Pine Ridge Care Center

In the surveyor’s words

From the most serious findings on record at Pine Ridge Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 21, 2023

  Based on interview and record review, the facility failed to supervise and assist two of two residents with generalized muscle weakness and requiring assistance with personal care (Residents 1 and 2) to prevent accidents. For Resident 1, the facility failed to supervise and assist the resident while using the commode (a portable toilet chair with a removable basin placed next to the bed of residents with mobility deficits to facilitate toileting). This failure resulted in Resident 1 getting up unassisted from the commode and falling forward face down on the floor, causing a neck fracture (broken bone) requiring hospitalization and surgical repair. For Resident 2, the facility failed to supervise and assist the resident while attempting to get out of the bed to use the commode. […]

• Actual harm, isolatedF689May 24, 2023

  Based on observations, interviews, and record reviews, the facility failed to ensure the safety of one resident, Resident 1, when she was not provided adequate supervision and assistance with transfer and mobility, based on her plan of care to prevent falls and plan of care related to visual deficit (a lack or deficiency in vision). This failure had resulted in a fall with fracture (broken bone) to Resident 1 that caused her to be in severe pain and required a surgical procedure to repair the affected hip. […]

• No harm, potential for more than minimal, widespreadF756Dec 5, 2025

  Based 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.Findings:During a review of the MRR facility binder on 12/4/25 at 9:21 a.m., the Consulting Pharmacist's October 2025 MRR report was not observed in the MRR.During an interview with the Director of Nursing (DON) on 12/5/25 at 11:30, a copy of the October 2025 MRR… […]

• No harm, potential for more than minimal, widespreadF812Dec 5, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF576Aug 12, 2021

  Based 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. Findings: During an interview with Resident #40 on 8/2/21 at 11:22 a.m., he stated: All our mail is open, two state letters opened. Resident deliveries are left outside front door and the Administrator has to go through it. Resident 40 stated this was a violation of privacy. During an interview with Resident #40 on 8/3/21 at 11:07 a.m., he stated: I had a letter from CDPH that was opened. […]