Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Ridge Post Acute during CMS and state inspections, most recent first.
Resident Called Hardheaded During ADL Care: A resident with altered mental status and HF, with moderate cognitive impairment on MDS, said a CNA called her a name meaning hardheaded or stubborn while helping change her brief. The CNA said she used a Tagalog term of endearment and did not know the English meaning, while the DSD stated staff are not allowed to call residents hardheaded or stubborn and must address residents respectfully by name.
Staff were not trained and competent in using Wander Management Transmitters for two residents with wander guards ordered for elopement risk. An LVN could not verify one resident’s device, another LVN was unsure how to check whether a transmitter was functioning, and the DON, DSD, and ADM gave conflicting information about the tester and could not provide the manufacturer’s user guide or evidence of prior inservice training.
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, including missing care plans for bed rails ordered to assist with mobility, lack of documented implementation of a care-planned intervention to monitor and record O2 saturation every shift for a hospice resident on continuous oxygen, and absence of an activity care plan for a resident from admission until much later. These issues were identified through observation, record review, and staff interviews and were not consistent with the facility’s own policies on care planning, oxygen administration, and activity evaluation.
Failure to Maintain Required Nurse Staffing Data: The facility did not keep and maintain nurse staffing data for the required retention period, and the DON and ADM acknowledged they did not have the DHPPD reports needed to dispute the CMS CASPER PBJ staffing results. The available DHPPD reports showed low actual staffing and CNA DHPPD on several dates, and no reports were provided for the end of the review period.
The facility failed to timely notify the LTC Ombudsman of two residents’ hospital transfers. One resident was transferred for hypotension and desaturation, and another was transferred for hyperglycemia and an altered LOC, but there was no documentation that Ombudsman notices were sent. The social services director confirmed the notices were not sent, despite facility policy stating transfer notice is provided to the LTC ombudsman when practicable.
Activity assessments were not reviewed and updated at least quarterly for two residents. One resident with catatonic schizophrenia was confused and unable to answer questions, and his activity assessment had last been updated years earlier. Another resident receiving palliative care was alert and oriented, but her activity assessment also had not been updated quarterly. The AD, ADON/IP, and DON confirmed the assessments were overdue, and the facility policy required activity evaluations at least quarterly.
Failure to follow PASARR mental health recommendations for a resident with schizophrenia and major depressive disorder. The PASARR report called for Specialized Add-on Services, including psych consult and/or follow-up care, but there was no documentation of a psych consult after the PASARR determination and before the psych NP visit. The resident was being monitored for multiple behavioral and mood concerns, and during the later psych NP visit he stated he had a plan to harm another resident and was transferred on a 5150 hold for emergency psychiatric evaluation.
A resident with CHF and a physician order for furosemide 40 mg BID with a hold parameter for SBP below 100 mmHg received the medication even though the SBP was 94 mmHg. During the med pass, an LVN administered the dose, and later acknowledged it should not have been given; the DON verified the parameter order should have been followed.
An LVN failed to follow infection control practices during medication pass when she touched a garbage container with gloved hands and then administered medications without removing the contaminated gloves, performing hand hygiene, and putting on a new pair of gloves. The LVN acknowledged the error, and the DON verified the lapse; the facility policy required hand hygiene before handling medications and after contact with objects.
Multiple two-bed resident rooms, including Rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 115, 116, 117, 118, 120, and 121, measured only 69.51 square feet per resident, below the 80-square-foot minimum for shared rooms. Surveyors observed that staff and residents moved freely in the rooms, and wheelchairs and walkers were easily accommodated.
The facility failed to implement proper infection control practices, including leaving clean linens uncovered near dirty ones, not sanitizing laundry carts, and improper storage of cleaning chemicals. Kitchen staff lacked knowledge of sanitizer testing, and a medication room was inadequately cleaned, with a silverfish bug found in the sink. These deficiencies could affect the health and safety of 48 residents.
The facility was found deficient in maintaining an effective pest control program when two live cockroaches were observed in the social services office during a recertification survey. The facility's policy, revised in May 2008, mandates a pest-free environment, which the administrator acknowledged was not upheld.
A medication error rate of 12.12% was identified in an LTC facility, involving four residents. Errors included incorrect dosing of Lamotrigine, administering Metformin without a meal, unavailability of Lidocaine patches, and improper inhalation technique for a resident. These actions were contrary to physician orders and facility policies.
