Eagle Ridge Post Acute

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Rights Deficiencies

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Environmental Deficiencies

Keep all essential equipment working safely.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Pharmacy Service Deficiencies

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.

Pharmacy Service Deficiencies

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.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Based on observations, record review and interviews, the facility failed to ensure one (#4) of three residents reviewed for abuse out of eight sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #4 from verbal abuse and physical abuse by Resident #5. .. Based on record review and interviews, the facility failed to ensure one ( #1) of three residents were provided the care and services necessary to ensure a safe discharge from the facility to the community out of eight sample residents. Specifically, the facility failed to:.. Based on record review and interviews, the facility failed to ensure that residents requiring treatments and services for mental disorders or psychosocial adjustment difficulties received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well being for one (#1) of three residents reviewed out of eight sample residents. .. III. Failed to ensure Resident #2' s representative was notified when the resident was sent to a cardiology appointment and started on an anticoagulant medication A. Resident status .. *** CITATION TEXT NOT FOUND *** A complaint survey, prompted by #CO40339, #CO40453, #CO40491, #CO40523, Incident #40065, Incident #40413 and Incident #40443 was conducted on 6/30/25 to 7/1/25. Four deficiencies were cited. .. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A complaint survey, prompted by #CO37351, #CO37668, #CO39117, #CO39118 and #CO39236 was conducted on 2/10/25 to 2/11/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow up with residents' concerns regarding call light times. Findings include: I. Facility policy and procedure The Grievance/Complaints, Filing policy, revised April 2017, was provided by the nursing home administrator (NHA) on 2/11/25 at 5:12 p.m. The policy read in pertinent part, "Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of residents and/or representatives."Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility."All grievances, complaints or recommendations stemming from resident or family groups concerning resident care issues in the facility will be considered. Actions on such issues will be responded to in writing, including irrational for response. "Upon receipt of a grievance and/or complaint, the grievance officer will review, investigate the allegations and submit a written report of such findings to the administrator within seven working days of receiving the agreements and/or complaint. "The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken."The resident, or person filing the grievance and or complaint on behalf of the resident, will be informed verbally and in writing of the findings of the investigation and the actions that would be taken to correct any identified problems." The Resident Council policy, revised April 2017, was provided by the NHA on 2/11/25 at 6:15 p.m. The policy read in pertinent part, "A resident council response form will be utilized to track issues and their res..

A complaint survey, prompted by #CO37114 was conducted on 8/19/24 to 8/20/24. Two deficiencies were cited. Based on record review and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident' s dignity and respect, in full recognition of his or her individuality for one (#1) of five residents reviewed for respect and dignity out of 11 sample residents. Specifically, the facility failed to assist Resident #1, who was dependent on staff for all care, to turn in bed when he requested assistance.Findings include:I. Facility policy and procedureThe Resident Rights policy, revised December 2016, was provided by the director of nursing (DON) on 8/22/24 at 11:26 a.m. It read in pertinent part,"Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident' s right to self-determination, and to be informed of, and participate in, his or her care planning and treatment."II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 12/27/17. According to the August 2024 computerized physician orders (CPO), diagnoses included complete paraplegia (paralysis below the waist) and incomplete quadriplegia (weakness or paralysis in all four limbs), bipolar disorder, and anxiety disorder.The 7/2/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for m.. Based on record review and interviews, the facility failed to ensure one (#8) of one resident out of 11 sample residents was free of significant medication errors.Specifically, the facility failed to ensure Resident #8 received her full three-week course of antibiotics as recommended by the hospital.Findings include:I. Professional referenceCombating Antibiotic Resistance, reviewed 10/29/19, was retrieved on 8/23/24 from https://www.fda.gov/consumers/consumer-updates/combating-antibiotic-resistance. It read in pertinent part,"Antibiotic resistance is a growing public health concern worldwide."In cooperation with other government agencies, the Food and Drug Administration (FDA) has launched several initiatives to address antibiotic resistance. The agency has issued drug labeling regulations, emphasizing the prudent use of antibiotics. The regulations encourage health care professionals to prescribe antibiotics only when clinically necessary, and to counsel patients about the proper use of such drugs and the importance of taking them as directed."It is important to take the medication as prescribed by your doctor, even if you are feeling better. If treatment stops too soon, and you become sick again, the remaining bacteria may become resistant to the antibiotic that you have taken."II. Resident #8A. Resident statusResi..