Pine Grove Healthcare & Wellness Centre, LP

Inspectors wroteBased on interview and record review, the facility failed to ensure competencies and skills sets to provide nursing and related services were completed for five (5) of 5 sampled nursing staff in accordance with the facility assessment and policy and procedures (P&P). This deficient practice has the potential to result in an increased risk for improper care provided to the residents which could negatively affect the residents' overall wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage was properly disposed of in accordance with the facility's policy and procedure titled, Waste Management. This deficient practice had the potential to attract pests and rodents and may cause disease and other health issues to residents, staff, and the community.

Inspectors wroteBased on interview and record review, the facility failed to ensure vital (objective, measurable indicators of the body's most essential physiological functions, used to evaluate physical health, monitor illness, which includes blood pressure) were documented accurately for two (2) of three (3) sampled residents (Residents 5 and 82) reviewed for dialysis. This failure resulted in the facility not documenting blood pressure readings were taken in the correct arm for Residents 5 and 82 which can lead to potential harm and/ or injury to the residents.

Inspectors wroteBased on interview and record review, the facility did not implement water testing samples (to collect and deliver for analysis a sample of water representative of the bulk of water being examined) to initially validate the facility's water management program control measures (actions that can be taken to reduce the potential of exposure to a hazard) to ensure the facility's water was free of waterborne (carried or transmitted by water and especially by drinking water) pathogens (any organism that can cause disease) such as legionella (a bacterium which cases legionnaires' disease [a severe form of pneumonia - lung inflammation usually caused by infection]). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence or written notice of why a room change was required and failed to accommodate the request to be roomed together as a married couple from 5/5/2025 to 7/21/2025 for two (2) of 19 sampled residents (Residents 43 and 44) when they did not in accordance with the facility's policy and procedure titled Resident Rights. This failure resulted in violation of Residents 43 and 44 right to be notified of the reason why they needed to change rooms and had the potential to result in Residents 43 and 44 feeling sad, lonely and abandoned.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 34) reviewed for restraint (restricting freedom of movement) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body) by failing to conduct an assessment for the use of wheelchair and bed alarm (monitoring devices used in healthcare settings to detect when a person attempts to rise, triggering an alert for caregivers). This deficient practice had the potential to negatively affect Resident 34's physical and psychological wellbeing and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) for one of two sampled residents (Resident 9) to reflect the antipsychotic (drug that works by altering brain chemistry to help reduce psychotic symptoms like hallucinations [an experience which a person sees, hears, feels, or smells something that does not exist], delusions [fixed false beliefs], and disordered thinking) medication taken and Antipsychotic Medication Review (a structured, interprofessional evaluation of a resident's antipsychotic drug therapy to assess effectiveness, monitor side effects, and determine the need for continued use, dose reduction, or withdrawal). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one (1) of three (3) sampled residents (Resident 1) meal trays that were appetizing and palatable (agreeable to one's sense of taste). This failure had the potential to result in dissatisfaction, decreased food intake and placed Resident 1 at risk for unplanned weight loss.

Inspectors wroteBased on interview and record review, the facility failed to follow its hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) agreement to coordinate care for one out of two sampled residents (Resident 42) reviewed for hospice by failing to develop an effective communication process for Resident 42's plan of care, hospice visitation, and physician's orders. This deficient practice had the potential for Resident 42 not to receive the hospice care and services necessary to promote comfort and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light for one (1) of 1 sampled resident (Resident 83) reviewed for environment was within reach. This failure had the potential to put Resident 83 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident and unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq.ft. - unit of measurement) per resident in multiple resident bedrooms for 13 of 35 residents' rooms (Rooms 5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22, and 23) in the facility. This deficient practice had the potential to affect the ability to provide care, safety, and a home-like environment for the residents.

Inspectors wroteBased on interview and record review, the facility failed to prevent sexual abuse (non-consensual sexual contact of any type with a resident) for one of two sampled residents (Resident 1) on 2/11/2026 in the facility's hallway. On 2/11/2026, Visitor (Visitor 1) witnessed Resident 2's hand was inside Resident 1's pants. This failure can result in Resident 1 and 2 experiencing emotional trauma (response to deeply distressing or disturbing events) or psychological trauma (damage to the mind that occurs as a result of a severely distressing event).

