Pine Grove Manor

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), who was non-weight bearing on his/her left leg and required the use of a Hoyer (mechanical lift) for transfers, received adequate assistance to prevent accidents when Certified Nurse Aide (CNA) A and Certified Medication Technician (CMT) B performed an assisted transfer without the use of a mechanical lift or gait belt. The resident reported pain during the transfer and sustained a fractured fibula (calf bone). The sample was 7. The census was 52 The Administrator was notified on 07/01/26 of the past non-compliance, which occurred on 05/05/26. Nursing staff were in-serviced on resident transfers. The deficiency was corrected on 05/14/26. Review of the facility's Total Mechanical Lift policy, revised 06/2020, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were followed by not accurately coding one resident (Resident # 8's) medication as not given on the medication administration record (MAR) and by failure to document if one resident (Resident #7's) medications, treatments, and skin assessments were completed on the MAR. In addition, the facility failed to ensure that skin assessments were completed as physician ordered for two residents (Residents #5 and #48). The resident sample is 18. The census was 53. Review of facility's physician order policy, last revised, June 2020, showed: -Purpose: This will ensure that all physician orders are complete and accurate; -Procedure: -A licensed nurse will transcribe telephone orders with date, time, and signature of the person receiving the orders; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL, bathing, dressing, eating, transferring and toileting) care was provided for four of 18 sampled residents. The facility failed to ensure one resident was toileted in a timely manner (Resident #28), failed to ensure two residents received at least two showers a week and were assisted by staff (Residents #4 and #38), and failed to ensure one resident was assisted with unwanted facial hair removal (Resident #5). The census was 53. Review of the facility's showering a resident policy, undated, showed:-Purpose: a shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors;-Policy: residents are offered a shower at a minimum of once weekly and given per resident request. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess resident activity preferences and to provide an ongoing activity program that supports residents in their choices of activities (Residents #2, #4, #5, #10, #16, #25, and #48). In addition, the facility failed to provide one to one (1:1) activities to three residents who were identified as having the potential to benefit from them (Residents #6, #7, and #9). The sample was 18. The census was 53. Review of the facility's Activities Program policy, dated 6/2020, showed:-Purpose: To encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning;-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for two out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 53. Review of the facility's Storage of Controlled Substances policy, last revised August 2020, showed:-Policy: Medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations;-Procedures: -At each shift change, or when keys are transferred, a physical inventory of all controlled substances including refrigerator times, is conducted by two licensed personnel and is documented; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly medication reviews were completed and that the physician provided responses to recommendations for five of 18 residents sampled. (Residents' #1, #3, #6, #5, and #8). The census was 53. Review of the facility's Drug Regimen Review policy, revised January 2025, showed:-Purpose: -The intent is that the facility maintains the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing (DON);-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and serve food in accordance with professional standards for food service safety. The facility failed to maintain kitchen equipment in a clean condition and failed to ensure that the floors were swept and mopped during five of five days of observation. The facility also failed to ensure that a pipe was repaired from the underneath the sink and that the floor was repaired. The census was 53.1. Observations of the kitchen on 3/9/26 at 8:57 A.M., 3/10/26 at 3:33 P.M, 3/11/26 at 7:20 A.M., 3/12/26 at 10:48 A.M., and 3/13/26 at 1:10 P.M. showed:-Stove: -Caked-on stains along the front and on the top of the stove; -Heavy caked-on stains and spots on the burners on the stove; -Oven: -Heavy caked-on stains along the front inside doors; -Heavy caked-on stains along the bottom, top, and sides of oven;-Reach in cooler: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bathrooms on the second floor were cleaned routinely, affecting one of 18 sampled residents (Resident #10). The sample was 18. The census was 53 Review of the facility's Housekeeping policy, dated 8/2020, showed:-Purpose: To ensure that the facility is clean, sanitary, and in good repair at all times so as to promote the health and safety of residents, staff, and visitors;-Policy: All rooms of the facility are kept clean and as free as possible of germs and other contaminating agents at all times, while maintaining a pleasant and homelike atmosphere for our residents;-Procedure: The housekeeping department is responsible for completing the daily, weekly, and monthly cleaning procedures. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards by not obtaining dressing change orders on admission and transcribing the wound physician orders for one resident (Resident #57). The sample was 18. The census was 53. Review of facility's physician order policy, last revised, June 2020, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident had weekly skin assessments completed, and was repositioned and cleaned after being incontinent of urine for an extended period. The facility failed to ensure treatments orders were accurate and completed on a newly identified pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) (Resident #28). The sample size was 18. The census was 53. Review of the facility's Pressure Injury Prevention policy, last revised, June 2020, showed:-Purpose: To identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure injury and minimize complications;-Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Resident #9 and Resident #6) received appropriate gastrostomy tube (g-tube, a tube surgically inserted