Pine Ridge Health Care LLP

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents with IV (intravenous) lines (Resident #75) and 1 of 2 staff performing fingerstick blood sugar checks (RN F) reviewed for infection control. *The facility did not initiate Enhanced Barrier Precautions (EBP) and ensure staff wore appropriate PPE when providing care on Resident #75 with a midline IV. *The facility did not ensure glucometers were disinfected with the appropriate EPA approved disinfectant by RN F. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical and electrical equipment in safe operating condition for 1 of 1 facility kitchen. The vegetable freezer had accumulation of ice build-up with damaged and worn freezer door seals. This failure had the potential to affect residents by placing them at risk for food borne illness. Findings An observation of the vegetable freezer and interview on 05/18/2026 at 9:45 a.m., indicated the temperature was 20 degrees Fahrenheit. The vegetable freezer had excessive amount of ice built-up around the bottoms of door 1 and door 2 and both door seals were worn and torn. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the services provided met professional standards of quality, for 1 of 2 residents (Resident #76) reviewed for PICC line/midline. *The facility did not ensure LVN B used the appropriate size syringe for the Heparin flush to flush Resident #76's midline. This failure could place residents at risk of increased pressure in the PICC line/midline which can cause catheter damage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer parenteral fluids consistent in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, for 1 of 2 (Resident #76) residents reviewed for IV (intravenous: administering fluids or medications directly into a vein) fluids. *The facility did not ensure LVN B used the appropriate size syringe for the Heparin flush to flush Resident #76's midline. This failure could place residents at risk of increased pressure in the PICC line/midline which can cause catheter damage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 7 residents (Resident #46) reviewed for respiratory therapy. The facility failed to keep the oxygen concentrator filter clean for Resident #46. This failure could place residents at risk of receiving incorrect or inadequate oxygen support which could result in a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications for 1 of 23 residents (Resident #57) reviewed for unnecessary medications. The facility did not monitor Resident #57's Eliquis (blood thinner) medication for side effects. This failure could place residents at risk for unintended, harmful events attributed to the use of medication without monitoring for side effects.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 1 of 18 residents (Resident #41) reviewed for ADLsS. The facility failed to ensure Resident #41's fingernails were trimmed. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of physical, mental, and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident maintained acceptable nutritional status, such as usual body weight or desirable body weight, unless the resident clinical condition demonstrated this was not possible for one of 18 residents (Resident #12) reviewed for nutritional status. The facility failed to identify Resident #12's significant weight loss over the previous 6 months. This failure could place residents at risk for not receiving care and services to maintain their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs to each resident for 1 of 10 residents reviewed for medications. (Resident #111) The facility failed to ensure Resident #111 was not administered a saline IV flush before administration of an IV antibiotic, IV saline, and an IV heparin flush after medication administration (SASH-saline administer, saline heparin) without a physician's order. This failure could place residents at risk of consuming unprescribed medications, harm, and hospitalization.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 (Resident #16) residents observed for infection control. The facility failed to ensure LVN B and LVN C followed the EBP (enhanced barrier precautions) for Resident #16. This failure could place the residents at risk of cross-contamination and the development of infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 laundry room reviewed for essential equipment. The facility did not ensure 1 of 2 washing machines (right washing machine) and 2 of 3 dryers (middle and right dryer) were in safe operating condition. This failure could place the residents at risk of a fire and not receiving their clothes in a timely manner.

Inspectors wroteBased on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 4 residents (Resident #1) reviewed for neglect. The facility failed to develop and implement a written abuse and neglect policy for reporting abuse or neglect causing serious bodily injury immediately, but no later than 2 hours to the State Survey Agency (THHSC) which resulted in a failure to report an allegation of neglect with serious bodily injury of Resident #1. This failure could place all residents at risk for potential abuse due to unreported allegations of abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all alleged violations involving neglect that resulted in serious bodily injury of resident was reported immediately to the administrator or abuse coordinator and to THHSC within the 2-hour period for 1 of 4 residents (Resident #1) reviewed for neglect. The facility failed to ensure allegations of resident neglect with serious bodily injury were immediately reported to the administrator or abuse coordinator and to the State Agency no later than 2 hours after the incident occurred or was suspected. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. * The facility did not ensure baking sheets did not have brown and/or black baked on build up and stacked together. * The facility did not ensure the juice dispenser wand did not have cream colored build up inside. * The facility did not ensure a handwashing sink had a trash can for disposable paper towels. * The facility did not ensure skillets did not have brown baked on build up and stacked together. * [NAME] A did not ensure food was at a safe temperature prior to serving food to residents. * The facility did not ensure muffin pans did not have brown baked on build up and stacked together. These failures could place residents who eat from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for services for 2 of 3 residents reviewed for PASRR (Residents #04 and #50). * The facility did not have an accurate PASRR Level 1 Screening (P1) for Residents #04 and #50 upon admission therefore a PASRR Evaluation (PE) was not conducted. This failure could place residents who have a diagnosis of mental disorder, developmental disability or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice for 3 of 18 residents reviewed for respiratory care and services. (Residents #6, #265, and #314) The facility failed to obtain a physician order for oxygen administration for Resident #6, Resident #265, and Resident #314. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the right to formulate an advance directive was provided for 2 of 2 residents reviewed for advanced directives. (Residents #50 and #164) The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Residents #50 and #164. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 2 of 13 residents (Residents #23 and #57) reviewed for MDS assessment accuracy. * The facility did not accurately code Resident #23's MDS assessment for smoking. * The facility did not accurately code Resident #57's MDS assessment for weight loss. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure nurse aides were able to demonstrate competency in providing incontinence care necessary to care for 1 of 1 CNAs (CNA B) observed for incontinent care. * CNA B did not change gloves, sanitize/wash hands between glove changes, touched clean items with dirty gloves, and did not completely clean Resident #04 when providing incontinent care. This failure could place residents who required incontinent care at risk for an unsanitary environment, cross contamination, and infection.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #04) observed for incontinent care. * CNA B did not change gloves, sanitize/wash hands between glove changes, touched clean items with dirty gloves, and did not completely clean Resident #04 when providing incontinent care. This failure could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 11 residents (Resident #7) reviewed for accuracy of clinical records. The facility did not ensure the code procedure for Resident #7 was accurately timed in nurse's note. This failure could place residents at risk of not receiving care and services to meet their needs.