Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Ridge Health Care Llp during CMS and state inspections, most recent first.
A facility failed to provide necessary nail care for a diabetic resident, resulting in unkempt and potentially hazardous fingernails. Despite the resident's request for assistance weeks prior, the nursing staff did not fulfill the request, and the facility's policy on routine nail care was not followed.
A resident with Alzheimer's and dysphagia experienced significant weight loss over six months, which the facility failed to address. Despite dietary interventions, the weight loss was not identified or communicated effectively among staff, leading to continued decline without appropriate care plan adjustments.
A facility failed to obtain physician orders for necessary saline and heparin flushes (SASH protocol) for a resident receiving IV antibiotics for pneumonia. The nurse administered these flushes without orders, and the DON confirmed the oversight in documentation. Facility policies require written physician orders for all treatments, including IV flushes, to prevent complications.
A facility failed to maintain an effective Infection Prevention and Control Program when two LVNs did not adhere to Enhanced Barrier Precautions (EBP) while treating a resident with multiple pressure ulcers. Despite being trained and aware of the need for gowns, the LVNs did not wear them, citing nervousness and forgetfulness. The facility's policy requires gowns and gloves during high-contact care to prevent infection spread, which was not followed, posing a risk of cross-contamination.
The facility failed to maintain safe operating conditions in the laundry room, with one washing machine missing a cover and two dryers having open top covers, exposing wiring and gas burners. Staff indicated the covers were left off for over a year and opened for additional heat. Supervisors acknowledged the need for covers to prevent accidents, and the administrator stressed the importance of closed service panels, although no accidents had occurred.
A resident with multiple health conditions and cognitive impairment experienced a fall resulting in a serious injury, specifically a subdural hematoma. The facility failed to report the incident to the state agency within the required timeframe. The nursing staff applied pressure to the resident's head wound and called EMS, but the Director of Nursing was informed via text and did not take immediate action to notify the abuse coordinator or administrator, leading to a delay in reporting.
A resident with dementia and chronic heart failure was found on the floor with a head laceration, later diagnosed as a subdural hematoma. The incident was not reported to the state agency within the required 2-hour timeframe due to communication lapses and unclear policy guidelines. The DON was informed via text, which was not seen until the next day, delaying the notification to the abuse coordinator and state agency.
Neglect in Nail Care for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain personal grooming and hygiene. Specifically, the facility did not trim the fingernails of a resident with diabetes, which is crucial to prevent infections. The resident, who was cognitively intact and required assistance with bathing and grooming, had requested nail care weeks prior, but the request was not fulfilled. During an observation, the resident's fingernails were found to be unkempt, with a thick dark brown substance underneath, and extended beyond the fingertips. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed that the responsibility for nail care, especially for diabetic residents, was assigned to the nursing staff. However, the RN admitted that nail care was not scheduled for a specific day, and the DON acknowledged the need for the resident's nails to be cleaned and trimmed. The facility's nail care policy mandates routine cleaning and inspection of nails as part of ADL care, with licensed nurses responsible for trimming the nails of diabetic residents. Despite this policy, the resident's nail care needs were neglected, leading to the deficiency.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident maintained an acceptable nutritional status, as evidenced by a significant weight loss over a six-month period. The resident, an elderly female with Alzheimer's disease, cognitive communication deficit, and dysphagia, experienced an 11.08% weight loss from 155.2 pounds to 138.0 pounds. Despite dietary orders for regular meals, house shakes, and magic cups, the facility did not identify or address the significant weight loss in a timely manner. The deficiency was further compounded by a lack of communication and documentation among the facility staff. The dietician noted the weight loss but did not immediately report it to the Director of Nursing (DON) due to inexperience in long-term care. The Licensed Vocational Nurse (LVN) completed a malnutrition risk assessment but failed to notify the dietician of the results. Additionally, the DON had implemented a quality assurance plan to monitor weights but closed it prematurely, believing the system was effective, which led to the oversight of the resident's weight loss. Observations and interviews revealed that the resident was often fed by a Certified Nursing Assistant (CNA) or family member and typically consumed less than 50% of her meals. The facility's policy required monitoring and intervention for significant weight changes, but these measures were not effectively implemented. The lack of timely intervention and communication among staff members contributed to the resident's continued weight loss without appropriate adjustments to her care plan.
