Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Vista Center At The Ridge during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was admitted with a DNRCC order, but during a medical emergency, an LPN found no Advance Directive information in the electronic record and a Full Code indicator in the physical chart, leading to the initiation of CPR. The DNRCC order had been signed and placed in the chart after a care conference, but no physician's order was entered and the code status was not updated in the system, resulting in the resident's wishes not being honored.
Surveyors found that the facility did not maintain a clean and sanitary environment, with multiple residents affected by unclean rooms, overflowing trash, food debris, stained linens, soiled bathroom fixtures, and pest presence. Staff interviews and cleaning schedules confirmed that housekeeping was not performed daily, and some staff used personal supplies to address ongoing messes, contrary to facility policy.
A resident with multiple medical conditions was discharged to a hotel without being provided a 30-day discharge notice or comprehensive discharge planning. The facility did not notify the Ombudsman or document coordination of discharge services, and there was no evidence the resident agreed to the discharge plan or was assisted in securing safe housing beyond a hotel arrangement.
The facility failed to label and date food items in the kitchen, potentially affecting 143 residents. During a kitchen tour, several undated and unlabeled items were found in the refrigerators, including a pork loin, hard-boiled eggs, ham, a Chef salad, and an unidentified substance. A staff member confirmed the items were unlabeled and undated, and the facility's policy requires all foods to be labeled and monitored.
The facility failed to document the offering and education of the COVID-19 vaccine to staff, affecting all 144 residents. Personnel records lacked documentation for several CNAs and an LPN, except for newly hired staff. Interviews confirmed the oversight, despite the facility's policy requiring such documentation.
Staff at the facility failed to adhere to PPE protocols during care for several residents, including those with indwelling devices and on droplet precautions. CNAs and RNs did not wear gowns or eye protection as required by Enhanced Barrier Precautions and droplet precautions, despite signage indicating the need for such measures. This non-compliance was observed across multiple residents, including those with tube feedings, urinary catheters, and intravenous therapy.
The facility failed to maintain a clean and safe environment, affecting residents and common areas. Furniture in the 200-hall was soiled and damaged, and Resident #63's room had persistent urine issues with no effective interventions. Resident #23's wheelchair was dirty, and the facility lacked a cleaning policy. The laundry room had excessive dust and debris, with unclear cleaning responsibilities. These deficiencies were confirmed by staff interviews and observations.
A facility failed to accurately document a resident's urinary catheter status. The resident was noted to have an indwelling catheter in the MDS assessment, but subsequent records and interviews indicated otherwise. Observations showed no catheter present, and staff confirmed its absence upon admission. The DON acknowledged the documentation inconsistencies.
A resident with chronic vascular ulcers did not have their daily wound dressing changes documented as completed on multiple occasions. Despite the presence of a nurse practitioner on some days, the facility failed to ensure proper documentation and adherence to treatment orders, affecting the resident's care.
Two residents in a LTC facility were found to have inadequate incontinence care and toileting assistance. One resident was left in a room with a strong urine odor and wet clothing, while another had multiple urine puddles and stained tiles in his room. Despite care plans requiring assistance, staff failed to provide timely care, and no toileting program was in place for the resident on diuretic therapy. Staff interviews confirmed the issues, and the facility's incontinence care policy was not followed.
The facility failed to follow its weight monitoring policy for two residents, resulting in unreported significant weight loss and missed weekly weigh-ins. One resident lost 8.7% of their weight in 30 days without physician notification or reweighing, while another resident's weekly weights were not recorded as ordered. These lapses were confirmed by the RD, indicating a breach in protocol.
A facility failed to administer oxygen as ordered and did not change the oxygen tubing weekly for a resident with COPD. The resident's oxygen was set at four liters per minute instead of the ordered three liters, and the tubing had not been changed since 01/23/25. An LPN confirmed these discrepancies, which affected the resident and potentially impacted four other residents receiving oxygen therapy.
The facility failed to complete accurate pre and post dialysis assessments for two residents requiring dialysis. One resident, moderately cognitively impaired, and another, cognitively intact, both had multiple instances of missing or incomplete assessments. Despite care plans requiring monitoring and communication with dialysis staff, these were not consistently documented, as confirmed by an LPN aware of the inconsistencies.
A facility failed to provide a trauma-informed care plan for a resident with PTSD, lacking documentation of triggers and interventions. Despite the facility's policy, staff were unaware of the resident's trauma history, and the care plan did not reflect necessary measures to prevent re-traumatization.
