Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Rehab & Skilled Nursing Center during CMS and state inspections, most recent first.
A resident had an order for lorazepam for generalized anxiety disorder and the MDS showed psychotropic medication use, but the care plan did not include any area for psychotropic or antianxiety medication. The DON confirmed the omission and stated that she and the Unit Manager were responsible for auditing care plans to ensure they reflected residents’ care and treatment.
A resident was not assessed for the safety of self-administering medications, and no physician's orders were obtained for this practice. The resident, with multiple health conditions, was found with a medication cup filled with pills on the bedside table. An LPN left the medications with the resident after being distracted, contrary to the facility's policy of supervising medication intake. The DON confirmed that the LPN should have ensured the resident took the medications or retrieved them if necessary.
The facility failed to provide written information to three residents regarding their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. Interviews revealed that these residents, with various medical conditions, did not receive the necessary documentation upon admission. The Social Services Director was unaware of the requirement to provide such information.
The facility failed to follow care plans for oxygen therapy for two residents, leading to incorrect oxygen flow rates. One resident received oxygen at rates not matching the physician's order, while another received oxygen without any physician order. The DON confirmed discrepancies in care plans and orders.
The facility failed to administer oxygen according to physician orders for two residents. One resident received oxygen without a documented order, while another received incorrect flow rates. The DON confirmed the discrepancies, and an LPN had not initially contacted the physician about the incorrect rates.
A facility failed to comply with its policy on PRN psychotropic medications by not setting a stop date for a resident's lorazepam prescription. Despite the resident being on hospice, the DON confirmed that all residents require a stop date for such medications. The oversight was acknowledged by the RN, who noted that hospice entered the orders, but the facility approved them without the necessary stop date.
Missing Care Plan for Psychotropic Medication Use
Penalty
Summary
Failure to develop a care plan for psychotropic/antianxiety medication use was identified for one resident, R19. The facility policy titled Care Plans stated that resident statuses and changes in needs would be reviewed timely, and the DON was responsible for ensuring care was provided in accordance with the care plan. R19’s MDS OBRA Quarterly Assessment dated 9/24/2025 showed psychotropic medications were administered and prescribed during the look-back period, and the physician’s orders dated 2/27/2025 included lorazepam 0.5 mg PO daily at bedtime for generalized anxiety disorder. Review of R19’s care plan showed no care plan area addressing psychotropic or antianxiety medication use. During interview, the DON confirmed that R19 did not have a care plan for psychotropic or antianxiety medications and stated that she and the Unit Manager were responsible for auditing care plans to ensure all care areas reflected residents’ care and treatment; she acknowledged the oversight was an error.
Failure to Assess and Secure Self-Administered Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for the safety of self-administering medications, did not obtain physician's orders for self-administration, and did not secure medications properly. The facility's policy requires that self-administered medications be monitored and recorded, with a physician's order specifying dosage, route, and instructions. The policy also mandates an assessment of the resident's competency to self-administer medications, which was not documented for the resident in question. The resident, who was newly admitted with conditions including spondylosis with myelopathy, type two diabetes mellitus, and dysthymic disorder, did not have a completed Minimum Data Set assessment or documented evaluation for self-administration of medications. During an observation, the resident was found with a medication cup filled with pills on the bedside table, which she identified as her morning medications. An LPN admitted to leaving the medications with the resident after being distracted, which is against the facility's normal practice of ensuring residents swallow their medications under supervision. The DON confirmed that the LPN should have either watched the resident take the medications or taken them back if an issue arose. This oversight had the potential to result in medication errors and unauthorized access to medications by other residents.
Failure to Provide Written Information on Medical Rights
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding their rights to accept or refuse medical or surgical treatment, as well as to formulate an advance directive. This deficiency was identified for three residents during a review of the facility's policies, admission packets, and interviews with residents and staff. The facility's policy, dated 1/1/2017, mandates that each resident with decision-making capacity has the right to make their own medical care decisions, including the right to refuse or alter treatment plans. However, the facility's Admission Packet lacked language about providing written information on these rights. Interviews with residents R437, R438, and R25 revealed that they were not provided with any written information regarding their rights to accept or refuse medical or surgical treatment upon admission. R437, who was newly admitted with chronic respiratory failure and other conditions, stated she had an advance directive but did not recall receiving any written information from the facility. Similarly, R438 and R25, both with significant medical histories, reported not receiving any written information about their rights. The Social Services Director, responsible for providing this information, admitted to being unaware of the requirement to provide consent forms for accepting or denying medical and surgical treatment.
