Pine Ridge Health and Rehabilitation Center

Inspectors wrote2. Resident #2 was admitted to the facility 10/17/2009 with diagnoses including heart failure and diabetes. The most recent quarterly Minimum Data Set assessment dated [DATE] assessed Resident #2 to be moderately cognitively impaired and she received oxygen therapy. A physician order dated 4/3/25 specified for oxygen to be administered at 2 liters per minute by nasal cannula. Resident #2 was observed on 6/2/25 at 1:54 PM. She had oxygen administered by nasal cannula at 2 liters per minute. No oxygen cautionary sign was noted on the door to her room or in her room. Resident #2 was observed with oxygen administered by nasal cannula at 2 liters per minute on 6/3/25 at 8:53 AM. No cautionary oxygen sign was observed. An observation of Resident #2 oxygen administered by nasal cannula at 2 liters per minute was conducted on 6/4/25 at 2:58 PM and no cautionary oxygen sign was observed. [...]

Inspectors wroteBased on record reviews and Medical Director and staff interviews, the facility failed to hold blood pressure medications as ordered by the physician (Resident #13). This was for 1 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and Medical Director and staff interviews, the facility failed to prevent Resident #83 from receiving a dose of Lyrica (a medication used to treat nerve and muscle pain) that was prescribed for Resident #13. This affected 1 of 6 residents whose medications were reviewed (Resident #83).

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to provide treatments as ordered by the physician for a non-pressure wound for 1 of 4 residents reviewed for non-pressure skin integrity (Resident #292).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide effective supervision for residents with severely impaired cognition that resided on the memory care unit. Resident #91 had a history of wandering and wandered into Resident #92's room and Resident #91 hit Resident #92 in the nose, which caused Resident #92 to sustain a closed fracture of the nasal bone. This was for 1 of 3 residents reviewed for accidents (Resident #92).

Inspectors wrote3. Resident #63 was admitted to the facility 7/30/24 with her most recent readmission on [DATE]. Diagnoses for Resident # 63 included stroke and feeding tube. a. Review of the medical record for Resident # 63 revealed a nursing change of condition note dated 10/30/24 at 11:53 PM. The note documented a change of condition for Resident #63 and a physician order was received to transfer her to the hospital for evaluation and treatment. A nursing progress note dated 11/4/24 documented Resident #63 was readmitted to the facility. Review of the medical record revealed no notice of transfer was in the record for the hospitalization from 10/30/24 to 11/4/24. b. [...]

Inspectors wrote2. Resident #1 was initially admitted to the facility on [DATE]. A review of Resident #1's active physician orders included the following orders: - An order dated 8/18/24 for oxygen at 3 liters per minute via nasal cannula. - An order dated 4/3/25 for oxygen at 2 liters per minute via nasal cannula. Keep oxygen saturations greater than 90%. A review of the May 2025 and June 2025 Medication Administration Records (MARs) revealed an entry for oxygen at 3 liters per minute via nasal cannula. The MARs had a check mark and staff initials for day and night shift. In addition, the MARs had entry for oxygen at 2 liters per minute via nasal cannula. Keep oxygen saturations greater than 90%. The MARs had a check mark and staff initials for day and night shift. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to: 1) Discard expired medications stored on 1 of 2 medication (med) carts (200 Hall Med Cart) and in 1 of 1 Med Storeroom (100/200/300 Hall Medication Storeroom); 2) Date injectable medications as to when they were opened to allow for the determination of its shortened expiration date for medications stored on 1 of 2 med carts (200 Hall Med Cart) and in 1 of 1 Med Storeroom (100/200/300 Hall Medication Storeroom); and 3) Store medications in accordance with the manufacturer's storage instructions on 1 of 2 med carts (200 Hall Med Cart).

Inspectors wroteBased on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint surveys completed on 6/17/21 and a complaint investigation completed on 2/24/22. This was for 4 deficiencies that were cited in the areas of: Resident Rights/Exercise of Rights (550) which was cited on 6/17/21, 2/24/22 and recited on the current recertification and complaint survey of 4/13/24; Right to Participate in Planning Care (553) which was cited on 6/17/21 and recited on the current recertification and complaint survey of 4/13/24; Develop/Implement Comprehensive Care Plan (656) which was cited on 6/17/21 and recited on the current recertification and complaint survey of 4/13/24; [...]

Inspectors wroteBased on record review, resident, staff interviews and student interviews, the facility failed to treat a resident in a dignified manner for 1 of 23 residents reviewed for dignity (Resident #17). Nurse #2 told Resident #17, in a loud and demeaning tone, to get back in her room and stop stalking her. Resident #17 stated Nurse #2's statement made her feel embarrassed and humiliated to be spoken to as if she were a child.

Inspectors wroteBased on record reviews, residents, family and staff interviews the facility failed to offer 2 residents (Resident #47 and Resident #49) and 1 family member (Resident #80) the opportunity to participate in care plan meetings. This was discovered for 3 of 5 sampled residents reviewed for care planning

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan which included an area of focus related to nutrition for 2 of 5 residents (Resident #90 and Resident #75) reviewed for nutrition.

Inspectors wroteBased on staff and consultant pharmacist interviews and record reviews, the facility failed to limit the duration of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) ordered on an as needed (PRN) basis to 14 days and/or indicate the duration and rationale for the PRN order to be extended beyond 14 days, when appropriate. This occurred for 2 of 7 residents whose medications were reviewed (Resident #71 and Resident #73).

Inspectors wroteBased on record review and staff interviews the facility failed to provide consents with the benefits and risks of receiving the influenza vaccine for 2 of 5 residents (Resident #64 and Resident #80). Resident #64 did not receive the influenza vaccine at the Responsible Party's request and Resident #80 was not offered the influenza vaccine.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain walls (Rooms 111 B, 114 B, and 115 A) and a door (room [ROOM NUMBER]B) in good repair for 3 of 15 rooms (rooms [ROOM NUMBER]) on the 100-hall reviewed for environment.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to have written physician orders for the continued care of the indwelling urinary catheter for 1 of 3 residents reviewed for indwelling urinary catheter care (Resident #8).

Inspectors wroteBased on record review, observation, and staff interviews the facility failed to maintain a medication administration error rate of less than 5% as evidenced by a medication rate of 8% (2 out of 25 opportunities) (Resident #69).