Pine Grove Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for supervision to prevent accidents. The facility failed to ensure Resident #1 was in safe position prior to incontinent care. Resident #1 rolled off her bed during incontinent care on 12/06/25. Resident #1 sustained a comminuted distal left femur fracture with apex posterior angulation and mild impaction (lower leg bone broken into multiple pieces tilted at an angle and slight displacement of the bone fragments) and a non-displaced fracture of the right distal femoral shaft(middle section of the femur-the bone breaks in one spot and remains aligned). This failure could place residents at risk of severe injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 vaccine/medication storage refrigerators reviewed for labeling and storage. The facility failed to monitor and record temperatures of the refrigerator used for vaccine storage twice daily as required per the Centers for Disease Control (CDC) guidelines for vaccine storage. The facility failed to document date when opened on one vial of tuberculin skin testing (TST) solution in the vaccine/medication refrigerator. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services. The facility failed to store food in accordance with professional standards in that: 1. Dry storage items were improperly stored. 2. Frozen foods were unlabeled and open to air. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 3 of 12 residents (Resident #12, #48, and #35) reviewed for ADLs. The facility failed to provide incontinent care to Residents #12 and #48 in a timely manner on 7/22/2024. The facility failed to provide denture care for Resident #35 on 7/23/2024. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in feelings of poor self-esteem, lack of dignity, and poor health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 3 of 12 resident's (Resident #5, Resident #43, and Resident #51) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure the refrigerator for Resident #43 did not contain an unlabeled, undated clear container of an unknown food item with a green, powdery substance covering it. The facility failed to ensure the refrigerator for Resident #5 and Resident #51 did not contain an unlabeled, undated clear container with fruit with a whit, grey fuzzy growth on the fruit and a zipper bag of food not labeled or dated. This failure could place residents at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 12 residents (Resident #12, #30 and #259) reviewed for infection control. CNA A failed to perform hand hygiene during incontinent care for Resident #12 and failed to properly bag soiled linen before leaving Resident #12's room on 7/23/2024. CNA C failed to perform hand hygiene and follow EBP (enhanced barrier precautions) during incontinent care for Resident #30 on 7/23/2024. CNA E failed to perform hand hygiene during incontinent care for Resident #259 on 7/22/2024. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 1 facility reviewed for accident hazards. The facility failed to develop and implement a policy and procedure to properly handle care of Hoyer lift slings including interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service. This deficient practice could result in falls and injuries if damaged lift sling broke during mechanical lift transfers.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 2 of 16 residents reviewed for call lights. (Resident #9 and Resident #19) The facility failed to ensure Resident #9's and Resident #19's emergency call light in the bathroom had a cord enabling it to be reachable from the floor. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. The dish machine tested at 10 ppm of chlorine and the temperature gauge was stuck at 110 degrees F. The grease in the deep fryer was black. These failures could place the residents at risk of foodborne illnesses.

Inspectors wroteBased on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 9 of 12 months (May 2022, June 2022, July 2022, August 2022, October 2022, December 2022, January 2023, February 2023, and March 2023) reviewed for pharmacy services. The facility did not have a licensed pharmacist and two witnesses initial the attached pages of controlled medication destruction inventory sheets. This failure could put residents at risk for misappropriation and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident # 24, Resident # 35, and Resident #60) reviewed for infection control. 1. CNA A failed to properly handle soiled linen and soiled brief for Resident #24 after personal care. 2. CNA B failed to properly handle soiled linen and soiled brief for Resident #60 after personal care and failed to appropriately perform hand hygiene after incontinent care. 3. Treatment nurse failed to clean the scissors used to cut wound care dressings for Resident #35 and she stored the scissors in her pocket. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 7 residents (Resident # 60) observed for care in that: CNA B failed to close the blinds and pull the privacy curtain during personal care for Resident #60. This failure could affect all residents in the facility who received care and could result in residents not being treated with dignity and respect and being exposed during care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 of 16 resident personal refrigerators reviewed for food safety (Resident #315 & Resident #11). The facility failed to ensure the refrigerator for Resident #315 had a thermometer for checking the temperature and that the refrigerator for Resident #11 did not contain an unlabeled, undated sandwich, or expired cranberry juice. This failure could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove in the kitchen reviewed for essential equipment. The facility did not ensure the stove was in working order. Two of the six burners on the stove did not light, when the knobs were turned. DM turned knobs on for the middle burners to light (they did not) and left gas on, when the burners on the right side of the stove lit the [NAME] shot across the top of the stove and lit the middle burners. This failure could place the residents at risk of a fire and not having safe operating equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 2 of 21 residents reviewed for call lights. (Resident #6 and Resident #316). The facility failed to ensure Resident #6 and #316's emergency call light in the bathroom would reach the floor. The call light cord for Resident #6 was too short and Resident #316's was wrapped around the support bar. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow established policy regarding smoking, smoking areas, and smoking safety for 1 of 6 residents reviewed for smoking (Resident #53). The facility failed to keep cigarette butts out of the trash can in the smoking area (Front Porch of the Facility), and there were no ash trays or a red metal trash cans available for residents to extinguish their cigarettes. The residents were putting there cigarettes out on the bricks of the building. The residents were then placing the cigarettes in a plastic garbage can with paper goods in it This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment.