Eagle Ridge Post Acute

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure one resident (#3) of three sample residents, was free from significant medication errors out of 13 sample residents. Resident #3 was admitted to the facility on [DATE] with a diagnosis of type 1 diabetes mellitus with a history of experiencing low blood glucose levels. Resident #3 had a physician's order to receive 29 units of Lantus (insulin glargine - long acting insulin) injected subcutaneously each day at bedtime. The resident had another physician's order for Humalog insulin (lispro - short acting insulin) 100 units per milliliters (ml) injected daily at 6:00 a.m., 11:00 a.m. and 4:00 p.m. On 10/22/25 at 7:33 p.m. registered nurse (RN) #1 administered 29 units of Humalog (quick acting insulin) instead of the scheduled Lantus (long acting insulin), which caused the resident's blood glucose to drop. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide, implement and maintain an effective training program for new and existing staff. Specifically the facility failed to provide:-All staff the required annual abuse identification, abuse prevention and abuse reporting training, for 75 out of 83 staff; -All staff dementia management training, for 39 out of 83 staff;-All staff resident rights training, for 31 out of 83 staff; -All staff quality assurance and performance improvement (QAPI) training, for 30 out of 83 staff;-All direct care staff effective communication training, for 49 out of 49 staff; -All staff infection control training, for 20 out of 83 staff members; -All staff compliance and ethics training, for 16 out of 83 staff; and, - All direct care staff behavioral health training, for 13 out of 49 staff.

Inspectors wroteBased on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and resident abuse prevention. Specifically the facility failed to provide 75 of 83 staff members annual training on abuse identification, prevention, reporting and evidence gathering.

Inspectors wroteBased on interviews and record review, the facility failed to serve food that accommodates resident allergies, intolerances, and preferences for one (#1) of five residents reviewed out of five sample residents. Specifically, the facility failed to ensure Resident #1 was not served food the resident was allergic to, causing an allergic reaction to Resident #1 which required hospitalization for anaphylactic shock (a severe, potentially life-threatening allergic reaction that can cause a range of symptoms affecting multiple body systems, including skin, respiratory, and cardiovascular). Resident #1 was admitted on [DATE] for long term care with diagnoses of unspecified lack of expected physiological development in childhood, cognitive communication deficit, muscle weakness, lack of coordination and history of anaphylaxis (severe allergic reaction). [...]

Inspectors wroteIII. Failed to ensure Resident #2's representative was notified when the resident was sent to a cardiology appointment and started on an anticoagulant medication A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included type 2 diabetes mellitus without complications, other specified diabetes mellitus with diabetic neuropathy, presence of cardiac pacemaker, dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and unspecified atrial fibrillation. The 4/23/25 MDS assessment identified Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #2 used a walker for mobility and was independent with most of his activities of living (ADL). B. Resident interview Resident #2 was interviewed on 6/30/25 at 4:40 p. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#4) of three residents reviewed for abuse out of eight sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #4 from verbal abuse and physical abuse by Resident #5.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one ( #1) of three residents were provided the care and services necessary to ensure a safe discharge from the facility to the community out of eight sample residents. Specifically, the facility failed to: -Allow Resident #1 to return to the facility after an unplanned discharge to the hospital; -Provide documentation made by Resident #1 ' s physician, including the specific resident needs the facility could not meet, the facility ' s efforts to meet those needs and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at the current facility; and, -Reassess Resident #1 for readmission after he was stabilized at the hospital and ready to return to the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents requiring treatments and services for mental disorders or psychosocial adjustment difficulties received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well being for one (#1) of three residents reviewed out of eight sample residents. Specifically, the facility failed to provide mental health counseling services for Resident #1.

Inspectors wroteBased on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow up with residents' concerns regarding call light times.

Inspectors wroteBased on record review and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#1) of five residents reviewed for respect and dignity out of 11 sample residents. Specifically, the facility failed to assist Resident #1, who was dependent on staff for all care, to turn in bed when he requested assistance.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#8) of one resident out of 11 sample residents was free of significant medication errors. Specifically, the facility failed to ensure Resident #8 received her full three-week course of antibiotics as recommended by the hospital.

Inspectors wroteBased on observations, 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 qualify of care, quality of life, and resident safety. Specifically, the facility's quality assurance and performance improvement (QAPI) program committee failed to effectively identify and address concerns related to residents' quality of care, quality of life, staff training and infection prevention and control.

Inspectors wroteBased on observations and interviews, the facility failed to ensure a qualified infection preventionist (IP) was in place for providing guidance to the facility on the infection control policy and programs which had the potential to affect all 74 residents residing in the facility at the time of the survey. Specifically, the facility failed to have a designated IP who had the time necessary to properly assess, develop, implement, monitor, and manage the infection prevention and control program (IPCP) for the facility.

