Pine Ridge Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by another resident, when Resident 6 yelled and cursed at one of four residents sampled for abuse (Resident 7) after they became roommates on 12/10/25. This failure caused Resident 7 to be upset and angry and had the potential to negatively impact her psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled resident's (Resident 6) Minimum Data Set (MDS, a federally mandated resident assessment tool) accurately reflected the resident's condition when Resident 6 was assessed as having no verbal behaviors impacting other people. This failure placed Resident 6 at risk for inadequate care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one resident (Resident 1) with respect and dignity when Resident 1's personal motorized wheelchair was taken from her after she had difficulty returning to the facility after an outing to see a movie. This failure caused the resident to lose her independence and subjected her to the discomfort of a facility wheelchair that was not appropriate for her medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Consulting Pharmacist conducted a monthly Medication Regimen Review (MRR- the process by which a Consultant Pharmacist reviews medication used for a patient and identifies medications that may no longer be necessary or may be more appropriate in a lower dose) for a census of 81 residents. This failure decreased the facility's potential to ensure residents were not administered unnecessary medications that can cause serious side effects or adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food service safety for a census of 83 when:1. One cook did not cover his beard while working around food in the kitchen;2. Prepared sandwiches were unlabeled and undated in Refrigerator 1 and an open bag of chicken breasts was unlabeled and undated in Freezer 1;3. Two seasoning containers were past their use-by dates;4. Sealed cardboard boxes labeled Mashed Potatoes, received 11/26/25, were found directly on the floor in dry storage area on 12/2/25; and5. A manual can opener had missing metal on the tip of the blade. These failures had the potential to contribute to the spread of foodborne illnesses among a vulnerable resident population.

Inspectors wroteBased on interview and record review, the facility staff failed to inform and offer written information regarding Advance Directives (AD-a legal document which specifies healthcare wishes and appoints someone to make decisions in cases of an inability to communicate with the healthcare team) to 9 residents (Residents 45, 2, 67, 76, 6, 73, 16, 53, and 84) out of a census of 83 residents when there was no documented evidence of written or verbal information was communicated to each resident regarding the formulation and execution of an AD upon admission or thereafter as legally mandated. This failure decreased the facility's potential to provide care consistent with residents' wishes should they become incapacitated.

Inspectors wroteBased on interviews and record reviews, the Interdisciplinary Team (IDT, a group of professionals from different fields who work closely and collaboratively to coordinate care to achieve resident goals) failed to meet as a complete team to provide quarterly care conferences for four residents (Resident 5, Resident 76, Resident 67, and Resident 3) of 21 sampled residents. This failure resulted in a lack of oversight to determine whether resident goals were achieved and what revisions needed to be made to assist the residents to achieve their goals.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to serve food that was palatable, attractive, and appetizing for 6 residents (Resident 51, Resident 63, Resident 70, Resident 75, Resident 89, and Resident 90) of 21 sampled residents when they complained the food was terrible and dissatisfying. This failure decreased the facility's potential to prevent unplanned weight loss and could negatively affect the health and well-being of the affected residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide drinks consistent with resident preferences for six residents (Residents 21, 29, 33, 43, 69, and 74) of 16 sampled residents when hot beverage service was unavailable for over two weeks. This failure caused the residents to feel unhappy and dissatisfied with the dietary services provided.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge for one resident (Resident 100) of four sampled residents when Resident 100 required assistance with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and was discharged to an Independent Living Facility (ILF) that did not provide assistance. This failure decreased the facility's potential to ensure the Resident 100's continuity of care needs was met upon discharge into the community.

Inspectors wroteBased on observation, interview, and record review, nursing staff failed to develop a care plan for one resident (Resident 53) when there was no care for Resident 53's use of oxygen therapy. This failure decreased the facility's potential to meet Resident 53's needs, as well as cause a decline in Resident 53's physical health and emotional well-being.

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide communication services to one resident (Resident 8) out of 21 sampled residents when translation services were not used to communicate with Resident 8 whose primary language was Mandarin. This failure decreased the facility's potential to prevent a decline in Resident 8's ability to perform Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and a decline in ensuring Resident 8 received necessary care and services.

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident 67) of 21 sampled residents was screened for a need for trauma-informed care when upon admission. This failure decreased the facility's potential to provide culturally competent care that minimized triggers or further traumatized Resident 67.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment was clean and in a usable state for one resident (Resident 76) out of 21 sampled residents when the rented oxygen concentrator in Resident 76's room had visible dust and debris in the vents and needed a filter change. This failure decreased the facility's potential to prevent bacteria and debris directly enter Resident 76's lungs, placing her at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from abuse when Resident 2 struck her on the left cheek. This failure had the potential to result in serious physical harm to Resident 1.