The facility failed to follow the recipe for making carrot puree, as the lead cook added excessive milk and food thickener, deviating from the specified instructions. This oversight could affect the palatability and intake of food for six residents on a puree diet.
A resident underwent an unnecessary and improper blood sugar check when an LVN failed to allow the alcohol to dry before pricking the finger, contrary to facility policy. This resulted in a potentially inaccurate result and an additional painful finger prick. The LVN acted without a specific physician order for the timing of the blood sugar check.
A resident was inappropriately assisted with feeding by a restorative nursing assistant (RNA) who provided total assistance instead of set-up help, contrary to the resident's care plan. The resident had adaptive utensils to encourage self-feeding, and the discrepancy was confirmed by the Infection Preventionist (IP) and Director of Nursing (DON).
A facility failed to ensure safe equipment conditions for four residents when a rusted commode was found in their shared toilet. An LVN admitted the commode should have been checked, while the EVSS noted the absence of a monitoring log and stated that nurses were responsible for commode maintenance. The IP confirmed no replacement request was logged, despite the facility's policy assigning maintenance responsibility to the maintenance department.
The facility was found to have multiple resident rooms with two beds that did not meet the required minimum of 80 square feet per resident, providing only 69.51 square feet per resident. Despite this, the room size did not hinder care provision or resident mobility, and both staff and residents reported no concerns regarding the room size.
The facility failed to monitor and document care for two residents, leading to potential safety risks. One resident with a history of wandering was not monitored after incidents, and another resident's admission assessment was delayed. Follow-up assessments and documentation were also completed late, contrary to facility policies.
The facility failed to provide social services support for two residents after an altercation and an abuse allegation. One resident with schizophrenia and dementia was involved in an altercation, but no follow-up was documented. Another resident, who had undergone hip surgery, reported distress after the same resident entered her room, but no social services intervention occurred. The facility lacked social services personnel during this period, and no assessments were documented for the affected residents.
A female resident, post-hip surgery, experienced an unreported abuse incident when a male resident entered her room and sat on her bed, causing her distress. Despite the facility's policy requiring immediate reporting of such incidents, the LVN documented but did not report it to authorities, leaving agencies unaware. The resident has since required mental health therapy.
Resident Called Hardheaded During ADL Care
Penalty
Summary
The facility failed to ensure dignity for one of three sampled residents when a CNA called the resident hardheaded or stubborn during ADL care. Resident 1 was admitted with diagnoses including altered mental status and heart failure, and the MDS dated 4/6/2026 showed a BIMS score of 12, indicating moderate cognitive impairment. During an interview, Resident 1 stated that while the CNA was helping change her brief, the CNA called her a name that in English means hardheaded, and the resident said she was not a kid and was 95 years old. During an interview, the CNA stated she was assisting the resident with brief changes, called her "Nanay" and spoke to her in Tagalog in a nice way, and did not know the English meaning was stubborn. The CNA stated the resident became mad and that she immediately called the nurse on duty and did not return to the room. The Director of Staff Development stated staff are to call residents by their first or last name and that calling residents hardheaded or stubborn is not allowed. The facility policy on dignity stated residents are to be treated with dignity and respect at all times and staff are to speak respectfully to residents, including addressing them by their name of choice.
Staff Competency for Wander Guard Use
Penalty
Summary
The facility failed to ensure nurses and nurse aides were trained and competent in the use of Wander Management Transmitters for two residents who had physician orders for wander guards due to episodes of leaving the facility unassisted. Resident 7 had diagnoses including dementia and type 2 diabetes mellitus, and her care plan identified her as wandering and at risk for elopement. Resident 35 had diagnoses including CHF and schizophrenia, and his care plan also identified him as at risk for elopement. Both residents had orders to apply a wander guard to the right ankle and to check placement and functioning every shift. During observation and interview, LVN C stated the door would alarm when a resident got close to it and that nurses should check that the wander guard was intact, but she was unable to verify Resident 7’s device because the resident was asleep and covered by a blanket. LVN D stated he was pretty sure there was a way to check whether the wander guard was functioning, then checked Resident 35’s device and confirmed there was no light on it. The DON stated there was a device that lights up and is used as a tester to test whether the wander guard is functioning, and said nurses should know how to use it. The DSD was unable to find documentation of an inservice related to wander guard use and stated training of nurses regarding the device started on 1/9/26. The administrator later stated the testing device tested the function of the door alarm and that there was nothing to test the wander guard’s functioning, and the facility was unable to provide the manufacturer’s user manual for the transmitter.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for multiple residents. One resident with catatonic schizophrenia was observed in bed with a 1/3 left bed rail raised, and his record showed an active order for this bed rail to assist with bed mobility and transfers, but there was no corresponding comprehensive, person-centered care plan addressing the bed rail. Another resident with hemiplegia affecting the left dominant side had an order for 1/5 bilateral bed rails to assist with bed mobility and transfers every shift, yet her care plans did not include a comprehensive, person-centered care plan for the use of these bed rails. A third resident, under hospice care and dependent on supplemental oxygen at 2 L/min via nasal cannula for shortness of breath and comfort, had a care plan intervention directing staff to monitor and record oxygen saturation every shift, but there was no documentation that this monitoring and recording occurred as specified. A fourth resident, admitted in November, had no documented activity care plan from admission until an activity care plan was created in early January, despite facility policy requiring an activity evaluation as part of the comprehensive assessment to develop an activities plan reflecting the resident’s choices and interests. These findings were identified through observation, record review, and staff interviews, and were inconsistent with the facility’s policies on comprehensive person-centered care plans, oxygen administration, and activity evaluation.
