Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ridgeview Skilled Nursing Facility during CMS and state inspections, most recent first.
A resident with a Foley catheter and neurogenic bladder experienced multiple episodes of low or unrecorded urine output, but the physician was not notified as required by facility policy and physician expectations. Documentation of urine output was inconsistent, and staff interviews confirmed that changes in the resident's condition were not promptly communicated to the physician.
A resident with a Foley catheter and neuromuscular bladder dysfunction was admitted with a care plan requiring intake and output monitoring. Although staff reported that urine output was being recorded and communicated to the charge nurse, the DON could not provide any documentation to verify this. The absence of intake and output records demonstrated a failure to follow the written care plan as required by facility policy.
A resident with neurogenic bladder and a Foley catheter did not have urine output consistently monitored or documented as ordered, with several shifts missing output records and no intake record available. Staff interviews confirmed incomplete documentation, and the DON was unable to provide required records, while facility policy lacked clear guidance.
A resident with hemiplegia, hemiparesis, and a history of falls, who required total assistance for ADLs, fell from a narrow bed without bedrails during a brief change when staff failed to provide adequate support. The resident was left unsupported while the CNA retrieved supplies, resulting in a fall and a leg fracture. Staff interviews indicated inconsistent use of support measures, and the care plan for high fall risk was not effectively followed.
The facility failed to ensure food items were labeled, dated, and free from mold, potentially causing food-borne illness. Unlabeled, expired, and moldy items were found in the kitchen, and staff interviews confirmed the importance of proper food handling to prevent illness.
The facility failed to offer COVID-19 vaccine boosters to four residents, including those with pneumonia due to COVID-19, hip fracture, lung cancer, and COPD. The ICN admitted to not tracking vaccination statuses properly, and the DON confirmed that the vaccine should have been offered upon admission or re-admission, as per facility policy.
A facility failed to ensure proper documentation for a resident receiving hospice care, leading to a potential disruption in care coordination. The hospice visiting calendar and communication log did not reflect required visits by a hospice licensed nurse, and a visit note was initially missing from the resident's clinical record. Interviews with staff revealed gaps in documentation and communication, contrary to the facility's policy on hospice documentation.
Failure to Notify Physician of Low Urine Output in Resident with Foley Catheter
Penalty
Summary
The facility failed to follow its policy and procedure regarding physician notification for a resident with a Foley catheter who experienced episodes of low urine output on multiple shifts. The resident, admitted with a nondisplaced sacral fracture and neuromuscular bladder dysfunction, had a Foley catheter in place for neurogenic bladder. Documentation showed inconsistent and sometimes missing records of urine output, with several shifts lacking any recorded output. Despite a physician order to monitor urine output every shift, there were instances where low or absent output was not communicated to the physician as required by facility policy and the physician's expectations. Interviews with nursing staff, the resident's family member, and the physician confirmed that the physician was not notified of low urine output, even though the physician stated that outputs less than 250 ml required notification. The family member also reported that voiding was not documented and a bladder scan was not performed when the Foley catheter was removed and later reinserted. The facility's policy required prompt notification of the physician for significant changes in a resident's condition, but this was not followed in the case of this resident's urinary output.
Failure to Document Intake and Output for Resident with Foley Catheter
Penalty
Summary
The facility failed to follow the written care plan for a resident who had a Foley catheter and was experiencing low urine output. The care plan, initiated upon admission, included an intervention to observe and document intake and output according to facility policy. Interviews with nursing staff indicated that Certified Nursing Assistants (CNAs) were responsible for emptying the urinary bag, recording the output, and informing the charge nurse of the total urine output at the end of each shift. However, when documentation was requested, the Director of Nursing (DON) was unable to provide any records of the resident's intake and urine output, stating that it was past the 30-day period since the resident's admission and discharge. A review of the facility's policy confirmed that each patient's care plan should be implemented according to their needs, including the documentation of intake and output. Despite staff statements that output was being recorded, there was no evidence or documentation available to verify that the resident's intake and urine output had been monitored as required by the care plan. This lack of documentation constituted a failure to implement the care plan as written for the resident with a Foley catheter and neuromuscular bladder dysfunction.
Failure to Monitor and Document Urine Output for Resident with Foley Catheter
Penalty
Summary
The facility failed to adequately monitor and document urine output for a resident with a history of neurogenic bladder and an indwelling Foley catheter. Despite physician orders to monitor urine output every shift, there were multiple instances where no output was recorded, and the intake record could not be provided by the facility. Interviews with staff confirmed that urine output was to be recorded and reported, but documentation was incomplete, and the facility was unable to produce intake records for the period in question. Additionally, the facility's policy on bowel and bladder management did not provide clear guidance on these procedures. The resident involved had diagnoses including a nondisplaced sacral fracture and neuromuscular dysfunction of the bladder, requiring close monitoring of urinary function. Family members reported concerns about the lack of documentation and absence of bladder scans when the Foley catheter was not in place. The Director of Nursing acknowledged the importance of accurate intake and output documentation but was unable to provide the necessary records, citing limitations in record access after 30 days. These actions and omissions resulted in a failure to properly monitor and communicate episodes of low urine output to the physician.