into the abdomen used for liquid nutrition, fluids and medications) care to avoid potential complications from the tube feeding. Facility staff failed to label the water flush bag and failed to ensure the resident's head of bed was elevated to prevent aspiration (choking). The facility also failed to include Resident #6's tube feeding care on the care plan. The sample was 18. The census was 53. Review of the facility's Tube Feeding/Total Parenteral Nutrition (TPN)/Partial Parenteral Nutrition (PPN) operational manual revised, 9/24/24, showed:-Purpose: -To ensure that the facility meets the nutritional guidelines and residents' nutritional requirements per physician orders;-Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received respiratory care in accordance with professional standards of practice by failing to ensure oxygen tubing was dated and/or stored properly when not in use for two residents (Residents #48 and #6) and by failing to ensure physician orders for oxygen use included flow rate and usage instructions for one resident (Resident #6). The sample was 18. The census was 53. Review of the facility's Oxygen Administration policy, dated 6/2020, showed:-Purpose: To prevent or reverse hypoxemia (low oxygen levels in the blood) and provide oxygen to the tissues;-Policy:-Initiation of oxygen: A physician's order is required to initiate oxygen therapy, except in an emergency situation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who require such service, consistent with professional standards of practice for two residents (Resident # 57 and Resident #2) The sample size was 18. The census was 53. Review of facility's Pain Management policy, last revised, June 2020, showed:-Purpose: To ensure accurate assessment and management of the resident's pain;-Policy: A licensed nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status; Facility staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain;Procedure: [...]

Inspectors wroteBased on observation and interview, the facility failed to post the nurse staffing information daily in a prominent place readily accessible to residents and visitors. The census was 53. Review of the facility's nursing department staffing, scheduling, posting policy, dated 6/2020, showed:-Procedure: The facility will post the following information on a daily basis: facility name, current date, the total number and actual hours worked for nursing staff;-The facility will post the nurse staffing data specified above, on a daily basis at the beginning of each shift. Data must be posted in a clear and readable format and in a prominent place readily accessible to residents and visitors. Observations on 3/10/26 at 10:32 A.M., 3/11/26 at 10:00 A.M., and 3/12/26 at 9:12 A.M., showed the nurse staffing sheet hung on a bulletin board behind the first floor nurse's station. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being by not identifying ongoing psychological and counseling needs for two residents (Resident #4 and Resident #2) and by not addressing one resident's behavior (Resident # 38). The sample was 18. The census was 53. Review of the facility's Behavior Management policy, last revised June 2020, showed:-Purpose: To implement the most desirable and effective interventions to change, modify, decrease or eliminate behaviors that are distressing to the resident, and or are decreasing or negatively impacting the resident's quality of life. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a system in place to ensure drugs and biologicals were labeled with a date opened and expiration date. Issues were identified with one out of three mediations carts reviewed. The census was 53. Review of the facility's Storage of Medications policy, last revised, August 2020, showed:-Certain medication or package types such as ophthalmics (eye) require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency;-Drugs dispensed in the manufacturer's original container will carry the manufacturer's original expiration date; [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and vaccinate eligible residents for pneumococcal pneumonia (pneumonia caused by bacteria) for two out of five residents reviewed (Resident #2 and Resident #27), and influenza (flu) vaccine for one out of five residents (Resident #4) sampled for immunizations. The census was 53. Review of the facility's Pneumococcal Disease Prevention policy, last revised, June 2020, showed:-Purpose: To ensure that the facility prevents and control the spread of pneumococcal disease in the facility;-Policy: -The facility will offer training to facility staff upon hire and inform residents on precautions and best practices to control the infection and spread pneumococcal disease in the facility; -The pneumococcal vaccine is recommended for all adults 65 ears of age and older; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide cardiopulmonary resuscitation (CPR, life saving measures) effectively to include rescue breaths, to a resident when the supplies needed to run a code were not available on the crash cart. This resulted in a delay of up to 9 minutes from the time CPR was initiated until rescue breaths and oxygen could be administered, for one resident (Resident #1). Staff were not knowledgeable on how to work the suction machine, resulting in an occluded airway. In addition, staff failed to ensure Emergency Medical Services (EMS) was in the room and ready to take over compressions before stopping CPR. Eighteen residents were identified to be a full code. The census was 48. The Interim Administrator was notified on [DATE] at 2:50 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors when staff failed to prime pre-filled insulin pens before insulin administration for two residents (Residents #6 and #4). The sample was 7. The census was 48. Review of the facility's Medication Administration of Insulin policy, revised May 2014, showed: -Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes;-The type of insulin, dosage requirements, strength, method of administration must be verified before administration, to assure that if corresponds with the order on the medication sheet and the physician's order;-The policy did not address the use of insulin pens. