Ridge Pinehurst LLC

A licensure complaint, prompted by #CO41620 was completed on 3/3/26. Deficiencies were cited. Based on interview and record review, the residence failed to either directly or indirectly through a resident agreement provide protective oversight, affecting one former resident (#5). (Cross-reference U1150)Specifically, Former Resident #5 had assistance by Staff #5 to use the restroom in the memory care unit on 1/26/27 at around 8:00 p.m. When Staff #5 assisted the former resident, the staff member had turned her back to replace the toilet paper while the former resident was on the toilet and during that time, the former resident fell face first off the toilet. This fall resulted in an injury near the eye and an injured jaw. The former resident required two staff to assist her with toileting and transferring, however, one staff member had transferred her and the resident fell. Emergency services were not called or contacted. The resident passed away four days later. Findings include:Former Resident #5 was admitted to the residence on 8/7/22, with diagnoses including dementia and Alzheimer ' s.1. Record ReviewA care plan, dated 3/16/23, did not mention the resident required a two person transfer or two person toileting assistant.A policy titled Fall Reduction and Management dated January 2022 read in part" The resident will have a service plan implemented with an individualized approach."An incident report dated 1/26/26 at 8:11 p.m. rea.. Based on interview and record review, the residence failed to ensure each care plan detailed specific personal service needs along with the staff tasks necessary to meet those needs, affecting one former resident (#5). (Cross-reference U1110)Findings include:Former Resident #5 was admitted to the residence on 8/7/22 with a diagnosis including dementia, Alzheimer ' s disease, and major depressive disorder.Record Review:A care plan dated 3/16/23 and 1/29/26 read in part "I often need 2 person assistance for dressing and showers and invite, escort me to all activities of interest and if able." However, the care plan did not mention she required two person transfer and toileting assistance.A policy titled Fall Reduction and Management dated 1/22 was reviewed on 3/3/26 read in part"The assisted living director or designee will investigate the fall with the intention of reducing the incident of falls for the person who fell. Changes to the service plans will be made, as needed." An assessment dated 10/30/25 and 1/27/26 read in part the resident required stand by assistance for transfers and she required the assistance of one staff member for transfers. Interviews:On 3/3/26 at 10:39 a.m., an interview was conducted with the power of attorney for former resident #5. The power of attorney stated that before former resident #5 had a fall on 1/26/26, ..

A relicensure survey with complaint #CO37064 and #CO36396 was completed on 1/7/25. A deficiency was cited. Based on record review, interviews, and observations the residence failed to detail in each resident ' s care plan the individualized approach necessary to address fall risks, affecting two of six sample residents (#44, #50). Specifically, Resident #50 was admitted to the residence on 5/9/23 with diagnoses including muscle weakness, osteoarthritis and anemia. The resident fell six times between 10/14 and 12/31/24. Five of these falls resulted in injuries such as bruises, knee pain, head injury, pain in the back, legs, knees and hips, and a skin tear. There were care plans dated 6/1/24, 11/13/24 and 1/2/25, however, the care plans were not updated after falls with individualized approaches necessary to address all the falls the resident experienced. Findings include:1. Residence PolicyThe Residence Fall Reduction and Management policy, undated, read: "Reduction of falls is the responsibility of all associates. The assisted living director or designee will investigate the fall with the intention of reducing the incidents of falls for the person who fell. Changes to service plans will be made, as needed." 2. Resident #50 was admitted to the residence on 5/9/23 with diagnoses of muscle weakness, osteoarthritis, and anemia. a. Record ReviewA residence care plan with fall interventions, revised 6/1/24, read that Resident #50 was not able to ambulate long distances without guidance, used her walker for ambulation, and was independent with ambulation. The care plan read that Resident #50 was educated to lock her brakes on her wheelchair, wear gripper socks, ensure her walker was close by, and call for assistance with the bathroom during the night. The care plan, revised 6/1/24, read that Resident #50 lived with moderate dementia and moderate disorientation with difficulty recalling information. A progress note, dated 10/14/24 read that Resident #50 was "sitting up on her bottom leaning up against her recliner in her living room. Resident (#50) had no shoes on and no socks. Noticed there was a tiny skin tear the size of a grain of rice on R..

A complaint revisit was completed on 1/7/25 for all previous deficiencies cited on 6/21/23. Deficiencies were cited. Based on record review, interviews, and observations the residence failed to detail in each resident' s care plan the individualized approach necessary to address fall risks, affecting two of six sample residents (#44, #50). This deficiency was cited previously during a complaint revisit on 6/21/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Specifically, Resident #50 was admitted to the residence on 5/9/23 with diagnoses including muscle weakness, osteoarthritis and anemia. The resident fell six times between 10/14 and 12/31/24. Five of these falls resulted in injuries such as bruises, knee pain, head injury, pain in the back, legs, knees and hips, and a skin tear. There were care plans dated 6/1/24, 11/13/24 and 1/2/25, however, the care plans were not updated after falls with individualized approaches necessary to address all the falls the resident experienced. Findings include:1. Residence PolicyThe Residence Fall Reduction and Management policy, undated, read: "Reduction of falls is the responsibility of all associates. The assisted living director or designee will investigate the fall with the intention of reducing the incidents of falls for the person who fell. Changes to service plans will be made, as needed." 2. Resident #50 .. 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