A facility failed to ensure pharmacist recommendations for a resident's medications were addressed by the physician. The resident, with multiple health conditions, was on Lasix and Hydroxyzine. The pharmacist recommended monitoring Lasix side effects and discontinuing Hydroxyzine, but the physician did not document actions or rationale, contrary to facility policy.
The facility failed to secure medications, affecting three residents. A resident with moderate cognitive impairment had multiple oral medications unsecured in their room. Another resident, cognitively intact, had unsecured nasal sprays and ophthalmic solutions. A third resident had unsecured nasal sprays on their bedside table. No orders or assessments for self-administration were present.
A facility failed to administer pneumococcal and Covid-19 vaccines to a resident with multiple health conditions, despite the resident's signed request for these vaccinations. The resident's medical record showed no provider orders for the vaccines, and the MDS assessment indicated the pneumococcal vaccine was not offered. An interview confirmed the resident had not received the Covid-19 vaccine, contrary to facility policy requiring vaccines to be offered upon admission.
A resident with dementia and Alzheimer's disease, assessed as high risk for falls, experienced multiple falls due to the facility's failure to implement physician-ordered interventions. Despite orders to keep a walker within reach and use a wheelchair, the resident was often found without these aids. Staff interviews revealed a lack of awareness and adherence to the care plan, leading to repeated falls and injuries.
The facility failed to ensure an effective pest control program, affecting 122 residents who eat meals from the kitchen. A resident reported flying ants, and a kitchen aide confirmed gnats in the kitchen despite using a green liquid in the mop water. Observations confirmed gnats around the food cart, dishwasher, and sink area. The maintenance director acknowledged the issue. The facility's Pest Control policy was not effectively implemented.
Failure to Honor and Document Resident's Advance Directive Code Status
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive and code status were accurately documented and honored. The resident, who was severely cognitively impaired and had diagnoses including diabetes, dementia, muscle weakness, depression, and breast cancer, was admitted with a Do Not Resuscitate; Comfort Care (DNRCC) order according to her wishes and those of her son, who was her Power of Attorney. However, during a medical emergency when the resident was found unresponsive, the LPN checked the electronic record and found no information regarding Advance Directives. Upon reviewing the physical chart, the LPN found a yellow sheet indicating Full Code status and initiated CPR, also calling emergency services. The resident's son was notified and arrived after the resident had expired. It was only discovered days later that the resident was actually a DNRCC at the time of the incident. Further review revealed that after a care conference with the resident's son, the Social Service Designee faxed the DNRCC form to the nurse practitioner, who signed and placed it in the physical chart. The Social Service Designee also notified an RN to update the order, but there was no physician's order for the DNRCC in the resident's chart, nor was the code status updated in the electronic record. The facility's policy required that residents' Advance Directive wishes be honored and documented, with appropriate physician orders written for those choosing Advance Directives. This failure to accurately document and communicate the resident's code status led to the initiation of CPR against the resident's documented wishes.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for residents on the 400 unit, as evidenced by multiple observations and record reviews. Six residents, most with impaired cognition and psychiatric or neurological diagnoses, were directly affected. Observations included dried coffee stains, food and paper debris on the floors, overflowing trash, food stored improperly in dresser drawers, stained linens, and a heavily soiled pillow. Additionally, one room had a strong urine odor, a wet and rusted bathroom floor, and a toilet seat covered with dried feces. Another room had a significant presence of gnats around the sink and countertop. Interviews with staff revealed that housekeeping services were not provided daily on the unit, and a CNA reported bringing in personal cleaning supplies to address the ongoing mess. The housekeeping cleaning schedule showed missed cleaning days, and the facility's policy required maintaining a homelike environment. The Housekeeping Director confirmed the findings during the survey, and a housekeeper assigned to the unit was pulled from another area, indicating inconsistent cleaning practices.
