Below average — CMS composite of the measures below.
The next survey window likely opens around September 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 Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence on staff for dressing and hygiene was left in a heavily soiled shirt for several hours, despite multiple staff interactions and being present in common areas with other residents and visitors. Staff did not assist the resident with a clothing change, failing to uphold the resident's dignity.
Failure to Protect a Resident from Physical Abuse During Care: A resident with severe cognitive impairment, hospice status, and frailty sustained a displaced humerus fracture and a radius fracture after staff reported she was resistive during cares. Staff described the resident as usually not physically combative, while multiple nurses and the MD stated routine care should not have caused injuries of this severity and that the trauma required would have been dramatic. The resident was later sent to the ED, where imaging confirmed the fractures, and the facility's abuse policy stated residents have the right to be free from abuse and neglect.
Food was found improperly stored in the kitchen freezer with multiple opened, unlabeled, and undated items left exposed, including ice cream and other foods. In the 200 hall dining room, refrigerators and a microwave had dried food and spill residue, and no completed cleaning logs were produced. During meal service, dietary staff repeatedly handled ready-to-eat foods with gloved hands while touching counters, utensils, diet slips, and other surfaces without changing gloves or washing hands between tasks, despite the facility policy requiring clean hands and fresh gloves for food handling.
Failure to Carry Out QA Activities to Prevent Repeat Deficiencies: The facility had repeated CMS survey deficiencies involving QAPI, food sanitation, the QAA committee, and infection prevention & control. Prior survey findings were cited again on a later survey, and the DON stated the facility had worked on the previously cited deficiencies. The QAPI plan described oversight through a committee structure accountable to executive leadership, with the leadership team and QAPI Steering Committee responsible for planning and coordinating QAPI activities.
QAPI committee meetings lacked the required IP at 3 of 4 quarterly meetings. Review of QAPI sign-in sheets showed the IP was not present at multiple meetings, and the DON stated the prior ADON did not attend. The facility’s QAPI plan and key personnel list identified an IP as part of the program structure.
EBP was not used for two residents during direct care. One resident had ESRD, dialysis, and pressure ulcers, and staff provided incontinent care and transfer assistance without gowns and gloves despite an EBP sign and care plan direction. Another resident had a G-tube, and an RN performed tube feeding without EBP even though PPE was available and the room was posted for EBP. Staff interviews showed confusion about when EBP was required for wounds and indwelling devices.
Dialysis care was not provided as directed for a resident with ESRD and DM. Staff documented vital signs before and after dialysis, but the MAR, progress notes, and EHR lacked required dialysis access assessments for bleeding, bruit, and thrill. The resident said staff checked vitals but did not check the access site, and the RN, IP, and DON described dialysis assessment expectations that were not reflected in the documentation or policy.
The facility failed to assist three residents with eating in a dignified manner. A resident with severe cognitive impairment was fed by staff standing over her, contrary to expectations. Another resident, dependent on staff for eating, was left reclined and asleep during meals, receiving minimal assistance. A third resident was also left asleep in a reclined position before being fed by standing staff. Facility policies require meal assistance to ensure safety, comfort, and dignity.
A resident on anticoagulant therapy experienced a critical health event due to the facility's failure to hold warfarin administration despite high INR levels. The resident was found with bleeding and was hospitalized, revealing systemic communication and procedural lapses in managing medication orders and lab results.
The facility failed to maintain food at safe temperatures during meal service, with observed temperatures falling below the required 135 degrees F. Staff interviews revealed ongoing issues with outdated equipment and resident complaints, particularly from those receiving room trays.
The facility failed to follow standard food handling practices during meal service, as Staff B repeatedly used the same gloves for multiple tasks, risking cross-contamination. Despite the facility's policy requiring glove changes between tasks, Staff B handled food and touched various surfaces without changing gloves. Interviews confirmed the expectation for glove changes, which was not adhered to.
A resident with dementia and impaired balance was transported backwards in a Broda chair by a CNA, who held the resident's feet, violating the facility's dignity policy. Staff interviews confirmed the resident should face forward with foot pedals used during transport.
A facility failed to complete an Admission MDS assessment in a timely manner for a resident, with the assessment being completed nearly a month late. The MDS Coordinator confirmed the delay, and the Administrator acknowledged the absence of a policy addressing MDS completion.
The facility failed to complete quarterly MDS assessments on time for two residents. One resident's assessment was delayed due to waiting for other staff, while the other was delayed due to the MDS Coordinator's workload and lack of backup. The facility also lacked a policy for MDS completion.