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect each resident's right to be free from any physical restraint when Resident #2 was found by staff with the sleeves of his/her long sleeve shirt tied together at the end, preventing freedom of movement, and resulted in limiting normal access to the use of his/her hands. The census was 48. Review of the facility's Restraints policy, dated 6/2020, showed:-Purpose: Residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used;-Physical restraint is defined as 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. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure treatment orders for wound care were appropriately transcribed, resulting in one resident (Resident #4) not receiving wound care as ordered by the physician. The sample was 7. The census was 48. Review of the facility's Physician's Orders policy, dated June 2020, showed:-Purpose: This will ensure that all physician orders are complete and accurate;-Orders will include a description complete enough to ensure clarity of the physician's plan of care;-Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order;-Medication/treatment orders will be transcribed onto the appropriate resident administration record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining safe water temperatures in resident rooms on the North and South halls between 105 degrees Fahrenheit (F) and 120 F for 16 (Residents #49, #14, #12, #15, #54, #34, #8, #3, #27, #5, #43, #258, #18, #11, #52, and #40) of 31 sampled residents. The hot water temperatures in these resident room bathrooms ranged from 141 to 153 degrees F. The census was 55. The administrator was notified on 3/28/24 at 7:00 P.M., of an immediate jeopardy (IJ), which began on 3/28/24. The IJ was removed on 3/29/24 as confirmed by surveyor verification. Review of the facility's Safety of Water Temperatures Policy, dated December 2009, showed: -Policy Statement: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meaningful activities or one on one activities for residents dependent on staff for their needs, for four (Residents #27, #5, #28, and #33) of 31 sampled residents. The census was 55. 1. Review of the facility's March and April 2024 activity's calendar, included: -3/28/24: 8:30 A.M., Coffee talk time; 11:30 A.M., Movie Lunch; 2:00 P.M., Resident Council and 5:00 P.M., cards; -3/29/24: 8:30 A.M., Coffee talk time; 10:30 A.M., one on ones; 12:00 P.M., 70s/80s musical lunch; 2:00 P.M., Easter Party; 5:00 P.M., cards; -3/30/24: 8:30 A.M., Coffee talk time; 1:00 P.M., coloring club; 5:00 P.M., cards; -3/31/24: 8:30 A.M., Coffee talk time; 1:00 P.M., book club; 5:00 P.M., cards; -4/1/24: 8:30 A.M., Coffee talk time; 12:00 P.M., 50s/60s musical lunch; 2:00 P.M., Resident council; 5:00 P.M., cards; -4/2/24: 8:30 A. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the activity program was directed by a qualified professional. The census was 55. Review of the facility's undated Job Description for Activity Director, showed: -Qualifications; -A minimum of a high school diploma; -Completed a state approved activities director course; -One year experience in a resident activities program in a health care setting; -If an applicant has not met the last two of the above requirements, a consultant may be provided aimed at assisting the individual at achieving the requirements. During an interview on 4/3/24 at 9:10 A.M., the Activity Director said she was the only one doing activities for the facility. She had not been trained on how to run an activity program. She was enrolled in the course, but had not started the program yet. She had been employed at the facility for about two years. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the ice machine in the main kitchen had an air gap between the drain pipe to prevent back siphonage. This had the potential to affect all residents who consumed drinks with ice. The census was 55. Review of the facility Air Gap Policy for Ice Machine Draining Pipe, undated, showed: -Objective: To ensure the sanitary operation of the ice machine by preventing the backflow of drain water into the ice machine through the establishment of an effective air gap; -Policy Statement: -All ice machines must have an air gap between the drain pipe of the ice machine and the floor drain or any other drainage system it connects to. This air gap is critical to prevent the possibility of contaminated water flowing back into the ice machine; -Definition: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection control when staff failed to provide perineal care (peri care, cleansing the surface area between the thighs, extending from the pubic bone to the tail bone) per their policy for two residents (Resident #28 and #35) and when staff failed to perform hand hygiene and/or change both gloves during care for two residents. (Resident #258 and #46). The sample was 31. The census was 55. Review of the facility's Perineal Care policy, undated, showed: -Purpose: The purpose of this procedure is to provide cleanliness and comfort to the residents to prevent infections and skin irritation, and to observe the resident's skin condition; -Steps in the procedure: -For a female resident: wet the washcloth and apply soap or cleansing agent; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete pre (before) and post (after) dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys are not working properly) assessments and failed to have an accurate care plan for one of one resident reviewed for dialysis services (Resident #34). The census was 55. Review of the facility's Care of a Resident with End-Stage Renal Disease (ESRD) Policy, date revised September 2010, showed: -Residents with ESRD will be cared for according to currently recognized standards of care; -Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents; -Education and training of staff includes, specifically: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure interventions to prevent falls were utilized as care planned, the interventions were reevaluated for effectiveness and additional appropriate interventions to prevent falls were addressed for two of three sampled residents (Resident #2 and #3). The census was 62. Review of the facility's Fall Protocol, undated, showed the following: -Purpose: To identify and intervene to decrease the risks and injuries related to resident falls and other injuries: -Responsibilities: The charge nurse is responsible for the initial completion of the Fall Risk Assessment upon admission. The charge nurse is responsible for obtaining the therapy screening when needed for a Fall Risk Assessment score of 10 or greater and when a resident has a fall or is noted to have a change of condition that puts the resident at risk for a fall. [...]