Failure to Provide 30-Day Discharge Notice and Adequate Discharge Planning
Penalty
Summary
The facility failed to provide a 30-day discharge notice and appropriate discharge planning for a resident who was being discharged. The resident, who had diagnoses including morbid obesity, difficulty in walking, and epilepsy, was admitted from a hotel and was unable to return there due to eviction. The resident was cognitively intact and had no family involvement. During a care conference, it was noted that the resident was homeless and unable to secure alternative housing. The facility determined that the resident no longer required skilled nursing care or therapy and issued a Notice of Adverse Decision, denying continued stay. Social services assisted the resident in finding a hotel room and made arrangements for a primary care provider appointment and home health referral. However, there was no evidence in the medical record that a 30-day discharge notice was provided, that the Ombudsman was notified or involved in the discharge process, or that the resident was assisted in securing safe housing beyond the hotel arrangement. The resident was discharged to a hotel, and documentation did not confirm the resident's agreement to this discharge plan. Interviews with facility staff confirmed that the resident did not want to pay for continued stay and chose to be discharged to a hotel, but the Ombudsman was not notified, and there was no documentation of coordination with the Ombudsman or evidence of comprehensive discharge planning. The facility's policy required notification of the Ombudsman and a post-discharge plan of care, but these steps were not documented or completed for this resident.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to ensure that food items in the kitchen were labeled and dated appropriately, which could potentially affect 143 of the 144 residents who received meals from the facility kitchen. During an initial kitchen tour, it was observed that the main walk-in refrigerator contained a pork loin in a metal container that was undated and unlabeled. Additionally, the reach-in refrigerator had several items that were undated and unlabeled, including a metal container of 12 quartered hard-boiled eggs, a metal container of ham, a Chef salad, and a metal container of an unidentified gelatinous brown-green substance. An interview with a staff member confirmed that these items were unlabeled and undated, and the staff member was unaware of when they were placed in the refrigerators. The facility's policy on food storage requires all foods to be covered, labeled, and routinely monitored to ensure they are consumed by their use dates, frozen, or discarded as applicable.
Failure to Document COVID-19 Vaccine Education and Offering
Penalty
Summary
The facility failed to maintain proper documentation regarding the offering and education of the COVID-19 vaccine to its staff, which had the potential to affect all 144 residents. A review of personnel records for several CNAs and an LPN revealed no documentation that the facility had provided education or offered information and consent regarding the COVID-19 vaccine. Interviews with the Infection Control Preventionist and the Human Resources Manager confirmed that the facility did not maintain the necessary documentation for staff education and vaccine offering, except for newly employed staff hired within the last year. The facility's policy on COVID-19 vaccination, revised in December 2021, required that education on the benefits and potential side effects of the vaccine be provided before offering it to staff. The policy also stated that the refusal of the vaccine and the reason for refusal should be documented in the staff member's personnel file. However, the facility failed to adhere to this policy, as evidenced by the lack of documentation in the personnel files of existing staff members, except for those newly hired. This oversight in documentation and adherence to policy was verified through interviews with facility staff.
Failure to Adhere to PPE Protocols in Resident Care
Penalty
Summary
The facility failed to ensure that staff donned the appropriate personal protective equipment (PPE) when providing direct care to several residents, which was observed during a survey. For Resident #50, who was at risk for infection due to an ostomy and had orders for Enhanced Barrier Precautions (EBP) related to tube feedings, Certified Nursing Assistants (CNAs) entered the room and provided incontinence care wearing only gloves, without gowns, despite signage indicating the need for EBP. The CNAs admitted to not knowing where to find the gowns, as there was no supply cart with PPE outside the resident's room. Resident #16, who had an indwelling urinary catheter and was at risk for infection, also did not receive care with the appropriate PPE. A CNA assisted the resident with bathing and dressing, wearing only gloves and not a gown, as required by the EBP signage. The CNA acknowledged forgetting to wear a gown, which was located on a linen cart in the hallway. Similar deficiencies were noted for Resident #13, who was receiving intravenous therapy through a PICC line, and Resident #119, who had an enteral tube. In both cases, staff failed to wear gowns during high-contact care activities, despite EBP orders. Additionally, for Resident #36, who was on droplet precautions due to influenza A, staff did not wear the required eye protection and failed to change masks upon exiting the room, as indicated by the droplet precautions signage. These observations highlight a pattern of non-compliance with PPE protocols across multiple residents and care situations.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by several observations and interviews. In the 200-hall common area, furniture was found to be heavily soiled and damaged, with exposed metal and wood framing, and a large crack in the wall was noted. The Director of Nursing (DON) confirmed these findings during an interview. Additionally, Resident #63's room was in poor condition, with multiple puddles of urine, stained tiles, and a pervasive urine smell. The Registered Nurse (RN) and DON verified the room's condition, acknowledging that the room had been like this for some time and that housekeeping only cleaned once a day despite the ongoing issue. Resident #63, who has dementia and other medical conditions, was observed urinating in inappropriate places, contributing to the room's unsanitary state. The care plan for Resident #63 did not include interventions to prevent urination in inappropriate places, and there was no evidence of a toileting program in place. The Maintenance Director confirmed that the tiles and baseboards needed replacement due to urine damage. Furthermore, Resident #23's wheelchair was found to be dirty, with dried food and a brown/black substance on the seat and brakes. The facility lacked a policy or schedule for cleaning wheelchairs, as confirmed by the Administrator. The laundry room was also found to be in poor condition, with a thick coating of dust and debris behind the washing machines. The Laundry Aide and Maintenance Director had conflicting views on who was responsible for cleaning behind the machines, indicating a lack of clarity in cleaning responsibilities. Overall, the facility's failure to maintain cleanliness and address ongoing issues with resident care and the environment was evident in multiple areas, affecting the quality of care provided to the residents.