The facility failed to submit a resident's MDS assessment within the required timeframe, resulting in a deficiency. The assessment, completed in early April, was not submitted until mid-May. The MDS Coordinator admitted to submitting assessments bi-weekly, and the facility lacked a policy for timely MDS submissions.
A resident's MDS assessment inaccurately documented the use of multiple medication classes, including antianxiety and opioids, when only anticoagulant medication was administered. The error occurred because the MDS Coordinator reviewed the wrong person's information. The facility lacked a policy to ensure MDS accuracy.
The facility failed to complete Baseline Care Plans within 48 hours for two newly admitted residents. One resident, cognitively intact, was admitted with heart failure and diabetes, while another, with moderate cognitive impairment, had atrial fibrillation and respiratory failure. Both lacked documented care plans addressing their needs. Interviews revealed confusion over responsibility for care plan completion, and the facility lacked a policy on Baseline Care Plans.
The facility failed to update care plans for two residents: one whose anticoagulant medication was discontinued and another who required a left hand brace. The care plan for the first resident still indicated anticoagulant therapy despite its discontinuation, while the second resident's care plan lacked instructions for the brace's application and removal. Staff interviews confirmed these oversights, highlighting a lapse in communication and documentation.
A facility failed to coordinate care with hospice services for a resident who was transferred to the hospital without notifying hospice staff. The resident, who was on hospice care, experienced a fall and was found with a head injury and low oxygen levels. Despite the resident's request to go to the hospital, hospice was not informed, which was against protocol. Interviews with staff revealed a lack of communication and the absence of a policy for hospice coordination.
The facility failed to effectively implement QA activities, resulting in the recurrence of deficiencies F550, F641, F657, F812, and F880. Despite staff education, these issues persisted, as noted in both the Recertification and Complaint Surveys. The facility's QA plan, revised in August 2024, includes monitoring and auditing procedures, but these measures did not prevent the recurrence of the cited deficiencies.
The facility failed to ensure proper PPE use and infection control during care for residents with COVID-19, tracheostomy, and wound care. Staff did not consistently use N95 masks, goggles, or change gloves as required, leading to deficiencies in infection prevention protocols.
The facility's QAA committee meetings did not include the required members, as the DON and Infection Preventionist were absent from the February meeting, and the Medical Director was absent from the July meeting. The facility's policy mandates these members' attendance, along with quarterly meetings.
The facility failed to document QAPI program education for an RN and three LPNs. A review of human resources files showed no evidence of such training, and the administrator confirmed the absence of a policy for QAPI training. The facility had 51 residents at the time.
A resident with severe cognitive impairment eloped from the facility, resulting in injuries from a fall. The door alarm was triggered, but staff failed to properly investigate or account for all residents, leading to a delay in recognizing the resident's absence. The resident was found hours later on a neighboring property. Staff interviews revealed inadequate response to the alarm and poor communication during shift changes.
The facility failed to provide appropriate urinary catheter care and adhere to infection control practices for two residents. A CNA and another staff member did not follow Enhanced Barrier Precautions, such as wearing gowns and changing gloves and washcloth surfaces during catheter care. These actions were inconsistent with the facility's policies, as confirmed by the DON.
A resident in an LTC facility was hospitalized due to symptoms of medication withdrawal after not receiving Ingrezza as prescribed. The facility changed pharmacies, and the new pharmacy overlooked the order, leading to a week-long lapse in medication administration. The resident experienced involuntary movements and was treated at the hospital. The DON was unaware of the issue until after the hospitalization.
Failure to Maintain Resident Dignity by Not Assisting with Clothing Change
Penalty
Summary
Staff failed to provide care that promoted a resident's dignity by not assisting a dependent resident to change out of a heavily soiled shirt, which the resident continued to wear throughout the day in the presence of other residents and visitors. The resident, who had severe cognitive impairment, non-Alzheimer's dementia, depression, hypertension, and was always incontinent of urine, required maximum assistance with dressing and personal hygiene. Observations showed the resident wearing a white T-shirt with multiple large and small brown stains on the chest area from early morning through the afternoon, despite being present in common areas and during meals with other residents and visitors. Multiple staff interactions occurred throughout the morning, including the use of mechanical stand lifts for incontinence care, but the resident remained in the same soiled clothing after each care episode. Staff interviews confirmed that the resident was cooperative with care and that staff were expected to assist with clothing changes as needed. Despite these expectations and the resident's dependence on staff for dressing and hygiene, the resident was not changed out of the soiled shirt for several hours.