Failure to Provide Adequate Supervision and Assistance During Bedside Care Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement interventions consistent with a resident's needs to eliminate or reduce the risk of falling. The resident, who had diagnoses including hemiplegia, hemiparesis, and a left femur fracture, required total assistance with activities of daily living. The resident was assessed as high risk for falls and was dependent for bed mobility, requiring the assistance of two or more helpers. During a brief change, the resident was turned to the left side on a narrow bed without bedrails, and staff did not provide adequate support or supervision. The resident had nothing to hold on to and subsequently rolled off the bed, resulting in a fall and a fracture to the left leg. Interviews with staff revealed that the resident was sometimes allowed to hold onto a bedside table for support due to the lack of bedrails, but this was not consistently implemented. On the occasion of the fall, the CNA let go of the resident to retrieve wipes, leaving the resident unsupported, which led to the fall. The care plan identified the resident as high risk for falls, but individualized precautions were not effectively implemented during care. The DON stated that staff were expected to communicate concerns regarding fall risks, but was not aware of any issues related to this resident's care prior to the incident.
Food Labeling and Expiration Issues in Kitchen
Penalty
Summary
The facility did not ensure that food items were properly labeled, dated, and free from mold, which had the potential to cause food-borne illness for the residents. During an initial tour of the facility's kitchen, several items were found unlabeled and undated, including a package of fresh mushrooms, a bowl of tartar sauce, a tray of individual salad dressings, cans of garbanzo beans, banana pudding, canned peaches, bags of marble rye bread, hamburger buns, and Texas toast bread. Additionally, expired items were found, such as vanilla shakes, sherbet, chocolate ice cream, hot dog buns, pre-packaged salad greens, and a commercially-prepared chocolate sheet cake. Moldy items, including a box of fresh red onions with four moldy onions, were also discovered. Interviews with the chef, Director of Nursing (DON), and Registered Dietician (RD) confirmed the importance of labeling, dating, and checking the freshness of food items to prevent illness. The chef acknowledged that food items need to be dated and labeled, and fresh produce needs to be checked for mold and freshness. The DON emphasized that unlabeled and expired food could make residents sick, and moldy food is unacceptable. The RD stated that expired food items could cause health conditions and that items should have a received by date and a use by date. The facility's policy on food storage, dated [DATE], indicated that all food items should be inspected, labeled, and dated upon receipt, opening, and preparation, and any expired or outdated food products should be discarded.
Failure to Offer COVID-19 Vaccine Boosters
Penalty
Summary
The facility failed to offer COVID-19 vaccine boosters to four out of five residents reviewed for infection control. Resident 4, who was readmitted with pneumonia due to COVID-19, had no documented evidence of being offered a follow-up COVID-19 vaccination upon return from hospitalization. The resident's Responsible Party could not recall being asked for consent but stated they would have agreed to prevent further infection. Resident 6, admitted with a hip fracture, had no indication in their record of being offered a COVID-19 booster, and the resident expressed willingness to receive one if offered. Resident 114, admitted with lung cancer, also had no documentation of being offered a booster and expressed a desire to receive one. Resident 116, admitted with COPD, was not offered a booster but stated they would have refused due to a past reaction and doctor's advice against it. The Infection Control Nurse (ICN), who had been at the facility for three weeks, admitted to not having a spreadsheet to track residents' vaccination statuses and stated that the facility's plan to have an outside pharmacy administer vaccines was hindered by the low census. The ICN acknowledged that all residents should be offered vaccinations upon admission or re-admission and that the lack of offering the COVID-19 vaccine put residents at risk of contracting the virus. The Director of Nursing (DON) confirmed that the COVID-19 vaccine should have been offered to all residents on admission or re-admission and that failing to do so posed a risk of infection. The facility's policy, titled 'COVID-19 Immunization Guidelines for Residents,' mandates that the facility educate and offer the COVID-19 vaccine to all residents or their representatives unless contraindicated by a physician. This policy also requires documentation in the resident's medical record and arranging for vaccine administration as soon as feasible. The failure to adhere to this policy resulted in the deficiency noted in the report.
Failure to Document Hospice Care Coordination
Penalty
Summary
The facility failed to ensure a documented means of communication for coordination of care for a resident receiving hospice services. Resident 4, who was readmitted to the facility with dementia and other diagnoses, was observed to have severely impaired cognition and required moderate assistance with daily activities. Despite being admitted to hospice care, there was a lack of documentation indicating regular visits by a hospice licensed nurse (LN) between specific dates. The hospice visiting calendar and communication log did not reflect the required weekly visits by the hospice LN, and there was no evidence of a visit note for a particular date until it was later found and added to the resident's clinical record. Interviews with facility staff, including a hospice licensed nurse, the medical records director, and the director of nursing, revealed that the hospice visit notes were not properly documented or communicated. The hospice LN confirmed that visits should be documented on the hospice calendar and communication log, but there was a gap in documentation for a 14-day period. The medical records director could not locate the hospice visit note initially, and it was only found and added to the resident's record later. The director of nursing emphasized the importance of proper documentation for coordinating care and ensuring continuity between hospice and facility staff. The facility's policy on hospice documentation was not followed, leading to a potential disruption in the resident's care.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sharp Chula Vista Med Ctr Snf | 4.7 mi | ★★★★★ | 0 | 0 |
| Veterans Home Of California - Chula Vista | 4.9 mi | ★★★★★ | 10 | 0 |
| South Bay Post Acute Care | 6.7 mi | ★★★★★ | 1 | 0 |
| Reo Vista Healthcare Center | 8.4 mi | ★★★★★ | 6 | 0 |
| National City Post Acute | 8.4 mi | ★★★★★ | 25 | 0 |
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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 June 2026) and official state health department websites.