Inaccurate Documentation of Urinary Catheter Status
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's bowel and bladder assessment, specifically regarding the presence of an indwelling urinary catheter. Resident #13, who was admitted with multiple diagnoses including acute cystitis, cognitive decline, and morbid obesity, was documented in the Minimum Data Set (MDS) admission assessment as having an indwelling urinary catheter. However, subsequent CNA documentation indicated frequent urinary incontinence with occasional continence, and there was no care plan or interventions for an indwelling catheter. Additionally, there were no physician orders to discontinue the catheter, and nursing progress notes lacked documentation of its presence or discontinuation. Observations and interviews further revealed inconsistencies in the documentation. An observation on February 3rd showed no catheter tubing or urine drainage bag, and interviews with the resident and CNAs confirmed that the resident did not have an indwelling urinary catheter upon admission. The Director of Nursing verified these findings, acknowledging the inconsistent documentation. The NSO guidelines emphasize the importance of accurate and complete documentation to prevent liability, highlighting the deficiency in maintaining a complete and accurate clinical record for Resident #13.
Failure to Document Wound Treatments as Ordered
Penalty
Summary
The facility failed to complete wound treatments as ordered by the physician for a resident with chronic left lower extremity vascular ulcers. The resident, who was admitted with diagnoses including disorders of veins, peripheral vascular disease, congestive heart failure, and diabetes mellitus type two, required daily wound dressing changes for their medial and lateral ulcers. However, the treatment administration record revealed that these dressing changes were not documented as completed on several occasions, specifically on 12/20/24, 01/09/25, 01/11/25, 01/12/25, 01/13/25, 01/19/25, and 01/23/25. Interviews with the wound nurse confirmed the lack of documentation for these dates, and it was noted that on some occasions, the nurse practitioner was present and would have completed the dressing changes, but they were not signed off. Additionally, there was no documented evidence that the dressing changes were completed as ordered on 12/20/24 and 01/11/25. A corrective action form was completed for instances in December 2024 when a nurse had signed off on treatments that were not done, indicating a pattern of failure to adhere to treatment orders.
Inadequate Incontinence Care and Toileting Assistance
Penalty
Summary
The facility failed to provide adequate incontinence care and toileting assistance for two residents, leading to significant deficiencies in their care. Resident #56, who was admitted with multiple diagnoses including bladder incontinence, was found in a room with a strong odor of urine. His care plan required assistance with toileting and incontinence care, but on the morning of the observation, he had not been checked by staff since the start of their shift. His room contained wet clothing and a strong urine odor, indicating a lack of timely incontinence care. Resident #63, diagnosed with dementia and other conditions, was also inadequately managed for incontinence. His care plan noted a risk for impaired skin integrity due to incontinence, but there were no interventions to prevent urination in inappropriate places. Observations revealed multiple puddles of urine in his room, stained tiles, and a pervasive urine smell. Despite being on diuretic therapy, there was no toileting program in place for him, and staff were not cleaning his room more than once a day, allowing urine to accumulate and seep under tiles. Interviews with staff, including CNAs, RNs, and housekeeping, confirmed the ongoing issues with incontinence care for both residents. Staff acknowledged the conditions in Resident #63's room and the lack of a toileting program. The facility's policy on incontinence care was not being followed, as it required care after each episode of incontinence, which was not happening. The Director of Nursing and Maintenance Director were unaware of the room's condition, highlighting a lack of oversight and communication within the facility.
