not segregated, canned items with crusted food and debris on top, bread and cookies in dry storage without clear expiration or use-by dates, and opened, undated items such as jelly and breaded steak fritters exposed to air in refrigeration and freezer areas. An opened, undated bag of pretzel sticks was also found in a unit nourishment area, despite expectations that resident food be labeled with room number, open date, and use-by date. During a tray line observation, several TCS foods on the steam table, including noodles, meatballs, vegetables, and pureed items, were held below the required 135°F hot-holding temperature. Dietary staff and leadership acknowledged that staff are expected to label food with received, opened, and discard/use-by dates and that the dietary director is responsible for ensuring food service follows facility policies and regulatory requirements.
A resident with multiple medical conditions, intact cognition, and physician orders permitting smoking per facility policy was care planned as a smoker at risk for smoking-related injuries, with interventions to explain risks, policy, and smoking times. A smoking assessment documented that the IDT allowed the resident to smoke without supervision. However, surveyors observed the resident keeping loose tobacco, a carton of cigarettes, and two lighters in the room, even though the resident, a CNA, and an LPN all stated that smoking materials were supposed to be locked in a smoking cart and not stored by residents. The DON described expectations that smoking materials be secured in the cart and residents monitored, but also stated this resident was allowed to keep supplies in the room due to being alert and independent, which conflicted with the written policy prohibiting residents from possessing smoking materials and requiring staff-controlled storage.
The facility failed to implement a corrective action plan after detecting Legionella in its water system, with positive results in three residents' rooms and a nursing station. Despite the risk of respiratory complications, there was no documentation or follow-up action taken, and staff interviews revealed a lack of communication and awareness of the test results.
A resident with mental health diagnoses was discharged home with home health arrangements, but the MDS assessment inaccurately recorded a hospital discharge. Facility staff identified discrepancies between clinical records and the MDS, acknowledging the need for correction to ensure accurate data.
A resident was found with unauthorized medications on their bedside table, and the facility failed to assess and document their ability to self-administer medications. The resident's clinical record lacked necessary documentation, and the facility's policy on self-administration was not followed.
A resident's medical record contained incorrect documentation, including another resident's medication review, which violated privacy and confidentiality policies. The Health Information Director and DON confirmed the error, acknowledging it did not meet facility standards.
A deficiency was identified in a facility's ability to protect residents from abuse by other residents, following an altercation between two residents with cognitive impairments. Despite staff intervention, one resident reported being physically struck, although no injuries were observed. The facility's investigation found the incident unsubstantiated, but the report highlights a failure to ensure residents' safety from abuse.
The facility failed to protect residents from abuse, with incidents involving physical aggression between residents and inappropriate handling by staff. A resident with severe cognitive impairment was punched by another resident, while another resident was pushed during an altercation. Additionally, a resident was inappropriately handled by an LPN during medication administration, and another resident's room was tied shut by staff, leading to findings of abuse and neglect.
A resident with a history of wandering and cognitive impairments exited the facility through an unsecured window, leading to police involvement after being found in a nearby neighborhood. The facility's failure to identify and supervise the resident adequately resulted in a deficiency in maintaining a safe environment.
Improper Food Storage, Labeling, and Hot Holding Temperatures in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food procurement, storage, labeling, and dating practices during multiple kitchen and nourishment room observations. In the main kitchen dry storage, they found a 32-ounce can of vegetables with a small dent on the top and a large dent on the side that was not segregated in the designated dented-can area. Brown crusted food and grey, dust-like debris were observed on top of four canned items in dry storage. A bag of sliced sandwich bread in a clear plastic bag with twist ties was labeled with a date of October 21, 2025, but had no indication of an expiration or use-by date, and the dietary aide present could not identify what the manufacturer’s dates represented. Two plastic sleeves of chocolate chip cookies, one of which was open and exposed to air, were unlabeled and undated. In the main walk-in refrigerator, surveyors observed a two-quart container of jelly covered with plastic wrap and no visible dates, and in the main freezer, an opened cardboard box containing breaded steak fritters was found with the product exposed to air and no received, opened, or expiration dates. During interviews, the dietary aide stated that dates written on food items represent the received date, indicated by an “R,” and that opened food items should be labeled with an expiration date, but she needed clarification on the bread loaf dating. The assistant dietary manager acknowledged that new employees might be unfamiliar with proper dating and labeling policies and stated that kitchen staff are expected to label food with received, opened, and discard dates, and that unlabeled food is thrown out. The Dietary Services Manager further explained that staff are expected to label food with received, opened, and use-by dates, that most food items are typically discarded six days after the received, use-by, or open date, and that she recognized the risk of not knowing how long food had been stored if it was not properly dated and labeled. In a nourishment refrigerator and storage area on one unit, surveyors also found an undated, opened bag of pretzel sticks in the resident food storage area, despite the manager’s statement that residents’ food must be labeled with room number, open date, and use-by date. Surveyors also identified deficiencies in safe food preparation and hot holding practices during a tray line observation. When steam table temperatures were checked, egg noodles measured 90°F, beef meatballs 116°F, green beans 128°F, pureed meatballs 122°F, pureed bread 122°F, and pureed beans 132°F, all below the 135°F hot-holding temperature specified in local environmental services guidance for time/temperature control for safety (TCS) foods. The Dietary Services Manager acknowledged that the steam table temperatures were lower than required and suggested there may not have been enough water in the table, and that staff might need education on proper steam table use. The Administrator stated that the dietary director is responsible for the food served from the kitchen and is expected to follow facility regulations and policies. Facility policies reviewed by surveyors required that foods brought by family be labeled and stored distinctly, and that all refrigerated and frozen foods be labeled, dated, and monitored for use-by, frozen, or discard dates, and that dry goods be handled and stored to maintain packaging integrity.