Failure to Follow Oxygen Therapy Care Plans
Penalty
Summary
The facility failed to adhere to the care plan for oxygen therapy for two residents, R437 and R28, which resulted in the oxygen flow rate not being set according to the physician's order. For R437, the medical record indicated a diagnosis of chronic respiratory failure and a physician's order for oxygen at 2 liters per minute (LPM) via nasal cannula to maintain oxygen saturation above 90%. However, observations on multiple occasions revealed that the oxygen was administered at rates of 3 LPM and 2.5 LPM, which were not in accordance with the prescribed rate. The Director of Nursing confirmed that the oxygen settings were not as ordered and acknowledged that nurses should verify the oxygen rate upon starting their shifts. For R28, the resident was observed receiving oxygen at a rate of 2 LPM despite there being no physician orders for oxygen administration. The MDS Coordinator, responsible for completing care plans, stated that care plans were generic and did not specify oxygen rates due to time constraints in updating them with every order change. The Director of Nursing confirmed that the orders, care plan, and MDS did not align for R28, and the care plan lacked specificity for the resident's needs.
Oxygen Administration Not in Accordance with Physician Orders
Penalty
Summary
The facility failed to ensure oxygen was administered according to physician orders for two residents, R28 and R437, who were receiving oxygen therapy. For R28, there was no documented physician order for oxygen administration, yet the resident was observed receiving oxygen at 2 liters per minute (LPM) via nasal cannula. The Director of Nursing (DON) confirmed that there were no specified orders for oxygen for R28, despite the resident's diagnoses of chronic respiratory failure and congestive heart failure. For R437, the active orders included oxygen at 2 LPM via nasal cannula to maintain oxygen saturation above 90%. However, observations revealed that R437 was receiving oxygen at incorrect flow rates of 3 LPM and 2.5 LPM. The DON confirmed these flow rates were incorrect and that the oxygen order had not been increased. The Licensed Practical Nurse (LPN) involved had not initially contacted the physician regarding the oxygen rate, but later it was revealed that the physician was contacted and advised an increase, although this was not documented at the time.
Failure to Adhere to PRN Psychotropic Medication Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the use of psychotropic medications, specifically concerning the administration of PRN (as needed) orders for psychotropic drugs. The policy mandates that PRN orders for such medications are limited to 14 days unless the attending physician or prescribing practitioner documents a rationale for extending the order and specifies the duration. However, for one resident, identified as R25, the facility did not comply with this requirement. R25, who was admitted with diagnoses including dementia with behavioral disturbance, major depressive disorder with psychotic symptoms, and anxiety, was prescribed lorazepam, an antianxiety medication, with an indefinite end date, contrary to the policy. Interviews with facility staff, including an LPN and the DON, revealed a misunderstanding or misapplication of the policy. The LPN believed that because R25 was on hospice care, a stop date for the antianxiety medication was not necessary. However, the DON clarified that all residents, regardless of hospice status, require a stop or end date for PRN psychotropic medications. The RN confirmed that hospice entered the orders, but the facility was responsible for approving them, and acknowledged that the order for lorazepam should have included a stop date, which it did not.
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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) |
|---|---|---|---|---|
| Orchard View Rehabilitation & Skilled Nursing Ctr | 0.8 mi | ★★★★★ | 14 | 0 |
| Spring Harbor At Green Island | 2.6 mi | ★★★★★ | 9 | 0 |
| River Towne Center | 3.7 mi | ★★★★★ | 8 | 0 |
| Magnolia Manor Of Columbus Nursing Center - East | 4.9 mi | ★★★★★ | 12 | 0 |
| Magnolia Manor Of Columbus Nursing Center - West | 5 mi | ★★★★★ | 3 | 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 July 2026) and official state health department websites.