Ridgeview Post Acute

Based on record review and interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with state law for four of four allegations of abuse.Specifically, the facility failed to:-Report an allegation of physical abuse between Resident #1 and Resident #2 on 11/18/25 within two hours of the incident; .-Report an allegation of physical abuse between Resident #3 and Resident #4 on 1/19/26 within two hours of the incident;-Report an allegation of physical abuse between Resident #5 and Resident #6 on 2/8/26 within two hours of the incident; and,-Report an allegation of physical abuse between Resident #4 and Resident #11 on 3/22/26 within two hours of the incident.Findings include:I. Facility policy and procedureThe Abuse Prevention and Reporting policy, revised June 2025, was provided by the nursing home administrator (NHA) on 4/7/26 at 2:32 p.m. It read in pertinent part, The administrator/designee will complete the initial report to the state survey and certification agency within 24 hours electronically via the occurrence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#3) of four residents reviewed out of 16 sample residents was kept free from resident-to resident physical abuse.Specifically, the facility failed to protect Resident #3 from physical abuse by Resident #4.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/6/26 to 4/8/26, resulting in the deficiency being cited as past noncompliance with a correction date of 3/25/26.I. Incident of physical abuse by Resident #4 toward Resident #3 on 1/19/26On 1/19/26 at 5:00 a.m. certified nurse aide (CNA) #3 heard activity from the room shared by Resident #3 and Resident #4. When CNA #3 entered the residents' room, she observed Resident #4 was standing near Resident #3's bed and was attempting to remove a pillow from beneath Resident #3's head. CNA #3 separated the residents and assisted Resident #4 to her side of the room. Approximately 20 minutes later, CNA #3 saw…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public on one of four units. Specifically, the facility failed to provide the necessary housekeeping and maintenance services to maintain resident room [ROOM NUMBER], #307, #316, #318, #303, #302 and #311 in a sanitary and comfortable manner. Findings include: I. Facility policy and procedures The Safe and Homelike Environment policy, revised 12/2023, was provided by the director of nursing (DON) on 7/16/24 at 11:33 a.m. The policy revealed the term environment referred to any environment in the facility that was frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A homelike environment de-emphasized the institutional character of the facility setting, to the extent possible; and allowed the resident to use personal belongings that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews the facility failed to ensure two (#19 and #100) of three residents reviewed for out of 45 sample residents were free from involuntary seclusion. Specifically, the facility failed to ensure Resident #19 and Resident #100 who resided in the secured unit, had the required ongoing documentation of the review and revision to meet the criteria and if the interventions met the needs of the resident. Findings include: I. Facility policy and procedure The Elopement and Unsafe Wandering policy, revised December 2023, was provided by the director of nursing (DON) on 7/16/24 at 5:25 p.m. It read in pertinent part, It is the facility's policy to provide a safe environment for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement. Care plan interventions will consider the elements of the evaluation or behavior observations that identified the resident at risk. II. Resident #19 A.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents were provided services that meet professional standards. Specifically, the facility failed to ensure narcotic medications were documented on the narcotic log at the time of removal from the locked narcotic drawer on two of four medication carts. Findings include: I. Facility policy and procedure The Controlled Medications Storage and Reconciliation policy, revised January 2024, was provided by the director of nursing (DON) on 7/15/23 at 12:23 a.m. It read in pertinent part, It is the policy of this facility to safeguard access and storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse using separately locked, permanently affixed compartments, with the exception that controlled medications and those medications subject to abuse may be stored with non-controlled medications as part of a single unit package medication distribution…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in two of four medication carts and one of two medication storage rooms. Specifically, the facility failed to ensure: -Medications were labeled with the date it was opened; -Discontinued medications were removed from the medication cart in a timely manner; -Medications were properly disposed in a disposal receptacle; and, -Resident medication was stored in the proper location. Findings include: I. Facility policy and procedure The Storage of Medication Policy, revised [DATE], was provided by the director of nursing (DON) on [DATE] at 2:56 p.m. The policy read in pertinent part, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. Eye medications are stored separately from ear medications and inhalers. Outdated, contaminated, discontinued or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services for one (#54) of one resident reviewed for hospice care services out of 45 sample residents. Specifically, the facility failed to: -Establish a communication process, including how the communication would be documented between the facility and the hospice provider for Resident #54; and, -Ensure hospice agency staff notes were easily accessible to the facility staff and have consistent documentation of hospice care visits in Resident #54's record. Findings include: I. Facility policy and procedure The End of Life Care, Hospice and Palliative Care policy, revised December 2023, was provided by the director of nursing (DON) on 7/11/24 at 9:13 a.m. It revealed in pertinent part, Hospice services will be offered as appropriate and as ordered by the physician. The services will be integrated into the overall individualized,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to take steps to protect one (#19 and #256) of eight residents from physical abuse out of 45 sample residents reviewed for abuse. Specifically, the facility failed to prevent Resident #19 from physical abuse by Resident #256. Findings include: I. Facility policy and procedure The Abuse: Prevention of and Prohibition Against policy, revised 11/29/23, was provided by the director of nursing (DON) on 7/10/24 at 2:28 p.m. It read in pertinent part, Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. II. Incident of physical abuse between Resident #256 and Resident #19 on 6/13/24 A. Facility investigation of the altercation on 6/13/24 The witness statement, dated 6/13/24, written by a certified nurse aide (CNA), documented Resident #256…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility document review, the facility failed to ensure the employee performing the Registered Dietitian (RD) role and signing resident assessments as an RD was, in fact, registered as a dietitian with the Commission on Dietetic Registration (CDR). This had the potential to affect all 96 residents. Findings included: A review of the Colorado Revised Statues Title 6. Consumer and Commercial Affairs § 6-1-707. Use of title or degree-deceptive trade practice, dated 01/01/2019, revealed, (1) A person engages in a deceptive trade practice when, in the course of the person's business, vocation, or occupation, the person: (a)(I) Claims either orally or in writing, to possess either an academic degree or an honorary degree or the title associated with said degree, unless the person has, in fact, been awarded said degree from an institution. (b) Claims either orally or in writing to be a dietitian, dietician, certified dietitian, or certified dietician or uses the abbreviation C.D. or D to indicate that such person is a dietitian, unless such person:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to infection control and COVID-19 testing. Findings include: I. Facility policy The Improvement Performance QAPI (quality assurance performance improvement) policy, updated December 2020, was provided by the nursing home administrator on 1/19/22 at 11:19 a.m. It documented in pertinent part, It is the policy of this facility to develop, implement, and maintain an ongoing program designed to monitor and evaluate the quality of resident care, and to resolve identified problems. The primary purposes of Quality Assessment and Assurance Plan are .To identify quality deficiencies and develop and implement plans of action to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure services provided met professional standards of quality for one (#79) of eight out of 47 sample residents. Specifically, the facility failed to ensure Resident #79's blood pressure was within physician ordered parameters prior to administering hypertensive medication. Findings include: I. Facility policy The Medication Administration policy, updated August 2020, was provided by the nursing home administrator on 1/19/22 at 11:19 a.m. It documented in pertinent part, It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician. All current drugs and dosage schedules must be recorded on the resident's medication administration record (MAR) as appropriate. Should a drug be withheld, refused, or given other than at the scheduled time it should be appropriately documented on the MAR. II.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.