Deficiency Records for Pine Ridge Skilled Nursing and Rehab
Updated as of March 01, 2024
A list of the most recent deficiencies for Pine Ridge Skilled Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-02-22 | 2022-07-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-02 | 2022-04-15 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-03-02 | 2022-04-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-03-02 | 2022-04-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-02 | 2022-04-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-02 | 2022-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-02 | 2022-04-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-02 | 2022-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-02 | 2022-04-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-02 | 2022-04-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-02 | 2022-04-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-03-02 | 2022-04-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-02 | 2022-04-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-02 | 2022-04-15 | N |
| Provide or obtain dental services for each resident. | Health | 2022-03-02 | 2022-04-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-22 | 2022-04-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-10 | 2021-11-12 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-11-10 | 2021-11-12 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-08-01 | 2019-10-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-08-01 | 2019-10-15 | N |
| Provide or obtain dental services for each resident. | Health | 2019-08-01 | 2019-10-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-07-31 | 2019-10-15 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-07-31 | 2019-10-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-31 | 2019-10-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-07-31 | 2019-10-15 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-07-31 | 2019-10-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-31 | 2019-10-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-31 | 2019-10-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-31 | 2019-10-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-31 | 2019-10-15 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-07-31 | 2019-10-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-31 | 2019-10-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-31 | 2019-10-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-03 | 2018-08-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-07-03 | 2018-08-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-07-03 | 2018-08-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-07-03 | 2018-08-22 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2018-07-03 | 2018-08-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-03 | 2018-08-22 | N |
| Keep all essential equipment working safely. | Health | 2018-07-03 | 2018-08-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-07-03 | 2018-08-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-07-02 | 2018-08-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-02 | 2018-08-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-02 | 2018-08-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-07-02 | 2018-08-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-07-02 | 2018-08-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-07-02 | 2018-08-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-07-02 | 2018-08-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-07-02 | 2018-08-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-02 | 2018-08-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-02 | 2018-08-22 | N |