Failure to Protect a Resident from Physical Abuse During Care
Penalty
Summary
The facility failed to provide a safe environment free from physical abuse for one resident, resulting in a displaced fracture of the lower end of the right humerus and a non-displaced fracture of the head of the right radius. The resident had multiple diagnoses including anemia, atrial fibrillation, coronary artery disease, hypertension, cerebrovascular accident, non-Alzheimer's dementia, and hospice status. Her MDS documented a BIMS score of 06, indicating severely impaired cognition, and her care plan identified cognitive impairment, calling out Mom/Dad, restlessness, agitation, and the need for one-person assistance with bed mobility and dressing, with instructions for staff to use caution during transfers and dressing to avoid striking her arms and hands on surfaces. On the morning of the incident, staff heard the resident crying out in pain while care was being provided. A CNA reported that the resident was combative and violently resisting cares, while another CNA stated the resident was half-dressed and screamed when her right arm was touched. The resident pointed at the CNA and said, "I don't want her in here, get her out!" Staff observed that the resident screamed whenever her right arm was lightly touched, and nursing documented swelling, distention, and a golf ball-sized lump protruding from the right arm. Hospice was contacted to reassess the resident, and imaging was delayed until the following day after hospice and family declined immediate x-ray. The resident was later sent to the emergency room, where imaging confirmed a significantly displaced fracture of the right humerus and a smaller fracture of the right radius. Multiple staff members stated they did not believe routine care could have caused a fracture of that severity, and several described the resident as frail and generally not physically resistive during care. The facility medical director stated the trauma required to fracture the arm would need to be dramatic and that the imaging was not consistent with a typical osteopenia fracture presentation. The DON stated standard nursing care should never result in a fracture of that magnitude, even with osteopenia or osteoporosis, and that the fracture could only have resulted from excessive force, which led to Staff Q being terminated. The facility abuse prevention policy defined neglect as failure to provide goods and services necessary to avoid physical harm and stated that all residents have the right to be free from abuse and neglect.
Improper Food Storage, Unsanitary Equipment, and Unsafe Food Handling
Penalty
Summary
Food was not stored properly in the main kitchen walk-in freezer during the initial tour. Observed items included a large bag of peas opened to air, several partially used ice cream containers with lids not secured and not dated, a partially used 5-gallon container of ice cream without a lid, and multiple other food items left open and not labeled or dated, including peach Danish, croissants, pizza dough, gluten free pizza crust, regular pizza crust, tilapia, and catfish. The Executive Chef stated that all food in the walk-in freezer should be dated once opened, bags should be sealed at all times, and ice cream should be covered. The facility policy directed staff to cover, label, and date unused portions and open packages. The refrigerators and microwave in the 200 hall dining room were observed with dried food and spill residue. One refrigerator had a brown dried substance on the inside door, dried purple substance on the first and second wire shelves and inside right side, and brown dried runs and liquid spills on the front. The microwave had dried brownish orange substance on the glass plate, smears on the handle and door, and run marks across the bottom of the front door. A second refrigerator had orange substance in the bottom below the shelf and dirt on the bottom seal. These conditions were unchanged on the next observation, and the facility did not produce completed cleaning logs. Staff stated the refrigerators and microwaves were supposed to be cleaned after every shift, but the DON stated she was not sure who was responsible for cleaning some unit refrigerators and that the microwaves should be cleaned by dietary. During meal service observations in multiple dining rooms, dietary staff handled food with gloved hands while touching counters, cabinets, utensils, diet slips, and other surfaces without changing gloves or washing hands between tasks. Staff were observed picking up and cutting food such as eggrolls, French toast, sweet potatoes, cold turkey sandwiches, and cookies while continuing to touch other items and surfaces. One dietary aide also wiped her face with her shirt during service and continued plating food without changing gloves or washing hands. Staff interviews confirmed that the expectation was to wash hands and use fresh gloves when handling food, and the facility policy stated gloves are to be worn for ready-to-eat foods, changed between tasks or if punctured or ripped, and hands washed after gloves are removed.
