Ridgeview Skilled Nursing: Resident Falls From Bed - CA
That decision, made during what should have been a routine care task at Ridgeview Skilled Nursing Facility, ended with a resident on the floor.
The resident, identified in inspection records only as Resident 1, was described by the CNA as petite but long. What the CNA also knew, or should have known, was that Resident 1 could do nothing to stop herself from falling. Her medical record coded her ability to roll left and right and return to lying on her back as fully dependent, meaning she did none of the effort herself and required two or more helpers to complete the movement at all.
There was one CNA.
When the aide let go of Resident 1's hip to pull wipes from a package sitting on the bed, the resident's legs went over the side. Then the rest of her followed. She landed on the floor.
The CNA later told inspectors she had not thought to place a bedside table on the other side of the bed for Resident 1 to brace against. She offered this not as an excuse but as a plain statement of fact: the precaution had not crossed her mind.
Federal inspectors cited Ridgeview under F0689, the regulation covering accidents and supervision, at a level of minimal harm or potential for actual harm. The citation covered a few residents. The inspection was conducted August 14, 2025, following a complaint.
The Director of Nursing was interviewed eight days after the inspection, on August 22. She told inspectors she expected CNAs to be familiar with providing care for residents and to communicate concerns to nursing staff so a resident's fall risk could be evaluated. She said she had not been aware of any concerns about caring for Resident 1.
That answer raises its own question. Resident 1's medical assessment, completed August 6, eight days before the inspection, documented her complete dependence for repositioning in bed. That assessment was in the chart. The facility's own falls policy, updated as recently as April 9, 2025, stated that all residents would be evaluated for fall risk and that those identified as high risk would receive individualized precautions noted in their care plan.
Whether Resident 1 had been identified as high risk, and whether any individualized precautions had been noted, the inspection record does not say. What it does say is that on the day she fell, there was one CNA, no second helper, no barrier on the far side of the bed, and no thought given to what would happen if the aide needed to reach for something.
A resident who cannot roll over without two people helping her cannot stop herself from rolling off a bed.
The CNA understood this afterward. Whether anyone understood it before is the question the inspection leaves open.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ridgeview Skilled Nursing Facility from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 25, 2026 · Our methodology
RIDGEVIEW SKILLED NURSING FACILITY in SAN DIEGO, CA was cited for violations during a health inspection on August 14, 2025.
That decision, made during what should have been a routine care task at Ridgeview Skilled Nursing Facility, ended with a resident on the floor.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.