Failure to Obtain Physician Orders for IV Flushes
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for a resident, specifically in the administration of intravenous (IV) medications. The resident, a female with pneumonia, was prescribed antibiotics Azithromycin and Cefepime HCL to be administered intravenously. However, there were no physician orders for the necessary saline and heparin flushes (SASH protocol) before and after the administration of these antibiotics. This oversight was observed during the administration of Cefepime HCL, where the nurse administered saline and heparin flushes without a physician's order. The nurse involved acknowledged the absence of physician orders for the SASH protocol and admitted that it was her responsibility to ensure these orders were documented in the medication administration record (MAR). The Director of Nursing (DON) confirmed that the nurse administering the IV medications was responsible for ensuring the physician orders for SASH were in the system. The DON also stated that the MAR should have included these orders, and it was an oversight that they were not documented. The facility's policies require that all medications and treatments, including IV flushes, must have a written order from the attending physician. The policy also specifies that midline catheters should be flushed and locked according to current standards of practice, which includes obtaining and verifying physician orders for the type of IV solution or medication. The failure to follow these protocols could lead to complications such as catheter occlusion, but the report does not detail any specific adverse outcomes for the resident involved.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of LVN B and LVN C, who did not adhere to Enhanced Barrier Precautions (EBP) while providing care to a resident. The resident, an elderly female with heart failure and peripheral vascular disease, was admitted with multiple pressure ulcers, including stage IV ulcers on her legs, which posed a high risk of infection. Despite the presence of an EBP sign on the resident's room door, indicating the need for specific precautions, LVN B and LVN C did not wear gowns during the treatment of the resident's wounds. Interviews with the involved staff revealed that they were aware of the requirement to wear gowns but failed to do so due to nervousness and forgetfulness. The Director of Nursing and the Administrator both confirmed that the expectation was for staff to follow EBP guidelines to prevent the spread of infections. The facility's policy on Enhanced Barrier Precautions, which includes the use of gowns and gloves during high-contact resident care activities, was not followed, leading to a potential risk of cross-contamination and infection development among residents.
Failure to Maintain Safe Operating Condition of Laundry Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition in the laundry room, which was observed during a survey. One of the two washing machines was missing a cover, leaving the wiring exposed by the handle of the door. Additionally, two of the three dryers had their top covers propped open, exposing the pilot light and gas burner. Laundry staff indicated that the cover had been off since a repair about a year ago, and the dryer covers were opened to provide heat in the laundry room and to help the middle dryer function properly. Interviews with the laundry and maintenance supervisors revealed that the equipment should have been maintained with covers on to prevent possible accidents. The maintenance supervisor acknowledged responsibility for replacing the washer cover if it was left off by a repairman and pointed out that the laundry room temperature could be adjusted if staff were cold. The administrator was unaware of why the service panels were open and emphasized the importance of keeping them closed to prevent accidents, although no accidents had occurred yet. The facility's policy on maintaining essential equipment in safe operating condition was not adhered to, as evidenced by the exposed wiring and open service panels.
Failure to Report Serious Injury in a Timely Manner
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified during a review of the case of a resident who experienced a fall resulting in a serious bodily injury, specifically a subdural hematoma. The facility did not report the incident to the State Survey Agency within the required timeframe, which is immediately or no later than two hours after the incident occurs or is suspected. The resident involved was an elderly individual with multiple health conditions, including atherosclerotic heart disease, hypertensive heart disease with heart failure, chronic systolic heart failure, protein-calorie malnutrition, peripheral vertigo, dementia, anxiety disorder, and major depressive disorder. The resident was cognitively impaired, with a BIMS score of 00, and required bed and chair alarms to monitor movement. The resident was dependent on staff for most activities of daily living and had a history of falls, as noted in the care plan. On the day of the incident, the resident was found on the floor with a laceration on the left side of the head, which was actively bleeding. The nursing staff applied pressure and called EMS for evaluation and treatment. However, the incident was not reported to the state agency within the required timeframe. The Director of Nursing (DON) was informed via text message but did not take immediate action to notify the abuse coordinator or administrator, resulting in a delay in reporting the serious bodily injury to the state agency.
Failure to Timely Report Resident Neglect with Serious Injury
Penalty
Summary
The facility failed to report an alleged incident of neglect involving a resident who sustained serious bodily injury within the required 2-hour timeframe. The incident involved a resident with multiple medical conditions, including dementia and chronic heart failure, who was found on the floor with a laceration on her head. The resident was later diagnosed with a subdural hematoma, indicating serious bodily injury. Despite the severity of the injury, the incident was not reported to the state agency until the following day, exceeding the mandated reporting period. The incident occurred when a CNA left the resident in the hallway to assist another staff member with a different resident. The resident was found on the floor shortly after, with a significant head injury. The nursing staff, including an RN and an LVN, responded to the scene, provided immediate care, and contacted emergency services. However, the facility's Director of Nursing (DON) was informed of the incident via text message, which he did not see until the next morning, delaying the notification to the abuse coordinator and the state agency. Interviews with facility staff revealed that the DON and the abuse coordinator were not promptly informed of the incident's severity. The abuse coordinator only became aware of the situation the next morning through incident report emails. The facility's policy did not clearly outline the required reporting timeframes for incidents involving serious bodily injury, contributing to the delay in reporting. This oversight in communication and policy adherence resulted in the failure to meet the regulatory requirement for timely reporting of the incident.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 29 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Livingston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timberwood Nursing And Rehabilitation Center | 16.4 mi | ★★★★★ | 7 | 0 |
| The Bradford At Brookside | 18.7 mi | ★★★★★ | 12 | 0 |
| Woodland Park Nursing & Rehab | 19.4 mi | ★★★★★ | 0 | 0 |
| Woodville Health And Rehabilitation Center | 20.5 mi | ★★★★★ | 2 | 0 |
| Dogwood Trails Manor | 22 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.