Pine Ridge Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 15, 2022

  Based 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. […]

• Actual harm, isolatedF689Feb 12, 2026

  Based 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. […]

• Actual harm, isolatedF600Jun 10, 2021

  Based on resident and staff interviews and record review, the facility failed to ensure residents were free from physical and sexual abuse for two (#10 and #16) out of seven residents reviewed for abuse out of 26 sample residents. Resident #10 was involved in three separate incidents of resident to resident abuse while residing in the facility. He was the victim of two of incidents of abuse involving Resident #20 and Resident #200. Resident #10 also sexually abused Resident #16's by touching her breast. The facility's failure to prevent abuse subjected Resident #10 and Resident #16 to abusive situations. Resident #10 experienced a cut lip and scratched face (separate incidents) and Resident #16 experienced a change in psychosocial condition immediately following a sexual abuse incident. […]

• Actual harm, isolatedF760Mar 12, 2021

  Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for [MEDICATION NAME] administration out of three sample residents did not experience a significant medication error. Resident #1 was admitted to the facility for skilled rehabilitation after a fall with multiple inoperable fractures. The resident had scheduled and as-needed (PRN) [MEDICATION NAME] (narcotic [MEDICATION NAME]) orders for pain management. Over the course of five days (,[DATE]-[DATE]), the resident experienced a significant medication error with multiple doses of scheduled and PRN [MEDICATION NAME] resulting in duplicative doses, which required two doses of [MEDICATION NAME] to reverse the effects of an [MEDICATION NAME] overdose. […]

• No harm, potential for more than minimal, widespreadF880Feb 12, 2026

  Based 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 Findings include: I. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, retrieved on 2/18/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, It read in pertinent part, CDC provides the following recommendations for hand hygiene in healthcare settings. […]