Pine Ridge Care Center

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from abuse when Resident 2 struck her on the left cheek.This failure had the potential to result in serious physical harm to Resident 1.Findings:A review of Resident 1's admission record indicated she was admitted in 5/19 with the diagnosis of cognitive impairment (persistent function deficits that can impact a person's ability to think, learn and remember).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/16/25, indicated she had severe cognitive impairment.A review of Resident 1's nursing note, dated 8/13/25 and written by Licensed Nurse 1 (LN 1), indicated a staff person had reported to him she had witnessed Resident 1 being struck in the left cheek by Resident 2.A review of Resident 2's admission record indicated he was admitted in 8/20 with the diagnosis of dementia (a progressive state of decline in mental abilities).A review of Resident 2's MDS, dated [DATE], indicated he had severe cognitive impairment.A review of Resident 2's nursing note, dated 8/13/25 and written by LN 1, indicated a staff person had reported to him she had witnessed Resident 2 strike Resident 1 in the left cheek.

During an interview on 9/8/25 at 11:56 a.m. with Activities Assistant 1 (AA 1), AA 1 stated she had been in the dining room on 8/13/25 and witnessed Resident 2 strike Resident 1 in her left cheek as he wheeled himself past her in his wheelchair. AA 1 stated Resident 1's cheek was a little red but she had not cried out in pain.

During an interview on 9/8/25 at 12:39 p.m. with the Social Services Director (SSD), the SSD stated she was aware of the incident that had occurred between Resident 1 and Resident 2 on 8/13/25.

The SSD agreed Resident 1 had suffered abuse by Resident 2 and confirmed it was the facility's responsibility to keep all residents safe.

During an interview on 9/8/25 at 1:24 p.m. with LN 1, LN 1 stated he assessed Resident 1 on 8/13/25 after she had been struck by Resident 2 and her left cheek was slightly reddened after the incident but there were no complaints of pain.During a review of the facility's policy titled, Abuse Prevention Program, undated, the policy stipulated, Our residents have the right to be free from abuse.This includes physical abuse.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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