Failure to Carry Out QA Activities to Prevent Repeat Deficiencies
Penalty
Summary
The facility failed to carry out QA activities to prevent reoccurrence of deficiencies after prior CMS survey findings. Review of the CMS 2567 report dated 9/26/24 showed deficiencies related to F0865 (QAPI Program/Plan, Disclosure/Good Faith Attempt) at a D, F0812 Food Procurement, Store/Prepare/Serve-Sanitary, F0868 QAA Committee, and F0880 Infection Prevention & Control. A subsequent survey dated 10/2/25 again identified deficiencies related to F0865 at a D, F0812 Food Procurement, Store/Prepare/Serve-Sanitary, F0868 QAA Committee, and F0880 Infection Prevention & Control. On 10/02/2025 at 12:49 PM, the DON reported the facility worked on the previously cited deficiencies. The facility also provided a QAPI Plan dated 8/25/17 stating that oversight of the QAPI program is provided through a committee structure accountable to executive leadership, and that the leadership team and QAPI Steering Committee are responsible for planning, designing, implementing, and coordinating consumer care and service and selecting QAPI activities to meet the needs of residents and families.
QAPI Committee Lacked Required Infection Preventionist Attendance
Penalty
Summary
The facility lacked the required Infection Preventionist at 3 of 4 quarterly Quality Assurance and Performance Improvement meetings. Based on staff interviews, facility sign-in sheets, and facility policy, the QAPI quarterly sign-in sheets dated 1/22/25, 4/23/25, and 7/23/25 did not show the IP in attendance. The facility reported a census of 55 residents. On 10/02/2025 at 12:49 PM, the DON stated that Staff A, the prior ADON, failed to attend the meetings. The facility’s QAPI Plan dated 8/25/17 stated that oversight of the QAPI program is provided through a committee structure accountable to Executive Leadership, and that the leadership team and QAPI Steering Committee are responsible for planning, designing, implementing, and coordinating consumer care and service and selecting QAPI activities to meet the needs of residents and families. The facility also provided a Key Personal list that included an IP.
Failure to Use Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Enhanced Barrier Precautions were not implemented for Resident #11, who had diagnoses including dependence on renal dialysis, end-stage renal disease, and diabetes mellitus, and whose care plan directed EBP for the duration of the stay or until the wound resolved or the indwelling medical device was discontinued. The resident also had a pressure ulcer to the right foot and left foot, with a progress note documenting a left heel pressure ulcer measuring 0.5 cm by 0.4 cm by 0.1 cm. On 9/29/2025, the resident's room door did not display an EBP sign, and two CNAs provided incontinent care and transferred the resident to a recliner without wearing EBP. The resident stated that staff who provided care did not wear EBP. Staff interviews showed conflicting understanding of when EBP was required, including whether dialysis or a wound required it, while the facility policy stated EBP was to be used for residents with wounds or indwelling medical devices during high-contact care activities. Enhanced Barrier Precautions were also not implemented for Resident #2, whose quarterly MDS documented anxiety, malnutrition, and an abdominal feeding tube, and whose care plan directed EBP for the duration of the stay or until the feeding tube was removed. During direct observation, an RN performed tube feeding without using EBP even though PPE was available outside the room and a sign instructed staff to wear EBP. The resident stated staff never wore gowns during care and was unsure what EBP was. Staff interviews reflected uncertainty about whether EBP was required for a feeding tube, while another RN stated that all indwelling medical devices and open wounds required EBP during in-room care. The DON stated the RN should have worn EBP as directed by the care plan and room posting.
Dialysis Access Assessments Not Completed
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required dialysis. Resident #11 had diagnoses including dependence on renal dialysis, end-stage renal disease, and diabetes mellitus, and the care plan directed staff to monitor, document, and report signs or symptoms of infection at the access site, as well as bleeding, hemorrhage, bacteremia, and septic shock. However, the Medication Administration Record directed vital signs before and after dialysis but did not direct nursing staff to assess the left arm for bleeding or to check for bruit and thrill, and the progress notes for the month reviewed lacked documentation of left arm assessment for bleeding or bruit and thrill. The electronic health record assessments from the reviewed period also lacked dialysis assessments. The resident stated that staff checked vital signs but did not check the dialysis site for bleeding and did not feel for thrill or listen for bruit. An RN stated dialysis assessments include listening to thrill and completing assessments before and after vital signs, and said the assessments were under dialysis notes in the EHR. The IP stated dialysis assessment is for staff to check and make sure the resident is not bleeding, and the DON stated the dialysis process needed work and that nursing needed to check the resident when she returned from dialysis. The facility policy titled End-Stage Renal Disease, Care of Resident with did not direct assessment of the access site.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to ensure that three residents were assisted to eat in a dignified manner, as observed during meal services. Resident #5, who had severe cognitive impairment and was dependent on staff for eating, was observed being fed by staff who stood over her rather than sitting next to her, as expected by the Director of Nursing. This occurred during both lunch and breakfast meals, where staff alternated in feeding the resident without maintaining a consistent presence or interaction. Resident #6, diagnosed with Alzheimer's disease and severe cognitive impairment, was also dependent on staff for eating. During observations, the resident was left reclined and asleep in a Broda Chair while meals were served to others. Staff attempted to wake the resident and repositioned her, but she remained largely unattended and asleep, consuming very little of her meal. Resident #8, with similar diagnoses and total dependence on staff for eating, was observed asleep in a reclined position in a Broda Chair during a lunch meal. The meal was left uncovered for a period before staff repositioned the resident and fed her while standing. The facility's policies required that residents receive meal assistance in a manner that ensures safety, comfort, and dignity, which includes not standing over residents while assisting them with meals.