Failure to Monitor and Document Weight Changes
Penalty
Summary
The facility failed to adhere to its policy regarding weight monitoring and physician notification for two residents, leading to deficiencies in nutritional care. Resident #36 experienced an 8.7% weight loss over 30 days, dropping from 322 pounds to 294 pounds. Despite this significant weight loss, there was no documented evidence that the physician was notified, nor was a reweigh conducted as per the facility's policy. The resident's care plan indicated a risk for nutritional status alteration, yet the necessary interventions, such as reweighing and physician notification, were not executed. The Registered Dietitian confirmed the absence of a reweigh, highlighting a lapse in following the dietary assessment note's recommendation. Similarly, Resident #37, who was at risk for nutritional and hydration alterations, did not have weekly weights obtained as ordered by the physician. The resident's weight record showed a decrease from 181 pounds to 174 pounds, a 3.86% weight loss, but lacked additional weekly weight records. The facility's policy required weekly weights for new admissions and reweighs for any significant weight variance, which were not followed. The Registered Dietitian confirmed the failure to obtain the required weekly weights, indicating a breach in the facility's weight monitoring protocol.
Oxygen Administration and Tubing Change Deficiency
Penalty
Summary
The facility failed to administer oxygen to Resident #128 as per the physician's orders and did not change the oxygen tubing as required. Resident #128, who was cognitively intact, had a medical history that included chronic obstructive pulmonary disease (COPD), kidney disease, and a history of stroke. The care plan for Resident #128 included interventions for altered breathing patterns due to COPD, which required oxygen administration according to the physician's orders. However, during an observation, it was noted that the oxygen was set at four liters per minute instead of the ordered three liters per minute, and the oxygen tubing had not been changed weekly as ordered, with the last change dated 01/23/25. The facility's policy on oxygen therapy stated that oxygen should be administered in accordance with the physician's orders and that tubing, nasal cannulas, and humidifiers should be changed as per the physician's orders. An interview with an LPN confirmed the discrepancies in the oxygen administration and the overdue tubing change. This deficiency affected Resident #128 and had the potential to impact four additional residents who were also receiving oxygen therapy.
Incomplete Dialysis Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate and complete pre and post dialysis assessments for two residents who required dialysis services. Resident #37, who was moderately cognitively impaired and dependent on staff for various activities, had multiple instances where pre and post dialysis assessments were not completed on specified dates. Additionally, when assessments were completed, they often lacked necessary relevant information. The resident's care plan included interventions such as assisting with transfers to dialysis and monitoring the shunt for infection, but these were not adequately documented in the assessments. Similarly, Resident #83, who was cognitively intact but required assistance for daily activities, also had numerous dates where pre and post dialysis assessments were not completed. The resident's care plan outlined similar interventions as Resident #37, including monitoring the disease process and maintaining communication with dialysis staff. However, the assessments were either incomplete or missing, as confirmed by an LPN who acknowledged the inconsistencies. The facility's policy required nurses to obtain vital signs and assess the dialysis site, but these actions were not consistently documented.
Lack of Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to provide an individualized care plan with interventions for a resident diagnosed with post-traumatic stress disorder (PTSD). This deficiency was identified during a review of the medical records and interviews with staff and the resident. The resident, who had a history of trauma and PTSD, did not have any triggers or interventions documented in their care plan to prevent re-traumatization. Despite the facility's policy on trauma-informed care, which requires the assessment and documentation of trauma-related triggers, the care plan lacked this critical information. Interviews with staff, including a Certified Nursing Assistant, a Registered Nurse, and the Director of Nursing, revealed a lack of awareness regarding the resident's past trauma and potential triggers. The Psychiatric Nurse Practitioner's progress note indicated the resident had a history of abuse and trauma, yet this information was not reflected in the care plan. The facility's failure to incorporate trauma-informed care practices into the resident's care plan affected the resident and had the potential to impact other residents diagnosed with PTSD.
Failure to Address Pharmacist Recommendations for Resident Medications
Penalty
Summary
The facility failed to ensure that pharmacist recommendations for a resident were addressed by the physician, affecting one of three residents reviewed for unnecessary medication. The resident, who was cognitively intact, had multiple diagnoses including hypertension, anxiety, malnutrition, muscle weakness, prostate disorder, depression, and diabetes. The resident required varying levels of assistance for daily activities. The physician's orders included Lasix and Hydroxyzine, with the latter being recommended for discontinuation by the pharmacist due to its unsuitability for elderly patients. The medication regimen review conducted by the pharmacist highlighted the need for monitoring potential side effects of Lasix and recommended discontinuing Hydroxyzine. However, there was no documented evidence that the physician addressed the recommendation for Lasix, and although the physician chose to continue Hydroxyzine, no rationale was provided for this decision. The Director of Nursing confirmed that the medication regimen reviews were not appropriately addressed by the physician, which was contrary to the facility's policy requiring physician action or documented rationale for rejecting pharmacist recommendations.