Inspectors wroteBased on interviews and record review, the facility failed to provide adequate intervention such as bed alarm (a safety device, often for the elderly or those with dementia, that alerts caregivers when a person tries to get out of bed), to monitor/document sleeping pattern and inform the resident's physician of any insomnia (trouble falling asleep or staying asleep) or anxiety (natural feeling of worry, fear, or unease, often a physical and emotional reaction) for one (1) of two (2) sampled residents (Resident 1) who was assessed as at risk for fall. This deficient practice resulted in Resident 1 sustaining a fall in the resident's room on 12/31/2025 around 5:30 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic time- out (ATO-a structured process where healthcare providers review and assess the need for ongoing antibiotic therapy) was completed within 48 to 72 hours for two (2) of three (3) sample residents (Residents 1 and 3), sampled for antibiotic use, as indicated in the facility's policy. These failures had the potential to result in Residents 1 and 3 to receive unnecessary antibiotic therapy with the risk of creating antibiotic resistance (bacteria develop and resist the effects of the antibiotics used to kill them).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' room temperature level between 71 to 81-degree Fahrenheit (° F-a unit of temperature measurement on the Fahrenheit scale, where water freezes at 32 degrees Fahrenheit and boils at 212 degrees Fahrenheit) for three (3) of eleven (11) sampled residents (Resident 126, Resident 63, and Resident 36). This deficient practice resulted in the resident's increased level of discomfort and had the potential to negatively impact the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food service area was maintained in a clean and sanitary manner and proper food handling was provided in accordance with the facility's policy and procedure(P&P) by failing to: 1. Ensure one can opener was sanitized and was not rusted (a reddish-brown substance that forms on the surface of iron and steel as a result of reacting with air and water) according to the facility's P&P titled, Can Opener Use and Cleaning. 2. Ensure [NAME] non- stick spray oil was properly covered with a lid. 3. Ensure cheese stored in the refrigerator was labeled with an open date or use by date (a calendar date that indicates when a product is best quality) and in a sealed container. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three (3) of 3 dumpsters (a movable waste container designed to be brought and taken away) were closed and not overflowing, in accordance with the facility's Waste Management. Policy and Procedure. This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) and may cause disease and other health issues to residents, staff, and the community.

Inspectors wroteBased on interview and record review, the facility failed to observe infection control measures as indicated on the facility policy when facility failed to establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease (LD, a serious and often deadly form of lung infection [pneumonia, lung inflammation usually caused by infection], acquired by breathing in water droplets caused by the bacteria, legionella [the bacteria that causes LD]). This failure had the potential to place the residents at risk for developing severe respiratory infection (pneumonia).

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home like environment for two (2) of 11 sampled residents (Residents 15 and 23) by failing to: 1. Ensure the bedside control (used to adjust the bed height, head of bed and/ or foot of the bed) wires for Residents 15 and 23 were not exposed (occur when the insulation around electrical cords and cables is frayed or damaged, revealing the wires within). 2. Facility failed to ensure the trash cans were not overflowing for Rooms A, B and C. These deficient practices caused an unsanitary and had a potential for residents to be placed at risk for serious illness and/ or injury.