Failure to Manage Anticoagulant Therapy Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to appropriately manage the administration of warfarin, an anticoagulant medication, for a resident, leading to a significant health risk. The resident, who was on anticoagulant therapy due to a cardiac arrhythmia, had an International Normalized Ratio (INR) of 7.8, which was significantly higher than the standard therapeutic range. Despite receiving orders to hold the medication on specific days, the resident was administered warfarin on those days, resulting in an even higher INR of 9.3. This oversight in medication management was a critical error, as the resident was at increased risk for bleeding. The resident was subsequently found with blood on their arms and legs, indicating bleeding complications, and was sent to the hospital. At the hospital, the resident's INR was recorded at 8.2, and they were treated with Vitamin K, an antidote for warfarin overdose. The resident's hemoglobin levels were also low, further indicating the severity of the bleeding. The facility's failure to adhere to the prescribed medication orders and monitor the resident's condition effectively led to this immediate jeopardy situation. Interviews with staff revealed communication and procedural lapses. The nurse responsible for holding the medication did not have adequate access to the electronic health record system to document and manage lab results and medication orders properly. Additionally, there was a lack of timely communication and coordination between the facility and the anticoagulation clinic managing the resident's warfarin therapy. These systemic issues contributed to the failure in managing the resident's medication regimen safely.
Removal Plan
- The identified resident's Coumadin/warfarin was discontinued
- All other residents with Coumadin/warfarin orders were reviewed for accuracy
- Implemented new procedure regarding Coumadin/warfarin administration
- Enter Coumadin/warfarin order into Electronic Health Record
- Nurse will document order on Coumadin/warfarin log located at each station
- DON/Designee will check all new Coumadin/warfarin orders and the log to ensure dosing and follow-up labs are entered as ordered on the log and in Electronic Health Record
- The Nurse who took the order to hold Coumadin/warfarin is no longer employed at the facility
- All nurses will be educated on the new procedure. Additionally, all nurses will be educated on how to properly enter orders in Electronic Health Records
- New employees and agency staff will be trained on how to complete this procedure including entering orders in Electronic Health Records during their orientation
- Audit tool implemented to ensure nurses are administering Coumadin/warfarin according to physician orders
- Audits will be completed weekly for one month and then monthly ongoing as needed
- The audit results will be brought to the Quarterly QA meeting
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain food at a safe and appetizing temperature during meal service, as observed during a survey. On 9/24/24, temperatures of pureed lasagna and ground meat were recorded at 148.4 degrees F and 153.6 degrees F, respectively, before meal service. However, by the end of the meal service, these temperatures had dropped to 127 degrees F and 130 degrees F. Additionally, a test tray revealed that beans and potato wedges were served at 120.1 degrees F and 114.4 degrees F, respectively, which were described as lukewarm by the State Agency. The facility's policy requires hot food to be held at 135 degrees F or higher, indicating a failure to adhere to these guidelines. Interviews with staff revealed ongoing issues with maintaining appropriate food temperatures. Staff B, a cook, acknowledged past problems with keeping food at required temperatures, attributing some issues to the lack of a heat lamp on the steam table. The Director of Dining Services also confirmed occasional problems with food temperatures and noted that both the steam table and warmers were outdated and scheduled for replacement. Resident complaints about food temperatures were reported, particularly from those receiving room trays, which comprised 40 to 50% of the meals served. Despite these issues, the last resident complaint at a council meeting was reported to have occurred months ago.