Failure to Maintain Required Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that nurse staffing information was kept and maintained for at least 18 months when the direct care service hours per patient day (DHPPD) for 7/1/25 to 9/30/25 were not available and were not provided when requested. During interviews on 1/12/26, the DON and the administrator acknowledged that they did not have the DHPPD staffing data reports for that period to dispute the excessively low weekend staffing and one-star staffing rating shown in the CMS CASPER PBJ Staffing Data Report. The CMS CASPER PBJ Staffing Data Report for 7/1/25 to 9/30/25 showed excessively low weekend staffing and a one-star staffing rating. DHPPD staffing data reports later emailed on 1/14/26 showed low actual staffing and CNA DHPPD on 7/6/25, 7/12/25, and 8/30/25, and no DHPPD staffing data reports were provided for 9/21/25 to 9/30/25. The survey also cited CMS SOM Appendix PP guidance stating that the facility must maintain posted daily nurse staffing data for a minimum of 18 months, or longer if required by State law.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to timely notify a representative of the Office of the State Long-Term Care Ombudsman regarding the transfers of two residents. Resident 3 was transferred to the hospital for hypotension and desaturation, and there was no documentation that a notice was sent to the Ombudsman about the transfer. Resident 7 was transferred to the hospital for hyperglycemia and an altered level of consciousness, and there was also no documentation that a notice was sent to the Ombudsman regarding the transfer. During interview, the social services director stated that the notices for Residents 3 and 7 were not sent to the Ombudsman. The facility policy, Transfer or Discharge, Facility-Initiated, dated 10/2022, stated that notice of transfer is provided to the LTC ombudsman when practicable.
Activity assessments not updated quarterly for two residents
Penalty
Summary
The facility failed to ensure that resident assessments were reviewed and updated at least every 3 months for two sampled residents, specifically their activity assessments. Resident 12 was observed lying in bed, calm, comfortable, confused, and unable to answer questions. His admission record showed he was readmitted with a primary diagnosis of catatonic schizophrenia. Review of his assessments showed that his activity assessment had not been reviewed and updated quarterly and was last updated on 4/26/22. The ADON/IP, AD, and DON each confirmed that the activity assessment had not been updated quarterly and that assessments are expected to be updated every 3 months. Resident 40 was observed lying in bed, comfortable, alert, oriented, and able to answer questions. Her admission record showed she was admitted with a primary diagnosis of encounter for palliative care. Review of her assessments showed that her activity assessment had not been reviewed and updated quarterly and was last updated on 5/27/25. The AD confirmed that she had not been able to update the activity assessment quarterly and stated that activity assessment updates should be done every three months. The facility policy titled, Activity Evaluation, stated that an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect participation in planned activities.
Failure to Follow PASARR Mental Health Recommendations
Penalty
Summary
The facility failed to follow the recommendations in the PASARR Individualized Determination Report for Resident 39, who was admitted with diagnoses including schizophrenia and major depressive disorder. The resident’s physician orders showed staff were monitoring him for skin picking on his fingers, fidgeting, verbalization of sadness related to his health condition, difficulty sleeping, inappropriate sexual behavior, and rapid speech leading to exhaustion. The PASARR report dated 5/19/25 indicated the resident required Specialized Add-on Services for mental health needs and recommended Psychiatry consultation and/or follow-up care. There was no documentation that Resident 39 received a psych consult after the PASARR report and before the psych NP visit on 1/8/26. During interview, the social services director stated the psych NP was coming that afternoon in response to two abuse allegations involving the resident, and the social services note from that date indicated the resident told the psych NP he had a plan to harm another resident and was transferred to a psychiatric facility on a 5150 hold for emergency psychiatric evaluation and treatment. The DON stated there were no psych consults for Resident 39 after May 2025 and identified the 1/8/26 psych NP visit as the latest one.