Inspectors wroteBased observation, interview and record review, the facility failed to ensure one resident was free from verbal abuse and intimidation (Resident #3). On 9/25/23 at 4:48 A.M., Certified Nurse Aide (CNA) A went into the resident's room and cursed at the resident to lay in his/her bed, calling the resident derogatory names and verbally threatening physical harm to the resident. The census was 65. The administrator was notified on 10/26/23, of the past non-compliance. The facility provided training and in-services for all staff regarding the facility's abuse prevention and resident rights policies. Review of the facility's Abuse Policy, revised 9/1/18, showed: -Purpose: The facility maintains a no tolerance policy on any form of abuse towards our residents. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain food under sanitary conditions when staff failed to label and date opened/stored food, to ensure dishes were air dried, kitchen equipment remained clean and floors were free of dust, grease and grime. In addition, staff failed to routinely test the chemical dishwasher prior to use. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 59. Review of the Food Storage Policy, procedure guidelines, undated, showed: Food stored in freezers and refrigerators are covered, labeled and dated, especially foods taken from their original containers and leftovers. Review of the Infection Control/Sanitation/Mechanical Dishwasher policy, undated, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with a clean, comfortable and homelike environment by not ensuring common areas, such as dining rooms and restrooms, were clean and free of hazards. The facility also failed to provide a homelike environment to one resident by not providing a functional dresser to keep the resident's clothes in private, clean and in proper order. The census was 59. Review of the facility's Cleaning and Disinfection of Environmental Surfaces policy, dated August 2019, showed: -Environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendation for disinfection of healthcare facilities; -Non-critical items are those that come in contact with intact skin but not mucous membranes: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all facility staff received training in cardiopulmonary resuscitation (CPR) for healthcare providers, resulting in some staff responsible for providing CPR not receiving the correct CPR training. The census was 59. Review of the documentation provided by the facility staff assignment sheets for the dates of [DATE] through [DATE], showed the facility identified staff CPR certified and responsible to provide CPR in the event of an emergency for each shift. Review of the documentation of CPR certification, provided by the facility for the staff identified on the staff assignment sheets, showed: -The Minimum Data Set (MDS) coordinator's CPR certification for CPR and automated external defibrillator (AED, portable device used to correct irregular heart rates): -The certification was not specified for healthcare providers; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each reside receives food prepared to provide proper nutritive value and texture for two residents (Residents #111 and #38). The facility identified three residents who received pureed diets. The census was 59. The sample was 15. Review of the facility's Pureed Food Guidelines, dated 2019, showed the following for casseroles: -1 cup cooked; -half slice bread; -Broth or water; -Place bread, then food to be pureed, in blender or food processor. Begin with half cup liquid, puree, then continue to alternate adding half cup liquid and pureeing until product is correct consistency; -The consistency of the pureed food should not be thinner than pudding or thicker than mashed potatoes. 1. Review of the facility's dinner menu for Tuesday 6/7/22, showed: -Chicken pasta bake; -Sweet peas and carrots; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct regular inspection of all bed frames, mattresses and bed rails, as part of a regular maintenance program to identify areas of possible entrapment for four of 15 sampled residents (Residents #57, #111, #42 and #13). The census was 59. Review of the facility's Proper Use of Assist Rails policy, dated December 2016, showed: -Purpose: The purse of these guidelines are to ensure the safe use of assist rails as resident mobility aides and to prohibit the use of side rails as restraints; -Assist rails are only permissible if they assist with mobility and transfer of residents; -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using assist rails. When used for mobility or transfer, an assessment will include a review of the resident's: -Bed mobility; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a sufficient surety bond (one and one-half times the average monthly balance) to ensure protection of resident funds. The facility held funds for 41 residents. The census was 59. Review of the facility's Resident's Rights and Handling Resident Funds and Property Policy and Procedure, dated August 2008, showed: -With written authorization of a resident, the facility can hold and manage a resident's personal fund, limited to Veteran's pension, Social Security income, and personal spending money from Department of Mental Health and Medicaid residents; -The facility is bonded for 1.5 times the average monthly balance of personal funds, including petty cash, rounded to the nearest $2000. [...]