Inspectors wroteBased on observation and interview and record review, the facility failed to provide reasonable accommodations for Resident 36's needs and preferences with a wheelchair that was comfortable for his size, was not damaged, ripped, dusty and old. This failure had the potential for Resident 36 to be placed at risk for negative impact of his psychosocial wellbeing, result in delayed provision of services and/or risk for injury.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two (2) of five (5) sampled residents (Residents 66 and 225) were provided a communication board (a device that displays photos, symbols or illustrations to help people with limited language skills express themselves) that was readily accessible in the language the residents understood. This failure had the potential to result in Residents 66 and 225 experiencing a delay in receiving appropriate care and treatment and feeling misunderstood due to the staff not being able to properly communicate with the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming services for two (2) of five (5) sampled residents (Resident 53 and Resident 57) who were dependent with activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), in accordance with the facility's policy. This deficient practice resulted in Resident 53 and 57's unkempt and dirty fingernails potentially leading to skin injury, infection, and scarring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of six sampled residents (Resident 64) by failing to administer the resident's amlodipine 5 mg (milligrams - unit of measure, used to treat high blood pressure) one tablet and Vitamin C 500 mg one tablet, as indicated on the physician order. This deficient practice had the potential to place Resident 64 at risk of uncontrolled blood pressure, heart attack, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (5%). There were two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error which yielded a facility medication error rate of 7.69% for one (1) of six (6) sampled residents (Resident 64) observed during medication administration (med pass). 2 medications were not given within one hour from the scheduled 9 a.m. time. This deficient practice had the potential to place Resident 64 at risk of uncontrolled blood pressure, heart attack, or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to remove expired Osmolite 1.5 Cal (therapeutic nutrition that provide complete balanced nutrition for long- or short-term tube feeding for residents with increased calorie and protein needs.) from one (1) of two (2) Medication Rooms (Medication room [ROOM NUMBER]) located at nurse station 2. This deficient practice increased the risk for residents to receive nutrition that had become ineffective or toxic due to improper storage which could possibly lead to health complications resulting in harm and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure a coordination of care between the facility and hospice (a program that provides are and support for people who are nearing the end of their life) staff for one (1) of 1 sampled resident (Resident 64) in accordance with the facility's hospice program by not ensuring: a. Hospice staff visit progress notes were maintained in Resident 64's medical record. b. Hospice staff were signing in on their flow sheet in Resident 64's hospice binder. This failure resulted in Resident 64's medical record being inaccurate which had the potential for Resident 64 to not receive the required hospice care and services necessary to promote comfort and quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two (2) of 17 sampled residents (Residents 8 and 44) had their call light (device used by residents to call staff) within reach. This failure placed Residents 8 and 44 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the accurate and complete Census and Direct Care Service Hours Per Patient Day (DHPPD, refers to the actual hours of work performed per patient day by a direct caregiver) in a prominent location (accessible to residents and visitors) in accordance with the facility's policy and procedure by failing to: 1. Post the nurse staffing information in a prominent location on 2/4/2025. 2. Ensure the Daily Nurse Staffing Form (nurse staffing information) posted on 2/5/2025 was accurate to reflect the correct date and total number of projected hours and the actual hours of licensed and unlicensed nursing staff directly responsible for resident care per shift. These deficient practices have the potential for residents and visitors not to be informed of the facility census and staffing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 13 of 35 resident rooms (rooms 5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22, and 23) met the square footage requirement of 80 square feet (sq. ft., unit of measurement) per resident in a multiple resident room. This failure had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from the use of physical restraints (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) in accordance with the facility policy. On 10/3/24, Certified Nurse Assistant (CNA) 3 wrapped Resident 1's torso (the main part of the body that contains the chest, stomach, pelvis, and back) with a white sheet as an abdominal binder (a wide compression belt that encircles the stomach) preventing resident's normal access to his torso. This deficient practice had the potential to negatively affect Resident 1's physical and psychological wellbeing and quality of life. Cross reference with F609.

Inspectors wroteBased on interview and record review, the facility failed to report the suspected abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) and physical restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) of resident to the long-term care (LTC) ombudsman (advocates for residents of nursing homes), Law Enforcement, and State Survey Agency State Survey Agency within 2 hours after the allegation oh physical restraint occurred for one of two sample residents (Resident 1) in accordance with the facility's Restraint prevention policy by failing. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide the Resident's/ Resident's responsible parties' right to have a written information on how to formulate an Advanced Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for two (2) of 2 sampled residents (Resident 4 and 12) for advance directive care area. 1. Resident 4 did not have an advanced directive or a signature declining information on how to obtain an advanced directive. 2. Resident 12 did not have a copy of advance directive filed under the advance directive tab in the resident's physical medical chart where staff can access during a medical emergency. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure injury/ ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) was set up accurately for two (2) of three (3) sampled residents (Resident 12 and Resident 16) for pressure ulcer care area. This deficient practice had the potential for the resident to worsen or develop new pressure injury.