Medication Given Despite Blood Pressure Hold Parameter
Penalty
Summary
The facility failed to ensure that Resident 53’s medication was administered according to the physician’s order when furosemide 40 mg was given despite a hold parameter for systolic blood pressure below 100 mmHg. During a medication pass observation, LVN A administered one tablet of furosemide 40 mg by mouth. Review of the resident’s order listing showed an active order for furosemide 40 mg twice daily for CHF with instructions to hold the medication if systolic blood pressure was below 100 mmHg. Review of the MAR showed that on 1/6/26 at 9:00 a.m., the resident received furosemide 40 mg even though the systolic blood pressure was 94 mmHg. During interview, LVN A acknowledged that the medication should not have been given because the blood pressure was 94 mmHg. The DON also verified that the medication parameter order should have been followed and that the furosemide should not have been administered at that time.
Infection Control Lapse During Medication Pass
Penalty
Summary
Infection control practices were not followed during medication administration for one resident when an LVN prepared medications with sanitized hands and then put on a new pair of gloves. After that, the LVN threw garbage into the garbage container attached to the side of the medication cart and touched the container with the gloved hand to fix it, but then proceeded to give the resident’s medications without removing the contaminated gloves, performing hand hygiene, and putting on a new pair of gloves first. During interview, the LVN acknowledged that she should have removed the dirty gloves, sanitized her hands, and put on a new pair of gloves before giving the medications and stated she would not do it next time. The DON also verified that the LVN should have observed proper infection control and should have removed the dirty gloves, sanitized her hands, and put on a new pair of gloves before giving the medications. The facility policy stated hand hygiene is the primary means to prevent the spread of infections and should be performed before preparing or handling medications, after contact with objects, and in the immediate vicinity of the resident.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that multiple resident rooms with two beds, including Rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 115, 116, 117, 118, 120, and 121, measured at least 80 square feet per resident. Surveyor observation, interview, and record review showed that these rooms all measured 69.51 square feet per resident, which was below the required minimum for multiple-occupancy rooms. The report stated that none of the rooms were observed to inhibit staff from providing care or residents from receiving adequate care, and that staff and residents moved freely in the rooms. Wheelchairs and walkers were easily accommodated, and residents and staff stated that the square footage of the rooms was not a concern.
Infection Control Deficiencies in Laundry, Kitchen, and Medication Storage
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several areas, as observed during a survey. In the laundry room, a cart with clean linens was left uncovered in a passageway where dirty linens were transported, posing a risk of contamination. Additionally, a laundry staff member did not sanitize a cart before placing clean linens inside, and a bucket of soiled linens was left uncovered near the washer. These actions were contrary to the facility's policy, which mandates that clean linens be stored separately from soiled ones and that linen carts be sanitized before use. In the kitchen, two out of three staff members were unable to correctly interpret sanitizer test strip readings, which are essential for ensuring the effectiveness of cleaning solutions. This lack of knowledge could compromise the sanitation of kitchen equipment and surfaces. Furthermore, cleaning chemicals were improperly stored in the emergency food storage area, which should only contain food items, according to the facility's policy. The medication storage room was found to have a silverfish bug and a disposable spoon in the sink, along with yellowish stains, indicating inadequate cleaning practices. The housekeeping supervisor confirmed that there was no proper log for cleaning the medication room, despite the facility's policy requiring nursing staff to maintain medication storage areas in a clean and sanitary manner. These deficiencies highlight lapses in the facility's adherence to its own infection control policies, potentially affecting the health and safety of the 48 residents.
