Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 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.
Infection control failures occurred when staff did not use EBP for a resident with an IV midline and did not wear appropriate PPE during direct care and IV antibiotic administration. In a separate event, an RN cleaned a glucometer with alcohol pads after a fingerstick blood sugar check instead of using the facility’s approved EPA-registered disinfectant wipes. The DON stated the alcohol pads were not an approved disinfectant for the glucometer.
Vegetable Freezer Not Maintained Safely: Surveyors found the kitchen vegetable freezer at 20 degrees with heavy ice buildup, worn and torn door seals, dripping water, and food items that were soft and not frozen solid. The DM said he had reported the damaged seals about a month earlier but had no evidence of a repair request, and the MS was unaware the seals needed replacement. The freezer contained vegetables, soup, and buns that were not frozen solid, and maintenance logs showed no service entry or seal replacement.
Improper syringe size was used for a resident’s midline heparin flush. An LVN flushed the line with Heparin lock flush in a 5 mL syringe, while another RN stated a 10 mL syringe should always be used for PICC, midline, or central line IV flushing. The DON and LVN acknowledged the issue, and the facility policy required syringes no smaller than 10 mL when assessing patency.
Improper Syringe Size Used for Midline Heparin Flush: A resident receiving IV therapy for cellulitis, COPD, hypertensive heart disease, and hyperlipidemia had orders for midline SASH flushing and IV antibiotics. An LVN was observed flushing the midline and using Heparin lock flush in a 5 ml syringe, while another RN later used a 10 ml syringe. The DON and staff acknowledged that a 10 ml syringe should be used for PICC, midline, or central line flushing, consistent with facility policy.
A resident with COPD and HF was receiving O2 at 2 L via NC, with orders to change tubing weekly and check and clean the concentrator filter weekly. Surveyors observed the concentrator filter repeatedly soiled with a thick grayish/white powdery substance. The RN, LVN, UM, ADON, DON, and Administrator stated the Sunday night nurse was responsible for cleaning the filter and acknowledged it had been overlooked.
Failure to Monitor Anticoagulant Side Effects: A resident with chronic embolism, DVT, and PVD was prescribed Eliquis 5 mg BID, but the facility did not document monitoring for anticoagulant side effects in the electronic record. Staff said the nurse entering the order was responsible for adding the monitoring, and leadership later confirmed the resident’s monitoring was overlooked during a system change from TASK to the MAR. The resident was observed confused in a wheelchair, with no bruising or bleeding noted.
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.
Infection Control Failures With IV Precautions and Glucometer Disinfection
Penalty
Summary
The facility failed to maintain an infection prevention and control program for a resident receiving IV antibiotics and for a nurse performing fingerstick blood sugar checks. Resident #75 was admitted with diagnoses including chronic obstructive pyelonephritis and UTI, and had an order for Ertapenem Sodium Injection Solution 1 gram IV every 24 hours. Record review showed the medication was started, but there was no order for Enhanced Barrier Precautions and no indication that EBP had been initiated in the MAR. During observations, Resident #75 was in bed with an IV line to the right upper extremity and a dressing dated 05/12/26. There was no EBP sign or setup outside the room during multiple observations. CNA G entered the room to provide direct care without PPE and stated the resident was not in isolation. RN F later administered the IV antibiotic through the resident’s line and wore gloves only, with no EBP sign or setup outside the door. RN F stated the resident had a midline IV and said she would not have done anything different. The facility also failed to ensure proper glucometer disinfection. Resident #10 had a diagnosis of type 2 diabetes mellitus and an order for blood sugar checks before meals and at bedtime. During an observation, RN F performed a fingerstick blood sugar check and then cleaned the glucometer with alcohol pads, stating the alcohol pads were a disinfectant and that she could clean for 2 minutes. The DON stated alcohol pads were not an approved disinfectant for glucometers and that the disinfectant wipes provided should be used. The facility policy stated glucometers are to be disinfected with an EPA-registered healthcare disinfectant effective against HIV, Hepatitis C, and Hepatitis B virus.
Vegetable Freezer Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain the vegetable freezer in safe operating condition in the kitchen. During observations on 05/18/2026, surveyors found the freezer at 20 degrees Fahrenheit with excessive ice buildup around the bottoms of both doors, worn and torn door seals, water dripping from the lower seals, and a 1/8-inch-thick sheet of ice about 6 inches long at the bottom of both freezer doors. Multiple frozen water drops were also observed on the ceiling of the freezer, and a sign instructed staff to make sure the doors close after opening. At the time of the observations, the freezer contained a bag of vegetable blend garden, a bag of creamy tomato soup, and a package of buns that were soft to touch and not frozen solid. The DM stated at one point that he thought the freezer door may have been left ajar, and later said he had reported the damaged door seals to maintenance about a month earlier but had no evidence that a requisition had been made for the repairs. The MS stated he was not aware the door seals needed replacement and later said the dripping water was from the freezer's defrost cycle, though he also acknowledged the ice buildup and defrosting food could be related to the damaged seals. The DM later reported that his boss toured the kitchen, assessed the freezer, and instructed him to dispose of all foods that were not frozen solid, resulting in disposal of approximately $2,000 worth of frozen foods. The Administrator stated she also assessed the freezer and directed disposal of all food that was not frozen solid because of concern that improperly defrosted or freezer-burnt food could make residents sick. On 05/19/2026, the freezer temperature was -2 degrees, no bagged vegetables, soup, or buns were present, and no ice buildup or leaking water was observed. Maintenance logs for April and May 2026 contained no entry to service the vegetable freezer or replace the door seals, despite the facility policy requiring maintenance requests and documentation for equipment service.