Inspectors wroteBased on record review and interviews, the facility failed to act promptly upon the grievances concerning issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to timely create effective interventions and maintain a systematic approach to ongoing resident grievances of call light response times addressed in resident council.

Inspectors wroteBased on record review and interviews, the facility failed to coordinate assessment with the preadmission screening resident review (PASRR) program for five (#26, #36, #4, #18 and #22) of eight residents reviewed for PASRR out of 45 sample residents. Specifically, the facility failed to coordinate a PASRR Level II evaluation for Resident #26, #36, #4, #18 and #22.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four out of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #5, CNA #4 and CNA #3.

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and three of three unit refrigerators. Specifically, the facility failed to: -Ensure staff followed appropriate hand washing and glove usage in the main kitchen; and, -Ensure food was labeled and stored appropriately in the main kitchen refrigerator and freezer and in three unit refrigerators.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition. Specifically, the facility failed to ensure facility staff used a blood pressure cuffs which were rated for medical use.

Inspectors wroteBased on record review and interview, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. Specifically, the facility failed to: -Ensure the activities assistant (AA), the cook (CK) and housekeeper (HSKP) #1 received annual training that covered abuse, reporting incidents of abuse and resident abuse prevention over the last 12 months; and, -Ensure the CK, dietary aide (DA) #2 and the maintenance assistant (MA) received annual training that covered dementia management.

Inspectors wroteBased on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for four out of five staff reviewed. Specifically, the facility failed to ensure CNA #2, #5, #4 and #1 received 12 hours of continuing education annually in all required training topic areas, including dementia management training and resident abuse prevention training.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that personal funds accounts were managed adequately for one (#19) of five residents out of 45 sample residents. Specifically, the facility failed to have personal funds withdrawal sheets signed to ensure the Resident #19' s permission was obtained to withdraw funds from his personal needs account.

Inspectors wroteBased on record review and interviews, the facility failed to inform one (#216) of three residents reviewed for beneficiary notices out of 45 sample residents of changes in their services covered by Medicare in a timely manner. Specifically, the facility failed to provide a Notice of Medicare Provider Non-Coverage (NOMNC) to Resident #216 two days prior to discharge of Medicare Part A funded services.

Inspectors wroteBased on record review and interviews, the facility failed to investigate an allegation of abuse for one (#17) of three residents reviewed for abuse out of 45 sample residents. Specifically, the facility failed to investigate an incident where Resident #17 reported a staff member threatened him.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a discharge summary was in place for one (#65) of three residents reviewed for discharge out of 45 sample residents. Specifically, the facility failed to ensure Resident #65's discharge summary included a recapitulation of the resident's stay and a complete final summary of the resident's status.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#19) of one resident reviewed for vision problems out of 45 sample residents. Specifically, the facility failed to ensure Resident #19 was assisted to receive his new glasses.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#54) of three residents with limited range of motion received appropriate treatment and services out of 45 sample residents. Specifically, the facility failed to provide restorative therapy services to Resident #54.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for one (#22) of five residents reviewed for medications out of 45 sample residents. Specifically, the facility failed to ensure as needed (PRN) psychotropic medications were discontinued after 14 days for Resident #22.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards in one of two medication storage rooms and one of two medication storage carts. Specifically, the facility failed to: -Ensure all medications and biologicals were stored appropriately in a secure location; and, -Maintain a medication refrigerator temperature log for one of three medication refrigerators.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure two (#62 and #4) of six residents with an order for an altered mechanical soft texture, out of 45 sample residents received food and fluids prepared in a form designed to meet their needs per physician orders. Specifically, the facility failed to provide Resident #62 and Resident #4 the correct mechanically altered diet texture.

Inspectors wroteBased on record review and interviews, the facility failed to meet all the requirements for the provision of hospice care for one (#19) of four residents out of 45 sample residents. Specifically, the facility failed to ensure the hospice agency notes regarding Resident #19's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency.

