The Haven of Ridgeview

In the surveyor’s words

From the most serious findings on record at The Haven of Ridgeview, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 2, 2026

  Based on interview and record review the facility failed to safely transfer 1 of 3 (R1) residents reviewed for accidents in a sample of 7. This failure resulted in R1 falling out of a whole-body lift machine onto the floor and sustaining a right hip fracture, a fracture of the distal right femur and a fracture of the right tibia.This past noncompliance occurred on 1/24/2026.Findings included:R1's admission Record documents R1 was admitted to this facility on 5/20/2025 with diagnoses of dependence on dialysis, end stage renal disease, morbid obesity and chronic obstructive pulmonary disease among others.R1's MDS (minimum data set) dated 11/15/25, documents R1 needs two staff assistance for all transferring activities and the staff utilize a full body lifting machine for lifting R1. […]

• Actual harm, isolatedF686Jan 7, 2025

  Based on interview and record review, the facility failed to implement interventions to prevent the development of pressure ulcers for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 7. This failure resulted in R1 developing facility acquired moisture associated skin damage to the buttocks, a stage 2 pressure ulcer to the Left Ischium, a stage 3 pressure ulcer to the Right Ischium, and a stage 3 pressure ulcer to the Sacrum. Findings include: R1's Admission Record documented an initial admitted [DATE] and a readmitted [DATE]. […]

• Actual harm, isolatedF697Oct 10, 2024

  Based on interview and record review, the facility failed to assess and manage pain for 1 (R198) of 2 residents reviewed for pain management in the sample of 34. This failure resulted in R198 experiencing severe pain and anxiety, resulting in a transfer to the ER (emergency room ). Findings include: 1. R198's Admission Record documented an admitted [DATE] and listed diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety Disorder. R198's Minimum Data Set, dated dated dated [DATE] documented that R198 has no deficit in cognition A Hospice Center Discharge Instructions Sheet dated 9/21/24 documented, Medications: Ativan 2mg. (milligrams) per ml. (milliliter), give 0.5ml by mouth every hour prn (as needed) for anxiety. Morphine Sulfate 20mg./ml. […]

• Actual harm, isolatedF580Jan 30, 2024

  Based on interview and record review, the facility failed to notify the physician in a timely manner for 1 (R2) of 3 residents reviewed for physician notification. This failure resulted in the hospitalization of R2 for 2 days with a diagnosis of cellulitis of the right abdominal pannus and left lower extremity cellulitis, and insertion of a Peripherally Inserted Central Catheter (PICC) line for intravenous (IV) antibiotic therapy. The findings include: R2 ' s face sheet documents that R2 was admitted to the facility on [DATE] with a primary diagnosis of Morbid (Severe) Obesity due to excess calories. R2 ' s Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score of 15, indicating that R2 is cognitively intact. […]

• Actual harm, isolatedF689Jan 30, 2024

  Based on interview, observation, record review, the facility failed to follow fall interventions for 1 (R1) of 3 residents reviewed for falls. This failure resulted in R1 experiencing a fall and receiving a broken rib. Findings: 1. R1's face sheet documents that R1 admitted to the facility on [DATE] with a diagnosis of Other Idiopathic Peripheral Autonomic Neuropathy. R1's Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score is 13, indicating that R1 is cognitively intact. […]