Improper Syringe Size Used for Midline Heparin Flush
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality for Resident #76, who was admitted with diagnoses including cellulitis of the left lower leg, COPD, hypertensive heart disease, and hyperlipidemia. Physician orders in May 2026 included midline flushing with SASH every shift and as needed, along with IV Zosyn three times a day and IV Vancomycin daily. The resident’s admission MDS was still in process, and the care plan identified IV therapy with a goal of having no complications related to IV therapy through the review. During observation on 05/19/26, LVN B removed a completed IV antibiotic and flushed the midline with saline using a 10 mL syringe, then used Heparin lock flush 10 U/5 mL in a 5 mL syringe. Later that day, RN F was observed removing a completed IV antibiotic and used Heparin lock flush 10 U/5 mL in a 10 mL syringe, stating that a 10 mL syringe should always be used for PICC line, midline, or central line IV flushing. The DON stated she did not realize the facility had Heparin flush in a 5 mL syringe for midline IV lines, and LVN B stated she should have used a 10 mL syringe with the heparin. The facility policy stated syringes no smaller than 10 mL should be used when assessing patency to avoid catheter damage.
Improper Syringe Size Used for Midline Heparin Flush
Penalty
Summary
The facility failed to administer parenteral fluids in accordance with physician orders, the comprehensive person-centered care plan, and the resident’s goals and preferences for Resident #76, who was admitted with cellulitis of the left lower leg, COPD, hypertensive heart disease, and hyperlipidemia. The resident had orders for midline flushing with SASH every shift and as needed, along with IV Zosyn three times daily and IV Vancomycin daily. The care plan identified IV therapy with a goal of having no complications related to IV therapy through the review. During observation, LVN B flushed the resident’s midline with saline in a 10 ml syringe and then used Heparin lock flush 10 U/5 ml in a 5 ml syringe. Later the same day, RN F was observed using Heparin lock flush 10 U/5 ml in a 10 ml syringe. RN F stated that a 10 ml syringe was always to be used to flush a PICC line, midline, or central line IV, and that using a smaller syringe could cause the catheter tip to rupture. The DON stated she did not realize the Heparin flush was in a 5 ml syringe for the midline IV lines. LVN B stated she should have used a 10 ml syringe with the heparin and acknowledged that not using a 10 ml syringe could cause the tip of the line to blow out. The facility policy stated syringes no smaller than 10 ml should be used when assessing patency to avoid catheter damage.
Soiled oxygen concentrator filter not cleaned as ordered
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with COPD and heart failure who was receiving oxygen at 2 liters per nasal cannula for shortness of breath. The resident’s care plan directed oxygen therapy as ordered, and the physician’s orders required weekly oxygen tubing changes and weekly filter checks with washing or replacement as needed. The resident was cognitively intact and was observed using oxygen connected to an oxygen concentrator. During observations on two separate days, the resident’s oxygen concentrator had a black filter on the side that was soiled with a thick grayish/white powdery substance. The resident stated she wore her oxygen all the time and said staff changed the tubing at night sometimes and probably cleaned the filters then. The filter remained visibly soiled during the later observation. In interviews, the LVN, ADON, DON, Administrator, RN, and UM all stated that the Sunday night nurse was responsible for cleaning the oxygen concentrator filters when tubing was changed, with management performing spot checks. They acknowledged the resident’s filter had been overlooked. The facility policy stated staff responsible for oxygen concentrators must receive training on oxygen safety and follow manufacturer recommendations for cleaning filters and servicing the device.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that Resident #57’s drug regimen was free from unnecessary medications by not monitoring her Eliquis for side effects. Resident #57 was an elderly female with diagnoses including chronic embolism, thrombosis of deep veins, and peripheral vascular disease. A physician order showed she was prescribed Eliquis 5 mg twice daily, and her MDS indicated she was severely cognitively impaired and receiving an anticoagulation medication during the lookback period. Record review from 01/30/2026 through 05/19/2026 did not show monitoring for side effects of Eliquis in the electronic record. The resident’s care plan identified anticoagulant use as a high-risk drug and included interventions for observation for bleeding and side effects of Eliquis, but the monitoring was not documented in the computer system. During observation, Resident #57 was sitting in a wheelchair, confused, and unable to answer questions, with no observed bruising or bleeding. During interviews, the LVN, ADON, UM, MDS nurse, DON, and Administrator stated that the nurse receiving the anticoagulant order was responsible for entering side effect monitoring into the computer system, with leadership staff serving as backup checks. They stated Resident #57’s monitoring was overlooked during a change from the TASK section to the Medication Administration Record section of the computer system. The facility policy on high-risk medications stated that anticoagulants require the resident’s plan of care to alert staff to monitor for adverse consequences, including bleeding and hemorrhage.
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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Illustrative
What surveyors actually found near you
We read the 14 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
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Illustrative
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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 | ★★★★★ | 2 | 0 |
| Woodland Park Nursing & Rehab | 19.4 mi | ★★★★★ | 1 | 0 |
| Woodville Health And Rehabilitation Center | 20.5 mi | ★★★★★ | 2 | 0 |
| Dogwood Trails Manor | 22 mi | ★★★★★ | 2 | 0 |
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