Pine Ridge Rehabilitation and Healthcare Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for one (#5) of six residents reviewed for accident hazards out of 32 sample residents. Resident #5 was admitted on [DATE] with a diagnosis of dementia. Resident #5 was at risk for falls related to impaired mobility and cognition. Resident #5, who had a history of falls with major injury, sustained an unwitnessed fall on 8/14/25. The facility re-educated the resident on the use of the call light. However, the resident had impaired cognition and did not always remember to use the call light. On 8/22/25 the resident sustained another unwitnessed fall. The resident sustained a laceration to her hand and a fracture of the metacarpal base to her left hand The resident was sent to the hospital and received sutures to the laceration. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for two out of four units. Specifically, the facility failed to:- Use appropriate infection control practices related to hand hygiene.- Follow infection prevention practices during the wound care of Resident #2

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure COVID-19 vaccinations were administered for five (#10,#24, #30, #35 and #5) of five residents out of 32 sample residents. Specifically, the facility failed to offer COVID-19 vaccine to Residents #10, #24, #30, #35 and #5, who requested one when they were offered.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#10 and #31) of eight residents out of 32 sample residents were free from abuse. Specifically, the facility failed to protect Resident #10 and Resident #31 from physical abuse toward each other.

Inspectors wroteBased on record review and interviews, the facility failed to report an alleged violation to the state survey and certification agency in accordance with state law for one (#49) of eight residents reviewed for an injury of unknown source out of 32 sample residents. Specifically, the facility failed to report Resident #49's death which resulted from an injury of unknown source, to the state oversight office, when the resident was found on the floor, unresponsive, with her head and neck lying on a trash can, with a coroner's finding of preliminary cause of death to be positional asphyxiation (suffocation).

Inspectors wroteBased on record review and interviews, the facility failed to fully investigate and document an investigation for one (#49) of eight residents reviewed out of 32 sample residents. Specifically, the facility failed to conduct and document a thorough investigation of Resident #49's death which resulted from an injury of unknown source, when the resident was found on the floor, unresponsive, with her head and neck lying on a trash can, with a coroner's finding of preliminary cause of death to be asphyxiation (suffocation).

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being one (#15) of six residents reviewed for unnecessary medications out of 32 sample residents. Specifically, the facility failed to discontinue or reevaluate a physician's order for Resident #16's as needed (PRN) lorazepam (an antianxiety medication) after 14 days.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of two medication storage carts. Specifically, the facility failed to:-Date residents' insulin pens and inhaler with the date they were opened; -Label a nasal spray with the resident's name;-Ensure a medication was not at the resident's bedside without an order; and,-Discard medications that have expired.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure four (#11, #12, #21 and #46) out of 18 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure blood pressure medication was ordered with administration parameters for Residents #11, #12, #21 and #46.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically, the facility failed to: -Ensure reheated food reached the appropriate temperature; and, -Ensure beard nets were worn in the kitchen.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#44 and #16) of seven residents reviewed for unnecessary medications out of 18 sample residents were free from unnecessary medications. Specifically, the facility failed to: -Ensure Resident # 44 was assessed by the interdisciplinary team (IDT) prior to implementation of a psychotropic medication treatment and appropriate non-pharmacological interventions were initiated; -Ensure Resident #16's psychoactive medication, an antidepressant, was not increased without evidence and documentation of change of behaviors or attempts of non-pharmacological interventions, and, -Resident # 16's hours of sleep were documented for hypnotic medication use.

Inspectors wroteBased on observations and interviews the facility failed to ensure one of one medication refrigerators stored narcotic medications in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator.

Inspectors wroteBased on record review and interviews, the facility failed to keep residents safe from accident hazards related to elopement for two (#43 and #10) of two residents reviewed out of 25 sample residents. Specifically, the facility failed to keep residents safe from elopement with the potential for serious injury on two back-to-back occasions. Resident #43 had severe dementia, was at risk for and had a history of elopement, and was discovered missing from the facility on 4/3/22 at 1:00 p.m. She had left the building at 9:35 a.m. and staff were unaware she was gone until they viewed camera footage more than four hours later. She was found by a neighbor and former staff member and returned by law enforcement to the facility at 3:35 p.m. She had been found sitting on the neighbor's front porch. Resident #43 was not injured. She had been missing for more than six hours. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to prepare, distribute and serve food in a sanitary manner in one of one kitchen. Specifically, the facility failed to: -Prevent potential cross contamination during meal preparation; -Demonstrate appropriate use of gloves during the meal service; -Ensure cold food items were stored and served at proper temperature to prevent potential food-borne illnesses; and, -Ensure food surfaces were properly sanitized.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement effective quality assurance/process improvement (QAPI) action plans to identify and address quality deficiencies regarding resident rights and resident care. Specifically, the facility failed to correct recurring deficiencies related to abuse, investigations, accident hazards, and infection control.

Inspectors wroteBased on interviews and record review, the facility failed to take timely action to follow up on grievances of the resident council group. Specifically, residents who regularly participated in resident council said facility staff did not take action on their grievances involving: -Residents who did not receive adequate staff supervision and dignified treatment, and repeatedly set off alarms and wandered into other residents' rooms; and, -Food quality and palatability, snacks and dining room concerns/choices. Residents said nothing ever gets done in resident council, and the concerns they brought forward were unresolved and ongoing. Residents further stated the concerns they discussed in resident council were not documented in the minutes.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents were free of abuse for six (#17, #45, #26, #28, #41 and #16) of eight out of 25 sample residents. Specifically, the facility failed to ensure: -Residents #17 and #45 were free from verbal abuse from staff; -Repeated resident-to-resident physical abuse incidents by Resident #16 directed toward other residents including Residents #26, #28 and Resident #41; and, -Physical abuse by Resident #22 against Resident #16 on two occasions. Cross-reference F610: failure to investigate an allegation of abuse.

Inspectors wroteBased on observations, record review and interviews, the facility failed to effectively address the treatment and service needs of three (#16, #39 and #22) of five residents reviewed for dementia care of 25 sample residents. Specifically, the facility failed to: -Provide dementia care and services to ensure Resident #39 was provided an appropriate level of meal assistance while promoting a dignified meal experience. -Provide dementia care and services to provide for resident needs and address repeated incidents of resident-to-resident aggression and abuse for Resident #16; and, -Provide dementia care and services for Resident #22.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper infection control practices for one of one dining rooms and one of one laundry rooms. Specifically, the facility failed to ensure: -Residents were offered hand hygiene prior to meals; and, -Proper personal protective equipment (PPE) was utilized in the laundry room.

Inspectors wroteBased on interviews and record review, the facility failed to investigate allegations of abuse for two (#17 and #45) out of 25 sample residents. Specifically, the facility failed to investigate abuse allegations against a staff member brought forward by Resident #17 and Resident #45. Cross-reference F600 for abuse.

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan for four (#14, #18, #24 and #39) of 12 out of 25 sample residents for services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to: -Develop a comprehensive, person-centered care plan to effectively address multiple falls and psychotropic medications for Resident #39; -Continue to provide updated care planned fall interventions for Resident #14 after his multiple falls; -Develop a comprehensive, person-centered care plan to effectively address multiple falls and weight loss for Resident #18; and, -Develop a person-centered care plan for multiple falls, restorative services and activities needs for Resident #24.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of one medication storage rooms and one of two medication storage carts. Specifically, the facility failed to ensure proper date of opening for a multi use tuberculin vial and an insulin pen.