Failure to Follow Food Handling Practices
Penalty
Summary
The facility failed to adhere to standard food handling practices during meal service, as observed on 9/24/24. Staff B, while wearing gloves, repeatedly engaged in actions that could lead to cross-contamination. At 11:44 AM, Staff B picked up a bun with gloved hands, touched the edge of a tray, and then handled the bun again without changing gloves. At 11:47 AM, after performing hand hygiene and changing gloves, Staff B touched a tray, picked up a phone, and then handled another plate and bun without changing gloves. At 12:07 PM, Staff B touched multiple surfaces with gloved hands, handled bread, opened a can of soup, and used the microwave, all without changing gloves. Interviews with Staff B and the Director of Dining Services revealed an expectation for gloves to be changed when switching tasks or touching surfaces, which was not followed. The facility's policy, revised in January 2024, requires gloves to be changed between tasks when handling ready-to-eat foods.
Resident Dignity Compromised During Transport
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified manner, as observed during a survey. The resident, who has a self-care performance deficit related to dementia and impaired balance, was seen being transported backwards down a hallway in a Broda chair by a CNA. The CNA was holding the resident's feet while moving the chair rapidly, which is against the facility's policy for resident dignity and proper transport procedures. Interviews with staff, including a CNA and the Assistant Director of Nursing, confirmed that the resident should have been facing forward and that foot pedals should have been used during transport. The facility's policy on dignity, revised in 2021, emphasizes that residents should be treated with dignity and respect at all times, which was not adhered to in this instance.
Delayed MDS Assessment Completion
Penalty
Summary
The facility failed to ensure the timely completion of an Admission Minimum Data Set (MDS) assessment for a resident. The resident was admitted to the facility on January 16, 2024, and the MDS assessment, which should have been completed in a timely manner, was not completed until February 16, 2024. This delay was confirmed by the MDS Coordinator. Additionally, upon request for a facility policy addressing MDS completion, the Administrator explained that the facility did not have such a policy in place.
Failure to Timely Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of quarterly Minimum Data Set (MDS) assessments for two residents. Resident #13's quarterly MDS assessment, with an Assessment Reference Date (ARD) of June 25, 2024, was completed on July 11, 2024. Similarly, Resident #38's quarterly MDS assessment, with an ARD of April 23, 2024, was completed on May 9, 2024. During an interview, the MDS Coordinator acknowledged issues with completing quarterly assessments on time, citing delays due to waiting for other staff to complete their sections and personal workload without a backup. Additionally, the facility lacked a policy to address MDS completion, as confirmed by the Administrator.
Failure to Submit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely submission of Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. Specifically, the Quarterly MDS assessment for a resident with an Assessment Reference Date (ARD) of April 2, 2024, was completed on April 16, 2024, but was not submitted until May 16, 2024. During an interview on September 26, 2024, the MDS Coordinator admitted that submissions were made every other week on Friday and acknowledged the late submission of this resident's MDS. Furthermore, the facility lacked a policy addressing the timely submission of MDS assessments, as confirmed by the Administrator via email on April 26, 2024.
Inaccurate MDS Medication Coding for a Resident
Penalty
Summary
The facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) assessment for a resident reviewed for unnecessary medications. The resident, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status (BIMS) exam, was inaccurately documented as taking antianxiety, opioid, and antiplatelet medications, in addition to the anticoagulant medication they were actually taking. This discrepancy was discovered through a review of the resident's Medication Administration Record (MAR), which showed that the resident only took anticoagulant medication. The MDS Coordinator admitted to looking at the wrong person, which led to the error. Additionally, the facility did not have a policy in place to address MDS accuracy, as confirmed by the Administrator.
Failure to Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to complete a Baseline Care Plan within 48 hours of admission for two newly admitted residents. Resident #32, who was cognitively intact with a BIMS score of 13, was admitted with diagnoses including acute chronic systolic heart failure and type 2 diabetes mellitus. The Clinical Admission Assessment for this resident did not identify Focus Areas, Goals, or Interventions for their risk factors, diagnoses, or care needs. Interviews revealed a lack of clarity regarding responsibility for completing the Baseline Care Plan, with the MDS Coordinator and admitting nurse each assuming the other was responsible. Similarly, Resident #53, who had a moderate cognitive impairment with a BIMS score of 9, was admitted with diagnoses including atrial fibrillation, coronary artery disease, and respiratory failure. The Skilled Evaluation for this resident also lacked identification of Focus Areas, Goals, or Interventions. The Director of Nursing expected the nurses caring for the resident in the first 48 hours to develop the Baseline Care Plan, but this was not done. The facility did not have a policy on Baseline Care Plans, contributing to the oversight.