Failure to Enforce Smoking Policy and Control Resident Smoking Materials
Penalty
Summary
The facility failed to implement its smoking policy for one cognitively intact resident who was care planned as a smoker at risk for smoking-related injuries. The resident had multiple medical diagnoses including malnutrition, hypertension, hyperlipidemia, GERD, homelessness, mood disorder, epilepsy, muscle weakness, coronary heart disease, and adult failure to thrive. Physician orders documented that the resident was permitted to smoke per facility policy, and a quarterly MDS showed a BIMS score of 15 with no psychosis, behaviors, or physical impairments. The care plan identified the resident as a smoker with goals to ask staff for assistance with smoking and to continue to demonstrate safe smoking, with interventions including explaining risks, the smoking policy, and smoking times. A smoking observation/assessment documented that the IDT determined the resident could smoke without supervision. Despite the written policy and staff descriptions of practice, surveyors observed the resident with a bag of loose tobacco on the bed, a carton of cigarettes, a flameless lighter, and a second lighter in his possession. The resident stated that residents were not supposed to store smoking materials in their rooms and that smoking supplies were stored in a smoking cart and used during assigned smoking times. A lead CNA and an LPN both stated that, per facility policy, residents were not allowed to store their own smoking items and that all smoking materials were to be locked in a smoking cart and brought out during designated smoking times. The DON stated that the smoking policy addressed designated smoking areas, storage of smoking materials, evaluation of smokers, care planning, and education, and that staff were expected to store residents’ smoking materials in the smoking cart and monitor supervised smokers. However, the DON also stated that this resident was allowed to keep smoking supplies in his room because he was alert, oriented, and independent, which conflicted with the undated facility policy stating that residents are not permitted to keep smoking materials in their possession and that such materials must be kept by designated staff and presented to the charge nurse when brought into the facility.
Failure to Implement Corrective Action for Legionella Detection
Penalty
Summary
The facility failed to implement a corrective action plan after detecting Legionella in its water system, which could lead to respiratory complications for residents. Water samples collected on June 6, 2024, revealed that three residents' rooms and one nursing station tested positive for Legionella pneumophila serotype 2-15, with concentrations ranging from 0.6 CFU/ml to 25 CFU/ml. Despite these findings, there was no documentation in the Legionella program or Infection Prevention and Control program addressing the detection of Legionella. Interviews with facility staff, including the Maintenance Director and the Infection Control Preventionist, revealed a lack of communication and follow-up regarding the positive test results. The Maintenance Director, who was not in position at the time of the initial testing, was unaware of the results, and the facility's administrator stated there was no need for follow-up. The water company representative confirmed that the facility's water was poorly controlled and that a corrective action plan should have been implemented, but no such plan was documented.
Inaccurate MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure an accurate discharge Minimum Data Set (MDS) assessment for a resident, which could lead to inaccurate discharge tracking information and data for quality monitoring. The resident, who had diagnoses including altered mental status, catatonic disorder, anxiety disorder, and auditory hallucinations, was admitted with a goal to discharge home. Progress notes and a social services note indicated that the resident was discharged home with home health arrangements. However, the discharge MDS assessment inaccurately recorded the resident as being discharged to a short-term general hospital. Interviews with facility staff, including a Registered Nurse, the MDS Coordinator, and the Director of Nursing, revealed discrepancies between the clinical records and the MDS assessment. The staff confirmed that the resident was discharged home, as supported by the clinical record and social services note, but the MDS assessment inaccurately reflected a hospital discharge. The Director of Nursing acknowledged the inaccuracy and the need for correction, highlighting the potential for incorrect MDS data due to this error.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for self-administration of medication, which could lead to unauthorized access to medications. The resident, who was admitted with conditions including chronic obstructive pulmonary disease, anxiety disorder, obstructive sleep apnea, and arthritis, was observed with medications on their bedside table that were not authorized for self-administration. The resident's clinical record did not contain documentation of an assessment or clearance for self-administration, nor did it include a care plan or physician's orders for the medications found. During a medication administration observation, it was noted that the resident had Neosporin and Calmoseptine on their bedside table, which were not documented in their medication administration record. The Director of Nursing stated that the facility was in the process of training the resident for self-administration, but the necessary assessments and documentation were not completed prior to the observation. The facility's policy requires that the interdisciplinary team assess and document the safety and appropriateness of self-administration, which was not adhered to in this case.