Inspectors wroteBased on interviews and record reviews, the facility failed to immediately notify the responsible party (RP, a person who is designated in making decisions about health care and financial matters) for one out of two residents (Resident 1), when Resident 1's RP was not notified until 4/20/25 that Resident 1 fell on 4/18/25 and 4/19/25. This failure was a violation of residents' rights.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a summary of the baseline care plan (BCP, a document created within 48 hours of a resident's admission to a nursing home, outlining the initial care needed to ensure residents' safety and well-being, focusing on basic needs and resident-specific information) was provided for one resident out of two sampled residents (Resident 1), when there was no documentation indicating Resident 1's responsible party (RP, a person who is designated in making decisions about health care and financial matters) was provided the BCP summary. This failure has the potential to decrease the RP's ability to be informed about Resident 1's care and services.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was provided an environment free of accident hazards and received adequate supervision to prevent accidents, when Resident 1 fell from a wheelchair (WC) provided by the facility. This failure could result in the increased risk of accidents.

Inspectors wroteBased on interview and record review, the facility failed to report to the Department an injury of unknown source (an injury which was not observed, cannot be explained by the resident, and is suspicious because of the extent or location) for one of four sampled residents (Resident 1) when Resident 1 sustained a broken left arm. The facility was aware of Resident 1's injury on 7/6/25, but did not report it to the Department until 7/8/25. This failure resulted in a delay in the Department's investigation into Resident 1' s injury and its cause, putting Resident 1 at risk for additional harm. [...]

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure nursing staff were able to correctly state the facility ' s policy on how and when to perform Cardiopulmonary Resuscitation (CPR - an emergency procedure that combines chest compressions (the action of pushing hard and fast on the chest while performing CPR) and rescue breathing to restart a person ' s heartbeat and breathing) and Basic Life Support (BLS- a set of life-saving procedures performed on someone if/when their heart stops beating or the person has difficulty breathing until advanced medical help arrive) when four nursing staff (Certified Nursing Assistant A (CNA A), Licensed Nurse C (LN C), LN D, and LN G) of six nursing staff incorrectly stated the facility ' s policy; 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of nursing care for one resident (Resident 1) of three sampled residents when laboratory tests were not completed per physican orders. This failure had the potential to delay treatment for Resident 1.

Inspectors wroteBased on record review, interview, and document review, the facility failed to complete the quarterly Minimum Data Set (MDS) for 2 (Resident #5 and Resident #22) of 18 sampled residents. The facility further failed to timely complete a quarterly MDS for 2 (Resident #1 and Resident #48) of 18 sampled residents.

Inspectors wroteBased on observation, interview, record review, document review, and facility policy review, the facility failed to ensure staff provided a communication board and a pointer to 1 (Resident #189) of 2 sampled residents reviewed for communication.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the environment of a resident did not provide a means to exit the facility without staff knowledge for 1 (Resident #13) of 3 sampled residents reviewed for accidents.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 7 (Rooms 26 through 29, room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 45 resident rooms in the facility.

Inspectors wroteBased upon observation, interview and record review, the facility failed to ensure the safety of one sampled resident (Resident 1), when he was allowed to leave out on pass (physician approval to leave for a few hours at a time) without a physician ' s order and against facility policy. This failure resulted in Resident 1 purchasing alcohol, consuming three fifths of vodka and attempting to leave the facility against medical advice (without the doctors orders or a discharge plan) while intoxicated.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse within the required timeframes when allegation was not reported to authorities within the required two hours timeframe after the facility was notified of the allegation. This failure to report allegations of abuse within the federally mandated requirement of two hours, had the potential to contribute to ongoing resident physical abuse, as well as the potential for mental and emotional harm. It also delayed the timely investigation by authorities.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) received care in accordance with professional standards of practice when Resident 1 had a physician's order for monthly body weights and the facility did not weight Resident 1 monthly. This failure had the potential for Resident 1 to have undetected weight loss or gain and not receive respective medical interventions.

Inspectors wroteBased on interviews and a record review, the facility failed to ensure residents' privacy as well as residents' timely receipt of mail items when two residents (Resident 40 and Resident 19) had received opened mail, and all residents did not receive mail promptly on weekends. This failure had the potential to cause residents to feel isolated from society and disrespected by the facility.