Care Plan Deficiencies in Medication and Equipment Updates
Penalty
Summary
The facility failed to update the care plan for a resident following the discontinuation of anticoagulant medication. The resident, who had intact cognition, was noted in the Minimum Data Set (MDS) assessment to not be taking anticoagulant medication. However, the care plan, last revised several months prior, still indicated that the resident was on anticoagulant therapy. The MDS Coordinator acknowledged the oversight and noted that the care plan should have been revised to reflect the discontinuation of the medication. The Director of Nursing (DON) confirmed that care plans should be revised whenever there is a change in the resident's condition or treatment. Another deficiency was identified when the facility failed to update the care plan for a resident who required a left hand brace. The resident, who was cognitively intact, had a physician's order for an occupational therapy evaluation for a left hand brace. However, the care plan did not include instructions for the application and removal of the brace. Staff interviews revealed that the brace was to be applied in the morning and removed at night, but this information was not documented in the care plan. The DON stated that any nurse could update the care plan, but it appeared that the MDS Coordinator had not been informed of the order for the brace.
Failure to Coordinate Care with Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination of care between its staff and hospice staff for a resident receiving hospice services. The resident, who had intact cognition, was admitted to hospice care but the facility's electronic health record lacked an order for this admission. An incident occurred where the resident was found on the floor with a head injury and low oxygen saturation. Despite the resident's request to be evaluated at the hospital, hospice staff were not notified of the transfer, which was a breach of protocol. Interviews with facility staff, including the Hospice Case Manager and the Director of Nursing, revealed a lack of communication and coordination with hospice services. The Hospice Case Manager acknowledged that the resident had been sent to the hospital without hospice being informed, which was against the expected procedure. The Director of Nursing confirmed that hospice should have been notified in such situations, and admitted that there was a lapse in communication. The facility did not have a policy in place to address hospice coordination, which contributed to the deficiency.
Recurrent Deficiencies in QA Activities
Penalty
Summary
The facility failed to carry out Quality Assurance (QA) activities effectively, leading to the recurrence of deficiencies identified in both the Recertification Survey and Complaint Survey. The deficiencies cited include F550, F641, F657, F812, and F880. Despite the staff being educated on these issues, the problems persisted, as confirmed by the Administrator during an interview. The facility's Quality Assurance Process Improvement Plan, revised in August 2024, outlines procedures for monitoring adherence to quality standards and performing audits to ensure compliance with clinical and administrative policies. However, the plan's implementation did not prevent the recurrence of the cited deficiencies.
Inadequate PPE Use and Infection Control in Resident Care
Penalty
Summary
The facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when providing care to residents with specific health conditions, including COVID-19, a tracheostomy, and wound care. For Resident #257, who had moderate cognitive impairment and was diagnosed with COVID-19, staff did not consistently use N95 masks or goggles as required. Observations showed that staff entered the resident's room without the necessary PPE, such as N95 masks and goggles, despite the availability of these items outside the room. Interviews with staff revealed a lack of understanding and adherence to the facility's PPE protocols for COVID-19 isolation. For Resident #15, who had a tracheostomy and required respiratory treatments, the facility's staff did not follow proper infection control procedures during tracheostomy care. Staff F, a Registered Nurse, failed to change gloves and perform hand hygiene after removing a soiled dressing before applying a new one. This was contrary to the facility's expectations and infection control policies, which required changing gloves and performing hand hygiene between dressing changes. Resident #53, who had a lesion on her back and required wound care, was not placed under Enhanced Barrier Precautions as needed. During wound care, Staff F did not wear an isolation gown and failed to change gloves after cleansing the wound before applying new dressings. The facility's policy required the use of gowns and gloves during wound care to prevent the transfer of Multi-Drug Resistant Organisms (MDRO). The Director of Nursing confirmed that Enhanced Barrier Precautions should have been in place for residents with certain conditions, including wounds.
QAA Committee Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee meetings included the minimum required members, as specified in their policy. A review of the QAA sign-in sheets revealed that during the February 2024 meeting, both the Director of Nursing (DON) and the Infection Preventionist were absent. Additionally, the Medical Director or an appointed designee did not attend the July 2024 meeting. The facility's policy, revised in March 2020, mandates that the QAA committee should include the Administrator or a designee, the DON, the Medical Director, the Infection Preventionist, and representatives from various departments as needed. The policy also requires the committee to meet at least quarterly. The Administrator confirmed these absences during an interview conducted in September 2024.
