Pheasant Ridge Nursing and Rehabilitation

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to notify the medical provider of a significant change in condition in a timely manner for two (2) of 51 residents in the survey sample, Resident #95 and Resident #6. The facility's failure to recognize, act upon, and report a heart rate of 131 beats per minute to a medical provider for approximately six hours, likely caused and/or hastened the resident's death which occurred one to two hours after being sent out to the hospital with complaints of shortness of breath and chest pain. This resulted in the identification of Immediate Jeopardy for Resident #95. The survey team informed the facility on [DATE] at 3:28 PM of the Immediate Jeopardy situation regarding Resident #95. The scope and severity were originally cited at level IV isolated. [...]

Inspectors wroteBased on family interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 6 of 51 sampled residents, Resident #94, Resident #2, Resident #33, Resident #95, Resident #29, and Resident #43. For Resident #94, the facility staff failed to remove the anticoagulant, Eliquis from the resident's active medication supply when discontinued on [DATE]. 12 Eliquis tablets were missing from Resident #94's Eliquis supply and were unaccounted for. Lab results obtained on [DATE] revealed a critically low hemoglobin of 6.7, a low hematocrit of 20.9, and PT/INR levels that were unable to be determined due to no clotting endpoint on the lab instrument. Resident #94 died on [DATE] while actively bleeding from the nose, mouth, urinary tract, and rectum. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to obtain lab testing as ordered by the medical provider for 8 of 51 sampled residents, Resident #94, Resident #2, Resident #3, Resident #5, Resident #7, Resident #8, Resident #12, and Resident #6. For Resident #94, the facility staff failed to obtain PT/INR results as ordered following the transition of Eliquis to Coumadin using a limited Lovenox bridge on four separate occasions from [DATE] through [DATE]. Lab results obtained on [DATE] and received by the lab on [DATE] resulted in a PT greater than 90 (reference range 9.60-11.33) and INR results that could not be calculated as the result greater than linearity. Resident #94 began showing signs of active bleeding on [DATE]. [...]

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to protect the resident's right to be free from sexual abuse and physical abuse by another resident of the facility for 1 of 39 current sampled residents, Resident #69. The facility staff failed to (1) protect Resident #69 from sexual abuse by another resident (Resident #98) on 4/15/26 and (2) protect Resident #69 from physical abuse resulting from an altercation with another resident (Resident #64) on 7/04/26. The facility's investigation determined that the altercation on 7/04/26 resulted in a closed fracture of the right fourth metatarsal neck thus constituting harm to Resident #69. The fourth metatarsal bone is a long bone located in the midfoot region connecting the midfoot to the fourth toe.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure competent staff to recognize a significant change in condition for one of 12 closed record reviews, Resident #95. The facility staff also failed to ensure nurse competencies, including skills assessments were completed for licensed nursing staff, Registered Nurse #7.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review the facility staff failed to protect residents from misappropriation of medications for 4 of 51 residents, Resident #12, Resident #44, Resident #90, and Resident #91.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review the facility staff failed to provide ADL (activities of daily living) care for 7 of 51 sampled residents, Resident #8, Resident #12, Resident #71, Resident #3, Resident #10, Resident #13, and Resident #89.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to follow medical provider orders for (11) eleven of (51) fifty-one sampled residents, Resident #9, Resident #10, Resident #13, Resident #43, Resident #8, Resident #48, Resident #33, Resident #69, Resident #42, Resident #55, and Resident #79.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide pharmacy services to meet the needs of the residents for nine of 51 residents, Residents #23, #44, #92, #8, #12, #2, #6, #33, and #90.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility kitchen.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered care plan for 3 of 51 sampled residents, Resident #94, Resident #2, and Resident #12.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to meet professional standards of practice for the documentation of medication administration for 2 of 51 residents, Resident #12 and Resident #90.

Inspectors wroteBased on staff interview, clinical record review and facility policy review, the facility staff failed to provide care and services to meet professional standards of quality for 1 of 7 resident's in the survey sample, Resident #2.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to maintain acceptable levels of nutritional status resulting in a significant 16-pound weight loss for 1 of 7 residents in the survey sample, Resident #2.

Inspectors wroteBased on staff interview, clinical record review and facility policy review, the facility staff failed to provide pain management to residents who require such services that are consistent with professional standards of practice for 1 of 7 residents in the survey sample, Resident #2.

Inspectors wroteBased on staff interview, clinical record review, facility document review and facility policy review, the facility staff failed to provide or obtain radiology services to meet the needs of its residents for 1 of 7 residents in the survey sample, Resident #5. This failure resulted in a delay in treatment for a left hip fracture sustained after a fall thus constituting harm.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to follow medical provider orders for one of seven residents in the survey sample, Resident #2.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to obtain medical provider ordered laboratory tests for one of seven residents in the survey sample, resident #2.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to maintain medical records in accordance with accepted professional standards and practices for 1 of 8 residents in the survey sample, Resident #8 (R#8).

Inspectors wroteBased on interviews, clinical record review, and facility document review, the facility staff failed to appropriately respond to a decline/change in condition (lethargy, oriented to person only, clammy skin, Cheyne-Stokes labored irregular breathing) for one 1 of nine 9 sampled residents (Resident #9), resulting in death. The scope and severity was originally cited at Immediate Jeopardy, Level IV isolated, and was reduced to a Level III isolated after the facility was cleared of Immediate Jeopardy. The Administrator, Director of Nursing (DON), and Quality Assurance (QA) Nurse were notified on [DATE] at 1:45 p.m. that the survey team had identified Immediate Jeopardy in the area of Quality of Care. Upon verification of the removal plan, the Immediate Jeopardy was cleared on [DATE] at 2:45 p.m.

