West Ridge Specialty Care

In the surveyor’s words

From the most serious findings on record at West Ridge Specialty Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Nov 17, 2022

  Based on observation, record review, and staff and physician interviews, the facility failed to obtain and clarify physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1). The failure resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility also failed to implement appropriate interventions in a timely manner for Resident #1, and Resident #6, when significant changes of condition that included pain level rated at 10 out of 10 on a 0 to 10 pain scale, with 10 assigned to the highest level of pain, and circulation changes that included the development of worsened pitting [CONDITION(S)] that weeped fluid, did not implement appropriate interventions, and did not notify the physician of Resident #1's and Resident #6's condition changes or seek direction… […]

• Immediate jeopardy, isolatedF689Jun 8, 2021

  Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to prevent an elopements for 1 of 4 residents sampled (Resident #1) for falls. The Wander Guard system failed to sound on [DATE], allowing Resident #1 to exit the facility without staff knowledge. Despite knowledge of the wander guard system not alarming, the facility continued to use it as a means to alert staff when at risk residents breech an exit door. The facility failed to implement additional interventions to mitigate Resident #1's risk for elopement. On [DATE], the staff again discover Resident #1 outside unattended. The wander guard system failed to alarm. The nurse on duty failed to report the incident and no action taken to address the resident's risk for elopement. […]

• No harm, potential for more than minimal, patternF676Apr 23, 2026

  Based on electronic record review, resident interviews, staff interviews, and policy review, the facility failed to provide restorative programs as care planned for 3 of 4 residents reviewed for restorative care (Residents #2, #7, and #8). The facility reported a census of 71. Findings include: 1. Resident #7's Minimum Data Set (MDS) Assessment completed on 10/2/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Diagnoses included a right femur (thigh bone) fracture, lack of coordination, history of falling, and cognitive communication deficit (difficulty speaking or understanding). […]

• No harm, potential for more than minimal, patternF677Apr 23, 2026

  Based on electronic record review, resident interviews, staff interviews, and policy review, the facility failed to provide resident showers as scheduled for 5 of 5 residents reviewed for activities of daily living (Residents #1, #2, #4, #5, and #7). The facility reported a census of 71. Findings include: 1. Resident #3's Minimum Data Set (MDS) Assessment completed on 3/18/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The DMS included diagnoses of arthritis (joint inflammation), low back pain, malnutrition (lack of proper nutrition), and osteoporosis (brittle bones). The MDS noted the use of a motorized wheelchair for mobility. […]

• No harm, potential for more than minimal, patternF550Nov 4, 2025

  Based on clinical record review, staff interview, policy review, and resident interviews, the facility failed to protect the resident's right to a dignified existence by failing to carry out perineal cares in a timely manner after incontinence episodes for 1 of 1 residents reviewed for incontinence care assistance (Resident #1) and for multiple, random residents affected, as reported by multiple staff members. The facility reported a census of 74 residents. Findings: 1. The Minimum Data Set(MDS) assessment tool, dated 10/24/25, listed diagnoses for Resident #1 which included hemiplegia(one-sided paralysis), anxiety, and depression. The MDS stated the resident was frequently incontinent with bowel and bladder and stated the resident was dependent on staff assistance for toileting hygiene. […]