Inspectors wroteBased on observations, interviews and record review, the facility failed to post nurse staffing information daily. Specifically, the facility failed to: -Post the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift; and, -Maintain staffing data for 18 months as required.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#54) of five residents out of 45 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #54 was admitted to the facility for long term care on 11/10/23 with diagnoses of chronic obstructive pulmonary disease (COPD), diabetes and generalized muscle weakness. The resident was initially weighed on 11/19/23 and weighed 149 pounds (lbs). The resident was admitted to the hospital from [DATE] to 1/8/24 for electrolyte imbalances. Upon readmission to the facility the resident weighed 135.2 lbs. On 1/22/24 and 1/29/24 the resident weighed 123.6 lbs. On 2/5/24 the resident weighed 123 lbs. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure housekeeping staff changed gloves and performed hand hygiene consistently when appropriate during resident room cleaning; -Ensure housekeeping staff properly used a disinfectant chemical per manufacturer's instructions when cleaning resident rooms; -Ensure staff donned (put on) the appropriate personal protective equipment (PPE) when providing direct care to residents on enhanced barrier precautions (EBP); -Ensure a process was in place to ensure staff were aware of which residents required EBP; -Provide clean linens after performing wound care and a wound dressing change; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents consistently received food prepared by methods that conserve nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure food was served palatable, attractive and served at the appropriate temperature.

Inspectors wroteBased on record review and interviews, the facility failed to inform the resident's representative of a change of condition for one (#173) of four residents reviewed for notification of change out of 45 sample residents. Specifically, the facility failed to ensure Resident #173' s responsible party was notified after an unwitnessed fall.

Inspectors wroteBased on record review and interviews, the facility failed to provide adequate supervision and assistance to prevent falls, and failed to assess, implement and monitor interventions consistent with resident needs for one (#173) of four residents reviewed for falls out of 45 sample residents. Specifically, the facility failed to: -Assess Resident #173 after a potential fall and after injuries were identified and report the potential fall; -Monitor Resident #173 after facial injuries were identified; -Ensure safe smoking practices were conducted for Resident #173 and care planned; and, -Ensure interventions were care planned for Resident #173 who was identified at moderate risk for falls.

Inspectors wroteBased on record review and interviews, the facility failed to take steps to prevent one (#2) of three residents reviewed for wandering of 12 sample residents safe from eloping from the facility. Specifically, the facility: -Failed to identify goals and interventions on the baseline care plan to ensure Resident #2 ' s health and safety related to elopement; -Failed to ensure a thorough shift report was provided to the oncoming nurse during change of shift to inform of Resident #2 ' s wandering activities, and -Failed to ensure Resident #2 did not elope from the facility.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#11) of four residents reviewed of 31 sample residents received timely treatment and care in accordance with professional standards of practice and facility policy. For Resident #11, the facility failed to: -Timely respond, assess, communicate and report to the physician the resident's severe acute pain; -Timely acknowledge, and sign off on, and implement physician orders; -Schedule Resident #11's outpatient ultrasound in a timely manner although the resident was experiencing pain; and -Notify the physician of a change in status and the resident's increased pain. These failures resulted in the resident having a delayed transport to the outpatient imaging center, while the resident was experiencing new acute pain at levels of 7-10 on a scale of 0 out of 10. [...]

Inspectors wroteBased on resident, family and staff interviews and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for nine (#60, #36, #63, #13, #29, #14, #24, #34, #43) of 31 sample residents. Resident, family, and staff interviews revealed the facility failed to consistently provide adequate nursing staff resulting in delayed call light response, and prolonged wait times for assistance with activities of daily living such as assistance to and from the toilet.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a safe, clean, comfortable and homelike environment in two (east and west) of three resident hallways. Specifically, the facility failed to ensure residents had adequate access to clean bath linens at all times.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#46) of three residents reviewed for bathing and grooming received the necessary assistance with activities of daily living (ADLs) of 31 sample residents. Specifically, the facility failed to ensure Resident #46 received timely assistance with wheelchair positioning, and clothing and eye cleanliness.

Inspectors wroteBased on interviews and record review, the facility failed to monitor and document pain management for one (#20) of four residents reviewed for pain management of 31 sample residents. Specifically, the facility failed to implement the resident's pain management care plan, and monitor, document and assess Resident #20's level of pain at least every shift.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly interior in three of three hallways for residents residing in the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that all drugs and biologicals were properly stored in three of three medication storage refrigerators. Specifically, the facility failed to ensure that vaccines were stored according to practice standards and manufacturer guidelines.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure the resident's environment remained as free from accident hazards as possible for one (#45) of six residents reviewed for falls of 32 sample residents. Specifically, the facility failed to ensure the call light was placed in a safe position and remained within reach for Resident #45.

Inspectors wroteBased on record review and interviews, the facility failed to ensure accuracy of the electronic medical record (EMR) for two (#63 and #45) of four residents reviewed for weight discrepancies of 32 sample residents. Specifically, the facility failed to ensure that resident weights were both timely and accurately documented for Residents #63 and #45.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure infection control standards of practice were followed for one of three blood glucose monitoring devices. Specifically, the facility failed to properly disinfect and store the blood glucose monitoring device after use on Resident #48.