Medication Security Deficiency
Penalty
Summary
The facility failed to ensure that all medications were secured and stored in locked compartments, limiting access only to authorized personnel. This deficiency affected three residents on the 200-nursing unit. Resident #13, who had moderate cognitive impairment, was observed with multiple oral medications left unsecured in their room without a physician's order or assessment for self-medication. The medications included antidepressants, supplements, a hormone, a proton pump inhibitor, a schedule III pain medication, and others. A registered nurse confirmed the medications were left unattended. Resident #16, who was cognitively intact, had unsecured medications on a computer desk in their room, including nasal sprays and ophthalmic solutions. There was no provider order or assessment for self-administration of these medications. Similarly, Resident #95, with a history of respiratory failure and schizoaffective disorder, had unsecured nasal sprays on their bedside table without an order or assessment for self-administration. A medication technician confirmed the presence of these unsecured medications.
Failure to Administer Pneumococcal and Covid-19 Vaccines
Penalty
Summary
The facility failed to administer the pneumococcal and Covid-19 vaccines to Resident #125, who was admitted with diagnoses including malignant neoplasm of the stomach, bipolar disorder, and feeding difficulties with gastrostomy. Despite Resident #125's signed request for these vaccinations on 11/11/24, a review of the electronic medical record from 11/08/24 to 02/04/25 showed no provider orders for the vaccines. The Minimal Data Set (MDS) 3.0 assessment completed on 12/19/24 indicated that the pneumococcal vaccine was not offered, and the resident was not up to date with the vaccine. Additionally, there was no documentation regarding the Covid-19 vaccination status in the MDS assessment. An interview with Resident #125 on 02/04/25 confirmed that she had not received the Covid-19 vaccine and had requested the pneumonia vaccine upon admission. The facility's policy stated that residents would be offered the influenza and pneumococcal vaccines upon admission, with a physician order obtained at the time of consent, and that the Covid-19 vaccine would be offered per manufacturer guidelines via an authorized provider.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to maintain fall prevention interventions as ordered by the physician for a resident, leading to multiple falls. The resident, who was admitted with diagnoses including encephalopathy, dementia, and Alzheimer's disease, was assessed as high risk for falls. Despite this, the resident experienced falls on three separate occasions, with injuries noted after each incident. The care plan and physician orders specified that the resident should have a walker within reach and be redirected to a wheelchair until strength was regained, but these interventions were not consistently implemented. Observations revealed that the resident was often found sitting in a stationary chair without access to a walker or wheelchair, contrary to the care plan and physician orders. Staff interviews confirmed that the resident was supposed to use a walker for ambulation and sit in a wheelchair, yet these measures were not followed. The staff, including STNAs and a Medication Aid, failed to ensure the resident had the necessary mobility aids, and there was a lack of awareness among staff about the resident's required level of assistance. The Director of Nursing confirmed the resident's recent falls and the interventions that were supposed to be in place. However, observations showed that the resident continued to be seated in a stationary chair without the required mobility aids. The facility's policy on fall management was not effectively implemented, as evidenced by the repeated falls and the failure to adhere to the prescribed interventions for the resident.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to ensure an effective pest control program, which had the potential to affect 122 out of 125 residents who eat meals from the kitchen. An interview with a resident revealed concerns about flying ants, while a kitchen aide confirmed the presence of gnats in the kitchen despite using a green liquid in the mop water to control them. Observations confirmed multiple gnats flying around the food cart, dishwasher, and sink area. The maintenance director acknowledged the gnat problem. The facility's undated Pest Control policy aimed to prevent and control pest infestations, but it was not effectively implemented. This deficiency was investigated under Complaint Number OH00152338.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mineral Ridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aventura At Humility House | 2.3 mi | ★★★★★ | 5 | 0 |
| Briarfield At Ashley Circle | 2.5 mi | ★★★★★ | 6 | 0 |
| Briarfield Manor | 3.9 mi | ★★★★★ | 5 | 0 |
| Omni Manor Nursing Home | 3.9 mi | ★★★★★ | 1 | 0 |
| Autumn Hills Care Center | 4.3 mi | ★★★★★ | 2 | 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.