Inspectors wroteBased on observation and interview, the facility failed to post the results of recent Federal or State surveys, including plans of correction, in an area accessible to all residents. This failure did not ensure residents' rights to access survey results for review

Inspectors wroteBased on observation, interview, and record review, the facility failed to post grievance and complaint notices in a manner accessible to all residents, when it posted grievance and complaint notices in areas that were difficult for residents using wheelchairs to view. This failure did not ensure resident rights, and had the potential to delay the facility's identification and response to resident needs or complaints.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and modify comprehensive care plans for five sampled residents (Residents 42, 45, 51, and 87) that were person-centered. These failures had the potential result in care and services that did not meet residents' needs, as well as cause a decline in residents' physical health and emotional well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety of residents when: 1. Two residents (Residents 19 and Resident 79) left the facility without supervision; and 2. The facility disposed unused medications using sharps containers (a sturdy, puncture-resistant plastic container for sharp items) and placed sharps containers in an unlocked storage room. These failures had the potential to result in accidents and/or injuries to Residents 19 and 79 while alone and unsupervised, and had the potential to result in diversion of medication or resident injury arising from access to harmful medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the usual body weight of one resident (Resident 42) as evidenced by repeated delayed assessment and follow-up by the registered dietitian and repeated delayed implementation of registered dietician's recommendations. This failure could lead to the potential for further decline for Resident 42 who was considered at nutritional risk and experiencing impaired nutrition status. Weight loss is also associated with other negative outcomes such as impaired wound healing or increased risk of death.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure attending physicians responded to the Consultant Pharmacists recommendations for Antipsychotic Medications (e.g., medication that alters brain chemistry to reduce psychotic symptoms such as harmful behaviors, hallucinations, delusions, and disordered thinking) for 10 residents (Residents 86, 62, 45, 55, 76, 59, 75, 66, 71 and 37). This failure had the potential for resident harm, including death, due to the increased risk of adverse side effects related to Antipsychotic Medication use.

Inspectors wroteBased on observation, interview and record review, the facility failed to initiate Gradual Dose Reductions (GDR), for 10 residents (Residents 86, 62, 45, 55, 76, 59, 75, 66, 71, and 37) on Antipsychotic Medication (e.g., medication that alters brain chemistry to reduce psychotic symptoms such as harmful behaviors, hallucinations, delusions, and disordered thinking), when the facility did not implement a GDR as recommended by the facility's pharmaceutical consultant, or document specific clinical contraindications for a GDR when a GDR was not performed. These failures had the potential to cause harmful side effects for residents receiving due to prolonged use of antipsychotic medications, including death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure there was enough dietary and food nutrition staff in the kitchen to carry out the functions of the food and nutrition service safely and effectively. This failure resulted to the Dietary Manager cooking dinner and breakfast for two days in the absence of a cook.

Inspectors wroteBased on observation and record review, the facility failed to follow the approved menu and physician diet orders for 1 of 15 residents on puree diet (Resident 24), 1 of 2 residents on low fat low cholesterol renal diet (Resident 43), 1 of 7 residents on small portion regular diet (Resident 9), and 1 of 13 residents on low fat low cholesterol diet (Resident 93). This failure can result in undesirable changes of nutritional status, impaired healing, or poor well-being of residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Kitchen staff practiced safe food handling habits to prevent contamination of food; and 2. Expired food items were disposed by expiration date. These failures could potentially result to food safety hazards, food contamination and outbreak of foodborne illness among residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure its Medical Director coordinated physician services for residents, when the Medical Director did not ensure attending physicians followed policy for Gradual Dose Reductions (GDR) and monitoring of residents on antipsychotic medications. This failure did not demonstrate appropriate physician leadership and had the potential to cause resident harm related to side effects of prolonged use of antipsychotic medications.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Performance Improvement (QAPI) committee failed to identify and address quality deficiencies, when the facility's QAPI committee: 1. Had knowledge of a concern raised by its pharmaceutical consultant but the committee did not develop an action plan to correct the concern; 2. Did not prioritize known deficiencies, or establish goals for monitoring, tracking, and correcting deficiencies for Resident Care. These failures did not ensure the facility implemented QAPI system, and had the potential to negatively impact residents' quality of care and quality of life through the facility not addressing resident care issues or ensuring its provision of care was performed at the highest level and in the safest environment.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Performance Improvement (QAPI) committee failed to develop and implement a plan of action to correct an identified quality deficiency, when the facility's QAPI committee did not develop or implement a plan of action to correct a quality deficiency concerning antipsychotic prescribing and gradual dose reductions (GDR). This failure did not comply with facility policy or ensure care to maintain the highest level of resident functioning.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe and sanitary environment in the kitchen as evidence by cracked tiles on several areas in the kitchen floor. This failure could cause trips and falls among the kitchen staff and cause dirt to build up on the floor attracting cockroaches and rodents.