Inspectors wroteBased on interviews, clinical record review, and facility document review, the facility staff failed to ensure medical provider orders were signed by the provider when the orders were entered into the residents' clinical records by non-prescribing facility staff members.

Inspectors wroteBased on interviews, clinical record review, and facility document review, the facility staff failed to respond to a request for a copy of clinical documentation in the required time frame for one (1) of nine (9) sampled residents (Resident #9).

Inspectors wroteBased on interviews, clinical record review, and facility document review, the facility staff failed to ensure a medical provider and/or a resident representative were promptly notified of a change in condition for two (2) of nine (9) sampled residents (Resident #8 and Resident #9). 1. The facility staff failed to promptly notify Resident #9's resident representative when the resident experienced a decline/change in condition. Resident #9's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/13/24, was signed as completed on 10/22/24. Resident #9 was assessed as able to make self understood and as able to understand others. Resident #9's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact or borderline cognition. [...]

Inspectors wroteBased on interviews, clinical record review, and facility document review, the facility staff failed to ensure one (1) of the medications ordered to be continued after hospital discharge was promptly ordered when admitted to the facility for one (1) of nine (9) sampled residents (Resident #9).

Inspectors wrote3. For Resident #9 the facility staff failed to develop and implement a baseline care plan. Resident #9's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/13/24, was signed as completed on 10/22/24. Resident #9 was assessed as able to make self understood and as able to understand others. Resident #9's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact or borderline cognition. This surveyor was unable to locate a baseline care plan in Resident #9's clinical record. On 11/21/24 at 12:40 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), and Quality Assurance Nurse (QAN). During this meeting, this surveyor asked for Resident #9's baseline care plan. On 11/21/24 at 3:55 p.m., the DON reported a baseline care plan for Resident #9 was unable to be found. [...]

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to develop and implement a comprehensive person centered care plan for one of nine residents in the survey sample, resident #2.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review the facility staff failed to provide necessary respiratory services for 1 of 7 residents, Resident #101.

Inspectors wroteBased on interviews, clinical record review, and facility document review, the facility staff failed to ensure a medication administered to Resident #9 (that had been dispensed by the pharmacy for another resident) was replaced to ensure its availability for the intended resident.

Inspectors wroteBased on interviews, clinical record review, and facility document review, the facility staff failed to maintain complete and/or accurate clinical records for one (1) of nine (9) sampled residents (Resident #9).

Inspectors wroteBased on observations and staff interviews, the facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This requirement was not met as evidenced by the fact that the facility staff failed to properly clean the convection oven, failed to properly clean the high-temperature dishwasher, and stacked wet pans together in the facility kitchen.

Inspectors wroteBased on staff interview, CRR, the facility staff failed to notify the physician of the failure to follow physician orders for 1 of 19 current residents reviewed (Resident #71). Resident #71 was admitted to the facility with diagnoses including traumatic spinal cord injury, quadriplegia, contractures of limbs, neurogenic bladder, coronary artery disease, hypertension, peripheral vascular disease, depression, and asthma. On the most recent minimum data set assessment, the resident scored 15/15 on the brief interview for mental status and without signs of delirium, psychosis, or behaviors affecting care. The resident had not rejected care in the 7 days prior to the assessment. During clinical record review, the surveyor noted a physician order dated 11/22/2023 to start 11/23/2023: Shower in shower room [ROOM NUMBER]x's (three times per) week. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure the residents call system was within reach for 1 of 19 current residents, Resident #15.

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to accurately document the completion dates of resident interview sections of Minimum Data Set (MDS) assessments for one (1) of 27 residents (Resident #91).

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to provide discharge information and follow-up discharge contact for one (1) of eight (8) discharged residents (Resident #91).

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide activity of daily living (ADL) care for 2 of 19 current residents. Resident #15 and Resident #84.

Inspectors wroteBased on observation, staff interview, resident interview, and clinical record review, facility document review, the facility staff failed to obtain ensure the highest practicable well-being for 3 of 27 residents, Residents #345, Resident #71, and Resident #91.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to act upon a pharmacist recommendation for 1 of 19 current residents, Resident #50.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 1 of 19 current residents, Resident #34.

Inspectors wroteBased on staff interviews and facility document review, the facility staff failed to ensure (a) a minimum of 18 months of posted daily nurse staffing information was maintained and (b) the posted daily nurse staffing information consistently and clearly included the resident census.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to provide Activities of Daily Living (ADL) care for 2 of 18 residents, Resident #29 and Resident #68. 1. Resident #29 was observed to have long, thick, and jagged fingernails and toenails. 2. Resident #68, the facility staff failed to provide ADL care in regards to bathing.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure 1 of 18 residents, Resident #28 were free of accident hazards. Resident #28 did not have their physician ordered wanderguard or chair alarm in place.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure 1 of 18 residents in the survey sample was free of unnecessary medication, Resident #45. For Resident #45, the facility staff administered Metoprolol Tartrate, a medication used to treat high blood pressure, on four separate occasions when it should have been held.

Inspectors wroteBased on staff interview, Resident interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 2 of 18 residents, Resident #286 and Resident #84. 1. For Resident #286, the facility staff documented that the resident has an arteriovenous (A-V) shunt for hemodialysis, when they do not. An A-V shunt is a connection, made by a surgeon, of a vein to an artery, in order to deliver hemodialysis treatments. 2. For Resident #84, the facility staff failed to follow their policy in regards to obtaining a signature on the inventory sheet upon discharge.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure that residents receive treatment and care by not following a physician ordered medication was kept under direct observation by the nursing staff until consumed by the resident for 1 of 23 of residents, Resident #71.