Inspection Reports for
Eagle Ridge Post Acute

The facility failed to ensure food served accommodated resident allergies, resulting in one resident being served fish despite a known allergy, causing anaphylactic shock requiring ICU admission. The facility implemented corrective education, audits, and system changes to prevent recurrence.

The facility failed to prevent Resident #1 from being served fish, which caused an anaphylactic shock requiring hospitalization. The investigation revealed staff did not check diet orders properly, resulting in disciplinary actions and terminations. The facility implemented immediate staff education, allergy audits, new signage, and monitoring to prevent recurrence.

The complaint investigation substantiated failures in notification of resident representatives, protection from abuse, discharge and readmission procedures, and provision of mental health services.

The facility failed to notify representatives of residents' significant changes in condition, failed to protect a resident from verbal and physical abuse by another resident, failed to allow a resident to return after hospital discharge with proper documentation, and failed to provide mental health counseling services to a resident with behavioral symptoms.

The facility failed to notify representatives of significant resident condition changes for two residents, failed to protect one resident from verbal and physical abuse by another resident, failed to allow a resident to return after hospital discharge with proper documentation, and failed to provide mental health counseling services to a resident with behavioral symptoms.

The complaint investigation was substantiated. Residents reported long waits for call light responses, some up to 46 minutes or more. Grievances submitted by Resident #20 regarding delayed care and call light response were not properly handled or followed up. The facility's grievance process was found deficient in tracking and responding to these concerns.

The facility failed to ensure prompt action was taken on grievances related to long call light response times and delayed care. Multiple residents reported wait times ranging from 30 minutes to over an hour for assistance, and grievances were not properly tracked or addressed in a timely manner.

The complaint investigation was substantiated with findings that residents experienced long waits for call light responses and delayed care, including being left in soiled bedding for extended periods. Grievances submitted by residents were not properly handled or followed up on by staff and administration.

The facility failed to ensure prompt action was taken upon the filing of grievances related to long call light response times and delayed care. Multiple residents reported wait times ranging from 30 minutes to over an hour for assistance, and grievances were not properly tracked or addressed in a timely manner.

The complaint investigation substantiated that Resident #1 was not assisted with turning in bed as requested, and Resident #8 did not receive all prescribed antibiotic doses due to medication refill failures.

The facility failed to assist Resident #1 with turning in bed upon request, violating resident rights to dignity and respect. Additionally, the facility failed to ensure Resident #8 received the full prescribed course of antibiotics, resulting in a significant medication error.

The complaint investigation found substantiated issues related to Resident #1's dignity and care preferences not being honored and Resident #8 missing seven doses of prescribed antibiotics due to pharmacy refill and communication failures.

The facility failed to ensure Resident #1 was assisted to turn in bed when requested, impacting dignity and care, and failed to ensure Resident #8 received all prescribed doses of antibiotics, resulting in a significant medication error.

The facility had multiple deficiencies including failure to promptly address resident grievances about call light response times, inadequate management of personal funds, failure to provide timely Medicare non-coverage notices, incomplete investigations of abuse allegations, failure to coordinate PASRR assessments, incomplete discharge summaries, failure to provide restorative therapy services, incomplete staff performance reviews and training, failure to post nurse staffing information, improper medication storage, failure to ensure proper diet textures, inadequate infection preventionist staffing, use of non-medical grade blood pressure cuffs, failure to maintain sanitary food preparation and storage, incomplete hospice care documentation, and ineffective quality assurance program implementation.

The facility failed to notify a resident's representative after a fall, did not provide restorative therapy services to a resident with limited range of motion, failed to prevent falls and monitor injuries, did not adequately address severe weight loss in a resident, served food that was often unpalatable and improperly prepared, failed to maintain infection control protocols including PPE use and cleaning procedures, did not offer hand hygiene before meals, failed to change soiled linens after wound care, and lacked an effective water management program.

The complaint investigation focused on multiple resident care concerns including call light response times, personal funds management, abuse allegations, PASRR assessments, discharge summaries, restorative therapy, staff training, medication management, food service, hospice care coordination, infection control, and quality assurance program effectiveness.

The facility failed to promptly address resident grievances about call light response times, failed to manage personal funds properly, did not provide timely Medicare non-coverage notices, failed to investigate an abuse allegation, failed to coordinate PASRR Level II evaluations, failed to complete discharge summaries, failed to assist a resident with new eyeglasses, failed to provide restorative therapy services, failed to complete annual CNA performance reviews and in-service training, failed to post nurse staffing information, failed to limit PRN psychotropic medications to 14 days, failed to properly store medications, failed to provide food according to physician orders and in a sanitary manner, failed to ensure hospice documentation was accessible, failed to maintain an effective QAPI program, failed to have a qualified infection preventionist, failed to use medical grade blood pressure cuffs, and failed to provide required staff training on abuse and dementia care.

The facility was found deficient in multiple areas including failure to notify resident representatives of changes in condition, failure to provide restorative therapy services, inadequate fall prevention and supervision, failure to maintain adequate nutrition and food quality, lapses in infection control practices including housekeeping and PPE use, failure to offer hand hygiene before meals, failure to change soiled linens after wound care, and lack of an effective water management program.

The complaint investigation was substantiated as the facility failed to prevent elopement of Resident #2, who was at risk for wandering. The resident eloped on 7/15/23, was missing for over seven hours, and was found with minor injuries. Staff interviews revealed lack of communication and inadequate monitoring.

The facility failed to identify goals and interventions on the baseline care plan to ensure Resident #2's safety related to elopement, failed to provide thorough shift reports about the resident's wandering, and failed to prevent Resident #2 from eloping. The resident was found after being missing for over seven hours with minor injuries. The facility lacked proper monitoring and use of wander guards despite documented risk.

The complaint investigation focused on Resident #2, who eloped from the facility on 7/15/23 and was missing for over seven hours. The resident was found with minor injuries on railroad tracks approximately four blocks from the facility. The family did not want the resident to return to the facility after discharge. The investigation found failures in care planning, supervision, and communication among staff.

The facility failed to identify goals and interventions on the baseline care plan for Resident #2's elopement risk, did not provide thorough shift reports about his wandering, and failed to prevent his elopement. Resident #2 was found missing for over seven hours with minor injuries after eloping from the facility.

The facility was found deficient in multiple areas including failure to provide adequate clean linens consistently, failure to ensure timely assistance with activities of daily living for residents, failure to provide timely treatment and care for acute pain resulting in delayed surgery, failure to monitor and document pain management properly, and failure to maintain sufficient nursing staff to meet resident needs.

The facility was found deficient in multiple areas including inadequate linen supply, failure to provide timely assistance with activities of daily living, delayed treatment for acute pain, failure to monitor and document pain management, and insufficient nursing staff resulting in delayed call light response and prolonged wait times for resident care.

The facility was found deficient in maintaining a sanitary and safe environment, ensuring proper call light placement and function for a high-risk resident, storing vaccines and medications according to guidelines, accurately documenting resident weights, and following infection control procedures for blood glucose monitoring devices.

The facility was found deficient in maintaining a sanitary and safe environment, ensuring proper fall prevention measures, accurate resident weight documentation, proper medication storage, and infection control practices. Several environmental hazards, malfunctioning call lights, improper vaccine storage, inaccurate weight records, and cross-contamination risks with blood glucose monitoring devices were identified.