Ridgecrest Village

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

take report from Staff P about the situation and was very familiar with Resident #64. She stated she was told by Staff P something was wrong with the resident's arm, and that hospice had assessed but he felt the arm needed reassessment. She felt the resident's arm had been fractured. She stated the resident appeared frail, but never resisted cares. She would occasionally move away from things that caused her discomfort but never lashed out and kicked or hit at staff members. She stated in her professional nursing opinion, she does not believe that normal cares could have fractured the resident's arm so significantly. She stated she had cared for Resident #64 countless times and had always used what she considered normal amounts of force which had never even resulted in the resident expressing discomfort. In an interview on 10/02/2025 at 12:58 PM with Staff M, RN, she stated she was familiar with Resident #64 and did not believe standard care practices could have resulted in a fracture of such magnitude. In an interview on 10/01/2025 at 12:23 PM with the Facility Medical Director, she stated she was very familiar with Resident #64 and had cared for her for some time, she noted the resident had been diagnosed in 2017 with age related osteopenia and noted the loss of some bone mineralization in the hospital findings, which could contribute to a fracture. She confirmed the findings of the Hospital imaging was consisted with a significant fracture of the humerus and a less severe fracture of the radius and was not consistent with a typical osteopenia fracture presentation. She stated based on her medical opinion, she could not make a judgement as to whether or not the fracture was intentional, but further noted the kind of trauma required to fracture the resident's arm would need to be dramatic. She further noted the amount of times the resident underwent standard cares such as dressing without any issue gave her caution as to whether or not simple dressing practices would have been enough to fracture the residents arm. She stated she had directly performed some cares on Resident #64 and had never had an issue with the resident violently resisting cares, pushing her away, or ever becoming violent. In an interview on 10/02/2025 at 08:49 AM with the Director of Nursing, she stated her expectation is for staff members to perform cares as gently as possible to avoid injuries to frail and elderly residents. She acknowledged staff members should never rush cares as

it increases the likelihood of injury. She further acknowledged that standard nursing cares should never result in a fracture of the magnitude Resident #64 suffered, even with osteopenia or osteoporosis. She finally stated that in her professional nursing opinion, the fracture Resident #64 suffered could only have resulted from excessive force, which is why Staff Q was terminated. Review of a facility provided document titled Abuse Prevention, Identification, investigation, And reporting, with a last revised date of 06/26/2024, it identifies under key definitions subsection #9 that Neglect is the failure of the facility, its employee or service providers to provide goods and services to a resident that are necessary to avoid physical harm.

The policy further states All residents have the right to be free from abuse and neglect.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ridgecrest Village

4130 Northwest Boulevard Davenport, IA 52806

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews and facility policy review the facility failed to complete dialysis site assessments before and after dialysis for 1 of 1 residents reviewed (Resident#11). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE REDACTED] listed diagnoses of dependence of renal dialysis, end-stage renal disease, and diabetes mellitus (DM). The Brief Interview for Mental Status listed a score of 15, intact cognition. The Care Plan for Resident #11 dated 5/30/25, reflected she needed dialysis related to renal failure. The Care Plan directed staff to monitor/document/report as needed (PRN) any signs or symptoms (s/s) of infection to access site: redness, swelling, warmth or drainage. Monitor/document/report PRN for s/s of the following: bleeding, hemorrhage, bacteremia, and septic shock.The Medication Administration Record (MAR) dated 9/25, directed vital signs

before and after dialysis appointment two times a day every Monday, Wednesday, and Friday. The MAR failed to direct nursing staff to assess her left arm for s/s of bleeding or the bruit and thrill. The Progress Notes for Resident #11 dated 9/1/25-9/30/25, lacked assessment of her left arm for s/s of bleeding or the bruit and thrill.The Assessment in the Electronic Health Record (EHR) dated 8/2/25 through 10/1/25 lacked dialysis assessments. On 09/29/2025 at 1:58 PM Resident #11 reported the staff check her vitals but they failed to check on the dialysis site for bleeding, failed to feel (thrill) or listen (bruit). On 10/02/2025 at 9:46 AM Staff D, Registered Nurse (RN) reported the dialysis assessments include listen to thrill, complete

before and after vitals. She said the assessments are under the notes of dialysis under assessments in the EHR. On 10/02/2025 at 10:00 AM the Infection Preventionist (IP) reported dialysis assessment are for staff to check and make sure she's not bleeding.On 10/02/2025 at 10:45 AM the Director of Nursing (DON) reported the dialysis process needed work. The DON said at minimum nursing needed to check her when

she gets back form dialysis. The facility provided a policy titled End-Stage Renal Disease, Care of Resident with dated 9/2010, failed to direct assessment of the access site.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Federal health inspectors cited Ridgecrest Village in DAVENPORT, IA for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-10-02.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of Ridgecrest Village.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-27.

Federal health inspectors cited Ridgecrest Village in DAVENPORT, IA for a deficiency under regulatory tag F-F0865 during a standard health inspection conducted on 2025-10-02.

Category: Administration Deficiencies

The facility was found deficient in the following area: Have a plan that describes the process for conducting QAPI and QAA activities.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of Ridgecrest Village.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-27.

Federal health inspectors cited Ridgecrest Village in DAVENPORT, IA for a deficiency under regulatory tag F-F0868 during a standard health inspection conducted on 2025-10-02.

Category: Administration Deficiencies

The facility was found deficient in the following area: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of Ridgecrest Village.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-27.

Federal health inspectors cited Ridgecrest Village in DAVENPORT, IA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-10-02.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of Ridgecrest Village.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-27.