Pest Control Deficiency in Social Services Office
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the observation of two live cockroaches in the social services office during a recertification survey. On October 24, 2024, at 2:30 p.m., a live cockroach was observed on the floor under the desk, and at 2:47 p.m., another live cockroach was seen on top of the desk. During a concurrent interview and record review on October 25, 2024, with the administrator, it was confirmed that the facility's policy and procedure titled 'Pest Control,' revised in May 2008, required the facility to be free of pests and rodents. The administrator acknowledged that an effective pest control program was necessary to ensure a pest-free environment.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 12.12%, exceeding the acceptable threshold of 5%. This was determined through observations, interviews, and record reviews involving four residents. For Resident 27, the nursing staff failed to administer the correct dose of Lamotrigine as ordered by the physician. The nurse administered 150 mg instead of the prescribed 225 mg twice a day. This discrepancy was confirmed by both the Director of Nursing and the Consultant Pharmacist, who verified the physician's order and the available stock doses. Resident 12 was administered Metformin without a meal, contrary to the physician's order which specified that the medication should be given with breakfast and dinner. The Registered Dietician confirmed the meal times, and the Director of Nursing verified the physician's order. The facility's policy also indicated that medications should be administered in accordance with the physician's order, which was not followed in this case. For Resident 46, the Lidocaine 5% patch was not administered as it was unavailable at the time of the scheduled dose. The Director of Nursing confirmed that the medication was not given as ordered. Additionally, Resident 154 did not receive the inhalation solution correctly, as the nurse failed to instruct the resident to close their lips around the inhaler mouthpiece, leading to improper administration. The Director of Nursing and facility policies outlined the correct procedure for administering inhaled medications, which was not adhered to in this instance.
Failure to Follow Recipe for Pureed Carrots
Penalty
Summary
The facility failed to ensure that the recipe for making vegetable puree was followed, specifically when the lead cook did not adhere to the recipe for carrot puree. During an observation, the lead cook was seen preparing vegetable puree using 48 ounces of carrots for 12 servings. The cook added 2 cups of milk before pureeing, which was not in accordance with the facility's recipe. The recipe specified that pureeing should occur on low speed to a paste consistency before adding any liquid, and only 1/4 cup to 3/4 cup of warm fluid should be added for 12 servings. The lead cook further added 1 cup of milk and food thickener after pureeing, which was also not in line with the recipe instructions. The registered dietitian confirmed that the lead cook should have followed the recipe for making the carrot puree. The facility's policy on food preparation emphasized that food should be prepared by methods that conserve nutritive value, flavor, and appearance, using approved and standardized recipes. This failure to follow the recipe had the potential to decrease the palatability of the food, which could lead to decreased food intake for the six residents on a puree consistency diet out of the facility's census of 48.
Improper Blood Sugar Check Conducted
Penalty
Summary
The facility failed to ensure care was provided in accordance with professional standards of quality for a resident when an unnecessary and improper blood sugar check was conducted. During an observation, an LVN cleaned the resident's finger with an alcohol swab and immediately pricked it, without allowing the alcohol to dry, which is against the facility's policy. This resulted in a potentially inaccurate blood sugar result and an additional painful finger prick. The LVN stated that he was following an order to check blood sugar at a specific time, but there was no specific physician order for this timing. The Director of Nursing confirmed that the alcohol should have been allowed to dry before the finger was pricked. The resident's physician orders indicated scheduled enteral feeds and insulin injections, but there was no specific order for a blood sugar check at the time it was performed. The facility's policy requires that the first drop of blood be discarded if alcohol is used, as it may alter results, and that medications be administered in a timely manner according to physician orders. The LVN's actions did not align with these policies, leading to the deficiency.
Inappropriate Feeding Assistance Provided to Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident, identified as Resident 8, by not adhering to the resident's feeding care plan. During a dining observation, a restorative nursing assistant (RNA) was seen totally assisting Resident 8 with feeding, rather than providing set-up help only. The RNA admitted to not checking the resident's feeding care plan before assisting him. This oversight was confirmed during an interview with the Infection Preventionist (IP), who noted that Resident 8 had specialized adaptive utensils designed to encourage self-feeding and should not have been fully assisted. A review of Resident 8's most recent minimum data set (MDS) indicated that the resident required set-up or clean-up assistance for eating, as coded in Section GG0130A. This discrepancy between the assessed needs and the assistance provided was acknowledged by the Director of Nursing (DON), who confirmed that the RNA did not provide the appropriate level of assistance. The failure to follow the care plan potentially impacted Resident 8's ability to maintain or achieve the highest level of self-care or independence in feeding.