Lack of QAPI Training Documentation for Nursing Staff
Penalty
Summary
The facility failed to document nursing education on the Quality Assurance and Performance Improvement (QAPI) program for four staff members, including one RN and three LPNs. A review of the human resources files revealed that there was no documentation indicating these nurses received education on the QAPI program. The facility's administrator confirmed that while the staff had been trained, the QAPI program was not included in their training. Additionally, during an interview, the administrator admitted that the facility did not have a policy in place for training staff on the QAPI program. The facility reported a census of 51 residents at the time of the survey.
Failure to Prevent Resident Elopement and Injury
Penalty
Summary
The facility failed to identify and respond to an elopement incident involving a resident with severe cognitive impairment and a history of non-Alzheimer's dementia. The resident, who was independently mobile but required supervision for safety, eloped from the facility during the early morning hours. The door alarm was triggered, but staff did not adequately assess the situation or account for all residents, leading to a delay in recognizing the resident's absence. The resident was discovered several hours later on a neighboring property, having sustained injuries from a fall. The facility's records indicated that the resident was wearing a WanderGuard bracelet, which should have activated the door alarm system. However, staff failed to check the placement and functionality of the bracelet on the night of the incident, and the door alarm was not properly investigated when it sounded. Interviews with staff revealed a lack of proper response to the door alarm and inadequate shift-to-shift communication regarding the resident's whereabouts. The facility's policy on wandering and elopement was not followed, as staff did not conduct a thorough search or initiate the missing resident emergency procedure promptly. The incident highlighted deficiencies in staff training and adherence to safety protocols, which contributed to the resident's elopement and subsequent injuries.
Failure to Follow Catheter Care and Infection Control Protocols
Penalty
Summary
The facility failed to provide appropriate urinary catheter care and did not adhere to standard infection control practices during observations of catheter care for two residents. Resident #5, who had diagnoses including anxiety and generalized weakness, required extensive staff support for daily activities and used a urinary catheter. During an observation, a CNA did not follow Enhanced Barrier Precautions, as they entered the resident's room without a gown, used the same gloves throughout the procedure, and did not change the surface of the washcloth with each pass, contrary to the facility's urinary catheter care policy. Resident #7, diagnosed with obstructive uropathy and non-Alzheimer's dementia, also required moderate staff assistance and used a urinary catheter. During the observation, there was no Enhanced Barrier Precaution sign or isolation cart near the resident's room. Staff L did not wear a gown, used the same gloves throughout the procedure, and failed to change the surface of the washcloth with each pass, which was inconsistent with the facility's policy. The Director of Nursing later confirmed that staff should follow Enhanced Barrier Precautions and change gloves and washcloth surfaces as needed. Both observations revealed a lack of adherence to the facility's policies for catheter care and Enhanced Barrier Precautions, which are critical for preventing infections and ensuring resident safety. The facility's failure to implement these protocols during high-contact resident care activities, such as catheter care, was evident in the actions of the staff involved.
Medication Administration Failure Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, resulting in the resident's transfer to a hospital emergency department for treatment of symptoms associated with medication withdrawal. The resident, who had diagnoses including anxiety and bipolar disorder, was prescribed Chlorpromazine and Ingrezza. The facility's records showed that Ingrezza was not administered on several days in May 2024. The resident experienced involuntary head movements, a symptom of tardive dyskinesia, which was relieved by medication administered at the hospital. The deficiency occurred due to a change in the facility's pharmacy on May 1, 2024, which led to the oversight of the resident's Ingrezza order. Despite daily requests from the nursing staff, the pharmacy did not send the medication due to its cost and the need for special authorization. The Director of Nursing was not informed of the issue until after the resident was sent to the hospital. The resident's Power of Attorney was notified of the situation and expressed upset over the oversight, which resulted in the resident not receiving the medication for seven days.
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 171 citations issued within 25 miles in the last 12 months — including the 7 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 Davenport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Davenport Lutheran Home | 0.9 mi | ★★★★★ | 10 | 0 |
| Ivy At Davenport | 1.7 mi | ★★★★★ | 26 | 2 |
| Harmony Davenport | 2 mi | ★★★★★ | 14 | 0 |
| Kahl Home For The Aged & Infirmed | 2.8 mi | ★★★★★ | 9 | 0 |
| Harmony Utica Ridge | 3.2 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ridgecrest Village.
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 July 2026) and official state health department websites.