Inspectors wroteBased on observation and interview the facility failed to maintain a clean [NAME] Valve (a stopcock-like device, which allows the health care worker to access enteral systems without breaking open the lines) for gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach) for one of two sampled residents (Resident 34). This deficient practice had the potential to result in complications including infections and stomach discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for three (3) of 3 sampled residents (Resident 4, 125, and 224) for oxygen care area in accordance with the facility's policy and procedure when: 1. Resident 4's oxygen humidifier (medical device used to humidify supplemental oxygen) and nasal cannula (a device that delivers extra oxygen through a tube and into your nose) tubing were not on the floor. Resident 4's oxygen concentrator was also left on when Resident 4 was not on oxygen therapy. 2. Resident 125 did not receive oxygen as indicated on the physician's order. 3. Resident 224's nasal cannula tubing and humidified sterile water was not properly labeled. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent food contamination and the spread of foodborne illness as indicated on the facility policy when the facility failed to ensure: 1. The sanitary storage and disposal of expired food. These deficient practices have the potential to result to pathogen (germ) exposure and place residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to hospitalizations. 2. Seven (7) of 32 kitchen mounted ceiling lights have a protective plastic cover. This deficient practice had the potential of breakage with particles of glass potentially landing on food preparation areas or residents' trays.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose garbage and refuse (disposable material, which includes both recyclable and non-recyclable material) from the kitchen properly when Dietary Aid was observed dumping four(4) clear bags of kitchen trash on top of the regular facility trash at the the facility's parking area on the North/East side of the facility building on 2/14/2024 This failure had the potential to result in the attraction and spread of vermin (animals that are believe to be harmful, or that carry diseases, e.g., rodents parasitic worms or insects) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary environment when multiple piles of trash bags were observed on the ground near the facility's parking area on the North/East side of the facility building. This failure had the potential to result in the attraction and infestation of vermin (wild animals that are believed to be harmful such as rodents, parasitic worms or insects) that could potentially infiltrate the facility, affect resident care areas and pose a direct disease and infection threat to residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote respect and dignity for one (1) of 1 sampled resident (Resident 34) for dignity care area when resident was left in bed sleeping with food around his mouth and on the resident's gown. This deficient practice had the potential to result in Resident 34's feelings of decreased self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented for one of 20 sampled residents (Resident 174). This deficient practice placed Resident 174 at risk of not having goals and interventions to fulfill resident's needs which had the potential to negatively affect Resident 174's well-being.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for two (2) of 20 sampled Residents (Resident 4 and 18) as indicated on the facility's policy. 1. Resident 4's oxygen therapy order was not revised on 2/12/2024 when order was changed to as needed from continuous use. 2. Resident 18's care plan to prevent injury was not revised when Resident 18 was non compliant with the use of soft helmet (a special kind of protective headgear that is designed to reduce the risk or severity of head injuries for residents with epilepsy (a disorder of the brain characterized by repeated seizures [abnormal brain activity]). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide one (1) to 1 feeding assistance (help residents in a nursing facility eat and drink) while eating for 1 of 1 sampled resident (Resident 34) for ADL care area, as indicated on the physician's order. This deficient practice had the potential for Resident 34's functional ability to decline, suffer a weight loss, and risk for accident such as choking, which coould result to harm.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to elevate bilateral lower extremities (BLE, everything from your hip to your toes, including your hip, thigh, knee, leg, ankle, foot, and toes) and implement care plan for one of 20 sampled (Resident 224). This deficient practice had the potential to result in a delay in reducing the swelling in the affected extremities.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to ensure the safety of one of two sampled residents (Resident 18) by not ensuring Resident 18 was wearing a soft helmet (a special kind of protective headgear that is designed to reduce the risk or severity of head injuries for people with epilepsy [uncontrolled shaking] ) and that had side rails remained padded (provides added cushioning to help reduce injuries). This failure had the potential to cause injury to Resident 18 during seizures (uncontrollable shaking).

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove an intravenous (IV, within the vein) catheter saline lock (a thin plastic tube that is threaded into a vein, flushed with saline, and then capped off for later use) used in the administration of parenteral fluid (delivery of fluid or medication through an IV, subcutaneous [beneath, or under, all the layers of the skin], intramuscular [within or into the muscle] or mucosal [the moist, inner lining of some organs and body cavities] route to maintain adequate hydration, restore and/or maintain fluid volume, establish lost electrolytes [minerals in your blood and other body fluids that carry an electric charge], or provide nutrition which includes total parenteral nutrition [TPN, IV administered nutrition]) and left it inserted for more than 96 hours for one (1) of 20 sampled residents (Resident 174), in [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents comfort and independence), utilize a plate guard (unique spill guard which prevents food from accidentally being pushed off the plate) and built up spoon (specialized utensil with built up handle designed to assist residents with limited or weakened grasping strength) during meal, as indicated on the physician's order, for one of one sampled resident (Resident 39) in Activities of Daily Living care area. This deficient practice placed Resident 39 at risk for further decline in physical functioning and decline to perform self-feeding skills.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the daily nurse staffing information (list of total number of staff and the actual hours worked by the staff to meet this regulatory requirement) was placed in a visible and prominent place that is readily accessible to the residents and/ or visitors on 2/12/2024 and 2/14/2024. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 13 out of 35 rooms (5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22 and 23) met the square footage requirement of 80 square feet (sq. ft.) per resident in a multiple resident room. This deficient practice has the potential to cause the residents in these rooms not to have enough room for activities of daily living and hinder staff from providing care to the residents.

Inspectors wroteRevised with comments/ questions: Based on observation, interview, and record review, the facility failed to ensure the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was within reach (an arm's length) for one of four sampled residents (Resident 1). This had the potential to result in a delay in care for Resident1 not to receive the necessary care and services which can lead to illness or serious injury.