Failure to Maintain Safe Equipment
Penalty
Summary
The facility failed to ensure that essential equipment was in safe operating condition for four residents when a commode with noticeable rust was found in their shared toilet. During an observation and interview, a Licensed Vocational Nurse (LVN) acknowledged that the commode should have been checked before being placed in the residents' toilet. The Maintenance Director/Environment Services Supervisor (EVSS) confirmed that there was no log to monitor commodes and stated that nurses, not the maintenance department, were responsible for maintaining the commode log. The Infection Preventionist (IP) verified that the Maintenance Log for October 2024 did not contain any request to replace the commode. The facility's policy and procedure indicated that the maintenance department is responsible for maintaining equipment in a safe and operable manner at all times.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that multiple resident rooms with two beds met the required minimum of 80 square feet per resident. Specifically, rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 115, 116, 117, 118, 120, and 121 were found to provide only 69.51 square feet per resident. Despite this deficiency, observations indicated that the room size did not inhibit staff from providing care or residents from receiving adequate care. Both staff and residents reported that the room size was not a concern, and mobility aids such as wheelchairs and walkers were easily accommodated within the space.
Failure to Monitor and Document Resident Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents, leading to potential safety and well-being compromises. Resident 2, who had a history of wandering and was at high risk for elopement, was not monitored appropriately after an incident on January 15, 2023, where they were found in another resident's bed. Despite having a wander guard, there was no documentation of monitoring Resident 2's whereabouts until another incident occurred on June 15, 2023, involving Resident 1. This lack of monitoring and documentation was confirmed by staff interviews and record reviews. Resident 1, who was admitted with multiple fractures and a history of falling, did not have their Admission Assessment completed in a timely manner. The assessment was only completed two days after admission, which was confirmed by the Director of Nursing and other staff members. This delay in completing the assessment could have impacted the care and safety measures needed for Resident 1, who was discharged shortly after the assessment was completed. Additionally, the facility failed to complete timely follow-up assessments and documentation for Resident 2 after the June 15, 2023 incident. The Alert Charting and interdisciplinary team notes were completed months after the incident, which was acknowledged by the Director of Nursing. The facility's policies on wandering, elopement, and documentation were not adhered to, as evidenced by missing documentation and late entries in the residents' records.
Lack of Social Services Support Following Resident Incidents
Penalty
Summary
The facility failed to provide appropriate social services support for two residents following an altercation and an abuse allegation. Resident 2, who has diagnoses including catatonic schizophrenia, major depressive disorder, and dementia, was involved in an altercation with Resident 3 after sleeping on Resident 3's bed. Despite the incident, there was no social services follow-up or support documented for either resident in the days following the altercation. Interviews with the Director of Nursing and the Administrator in Training confirmed the lack of social services intervention. Additionally, the facility did not provide social services support following an abuse allegation involving Resident 2 and Resident 1. Resident 1, who had recently undergone hip replacement surgery and had a history of major depressive disorder, reported that Resident 2 entered her room and sat on her bed, causing her distress. Despite Resident 1's anxiety and subsequent nightmares, there was no social services follow-up documented. The Social Service Director confirmed that planned interventions for Resident 2's behavior were not implemented, and she was unaware of these interventions. The facility also failed to provide social services support for Resident 1 after another incident where Resident 2 entered her room and sat on her bed. Resident 1, who was cognitively intact, expressed fear and requested discharge due to the lack of response to her distress. The facility had no social service personnel on site during the period of the incident, and the Administrator confirmed that there was no documented social services assessment for Resident 1's psychosocial well-being after the event.
Failure to Report Abuse Allegation Incident
Penalty
Summary
The facility failed to report an abuse allegation incident involving two residents. A female resident, who had been admitted following a left hip replacement surgery, was found in a situation where a male resident entered her room and sat on her bed. Despite the female resident expressing fear and distress, the incident was not reported to the authorities as required by the facility's policy. The Licensed Vocational Nurse (LVN) who was informed of the incident documented it but did not escalate it to the appropriate authorities. The facility's policy mandates immediate reporting of any suspected abuse, neglect, or exploitation to the administrator and relevant authorities. However, the incident was not reported, leaving public agencies unaware. Interviews with staff confirmed the failure to report, and the female resident expressed ongoing distress from the incident, requiring mental health therapy after her discharge. The facility's administrator acknowledged the oversight in reporting the incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 290 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Jose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Inspire Behavioral Health | 1.8 mi | ★★★★★ | 16 | 1 |
| Vista Manor Nursing Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Canyon Springs Post-acute | 2.2 mi | ★★★★★ | 1 | 0 |
| Mission De La Casa | 2.8 mi | ★★★★★ | 0 | 0 |
| San Jose Healthcare & Wellness Center | 4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Ridge Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.