Inspection Reports for
Pine Ridge Rehabilitation and Healthcare Center
119 BASTILLE DR, PAGOSA SPRINGS, CO, 81147-9388
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 4
Date: Jan 10, 2024
Visit Reason
Routine inspection to evaluate compliance with professional standards of care, medication management, psychotropic medication use, medication storage, and food safety practices at Pine Ridge Rehabilitation and Healthcare Center.
Findings
The facility failed to ensure blood pressure medications had administration parameters for some residents, psychotropic medications were used appropriately with proper assessments and non-pharmacological interventions, controlled medications were stored securely, and dietary staff followed safe food reheating and hair restraint practices.
Deficiencies (4)
F 0658: The facility failed to ensure blood pressure medication was ordered with administration parameters for Residents #11, #12, #21, and #46, risking adverse effects from hypotension and bradycardia.
F 0758: The facility failed to ensure two residents (#44 and #16) were free from unnecessary psychotropic medications, lacking interdisciplinary assessments, non-pharmacological interventions, and proper documentation.
F 0761: The facility failed to ensure controlled medications in the medication refrigerator were stored in locked containers permanently affixed to the refrigerator, risking unauthorized access.
F 0812: The facility failed to ensure reheated food reached the appropriate temperature and that dietary staff wore beard nets in the kitchen to prevent food contamination.
Report Facts
Sample residents reviewed: 18
Residents affected by blood pressure medication deficiency: 4
Residents affected by psychotropic medication deficiency: 2
Medication administration dates: 3
Blood pressure readings: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding blood pressure medication administration and medication refrigerator storage |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration policies and medication storage |
| Corporate Dietary Manager | Corporate Dietary Manager | Interviewed regarding food reheating practices and hair restraint policies |
| Medical Director | Medical Director | Interviewed regarding psychotropic medication prescribing for Resident #44 |
Inspection Report
Routine
Deficiencies: 10
Date: Sep 15, 2022
Visit Reason
Routine inspection of Pine Ridge Rehabilitation and Healthcare Center to assess compliance with regulatory requirements including resident rights, abuse prevention, care planning, elopement prevention, medication storage, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to follow up on resident grievances, failure to prevent resident-to-resident abuse, failure to investigate abuse allegations, inadequate care planning for residents with falls, weight loss, and dementia, failure to prevent elopement resulting in immediate jeopardy, improper medication storage, food safety violations, and inadequate infection control practices.
Deficiencies (10)
F 0565: Facility failed to take timely action to follow up on grievances of the resident council group regarding staff supervision, dignified treatment, and food quality concerns.
F 0600: Facility failed to protect residents from verbal and physical abuse by staff and other residents, including repeated resident-to-resident abuse involving Resident #16 and failure to investigate abuse allegations.
F 0610: Facility failed to investigate abuse allegations against staff brought forward by Residents #17 and #45 in a timely and effective manner.
F 0656: Facility failed to develop and implement comprehensive, person-centered care plans for multiple residents (#14, #18, #24, #39) addressing falls, weight loss, restorative services, and psychotropic medication use.
F 0689: Facility failed to ensure residents were safe from elopement, resulting in two residents (#43 and #10) eloping on separate occasions with delays in discovery and return, creating immediate jeopardy.
F 0744: Facility failed to provide appropriate dementia care and services to residents (#16, #22, #39), including failure to address repeated resident-to-resident aggression and provide adequate meal assistance.
F 0761: Facility failed to ensure proper labeling and storage of medications, including unlabeled multi-use tuberculin vial and insulin pen without date of opening.
F 0812: Facility failed to prevent potential cross contamination during meal preparation and service, failed to demonstrate appropriate glove use, failed to maintain cold food at proper temperature, and failed to properly sanitize food surfaces.
F 0867: Facility failed to develop and implement effective quality assurance and process improvement plans to address recurring deficiencies related to abuse, investigations, accident hazards, and infection control.
F 0880: Facility failed to ensure residents were offered hand hygiene prior to meals and failed to ensure proper personal protective equipment use in the laundry room.
Report Facts
Resident falls: 10
Resident falls: 9
Resident falls: 8
Resident falls: 7
Residents involved in abuse incidents: 6
Residents affected by abuse: 8
Residents affected by elopement: 2
Sanitizer solution concentration: 10
Cold food temperature: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nurse Aide | Named in verbal abuse allegations substantiated by facility |
| LPN #2 | Licensed Practical Nurse | Failed to report abuse allegations from Resident #17 |
| Cook #2 | Cook | Observed violating infection control practices during meal service |
| Dietary Director | Dietary Manager | Newly promoted, responsible for dietary infection control |
| Nursing Home Administrator | Administrator | Interviewed regarding abuse, elopement, care planning, and quality assurance |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse, elopement, care planning, and quality assurance |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 10, 2021
Visit Reason
The investigation was conducted due to allegations of resident-to-resident physical and sexual abuse involving multiple residents, including failure to prevent abuse and failure to thoroughly investigate alleged violations of abuse.
Complaint Details
The complaint investigation was triggered by allegations of resident-to-resident physical and sexual abuse involving residents #10, #16, #20, and #200. The facility was found to have failed to prevent abuse and failed to conduct timely and thorough investigations of these allegations.
Findings
The facility failed to protect residents from physical and sexual abuse and failed to conduct timely and thorough investigations of abuse allegations. Additionally, the facility failed to provide adequate supervision to prevent accidents, ensure proper infection control practices, and ensure proper medication administration procedures.
Deficiencies (7)
F 0600: The facility failed to protect residents from physical and sexual abuse and failed to prevent abusive situations involving residents #10, #16, #20, and #200.
F 0610: The facility failed to timely and thoroughly investigate alleged violations of physical and sexual abuse for residents #10, #16, #20, and #200.
F 0689: The facility failed to ensure adequate supervision and fall prevention interventions for residents, including Resident #5 who had a recent hip fracture and was left alone in the bathroom without proper fall risk identification.
F 0689: The facility failed to ensure Resident #1 had a working and accessible call bell and failed to offer timely assistance despite the resident's high fall risk.
F 0689: The facility failed to ensure Resident #19, a smoker requiring oxygen, did not smoke with oxygen on and failed to complete a smoking assessment prior to 6/8/21.
F 0880: The facility failed to maintain an infection control program including proper PPE use, resident mask encouragement, hand hygiene before meals, and proper disposal of soiled PPE in isolation rooms.
F 0880: Staff failed to don gloves when applying medicated transdermal patches, risking cross-contamination and medication absorption through hands.
Report Facts
Residents reviewed for abuse: 26
Residents affected by abuse: 7
Residents involved in abuse incidents: 4
Fall incidents for Resident #5: 2
Fall risk assessment BIMS score: 7
Fall risk assessment BIMS score: 5
Fall risk assessment BIMS score: 5
Dates of abuse incidents: 3
Date of survey completion: Jun 10, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Interviewed regarding abuse investigations and infection control |
| Registered Nurse #1 | Infection Control Preventionist | Interviewed regarding PPE use and infection control |
| Certified Nurse Aide #2 | CNA with medication authority | Observed applying medicated transdermal patch without gloves |
| Licensed Practical Nurse #2 | LPN | Observed applying medicated transdermal patch without gloves |
| Corporate Consultant | CC | Interviewed regarding infection control and fall prevention |
| Director of Nursing | DON | Interviewed regarding abuse investigations, infection control, and medication administration |
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