Inaccurate Documentation of Resident Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation of electronic medical records for a resident, which could result in the medical record not reflecting the resident's condition and the care and services provided. Specifically, the medical record of a resident admitted with diagnoses of dementia, type 2 diabetes mellitus, major depressive disorder, and anxiety disorder contained a New Admission Medication Review that belonged to another resident. This incorrect documentation included another resident's name, date of birth, and medications, which were no longer relevant to the current resident. Interviews with the Health Information Director and the Director of Nursing confirmed that the incorrect records were identified in the resident's file. Both staff members acknowledged that the records were inaccurately placed and did not meet the facility's expectations for maintaining privacy and confidentiality. The facility's policies on confidentiality and resident rights emphasize safeguarding personal privacy and confidentiality, which were not adhered to in this instance.
Resident Altercation and Abuse Prevention Deficiency
Penalty
Summary
The facility failed to ensure that residents were free from abuse by other residents, as evidenced by an altercation between two residents on the Sunset Secured Behavioral Unit. Resident #8, who was cognitively intact, and Resident #26, who had moderate cognitive impairment and exhibited delusional behaviors, were involved in a verbal altercation that escalated. Staff were present and intervened to separate the residents, but Resident #8 reported being physically struck by Resident #26, although no injuries were observed. Resident #8 had a history of dementia and anxiety, while Resident #26 had diagnoses including major depressive disorder, PTSD, and dementia with agitation. The altercation occurred after Resident #8 felt uncomfortable with Resident #26's prolonged staring and attempted to address it. Despite staff intervention, Resident #8 claimed that Resident #26 used profanity and physically assaulted him, leading to a physical response from Resident #8. Staff interviews and documentation indicated that the residents were separated without injury, but Resident #8's account suggested physical contact occurred. The facility's investigation concluded that the incident was unsubstantiated due to a lack of willful intent and no confirmed physical contact. However, the report highlights a deficiency in protecting residents from abuse by other residents, as the altercation could have resulted in physical and emotional harm. The facility's policy emphasizes the right of residents to be free from abuse, neglect, and exploitation, but the incident suggests a lapse in ensuring this protection.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect three residents from abuse, as evidenced by multiple incidents involving physical aggression and inappropriate handling by staff. Resident #152, who has severe cognitive impairment, physically assaulted Resident #20 by punching them in the face multiple times. This incident was witnessed by a CNA and reported to an RN, who separated the residents and provided care to Resident #20. Another incident involved Resident #153, who pushed Resident #15 after the latter entered their room and refused to leave. This altercation was reported by a resident and confirmed by staff interviews. In a separate incident, Resident #127, who has moderately impaired cognition, was subjected to inappropriate handling by an LPN. The LPN attempted to administer medication by hitting the resident on the head and shaking them to ensure the medication was swallowed. This behavior was observed by a CNA, who questioned the LPN's actions. The LPN acknowledged the rough handling and admitted it could be considered abuse. Additionally, Resident #20 was involved in another incident where their room door was tied shut with a gown by staff, effectively secluding the resident. This was reported by a CNA and confirmed by another staff member. The facility's policy on abuse, which states that residents have the right to be free from abuse and neglect, was not adhered to in these instances, leading to the deficiency findings.
Failure to Prevent Unsafe Wandering
Penalty
Summary
The facility failed to identify and adequately supervise a resident at risk of unsafe wandering, leading to a deficiency in ensuring a safe environment. The resident, who was admitted with diagnoses including aphasia, stroke, muscle weakness, and repeated falls, was noted to be confused and disoriented. Despite these conditions, the facility's wandering risk assessments identified the resident as forgetful with a short attention span and a known history of wandering. However, the facility did not implement effective measures to prevent the resident from wandering unsafely. On a specific date, the resident was found outside the facility by the police after wandering through a residential neighborhood. The resident had exited the facility through a window in their room, which had been opened and the screen pushed out. The incident report indicated that the resident was agitated and had sustained a small skin tear. Interviews with facility staff revealed that certain areas of the facility were not locked or secured, and the level of independence for residents was determined by their risks and cognition levels. The facility's policy on Wandering and Elopement emphasized identifying at-risk residents and including safety strategies in their care plans, which was not effectively executed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.